Frailty Nurse

The post is funded through the Single Neighbourhood programme and is offered as a fixed-term contract for 7 months in the first instance, with the potential for extension subject to ongoing funding and service requirements.

An exciting opportunity has arisen to join Dartford MODEL PCN as a Frailty Nurse, supporting the delivery of our new Single Neighbourhood programme. Working across our member practices, patients’ own homes and care home settings, you will play a key role in providing proactive, person-centred care for adults living with frailty and complex health needs. As part of a supportive multidisciplinary team, you will undertake comprehensive geriatric assessments, coordinate care, promote anticipatory care planning and work collaboratively to improve patient outcomes and help reduce avoidable hospital admissions. This is an excellent opportunity for an enthusiastic and compassionate nurse who enjoys autonomous working, values integrated care and is passionate about improving the lives of frail/older people.

Dartford MODEL Primary Care Network is a forward-thinking and collaborative organisation serving a population of around 34,000 patients across three GP practices in Dartford, North Kent: The Wellcome Practice, Lowfield Medical Centre and Dr C J Shimmins & Partners.

Interviews due to take place week commencing 31st August 2026.

Job Description

The Frailty Nurse will play a key role in delivering the Single Neighbourhood (SNH) programme across the Primary Care Network (PCN). Working as part of a multidisciplinary team, the post holder will provide proactive, holistic care for patients living with frailty and complex health needs, with a particular focus on housebound patients, care home residents, patients receiving palliative care and those identified through the PCN’s frailty registers.

The post holder will undertake comprehensive geriatric assessments (CGAs), coordinate care, support anticipatory care planning and work collaboratively with patients, carers and partner organisations to improve patient outcomes, promote independence and reduce avoidable emergency department attendances and hospital admissions.

Main Duties and Responsibilities
Clinical Responsibilities

• Deliver high-quality, patient-centred nursing care for patients living with frailty across GP practices, patients’ own homes and care home settings.
• Undertake comprehensive geriatric assessments (CGAs), assessing patients’ physical, psychological, functional and social needs, and contribute to personalised care planning.
• Develop and review anticipatory care plans in partnership with patients, carers and the multidisciplinary team.
• Monitor patients with frailty and complex needs, identifying changes in health status and escalating concerns appropriately.
• Recognise and manage common frailty syndromes including falls, delirium, immobility, continence issues, malnutrition and medication-related problems.
• Assess nutritional risk where appropriate and work collaboratively with dietitians, pharmacists and other healthcare professionals to optimise nutritional care.
• Work alongside the PCN pharmacy team and other prescribers to support structured medication reviews and medicines optimisation.
• Carry out cognitive assessments where appropriate and make timely referrals to memory assessment services and other specialist services in accordance with local pathways.
• Identify patients who may benefit from a palliative approach to care and facilitate referrals to appropriate services.
• Support patients and clinicians with ReSPECT discussions and documentation, ensuring patients’ wishes are appropriately recorded.
• Undertake and record NEWS2 observations where clinically indicated, recognising deterioration and escalating concerns promptly.
• Record patients’ preferred place of care and preferred place of death where appropriate.

Care Coordination

• Coordinate care for patients with frailty and complex needs, ensuring continuity across primary, community and secondary care services.
• Promote proactive management by identifying patients at risk of deterioration and supporting interventions to reduce avoidable emergency department attendances and hospital admissions.
• Support timely follow-up following hospital discharge or significant clinical events where appropriate.
• Liaise with patients, carers and families, providing education, support and signposting to appropriate health, social care and voluntary sector services.

Multidisciplinary Working

• Work collaboratively within multidisciplinary team (MDT) meetings, contributing to case discussions and coordinated care planning.
• Develop effective working relationships with GPs, pharmacists, community nurses, therapists, geriatricians, social care, care home staff, hospices and voluntary sector organisations.
• Support delivery of the Enhanced Health in Care Homes (EHCH) model through collaborative working with care home teams and community services.

Quality, Governance and Service Development

•  Support practices with frailty identification, dementia and palliative care coding, ensuring accurate clinical records.
• Maintain accurate, contemporaneous documentation using EMIS Web and ensure appropriate clinical coding.
• Contribute to clinical audit, service evaluation, quality improvement initiatives and data collection to support delivery of the Single Neighbourhood programme.
• Participate in reporting requirements and service evaluation, including preparation of information for the ICB where required.
• Ensure compliance with CQC standards, safeguarding policies, NICE guidance and local clinical policies.
• Participate in mandatory training, clinical supervision, appraisal and continuing professional development.
• Practise in accordance with the NMC Code and maintain professional registration at all times.

General Responsibilities

• Maintain patient confidentiality and comply with GDPR and Information Governance requirements.
• Work flexibly across the PCN to meet service needs.
• Undertake any other duties commensurate with the grade of the post.