Practice Nurse - Frailty

Position Summary

Frailty Nurse to support the delivery of a proactive frailty service within our GP practice, focusing on the identification, assessment and ongoing management of patients living with moderate to severe frailty. The post holder will work autonomously to manage a defined cohort of patients, with the aim of improving patient outcomes, reducing avoidable hospital admissions and supporting patients to remain safely within the community.

• Undertake comprehensive frailty assessments, including home visits where required
• Complete initial and follow‑up frailty reviews in line with service requirements
• Develop, implement and review personalised care plans in collaboration with patients, carers and the wider multidisciplinary team
• Identify and manage clinical risk, including falls risk, polypharmacy concerns and safeguarding issues
• Escalate complex or high‑risk cases to GPs or wider MDT as appropriate
• Work closely with GPs, pharmacists, district nurses, community teams and secondary care services to coordinate care
• Act as a key point of contact for patients within the frailty cohort and support proactive case management of high‑risk and vulnerable patients
• Contribute to the development and ongoing improvement of the practice frailty service and the delivery of contractual requirements relating to frailty care
• Ensure activity is coded, recorded and monitored accurately in EMIS and support service evaluation, audits and reporting
• Maintain accurate, contemporaneous and high‑quality clinical records using EMIS and ensure all patient interactions and care plans are clearly documented
• Support the wider team as required in delivering safe and effective patient care across both practice sites and patient homes

2 days per week. This post is initially offered on a fixed term basis linked to current service funding, with the potential for extension subject to ongoing service need and funding.

• Registered Nurse with a valid NMC registration
• Additional training in frailty, geriatrics or long‑term condition management (preferred)

• Experience of working with elderly or frail patients in a community, primary care or similar setting
• Demonstrable experience of clinical assessment and care planning
• Experience of managing patients with complex health and social needs
• Experience of working within a GP practice
• Experience of case management or care coordination
• Experience of working within multidisciplinary teams across organisational boundaries

• Strong clinical assessment and decision‑making skills
• Ability to work autonomously and manage a defined caseload
• Ability to identify and manage clinical risk
• Good understanding of safeguarding and risk management
• Effective communication skills with patients, carers and professionals
• Ability to prioritise workload and work flexibly in a changing environment
• Knowledge of frailty pathways and community services
• Understanding of primary care systems and processes within NHS Wales
• IT literacy including use of clinical systems such as EMIS

• Full UK driving licence and access to a vehicle
• Willingness to undertake home visits as a routine part of the role
• Ability to work across both practice sites

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and will require a submission for Disclosure to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.