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.

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.

• 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.li>
• Record patients' preferred place of care and preferred place of death where appropriate.

• 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…