Frailty​/ICST Nurse

Job summary

An exciting opportunity has arisen for an experienced Registered Nurse to join Nexus MK PCN as a Frailty/ICT Nurse.

Working across Nexus MK PCN member practices, the successful candidate will lead on the proactive identification, assessment, and management of patients living with frailty. The role will involve delivering regular care home ward rounds, supporting patients within their own homes and care settings, and representing frailty patients at Integrated Neighbourhood Team (INT) and Multidisciplinary Team (MDT) meetings.

This role is central to the PCN's frailty agenda, working closely with GPs, care home staff, community services, social care teams, and the wider multidisciplinary team to deliver proactive, person-centred care. The aim is to improve patient outcomes, reduce avoidable hospital admissions, and support frail patients to remain independent and well within their usual place of residence wherever possible.

• Proactively identify and assess patients living with moderate to severe frailty.
• Undertake comprehensive frailty assessments and clinical reviews.
• Develop, implement, and review personalised care and support plans in partnership with patients, families, and carers.
• Deliver regular ward rounds within designated care homes across the PCN.
• Support the management of patients at risk of deterioration, crisis, or unplanned hospital admission.
• Work collaboratively with GPs and the wider multidisciplinary team to coordinate care and ensure timely interventions.
• Present complex and high-risk patients at MDT and INT meetings, coordinating appropriate follow-up actions.
• Support advance care planning discussions, including ReSPECT forms and end-of-life care planning where appropriate.
• Contribute to improving the quality and continuity of care for frail and vulnerable patients.
• Maintain accurate and contemporaneous clinical records in line with professional and organisational standards.
• Contribute to service development, audit, quality improvement projects, and PCN reporting requirements.

Nexus MK PCN is a collaborative network of 5 GP practices working together to deliver high-quality, integrated healthcare services across Milton Keynes. Our multidisciplinary workforce includes GPs, Nurses, Clinical Pharmacists, First Contact Practitioners, Social Prescribers, Care Coordinators, and other healthcare professionals dedicated to improving outcomes for our local population.

We are committed to providing proactive, personalised care to our patients, particularly those with complex needs and frailty. As part of our continuing service development, we are seeking an enthusiastic and motivated Frailty Nurse to join our growing team.

The Frailty Nurse will work as part of the Nexus MK PCN multidisciplinary team to proactively identify, assess, and support patients living with frailty across member practices, care homes, and community settings.

The post holder will provide clinical leadership in frailty management, working collaboratively with primary care, community services, social care, care homes, and secondary care providers to improve outcomes and reduce health inequalities for frail and elderly patients.

The role will focus on preventative care, personalised care planning, admission avoidance, and coordinated multidisciplinary working to ensure patients receive the right care at the right time.

• Registered Nurse with current NMC registration.
• Significant post-registration clinical experience.
• Experience of working with older people, frailty, long term Conditions, or complex care management.
• Experience of multidisciplinary team working.
• Excellent communication and clinical assessment skills.
• Ability to work autonomously…