Job summary
Are you passionate about improving the lives of older people and helping them remain safe, independent and well at home? We are looking for an enthusiastic and compassionate Frailty Nurse to join our team and make a real difference to some of our most vulnerable patients.

This is a community-focused role, working primarily with patients who are housebound or find it difficult to attend the surgery. Through proactive home visits, you will carry out comprehensive frailty assessments, develop personalised care and support plans, identify unmet needs, and coordinate care with families, carers and partner organisations.

The role is focused on prevention, helping patients stay healthier for longer and reducing avoidable hospital admissions by identifying risks early, supporting self-management where appropriate, and ensuring patients have the right care in place at the right time. You will have the opportunity to build meaningful relationships with patients and play a key role in improving their quality of life.

At Fenland Group Practice, we are committed to delivering proactive, person-centred care and investing in innovative services that support our local population. This is an exciting opportunity to help shape and develop our frailty service, giving you the autonomy to make a genuine impact while being supported by experienced colleagues across the wider multidisciplinary team.

Main duties of the job
This role offers the opportunity to deliver proactive, person-centred care to some of our most vulnerable patients in their own homes. You will undertake home visits for patients who are housebound or who struggle to access GP services, providing holistic assessment, care planning and ongoing support.

Your work will include managing acute and chronic health needs, undertaking long-term condition reviews, supporting patients living with frailty, coordinating care with the wider multidisciplinary team, and helping patients and families navigate health and social care services. You will also play an important role in advance care planning and end of life care discussions, ensuring patients' wishes are understood and respected.

A key aspect of the role will be working closely with carers, identifying support needs and connecting patients and families with appropriate community resources. Through proactive intervention, early identification of deterioration and personalised care planning, you will help improve patient outcomes, enhance quality of life and reduce avoidable hospital admissions.

About us
Fenland Group Practice is a large, forward-thinking GP practice serving communities across Cambridgeshire. We are committed to delivering high-quality, patient-centred care and continually look for innovative ways to improve services for our patients.

Our multidisciplinary team includes GPs, nurses, paramedics, healthcare assistants, care coordinators, social prescribers and administrative colleagues who work together to provide excellent care. We are proud of our supportive culture, where teamwork, compassion and mutual respect are at the heart of everything we do.

We are passionate about proactive healthcare, particularly for patients who are vulnerable, living with long-term conditions or at risk of hospital admission. As a result, we are continually developing services that help patients receive the right care at the right time.

We recognise that our staff are our greatest asset and are committed to creating a positive working environment where people feel valued, supported and able to develop their skills. This is an exciting opportunity to join a practice that encourages innovation, embraces change and empowers staff to make a genuine difference to patients and the wider community.

Job responsibilities

• Undertake home visits for housebound patients and those who have difficulty accessing practice services.
• Complete holistic frailty assessments and develop personalised care and support plans.
• Assess, manage and monitor acute and chronic health conditions within the community setting.
• Conduct long-term condition reviews and support patients to optimise their health and wellbeing.
• Identify patients at risk of deterioration and implement interventions to prevent avoidable hospital admissions.
• Support advance care planning and end of life care discussions in line with patient wishes.
• Provide advice, education and support to patients, families and carers.
• Work collaboratively with GPs, community teams, social care providers and voluntary organisations.
• Coordinate care for patients with complex needs and ensure appropriate follow-up arrangements are in place.
• Promote independence, self-management and healthy ageing wherever possible.
• Participate in safeguarding processes and identify concerns relating to vulnerable adults.
• Maintain accurate clinical records and contribute to audits, service evaluation and quality improvement activities.
• Support the development of proactive care services for frail and vulnerable patients across the practice.

Person Specification
Knowledge and skills
Essential

• Registered healthcare professional with current registration with the appropriate professional body (NMC, HCPC or equivalent) and an independent prescribing qualification.
• Significant experience managing patients with frailty, multiple long-term conditions and complex health needs.
• Ability to undertake comprehensive clinical assessments, formulate management plans and prescribe safely within scope of practice.
• Excellent communication and interpersonal skills, with experience of working collaboratively with patients, carers and multidisciplinary teams.
• Ability to work autonomously, manage a caseload, prioritise workload and make sound clinical decisions in a community setting.

Desirable

• Experience working in primary care, community services, urgent care, intermediate care or care home settings.
• Experience of advance care planning, palliative care and end of life care discussions.
• Knowledge of local health, social care and voluntary sector services supporting older adults and carers.
• Experience of service development, quality improvement or initiatives aimed at reducing hospital admissions and improving patient outcomes.

Qualifications
Essential

• Prescriber level qualification

Experience
Essential

• Experiance of working in the community

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).