Job summary
This role is centred on structured care home ward rounds and proactive care home reviews - this will form the core and majority of the workload.

Main duties of the job
This role is centred on structured care home ward rounds and proactive care home reviews - this will form the core and majority of the workload.

You will:

• Conduct regular care home ward rounds
• Review new care home residents
• Manage acute presentations within care homes
• Lead long-term condition management for frail residents
• Support QOF work relating to care home patients

In addition to care home rounds, the role will also include:

• In-practice frailty reviews for patients attending appointments
• Remote consultation frailty reviews where appropriate

You will work closely with the Frailty & Care Home Lead GPs and be supported by a comprehensive, well-established MDT. The role includes attendance at regular MDT meetings, educational sessions and governance meetings.

About us
The Health Triangle PCN is a 3 Practice, 7-site PCN, looking after approximately 52,000 patients across Bracknell, Crowthorne, Sandhurst and Owlsmoor. The PCN has 5 Care Homes based in Crowthorne and Sandhurst. We have a large MDT consisting of GPs, Nurses, Paramedics, Clinical Pharmacists, Mental Health Practitioners, Physician Assistants, Pharmacy Technicians and First Contact Physiotherapists. The PCN is a learning environment and Ringmead Medical Group is a training practice with Paramedic, Pharmacist, GP, Nursing and Physician Assistant students.

Job responsibilities
The Health Triangle PCN- Frailty Nurse Job Description
Job Title
Frailty Nurse
Employer
Health Triangle Primary Care Network
Practices
Ringmead Medical Group, Evergreen Surgery, Crownwood Medical Practice
Reports To
Clinical: Frailty Lead GP
Administration: PCN Manager
Job Purpose
The Frailty Nurse will play a central role in delivering high-quality, proactive, and patient-centred care to frail, elderly and housebound patients across Health Triangle PCN.

The core focus of the role is the delivery of structured care home ward rounds and proactive clinical oversight across the care homes within the PCN. The post holder will also support frailty reviews within practice, undertake home visits where appropriate, and provide remote consultations.

The role aims to improve outcomes for frail patients, reduce avoidable hospital admissions, optimise long-term condition management, and support quality improvement across the network.

Key Responsibilities
1. Clinical Responsibilities
The post holder will:

• Undertake comprehensive history taking and physical assessment
• Diagnose and manage acute and chronic conditions within scope of practice
• Conduct regular, structured care home ward rounds (primary component of role)
• Review new care home residents
• Manage acute presentations within care homes
• Lead long-term condition management for frail and elderly patients
• Ensure that all eligible residents in aligned care homes are identified and offered both seasonal and routine vaccinations
• Contribute to anticipatory care planning and personalised care discussions
• Provide remote consultations where clinically appropriate
• Deliver in-practice frailty reviews for patients attending appointments
• Recognise professional limitations and escalate appropriately to GP or MDT colleagues
• Maintain accurate, contemporaneous and high-quality clinical records in GP clinical system

2. Care Home & Frailty Service Delivery

• Provide consistent clinical oversight to PCN care homes
• Build effective working relationships with care home staff
• Ensure medical queries are reviewed promptly and safely
• Support safe medicines optimisation in collaboration with pharmacists and GPs
• Contribute to reducing avoidable admissions and improving continuity of care
• Participate in service development and refinement of frailty pathways

3. QOF & Quality Improvement
The Frailty Nurse will:

• Support QOF-related work for care home patients
• Contribute to chronic disease reviews and monitoring
• Ensure accurate clinical coding and documentation
• Participate in audit and quality improvement initiatives
• Contribute to governance discussions and service evaluation

4. Multidisciplinary Working

• Work collaboratively within a comprehensive and well-established MDT
• Liaise closely with the Frailty & Care Home Lead GPs
• Attend regular MDT meetings
• Participate in clinical governance and educational meetings
• Contribute to coordinated, team-based patient care

5. Professional Responsibilities

• Maintain active NMC registration
• Work within professional scope of practice and competencies
• Demonstrate safe, evidence-based clinical decision-making
• Engage in continuous professional development
• Maintain revalidation requirements
• Uphold confidentiality, safeguarding and data protection standards

Person Specification
Essential

• Registered Nurse (NMC)
• Experience managing frail, elderly or housebound patients
• Strong clinical assessment and diagnostic skills
• Ability to work autonomously and within a team
• Excellent communication and interpersonal skills
• Ability to prioritise, triage and make safe clinical decisions
• Access to car and clean driving license

Desirable

• Non-Medical Prescribing qualification
• Experience working in primary care and/or care home settings
• Experience contributing to QOF achievement
• Experience participating in MDT working
• Experience using EMIS Web clinical system

Terms & Benefits

• 0.75 WTE (approximately 2830 hours per week)
• Competitive salary (pro rata)
• Private healthcare scheme
• Birthday day off in addition to annual leave entitlement
• Supportive and forward-thinking working environment
• Strong clinical mentorship and MDT support
• Opportunities for service development and innovation

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.