Job summary
This is a new role to support the development of our Integrated Network Team that is developing in Bude. The successful candidate will be employed by Stratton Medical Centre but the job requires working with all our local partners including the hospital, community teams, social services and voluntary sector.

The role is to provide autonomous, frailty based clinical care to patients within the frailty and complex care cohort, registered with our primary care services in Bude and surrounding areas.

The role combines clinical assessment, diagnosis, treatment, and care planning with proactive case management, MDT leadership, and close collaboration with health, social care, mental health teams and voluntary sector partners. A significant proportion of work will involve care home residents and housebound patients, supporting admission avoidance, early intervention, and high-quality end-of-life care where appropriate.

This role will play a key part in delivering continuity of care, reducing fragmentation, and supporting patients to remain well and independent in their own homes, wherever possible, and facilitating timely discharge from secondary care.

Main duties of the job

• Undertake comprehensive frailty and complex care assessments within patients' homes, care homes and other community settings.
• Assess and manage patients presenting with acute deterioration, urgent clinical concerns and exacerbations of long-term conditions
• Undertake urgent and routine home visits
• Support proactive management of patients identified through frailty risk stratification, MDT discussions and care home reviews.
• Work collaboratively with wider MDT group
• Develop, implement and review personalised care and support plans.
• Support patients following discharge from hospital.
• Undertake comprehensive assessments.
• Participate in regular Frailty MDT meetings.
• Provide health promotion, self-management support and preventative interventions.
• Facilitate referrals to community, social care, mental health and voluntary sector services as appropriate.
• Contribute to anticipatory care planning, advance care planning and end-of-life discussions.

About us
Stratton Medical Centre is a busy town practice on the outskirts of Bude. We have over 10,700 patients who are looked after by an integrated team of 9 GPs, 2 Nurse Practitioners, a Paramedic, 2 Nurses, 3 Health Care Assistants and a Phlebotomist.

We are part of a wider Primary Care Network (PCN) where the team at Stratton benefit from Pharmacists and Pharmacy Technicians, Home Visiting Paramedics, Mental Health Practitioners and Social Prescribers.

We are a well organised team that is led by a Practice Manager and 2 GP Partners. We benefit from being able to respond quickly to situations and to listening to our staff to ensure that we remain a happy, well functioning team.

We all meet every morning to ensure we are aware of the issues for the day and pick up any concerns that may be present.

We also have regular team meetings, for all staff, to ensure that everyone has the opportunity to input into decisions or raise concerns.

Details
Date posted: 11 August 2026
Pay scheme: Other
Salary: Depending on experience
Contract: Fixed term
Duration: 18 months
Working pattern: Part-time
Reference number: A5946-26-0004
Job locations: Stratton Medical Centre, Hospital Road, Stratton, Bude, Cornwall, EX23 9BP, United Kingdom

Job responsibilities
The Frailty and Complex Care Nurse (either registered nurse or ANP) will provide medical care for frail, housebound, and care home patients within the Bude population and surrounding areas.

The role is to provide autonomous, frailty based clinical care to patients within the frailty and complex care cohort, registered with our primary care services and supported through the Coast & Country INT.

The role combines clinical assessment, diagnosis, treatment, and care planning with proactive case management, MDT leadership, and close collaboration with health, social care, and voluntary sector partners. A significant proportion of work will involve care home residents and housebound patients, supporting admission avoidance, early intervention, and high-quality end-of-life care where appropriate.

This role will play a key part in delivering continuity of care, reducing fragmentation, and supporting patients to remain well and independent in their own homes, wherever possible, and facilitating timely discharge from secondary care.

Working alongside other professionals including the community teams, local hospital, primary care teams, social services and the voluntary sector, the post holder will support the delivery of proactive, person-centred care for patients living with frailty and complex health needs.

Over time, the service will expand to support patients living with moderate/ mild frailty within the community.

A key part of this role will involve undertaking home visits to support patients living with frailty and complex health needs, including housebound patients, care home residents and patients requiring enhanced support following hospital discharge.

Working Relationships
The Frailty & Complex Care Nurse will work as part of a multidisciplinary team that is developing within the Bude and surrounding areas.

GP support will be provided initially by Primary Care GPs:
Providing clinical leadership, oversight of complex cases, medication management, diagnostic support, advanced care planning and senior clinical decision making.

We are aiming to develop the team with a Frailty Care Co-ordinator to help with administration, action tracking and patient navigation across the service. Plus, other roles will be identified over time which we can recruit to, to support the work of the team.

Wider Neighbourhood Team
Including General Practice teams, Community Nursing, Adult Social Care, Therapies, Mental Health Services, Care Homes, Community Providers and Voluntary Sector Partners.

Person Specification
Experience
Essential

• Experience of working within a nursing team.
• Experience of working with MDT's to support frail and elderly patients.

Desirable

• Experience of setting up services to support frail elderly and complex patients.
• Experience of working in General Practice.

Qualifications
Essential

• Nursing Degree or equivalent.
• Prescriber.

Disclosure and Barring Service Check
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.

UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details
Employer name: Stratton Medical Centre
Address: Stratton Medical Centre, Hospital Road, Stratton, Bude, Cornwall, EX23 9BP, United Kingdom
Employer's website: https://www.strattonmedicalcentre.co.uk (Opens in a new tab)

Employer contact details
For questions about the job, contact:
Practice Manager
Angela Sundberg
angela.sundberg@nhs.net
01288353358

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.