Senior Community Nurse in England

We are looking for an experienced and enthusiastic Senior Community Nurse (Band 6) to join our Frailty and Community Outreach Team within East and Central Brighton Primary Care Network. This is a varied and autonomous role for a nurse who enjoys looking beyond a single diagnosis and understanding the wider needs of a person. Working alongside our Community Specialist Nurse, you will assess patients referred by GP practices using a holistic, preventative approach. This includes people with mild to moderate frailty, using Comprehensive Geriatric Assessment (CGA) to identify needs and support health, function and independence. Our work extends beyond frailty. We support people with multimorbidity and those who struggle to access or engage with primary care. Mental health difficulties, neurodivergence, substance use, self-neglect and wider social challenges are common within our caseload. The team also supports annual health reviews for housebound patients with long-term conditions. You will manage your own caseload while working closely with our multidisciplinary team and wider services. Finding the right person is important to us. We are looking for someone passionate about holistic community care, curious and proactive, who enjoys autonomy and variety. You may not have experience in every aspect of the role, and we are keen to support the right candidate to develop. If this sounds like you, we encourage you to get in touch for an informal conversation about the role and our team.

Main duties of the job:

• Undertaking holistic assessment of patients referred by GP practices, using Comprehensive Geriatric Assessment (CGA) principles where appropriate.
• Developing personalised plans to address identified health, functional, psychological and social needs.
• Supporting people living with frailty, multimorbidity and complex long-term conditions.
• Working with patients experiencing mental health difficulties, neurodivergence, substance use, self-neglect or barriers to accessing and engaging with healthcare.
• Recognising deterioration and risk, including safeguarding and mental capacity concerns, and coordinating appropriate intervention.
• Reviewing medication, supporting medicines optimisation and liaising with prescribers and pharmacy colleagues.
• Coordinating care and working collaboratively with GP practices, community, mental health, social care and voluntary-sector services.
• Supporting housebound patients with annual long-term condition health reviews on behalf of GP practices.
• Managing your own caseload, follow-up and onward referrals, with appropriate senior clinical support.
• Contributing to MDT discussion where this would benefit an individual patient.

About us:

East and Central Brighton Primary Care Network brings together nine GP practices serving a diverse population across East and Central Brighton. Our practices work collaboratively to share expertise, develop services and respond to the needs of our local communities. Our approach is built around three core principles: proportionate universalism, integrating care and supporting primary care. We aim to improve health for those with the greatest need, strengthen links between primary care and wider community services, and provide holistic and preventative healthcare closer to home. Our PCN workforce brings together professionals from a range of clinical and non‑clinical backgrounds. We value collaborative working, professional autonomy and developing services around the needs of our population. The Frailty and Community Outreach Team reflects this approach, working across practice and organisational boundaries to support patients who benefit from proactive, personalised and coordinated care.

Job Purpose:

To work as an autonomous registered nurse within the Frailty and Community Outreach Team, undertaking holistic assessment, clinical intervention and ongoing management of patients within their own homes. The post holder will manage an allocated referral‑based caseload and contribute to the delivery of annual long‑term condition reviews for housebound patients. They will work closely with the Community Specialist Nurse and wider health and care professionals to provide safe, personalised and preventative care.

Clinical Practice:

• Undertake autonomous holistic assessment of patients within their own homes.
• Apply Comprehensive Geriatric Assessment (CGA) principles where clinically appropriate.
• Undertake physical assessment, clinical observations and examination within professional competence.
• Assess frailty, function, falls risk, cognition, psychological wellbeing and social circumstances.
• Use clinical reasoning to identify priorities and develop personalised plans of care.
• Recognise deterioration and initiate appropriate treatment, escalation or onward referral.
• Support patients with multimorbidity and long‑term conditions, including annual health reviews for the housebound cohort.
• Review medication as part of holistic assessment, identifying adherence, safety or optimisation concerns and liaising with prescribers or pharmacy colleagues as required.
• Support advance and future care planning where appropriate.
• Promote independence, self‑management and prevention of avoidable deterioration.

Mental Health and Engagement:

• Recognise and assess mental health and psychological needs alongside physical health needs.
• Work confidently with patients with established mental health diagnoses or psychological distress.
• Understand how neurodivergence, substance use, self-neglect and wider psychosocial circumstances may affect health, behaviour and engagement with services.
• Recognise mental health deterioration and risk and escalate appropriately.
• Develop effective therapeutic relationships with patients who may experience difficulty accessing or engaging with conventional healthcare.
• Work collaboratively with primary care and specialist mental health services where appropriate.

Safeguarding, Capacity and Risk:

• Identify and respond appropriately to safeguarding concerns and self-neglect.
• Apply the Mental Capacity Act in clinical practice and undertake decision‑specific mental capacity assessments within professional competence.
• Contribute to best‑interests decision‑making where required.
• Assess and manage clinical and environmental risk proportionately, balancing safety with patient autonomy.
• Escalate significant clinical, safeguarding or professional concerns appropriately.

Caseload and Care Coordination:

• Manage and prioritise an allocated caseload autonomously.
• Plan appropriate follow‑up and review according to individual patient need.
• Coordinate care across primary care, community health, mental health, social care and voluntary‑sector services.
• Liaise effectively with patients, families, carers and professionals.
• Participate in multidisciplinary discussion where this would benefit an individual patient's care.
• Ensure appropriate transfer or discharge when active team involvement is no longer required.

Professional and Leadership Responsibilities:

• Maintain accurate and contemporaneous clinical records.
• Work in accordance with the NMC Code, evidence‑based practice and organisational policies.
• Recognise the limits of own competence and seek senior or specialist advice when required.
• Provide clinical support and guidance to less experienced colleagues, nursing associates, support workers and students as appropriate.
• Participate in clinical supervision, audit, quality improvement and service development.
• Maintain professional competence and continuing professional development.
• Contribute positively to multidisciplinary team working and the ongoing development of the Frailty and Community Outreach Team.

Person Specification:

Experience:

• Significant post‑registration nursing experience.
• Experience working autonomously and making clinical decisions within own scope of practice.
• Experience undertaking holistic assessment of adults with multiple and interacting health needs.
• Experience caring for people with frailty, multimorbidity and/or long‑term conditions.
• Experience recognising clinical deterioration and initiating appropriate escalation or onward referral.
• Experience supporting people with mental health needs alongside physical health needs.
• Experience working with people who may have difficulty accessing or engaging with healthcare services.
• Experience identifying and responding to safeguarding concerns, including self‑neglect.
• Experience applying the Mental Capacity Act in clinical practice.
• Experience managing and prioritising a clinical caseload.
• Experience working across professional and organisational boundaries as part of multidisciplinary care.

Desirable:

• Experience working in primary care, community nursing, frailty, outreach or a similar community‑based service.
• Experience applying Comprehensive Geriatric Assessment (CGA) principles.
• Experience working with people with significant mental health or psychosocial complexity, including substance use, neurodivergence or self‑neglect.
• Experience undertaking cognitive or memory assessments.
• Experience undertaking long‑term condition reviews.
• Experience of advance care planning and ReSPECT.
• Experience supporting or supervising students, nursing associates or less experienced staff.
• Experience contributing to audit, quality improvement or service development.

Additional Requirements:

• Full UK driving licence and access to car for work purposes.
• Applicants must have the right to work in the UK. Unfortunately, we are unable to offer visa sponsorship for this role.

Qualifications:

• Registered Nurse with current NMC registration.

Desirable:

• Relevant post‑registration education or training in clinical assessment, frailty, long‑term conditions or community nursing.
• Competent in venepuncture/phlebotomy, or willing to undertake training and competency assessment.
• Training or competency in physical assessment and clinical examination.

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.