PCN Frailty Team Nurse in Coleford

We are recruiting a Frailty Practitioner to join our developing PCN. This is an exciting time to join our PCN as the successful candidate will have the opportunity to help shape the service alongside the Lead GP. We are looking for a highly skilled healthcare practitioner responsible for delivering proactive, personalised care to individuals living with frailty in community settings. This role interfaces with primary, secondary, social care and VCSE organisations, ensuring holistic management of frailty.

With a focus on prevention, the role is pivotal in the delivery of the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working collaboratively with multi‑agency multi‑disciplinary teams (MDTs) and system partners to enhance independence and quality of life and in turn reduce the risk of unplanned hospital admissions. A key element of the role is to work with people living with frailty in a strength based, collaborative way that focuses on what matters to them.

Although there may be some opportunities to work from home, you must be prepared to work across various locations in the Forest of Dean and occasionally may be required to attend GDOC offices in Gloucester. The post holder will work closely with the PCN Frailty Team and the PCN Leadership team including the Clinical Director, Business Manager, Digital Transformation and Practice Leads. Approx 20 hours per week. Applications may close early depending on response.

• Moderate and Severe Frailty
• Case Identification using eFI/Personal Proactive Whiteboard
• Triage patients and complete a comprehensive geriatric assessment (CGA) where appropriate
• Producing Personalised Care and Support Plan (PCSP) and agree with patient/Carer
• Dementia Co‑diagnosis
• Coordinate and lead MDT meetings
• General leadership and support to the Care Coordinator and Frailty Team Administrator
• Clinical assessment, diagnosis, and case management of people living with frailty in the community using agreed standardised tools and templates
• Support the development of frailty awareness and skills for other practitioners, carers, and patients
• Contribute to the design, implementation, and evaluation of frailty pathways and services
• Identify and manage clinical risks
• Collect and analyse data to support risk stratification, use of the Personalised Proactive Whiteboard, and monitoring outcomes

The job is primarily working with practices in the Forest of Dean (Blakeney, Coleford, Lydney, Yorkley and surrounding areas) and you will be required to travel independently between practices. You will be required to be immunised in compliance with Green Book and NHS recommendations for your role (unless medically exempt), including immunisations against Covid.

The Care Quality Commission requires us to have a complete employment history from the age of 16, including explanations for any gaps in employment.

The West Forest of Dean PCN is hosted by, and core team staff employed by GDOC Ltd. GDOC Ltd is a not‑for‑profit limited company owned by GP practices in Gloucestershire.

Detailed responsibilities are documented in the job description and include: Continuous care planning, clinical assessment, partnership working, care coordination, MDT coordination, education and training, service development, risk management, patient advocacy, and data and audit responsibilities.

• Minimum of 2 years post‑registration experience
• Broad knowledge of General Practice
• Experience of managing a team, including direct reports
• Experience of delivering contractual requirements e.g. KPIs, QOF
• Clear, polite telephone manner
• Polite and confident
• Flexible and cooperative, motivated
• High levels of integrity and loyalty
• Demonstrates empathy, respect, and kindness in all interactions
• Collaborative and able to work effectively across disciplines and organisations to deliver joined‑up care
• Person centred (Prioritises the individual's needs, preferences, and dignity)
• Innovative: Seeks out and applies evidence‑based practices and new models of care
• Takes responsibility for clinical decisions and service outcomes
• Engages in continuous professional development and reflective practice
• Promotes equality, diversity, and cultural competence in care delivery
• Able to use own initiative but also know when to seek assistance
• Ability to work under pressure

• Excellent communication skills (written and oral)
• Advanced clinical assessment and diagnostic skills, particularly in geriatric and frailty syndromes
• Knowledge of national standards that inform practices e.g. NICE guidelines
• Expertise in frailty identification and screening tools (e.g. Clinical Frailty Scale, eFI).
• Knowledge of clinical and information governance as appropriate to role
• Sound understanding of long‑term condition management, rehabilitation and end‑of‑life care
• Proven ability to work effectively within MDTs and across organisational boundaries
• Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
• Ability to engage with and enable people, families and carers using health coaching approaches
• Ability to enable efficient multi‑agency working with practitioners across the system adopting a team of teams approach, especially with the local Integrated Neighbourhood Team
• Competence in using digital health records and remote monitoring tools
• Willing to become competent in use of SystmOne if not already
• Competent in the use of Office and Outlook
• Ability to follow policy and procedure
• Able to identify and resolve risk management issues according to policy or protocol
• Ability to assess, implement and evaluate a programme of care
• Effective time management (planning and organising)
• Ability to work as a team member and autonomously
• Good interpersonal skills
• An ability to drive, current UK driving licence and daily access to a vehicle
• Competent in use of SystmOne
• Understanding of the wider determinants of health, including social, economic and environmental factors and their impact on communities

• Registered Adult Nurse/Registered General Nurse or other qualification recognised by the NMC as equivalent
• Current registration with Nursing & Midwifery Council
• Post‑graduate training in a relevant subject

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.