PCN Frailty Team Nurse

We are recruiting a Frailty Practitioner to join our developing Primary Care Network (PCN). The successful candidate will help shape the service alongside the Lead GP and deliver proactive, personalised care to individuals living with frailty in community settings. The role interfaces with primary, secondary, social care and VCSE organisations to ensure holistic frailty management. The role supports prevention and is pivotal in delivering the NHSE Proactive Care Framework at PCN level for people living with moderate or severe frailty, working with multi-agency MDTs and system partners to enhance independence and quality of life and reduce unplanned hospital admissions. The post holder will work with people living with frailty in a strength-based, collaborative way that focuses on what matters to them. Opportunities to work from home may exist, but the role requires travel across Forest of Dean locations and may require attendance at GDOC offices in Gloucester.

Main duties and environment:

• 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.

Responsibilities:

• Moderate and Severe Frailty
• Case Identification using eFI/Personal Proactive Whiteboard
• Triage patients and complete a comprehensive geriatric assessment (CGA) where appropriate
• Produce 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 standardised tools
• 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 and monitor outcomes

Travel between Forest of Dean practices (e.g., Blakeney, Coleford, Lydney, Yorkley and surrounding areas).

Immunisation requirements in line with Green Book and NHS recommendations (unless medically exempt), including Covid immunisation.

Maintain a complete employment history from age 16 with explanations for any gaps.

About Us:

The West Forest of Dean PCN is hosted by, and core team staff are employed by GDOC LTD. GDOC LTD is owned by all GP Practices in Gloucestershire; practices are shareholders. We operate on a not-for-profit basis: profits are redistributed into primary care in Gloucestershire. We are a limited company run by a Board of Directors, most of whom are experienced local GPs. We run multiple GP practices and other county-wide services.

Employment Details:

• Salary £20 per hour
• Contract Permanent
• Working pattern Part-time
• Date posted 24 November 2025
• Location Quayside House, Quay Street, Gloucester, GL1 2TZ, with Forest of Dean location to be agreed.

Experience:

• Essential: Minimum of 2 years post-registration experience
• Desirable: Broad knowledge of General Practice; experience managing a team and delivering contractual requirements (e.g., KPIs, QOF)

Personal Qualities:

• Clear, polite telephone manner; confident, flexible, cooperative
• High integrity, empathy, respect, and kindness; collaborative; person-centred
• Innovative, takes responsibility for clinical decisions and service outcomes
• Committed to continuous professional development and equality, diversity, and inclusion
• Ability to work under pressure and to use initiative while seeking assistance as needed

Skills:

• Excellent communication (written and oral) and strong IT skills
• Advanced clinical assessment and diagnostic skills in geriatric and frailty syndromes
• Knowledge of NICE guidelines and frailty screening tools (e.g., Clinical Frailty Scale, eFI)
• Experience working within MDTs and across organisational boundaries
• Knowledge of personalised care and wider determinants of health
• Proficiency with digital health records and remote monitoring; willing to use SystmOne
• Driving licence and access to a vehicle

Qualifications:

• Essential: Registered Adult Nurse/Registered General Nurse or equivalent; current NMC registration
• Desirable: Post-graduate training in a relevant subject

Other Requirements:

• Disclosure and Barring Service (DBS) check in line with policy
• Current UK professional registration

Safeguarding, Health & Safety, and Other Obligations:

Safeguarding is everyone’s responsibility. Familiarise yourself with GDOC safeguarding procedures and report concerns promptly. Comply with Health & Safety policies, including risk management, fire safety, sharps, and driving requirements. Ensure appropriate handover and follow-up for patients. Be aware of safeguarding or regulatory issues and report as required.

Equality, Diversity, and Quality:

Support equality, diversity and rights of patients, carers and colleagues. Maintain quality and patient safety, participate in Significant Event Analysis when applicable, and contribute to audits and outcomes reporting. Maintain professional development and engage with team-based quality improvements.

Disclosure and Registration Notes:

Disclosure and Barring Service check is required. UK registration with the appropriate professional body is required.