Admiral Nurse - Frailty in Retford

In collaboration with Dementia UK, an exciting opportunity has arisen for an Admiral Nurse to join the Retford and Villages PCN, working closely with the PCN Frailty Service Team and Bassetlaw Integrated Neighbourhood Teams. We value innovation, teamwork, and compassionate care. This role offers the chance to improve services and be part of an ambitious team making real change on the ground.

The Frailty Admiral Nurse will work as part of the Retford and Villages PCN Frailty Team, in line with the Admiral Nurse Competency framework, to support families living with dementia experiencing:

• Modifiable stages of frailty - mild to moderate stages of frailty by undertaking specialist bio-psychosocial assessment and care planning.
• Moderate to severe stages of frailty - recognising the stage of dementia and supporting MDT decision making for future care planning.

The Admiral Nurse will lead, deliver and coordinate relationship-centred dementia care within operational areas of Retford and Villages PCN to improve the experience of carers/families affected by dementia coexisting with frailty.

Main duties of the job

Your role will:

• Provide expert clinical leadership and compassionate, relationship-centred care for people living with dementia and frailty, and supporting carers and families.
• Work across the dementia pathway from peri-diagnosis through end-of-life and bereavement, help improve experiences, empower families through proactive specialist support.
• Deliver high-quality one-to-one clinical support for families with complex needs, using the ANAF and contributing to CGAs.
• A holistic, strengths-based approach addresses cognition, mood, functional ability, frailty, falls risk, polypharmacy, social and financial pressures, and goals for care.
• Use interventions to promote wellbeing, resilience, and positive risk-taking.
• Co-produce and regularly review personalised care plans.
• Manage a defined clinical caseload, support transitions of care, and work closely with partner services to ensure continuity in the community.
• Champion safeguarding, advocacy, and rights-based practice, embedding the Mental Capacity Act and related legislation into clinical decision-making.
• Contribute to MDT meetings, advance care planning, and RESPECT and DNAR decisions, supporting families through sensitive conversations and working collaboratively across health, social care, and voluntary services.
• Maintain accurate records in line with GDPR, provide education and leadership to build confidence in dementia and frailty care, contribute to local policy, and support audit, evaluation, and service improvement.

About us

Retford & Villages PCN comprises of 5 General Practices including Riverside Health Partnership, Kingfisher Family Practice, Crown House Surgery, Tuxford Medical Centre and North Leverton Surgery. With a patient population of nearly 60,000 people, we are the largest of the three PCNs in Bassetlaw. The area we cover is largely rural. Retford and Villages PCN is a collaborative and progressive network, committed to improving the health and wellbeing of our local population. You'll work with a strong network of practices and be supported by the wider Bassetlaw Integrated Neighbourhood Team, a model of partnership working that includes primary care, community services, and local authorities.

This is a community-based role where the ability to travel is essential. The role will be varied, involving visiting patients (in their homes) plus clinical administration, meetings, and training. Your role line management will be aligned to Tuxford Medical Centre, to whose policies and procedures you will adhere. However, you will have the opportunity to have flexible bases across the Practice sites and some remote working.

The Employer for this role will be Fidelium Health Limited (Retford and Villages PCN company). If you value innovation, teamwork, and compassionate care and you'd like to be a part of an ambitious team making real change on the ground then we would love to hear from you. Interviews are provisionally scheduled for Thursday 12th March 2026 to be held in Retford.

Job responsibilities

Band 7 Frailty Admiral Nurse 0.6 WTE - 22.5 hours per week. 2-year Fixed Term Contract Location: Agile working across Retford & Villages PCN.

Summary of Responsibilities:

The Frailty Admiral Nurse will work as part of the Retford and Villages PCN Frailty Team, to support families living with dementia experiencing:

• Modifiable stages of frailty - mild to moderate stages of frailty by undertaking specialist bio-psychosocial assessment and care planning.
• Moderate to severe stages of frailty - recognising the stage of dementia and supporting MDT decision making for future care planning.

The Admiral Nurse will lead, deliver and coordinate relationship-centred dementia care within operational areas of Retford and Villages PCN to improve the experience of carers/families affected by dementia coexisting with frailty.

In line with the Admiral Nurse Competency framework at an enhanced specialist level, the post holder will provide:

Main Duties and Responsibilities:

• Clinical Lead, deliver and co-ordinate relationship-centred care to improve the experience of carers and families affected by dementia and frailty.
• Deliver regular clinical 1:1 sessions for families affected by dementia and frailty who meet their referral criteria within designated areas/practices.
• Provide clinical leadership on the care of people with dementia and their carers/families with complex care needs from peri-diagnosis to post-bereavement support, to support reduced reliance on GP appointments.
• Provide specialist nursing assessment, using the Admiral Nurse Assessment Framework (ANAF) and contributing to comprehensive Geriatric Assessments (CGA) for carers/families affected by dementia and frailty, including positive risk taking, managing distressed behaviours and risk minimisation strategies.
• Use the ANAF and CGA to assess and evaluate functional capacity, falls risk, cognition, mood, polypharmacy, social support, financial concerns, care goals and advance care preferences.
• Provide a range of bio-psychosocial interventions to promote health and wellbeing for people with dementia and their carers/families.
• Work collaboratively with other professionals to improve the identification and management of comorbidities and frailty for people with dementia and their carers/families.
• Develop and support care plans for people with dementia and families including positive risk management.
• Support people with dementia, carers/families and staff to understand and respond to changes in behaviour and relationships as a result of dementia.
• Provide care coordination for a clinical caseload of families with complex needs as identified within triage assessment.
• Ensure the safeguarding of vulnerable adults and that all legal requirements relating to Mental Capacity Act 2005, Mental Health Act 1983 amended 2007, and Deprivation of Liberty Safeguards 2009 are considered and adhered to in relation to patient care.
• Act as an advocate for people with dementia and their carers/families to promote their rights and best interests.
• Participate and lead on case conferences, continuing healthcare processes and best interest meetings where required.
• Work collaboratively with health, social and voluntary sector services to achieve coordinated care.
• Work in partnership with colleagues to promote the use of advance care planning for people with dementia and to support and inform families, around advance care planning, best interest decisions and end of life care.
• Contribute to RESPECT and DNAR decision making.
• Work with the frailty team to support families living with dementia and frailty in the community through transitions of care.
• Regularly attend multi-disciplinary team meetings for long-term conditions to inform and receive information regarding patients who have a diagnosis of dementia.
• Refer to secondary care if there is deterioration in condition/a review of medication including antipsychotics is required or any other concerns regarding a person's health that cannot be managed in primary care, in line with their dementia expertise.
• Support and advise on carer assessments and reviews.
• Ensure that care is delivered in accordance with relevant local and national guidelines and all relevant Retford and Villages PCN policies.
• Recognise the limits of own competency and professional boundaries and make appropriate and timely referrals to other services where required.
• Ensure that clinical records are up to date and maintained and stored appropriately in line with local and national GDPR regulations.

Education and Leadership

• Supporting the education and training of colleagues in the delivery of evidenced-based dementia care when in combination with frailty.
• Facilitate and support the development and delivery of innovative dementia training and education to staff, to improve competence and confidence, in line with best practice and guidance.
• Participate in and/or lead formal training events promoting best practice in dementia care and disseminating Admiral Nursing work.
• Contribute to the delivery of local policy, procedures and protocol for Retford and Villages PCN to improve identification, assessment, ongoing support for people with dementia and their family carers.

Evaluation and Audit

• Support the audit and evaluation of quality improvements and initiatives aimed at improving the delivery of dementia care within Retford and Villages PCN where appropriate to role.
• Collect and review quantitative and qualitative data, as agreed, to evaluate and audit the Admiral Nurse Service and make necessary improvements.
• Undertake analysis and evaluation and make any recommendations to the Retford and Villages PCN Dementia Strategy Group or similar.
• Ensure service information and data recorded is relevant, accurate, complete and captured in a contemporaneous manner.
• Liaise with Dementia UK Insights and Evaluation team where appropriate, to ensure that the impact and effectiveness of Admiral Nurse interventions are well evaluated.
• Be fully aware of and comply with the Data Protection Act 2018 and the GDPR in relation to protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing.

Professional

• Ensure all nursing practice is carried out in accordance with the agreed policies and procedures of Retford and Villages PCN and the NMC Code.
• Attend and actively participate in practice development, clinical supervision, and continuing professional development supported by Dementia UK and underpinned by the Admiral Nurse Competency framework.
• Develop own competence through use of the Admiral Nurse Competency Framework and portfolio development using resources provided by Dementia UK.
• To maintain professional registration in line with NMC guidance, including re-validation.
• Contribute to and lead the development of policies, procedures and protocols relevant to dementia and Admiral Nursing within Retford and Villages including the Standard Operational Policy.
• Ensure compliance with Retford and Villages PCN clinical governance requirements, including all mandatory training.
• Participate in clinical supervision/mentoring within Retford and Villages PCN where appropriate.
• Maintain up-to-date knowledge of research and evidence-based recommendations on supporting people with dementia and their carers/families within the primary care setting.
• Agree a rotational working week to support families and GPs in the identified geographical areas.
• Maintain positive working relationships with Dementia UK.

Please note that this job description serves to provide an illustrative example of the duties and responsibilities the post holder will undertake during the course of their normal duties. It is not therefore an exhaustive list and the post holder may be required to undertake other responsibilities and duties that correspond with the band. All staff of Retford and Villages PCN conform to the policies and procedures of their aligned Practice - Tuxford Medical Centre, such as and not limited to Health & Safety, Confidentiality, Equality Diversity and Inclusion, Data Protection, Quality Improvement, Learning and Development.

Person Specification

Experience

• Significant post registration clinical experience of supporting people with dementia and frailty, and their carers/families.
• Completing holistic nursing assessments.
• Providing bio-psychosocial interventions.
• Working as an autonomous practitioner.
• Professional supervision and mentoring of staff.
• Collaborative/multi-agency working.
• Audit/evaluation of clinical practice.
• Facilitating and delivering training/development of staff.

Skills and Knowledge

• Ability to demonstrate the 6 Admiral Nurse competencies: person-centred care, therapeutic skills, triadic relationship centred working, sharing knowledge, critical reflective practice.
• Knowledge to enable clinical leadership, including an understanding of: Admiral Nursing and its application, relevant policies/national strategy in relation to dementia care and frailty, evidence-based practice in dementia care and frailty and practical application within the relevant setting.

Other Requirements

• Full driving licence.
• Access to a car during normal working hours.

Qualifications

• Registered Nurse (RN/RNMH/RNLD).
• Postgraduate qualification in relevant field, or evidence of specialist training/education within the field of dementia and frailty equivalent to this level.
• Evidence of continued professional development/training in relevant areas, including dementia and leadership.
• Further specialist training/education within the field of dementia and frailty equivalent to a master's level.

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.