Frailty Nurse in Southampton

Totton Primary Care Network is seeking an experienced and motivated Frailty Nurse to join our multidisciplinary team, supporting the delivery of proactive, high-quality care to our frail and elderly population. We serve the people of Totton and surrounding areas, including the outer parts of the New Forest, with a population of approximately 37,000 patients. We are an expanding, progressive organisation with excellent patient care as our central value.

Main duties of the job:

• Undertake comprehensive frailty assessments, including clinical, functional, psychological, and social aspects of care.
• Develop, implement, and regularly review personalised care and support plans in collaboration with patients, carers, and the wider MDT.
• Provide clinical reviews and ongoing monitoring for patients identified as moderately or severely frail.
• Support admission avoidance through early intervention, escalation planning, and coordination with community and acute services.
• Contribute to anticipatory care planning, including end-of-life and advance care planning where appropriate.
• Work closely with GPs, ANPs, Care Coordinators, Social Prescribers, pharmacists, and community teams.
• Participate in MDT meetings, case discussions, and proactive care planning forums.
• Act as a clinical resource for frailty-related advice within the PCN.
• Liaise with secondary care, community services, and voluntary sector organisations to ensure seamless care pathways.
• Contribute to the development and delivery of PCN frailty services in line with DES requirements.
• Support quality improvement initiatives related to frailty and proactive care.
• Ensure accurate and timely clinical documentation in patient records.
• Maintain awareness of current best practice, guidelines, and evidence relating to frailty care.

Qualifications:

• Registered Nurse with current NMC registration.
• Experience working with older adults and/or patients living with frailty.
• Experience of clinical assessment and care planning.
• Experience working within primary care, community services, or a similar healthcare setting.
• Strong clinical assessment and decision-making skills.
• Knowledge of frailty, long-term conditions, and proactive care approaches.
• Ability to work autonomously and manage a clinical caseload.
• Excellent communication and interpersonal skills.
• Ability to work collaboratively within a multidisciplinary team.
• Good IT skills and ability to maintain accurate clinical records.
• Organised, flexible, and adaptable approach to work.
• Patient-centred and compassionate care approach.
• Ability to manage workload effectively and prioritise competing demands.
• Commitment to equality, diversity, and inclusion.
• Willingness to travel between PCN sites as required.
• Commitment to ongoing professional development.
• Disclosure and Barring Service (DBS) check.
• Occupational Health clearance.
• Hold a valid driving licence with own car and business insurance to use for home visits.
• Experience of proactive or anticipatory care.
• Experience working with care homes or long-term conditions.
• Experience of working within a PCN or MDT setting.
• Degree-level qualification or equivalent experience.
• Non-medical prescribing qualification or willingness to work.
• Knowledge of PCN structures and DES requirements.
• Understanding of population health and personalised care.

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.