Frailty Specialist NurseNHS

Job summary

The Frailty and Complex Care Nurse will work within their scope of practice as part of the Lincoln Healthcare Partnership (PCN) Frailty and Complex Care Team, providing proactive, person-centred care to individuals living with frailty, multiple long-term conditions, and complex health needs across both care home and community settings.

The post holder will support the delivery of the Enhanced Health in Care Homes (EHCH) service, providing clinical assessment, care planning, proactive management, and multidisciplinary support to residents within care homes. They will work closely with care home staff, GP practices, community services, and wider partners to prevent unnecessary hospital admissions and improve resident outcomes.

In addition, the post holder will support the Community Frailty and Complex Care Service, delivering comprehensive assessment, case management, care coordination, and ongoing clinical support to patients living in their own homes who have frailty, advanced illness, or complex healthcare needs.

The role requires the ability to work autonomously, undertaking comprehensive history taking, holistic assessment, clinical examination, and clinical decision-making.

A key requirement of this role is demonstrable experience in frailty assessment and management, together with excellent history-taking and clinical assessment skills, enabling the practitioner to formulate appropriate management plans and coordinate timely interventions.

Main duties of the job

Undertake comprehensive clinical history taking and holistic patient assessments in care homes, clinics and patients' own homes.

Assess and manage patients living with frailty, multimorbidity and complex healthcare needs.

Contribute to Comprehensive Geriatric Assessments (CGA).

Participate in and lead MDT discussions where appropriate.

Support Enhanced Health in Care Homes ward rounds and resident reviews.

Deliver proactive care planning and admission avoidance interventions.

Identify and respond to clinical deterioration appropriately.

Support advance care planning, ReSPECT discussions and end-of-life care planning.

Provide clinical leadership and supervision to Care Coordinators within the team.

Maintain accurate clinical records and contribute to quality improvement initiatives.

Ensure compliance with practice CQC requirements and maintain accurate documentation.

Facilitate patient education, self-management of disease, and behaviour modification.

Collaborate closely with GPs and work independently to deliver safe, effective care

Promote / support health & wellbeing, helping patients to remain independent and well at home.

Contribute to Audit

The post holder will provide day-to-day leadership, supervision and line management to Care Coordinators within the frailty and complex care team, including workload management, wellbeing support, supervision, appraisals, performance, development and support.

Job description

Job Title: Frailty Specialist Nurse LHP PCN

Hours of Work: Full Time 37.5 hours per week

Location: The post holder will work across four GP practice sites within the Lincoln Healthcare Partnership (LHP) footprint and will provide care across care homes, community settings and patients own homes. The role requires regular travel throughout the locality to support delivery of the Enhanced Health in Care Homes (EHCH) Programme and Community Frailty and Complex Care Services.

Salary: Dependant on experience

Candidates who hold an Independent Prescribing qualification and can demonstrate advanced clinical practice skills may be considered for appointment at an enhanced pay scale, subject to experience, qualifications and organisational approval.

The salary offered will reflect the successful candidate's skills, experience and qualifications.

Responsible To: Frailty and Complex Care Clinical Lead

Accountable To: Clinical Director LHP

About Lincoln Healthcare Partnership (LHP)

Lincoln Healthcare Partnership (LHP) is committed to delivering integrated, neighbourhood-based healthcare that improves outcomes for local people and ensures patients receive the right care, at the right time, in the right place.

As the number of people living with frailty, multiple long-term conditions and complex healthcare needs continues to increase, proactive intervention and coordinated multidisciplinary care have become essential to improving quality of life, maintaining independence and reducing avoidable use of urgent and emergency care services.

Working collaboratively across Primary Care, Community Services, Social Care, Secondary Care, Virtual Wards and Care Home Providers, LHP is transforming the way care is delivered to some of the most vulnerable individuals within our population.

This role is central to achieving that ambition

Supporting proactive, personalised frailty and complex care management across care homes and community settings

Job summary

The Frailty and Complex Care Nurse will work within their scope of practice as part of the Lincoln Healthcare Partnership (PCN) Frailty and Complex Care Team, providing proactive, person-centred care to individuals living with frailty, multiple long-term conditions, and complex health needs across both care home and community settings.

The post holder will support the delivery of the Enhanced Health in Care Homes (EHCH) service, providing clinical assessment, care planning, proactive management, and multidisciplinary support to residents within care homes. They will work closely with care home staff, GP practices, community services, and wider partners to prevent unnecessary hospital admissions and improve resident outcomes.

In addition, the post holder will support the Community Frailty and Complex Care Service, delivering comprehensive assessment, case management, care coordination, and ongoing clinical support to patients living in their own homes who have frailty, advanced illness, or complex healthcare needs.

The role requires the ability to work autonomously, undertaking comprehensive history taking, holistic assessment, clinical examination, and clinical decision-making. The post holder will identify individuals at risk of deterioration, contribute to anticipatory and personalised care planning, coordinate multidisciplinary interventions, and support patients to maintain independence and achieve the best possible quality of life.

A key requirement of this role is demonstrable experience in frailty assessment and management, together with excellent history-taking and clinical assessment skills, enabling the practitioner to formulate appropriate management plans and coordinate timely interventions.

Working under the leadership of the Frailty and Complex Care Clinical Lead and Lead GP, the post holder will work collaboratively with Frailty Care Coordinators, Clinical Pharmacists, General Practice teams, community services, and other healthcare professionals to deliver high-quality, integrated care.

The overarching aim of the role is to improve patient outcomes, reduce health inequalities, support people to remain safely in their usual place of residence, and reduce avoidable hospital admissions through proactive, coordinated care.

Please note: A full UK driving licence and access to a vehicle for work purposes are essential requirements of this role.

Key Responsibilities and duties

The post holder will:

• Undertake comprehensive clinical history taking and holistic patient assessments in care homes, clinics and patients' own homes.
• Assess and manage patients living with frailty, multimorbidity and complex healthcare needs.
• Contribute to Comprehensive Geriatric Assessments (CGA).
• Coordinate care across primary care, community services, social care, secondary care and voluntary sector partners.
• Participate in and lead MDT discussions where appropriate.
• Support Enhanced Health in Care Homes ward rounds and resident reviews.
• Deliver proactive care planning and admission avoidance interventions.
• Identify and respond to clinical deterioration appropriately.
• Support advance care planning, ReSPECT discussions and end-of-life care planning.
• Provide clinical leadership and supervision to Care Coordinators within the team.
• Maintain accurate clinical records and contribute to quality improvement initiatives.
• Operate in line with clinical protocols and guidelines, ensuring professional, compassionate support for patients, families, and carers.
• Ensure compliance with practice CQC requirements and maintain accurate documentation.
• Work within all relevant PCN practice policies and procedural guidelines
• Facilitate patient education, self-management of disease, and behaviour modification.
• Collaborate closely with GPs and work independently to deliver safe, effective care to individuals, including those residing in care homes and the community
• Promote / support health & wellbeing, helping patients to remain independent and well at home.
• Contribute to Audit
• Conduct thorough person-centred needs assessment to develop care plans for each patient.
• The post holder will provide day-to-day leadership, supervision and line management to Care Coordinators within the frailty and complex care team, including workload management, wellbeing support, supervision, annual appraisals, performance management, professional development and competency support.
• To undertake any other tasks commensurate with the post

Person Specification

Essential Qualifications

• Registered Nurse (NMC).
• Evidence of ongoing Continuing Professional Development.
• Full UK driving licence and access to a vehicle for business use.
• History taking Qualification

Essential Skills and Attributes

• Excellent clinical assessment skills.
• Clinical reasoning and decision-making.
• Ability to identify and manage clinical deterioration.
• Excellent communication and interpersonal skills.
• Leadership and line management skills.
• Ability to manage and prioritise a workload.
• Excellent organisational and time-management skills.
• Ability to work independently and within multidisciplinary teams.
• Ability to facilitate difficult conversations with compassion and professionalism.
• Competent IT and clinical system skills.
• Commitment to providing high-quality patient-centred care.

Essential Experience

• Significant experience working with older adults, frailty and complex care.
• Experience undertaking comprehensive clinical history taking and holistic assessments.
• Experience managing a clinical caseload autonomously.
• Experience working within community, care home, primary care or integrated care services.
• Experience identifying and managing clinical deterioration.
• Experience of multidisciplinary team working.
• Experience of care planning and case management.
• Experience supporting patients with multiple long-term conditions.
• Experience of admission avoidance and crisis prevention.
• Experience supporting or managing staff.

Essential Knowledge

• Knowledge of frailty syndromes and frailty management.
• Understanding of Comprehensive Geriatric Assessment (CGA).
• Knowledge of complex care management.
• Understanding of anticipatory care planning and ReSPECT.
• Understanding of safeguarding legislation and professional responsibilities.
• Knowledge of integrated neighbourhood working.
• Knowledge of safeguarding legislation and responsibilities

Desirable Experience

Experience of working in Primary Care and or General practice

Systmone experience

Experience of working with patients on the Frailty register

Experience carry out home visits

Long term condition or experience. Asthma, COPD, Diabetes, Heart disease

Professional Development

We are committed to supporting professional growth and career development. The successful candidate will have opportunities to further develop skills.

This role offers an excellent opportunity for an experienced clinician with strong history-taking and frailty assessment skills who wishes to develop within an innovative and expanding Frailty and Complex Care Service.

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.

About us

Lincoln Healthcare Partnership (LHP) PCN is made up of two practices in central Lincoln with a patient population of just under 40,000 people. The population of the LHP PCN has a higher percentage of working age adults and includes a high number of Lincoln University students. We have a smaller than average number of older residents and manage a number of care homes based in central Lincoln.

Being a city centre PCN with a younger than average population there is a higher level of deprivation and prevalence of mental health than the Lincolnshire average which influences our health care needs and the associated service provision.

Lincoln Healthcare Partnership (LHP) is committed to delivering integrated, neighbourhood-based healthcare that improves outcomes for local people and ensures patients receive the right care, at the right time, in the right place.

As the number of people living with frailty, multiple long-term conditions and complex healthcare needs continues to increase, proactive intervention and coordinated multidisciplinary care have become essential to improving quality of life, maintaining independence and reducing avoidable use of urgent and emergency care services.

Working collaboratively across Primary Care, Community Services, Social Care, Secondary Care, Virtual Wards and Care Home Providers, LHP is transforming the way care is delivered to some of the most vulnerable individuals within our population.

This role is central to achieving that ambition