Frailty Nurse in London inLondon PUBLISHED MON 9 JUN 2025 Jump to job information section

This role will be patient focused, utilising nursing skills to assess frail patients needs, complete appropriate care plans, working across multiple services. A particular focus for this role is ensuring a patient centred approach to all care that enables individuals to achieve their optimum physical, physiological and social wellbeing.

Lead in the care and development of anticipatory and current care planning for identified practice patients from all four practices in the PCN, to include treatment, preventative care, screening, future planning, and patient education in the practices and also in the patients home.

Using data from practice clinical systems (EMIS) and tools such as the Electronic Frailty Index, the Whole System Integrated Care dashboard WSIC dashboard to identify elderly and frail patients from the local PCN population who may benefit from a holistic healthcare review.

Hold a defined caseload of patients, either from data identification or on referral from the GP; and carry out a holistic healthcare review either at the one of the PCN practices or in the patients own home.

Complete Universal Care Plan which needs to include a crisis management plan, be flexible and adaptable to the patients needs and expectation of fluctuation in needs

Discussing with the patient (and their carers if appropriate) their views, wishes and help them make decisions about their care options particularly in the future when they may be less well, in hospital or receiving palliative care. (Including DNARs)

Review each patient on the caseload a minimum of 3 monthly/annually (as required/appropriate) and to amend care plans to reflect the patients changing needs.

Motivate patients in respect of self-care and self-management of their condition.

Signpost vulnerable and socially isolated patients to appropriate community services, groups and activities through liaison with the PCN Social Prescribing team.

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Discussing with the patient (and their carers if appropriate) their views, wishes and help them make

decisions about their care options particularly in the future when they may be less well, in hospital or receiving palliative care. (Including DNARs)

Review each patient on the caseload a minimum of 3 monthly/annually (as required/appropriate) and to amend care plans to reflect the patients changing needs.

Motivate patients in respect of self-care and self-management of their condition.

Signpost vulnerable and socially isolated patients to appropriate community services, groups and activities through liaison with the PCN Social Prescribing team.

Promote safe independent living and to motivate patients to improve and maintain their well-being.

Demonstrate an understanding of the prevention of abuse of vulnerable adults, recognition of the signs of abuse and procedures to follow in the event of an allegation of abuse.

To participate in multi-disciplinary meetings and team meetings as required to ensure excellent communication and good continuity of care.

To take appropriate action where any safeguarding issues are identified. Refer patients with Complex needs to Complex Patient Management Group (CPMG)