Job Description

Main Purpose of the Job

Work autonomously as a Community Frailty Specialist Nurse, across traditional boundaries, within the Frailty Team and with Primary Care Networks and provide a high level of expertise to ensure patient-centred clinical care. They will act as a highly specialised role model for advanced practice, working closely with the multidisciplinary team and other key stakeholders.



Exercise clinical expertise, levels of judgement, discretion and decision making whilst undertaking the skills of assessment, examination to provide a diagnosis and formulate management plans both reactive and proactive within an agreed scope of practice.



Evaluate investigations and revise treatment plans according to patient need and assess impact and outcome.



Undertake advanced clinical assessment and examination, including but not limited to:


Clinical data interpretation, investigation and treatment. Ability to develop advanced comprehensive care planning and reviewing and assessment of interventions. Diagnosis and disease management and delivery of expert clinical interventions and treatments. Non-medical prescribing, if qualification gained. Assess and treat varied clinical cases, having advanced skills to assess the patient with a differentiated or undifferentiated clinical diagnosis

Work collaboratively within the multi-professional team and support the education and development of both nursing, medical and allied-health professionals.

Lead MDT focussing on ageing well and frailty

Clinical skills


The Community Frailty Specialist Nurse will work collaboratively with their respective Primary Care Network in Sunderland and the wider Neighbourhood Team to meet the needs of patients.


Advanced communication, problem-solving and decision-making skills will be used to initial assess and provide on-going patient care. Working within local and nationally agreed protocols and guidelines, the Specialist exercises independent judgement to assess, investigate, diagnose, plan, implement and evaluate the clinical care and management of community patients.


The post holder will be part of a team that leads non-medical models of care across primary and community-based settings and within community teams, in collaboration with multi-professional and multi organisational colleagues. They will also play a crucial role in stepping up, stepping down and proactive care through timely assessment, referral, responsive intervention and care planning.



There will be dedicated time for continuous professional development.