Job Description

Main objectives Provide high-quality, community-based care to patients identified as living with frailty, particularly for those residing in areas of high deprivation. Work as part of a multidisciplinary team (MDT), including community nursing, social care, therapy, secondary care and voluntary sector colleagues, building relationships within the Integrated Neighbourhood Team. Contribute to anticipatory care planning, care home support, and end-of-life care. Participate in MDT meetings and care reviews to ensure a holistic approach to patient needs.



Support early identification of frailty and offer timely interventions to maintain independence and reduce hospital admissions. Clinical Duties: Provide direct patient care for frail individuals, including comprehensive geriatric assessments, medication reviews, and advance care planning. Lead or participate in regular multidisciplinary team (MDT) meetings. Contribute to and oversee the development of personalised care and support plans.



Work closely with care coordinators, Practice administration teams, community nurses, therapists, social care teams, and the voluntary sector to ensure holistic care. Support early identification and stratification of patients living with frailty. Manage end-of-life care planning and delivery in line with patient wishes and national guidance. Collaboration & Service Development: Actively engage with PCN colleagues and Bassetlaw Integrated Neighbourhood Team to improve pathways and care models.



Contribute to audit, quality improvement initiatives, and service development. Participate in local frailty-related learning and development activities. Leadership & Education: Share knowledge and expertise with colleagues, including mentoring and training where appropriate. Help develop the clinical skillset of wider team members in managing frailty and palliative care.