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Frailty Lead (Community Matron / ACP / ANP / Advanced Paramedic)
Meridian Primary Care Network View all jobs
Posted 7 day(s) ago
Reference: 2429608
Job summary
This role will support all our PCN practices to complete home visits and on-going care to those who need it need it most, or those who have recently been discharged from hospital.
As the team grows, we would expect this Frailty Lead to provide mentorship and clinical support to staff in the team, including Nursing Associate and HCA roles.
This is a growing and evolving role, and so flexibility to engage with future ICB and neighbourhood Frailty initiatives would be required.
Ideally a prescribing Advanced Nurse Practitioner or Advanced Care Practitioner will be best suited to this role. You will work with a high degree of autonomy in the community.
Main duties of the job
Primary Responsibilities
There may be, on occasion, a requirement to carry out other tasks; this will be dependent upon factors such as workload and staffing levels:
- To work with older people in surgery and out in the community including care homes.
- To manage their own caseload.
- Engage individuals as active partners in their treatment and support.
- To support onward referral to secondary and specialist services where indicated.
- To develop and maintain close relationships with the surgery teams.
- Maintain patient records.
Secondary responsibilities
- To assertively engage with service users, striving at all times to develop good relationships, becoming a trusted person.
- To develop professional networks, have an understanding of local resources in order to ensure that the service user is able to navigate the full health and social care system.
- To promote awareness of the professional role across the PCN.
- To demonstrate effective communication skills with people in an age-appropriate way and those whose understanding may be impaired
- To act within the appropriate professional code of conduct at all times
- To ensure that up to date written and electronic records and activity data are maintained in accordance with Professional standards and to provide specialist reports relevant to practice setting.
- To keep accurate and timely written and electronic record of each contact, using SystmOne and EMIS.
- To promote and safeguard the welfare of vulnerable adults.
About us
Primary Care Networks and Integrated Neighbourhood Teams are a new way of working that enables health and other services to work together to provide better access for patients.
PCNs build on existing primary care services and enable greater provision of proactive, personalised, coordinated and more integrated health and social care for people close to home.
We are hoping successful applicants will help us create new ways of working with partner organisations we need someone highly motivated, keen to help shape how communication can be improved between partner organisations to improve patient care.
Our PCN
The Meridian PCN is a collaboration of six GP surgeries across Cambridgeshire and North Hertfordshire; supporting a patient population of +48,000.
- Bourn Surgery
- Comberton & Eversden Surgery
- Harston Surgery
- Orchard Surgery - Melbourn
- Roysia Surgery - Royston
- Monkfield Medical Practice - Cambourne
Our Aims
- Support the local interpretation and implementation of NHS transformation plans
- Design and deliver primary care services at scale.
- Provide the operational people and infrastructure to allow practices to collaborate
- Be a voice for Primary Care, one that enables what we all want; sustainable and clinically excellent general practice
Details
Date posted
15 October 2026
Pay scheme
Other
Salary
£55,000 to £57,750 a year Dependant on experience
Contract
Permanent
Working pattern
Full-time, Part-time, Flexible working, Home or remote working
Reference number
M0056-26-0001
Job locations
25 Alms Hill
Bourn
Cambridgeshire
CB23 2SH
United Kingdom
Job description
Job responsibilities
Meridian is recruiting to a Community Frailty team, caring for our most frail, vulnerable and complex patients in the community. This role will focus on the assessment, triage and multi-disciplinary referral of multi-morbid and frail patients, including those that are housebound, living in care homes or recently discharged from hospital. This role will include semi-urgent and routine care, including visiting those living in the community with frailty and multiple long-term conditions. You will be working within the practices and with colleagues in CPFT and secondary care.
This role will support all our PCN practices to complete home visits and on-going care to those who need it need it most, or those who have recently been discharged from hospital.
As the team grows, we would expect this Frailty Lead to provide mentorship and clinical support to staff in the team, including Nursing Associate and HCA roles.
This is a growing and evolving role, and so flexibility to engage with future ICB and neighbourhood Frailty initiatives would be required.
Job description
Job responsibilities
Meridian is recruiting to a Community Frailty team, caring for our most frail, vulnerable and complex patients in the community. This role will focus on the assessment, triage and multi-disciplinary referral of multi-morbid and frail patients, including those that are housebound, living in care homes or recently discharged from hospital. This role will include semi-urgent and routine care, including visiting those living in the community with frailty and multiple long-term conditions. You will be working within the practices and with colleagues in CPFT and secondary care.
This role will support all our PCN practices to complete home visits and on-going care to those who need it need it most, or those who have recently been discharged from hospital.
As the team grows, we would expect this Frailty Lead to provide mentorship and clinical support to staff in the team, including Nursing Associate and HCA roles.
This is a growing and evolving role, and so flexibility to engage with future ICB and neighbourhood Frailty initiatives would be required.
Person Specification
Skills
Essential
- Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email and face to face
- Excellent interpersonal skills , communicating with patients, their families and healthcare professionals
- Ability to maintain accurate records
- Knowledge of IT systems, including ability to use word processing skills, emails and the internet to create simple plans and reports
- Be flexible and able to manage sudden and unexpected demands
- Effective time management (planning and organising)
- Demonstrate personal accountability, emotional resilience and work well under pressure
Personal Qualities
Essential
- Ability to follow legal, ethical, professional and organisational policies/procedures and codes of conduct
- Ability to use own initiative, discretion and sensitivity
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Flexible and cooperative
- Ability to identify risk and assess/manage risk when working with individuals
- Sensitive and empathetic in distressing situations
- Ability to maintain confidentiality
- Professional calm and efficient manner
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance and health and safety
Qualifications
Essential
- Qualified healthcare professional
- Educated to Masters degree as detailed within the HEE document titled Multi-professional framework for advanced clinical practice in England
- Registered on their appropriate professional register
- Teaching qualification
- ALS and PALS
Desirable
- Qualified independent prescriber - V300
Experience
Essential
- Experience of practice within the four pillars
- Job plan that demonstrates advanced clinical practice and has equity with peers working at this level
- Experience of working in a primary care environment
Desirable
- Experience of prescribing and undertaking medication reviews
Other requirements
Essential
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
- Evidence of continuing professional development
- Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home
Person Specification
Skills
Essential
- Ability to communicate complex and sensitive information effectively with people at all levels by telephone, email and face to face
- Excellent interpersonal skills , communicating with patients, their families and healthcare professionals
- Ability to maintain accurate records
- Knowledge of IT systems, including ability to use word processing skills, emails and the internet to create simple plans and reports
- Be flexible and able to manage sudden and unexpected demands
- Effective time management (planning and organising)
- Demonstrate personal accountability, emotional resilience and work well under pressure
Personal Qualities
Essential
- Ability to follow legal, ethical, professional and organisational policies/procedures and codes of conduct
- Ability to use own initiative, discretion and sensitivity
- Able to get along with people from all backgrounds and communities, respecting lifestyles and diversity
- Flexible and cooperative
- Ability to identify risk and assess/manage risk when working with individuals
- Sensitive and empathetic in distressing situations
- Ability to maintain confidentiality
- Professional calm and efficient manner
- Knowledge of and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance and health and safety
Qualifications
Essential
- Qualified healthcare professional
- Educated to Masters degree as detailed within the HEE document titled Multi-professional framework for advanced clinical practice in England
- Registered on their appropriate professional register
- Teaching qualification
- ALS and PALS
Desirable
- Qualified independent prescriber - V300
Experience
Essential
- Experience of practice within the four pillars
- Job plan that demonstrates advanced clinical practice and has equity with peers working at this level
- Experience of working in a primary care environment
Desirable
- Experience of prescribing and undertaking medication reviews
Other requirements
Essential
- Flexibility to work outside of core office hours
- Disclosure Barring Service (DBS) check
- Evidence of continuing professional development
- Access to own transport and ability to travel across the locality on a regular basis, including to visit people in their own home
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Additional information
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.
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details
Employer name
Meridian Primary Care Network
Address
25 Alms Hill
Bourn
Cambridgeshire
CB23 2SH
United Kingdom
Employer's website
Employer details
Employer name
Meridian Primary Care Network
Address
25 Alms Hill
Bourn
Cambridgeshire
CB23 2SH
United Kingdom