The Frailty Service provides specialist, person-centred care for adults living with frailty. It focuses on early identification, comprehensive assessment, and coordinated support to help individuals maintain independence and prevent avoidable hospital admissions. Through a multidisciplinary approach involving doctors, nurses, therapists, and social care professionals, the service aims to improve quality of life and ensure that care is proactive, holistic, and tailored to each person’s needs.
Key objectives
- Deliver proactive, personalised care for people living with frailty
- Support people to remain well, independent, and safe at home
- Reduce unplanned hospital admissions and crisis-driven care
- Improve coordination of care across the health and social care system
- Strengthen advance care planning and end-of-life support
- Empower patients, families, and carers through education and involvement
- Promote a population-health approach to frailty
- Reduce medication-related harm in people living with frailty
- Continually improve quality through evaluation and feedback
About the team
The Frailty Service is delivered by a multidisciplinary team, bringing together healthcare professionals to provide holistic, person-centred care. The team includes GP leads, specialist nurses, HCA, pharmacists and a care coordinator. Each member contributes their expertise to assess, plan, and implement interventions tailored to the individual’s needs. The MDT works in close collaboration with community services, social care, and voluntary organisations, ensuring that medical, functional, social, and emotional needs are fully supported. This integrated approach helps maintain independence, improve wellbeing, and enhance the overall quality of life for older adults.
Jolene Parker Frailty Specialist ANP, Victoria Weavers, HCA, Dr Anupam Sinha, Frailty service lead GP, Tani Assi, Panacea PCN Manager, Kadey Beasley, Care Co-Ordinator, Lisa Taylor, Frailty Specialist ANP, Dr Omar Qureshi, Frailty Service Lead GP
Who we support
Frailty means that a person is more vulnerable to getting unwell or having trouble with everyday life because their body and mind are not as strong as they used to be. It can be mild, moderate, or severe, depending on how much it affects daily life.
- Panacea Frailty Service is here for adults, over 18, who are frail or at risk of becoming frail. This includes people who:
- Have hospital admissions or have frequent falls
- Have trouble with moving around, eating well, or looking after themselves
- Live with several long-term health problems
- The goal is to give the right support early, help people stay independent, and improve their day-to-day wellbeing.
What we offer
Panacea Frailty Service helps adults stay independent and well by looking at all aspects of their health and daily life. This includes full health checks to see how they are doing physically and mentally, reviewing medications to make sure they’re safe, and checking mobility and balance to prevent falls. The team also helps with personalised care plans, works closely with community services, social care, and family carers, and can visit people at home if they can’t get to the clinic. The team meets regularly to keep everyone’s care up to date. All of this is done in a person-centred way to support each person’s individual needs and wellbeing.
Referral process
- Who can refer- Anyone involved in providing care or support to a patient can refer them into our service. This includes GPs, practice nurses, the hospital discharge team, community nursing teams, and other healthcare or social care professionals involved in the patient’s care.
- How to refer: via system one referrals systems, telephone or email
- Frailty Service Referral Pathway Guide (DOCX, 19KB)
Once a patient is referred to and accepted by the Frailty Service, they are triaged and assessed by our team to ensure we understand their needs and provide the most appropriate support. This is followed by a comprehensive assessment covering their health, mobility, medication, functional abilities and overall wellbeing. Using this information, the team develops a personalised care plan aligned with the patient’s goals and specific needs. The service then provides regular reviews and ongoing monitoring to ensure the care plan remains effective, making adjustments when required and offering additional support to help the individual remain as independent, safe and well as possible.
Support for patients and carers
The Frailty Service provides help and guidance for both patients and their careers. This includes referral to services to provide practical support like equipment, home safety adaptations, and mobility aids to make daily life easier and safer. There’s also social and emotional support, such as access to local activities, support groups, and social prescribing to reduce loneliness and stay connected.
Carers are supported too, with advice, guidance, and respite options to help them take breaks when needed.
The service also offers tips on healthy eating, exercise, and general wellbeing to help people stay strong and independent.
All of this is aimed at helping both patients and carers feel supported, informed, and confident in managing everyday life.
Contact us
The Panacea Frailty Team
Email: hnyicb-nel.frailty.panacea@nhs.net
Tel: 01472 801042
Available Monday to Friday 8am to 6pm
Patient stories / testimonials
Care home feedback from Rivelin care home
Your overall assessment of the Frailty Team’s contribution to resident care. Wonderful, very helpful, supportive.
Whether you have observed residents benefitting from the service. Definitely, They have helped with a variety of things, referrals, RESPECT forms being updated, ensuring residents get the support from outside agencies
Any areas in which you feel the service could be strengthened or improved? Can’t think of anything.
Any recommendations that may support further development of the service? No, they go above and beyond. Please pass on our thanks for their support.
From another carehome
We have found the frailty teams service invaluable. The service has been able to provide support and advise for our very frail residents much quicker than before. It used to be such a struggle to get everything in place for when we would have very poorly to potential EOL patients- Now, we only need to request a visit, and they are here and putting everything we need in place. They ensure not only the medications are put in place, but the district nurses and GP is updated every step of the way.
Our residents have benefitted greatly through this service. They have been provided with all the necessary service and support, especially during their end of life. Personally, I have experienced some incidences where we have tried to get things in place, but to no avail. This unfortunately has led to some very bad experiences for residents and the staff supporting them.
We feel we are now listened to and valued as a Care home. I also feel, through this service, my own skills and experiences have improved, and I can recognise early the support which we may need to put in place for residents.
I do not feel there is any improvements at this time because we have had such positive support from the team.
I know if we require any support and advise, the team is always happy to provide. Thank you!