Job summary
We are searching for a Frailty Care Navigator to join our Inner City PCN team. You will be supporting the Frailty Practitioner to identify frail patients on the GP systems and to make sure they get the support they need.
This position would be suitable for the right candidate that is willing to learn and is interested in working with older people.
You will be required to work across various locations in Gloucester. This will include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery .
Working Hours:18.5 hours per week.
Closing date:Sunday 1st March
Interview date:Thursday 12th March TBC
Applications may close early depending on response.
Main duties of the job
To work with the Frailty Practitioner to use the GP systems to identify people living with moderate or severe frailty to ensure they get the care and support they need.
To send out questionnaires to patients and ensure we get a response by following up on forms that arent returned.
To act as a central point of contact for people and their carers.
To provide administrative support for the Frailty Practitioner and the Frailty Project.
To work with social prescribers and community providers to ensure people are signposted to the right support.
The job is primarily working with practices in the PCN and you will be required to travel independently between practices and occasionally G DOCs offices in Gloucester, and to attend meetings etc., hosted by other agencies throughout Gloucestershire.
Reports to:the PCN Business Manager and the PCN Clinical Director.
Line Manager:PCN Business Manager
About us
G DOC LTD is a unique, GP-owned organisation all GP surgeries in Gloucestershire are our shareholders. We operate with a not-for-profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.
We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient-centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of countywide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high-quality primary care while fostering innovation and collaboration across the local health system.
By joining us, youll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. Youll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close-knit, community-focused teams.
Details
Date posted
10 February 2026
Pay scheme
Other
Salary
Depending on experience £27,485 - £30,162 pro-rata dependent on experience
Contract
Fixed term
Duration
2 years
Working pattern
Flexible working
Reference number
A
Job locations
Quayside House
Quay Street
Gloucester
GL1 2TZ
Job description
Job responsibilities
Duties
Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services.
Case Identification:
Support the Frailty Practitioner as required to undertake digital risk stratification
Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination
Holistic Assessment:
Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)
Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken
Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template
Personalised Care and Support Planning:
As determined by the Frailty Practitioner:
o Ensure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes
o Ensure a ReSPECT plan is completed for each patient who has a CGA
General
Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice
Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.
Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed.
Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing
Liaise and work with the ICB, practices, voluntary and other organisations to implement patient services
Assist the Business Manager in collating information for claims (e.g. ARRS, Care Homes, etc) and responding to queries
Monitor the PCNs generic mailboxes and respond appropriately to emails
Coordinate, organise and attend various MDT meetings (e.g. Care Homes, Dementia, Respiratory and Pain Management).
Assist the Lead education GP to organise training including PLT sessions
Support the Business Manager to deliver key projects, including quality improvement projects. This includes the provision of information and analysis using information, data, knowledge and technology systems to inform and support PCN agreed initiatives and meet the needs of the local population.
Support the PCN Leadership team in the delivery of the DES specifications and support Quality and Outcome Frameworks.
Assess data, monitor the PCN dashboard and liaise with the Digital and Transformation Leads, Practices, GPs and Nursing teams, with a view to achieving network targets and obtaining maximum investment and impact funding
Attend meetings on behalf of the PCN
Take minutes of meetings as required.
Raise awareness of health promotion in practices, implementing, co-ordinating and supporting a variety of projects.
Assist the Clinical Director and Business Manager to coordinate the Covid Vaccination programmes across practices
Support the PCN practices, contributing to the delivery of QOF and enhanced services.
Contributing to the management and development of the Primary Care Network, including the performance of work undertaken by the Practice as part of the PCN
Helping to ensure that the PCN remains safe and effective, including by the use of clinical audit and learning from significant events and complaints.
Working conditions
Frequent, prolonged VDU use
Time-pressured environment
High levels of accuracy and attention to detail essential at all times
Exposure to distressing situations and written material
Job Description for all G DOC workers
The job description for all G DOC workers also forms part of your job description.
Job description
Job responsibilities
Duties
Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services.
Case Identification:
Support the Frailty Practitioner as required to undertake digital risk stratification
Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination
Holistic Assessment:
Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)
Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken
Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template
Personalised Care and Support Planning:
As determined by the Frailty Practitioner:
o Ensure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes
o Ensure a ReSPECT plan is completed for each patient who has a CGA
General
Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice
Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.
Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.
Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed.
Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing
Liaise and work with the ICB, practices, voluntary and other organisations to implement patient services
Assist the Business Manager in collating information for claims (e.g. ARRS, Care Homes, etc) and responding to queries
Monitor the PCNs generic mailboxes and respond appropriately to emails
Coordinate, organise and attend various MDT meetings (e.g. Care Homes, Dementia, Respiratory and Pain Management).
Assist the Lead education GP to organise training including PLT sessions
Support the Business Manager to deliver key projects, including quality improvement projects. This includes the provision of information and analysis using information, data, knowledge and technology systems to inform and support PCN agreed initiatives and meet the needs of the local population.
Support the PCN Leadership team in the delivery of the DES specifications and support Quality and Outcome Frameworks.
Assess data, monitor the PCN dashboard and liaise with the Digital and Transformation Leads, Practices, GPs and Nursing teams, with a view to achieving network targets and obtaining maximum investment and impact funding
Attend meetings on behalf of the PCN
Take minutes of meetings as required.
Raise awareness of health promotion in practices, implementing, co-ordinating and supporting a variety of projects.
Assist the Clinical Director and Business Manager to coordinate the Covid Vaccination programmes across practices
Support the PCN practices, contributing to the delivery of QOF and enhanced services.
Contributing to the management and development of the Primary Care Network, including the performance of work undertaken by the Practice as part of the PCN
Helping to ensure that the PCN remains safe and effective, including by the use of clinical audit and learning from significant events and complaints.
Working conditions
Frequent, prolonged VDU use
Time-pressured environment
High levels of accuracy and attention to detail essential at all times
Exposure to distressing situations and written material
Job Description for all G DOC workers
The job description for all G DOC workers also forms part of your job description.
Person Specification
Personal qualities
Essential
* An interest in working with older people
* Clear, polite telephone manner
* Polite and confident
* Flexible and cooperative
* Motivated
* High levels of integrity and loyalty
* Sensitive and empathetic in distressing situations
* Ability to work under pressure
Experience
Desirable
* Experience of working with or supporting older people
* Experience of General Practice and/or Primary Care
* Previous experience in a GP practice or primary care.
* Experience of working with members of the public in a supportive role
* Understanding of Information Governance / data compliance
Other
Essential
* Disclosure Barring Service (DBS) check
* Evidence of continuing professional development
Skills
Essential
* Excellent communication skills (written and oral)
* Strong IT skills
* If not already competent in the use of SystmOne, Office & Outlook, willing and able to undertake training
* Ability to follow policy and procedure
* Effective time management (Planning & Organising)
* Ability to work as a team member and autonomously
* Good interpersonal skills
* Understanding of confidentiality and data protection
* or willing and able to undertake training
Desirable
* Competent in use of SystmOne
* Competent in the use of Office and Outlook
Qualifications
Essential
* Essential
* GCSE English Grade 5 or above (or equivalent or higher qualification)
* GCSE Maths Grade 5 or above (or equivalent or higher qualification)
Desirable
* Undergraduate degree or equivalent
* NVQ Level 2/3 in Health and Social Care or equivalent.
Person Specification
Personal qualities
Essential
* An interest in working with older people
* Clear, polite telephone manner
* Polite and confident
* Flexible and cooperative
* Motivated
* High levels of integrity and loyalty
* Sensitive and empathetic in distressing situations
* Ability to work under pressure
Experience
Desirable
* Experience of working with or supporting older people
* Experience of General Practice and/or Primary Care
* Previous experience in a GP practice or primary care.
* Experience of working with members of the public in a supportive role
* Understanding of Information Governance / data compliance
Other
Essential
* Disclosure Barring Service (DBS) check
* Evidence of continuing professional development
Skills
Essential
* Excellent communication skills (written and oral)
* Strong IT skills
* If not already competent in the use of SystmOne, Office & Outlook, willing and able to undertake training
* Ability to follow policy and procedure
* Effective time management (Planning & Organising)
* Ability to work as a team member and autonomously
* Good interpersonal skills
* Understanding of confidentiality and data protection
* or willing and able to undertake training
Desirable
* Competent in use of SystmOne
* Competent in the use of Office and Outlook
Qualifications
Essential
* Essential
* GCSE English Grade 5 or above (or equivalent or higher qualification)
* GCSE Maths Grade 5 or above (or equivalent or higher qualification)
Desirable
* Undergraduate degree or equivalent
* NVQ Level 2/3 in Health and Social Care or equivalent.
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.
Employer details
Employer name
G DOC Ltd
Address
Quayside House
Quay Street
Gloucester
GL1 2TZ
Employer's website
(Opens in a new tab)
Employer details
Employer name
G DOC Ltd
Address
Quayside House
Quay Street
Gloucester
GL1 2TZ
Employer's website
(Opens in a new tab)