Job Summary
We are recruiting a Care Coordinator to play a vital role in a brand new Frailty team within our developing PCN. We are looking for an experienced and highly organised Care Coordinator to work with people living with moderate or severe frailty and/or dementia to provide coordination and navigation of care and support across health, care and support services. The role works closely with GPs, Practice teams, Social Prescriber and the wider PCN team to deliver a personalised care approach. The Care Coordinator will act as a central point of contact to ensure appropriate support is available to people and their carers, enabling them to understand and manage their condition and ensuring their changing needs are addressed.
Job Locations
* Quayside House, Quay Street, Gloucester, GL1 2TZ
* Severnbank Surgery, Tutnalls Street, Lydney, Gloucestershire, GL15 5PF
Employment Details
* Salary: £13 to £13.50 an hour, depending on experience
* Contract: Permanent
* Working pattern: Part‑time, up to 30 hours per week
* Closing date: 30 November 2025
Key Responsibilities
1. Support the Frailty Practitioner with case identification using digital risk stratification
2. Transpose data onto the Personalised Proactive Whiteboard (PPW)
3. Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)
4. Assist with determining the action for patients not receiving a CGA, ensuring actions are undertaken
5. Contribute to the completion of CGAs by inputting information into a digital template
6. Ensure each patient with a CGA has a Personalised Care and Support Plan (PCSP) finalised with patient and carer/family
7. Ensure a ReSPECT plan is completed where required
8. Coordinate the care of each patient, ensuring close multi‑agency and multi‑professional working, particularly with the local Integrated Neighbourhood Team(s)
9. Use the PPW to manage and coordinate the care for each patient
10. Ensure relevant colleagues complete agreed interventions listed in the PCSP, escalating issues where necessary
11. Provide a single point of contact for patients, managing appointments and ensuring high‑quality written or verbal information
12. Assist people to access self‑management education courses, peer support, health coaching and other interventions
13. Explore and assist patients to access personal health budgets where appropriate
14. Engage in shared decision‑making conversations, supporting staff and patients to prepare for these discussions
15. Maintain records of referrals and interventions to enable monitoring and evaluation of the service
16. Update patient records including clinical coding and follow‑up on communications from out‑of‑hospital and in‑patient services
17. Support coordination and delivery of multidisciplinary teams (MDTs) and provide coordination across services
18. Work collaboratively with GPs, other general practice team members and with commissioners, Integrated Neighbourhood Team members and other agencies to further develop the Care Coordinator role
19. Provide support to the Frailty Team Administrator as required
20. Identify carers and help them access services, ensuring they are coded as a carer in the GP clinical system if they are a patient at the practice
Qualifications
* GCSE grade 4/C or above in maths & English, or equivalent
Personal Qualities
* Clear, polite telephone manner
* Polite and confident
* Flexible and cooperative, motivated
* High levels of integrity and loyalty
* Demonstrates empathy, respect, and kindness in all interactions
* Collaborative and able to work effectively across disciplines and organisations to deliver joined‑up care
* Person centred (prioritises the individual's needs, preferences, and dignity)
* Innovative: seeks out and applies evidence‑based practices and new models of care
* Promotes equality, diversity, and cultural competence in care delivery
* Able to use own initiative but also knows when to seek assistance
* Ability to work under pressure
* Willingness to embrace change and contribute to ongoing improvements within the service
* Takes responsibility for tasks and service outcomes, ensuring high standards in service delivery
* Engages in continuous professional development and reflective practice
Knowledge and Skills
* Excellent communication (written and oral) and interpersonal skills, comfortable and confident in communicating with a wide variety of people and organisations
* Strong IT skills
* Competent in using Microsoft Office software, including word processing and spreadsheets
* If not already competent in SystmOne, willing and able to undertake training and develop competency
* Ability to manage sensitive information with discretion and adhere to confidentiality requirements
* Proactive and problem‑solving skills and the ability to work under pressure in a fast‑paced environment
* Ability to follow policy and procedure
* Effective time‑management (organising and planning)
* Ability to work independently, as well as part of a team
* Strong organisational skills including planning, prioritising and record‑keeping
* Understanding of personalised care, wider determinants of health and equality, diversity and inclusion
* Ability to provide non‑judgemental, culturally sensitive support using health coaching approaches
* Understanding of the holistic needs of people living with frailty and long‑term conditions particularly in relation to promoting their independence
* Able to support data collection and use of tools to measure impact of services
* Knowledge of healthcare administration and familiarity with medical terminology
Desirable
* Competent in use of SystmOne
Experience
* Experience of working in an administrative role
Desirable Experience
* Experience in an NHS or other healthcare setting
* Broad experience of General Practice
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) is required to check for any previous criminal convictions.
Employer Details
* Employer name: G DOC Ltd
* Address: Quayside House, Quay Street, Gloucester, GL1 2TZ
* Website: https://ghac.co.uk/
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