Job summary An exciting opportunity has become available for a Frailty Service Coordinator to work in a new integrated community-based service supporting the frail housebound population across Easington and Sedgefield. This is a chance to play a key role in shaping and delivering proactive care to patients in partnership with local stakeholders. The proactive service has launched and is already showing early benefits, it is designed to bring joined-up, multidisciplinary care to patients. The post holder will be a vital link in the coordination and delivery of holistic care. Main duties of the job As the Frailty Service Coordinator, you will be instrumental in the smooth running of the service. Your key responsibilities will include: Managing clinician diaries and coordinating appointments Contacting patients and completing pre-assessment forms Processing referrals and maintaining patient records Supporting remote consultations and ensuring follow-up care Carrying out home visits to take baseline observations Assisting with digital tools to enable remote examinations Liaising with GP practices, patients, and families/carers Ensuring the effective use of digital technologies to enhance care deliver. Support team in issuing and fitting functional equipment and observing for signs of damage and wear and tear to feedback into the MDT discussion. This role combines administrative coordination with hands-on patient care and engagement. About us South Durham Health CiC is the managing agent for the 5 primary care networks (PCNs) in the Sedgefield and Easington localities. We also hold a number of NHS contracts providing additional services to our patient populations. We serve a combined patient population of 204,554 across 21 practices. We are early adopters of the Integrated Neighbourhood Team strategy and have already developed 2 Integrated Neighbourhood Teams (INTs) aligned to our future work against NHS key strategies. Details Date posted 01 December 2025 Pay scheme Other Salary £13.60 an hour Contract Fixed term Duration 2 years Working pattern Full-time Reference number B0611-25-0037 Job locations The Surgery Ashmore Terrace Wheatley Hill County Durham DH6 3NP Job description Job responsibilities JOB PURPOSE: The Frailty Service Coordinator will be pivotal in helping to launch and run a new service aimed at the housebound, frail population of Easington and Sedgefield. They will assist a multi-disciplinary team in delivering patient care within the community. Your role will involve managing clinicians diaries, contacting patients and booking appointments, completing pre-assessment forms, and coordinating patient flow. You will liaise with GP practices, process referrals, and support remote consultations and follow-up care. Home visits are an integral part of the role, where you will take baseline observations, facilitate remote examinations using digital tools, issue functional equipment and provide support to patients and their families. You will also maintain digital technologies to ensure smooth service delivery and effective communication, helping ensure high-quality care for patients in the local community. MAIN DUTIES AND RESPONSIBILITIES Organise and manage clinicians schedules efficiently, ensuring that appointments are correctly documented in ledgers to maintain smooth workflow. Schedule appointments for patients, ensuring effective communication with patients and their families/carers to confirm bookings and address any concerns. Oversee the completion and accurate documentation of pre-assessment forms, ensuring they are entered into patient records in a timely manner. Ensure efficient patient flow within the community frailty service, coordinating between the team members to minimise delays and ensure timely delivery of care. Identify and generate referrals for patients who require further services or specialist interventions, ensuring that they are referred in a timely and appropriate manner. Prepare and send necessary documentation regarding patient recommendations to general practices, ensuring all required information is included and communicated effectively. Maintain ongoing communication with local GP practices, providing updates and receiving necessary information regarding patient care and coordination. Responsible for organising the daily MDT meetings, ensuring that all relevant stakeholders are present, and support the team in discussing patient care. Arrange follow-up appointments and ensure that appropriate care and support are provided to patients in a timely manner. Utilise SystmOne to extract relevant patient data, ensuring that information is accurately gathered and available for clinical review. Set up and maintain the necessary technology for remote consultations, including configuring Teams links and ensuring clinicians have all relevant patient information beforehand. Oversee the management and upkeep of all digital technologies used within the service, ensuring they are functioning correctly and supporting patient care. Visit patients in their homes when required, facilitating remote consultations between patients and clinicians by setting up necessary digital devices. Support therapist in issuing and fitting functional equipment and observing for signs of damage and wear and tear to feedback into the MDT discussion. Conduct initial assessments by taking baseline vital signs, including blood pressure (lying and standing), pulse, oxygen saturation, respiratory rate, temperature, height, and weight. Support remote examinations through the use of a digital stethoscope and other technology to ensure comprehensive patient assessments. Provide support to patients and their families as needed, offering reassurance and assistance with understanding care plans or addressing concerns. Ensure recoding of full and chronological documentation according to information governance guidelines. Ensuring infection control guidelines are followed correctly when delivering safe and appropriate care. Managerial Carry out surveys and audits as appropriate to your area of work Support colleagues to access the most appropriate service by problem solving and directing referrals to the most appropriate level of care. Maintain and provide accurate and timely statistics and information within the required timescales Participate in team meetings. Manage time and caseload pressure in a rapidly changing environment, using appropriate prioritisation. Undertake any other professional duty as required within the service, in accordance with training, and experience following consultation with the trained member of the team. Plan own caseload, asking for support when required Communication Establish and maintain effective, collaborative working with colleagues in Primary/Secondary Care, Social Services, Voluntary and Independent Sectors in all aspects of patient care. Participate in multi-disciplinary team meetings and liaise with other disciplines to achieve comprehensive, effective and holistic ongoing care management planning for the patient. Demonstrate the ability to communicate information, sometimes of a complex and sensitive matter and respond appropriately to patients, carers and staff. Maintain accurate and contemporaneous record keeping to a high standard utilising specific templates on SystmOne. Demonstrate the ability to communicate information, sometimes of a complex and sensitive matter and respond appropriately to patients, carers and staff. Ensure timely and effective communication with the qualified staff on all team matters. Training Actively participate in your own personal development plan with your supervisor in order to develop the skills and knowledge required to carry out the responsibilities set out in the job description Ensure that personal support and development is gained through performance review, regular supervision and that training needs are identified with subsequent training as appropriate, in line with employers' policy. Job description Job responsibilities JOB PURPOSE: The Frailty Service Coordinator will be pivotal in helping to launch and run a new service aimed at the housebound, frail population of Easington and Sedgefield. They will assist a multi-disciplinary team in delivering patient care within the community. Your role will involve managing clinicians diaries, contacting patients and booking appointments, completing pre-assessment forms, and coordinating patient flow. You will liaise with GP practices, process referrals, and support remote consultations and follow-up care. Home visits are an integral part of the role, where you will take baseline observations, facilitate remote examinations using digital tools, issue functional equipment and provide support to patients and their families. You will also maintain digital technologies to ensure smooth service delivery and effective communication, helping ensure high-quality care for patients in the local community. MAIN DUTIES AND RESPONSIBILITIES Organise and manage clinicians schedules efficiently, ensuring that appointments are correctly documented in ledgers to maintain smooth workflow. Schedule appointments for patients, ensuring effective communication with patients and their families/carers to confirm bookings and address any concerns. Oversee the completion and accurate documentation of pre-assessment forms, ensuring they are entered into patient records in a timely manner. Ensure efficient patient flow within the community frailty service, coordinating between the team members to minimise delays and ensure timely delivery of care. Identify and generate referrals for patients who require further services or specialist interventions, ensuring that they are referred in a timely and appropriate manner. Prepare and send necessary documentation regarding patient recommendations to general practices, ensuring all required information is included and communicated effectively. Maintain ongoing communication with local GP practices, providing updates and receiving necessary information regarding patient care and coordination. Responsible for organising the daily MDT meetings, ensuring that all relevant stakeholders are present, and support the team in discussing patient care. Arrange follow-up appointments and ensure that appropriate care and support are provided to patients in a timely manner. Utilise SystmOne to extract relevant patient data, ensuring that information is accurately gathered and available for clinical review. Set up and maintain the necessary technology for remote consultations, including configuring Teams links and ensuring clinicians have all relevant patient information beforehand. Oversee the management and upkeep of all digital technologies used within the service, ensuring they are functioning correctly and supporting patient care. Visit patients in their homes when required, facilitating remote consultations between patients and clinicians by setting up necessary digital devices. Support therapist in issuing and fitting functional equipment and observing for signs of damage and wear and tear to feedback into the MDT discussion. Conduct initial assessments by taking baseline vital signs, including blood pressure (lying and standing), pulse, oxygen saturation, respiratory rate, temperature, height, and weight. Support remote examinations through the use of a digital stethoscope and other technology to ensure comprehensive patient assessments. Provide support to patients and their families as needed, offering reassurance and assistance with understanding care plans or addressing concerns. Ensure recoding of full and chronological documentation according to information governance guidelines. Ensuring infection control guidelines are followed correctly when delivering safe and appropriate care. Managerial Carry out surveys and audits as appropriate to your area of work Support colleagues to access the most appropriate service by problem solving and directing referrals to the most appropriate level of care. Maintain and provide accurate and timely statistics and information within the required timescales Participate in team meetings. Manage time and caseload pressure in a rapidly changing environment, using appropriate prioritisation. Undertake any other professional duty as required within the service, in accordance with training, and experience following consultation with the trained member of the team. Plan own caseload, asking for support when required Communication Establish and maintain effective, collaborative working with colleagues in Primary/Secondary Care, Social Services, Voluntary and Independent Sectors in all aspects of patient care. Participate in multi-disciplinary team meetings and liaise with other disciplines to achieve comprehensive, effective and holistic ongoing care management planning for the patient. Demonstrate the ability to communicate information, sometimes of a complex and sensitive matter and respond appropriately to patients, carers and staff. Maintain accurate and contemporaneous record keeping to a high standard utilising specific templates on SystmOne. Demonstrate the ability to communicate information, sometimes of a complex and sensitive matter and respond appropriately to patients, carers and staff. Ensure timely and effective communication with the qualified staff on all team matters. Training Actively participate in your own personal development plan with your supervisor in order to develop the skills and knowledge required to carry out the responsibilities set out in the job description Ensure that personal support and development is gained through performance review, regular supervision and that training needs are identified with subsequent training as appropriate, in line with employers' policy. Person Specification Experience Essential Ability to work effectively as a team player under appropriate supervision, and as part of a multi-disciplinary team. Desirable Experience of SystmOne. Previous experience in a Primary Care setting. Previous Health Care experience Therapy Assistant Competencies Attitudes Essential Professional approach to work Responsive and positive role model. Can recognise personal limitations and refer to more appropriate colleagues when necessary. Commitment to continued Professional Development through further study. Qualifications Essential GCSEs Grade A-C in Maths and English or key skills level 2 in Maths and English (to be evidenced by a test if relevant qualifications not available) Desirable Care certificate Skills and Abilities Essential Excellent interpersonal skills. Effective written, verbal, and non-verbal communication with patients, carers, and all members of the multidisciplinary teams. Ability to work with patients from a diverse range of religious, cultural, and social backgrounds to meet their needs. Flexible and adaptable to change. Strong team player as well as working on own initiative when required. Clear and concise record keeping Desirable Demonstrate an understanding of the data protection act and patient confidentiality, clinical and information governance and Caldicott requirements Phlebotomy skills Promote health and prevent ill health. Provide and monitor Care Ability to prioritise workload Clinical observation skills Person Specification Experience Essential Ability to work effectively as a team player under appropriate supervision, and as part of a multi-disciplinary team. Desirable Experience of SystmOne. Previous experience in a Primary Care setting. Previous Health Care experience Therapy Assistant Competencies Attitudes Essential Professional approach to work Responsive and positive role model. Can recognise personal limitations and refer to more appropriate colleagues when necessary. Commitment to continued Professional Development through further study. Qualifications Essential GCSEs Grade A-C in Maths and English or key skills level 2 in Maths and English (to be evidenced by a test if relevant qualifications not available) Desirable Care certificate Skills and Abilities Essential Excellent interpersonal skills. Effective written, verbal, and non-verbal communication with patients, carers, and all members of the multidisciplinary teams. Ability to work with patients from a diverse range of religious, cultural, and social backgrounds to meet their needs. Flexible and adaptable to change. Strong team player as well as working on own initiative when required. Clear and concise record keeping Desirable Demonstrate an understanding of the data protection act and patient confidentiality, clinical and information governance and Caldicott requirements Phlebotomy skills Promote health and prevent ill health. Provide and monitor Care Ability to prioritise workload Clinical observation skills 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 South Durham Health CIC Address The Surgery Ashmore Terrace Wheatley Hill County Durham DH6 3NP Employer's website https://www.southdurhamhealth.co.uk/ (Opens in a new tab) Employer details Employer name South Durham Health CIC Address The Surgery Ashmore Terrace Wheatley Hill County Durham DH6 3NP Employer's website https://www.southdurhamhealth.co.uk/ (Opens in a new tab)