Frailty Care Co-Ordinator

Carnon Downs Surgery; Hugh Town; On-site; GBP 17,000 - 25,000; Full time

Job summary

Carnon Downs Surgery is recruiting Frailty Care Co-ordinators to join the Coastal PCN, probably based at St Agnes Surgery and Perranporth Surgery. Roles are part time or full time, focusing on coordinating care, navigating health and care services, and delivering timely, person-centred support.

The post involves working with GP practices, community services and social care to improve outcomes, with home visits and MDT involvement as core elements.

Qualifications

• Experience working in health, social care, community or voluntary sector services.
• Experience supporting vulnerable individuals.
• Experience managing competing priorities and workloads.
• Experience communicating with a range of stakeholders and professionals.
• Experience maintaining accurate records and documentation.

Responsibilities

• Coordinate and support the delivery of personalised care plans.
• Act as a central point of contact for patients and their families where appropriate.
• Support patients to access the right services at the right time.
• Coordinate care across primary care, secondary care, community services, social care and voluntary sector organisations.
• Facilitate smooth transitions between services.
• Ensure patients receive timely follow-up and ongoing support.
• Provide assessment within patient home settings.
• Identify patients who may benefit from care coordination including frail and elderly patients, patients with multiple long-term conditions, patients experiencing frequent hospital admissions, patients with complex social needs and patients requiring support from multiple agencies.
• Maintain patient caseloads and prioritise support according to need.
• Monitor progress against agreed care plans.
• Escalate concerns and risks appropriately.
• Work alongside patients to identify their needs, goals and preferences.
• Support shared decision-making.
• Promote self-management and patient activation.
• Support patients in understanding available healthcare and community resources.
• Assist in developing personalised care and support plans.
• Participate in MDT meetings.
• Coordinate actions arising from MDT discussions.
• Support communication between clinicians, practices, community teams and partner organisations.
• Facilitate information sharing in accordance with information governance requirements.
• Support proactive management of patients identified through frailty, population health and risk stratification programmes.
• Assist with long-term condition reviews and follow-up.
• Coordinate annual reviews where appropriate.
• Support implementation of PCN and Integrated Care System initiatives.
• Work closely with Social Prescribing Link Workers.
• Assist patients to access community-based services and support networks.
• Signpost patients to appropriate statutory and voluntary sector services.
• Support reduction of social isolation and health inequalities.
• Support patients following discharge from hospital.
• Assist with post-discharge follow-up activity.
• Coordinate actions arising from discharge summaries.
• Identify patients at risk of avoidable admission and work with the wider MDT to provide support.
• Maintain accurate patient records using clinical systems.
• Record activity in accordance with PCN, INT and contractual requirements.
• Produce reports and performance information as required.
• Ensure documentation is accurate, contemporaneous and compliant with information governance standards.
• Recognise and respond appropriately to safeguarding concerns.
• Follow local safeguarding procedures for children and adults.
• Escalate clinical and non-clinical risks promptly.
• Maintain patient confidentiality at all times.
• Contribute to continuous quality improvement initiatives.
• Participate in service evaluation and audit activities.
• Support implementation of new pathways and services.
• Share best practice and contribute to innovation across the PCN.

Skills

Communication

Interpersonal skills

Organisation

Problem solving

Team collaboration

Patient advocacy

Education

GCSE English and Maths

Evidence of continuing professional development

Tools

SystmOne

Population health systems

Microsoft Office

Job description

Job summary

We currently have vacancies For Frailty Care Co-ordinators to join our new Frailty Team working in conjunction with Coastal PCN, likely to be based at St Agnes Surgery and Perranporth Surgery. We have both part time or full time posts available. The Care Coordinator plays a pivotal role within the Primary Care Network, working as part of a multidisciplinary team to support patients in navigating health and care services, coordinating care across organisational boundaries, and ensuring patients receive timely, appropriate and person-centred support.

Main duties of the job

The post holder will proactively identify and support individuals, particularly those with complex health needs, frailty, long-term conditions, mental health needs or those requiring support from multiple agencies. They will work closely with GP practices, community services, voluntary sector organisations, social care providers and other healthcare professionals to improve patient outcomes and reduce health inequalities.

The Care Coordinator will help patients understand and manage their care pathways, ensuring services are delivered in a joined-up and efficient manner with a view of performing basic physical health checks e.g. weight, blood pressure, blood tests etc. Training will be provided for this

About us

Coastal Primary Care Network (PCN) is an NHS collaboration of four GP practices serving communities across the north and central Cornwall coastal area. The PCN works to provide high-quality, coordinated primary care services, with a focus on integrated working, prevention, proactive care, social prescribing, and support for patients with long-term conditions and frailty.

The PCN serves approximately 30,000 registered patients and has one of the highest proportions of over-65s populations in Cornwall. It works closely with community nursing teams, local health and social care providers, and voluntary sector organisations to deliver joined-up care closer to home.

We consist of Carnon Downs Surgery, Chacewater Surgery, Perranporth Surgery and St Agnes Surgery.

• Improve access to healthcare services.
• Deliver coordinated and personalised patient care.
• Support population health management.
• Reduce health inequalities.
• Strengthen links between primary care, community services, social care and the voluntary sector.
• Provide innovative services through the Additional Roles Reimbursement Scheme (ARRS).

Key Responsibilities

• Coordinate and support the delivery of personalised care plans.
• Act as a central point of contact for patients and their families where appropriate.
• Support patients to access the right services at the right time.
• Coordinate care across primary care, secondary care, community services, social care and voluntary sector organisations.
• Facilitate smooth transitions between services.
• Ensure patients receive timely follow-up and ongoing support.
• Provide assessment within patient home settings.
• Identify patients who may benefit from care coordination including frail and elderly patients, patients with multiple long-term conditions, patients experiencing frequent hospital admissions, patients with complex social needs and patients requiring support from multiple agencies.
• Maintain patient caseloads and prioritise support according to need.
• Monitor progress against agreed care plans.
• Escalate concerns and risks appropriately.
• Work alongside patients to identify their needs, goals and preferences.
• Support shared decision-making.
• Promote self-management and patient activation.
• Support patients in understanding available healthcare and community resources.
• Assist in developing personalised care and support plans.
• Participate in multidisciplinary team (MDT) meetings.
• Coordinate actions arising from MDT discussions.
• Support communication between clinicians, practices, community teams and partner organisations.
• Facilitate information sharing in accordance with information governance requirements.
• Support proactive management of patients identified through frailty, population health and risk stratification programmes.
• Assist with long-term condition reviews and follow-up.
• Coordinate annual reviews where appropriate.
• Support implementation of PCN and Integrated Care System initiatives.
• Work closely with Social Prescribing Link Workers.
• Assist patients to access community-based services and support networks.
• Signpost patients to appropriate statutory and voluntary sector services.
• Support reduction of social isolation and health inequalities.
• Support patients following discharge from hospital.
• Assist with post-discharge follow-up activity.
• Coordinate actions arising from discharge summaries.
• Identify patients at risk of avoidable admission and work with the wider MDT to provide support.
• Maintain accurate patient records using clinical systems.
• Record activity in accordance with PCN, INT and contractual requirements.
• Produce reports and performance information as required.
• Ensure documentation is accurate, contemporaneous and compliant with information governance standards.
• Recognise and respond appropriately to safeguarding concerns.
• Follow local safeguarding procedures for children and adults.
• Escalate clinical and non-clinical risks promptly.
• Maintain patient confidentiality at all times.
• Contribute to continuous quality improvement initiatives.
• Participate in service evaluation and audit activities.
• Support implementation of new pathways and services.
• Share best practice and contribute to innovation across the PCN.

Person Specification

Essential Experience

• Experience working within health, social care, community or voluntary sector services.
• Experience supporting vulnerable individuals.
• Experience managing competing priorities and workloads.
• Experience communicating with a range of stakeholders and professionals.
• Experience maintaining accurate records and documentation.

Desirable Experience

• Experience within General Practice or Primary Care.
• Experience of care coordination or case management.
• Experience working within multidisciplinary teams.
• Experience supporting frail patients or individuals with long-term conditions.
• Knowledge of NHS systems and services.

Essential Qualifications

• Educated to GCSE level (or equivalent) including English and Mathematics.
• Evidence of continuing professional development.

Desirable Qualifications

• Care Coordinator Qualification or Personalised Care Institute training.
• NVQ Level 3 in Health and Social Care, Business Administration or equivalent experience.
• Health Coaching qualification.
• Level 3 or above qualification in health, social care or related field.
• Mental Health First Aid training.
• Safeguarding qualifications.

Essential Other Requirements

• Commitment to delivering high-quality patient-centred care.
• Flexible and adaptable approach to working across multiple sites.
• Ability to travel between PCN locations as required.
• Ability to perform home visits.
• Full UK Driving License and access to a vehicle.

Essential Knowledge

• Understanding of person-centred care.
• Knowledge of confidentiality and data protection requirements.
• Understanding of safeguarding responsibilities.
• Awareness of health inequalities and wider determinants of health.
• Understanding of multidisciplinary working.

Desirable Knowledge

• Knowledge of Primary Care Networks.
• Understanding of personalised care approaches.
• Knowledge of community and voluntary sector services.
• Understanding of frailty and long-term condition management.

Essential Skills and Competencies

• Excellent communication and interpersonal skills.
• Ability to build effective relationships with patients and professionals.
• Strong organisational and time management skills.
• Ability to work independently and as part of a team.
• Good problem-solving skills.
• Strong IT skills, including Microsoft Office applications.
• Ability to maintain confidentiality and professionalism.
• Ability to manage sensitive and potentially distressing situations.

Desirable Skills and Competencies

• Knowledge of SystmOne.
• Experience using population health and reporting systems.
• Facilitation and meeting coordination 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: Carnon Downs Surgery
Address: St Agnes Surgery, Pengarth, St Agnes, Cornwall, TR5 0TN, United Kingdom
Employer's website: https://www.carnondownssurgery.co.uk/index.aspx

For questions about the job, contact:
Operations Lead, Helen Perkin, [e-mail]

Closing date: 09 November 2026