Frailty Care Coordinator in Wotton-under-Edge

Culverhay Surgery is looking for an enthusiastic Frailty Care Coordinator to join our established and supportive team. Located on the edge of the beautiful Cotswolds, our practice includes 3 fully integrated sites in the south of Gloucestershire, and is easily accessible from Bristol, Bath, Gloucester, and Cheltenham. The role will involve working as a member of our frailty team to support a caseload of frail patients in their own homes. Please note, a valid driving licence and access to your own vehicle are essential for this role.

Main duties of the job

• The postholder will engage in positive, empathetic conversations with residents, families, and carers to identify needs and support the development, implementation, and regular review of personalised care plans.
• The postholder will be expected to recognise areas of frailty and support/signpost to allow ongoing independence at home, with the aim to reduce and avoid hospital admissions.
• You will be expected to develop knowledge and skills in frailty to support the work of the practice team and the work of the MDT in the community.

About us

Culverhay Surgery looks after over 18,000 patients across our 3 sites in Wotton under Edge, Berkeley and Frampton on Severn. Our team consists of 4 partners (1 Practice Manager partner), 14 salaried GPs, a full skill mix of nurses including a nurse prescriber, senior clinical pharmacist, pharmacy technicians, frailty care co-ordinators, paramedic, social prescriber, and practice counsellors. Not forgetting our fantastic reception, secretarial and admin teams, who work very hard to minimise the administrative burden for the clinical team.

Job responsibilities

• To communicate and liaise with the practice nurses, care coordinators, district nurses, GPs, social prescriber, well-being coordinators and other professionals both in the community and the practice, and visit patients in their own homes as instructed by the primary care team.
• Responsible for daily planning and operation of the workload list, in liaison with the care coordinator team.
• Discuss patients concerns sensitively with them/their family member or carer (as appropriate and with patient consent) and relay information back to the lead frailty nurse and team.
• Support patients to live independently at home as well as able.
• To discuss future wishes around ageing well and future care planning.
• To give appropriate health advice and support and to reinforce information previously given to patients by other health care providers.
• Holistically bring together all of a person's identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
• Help people to manage their needs through answering queries, making and managing appointments, and ensuring that people have good quality written or verbal information to help them make choices about their care.
• Support people to access appropriate benefits where eligible.
• Assist people to access self-management courses, peer support or interventions that support them in their health and wellbeing and increase and improve their activation level.
• Carry out clinical tasks including phlebotomy, baseline observations, patient health checks, flu and covid vaccinations.
• Communication skills require tact, empathy, sensitivity and reassurance. The post holder may work with people who experience sensory loss, dementia, learning difficulties and whose first language may not be English.
• The post holder must communicate within a framework of confidentiality according to NHS/Practice Policy.
• Participate in regular team clinical meetings, and other practice meetings.
• Support the coordination and delivery of MDTs within the PCN and ICB.
• Uphold all practice policies including lone worker, health and safety and human resource procedures.
• Participate in audit and data collection as required.

Person Specification

Qualifications

• Good standard of general education.
• GCSE English C or above, level 2 numeracy and literacy equivalent.
• Healthcare qualification (level 3 or 4) or working towards gaining equivalent level.

Experience

• Experience of direct adult patient care in a health or social care setting.
• Experience of team working in a healthcare setting.
• Experience of working in a primary care environment.
• Proven ability to work unsupervised.
• Experience of delivering care within patients' homes.
• Experience of supporting patients with a diverse range of long term conditions, disabilities and life limiting diagnoses.

Clinical Knowledge and Skills

• Understanding and adherence to infection control.
• Ability to record accurate clinical notes.
• Patient health checks including height, weight, BP, Pulse.
• Administering flu and covid vaccinations.

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.