Frailty Care Coordinator

Culverhay Surgery is looking for an enthusiastic Frailty Care Coordinator to join our established and supportive team. Located on theedge 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.

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 allowongoing independence at home, with the aim to reduce and avoid hospitaladmissions. You will be expected to develop knowledge andskills in frailty to support the work of the practice team and the work of theMDT in the community.

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 Managerpartner), 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 fantasticreception, secretarial and admin teams, who work very hard to minimise the administrative burden for the clinical team.

To communicate andliaise 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 instructedby the primary care team.

Responsible for daily planning and operation of the workload list, in liaison with the carecoordinator team.

Discuss patientsconcerns sensitively with them/their family member or carer (as appropriate andwith patient consent) and relay information back to the lead frailty nurse andteam.

Support patients to live independently at home as well as able.

To discuss future wishes around ageing well and future care planning.

To give appropriatehealth advice and support and to reinforce information previously given to patients by other health care providers.

Holistically bring together all of a persons identified care and support needs, and exploreoptions 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 helpthem make choices about their care.

Support people toaccess appropriate benefits where eligible.

Assist people to accessself-management courses, peer support or interventions that support them intheir 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 whoexperience sensory loss, dementia, learning difficulties and whose firstlanguage may not be English. In addition, the post holder may be required to work with individuals or their family members/carers who do not comply with care prescribed by primary care orthose who decline to cooperate to resolve identified risks e.g. leg elevation.

The post holder mustcommunicate within a framework of confidentiality according to NHS/Practice Policy.

Participate in regular team clinical meetings, and other practice meetings.

Support thecoordination and delivery of MDTs within the PCN and ICB.

Uphold all practice policies including lone worker, health and safety and human resourceprocedures.

Participate in auditand data collection as required.

• Good standard…