Care Co-ordinator: Frailty

Portsdown Group Practice

Information:

This job is now closed

Job summary

Portsdown Group Practice is looking for a Frailty Care Coordinator to work with patients and their families, who are identified as being frail or at risk of frailty. The aim of the role is to support individuals to manage their health and wellbeing to enable them to continue to live independently in their own homes for as long as possible.

Main duties of the job

The aim of the role is to support individuals to manage their health and wellbeing and continue to live independently in their own homes for as long as possible.

The post holder will provide an innovative, integrated service to anyone who has been identified as frail or at risk of frailty. The role requires a caring, dedicated, reliable and patient focused individual who enjoys meeting new people.

The post holder will work both as part of the general practice team, playing a role in coordinating care and support to individuals. They will manage a short term caseload supporting the arrangements for appropriate care and support and ensuring that unplanned, changing needs are addressed and that individuals are accessing appropriate support.

About us

Portsdown Group Practice covers the whole of Portsmouth from postcodes PO1 to PO7. We operate from 6 surgeries: Cosham Park House (PO6 3BG), Crookhorn Lane (PO7 5XP, Heyward Road (PO4 0DY), Kingston Crescent (PO2 8AL), Paulsgrove (PO6 4HJ), and Somerstown (PO5 4EZ).

We are our own Primary Care Network (PCN). We have 12 Clinical Partners, 12 Salaried GPs and a comprehensive Nursing and extended clinical team overseen by our Clinical Team Manager and consisting of 15 Nurse / Paramedic Practitioners, 14 Registered Nurses, 12 HCAs, 1 Physician Associate , 3 MSK Physio Therapists and 3 care co-ordinators. The Pharmacy team consists of 3 Clinical Pharmacists, 2 Pharmacy Technicians and 1 pre-registration trainee Pharmacy Technician.

The Practice is well established, financially secure and successful. Over the last few years we have earned maximum QOF points.

Our last CQC Inspection was in January 2020. We were rated Good overall and Outstanding for the care we provide to Working Age People.

Job description

Job responsibilities

Title: Care Co-ordinator: Frailty

Responsible To: Clinical Team Manager

Main Purpose of the Post: The aim of the role is to support individuals to manage their health and wellbeing and continue to live independently in their own homes for as long as possible.

The post holder will provide an innovative, integrated service to anyone who has been identified as frail or at risk of frailty. The role requires a caring, dedicated, reliable and patient focused individual who enjoys meeting new people.

The post holder will work both as part of the general practice team, playing a role in coordinating care and support to individuals. They will manage a short term caseload supporting the arrangements for appropriate care and support and ensuring that unplanned, changing needs are addressed and that individuals are accessing appropriate support.

Duties & Responsibilities of the Post:

Main Duties:

  • To visit and support patients at home to assess whether there is any unmet health or care needs.
  • To complete holistic person centred care planning.
  • Where unmet needs are identified to complete relevant referrals
  • To attend Multidisciplinary Team (MDT) meetings.
  • There will be an element of clinical assessment required such as observations (training will be provided)

It is important to note that this is a new venture and both the role and the team will develop and adapt as necessary. Its an exciting venture for both Portsdown Group Practice and the successful applicants and its success will be created by everyone who will work within the newly formed team.

Assessment:

Carry out a holistic, person centred assessment which looks at the health and social

needs of the person, conducted in partnership with the individual person, their family

and carers. The assessment will be conducted, whenever possible, in the persons

own home to take account of environmental factors and to fully understand the

persons functional ability in a familiar setting.

Carry out agreed specific assessments including a basic falls risk assessment

Develop and agree care plans and if necessary reviews for ongoing needs.

Intervention:

Refer and liaise with a range of statutory and voluntary sector support agencies,

ensuring the person has access to a wide range of support

Where necessary identify urgent needs taking relevant action or liaison.

Refer for relevant equipment to increase the persons independence.

Provide guidance and support to increase the use of self-care methods.

Conduct clinical screening such as dementia screening and blood pressure

checks as directed by the lead health professional. (Where relevant training has been

received)

Carry out falls assessment/screening and provide advice and information on

falls prevention, including referral for equipment where necessary.

Monitor and review care plans and agreed outcomes in partnership with the person

and to evaluate outcomes. This would involve re-negotiating care plans as and when

required

Act as the key advocate for the person as and when required

Confidentiality:

As per both Government legislation and Practice Policies ensure that all confidentiality, data protection and information governance policies and guidelines are followed and strictly adhered to, reporting any infringements to the Operations Office immediately.

Health & Safety:

The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the practice Health & Safety policy, the practice Health & Safety manual, and the practice Infection Control policy and published procedures. This will include:

  • Using personal security systems within the workplace according to practice guidelines
  • Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
  • Making effective use of training to update knowledge and skills
  • Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards
  • Actively reporting of health and safety hazards and infection hazards immediately when recognised
  • Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holders role
  • Undertaking periodic infection control training (minimum annually)
  • Reporting potential risks identified
  • Demonstrate due regard for safeguarding and promoting the welfare of children.
  • Reporting potential risks identified.

Equality and Diversity:

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

  • Acting in a way that recognizes the importance of peoples rights, interpreting them in a way that is consistent with Practice procedures and policies, and current legislation.
  • Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues.
  • Behaving in a manner which is welcoming to and of the individual, is non-judgmental and respects their circumstances, feelings priorities and rights.

Personal/Professional Development:

The post-holder will participate in any training programme implemented by the Practice as part of this employment, such training to include:

  • Participation in an annual staff performance review.
  • Taking responsibility for own development, learning and performance and demonstrating skills and activities to others who are undertaking similar work.

Quality:

The post-holder will strive to maintain quality within the Practice, and will:

  • Alert other team members to issues of quality and risk.
  • Assess own performance and take accountability for own actions, either directly or under supervision.
  • Lead on induction and training of new staff at site
  • Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance.
  • Work effectively with individuals in other agencies to meet patients needs.
  • Effectively manage own time, workload and resources.

Communication/Information:

The post-holder should recognize the importance of effective communication within the practice and management team and will strive to:

  • Communicate effectively with other team members.
  • Communicate effectively with patients and carers.
  • Recognise peoples needs for alternative methods of communication and respond accordingly.

Contribution to the Implementation of Services:

The post-holder will:

  • Apply practice policies, standards and guidance
  • Discuss with other members of the team how the policies, standards and guidelines will affect own work
  • Participate in audit where appropriate

Any other delegated duties considered appropriate to the post.

This job description is not intended to be exhaustive, but to indicate the main areas of responsibility. It may be changed after consultation with the post holder. The employee shares with the employer the responsibility for review and modification of duties. Suggestions and discussions are welcome.

Policies and Procedures - the duties and responsibilities of the post will be undertaken in accordance with the policies, procedures and practices of the Practice, which may be amended from time to time. You are required to be flexible and the practice reserves the right to alter such fixed hours as may be considered necessary to ensure the surgery runs smoothly.

The business operates between the hours of 0700 2100 hours Monday to Friday (0800 1300 Saturday), with possible requirement for some future evening and weekend working as the business develops.

Person Specification

Other

Essential

  • Current driving licence and access to own vehicle
  • Highly motivated and proactive.

Knowledge

Desirable

  • Knowledge of public health issues in the local area
  • Awareness of frailty and chronic conditions
  • Knowledge of health promotion strategies
  • Understanding of role of patient advocate.

Skills

Essential

  • Excellent interpersonal, verbal and written communication skills
  • Time Management and ability to prioritise workload
  • Able to work independently and effectively within a team
  • Able to recognise and work within own limitations

Desirable

  • Ability to adapt to change within working situations

Experience

Essential

  • Previous experience working with the general public.
  • Working autonomously and as part of a team

Desirable

  • Previous experience working with frail, older people

Qualifications

Desirable

  • NVQ level 3 or working towards
  • English and Maths to GCSE Grade C or above or equivalent.

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.

Tier 2 Certificate of Sponsorship

Applications from job seekers who require current Tier 2/skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website.

From 6 April 2017, Tier 2/skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants.

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Portsdown Group Practice

Address

92 Kingston Crescent

Portsmouth

PO2 8AL


Employer's website

https://www.portsdowngrouppractice.co.uk/


For help with your application, contact:

Ian Cummings

ian.cummings@nhs.net

02392627765

Date posted

16 July 2021

Pay scheme

Other

Salary

£11.50 an hour

Contract

Permanent

Working pattern

Full-time

Reference number

A2111-21-3639

Job locations

92 Kingston Crescent

Portsmouth

PO2 8AL


Crookhorn Lane

Waterlooville

Hampshire

PO7 5XP


3 Heyward Road

Southsea

Hampshire

PO4 0DY


Cosham Park Avenue

Portsmouth

PO6 3BG


Supporting documents

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+44 300 330 1013

Opening times:

Monday to Friday: 8am to 6pm

Saturday: 9am to 3pm

Closed Bank Holidays including Easter Sunday, Christmas Day, Boxing Day and New Year's Day.