Frailty Care Coordinator

Eden Medical Group


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Job summary

An exciting opportunity to join a dynamic and innovative nurse led team working with frail, older adults.

CNICC is looking for a Frailty Care Coordinator to work predominately with Eden Medical Group 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 role requires integrated working within the ICC and Third sector. The post holder will need to be able to work independently in a range of different environments including the GP practices and within patients own homes. Use of own transport is essential.

About us

Carlisle Network Integrated Care Community (CNICC) covers 5 General Practices which include; Eden Medical Group, Spencer Street Surgery, Fusehill Medical Practice, Warwick Square Group Practice, Warwick Road Surgery. Our CNICC Frailty team consists of 2 Advanced Nurse Practitioners, a Specialist Frailty Nurse and 4 Frailty Coordinators.

Job description

Job responsibilities

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 and a wider multi-disciplinary ICC 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 either from statutory or third sector services.

The main responsibilities include:-

  • 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 completed relevant referrals into wider ICC and third sector.
  • To attend the weekly ICC MDT meetings.
  • There will be an element of clinical assessment required such as venepuncture and observations (training can 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 as North Cumbria moves towards an Integrated Health and Care System. Its an exciting venture for both the ICC and the successful applicants and its success will be created by everyone who will work within the newly formed team.

The post holder is expected to work within the ICC and Frailty operational guidelines, with particular reference to standardised approaches to case management, care planning and MDT working.

Case finding

  • Use the eFi frailty reports to proactively target patient groups with frailty. Using EMIS searches where necessary to target individuals.

  • Referrals as triaged by the team.


  • 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.


  • 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 including telecare to increase the persons independence.

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

  • Conduct low level clinical screening such as dementia screening, blood pressure checks and venepuncture as directed by the lead health professional. (Where relevant training has been received)

  • Carry out low level 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.


  • Keep timely, accurate and complete electronic patient records and activity data, all of which will be maintained and stored in accordance with professional and organisational standards.

    • To have responsibility for appropriate documentation related to patients in their care to be disseminated to all relevant professionals in a timely manner and in accordance with operating standards.


    • To participate in discussions about the direction of service developments and improvements.

    • To participate in service audits and changes.

    • To participate in discussion for the implementation of policies and procedures

    • To contribute to the health and safety of others and the environment

    • To participate in appraisal processes and participate in CPD/ personal development plan.

    • To pro-actively participate in mandatory training and in-service training.

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


  • To provide, and receive, information with empathy and understanding, and to adapt communication when barriers to understanding arise (seeking senior guidance when necessary).

  • Take an active role in the ICC MDT process providing input around the persons history, family circumstances etc.

  • Provide a point of contact for the person (and their family/carers) and the range of professionals involved in the care package

  • To develop and maintain effective working relationships with other members of the primary care / ICC team.

Person Specification



  • English and Maths to GCSE Grade C or above or equivalent.


  • NVQ level 3 or working towards



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


  • Previous experience working with frail, older people.

Skills, Knowledge and Aptitudes


  • Excellent interpersonal, verbal and written communication skills
  • Be able to provide high quality care.
  • Ability to recognise risk and refer appropriately and safely
  • Time Management and ability to prioritise workload
  • Able to work independently and effectively within a team
  • Flexible and motivated
  • Excellent computer skills
  • Able to recognise and work within own limitations
  • Understanding of equal opportunity and diversity issues


  • Ability to adapt to change within working situations
  • Reflective working
  • Awareness of frailty and chronic conditions
  • Knowledge of the ICC and 3rd sector working.
  • Understanding of role of patient advocate.

Other Requirments


  • Current driving licence and access to own vehicle
  • Highly motivated and proactive.
  • Flexibility of working hours / ability to work at desired times which includes working late on an evening to cover extended access, and to include working weekends and bank holidays to cover 7 day opening / operation of the practice

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

Eden Medical Group


Port Road




Employer's website (Opens in a new tab)

For questions about the job, contact:

Louise Fitzpatrick


Date posted

10 June 2021

Pay scheme



£19,500 a year



Working pattern


Reference number


Job locations

Port Road




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