Care Co-ordinator - HIPC PCN

Job summary

The Care Co-ordinator plays a key role within the Primary Care Network (PCN) by delivering timely, personalized care and aiding multidisciplinary care planning.

This role expands on existing support for cancer, safeguarding, and complex needs by explicitly integrating Frailty Co-ordination aligned with Community Frailty Hub standards.

Main duties of the job

Working as part of a multidisciplinary team (MDT), the post holder will support the proactive identification, care planning, and navigation of older adults and vulnerable patients living with frailty.

The core objective is to promote independence, safety, and wellbeing in the community, preventing avoidable deterioration and hospital admissions through robust signposting, home/community liaison, and physical observation monitoring under clinical guidance.

About us

Holistic Person-Centred Care Primary Care Network (PCN) consists of four GP surgeries in North Stoke-on-Trent, serving a diverse population of approximately 37,000 patients. Our mission is to work collaboratively to develop high-quality, sustainable services that improve health outcomes enabling our community to live well for longer while building a resilient future for primary care.

Details

• Date posted: 27 August 2026
• Pay scheme: Other
• Salary: Depending on experience
• Contract: Permanent
• Working pattern: Full-time, Part-time, Flexible working
• Reference number: B0070-26-0030
• Job locations: Holistic Person-Centred Care (HIPC) PCN, Tunstall and Surrounding Area, Stoke on Trent, ST6 6BE, United Kingdom, Cobridge Community Health Centre, Church Terrace, Stoke-on-trent, ST6 2JN, United Kingdom, Tunstall Primary Care Centre, Beaumont Road, Stoke-on-trent, ST6 6BE, United Kingdom, Lucie Wedgwood Health Centre, Chapel Lane, STOKE-ON-TRENT, ST6 2AB, United Kingdom

Job responsibilities

Main Duties & Responsibilities

Frailty & Community Hub Co-ordination

Frailty Identification & Navigation:

Support the proactive identification and coding of moderately and severely frail patients. Serve as a central point of co-ordination between GP practices, the Community Frailty Hub, District Nurses, Community Therapy Teams, and Adult Social Care.

Personalised Care & Reablement Support: Assist in delivering person-centred care plans that encourage patient independence, goal engagement, and safe living within their own homes.

Physical Observations & Early Warning: Perform and accurately record basic physical observations (e.g., blood pressure, pulse oximetry, blood sugar) when indicated or instructed by a clinician. Monitor patients for subtle changes in condition and immediately escalate concerns to clinical staff.

Assessment & Visit Workflow: Facilitate first visit assessment documentation, maintain pre-visit summaries and ensure pre-visit data is accurately communicated across the MDT.

Signposting & Referral Pathways: Actively refer and signpost patients and carers to appropriate community services, voluntary agencies, and reablement programmes (e.g., home exercise plans set by therapy teams) to mitigate admission risks.

Cancer Care & Prevention

Co-ordinate contact with newly diagnosed cancer patients and monitor the 2 week wait referral process.

Proactively invite patients for screening (cervical, breast, bowel) and target non-responders to increase uptake.

Track necessary routine monitoring tests for cancer management and present learning/data at monthly governance meetings.

End of Life Care (EOLC) & Complex Needs

Assist in identifying and correctly coding palliative and complex patients.

Ensure regular annual and clinical reviews occur, assisting with correct DNAR record coding and reviews.

Liaise with social prescribing link workers, health/wellbeing coaches, and community providers to manage physical and psychological needs.

Learning Disabilities (LD) & Safeguarding

Support LD register patients with annual reviews, accessible communications, and uptake of preventative measures (flu/COVID jabs, screening).

Oversee safeguarding workflow, record management, document summarising, and coding across PCN practices, maintaining child/adult registers and liaising with MASH.

General Administrative & MDT Duties

Maintain accurate, timely electronic records (/EMIS Web) for all contact points, ensuring CQC documentation requirements are met.

Participate in vaccination call/recall campaigns and support practice reception/triage cover when required.

Contribute to safe service delivery through planned/unplanned cover and active involvement in team training and 1-to-1 performance reviews.