Care Co-ordinator - HIPC PCN


Company:	NHS Jobs
Salary:	Negotiable
Hours:	Full-time
Location:	Stoke on Trent, ST6 6BE
Job type:	Permanent
Posting date:	27 Aug 2026
Closing date:	11 Sept 2026

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Summary

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.

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