G DOC Ltd

Frailty Care Navigator Inner City PCN

The closing date is 01 March 2026

Job summary

We are searching for a Frailty Care Navigator to join our Inner City PCN team. You will be supporting the Frailty Practitioner to identify frail patients on the GP systems and to make sure they get the support they need.

This position would be suitable for the right candidate that is willing to learn and is interested in working with older people.

You will be required to work across various locations in Gloucester. This will include our Inner City PCN Surgeries Gloucester Health Access, Pavilion and St James Family Doctors, Severnside Medical Practice and Kingsholm Surgery .

Working Hours:18.5 hours per week.

Closing date:Sunday 1st March

Interview date:Thursday 12th March TBC

Applications may close early depending on response.

Main duties of the job

To work with the Frailty Practitioner to use the GP systems to identify people living with moderate or severe frailty to ensure they get the care and support they need.

To send out questionnaires to patients and ensure we get a response by following up on forms that arent returned.

To act as a central point of contact for people and their carers.

To provide administrative support for the Frailty Practitioner and the Frailty Project.

To work with social prescribers and community providers to ensure people are signposted to the right support.

The job is primarily working with practices in the PCN and you will be required to travel independently between practices and occasionally G DOCs offices in Gloucester, and to attend meetings etc., hosted by other agencies throughout Gloucestershire.

Reports to:the PCN Business Manager and the PCN Clinical Director.

Line Manager:PCN Business Manager

About us

G DOC LTD is a unique, GP-owned organisation all GP surgeries in Gloucestershire are our shareholders. We operate with a not-for-profit ethos, ensuring every decision and service is focused on improving patient outcomes and reinvesting in local Primary Care across the county.

We directly manage several GP surgeries in Gloucester and the Forest of Dean, providing patient-centred care to more than 45,000 patients. We value continuity of care and practice teams are at the heart of all we do. In addition to our surgeries, we deliver a range of countywide commissioned services designed to improve access, increase capacity, or provide specialist support. Our teams are committed to delivering sustainable, high-quality primary care while fostering innovation and collaboration across the local health system.

By joining us, youll be part of an organisation that puts people first supporting staff wellbeing, professional development, and a collaborative culture. Youll benefit from the stability, support, and career opportunities of a larger organisation, while still working in close-knit, community-focused teams.

Date posted

10 February 2026

Pay scheme

Other

Salary

Depending on experience £27,485 - £30,162 pro-rata dependent on experience

Contract

Fixed term

Duration

2 years

Working pattern

Flexible working

Reference number

A0782-26-0012

Job locations

Quayside House

Quay Street

Gloucester

GL1 2TZ

Job description

Job responsibilities

Duties

Assist practices to identify and work with frail/elderly people and their carers, to provide coordination and navigation of care and support across health and care services.

Case Identification:

Support the Frailty Practitioner as required to undertake digital risk stratification

Transpose data onto the Personalised Proactive Whiteboard (PPW), ready to enable care coordination

Holistic Assessment:

Support the Frailty Practitioner to triage potential patients to determine who receives a Comprehensive Geriatric Assessment (CGA)

Support the Frailty Practitioner to determine what action to take with those patients who do not receive a CGA, including ensuring actions are undertaken

Contribute to the completion of CGAs as determined by the Frailty Practitioner, inputting the information gleaned into a digital template

Personalised Care and Support Planning:

As determined by the Frailty Practitioner:

o Ensure each patient who has a CGA has a Personalised Care and Support Plan (PCSP) that has been discussed and finalised with the patient and any carer/family; this will help to manage their needs and achieve better health and wellbeing outcomes

o Ensure a ReSPECT plan is completed for each patient who has a CGA

General

Identify carers and help them access services to support them, ensuring they are coded as a carer on the GP clinical system if they are a patient at the Practice

Provide a single point of contact to answer queries, make and manage appointments, and ensure that people have good quality written or verbal information to help them make choices about their care.

Assist people to access self-management education courses, peer support, health coaching and other interventions to enable them to better manage their health and wellbeing.

Work closely with GPs and practice teams to support them to manage patients to develop individual personalised care and support plans, ensuring appropriate support is made available to patients and carers, helping them to understand and manage their condition and ensure changing needs are addressed.

Review patients needs and help them access the services and support they require to understand and manage their own health and wellbeing

Liaise and work with the ICB, practices, voluntary and other organisations to implement patient services

Assist the Business Manager in collating information for claims (e.g. ARRS, Care Homes, etc) and responding to queries

Monitor the PCNs generic mailboxes and respond appropriately to emails

Coordinate, organise and attend various MDT meetings (e.g. Care Homes, Dementia, Respiratory and Pain Management).

Assist the Lead education GP to organise training including PLT sessions

Support the Business Manager to deliver key projects, including quality improvement projects. This includes the provision of information and analysis using information, data, knowledge and technology systems to inform and support PCN agreed initiatives and meet the needs of the local population.

Support the PCN Leadership team in the delivery of the DES specifications and support Quality and Outcome Frameworks.

Assess data, monitor the PCN dashboard and liaise with the Digital and Transformation Leads, Practices, GPs and Nursing teams, with a view to achieving network targets and obtaining maximum investment and impact funding

Attend meetings on behalf of the PCN

Take minutes of meetings as required.

Raise awareness of health promotion in practices, implementing, co-ordinating and supporting a variety of projects.

Assist the Clinical Director and Business Manager to coordinate the Covid Vaccination programmes across practices

Support the PCN practices, contributing to the delivery of QOF and enhanced services.

Contributing to the management and development of the Primary Care Network, including the performance of work undertaken by the Practice as part of the PCN

Helping to ensure that the PCN remains safe and effective, including by the use of clinical audit and learning from significant events and complaints.

Working conditions

Frequent, prolonged VDU use

Time-pressured environment

High levels of accuracy and attention to detail essential at all times

Exposure to distressing situations and written material

Job Description for all G DOC workers

The job description for all G DOC workers also forms part of your job description.