Job summary
As part of our Primary
Care Network (PCN) services, we are looking for a Care Coordinator to join our Care
Homes team, supporting and improving the health and wellbeing of our care home
residents.
The successful
candidate will play an important role, working with people, including the
frail/elderly, those with learning difficulties and those with long-term
conditions, helping to provide proactive coordination and navigation of care
and support across health and care services.
The successful
candidate will be based at Grayshott Surgery, part of West of Waverley PCN.
They will be caring, dedicated, reliable and person-focused and enjoy working
with a wide range of people including GPs, Nurses, and Care Home staff, as
well as the residents and their families. They will have good written and
verbal communication skills and strong organisational and time management
skills. They will be highly motivated and proactive with a flexible attitude,
keen to work and learn as part of a team and committed to providing patients,
their families and carers with high quality support.
Please note that
this is not a clinical role.
Main duties of the job
As the care homes Care Coordinator, you will work with
a team comprising of the PCN care homes Nurses, care homes Pharmacist, Pharmacy
Technician, and practice staff including GPs to provide care for patients in
our care homes. We seek a motivated individual with the ability to work
independently, but also an excellent communicator to deliver a high standard of
care across the care homes in the network. The post holder will be part of the
significant developments in primary care, improving the care of a diverse
population of care homes patients with varying requirements.
About us
Procare Health
Procare Health is the GP Federation for Guildford & Waverley. Our aim is to support General Practice to work at scale in order to achieve efficiencies of scale whilst respecting the autonomy of individual General Practices. This includes working with other local healthcare providers to develop and provide health services to the benefit of our patients.
We help member practices to work together to jointly address issues which are difficult to resolve individually and offer extra expertise and skills. By working at scale, we can ensure the projects we take forward on behalf of our members will allow patients in our area to have more consistency in, as well as choices about, their care.
Procare provide community and district nurses in our area supporting better integration of Primary and Community services. Our ICP area is served by Royal Surrey County Hospital and is located in the Surrey Heartlands ICS area which is one of the original 10 ICS areas in the UK and one of two that has combined Health and Social Care organisations.
West of Waverley PCN
West of Waverley PCN covers four like-minded practices in the beautiful countryside of South
West Surrey covering a population of just under 50,000 patients. Our population
has a higher socio-economic and age demographic than average with a care home
population of approximately 900 beds.
Job description
Job responsibilities
In your role you will work as a key part of the PCN
multidisciplinary team. You will provide extra time and expertise to support
care home patients in preparing for or in following up clinical conversations
they have with primary care professionals. Helping people to manage their
needs through answering queries, making and managing appointments, and ensuring
that people have good quality written or verbal information to help them make
choices about their care. Using tools to understand peoples level of knowledge
and confidence skills in managing their own health.
Acting as a point of contact between GPs, PCN care
homes Nurses, practice staff, patients, carers and other agencies.
You will:
- Liaise with GPs and the PCN care homes
Nurses to identify care home patients who are elderly, frail or who have long
term health needs and coordinate support appropriately.
- Support the care homes Nurses to manage
care home patients on the PCNs case load, responding to on-demand needs of the
care homes and following any unplanned hospital admissions where appropriate.
- Organise and participate in MDT meetings to
discuss patients actively being managed by the Care Homes Team needing
discussion.
- Maintain a weekly register of hospital
admissions to be shared with practices.
- Maintain a weekly register of hospital
discharges to be shared with practices.
- Maintain a weekly register of care homes
deaths.
- Raise awareness of health promotion,
screening and NHS Health Checks and Learning Disability Health Checks in
practices.
- Document and monitor aspects of patient
co-ordination and service delivery, supporting data collection and audit using
the practices clinical system and coding contacts correctly into patient
records.
- Demonstrate the ability to recognise and
respond appropriately when faced with a sudden deterioration or emergency
situation, alerting the team or enabling a rapid response.
- Support national screening and immunisation
programmes and encourage uptake.
- Monitor referrals to
ensure tasks are completed and care delivered by keeping in regular telephone
contact with the care homes you support.
Professional
development
Work with the team lead for
advice and support.
Undertake continual personal
and professional development, taking an active part in reviewing and developing
the role and responsibilities, and provide evidence of learning activity as
required.
Adhere to organisational
policies and procedures, including confidentiality, safeguarding, lone working,
information governance, equality, diversity and inclusion training and health
and safety.
For further information, please see full job description.
Job description
Job responsibilities
In your role you will work as a key part of the PCN
multidisciplinary team. You will provide extra time and expertise to support
care home patients in preparing for or in following up clinical conversations
they have with primary care professionals. Helping people to manage their
needs through answering queries, making and managing appointments, and ensuring
that people have good quality written or verbal information to help them make
choices about their care. Using tools to understand peoples level of knowledge
and confidence skills in managing their own health.
Acting as a point of contact between GPs, PCN care
homes Nurses, practice staff, patients, carers and other agencies.
You will:
- Liaise with GPs and the PCN care homes
Nurses to identify care home patients who are elderly, frail or who have long
term health needs and coordinate support appropriately.
- Support the care homes Nurses to manage
care home patients on the PCNs case load, responding to on-demand needs of the
care homes and following any unplanned hospital admissions where appropriate.
- Organise and participate in MDT meetings to
discuss patients actively being managed by the Care Homes Team needing
discussion.
- Maintain a weekly register of hospital
admissions to be shared with practices.
- Maintain a weekly register of hospital
discharges to be shared with practices.
- Maintain a weekly register of care homes
deaths.
- Raise awareness of health promotion,
screening and NHS Health Checks and Learning Disability Health Checks in
practices.
- Document and monitor aspects of patient
co-ordination and service delivery, supporting data collection and audit using
the practices clinical system and coding contacts correctly into patient
records.
- Demonstrate the ability to recognise and
respond appropriately when faced with a sudden deterioration or emergency
situation, alerting the team or enabling a rapid response.
- Support national screening and immunisation
programmes and encourage uptake.
- Monitor referrals to
ensure tasks are completed and care delivered by keeping in regular telephone
contact with the care homes you support.
Professional
development
Work with the team lead for
advice and support.
Undertake continual personal
and professional development, taking an active part in reviewing and developing
the role and responsibilities, and provide evidence of learning activity as
required.
Adhere to organisational
policies and procedures, including confidentiality, safeguarding, lone working,
information governance, equality, diversity and inclusion training and health
and safety.
For further information, please see full job description.
Person Specification
Knowledge and Understanding
Essential
- Knowledge of how the NHS works, including primary care and PCNs
- Understanding of, and commitment to, equality, diversity and inclusion
Desirable
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
Other
Essential
- Meets DBS reference standards
Desirable
- Holds a full, current UK driving licence
Skills and Competencies
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- High level of written and verbal communication skills
- Computer literate with a sound knowledge of Microsoft Office
Attributes
Essential
- Demonstrate personal accountability, emotional resilience and work well under pressure
- Organised, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Personable and approachable, caring and sympathetic
- Self-confident and able to work with minimum direction
- Adaptable and innovative
- Enthusiasm, energy and drive
- Trustworthy, discrete, honest and reliable
- Determined and willing to persevere
Qualifications and Experience
Essential
- Evidence of a sound general education (GCSEs or equivalent) to include English and Maths grade C or above
- Experience of supporting people, their families and carers in a related role
- Experience of data collection and using tools to measure the impact of services
Desirable
- NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi-professional team environments
Person Specification
Knowledge and Understanding
Essential
- Knowledge of how the NHS works, including primary care and PCNs
- Understanding of, and commitment to, equality, diversity and inclusion
Desirable
- Knowledge of, and ability to work to policies and procedures, including confidentiality, safeguarding, lone working, information governance, and health and safety
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social
Other
Essential
- Meets DBS reference standards
Desirable
- Holds a full, current UK driving licence
Skills and Competencies
Essential
- Ability to actively listen, empathise with people and provide personalised support in a non-judgemental way
- Ability to provide a culturally sensitive service supporting people from all backgrounds and communities, respecting lifestyles and diversity
- Ability to support people in a way that inspires trust and confidence, motivating others to reach their potential
- Ability to communicate effectively, both verbally and in writing, with people, their families, carers, community groups, partner agencies and stakeholders
- Ability to identify risk and assess / manage risk when working with individuals
- Ability to maintain effective working relationships and to promote collaborative practice with all colleagues
- High level of written and verbal communication skills
- Computer literate with a sound knowledge of Microsoft Office
Attributes
Essential
- Demonstrate personal accountability, emotional resilience and work well under pressure
- Organised, plan and prioritise on own initiative, including when under pressure and meeting deadlines
- Personable and approachable, caring and sympathetic
- Self-confident and able to work with minimum direction
- Adaptable and innovative
- Enthusiasm, energy and drive
- Trustworthy, discrete, honest and reliable
- Determined and willing to persevere
Qualifications and Experience
Essential
- Evidence of a sound general education (GCSEs or equivalent) to include English and Maths grade C or above
- Experience of supporting people, their families and carers in a related role
- Experience of data collection and using tools to measure the impact of services
Desirable
- NVQ Level 3 in adult care - advanced level or equivalent qualifications or working towards
- Experience of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement
- Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation
- Experience of working in health, social care and other support roles in direct contact with people, families or carers (in a paid or voluntary capacity)
- Experience of working within multi-professional team environments
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.
