Job summary
LOCATION:York Road PCN - You will be based at one of the 5 surgeries in the PCN but
will be expected to travel between the practices in the PCN when required.
An exciting opportunity has arisen for a Care Coordinator to
support York Road Primary Care Network (PCN), with the primary focus on
coordinating care within the PCNs two registered Care Homes. The post holder
will work closely with GPs, nurses, pharmacists, care-home staff and the wider
multidisciplinary team to deliver high-quality, person-centred care to
residents, many of whom are living with frailty, dementia or long-term
conditions.
A significant part of the role includes supporting weekly GP
ward rounds, completing or assisting with dementia reviews, and coordinating
and minuting weekly MDT meetings for each care home, ensuring all residents
receive timely, proactive and well-organised care.
The post holder will act as a consistent point of contact
for residents, patients, families and carers, care home staff and ensuring
continuity, holistic support and improved outcomes.
Main duties of the job
In addition to care-home responsibilities, the Care
Coordinator may also be expected to support the wider PCN team by working with
vulnerable patients in the community. This includes proactively coordinating
personalised care and support planning for people who are frail, elderly or
living with long-term conditions. The role involves meeting with patients,
families and carers whether in the practice, at home, in community settings
or in care homes to review needs, help them access services, and support them
to understand and manage their own health and wellbeing. Referrals to other
health and social care professionals will be made where appropriate.
About us
Depending on experience, they may also carry out delegated clinical tasks such as phlebotomy, blood pressure monitoring and general observations.
Job description
Job responsibilities
Duties & Responsibilities (Including Wider PCN & Community Support)
Primary Care-Home Responsibilities
- Lead and organise weekly GP ward rounds in each care home, ensuring residents due for review are prepared and all follow-up actions are recorded and communicated.
- Support and/or complete dementia reviews, gathering information, engaging with families and care-home staff, and updating clinical records.
- Coordinate, prepare for and minute weekly MDT meetings for each care home, ensuring high-quality communication across the multidisciplinary team.
- Develop and maintain Personalised Care and Support Plans (PCSPs) for care-home residents, ensuring a holistic, person-centred approach.
- Proactively identify residents at risk of deterioration, escalating appropriately to prevent unplanned hospital admissions.
Wider PCN & Community Care Responsibilities
- Support the PCN team in coordinating personalised care for vulnerable patients living in the community, including frail/elderly individuals and those with multiple long-term conditions.
- Meet with people, families and carers in practices, in their homes, in community locations or in care homes to review needs, co-ordinate care and help them access appropriate services.
- Assist patients and families in understanding their health conditions, navigating support options and managing their own wellbeing.
- Refer patients to primary care, social care, community and voluntary-sector services where appropriate.
- Work jointly with PCN staff including social prescribers, pharmacists, mental health teams and community services to ensure high-quality joined-up care.
Clinical & Monitoring Tasks (if trained/competent)
- Undertake delegated tasks such as phlebotomy, blood pressure checks, observations and health checks within care homes and the wider community.
- Support clinicians by preparing information for reviews and completing agreed follow-up actions.
Communication & Coordination
- Act as a central point of contact for residents, patients, families, care-home staff and PCN colleagues.
- Communicate sensitively using language appropriate to the patient or carers level of understanding.
- Promote shared decision-making and help individuals prepare for clinical conversations.
Administration, Record Keeping & Data
- Prepare documentation for ward-rounds, dementia reviews and MDT meetings.
- Update care plans and patient records accurately, using appropriate coding.
- Analyse data to identify priority residents or patient groups requiring targeted intervention.
- Maintain strict confidentiality in line with GDPR and organisational policies.
Safeguarding
- Identify safeguarding concerns and escalate in line with local policy.
- Support safeguarding processes and investigations when required.
Partnership Working
- Build strong working relationships with care-home teams, community health professionals, social care and voluntary-sector organisations.
- Improve access to support services for both care-home residents and vulnerable community patients.
- Contribute to PCN initiatives and public health campaigns, including vaccinations and screening.
Job description
Job responsibilities
Duties & Responsibilities (Including Wider PCN & Community Support)
Primary Care-Home Responsibilities
- Lead and organise weekly GP ward rounds in each care home, ensuring residents due for review are prepared and all follow-up actions are recorded and communicated.
- Support and/or complete dementia reviews, gathering information, engaging with families and care-home staff, and updating clinical records.
- Coordinate, prepare for and minute weekly MDT meetings for each care home, ensuring high-quality communication across the multidisciplinary team.
- Develop and maintain Personalised Care and Support Plans (PCSPs) for care-home residents, ensuring a holistic, person-centred approach.
- Proactively identify residents at risk of deterioration, escalating appropriately to prevent unplanned hospital admissions.
Wider PCN & Community Care Responsibilities
- Support the PCN team in coordinating personalised care for vulnerable patients living in the community, including frail/elderly individuals and those with multiple long-term conditions.
- Meet with people, families and carers in practices, in their homes, in community locations or in care homes to review needs, co-ordinate care and help them access appropriate services.
- Assist patients and families in understanding their health conditions, navigating support options and managing their own wellbeing.
- Refer patients to primary care, social care, community and voluntary-sector services where appropriate.
- Work jointly with PCN staff including social prescribers, pharmacists, mental health teams and community services to ensure high-quality joined-up care.
Clinical & Monitoring Tasks (if trained/competent)
- Undertake delegated tasks such as phlebotomy, blood pressure checks, observations and health checks within care homes and the wider community.
- Support clinicians by preparing information for reviews and completing agreed follow-up actions.
Communication & Coordination
- Act as a central point of contact for residents, patients, families, care-home staff and PCN colleagues.
- Communicate sensitively using language appropriate to the patient or carers level of understanding.
- Promote shared decision-making and help individuals prepare for clinical conversations.
Administration, Record Keeping & Data
- Prepare documentation for ward-rounds, dementia reviews and MDT meetings.
- Update care plans and patient records accurately, using appropriate coding.
- Analyse data to identify priority residents or patient groups requiring targeted intervention.
- Maintain strict confidentiality in line with GDPR and organisational policies.
Safeguarding
- Identify safeguarding concerns and escalate in line with local policy.
- Support safeguarding processes and investigations when required.
Partnership Working
- Build strong working relationships with care-home teams, community health professionals, social care and voluntary-sector organisations.
- Improve access to support services for both care-home residents and vulnerable community patients.
- Contribute to PCN initiatives and public health campaigns, including vaccinations and screening.
Person Specification
Other requirements
Essential
- Right to work in the UK
- Car owner and has valid UK driving licence to travel across the PCN area and attend city wide meetings
- Professional attitude and appearance
- Reliability and ability to adapt to a changing environment including remote working when required
- Flexibility to develop the role as care coordinator to meet the needs of the PCN Service Specifications
Experience
Essential
- 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)
- Signposting to patient services
- Administrative duties including preparing for meetings and writing minutes
- Working in partnership with other organisations to improve outcomes
- Working in a changing environments with high demand
- Completing audits and writing reports
- Microsoft Word/ Excel/ PowerPoint/ Teams applications
- Multidisciplinary team working including health, social and 3rd sector organisations
Desirable
- Experience in phlebotomy, general observations, wound care, health checks
- Understands about primary care and community services
- Using clinical systems and other digital software
- Working with patients/service users in a face-to-face role in the delivery of personal services
Skills and knowledge
Essential
- General Data Protection Regulations and Confidentiality
- Effective verbal, written and digital communication skills
- Health inequalities and wider determinants of health
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Understanding of medical terminology around frailty, population health management and long term conditions
- Ability to use own initiative and prioritises own workload without direct supervision
- Collecting and analysing patient data sets / reports to identify patient cohorts to prioritise
- Willing to develop and undertake training as required
Desirable
- Understanding of the current issues facing the NHS including Primary Care Networks
Qualifications
Essential
- Education and Qualification
- GCSEs/Diploma/HNC level (or relevant experience)
Desirable
- NVQ Level 3 in a health or social care related discipline (or relevant experience)
- Care Certificate
- ECDL or other equivalent IT qualification
Person Specification
Other requirements
Essential
- Right to work in the UK
- Car owner and has valid UK driving licence to travel across the PCN area and attend city wide meetings
- Professional attitude and appearance
- Reliability and ability to adapt to a changing environment including remote working when required
- Flexibility to develop the role as care coordinator to meet the needs of the PCN Service Specifications
Experience
Essential
- 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)
- Signposting to patient services
- Administrative duties including preparing for meetings and writing minutes
- Working in partnership with other organisations to improve outcomes
- Working in a changing environments with high demand
- Completing audits and writing reports
- Microsoft Word/ Excel/ PowerPoint/ Teams applications
- Multidisciplinary team working including health, social and 3rd sector organisations
Desirable
- Experience in phlebotomy, general observations, wound care, health checks
- Understands about primary care and community services
- Using clinical systems and other digital software
- Working with patients/service users in a face-to-face role in the delivery of personal services
Skills and knowledge
Essential
- General Data Protection Regulations and Confidentiality
- Effective verbal, written and digital communication skills
- Health inequalities and wider determinants of health
- Understanding of the needs of older people / adults with disabilities / long term conditions particularly in relation to promoting their independence
- Understanding of medical terminology around frailty, population health management and long term conditions
- Ability to use own initiative and prioritises own workload without direct supervision
- Collecting and analysing patient data sets / reports to identify patient cohorts to prioritise
- Willing to develop and undertake training as required
Desirable
- Understanding of the current issues facing the NHS including Primary Care Networks
Qualifications
Essential
- Education and Qualification
- GCSEs/Diploma/HNC level (or relevant experience)
Desirable
- NVQ Level 3 in a health or social care related discipline (or relevant experience)
- Care Certificate
- ECDL or other equivalent IT qualification
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.
