About this role
Job summary
An exciting opportunity has become available for an enthusiastic and forward-thinking Care Co-Ordinator to join the First Coastal PCN in a new role that will be developed as it progresses. The successful candidate will be joining our Primary Care Community team, working with GPs, and community staff, Care Co-Ordinators, Occupational Therapist, Physiotherapists and Social Prescribing Link Workers.
Main duties of the job
First Coastal PCN has a number of residential, nursing, or joint care homes with a significant number of residents. These range in size from smaller units with less than 10 beds to homes with over 30 beds and include some supporting those living with dementia and /or complex physical health needs. The post holder will work as part of our local multi-disciplinary team to ensure that all those living in care homes are able to live and age well and, when the time comes, to meet their end of life care wishes. You will build relationships with care home leads and their staff and act as a point of contact for residents, families and professionals who visit care homes, such as MDT members and in-reach specialists.
The Care Coordinators role will support the PCN leadership team and GPs in coordinating all key activity including improving access to services, providing advice and information, and ensuring health and care planning is timely, efficient, and patient-centred. The role will include supporting digital initiatives and includes responsibilities for the co-ordination of the patients journey through primary care.
The successful candidate will have great negotiation and communication skills and will have an understanding of primary care services & community health services.
The post holder will also be required to travel from practice to practice and to other venues during fulfilment of their duties.
About us
First Coastal PCN covers a population of approximately 84,000 patients this is made up of seven practices, Marsico Medical Practice (Mablethorpe), Hawthorn Medical Practice (Skegness), Beacon Medical Practice (Skegness), Merton Lodge (Alford), Spilsby Surgery, Stickney Surgery and Old Leake Medical Practice. These practices work together across to deliver care to the local population.
Job description Job responsibilities
KEY RESPONSIBILITIES-
Care planning
Ensure every resident has a co-produced comprehensive care plan created within seven days of arriving as a resident.
Use provided templates and tools to undertake core assessment elements for inclusion in the care plan.
Holistically bring together all of a persons identified care and support needs, and explore options to meet these within a single personalised care and support plan (PCSP), in line with PCSP best practice, based on what matters to the person.
Identify those elements of the care plan which require specialist input (pharmacist, dietician, nurse, medic etc.) and ensure that these are completed in timely manner.
Identify where technology can be utilised to support continued independence or to aid remote monitoring of health and wellbeing.
Communicate effectively and sensitively and use language appropriate to a patient and carer/relatives condition and level of understanding.
Effectively use all methods of communication and be aware of and manage barriers to care.
Care home rounds and MDTs
Supporting the weekly PCN-led MDT meetings (including the weekly virtual Care Home (s) MDT.
Support the PCN to deliver the EHCH contractual obligations (all new residents are reviewed in the MDT within four weeks of arrival, all residents returning home from an acute admission are reviewed within seven days of return).
Ensure actions from the MDT are recorded and care plans are correctly updated.
Liaise with all clinical and non-clinical members in the MDT to ensure effective MDT function.
Support the progress against actions and ensure follow-up where necessary.
Stakeholder Relationships:
Work with the care home leads to identify skills, education and training needs and assist in the co-ordination and delivery of an agreed training programme.
Work as part of the wider holistic team to provide cover and support as necessary.
To link with partners to maximise the opportunities available to care home residents including access to on-line peer support and group programmes where the resident is unable to physically attend.
Build and maintain relationships with care home staff and leads, together with members of the local support team including named GPs, pharmacist, community nursing team, therapists, dementia nurses etc.
As this is a new and evolving role, this is not an exhaustive list of duties and responsibilities, and the post holder may be required to undertake other duties that fall within the grade of the job, in discussion with their line manager.
The content of this job description will be reviewed regularly in the light of changing service requirements and any such changes will be discussed with the post holder.
Key working relationships
Local care homes
PCN EHCH Multi-Disciplinary Team
GP Practices within the PCN
Practice Leaders (Partners and Practice Managers)
PCN Clinical Pharmacists
Community Health Teams both physical and mental health
CONFIDENTIALITY
In the course of seeking treatment, patients entrust us with, or allow us to gather sensitive information in relation to their health and other matters. They do so in confidence and have the right to expect that staff will respect their privacy and act appropriately.
In the performance of the duties outlined in this job description, the post-holder may have access to confidential information relating to patients and their carers, practice staff and other healthcare workers. They may also have access to information relating to the PCN as a business organisation. All such information from any source is to be regarded as strictly confidential.
Information relating to patients, carers, colleagues, other healthcare workers or the business of the PCN may only be divulged to authorised persons in accordance with the employing practice policies and procedures relating to confidentiality and the protection of personal and sensitive data.
EQUALITY AND DIVERSITY
The post-holder will support the equality, diversity and rights of patients, careers and colleagues, to include:
Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with PCN and the member practices procedures and policies, and current legislation. Respecting the privacy, dignity, needs and beliefs of patients, carers and colleagues. Behaving in a manner which is welcoming to and of the individual, is non-judgemental and respects their circumstances, feelings, priorities and rights.
PERSONAL AND PROFESSIONAL DEVELOPMENT
The post-holder will participate in any training programme implemented by the PCN as part of this employment, with such training to include:
Participation in an annual individual performance review, including taking responsibility for maintaining a record of their own personal and/or professional development. Participation in the PCN mandatory training programme. Taking responsibility for own development, learning and performance, demonstrating skills and activities to others who are undertaking similar work.
QUALITY
The post-holder will strive to maintain quality within the PCN and will:
Alert other team members to issues of quality and risk. Assess own performance and take accountability for their own actions, either directly or under supervision. Contribute to the effectiveness of the team by reflecting on own and team activities and making suggestions on ways to improve and enhance the teams performance. Work effectively with individuals in other agencies to meet patients needs. Effectively manage own time, workload and resources.
COMMUNICATION
The post-holder should recognise the importance of effective communication within the team and will strive to:
Communicate effectively with patients and carers. Recognise peoples needs for alternative methods of communication and respond accordingly. Communicate effectively with other team members.
Person Specification
Qualifications Essential
Good standard of general education. Grade C GCSE English and Maths or equivalent qualifications. Excellent computer skills including email, word and excel. Full UK driving licence and use of car insured for work purposes.
Desirable
Accredited Care Co-ordinator Training.
Experience Essential
At least 2 years' experience of working in health, social care or 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. Experience of working with elderly or vulnerable people, complying with best practice and relevant legislation. Evidence of good verbal and written communication skills. Ability to collect and record information and data, for record-keeping, monitoring and evaluation. Strong organisational skills including planning, prioritising, time management, and record keeping. Ability to recognise and work within limits of competence and seek advice when needed. Ability to work effectively under pressure, delivering against agreed objectives. Willingness to take a pro-active and flexible approach to the role as it develops over time.
Desirable
Experience or training in person-centred care planning. Experience of using the SystmOne computer system. Up-to-date knowledge of the services and organisations available to support patients and carers.
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.
Employer details Employer name First Coastal PCN
Address Marisco Medical Practice
Stanley Avenue
MABLETHORPE
Lincolnshire
LN12 1DP
United Kingdom
Employer's website https://www.mariscomedicalpractice.com/ (Opens in a new tab)