About this role
Job summary
Job Summary
Bury GP Federation is seeking a dedicated Vulnerable Care Home Care Coordinator to assist us with patients across the Horizon PCN network residing in a care home. The role is full-time (37.5 hrs) and permanent, working Monday to Friday between the core hours of 8am - 6pm.
You will be responsible for taking calls and using agreed lines of communication to liaise with care homes, GP practices, patients and Care Home team members determining patient needs, developing care plans, coordinating patient-care services and working with the care team to evaluate interventions.
Horizon PCN comprises of the following practices: -
Tower (3 sites) - Tottington, Spring Lane, Greenmount, Minden
Woodbank
Peel
Garden City
Mile Lane
Ribblesdale
Redbank
The successful applicant will display a compassionate nature, be knowledgeable about health care practices, and provide exceptional patient service.
Main duties of the job
Duties and Responsibilities
Care Coordination in Care Homes
Support GP practices with scheduling and coordinating regular care home ward roundsLiaise with care home staff to identify residents needing reviews, urgent visits, or MDT inputAct as a key point of contact between practices and care homes, maintaining clear communicationSupport for Small Non-Elderly Care Homes
Build relationships with smaller homes supporting adults with learning disabilities, mental health needs, or complex careEnsure these homes are included in PCN support plans and pathwaysPromote equitable access to primary care services and health reviewsMultidisciplinary Team (MDT) Support
Work with the occupational therapist to identify residents who may benefit from assessments or interventionsCoordinate actions from MDT meetings, ensuring timely follow-upSupport case-finding for anticipatory care and within the EHCH frameworkHolistic Care Planning
Collaborate with patients (where appropriate), their families, and carers to enable personalised care and shared decision-makingFacilitate advanced care planning and documentation alongside clinical colleaguesData, Documentation, and Reporting
Maintain accurate EMIS (or relevant system) records of interventions and outcomesSupport data collection for PCN reporting and service evaluationIdentify trends, gaps, and improvement opportunities across supported homes
About us
About Us
Bury GP Federation is a federation of 23 GP practices within Bury, Greater Manchester, providing a platform for collaboration, knowledge-sharing and co-ordination. Through working at scale, we redirect resources into delivering at-scale support, relieving capacity pressures and enabling local general practice to maintain high standards of care for patients and to keep pace with best practice. We are proud of the services that we run.
Our four core objectives are as follows:
A reliable support organisation providing a range of services for our practices, achieving greater organisational efficiency through collaboration and reducing duplication, maximising the economic advantages of delivering primary care at scale
A respected service provider able to attract investment into primary care to help sustain local general practice, delivering a more expansive range of at-scale services available closer to patients homes
A GP led, patient-centred partner organisation working collaboratively with our practices and our partners across health and social care to facilitate the enhanced delivery of responsive, high quality and innovative services across Bury and GM
A trusted voice for primary care providing at-scale leadership and in partnership with the LMC and PCNs, able to advocate for and support our shareholder practices
Job description Job responsibilities
JOB DESCRIPTION
POST TITLE: Vulnerable Care Home Care Coordinator
SALARY: £28,822.08
HOURS PER WEEK: 37.5 hours
CONTRACT TYPE: 12 month fixed-term
RESPONSIBLE TO: PCN Development Manager
ACCOUNTABLE TO: PCN Clinical Director
Job Summary
Horizon PCN is seeking a dedicated Care Coordinator to assist us with patients across the Network residing in a care home. You will be responsible for taking calls and using agreed lines of communication to liaise with care homes, GP practices, patients and Care Home team members determining patient needs, developing care plans, coordinating patient-care services and working with the care team to evaluate interventions.
The successful applicant will display a compassionate nature, be knowledgeable about health care practices, and provide exceptional patient service.
Duties and Responsibilities
Care Coordination in Care Homes
Support GP practices with scheduling and coordinating regular care home ward rounds
Liaise with care home staff to identify residents needing reviews, urgent visits, or MDT input
Act as a key point of contact between practices and care homes, maintaining clear communication
Support for Small Non-Elderly Care Homes
Build relationships with smaller homes supporting adults with learning disabilities, mental health needs, or complex care
Ensure these homes are included in PCN support plans and pathways
Promote equitable access to primary care services and health reviews
Multidisciplinary Team MDT Support
Work with the occupational therapist to identify residents who may benefit from assessments or interventions
Coordinate actions from MDT meetings, ensuring timely follow-up
Support case-finding for anticipatory care and within the EHCH framework
Holistic Care Planning
Collaborate with patients (where appropriate), their families, and carers to enable personalised care and shared decision-making
Facilitate advanced care planning and documentation alongside clinical colleagues
Data, Documentation and Reporting
Maintain accurate EMIS (or relevant system) records of interventions and outcomes
Support data collection for PCN reporting and service evaluation
Identify trends, gaps, and improvement opportunities across supported homes
Other
Following referral from the GP practice, communicate with the Care Home Team and liaise with the relevant team member to arrange patient interventions
Assist in developing and updating Personalised Care and Support Plans to address patients personal health care needs
Consult and collaborate with other health care providers and specialists to set up patient appointments and treatment plans
Communicate with Care Homes on a regular basis to check on patient progress and evaluate and document as appropriate
Assist the care home team with developing and accessing health interventions.
Support regular meetings of the Care Home Team to discuss operational issues and liaise with clinical lead and PCN Development Manager as required
Build effective relationships across the PCN and multidisciplinary team to embed the care coordinator role and the work of the Care Home Team.
Treat patients and staff with empathy and respect and conduct oneself in a professional manner
Be responsible for the organisation, planning and of own workload to meet set deadlines
Comply with organisational guidelines and health care laws and regulations
Set up and run searches in practice clinical systems, analysing and managing the data to ensure the work of the Care Home Team is targeted appropriately
Communicate new team changes/updates with care homes and practices
Develop and review processes to help ensure the team works as efficiently and effectively as possible
Proactively identifying issues and using a solutions-focused approach to overcoming these
Liaise with PCN and GP Federation teams to assist with the induction of new starters
Using data from appropriate sources, research findings and patterns relating to outcomes and analyse with the support of clinical lead
Identify and report significant and adverse events
Coordinating patients initial admission to care home/GP surgery ensure they are registered promptly, appropriately coded, appropriate referrals are actioned, and completing any necessary further administrative tasks
Have an understanding of the PCN DES/IIF and GP QOF requirements
Keep up to date with relevant staff changes in practices
Team Working
Understand own role and scope and identify how this may develop over time in communication with the Care Home team, care home staff, GP Partners and Managers.
Work as an effective and responsible team member, supporting others and working with the Care Home team, care home staff, GP Partner and nursing team exploring the mechanisms to develop new ways of working.
Prioritise own workload and ensure effective time-management strategies are embedded within the culture of the team.
Work effectively with others to clearly define values, direction and policies impacting upon care delivery.
Discuss, highlight and work with the team to create opportunities to improve patient care.
Managing Information
Understand responsibility of self and others to the Primary Care Network practice regarding the Data Protection and Freedom of Information Act
Equality and Diversity
The post-holder will support and promote the equality, diversity and rights of patients, carers and colleagues, in a non-discriminatory culture to include:
Acting in a way that recognises the importance of peoples rights, interpreting them in a way that is consistent with Practice 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-judgmental and respects their circumstances, feelings priorities and rights
Health, Safety and Security
The post-holder will assist in promoting and maintaining their own and others health, safety and security as defined in the Practice Health & Safety Policy, the Infection Control policy and published procedures to include:
Using personal security systems within the workplace according to Practice guidelines
Identifying the risks involved in work activities and undertaking such activities in a way that manages those risks
Making effective use of training to update knowledge and skills
Using appropriate infection control procedures, maintaining work areas in a tidy and safe way and free from hazards
Actively reporting of health and safety hazards and infection hazards immediately when recognised.
Keeping own work areas and general / patient areas generally clean, assisting in the maintenance of general standards of cleanliness consistent with the scope of the job holders role.
Undertaking periodic infection control training.
Reporting potential risks identified
Conform to health and safety legislation, taking the necessary actions to manage risks and acting as a role model in promoting health, safety and security
Attend statutory and mandatory training at the required times to maintain and update skills.
Maintain high standards of infection control
To ensure the security of the premises, property and self
Personal/Professional Development
The post-holder will participate in an annual individual performance review conducted by their line manager, informed by colleagues as appropriate
Attend any training programme implemented by the GP Federation as part of
this employment
Take responsibility for own personal and/or professional development maintaining a record of own learning
Participate in any training programme agreed by the Federation as part of this employment. Training may need to be undertaken outside of normal working hours and/or off site
Setting an example
Positively and effectively project the BGPFs values, philosophy, activity and outcomes with all levels and disciplines of staff
Communication
The post-holder will establish and maintain effective communication pathways at all times with colleagues, management, patients, carers and other health care Professionals
Excellent people skills are essential to engaging all levels of contributors and stakeholders in a diplomatic and meaningful way
Patient confidentiality
The post-holder must at all times respect patient confidentiality and, in particular, the confidentiality of electronically stored personal data in line with the requirements of the Data Protection Act
The post-holder should not divulge patient information unless sanctioned by the requirements of the role
Any other duties
This job description constitutes an outline of the tasks, responsibilities and outcomes required of the role. The job holder will also be required to carry out any other duties as may reasonably be required by their line manager. The job requirements may be reviewed on an ongoing basis in accordance with the changing needs of the BGPF
Person Specification
Qualifications Essential
Educated to GCSE or equivalent
Desirable
NVQ Level 3 in a health or social care related discipline (or equivalent experience) Experience in a health or social care profession
Experience Essential
Experience of working in health, social care and other support roles in direct contact with people, families and carers Understanding of the current issues facing the NHS including Primary Care Networks Has attention to detail, able to work accurately, identifying errors quickly and easily Has a planned and organised approach with an ability to prioritise their own workload to meet strict deadlines. Excellent communication skills, verbal and written, with the ability to adjust communication style and content to suit the audience An excellent understanding of data protection and confidentiality issues Able to arrange suitable meetings with multiple individuals with often conflicting priorities Self-motivated and proactive Continued commitment to improve skills and abilities in new areas of work Able to undertake the demands of the post with reasonable adjustment if required Able to access transport to work across the practices within the Primary Care Network, Care Homes and attend meetings in other locations Excellent time keeping and prioritisation skills Professional attributes and appearance
Desirable
Experience in care coordinator role with vulnerable patients
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 Bury GP Federation
Address Business Lodge
Barcroft Street
Bury
Lancashire
BL9 5BT
United Kingdom
Employer's website https://www.burygpfederation.com/ (Opens in a new tab)