Job Description

Job summary:

The successful candidate will join the Personalised Care Team (PCT) based within Boroughbury Medical Practice. The PCT is a dedicated team that supports patients with non-medical concerns affecting their wellbeing, helping them identify and prioritise their ideas, concerns, and expectations to maintain independent living.

Our team focuses on promoting health and social support tailored to each individual's unique needs, preferences, and circumstances. The PCT also leads on various projects that typically involve a multidisciplinary approach across the practice and its three sites. By working collaboratively, we aim to develop and deliver care that truly reflects what matters most to our patients, improving both outcomes and satisfaction.

This role forms an integral part of the practice's multidisciplinary team, working alongside Social Prescribing Link Workers, Care Coordinators, the Health, Recovery and Wellbeing Lead, and supporting the Health Inequalities Lead and GPs to promote and embed a personalised care approach throughout the organisation.

You will be a caring, dedicated, reliable and person-focused individual who enjoys working with a wide range of people. You will have a strong working knowledge of Microsoft Office programs and general IT, good written and verbal communication skills and proven strong organisational and time management skills.

You may be requested to undertake duties/tasks that have not been identified in this job description these will be discussed prior to undertaking them.

The post holder will demonstrate excellent organisational and communication skills, be flexible in their approach, able to exercise initiative and demonstrate consistently high standards of professionalism. The post holder must at all times be aware of the need for confidentiality and integrity.

Core Duties and areas of responsibilities

Take referrals from GPs and MDT team within practices of Boroughbury PCN and working with allied health professionals, fire service, police, job centres, social care services, housing associations, and voluntary, community and social enterprise (VCSE) organisations (list not exhaustive) to help signpost patients to relevant organisations for support.

Provide personalised support to individuals, their families and carers to take control of their wellbeing, live independently and improve their health outcomes. Develop trusting relationships by giving people time and focus on 'what matters to me'. Take a holistic approach, based on the person's priorities and the wider determinants of health. Co-produce a personalised support plan to improve health and wellbeing, introducing or reconnecting people to community groups and statutory services. It is vital that you have a strong awareness and understanding of when it is appropriate or necessary to refer people back to other health professionals/agencies, when what the person needs is beyond the scope of the link worker role - e.g. when there is a mental health need requiring a qualified practitioner.

Build relationships with key staff in GP practices within the local Primary Care Network (PCN), attending relevant meetings, becoming part of the wider network team, giving information and feedback on social prescribing.

Be part of the practice teams for anticipatory care planning and attend integrated care team meetings as part of the regular cluster catch ups within the network.

Be proactive in developing strong links with all local agencies to encourage referrals, recognising what they need to be confident in the service to make appropriate referrals.

Work in partnership with all local agencies to raise awareness of social prescribing and how partnership working can reduce pressure on statutory services, improve health outcomes and enable a holistic approach to care.

Provide referral agencies with regular updates about social prescribing, including training for their staff and how to access information to encourage appropriate referrals.

Seek regular feedback about the quality of service and impact of social prescribing on referral agencies.

Be proactive in encouraging self-referrals and connecting with all local communities, particularly those communities that statutory agencies may find hard to reach.

To work as part of the practice Multi-Disciplinary Team and receive and share information within that team to safeguard individuals and support them to work towards their goals and aspirations.

To maintain accurate information systems of records and activities, complete data sheets and monitoring and evaluating data.

To organise and facilitate group-based workshops and activities, ensuring self-help and peer support groups cover a flexible timetable.

To support service design, co-production, development and improvement ensuring quality is maintained throughout.

To manage a caseload of individuals with complex needs.

To develop appropriate resources and materials for the service.

Please note: This job description is not exhaustive and may be adjusted periodically after review and consultation. You will also be expected to carry out any reasonable duties, which may be requested from time-to-time.

Education, Qualifications and Training

Effective communication skills to work with multiagency team, and ability to work independently. A focus on professionalism and confidentiality.

Strong organisational skills and ability to manage multiple data requests efficiently.

4 GCSE's grade A*- D

Awareness clinical systems or the desire and ability to learn new systems, pathways and new roles quickly will also be considered

Strong attention to detail and ability to maintain data integrity.

Experience

Demonstrate an understanding of customer care when liaising with the public on the telephone, electronic and / or face to face

Ability to communicate effectively and sensitively

Experience of team working

Knowledge of Personalised Care Team Module and patient focused delivered care

Awareness of CQC and QOF standard

Awareness/Experience in supporting audit and compliance activities.

Knowledge and Skills

Experience of working directly in a community development context, adult health and social care, learning support or public health/health improvement (including unpaid work).

Experience working with people with multiple needs.

Experience of working with individuals (1-2-1) and groups of people in different settings to help them achieve their goals.

Accuracy and attention to detail. Experience of managing a caseload of clients and keeping up to date records using a database.

Basic computer skills i.e. able to use email and internet to send and retrieve information

Ability to maintain strict confidentiality at all times

Ability to work under supervision and confidence to seek advice when appropriate.

Experience of working with a range of agencies and organisations to develop effective working relationships.

Knowledge of Personalised Care Team Module and patient focused delivered care

Excellent communication skills.

Ability to maintain effective working relationships and to promote collaborative practice with all colleagues

Excellent consultation skills

Highly motivated

Excellent timekeeping.

Able to carry out basic clerical tasks following instruction

Evidence of ability to complete tasks effectively

Relevant IT qualification or willing to work toward

Familiarity with clinical systems and be able to extract relevant patient data from clinical systems and digital systems to support service delivery, those with the desire and ability to learn new systems quickly will also be considered

Other Job-Related Requirements

To have a professional appearance at all times and be willing to adhere to the relevant dress code

Ability to work the hours required of the post

Willing to work in other areas of the Practice or as and when required to do so.

Presentable in personal appearance.

Approachability to staff and customers.

Good level of self-motivation

Outwardly enthusiastic and confident

Show a flexible approach to work

Friendly, efficient and willing to use initiative

Be highly adaptable and flexible, transition between tasks and projects in a fast-paced, dynamic team environment with constantly evolving priorities.

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

Confidentiality requirements

Given the work environment where patient data is accessible by staff, the post-holder must observe strict confidentiality when accessing patient data.

Information relating to patients, carers, colleagues, other healthcare workers or the business of the practice may only be divulged to authorised persons in accordance with practice policies on confidentiality and the protection of personal and sensitive data.

Health and Safety

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, 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 Reporting potential risks identified.

Health and Safety

The post-holder will support the equality, diversity and rights of patients, carers and colleagues, to include:

Acting in a way that recognises the importance of people's 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
This job description is intended to be part of an agreement for employment, however, it will be reviewed periodically, and the post holders will be invited to contribute to the review.

Job Type: Part-time

Pay: 14.00 per hour

Benefits:

Company pension
Ability to commute/relocate:

Peterborough PE1 2EJ: reliably commute or plan to relocate before starting work (required)
Education:

GCSE or equivalent (preferred)
Experience:

Training: 1 year (preferred) Health and Social Care: 1 year (preferred)
Licence/Certification:

Driving Licence (preferred)
Work Location: In person

Application deadline: 11/02/2026