Job Description

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) - Ribblesdale, Mile Lane, Red Bank

Woodbank

Peel

Garden City

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 patient's 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 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
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 holder's 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 BGPF's 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

Job Types: Full-time, Permanent

Pay: 27,824.88 per year

Benefits:

Casual dress Company pension Cycle to work scheme Free parking On-site gym On-site parking Sick pay
Shift:

Day shift
Work days:

Monday to Friday No weekends
Application question(s):

Have you got experience of working in health, social care and other support roles in direct contact with people, families and carers?
Work Location: In person

Application deadline: 27/06/2025
Reference ID: Vulnerable Care Home CC