We are looking for a motivated and compassionate Care Coordinator to join our Complex Care Team on a 12-month fixed-term basis.
This is an exciting opportunity to be part of a proactive, multidisciplinary team supporting patients with complex needs, particularly older people, those living with frailty, and individuals with long-term conditions in their own homes.
About the Role
As a Care Coordinator, you will manage a defined caseload of patients, taking a proactive and person-centred approach to care. You will focus on understanding what matters most to each individual, helping to develop and coordinate personalised care plans that reflect their needs, goals, and preferences.
You will act as a central point of contact for patients and their carers, supporting them to navigate health and social care services. Working closely with Advanced Care Practitioners, GPs, social prescribers, and voluntary sector partners, you will help ensure patients receive the right support at the right time.
A key part of the role will involve coordinating the multidisciplinary team (MDT), facilitating communication across services, and ensuring care is well‑organised, joined‑up, and responsive to changing needs.
The post holder’s main base will be at Harbourside Family Practice; however, they will also be required to work at Clevedon Medical Centre as part of the role.
Main duties of the job
Key Responsibilities
* Proactively manage a caseload of patients with complex care needs
* Develop and support personalised, holistic care plans
* Act as the first point of contact for patients and carers
* Coordinate care across health, social care, and voluntary services
* Support and facilitate multidisciplinary team working
* Assist with treatment coordination, preventative care, and health promotion
* Monitor and adapt care in response to patient needs
About You
You will be highly organised, with excellent communication and interpersonal skills. You will be passionate about delivering person-centred care and confident working collaboratively within a multidisciplinary environment.
Experience in health, social care, or a related setting is desirable, along with an understanding of the challenges faced by patients with complex needs.
About us
Gordano Valley PCN are a well established PCN in Woodspring, North Somerset, serving a combined patient list size of approx. 52,000 across 4 local GP practices.
What We Offer
* Opportunity to work within a supportive, forward-thinking multidisciplinary team
* A rewarding role making a real difference to patients lives
* Flexible working hours (30 - 37.5 hours per week)
Job responsibilities
Job Purpose
* The Care-co-ordinatorwill function at a higher competency level than that of other health caresupport workers and work unsupervised, undertaking a range of activities andextended roles having received training and been assessed as competent.
* Undertake holisticassessments for service users as delegated by senior members of the team
* Promote optimumindependence through linking the service user and carer to appropriate support
* To provide a safe,patient centred, effective and evidence-based care
* To deliver a fullrange of clinical, health and social care activities,supported by arobust competency framework to service users within their own home
* Beable to and willing to work flexibly and to travel throughout the servicedelivery geographical area from a base at Marina Healthcare Centre inPortishead to Clevedon Medical Centre.
* To work with theAdvanced care practitioners, GPs and other primary care professionals to managea caseload of patients.
* To undertake homevisits to meet these patients and their carers
* To undertake andcomplete appropriate training and competencies in order to carry out the roleof community care co-ordinator
* To use a what mattersmost to you approach to assess patients and help create personalised care andsupport plans, in line with best practice and with support from the wider team.
* Take a link rolewithin the Multidisciplinary/Frailty Team
* Monitor long termconditions, care and treatment plans as per policy, protocol or guidelinesescalating to the Advanced care practitioner for support and guidance whenrequired
* Prioritises ownworkload
* Acts as a role modelby upholding and implementing good practice in the workplace, always ensuringthe highest standards of evidenced base care
* To maintain accurate, timely written andcomputerised documentation in line with professional and legal requirements
* To function as a pointof contact helping to facilitate communication between the patient and careproviders
* To evaluate and riskassess all aspects of community work and to minimise the risk to self, patientsand carers whilst delivering care.
* To contributeobservations and experiences to the ongoing learning and evaluation of theprogramme
Person Specification
Qualifications
* Successful completion of relevant Foundation Degree modules / Diploma in Clinical Health and Social Care / diploma level 3 or equivalent.
* Undertake any training relevant to the role
Experience
* Able to carry out the relevant clinical competencies required of the post, implement and evaluate care, using agreed protocols reporting adverse signs to registered professionals, sepcialist services, GPs or others
* Contribute to the holistic assessment of a service user
* Communicate in varied ways with colleagues, service users and other stakeholders
* Able to use a variety of IT platforms i.e. EMIS; email
* Demonstrate knowledge and understanding of Clinical Governance, - Clinical Risk and to use Evidence Based Practice in order to provide optimum care to patients.
* Participate in supervision and the induction of new members of staff and undertake an assessor course or equivalent, if appropriate
* Experience of direct client care in a health or social care setting.
* Experience of team working and working without direct supervision.
* An understanding of team dynamics, including what factors make a team work well and what can go wrong and why.
* An understanding of the issues of equality and diversity
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.
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