Care Coordinator for Enhanced Health in Care Homes in Taunton inTaunton PUBLISHED THU 30 OCT 2025 Jump to job information section

Job summary
Within the Enhanced Health in Care Homes (EHCH) Team, the CareCo-coordinator plays an important role within a Primary Care Network (PCN) to proactively identify andwork with people living in care homes, including the frail/elderly and thosewith long-term conditions, to provide coordination and navigation of care andsupport across health and care services.They work closely with GeneralPractice and Neighbourhood teams to manage a caseload of patients, acting as acentral point of contact to ensure appropriate support is made available tothem and their carers; supporting them and their carers to understand andmanage their condition and ensuring their changing needs are

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ed.This is achieved by bringingtogether all the information about a persons identified care and support needsand exploring options to meet these within a single personalised care andsupport plan, based on what matters to the person.The successful candidate will becaring, dedicated, reliable and person-focused and enjoy working with a widerange of people. They will have good written, verbal communication skills, ITskills, strong organisational and time management skills. They will be highlymotivated and proactive with a flexible attitude, keen to work and learn aspart of a team and committed to providing patients with high quality support tomeet the needs of our patient population.

Main duties of the job
Care Coordinators, reviewpatients needs and help them and their carers access the services and supportthey require to understand and manage their own health and wellbeing, referringto social prescribing link workers, health and wellbeing coaches, and otherprofessionals where appropriate.Care Coordinators alongside theEHCH team to build a long term working relationship with care homes.Thisrole essential to supporting the Care Home Multidisciplinary Team meetingswhichrun weekly consisting of CareHome teams, General Practice, Neighbourhood Health and Social Care teams asall-encompassing approach to personalised care and promoting shared decisionmaking whilst supporting clients with complex needs.Please note that the role of a care coordinatoris not a clinical role.

About us
Tone Valley PCN consists of 5like-minded Somerset practices; Lyngford Park Surgery, Taunton Vale Healthcare,Creech Medical Centre, Warwick House Medical Centre, North Curry Health Centreand are responsible for the care of around 36,500 patients.

Details

Date posted
30 October 2025

Pay scheme
Other

Salary
Depending on

Experience
Based on Agenda for Change Band 4

Contract
Permanent

Working pattern
Full-time

Reference number
A3705-25-0002

Job location
sCreech Medical CentreHyde LaneCreech St. MichaelTauntonSomersetTA3 5FA

Job description

Job responsibilities
Salary
: based on indicative Agenda for Change Band 4Interview: expected to take place week commencing 24 November 2025 at Creech Medical CentreKey responsibilitiesThe aim of EHCH is to provide proactive and personalised healthcare forpeople with multiple long-term conditions, including frailty and healthinequalities delivered through multi-disciplinary teams in local communities.Working with clinicians to provide support in care homes with an emphasis onself-management and prevention of avoidable illness, whilst, building along-term working relationship with care homes.Provide coordination and navigation for health, social care andneighbourhood services helping to ensure patients receive a joined-up serviceand the most appropriate support.Provide coordination of weekly care home rounds across the PCN.Work collaboratively with GPs and other primary care professionals withinthe PCN to proactively identify residents who would benefit fromMuli-Disciplinary Team review and where appropriate, refer to other healthprofessionals within the PCN / Neighbourhood.Support the coordination, administrative tasks and delivery ofmultidisciplinary teams with the PCN.Support professionalmeetings, inclusive of minuting the Multidisciplinary Team meeting and MultiAgency Risk Meetings as required by the team.Carry out holistic assessments to aid patients in managing any long-termconditions they may have, supporting self-management and access to care.Work closely with patientfamilies and or advocates to enable them to support their loved ones indecision making and personalised care planning.Support PCNs in developing communication channels between GPs and CareHomes including in reaching into secondary care services and follow up postdischarge.Liaise with key stakeholdersas needed for the collective benefit of the patient.Maintain accurate and timely records of referrals and interventions toenable monitoring and evaluation of the service.Support practices to keep care records up to date by identifying andupdating missing or out-of-date information about the patient's circumstances.Contribute to risk and impact assessments, monitoring and evaluations ofthe service.Cross cover care-coordinators and administrative duties within theProactive Care Team as required by the service.Key Tasks1. Enable access to personalised care and support:a.Take referrals forindividuals or proactively identify patients who could benefit from support through care coordination;b. Supportpatients to develop and implement personalised care and support plans;c.Reviewand update personalised care and support plans at regular intervals;d.Ensurepersonalised care and support plans are communicated to the GP and any otherprofessionals involved in the patient's care and uploaded to the relevantonline care records, with activity recorded using the relevant SNOMED codes;2. Coordinate and integrate care:a.Help totransition seamlessly between services and support them to navigate through thehealth and care system;b.Referonwards to appropriate health and social care professionals where required;c.Facilitatinga coordinated approach to care and ensuring effective communication betweenteams for accurate records;d. Actively participatein multidisciplinary team meetings in the PCN and individual practices as andwhen appropriate. This may include minuting and administrative tasks that arisefrom the meeting;e.Regularly liaise with the range ofmultidisciplinary professionals and colleagues involved in the persons care,facilitating a coordinated approach and ensuring everyone is kept up to date sothat any issues or concerns can beappropriately

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ed and supported;f.Identifywhen additional support is needed alerting a named clinical contact in additionto relevant professionals and highlighting any safety concerns;g.Keepaccurate and up-to-date records of contacts, appropriately using GP and otherrecords systems relevant to the role, adhering to information governance anddata protection legislation;h.Encouragepatients to provide feedback and to share their stories about the impact ofcare coordination on their lives;i.Recordand collate information according to agreed protocols and contribute toevaluation reports required for the monitoring and quality improvement of theservice;j.Runnecessary reports as required by the EHCH team;k.Completenecessary administration responsibilities as required by the EHCH Team;3. Professionaldevelopment:a.Workwith a named clinical point of contact for advice and support;b.Undertakecontinual personal and professional development, taking an active part inreviewing and developing the role and responsibilities, and provide evidence oflearning activity as required;c.Adhereto organisational policies and procedures, including confidentiality,safeguarding, lone working, information governance, equality, diversity andinclusion training and health and safety;4. Miscellaneous:a.Establishstrong working relationships with GPs, practice teams, care homes and workcollaboratively with other care coordinators, social prescribing link workersand health and wellbeing coaches, supporting each other, respecting eachothers views and meeting regularly as a team;b.Act as achampion for personalised care and shared decision making within the PCN;c.Demonstratea flexible attitude and be prepared to carry out other duties as may bereasonably required from time to time within the general character of the postor the level of responsibility of the role, ensuring that work is delivered ina timely and effective manner;d.Identifyopportunities and gaps in the service and provide feedback to continuallyimprove the service and contribute to business planning;e.Contributeto the development of policies and plans relating to equality, diversity andreduction of health inequalities;f.Work inaccordance with the practices and PCNs policies and procedures;g.Dutiesmay vary from time to time without changing the general character of the postor the level of responsibility;h.Contributeto the wider aims and objectives of the PCN to improve and support primarycare;i. To support in the delivery of the PCN Network DES,enhanced services and other service requirements on behalf of the PCN;

Job description
AgreementThis

Job description
isflexible, and the post holder will be expected to undertake any other dutiesappropriate to the role as may be required by the PCN. This

Job description
issubject to change from time to time with organisational need and the post holdersagreement should not unreasonably be denied.

Job description

Job description
AgreementThis

Person Specification

Experience
Essential

Experience
of working in health, social care and 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 supporting people, their families and carers in a related role.

Experience
of working with elderly or vulnerable people, complying with best practice and relevant legislation.

Experience
of administrative duties / minute taking.

Experience
of data collection and using tools to measure the impact of services.Basic knowledge of long-term conditions and the complexities involved: medical, physical, emotional and social.Desirable

Experience
of working directly in a care coordinator role, adult health and social care, learning support or public health / health improvement.

Experience
or training in personalised care and support planning.Knowledge/familiarity with medical terminology.

Qualifications
EssentialGrade 4 GCSE standard pass in English Language and Mathematics.Demonstrable commitment to professional and personal development.Ability to use Microsoft Office applications - Word, Excel, PowerPoint, Outlook.Access to own transport.Ability to travel across the locality.DesirableNVQ Level 3 in adult care - advanced level or equivalent

Qualifications
or working towards

Person Specification

Experience
Essential

Qualifications
or working towards

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