Nurse (RGN) / Care Co-ordinator in Leeds

We do not support sponsorships for visas as we are a funded organisation. Monday to Friday 8.30pm till 4.30pm that is a 37.5 hours per week role.

BWM PCN is seeking an organised, compassionate and motivated Registered General Nurse (RGN) / Care Co-ordinator to join our team in delivering the new Proactive Care Contract in partnership with the West Yorkshire Integrated Care Board (WYICB). WYICB is transforming healthcare by shifting the focus from reactive treatment to personalised, proactive, community-based care for people living with frailty and long-term conditions. This approach brings together multidisciplinary teams across primary care, community services, pharmacy and social care to provide coordinated, preventative support that enables patients to remain independent and receive the right care at the right time.

As part of this exciting role, you will play a key role in coordinating proactive care for our patients, working closely with GP practices, community partners and the wider multidisciplinary team. You will help identify patients who would benefit from proactive interventions, support care planning, coordinate services and ensure patients receive seamless, person-centred care. A key aspect of the role will also involve supporting our Senior Frailty Nurse, assisting with the delivery of high-quality frailty services within our care homes.

Main duties of the job:

• This will include helping to coordinate resident reviews, supporting multidisciplinary working and contributing to the ongoing development of our proactive frailty service.
• This is an exciting opportunity for someone who is passionate about improving outcomes for patients, enjoys working collaboratively across organisations and wants to be part of shaping the future of community healthcare.

Scope of the role:

The Care Co-ordinator part will play a key role in supporting the delivery of the PCN Proactive Care (Catalyst) contract. Working closely with the Lead Care Co-ordinator, PCN multidisciplinary teams, neighbourhood teams, community services, and voluntary sector partners, the postholder will identify, engage, and support patients who would benefit from proactive care interventions. The aim of the role is to help people live well and independently for longer, improve patient outcomes and experience, and reduce avoidable demand on NHS services through coordinated, person-centred care. The Care Coordinator will act as a central point of contact for patients within the project, ensuring they are connected to the most appropriate services and receive coordinated support without duplication of care.

About us:

BWM Primary Care Network Ltd is a mature PCN that provides enhanced clinical services for four GP surgeries across Bramley, Wortley & Middleton area, with a patient population of approximately 30k. BWM PCN Ltd currently benefits from the following clinical teams, directly employed by ourselves: Social Link Prescribers, Advanced Nurse Practitioners, Physiotherapists, Occupational Health Therapist, Health and Wellbeing Coach, Enhanced Access Lead.

Job responsibilities:

• Patient identification and engagement.
• Support the identification of patients eligible for the Proactive Care contract using agreed criteria and patient lists.
• Proactively contact patients to explain the programme and encourage engagement.
• Build positive relationships with patients, carers, and families to understand their needs and goals.
• Ensure patients are supported to access appropriate services and interventions.
• Co-ordinate appointments and assessments with clinicians and members of the multidisciplinary team where required.
• Arrange and manage bookings for proactive care reviews and follow-up interventions.
• Support patients to navigate health, social care, and community services.
• Monitor patient progress and maintain regular contact where appropriate.
• Code as necessary in System One.
• Work closely with PCN teams, GP practices, neighbourhood teams, community healthcare providers, and social care service providers.
• Develop strong links with voluntary, community, and faith sector organisations to maximise support available to patients.
• Facilitate appropriate referrals and signposting to community-based services and wellbeing programmes.
• Promote integrated working and information sharing across organisations in line with governance requirements.
• Work with neighbourhood teams to ensure patients receive co-ordinated, high-quality care.
• Help identify and reduce duplication of services and interventions.
• Contribute to multidisciplinary team meetings and case discussions.
• Escalate concerns regarding patient wellbeing, safeguarding, or deterioration to the appropriate clinical professional.
• Administration and data management with support from other team members.
• Maintain accurate and timely records on clinical systems and project databases.
• Support data collection and reporting requirements for the project.
• Ensure all contacts, referrals, and outcomes are appropriately documented.
• Assist with monitoring project activity and performance against agreed targets.

RGN Nurse role:

Clinical Assessment:

• Holistic patient assessments.
• Frailty assessments (including use of recognised frailty tools).
• Physical health assessments.
• NEWS2 scoring.
• Nutritional assessments (e.g. MUST).
• Mental capacity assessments (within their competence).
• Continence assessments.
• End-of-life care assessments.
• Long-term condition reviews (where appropriately trained).

Clinical Care:

• Wound care and dressings.
• Venepuncture (blood taking).
• Vaccinations and immunisations.
• ECG recording.
• Urinalysis.
• Basic respiratory assessments.
• Health promotion and lifestyle advice.

Care Planning:

• Develop personalised care and support plans.
• Coordinate advance care planning discussions.
• Review and update care plans.
• Support patients with self-management.
• Coordinate multidisciplinary team (MDT) meetings.
• Liaise with GPs, community nurses, therapists, pharmacists and social care.
• Refer patients to appropriate community services.
• Support admission avoidance initiatives where appropriate.
• Monitor patients identified as high risk.
• Ensure patients receive appropriate follow-up.

Care Home Support:

• Support proactive frailty rounds.
• Identify deteriorating residents early.
• Work alongside Frailty ANP Lead and pharmacy teams.
• Support care home staff with clinical advice.
• Support carers with disease management.

Documentation:

• Maintain accurate clinical records.
• Document consultations in SystemOne (S1).
• Record clinical coding.
• Complete referrals and clinical correspondence.

Quality Improvement:

• Participate in clinical audits.
• Monitor quality indicators.
• Contribute to PCN and ICB targets.

For a PCN Proactive Care role, an RGN is particularly well placed to:

• Carry out comprehensive frailty reviews.
• Visit housebound patients and care homes.
• Identify patients at risk of deterioration.
• Coordinate care across health and social care services.
• Deliver preventative interventions.
• Help reduce avoidable hospital admissions and improve patient outcomes.

This combination of clinical nursing skills and care coordination makes the role an excellent fit for delivering proactive, community-based care. The working week will be set as a rota with support from team around.

Person Specification:

• Qualifications: GCSE grade A to C in English and Maths.
• NMC registration.
• Experience of Working in the Community.
• Excellent System One knowledge.
• Access to car with own insurance (Mileage paid).
• Full Driving Licence.
• Care Home experience.
• Computer literate and ability to learn new systems of work.
• Knowledge of Proactive Care and the requirements to meet targets over the next few years.
• Clinical Skills experience.
• Competent in delivering evidence based nursing care to people living with diverse health needs.
• Experience of lone working or working autonomously alongside experience of working within a team.
• Evidence of willingness to develop in role.
• 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.
• UK Registration: Applicants must have current UK professional registration.