Job summary ARRS CARE COORDINATOR - Full-Time (37.5 hours / week) Are you passionate about improving patient care and making a real difference in peoples lives? We are looking for a Care Coordinator to join our friendly and supportive GP practice, helping patients navigate their healthcare journey with ease. As a key part of our multidisciplinary team, you will work closely with GPs, pharmacists, nurses, and social prescribers, Age UK, Safeguarding and Palliative Care Teams, to ensure patients receive the right care at the right time. You will coordinate referrals, assist with care planning, and support patients with long-term conditions, complex health & care needs, be required to see patients face to face, reducing hospital admissions and enhancing their wellbeing. This is an exciting opportunity to work in a fast pace patient centred environment where your organisational skills, compassion, and problem-solving abilities will truly make an impact. If you thrive in a collaborative setting and want to be part of a team that values and promotes professional growth and patient-centred care, wed love to hear from you. Main duties of the job The Care Coordinator will support patients with mental health needs, dementia, learning disabilities, cancer, and general wellbeing concerns by managing caseloads and coordinating their care across Primary, Secondary, and Community services. The role involves referring patients to appropriate health professionals, supporting external referrals, and ensuring patients benefit from available services. Additionally, the post holder will provide administrative support, assist with QOF and DES/LES work, coordinate care plans, engage with vulnerable patient groups and their carers, and organise key meetings to facilitate effective patient care. Fulfil other administrative duties as required to support the smooth running of the practice. About us ABOUT ALBANY HOUSE MEDICAL CENTRE, OUR VALUES AND BEHAVIOURS Our purpose is to deliver the best possible care for all the people who visit our practices, either as patients, the public or as staff. As one of the largest and busiest surgeries in Wellingborough, our vision is to move from where we are now to where we want to be, the journey from good to great. In undertaking this role you are expected at all times to behave in accordance with our practice values which demonstrate your commitment to the delivery of high quality services to patients. This will be in accordance with agreed objectives, quality standards, and resource constraints. Our values are: We treat patients, service users, and each other with kindness, dignity and respect Services are always designed around the Patient We deliver services that are well managed, efficient, convenient and accessible for patients We do what we say we are going to do We are one team and work best when we work together Date posted 14 March 2025 Pay scheme Other Salary Depending on experience Contract Permanent Working pattern Full-time Reference number A3074-25-0001 Job locations 3 Queen Street Wellingborough Northants NN8 4RW Albany House Medical Centre 25 St. Michaels Lane Wollaston Wellingborough Northamptonshire NN29 7QH 3 School Road Irchester Wellingborough Northamptonshire NN29 7AW Job description Job responsibilities Key Working Relationships Patients / members of the public GPs, Registrars and medical students Practice Staff Local Health Authorities District Nurses Health Visitors and Midwives Community and Practice Clinical Pharmacists Social Prescribers Age Well/Age UK and other Primary Care Network assets CCG Safeguarding nurse for primary care 0-19 nursing team (health visitor & school nurses) Community midwife MASH health MARAC health MAPPA coordinator Early Help Acute and community trust safeguarding leads KEY DUTIES: Safeguarding Safeguarding policies Help the practice to ensure safeguarding policies and procedures are up to date and consistent with agreed best practice as defined by local and national guidelines. Safeguarding training Support the practice in developing/accessing appropriate role-based training for members of staff. Help the practice run training events which encourage a multidisciplinary approach to safeguarding. Information governance Provide advice and training on the recording and coding of safeguarding relevant information within the electronic patient record. Support the preparation of timely, relevant, and proportionate safeguarding reports. Clinical Governance Facilitate the implementation of templates and other decision support tools to support best practice in safeguarding, as recommended by the Northamptonshire safeguarding team and audit the use of same. Safeguarding assurance Support the practice in achieving CQC compliance with respect to the safeguarding of staff and patients. MDT facilitator Take a key role in the development and running of an effective practice safeguarding MDT for children and vulnerable adults. Ensure that the practice has a vulnerable patient register which is kept up to date. Working together Help the practice foster effective relationships with local safeguarding partners. Ensure the timely sharing of relevant information, both verbally and in a structured report, when safeguarding concerns arise in respect of both children and adults. System learning Support the practice in responding to statutory requests for information required by the local authority to carry out local child or adult safeguarding case reviews and assist the practice with section 42 enquiries. Disseminate learning and support the implementation of review recommendations. Audits and reporting Undertake regular audits as requested by line manager and present at educational meetings to ensure compliance and enhance education Referral pathways Promote the understanding of local safeguarding referral pathways, including Early Help and support services for victims of domestic abuse. Meetings/Training Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required. QOF/LES/DES Reviews Identify patients who fall within national and practice criteria Call/Recall patients in a timely manner Perform initial telephone/video/face to face assessments Liaise with usual GP with any area of concern Update SystmOne care plans as appropriate Coordinate referrals to social prescribers Work with Wellingborough PCN teams for patient care plans and reviews Where appropriate work with clinicians to discuss escalation care plans and where required end of life preferences with patients and their carers Coordinate any safeguarding concerns with the practice safeguarding leads and attend internal safeguarding meetings Action Discharge summaries Review hospital discharge summaries for adults, families, carers (excluding care homes) Code admission and reason Contact the patient within 48 hours of discharge to offer support and discuss care needs. Signpost to services as appropriate i.e. Practice social prescriber, clinical pharmacist and local frailty teams. Diarise to follow up with patient as appropriate Liaise with usual GP with any area of concern. Where appropriate liaise with hospital staff whilst patient is an inpatient and support to enable discharge Set up a spreadsheet to record contacts and outcomes Audit hospital admissions in 3 months to identify any common themes, frequent flyers Attend meetings as and when required including MDT, Practice meetings Provide a quarterly update to CCG as per contract July, October, January and April This list is not exhaustive and any tasks/roles that will assist the practice may be required. Job description Job responsibilities Key Working Relationships Patients / members of the public GPs, Registrars and medical students Practice Staff Local Health Authorities District Nurses Health Visitors and Midwives Community and Practice Clinical Pharmacists Social Prescribers Age Well/Age UK and other Primary Care Network assets CCG Safeguarding nurse for primary care 0-19 nursing team (health visitor & school nurses) Community midwife MASH health MARAC health MAPPA coordinator Early Help Acute and community trust safeguarding leads KEY DUTIES: Safeguarding Safeguarding policies Help the practice to ensure safeguarding policies and procedures are up to date and consistent with agreed best practice as defined by local and national guidelines. Safeguarding training Support the practice in developing/accessing appropriate role-based training for members of staff. Help the practice run training events which encourage a multidisciplinary approach to safeguarding. Information governance Provide advice and training on the recording and coding of safeguarding relevant information within the electronic patient record. Support the preparation of timely, relevant, and proportionate safeguarding reports. Clinical Governance Facilitate the implementation of templates and other decision support tools to support best practice in safeguarding, as recommended by the Northamptonshire safeguarding team and audit the use of same. Safeguarding assurance Support the practice in achieving CQC compliance with respect to the safeguarding of staff and patients. MDT facilitator Take a key role in the development and running of an effective practice safeguarding MDT for children and vulnerable adults. Ensure that the practice has a vulnerable patient register which is kept up to date. Working together Help the practice foster effective relationships with local safeguarding partners. Ensure the timely sharing of relevant information, both verbally and in a structured report, when safeguarding concerns arise in respect of both children and adults. System learning Support the practice in responding to statutory requests for information required by the local authority to carry out local child or adult safeguarding case reviews and assist the practice with section 42 enquiries. Disseminate learning and support the implementation of review recommendations. Audits and reporting Undertake regular audits as requested by line manager and present at educational meetings to ensure compliance and enhance education Referral pathways Promote the understanding of local safeguarding referral pathways, including Early Help and support services for victims of domestic abuse. Meetings/Training Attend meetings and training sessions (internal and external) in regards to safeguarding matters, representing the practice and sharing knowledge and information as required. QOF/LES/DES Reviews Identify patients who fall within national and practice criteria Call/Recall patients in a timely manner Perform initial telephone/video/face to face assessments Liaise with usual GP with any area of concern Update SystmOne care plans as appropriate Coordinate referrals to social prescribers Work with Wellingborough PCN teams for patient care plans and reviews Where appropriate work with clinicians to discuss escalation care plans and where required end of life preferences with patients and their carers Coordinate any safeguarding concerns with the practice safeguarding leads and attend internal safeguarding meetings Action Discharge summaries Review hospital discharge summaries for adults, families, carers (excluding care homes) Code admission and reason Contact the patient within 48 hours of discharge to offer support and discuss care needs. Signpost to services as appropriate i.e. Practice social prescriber, clinical pharmacist and local frailty teams. Diarise to follow up with patient as appropriate Liaise with usual GP with any area of concern. Where appropriate liaise with hospital staff whilst patient is an inpatient and support to enable discharge Set up a spreadsheet to record contacts and outcomes Audit hospital admissions in 3 months to identify any common themes, frequent flyers Attend meetings as and when required including MDT, Practice meetings Provide a quarterly update to CCG as per contract July, October, January and April This list is not exhaustive and any tasks/roles that will assist the practice may be required. Person Specification Experience Essential - Experience of working within a healthcare team - Experience of dealing with vulnerable patient Desirable - Experience of working in primary care - Experience of working in a GP practice - Experience of utilising SystmOne - knowledge of QOF and DES/LES requirements Qualifications Essential - GCSE grade A to C in English and Maths Desirable - Qualified to NVQ level 2 in Health and Social Care Person Specification Experience Essential - Experience of working within a healthcare team - Experience of dealing with vulnerable patient Desirable - Experience of working in primary care - Experience of working in a GP practice - Experience of utilising SystmOne - knowledge of QOF and DES/LES requirements Qualifications Essential - GCSE grade A to C in English and Maths Desirable - Qualified to NVQ level 2 in Health and Social Care 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 Employer name Albany House Medical Centre Address 3 Queen Street Wellingborough Northants NN8 4RW Employer's website https://www.albanyhousemedicalcentre.co.uk/ (Opens in a new tab)