CARE COORDINATOR, GENERAL PRACTICE

Job summary

We are looking to recruit a Care Coordinator to work within our Care Team. If you are very passionate about delivering outstanding patient service then this may well be the role for you!

Main duties of the job

The role of the Care Coordinator is tosupport our most vulnerable patients across all cohorts within the Practice. To coordinate safeguarding meetings, reviews and care planning with key professionals. Contact patients who have lost loved ones. Identify and work with carers to ensure adequate support provided.

About us

Abbey Medical Practice looks after 28,800 patients in Wellingborough and has a small Practice in Earls Barton.

The Practice is led by 7 GP Partners and managed by our Head of Practice, along with the Senior Practice Manager, Patient Services Manager and Operations Manager. The Practice has 6 additional GPs in salaried roles with Advanced Nurse Practitioners, Treatment Area Nurses, Health Care Assistants led by the Nursing Manager. Healthy Minds Practitioner and Clinical Pharmacists are also in post. There is an extensive Patient Services Team who work extremely hard to support patients and staff.

The Practice is part of Wellingborough and District PCN hub offering access to multidisciplinary teams and additional clinicians ensuring patients are seen by the most appropriate professionals.

Abbey Medical Practice is registered and regulated by the Care Quality Commission (CQC) and works within National NHS guidelines and local commissioners to provide safe, effective and responsive services to our patient population.

The Practice is very sociable and have regular social events to have a good work-life balance. In summary, we work hard and we play harder!

Details

• Date posted: 30 July 2026
• Pay scheme: Other
• Salary: £13.21 to £13.46 an hour
• Contract: Fixed term
• Duration: 12 months
• Working pattern: Full-time
• Reference number: A1878-26-0008
• Job locations: Irthlingborough Road, Wellingborough, Northamptonshire, NN8 1LT, United Kingdom

Job responsibilities

Adult/Child safeguarding

• Support the Practice Safeguarding Leads in coordinating audit and child safeguarding activity.
• Organise and coordinate safeguarding MDT meetings, ensuring patients are appropriately prepared for discussion and actions are documented and followed up.
• Annotate patient records as appropriate
• Support safeguarding audits and policy reviews
• Assist with updating the practice policies and procedures
• Review patient correspondence received from external agencies and action as appropriate.
• Undertake child new patient registration audit

Frailty/Care Plans

• Organise and attend MDT meetings with Practice staff and other care coordinator professionals including Age well. Minute and develop action plans
• Identify patients who fall within the Practice criteria to be added to the Practice frailty register
• Work with PCN frailty clinician for patient reviews
• Work with Nurse Practitioner to organise home visits (as appropriate) for visits relating to care plans
• Review current care plan list and identify patients that require contact by the Practice.
• Where clinicians are due to undertake visits, advise of the requirement to review care plan as appropriate. Update SystmOne/care plans as appropriate and ensure copies are provided to patients where required.

Palliative Care

Provide administrative support for any palliative referrals

Maintain the Practice palliative care register

Finalise completed Respect forms and update to NCR

Work with clinicians to ensure all end-of-life paperwork is issued to relevant parties

Audit ongoing requirements for palliative care patients

Attend palliative care meetings to discuss patients and undertake any associated actions

Action Discharge summaries

• Review hospital discharge summaries for patients and identify and follow-up actions required for patients and their carers
• Inform Community Care Coordinators when a care home patient has been discharged from hospital for care plans to be reviewed
• Code admission and reason
• Contact the patient within 48 hours of discharge to offer support and discuss care needs. Signpost to services as appropriate ie social prescriber, volunteer services.
• Diarise to follow up with patient as appropriate
• Liaise with usual GP with any areas of concern.
• Where appropriate liaise with hospital staff whilst patient is an inpatient and support to enable discharge
• Undertake periodic audits of hospital admissions to identify trends, high-risk patients and opportunities for proactive intervention
• Attend meetings as and when required including MDT, Practice meetings

Bereavement

Liaise with GP/Medical Examiner for the issue of the Death Certificate

Contact the family of those who have lost loved ones following initial contact by clinician.

Issue with sympathy cards/bereavement information and signpost to appropriate services to support. Follow up in one month

Update SystmOne and process patient deduction.

Screening Programmes

Support Practice screening programmes including cervical, bowel and breast screening

Monitor non responder reports

Process results, correspondence and follow up actions in accordance with Practice protocols

Maintain accurate coding and recording of patient outcomes

Support achievement of national screening targets

Cancer Champion (in the event of staff absence)

Contact patients who have been newly diagnosed within 1 month

Undertake referrals to Social Prescriber for patients to discuss social and financial needs.

Ensure sufficient supply of information available on reception desks and waiting area to educate patients of support services available. Update noticeboards with up to date information.

Review national campaigns, communicate to staff and patients

Contact patient to attend review with GP

Undertake audits as and when required.

Learning Disabilities and Mental Health Reviews:

Booking and coordination of annual review appointments for the mental health and Learning Disabilities registers

Engage with patients to ensure pre-appointment documentation is completed and any relevant investigations are arranged prior to review

Participate in MDT meetings with other CCOs/HMP/ANPS/SPLWs/MHW (including PCN services) looking after LD patients

Monitor compliance with the SMI annual review requirements, ensuring eligible patients receive all elements of the required health check.

Keep all spreadsheets up to date and regularly review for patients with outstanding reviews.

Carers

• New Patient Registrations provide a comprehensive information pack and personalised covering letter to Carers identified at the time of registering with the Practice
• Existing Patients provide a comprehensive information pack and personalised covering letter to Carers who have been identified at the Practice (if not already provided by Clinician). Issue regular questionnaires to identify further needs.
• Ensure there are sufficient supplies of Carers packs in clinical rooms for distribution at time of consultation
• Update SystmOne with read coding in relation to patients who are currently carers.
• Action tasks received to the Carers Task box within 48 hours or sooner for immediate issues
• Liaise with Northamptonshire Carers to obtain the required Level Activity to meet contractual obligations. Provide regular updates to Practice Management, clinicians, administrative staff and patients as appropriate.

Over 75s

Reviewing patients over the age of 75 who have not made contact with the Practice. Discuss with clinicians as appropriate and make contact as appropriate.

Housebound patients

Coordinate reviews, vaccinations and long-term conditions monitoring for housebound patients where appropriate.

Health Checks

Identify patients who are eligible for a free NHS Health Check and invite to attend appointment with a clinician for a review.

Complete audits to ensure checks are compliant with contract.

Weight Management

Assist in identifying patients who may be eligible for weight management services and support referral pathways.

Book appointments with clinicians as appropriate and follow up with any administrative actions.

Care Homes

Point of contact for all Care Home Managers/staff to discuss any patient requirements.

Patient Focus

• To deliver an excellent, patient-centred service to all patients in accordance with the Practice mission statement