Job summary
As our Band 5 Frailty Coordinator, you 'll be the coordination heartbeat of our new Community Healthy Ageing Hub (CHAH) at Newton Abbot Hospital. You'll steer patients through frailty pathways (Virtual Ward, SDEC, ambulatory care and--in some cases--bedded care), making timely, person-centred decisions that keep people closer to home. This is a 5-day service, and you'll be central to delivering safe, rapid comprehensive geriatric assessment (CGA) care and discharge alongside an experienced multidisciplinary teams (MDT). If you love fast-paced, people-first care and tangible outcomes, you'll thrive here.
Main duties of the job
We're looking for calm, compassionate communicators who are organised and proactive, who are able to build relationships and agreements that are communicated seamlessly across multidisciplinary teams (MDT). Using IT confidently, and staying focused you will contribute to improving care and patient-centred outcomes.
What you'll do and what we value:
- Coordinate flow end-to-end: triage inputs, line up the right professional at the right time, and plan discharge from the start. Track each patient's journey to minimise delays.
- Make every contact count: seek background info before arrival, record Rockwood CFS, and ensure CGA recommendations reach community teams and primary care. Be the go-to contact for patients and carers post-discharge.
- Communicate brilliantly: handle sensitive conversations, negotiate shared plans when views differ, and keep patients, families and colleagues informed--especially when anxious or under pressure.
- Orchestrate the MDT: connect wards, UCR, Virtual Ward, locality teams, discharge hub, care agencies and voluntary sector so assessments and actions happen on time.
- Use systems with confidence: EPR systems, Paris, CareFirst, PAS, CyberLab--confidently capture what matters, arrange transport, and keep EDDs accurate.
- Do the right thing, safely: apply the Care Act principles, aid screening for CHC, escalate safeguarding concerns, and follow Torbay and South Devon Trust policies.
About us
Why Work With Us
You'll join a friendly, supportive team spanning our Virtual Ward, Urgent Community Response, hospital clinicians and the Newton Abbot ward team including Trust GPs, ACPs/trainee ACPs, therapists, nurses, consultants and a consultant nurse.
We value kindness, respect and listening. We share learning, and celebrate successes and welcome ideas that improve the patient experience. You'll be trusted to take ownership--and you'll see the impact of your work every shift.
Job description
Job responsibilities
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Coordinate each patients journey: book the right assessments, prioritise whats needed, and keep everyone informed.
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Keep records clear and timely: capture key details, track progress, and share simple next steps with patients and families.
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Support safe, timely discharge: arrange referrals, follow-up, transport and any community support needed.
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Bring people together: organise brief case discussions when needed so decisions are made quickly and safely.
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Protect people and standards: follow safeguarding guidance and Trust policies; escalate risks promptly.
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Help us improve: feed in ideas and data that make our service smoother and easier for patients and staff.
Job description
Job responsibilities
-
Coordinate each patients journey: book the right assessments, prioritise whats needed, and keep everyone informed.
-
Keep records clear and timely: capture key details, track progress, and share simple next steps with patients and families.
-
Support safe, timely discharge: arrange referrals, follow-up, transport and any community support needed.
-
Bring people together: organise brief case discussions when needed so decisions are made quickly and safely.
-
Protect people and standards: follow safeguarding guidance and Trust policies; escalate risks promptly.
-
Help us improve: feed in ideas and data that make our service smoother and easier for patients and staff.
Person Specification
Qualifications and training
Essential
- oNVQ level 4 in Health and Social Care or evidence of working towards this
Desirable
- oWorking at degree level. Degree level education or equivalent ILM 5
Knowledge and experience
Essential
- oKnowledge of legislation and policy that has shaped current health and social care provision e.g. Community Care Act; Disability discrimination Act; 'Your Health Your Care Your Say'; The Care Act
- oExperience of health and/or social care IT systems.
- oExperience completing patient related documentation; legibly, accurately and to a high standard.
- oExcellent knowledge of community-based resources including those provided and commissioned by Torbay and South Devon NHS Foundation Trust and those provided by the voluntary sector.
- oKnowledge and understanding of competing priorities in acute and community settings.
- oEvidence of good problem-solving skills; ability to think laterally and creatively under pressure
Desirable
- oUnderstanding of the national Agenda for Frailty (as laid out in the NHS 10 Year Plan)
- oHave an awareness/knowledge of local community & specialist services supporting older people/those living with Frailty
Specific skills
Essential
- oExperience of carrying out assessments considering the wishes of the individual and/or their carer.
- oExperience of working with service users with a wide range of disabilities and clinical conditions e.g. physical, sensory and learning disabilities, cardiac and respiratory conditions, neurological conditions
- oExperience of resolving conflict effectively
- oAbility to demonstrate a clear understanding of differing needs of service users with different disabilities and clinical conditions.
Desirable
- oExperience as a HSCC or CCW (or comparable health role)
- oExperience of previous hospital or community working
- oExperience of completing needs-led assessments with service users and/or carers resulting in provision of services
- oExperience of working with service users with life limiting conditions towards the end of their life.
Person Specification
Qualifications and training
Essential
- oNVQ level 4 in Health and Social Care or evidence of working towards this
Desirable
- oWorking at degree level. Degree level education or equivalent ILM 5
Knowledge and experience
Essential
- oKnowledge of legislation and policy that has shaped current health and social care provision e.g. Community Care Act; Disability discrimination Act; 'Your Health Your Care Your Say'; The Care Act
- oExperience of health and/or social care IT systems.
- oExperience completing patient related documentation; legibly, accurately and to a high standard.
- oExcellent knowledge of community-based resources including those provided and commissioned by Torbay and South Devon NHS Foundation Trust and those provided by the voluntary sector.
- oKnowledge and understanding of competing priorities in acute and community settings.
- oEvidence of good problem-solving skills; ability to think laterally and creatively under pressure
Desirable
- oUnderstanding of the national Agenda for Frailty (as laid out in the NHS 10 Year Plan)
- oHave an awareness/knowledge of local community & specialist services supporting older people/those living with Frailty
Specific skills
Essential
- oExperience of carrying out assessments considering the wishes of the individual and/or their carer.
- oExperience of working with service users with a wide range of disabilities and clinical conditions e.g. physical, sensory and learning disabilities, cardiac and respiratory conditions, neurological conditions
- oExperience of resolving conflict effectively
- oAbility to demonstrate a clear understanding of differing needs of service users with different disabilities and clinical conditions.
Desirable
- oExperience as a HSCC or CCW (or comparable health role)
- oExperience of previous hospital or community working
- oExperience of completing needs-led assessments with service users and/or carers resulting in provision of services
- oExperience of working with service users with life limiting conditions towards the end of their life.
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Additional information
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.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
