Job summary
We're looking for an enthusiastic and organised Frailty Coordinator (Band 5) to be the coordination heartbeat of our brand-new Community Healthy Ageing Hub (CHAH) at Newton Abbot Hospital.
In this dynamic role, you'll guide patients through the frailty pathway--including the Virtual Ward, Same Day Emergency Care (SDEC), ambulatory care, and where required, short-stay bedded care. You'll help ensure people receive the right care, in the right place, at the right time--supporting them to remain as independent as possible and closer to home.
Working as part of an experienced multidisciplinary team (MDT), you'll play a vital role in delivering safe, rapid Comprehensive Geriatric Assessment (CGA), coordinating care and discharge planning across multiple services.
This is a five-day service, offering a fast-paced and rewarding environment where you'll make a real difference to patient journeys. If you're passionate about people-first care, enjoy working collaboratively, and take pride in achieving tangible outcomes, we'd love to hear from you.
Main duties of the job
We're looking for calm, compassionate communicators who are organised, proactive, and skilled at building strong relationships across the multidisciplinary team (MDT). You'll use your coordination skills, IT confidence, and patient focus to help deliver safe, seamless, and person-centred care.
What you'll do and what we value:
-
Coordinate patient flow end-to-end: Triage referrals, align the right professional at the right time, and plan discharge from the outset. Track each patient's journey to minimise delays and ensure smooth transitions of care.
-
Make every contact count: Gather background information before arrival, record Rockwood Clinical Frailty Scores (CFS), and ensure Comprehensive Geriatric Assessment (CGA) recommendations are shared promptly with community teams and primary care. Act as the main point of contact for patients and carers following discharge.
-
Communicate: Manage sensitive conversations with empathy and professionalism. Negotiate shared plans when views differ and keep patients, families, and colleagues informed--particularly during times of pressure or uncertainty.
-
Orchestrate the MDT: Connect and coordinate across wards, Urgent Community Response (UCR), Virtual Ward, locality teams, the discharge hub, care agencies, and voluntary sector partners to ensure assessments and actions happen on time.
-
Use systems with confidence: Work effectively with EPR systems, Paris, CareFirst, PAS, and CyberLab to record what matters, arrange transport, and keep Estimated Dates of Discharge (EDDs) accurate and up to date.
-
Do the right thing, safely: Apply Care Act principles, support Continuing Healthcare (CHC) screening, escalate safeguarding concerns, and uphold Torbay and South Devon NHS Foundation Trust policies at all times.
About us
You'll be part of a friendly, supportive team working across our Virtual Ward, Urgent Community Response, hospital clinicians, and the Newton Abbot ward team--including Trust GPs, Advanced Clinical Practitioners (ACPs) and trainees, therapists, nurses, consultants, and our consultant nurse.
We value kindness, respect, and listening in everything we do. Collaboration is at the heart of our culture--we share learning, celebrate successes, and welcome ideas that improve the patient experience.
You'll be trusted to take ownership, empowered to make decisions, and see the real impact of your work every shift.
Browse ourinteractive bookletto explore our staff benefits!
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.
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).
