Discharge Planning Facilitator/Social Worker

Transformationunitgm; Cambridge; On-site; GBP 37,000 - 45,000; Part time

Job summary

An established health organization is seeking a part-time Discharge Planning Specialist to enhance patient care through effective discharge strategies. This role involves collaborating with multidisciplinary teams to ensure timely and safe discharges while addressing patients' needs and concerns. The ideal candidate will possess strong assessment and communication skills, along with a commitment to high-quality care. Join a dedicated team that values compassion and strives to improve the health and wellbeing of the community. This position offers flexible working hours and the opportunity to make a significant impact in patients' lives.

Qualifications

• Expert knowledge in discharge options and services available.
• Experience in assessing and managing patient needs.
• Ability to work closely with multidisciplinary teams.

Responsibilities

• Act as a link between wards and community teams for discharge planning.
• Identify and assess social care needs of older patients.
• Provide training and oversee discharge planning across the Trust.

Skills

Discharge Planning

Assessment Skills

Communication Skills

Time Management

IT Skills

Education

Relevant Degree/Diploma in AHP/Social Work

Continuing Professional Development

Continuing Health Care Assessment Training

Tools

SystmOne

Mosaic

Microsoft Teams

Job description

Main area Discharge Planning Grade Band 6 Contract 12 months (Fixed term end date March/April 2026) Hours Part time - 21 hours per week (Flexible days Monday-Friday) Job ref 310-OPAC-7004513

Employer Cambridgeshire and Peterborough NHS Foundation Trust Employer type NHS Site Fulbourn Hospital Town Cambridge Salary £37,338 - £44,962 per annum pro rata Salary period Yearly Closing 21/05/2025 23:59

Band 6

Job overview

The post holder will demonstrate expert knowledge in discharge options, services available, whilst providing support to the patient, their family/carer and care workers in communicating the possible plan, estimated date of discharge and managing expectations and any concerns raised. The post holder will aim for a safe and sustainable discharge by highlighting and managing any potential risks thus reducing the risk of readmission.

The purpose of the role is to contribute at the multidisciplinary team meeting by ensuring that the patient’s wishes are heard, needs are assessed and are well managed to achieve a timely discharge. Also, to promote advanced care planning where appropriate to avoid unnecessary hospital admissions.

To identify social care needs of older people and to be aware of / able to access adult social care processes which facilitate the provision of care on discharge from hospital.

Main duties of the job

To act as a link between the wards and community teams/services for discharge planning.

The identification, assessment, planning, implementing and evaluating care as a practitioner with specialist Discharge Planning Skills. This involves the completion of specialist discharge planning liaising with the discharge planning nurse to complete specialist nursing assessments.

This role is to work closely with healthcare professionals, clinicians, social work teams, family members, personal care services and other multi-disciplinary team members to deliver a high quality, patient focused service

Working for our organisation

Cambridgeshire and Peterborough NHS Foundation Trust is a health and social care organisation dedicated to providing high-quality care with compassion to improve the health and wellbeing of the people we care for, as well as supporting andempowering them to lead a fulfilling life.

Our clinical teams deliver many NHS services, not only via inpatient and primary care settings, but also within the community. These services include children's, adult and older people's mental health, forensic and specialist mental health, learning disabilities, primary care and liaison psychiatry, substance misuse, social care, research and development.

To achieve our goal, we look to recruit high-calibre candidates who share our vision and values. As an equal opportunities employer, we encourage applications from all sectors of the community, particularly from under-represented groups including people with long term conditions and members of our ethnic minority and LGBTQ+ communities.

Please be advised we reserve the right to close adverts earlier than the closing date should we receive sufficient applications.

Regrettably, we cannot offer sponsorship for all our job roles. If you apply for a role that we cannot offer sponsorship for, unfortunately, your application form will be rejected from the process.

Detailed job description and main responsibilities

Please refer to the attached job description and person specification for full details of responsibilities.

1. Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act.

2. Any data that is taken/shared as part of a phone call or transported, or transferred electronically must be undertaken with regard to CPFT information Governance and information Security policies.

3. The post holder must adhere to CPFT risk assessment and risk management processes.

4. The post holder must adhere to infection control policies and procedures.

5. Undertake mandatory training and any other training relevant to the role as required by Cambridgeshire & Peterborough NHS Foundation Trust (CPFT).

6. The post holder must participate in clinical and other audits as required.

7. Provide patients and their families/carers with information on standards they should expect from the team.

8. Provide discharge planning training programmes and oversee issues across the Trusts to ensure all professional needs are met, thus ensuring the Trust’s discharge policies are adhered to.

9. Create discharge education packages appropriate to different grades/disciplines across different settings.

10. Identify, monitor, investigate and record reasons for delayed discharges and review ways of working with multi-disciplinary teams in order to reduce these delays.

Person specification

Education

• AHP/Social Work - with Relevant Degree/Diploma and registration
• Evidence of continuing Professional development
• Continuing Health Care assessment training

Experience

• Significant amount of months post registration.
• Working within older adults
• Previous experience of undertaking assessments and evaluating needs
• Experience of working in an acute setting.

Skills & Abilities

• Able to demonstrate commitment to high quality care and service provision
• Ability to work flexibly as part of a team
• Able to assess plan and implement care
• Good IT skills and ability to communicate through
• Microsoft Teams or Skype to engage family members and other professionals when they are not able to visit the ward.
• Time Management and prioritisation skills
• Audit
• Research
• Accepts responsibility and accountability for own work and can define the responsibilities of others
• Seeks and uses professional support appropriately
• Understands the principle of confidentiality
• SystmOne
• Mosaic

Here at Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) we are dedicated to providing high quality care with compassion. We deliver many of the NHS services that are provided outside of hospital and in the community such as physical, mental health and specialist services.

We are a health and social care organisation, offering a wide range of services, including:

• Integrated physical and mental health services for adults and older people;
• Specialist mental health and learning disability services;
• Children’s community services in Peterborough;
• Ground-breaking research

We strongly encourage applications from all sections of the community, particularly from under-represented groups including disabled people and members of our ethnic minorities and LGBTQ+ communities. For further information about our positive equality, diversity and Inclusion work, please visit https://www.cpft.nhs.uk/equalityanddiversity .

CPFT is looking to build upon its pool of temporary workers with Temporary Staffing Services (TSS). You will be asked at interview if you would be willing to register with TSS. This is an excellent opportunity for those looking to take on additional hours that are flexible around your personal circumstances.

Please be advised that in line with the WHO Health Workforce Support and Safeguards List, 2020 Cambridgeshire and Peterborough NHS Foundation Trust currently are unable to accept applications from overseas candidates whose country of residence is classed as a ‘Red List’ country.

Applicants who require entry into the UK will be required to provide a valid police certificate from the relevant authority from each country (except the UK) where the applicant has been present for 12 months or more, 10 years before the date of visa application, while aged 18 or over.

If you are successful at interview you will be subject to pre-employment checks, including a DBS (if appropriate), references and Occupational Health. To ensure a smooth process please bring all identity documents to your interview. A list of required identity documents will be attached to your interview invitation.

All communications will be sent to you via TRAC Systems. By applying for this post you are agreeing to CPFT transferring the information contained in this application to TRAC. If you are made an offer, information will also be transferred into the national NHS Electronic Staff Records system.

Employer certification / accreditation badges

You must have appropriate UK professional registration.

The postholder will have access to vulnerable people in the course of their normal duties and as such this post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service to check for any previous criminal convictions.