Adults Social Worker 2 yrs +

Social Worker Role Overview Transfer of Care Hub (TOCH) Post-Discharge Team

Role at a glance

A fast-paced, varied social work role supporting adults after discharge from hospital. The focus is on safe recovery at home, maximising independence and identifying the most appropriate ongoing pathway. About the service

The TOCH Post-Discharge Team is a multidisciplinary service supporting adults once they have returned home following a hospital admission. The team provides short-term, intensive intervention, with eligible clients receiving up to six weeks of enablement and rehabilitation support. The overall aim is to help people recover safely, maximise independence and reduce reliance on long-term care wherever possible.

Social workers work alongside occupational therapists, physiotherapists, nurses, enablement officers, case management officers and business support colleagues. The team also works closely with hospital services, brokerage, neighbourhood teams and other community partners to provide coordinated support and continuity between hospital and community services.

What the social worker role entails

•    Completing Care Act Assessments and reviewing a person’s eligible care and support needs following discharge. •    Completing Mental Capacity Assessments and supporting Best Interest decision-making where required. •    Undertaking welfare checks, home visits and reviews to monitor safety, wellbeing and progress. •    Reviewing existing or short-term support and helping to determine the most appropriate pathway at the end of the intervention. •    Developing care and support plans and, where necessary, completing panel submissions and coordinating with brokerage to arrange care packages. •    Identifying and responding to safeguarding concerns. Where a concern progresses to a Section 42 enquiry requiring ongoing investigation, the case may be transferred to the relevant neighbourhood team. •    Providing support and guidance regarding housing, financial assessments and direct payments where appropriate. •    Coordinating with other professionals and services, including Urgent Community Response, Virtual Ward, hospital teams and neighbourhood services. •    Maintaining accurate and timely case records, including LAS updates and relevant discharge documentation.

Caseload and pace of work

The expectation is for a social worker to receive at least three new allocations per week. However, this may be fewer depending on the complexity, level of risk and work required for the cases already allocated. The service is fast-paced, so the role requires effective organisation, prioritisation, timely recording and the ability to respond flexibly to changing needs.

Working arrangements

The role offers flexible working arrangements. Social workers can work from the office and may also work from home where appropriate. Home visits form an important part of the role, and there may occasionally be a requirement to attend face-to-face team meetings, multidisciplinary meetings, training or other service-related meetings.

What the role offers

This is a rewarding opportunity for a social worker who enjoys varied, short-term work and multidisciplinary practice. The role allows the social worker to support people at an important point in their recovery, complete a broad range of statutory social work tasks, contribute to timely decision-making and help individuals achieve the greatest possible level of independence.