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Virtual Ward Co-ordinator

South Tyneside and Sunderland NHS Foundation Trust
£43,742 to £50,056 a year
Closing date
29 Sep 2023

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Other Health Profession
Band 7
Contract Type
Full Time

The position is a permanent post but would also welcome any applicants who would like to explore/consider a secondment opportunity for a minimum period of 12 months

The Virtual Ward initiative is a new opportunity for Recovery at Home who currently provide Urgent Community Response to increase their capacity to support patients to receive hospital at home care across Sunderland and South Tyneside. The teams are based in Clarendon in Hebburn and Lechmere in Sunderland.

We are inviting potential candidates to come and meet the team and discuss the post, on the 21stAugust at 9am at Leechmere and 22ndAugust 9am at Clarendon if you would like to attend, please contact us we look forward to hearing from you.

Main duties of the job

This is a new and exciting initiative we are looking for an individual that fits the job description criteria.

The skills we need are extensive experience working with multi professional teams, strong leadership and communication skills.

Acute and community experience would support this role along with the ability to take patients histories, assess their need and make a clinical decision.

As a band 7 you will be part of the leadership support to the whole team and able to support junior staff with their development.

The role will cover 24 hours 7 days a week as a full time employee you will have the opportunity to work over 3 long days.

Support and development is key to roles in this Trust, you will have a supportive yearly appraisal and development plan.

As a new role and service you will be key to the service development and implementation.

A site visit or a discussion with the team manager would be advisable.

About us

Please help us by adding your telephone number to your application form this will allow us to contact you quickly if required.

One Team One Trust - There are many reasons to work at our Trust. From our commitment to putting people first to our accessible services and award winning teams. We have a passion for research, innovation and tackling inequalities. We are committed to respect, fairness and civility and promote a compassionate, caring and positive culture / working environment.

We welcome all applications irrespective of peoples race, disability, gender, sexual orientation, religion/belief, age, gender identity, marriage and civil partnership, pregnancy/maternity and in particular those from under- represented groups. Looking after our workforces health and wellbeing is a priority for STSFT. We also provide access to high quality education, training, career progression and support.

The Trust employs around 8,300 people and provides a range of hospital services to a local community of around 430,000 residents. We also provide a range of more specialised services outside this area, in some cases to a population as great as 860,000. We offer our staff outstanding benefits - Fitness Centre (SRH), libraries at both hospital sites, chaplaincy support and access to a Childcare Co-ordinator to help staff with childcare arrangements.

Job description

Job responsibilities


Main Purpose of the Job:

The post holder will work as a senior Coordinator for the Recovery at Home Team, based within the Hospital site and Community Site when needed.

The post holder will need to work closely with key stakeholders within the Acute Trust and including all Community Services delivering a community driven, discharge to assess approach to discharge enabling the effective flow of people into the right service at the right time.

Where necessary such as at the point of discharge from the virtual ward, the post holder should ensure good communication and joined up working is in place with the person's registered GP practice

To work autonomously, assessing an individual patients needs, identifying people appropriate for Virtual Ward based care: determining a plan of care and initiating appropriate holistic, research-based health information and care.

To work within agreed Trust Pathways of Care, ensuring safe, prompt and effective decision making.

Lead and manage a Multi-disciplinary Team to ensure the day-to-day operational delivery of high-quality care for those patients admitted to the Virtual Ward. This role will include working across the wider health system to ensure the delivery of proactive management of this group of patients

Work collaboratively with Multi-Disciplinary Teams to ensure practice is efficient, effective, evidence based and to help create clinical management plans to support patients to remain safely at home.

To act as a resource for all members of the Multi-Disciplinary Team, providing expert advice concerning aspects of the persons management plan.

Alongside the Virtual Ward team to deliver effective communication about the virtual ward patient with the person's registered general practice, ensuring that information is conveyed appropriately and supports delivery of a seamless care pathway

As Virtual Ward Coordinator, you will ensure successful and timely onward transition to the next step in a persons pathway.

The Virtual Ward Coordinator will use a problem- solving approach, working with members of the multidisciplinary team to facilitate effective discharges into the Virtual Ward, with a focus on a persons clinical and holistic needs working within the Virtual Ward pathways

To work to ensure a seamless interface between acute colleagues identifying people medically fit for discharge, then ready to leave hospital.

To contribute to the overall management and development of the service

To lead, motivate and support the colleague's approach to delivering new and innovative models of care for people.

To lead a continuously improving service, by ensuring systems are in place to support clinical governance, quality monitoring and ongoing research and audit of practice.

Ensure systems and processes are in place to maintain patient safety.

To be responsible for ensuring that agreed professional standards are reflected in practice and to have overall responsibility for monitoring the standard of care.

To improve the patient journey by increasing access to assessment and appropriate care and treatment, by auditing and reviewing the Virtual Ward regularly

Support the development and delivery of new national initiatives both in relation to, Virtual Wards

Proactively plan for and enable timely discharge of patients from the Virtual Ward, liaising with other agencies to provide ongoing care if required

The role may include caring for people and their relatives/informal carers who are anxious, confused or distressed and clear communication skills and empathy is required to offer reassuring and guidance. A part of each working day involves talking to patients either via the telephone, videocall or face to face.

Provide a high-quality support service to patients on the Virtual Ward caseload.

Promote the knowledge and understanding of the range of services available across organisations

Act as a link person between the wider Virtual Ward team and other agencies, maintaining and promoting positive working relationships with all referring agencies

Participate in the development of initiatives within the service

If required, will manage staff including assuring completion of supervision, appraisals and compliance with mandatory training

Oversee and delegate remote monitoring of patients across a variety of clinical pathways including respiratory and frailty

Undertake clinical assessment of patients on the Virtual Ward and develop, implement and evaluate care and treatment plans.

Use their advanced assessment skills to assess patients who are on the virtual ward, and whose observations taken via remote monitoring require further assessment and review face to face.

Ensure there is an effective referral pathway for the Virtual Ward including initial triage. Referrals will be received

The Virtual Ward Coordinator will support caseload management, ensuring that service delivery is implemented to the highest standard inclusive of best practice and utilises a patient centred approach.

The Virtual Ward Coordinator will be a liaison and a single point of coordination for those readmitted to Hospital or stepped up to SDEC for investigations. The Coordinator will discuss the outcome of assessments with the clinical team and support, where possible a timely discharge back to the Virtual Ward.

The post holder will provide patients with a physical health and biopsychological assessment and where necessary will complete frailty assessments for frailty patients. In partnership with the Frailty Team ensure monitoring of Clinical Frailty Score for all patients identified with frailty alongside a Comprehensive Geriatric Assessment.

To work alongside Assistive Technology teams to ensure that all patients have access to tablet and a data connection.

The post holder will demonstrate detailed knowledge of digital monitoring and be able to support patients with familiarising themselves with technology and monitoring devices such as BP or SP02 monitors.

Person Specification



  • Degree in a health-related subject and current professional registration (NMC or HCPC)
  • Mentorship/ Practice Assessor/ Educator qualification or equivalent qualification or equivalent
  • Advanced physical assessment and history taking course


  • Masters in health / leadership related subject
  • Management and leadership training
  • ILM qualification
  • Independent NMP Prescribing Qualification



  • Extensive post registration experience, some of which will be at a senior level within the required specialist area of practice
  • Portfolio of evidence of continuous professional development
  • Experience of practice development, clinical education or leading change
  • Experience of leading clinical Audits
  • Experience of working in Community/Acute Setting with experience of managing frailty and or patients with long term conditions.
  • Previous experience of multiagency collaboration working across professional boundaries
  • Experience of practice development, clinical education or leading change in practice to upskill and support staff
  • Clinically credible, with significant experience at Senior Nurse level


  • Caseload management
  • Involvement in service review and development
  • Knowledge of Digital Health Monitoring Systems

Skills and Knowledge


  • Demonstrable leadership skills and an understanding of own leadership style
  • Excellent interpersonal and communication skills
  • Evidence of ongoing professional development,
  • Expert assessment, analytical, interpretation and clinical decision making
  • Ability to work autonomously within role in a complex / changing environment
  • Significant knowledge of Community service provision, including social care and charity delivered services
  • Knowledge and understanding of relevant National polices and guidelines relevant to the area (admission avoidance and early supported discharge services)
  • In depth knowledge of frailty and Long-Term Conditions
  • Ability to effectively challenge stakeholders while maintain professional relationships
  • Excellent written and verbal communication skills
  • Effective time management skills
  • Effective team working
  • Effective planning and organisational skills - ability to prioritise workload
  • Competent in IT skills


  • Caseload management
  • Understanding of budget and financial control systems
  • Research skills
Any attachments will be accessible after you click to apply.


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