Specialist Social Worker

Job overview

This post will work across the life span of both Paediatric and Adult Cystic Fibrosis patients. The post holder will provide a social work service to meet the needs of children, adolescents and adults with their families who have CF. The service framework is set out by the Regional Cystic Fibrosis Clinical Network and from national guidelines for best practice.

Working as part of the core MDT with an important role in supporting, assisting  patients and families to enable them to manage the many psychosocial and practical issues. Supporting patients and their families with the challenges associated with living with CF.

Support will also be around the impact of CF at key stages such as diagnosis, transition, deteriorating health, transplantation and end of life care.

The CF teams work together to provide a seamless service and this post will be integral in linking both teams as it will contribute and be proactive within transition to ensure a smooth preparation and transfer to adult care.

The philosophy of the CF services is to provide patient and family centred care and there is a strong MDT to support this.

The post holder will work across inpatient, outpatient, and community settings. The role includes collaboration with statutory and voluntary agencies to ensure coordinated, patient-centred care across organisational and geographical boundaries.

The SW will play a key role in addressing barriers to  engagement, and promoting wellbeing across the lifespan.

Main duties of the job

• Manage a caseload of patients with cystic fibrosis across children’s and adult services.
• Undertake holistic psychosocial assessments and develop care plans in collaboration with patients and families.
• Provide emotional support and brief interventions to support adjustment, coping, and engagement with treatment.
• Identify and address barriers to treatment adherence, including social, psychological, and practical factors.
• Provide advice and support regarding welfare benefits, housing, education, and employment.
• Act as an advocate for patients and families within health, social care, and other agencies.
• Work as a core member of the cystic fibrosis MDT, attending clinics, ward rounds, and team meetings.
• Liaise and work jointly with local authority teams, community services, and outlying providers.
• Contribute to safeguarding processes for children and adults, including risk assessment and information sharing.
• Undertake community visits, including home visits, where appropriate.
• Maintain accurate and timely clinical records.
• Participate in supervision, training, and continuing professional development.
• Contribute to service development, audit, and quality improvement activities.

Detailed job description and main responsibilities

Undertake comprehensive psychosocial assessments, considering the impact of cystic fibrosis on emotional wellbeing, family functioning, and daily living.

Demonstrates awareness and is mindful of Local Authority Social Services policies and procedures.

Develop, implement, and review care plans in partnership with patients, families, and the MDT.

Provide ongoing support to patients and families across the disease trajectory and deliver brief psychosocial interventions to support coping, adjustment, and engagement.

Responds independently to crises and the needs of the patients in conjunction with medical staff, psychological professionals, and the multi-disciplinary team

Demonstrates knowledge of, and understanding of, the voluntary sector services across the Trust’s geographical area and the wider region covered by the role, so as to be able to signpost and refer to services appropriate to individuals’ needs.

Regularly support individuals and families who are coming to terms with the trauma of diagnosis and managing a lifelong illness.

Ability to undertake difficult conversations with people who may be experiencing high levels of psychological distress and/or complex mental health difficulties.

Family and Lifespan Working

Work effectively with children, young people, adults, and families, adapting approaches to developmental and individual needs.

Support parents and carers in managing the impact of cystic fibrosis on family life and contribute to planning and supporting transition from paediatric to adult services.

Advocacy and Practical Support

Provide information, advice, and practical support relating to welfare benefits, financial hardship, housing needs, accommodation issues, education, and employment. Advocate on behalf of patients and families with statutory services, healthcare providers, and voluntary organisations.

MDT and Partnership Working

Work as an active member of the cystic fibrosis MDT and attend outpatient clinics, ward rounds, and MDT meetings. Liaise with professionals in local authority services, community teams, and outlying or non-specialist services to promote continuity of care.

Safeguarding and Risk Management

Identify safeguarding concerns in line with statutory guidance and local procedures. Undertake risk assessments, contribute to safeguarding plans, and work collaboratively with safeguarding partners.

Community and Outreach Working

Undertake home visits and community-based work where appropriate and support patients who may find it difficult to engage with hospital-based services.

Develop positive working relationships with other organisations, including the CF trust, other CF hospital centres, and third-sector organisations.

Professional Responsibilities

Maintain registration with Social Work England and adhere to professional standards. Participate in supervision, appraisal, and continuing professional development.

Keep up to date with trust training requirements and social work research/training

Is professionally accountable for all aspects of work according to professional code of conduct.

Demonstrates awareness and good working knowledge of statutory legislation and practice guidance applicable to children and adults.

Ensure all child protection, adult safeguarding, Mental Capacity Act issues are responded to according to policy and procedure.

Service Development and Quality Improvement

Contribute to audit, evaluation, and service development initiatives and support student placements where appropriate.