Job summary
37.5 hours per week
An exciting opportunity has arisen within our Bed Bureau Service for a
highly motivated individual who has the relevant transferable skills to join
our team as an assessor.
This post will support the improvement in hospital discharge
arrangements from Derriford and Mount Gould hospitals to nursing and
residential homes in Plymouth. Working closely with the Bed Bureau Manager and
the local authority's Quality Assurance & Improvement Team (QAIT) in
improving patient experience, clinical safety and patient flow.
The post holder will act on behalf of care home providers to ensure
appropriate care plans are in place, to support and facilitate timely and safe
discharges from hospital to care homes, providing expert nursing knowledge and
advice to the processes of assessment of individuals for care home placements.
The post would suit a dynamic individual who is committed to the
delivery of excellent care and collaborative working. We are seeking a
dedicated individual with a high level of emotional intelligence, excellent
communication, and interpersonal skills. You will be required to work with a
wide variety of stakeholders, including patients and public, University
Hospitals Plymouth NHS Trust, Livewell Southwest, the local authority, and the
ICB.
Staff are currently working a hybrid model of office, community and home
working and the role will require travel across multiple sites.
Main duties of the job
- Working with Integrated hospital, Community discharge teams and Devon ICB, in developing processes for referrals and assessments and work within agreed assessment formats with adherence to established pathways.
- Responsible for the management of junior staff.
- Promote timely discharge to Care Home setting, where this is the persons existing home or a new placement - advising hospital staff on the care/facilities within Care Homes and the community support to Care Homes on discharge.
- Liaising with Community Teams and other Specialist Nurses and professionals to support person centred care planning appropriate to the complex needs of individuals ensuring that arrangements are made for input/training/follow-up with specialist teams where necessary.
- Work in partnership with care home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues, access to specialist advice, training of Care Home staff.
- Report on issues raised by Care Homes about quality of discharge, working closely with the lead Trusted Assessor, Integrated Hospital Discharge Team and Bed Bureau.
- Working with the Plymouth QAIT team, Care Home liaison service and Bed Bureau to facilitate the further development and implementation of best practice, good partnership working and communications within the Care home community.
About us
Livewell Southwest is an independent, award-winning social enterprise providing integrated health & social care services for people across Plymouth, South Hams & West Devon, as well as some specialist services for people living in parts of Devon & Cornwall. With teams in community hospitals, GP practices, sports centres, health & wellbeing hubs.
As an organisation with a strong social conscience, we always value being kind, respectful, inclusive, ambitious, responsible and collaborative. Transforming services to make them sustainable, ensuring that we value, support & empower each other.
We are committed to involving the people we care for, families & carers in everything that we do, working towards co-production where we can. Helping us to deliver the right care for people, in the right place & at the right time. By putting people at the centre of what we do, we ensure to support people to lead, healthy independent lives & be the very best at helping people to live well.
Valuing our employees making an investment in their development a priority. We offer:
Protected CPD time for registered staff
Various development pathways and ongoing regular training packages for all staff
Leadership & mentoring programmes
Access & funding for training including Care Certificate, Assistant Practitioners Course & Scholarship into Nurse Training
A Robust Preceptorship
A bespoke induction programme
Existing members of the NHS Pension Scheme can continue their membership when they join the organisation.
Job description
Job responsibilities
Key Tasks & Responsibilities
- Support improvement in hospital discharge arrangements from hospital to Care Homes and thus improve patient experience, clinical safety and patient discharge.
- Promote person-centred discharge planning to Care Home settings, ensuring that relevant risk assessments, complex needs and patient information are all provided in detail, as part of the discharge plan from hospital.
- Facilitate discharge where issues have arisen which could compromise the quality or timeliness of discharge from hospital, working with all relevant staff across organizational boundaries with a problem-solving approach
- This post is to work with hospital discharge teams, to act on behalf of care home providers, to ensure appropriate nursing risk assessments and care plans are in place, to support and facilitate timely and safe discharges from hospital to care homes.
- Assist Care Home Managers with their assessment process by liaising with Care Homes, where there is an existing resident in hospital, for whom there is a potential change of needs. Undertaking assessments of new patients, on behalf of care home staff.
- Although this post will primarily focus on the assessments of patients with complex needs awaiting discharge to Care Homes - other residents, who have complex needs from other Care Home settings may also need input from the Trusted Nurse Assessor.
Knowledge & Skills - Undertake nursing assessments and re-assessments of hospitalised Care Home residents, on behalf of care home providers in Plymouth according to agreed criteria.
- Undertake nursing assessments of patients referred for a Care Home on discharge on behalf of care home providers in Plymouth according to agreed criteria identifying the nursing needs of patients with complex presentations and ongoing nursing needs.
- Provide data for reporting information as agreed on assessments, information dissemination, discharges, bed-days saved, case studies.
- Work closely with the Bed Bureau Manager to identify gaps in the market and provide data to support future commissioning intentions and/or projects.
Communication & Relationships
- Act as a point of contact for ward staff/MDT/care homes, when residents are admitted to hospital from a Care home setting, to monitor progress and keep on-going communications.
- Work in partnership with care home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues, access to specialist advice, training of Care Home staff.
- Working with Integrated Hospital Discharge Team, Bed Bureau, Quality Improvement Team and care home liaison service to deliver training and guidance to Care home and hospital staff, relating to admission and discharge processes organise specialist training from other teams, where this is needed.
- Act in a supervisory role, to support, advise and empower Care Home staff to deliver specific elements of care to individuals with complex needs.
Contributing to Integrated Care - Ensure that wherever possible the views and needs of older people within the care home setting are sought and represented with due regard to the persons mental capacity.
- Work with clinical teams on the wards, to ensure that discharge documentation, risk assessments, clinical equipment and medication are in place to accompany the resident on hospital discharge.
- Liaise with care homes about the discharge arrangements in order to streamline the process and ensure the best possible outcomes for vulnerable people.
For full details please refer to job description in supporting documents section.
Job description
Job responsibilities
Key Tasks & Responsibilities
- Support improvement in hospital discharge arrangements from hospital to Care Homes and thus improve patient experience, clinical safety and patient discharge.
- Promote person-centred discharge planning to Care Home settings, ensuring that relevant risk assessments, complex needs and patient information are all provided in detail, as part of the discharge plan from hospital.
- Facilitate discharge where issues have arisen which could compromise the quality or timeliness of discharge from hospital, working with all relevant staff across organizational boundaries with a problem-solving approach
- This post is to work with hospital discharge teams, to act on behalf of care home providers, to ensure appropriate nursing risk assessments and care plans are in place, to support and facilitate timely and safe discharges from hospital to care homes.
- Assist Care Home Managers with their assessment process by liaising with Care Homes, where there is an existing resident in hospital, for whom there is a potential change of needs. Undertaking assessments of new patients, on behalf of care home staff.
- Although this post will primarily focus on the assessments of patients with complex needs awaiting discharge to Care Homes - other residents, who have complex needs from other Care Home settings may also need input from the Trusted Nurse Assessor.
Knowledge & Skills - Undertake nursing assessments and re-assessments of hospitalised Care Home residents, on behalf of care home providers in Plymouth according to agreed criteria.
- Undertake nursing assessments of patients referred for a Care Home on discharge on behalf of care home providers in Plymouth according to agreed criteria identifying the nursing needs of patients with complex presentations and ongoing nursing needs.
- Provide data for reporting information as agreed on assessments, information dissemination, discharges, bed-days saved, case studies.
- Work closely with the Bed Bureau Manager to identify gaps in the market and provide data to support future commissioning intentions and/or projects.
Communication & Relationships
- Act as a point of contact for ward staff/MDT/care homes, when residents are admitted to hospital from a Care home setting, to monitor progress and keep on-going communications.
- Work in partnership with care home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues, access to specialist advice, training of Care Home staff.
- Working with Integrated Hospital Discharge Team, Bed Bureau, Quality Improvement Team and care home liaison service to deliver training and guidance to Care home and hospital staff, relating to admission and discharge processes organise specialist training from other teams, where this is needed.
- Act in a supervisory role, to support, advise and empower Care Home staff to deliver specific elements of care to individuals with complex needs.
Contributing to Integrated Care - Ensure that wherever possible the views and needs of older people within the care home setting are sought and represented with due regard to the persons mental capacity.
- Work with clinical teams on the wards, to ensure that discharge documentation, risk assessments, clinical equipment and medication are in place to accompany the resident on hospital discharge.
- Liaise with care homes about the discharge arrangements in order to streamline the process and ensure the best possible outcomes for vulnerable people.
For full details please refer to job description in supporting documents section.
Person Specification
Skills & Attributes
Essential
- Ability to communicate effectively (written, verbal and non verbal communication) with patients/relatives and carers and all members of the multi-disciplinary team.
- Ability to develop effective and appropriate relationships with people, their families, carers and colleagues
- Ability to advocate on behalf of service users
- Good listening /observation skills
- Confident in own clinical decisions
- Courteous, respectful, and helpful at all times
- Ability to work on own initiative
- Ability to organise and prioritise own delegated workload
- Ability to take part in reflective practice and clinical supervision activities
- Commits to maintaining personal development and meeting requirements of revalidation
- Ability to deliver training
- Meets requirements of all Nursing & Midwifery standards
- Ability to deal with non-routine and unpredictable nature of the workload and individual patient contact
Desirable
- Established liaison and negotiation skills.
Qualifications
Essential
- Registered Nurse on the NMC register.
- Educated to degree level in relevant subject or equivalent level qualification or significant experience of working at a similar level in specialist area.
- Registered General Nurse with relevant CPD and recent clinical experience.
Experience
Essential
- Demonstrable experience completing nursing assessments
- Involvement in patient transfer processes from a variety of settings
- Demonstrable experience of Multi-agency working
- Experience of and the ability to work effectively as a team player under appropriate supervision, and as part of a multi-disciplinary team
- Ability to work independently with a delegated caseload, use initiative whilst understanding limits of scope
- Experience of providing and receiving complex, sensitive information
- Insight into how to evaluate own strengths and development needs, seeking advice where appropriate
- Ability to support the development of less experienced staff
Desirable
- Experience of delivering clinical training.
- Experience of working in hospital setting.
Knowledge
Essential
- Knowledge and demonstrable experience of clinical assessment tools.
- Knowledge of long term condition management/case management.
- Knowledge of Mental Capacity Act.
- Understanding of Safeguarding policies.
- Understands and acts in line with NMC professional standards for practice contained within The Code, including requirements for professional Revalidation.
- Understanding of evidence-based practice.
- Understanding of the importance of following procedures and treatment plans.
- Knowledge of when to seek advice and escalate to the appropriate professional for expert help and advice.
Desirable
- Knowledge of current standards of healthcare.
Person Specification
Skills & Attributes
Essential
- Ability to communicate effectively (written, verbal and non verbal communication) with patients/relatives and carers and all members of the multi-disciplinary team.
- Ability to develop effective and appropriate relationships with people, their families, carers and colleagues
- Ability to advocate on behalf of service users
- Good listening /observation skills
- Confident in own clinical decisions
- Courteous, respectful, and helpful at all times
- Ability to work on own initiative
- Ability to organise and prioritise own delegated workload
- Ability to take part in reflective practice and clinical supervision activities
- Commits to maintaining personal development and meeting requirements of revalidation
- Ability to deliver training
- Meets requirements of all Nursing & Midwifery standards
- Ability to deal with non-routine and unpredictable nature of the workload and individual patient contact
Desirable
- Established liaison and negotiation skills.
Qualifications
Essential
- Registered Nurse on the NMC register.
- Educated to degree level in relevant subject or equivalent level qualification or significant experience of working at a similar level in specialist area.
- Registered General Nurse with relevant CPD and recent clinical experience.
Experience
Essential
- Demonstrable experience completing nursing assessments
- Involvement in patient transfer processes from a variety of settings
- Demonstrable experience of Multi-agency working
- Experience of and the ability to work effectively as a team player under appropriate supervision, and as part of a multi-disciplinary team
- Ability to work independently with a delegated caseload, use initiative whilst understanding limits of scope
- Experience of providing and receiving complex, sensitive information
- Insight into how to evaluate own strengths and development needs, seeking advice where appropriate
- Ability to support the development of less experienced staff
Desirable
- Experience of delivering clinical training.
- Experience of working in hospital setting.
Knowledge
Essential
- Knowledge and demonstrable experience of clinical assessment tools.
- Knowledge of long term condition management/case management.
- Knowledge of Mental Capacity Act.
- Understanding of Safeguarding policies.
- Understands and acts in line with NMC professional standards for practice contained within The Code, including requirements for professional Revalidation.
- Understanding of evidence-based practice.
- Understanding of the importance of following procedures and treatment plans.
- Knowledge of when to seek advice and escalate to the appropriate professional for expert help and advice.
Desirable
- Knowledge of current standards of healthcare.
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).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
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).
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
