Job responsibilities
KEY DUTIES
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 St Helens hospital discharge team, 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 St Helens according to agreed criteria.
Undertake nursing assessments of patients referred for a Care Home on discharge on behalf of care home providers in St Helens 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 Care Arranging team and Local Authority commissioner 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 St Helens Integrated Hospital Discharge Team, Care Arranging 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.
The Trust is a non-smoking site. Failure to follow this rule could lead to disciplinary action.
GENERAL DUTIES
To observe the provisions of and adhere to all Trust policies and procedures.
To actively participate in the annual performance review to identify personal development needs
To attend Trust Statutory and Mandatory training sessions as required and any other training courses relevant to the post.
To fully comply with the relevant sections of the Health and Safety at Work Act. They must also understand and implement Mersey and West Lancashire Hospitals NHS Hospitals Trust Statement of Policy on Health and Safety at Work and the Trust corporate Health and Safety Policies and Procedures. You are required to follow all applicable rules and procedures relating to Health and Safety at Work and to take all responsible precautions to avoid actions.
To be aware of the confidential aspects of the post. To keep up to date with the requirements of information governance; undertake mandatory training and follow Trust policies and procedures to ensure that trust information is dealt with legally, securely, efficiently and effectively. Breaches of confidentiality will result in disciplinary action that may involve dismissal. You must maintain the confidentiality of information about service user staff and organisational business in accordance with the General Data Protection Regulation 2018 (GDPR) and Caldicott principles.
The post holder should also be aware that, regardless of any action taken by the employing authority, breaches of confidentiality could result in civil action for damages.
All staff will be treated with respect by management, colleagues, patients and visitors and equally staff will treat management, colleagues, patients and visitors with the same level of respect. Staff will be supported to challenge any discriminatory behaviour that may be based on differences in race, disability, language, culture, religion, sexuality, age, and gender or employment status.
You will be expected to undertake the Trusts commitment to safeguarding and promoting the welfare of children, young people and vulnerable adults.
To ensure that when creating, managing and sharing information records it is done in an appropriate way, subject to statutory requirements and agreed security and confidentiality policies, procedures and guidelines. All employees are responsible for implementing and maintaining data quality, ensuring that records are legible and attributable and that the record keeping is contemporaneous
In accordance with the Health and Social Care Act 2008, the post holder will actively participate in the prevention and control of infection within the capacity of their role. The Act requires the post holder to attend infection prevention and control training on induction and at regular updates and to take responsibility for the practical application of the training in the course of their work. Infection prevention and control must be included in any personal development plan and/or appraisal.
To adhere to relevant Code of Practice of Professional body (if appropriate)
The post holder must be flexible in the duties performed and it is expected that similar duties, not specifically listed above, will be carried out as required and may be cross site.
The duties contained in this job description are not intended to be exhaustive. The duties and responsibilities of this post are likely to evolve in line with the Trusts continued organisational development.
To adhere to the NHS Constitution and its principles and values. You must be aware of your Duty of Candour which means that you must be open and honest during your employment and if you see something wrong, you must raise it. You must read the NHS Constitution in full and can download this from the Trusts intranet site or the www.gov.uk website. Hard copies are available from the HR Department on request.
The Trust is a non-smoking site. Failure to follow this rule could lead to disciplinary action.
