Homeward Coordinating Nurse

Norfolk Community Health and Care NHS Trust


This job is now closed

Job summary

Don't miss out on this exciting opportunity to join the expanding Homeward and Unplanned Care Team. We are looking for experienced nurses who enjoy the diversity and variety of working as part of a large community multi-disciplinary team providing holistic support for patients in crises, as well as supporting people to have the highest quality of end of life care

Main duties of the job

This role involves

  • Nurse led coordinating role of the Homeward service
  • Clinical, holistic patient-centred assessments, general nursing or palliative /end of life case management reviews for patients in crisis often with complex multi-pathologies in their own homes
  • Triaging admission avoidance referrals as part of NEAT (Network of Escalation Avoidance Teams)
  • Providing structured clinical supervision, appraisal and ad hoc support for other members of staff
  • Incident review and management
  • Close working with the Clinical Operations Managers to ensure the continued successful delivery of this high quality service.

Flexibility, good communication and collaboration as part of the Homeward nursing and therapy team is essential. You will have regular supervision and professional development opportunities.

About us

Homeward is a short term admission avoidance service, primarily to secondary care, keeping people safe to remain in their own homes, including people at the end of their life, and also supporting discharges from secondary care or in-patient units. Due to the success and further expansion of our service within the Norwich Place, we are recruiting additional Band 6 nurses to the Homeward and Unplanned team at this Outstanding organisation.

Apply now to join an organisation that has been awarded an 'Outstanding' rating by the Care Quality Commission (CQC), the highest possible rating and the first stand-alone NHS community trust in the country to be awarded the title

Job description

Job responsibilities

Duties & Responsibilities

  • To assess and prescribe care packages for patients with long term conditions, the frail & elderly, palliative care, rehabilitation needs and end of life needs.
  • To work within the integrated team to facilitate early discharge from hospital
  • To work within the integrated team to prevent unnecessary admission to hospital
  • To work with all health care professionals, and statutory/non statutory agencies to provide a seamless, integrated service to our service users.
  • Respond to the deteriorating patient, assessing individual needs and escalating or intentifying the package of care required.
  • Coordination of the team on a daily basis


The post holder will:

  • Assess, plan, implement and evaluate all aspects of patient care, and develop treatment/care plans that may need to be delivered from a range of options including end of life care.
  • In relation to end of life care, following a holistic assessment, to enable patients to die in their preferred place for care
  • Following a holistic assessment, devise an individualised care programme for each patient, modifying it as required.
  • Using clinical judgement assess the level and amount of intervention required to support the individual.
  • Using clinical judgement, including risk analysis to assess each case individually regarding continued care or discharge from service. This includes informing key individuals including family or other agencies involved.
  • To ensure Best Interests decisions are communicated to the multi-disciplinary team, ensuing the family remain at the core of decision making.
  • Be aware of Assistive Technology and utilise where required.
  • Assess patients holistic needs using clinical judgement, communicating complex and sensitive information to patients and carers as to their assessment, diagnosis, prognosis and treatment plan, including informing key individuals or other agencies involved .
  • Where there are barriers to understanding, such as hearing impairment, mental capacity impairment and other difficulties in comprehension, explanations require adjustments in order to gain understanding, consent and concordance.
  • Be required to use tact and persuasive skills in order to gain the patients co-operation in their treatment/care/management plan.
  • Liaise with GPs, Social Services, inpatient teams, other allied health care professionals and the voluntary sector to ensure identified needs are met and care co-ordinated appropriately.
  • Assess and refer to a Personal Health Advisor as required.
  • Contribute to Personal Health Plans as required.
  • Be required to undertake risk assessments and act upon them appropriately.
  • To participate in multi-disciplinary/multi-agency meetings as appropriate, e.g. Gold Standard Framework.
  • Plan and organise specialist services within the integrated team.
  • Respond to medical emergencies as required
  • Support Healthcare Assistance clinically as required
  • Ensure activity data and all clinical information is recorded on SystmOne and completed on a daily basis, this includes the creation and maintenance of detailed care plans
  • Demonstrate dexterity and co-ordination when using specialist equipment and fine tools, advanced sensory skills, manual and mobilising skills.
  • Order equipment and supplies via the electronic ordering systems used within the team.
  • Ensure informed consent is obtained prior to initiating interventions.
  • Will be exposed to bodily fluids, infected material, blood products on a daily basis, therefore must utilise universal precautions and adhere to infection control policies.
  • Undertake CHC checklist and fast track assessments , referring for full assessment as appropriate
  • Receive and manage referrals from NEAT and work collaboratively with the EEast
  • Professional Responsibilities

The post holder will:

  • Be responsible for ensuring workload for self and others is planned and prioritised according to patient need, service targets and needs.
  • Ensure own paperwork and records are maintained, and those maintained by the team ensuring that all SystmOne input is correct, that reports are accurate and data analysed particularly with respect to other staff.
  • Be required to undertake risk assessments and act upon them appropriately.
  • Contribute to the supervision of workload within the integrated team, including undertaking clinical supervision.
  • Be aware of budget and ensure all effort is made to work within this.
  • Actively contribute to multidisciplinary team meetings and other meetings where appropriate.
  • Support all team members within the integrated team, respecting them, their roles and contributions.
  • Provide support and advice to Healthcare Assistants either by telephone or in person as appropriate
  • Attend in-house training as required to develop current job role.
  • Will be able to make own travel arrangements to patients homes, clinics, base and meetings etc, as required.
  • Be responsible for safe use and maintenance of equipment and supplies.
  • Remain accountable for own professional actions as determined by the professional bodies.
  • Actively ensure the service has adequate staffing 7 days a week
  • Will be required to demonstrate own duties to students, new starters and/or less experienced staff.
  • Identify needs for own and others professional development
  • Provide mentorship for students undertaking pre/post registration course.
  • Provide advice/training to less experienced staff and supervise and support band 3 and 4 and 5 staff; and students where appropriate.
  • Mentor existing staff and provide training in specialist area as appropriate.
  • Contribute to the induction process for new staff/students.
  • Demonstrate basic IT/standard keyboard skills
  • Demonstrate leadership skills within own competence
  • Maintain own continuous professional development.
  • Be aware of the Trusts behaviour framework and ensure behaviours are displayed and embedded in the role
  • Undertake mandatory training as required
  • Organisational
  • The post holder will:
  • Participate in an annual Personal Development Review.
  • Undertake Personal Development Plans for more junior staff members.
  • Take part in clinical supervision as per Trust Policy.
  • Follow Trust policies, and local procedures, and use discretion in interpreting them according to the setting and circumstances.
  • Comment on draft policies.
  • Ensure absence reporting is undertaken as determined by Team Leader and Trust Policy.
  • Contribute to clinical audit as required.
  • Complete the staff survey as required.
  • Complete risk assessments, RCAs and DATIX as required.
  • Be involved in the recruitment and selection of staff

Person Specification



  • Registered general nurse
  • Assessor/mentorship preparation; ENB 998 or equivalent
  • Evidence of continuing professional development
  • Current NMC registration


  • Independent/supplementary prescribing qualification
  • Consultation skills



  • Evidence of working at band 5 level within the community setting
  • Knowledge of additional specialist areas through in-house training & short courses

Skills, Abilities and Knowledg


  • Highly motivated
  • Able to provide high standards of care
  • Ability to use own initiative
  • Ability to manage stressful situations
  • Concentrate when undertaking patient care & inputting data/patient records
  • A team player
  • Work flexibly to accommodate patient/service needs.



  • Good communication skills
  • Good observational & reporting skills
  • Good interpersonal skills
  • Able to communicate effectively in written and verbal English Language
  • Tact & diplomacy
  • Empathy & sensitivity

Personal Attributes


  • Be able to kneel, bend & stoop, and work in cramped environments
  • Be able to Manoeuvre limbs of around 5-6 kg
  • Be able to manoeuvre patients using handling aids



  • Able to identify with the Trust's commitment to safeguarding and promoting the welfare of children and young people/vulnerable adults.

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.

Certificate of Sponsorship

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).

Employer details

Employer name

Norfolk Community Health and Care NHS Trust


Norwich Community Hospital



Employer's website

https://www.norfolkcommunityhealthandcare.nhs.uk (Opens in a new tab)

For questions about the job, contact:

Cheryl Mortimer



Date posted

04 April 2022

Pay scheme

Agenda for change


Band 6


£32,306 to £39,027 a year pro rata pa



Working pattern

Full-time, Part-time

Reference number


Job locations

Norwich Community Hospital



Supporting documents

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