Job summary 23 hours per week - 12-months' fixed term contract. Great Development Opportunity An exciting opportunity has arisen for an experienced registered nurse to join the Discharge to Assess team. Discharge to Assess (DTA) is a multi-skilled team consisting of nurses, social workers, occupational therapists, physiotherapists, community care workers and support workers. Our purpose is to support a safe and timely hospital discharge of people who are medically fit, and no longer need hospital care, to a place more suitable to the person's needs. Assessments and care provision can then be tailored to support people to regain strengths and skills so that they can live as independently as possible. This role requires specialist nursing expertise to undertake and be responsible for completion of timely and comprehensive holistic evidence-based assessments, in a range of settings, and to apply the relevant nationally approved criteria to establish eligibility for services and care. This role may not be eligible for sponsorship under the Skilled Worker route; please refer to the Direct Gov website for more information with regards to eligibility. Please note that Livewell may close the job advertisement earlier than the specified deadline. All LW staff are expected to be able and willing to work across a 7 day service. Job Share(s) Considered Main duties of the job The post holder will be clinically responsible for the provision of quality nursing for the Discharge to Assess (DTA) Team who are referred from the acute general hospital setting. Those referred may experience a wide variety of health conditions and social care situations. To work as a member of a Multi-professional Team, delivering assessments and intermediate care ensuring high standards of clinical practice are set, monitored and reviewed.As a worker in DTA you will use broad ranging generic skills and capabilities while maintaining quality and standards in Profession-Specific skills.The team comprises Health and Social Care staff, registered and non-registered professionals, working towards integrating their approach in early supportive discharge situations and complex hospital discharges.The post holder works as assessor, responder and reviewer and provides comprehensive assessment and intervention planning, aiming to enable and empower people to remain in their own homes, or be cared for as close to home as possible, while continuing their recovery. As an experienced Nurse you will use your broad ranging skills and capabilities, undertaking an active role in assessing, planning, coordinating, delivering, developing and evaluating care to patients referred to DTA. You will supervise and manage performance of any staff line managed by this post and provide leadership for support staff through supervision and appraisal. About us Livewell Southwest is an independent, award-winning social enterprise delivering integrated health and social care services across Plymouth, South Hams, and West Devon, with specialist services in parts of Devon and Cornwall. Our teams work in community hospitals, GP practices, sports centres, and health hubs. As an organisation with a strong social conscience we are guided by our values, kindness, respect, inclusivity, ambition, responsibility, and collaboration. We focus on transforming services to ensure sustainability, while empowering staff and those we serve. We involve the people we care for, along with their families and carers, in shaping the care they receive, striving to deliver the right care at the right time and place. Centering our work on individual needs helps people lead healthy, independent lives. We prioritise employees' development, offering protected CPD time, training pathways, leadership programs, and funding for qualifications like the Care Certificate and Nurse Training Scholarships. Our induction and preceptorship programs ensure a smooth transition into our organisation. Livewell Southwest values diversity and encourages applications from all sections of the community, including those with armed forces experience, lived experience of mental health, neuro-diverse conditions and learning disabilities. If you need assistance or reasonable adjustments during the application process, contact the Recruiting Manager listed in the job advert. Date posted 27 February 2025 Pay scheme Agenda for change Band Band 6 Salary £37,338 to £44,962 a year pa, pro rata Contract Fixed term Duration 12 months Working pattern Part-time, Job share, Flexible working Reference number B9832-2025-NM-9618-2 Job locations 200 Mount Gould Road Mount Gould Plymouth Devon PL4 7PY Job description Job responsibilities The post holder will be clinically responsible for the provision of quality nursing for the Discharge to Assess (DTA) Team who are referred from the acute general hospital setting. Those referred may experience a wide variety of health conditions and social care situations. To work as a member of a Multi-professional Team, delivering assessments and intermediate care ensuring high standards of clinical practice are set, monitored and reviewed. As a worker in DTA you will use broad ranging generic skills and capabilities while maintaining quality and standards in Profession-Specific skills. The team comprises Health and Social Care staff, registered and non-registered professionals, working towards integrating their approach in early supportive discharge situations and complex hospital discharges. The post holder works as assessor, responder and reviewer and provides comprehensive assessment and intervention planning, aiming to enable and empower people to remain in their own homes, or be cared for as close to home aspossible, while continuing their recovery. You will liaise with planned resources bothinternal and external to the organisation and you will work in partnership to offer optimum opportunity for people to meet their desired outcomes. As an experienced Nurse you will use your broad ranging skills and capabilities, undertaking an active role in assessing, planning, coordinating, delivering, developing and evaluating care to patients referred to DTA. You will supervise and manage performance of any staff line managed by this post and provide leadership for support staff through supervision and appraisal. You will maintain electronic record keeping and you will have opportunities for mobile working. You will be able to demonstrate a high level of communication skills in terms of use of verbal, electronic and written formats. You will be required to engage with patients who can be challenging and /or acutely distressed. Post holders will be expected to participate in the shift patterns over a 7 day period including weekends and bank holiday. Professional /Clinical Responsibilities The Post-holder will: Work autonomously and unsupervised in the community setting, recognising the risks associated with lone working, e.g. aggressive behaviour, and work proactively to reduce those risks. To provide holistic evidence based/ best practice care to patients in accordance with National and organisation approved policies/procedures and individual care plans, examples include hospital passport, Continuing Health Care decision support tools and fast tracks. To be responsible for the assessing, planning, implementation and evaluation of patient care on a day-to-day basis, as part of a multi professional team. The work may be unpredictable and complex and often of a sensitive nature. To problem solve and liaise as soon as possible to the relevant clinician problems that may arise. To be involved in discussions around referrals and discharge planning. To undertake comprehensive risk assessments of all situations associated with the care of Patient's in order to ensure the safety of patients' carers and team members. This might include the assessment and provision of equipment ensuring it is used safely. Assess and prescribe community equipment within clinical competency, with awareness of budget requirements. The post holder is required to comply with all infection control policies and guidance, attend relevant updates and report issues of concern to their immediate line manager (if no action or explanation received, then it is the individual's responsibility to escalate to Director of Operations/ Chief executive office) To monitor and maintain the health, safety and security of self and others. To be conversant with the vulnerable adult and child protection procedures and policies of the organisation. To be responsible for organising own time management on a daily basis in line with caseload demands balancing patient needs with the administrative aspect of the role. And escalating concerns appropriately. To work within challenging and unpredictable environments e.g. patients' homes, which may have constraints and require adaptability To act as a clinical advisor on health care issues within their area of expertise and act as a Link Nurse. To provide education and continuing support to patients, family and carers. To identify areas of improvement of practice and communicate to the multi disciplinary team. To be involved with health promotion activities as required by the organisation. To be aware of organisational, professional and national developments and work within these guidelines e.g. NSF/ NICE/ NMC. To initiate and participate in Clinical Supervision, maintain professional portfolio, participate in mandatory and role specific training. To be involved in audit and research. To be aware of and abide by the organisations approved Policies, Patient Group Directives, Standards and Quality Assurance Initiatives. To be involved in all aspects of clinical governance including audits and effective and safe use of resources and equipment. Communication To report and record of all incidents and near misses relating to health, safety, security, fire, physical violence, aggression and verbal abuse. To develop and maintain effective and appropriate communication networks with other members of the wider health and social care community and other agencies. To effectively communicate with patients, their relatives and carers, including sensitive and accurate information about their condition. To provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability as well as dealing with concordance and barriers from patients to the prescribed treatment. To be able to communicate the role and eligibility criteria of the service. To maintain accurate and up to date patient records and inform other professionals about changes in patients' condition. To act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by theservice. If the post holder is supplied with a mobile phone and a lone worker device they are for work purposes and are expected to abide by policy. Management & Leadership: To share knowledge and information to promote a cohesive team. To be responsible in the absence of a senior clinician to delegate care to appropriately skilled staff and ensure that they are supported. To act as a role model for all staff and students demonstrating clinical skills and high standards of practice and professional conduct. To participate in the recruitment and selection of new staff. To participate in team activities so as to develop and consolidate a cohesive and supportive team ensuring openness within the team. To contribute to national and local policy development. To utilise resources economically and effectively and promote cost consciousness throughout the service. In collaboration with the budget holder may be an authorised signatory for ordering stores, equipment and stationary. To complete and submit in a timely manner all necessary forms, documentation, including IT data and forward as required by the manager/organisation. The post holder will be required to use a computer, being responsible for timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering. To preserve confidentiality and be aware of the Data Protection Act, Access to Health Records and Consent for Treatment. To have a flexible approach to the working day in order to meet the needs of the patient/service. To report to the line manager any untoward incidents e.g. complaints, accidents, defective equipment and take appropriate action to ensure safety of patients, relatives, self and colleagues. To be aware of pressures facing your work colleagues and offer support and ensure they are aware of organisation support services available to them. Education & Training: To maintain own professional expertise by attending meetings, study days and in-service training and learn new specialist skills required for service development. To attend and participate in working groups and research projects as required. To participate in Reflective Practice, Clinical Supervision and Appraisals as per organisation policies. Assess, teach, support, and supervise colleagues including pre and post registration nursing students and medical students. In the absence of the team manager take responsibility for the management of the team and patient care provided by the team to agreed local and national standards. Assist the manager in the appraisal of the team's effectiveness and its resources. Support the team manager in the supervision, monitoring and appraisal of the performance of registered and non-registered staff within the team. Professional: Works within the NMC Code. Remains updated and competent and ensures that clinical practice is evidence-based. Have an up to date personal development plan and professional portfolio. To participate in an annual appraisal of their work in line with the Knowledge and Skills Framework (KSF) where the job description will be reviewed and objectives set. In line with the annual development plan the post holder will be expected to undertake any training or development required to fulfil their role. Work within policies and procedures within Livewell South-West Job description Job responsibilities The post holder will be clinically responsible for the provision of quality nursing for the Discharge to Assess (DTA) Team who are referred from the acute general hospital setting. Those referred may experience a wide variety of health conditions and social care situations. To work as a member of a Multi-professional Team, delivering assessments and intermediate care ensuring high standards of clinical practice are set, monitored and reviewed. As a worker in DTA you will use broad ranging generic skills and capabilities while maintaining quality and standards in Profession-Specific skills. The team comprises Health and Social Care staff, registered and non-registered professionals, working towards integrating their approach in early supportive discharge situations and complex hospital discharges. The post holder works as assessor, responder and reviewer and provides comprehensive assessment and intervention planning, aiming to enable and empower people to remain in their own homes, or be cared for as close to home aspossible, while continuing their recovery. You will liaise with planned resources bothinternal and external to the organisation and you will work in partnership to offer optimum opportunity for people to meet their desired outcomes. As an experienced Nurse you will use your broad ranging skills and capabilities, undertaking an active role in assessing, planning, coordinating, delivering, developing and evaluating care to patients referred to DTA. You will supervise and manage performance of any staff line managed by this post and provide leadership for support staff through supervision and appraisal. You will maintain electronic record keeping and you will have opportunities for mobile working. You will be able to demonstrate a high level of communication skills in terms of use of verbal, electronic and written formats. You will be required to engage with patients who can be challenging and /or acutely distressed. Post holders will be expected to participate in the shift patterns over a 7 day period including weekends and bank holiday. Professional /Clinical Responsibilities The Post-holder will: Work autonomously and unsupervised in the community setting, recognising the risks associated with lone working, e.g. aggressive behaviour, and work proactively to reduce those risks. To provide holistic evidence based/ best practice care to patients in accordance with National and organisation approved policies/procedures and individual care plans, examples include hospital passport, Continuing Health Care decision support tools and fast tracks. To be responsible for the assessing, planning, implementation and evaluation of patient care on a day-to-day basis, as part of a multi professional team. The work may be unpredictable and complex and often of a sensitive nature. To problem solve and liaise as soon as possible to the relevant clinician problems that may arise. To be involved in discussions around referrals and discharge planning. To undertake comprehensive risk assessments of all situations associated with the care of Patient's in order to ensure the safety of patients' carers and team members. This might include the assessment and provision of equipment ensuring it is used safely. Assess and prescribe community equipment within clinical competency, with awareness of budget requirements. The post holder is required to comply with all infection control policies and guidance, attend relevant updates and report issues of concern to their immediate line manager (if no action or explanation received, then it is the individual's responsibility to escalate to Director of Operations/ Chief executive office) To monitor and maintain the health, safety and security of self and others. To be conversant with the vulnerable adult and child protection procedures and policies of the organisation. To be responsible for organising own time management on a daily basis in line with caseload demands balancing patient needs with the administrative aspect of the role. And escalating concerns appropriately. To work within challenging and unpredictable environments e.g. patients' homes, which may have constraints and require adaptability To act as a clinical advisor on health care issues within their area of expertise and act as a Link Nurse. To provide education and continuing support to patients, family and carers. To identify areas of improvement of practice and communicate to the multi disciplinary team. To be involved with health promotion activities as required by the organisation. To be aware of organisational, professional and national developments and work within these guidelines e.g. NSF/ NICE/ NMC. To initiate and participate in Clinical Supervision, maintain professional portfolio, participate in mandatory and role specific training. To be involved in audit and research. To be aware of and abide by the organisations approved Policies, Patient Group Directives, Standards and Quality Assurance Initiatives. To be involved in all aspects of clinical governance including audits and effective and safe use of resources and equipment. Communication To report and record of all incidents and near misses relating to health, safety, security, fire, physical violence, aggression and verbal abuse. To develop and maintain effective and appropriate communication networks with other members of the wider health and social care community and other agencies. To effectively communicate with patients, their relatives and carers, including sensitive and accurate information about their condition. To provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability as well as dealing with concordance and barriers from patients to the prescribed treatment. To be able to communicate the role and eligibility criteria of the service. To maintain accurate and up to date patient records and inform other professionals about changes in patients' condition. To act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by theservice. If the post holder is supplied with a mobile phone and a lone worker device they are for work purposes and are expected to abide by policy. Management & Leadership: To share knowledge and information to promote a cohesive team. To be responsible in the absence of a senior clinician to delegate care to appropriately skilled staff and ensure that they are supported. To act as a role model for all staff and students demonstrating clinical skills and high standards of practice and professional conduct. To participate in the recruitment and selection of new staff. To participate in team activities so as to develop and consolidate a cohesive and supportive team ensuring openness within the team. To contribute to national and local policy development. To utilise resources economically and effectively and promote cost consciousness throughout the service. In collaboration with the budget holder may be an authorised signatory for ordering stores, equipment and stationary. To complete and submit in a timely manner all necessary forms, documentation, including IT data and forward as required by the manager/organisation. The post holder will be required to use a computer, being responsible for timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering. To preserve confidentiality and be aware of the Data Protection Act, Access to Health Records and Consent for Treatment. To have a flexible approach to the working day in order to meet the needs of the patient/service. To report to the line manager any untoward incidents e.g. complaints, accidents, defective equipment and take appropriate action to ensure safety of patients, relatives, self and colleagues. To be aware of pressures facing your work colleagues and offer support and ensure they are aware of organisation support services available to them. Education & Training: To maintain own professional expertise by attending meetings, study days and in-service training and learn new specialist skills required for service development. To attend and participate in working groups and research projects as required. To participate in Reflective Practice, Clinical Supervision and Appraisals as per organisation policies. Assess, teach, support, and supervise colleagues including pre and post registration nursing students and medical students. In the absence of the team manager take responsibility for the management of the team and patient care provided by the team to agreed local and national standards. Assist the manager in the appraisal of the team's effectiveness and its resources. Support the team manager in the supervision, monitoring and appraisal of the performance of registered and non-registered staff within the team. Professional: Works within the NMC Code. Remains updated and competent and ensures that clinical practice is evidence-based. Have an up to date personal development plan and professional portfolio. To participate in an annual appraisal of their work in line with the Knowledge and Skills Framework (KSF) where the job description will be reviewed and objectives set. In line with the annual development plan the post holder will be expected to undertake any training or development required to fulfil their role. Work within policies and procedures within Livewell South-West Person Specification Experience Essential 2 years recent experience as a Band 5 Nurse either working in acute or community setting Ability to demonstrate transferable skills. Experience or understanding of community working. Relevant clinical experience and competence including: medicines management. Complex care co-ordination. Desirable Experience of inter-agency and partnership working. Supporting self-care, self- management and enabling independence. Managing care at end of life. Knowledge and Skills Essential Evidence of post registration development. General understanding of Continuing Healthcare and the assessment process for this. Time management. Ability to manage environmental stress. Background knowledge of Government policies relating to intermediate care and home first. Understanding of Clinical Governance Current and up to date knowledge of The Code (NMC) Excellent interpersonal skills and ability to build and maintain relationships with other health and social care professionals, patients, carers and the public. Excellent written and verbal communication skills. Ability to work autonomously without supervision Ability to adapt to the demands of a constantly changing environment. Excellent organisational skills. Ability to use support systems, good computer literacy. Desirable Knowledge of Secondary & Primary Care Sector Knowledge of Mental Capacity Act and Deprivation of Liberty. Ability to meet deadlines and work under pressure. Infection control experience Ability to discuss complex patient care with senior clinician Evidence of recent study Qualifications Essential Registered Nurse (Adult) Desirable Post qualification experience of at least 2 years Leadership qualifications. Teaching Qualification. Valid UK Driving license Person Specification Experience Essential 2 years recent experience as a Band 5 Nurse either working in acute or community setting Ability to demonstrate transferable skills. Experience or understanding of community working. Relevant clinical experience and competence including: medicines management. Complex care co-ordination. Desirable Experience of inter-agency and partnership working. Supporting self-care, self- management and enabling independence. Managing care at end of life. Knowledge and Skills Essential Evidence of post registration development. General understanding of Continuing Healthcare and the assessment process for this. Time management. Ability to manage environmental stress. Background knowledge of Government policies relating to intermediate care and home first. Understanding of Clinical Governance Current and up to date knowledge of The Code (NMC) Excellent interpersonal skills and ability to build and maintain relationships with other health and social care professionals, patients, carers and the public. Excellent written and verbal communication skills. Ability to work autonomously without supervision Ability to adapt to the demands of a constantly changing environment. Excellent organisational skills. Ability to use support systems, good computer literacy. Desirable Knowledge of Secondary & Primary Care Sector Knowledge of Mental Capacity Act and Deprivation of Liberty. Ability to meet deadlines and work under pressure. Infection control experience Ability to discuss complex patient care with senior clinician Evidence of recent study Qualifications Essential Registered Nurse (Adult) Desirable Post qualification experience of at least 2 years Leadership qualifications. Teaching Qualification. Valid UK Driving license 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). Additional information 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 Livewell Southwest Address 200 Mount Gould Road Mount Gould Plymouth Devon PL4 7PY Employer's website https://www.livewellsouthwest.co.uk/ (Opens in a new tab)