Job summary JOB PURPOSE The focus of the Complex Discharge Service is to support the timely identification, assessment and support for discharge to the most vulnerable patients in the Royal Surrey. The Complex Discharge Service supports the identification and planning of complex discharge in addition to ensuring patients are transferred to the most appropriate care setting in a timely manner whilst providing a safe, effective and positive patient experience. The principle responsibilities of this team are: To provide clinical expertise and decision-making for timely effective discharge and the management of patients admitted from care home. To provide clinical expertise and decision-making for timely effective discharge and the management of patients referred to the Complex Discharge Service Work with the Team Lead and provide support the Complex Discharge Coordinators, providing guidance and oversight to ensure high standards of care and service delivery. Conduct and oversee mental capacity assessments to determine patients' ability to make informed decisions about their care. Make and support best interest decisions for patients who lack capacity, ensuring their needs and preferences are prioritised. Act as the primary point of contact between the hospital, care providers, and community services to ensure coordinated and continuous care. Main duties of the job JOB SUMMARY: To work with the team lead to prioritise and allocate workload on a daily basis, liaising with other teams as required to identify new patients admitted or referrals. To assess all newly admitted patients within allocated workload to devise a Transfer of Care management plan. This will involve understanding the patient's current condition and previous level of functioning. Information will be obtained from families/carers. GP's, Community Providers, Social Care and other relevant providers to identify and address issues early that may impact on a timely transfer of care. To have an in-depth knowledge of all aspects of care and discharge pathways and utilise a holistic knowledge and expertise to assist in leading the MDT to support timely discharge. To ensure the patient and family are informed on admission about the transfer of care process and agree and negotiate how they will be involved throughout the patient journey. To be the point of contact for patients/families, care homes and carers for issues relating to transfers of care and identifying concerns or potential complaints early. About us Royal Surrey is a compassionate and collaborative acute and community Trust. Recognising that our 5000 colleagues are our greatest strength, we offer a comprehensive health and wellbeing program along with a commitment to developing and advancing your career. Our diverse and welcoming Royal Surrey family will ensure you that you feel valued from your initial interview through your entire tenure. We are clinically led and provide joined up care by bridging the gap between hospital and community services alongside regional specialist cancer care. Our main acute hospital site is in Guildford with community hospital sites at Milford, Haslemere and Cranleigh. We provide adult community health services in homes across Guildford and Waverley. The Care Quality Commission (CQC) have given us an overall rating of Outstanding. Royal Surrey has a strong reputation and history to build on. We are proud of our achievements and we are investing in our colleagues through our commitment to supporting professional development as well as investing more than £45 million in our physical environment and new equipment in the next few years. There has never been a better time to join us. Although it isn't the Trusts normal practice, adverts may close early, so you are encouraged to submit an application as soon as possible. A video about the Royal Surrey - https://www.youtube.com/watch?vR96pMboIYdo Date posted 14 February 2025 Pay scheme Agenda for change Band Band 6 Salary £37,162 to £44,629 a year Per annum (pro rata) inc HCAS Contract Fixed term Duration 10 months Working pattern Full-time Reference number 384-AGB-EMF17028-A Job locations Royal Surrey County Hospital Egerton Road Guildford GU2 7XX Job description Job responsibilities CASE MANAGER Permanent Full Time 37.5 hours per week x 1 maternity leave cover Salary: Band 6 Do you have a passion for complex discharge planning or are you interested in developing your knowledge and skills in this area? We are looking for a keen nurse or health care professional who would like to explore the world of complex discharge. The Case Management Service works alongside the Multi-disciplinary Teams to support the patients pathway through the hospital. We aim to ensure patients are transferred home or to the most appropriate care setting in a timely manner whilst providing a safe, effective and positive patient experience. As a Case Manager you will support both the medical and surgical wards as well as the opportunity to work across the community hospitals with complex discharge planning and facilitation of appropriate and timely referrals to the most appropriate community service in line with National Guidance. You will also be working to support internal patient flow by escalating any issues which may impact on discharge. You will require excellent communication and organisational skills and have experience of working as part of a Multi-disciplinary team. You will be an experienced nurse or allied health professional who has an understanding of the complexities of discharge planning and communication across the MDT and with patients, families and other agencies. Support and training to develop knowledge and skills will be provided as part of the role. If you want to be part of a busy supportive team that works in partnership with Social Services, Community providers and voluntary sector organisations to provide a positive and coordinated patient experience, please contact Sarah Holbrook, Lead Nurse for Patient Flow on ext 2065/6527 sarah.holbrook1nhs.net Not sure you have the necessary knowledge and skills at band 6 level? I would still like to consider individuals who looking for their next adventure or those willing to develop their career further. Full details of the role, responsibilities and person specification can be found in the Job Description, included. Please email me with your expression of interest by Tuesday 24th September and I will contact you to arrange an interview. Job description Job responsibilities CASE MANAGER Permanent Full Time 37.5 hours per week x 1 maternity leave cover Salary: Band 6 Do you have a passion for complex discharge planning or are you interested in developing your knowledge and skills in this area? We are looking for a keen nurse or health care professional who would like to explore the world of complex discharge. The Case Management Service works alongside the Multi-disciplinary Teams to support the patients pathway through the hospital. We aim to ensure patients are transferred home or to the most appropriate care setting in a timely manner whilst providing a safe, effective and positive patient experience. As a Case Manager you will support both the medical and surgical wards as well as the opportunity to work across the community hospitals with complex discharge planning and facilitation of appropriate and timely referrals to the most appropriate community service in line with National Guidance. You will also be working to support internal patient flow by escalating any issues which may impact on discharge. You will require excellent communication and organisational skills and have experience of working as part of a Multi-disciplinary team. You will be an experienced nurse or allied health professional who has an understanding of the complexities of discharge planning and communication across the MDT and with patients, families and other agencies. Support and training to develop knowledge and skills will be provided as part of the role. If you want to be part of a busy supportive team that works in partnership with Social Services, Community providers and voluntary sector organisations to provide a positive and coordinated patient experience, please contact Sarah Holbrook, Lead Nurse for Patient Flow on ext 2065/6527 sarah.holbrook1nhs.net Not sure you have the necessary knowledge and skills at band 6 level? I would still like to consider individuals who looking for their next adventure or those willing to develop their career further. Full details of the role, responsibilities and person specification can be found in the Job Description, included. Please email me with your expression of interest by Tuesday 24th September and I will contact you to arrange an interview. Person Specification Qualifications Essential Registered Nurse, Allied Health Professional or Social Care Practitioner Completion of Mental Capacity Assessment and Best Interest Decision Making training Desirable Evidence of Continuing Professional Development/Relevant Post Registration Qualification Knowledge Essential Significant post qualification experience Demonstrable knowledge of the needs of patients and the key issues relating to discharge Demonstrable experience in communicating sensitive, highly complex and confidential information to patients and families utilising empathy and counselling skills Demonstrates experience in continuing to the development and implementation of standard operating procedures, guidelines and policies Experience in completing assessments in line with trusted assessor model Experience of completing mental capacity assessment and best interest decision making Demonstrate professional awareness and knowledge of relevant legislation and policies Can demonstrate up-to-date clinical credibility/competence Desirable Experience in line management or day to day management of staff Demonstrates an understanding of clinical governance and evidence based practice Understanding of issues within Acute trust and other relevant organisations Person Specification Qualifications Essential Registered Nurse, Allied Health Professional or Social Care Practitioner Completion of Mental Capacity Assessment and Best Interest Decision Making training Desirable Evidence of Continuing Professional Development/Relevant Post Registration Qualification Knowledge Essential Significant post qualification experience Demonstrable knowledge of the needs of patients and the key issues relating to discharge Demonstrable experience in communicating sensitive, highly complex and confidential information to patients and families utilising empathy and counselling skills Demonstrates experience in continuing to the development and implementation of standard operating procedures, guidelines and policies Experience in completing assessments in line with trusted assessor model Experience of completing mental capacity assessment and best interest decision making Demonstrate professional awareness and knowledge of relevant legislation and policies Can demonstrate up-to-date clinical credibility/competence Desirable Experience in line management or day to day management of staff Demonstrates an understanding of clinical governance and evidence based practice Understanding of issues within Acute trust and other relevant organisations 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. 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. 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 Royal Surrey NHS Foundation Trust Address Royal Surrey County Hospital Egerton Road Guildford GU2 7XX Employer's website https://www.royalsurrey.nhs.uk/ (Opens in a new tab)