Job summary Home First are excited to advertise for a Highly Specialist Band 7 Occupational Therapist to support the ongoing development of the Milton Keynes Health and Social Care improving patient flow projects. Home 1st provide admission avoidance assessment for access to community admission avoidance beds, support discharge for the people of Milton Keynes who have been admitted to local acute services and Physiotherapy and Occupational Therapy intervention in the community for those requiring a period of rehabilitation following illness. This role will provide expertise knowledge and advice to the Milton Keynes hospital, integrated discharge hub. As a case manager for highly complex discharge planning for patients on pathway 1 and 2, this role will require excellent communication and liaison skills enabling you to represent the Home 1st services. Working closely with the Milton Keynes Council Home 1st Reablement team and the hospital therapy teams, your broad clinical experience will be vital in the decision-making and sign posting required to reduce barriers to accessing rehabilitation for the people of Milton Keynes and expediting their discharge from hospital to home. An expert knowledge of community services, equipment prescription and environmental risk assessment is key. Experience of triaging and prioritising referrals, managing waiting lists and allocating workload are essential. It is essential to be a car driver. Main duties of the job To support the delivery of Home 1st Therapy services to people in Milton Keynes considering the holistic management of those with long-term conditions and frailty. To provide highly specialist holistic assessments and deliver person-centred rehabilitation- based discharge planning advice to patients requiring supported discharge from Milton Keynes University Hospital (MKUH), providing in-reach support as required. To work in partnership with the integrated discharge and therapy teams at MKUH to support the case management of discharge plans in to the community, for patients with highly complex frailty or social presentations. To work closely by liaising with other Home 1st teams providing specialist support to expedite transfer of care To work in collaboration with Milton Keynes Council Social care teams to triage, allocate and respond to referrals requiring joint integrated care and therapy assessment in order to support discharge from hospital. To provide sign-posting advice to individuals seeking support from community services. To undertake all aspects of clinical duties as an autonomous practitioner. To communicate effectively and work collaboratively with all members of the multidisciplinary team both internal to CNWL and across partner organisations. To participate in development of the Home 1st Therapy service. About us But it doesn't stop there we can offer coaching and opportunities for daily debriefs, access to remote working, regular 1:1 formal and informal supervision, peer group CPD sessions and in-service training, QI project work and volunteering for champion roles. Home1st is based in Bletchley and the modern office is a central hub for multi-disciplinary working. You will be provided with ICT laptop, mobile phone, uniform and have mileage expenses paid for. And if you thought there was something more you were looking for, then CNWL can offer: Flexible working Buying and selling annual leave An attractive pension scheme Employee assistance programme: a free and confidential service to help with personal life Staying well at work service for tailored employment related support to staff Physio Med: an education zone, advice line and treatment service for staff Staff wellbeing zone for free and confidential online health and wellbeing programmes A range of staff networks Discounts and savings at hundreds of retailers nationwide with Vivup Childcare vouchers Salary sacrifice Travel discounts Date posted 06 February 2025 Pay scheme Agenda for change Band Band 7 Salary £46,148 to £52,809 a year pro rata Contract Permanent Working pattern Part-time Reference number 333-D-MK-CM-1122 Job locations Home 1st, Bletchley Community Health Services Whalley Drive Bletchley, Milton Keynes MK3 6EN Job description Job responsibilities To be professional and legally accountable for all aspects of your work including the delivery of highly specialist therapy intervention and caseload management of patients in your care. To use specialist professional and clinical knowledge across a range of procedures based on a sound knowledge of evidence-based practice and treatment options, using clinical assessment, reasoning skills and knowledge of treatment skills. To undertake comprehensive holistic assessment of patients to determine suitable management of their rehabilitation needs. Use clinical reasoning skills to triage and risk assess appropriate therapeutic intervention response times for patients referred to Home 1st. To assess patient understanding of treatment proposals, gain valid informed consent and have the capacity to work within a legal framework with patients who lack capacity to consent to treatment. Use a range of verbal or non-verbal communication tools to communicate effectively with patients, relatives, carers and other health and social care professionals to progress rehabilitation and treatment programmes and discharge plans as required. This will include patients who may have difficulties in understanding or communicating. To manage clinical risk within the Home 1st Therapy waiting list to prevent the deterioration of patients requiring therapeutic input. Following assessment, be able to prescribe, order and review the equipment needs for patients requiring supported discharge, that require high level equipment packages for discharge. To support in-reach assessment, access visits or home visits for people with complex needs to expedite discharge plans in collaboration with PW1 and PW2 requirements. To attend MKUH integrated discharge hub multidisciplinary meetings to represent community services in discharge planning for those with complex needs. On completion of risk assessments, be able to make recommendations to the multi-professional teams, about the level of support need required to meet individualised packages of care on discharge. To be able to promote a risk enabling approach to staff to encourage therapeutic intervention and functional activities, preventing deconditioning and reducing length of stay. To be responsible for the safe and competent use of all appropriate equipment. Work collaboratively with the multi-professional teams, including GPs, other clinicians, medical and therapy colleagues, social services and the voluntary sector to ensure needs led comprehensive treatment plans are in place. Provide a comprehensive and highly specialist level of communication / liaison between the MKUH Integrated discharge hub, CNWL Single Point of Access (SPA), Acute Adult Frailty Team (AAFT), Seacole Inpatient Units and the Virtual ward team to promote patients therapy requirements in treatment and discharge planning. To attend the Virtual Ward / AAFT / Inpatient multidisciplinary meetings as required. Ensure accurate electronic records are maintained timely and effectively. To work with members of the Home 1st team to deliver seamless therapeutic treatment plans in the transition from hospital to home. Take part in service audit to assess the effectiveness of the Home 1st clinical pathways. To work collaboratively in partnership with CNWL, MKUH and BLMK ICB to implement system flow response as part of escalation processes. To actively seek patient and carer feedback, to enable informed decision-making when reviewing service interventions. To take responsibility for analysis of Datix incidents regarding patient discharge from hospital and implement recommended actions to prevent recurrent risk. To supervise and support development of Band 5 therapists on rotation Job description Job responsibilities To be professional and legally accountable for all aspects of your work including the delivery of highly specialist therapy intervention and caseload management of patients in your care. To use specialist professional and clinical knowledge across a range of procedures based on a sound knowledge of evidence-based practice and treatment options, using clinical assessment, reasoning skills and knowledge of treatment skills. To undertake comprehensive holistic assessment of patients to determine suitable management of their rehabilitation needs. Use clinical reasoning skills to triage and risk assess appropriate therapeutic intervention response times for patients referred to Home 1st. To assess patient understanding of treatment proposals, gain valid informed consent and have the capacity to work within a legal framework with patients who lack capacity to consent to treatment. Use a range of verbal or non-verbal communication tools to communicate effectively with patients, relatives, carers and other health and social care professionals to progress rehabilitation and treatment programmes and discharge plans as required. This will include patients who may have difficulties in understanding or communicating. To manage clinical risk within the Home 1st Therapy waiting list to prevent the deterioration of patients requiring therapeutic input. Following assessment, be able to prescribe, order and review the equipment needs for patients requiring supported discharge, that require high level equipment packages for discharge. To support in-reach assessment, access visits or home visits for people with complex needs to expedite discharge plans in collaboration with PW1 and PW2 requirements. To attend MKUH integrated discharge hub multidisciplinary meetings to represent community services in discharge planning for those with complex needs. On completion of risk assessments, be able to make recommendations to the multi-professional teams, about the level of support need required to meet individualised packages of care on discharge. To be able to promote a risk enabling approach to staff to encourage therapeutic intervention and functional activities, preventing deconditioning and reducing length of stay. To be responsible for the safe and competent use of all appropriate equipment. Work collaboratively with the multi-professional teams, including GPs, other clinicians, medical and therapy colleagues, social services and the voluntary sector to ensure needs led comprehensive treatment plans are in place. Provide a comprehensive and highly specialist level of communication / liaison between the MKUH Integrated discharge hub, CNWL Single Point of Access (SPA), Acute Adult Frailty Team (AAFT), Seacole Inpatient Units and the Virtual ward team to promote patients therapy requirements in treatment and discharge planning. To attend the Virtual Ward / AAFT / Inpatient multidisciplinary meetings as required. Ensure accurate electronic records are maintained timely and effectively. To work with members of the Home 1st team to deliver seamless therapeutic treatment plans in the transition from hospital to home. Take part in service audit to assess the effectiveness of the Home 1st clinical pathways. To work collaboratively in partnership with CNWL, MKUH and BLMK ICB to implement system flow response as part of escalation processes. To actively seek patient and carer feedback, to enable informed decision-making when reviewing service interventions. To take responsibility for analysis of Datix incidents regarding patient discharge from hospital and implement recommended actions to prevent recurrent risk. To supervise and support development of Band 5 therapists on rotation Person Specification Experience Essential Experience of providing triage / referral / waiting list management Extensive experience of working in acute / community NHS settings at a Band 6 level Experience of working with people with long term conditions Experience of working in admission avoidance / supported discharge pathways Evidence of CPD relevant to frailty / long term conditions / management of complex presentations Qualifications Essential UK HCPC registration Degree level education in Occupational Therapy Demonstrate/evidence of continuing professional development appropriate to role Desirable Completion of a Frailty specific educational course or willingness to work towards (MSc or BSc equivalent) Others Essential Car owner/driver Person Specification Experience Essential Experience of providing triage / referral / waiting list management Extensive experience of working in acute / community NHS settings at a Band 6 level Experience of working with people with long term conditions Experience of working in admission avoidance / supported discharge pathways Evidence of CPD relevant to frailty / long term conditions / management of complex presentations Qualifications Essential UK HCPC registration Degree level education in Occupational Therapy Demonstrate/evidence of continuing professional development appropriate to role Desirable Completion of a Frailty specific educational course or willingness to work towards (MSc or BSc equivalent) Others Essential Car owner/driver 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 Central and North West London NHS Foundation Trust Address Home 1st, Bletchley Community Health Services Whalley Drive Bletchley, Milton Keynes MK3 6EN Employer's website https://www.cnwl.nhs.uk/work (Opens in a new tab)