Job summary This is an opportunity for a shared post between two teams - The Integrated Discharge Team and Rapid Response Team who are expanding to meet the new Urgent Community Response & Virtual Ward requirements. You will have experience of undertaking comprehensive nursing assessment and treatment planning, preferably with community experience and knowledge of discharge planning. Working autonomously with both our Integrated Discharge Team based at the Luton and Dunstable Hospital and our community based Rapid Response Team, will allow you to experience two different environments. These teams play a vital role in preventing hospital admissions or facilitating early and complex discharges. This is the role for you if you have passion for nursing, drive to put patients at the centre of their care, enjoy working as part of a team and in a fast-paced environment. The successful applicant will be in an exciting position to contribute to: service development by developing new ways of working (e.g. clinical triage, patient assessment, discharge planning ) additional resilience in both services by supporting periods of high demand strengthening collaborative working, both across the teams and with system partners (e.g. GPs, social care and voluntary organisations) Join us and be part of transforming and providing high quality health care within an integrated team model. In return we will actively encourage and support to develop. Main duties of the job To be responsible for, as part of the integrated team, providing safe, effective and efficient discharge for patients as they return to the community from any point in their hospital pathway including admission aversion. To assess patients and work with families and the multidisciplinary team to ensure full understanding of the community options when organising health funded packages of care. Support the provision of community nursing care within the Integrated Community Nursing Team, providing scheduled and unscheduled care, to the population of Luton with a Luton GP. Respond to urgent / unplanned care within the Community Nursing Service i.e. supporting the single point of access by prioritising, visiting or allocating patient visits as required using clinical skills and knowledge, supporting community nursing teams when required. Work in partnership with other colleagues across primary and secondary care and other related services in order to provide a holistic care package designed to meet the specific needs of the individual, to facilitate hospital discharge and or prevent unnecessary hospital admission. Work with the team lead in providing clinical leadership within the Community Nursing Service, providing line management and team support when required. Work with other agencies to deliver strategic national and local health priorities About us Rated 'Outstanding' by the Care Quality Commission, we are proud to provide high quality innovative services across most of the east of England that enable people to receive care closer to home and live healthier lives. There's one reason why our services are outstanding - and that's our amazing staff who, for the seventh year running, rated us incredibly highly in the national staff survey. If you share our passion for innovative and high-quality care delivery, then please submit your application and join us on our exciting journey as a leading-edge specialist community provider. All are welcome to apply and our promise to you is a culture which prioritises staff engagement and development. Date posted 07 March 2025 Pay scheme Agenda for change Band Band 6 Salary £37,338 to £44,962 a year per annum, pro-rata Contract Permanent Working pattern Full-time Reference number 448-LCA-7054871 Job locations Luton & Dunstable Hospital / The Poynt The Poynt unit 2-3 Luton LU4 0LA Job description Job responsibilities Prevent avoidable hospital admissions by providing a holistic assessment, care planning, implementation, treatment and evaluation of patient care packages to meet the individual needs of the patient in accordance with Trust guidelines. Support the aversion of hospital admission by assessing, organising and delivering specialised care packages for patients discharged into the care of the team. Undertake core nursing procedures as required whilst attending the patient e.g. wound dressing, observations, pressure area care, risk assessments e.g. Purpose T, MUST. Undertake highly developed physical skills e.g. delivery of intravenous therapy, cannulation, syringe driver, catheterisation. Undertake diagnostic procedures/tests as required and to, when competent to do so, gain a full insight into patients condition, e.g. ECGs, phlebotomy, spirometry, blood glucose testing, Point of Care Testing. Undertake responsibility for prescribing medication where applicable in line with independent nurse prescribing guidelines following accredited training and competence. To be confident in using these skills & nursing knowledge to work autonomously to plan and implement episodes of care, referring appropriately to other services to support the plan of care as required. To facilitate clear and effective communication channels between patients, relatives, carers and professional community colleagues to ensure seamless patient care. Respond to urgent calls from health and social care professionals and utilise sound clinical decision making and triage processes to assess, plan and implement evidence-based treatment plans in response to clinical assessment. To obtain and analyse information gathered from GPs via the telephone making judgements and advising the GP as to the most appropriate outcome for the patient Assess and prioritise unscheduled requests for nursing intervention and allocation to the appropriately skilled clinician. Ensure at all times patients are treated with care and compassion. To be accountable for the holistic assessment, care planning, implementation and evaluation of patient care packages related to Care Interventions, treatment plans. Assess and identify any complications surrounding patient care and to act accordingly to enable the patient to remain at home where appropriate. Assess and implement care interventions to meet identified health needs of individuals, families and communities. Maintain associated records. Refer patients to other services / agencies as appropriate e.g., Social Services, specialist services Identify unpredicted crisis situations and manage accordingly i.e., staff, caseload, support network and supervision. Identify to senior managers the situation, risk, action and outcome. Manage team members and own workload to support the delivery of care in the community and prevent inappropriate hospital admissions Organise and coordinate the overall care to meet clients care needs, which may be complex involving other professionals and agencies. Provide individuals and their families with specialist advice for them to make informed choices about their health Take responsibility for identifying and developing a range of clinical skills/knowledge appropriate to necessitate safe discharge or prevention of admission. Take a lead in the setting of standards of care amongst the team members and to teach, deploy, co-ordinate and supervise the team, recognising their knowledge/skills and development potential. Plan and co-ordinate for self and others; off duty, covering annual leave, sickness and study leave in the most cost-effective way when required to do so. To be accountable and responsible for the management of work priorities for self and team members. Develop patients personalised care plans, which use evidence-based care and ensure that the most appropriate member of the team delivers the care required. Provide education to patients on nature of their condition, treatment, side effects and expected outcome. Enable patients and carers to participate in their care, thus encouraging independence and self-reliance. Job description Job responsibilities Prevent avoidable hospital admissions by providing a holistic assessment, care planning, implementation, treatment and evaluation of patient care packages to meet the individual needs of the patient in accordance with Trust guidelines. Support the aversion of hospital admission by assessing, organising and delivering specialised care packages for patients discharged into the care of the team. Undertake core nursing procedures as required whilst attending the patient e.g. wound dressing, observations, pressure area care, risk assessments e.g. Purpose T, MUST. Undertake highly developed physical skills e.g. delivery of intravenous therapy, cannulation, syringe driver, catheterisation. Undertake diagnostic procedures/tests as required and to, when competent to do so, gain a full insight into patients condition, e.g. ECGs, phlebotomy, spirometry, blood glucose testing, Point of Care Testing. Undertake responsibility for prescribing medication where applicable in line with independent nurse prescribing guidelines following accredited training and competence. To be confident in using these skills & nursing knowledge to work autonomously to plan and implement episodes of care, referring appropriately to other services to support the plan of care as required. To facilitate clear and effective communication channels between patients, relatives, carers and professional community colleagues to ensure seamless patient care. Respond to urgent calls from health and social care professionals and utilise sound clinical decision making and triage processes to assess, plan and implement evidence-based treatment plans in response to clinical assessment. To obtain and analyse information gathered from GPs via the telephone making judgements and advising the GP as to the most appropriate outcome for the patient Assess and prioritise unscheduled requests for nursing intervention and allocation to the appropriately skilled clinician. Ensure at all times patients are treated with care and compassion. To be accountable for the holistic assessment, care planning, implementation and evaluation of patient care packages related to Care Interventions, treatment plans. Assess and identify any complications surrounding patient care and to act accordingly to enable the patient to remain at home where appropriate. Assess and implement care interventions to meet identified health needs of individuals, families and communities. Maintain associated records. Refer patients to other services / agencies as appropriate e.g., Social Services, specialist services Identify unpredicted crisis situations and manage accordingly i.e., staff, caseload, support network and supervision. Identify to senior managers the situation, risk, action and outcome. Manage team members and own workload to support the delivery of care in the community and prevent inappropriate hospital admissions Organise and coordinate the overall care to meet clients care needs, which may be complex involving other professionals and agencies. Provide individuals and their families with specialist advice for them to make informed choices about their health Take responsibility for identifying and developing a range of clinical skills/knowledge appropriate to necessitate safe discharge or prevention of admission. Take a lead in the setting of standards of care amongst the team members and to teach, deploy, co-ordinate and supervise the team, recognising their knowledge/skills and development potential. Plan and co-ordinate for self and others; off duty, covering annual leave, sickness and study leave in the most cost-effective way when required to do so. To be accountable and responsible for the management of work priorities for self and team members. Develop patients personalised care plans, which use evidence-based care and ensure that the most appropriate member of the team delivers the care required. Provide education to patients on nature of their condition, treatment, side effects and expected outcome. Enable patients and carers to participate in their care, thus encouraging independence and self-reliance. Person Specification Qualifications and Training Essential RGN Educated to degree level or equivalent e.g. Community Specialist practitioner / PgDip Evidence of CPD MSPP or equivalent Desirable Post Graduate study in relevant area Independent Nurse Prescribing or willingness to undertake Experience Essential Significant post registration experience Understanding of staff and resource management Understanding of multidisciplinary care collaboration Ability to work within a skill mixed team, working within quality standards Knowledge of Discharge Planning Able to demonstrate experience and a knowledge of clinical / governance and audit Demonstrate an understanding of research and its impact on clinical practice Knowledge of DoH Continuing Health Care process - Fast Track Knowledge of Safeguarding Children/Vulnerable Adults and procedure for reporting Evidence of involvement in project development work or health promotion group work Desirable Experience of working within a high ethnic population DN / Community experience Demonstrate an understanding of Mental Capacity Act (MCA) 2005 Experience of discharge planning Experience of working within a multi-disciplinary Primary Health Care Team Able to demonstrate an understanding of DoH Continuing Health Care processes - Checklists, Decision Support Tool, review Skills Essential Time Management and prioritisation skills, ability to work under pressure in a changing work environment Ability to work flexibly as part of a team. Evidence of effective communication Recognises the limits of own authority within the role Seeks and uses professional support appropriately Understands the principle of confidentiality Demonstrates professional curiosity Identify and challenge unacceptable behaviour and its effect on others Desirable Experience of Systmone Person Specification Qualifications and Training Essential RGN Educated to degree level or equivalent e.g. Community Specialist practitioner / PgDip Evidence of CPD MSPP or equivalent Desirable Post Graduate study in relevant area Independent Nurse Prescribing or willingness to undertake Experience Essential Significant post registration experience Understanding of staff and resource management Understanding of multidisciplinary care collaboration Ability to work within a skill mixed team, working within quality standards Knowledge of Discharge Planning Able to demonstrate experience and a knowledge of clinical / governance and audit Demonstrate an understanding of research and its impact on clinical practice Knowledge of DoH Continuing Health Care process - Fast Track Knowledge of Safeguarding Children/Vulnerable Adults and procedure for reporting Evidence of involvement in project development work or health promotion group work Desirable Experience of working within a high ethnic population DN / Community experience Demonstrate an understanding of Mental Capacity Act (MCA) 2005 Experience of discharge planning Experience of working within a multi-disciplinary Primary Health Care Team Able to demonstrate an understanding of DoH Continuing Health Care processes - Checklists, Decision Support Tool, review Skills Essential Time Management and prioritisation skills, ability to work under pressure in a changing work environment Ability to work flexibly as part of a team. Evidence of effective communication Recognises the limits of own authority within the role Seeks and uses professional support appropriately Understands the principle of confidentiality Demonstrates professional curiosity Identify and challenge unacceptable behaviour and its effect on others Desirable Experience of Systmone 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 Cambridgeshire Community Services NHS Trust Address Luton & Dunstable Hospital / The Poynt The Poynt unit 2-3 Luton LU4 0LA Employer's website https://www.cambscommunityservices.nhs.uk/careers (Opens in a new tab)