Job summary We are looking for a dynamic individual to join the Integrated Discharge Team. The team work across acute (Warwick Hospital) community hospitals and in specifically commissioned D2A Care homes, located in South Warwickshire. You will manage a caseload of patients by delivering a high - quality service, ensuring discharges are planned with a home first mind set, ensuring patients are discharged to the least restrictive option through several Discharge To Assess (D2A) pathways. You will work collaboratively across all divisions within the trust, whilst sustaining partnership working with links across the local health and social care economy. Working with a variety of staff groups and voluntary sectors; you must be confident in sensitivity challenging conventional thinking and demonstrate negotiating and influencing skills. The successful candidate will be proactive, forward thinking and committed to maintaining capacity and flow across the system, through safe and timely patient discharges, to reduce the detrimental outcomes associated with a protracted length of stay. You will contribute to the redesign of discharge pathways and facilitate in the delivery of local and national legislation and guidance related to patient discharge. Main duties of the job To coordinate complex patient discharges by liaising across the Health and Social Care economy and working collaboratively with Primary Care and third sector services, This is an integral role provided at both the acute sector and the community setting. The purpose is to assist the Trust to maintain capacity and flow throughout the whole system and to promote safe and timely discharges, with the intent to reduce the detrimental outcomes associated for patients who have a prolonged length of stay. The Trust have a number of discharge initiatives that aim to bring care closer to home, therefore the post holder must be confident and proactive in sensitively challenging conventional thinking. About us Come and join a Trust rated Outstanding by the CQC. South Warwickshire NHS Foundation Trust have been rated as outstanding following our latest inspection by the CQC and we are recruiting new staff to come and help us improve even further. We provide services across Warwickshire and beyond ranging from Hospitals in Warwick, Stratford-Upon-Avon, Royal Leamington Spa and Shipston-on Stour to Community Services across the county. We are a progressive, expanding organisation with great ambition around improving quality, integrating pathways and delivering high levels of productivity. Our values can be summed up in one sentence. We are 'Trusted to provide safe, effective and compassionate care'. Throughout the recruitment process you will be asked to think about how you demonstrate these values and how they impact on your work. It doesn't matter what role you do, whether it is patient facing or not, we are all working in the same way with our values at the core Date posted 01 November 2024 Pay scheme Agenda for change Band Band 6 Salary £37,338 to £44,962 a year Per annum Contract Permanent Working pattern Full-time Reference number 203-CS808 Job locations South Warwickshire University Foundation Trust Lakin Road Warwick CV34 5BW Job description Job responsibilities Work independently managing own allocated case load To respond to referrals within 1 working day. To work towards the specified Estimated Discharge Date (EDD) To prepare complex patients and their relatives at the earliest opportunity in relation to planning for discharge. Review daily, each complex patients progress towards discharge to determine if the plan needs to be revised and actioned in order to achieve a timely and safe discharge. To identify appropriate patients through the trusted assessment process to the various Discharge to Assess initiatives to bring care closer to home for patients. To undertake Mental Capacity assessments in accordance with the Mental Capacity Act (2005) in relation to specific decisions pertinent to the patients discharge plan. To cover and rotate through all areas as allocated by the Team Manager/ Leader including Acute, Community sectors and the D2A care homes. To participate in the delivery of new Trust initiatives related to the process of patient discharge. Ensure adherence to all measures stipulated in the Trusts in patient Discharge Procedure and other policies related to the discharge process. To assist in identifying, negotiating and co-ordinating the movement of patients who are suitable to transfer to other health or social care facilities. To promote integrated and collaborative working with health, social care teams and third sector providers. To initiate and lead patient case conferences or best interest meetings, as necessary with discussions and actions documented. The post holder will be required to use a computer, either stands alone or as part of a networked system and will be responsible for the quality of information recorded. To sensitively challenge conventional thinking that hinders or creates a delay in the process of patient discharge. The post holder will maintain accurate records both written and electronic, deal with highly sensitive information respecting confidentiality and security at all times in accordance with Trust policies and data protection. To support and actively participate in audits pertaining to patient discharge and whole system flow. To contribute to the development of standards, protocols, care pathways and clinical audit when requested. To contribute to strategies and use relevant information systems to collect and interpret data that will lead to the formulation of action plans that seek to improve the discharge process. Professional/Personal Responsibilities To be responsible for and provide evidence that all mandatory training is undertaken and up to date as per training matrix. Maintain active status on the NMC register or equivalent professional registration. Act always in accordance with the NMC Code of Conduct or professional registration and guiding documents. Take responsibility for personal development and education with regard to Revalidation and Personal Development Plan objectives. To be aware of your own learning needs and limitations to maintain professional expertise by embracing the concept of lifelong learning. Participate in clinical supervision for self and others and utilise reflective practice. To participate in team, professional and personal development activities and promote commitment to continuous development and improvement. Up-date and maintain professional knowledge to sustain a high level of awareness of relevant research issues and trends within the field of discharge planning. The post holder will be required to have access to independent means of transport for work purposes to travel across the acute and community Trust and to other agencies. Job description Job responsibilities Work independently managing own allocated case load To respond to referrals within 1 working day. To work towards the specified Estimated Discharge Date (EDD) To prepare complex patients and their relatives at the earliest opportunity in relation to planning for discharge. Review daily, each complex patients progress towards discharge to determine if the plan needs to be revised and actioned in order to achieve a timely and safe discharge. To identify appropriate patients through the trusted assessment process to the various Discharge to Assess initiatives to bring care closer to home for patients. To undertake Mental Capacity assessments in accordance with the Mental Capacity Act (2005) in relation to specific decisions pertinent to the patients discharge plan. To cover and rotate through all areas as allocated by the Team Manager/ Leader including Acute, Community sectors and the D2A care homes. To participate in the delivery of new Trust initiatives related to the process of patient discharge. Ensure adherence to all measures stipulated in the Trusts in patient Discharge Procedure and other policies related to the discharge process. To assist in identifying, negotiating and co-ordinating the movement of patients who are suitable to transfer to other health or social care facilities. To promote integrated and collaborative working with health, social care teams and third sector providers. To initiate and lead patient case conferences or best interest meetings, as necessary with discussions and actions documented. The post holder will be required to use a computer, either stands alone or as part of a networked system and will be responsible for the quality of information recorded. To sensitively challenge conventional thinking that hinders or creates a delay in the process of patient discharge. The post holder will maintain accurate records both written and electronic, deal with highly sensitive information respecting confidentiality and security at all times in accordance with Trust policies and data protection. To support and actively participate in audits pertaining to patient discharge and whole system flow. To contribute to the development of standards, protocols, care pathways and clinical audit when requested. To contribute to strategies and use relevant information systems to collect and interpret data that will lead to the formulation of action plans that seek to improve the discharge process. Professional/Personal Responsibilities To be responsible for and provide evidence that all mandatory training is undertaken and up to date as per training matrix. Maintain active status on the NMC register or equivalent professional registration. Act always in accordance with the NMC Code of Conduct or professional registration and guiding documents. Take responsibility for personal development and education with regard to Revalidation and Personal Development Plan objectives. To be aware of your own learning needs and limitations to maintain professional expertise by embracing the concept of lifelong learning. Participate in clinical supervision for self and others and utilise reflective practice. To participate in team, professional and personal development activities and promote commitment to continuous development and improvement. Up-date and maintain professional knowledge to sustain a high level of awareness of relevant research issues and trends within the field of discharge planning. The post holder will be required to have access to independent means of transport for work purposes to travel across the acute and community Trust and to other agencies. Person Specification Qualifications Essential Registered first level nurse or AHP or social care Diploma/degree level relevant qualification Evidence of continuing professional development in the last year Desirable Mentoring and assessing qualification Experience Essential Significant post registration experience in an acute hospital setting or equivalent or community setting Experience in effectively contributing and sustaining change Experience with working with electronic systems Skills Essential Demonstrates excellent communication and interpersonal skills Knowledge of the key legislation, best practice and health/social care policy and guidelines relating to own professional practice Able to manage, prioritise and organise own workload effectively Demonstrates up to date knowledge in the field of patient discharge Is innovative, positive and has ability to apply critical and lateral thinking Able to plan and achieve targets and to meet deadlines Act as a positive role model/expert in complex patient discharge Demonstrates ability to sensitively challenge conventional thinking Demonstrates experience of multi-disciplinary and collaborative working Ability to facilitate change effectively and motivate others Desirable Demonstrates IT skills Able to apply research and best practice operationally Can demonstrate characteristics of effective credible leadership Person Specification Qualifications Essential Registered first level nurse or AHP or social care Diploma/degree level relevant qualification Evidence of continuing professional development in the last year Desirable Mentoring and assessing qualification Experience Essential Significant post registration experience in an acute hospital setting or equivalent or community setting Experience in effectively contributing and sustaining change Experience with working with electronic systems Skills Essential Demonstrates excellent communication and interpersonal skills Knowledge of the key legislation, best practice and health/social care policy and guidelines relating to own professional practice Able to manage, prioritise and organise own workload effectively Demonstrates up to date knowledge in the field of patient discharge Is innovative, positive and has ability to apply critical and lateral thinking Able to plan and achieve targets and to meet deadlines Act as a positive role model/expert in complex patient discharge Demonstrates ability to sensitively challenge conventional thinking Demonstrates experience of multi-disciplinary and collaborative working Ability to facilitate change effectively and motivate others Desirable Demonstrates IT skills Able to apply research and best practice operationally Can demonstrate characteristics of effective credible leadership 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 South Warwickshire University NHS Foundation Trust Address South Warwickshire University Foundation Trust Lakin Road Warwick CV34 5BW Employer's website https://www.swft.nhs.uk/ (Opens in a new tab)