Job summary Are you a skilled nurse, with an interest in discharge planning, looking for your next opportunity? Do you thrive on a varied workload and enjoy supporting a range of different patients and teams? If so, BSW ICB is looking to recruit a Trusted Assessor to join our friendly team and support assessments, flow and discharge from the acute hospitals linking with community providers, residential and nursing homes and hospices. Main duties of the job Assist Care Home Managers with their assessment process: o By liaising where there is a potential change of needs. o Undertaking assessments on behalf of Care Home staff, to include existing Care Homes, new Care Home placements, Discharge to Assess placements, Continuing Health Care Fast Track placements and any other placement where a trusted assessment is requested. Support improvements in hospital discharge arrangements from acute and community hospitals to Older People Nursing and Residential Homes, improving patient experience, clinical safety and patient flow by assessing, planning and implementing care in partnership with Care Home providers. Facilitate discharge where issues have arisen which could compromise the quality or timeliness of discharge from hospital, working with all relevant staff across organisational boundaries with a problem-solving approach. This will include communicating sensitive information concerning patients' conditions, requiring persuasive reassurance skills. About us If you are interested in this role and would like an informal discussion, please contact Jo Williamson, Associate Director of Patient Flow, jo.williamson1nhs.net. Alternatively, please contact Sally Smith, Integrated Patient Flow Lead, sally.smith50nhs.net. Date posted 23 January 2025 Pay scheme Agenda for change Band Band 6 Salary £35,392 to £42,618 a year pro rata, per annum Contract Fixed term Duration 12 months Working pattern Full-time Reference number 983-ICB-7167KB Job locations Pierre Simonet Building Swindon SN25 4DL Job description Job responsibilities Improve and develop known process for referrals and assessments and work within agreed assessment formats with adherence to established pathways. The post holder will need to use their extensive skills and experience for assessing and interpreting acute and other patient/client conditions with recommendations for appropriate discharge processes. Undertake assessments and re-assessments of hospitalised residents on behalf of Care Home providers according to agreed criteria. This will require the post holder to have specialist knowledge across a range of conditions, procedures, local systems, and underpinned theory of them. Liaising with the wards to confirm the requirements for discharge, including any documentation and medication needs where required. Liaise with Care Homes, Discharge Liaison, Discharge Support Teams and Brokerage about the discharge arrangements to streamline the process and ensure the best possible outcomes for vulnerable people are achieved. This will include providing and receiving complex, sensitive information daily for many patients. Liaise with District Nurses and other Specialist Nurses to support person centered care planning, where required. The post holder will therefore need to assimilate complex facts or situations requiring a comparison of range of options for the patient. Ensure that, wherever possible the views and needs of older people within the Care Home setting are sought and represented with due regard to the persons mental capacity and undertake Mental Capacity Assessments where required Report on issues raised by Care Homes about quality of discharge, working closely with Discharge Teams, the Continuing Healthcare Team, the Care Homes Forum, the Ageing Well Working Group, Councils Contracts & Brokerage Team and future groups that may be developed to support this work stream. Provide support to Care Home and hospital staff relating to admission and discharge processes. Post holder to identify training needs and or requirements and support with arranging training to be completed prior to Care home admission. Will provide clinical supervision to other staff and students, in addition to mentoring support for Care Home staff (which will also include on a one-to-one basis), where appropriate. Act as a point of contact for ward staff/MDT/Care Homes, when residents are admitted to hospital from Care Home settings to monitor progress and keep on-going communications. Work in partnership with Care Home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues. Provide data for monthly reporting as agreed. Produce monthly monitoring reports, including case studies for submission within quarterly reports, and develop Key Performance Indicators relevant to the role. Support other areas of work at times, which may include supporting flow and end of life pathways, Continuing Healthcare Checklists, Nursing Needs Assessments (HANNA), Discharge to Assess referrals, training, education, performance improvement and support, safeguarding enquiries, health promotion. Work closely with the GWH Hospital Discharge team to resolve difficult or delayed discharges, especially on challenging situations where parties may not agree. The post holder will also be required to plan and organise activities that will enable delivery of the service e.g. discharge support and coordination. Facilitate the continuation of the development of and implementation of best practice within the Care Home community. Assist in developing effective links and communication between Care Homes, other care services and the wider community to deliver a seamless service for clients and staff in the Care Homes. Support the daily integrated flow meetings, multi-disciplinary team meetings and best interest meetings to expedite discharge wherever possible and to raise any issues or concerns that may be delaying a discharge. Job description Job responsibilities Improve and develop known process for referrals and assessments and work within agreed assessment formats with adherence to established pathways. The post holder will need to use their extensive skills and experience for assessing and interpreting acute and other patient/client conditions with recommendations for appropriate discharge processes. Undertake assessments and re-assessments of hospitalised residents on behalf of Care Home providers according to agreed criteria. This will require the post holder to have specialist knowledge across a range of conditions, procedures, local systems, and underpinned theory of them. Liaising with the wards to confirm the requirements for discharge, including any documentation and medication needs where required. Liaise with Care Homes, Discharge Liaison, Discharge Support Teams and Brokerage about the discharge arrangements to streamline the process and ensure the best possible outcomes for vulnerable people are achieved. This will include providing and receiving complex, sensitive information daily for many patients. Liaise with District Nurses and other Specialist Nurses to support person centered care planning, where required. The post holder will therefore need to assimilate complex facts or situations requiring a comparison of range of options for the patient. Ensure that, wherever possible the views and needs of older people within the Care Home setting are sought and represented with due regard to the persons mental capacity and undertake Mental Capacity Assessments where required Report on issues raised by Care Homes about quality of discharge, working closely with Discharge Teams, the Continuing Healthcare Team, the Care Homes Forum, the Ageing Well Working Group, Councils Contracts & Brokerage Team and future groups that may be developed to support this work stream. Provide support to Care Home and hospital staff relating to admission and discharge processes. Post holder to identify training needs and or requirements and support with arranging training to be completed prior to Care home admission. Will provide clinical supervision to other staff and students, in addition to mentoring support for Care Home staff (which will also include on a one-to-one basis), where appropriate. Act as a point of contact for ward staff/MDT/Care Homes, when residents are admitted to hospital from Care Home settings to monitor progress and keep on-going communications. Work in partnership with Care Home and hospital staff to find solutions to the perceived barriers to discharge including equipment issues. Provide data for monthly reporting as agreed. Produce monthly monitoring reports, including case studies for submission within quarterly reports, and develop Key Performance Indicators relevant to the role. Support other areas of work at times, which may include supporting flow and end of life pathways, Continuing Healthcare Checklists, Nursing Needs Assessments (HANNA), Discharge to Assess referrals, training, education, performance improvement and support, safeguarding enquiries, health promotion. Work closely with the GWH Hospital Discharge team to resolve difficult or delayed discharges, especially on challenging situations where parties may not agree. The post holder will also be required to plan and organise activities that will enable delivery of the service e.g. discharge support and coordination. Facilitate the continuation of the development of and implementation of best practice within the Care Home community. Assist in developing effective links and communication between Care Homes, other care services and the wider community to deliver a seamless service for clients and staff in the Care Homes. Support the daily integrated flow meetings, multi-disciplinary team meetings and best interest meetings to expedite discharge wherever possible and to raise any issues or concerns that may be delaying a discharge. Person Specification Qualifications Essential RN level 1 with 3 years post qualification and a graduate degree and relevant clinical and service specialist experience which would provide the appropriate knowledge for the role Experience Essential Working in at least one of hospital /community/Care Home setting Involvement in discharge processes in a variety of settings Minimum of 2 years in care of older people Working in a multidisciplinary team Multi agency working Supporting students Delivering training in various settings PERSONAL ABILITIES AND WORK APPROACH Essential Excellent communicator/verbal and non-verbal Excellent interpersonal skills Good listening /observation skills Established liaison skills Ability to advocate on behalf of service users Ability to deliver training Effective team player Ability to be assertive yet tactful and diplomatic Ability to work independently and use initiative Ability to question & analyse and make decisions on sound information Good Time management Innovative Flexible approach e.g. to working hours, base, daily work content Person Specification Qualifications Essential RN level 1 with 3 years post qualification and a graduate degree and relevant clinical and service specialist experience which would provide the appropriate knowledge for the role Experience Essential Working in at least one of hospital /community/Care Home setting Involvement in discharge processes in a variety of settings Minimum of 2 years in care of older people Working in a multidisciplinary team Multi agency working Supporting students Delivering training in various settings PERSONAL ABILITIES AND WORK APPROACH Essential Excellent communicator/verbal and non-verbal Excellent interpersonal skills Good listening /observation skills Established liaison skills Ability to advocate on behalf of service users Ability to deliver training Effective team player Ability to be assertive yet tactful and diplomatic Ability to work independently and use initiative Ability to question & analyse and make decisions on sound information Good Time management Innovative Flexible approach e.g. to working hours, base, daily work content 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 NHS Bath and North East Somerset, Swindon and Wiltshire ICB Address Pierre Simonet Building Swindon SN25 4DL Employer's website https://bsw.icb.nhs.uk/ (Opens in a new tab)