Responsible for the coordination and monitoring of care plans, ensuring all in-patients have effective plans at the point of hospital admission and are discharged in a timely manner with a smooth transition to other services. Responsible for maintaining a collaborative working interface with Home Treatment Team to identify patients suitable for discharge, and to work together to promote a smooth discharge pathway from inpatient services. Work with external services in a timely manner to identify practical help that can be provided to clients in achieving a prompt discharge. Works as an effective member of the multi-disciplinary team, maintaining and actively role modelling high standards of care.
To develop effective changes in practice to support in-patients receiving a high standard of care, meeting individual needs.
General Requirements
1. To take a lead role, in support of the Ward Manager and MDT in establishing, setting, monitoring, evaluating and auditing effective and timely discharge plans for all inpatients and leading on improving discharge processes, specifically as part of the acute care pathway.
2. To work closely between ward and community teams and other agencies in ensuring all in-patients have effective discharge plans and to monitor progress on discharge plans to ensure that patients are discharged in a timely fashion.
3. To work with Social Workers and other services to identify practical help that can be provided to clients in achieving a timely discharge.
4. To take a lead role in maintaining a collaborative working interface with Home Treatment teams to identify patients suitable for discharge, and to work together to promote a smooth discharge pathway from inpatient services.
5. To take a lead role, in support of the Ward Manager and MDT to ensure a recovery focused approach to discharge planning.
Principal Duties
1. To use relevant information in support of patient care, care planning and discharge planning, including available electronic information systems.
2. To ensure that decision making is appropriate in relation to the Mental Health Act, and Code of Practice regarding patient care.
3. To ensure that an appropriate therapeutic environment is maintained within the Ward.
4. To ensure positive approaches to patient engagement and ensure that patient care is delivered using a manner consistent with available local guidelines relating to care pathways.
5. To ensure that practice in relation to medicines is in line with local guidelines, individual professional requirements, and responsibilities, and ensures individual patient involvement, engagement, and concordance.
Service Development
1. Monitor and actively role model positive and high standards of nursing practice and professional behaviour of staff on the ward.
2. To ensure that discharge plans delivered by their team are appropriately audited on a regular basis.
3. Maintain and promote accurate clinical records of interventions and contracts with patients.
4. To participate with colleagues in the promotion of an active learning environment.
This is not an exhaustive list of duties and responsibilities and in discussion with the manager the postholder may be required to undertake other duties which fall within the Banding of the post.
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