Job summary
The post holder will demonstrate expert knowledge in discharge options, services available, whilst providing support to the patient, their family/carer and care workers in communicating the possible plan, estimated date of discharge and managing expectations and any concerns raised. The post holder will aim for a safe and sustainable discharge by highlighting and managing any potential risks thus reducing the risk of readmission.
The purpose of the role is to contribute at the multidisciplinary team meeting by ensuring that the patient's wishes are heard, needs are assessed and are well managed to achieve a timely discharge. Also, to promote advanced care planning where appropriate to avoid unnecessary hospital admissions.
To identify social care needs of older people and to be aware of / able to access adult social care processes which facilitate the provision of care on discharge from hospital.
Main duties of the job
To act as a link between the wards and community teams/services for discharge planning.
The identification, assessment, planning, implementing and evaluating care as a practitioner with specialist Discharge Planning Skills. This involves the completion of specialist discharge planning liaising with the discharge planning nurse to complete specialist nursing assessments.
This role is to work closely with healthcare professionals, clinicians, social work teams, family members, personal care services and other multi-disciplinary team members to deliver a high quality, patient focused service
About us
Cambridgeshire and Peterborough NHS Foundation Trust is a health and social care organisation dedicated to providing high-quality care with compassion to improve the health and wellbeing of the people we care for, as well as supporting andempowering them to lead a fulfilling life.
Our clinical teams deliver many NHS services, not only via inpatient and primary care settings, but also within the community. These services include children's, adult and older people's mental health, forensic and specialist mental health, learning disabilities, primary care and liaison psychiatry, substance misuse, social care, research and development.
To achieve our goal, we look to recruit high-calibre candidates who share our vision and values. As an equal opportunities employer, we encourage applications from all sectors of the community, particularly from under-represented groups including people with long term conditions and members of our ethnic minority and LGBTQ+ communities.
Please be advised we reserve the right to close adverts earlier than the closing date should we receive sufficient applications.
Regrettably, we cannot offer sponsorship for all our job roles. If you apply for a role that we cannot offer sponsorship for, unfortunately, your application form will be rejected from the process.
Job description
Job responsibilities
Please refer to the attached job description and person specification for full details of responsibilities.
1. Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act.
2. Any data that is taken/shared as part of a phone call or transported, or transferred electronically must be undertaken with regard to CPFT information Governance and information Security policies.
3. The post holder must adhere to CPFT risk assessment and risk management processes.
4. The post holder must adhere to infection control policies and procedures.
5. Undertake mandatory training and any other training relevant to the role as required by Cambridgeshire & Peterborough NHS Foundation Trust (CPFT).
6. The post holder must participate in clinical and other audits as required.
7. Provide patients and their families/carers with information on standards they should expect from the team.
8. Provide discharge planning training programmes and oversee issues across the Trusts to ensure all professional needs are met, thus ensuring the Trusts discharge policies are adhered to.
9. Create discharge education packages appropriate to different grades/disciplines across different settings.
10. Identify, monitor, investigate and record reasons for delayed discharges and review ways of working with multi-disciplinary teams in order to reduce these delays.
Job description
Job responsibilities
Please refer to the attached job description and person specification for full details of responsibilities.
1. Observe and maintain strict confidentiality with regards to any patient/family/staff/records and information in line with the requirements of the Data Protection Act.
2. Any data that is taken/shared as part of a phone call or transported, or transferred electronically must be undertaken with regard to CPFT information Governance and information Security policies.
3. The post holder must adhere to CPFT risk assessment and risk management processes.
4. The post holder must adhere to infection control policies and procedures.
5. Undertake mandatory training and any other training relevant to the role as required by Cambridgeshire & Peterborough NHS Foundation Trust (CPFT).
6. The post holder must participate in clinical and other audits as required.
7. Provide patients and their families/carers with information on standards they should expect from the team.
8. Provide discharge planning training programmes and oversee issues across the Trusts to ensure all professional needs are met, thus ensuring the Trusts discharge policies are adhered to.
9. Create discharge education packages appropriate to different grades/disciplines across different settings.
10. Identify, monitor, investigate and record reasons for delayed discharges and review ways of working with multi-disciplinary teams in order to reduce these delays.
Person Specification
Education
Essential
- AHP/Social Work - with Relevant Degree/Diploma and registration
- Evidence of continuing Professional development
Desirable
- Mentorship qualification
- Continuing Health Care assessment training
Experience
Essential
- Significant amount of months post registration.
- Working within older adults
- Previous experience of undertaking assessments and evaluating needs
Desirable
- Experience of working in an acute setting.
- Discharge planning work experience
Skills & Abilities
Essential
- Able to demonstrate commitment to high quality care and service provision
- Ability to work flexibly as part of a team
- Good communication skills
- Good report writing
- Able to assess plan and implement care
- Good IT skills and ability to communicate through
- Microsoft Teams or Skype to engage family members and other professionals when they are not able to visit the ward.
- Time Management and prioritisation skills
Desirable
Knowledge & Understanding
Essential
- Accepts responsibility and accountability for own work and can define the responsibilities of others
- Seeks and uses professional support appropriately
- Understands the principle of confidentiality
Desirable
Person Specification
Education
Essential
- AHP/Social Work - with Relevant Degree/Diploma and registration
- Evidence of continuing Professional development
Desirable
- Mentorship qualification
- Continuing Health Care assessment training
Experience
Essential
- Significant amount of months post registration.
- Working within older adults
- Previous experience of undertaking assessments and evaluating needs
Desirable
- Experience of working in an acute setting.
- Discharge planning work experience
Skills & Abilities
Essential
- Able to demonstrate commitment to high quality care and service provision
- Ability to work flexibly as part of a team
- Good communication skills
- Good report writing
- Able to assess plan and implement care
- Good IT skills and ability to communicate through
- Microsoft Teams or Skype to engage family members and other professionals when they are not able to visit the ward.
- Time Management and prioritisation skills
Desirable
Knowledge & Understanding
Essential
- Accepts responsibility and accountability for own work and can define the responsibilities of others
- Seeks and uses professional support appropriately
- Understands the principle of confidentiality
Desirable
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.
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.
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).
