Discharge Liaison and Transitions Lead - Cambridge, United Kingdom - Cambridgeshire Community Services NHS Trust

Tom O´Connor

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Are you looking for an exciting new challenge?

Do you have experience of working with young people who are transitioning into adult services?

Do you have experience, knowledge and understanding of working alongside other agencies and professionals including education, health, social care and the voluntary sector?


We are looking for an experienced Children's Nurse to lead on hospital discharge liaison and transitions across our dynamic Children's Community Specialist Nursing Service and Community Paediatrics.

We are an integrated team with a strong ethos of quality care provision.

You must be innovative, motivated, have excellent communication and leadership skills and the ability to work on your own initiative.

This 12-month secondment/fixed term post will be working across the 3 acute hospitals in Cambridgeshire and Peterborough.

The team bases include; The Oak Tree Centre in Huntingdon, The Peacock Centre in Cambridge and The City Care Centre in Peterborough.


To lead on the effective co-ordination of patient discharges in conjunction with the acute hospital trusts within the Cambridgeshire and Peterborough area and specialist areas as required.


To lead the transition process for children, young people and their families with research based, skilled and individualised family centred care within the community and other settings.


Cambridgeshire Community Services is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expects all staff and volunteers to share this commitment.


Due to the nature of the role it is essential that applicants are able to travel effectively and independently on a daily basis to and from the base, clients' homes and other venues around the geographical area whilst transporting equipment.

If necessary, adjustments can be considered, in accordance with the Disability Discrimination Act.


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.


Provide skilled paediatric nursing care to children and young people within their own home, school or nursery settings to ensure families are supported in the care of their children in the community.

To build and maintain positive working relationships with the acute hospital trusts to facilitate and coordinate effective discharge planning.

To liaise with multidisciplinary teams within hospital, community, primary and social care to promote a smooth transition to care in the Children's Community Specialist Nursing Service (CCSN).


To lead on ensuring effective pathways are in place to ensure early discharge, effective communication and accurate assessment of patient needs between hospital and community services.


To ensure accurate and relevant discharge information is available in the promotion and supporting of learning and development within the multidisciplinary team.


Attend discharge planning meetings, chairing if required, to ensure issues are resolved prior to discharge including complex cases and multiagency involvement.


To lead the co-ordination of transitional pathways to adult services for young people across the services by working in conjunction with adult services, ensuring that local and national guidelines and policies are adhered to and staff are supported and guided by best practices.


Act as a named nurse for a caseload of children and young people responsible for planning and co-ordinating care, delivering and evaluating the care given as well as on going complex case management.

Must be able to use own initiative and work autonomously to provide skilled care. Supervision and support available from Clinical Nurse Lead.


To ensure high standards of Transitional Care the post holder will help to identify gaps in current service provision and assist in developing effective, efficient patient pathways in conjunction with other members of the multidisciplinary team.


To provide clinical leadership in transitional care and maintain an effective learning environment for staff, acting as a facilitator in the supervision and teaching of staff.


To link with other transition leads across the system and represent the service at local and national transition meetings/working parties and action groups and disseminate relevant information to the leadership team and colleagues.

To lead on clinical audits in specialist area and undertake/participate in relevant research.

To lead and develop on protocols and clinical guidelines in specialist area.

Promote the health, comfort, dignity, privacy and quality of life for children young Work within the limits of the NMC code and guidelines, Trust policies, service operational policy

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