Job Description

Be response to system pressures and complete a range of tasks, working flexibly and interchanging between hospital and community settings. Undertake timely, complex and detailed assessments/ re-assessments requiring high levels of concentration. This may include preparing reports, plans of care, complex papers or tools such as the DoH Checklist and Decision Support Tools. Undertake assessments on behalf of care home providers in Plymouth according to agreed criteria.



Undertake re-assessments and assist Care Home Managers by liaising with them where there is an existing resident in hospital, for whom there is a potential change of needs. Ensure that wherever possible the views and needs of the individual are sought and represented with due regard to the persons mental capacity. Participate in case conferences as required. Ensure accurate minutes and record of meetings are kept and distributed as appropriate.



Participate in Best Interest Meetings as necessary. Maintain accurate records, which are confidential, up-to-date, and legible and that all care given has to be documented. These records may be paper or IT based system and must be maintained as specified in the Organisation Policies, NMC guidelines and Government directives. Work with clinical teams and care homes to ensure that discharge documentation, risk assessments, clinical equipment and medication are in place to accompany the resident on hospital discharge, to ensure the best possible outcomes for vulnerable people.



Proactively raise issues and provide solutions in partnership with other colleagues in relation to change management, working across agencies to enhance seamless care and improve patient experience. Act in a supervisory role, to support, advise and empower Care Home staff to deliver specific elements of care to individuals with complex needs. Provide data for reporting information as agreed on assessments, information dissemination, discharges, bed-days saved, case studies. Work closely with the Bed Bureau Manager to identify gaps in the market and provide data to support future commissioning intentions and/or projects.



Have good communication skills to effectively communicate with patients, their relatives and carers about sensitive and accurate information about their condition. Develop and maintain effective and appropriate communication networks with colleagues and staff from of other agencies. Ensure that robust systems for communication within the team are followed. Support the Bed Bureau in acting as a point of contact for ward staff/MDT/care homes, when residents are admitted to hospital from a Care home setting, to monitor progress and keep on-going communications.



Working with key stakeholders to deliver training and guidance to care home and hospital staff, relating to admission and discharge processes organise specialist training from other teams where this is needed. Participate in relevant internal and external working groups/projects, services and initiatives to provide information and analytical advice and expertise. Staff Management Be involved in the coordination of training, development and recruitment activity across the team. Demonstrate own duties to new or less experienced staff.



Support development of less experienced staff and students. Manage junior staff, undertaking appraisals, recruitment including progressing any disciplinary or capability issues, as necessary. Analytical and judgmental skills Engage in reflective practice including management of self and reflection on own reactions, asking questions and reflecting on answers give. Exercise judgment in assessing patient condition, comfort and wellbeing using analysis of a range of possible factors where there may be conflicts of interest situations.



Planning and Organisation Work in an effective and organised manner demonstrating excellent time management and organisational skills to effectively deliver person-centred care for an allocated group of individuals. Participate in line management and practice/clinical supervision. Recognise tasks outside sphere of competence. Health Safety and Security To adhere to organisational policies and procedures and promote Health and Safety at work.



To identify and assess the potential risks involved in work activities procedures for self and others and identify solutions to the management of any risks identified. To take the appropriate action to manage an emergency summoning assistance as necessary and completing accurate reporting systems. Report all accidents and incidents involving self, patients, staff or visitors according to organisational policy. Being an Accountable Professional Act in the best interests of the people they care for.



Put people first and provide care that is person centred, safe and compassionate. Act professionally at all times. Use knowledge and experience to make evidence-based decisions and problem solve their actions. Carry out their responsibilities to the Nursing & Midwifery Council and the Professional Code.



Physical Skills and Effort Safely carry out the manual handling of individuals and equipment. Use electronic resources to input, save and retrieve information. Frequent moderate effort is required when undertaking the moving and handling of individuals and objects in line with organisational guidelines. A combination of standing, walking bending and stretching is required throughout the shift.



Mental Effort Frequent concentration is required, on occasion work patterns can be unpredictable with interruptions, some requiring immediate response. Emotional Effort Must maintain a professional approach while working in challenging, distressing situations or dealing with challenging behaviour. Support individuals, their families and carers when faced with unwelcome news and life changing diagnoses. Financial and Physical Resources Exercise personal duty of care in the safe use and storage of equipment.



Be environmentally aware and prudent in use of resources and energy. Human Resources Acts in ways which support equality and value diversity. Demonstrate own duties to new or less experienced staff. Support development of less experienced staff and students Information Resources Develop skills to maintain professional standards of record keeping.



Follow all information governance guidance and policies. Maintain confidentiality as outlined within data protection policies. Other Responsibilities: To understand the importance of personal resilience and wellbeing to professional performance.