Transfer of Care Nurse in South Shields

To be responsible and accountable for the safe, effective and compassionate nursing care for all patients in a ward/department area. To exercise accountability as set out in the NMC Code. To supervise, support and educate junior members of the team, acting as a role model.

Support Unit manager to ensure organisational goals/objectives are met within the unit. When taking charge of the unit or in the absence of the unit manager, is directly responsible for ensuring that clinical, professional and cleanliness standards are maintained in the entire unit. To ensure effective communication internally and externally, regarding patient care and resources.

To accept and action appropriate Discharge to Assess referrals as allocated by the TOCH coordinator and ensure all necessary evidence is available to support the request for the referral to be progressed. Work at all times within the agreed framework and to the agreed timescale that the patient will be transferred to the Discharge Lounge within one hour from the time of the ward/board round and transferred to the care of community and/or social care services with two hours from arrival in the Discharge Lounge.

To enable patients to leave hospital the day that they are identified as being medically optimised/fit, in order to minimise discharge delays, improve inpatient flow and reduce the possibility of clinical deconditioning. To work collaboratively, as part of a Trust wide TOCH, with ward based multidisciplinary teams and community health and social care partners to agree discharge plans that reflect the ongoing care needs of patients, and respect their wishes.

To ensure safe discharge by confirming that the next of kin has been informed that the patient is being transferred to the Discharge Lounge for the finalisation of their same day discharge. To inform the Discharge Lounge coordinator when the patient discharge progress is complete and communicate timely and effectively with the Discharge Lounge Coordinator to facilitate safe discharge.

To alert the Band 7 Coordinator to issues which are contentious or complex and may prevent same day discharge. To alert the Band 7 Coordinator of any safeguarding issues as appropriate who will escalate to the safeguarding team as deemed necessary. To action all Discharge to Assess referrals to members of the multi-disciplinary.

To attend ward/board rounds, at least monthly acting as a resource for all wards to support education and training in the Discharge to Assess pathway. To support and educate ward teams in their understanding of the Red to Green process up to the point of the recording that the patient is deemed medically fit/medically optimised and allocating the correct discharge pathway on Meditech to enact the discharge process.

To ensure that ward staff understand the process and confirm that pre discharge discussions have taken place and the patient/Next of Kin has either been given the NHS 'Your Hospital Discharge Home' or 'Your Hospital Discharge: another place of care' documents including the ward contact details. Collect any background information and data for any complaints for the TOCH Coordinator.

To have good knowledge of local community services that are available including the voluntary sector across the various ICBs in the region. To provide clinical expertise and advice to other staff and to be a role model to them. To act as an expert Nurse/AHP in providing advice to nursing/AHP staff on wards about professional issues in relation to patient care required for discharge progression.

Deputise in the absence of the TOCH Coordinator and act up as appropriate. To ensure that all documentation is accurate and completed as per Trust standard. To promote joint working between agencies by recognising and acknowledging the abilities and constraints of health and social services and community services in identifying and completing appropriate multi-disciplinary referrals.

To identify and support with documentation required for CHC. Participate in daily review of patients who have a long length of stay in line with NHS Improvement guide to reducing long hospital stay. Must possess the specialist skills and expertise to provide advice and guidance on all aspects of simple and complex discharge and ensure the highest standards of patient care delivery.

Will act as a champion for professional accountability and standards, ensuring that professional practices are in line with the requirements of the Nursing and Midwifery Council (NMC) and/or the Health and Care Professional Council (HCPC) and Trust Policy. Liaise with ward staff, members of the multi-disciplinary team, patients, relatives, carers, primary care and social work department both hospital based and community area teams.

Must possess the specialist skills and expertise to provide advice and guidance on all aspects of patient discharge and ensure the highest standards and safe patient discharge. Recognition and minimisation of risks associated with discharge. Support the standardisation of discharge documentation, policy and procedure across the Trust and demonstrate effectiveness.

Support and contribute to the development of patient care within the Directorate. Contributing to Trust wide projects as required. To comply with the Trusts vision, values and behavioural compact.