Livewell Southwest CIC
£35,392 to £42,618 a year pro-rata
Closing date
1 Dec 2023

View more

Band 6
Contract Type
Part Time
22,.5 hours per week. Are you an experienced Nurse who wants to make a difference in the lives of Plymouth and Devon adults who require have complex care after discharge from hospital? If so, then we need you to help us in facilitating and organising complex care for patients leaving Derriford and our community hospitals.

Based in UHP (Derriford Hospital) and the Discharge Assessment Unit(Mount Gould hospital), the post holder will be accountable to the IHDT Deputy Team Manager on a day-to-day basis for the leadership and management of the discharge team. The team consists of Nurse Assessors, Social Workers, CCWs, IHDT Coordinators and a team of Discharge Case Managers.

Complex discharge from hospital is ever changing. We are looking for a nurse who is innovative, proactive, adaptable, a team player and who can work autonomously.

Main duties of the job

The post holder will have knowledge and understanding of acute and community discharge pathways including, but not limited to Homefirst, Discharge to Assess, End of Life, Community Hospitals and Specialist Pathways such as neurological or stroke care. Knowledge of the wider market place such as care homes, domiciliary care and support services, underpinned by an understanding of commissioning, will be invaluable, and you will need to be able to demonstrate understanding of legislative and policy frameworks such as CHC and the Care Act.

Due to the complexity of some people requiring discharge, there will be a need to provide advice to staff regarding safeguarding, and to assist in Mental Capacity assessments and Best Interest decisions, including chairing meetings where required. This is also an opportunity to develop and embed strength-based practice within a broad and well established team environment.

The service covers seven day a week. An important part of the role is liaison with ward staff, patients and their families and carers, to ensure safe, timely discharge from hospital. The post holder will also be able to provide a professional and trusted interface between hospital, primary care, community and social care settings.

This role may not be eligible for sponsorship under the Skilled Worker route, please refer to the Direct Gov website for more information with regards to eligibility.

About us

Livewell Southwest is an independent, award-winning social enterprise providing integrated health & social care services for people across Plymouth, South Hams & West Devon, as well as some specialist services for people living in parts of Devon & Cornwall. With teams in community hospitals, GP practices, sports centres, health & wellbeing hubs.

As an organisation with a strong social conscience, we always value being kind, respectful, inclusive, ambitious, responsible and collaborative. Transforming services to make them sustainable, ensuring that we value, support & empower each other.

We are committed to involving the people we care for, families & carers in everything that we do, working towards co-production where we can. Helping us to deliver the right care for people, in the right place & at the right time. By putting people at the centre of what we do, we ensure to support people to lead, healthy independent lives & be the very best at helping people to live well.

Valuing our employees making an investment in their development a priority. We offer:

Protected CPD time for registered staff

Various development pathways and ongoing regular training packages for all staff

Leadership & mentoring programmes

Access & funding for training including Care Certificate, Assistant Practitioners Course & Scholarship Into Nurse Training

A Robust Preceptorship

A bespoke induction programme

Existing members of the NHS Pension Scheme can continue their membership when they join the organisation.

Job description

Job responsibilities


1.To be professionally responsible and accountable for all aspects of your own work including caseload management.

2.To act as a Care Coordinator for patients/Carers and arrange for appropriate care packages to be set up

3.To be responsible for assessing, diagnosing, implementing, planning and reviewing complex needs and packages of care in partnership with patients, carers and multi-professional agencies including case conferences.

4.Through liaison with other registered practitioners, and without face to face patient assessment, care needs may be agreed and implemented.

5.To use clinical reasoning and utilise a wide range of appropriate treatment options to formulate individualised programmes of care and to provide intervention plans for people with a wide range of complex conditions.

6.Have good communication skills as to effectively communicate with patients and their carers, including sensitive and accurate information about their condition.

7.The post holder will have to provide and receive complex, sensitive and confidential information and overcome potential barriers to communication, such as language, disability as well as dealing with concordance and barriers from patients to the prescribed treatment.

8.To provide good quality advice and information regarding the range of realistic options available for meeting the persons care needs and to arrange for care to be set up effectively with supporting documentation.

9.Maintain effective working relationships with multidisciplinary team and deliver a cost effective quality service to patient/carers within a defined geographical area.

10.Involvement in initiation and participation of reviewing existing clinical policies and procedures in steering groups and committees.

11.To co-ordinate and manage a caseload (or caseloads) and delegation of tasks within the skill mix of the Team.

12.To be accountable for the delivery of service by facilitating holistic evidenced based practice to patients, in accordance with National and organisation approved policies/procedures and individual care plans.

13.The aim of which is ensuring maximum independence and quality of life in a constantly changing environment.

14.To take a Lead role within the team when dealing with complex/urgent situations which can be emotionally challenging e.g. terminal illness

15.To supervise, monitor, develop standards and audit of care delivered to patients and Carers by the multi-disciplinary team.

16.To undertake, develop and maintain nursing skills and competencies which are required for their role.

17.To enhance the skill mix of the multi-disciplinary team and ensure that the ever-changing health needs of patients are met.

18.To act as advisor/professional leader in health care issues and clinical practice which are often complex and urgent.

19.Support links across & liaison with patients, carers and the wider health, social care and voluntary community.

20.To triage and accept appropriate referrals directly from other disciplines, or refer to other agencies where appropriate.

21.To Case Manage/Care Co-ordinate packages of care and to work within the framework of the Care Co-ordination Team by providing holistic care and demonstrate positive leadership skills.

22.To ensure privacy, dignity and human rights are respected for all patients and carers.

23.To report and records all incidents and near misses relating to health, safety, security, fire, physical violence, aggression and verbal abuse.

24.To be responsible for ordering, monitoring and authorising suitable equipment, within individual competence.

25.To maintain accurate records, which are confidential, up to date, 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.

26.The post holder will be expected to oversee the standard of patients records by audit or peer review, and have a regular open discussion with team members.

27.The post holder is required to comply with all infection control policies and guidance, attend relevant updates and report issues of concern to their immediate line manager (if no action or explanation received, then it is the individuals responsibility to escalate to Director of Operations or Chief executive office)

28.To monitor and maintain the health, safety and security of self and others.

29.To be responsible for organising own time management on a daily basis in line with caseload demands balancing patient needs with the non-clinical aspect of

30.To act as a clinical advisor on health care issues within their area of expertise.

31.To undertake health promotion whenever possible to all age groups and also contribute to planned health promotion activities.

32.To act as a role model for other staff and students demonstrating high standards of practice and professional conduct.

33.To be involved with the development, implementation and monitoring of standards.

34.Develop links with other professional and voluntary bodies to ensure maximum effectiveness of the service and patient care.

35.To work alongside the Community Practitioners if appropriate in monitoring complex health needs of the patients' and reduce hospital admissions.

36.Ensure that work which is often unpredictable is prioritised and suitably delegated to other members of the multi-disciplinary team.

37.Implement, participate and facilitate Clinical Supervision as per organisational Policy.

38.To participate in an annual appraisal where the job description will be reviewed and objectives set. In line with the annual development plan the post holder will be expected to undertake any training or development required to fulfil their role.

39.Be conversant with the vulnerable adult and child protection procedures and policies of the organisation.

40.Identifying and bring to resolution delays relating to patients progress and timely discharge from the service. Escalating to a more senior level if required.


1.To undertake appraisals for Discharge Case Managers who are line managed by this post holder.

2.To facilitate and develop Discharge Case Managers.

3.To participate in Reflective Practice, Clinical Supervision and Appraisals for Discharge Case Managers as per organisation policies.

4.Identify areas of practice/role development and enable and support staff to initiate change.

5.To Manage and prioritise a defined caseload and delegate where appropriate.

6.To participate in policy development through professional forums and implement practice ensuring the clinical practice reflects national and local drivers.

7.To be responsible for recruitment and selection of new staff, including chairing appointments panels.

8.To be accountable for effective time and staff management within the constraints of the budget.

9.To support, complete and monitor staff to ensure the submission of all necessary forms, documentation, including IT data and forward as required by the manager/organisation are undertaken in a timely manner.

10.To have a flexible approach to the working week in order to meet the needs of the patient and the service.

11.To be aware of pressures facing your work colleagues and offer support and ensure they are aware of the organisation support services available to them.

12.To be responsible for maintaining lone working information for identified staff group and monitoring staff adherence to lone working policy and use of devices.

13.To maintain own clinical professional development (CPD) by keeping abreast of any new trends and developments, National Service Frameworks and guidelines, and incorporate them as necessary into your own practice.

14.To lead and participate in team activities so as to develop and consolidate a cohesive and supportive team ensuring openness within the team.

15.The post holder will be required to use a computer, being responsible for timely recording patient activities for IT data collection, dealing with e-mail queries, stock and equipment ordering.

16.Preserve confidentiality and be aware of the Data Protection Act, Access to Health Records and Consent for Treatment.

17.Able to communicate the role and eligibility criteria of the IHDT

18.Maintain accurate and up to date patient records and inform other professionals about changes in patients condition.

19.Act as a patient advocate as required ensuring individual needs, preferences and choices are delivered by the Service.

20.To works within the NMC Code

21.To remain updated and competent and ensure that clinical practice is evidence based.

22.To have an up to date personal development plan and professional portfolio

23.Assume responsibility for own professional development and personal knowledge.

24.Monitor own performance against agreed objectives through the process of annual appraisal and personal development plans, NMC regulations and maintain professional expertise by arranging and attending meetings, study days and in service training for the team members.

Please refer to Supporting Documents for full JD/Spec.

Person Specification



  • Experience of working within an acute or community hospital setting



  • Registered Nurse
  • Mentorship Course or willingness to undertake
  • Demonstrable leadership skills
  • Diploma in Nursing or Health Related Studies or equivalent demonstrable experience or working towards degree.
  • Specific post basic qualification or equivalent experience relevant
    Any attachments will be accessible after you click to apply.


Get job alerts

Create a job alert and receive personalised job recommendations straight to your inbox.

Create alert