Transfer of Care Nurse

Go back South Tyneside and Sunderland NHS Foundation Trust

Transfer of Care Nurse The closing date is 27 February 2026

We have an exciting opportunity within the transfer of carehub for a band 6 discharge specialist nurse. The successful candidate will work alongside a team of nurses and support the Band 7 nurses to manage complex patient discharges as an autonomous practitioner. The successful candidate will carry out patient assessment to facilitate safe discharges for all those patients who are community ready to leave hospital.

The successful post holders duties will involve attending wards daily educating junior members of staff along with educating ward teams. The successful candidate will work closely with all members of the ward systems to ensure a home first approach is followed from the moment the patient is admitted to hospital.

If you are enthusiastic with a passion for improving patient outcomes within our home first approach, come and join our team.

Main duties of the job The successful candidate will spend most of the working day based on their allocated ward areas, attending board rounds, supporting ward teams and other professionals with the discharge processes. Attending ward areas to speak with patient and relatives about their discharge plans with a home first approach.

To accept and action appropriate discharge to assess referrals allocated by the coordinator and ensure all necessary evidence is available to support the request for the referral to be progressed.

To enable patients to leave hospital in a timely manner once identified as being community ready and no longer have the right to reside. To minimise delayed discharges, improve patient flow and reduce the possibility of clinical deconditioning.

To work collaboratively, as part of the trust wide transfer of care hub, with ward based multi-disciplinary teams and community health and social care partners to agree discharge plans that reflect the ongoing care needs of patients and respect their wishes.

The service hours are 08.00-18.00 7 days per week. The post holder would be required to work four 08.00-18.00hrs shifts per week.

About us Please add your telephone number to your application form so we can contact you quickly if required.

One Team One Trust - There are many reasons to work at our Trust. From our commitment to putting people first to our accessible services and award winning teams. We have a passion for research, innovation and tackling inequalities. We are committed to respect, fairness and civility and promote a compassionate, caring and positive culture / working environment.

We welcome all applications irrespective of peoples race, disability, gender, sexual orientation, religion/belief, age, gender identity, marriage and civil partnership, pregnancy/maternity and in particular those from under- represented groups. Looking after our workforces health and wellbeing is a priority for us. We also provide access to high quality education, training, career progression and support. Flexible working is supported via our Flexible Working Policy.

The Trust employs around 8,746 people and provides a range of hospital services to a local community of around 430,000 residents. We also provide a range of more specialised services outside this area. We offer our staff outstanding benefits - Fitness Centre (SRH), libraries at both hospital sites, chaplaincy support and access to a Care Co-ordinator to help staff with childcare arrangements. If you use AI, and it poses a risk to the integrity of your individual recruitment process, we may withdraw your application at any stage of the process.

Job responsibilities PLEASE REFER TO THE ATTACHED JOB DESCRIPTION FOR FULL DUTIES OF THE ROLE.

• 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 elevate 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 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 Trust's vision, values and behavioural compact.

Person Specification Experience

• Experience as a Band 5.
• Experience of leading a team.
• Experience of coordinating a team in caring for patients from admission to discharge.
• Expertise within the speciality.
• Experience of line management of staff.

Qualifications

. click apply for full job details