Lead Transition Nurse

East Of England Community Health And Care Nhs Trust; Bedford; On-site; GBP 36,000 - 48,000; Full time

Job summary

East of England Community Health and Care NHS Trust is seeking an enthusiastic Transition Nurse Specialist to lead and coordinate care for young people moving from children’s to adult services. You will work across health, social care, education and community partners to ensure seamless, person-centred transitions that support independence, self-management and positive long-term health outcomes.

You will manage a specialist caseload of young people with complex needs, act as a key point of

Qualifications

• Registered Nurse with current NMC registration.
• Experience coordinating complex transition pathways across services.
• Proven leadership and partnership-working skills in multi‑agency settings.
• Knowledge of safeguarding and consent principles in care planning.

Responsibilities

• Provide professional and clinical leadership for the Transition Service.
• Lead and coordinate complex transitions across children’s and adult services, social care, education and community partners.
• Act as named Transition Coordinator for young people and families throughout the journey.
• Manage a specialist caseload with complex health needs and develop personalised transition plans.
• Deliver training and support to healthcare professionals and partner organisations.

Skills

Nursing

Clinical leadership

Care coordination

Partnership working

Communication

Education

NMC registration

Nursing degree

Postgraduate transition care

Job description

Job summary
We are looking for an enthusiastic and compassionate Transition Nurse Specialist to lead and coordinate care for young people moving from children's to adult services. Working across health, social care, education and community partners, you will ensure seamless, person-centred transitions that support independence, self-management and positive long-term health outcomes.
You will manage a specialist caseload of young people with complex needs, act as a key point of contact for families and professionals, and provide expert assessment, care coordination and clinical leadership. The role offers the opportunity to influence service development, reduce health inequalities, improve patient experience and deliver education and support to patients, families and healthcare professionals.
This is an exciting opportunity for an experienced nurse with excellent communication, leadership and partnership-working skills who is passionate about improving outcomes for young people as they transition into adult services.
\"(Should we receive a high number of applications we reserve the right to close this vacancy at any point after 22/09/2026)\"
Main duties of the job

• Coordinating complex transition pathways across multiple agencies and services.
• Providing specialist assessment, care planning and case management.
• Supporting young people and families to develop confidence, independence and self-management skills.
• Working collaboratively with multidisciplinary teams to ensure continuity of care.
• Leading service improvement, education, audit and quality initiatives.
• Promoting safeguarding, patient advocacy and equitable access to services.

This role involves working across a range of acute, community and educational settings, with regular travel required across the locality.
About us
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.
If you share our passion for innovative and high-quality care delivery, then
our promise to you is a culture which prioritises staff engagement and development.
Please be aware that East of England Community Health and Care NHS Trust will never ask applicants to pay fees at any stage of the recruitment process, including job applications, sponsorship arrangements, or employment offers. All recruitment communications and job applications should only be made through our official careers website and published contact details.
If you receive a suspicious job offer or recruitment-related communication, do not make any payments, share personal information, or provide identity documents. We encourage you to report the matter to your local police or relevant law enforcement agency. Any concerns relating to potential recruitment fraud should also be reported to our Local Counter Fraud Specialist (LCFS) as soon as possible.
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Job responsibilitiesClinical Leadership and Care Coordination

• Provide professional and clinical leadership for the Transition Service, ensuring the delivery of safe, effective and person-centred care.
• Lead and coordinate complex transition pathways across children's and adult health services, social care, education, community services and voluntary sector partners.
• Act as the named Transition Coordinator and primary point of contact for children, young people, families, carers and professionals throughout the transition journey.
• Manage a specialist caseload of children and young people with complex physical, developmental and psychosocial needs.
• Undertake comprehensive assessments and develop personalised transition plans that support independence, self-management and achievement of agreed outcomes.
• Monitor progress throughout the transition process and ensure timely escalation of concerns or emerging risks.

• Undertake highly complex assessments involving clinical, psychological, social and environmental factors.
• Exercise advanced clinical judgement and autonomous decision-making in the planning and delivery of care.
• Provide specialist advice and consultancy regarding transition planning, complex case management and best practice.
• Act as a specialist resource in safeguarding, ensuring concerns are recognised, escalated and managed appropriately.
• Ensure Mental Capacity Act principles, consent processes, advocacy and safeguarding responsibilities are embedded within practice.

• Develop and maintain effective relationships with multidisciplinary, multi-agency and cross-sector partners.
• Chair and contribute to multidisciplinary meetings, case conferences and complex care-planning forums.
• Facilitate effective communication between children's and adult services to ensure continuity of care.
• Support integrated working across acute, community, primary care, social care and education settings.

• Provide education, coaching and support to young people, families and carers to enhance knowledge, confidence and self-management skills.
• Design and deliver specialist training programmes for healthcare professionals and partner organisations.
• Support workforce development through supervision, mentorship, preceptorship and education of students and staff.
• Maintain expert knowledge of transition policy, legislation, professional standards and evidence-based practice.

• Lead and contribute to service improvement initiatives, audit, research and evaluation activities.
• Monitor transition outcomes and use data to improve service quality, patient experience and clinical outcomes.
• Identify service gaps, health inequalities and opportunities for pathway redesign and innovation.
• Contribute to the development of policies, guidelines, standard operating procedures and integrated care pathways.
• Support business planning, workforce development and delivery of Trust and Integrated Care System priorities.

• Maintain accurate, timely and legally compliant clinical records.
• Ensure compliance with Information Governance, GDPR, professional standards and Trust policies.
• Analyse activity, performance and outcome data to support clinical governance and service improvement.
• Report and manage incidents, complaints, risks and safeguarding concerns appropriately.

• Ensure the safe and effective use of equipment and resources.
• Promote cost-effective use of financial and physical resources.
• Plan and manage a complex workload, balancing competing priorities and service demands.
• Travel across healthcare, community and educational settings as required to support service delivery.
• Undertake any other duties consistent with the grading and responsibilities of the post.

Person SpecificationQualifications and trainingEssential

• Registered Nurse (Children's, Adult or Dual Registered) with current NMC registration.
• Degree in Nursing or relevant healthcare subject, or equivalent experience.
• Evidence of continuing professional development relevant to transition care and long-term conditions.
• Evidence of leadership development or quality improvement training.
• Postgraduate qualification in a relevant clinical specialty, leadership or healthcare management
• Practice Assessor/Supervisor qualification or recognised teaching qualification.
• Quality Improvement, Project Management or Change Management qualification.
• Significant post-registration experience caring for children and young people with complex health needs and long-term conditions.
• Experience of coordinating complex transition pathways and managing a specialist caseload.
• Experience of working collaboratively across multidisciplinary and multi-agency teams, including health, social care, education and voluntary sector organisations
• Experience of leading or contributing to quality improvement, audit or service development initiatives.
• Experience of providing specialist advice, education, supervision or mentorship to colleagues and students.
• Demonstrable knowledge and experience of safeguarding children, young people and vulnerable adults.
• Experience working across both children's and adult healthcare services
• Experience of leading service redesign or pathway development.
• Experience of representing services at Trust or system-wide meetings
• Experience managing clinical resources, including the safe use of specialist equipment and consumables

Skills and KnowledgeEssential

• Comprehensive knowledge of transition planning, long-term conditions and the health needs of adolescents and young adults.
• Knowledge of national legislation, policies and guidance relating to transition, safeguarding, consent, mental capacity, equality and diversity.
• Understanding of clinical governance, quality improvement, audit, risk management and evidence-based practice
• Ability to analyse audit, patient experience and outcome data to improve services and patient care
• Knowledge of children's, adult and community healthcare pathways and available support services.
• Comprehensive knowledge of transition planning, long-term conditions and the health needs of adolescents and young adults.
• Demonstrates excellent clinical assessment, decision-making and problem-solving skills in managing complex cases.
• Ability to work autonomously whilst leading and coordinating complex transition pathways.
• Excellent care coordination and case management skills across organisational and professional boundaries. Ability to build effective relationships and influence practice within multidisciplinary and multi-agency teams.
• Excellent communication, negotiation and interpersonal skills, including communicating highly sensitive or complex information to young people, families and professionals
• Ability to develop and deliver education, training and clinical support to healthcare professionals and partner agencies.
• Excellent organisational, workload management and prioritisation skills, with the ability to manage competing demands effectively.
• Knowledge of Integrated Care Systems and national transition programmes

(This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.)

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).