Lead Transition Nurse

NHS Jobs; Bedford; On-site; GBP 50,000 - 70,000; Full time

Job summary

East of England Community Health & Care NHS Trust is seeking a Clinical Leader to oversee Transition Service and coordinate care for children and young people through complex pathways across health and social care sectors.

You will act as Transition Coordinator, lead multi-agency collaboration and drive improvement in outcomes, safeguarding, and information governance while supporting education and workforce development.

Responsibilities

• Provide professional and clinical leadership for the Transition Service.
• Lead and coordinate complex transition pathways across health, social care, education and community partners.
• Act as Transition Coordinator and primary contact for families and professionals.
• Manage a specialist caseload of children and young people with complex physical, developmental and psychosocial needs.
• Undertake comprehensive assessments and develop personalised transition plans.
• Monitor progress and escalate concerns or risks.
• Undertake complex assessments and exercise advanced clinical judgement.
• Chair multidisciplinary meetings and care planning forums.
• Deliver education, coaching and training for staff and partners.
• Lead service improvement, audits and evaluation.
• Maintain records and governance in line with policy.
• Travel across settings to support service delivery.

Job description

Clinical 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.

Specialist Practice

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.

Partnership Working

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.

Education and Development

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.

Service Development and Quality Improvement

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.

Governance and Information Management

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.

Resources and Professional Responsibilities

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.

East of England Community Health & Care NHS Trust

Bedfordshire Hospitals NHS Foundation Trust