Lead Transition Nurse

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.

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.

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 please submit your application and join us on our exciting journey as a leading-edge specialist community provider. All are welcome to apply and 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.

Qualifications and training

Experience

Skills and Knowledge

Desirable: - Knowledge of Integrated Care Systems and national transition programmes