All-Age Complex and Continuing Care are a team of clinical, business, commissioning specialists who provide continuing healthcare (CHC) children and young people’s continuing care (CYPCC) and complex care commissioning to individuals across the Thames Valley footprint.
Our operating model has three main areas of activity,
Neighbourhood teams work alongside health and social care partners within the community assessing, reviewing and case managing care for adults and children within Oxford, Buckinghamshire or Berkshire, working directly with individuals and families.
Central services teams act as the front door and end to end service delivery, managing referrals into the service, business, administration and invoicing functions. Working closely with individuals and their families.
Commissioning Contracting and Brokerage team work closely with care providers and social care to commission individualised care for individuals.
This post has subject matter expertise and specialist knowledge to assess children and young people in the community/ home and hospitals. Utilising the national assessment tools and adhere to the required timescales. Oversee, Co-ordinate, participate and support the assessment process with the multidisciplinary team (MDT). The role links closely with the CYPCC team and will be part of the MDT and determine the individual’s eligibility in line with the National Framework for Children and Young People's Continuing Care (2016).
The role will require travel on occasions, to carry out assessments and reviews. Access to transport is therefore necessary, be it personal or public.
Please note it is proposed that this post will be in scope to transfer to Frimley Health NHS Foundation Trust (FHFT) on the 1 September 2026. If you are appointed prior to 1 September 2026, you will join Thames Valley ICB initially, but it is proposed that your employment will then transfer to FHFT in accordance with TUPE/ CoSOP regulations. If your start date is on or after the 1 September 2026 it is planned that you will be employed directly by FHFT from commencement.
Support the commissioning of health care packages at home for CYP shared care eligible children and other community settings to prevent hospital admissions; in addition, they will help support early discharge from hospital wherever possible, working with the clinical practitioners .
In the absence of senior CYP clinical manager, act in a deputising role, which would include undertaking duty management and responding to package breakdowns, enquiries for new referrals, checklists and prioritising workload.
To help support the daily duty system for CYP shared care, working with the duty nurses; responding in a timely manner to support the caseload.
To act as a member of the multidisciplinary team to co-ordinate the process, establish eligibility and assist in identifying a suitable care package or respite setting.
To be responsible to ensure that the review process for all commissioned care is undertaken in accordance with current guidance.
Assist when required with the monitoring and providing assurance on the quality of service providers for Children and Young People’s Continuing Care, this includes residential placements and short breaks environments.
Advising AACC Procurement on clinical needs and best practice in relation to services for children with complex health needs and providing clinical input to all parts of the commissioning process.
To assist with the personal health budget (PHB) process for children’s families / carer’s who would like to be in receipt of a personal health budget and ensure that the NHS Surrey & NHS Sussex’s procedures are monitored.
To be responsible for planning, managing, co-ordinating and undertaking annual reviews of the Children and young people’s eligible for Continuing HealthCare, within the caseload. Responding to any health needs reported and reviewing the DST and care package accordingly.
Communicate, with support from the nurse specialists, complex information, with empathy and consideration to the children, young people, parents and carers. This may relate to a diagnosis, prognosis and funding issues, which therefore could be highly sensitive or distressing and associated with high degrees of emotion or conflict. This may include end of life discussions.
Work alongside other agencies, e.g., Local hospices, as well as social services and specialist educational schools, to provide joint care packages where appropriate, ensuring that families receive the most appropriate and equitable service for their child.
Participate in on going professional development and clinical supervision, including safeguarding supervision.
Assisting CYPCC team in the delivery of informal educational sessions to varying groups of staff on subjects related to Children’s Continuing care.
Organise own workload, with oversight from a Clinical Manager.
Be aware of and follow local Safeguarding policy and follow child protection procedures, providing any reports and attending child protection conferences as necessary.
Supporting with Transition from CYPCC to the Adults CHC pathway.
Project Management
Contribute to performance improvement, taking a lead for identified areas where agreed.
Provide coordination of and participate in relevant internal and external working groups and provide project advice, expertise and support as requested.
Provide relevant and timely specialist advice and guidance on own portfolio of projects/function
Work with members of the Team to investigate the causes of any variance from target/plan and proactively contribute to the implementation of solutions.
Management of a risk and issues tracking mechanism and its proactive resolution and escalation processes.
Financial and Physical Resources
Provide regular reporting on the targeting of resources and monitoring their implementation from a value for money perspective.
Provide oversight and monitoring of all aspects of team budgets
Evaluate projects/function within identified portfolio for delivery against financial recovery/savings plans through providing sophisticated, high quality project analysis.
Take a lead in the coordination of training, development and recruitment activity across the team.
Manage colleagues, including undertaking appraisals, recruitment and induction processes, and progressing any informal and formal processes as necessary e.g. disciplinary or capability issues.
Information Management
Devise and provide improvements to current management information, analysing, reporting and suggesting procedures to enhance decision making processes. Ensure timely and accurate information analysis and reporting to management on agreed areas of work.
Research and Development
Contribute to the development of key performance indicators for the successful assessment of individual and workstream success.
Delegate aspects of research and development activities, collating information, analysing and reporting findings.
Planning and Organisation
Contribute to the strategic planning of team projects, identifying interdependencies across projects/functions, potential impacts on wider organisation, resource requirements and building in contingency and adjustments as necessary.
Contribute to the development of performance and governance strategies and the development and implementation of improvement programmes, in accordance with ICB and regional priorities.
Contribute to short, medium and long-term business plans, achieving quality outcomes.
Policy and Service Development
Contribute to the review and development of existing information management systems and contribute to the development of an integrated approach to service or initiative management.
Develop policies and procedures in own work function with an impact on the wider organisation, as required.
The job description is an outline of the tasks, responsibilities and outcomes required of the role. The postholder will carry out any other duties as may reasonably be required by their line manager. The job description will be reviewed on a regular basis in accordance with the changing needs of the department and the organisation.
