Job summary
The post holder will manage a caseload of
individuals with complex needs and long-term conditions who are identified as
being at high risk of unnecessary admission to hospital. You will need
to have the nursing skills, experience, and expertise to assess, diagnose,
treat, and evaluate health and needs.
As part of the
Proactive Integrated Care Service, you will work alongside social care, mental
health, ambulance, and acute colleagues to ensure coordinated, responsive, and
safe care.
All community
nurses use EMIS as the clinical record system and are provided with a work Ipad
and Iphone. We offer Agenda for Change Terms and Conditions and
NHS Pension. Procare are committed to supporting the development of all
employees to their full potential and all employees working within the Procare
Community Services adult community nursing service will additionally have
access to the staff benefits, learning and development opportunities offered by
the Royal Surrey NHS Foundation Trust.
To encourage applicants and support our vision, we are offering a £2000 Golden Hello (Terms and Conditions will apply).
Although it isn't Procare's normal practice, adverts may
close early, so you are encouraged to submit an application as soon as
possible.
Main duties of the job
We are seeking a highly motivated and highly
skilled Registered Nurse with level 6/level 7 health assessment and Non Medical
Prescribing (or working towards). The
ideal candidate will be a highly respected Registered Nurse with significant experience
at minimum band 6. You will have a high
level of clinical and nursing skills, particularly in the management of complex,
frail patients and long term conditions. You will
need to have experience of working across primary and community care and with
the acute hospital, social care, and mental heath services.
As a Community Matron
you will be required to work within the Community Coordination Centre on a rotational basis to cover late shifts and weekends, to clinically review and priortise new, complex, and
urgent referrals. You will need to be able to travel
to patients homes frequently throughout the day across the locality and across
Guildford and Waverley and have experience to support the District Nursing
service at times of business continuity.
About us
The Procare
board are community focused, including local
GP's and our Nurse Director has
considerable community experience in governance and quality. Our clinically led
board ensures that Procare has the experience and knowledge base from which to
build sustainable integrated services.
With high quality care, patient safety and a
positive patient and carer experience at the centre of our strategy, our aim is
to ensure high quality care for our local community, through being a great place
to work with a highly skilled and competent workforce.
We are an innovative, ambitious, friendly, and supportive local team and
pride ourselves in a clinically led and flat management structure that ensures
good visibility of all directors. We are seeking someone with all the right
skills and attributes, who is pragmatic, and solution focused and wants be part
of our local revolution in Adult Community Nursing Services.
Job description
Job responsibilities
To deliver nursing care in accordance with national and local policy and guidance and in accordance with the Nursing
and Midwifery Council.
In conjunction with GPs, practice/district nurses, social care, mental health colleagues, medicines management,
ambulance services, therapists and the voluntary sector the Community Matron will lead and facilitate a patient
focused, coordinated MDT and case management approach for people who are most vulnerable to and at high risk of
unnecessary admission to hospital. The role will require working in partnership with individuals, carers and families
and developing MDT proactive care plans to reduce risks, promote self-management and prevent the need for urgent
care.
The post holder will work as part of the Proactive Care Service as a highly skilled and experienced Registered Nurse to
improve outcomes for local people and reduce unnecessary unplanned admission to hospital. The post holder will be
a named Community Matron for nominated GP practices but will work across the Primary Care Network area to ensure
equity of access. The post holder is responsible for:
proactive identification of adults at high risk of unnecessary admission to hospital who would benefit from a
proactive approach to health and care needs
collaborative working with adult social care, mental health, ambulance, GPs, community therapists,
community nursing, geriatricians to ensure the best outcomes for individuals, families and carers
supporting the implementation of work streams and improved pathways for individuals with long term
conditions and complex needs
using a proactive and anticipatory approach to assessment, implementation and evaluation of health and care
The post holder will use an electronic patient held record system, EMIS as a record of care and all our nurses are
provided with a work Iphone and Ipad for mobile working.
Communication
- Builds and maintains strong working relationships and communicates effectively with GPs, community nursing
teams, Adult Social Care, Mental Health, acute / community hospital colleagues and therapists
- Interprets complex information and formulates solutions to recommend on the best course of action /
treatment for the individual e.g. medication reviews
- Responsible for ensuring effective communication with all relevant personnel pertaining to patient care and
any change in treatment/management plans, part of this will include the effective use of electronic notes
system, including assessment tools
- Responsible for establishing, communicating and maintaining effective professional relationships with
community nursing colleagues, GPs and health/social care/voluntary service networks to provide a planned,
co-ordinated, seamless service for individuals
- Maintains accurate clinical records and activity data and uses information from a wide range of sources, some
of which may be conflicting, to inform clinical decision making - with due regard to confidentiality and data
protection at all times
- Actively participates in MDTs for proactive care and risk stratification / population health management
- Utilises a range of effective communication skills, tools and techniques that may be complex and sensitive and
that overcomes barriers to understanding
- Acts as an advocate for all individuals and carers to ensure a culture where needs, wishes and preferences of
individuals are at the forefront of care
- Embraces the use of technology to support communication channels and new ways of working across care
homes whilst adhering to confidentiality and information governance
- Attends and actively participates in weekly Primary Care Network MDTs to discuss complex cases and seeks
to minimise the risk of unnecessary admission to hospital
Patient Care / Safety / Quality
- Identifies patients at high risk of unnecessary admission to hospital and uses proactive management approach
to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve
patient outcomes
- Responsible for the effective review and prioritisation of own caseload, and the referrals, requests, and
enquiries to the Community Coordination Centre when on duty as the lead clinician
- Works clinical pharmacists, therapists, paramedics, dietitians and others working within the Primary Care
Network locality to support all aspects of proactive case management
- Responsible for making rapid autonomous decisions, escalating to the Clinical Lead / GP / Adult Social Care /
Safeguarding as required
- Uses advanced clinical assessment skills, Chronic Disease Management and End of life care to support
personalised, anticipatory and advanced care planning and the prevention of unnecessary admission to
hospital
- Monitor indicators of long-term conditions, anticipating possible decline and proactively managing this to
enhance well being, and maintain independence
- Works within the Surrey wide multi-agency safeguarding policy to ensure vulnerable adults are protected
- Ensures that patients and their carers experience a high quality, safe, responsive service, ensuring that care is
accessible, effective and delivered at a time and place according to clinical need
- Trained and competent to undertake physical examination of the circulatory, respiratory and other systems
including listening to heart and lungs and regularly undertaking the following: venepuncture, male and female
catheterisation, rectal examination, injections and wound care
- Interprets findings from diagnostic tests/examination and uses this to make clinical decisions about care and
treatment
- Works in partnership with hospital teams including specialists, Social Care, MDT's and GP's in facilitating safe
discharge home from hospital or following an A&E attendance
- Responsible for preparing the patient and their family for changes in condition and support choice about end-of-life care, ensuring that patients needs, and those of their families are met, this will include active
management of complex pain and symptom control
- Provides information about the disease process to assist patients and their families in understanding and self-managing their long term condition
- Responsible for prescribing the correct use of aids and equipment relevant to Community Matron role and in
line with patient need
Development of self and others
- Acts as a professional role model for all company, NHS, and professional
- Actively participates in meetings to continually develop the community nursing service and integrated
working, through disseminating information, consulting with colleagues to positively effect change
- Actively involved in the development and implementation of service developments and initiatives, attends
relevant working and professional groups
- Participates in clinical audit and the implementation of recommendations and action plans
- Undertakes presentations to share best practice for community nursing, team members and students / visitors
- Accountable for own professional actions in line with the NMC code and local policy and guidelines
- Recognises own limitations in the provision of clinical care and urgency of patients needs, referring to other
health care professionals accordingly and is accountable for his/her own actions often without direct
supervision
- Responsible for the self- development of skills and competencies through participation in learning and
development activities, and to maintain up to date technical and professional knowledge relevant to the post
- Responsible for completing all own mandatory training and for any direct reports
- Participates in own annual appraisal and undertakes continuing professional development, clinical
supervision, and peer review for self to maintain and develop knowledge and skills
- Access regular 1-1 meetings with line manager
- Responsible for receiving and facilitating clinical supervision and undertaking peer reviews within the team
- Provides specialist clinical and supervisory leadership to junior team members, non-registrants, new
employees, and students within the team
- Keeps up to date with professional nursing and regulatory requirements, health care developments, clinical
evidence, National Service Frameworks for practice, national and local policies, and guidelines to maintain up
to date technical and professional knowledge relevant to the post
- Responsible for the self-development of skills and competencies through participation
in learning and development activities and continuing professional development to maintain up to date
technical and professional knowledge relevant to the post
- As a non-medical prescriber (NMP), work within the scope of national and local protocols. This will include
attending regular updates in line with CPD and revalidation requirements, the initiation of medication regimes,
agreeing changes, monitoring the effects of medications, advising patients on the safe storage and disposal of
drugs
Job description
Job responsibilities
To deliver nursing care in accordance with national and local policy and guidance and in accordance with the Nursing
and Midwifery Council.
In conjunction with GPs, practice/district nurses, social care, mental health colleagues, medicines management,
ambulance services, therapists and the voluntary sector the Community Matron will lead and facilitate a patient
focused, coordinated MDT and case management approach for people who are most vulnerable to and at high risk of
unnecessary admission to hospital. The role will require working in partnership with individuals, carers and families
and developing MDT proactive care plans to reduce risks, promote self-management and prevent the need for urgent
care.
The post holder will work as part of the Proactive Care Service as a highly skilled and experienced Registered Nurse to
improve outcomes for local people and reduce unnecessary unplanned admission to hospital. The post holder will be
a named Community Matron for nominated GP practices but will work across the Primary Care Network area to ensure
equity of access. The post holder is responsible for:
proactive identification of adults at high risk of unnecessary admission to hospital who would benefit from a
proactive approach to health and care needs
collaborative working with adult social care, mental health, ambulance, GPs, community therapists,
community nursing, geriatricians to ensure the best outcomes for individuals, families and carers
supporting the implementation of work streams and improved pathways for individuals with long term
conditions and complex needs
using a proactive and anticipatory approach to assessment, implementation and evaluation of health and care
The post holder will use an electronic patient held record system, EMIS as a record of care and all our nurses are
provided with a work Iphone and Ipad for mobile working.
Communication
- Builds and maintains strong working relationships and communicates effectively with GPs, community nursing
teams, Adult Social Care, Mental Health, acute / community hospital colleagues and therapists
- Interprets complex information and formulates solutions to recommend on the best course of action /
treatment for the individual e.g. medication reviews
- Responsible for ensuring effective communication with all relevant personnel pertaining to patient care and
any change in treatment/management plans, part of this will include the effective use of electronic notes
system, including assessment tools
- Responsible for establishing, communicating and maintaining effective professional relationships with
community nursing colleagues, GPs and health/social care/voluntary service networks to provide a planned,
co-ordinated, seamless service for individuals
- Maintains accurate clinical records and activity data and uses information from a wide range of sources, some
of which may be conflicting, to inform clinical decision making - with due regard to confidentiality and data
protection at all times
- Actively participates in MDTs for proactive care and risk stratification / population health management
- Utilises a range of effective communication skills, tools and techniques that may be complex and sensitive and
that overcomes barriers to understanding
- Acts as an advocate for all individuals and carers to ensure a culture where needs, wishes and preferences of
individuals are at the forefront of care
- Embraces the use of technology to support communication channels and new ways of working across care
homes whilst adhering to confidentiality and information governance
- Attends and actively participates in weekly Primary Care Network MDTs to discuss complex cases and seeks
to minimise the risk of unnecessary admission to hospital
Patient Care / Safety / Quality
- Identifies patients at high risk of unnecessary admission to hospital and uses proactive management approach
to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve
patient outcomes
- Responsible for the effective review and prioritisation of own caseload, and the referrals, requests, and
enquiries to the Community Coordination Centre when on duty as the lead clinician
- Works clinical pharmacists, therapists, paramedics, dietitians and others working within the Primary Care
Network locality to support all aspects of proactive case management
- Responsible for making rapid autonomous decisions, escalating to the Clinical Lead / GP / Adult Social Care /
Safeguarding as required
- Uses advanced clinical assessment skills, Chronic Disease Management and End of life care to support
personalised, anticipatory and advanced care planning and the prevention of unnecessary admission to
hospital
- Monitor indicators of long-term conditions, anticipating possible decline and proactively managing this to
enhance well being, and maintain independence
- Works within the Surrey wide multi-agency safeguarding policy to ensure vulnerable adults are protected
- Ensures that patients and their carers experience a high quality, safe, responsive service, ensuring that care is
accessible, effective and delivered at a time and place according to clinical need
- Trained and competent to undertake physical examination of the circulatory, respiratory and other systems
including listening to heart and lungs and regularly undertaking the following: venepuncture, male and female
catheterisation, rectal examination, injections and wound care
- Interprets findings from diagnostic tests/examination and uses this to make clinical decisions about care and
treatment
- Works in partnership with hospital teams including specialists, Social Care, MDT's and GP's in facilitating safe
discharge home from hospital or following an A&E attendance
- Responsible for preparing the patient and their family for changes in condition and support choice about end-of-life care, ensuring that patients needs, and those of their families are met, this will include active
management of complex pain and symptom control
- Provides information about the disease process to assist patients and their families in understanding and self-managing their long term condition
- Responsible for prescribing the correct use of aids and equipment relevant to Community Matron role and in
line with patient need
Development of self and others
- Acts as a professional role model for all company, NHS, and professional
- Actively participates in meetings to continually develop the community nursing service and integrated
working, through disseminating information, consulting with colleagues to positively effect change
- Actively involved in the development and implementation of service developments and initiatives, attends
relevant working and professional groups
- Participates in clinical audit and the implementation of recommendations and action plans
- Undertakes presentations to share best practice for community nursing, team members and students / visitors
- Accountable for own professional actions in line with the NMC code and local policy and guidelines
- Recognises own limitations in the provision of clinical care and urgency of patients needs, referring to other
health care professionals accordingly and is accountable for his/her own actions often without direct
supervision
- Responsible for the self- development of skills and competencies through participation in learning and
development activities, and to maintain up to date technical and professional knowledge relevant to the post
- Responsible for completing all own mandatory training and for any direct reports
- Participates in own annual appraisal and undertakes continuing professional development, clinical
supervision, and peer review for self to maintain and develop knowledge and skills
- Access regular 1-1 meetings with line manager
- Responsible for receiving and facilitating clinical supervision and undertaking peer reviews within the team
- Provides specialist clinical and supervisory leadership to junior team members, non-registrants, new
employees, and students within the team
- Keeps up to date with professional nursing and regulatory requirements, health care developments, clinical
evidence, National Service Frameworks for practice, national and local policies, and guidelines to maintain up
to date technical and professional knowledge relevant to the post
- Responsible for the self-development of skills and competencies through participation
in learning and development activities and continuing professional development to maintain up to date
technical and professional knowledge relevant to the post
- As a non-medical prescriber (NMP), work within the scope of national and local protocols. This will include
attending regular updates in line with CPD and revalidation requirements, the initiation of medication regimes,
agreeing changes, monitoring the effects of medications, advising patients on the safe storage and disposal of
drugs
Person Specification
Qualifications
Essential
- Registered Level 1 Nurse with current Nursing and Midwifery Council registration
- Qualification or experience equivalent to MSc / level 7
- Assessor / NMC Supervisor / Mentorship
- Evidence of recent and relevant continuing professional development
- Area of special interest in the management and treatment of long-term conditions and willing to undertake additional education in this area
- Non Medical Prescriber (V300), or willing to work towards
Desirable
- Management / Leadership qualification / module
Experience
Essential
- Evidence of implementing evidence-based practice, audit, and research-based practice
- Experience of caseload management including responsibility for complex care packages for frail / vulnerable people
- Evidence of service improvement and implementing change as a result of audit / best practice findings
- Project / Quality Improvement planning experience
Skills, Competencies and Attributes
Essential
- Knowledge of recent policy within health and social care and the impact / implications to care homes
- High level clinical and nursing assessment skills including signs of deterioration and exacerbation of Long Term Conditions
- Demonstrable commitment to and focus on quality, promotes high standards to consistently improve outcomes for local people
- Working knowledge of health and safety and risk management
- Teaching / presenting to groups / teams with a varied audience
- Able to use databases and other IT programmes, including MicroSoft Word, Excel, Powerpoint, Emails, Virtual Meeting platforms
- Ability to input and navigate around the community electronic patient record system. EMIS (training will be provided)
- Good negotiation and motivation skills
- Calm and organised
- Able to prioritise workload and adapt to unplanned to changes throughout the working day
- As a role model, displays personal and professional autonomy, with awareness of when to escalate
- Team player, willing to engage with and interact in training with and from peers and other professionals
- Demonstrates a strong desire to improve performance and outcomes to local care home residents
- Able to travel to frequently throughout the day to visit patients at home, at various locations across the locality and across Guildford and Waverley throughout the working day, at times travel across Surrey
- may be required
Person Specification
Qualifications
Essential
- Registered Level 1 Nurse with current Nursing and Midwifery Council registration
- Qualification or experience equivalent to MSc / level 7
- Assessor / NMC Supervisor / Mentorship
- Evidence of recent and relevant continuing professional development
- Area of special interest in the management and treatment of long-term conditions and willing to undertake additional education in this area
- Non Medical Prescriber (V300), or willing to work towards
Desirable
- Management / Leadership qualification / module
Experience
Essential
- Evidence of implementing evidence-based practice, audit, and research-based practice
- Experience of caseload management including responsibility for complex care packages for frail / vulnerable people
- Evidence of service improvement and implementing change as a result of audit / best practice findings
- Project / Quality Improvement planning experience
Skills, Competencies and Attributes
Essential
- Knowledge of recent policy within health and social care and the impact / implications to care homes
- High level clinical and nursing assessment skills including signs of deterioration and exacerbation of Long Term Conditions
- Demonstrable commitment to and focus on quality, promotes high standards to consistently improve outcomes for local people
- Working knowledge of health and safety and risk management
- Teaching / presenting to groups / teams with a varied audience
- Able to use databases and other IT programmes, including MicroSoft Word, Excel, Powerpoint, Emails, Virtual Meeting platforms
- Ability to input and navigate around the community electronic patient record system. EMIS (training will be provided)
- Good negotiation and motivation skills
- Calm and organised
- Able to prioritise workload and adapt to unplanned to changes throughout the working day
- As a role model, displays personal and professional autonomy, with awareness of when to escalate
- Team player, willing to engage with and interact in training with and from peers and other professionals
- Demonstrates a strong desire to improve performance and outcomes to local care home residents
- Able to travel to frequently throughout the day to visit patients at home, at various locations across the locality and across Guildford and Waverley throughout the working day, at times travel across Surrey
- may be required
Disclosure and Barring Service Check
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
Additional information
Disclosure and Barring Service Check
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.
UK Registration
Applicants must have current UK professional registration. For further information please see
NHS Careers website (opens in a new window).
