Job summary
Welcome to Waveney Primary Care Home (PCH) team.
We are seeking a Registered Nurse (Adult) with experience of supporting patients with long term chronic disease management to join our team. As core member of the PCH leadership team the Community Matron will ensure PCH patients with complex needs and those in crisis are treated effectively by providing independent specialist nursing input and clinical advice to patients and staff; lead on admission prevention, promote well-being and reduce demand on primary care and ECCH specialist services.
The successful candidate will have Non medical (v300) independent and supplementary prescribing qualification or confirm willingness to complete. This post is 80% clinically facing.
The PCH is a multidisciplinary team delivering health care to people in the South Waveney area. The combined skills of the team mean they are able to respond to the changing needs of patients and support those who may previously been admitted to hospital to remain at home. You will become an active member within this team of clinicians.
The PCH team provides community services 7 days per week 07:00- 20:30 hours
The core shift is 08:30- 16:30. Weekend and bank holiday working on a rotational basis as part of the Band 7 leadership role. The post is offered up to 37.5 hours per week. We are able to support flexible working arrangements and other shift patterns would be considered.
Main duties of the job
Develop and maintain clinical skills to meet the roles competency matrix that includes rapid top to toe assessment to identify and care for the deteriorating patient at home and the delivery of essential nursing care
Lead on admission prevention by providing independent specialist nursing input and clinical advice to patients, staff, and carers.
Participate in rapid assessment for patients in their own home with a variety of acute, chronic, and age-related conditions.
Provide short-term case management for patients with complex health needs and who present in crisis or are deteriorating, to ensure they are treated effectively.
Provide clinical support and advice to other members of the PCH team on the care of the deteriorating patient.
Hold a short-term caseload of patients; using a variety of approaches such as health coaching and problem lists to identify the key actions, abilities, and motivations to support their health and well being
Be the named nurse for identified General Practice(s), create relationships with the medical and non-medical care teams and practice management that ensure the timely referral and escalation of patients to the PCH and ECCH specialist services.
Provide clinical leadership, operational management, and professional support to other members of the multidisciplinary team within the PCH. This includes staff recruitment and retention, skill mix and team development.
Participate in the PCH Band 7 7-day leadership and virtual room rota
About us
ECCH is well established health care provider and has been successfully delivering NHS care within the community since 2011. We provide a range of NHS, community health and social care services predominantly across the easterly region of the Norfolk/Suffolk borders.
We are aligned to NHS terms and conditions, and offer many employee benefits, to find out more about us visit our website - www.ecch.org. We are a social enterprise and staff owned organisation which means staff can opt to be shareholders and have a real say in how ECCH is run and evolves to deliver healthcare for the future.
At the heart of our ambition, we work in partnership with and for the community to become the provider and employer of choice for community healthcare.
We encourage you to apply as early as possible as this job may close earlier than the advertised closing date once enough applications have been received.
We recognise that AI tools are increasingly used in
professional settings. While we encourage strong applications, we value
authenticity and an accurate reflection of skills and experience.
Applicants must declare if AI has been used to complete their
application, including responses that are directly copied or significantly
shaped by AI tools.
By submitting this application, you confirm that all
information provided is a true and accurate representation of your own skills,
knowledge, and experience.
Job description
Job responsibilities
We Listen, We Learn,
We Lead
- Contribute
to, support and promote ECCHs, strategic direction, values and culture in
relation to proactive and reactive services.
- Discuss all
treatment options with sensitivity, knowledge and expertise and to act as a
patient advocate when appropriate and respecting patient confidentiality with privacy
and respect for diverse cultural backgrounds and requirements.
- Offer a
supportive service to patients and their carers from diagnosis through all
stages of the disease process, in conjunction with other healthcare
professional using a range of communication skills to manage care and
information empathetically.
- Understand
and support the achievement of ECCH business plan objectives and performance
targets, and initiate and participate in screening and needs assessment as
required.
- Supervise
other health and social care professionals in the delivery of proactive health
promotion activated, e.g. chronic disease management with individuals and groups.
- Identify
the potential for service developments, risk and deficits and inform line
manager making recommendation based on specialist knowledge.
- Provide
leadership and management of locality nursing teams with identified lines of
responsibility.
- Plan and
organise a range of complex activities in a wide range of settings to ensure
best practice is delivered across your designated area of responsibility and
the wider community.
- To provide
clinical leadership within the Primary Care Home Team/s and the wider
integrated Community Care teams including Primary, Social Care, and all other
provider organisations to provide high standards of care to patients and where
appropriate avoiding unnecessary admission to secondary care.
- To be a key
driver for establishing integrated care teams both practically and
behaviourally.
- Assist with
the implementation of pathways and guidelines to support health care
professionals in establishing patient on evidence-based therapies.
- Develop
systems to monitor, evaluate and audit service quality in order to meet
nationally and locally set targets and develop reporting mechanisms.
- Effectively
communicate at all levels of the organisation, with a variety of health
professionals, users and carers, to provide the best health outcomes.
- Maintain a
high level of performance and be goal and outcome focussed when faced with
opposition or when working under conditions or pressure.
- Identify
potential service developments, risks and deficits and discuss with line
manager, making recommendations based on expert knowledge to enhance the
capacity and quality of community care.
- Monitor and
maintain standards / provide benchmarking data to allow comparison with other
healthcare provider.
- Participate
in teaching and clinical supervision with nursing teams and other provider
staff as require.
- Critically
evaluate research findings, national guidelines and implement changes in
clinical practice as appropriate.
- Participate
in clinical supervision with nursing teams as required.
- Provide
patients, families and carers with tailored education programmes, advice and
support, that may precipitate symptoms of acute exacerbation of underlying
conditions or illness and include lifestyle changes that would be advantageous
to health.
- Be
responsible for participating and maintaining a learning environment and
maximise opportunities for education and development in the clinical area to
enhance individual development and performance in the delivery of high
standards of care.
My Accountability,
My Responsibility- Take
responsibility for your own personal and professional development; maintain
competence, knowledge and skills commensurate with role.
- Using a
standardised approach but with a high degree of professional autonomy and
accountability, work across Health, Social Care, Voluntary and other health
providers and agencies, to identify a defined group of patients with complex
needs to provide a single plan of care co-produced with the patient.
- Using
advanced clinical practice skills assess the physical and psychosocial needs of
a defined client group.
- Critically
analyse complex clinical data and information to inform diagnosis and, where
appropriate, order investigations and/or instigate therapeutic treatments to
inform clinical decision making and improve health outcomes.
- Maintain
Key Worker responsibility for the patient when admitted to any inpatient
facility and provide baseline health data for the receiving team, to support
integrated and consistent care and facilitate Community Led discharge. Be
highly visible and accessible to patients, families and carers and be seen as
being in charge of their care.
- Provide
individualised care plan for patients with Long Term Conditions, so that their
condition remains as stable as possible and, where appropriate, hospital
admission is prevented and early discharge facilitated.
- Analyse
complex patient situations establishing a therapeutic relationship in which
they are able to utilize counselling skills to assist the individual to adjust
to their illness and care.
- Use
assessment tools/skills that will ensure an appropriate level of nursing or
therapeutic intervention so that patients who present with highly complex needs
are timely referred to the appropriate specialist.
- Be wholly
accountable for practice taking every reasonable opportunity to sustain and
improve knowledge and professional competence and, ensure that all aspects of
professional behaviour as required within Nursing and Midwifery Council Code
are followed at all times.
- Maintain
legible, accurate and contemporaneous patient records in accordance with ECCH
Policy and the Nursing and Midwifery Council standards for record keeping.
- Assist with
the investigations of complaints, participate in the risk management process,
critical incident reporting, evaluation, dissemination and change in practice.
- Be
responsible for understanding, following and implementing ECCH policies and
procedures, and influencing working practices to support this accordingly.
- Contribute
to the clinical governance agenda through participation in clinical risk
assessment and management, clinical audit.
- Create an
environment conducive to effective working, respecting and supporting staff to
deliver high quality clinical services.
- Ensure a
high standard of record keeping is achieved in line with ECCH and professional
standards.
- Take
responsibility to ensure compliancy with Health and Safety Policy, Fire and
Environmental Waste Regulations.
Respect
Our Resources: People, Time and Money
- Take
responsibility for the cost effective management and use expensive and highly
complex equipment, provide recommendations for effective use of resources and
contribute to the effective delivery of cost improvement planning.
- Analyse,
interpret compare and contrast complex information, service requirements and
options ensuring the effective approaches to service delivery and team working.
- Contribute
to the ongoing review of the wound care formulary and guidelines.
- Evaluate
the impact of training programmes, for patient and carers, to ensure that they
provide the necessary knowledge and skills to gain independence, safely manage
changing circumstances and plan for unavoidable progression of conditions.
Work Together, Achieve Together
- Using
advanced generalist clinical skills to evaluate the delivery of care,
identifying subtle changing health care needs. Being able to completely discuss
treatment options with other generalists and specialists.
- To be an
integral member of the primary care network team, working with a shared vision
and developing caseloads in partnership with each other to deliver both
proactive and reactive care.
- Demonstrate
responsibility and accountability for the clinical caseload and co-ordinate
care across the whole patient pathway within ECCH. This included ensuring a
robust relationship and constant interface with OOHT and secondary care as
required.
- Working
with partners in Primary and Social care to develop a model of care which
identifies and case manages those patients needing complex chronic disease
management or palliative care supporting the needs of the local community.
- Negotiate
and agree with the patient carers and other healthcare professionals,
individual roles and responsibilities with actions to be taken and outcomes to
be achieved, referring on to other services or professionals as appropriate.
- Work in
partnership with the patients to empower them to make informed choices about
their healthcare and support choices about end of life care.
- Establish
local networks in partnership with other health and social
professionals/agencies and national links with other generalists in order to
develop protocols according to national and local guidelines for the safe and
effective provision of a community nursing services.
- Work with
partners in nursing and residential care to provide proactive care to improve
the health outcomes of the residents and so prevent unnecessary hospital
admissions or extended in- patient care episodes.
- Provide
professional expertise and clinical leadership, acting as a resource to other
professionals within and outside your own organisation, regarding clinical
issues to ensure continuous service provision and inter-professional working.
- Work with
ECCH Colleagues, and other partner agencies and stakeholders including the
acute trust to contribute to the development and delivery of new innovative
models of service delivery, ensuring a leading edge approach to service
development in-line with evidence based practice.
- All roles within East Coast Community Healthcare CIC
(ECCH) require staff to demonstrate our Values and Signature Behaviours in the
care and service they provide to patients, service users, stakeholders and
colleagues. All members of staff should consider these as an essential part of
their job role.
- Our Values
outline the core behaviours that we can all achieve and are summarised as an
acronym within the word CARE.
These stand for: Compassion, Action, Respect and Everyone.
Job description
Job responsibilities
We Listen, We Learn,
We Lead
- Contribute
to, support and promote ECCHs, strategic direction, values and culture in
relation to proactive and reactive services.
- Discuss all
treatment options with sensitivity, knowledge and expertise and to act as a
patient advocate when appropriate and respecting patient confidentiality with privacy
and respect for diverse cultural backgrounds and requirements.
- Offer a
supportive service to patients and their carers from diagnosis through all
stages of the disease process, in conjunction with other healthcare
professional using a range of communication skills to manage care and
information empathetically.
- Understand
and support the achievement of ECCH business plan objectives and performance
targets, and initiate and participate in screening and needs assessment as
required.
- Supervise
other health and social care professionals in the delivery of proactive health
promotion activated, e.g. chronic disease management with individuals and groups.
- Identify
the potential for service developments, risk and deficits and inform line
manager making recommendation based on specialist knowledge.
- Provide
leadership and management of locality nursing teams with identified lines of
responsibility.
- Plan and
organise a range of complex activities in a wide range of settings to ensure
best practice is delivered across your designated area of responsibility and
the wider community.
- To provide
clinical leadership within the Primary Care Home Team/s and the wider
integrated Community Care teams including Primary, Social Care, and all other
provider organisations to provide high standards of care to patients and where
appropriate avoiding unnecessary admission to secondary care.
- To be a key
driver for establishing integrated care teams both practically and
behaviourally.
- Assist with
the implementation of pathways and guidelines to support health care
professionals in establishing patient on evidence-based therapies.
- Develop
systems to monitor, evaluate and audit service quality in order to meet
nationally and locally set targets and develop reporting mechanisms.
- Effectively
communicate at all levels of the organisation, with a variety of health
professionals, users and carers, to provide the best health outcomes.
- Maintain a
high level of performance and be goal and outcome focussed when faced with
opposition or when working under conditions or pressure.
- Identify
potential service developments, risks and deficits and discuss with line
manager, making recommendations based on expert knowledge to enhance the
capacity and quality of community care.
- Monitor and
maintain standards / provide benchmarking data to allow comparison with other
healthcare provider.
- Participate
in teaching and clinical supervision with nursing teams and other provider
staff as require.
- Critically
evaluate research findings, national guidelines and implement changes in
clinical practice as appropriate.
- Participate
in clinical supervision with nursing teams as required.
- Provide
patients, families and carers with tailored education programmes, advice and
support, that may precipitate symptoms of acute exacerbation of underlying
conditions or illness and include lifestyle changes that would be advantageous
to health.
- Be
responsible for participating and maintaining a learning environment and
maximise opportunities for education and development in the clinical area to
enhance individual development and performance in the delivery of high
standards of care.
My Accountability,
My Responsibility- Take
responsibility for your own personal and professional development; maintain
competence, knowledge and skills commensurate with role.
- Using a
standardised approach but with a high degree of professional autonomy and
accountability, work across Health, Social Care, Voluntary and other health
providers and agencies, to identify a defined group of patients with complex
needs to provide a single plan of care co-produced with the patient.
- Using
advanced clinical practice skills assess the physical and psychosocial needs of
a defined client group.
- Critically
analyse complex clinical data and information to inform diagnosis and, where
appropriate, order investigations and/or instigate therapeutic treatments to
inform clinical decision making and improve health outcomes.
- Maintain
Key Worker responsibility for the patient when admitted to any inpatient
facility and provide baseline health data for the receiving team, to support
integrated and consistent care and facilitate Community Led discharge. Be
highly visible and accessible to patients, families and carers and be seen as
being in charge of their care.
- Provide
individualised care plan for patients with Long Term Conditions, so that their
condition remains as stable as possible and, where appropriate, hospital
admission is prevented and early discharge facilitated.
- Analyse
complex patient situations establishing a therapeutic relationship in which
they are able to utilize counselling skills to assist the individual to adjust
to their illness and care.
- Use
assessment tools/skills that will ensure an appropriate level of nursing or
therapeutic intervention so that patients who present with highly complex needs
are timely referred to the appropriate specialist.
- Be wholly
accountable for practice taking every reasonable opportunity to sustain and
improve knowledge and professional competence and, ensure that all aspects of
professional behaviour as required within Nursing and Midwifery Council Code
are followed at all times.
- Maintain
legible, accurate and contemporaneous patient records in accordance with ECCH
Policy and the Nursing and Midwifery Council standards for record keeping.
- Assist with
the investigations of complaints, participate in the risk management process,
critical incident reporting, evaluation, dissemination and change in practice.
- Be
responsible for understanding, following and implementing ECCH policies and
procedures, and influencing working practices to support this accordingly.
- Contribute
to the clinical governance agenda through participation in clinical risk
assessment and management, clinical audit.
- Create an
environment conducive to effective working, respecting and supporting staff to
deliver high quality clinical services.
- Ensure a
high standard of record keeping is achieved in line with ECCH and professional
standards.
- Take
responsibility to ensure compliancy with Health and Safety Policy, Fire and
Environmental Waste Regulations.
Respect
Our Resources: People, Time and Money
- Take
responsibility for the cost effective management and use expensive and highly
complex equipment, provide recommendations for effective use of resources and
contribute to the effective delivery of cost improvement planning.
- Analyse,
interpret compare and contrast complex information, service requirements and
options ensuring the effective approaches to service delivery and team working.
- Contribute
to the ongoing review of the wound care formulary and guidelines.
- Evaluate
the impact of training programmes, for patient and carers, to ensure that they
provide the necessary knowledge and skills to gain independence, safely manage
changing circumstances and plan for unavoidable progression of conditions.
Work Together, Achieve Together
- Using
advanced generalist clinical skills to evaluate the delivery of care,
identifying subtle changing health care needs. Being able to completely discuss
treatment options with other generalists and specialists.
- To be an
integral member of the primary care network team, working with a shared vision
and developing caseloads in partnership with each other to deliver both
proactive and reactive care.
- Demonstrate
responsibility and accountability for the clinical caseload and co-ordinate
care across the whole patient pathway within ECCH. This included ensuring a
robust relationship and constant interface with OOHT and secondary care as
required.
- Working
with partners in Primary and Social care to develop a model of care which
identifies and case manages those patients needing complex chronic disease
management or palliative care supporting the needs of the local community.
- Negotiate
and agree with the patient carers and other healthcare professionals,
individual roles and responsibilities with actions to be taken and outcomes to
be achieved, referring on to other services or professionals as appropriate.
- Work in
partnership with the patients to empower them to make informed choices about
their healthcare and support choices about end of life care.
- Establish
local networks in partnership with other health and social
professionals/agencies and national links with other generalists in order to
develop protocols according to national and local guidelines for the safe and
effective provision of a community nursing services.
- Work with
partners in nursing and residential care to provide proactive care to improve
the health outcomes of the residents and so prevent unnecessary hospital
admissions or extended in- patient care episodes.
- Provide
professional expertise and clinical leadership, acting as a resource to other
professionals within and outside your own organisation, regarding clinical
issues to ensure continuous service provision and inter-professional working.
- Work with
ECCH Colleagues, and other partner agencies and stakeholders including the
acute trust to contribute to the development and delivery of new innovative
models of service delivery, ensuring a leading edge approach to service
development in-line with evidence based practice.
- All roles within East Coast Community Healthcare CIC
(ECCH) require staff to demonstrate our Values and Signature Behaviours in the
care and service they provide to patients, service users, stakeholders and
colleagues. All members of staff should consider these as an essential part of
their job role.
- Our Values
outline the core behaviours that we can all achieve and are summarised as an
acronym within the word CARE.
These stand for: Compassion, Action, Respect and Everyone.
Person Specification
Qualifications
Essential
- Professional registration with Nursing and Midwifery Council (NMC) Registered Nurse Level 1 (Adult)
- BSc Nursing Practice or equivalent
- Evidence of post registration study at Postgraduate Level
- Independent Nurse Prescribing or willing to undertake
Desirable
- MSc Advance Nurse Practitioner.
- Leadership and management qualification
- Advanced communication skills
- Health Coaching Programme
Experience
Essential
- Extensive clinical experience from a range of settings including secondary and community care
- Experience of case management
- Experience of long term/ chronic disease management
- Evidence of experience of partnership working with other care agencies eg Social services/ voluntary sector/ primary care
Desirable
- Experience of team leadership.
- Experience of working within primary care
- Experience of complaint investigation
- Project management experience.
- Experience of facilitating clinical supervision
- Experience of audit
Personal Attributes
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software
- Proven ability to problem-solve
- Extensive clinical skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Advanced communication skills
Skills and Knowledge
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software
- Proven ability to problem-solve
- Extensive clinical skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Advanced communication skills
Person Specification
Qualifications
Essential
- Professional registration with Nursing and Midwifery Council (NMC) Registered Nurse Level 1 (Adult)
- BSc Nursing Practice or equivalent
- Evidence of post registration study at Postgraduate Level
- Independent Nurse Prescribing or willing to undertake
Desirable
- MSc Advance Nurse Practitioner.
- Leadership and management qualification
- Advanced communication skills
- Health Coaching Programme
Experience
Essential
- Extensive clinical experience from a range of settings including secondary and community care
- Experience of case management
- Experience of long term/ chronic disease management
- Evidence of experience of partnership working with other care agencies eg Social services/ voluntary sector/ primary care
Desirable
- Experience of team leadership.
- Experience of working within primary care
- Experience of complaint investigation
- Project management experience.
- Experience of facilitating clinical supervision
- Experience of audit
Personal Attributes
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software
- Proven ability to problem-solve
- Extensive clinical skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Advanced communication skills
Skills and Knowledge
Essential
- Competent IT skills ability to use electronic diary and electronic clinical record systems and MS Office software
- Proven ability to problem-solve
- Extensive clinical skills
- Evidenced experience of negotiating and influencing skills
- Excellent interpersonal skills, including communication with different stakeholders
- Advanced communication skills
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).
