Community Matron

Job description

Job responsibilities

JOB PURPOSE.

• Providing short term case management of housebound service users with complex physical health needs discharging patients once they are stable. Provides physical health assessment, prescribing and treatment planning in the case management of housebound service users. They will co-ordinate an appropriate multi-agency response as needed to ensure the service users physical; psychological and social needs are considered.

• They will provide care for the following cohorts service users:

• Step up from the District Nursing team or GP following exacerbation of long term conditions or deteriorating patient with long term complex health needs.
• Step down from community and in-patient acute services during recovery from an acute exacerbation of a long term condition.

• Reduce the risk of further acute exacerbations through working in partnership with service users to promote self-management and disease awareness. Ensuring service users are supported to recognise and respond appropriately to signs of deterioration or exacerbation of their condition.

• Support service users to prepare for, and provide nursing care and case management for people at the end stages of their long term condition.

• Being a senior member of the community nursing team they will share clinical knowledge, expertise and advice and provide mentorship and supervision to pre and post-registration nurses in the community nursing team. Working within the community nursing team ensuring robust business continuity plans are in place and delivered during periods of high demand and/or reduced capacity.

• Working closely with other MPFT services and external partners to support the development and delivery of effective care pathways. Supporting the delivery of place based care within the attached locality.

• Understands population health needs within attached locality and develops and maintains networks within the community, acting as a key stakeholder to ensure these needs are met.

Responsibilities and Duties

1. Managing and co-ordinating a caseload of service users with complex physical health needs that require multi-systems health assessment; services users may have single disease; multiple co-morbidities or may not have a confirmed diagnosis but nursing needs are increasing, in addition they may have social and mental health needs that influence their treatment plans.

1. To work closely with the service users, their carers and families ensuring that they have the tools to manage and monitor their own condition and have robust management plans in place to recognise deterioration and access appropriate care.

1. Have an understanding of the demographics and population profile of their attached PCN/locality and adapt their knowledge and skills (particularly in the management of long term conditions and frailty) to ensure the physical health needs of the population are met.

1. Effective case management will be through initial physical health assessment; treatment planning; self-management agreements and independent prescribing. The post holder will take a proactive approach to care, working as part of the community nursing team and linking closely partners to identify patients who are frequent users of unplanned services. Accessing a range of local services to support the service user and their families to live with their conditions and understand when, and who to ask for help.

1. Will utilise a range of available and emerging technology to support the service user to manage and monitor their condition; including virtual consultations and remote monitoring.

1. The post holder will participate in service developments as a member of the community nursing team and wider primary care network, and will be a key stakeholder in the development of place based partnership working.

1. The assessment of need and delivery of safe and effective nursing interventions for service users with complex physical health needs (long term conditions; multiple co-morbidities and frequent users of unplanned services). Working to avoid and stabilise disease exacerbation and hospital admission and manage complex risks, in accordance with recognised clinical guidance and evidence based practice.

1. There will be no responsibility for finances other than to make efficient use of resources and to consider cost effectiveness when developing treatment plans and prescribing medication.

Systems and equipment

1. Maintain accurate contemporaneous records and data collection through daily use of a range of electronic clinical systems e.g. RiO; Safeguard; Microsoft Office Suite. Adhering to information governance standards; legal and professional requirements are maintained at all times.

1. Responsible for ensuring actions are carried out by themselves and their team where safety alerts are issued regarding equipment or medications used by the service.

1. Maintain an awareness of assistive technology available to support service users to manage their condition.

Decisions and judgements

1. To work autonomously as an experienced nurse using enhanced clinical expertise to assess; plan and evaluate care. Critically evaluate current evidence; clinical guidelines; policies and SOPs to support clinical decision making.

1. To evaluate and make decisions about treatment options taking into account both theoretical and therapeutic models and highly complex factors ascertained through holistic assessment and history taking.
2. Formulate plans of care and negotiate the implementation of such plans and the sharing of complex, sensitive, confidential, and at times contentious information e.g. explaining diagnosis and treatment plans; discussing disease progression and prognosis.

1. To contribute to the development, evaluation and monitoring of the services operational policies and services, through the deployment of professional skills in research, service evaluation and audit.

1. To exercise autonomous professional responsibility for the assessment, treatment and discharge of service users on their caseload.

1. To be able to access, critically appraise and apply relevant information/ knowledge in clinical practice. Utilising evidence-based literature and research to support practice in individual work and work with other team members.

1. To positively promote and act as a role model for community nursing.

1. To actively participate in the receipt of, and delivery of clinical and managerial supervisor in line with Trust policies.

1. Will provide mentorship to and assessment of pre and post registration nursing students in clinical practice. This will include evaluating their progress towards the standards for independent prescribing and health assessment programmes. This may include leading the development of performance plans if a student is not reaching the required standards.

1. Will have an awareness of the resources required to deliver the service; utilising a range of quality improvement tools to implement and review effective working practices.

1. Will have responsibility for the safety and maintenance of IT and clinical equipment that they utilise to carry out the role.

Communication and relationships

1. Communicate sensitive diagnosis and treatment related information with service users and their families, utilising highly developed communication skills to overcome barriers to understanding.

1. Establish therapeutic relationships with service users and families/carers, and implement evidence based therapeutic interventions with appropriate boundaries in accordance with professional code of conduct.

1. As a senior nurse, work collaboratively with practitioners from the MDT, service users and families to communicate clinical decisions, clinical rationales and treatment plans to optimise treatment plans.

1. Ensure that all members of the multi-disciplinary team, service users and appropriate others are kept informed and up to date about changes to a service users care or condition.

1. To produce treatment plans that are timely, relevant, accurate, evaluated, dated, signed, legible and objective, and communicate these to other relevant agencies. These must be in keeping with best practice guidance and evidence based practice.

1. As a senior member of the community nursing team they will lead by example, acting as a role model, embedding the trust values and professional standards in all of their interactions.

Physical demands of the job

1. The post holder will be expected to implement highly developed physical skills pertinent to the area of specialism daily, for example, such as de-escalation skills, driving, manual handling, and skills relevant to professional role.
2. Standard keyboard skills required for inputting data onto RiO; report writing; research etc.
3. Undertaking physical health assessments with patients, including chest auscultation; obtaining samples, wound swabs and venepuncture.

1. Using specific equipment e.g. hoists, sliding equipment, etc.

Most challenging/difficult parts of the job

1. The nature of the client group is such that the post holder will be required to concentrate when assessing and implementing programmes of care and will need to be able to address interruptions from other service users/staff as necessary.

1. Post holder will be frequently exposed to emotionally distressing clinical information and situations.

1. The post holder may be occasionally exposed to challenging behaviour; verbal abuse and threats from services users or their families.

1. To work with individuals and carers who may find it difficult to engage with the service or aspects of the service resulting in uncooperative or challenging behaviour.

1. Needing to be flexible and responsive to changing patient needs, necessitating frequent reorganisation and prioritisation of working schedule at short notice on a daily basis.

1. To be aware of possible safety implications of lone working for self and others.

Person Specification

Qualifications and Training

Essential

• Honours degree or evidence of working at this level
• Current NMC registration
• Post graduate qualification in nursing related subject and evidence of further education, training and development in role
• Physical Health Assessment Qualification
• V300 Independent Nurse Prescribing (or working towards)

Desirable

• Master's degree
• Long Term Conditions Module
• Frailty Module
• Mental Health Assessment Module

Exsperience

Essential

• Experience of assessment and management of people with long term conditions
• Proven experience in a NHS, social care or equivalent environment
• Experience of working effectively across different agencies and with other disciplines
• Experience of providing clinical information and advice to others, including the development of services and staff.

Desirable

• Qualification in project management or relevant experience
• Providing an effective contribution to workforce planning

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.

Certificate of Sponsorship

Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).

From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).

UK Registration

Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).

Employer details

Employer name

Midlands Partnership NHS Foundation Trust

Address

Hanford Health Centre

New Inn Lane

Stoke on Trent

ST4 8EX

Employer's website

https://www.mpft.nhs.uk (Opens in a new tab)