Job summary
This role is offered on a fixed term/secondment basis for 6 months. The hours are part-time, 15 hours per week.
Internal applicants who wish to be considered for a secondment opportunity should discuss with their line manager the suitability of apossible secondment
The Complex Care at Home Community Dementia Matron assumes the role of an autonomous Practitioner, responsible for overseeing the care of their assigned patients. This entails triaging, planning, managing, and coordinating intricate care and treatment requirements within the confines of patients' homes. As a member of the Complex Care at Home Multidisciplinary Team, they proactively take a lead clinical role, responsible for planning, managing, and coordinating the care of individuals with highly complex needs and long-term conditions within a defined caseload of people with dementia. The Community Dementia Matron collaborates closely with primary and secondary care services, including Physical and Mental Health, as well as statutory and non-statutory agencies. This collaborative approach enables the development of personalised care plans, consistently advocating for the 'What matters to you?' principle.
Main duties of the job
Complex Care at Home is an established and innovative complex case management service that serves Gloucester, Cheltenham, and the Forest of Dean localities.
The service collaborates closely with acute settings, community teams, social services and primary care to identify and support patients who would benefit from a case management approach.
Through a collaborative approach, the team works with patients, families, and carers, employing a coaching methodology to facilitate problem-solving and empower self-management.
Each patient is assigned to the Complex Care at Home Team for a specific period before being appropriately discharged.
The post holder will use case management approach to prevent avoidable deterioration in people's health and ultimately reducing the occurrence of unplanned hospital admissions.
The post- holder will continually develop their advanced skills and competences in and medicines management, clinical assessment, care co-ordination, identifying and assessment of cognitive impairment, supporting self-care, management and leadership skills in line with the Department of Health competency framework for Community Matrons.
The qualification, training & experience requirements for the role are underlined in the Job Description/Person Specification.
About us
We have a skilled and dedicated workforce of over 5000 colleagues working in a diverse range of services over 55 sites and within people's homes. We strive to enable a welcoming workplace culture that builds and celebrates civility, inclusivity and diversity, while providing a sense of belonging and trust.
Annual staff surveys, regular Pulse surveys and other engagement opportunities provide our people with lots of opportunity to tell us about their experiences of working with us. In the latest staff survey, 61% of colleagues gave us their views. It was great to hear that:
- 72% of colleagues would recommend the Trust as a place to work, ranking us 1st for Provider Trusts in the South West region on this question.
- 76% would recommend the standard of care provided in our services if a friend or relative needed treatment, also ranking us 1st in the South West region.
- 81% said that care of patients and service users is the Trust's priority, compared with an average in comparable NHS Trusts in England of 64%.
This high-level overview shows we are in a healthy position, with higher scores than average for comparable organisations, alongside a great response rate, indicating good staff engagement. However, we also know we have plenty of room for improvement in many areas. To that end, we continue to prioritise and invest in our commitment to genuinely becoming a Great Place to Work with consistent top-quartile performance in the annual staff survey and Pulse surveys.
Job description
Job responsibilities
- Take a lead role within a multidisciplinary team, proactively managing a caseload of complex patients living with dementia, long-term conditions, and/or frailty, and at risk of deterioration. Patients will be identified through an agreed case-finding approach and from referrals received from primary and acute care teams.
- Utilise a case management approach to support patients, carers and families to live well with their Dementia to prevent avoidable health deterioration & hospital admission, or unnecessary length of stay.
- Gather and interpret complex clinical data for the purposes of a comprehensive health and social care needs assessment involving a multi-agency/partnership case management approach. They will also be responsible for identifying and facilitating assessments of health and social care needs, gathering data, and interpreting complex clinical information to plan care appropriately.
- Ensure an effective and evidence-based service is delivered using advanced assessment and planning to implement case management programs for patients.
- Provide specialist knowledge and support to other team members. They will also advise on non-complex mental health issues such as depression and anxiety, understanding the opportunities and processes for referring or signposting individuals with more complex mental health problems.
- Work collaboratively with the patient, family and carers applying a health coaching/motivational interviewing skilled approach to problem solving and enabling appropriate self- management.
- Undertake a holistic assessment, care planning of identified patients, ensuring health gains and maximising independence.
- Ensure that all patients identified with a cognitive impairment have equity to GHC specialist memory assessment service by ensuring they adhere to the Complex Care at Home Dementia Pathway (2019)
- Work autonomously as a Mental Health Specialist linking in with Primary, Secondary and Territory service to promote equitable treatment and transition to appropriate care pathways.
- Act as an autonomous practitioner within own localities and will provide supervision and management support for other members of the team
- Responsible for developing and auditing the Dementia Matron Role service within Complex Care at Home to ensure that the Dementia Pathway is being adhere to across the three localities.
This role is not eligible for sponsorship as per the Governments UK VISA and Immigration Rules and Regulations. For more information please visit https://www.gov.uk/browse/visas-immigration/work-visas
Job description
Job responsibilities
- Take a lead role within a multidisciplinary team, proactively managing a caseload of complex patients living with dementia, long-term conditions, and/or frailty, and at risk of deterioration. Patients will be identified through an agreed case-finding approach and from referrals received from primary and acute care teams.
- Utilise a case management approach to support patients, carers and families to live well with their Dementia to prevent avoidable health deterioration & hospital admission, or unnecessary length of stay.
- Gather and interpret complex clinical data for the purposes of a comprehensive health and social care needs assessment involving a multi-agency/partnership case management approach. They will also be responsible for identifying and facilitating assessments of health and social care needs, gathering data, and interpreting complex clinical information to plan care appropriately.
- Ensure an effective and evidence-based service is delivered using advanced assessment and planning to implement case management programs for patients.
- Provide specialist knowledge and support to other team members. They will also advise on non-complex mental health issues such as depression and anxiety, understanding the opportunities and processes for referring or signposting individuals with more complex mental health problems.
- Work collaboratively with the patient, family and carers applying a health coaching/motivational interviewing skilled approach to problem solving and enabling appropriate self- management.
- Undertake a holistic assessment, care planning of identified patients, ensuring health gains and maximising independence.
- Ensure that all patients identified with a cognitive impairment have equity to GHC specialist memory assessment service by ensuring they adhere to the Complex Care at Home Dementia Pathway (2019)
- Work autonomously as a Mental Health Specialist linking in with Primary, Secondary and Territory service to promote equitable treatment and transition to appropriate care pathways.
- Act as an autonomous practitioner within own localities and will provide supervision and management support for other members of the team
- Responsible for developing and auditing the Dementia Matron Role service within Complex Care at Home to ensure that the Dementia Pathway is being adhere to across the three localities.
This role is not eligible for sponsorship as per the Governments UK VISA and Immigration Rules and Regulations. For more information please visit https://www.gov.uk/browse/visas-immigration/work-visas
Person Specification
Qualifications
Essential
- Registered Mental Health Nurse (RMN)
- Professional/clinical knowledge acquired through degree, supplemented by specialist training, experience, short courses, CPD to master's degree level or equivalent
- Facilitating Learning and Assessment in Practice qualification (FLAP) or equivalent
Desirable
- To have completed or willing to work towards the Dementia Lead course facilitated by GHC
Experience
Essential
- Several years' experience supporting people with cognitive impairment and physical health conditions
- Significant post registration experience spent in a variety of settings including the community
- Experience in managing a complex clinical caseload
- Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans
Specialist Knowledge
Essential
- Experience in managing clinical risks
- Experience in managing difficult situations that require advanced communication and negotiating skills
- Evidence of collaborative working with health and social care professionals and the voluntary sector
- Ability to identify opportunities to support colleagues and self in clinical competency acquisition and clinical supervision
- Ability to chair meetings related to service delivery or case management
- Ability to promote a positive risk-taking approach
- Have a good understanding on ways to identify patients who would benefit from case management using a variety of resources
- Ability to carry out specialist assessment including, or referring on for, diagnostic testing
- Evidence of long-term conditions case management in the wider nursing and allied health professional arena
Person Specification
Qualifications
Essential
- Registered Mental Health Nurse (RMN)
- Professional/clinical knowledge acquired through degree, supplemented by specialist training, experience, short courses, CPD to master's degree level or equivalent
- Facilitating Learning and Assessment in Practice qualification (FLAP) or equivalent
Desirable
- To have completed or willing to work towards the Dementia Lead course facilitated by GHC
Experience
Essential
- Several years' experience supporting people with cognitive impairment and physical health conditions
- Significant post registration experience spent in a variety of settings including the community
- Experience in managing a complex clinical caseload
- Experience of case management models of care including personalised goal setting, care planning and self-management plans and escalation plans
Specialist Knowledge
Essential
- Experience in managing clinical risks
- Experience in managing difficult situations that require advanced communication and negotiating skills
- Evidence of collaborative working with health and social care professionals and the voluntary sector
- Ability to identify opportunities to support colleagues and self in clinical competency acquisition and clinical supervision
- Ability to chair meetings related to service delivery or case management
- Ability to promote a positive risk-taking approach
- Have a good understanding on ways to identify patients who would benefit from case management using a variety of resources
- Ability to carry out specialist assessment including, or referring on for, diagnostic testing
- Evidence of long-term conditions case management in the wider nursing and allied health professional arena
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).
