Job summary
The Care Home Matron (CHM) will work closely with the Care Home Support Team and GP's to proactively identify patients (aged 18+) with high risk complex needs.
They will provide a proactive, holistic approach to managing patient's with long-term conditions that is centred on primary care and the prevention of avoidable hospital admissions. The focus will be on providing comprehensive holistic assessments, individualized care plans, creating an Urgent Care Plan and coordination for complex patients in their usual place of residence including Extra Care Housing / Care Homes.
The CHM will enable the patient, carers/extra care housing staff, care home staff and families to understand their disease or condition, how to recognize early symptoms and proactively manage their care decisions. The CHM will work as part of the Care Home Support Team and will develop care plans for the patients on the caseload.
Main duties of the job
CHM's will attend a weekly MDT Meeting with all members of the Care Home Support Team to refer and discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. District Nurses, Care of the Elderly Consultant, Social Services and third sector. The distance nurses travel each day is considerable and the CHM will require use of their own car to carry out their domiciliary visits.
The CHM works autonomously to provide a full range of services predominantly to house bound patients including Extra Care Housing, Residential and Nursing Homes and will be skilled in carrying out Holistic assessments and Urgent Care Planning.
As well as:
- Manage a caseload of patients residing in care homes and Extra Care Housing.
- Works closely with the Care Home Support Team to deliver positive patient outcomes mainly to prevent hospital admission.
- To promote partnership working with all partners including secondary care.
- To work with high Intensive users to avoid or reduce hospital admissions.
- To promote self- care and educate patient to manage own care with safe parameters.
- Patients are assessed using Advanced Assessment skills.
- Patients are prescribed medications according to the NMP guidance.
- Medication review and optimisation to ensure medications safety.
About us
Work in line with all CNWL Trust Values.
Encourage partnership working including independent providers and charities.
Close working with Care Home Support Team and Hillingdon GP Confederation.
Workingin line with allCNWL policies and guidance.
Job description
Job responsibilities
- Works independently
- Demonstrates an ability to identify priorities by effective time management
- Manages queries / concerns / complaints of patients or other nurses according to Trust Policy
- Ensures that feedback to others is positive and meaningful and that strengths are clearly acknowledged
- Identifies and manages a safe workload and reports areas of concern appropriately
- Negotiates confidently and asserts authority when necessary
- Knows the resources that are available and can access them at any given time
- Knows when to seek advice
- Manages internal and external relationships with other Care Home Support Team staff and partner organisations and services.
Clinical Nursing Practice1.1 Work closely with GPs to identify patients with high risk complex needs.1.2 Take responsibility for the proactive management of a defined dynamic caseload of high - risk adults who have long term conditions.1.3 Act as a role model in expert practice facilitating and supporting the delivery of effective patient care by use of clinical judgement and decision - making skills.1.4 Maintain accurate and contemporaneous clinical records using clinical record keeping system such as EMIS web, System One and Patient Knows Best, ensuring that they remain confidential and secure at all times.1.5 Undertake systematic holistic nursing examination, and establish a baseline data to inform the development of a comprehensive individualized patient care plan.1.6 Review and evaluate individualised care plans, based on best available evidence for and with the individual, their families and care provider.1.7 Recognise changes in the patients conditions, including the need to initiate further tests or diagnostic review.1.8 Initiate and interpret diagnostic investigations within agreed clinical management plan1.9 Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being and maintain independence.1.10 Enable patients, families or care provider to recognise changes in patients conditions where these may have an adverse effect on health and take appropriate action.1.11 Develop risk management plans that support individuals independence and daily living within their home setting.1.12 Secure appropriate expertise to provide specialist support to ensure that patients are referred to other practitioners when required.1.13 Develop key professional relationships to optimize patient management plans and ensure asmooth transitional pathway on and off the caseload.1.14 Ensure appropriate supplies and equipment is in place and maintained in line with best practice in relation to client care and review as per local policy.1.15 Enable individuals to use assistive technology and assistive devices where these will contribute to the enablement of self-care.1.16 Work within the organizations framework of informed consent1.17 Lead and facilitate clinical audits within the service.1.18 Facilitate and participate in Trust-wide groups as required.1.19 As an independent nurse prescriber, ensure that prescribing decisions are evidence based and that the independent nurse prescriber works within their competency level.
Job description
Job responsibilities
- Works independently
- Demonstrates an ability to identify priorities by effective time management
- Manages queries / concerns / complaints of patients or other nurses according to Trust Policy
- Ensures that feedback to others is positive and meaningful and that strengths are clearly acknowledged
- Identifies and manages a safe workload and reports areas of concern appropriately
- Negotiates confidently and asserts authority when necessary
- Knows the resources that are available and can access them at any given time
- Knows when to seek advice
- Manages internal and external relationships with other Care Home Support Team staff and partner organisations and services.
Clinical Nursing Practice1.1 Work closely with GPs to identify patients with high risk complex needs.1.2 Take responsibility for the proactive management of a defined dynamic caseload of high - risk adults who have long term conditions.1.3 Act as a role model in expert practice facilitating and supporting the delivery of effective patient care by use of clinical judgement and decision - making skills.1.4 Maintain accurate and contemporaneous clinical records using clinical record keeping system such as EMIS web, System One and Patient Knows Best, ensuring that they remain confidential and secure at all times.1.5 Undertake systematic holistic nursing examination, and establish a baseline data to inform the development of a comprehensive individualized patient care plan.1.6 Review and evaluate individualised care plans, based on best available evidence for and with the individual, their families and care provider.1.7 Recognise changes in the patients conditions, including the need to initiate further tests or diagnostic review.1.8 Initiate and interpret diagnostic investigations within agreed clinical management plan1.9 Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being and maintain independence.1.10 Enable patients, families or care provider to recognise changes in patients conditions where these may have an adverse effect on health and take appropriate action.1.11 Develop risk management plans that support individuals independence and daily living within their home setting.1.12 Secure appropriate expertise to provide specialist support to ensure that patients are referred to other practitioners when required.1.13 Develop key professional relationships to optimize patient management plans and ensure asmooth transitional pathway on and off the caseload.1.14 Ensure appropriate supplies and equipment is in place and maintained in line with best practice in relation to client care and review as per local policy.1.15 Enable individuals to use assistive technology and assistive devices where these will contribute to the enablement of self-care.1.16 Work within the organizations framework of informed consent1.17 Lead and facilitate clinical audits within the service.1.18 Facilitate and participate in Trust-wide groups as required.1.19 As an independent nurse prescriber, ensure that prescribing decisions are evidence based and that the independent nurse prescriber works within their competency level.
Person Specification
Education and Qualifications
Essential
- Registered Nurse Adult
- Numeracy skills required for the safe administration of medicines
- Advanced Assessment Skills/ Nurse Practitioner Qualification/ Community Matron qualification or willing to undertake within 6months of appointment.
- Evidence of relevant Continuous Professional Development
- Non- Medical Prescribing Qualification or willing to undertake within 12months of appointment
- BSc Community Nursing Qualification or Equivalent Post Registration qualification
- Assessor/Mentor
Desirable
Previous Experience
Essential
- Previous experience as a Band 6/7 nurse working in the community or primary care setting with LTC management, Frailty and End of Life Care.
Desirable
- Experience of working in A&E, ITU or HDU or other equivalent acute medicine speciality.
Skills and knowledge
Essential
- Able to communicate with the multi-disciplinary team, present cases, take note of actions, update others in the team and use handover effectively. Speaking face to face but also by telephone and writing letters and reports.
- Maintaining accurate, timely, concise and legible clinical records both electronic and handwritten which adhere to the CNWL policies.
- Able to talk to people about sensitive issues in a supportive manner but also challenge others assertively where necessary
- Able to maintain electronic patient records via EMIS, System one, CMC, PKB
- Use Microsoft Word for letter and report writing; PowerPoint of r presentation
- You are expected to have the skills required to act as a professional, registered nurse and adhere to the NMC Code of Conduct
- In addition there will be many other skills Band 7 nurses are required to have according to the area where they work: Clinical Skills Specific to Service: -Wound care -Palliative Care & End of life care -Injections -Diabetes Management -Venepuncture -Physical Examination -Prescribin
- Work well with other members of the Care Connect Team including communicating effectively, being kind and considerate, reliable and enthusiastic
- Manage others and contribute to the management of the team
- Contribute to the culture of the team and play a role in making it inclusive, kind and hard working
- Coordinate work allocation
- Help others in the team achieve their objectives and deliver safe, effective care
- Mentor, teach and support others in the team
- Supervise others in the team
- Facilitate appraisals
Desirable
- Able to use systems such as Patient Know Best and Coordinate my Care.
- Expertise in particular skills and evidence of how you developed them and use them in your current role
- Supervision, Line management and appraisal training
- HR skills training e.g. recruitment, managing absence
Other
Essential
- Access to Car or other motor vehicle for use for work purposes
- Able to work efficiently in the community
Person Specification
Education and Qualifications
Essential
- Registered Nurse Adult
- Numeracy skills required for the safe administration of medicines
- Advanced Assessment Skills/ Nurse Practitioner Qualification/ Community Matron qualification or willing to undertake within 6months of appointment.
- Evidence of relevant Continuous Professional Development
- Non- Medical Prescribing Qualification or willing to undertake within 12months of appointment
- BSc Community Nursing Qualification or Equivalent Post Registration qualification
- Assessor/Mentor
Desirable
Previous Experience
Essential
- Previous experience as a Band 6/7 nurse working in the community or primary care setting with LTC management, Frailty and End of Life Care.
Desirable
- Experience of working in A&E, ITU or HDU or other equivalent acute medicine speciality.
Skills and knowledge
Essential
- Able to communicate with the multi-disciplinary team, present cases, take note of actions, update others in the team and use handover effectively. Speaking face to face but also by telephone and writing letters and reports.
- Maintaining accurate, timely, concise and legible clinical records both electronic and handwritten which adhere to the CNWL policies.
- Able to talk to people about sensitive issues in a supportive manner but also challenge others assertively where necessary
- Able to maintain electronic patient records via EMIS, System one, CMC, PKB
- Use Microsoft Word for letter and report writing; PowerPoint of r presentation
- You are expected to have the skills required to act as a professional, registered nurse and adhere to the NMC Code of Conduct
- In addition there will be many other skills Band 7 nurses are required to have according to the area where they work: Clinical Skills Specific to Service: -Wound care -Palliative Care & End of life care -Injections -Diabetes Management -Venepuncture -Physical Examination -Prescribin
- Work well with other members of the Care Connect Team including communicating effectively, being kind and considerate, reliable and enthusiastic
- Manage others and contribute to the management of the team
- Contribute to the culture of the team and play a role in making it inclusive, kind and hard working
- Coordinate work allocation
- Help others in the team achieve their objectives and deliver safe, effective care
- Mentor, teach and support others in the team
- Supervise others in the team
- Facilitate appraisals
Desirable
- Able to use systems such as Patient Know Best and Coordinate my Care.
- Expertise in particular skills and evidence of how you developed them and use them in your current role
- Supervision, Line management and appraisal training
- HR skills training e.g. recruitment, managing absence
Other
Essential
- Access to Car or other motor vehicle for use for work purposes
- Able to work efficiently in the community
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.
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).
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.
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).
