Job summary
To work as part of the locality community nursing team and wider multi-disciplinary locality team, providing advanced clinical practice, personalised care planning and care co-ordination of health, social care and other services.
To improve the care of people with the long term conditions and complex needs, to prevent hospital admission, support timely and safe discharge and establish effective personalised care and treatment plans to support people to remain in their usual residence.
To provide education and support to individuals and their families to promote self-care strategies and independence, and to develop multi-disciplinary informed personalised treatment and management plans for their health condition, including planning interventions for fluctuations in health status.
This is a full time community matron position within the Centre House
District Nursing team with the base being at 68 Sheen Lane.
Main duties of the job
To provide assessment, diagnosis, individualised treatment planning, personalised case management and care co-ordination for patients with a range of complex long-term conditions whose condition is unstable and affecting their daily life.
To improve clinical outcomes for people with long term conditions and reduce the need for these people to attend or be admitted into hospital or long-term residential care.
To work in partnership with general practitioners, secondary care, care homes, community nursing, specialist nurses, rehabilitation services, social services and the wider multi-disciplinary locality team in proactive care planning for regular users of unplanned healthcare services.
Provide supervision, advice and training to nurses and others in the locality team undertaking case management/ care co-ordination of complex cases.
Support the locality nursing team manager in the development and deployment of a skilled, competent and motivated workforce, able to meet the needs of the patients on the locality team caseload.
The post holder will act as a nursing role model.
About us
Developmentand staff wellbeing
Your growthand personal happinessmattersto us.After all, we can't expect the best from you if we don't invest in your development and nurture your wellbeing.From the moment you join us, we're committed to fostering your professional and personal development within a supportive, empowering environment. Whether you're just starting your career or looking to advance further, we provide you with the tools and opportunities you need to succeed.We actively support colleagues to take part in research, quality improvement and innovation, whatever their role or level in the organisation.
To support your wellbeing, we offer an extensive range of resources, including an on-site staff nursery at Kingston Hospital, wellbeing practitioners, regular wellbeing classes, dedicated staff physiotherapist, comprehensive occupational health services, 24/7 employee assistance programme, and a range of other support and activities.
We also take every opportunity to thank and recognise the work our teams do, through weekly 'shoutouts' and patient feedback, monthly and annual awards.
Wherever you work across our organisation, we look forward to welcoming you.
At KRFT we are committed to supporting flexible working arrangements. Applicants are encouraged to discuss any flexibility they may need during the recruitment process.
Job description
Job responsibilities
Please refer to the attached JD and PS with a full breakdown of Job Purpose, Key Roles and Full list of responsibilities.
Job description
Job responsibilities
Please refer to the attached JD and PS with a full breakdown of Job Purpose, Key Roles and Full list of responsibilities.
Person Specification
Qualifications
Essential
- Registered Nurse NMC - RN1 ,RNA with current NMC registration
- 1st Level Degree
- Non-Medical Prescribing (V300) qualified or achieved within 12 months
- Post Graduate qualification in appropriate long term condition area
- Advanced Clinical Assessment Skills Module
- Up to date professional portfolio demonstrating evidence of reflective practice
- Mentorship or teaching qualification equivalent to ENB 998 / work place assessor
Desirable
- Evidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
- MSc Advanced Practice (or working towards)
Knowledge
Essential
- Understanding of case management, case finding systems and care co-ordination
- An understanding of the wider NHS and social care contexts
- Understanding of the Mental Capacity Act 2005 and DOLS
- Demonstrate an understanding of clinical governance
- Extended and advanced clinical knowledge base
- Understanding of Safeguarding Adults & Children
Experience
Essential
- Demonstrable post-graduate experience in a relevant area working with people with long term conditions
- Extensive post-graduate experience in a role undertaking assessments of complex needs
- Extensive post-graduate experience in a role undertaking assessments of complex needs
- Experience of working across professional boundaries
- Demonstrable Experience of clinical leadership
- Clinical experience of caring for people with cognitive impairment
- Experience of mentoring students
Desirable
- Experience of audit evaluation to improve healthcare
Skills
Essential
- Clinical Examination Skills, Physical Examination and assessment skills (top to toe).
- Act as a role model, educator, supervisor, coach and mentor, seeking to instil and develop the confidence of others.
- Ability to autonomously prioritise, coordinate caseload working to and work to deadlines and across boundaries
- Highly developed interpersonal and communication skills
- Ability to effectively delegate activities to appropriate staff
- Ability to effectively negotiate on patient management and promote self-care and across boundaries
- Ability to communicate clearly and effectively in English in both verbal and written formats
- Excellent organisational skills
- Excellent leadership skills
- Excellent problem solving skills to identify and resolve clinical issues
- IT literate with ability to use databases and other software packages and digital solutions with patients and in the operation of the service
- Able to produce well written and timely clinical records and service reports
- Ability to travel to multiple sites; car driver or competent cyclist
Desirable
- Motivational Interviewing skills
Personal Attributes
Essential
- Reliable, empathetic, approachable, understanding, non-judgemental and tolerant
- Demonstrates high ethical and professional standards
- Able to reflect and critically appraise own performance
- Committed to lifelong learning and achieving full compliance with the competencies and standards of this role
- Has a positive attitude to change and is prepared to work flexibly to meet the need of people and the service
- Willingness to undertake training and competencies for additional clinical interventions to support service development
- Willingness to learn and implememt new ways of working, including using digital solutions with patients and in the operation of the service
- Confident, self motivated and energetic
Person Specification
Qualifications
Essential
- Registered Nurse NMC - RN1 ,RNA with current NMC registration
- 1st Level Degree
- Non-Medical Prescribing (V300) qualified or achieved within 12 months
- Post Graduate qualification in appropriate long term condition area
- Advanced Clinical Assessment Skills Module
- Up to date professional portfolio demonstrating evidence of reflective practice
- Mentorship or teaching qualification equivalent to ENB 998 / work place assessor
Desirable
- Evidence of specialist clinical expertise within a relevant area such as COPD, Heart Failure
- MSc Advanced Practice (or working towards)
Knowledge
Essential
- Understanding of case management, case finding systems and care co-ordination
- An understanding of the wider NHS and social care contexts
- Understanding of the Mental Capacity Act 2005 and DOLS
- Demonstrate an understanding of clinical governance
- Extended and advanced clinical knowledge base
- Understanding of Safeguarding Adults & Children
Experience
Essential
- Demonstrable post-graduate experience in a relevant area working with people with long term conditions
- Extensive post-graduate experience in a role undertaking assessments of complex needs
- Extensive post-graduate experience in a role undertaking assessments of complex needs
- Experience of working across professional boundaries
- Demonstrable Experience of clinical leadership
- Clinical experience of caring for people with cognitive impairment
- Experience of mentoring students
Desirable
- Experience of audit evaluation to improve healthcare
Skills
Essential
- Clinical Examination Skills, Physical Examination and assessment skills (top to toe).
- Act as a role model, educator, supervisor, coach and mentor, seeking to instil and develop the confidence of others.
- Ability to autonomously prioritise, coordinate caseload working to and work to deadlines and across boundaries
- Highly developed interpersonal and communication skills
- Ability to effectively delegate activities to appropriate staff
- Ability to effectively negotiate on patient management and promote self-care and across boundaries
- Ability to communicate clearly and effectively in English in both verbal and written formats
- Excellent organisational skills
- Excellent leadership skills
- Excellent problem solving skills to identify and resolve clinical issues
- IT literate with ability to use databases and other software packages and digital solutions with patients and in the operation of the service
- Able to produce well written and timely clinical records and service reports
- Ability to travel to multiple sites; car driver or competent cyclist
Desirable
- Motivational Interviewing skills
Personal Attributes
Essential
- Reliable, empathetic, approachable, understanding, non-judgemental and tolerant
- Demonstrates high ethical and professional standards
- Able to reflect and critically appraise own performance
- Committed to lifelong learning and achieving full compliance with the competencies and standards of this role
- Has a positive attitude to change and is prepared to work flexibly to meet the need of people and the service
- Willingness to undertake training and competencies for additional clinical interventions to support service development
- Willingness to learn and implememt new ways of working, including using digital solutions with patients and in the operation of the service
- Confident, self motivated and energetic
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).
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