Community Matron

Job responsibilities

Bridgewater Community Healthcare NHS Foundation Trust and Warrington and Halton Teaching Hospitals NHS Foundation Trust plan to integrate and form a new organisation on the 1st April 2026. As such, if your start date is on or after 1st April 2026, you will be employed by the newly formed organisation. Should you join Bridgewater prior to this date, your employment will automatically transfer into the new organisation. We are confident that this transition will provide new opportunities and a continued commitment to excellence in patient care.

The post holder will be required to provide clinical case management to a group of patients who meet the Trust identified criteria, who have long term conditions and other complex medical and social problems. They will develop the clinical case management role and function across health and social care organisations. The primary function of the role is to maximise the patients health, clinically assess and treat patients in a defined group and reduce risks that contribute to ill health, thereby reducing unnecessary admissions to acute services, reducing demand on GP time and facilitating the delivery of efficient, effective, co-ordinated and timely high quality care to patients.

Duties and Responsibilities:

1. Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources.

2. Undertake clinical assessment and provide treatment for patients within the defined group

3. Link with existing services to facilitate early discharge from hospital and prevent re-admission.

4. Develop Partnerships and joint working within the local health and social care economy.

5. Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.

Clinical Requirements:

6. Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:

Review of health assessment including medical history

Physical examination

Assessment and review of medication

Prescribing in conjunction with management plans

Making referrals for diagnostic tests

Functional /cognitive assessment

Assessment of social care needs

7. Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others through:

Application of clinical knowledge about long term conditions

Analysis of symptoms and data

Identification of risk factors associated with exacerbation of patients condition

Recognition of early signs and symptoms of acute illness.

Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.

Documentation of progress and continuous reassessment

Referral and investigation

N.B. for 8 & 9 please see note below

8. Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs

9. Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patients needs by:

Prioritisation and co-ordination of multiple health and social care needs

Referrals to specialist services

Ensuring effective communication and sharing of appropriate information amongst professionals to avoid conflicting treatments.

Integration across health and social care (inc. voluntary sector and housing)

Identifying deficiencies in service provision and addressing these as appropriate (ie through commissioning services for individuals)

Understanding and working through entitlements to social care and necessary financial assessments

***8 & 9 Elements in these sections are existing care manager skills, i.e. District Nurse Team Leaders/ SPQ/level 7 and overlap with current Continuing Care practice***

10. Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.

Leadership Requirements

11. Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based and contribute to the collection of data to monitor outcomes measures for the caseload

12. Participate in the development of case management across the Trust.

13. Provide clinical leadership and mentoring to those staff developing into a case management role

14. Make, implement and communicate changes to clinical practice as necessary in relation to case management

15. Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high quality patient centred health and social care.

16. Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour.

17. Act as a role model so that patients receive the most effective care possible through:

Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible

Acting in patients interests at all times

18. Contributing to the development of policy and services to reflect the needs of the patient caseload.

MANAGERIAL RESPONSIBILITIES

19. Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis.

20. Undertake risk assessment in relation to individuals within the client group

21. Monitor and respond to the development of changing clinical and social situations with the identified patient group without recourse to others where possible

22. Ensure the safe management of care and service delivery

23. Line manage a defined team of staff; including performing appraisal, personal development reviews and the application of staff management procedures

Service Development Requirements

24. Encourage patient and carer participation in case management through:

The provision of information about disease prevention, progression and outcomes.

Ensuring that services are accessible to increase patient confidence

Empowering the patient to self manage whenever possible.

25. Contribute to the development of role and service redesign in long term condition management.

Analytical and Information Requirements

26. The postholder will utilise data and data tools (including databases) to produce appropriate monitoring reports on both patient care and service outcomes and produce appropriate communication for patients

Clinical Governance Requirements

27. Participate in individual and group clinical supervision and action learning sets, and to take responsibility for developing own learning.

28. Participate in research and audit relating to long term conditions management.

29. Ensure systems are in place for ongoing review and assessment of care provision and delivery.

30. Improve quality via Clinical Governance, Essence of Care and Clinical Supervision, by working closely with colleagues to address competency levels within the service.

31. Report any incidents through application of trust policies.

32. Participate in patient satisfaction reporting to improve patient care.

Education and Training Requirements

33. Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and provide mentorship and teaching to others developing a case management function.

34. Participate in the induction of new staff.

35. Provide education, advice and support to health and social care staff, people with long term conditions and their carers in both community and acute settings.

36. Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development.

Communication/Relationship Requirements

37. Liaise with patients and carers, community and specialist nursing and other health professionals, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector.

38. Work with patients and carers to:

Ensure that their values, beliefs and views are reflected in the case management plan

Encourage active participation in case management

Ensure that health advice and social care is provided in a professional, accessible and supportive way.

39. Work with other professional and statutory groups involved in case management to:

Ensure that there is consistent and high quality implementation of care

Avoid duplication, delay or distress to patient

Ensure that record keeping is consistent with Trust and Professional standards.

40. Communicate at all levels of the organisation to a variety of health and social care professionals to provide best outcomes for patients.

Please see attached Job Description and Person Specification attached.

Qualifications

Essential

• Relevant Clinical Professional Qualification
• Degree or equivalent clinical/advanced practice
• Extensive post registration experience
• Management/Clinical Leadership experience
• Clinical Masters Degree or working towards
• Prescribing qualification at V300 level
• Evidence of post registration/qualification

Desirable

• Specialist practitioner

Experience

Essential

• Experience of working with patients with long term conditions
• Experience of successful multi agency working including an understanding/ experience of working in a social care environment
• Evidence of influencing, motivating and negotiating with others to achieve change in relation to care
• Experience of initiating and implementing clinical

Desirable

• Experience of commissioning health and social care services

Job Specific Requirements

Essential

• The ability to travel independently across the Trust
• The ability to work flexibly in accordance with service needs
• Ability to undertake physical care

Relationships

Essential

• If you are related to a director or have a relationship with a director or employee of an appointing organisation, please state the relationship.

Sponsorship

Essential

• Do you have the right to stay and work in the UK without sponsorship (share-codes will be checked if applicable).

Skills and Knowledge

Essential

• Understanding of the principles of case management
• Awareness of long term condition management agenda
• Awareness of current national and local agenda in health and social care
• Understanding of how other agencies work (i.e. housing, social services, the independent sector etc)
• Evidence of being able to communicate complex information and advice on healthcare to patients/carers and colleagues
• Ability to work under pressure and manage a diverse work load
• Proficient IT skills
• Excellent interpersonal skills; including negotiation, influencing and presentation
• Risk Assessment skills
• Ability to understand and analyse complex data
• Self-management and motivation skills
• Confidence to challenge traditional practice and persistence to address difficult issues
• Networking knowledge and understanding of local services
• Report writing skills
• Research skills
• Awareness of factors which contribute to good health and the importance of promoting these in line with organisational public health policy
• Clinical Assessment skills (Clinical Masters level or equivalent for example; history taking, physical examination, ordering and review of blood tests and the ability to investigate and diagnose an unwell person etc)
• Working knowledge of Cognitive function and its effect
• Rehabilitation nursing and social care assessment skills
• Moving and handling skills (including ability to assess need)
• Clinical decision making
• Venepuncture
• Palliative/end of life care 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.

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).