Job summary
An exciting opportunity has arisen for a Community Matron to support our West Norwich patients.
The team provide advanced case management and clinical nursing care to patients with long term conditions who are often high intensity users of both primary and secondary care. You will work closely with PCN and NCHC community team colleagues to assess and provide advanced level interventions for patients with long term conditions. The team supports admission avoidance through joint working with our community virtual ward team, High Intensity User Service Team, and links with our colleagues at Norfolk & Norwich University Hospital to facilitate supported discharge.
The successful applicant will be expected actively look for, and progress, opportunities to improve and develop the service, working with our system partners to support patient autonomy.
Main duties of the job
Community Matron role is to provide advanced, intensive case management and clinical nursing care to patients predominantly in their home settings, including residential homes and supported living complexes.
The workload requires a good range of clinical skills to be applied in managing our patients with chronic unstable conditions. Including assessment and provision of advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible.
There is an expectation that the Community Matron will support Community Nurses in the team, as well as students and apprentices in the role of an assessor or supervision.
About us
Norfolk Community Health and Care NHS Trust is an organisation assessed as being 'Outstanding' by Care Quality Commission in 2018
The expectation of the community matrons will be to:
The post holder will participate in multi-disciplinary/multi-agency meetings as appropriate, e.g. Gold Standard Framework, Community Fully integrated care and support meeting (CFICS) as well as Community Nursing team meetings and handovers.
Work collaboratively with members of own team and the wider multi-disciplinary team to lead developments in professional practice and to support multi-disciplinary working around the needs of very high intensity users and those at high risk of hospital admission.
Use effective communication, negotiating and influencing skills to introduce new systems of working to improve the pathway of patients who are very high intensity users of health care and/or at high risk of hospital admission.
Have a working understanding of the NCHC behavioural frame work and act as role model in implementing the values that uphold the foundations of a Outstanding Trust .
Apply now to join an organisation that has been awarded an 'Outstanding' rating by the Care Quality Commission (CQC), the highest possible rating and the first stand-alone NHS community trust in the country to be awarded the title.
Job description
Job responsibilities
To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible, and to support them in their own environment.
To work within the integrated team to facilitate early discharge from hospital.
To work in conjunction with Norwich Practices supporting the Home Visiting Service with long term condition management.
To work within the integrated team to prevent unnecessary admission to hospital with adequate management plans and clear guidance.
To work with all health care professionals, and statutory/non-statutory agencies to provide a seamless, integrated service to our service users.
To support patients in coordinating their personal health plans.
To assess patients for assistive technology where appropriate.
To refer on to social care support where appropriate.
To support and manage Band 6 Case Managers
Track patients who are part of the Community Matron caseloads when entering hospital or nursing home step-up beds and ensure that they are followed up appropriately when discharged.
Working closely with GPs and the acute hospital and support service issues that may need resolving to ensure timely discharge.
Proactively find patients who are very high intensity users of primary and secondary healthcare and/or are at high risk of unplanned admission to hospital.
Educate and support the members of the multi-disciplinary teams to intensively case manage these patients.
Intensively manage their own caseload of patients with highly complex and unstable health needs.
Independently manage the caseload by maintaining a consistent throughput of patients. This should be achieved by; ensuring patients are discharged in a timely manner; promoting patient independence in managing their own health conditions; encouraging self-care and condition self-management; sign posting to other appropriate services; and by utilising strategies of health promotion and health coaching.
Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system.
Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact.
Accountable for the intensive case management and where appropriate intervention of a defined patient caseload.
Actively work with GPs and other agencies, and with appropriate information technology, to case find patients.
Be a champion for people with long term conditions.
Provide supervision and assessment for all learners as part of trust educational policy, particularly those undertaking pre/post registration nursing courses.
Job description
Job responsibilities
To assess and provide advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible, and to support them in their own environment.
To work within the integrated team to facilitate early discharge from hospital.
To work in conjunction with Norwich Practices supporting the Home Visiting Service with long term condition management.
To work within the integrated team to prevent unnecessary admission to hospital with adequate management plans and clear guidance.
To work with all health care professionals, and statutory/non-statutory agencies to provide a seamless, integrated service to our service users.
To support patients in coordinating their personal health plans.
To assess patients for assistive technology where appropriate.
To refer on to social care support where appropriate.
To support and manage Band 6 Case Managers
Track patients who are part of the Community Matron caseloads when entering hospital or nursing home step-up beds and ensure that they are followed up appropriately when discharged.
Working closely with GPs and the acute hospital and support service issues that may need resolving to ensure timely discharge.
Proactively find patients who are very high intensity users of primary and secondary healthcare and/or are at high risk of unplanned admission to hospital.
Educate and support the members of the multi-disciplinary teams to intensively case manage these patients.
Intensively manage their own caseload of patients with highly complex and unstable health needs.
Independently manage the caseload by maintaining a consistent throughput of patients. This should be achieved by; ensuring patients are discharged in a timely manner; promoting patient independence in managing their own health conditions; encouraging self-care and condition self-management; sign posting to other appropriate services; and by utilising strategies of health promotion and health coaching.
Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system.
Work with and refer appropriately to other agencies to enable identified patients to be intensively managed in a pro-active way with the aim of preventing hospital admission, supporting early discharge and reduce GP contact.
Accountable for the intensive case management and where appropriate intervention of a defined patient caseload.
Actively work with GPs and other agencies, and with appropriate information technology, to case find patients.
Be a champion for people with long term conditions.
Provide supervision and assessment for all learners as part of trust educational policy, particularly those undertaking pre/post registration nursing courses.
Person Specification
Qualifications
Essential
- 1st Level degree RN qualification
- Assessor/Mentorship preperation
- Current NMC Registration
- Evidence of continuing professional development related to a long-term condition such as COPD, Heart Failure etc.
- Master Degree or willingness to work towards
- CPD qualifications incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
- Independent/supplementary prescribing qualification
Desirable
- Long Term Conditions module
- Clinical assessment skills
- Consultation skills
- Evidence of leadership / management related study
Experience
Essential
- Post qualification experience including previous experience at Band 6 level or above
- Community Nursing or similar relevant post registration experience
- Experience of multi-disciplinary and partnership working in acute and community settings
- Advanced understanding of clinical conditions and clinical experience in managing long-term conditions
- Experience of being part of change management process; demonstrates positive attitude to change.
- Clinical Supervision experience
- Student mentorship / assessment skills and experience
Desirable
- Teaching in Clinical Practice
- Contribution to service planning
- Experience of audit
SKills, Abiliites and Knowledge
Essential
- Broad range of clinical skills
- An understanding of wider NHS and social care issues
- An understanding of intensive case management and systems for case finding
- Ability to influence and motivate staff at all levels
- Effective presentation skills
- Competent in use of IT hardware and software such as the Microsoft Office package
- Ability to priorities and work to deadlines
Desirable
- Ability to use and interpret information
- Awareness of Assistive Technology
- Experience of health coaching and empowerment model
Communication
Essential
- Demonstrates ability to adapt communication styles depending on audience including GP's, commissioners, patients and carers
- Ability to use tact & diplomacy in communicating potentially difficult messages
- Excellent observational & reporting skills
- Able to concentrate when undertaking patient care & inputting data/patient records
- Excellent interpersonal skills when working with both patients, carers, colleagues and fellow professionals
- Able to communicate effectively in written and verbal English Language
Personal and People Development
Essential
- Ability to work as part of a team
- Able to maintain a professional appearance
Personal attributes/ behaviours
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Pro-active and committed
- Ability to work autonomously and to use initiative
- Highly motivated to provide excellent patient care
- Able to empathise & be sensitive to the needs of patients and colleagues
Other
Essential
- Must hold full and valid driving licence and have access to a vehicle
- Will be able to make own travel arrangements to patients' homes, clinics, base and meetings etc, as required.
- Be able to kneel, bend & stoop, and work in cramped environments
- Be able to manoeuvre limbs of around 5-6 kg
- Be able to manoeuvre patients using handling aids
Person Specification
Qualifications
Essential
- 1st Level degree RN qualification
- Assessor/Mentorship preperation
- Current NMC Registration
- Evidence of continuing professional development related to a long-term condition such as COPD, Heart Failure etc.
- Master Degree or willingness to work towards
- CPD qualifications incorporating Advanced Clinical Practice and Independent Prescribing (or willingness to undertake)
- Independent/supplementary prescribing qualification
Desirable
- Long Term Conditions module
- Clinical assessment skills
- Consultation skills
- Evidence of leadership / management related study
Experience
Essential
- Post qualification experience including previous experience at Band 6 level or above
- Community Nursing or similar relevant post registration experience
- Experience of multi-disciplinary and partnership working in acute and community settings
- Advanced understanding of clinical conditions and clinical experience in managing long-term conditions
- Experience of being part of change management process; demonstrates positive attitude to change.
- Clinical Supervision experience
- Student mentorship / assessment skills and experience
Desirable
- Teaching in Clinical Practice
- Contribution to service planning
- Experience of audit
SKills, Abiliites and Knowledge
Essential
- Broad range of clinical skills
- An understanding of wider NHS and social care issues
- An understanding of intensive case management and systems for case finding
- Ability to influence and motivate staff at all levels
- Effective presentation skills
- Competent in use of IT hardware and software such as the Microsoft Office package
- Ability to priorities and work to deadlines
Desirable
- Ability to use and interpret information
- Awareness of Assistive Technology
- Experience of health coaching and empowerment model
Communication
Essential
- Demonstrates ability to adapt communication styles depending on audience including GP's, commissioners, patients and carers
- Ability to use tact & diplomacy in communicating potentially difficult messages
- Excellent observational & reporting skills
- Able to concentrate when undertaking patient care & inputting data/patient records
- Excellent interpersonal skills when working with both patients, carers, colleagues and fellow professionals
- Able to communicate effectively in written and verbal English Language
Personal and People Development
Essential
- Ability to work as part of a team
- Able to maintain a professional appearance
Personal attributes/ behaviours
Essential
- Demonstrates strong leadership skills
- Demonstrates excellent interpersonal, communication and negotiation skills
- Evidence of strong interdisciplinary and multiagency team working
- Innovative
- Pro-active and committed
- Ability to work autonomously and to use initiative
- Highly motivated to provide excellent patient care
- Able to empathise & be sensitive to the needs of patients and colleagues
Other
Essential
- Must hold full and valid driving licence and have access to a vehicle
- Will be able to make own travel arrangements to patients' homes, clinics, base and meetings etc, as required.
- Be able to kneel, bend & stoop, and work in cramped environments
- Be able to manoeuvre limbs of around 5-6 kg
- Be able to manoeuvre patients using handling aids
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).
