Matron - East Elmbridge PCN - Surrey Downs H&C

This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses, adult social care, voluntary organisations and community matrons to support the delivery of proactive healthcare and support to people living with frailty, multiple long-term conditions and/or complex needs to help them stay independent and healthy for as long as possible at home.

We are committed to your ongoing professional development and offer a structured training programme to support the requirements set out within the national Care Co-ordinator job profile.

If you’re looking for an employer that is working to push beyond and remove traditional boundaries and barriers, bringing care to patients when and where they need it, and you want to work alongside motivated, passionate, and visionary colleagues, come and work for Surrey Downs Health and Care!, The Community Matron will work across traditional organisational boundaries challenging inequities to co-ordinate and ensure health and social care needs of the individuals are met. As an autonomous practitioner the Matron will use a case management approach to ensure the individual’s condition remains as stable as possible and wellbeing is increased.

• Obtain information to inform the assessment of an individual

• Establish the individual’s functional capabilities in the context of long term conditions clinical management

• Investigate and diagnose an unwell individual as part of the long term conditions clinical management

• Plan, implement, monitor and review therapeutic interventions with individuals who have long term condition and their carers

• Assess individual’s needs and preferences

• Enable individuals with long term conditions to manage their medicines

• Plan, implement, monitor and review individualised care plans with individuals who have long term care conditions and their carers

• Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions, * Provide a clinical triage/assessment with inbound referrals and assign the appropriate urgency (i.e. 2 hr Rapid Response) and determine the best clinician to undertake the visit from their multi-disciplinary team.

• Support annual Learning Disability or Serious Mental Illness Health checks.

• Care coordination – both clinical and administrative, managing patient caseloads and offering proactive support (i.e. frequent attenders; support for cancer patients; CVD remote monitoring and support; blood pressure monitoring etc). i.e. Accept referrals from practices to proactively manage and support patients diagnosed with cancer, patients at risk of CVD and will act as a ‘step down’ from the Social prescriber/mental health team as appropriate to manage frequent attenders who have been discharged from their care with management plans in place.

• Anticipatory care – liaising with both primary, secondary and community teams to support the reduction of admission for patients with ambulatory care sensitive conditions and closing the hypertension diagnosis gap

• Enhanced Health in Care Homes – proactive and targeted visits for specific cohorts of patients

• To support the co-ordination with the delivery of all housebound annual vaccinations.

• Support and manage a small team of non-clinical care co-ordinators to support delivery of duties.

• Demonstrate clinical expertise and act as a professional role model to all co owners, both internal and external on behalf of SDHC, working as part of an integrated team taking the lead and developing services in line with the needs of the patient

• Treat all patients as individuals, respecting their privacy and dignity at all times

• Investigate and diagnose an unwell individual as part of the long term conditions clinical management

• Involving, supporting, informing and educating family/carers

• Promote the health of patients and the provision of support and advice

• Be responsible for planning cover, appropriate staffing and skill mix ensuring adequate cover when supporting community nursing teams or community matrons

• Provide specialist knowledge and advice to influence the SDHC strategic agenda

• Maintain clear and comprehensive, signed and contemporaneous records according to procedures

• Identify workforce planning issues and actively participate in the recruitment, selection and retention of clinical staff

• Provide support and an appropriate learning environment for both pre and post registration students as required

• Be responsible for ensuring that policies and procedures and standards of care, are adhered to at all times

• To work with other community matrons to ensure consistency of approach and share practice development

• Participate in research and development opportunities as appropriate

• Provide assistance with the resolution of complaints within the clinical specialty, or sphere of responsibility

• Have the ability to negotiate and work effectively across all agencies for the maximum effectiveness of care

• Undertake physical and social assessments and examinations and initiate appropriate diagnostics

• To work autonomously

• Help individuals with LTC to change their behaviour to reduce the risk of complications and improve their quality of life

• To work collaboratively with other specialist nurses and multidisciplinary teams such as GP’s, Community Nurses, Social Care and Voluntary Services

• Contribute to the development of Integrated care in the community

• Be aware of and act upon when necessary, procedures that are in place to protect vulnerable individuals

• Lead and implement the SDHC Clinical Governance Strategy within your practice area, facilitating and instigating clinical audit and monitoring of care

• Lead and implement the SDHC Risk Management Strategy within your practice area, ensuring that all processes are adhered to

• Maintain own professional and clinical integrity in line with NMC guidelines

• Undertake any other such duties as may be required from time to time as are consistent with the responsibilities of the post

• Be responsible for individual timely data entry and responsible for the corporate teams data entry

• Co-owners are employed to work within SDHC localities and may be reasonably requested to move base temporarily or on a more permanent basis, as requested by service needs

• To undertake clinical supervision and appropriate training for the role.

• 1st level registration with relevant post registration experience

• Evidence of continued professional development, with courses relevant to area of work

Desirable criteria

• Management qualification, * Previous experience of team management and multidisciplinary working

Clinical experience relevant to the role

Desirable criteria

• Specialist knowledge

• Experience of developing strategies, Clinical guidelines and policies, * Car owner with clean UK Licence

• Self-motivated

• Innovative and flexible, You must have appropriate UK professional registration.