My Care My Way Matron/Community Matron **£2000 Golden Hello **

Job description

Job responsibilities

Job Summary

The post holder will work and have a lead role in our My Care My Way service across the local Neighbourhoods and the ICS to deliver health improvement outcomes for patients.

Each Neighbourhood will have a chosen specialty that will be the focus for the health improvement outcomes identified by the Neighbourhood and the needs of the population. This will entail working within an ethos multi-professional model of care, that is committed to ensuring a culture of respect, collaboration and celebration of the multiple skills and contributions that the workforce can create.

Job Purpose

The post holder will -

Improve Integration and development of locally empowered Neighbourhood Teams.

Work with their Neighbourhood footprint to ensure it pulls together care across the system to allow coordination and improved response.

Focus on the key 1% cohort with multiple complex needs with data evidence of impact.

Work with the neighbourhood to reduce the contacts across the Partnership per individual to improve both outcome for people and the utilisation of clinical resource.

Ensure continuity of care and improved access which allows triage and direction to the designated teams and reduces transfers and complex navigation for the individual.

Recognise the value of partnership and seek to transform through outcomes.

Work in partnership with patients, carers, and families to support their care needs and provide ongoing navigation.

• All clinicians are provided with a work iPhone and iPad for mobile working and to access the electronic patient held record system, EMIS.

KEY RESPONSIBILITIES

Communication

To work within an ethos multi-professional model of care that is committed to ensuring a culture of respect, collaboration and celebration of the multiple skills and contributions that workforce can create

Act as an advocate for all individuals and carers to ensure a culture where individual needs, wishes and preferences are at the forefront of care

To work within a personalised care approach that supports care and develops a partnership approach with neighbourhoods

Constructively challenge tradition and take risks accepting joint responsibility for any arising problems and tensions and using these to inform future practice

Facilitate the Neighbourhood wide My Care My Way MDTs and provides clinical representation for nursing.

Actively contribute to meetings and participates in discussions concerning all elements of the aging well service and policy requirements

Demonstrate effective communication, joint working and networking across neighbourhoods

Works in partnership with hospital teams including specialists, Social Care, MDTs, and GPs, Voluntary services, charities in facilitating safe discharge home from hospital or following an A&E attendance

Interpret complex information and formulate solutions to recommend on the best course of action at individual patient level and at Neighbourhood level

Utilise complex data from a wide range of sources, some of which may be conflicting, to inform clinical decision making

Effective and contemporaneous use of electronic notes system, including assessment tools

Patient Care / Safety / Quality

Competent at Masters / level 7 to undertake physical examination of the circulatory, respiratory and other systems including listening to heart and lungs and regularly undertaking the following: venepuncture, male and female catheterisation, rectal examination, injections and wound care

Use advanced clinical assessment skills, Chronic Disease Management and End of life care to support personalised, anticipatory, and advanced care planning and the prevention of unnecessary admission to hospital for individuals and groups

Interpret findings from diagnostic tests/examination and uses this to make clinical decisions about care and treatment ensuring effective management of risk in the community setting

Seek to embed a proactive approach to promote wellness, early recognition of disease exacerbation, and appropriate intervention to improve patient outcomes through safe clinical decision making and the delivery of expert care

Ensure that patients and their carers experience a high quality, safe, responsive service, ensuring that care is accessible, effective, and delivered at a time and place according to clinical need

As an advanced and autonomous practitioner accepts clinical responsibility for a diverse and often complex caseload of patients, prioritising care needs efficiently and effectively

Receive referrals from and make referrals across all stakeholders within neighbourhoods.

Responsible for making rapid autonomous decisions, escalating as appropriate to the GP / Adult Social Care / Safeguarding in a timely manner

Work within the Surrey wide multi-agency safeguarding policy to ensure vulnerable adults are protected

Monitor individual and MDT wide indicators of long-term condition management, including the anticipating of possible decline and having effective personalised care plans in place

Service Development

Actively participates in service development and project meetings related to the My Care My Way programme to positively effect change, influencing change to integrate My Care My Way into practice

Effective delivery of presentations and effective chairing of MDT meetings

Actively participates in MDTs and risk stratification / population health management as required

Support service development for improved outcomes

Work with the wider team to help develop and evaluate the My Care My Way service across neighbourhoods, working with community and secondary care to continuously improving standards of patient care and wider MDT working

Works with the Professional Lead to establish relevant education and training

Utilise data and technology to systematically identify people at high risk of unnecessary admission to hospital, this is in conjunction with practice and PCN care coordinators

Effectively utilise technology to support communication channels and new ways of working, adhering to confidentiality and information governance

Assist with the development of data packs, including lightfoot and graphnet.

Is proactive in caseload identification and own caseload management.

Work with other streams of work in Procare Community Services to ensure best use of resources, no duplication and development of staff and services.

Professional Development

Accountable for own professional actions in line with the NMC code and local policy and guidelines

Maintain up to date technical and professional knowledge and clinical skills relevant to the post

Responsible for completing all own mandatory training and for overseeing direct reports

Participate in own annual appraisal

Access regular 1-1 meetings with line manager

Provide expert clinical and supervisory leadership to junior team members, non-registrants, new employees, and students within the team

Person Specification

Qualifications

Essential

• Registered Level 1 Nurse with current Nursing and Midwifery Council registration
• Evidence of study at MSc / level 7
• Evidence of study on the ANP pathway including history taking, clinical reasoning, health assessment or willingness to work towards
• Non-Medical Prescriber (V300), or has demonstrated a willingness to work towards
• Assessor / NMC Supervisor / Mentorship Qualification
• Evidence of recent and relevant continuing professional development

Desirable

• Management / Coaching / CBT / Quality Improvement / Leadership training

Experience

Essential

• Extensive experience in the management of long-term conditions in the community setting
• Extensive experience of effective complex care management for frail / vulnerable people
• Extensive experience of health and safety and risk management
• Extensive experience and working knowledge in primary care and / or adult community nursing.

Skills, Knowledge and Attributes

Essential

• Working knowledge of health and care policy
• Evidence of implementing sustainable service improvement from identification to evaluation
• Advanced clinical and nursing assessment skills
• Demonstrable improvement of outcomes for local people
• Evidence of delivering presenting to groups and effectively chairing meetings
• Able to use databases and other IT programmes, including Graphnet, Lightfoot, MicroSoft Word, Excel, Powerpoint, Emails,Virtual Meeting platforms. Training will be provided.
• Ability to input and navigate around the community electronic patient record system. EMIS (training will be provided)
• High level negotiation and motivation skills
• Effective role model, with evidence of resilience and a proactive and positive approach
• Effective workload prioritisation for self and others with the ability to calmly adapt to unplanned to changes throughout the working day
• Demonstrates a strong desire to improve performance and outcomes for local people
• Able to travel to frequently throughout the day to visit patients at home, at various locations across the locality and across Guildford and Waverley throughout the working day, at times travel across Surrey
• may be required

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).

Employer details

Employer name

Procare Community Services

Address

Haslemere District Hospital

Church Lane

Haslemere

Surrey

GU27 2BJ

Employer's website

https://www.procarehealth.co.uk (Opens in a new tab)