Job summary
Purpose
An exciting opportunity has
arisen for a Community Matrons to proactively
provide individualised care planning and care coordination over the lifetime of
the patient with long term conditions.
The post holder will deliver
expert nursing care, support, and advice in accordance with national and local
policy and guidance and in accordance with the Nursing and Midwifery Council.
Work as an integral part of
the multi-disciplinary team including GPs, community nurses, social care and
mental health colleagues, medicines management and voluntary sector in the
Northwest Surrey Locality Hubs.
The post holder will deliver
expert nursing care, support, and advice in accordance with national and local
policy and guidance and in accordance with the Nursing and Midwifery Council.
Work as an integral part of
the multi-disciplinary team including GPs, community nurses, social care and
mental health colleagues, medicines management and voluntary sector in the
Northwest Surrey Locality Hubs.
Lead and facilitate a patient
focused, coordinated case management approach, supporting people who are most
vulnerable to and at high risk of unnecessary admission to hospital to maintain
their independence.
Main duties of the job
Duties to include:Identifies patients at high
risk of unnecessary admission to hospital / decline in health and or wellbeing
and uses proactive management approach to promote wellness, early recognition
of disease exacerbation, and appropriate intervention to improve patient
outcomes and reduce the likelihood of unnecessary admissions to hospital Documents holistic nursing
assessments, considering physical and psychological social needs and those of
their carers to inform and agree individualised care plans with the patient. Interprets complex
information and formulates solutions to recommend on the best course of
action/treatment for the patients, e.g., medication reviews
Act as an independent
decision maker regarding referrals to other agencies and for the admission
/discharge from the Locality Hub caseload. Trained and competent 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 Interprets findings from
diagnostic tests/examination and uses this to make clinical decisions about
care and treatment
Works in partnership with
hospital teams including specialists, Social Care, MDTs, and GPs in
facilitating safe discharge home from hospital or following an A&E
attendance
About us
CSH Surrey are part of the NHS and are Surreys largest and longest
established NHS community services provider, so our 1500+ employees get
NHS pay and pensions, and also receive the Fringe High-Cost Allowance of
5%.
Our staff enjoy excellent training and development opportunities, including the
care certificate, apprenticeships, numeracy and literacy courses, access to
the Nursing Associate programme, and a wide variety of management and
leadership courses and programmes.
We CARE about our staff though through our values of Compassion,
Accountability, Respect and Excellence. Our active employee council called
The Voice, elect employee representatives to ensure colleagues' voices are
heard at Board level.
CSH is a diverse organisation, if you are a passionate, person-focused
individual then apply to join CSH Surrey today!
We welcome candidates from
all backgrounds who meet the essential criteria of the job you are applying for
and if you require any reasonable adjustments, please contact the named
individual for this advert, or our recruitment team.
Job description
Job responsibilities
Duties to include:
Identifies patients at high
risk of unnecessary admission to hospital / decline in health and or wellbeing
and uses proactive management approach to promote wellness, early recognition
of disease exacerbation, and appropriate intervention to improve patient
outcomes and reduce the likelihood of unnecessary admissions to hospital
Documents holistic nursing
assessments, considering physical and psychological social needs and those of
their carers to inform and agree individualised care plans with the patient.
Interprets complex
information and formulates solutions to recommend on the best course of
action/treatment for the patients, e.g., medication reviews
Act as an independent
decision maker regarding referrals to other agencies and for the admission
/discharge from the Locality Hub caseload
At all times, ensures that
patients and their carers experience a high quality and patient centred
service, ensuring that care is accessible, effective, and delivered at a time
and place according to clinical need
Trained and competent 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
Interprets findings from
diagnostic tests/examination and uses this to make clinical decisions about
care and treatment
As a non-medical prescriber
(NMP), work within the scope of national and local protocols. This will include
attending regular updates in line with CPD and revalidation requirements, the
initiation of medication regimes, agreeing changes, monitoring the effects of
medications, advising patients on the safe storage and disposal of drugs.
Works in partnership with
hospital teams including specialists, Social Care, MDTs, and GPs in
facilitating safe discharge home from hospital or following an A&E
attendance
Responsible for preparing the
patient and their family for changes in condition and support choice about
end-of-life care, ensuring that patients needs, and those of their families
are met, this will include active management of complex pain and symptom
control.
Provides information about
the disease process to assist patients and their families in understanding and
self-managing their long-term condition.
Responsible for prescribing
the correct use of aids and equipment relevant to Hub Matron role and in line
with patient need
Responsible for ensuring
effective communication with all relevant personnel pertaining to patient care
and any change in treatment/management plans, part of this will include the
effective use of electronic notes system, including assessment tools
Responsible for establishing,
communicating and maintaining effective professional relationships with nursing
colleagues, Primary Health Care Team and health/social care/voluntary service
networks to provide a planned, co-ordinated, seamless service for patients
clients
Influences efforts across
health and social care to shape integrated working designed to support patient
choice, improve quality of life, promote self-management, and assure early
intervention through the proactive provision of care in the least intensive
setting possible
Considers and uses new ways
of working, efficiencies, evidence-based research and best practice at all
times to support change management
Recognises own limitations in
the provision of clinical care and urgency of patients needs, referring to
other health care professionals such as specialist nurses without direct
supervision
Maintains accurate clinical
records and activity data and uses information from a wide range of sources,
some of which may be conflicting, to inform clinical decision always making -
with due regard to confidentiality and data protection
Reports any identified risk
ensuring steps are taken to mitigate any identified risks in daily work and
making rapid autonomous decisions to provide appropriate management of the
service.
Reports clinical incidents
and near misses and sets action plans to ensure learning is shared and to
mitigate against repeat incidents / near misses
Maintains own personal
knowledge and skills through continuous professional development, clinical
supervision, peer review, educational updates, and own clinical practice in
line with current research and evidence-based practice
Assess and participates in
clinical supervision and peer review in line with revalidation regarding
professional organisations
Responsible for teaching and
supervising others including post registration students, new Hub Matrons and
non-registrants working within the integrated care team.
Job description
Job responsibilities
Duties to include:
Identifies patients at high
risk of unnecessary admission to hospital / decline in health and or wellbeing
and uses proactive management approach to promote wellness, early recognition
of disease exacerbation, and appropriate intervention to improve patient
outcomes and reduce the likelihood of unnecessary admissions to hospital
Documents holistic nursing
assessments, considering physical and psychological social needs and those of
their carers to inform and agree individualised care plans with the patient.
Interprets complex
information and formulates solutions to recommend on the best course of
action/treatment for the patients, e.g., medication reviews
Act as an independent
decision maker regarding referrals to other agencies and for the admission
/discharge from the Locality Hub caseload
At all times, ensures that
patients and their carers experience a high quality and patient centred
service, ensuring that care is accessible, effective, and delivered at a time
and place according to clinical need
Trained and competent 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
Interprets findings from
diagnostic tests/examination and uses this to make clinical decisions about
care and treatment
As a non-medical prescriber
(NMP), work within the scope of national and local protocols. This will include
attending regular updates in line with CPD and revalidation requirements, the
initiation of medication regimes, agreeing changes, monitoring the effects of
medications, advising patients on the safe storage and disposal of drugs.
Works in partnership with
hospital teams including specialists, Social Care, MDTs, and GPs in
facilitating safe discharge home from hospital or following an A&E
attendance
Responsible for preparing the
patient and their family for changes in condition and support choice about
end-of-life care, ensuring that patients needs, and those of their families
are met, this will include active management of complex pain and symptom
control.
Provides information about
the disease process to assist patients and their families in understanding and
self-managing their long-term condition.
Responsible for prescribing
the correct use of aids and equipment relevant to Hub Matron role and in line
with patient need
Responsible for ensuring
effective communication with all relevant personnel pertaining to patient care
and any change in treatment/management plans, part of this will include the
effective use of electronic notes system, including assessment tools
Responsible for establishing,
communicating and maintaining effective professional relationships with nursing
colleagues, Primary Health Care Team and health/social care/voluntary service
networks to provide a planned, co-ordinated, seamless service for patients
clients
Influences efforts across
health and social care to shape integrated working designed to support patient
choice, improve quality of life, promote self-management, and assure early
intervention through the proactive provision of care in the least intensive
setting possible
Considers and uses new ways
of working, efficiencies, evidence-based research and best practice at all
times to support change management
Recognises own limitations in
the provision of clinical care and urgency of patients needs, referring to
other health care professionals such as specialist nurses without direct
supervision
Maintains accurate clinical
records and activity data and uses information from a wide range of sources,
some of which may be conflicting, to inform clinical decision always making -
with due regard to confidentiality and data protection
Reports any identified risk
ensuring steps are taken to mitigate any identified risks in daily work and
making rapid autonomous decisions to provide appropriate management of the
service.
Reports clinical incidents
and near misses and sets action plans to ensure learning is shared and to
mitigate against repeat incidents / near misses
Maintains own personal
knowledge and skills through continuous professional development, clinical
supervision, peer review, educational updates, and own clinical practice in
line with current research and evidence-based practice
Assess and participates in
clinical supervision and peer review in line with revalidation regarding
professional organisations
Responsible for teaching and
supervising others including post registration students, new Hub Matrons and
non-registrants working within the integrated care team.
Person Specification
Qualifications
Essential
- 1st level registered nurse/ Masters degree
- Mentorship qualification
- Clinical Supervisor/Assessor
Desirable
- Management of long term conditions
- District Nursing qualification
- Knowledge and experience of working in the community
- Teaching qualification
Person Specification
Qualifications
Essential
- 1st level registered nurse/ Masters degree
- Mentorship qualification
- Clinical Supervisor/Assessor
Desirable
- Management of long term conditions
- District Nursing qualification
- Knowledge and experience of working in the community
- Teaching qualification
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).
