Community Matron

Your Healthcare CIC

The closing date is 02 February 2025

Job summary

22.5 hours per week

Do you want to be part of an innovative, dynamic Organisation that is committed to delivering the best care by the best people? We are looking to appoint a Community Matron to work 3 days per week, who is passionate about high quality patient centered care to join our highly regarded Community Matron Team.

Our Matron service was rated OUTSTANDING for CARE by the CQC at their inspection in June 2022. Our highly skilled team require like-minded staff to join the team. Your Healthcare Community Matrons work in partnership together across the Royal Borough of Kingston Upon Thames. You will work with patients who have complex long-term conditions, to proactively case manage individuals and prevent inappropriate hospital admissions.

Main duties of the job

The role will incorporate working within a community matron team in partnership with the primary health care and social care professionals. This will include providing expert case management, clinical assessment, diagnosis and individualized treatment plans, as well as promoting self-management, planning interventions in light of fluctuating disease process and reduce inconsistencies in the care patients receive. If any of the caseload are admitted to the acute provider then the post holder will actively work to facilitate a timely and safe discharge.

A full driving license and access to a vehicle are essential.

This is an excellent opportunity to further develop your clinical and prescribing skills and knowledge of long-term conditions.

About us

Welcome to Your Healthcare CIC, we are a not for profit social enterprise, proud of delivering patient-led, high quality health and social care community services for residents in the Borough of Kingston, as part of the NHS family.

Your Healthcare is located in the South West of London within the Royal Borough of Kingston. Working as a Community Interest Company (CIC), our status allows us to invest any surplus or profit back into front line services, where it is needed most by you, our community. Our organisation offers access to the NHS pension scheme, staff discounts, Agenda for Change terms and conditions.

Your Healthcare proactively supports personal and professional development through an annual appraisal process, in-house and external training, induction and mentorship support.

Date posted

16 January 2025

Pay scheme

Agenda for change

Band

Band 7

Salary

£49,178 to £55,492 a year inclusive of 15% HCAS pro rata per annum

Contract

Permanent

Working pattern

Part-time

Reference number

B9811-25-0003

Job locations

Hollyfield House, 22 Hollyfield Road

Surbiton

KT5 9AL

Job description

Job responsibilities

Clinical Practice/Leadership

To identify, assess and signpost patients with complex long term conditions and nursing needs within the allocated caseload in conjunction with General Practitioners, physicians within the acute sector, other lead clinicians and social care colleagues.
To develop personalised management plans including self-care strategies to meet patients complex health and nursing needs.
To lead the introduction and use of assisted technical nursing treatments utilising robust evidence base to meet effective long term conditions management, and avoidance of unnecessary hospital admission for patients on the allocated caseload.
To prescribe, administer, monitor and review medications using the locally agreed medicines management formulary where applicable for patients with long term conditions on the caseload in ensuring such approaches are consistent with Your Healthcare's policies, procedures and standards and ensure compliance with all appropriate legislation.
To support patients with complex disease management who have repeated active hospital admissions to develop their knowledge and understanding about their health and wellbeing to enable self-management within individual abilities and to recognise deterioration in a timely manner.
To provide clinical practice advice, training and professional support to the community nursing team.
To ensure that supplies and associated equipment are available to support the achievement of clinical management plans.
To make independent referrals for diagnostic tests and/or opinions and care which requires free, open and informed discussion at all levels from consultants to GPs and specialist services.
To contribute actively through data collection and analysis towards the effective management of service delivery and development within the organisation.
To ensure that the community matron service is integrated with the district nursing teams and to offer clinical advice on the care of patients with complex needs as appropriate.
To work autonomously and as a member of the multi-disciplinary team, developing and maintaining effective working relationships with other agencies including acute, primary and voluntary sectors.
To manage a caseload and the care of patients independently whilst simultaneously recognising the limits of your knowledge and experience and seeking support appropriately.
To work flexibly to meet service requirements which may include evening and weekend working.

Personal and People Development

To provide an effective learning environment and mentorship for staff, and for students in training ensuring their experience meets their learning needs.
To participate in multidisciplinary team meetings to facilitate case management reviews and ensure critical learning that informs current and future care pathway development.
To participate in appraisal and clinical supervision as part of the learning culture within Your Healthcare.
To ensure own personal development through clinical supervision, appraisal and personal development plan, taking responsibility for own training and learning, reflection and professional registration requirements.
Support the locality manager and community nursing team in the recruitment and retention of staff in the team.
To provide leadership and professional support for the community nursing teams involved in receiving referrals of long term condition patients.
As an independent prescriber participate in professional development that supports on-going personal development and ensures accountability and safety in prescribing decisions.

Service Development

To ensure that robust monitoring systems are in place to identify any required improvements to the quality of the patient experience and that clinical and care standards are maintained in line with organisational policies.
To contribute actively and have a comprehensive understanding of national and local policy for older people and for people with long term conditions.
To have a comprehensive understanding of safeguarding adults and specifically Protecting adults at risk: London multi-agency policy and procedures to safeguard vulnerable adults from abuse and the Kingston safeguarding adults local protocol.
To ensure that the Mental Capacity Act is implemented as part of the on-going assessment and treatment processes for people who are case managed. This will include supporting the assessment of capacity and best interest decision making as appropriate.
Participate in policy reviews and ensure dissemination to all team members.
Undertake significant event reviews and complaint investigations including the development of action plans and reflective practice.
To proactively contribute to the development of care pathways across acute/primary and community care that deliver continued improvement in community service provision.

Quality

To participate in the training and education of qualified and unqualified staff in gaining knowledge and experience and the maintenance of fundamental nursing skills.
To ensure that records are kept up to date and evaluated to safeguard patients confidentiality by being aware of legal and ethical responsibilities.
To ensure adherence to Your Healthcare Clinical Governance requirements, NICE guidelines and professional codes of conduct.
To ensure that the Care Quality Commissions Core Standards are maintained and appropriate evidence is provided to contribute to Your Healthcare's registration.
To identify and carry out appropriate audits as identified and agreed by the Adult Services Governance Sub-Group and included in the annual quality/audit calendar.

Communication and working relationships

To ensure accurate and contemporaneous records are kept and collect/collate data as required by the service and the YH policy/protocol in accordance with NMC guidelines.
To identify patient groups by the use of case management tools and collate evidence of admission avoidance and reduction of secondary care use.
To liaise with other disciplines and statutory and voluntary agencies to ensure that patient centred care is delivered in a manner acceptable to the patient, recognising individual cultures and beliefs.
To act as a representative of Your Healthcare, communicating policy, procedures and standards in relation to care delivery and case management.
To work collaboratively with internal teams and external agencies.

Job description

Job responsibilities

Clinical Practice/Leadership

To identify, assess and signpost patients with complex long term conditions and nursing needs within the allocated caseload in conjunction with General Practitioners, physicians within the acute sector, other lead clinicians and social care colleagues.
To develop personalised management plans including self-care strategies to meet patients complex health and nursing needs.
To lead the introduction and use of assisted technical nursing treatments utilising robust evidence base to meet effective long term conditions management, and avoidance of unnecessary hospital admission for patients on the allocated caseload.
To prescribe, administer, monitor and review medications using the locally agreed medicines management formulary where applicable for patients with long term conditions on the caseload in ensuring such approaches are consistent with Your Healthcare's policies, procedures and standards and ensure compliance with all appropriate legislation.
To support patients with complex disease management who have repeated active hospital admissions to develop their knowledge and understanding about their health and wellbeing to enable self-management within individual abilities and to recognise deterioration in a timely manner.
To provide clinical practice advice, training and professional support to the community nursing team.
To ensure that supplies and associated equipment are available to support the achievement of clinical management plans.
To make independent referrals for diagnostic tests and/or opinions and care which requires free, open and informed discussion at all levels from consultants to GPs and specialist services.
To contribute actively through data collection and analysis towards the effective management of service delivery and development within the organisation.
To ensure that the community matron service is integrated with the district nursing teams and to offer clinical advice on the care of patients with complex needs as appropriate.
To work autonomously and as a member of the multi-disciplinary team, developing and maintaining effective working relationships with other agencies including acute, primary and voluntary sectors.
To manage a caseload and the care of patients independently whilst simultaneously recognising the limits of your knowledge and experience and seeking support appropriately.
To work flexibly to meet service requirements which may include evening and weekend working.

Personal and People Development

To provide an effective learning environment and mentorship for staff, and for students in training ensuring their experience meets their learning needs.
To participate in multidisciplinary team meetings to facilitate case management reviews and ensure critical learning that informs current and future care pathway development.
To participate in appraisal and clinical supervision as part of the learning culture within Your Healthcare.
To ensure own personal development through clinical supervision, appraisal and personal development plan, taking responsibility for own training and learning, reflection and professional registration requirements.
Support the locality manager and community nursing team in the recruitment and retention of staff in the team.
To provide leadership and professional support for the community nursing teams involved in receiving referrals of long term condition patients.
As an independent prescriber participate in professional development that supports on-going personal development and ensures accountability and safety in prescribing decisions.

Service Development

To ensure that robust monitoring systems are in place to identify any required improvements to the quality of the patient experience and that clinical and care standards are maintained in line with organisational policies.
To contribute actively and have a comprehensive understanding of national and local policy for older people and for people with long term conditions.
To have a comprehensive understanding of safeguarding adults and specifically Protecting adults at risk: London multi-agency policy and procedures to safeguard vulnerable adults from abuse and the Kingston safeguarding adults local protocol.
To ensure that the Mental Capacity Act is implemented as part of the on-going assessment and treatment processes for people who are case managed. This will include supporting the assessment of capacity and best interest decision making as appropriate.
Participate in policy reviews and ensure dissemination to all team members.
Undertake significant event reviews and complaint investigations including the development of action plans and reflective practice.
To proactively contribute to the development of care pathways across acute/primary and community care that deliver continued improvement in community service provision.

Quality

To participate in the training and education of qualified and unqualified staff in gaining knowledge and experience and the maintenance of fundamental nursing skills.
To ensure that records are kept up to date and evaluated to safeguard patients confidentiality by being aware of legal and ethical responsibilities.
To ensure adherence to Your Healthcare Clinical Governance requirements, NICE guidelines and professional codes of conduct.
To ensure that the Care Quality Commissions Core Standards are maintained and appropriate evidence is provided to contribute to Your Healthcare's registration.
To identify and carry out appropriate audits as identified and agreed by the Adult Services Governance Sub-Group and included in the annual quality/audit calendar.

Communication and working relationships

To ensure accurate and contemporaneous records are kept and collect/collate data as required by the service and the YH policy/protocol in accordance with NMC guidelines.
To identify patient groups by the use of case management tools and collate evidence of admission avoidance and reduction of secondary care use.
To liaise with other disciplines and statutory and voluntary agencies to ensure that patient centred care is delivered in a manner acceptable to the patient, recognising individual cultures and beliefs.
To act as a representative of Your Healthcare, communicating policy, procedures and standards in relation to care delivery and case management.
To work collaboratively with internal teams and external agencies.

Person Specification

Skills & Abilities

Essential

Proven written and oral communication skills including ability to deal with challenging and sensitive situations.
Ability to identify best practice and develop action plans to resolve areas of weak practice.
Effective time management skills.
High standard of fundamental nursing care.
Supervision, teaching and training skills.
Trained Mentor - Able to plan proactively, manage and evaluate students' own learning, to negotiate learning opportunities, establish learning contracts.
Understanding the principles of governance, particularly in relation to their service area.
An understanding of systems in health and social care that is wider than their immediate role.
Knowledge of long term condition management and care of the elderly.
Understanding of the expectations of the community matron role, particularly in terms of patient/ service outcomes.
Ability to prioritise and organise workload effectively.
Problem solving skills.
Ability to safely manage risk.
Ability to demonstrate innovative practice.
Knowledge of equality & diversity
Understands confidentiality, information security & governance.
Able to negotiate and influence.
Intermediate IT skills.
Expanded clinical skills including but not limited to:- intravenous therapy (including management of IV long lines), cannulation, venepuncture, syringe drivers, male and female catheterisation, digital rectal examination, management of PEG and RIG tubes,
Audit skills
Counselling skills.
Able to manage and work effectively as part of a team
Able to build effective working relationships at all levels.

Personal qualities

Essential

Ability to work within deadlines
Ability to prioritise care and care delivery.
Ability to make decisions and deal with conflict.
Able to mediate and lead others.
Self-confidence to challenge established methods of practice in a constructive manner and have the persistence to address difficult enduring issues.
Constructive, enquiring, flexible approach to others and to their work
Change and demonstrate innovative practice.

Qualifications

Essential

Registered Nurse Level 1
Physical Assessment and clinical decision Making
V300 non-medical prescribing or willing to work towards.
Qualified mentor

Desirable

Working towards Masters
Specialist practice community nursing qualification
Qualification in long term condition management

Experience

Essential

Experience of both community and acute nursing.
Team management experience.
Previous relevant experience of working with patients with long-term conditions.
Knowledge and experience of managing patients with dementia and its impact on physical health
Negotiating and working across organisational boundaries.
Mentoring students and other health care professionals.
Experience of lone working and decision making.

Desirable

Experience of using research and other evidence to inform practice.

Person Specification

Skills & Abilities

Essential

Proven written and oral communication skills including ability to deal with challenging and sensitive situations.
Ability to identify best practice and develop action plans to resolve areas of weak practice.
Effective time management skills.
High standard of fundamental nursing care.
Supervision, teaching and training skills.
Trained Mentor - Able to plan proactively, manage and evaluate students' own learning, to negotiate learning opportunities, establish learning contracts.
Understanding the principles of governance, particularly in relation to their service area.
An understanding of systems in health and social care that is wider than their immediate role.
Knowledge of long term condition management and care of the elderly.
Understanding of the expectations of the community matron role, particularly in terms of patient/ service outcomes.
Ability to prioritise and organise workload effectively.
Problem solving skills.
Ability to safely manage risk.
Ability to demonstrate innovative practice.
Knowledge of equality & diversity
Understands confidentiality, information security & governance.
Able to negotiate and influence.
Intermediate IT skills.
Expanded clinical skills including but not limited to:- intravenous therapy (including management of IV long lines), cannulation, venepuncture, syringe drivers, male and female catheterisation, digital rectal examination, management of PEG and RIG tubes,
Audit skills
Counselling skills.
Able to manage and work effectively as part of a team
Able to build effective working relationships at all levels.

Personal qualities

Essential

Ability to work within deadlines
Ability to prioritise care and care delivery.
Ability to make decisions and deal with conflict.
Able to mediate and lead others.
Self-confidence to challenge established methods of practice in a constructive manner and have the persistence to address difficult enduring issues.
Constructive, enquiring, flexible approach to others and to their work
Change and demonstrate innovative practice.

Qualifications

Essential

Registered Nurse Level 1
Physical Assessment and clinical decision Making
V300 non-medical prescribing or willing to work towards.
Qualified mentor

Desirable

Working towards Masters
Specialist practice community nursing qualification
Qualification in long term condition management

Experience

Essential

Experience of both community and acute nursing.
Team management experience.
Previous relevant experience of working with patients with long-term conditions.
Knowledge and experience of managing patients with dementia and its impact on physical health
Negotiating and working across organisational boundaries.
Mentoring students and other health care professionals.
Experience of lone working and decision making.

Desirable

Experience of using research and other evidence to inform practice.

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.