Bank Community Matron INW Job Purpose

Please not this role is 3 days a week for a minimum of 3 months
+ To co-ordinate care provision through a case management approach with the aim to prevent unnecessary hospital admission and facilitate timely discharge. The caseload supports patients with multiple co-morbidities including frailty, COPD, Parkinson's, diabetes, dementia, and CHD.
+ To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice.
+ To participate in the delivery of educational programmes to patients, carers and health and social care workers that promotes self-care principles.
+ To develop and promote robust multidisciplinary team (MDT) working across the wider Health and Social care sectors, including care homes, to ensure integrated service and support networks for patients.
+ To monitor the quality-of-care provision and to identify and promote areas for service development. To be the named Community Matron for a Primary Care Network (PCN), providing support and care coordination for the wider health team within the network.
+ To provide clinical leadership and support to end of life pathways, including the Universal Care Planning (UCP) framework., + To work in partnership with community health, social care and third sector organisations including care homes. Proactively case finding with GPs, district nursing colleagues and providing links across community nursing.
+ Working closely with care home aligned GPs and care home staff to support and offer your expert advice.
+ To work in partnership with acute Trusts through attending at high intensity user forums, linking with frailty and discharge teams and London Ambulance Service.
+ To support and coordinate the Westminster Integrated Domiciliary Service.
+ To work as a member of a PCN in line with the Westminster Integrated Care Partnership and the NWL Integrated Care Systems.
+ Liaise closely with NWL Leads and CLCH Academy on any new initiatives and training to support the service., + To use advanced skills and expert knowledge to carry out a thorough assessment and history taking, including a systematic physical examination, in order to develop a comprehensive care plan.
+ To initiate, and provide, advanced clinical / therapeutic care treatments, in partnership with other providers, based on best possible evidence that will improve health outcomes.
+ To use advanced clinical skills and expert knowledge to proactively identify subtle changes in a patient's condition as early as possible and to manage these in a manner that optimises well-being.
+ To take overall responsibility for coordinating the care, treatment, and complex health funded packages of care for case managed patients in a variety of settings. This includes planning, developing, implementing, monitoring, and reviewing specialised programmes of health interventions for case managed patients.
+ To review and complete UCPs for patients.
+ To work within the principles of the Single Assessment Process.
+ To maintain responsibility if a patient is admitted to an in-patient facility. This includes actively accessing the acute sector to provide base line health data to appropriately the receiving team and initiating early discharge for case managed patients.
+ To appropriately refer patients for a range of physical and functional tests and assessments, in order to inform decision making and care pathway development.
Due to the high number of applications that are received for some posts we may close this vacancy before the advertised closing date. Therefore please apply for this post as soon as you can, if you are interested and you meet the requirements of the Person Specification
Only those candidates who clearly demonstrate how they meet the person specification will be shortlisted for this job.
Interview arrangements will be communicated via email so please check your email regularly following the closing date.
At CLCH we appreciate and are proud of the diversity in the communities we serve and the workforce we employ. Applications are open and welcome to anyone, regardless of your age, sexual orientation, gender identity and expression, ethnicity, religion, and disability.
We are proud to say that we follow the workforce race equality standard and 28% of our senior staff (8A and above) are from a BAME background. CLCH also has active BAME and LGBTQI networks:
Disability and Wellbeing Network (DAWN)
Race Equality Network
Rainbow Network which supports LGBTQI staff.
Each network has a champion who is an executive director at the Trust and they hold regular meetings to discuss issues and make plans to improve CLCH.
The CLCH Equal opportunities statement is on our Website Equal opportunities :: Central London Community Healthcare NHS Trust (clch.nhs.uk)

We provide community health services to more than two million people across eleven London boroughs and Hertfordshire.
Every day, our professionals provide high-quality healthcare in people's homes and local clinics, helping them to:
+ stay well
+ manage their own health with the right support
+ avoid unnecessary trips to, or long stays in, hospital.
We support our patients at every stage of their lives, providing health visiting for new-born babies through to community nursing, stroke rehabilitation and palliative care for people towards the end of their lives.
Our vision: deliver great care closer to home.
Our mission: working together to give children a better start and adults greater independence

NHS AfC: Band 7
Central London Community Healthcare (CLCH) is one of the largest community healthcare organisations in London and Hertfordshire, providing our services to diverse communities/boroughs in 11 London Boroughs - Barnet, Brent, Ealing, Hammersmith & Fulham, Harrow, Hounslow, Kensington and Chelsea, Merton, Richmond, Wandsworth, Westminster - and Hertfordshire.
We are rated Good by the Care Quality Commission and are ranked among top NHS employers. Community healthcare is our focus and our passion. We champion the role of community health professionals to make sure our patients get great care closer to home.