Community Matron

NCH&C is proud to be the first standalone NHS community trust in the UK to achieve an 'Outstanding' rating from the Care Quality Commission (CQC). Our focus is on continually improving the quality of care we offer to local people and on improving access to that care, helping people to move seamlessly from one service to another. Praising NCH&C's "compassionate, inclusive and effective leadership at all levels", the CQC observed that our staff are well supported to make positive changes and innovations.
Norfolk Community Health & Care NHS Trust is committed to continuing to create a modern and inclusive work environment. As part of this commitment we actively promote flexible working opportunities where possible, to meet the needs and wishes of our workforce to maintain and improve their wellbeing. The trust offers a range of flexibility, including flexible working patterns, and we would encourage you to discuss this with the recruiting manager before or during the application process if this would interest you.
We welcome applications from people who share our values and can help us deliver outstanding care in our local community., Community Matron - North Place-predominately the NN4 area covering Brundall, Blofield, Wroxham and Hoveton surgeries.
We have an exciting opportunity for experienced and enthusiastic nurse to join North Place as a Community Matron at 22.5 hours on a substantive post.
The Community Matron role is integrated within the Community Nursing and Therapy Service, as well as linking with the other Community Matrons across the Place. Cover for those services is also a requirement of this role giving fantastic opportunities for demonstration of a broad scope of skills and abilities.
North Place is working alongside its commissioners and local service providers as part of the Primary Care Network to develop community based services that support patients to remain at home and receive the services they require in an effective and co-ordinated way. The Community Matron is essential part of this initiative., Community Matron role provides advanced, intensive case management and clinical nursing care to patients predominantly in their home settings, including residential homes and supported living complexes.
The workload requires a good range of clinical skills to be applied in managing our patients with chronic unstable conditions. Including assessment and provision of advanced level interventions for patients with long term conditions to achieve quality of life and independence where possible.
As Community Matron you will be supporting and advising a Community Assistant Practitioner (band 4) to ensure high quality assessment and management of patients within the caseload, as well as ensuring the optimal allocation of skill to patient need is achieved.
The Community Matrons support Community Nurses in the teams, as well as students and apprentices in the role of an assessor, and liaises with the Community Therapists in the teams for seamless handover of care.
Norfolk Community Health and Care is keen to deliver mobile working and any applicant must we able to engage with current and future transformation projects., + To assess and provide advanced level interventions for patients with long term
conditions to achieve quality of life and independence where possible.
+ To work within the integrated team to facilitate early discharge from hospital.
+ To work within the integrated team to prevent unnecessary admission to hospital.
+ To work with all health care professionals, and statutory/non-statutory agencies to
provide a seamless, integrated service to our service users.
+ To support patients in coordinating their personal health plans.
+ To assess patients for assistive technology where appropriate.
+ To refer on to social care support where appropriate.
+ To support and manage band 6 Case Managers and band 4 Assistant Practitioners
As part of transformation you will be required to
+ Work when needed in the hub
+ Engage with mobile working
+ Engage with referral to discharge standard processes
+ To be aware of the demand and capacity model which will reflect workload needs at any
given time.
Main Responsibilities
+ Facilitate and develop a service providing complex case management.
+ Track patients entering hospital or nursing home step-up beds and ensure that they are
discharged appropriately into the care of nurses and therapists of the integrated team.
+ Working closely with GPs and the acute hospital and support service issues that may
need resolving to ensure timely discharge.
+ Proactively find patients who are very high intensity users of primary and secondary
healthcare and/or are at high risk of unplanned admission to hospital.
+ Educate and support the members of the multi-disciplinary teams to intensively case
manage these patients.
+ Intensively manage their own caseload of patients with highly complex and unstable
health needs.
+ Independently manage the caseload by maintaining a consistent through put of patients. This should be achieved by - ensuring patients are discharged in a timely manner;
promoting patient independence in managing their own health conditions; encouraging
self-care and condition self-management; sign posting to other appropriate services; and
by utilising strategies of health promotion and health coaching.
+ Develop systems and processes to support intensive case management within the multidisciplinary team and with partners across the health system.
+ Work with and refer appropriately to other agencies to enable identified patients to be
intensively managed in a pro-active way with the aim of preventing hospital admission,
supporting early discharge and reduce GP contact.
+ Accountable for the intensive case management and where appropriate intervention of a
defined patient caseload.
+ Actively work with GPs and other agencies, and with appropriate information
technology, such as PARR ++, to 'case find' patients.
+ Be a champion for people with long term conditions.
+ To provide clinical supervision for other staff.
+ To clinically support the Norwich locality community teams at times of high/increased
demand.
Clinical Practice
+ Using expert knowledge, advanced clinical and autonomous decision making skills,
intensively case manage patients with highly complex and unstable health needs.
+ Comprehensively assess, review and evaluate the needs of both patients and their
carers to improve their physical and psychological well being whilst reducing acute
exacerbation of underlying conditions and need for hospitalisation.
+ Work in partnership with patients, carers, GPs, consultants, other health professionals
and social care as appropriate, to instigate diagnostic testing and therapeutic treatments
to ascertain diagnosis, and implement proactive treatment and care plans.
+ Use prescribing skills and knowledge of medicines to minimise the risk and
complications associated with medication and polypharmacy.
+ Maintain contact with patients who are admitted to hospital, ensuring the team providing
inpatient care have the most up-to-date and relevant information and help facilitate
discharge as soon as the acute treatment phase is complete.
+ Work with the multidisciplinary team in the development, implementation and evaluation
of policies, protocols and guidelines.
+ Provide clinical nurse leadership and support to other staff, enabling their own ongoing
professional development and understanding of service provided.
+ Develop care plans with patients involving others e.g. carers, advocates etc., to ensure
best outcomes for patients, focusing on their ability to function and their quality of life.
+ Communicate complex patient information effectively to ensure collaborative working.
+ Promote people equality, diversity and rights.
+ Challenge professional and organisational boundaries, identifying areas of skill/
knowledge development and applies these to practices to provide continuity and high
quality patient centered health care.
+ Actively assess patient for the use of assistive technology as a means to empower
patients to take more control over their long term conditions, and implement where
appropriate.
Leadership
+ Establish clinical credibility within the multi-disciplinary team and act as a role model for clinical excellence.
+ Work collaboratively with other case managers and other members of the multidisciplinary team to lead developments in professional practice and to support multidisciplinary working around the needs of very high intensity users and those at high risk
of hospital admission.
+ Use effective communication, negotiating and influencing skills to introduce new
systems of working to improve the pathway of patients who are very high intensity users
of health care and/or at high risk of hospital admission.
+ Provide high quality reports and data on clinical activity.
+ Encourage and support innovation, sharing of expertise and new ways of working within
the multi-disciplinary team to meet the needs of patients.
Education.
+ Champion the role and value of case finding an intensive case management at all level of the organisation and across all professional groups
+ Continually audit and evaluate the quality and effectiveness of clinical practice within
intensive case management, selecting and applying a wide range of valid and reliable
approaches and methods that are appropriate to the need and context.
+ Contribute to the wider development of practice by participating in research, audit, local
and national presentations, networks and publication as appropriate.
+ Develop, implement and evaluate educational programmes for workers in primary and
community services to provide the necessary knowledge and skills for effective case
management of patients with long term conditions and at high risk of hospital admission.
+ Educate and empower patients and carers to identify early signs of change in condition
and provide them with the necessary knowledge and skills to gain independence and
make informed choices to safely manage their condition.
Equal Opportunities - We are an equal opportunities employer and welcome all applications irrespective of age, disability, gender, sexual orientation, race or religion. Additionally, people with disabilities that fall under the Disability Confident Scheme will be offered an interview providing they meet the minimum criteria for the post (outlined in the Person Specification). All sites are Smoke Free.
Immigration Status - Norfolk Community Health & Care NHS Trust is a diverse employer and welcomes all job applications. However, potential applicants should note that although the Trust is registered with the Home Office as a sponsor organisation for migrant workers, sponsorship can only be offered against Skilled Worker visas. If you are an applicant from outside the UK and do not already hold a self-gained right to work, we recommend you check the Home Office eligibility requirements before making an application.
Please note: Although we are a registered sponsor organisation, we are unable to offer sponsorship for some job roles, and this will be identified through filtering questions at the start of any job application on the Trac recruitment system.
Redeployment - Please note that in the first instance priority for this vacancy will be given to NCH&C staff who are on the Trusts Redeployment Register.
DBS - If this post is subject to a Disclosure and Barring Service (DBS) check and you are not a current employee of Norfolk Community Health and Care NHS Trust or being recruited as an Apprentice then the cost of the DBS check will be automatically removed from your first month's salary. However if you are registered with the update service this may not be required.