Surrey Downs Health & Care

We are looking for an experienced nurse to join East Elmbridge Primary Care Network (PCN). You will work with the Clinical lead, GP lead and an Operational Manager and will provide clinical advice and support to the patients and community nurses in East Elmbridge PCN. You will carry your own caseload of complex patients as well as providing clinical support to the PCN team. You must enjoy working in the community and leading change.

Main duties of the job

The Community Matron will take a lead role to proactively identify vulnerable adults who have multiple and complex long-term conditions and who may be high intensity users of primary and secondary care services. The community matron will work across traditional organisational boundaries challenging inequities to co-ordinate and ensure health and social care needs of the individuals are met. As an autonomous practitioner the community matron will use a case management approach to ensure the individual's condition remains as stable as possible and wellbeing is increased.

About us

Surrey Downs Health and Care deliver care closer to people's own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.

Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes:

• The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
• CSH Surrey
• Epsom and St Helier's University Hospitals NHS Trust
• Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.

It's on those grounds that the Surrey Downs Health and Care was formed - we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.

In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.

Job description

Job responsibilities

Principal duties to include:

• Obtain information to inform the assessment of an individual
• Plan, implement, monitor and review individualised care plans with individuals who have long term care conditions and their carers
• Develop risk management plans to support individuals independence and daily living within their home
• Manage the use of physical resources
• The line management of the Community Matron team
• Build a partnership between the team, patient and carers
• Promote, monitor and maintain health, safety and security in the working environment (Including use of risk assessments)
• Provide clinical leadership and take responsibility for the continuing professional development of self and others (including a mentorship role)
• Promote the values and principles underpinning best practice
• Develop, sustain and evaluate collaborative work with others
• To manage a caseload of patients with complex long term conditions and co-morbidities
• To undertake physical and social assessments and examinations, and initiate appropriate diagnostics
• To work with other community matrons to ensure consistency of approach and share practice development
• To work collaboratively with other specialist and multidisciplinary teams, such as GPs, District Nurses, Intermediate Rehabilitation Service
• To participate in audit around the management of people with LTCs
• To act in accordance with the clinical governance framework
• To develop as a non-medical prescriber and be able to draw up and manage clinical management plans
• To interface with primary and secondary care teams to enable the implementation of managed care pathways in line with local and national guidance
• To be involved in the development of guidelines, policies and protocols
• To understand the concept of change and be able to influence the change process
• To act as a mentor/ preceptor to other staff

Training & Education

• To develop practice at an advanced level portraying an in-depth knowledge of all aspects of the management of LTCs that is based on evidence and research to provide effectively managed care
• Provide and create learning opportunities in the clinical setting that support the wider primary care team and contribute to the improvement of patient care delivery
• To share knowledge and skills with patients and families as a key therapeutic intervention and to enable self-care and autonomy
• Educate and empower patients and carers to identify subtle changes in their conditions that may precipitate an acute exacerbation of their underlying condition or illness to enable them to contribute to and follow an evidenced based action plan
• Deliver training for healthcare professionals in the area of Long-Term Conditions and Managed Care

Person Specification

Essential

Essential

• Registered General Nurse
• Mentor course or recognized alternative
• Minimum of 4 years post registration experience
• Knowledge of present NHS polices and direction
• Flexible
• Valid license to drive in UK and access to a car for business use

Desirable

• Educated to level 3
• Community Nursing Experience, e.g. District Nursing/Practice Nursing

Desirable

Desirable

• Educated to level 3
• Community Nursing Experience, e.g. District Nursing/Practice Nursing

Employer details

Employer name

Epsom and St Helier University Hospitals NHS Trust

Address

Molesey Hospital

Molesey - East Elmbridge

KT8 2LU

Any attachments will be accessible after you click to apply.

343-SDH&C-5799594