Surrey Downs Health & Care

This is an exciting and innovative role which will involve working alongside community GPs, paramedics, pharmacists, district nurses, adult social care, voluntary organisations and community matrons to support the delivery of proactive healthcare and support to people living with frailty, multiple long-term conditions and/or complex needs to help them stay independent and healthy for as long as possible at home.

We are committed to your ongoing professional development and offer a structured training programme to support the requirements set out within the national Care Co-ordinator job profile.

If you're looking for an employer that is working to push beyond and remove traditional boundaries and barriers, bringing care to patients when and where they need it, and you want to work alongside motivated, passionate, and visionary colleagues, come and work for Surrey Downs Health and Care!

Main duties of the job

The Community Matron - Proactive Care 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 - Proactive Care 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 Proactive Care Matron will use a case management approach to ensure the individual's condition remains as stable as possible and wellbeing is increased.

• Obtain information to inform the assessment of an individual
• Establish the individual's functional capabilities in the context of long term conditions clinical management
• Investigate and diagnose an unwell individual as part of the long term conditions clinical management
• Plan, implement, monitor and review therapeutic interventions with individuals who have long term condition and their carers
• Assess individual's needs and preferences
• Enable individuals with long term conditions to manage their medicines
• Plan, implement, monitor and review individualised care plans with individuals who have long term care conditions and their carers
• Co-ordinate and review the delivery of care plans to meet the needs of individuals with long term conditions

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

• Provide a clinical triage/assessment with inbound referrals and assign the appropriate urgency (i.e. 2 hr Rapid Response) and determine the best clinician to undertake the visit from their multi-disciplinary team.
• Support annual Learning Disability or Serious Mental Illness Health checks.
• Care coordination both clinical and administrative, managing patient caseloads and offering proactive support (i.e. frequent attenders support for cancer patients CVD remote monitoring and support blood pressure monitoring etc). i.e. Accept referrals from practices to proactively manage and support patients diagnosed with cancer, patients at risk of CVD and will act as a step down from the Social prescriber/mental health team as appropriate to manage frequent attenders who have been discharged from their care with management plans in place.
• Anticipatory care liaising with both primary, secondary and community teams to support the reduction of admission for patients with ambulatory care sensitive conditions and closing the hypertension diagnosis gap
• Enhanced Health in Care Homes proactive and targeted visits for specific cohorts of patients
• To support the co-ordination with the delivery of all housebound annual vaccinations.
• Support and manage a small team of non-clinical care co-ordinators to support delivery of duties.
• Demonstrate clinical expertise and act as a professional role model to all co owners, both internal and external on behalf of SDHC, working as part of an integrated team taking the lead and developing services in line with the needs of the patient
• Treat all patients as individuals, respecting their privacy and dignity at all times
• Investigate and diagnose an unwell individual as part of the long term conditions clinical management
• Involving, supporting, informing and educating family/carers
• Promote the health of patients and the provision of support and advice
• Be responsible for planning cover, appropriate staffing and skill mix ensuring adequate cover when supporting community nursing teams or community matrons
• Provide specialist knowledge and advice to influence the SDHC strategic agenda
• Maintain clear and comprehensive, signed and contemporaneous records according to procedures
• Identify workforce planning issues and actively participate in the recruitment, selection and retention of clinical staff
• Provide support and an appropriate learning environment for both pre and post registration students as required
• Be responsible for ensuring that policies and procedures and standards of care, are adhered to at all times
• To work with other community matrons to ensure consistency of approach and share practice development
• Participate in research and development opportunities as appropriate
• Provide assistance with the resolution of complaints within the clinical specialty, or sphere of responsibility
• Have the ability to negotiate and work effectively across all agencies for the maximum effectiveness of care
• Undertake physical and social assessments and examinations and initiate appropriate diagnostics
• To work autonomously
• Help individuals with LTC to change their behaviour to reduce the risk of complications and improve their quality of life
• To work collaboratively with other specialist nurses and multidisciplinary teams such as GPs, Community Nurses, Social Care and Voluntary Services
• Contribute to the development of Integrated care in the community
• Be aware of and act upon when necessary, procedures that are in place to protect vulnerable individuals
• Lead and implement the SDHC Clinical Governance Strategy within your practice area, facilitating and instigating clinical audit and monitoring of care
• Lead and implement the SDHC Risk Management Strategy within your practice area, ensuring that all processes are adhered to
• Maintain own professional and clinical integrity in line with NMC guidelines
• Undertake any other such duties as may be required from time to time as are consistent with the responsibilities of the post
• Be responsible for individual timely data entry and responsible for the corporate teams data entry
• Co-owners are employed to work within SDHC localities and may be reasonably requested to move base temporarily or on a more permanent basis, as requested by service needs
• To undertake clinical supervision and appropriate training for the role.

Person Specification

Essential

Essential

• Professional Registration
• Previous experience in community setting

Desirable

• Understanding of Proactive Care Process
• Ability to work in MDT environment

Desirable

Essential

• Previous experience in community role

Desirable

• Able to work in MDT environment

Employer details

Employer name

Epsom and St Helier University Hospitals NHS Trust

Address

Molesey Community Hospital

High Street

Molesey

KT8 2LU

Any attachments will be accessible after you click to apply.

343-SDH&C-6417522-B