Job Description
Job Title Community Matron
Salary Band Band 7
Division/Service Line Adult Community Services
Department Integrated Care
Job Overview The purpose of the post is: • To take a lead role in the development of primary care for older people with multiple chronic diseases who are at high risk of hospital admission, through proactive management of a high- risk caseload and focussing on ways to demonstrate overall improvements in health care. To work collaboratively with the multidisciplinary team to establish a whole systems approach to managing health care for these individuals. Key Dimensions of the post are: • The nurse is based in General Practice and has overall responsibility for a caseload of 50-60 patients who require intensive support and management and who meet the following criteria: Has two or more emergency admissions to hospital in the past year Suffer from chronic disease Take 4 or more medications The nurse works within the community nursing service and is responsible for provision of evaluation data & promotion of the service within her area of expertise. The nurse is responsible for management of resources within her caseload & area of practice. Main tasks are to: • Act as “case finder” identifying patients with multiple chronic diseases within a practice population who are at high risk to numerous admissions to hospital and admitting them to the Community Matron’s caseload. • Managing patients with chronic disease through advanced level autonomous practice including taking managed risks. For example where the patient is kept at home, rather than hospital admittance as would previously been the practice. • Take clinical responsibility for the patient and work collaboratively with all professionals, carers and relatives to gain a deep understanding of all aspects of the patient’s physical, emotional and social situation. This includes physical examination and detailed history taking, diagnosis and treatment planning.
JD No: 201-19-314 • Act as commissioner of care and services to meet patient’s needs including advising expenditure of devolved intermediate care budgets. • Develop a personalised care plan for the patient based on the full assessment of medical, nursing and care needs. This includes preventative measures and anticipation of future needs. • Ensure regular personal contact with the patient, monitoring their condition regularly and diagnosing deterioration in condition that may lead to hospital admission without intervention by the Community Matron. • Order investigations and tests and interpret and act on results, using clinical guidelines and policies to support clinical decision-making. • Maintain competence in prescribing according to level of prescribing qualification i.e. Nurse Prescriber or Independent Prescriber and participate in regular continuing professional development in relation to the role. • Prescribe medication within nurse prescribing formulary if appropriate. If qualified as an Independent Prescriber, prescribe in accordance with the local Non-medical Prescribing Policy, Cornwall and Isles of Scilly Formulary and local and national prescribing guidance. It is expected that all prescribers will prescribe within the limits of their individual competence. • Update the patient’s medical records using Community Matron patient record and on GP’s computerised systems. • Liaise with other local agencies to mobilise resources to meet patient needs and to support them at home securing additional support as required in acute episodes. • Teach patients and carers to recognise subtle, often hidden, changes in condition that could lead to deterioration in their health and when to call for help, acting as first point of contact for the patient when deterioration occurs. • Maintain contact with the patient if he/she is admitted to hospital, providing information about home circumstances to the hospital staff and ensuring that discharge of the patient is rapid, planned and safe. • Act as a resource for other community team members, providing teaching and education to them as required. • The Community Matron has a responsibility to participate in the evaluation of the service and service development, plus research and development relating to the evolving Community Matron role nationally. Organisational Chart
Locality Director
Integrated Care Manager
CMs throughout Cornwall Community Matron
(this post)
JD No: 201-19-314 Duties and Responsibilities Knowledge, Skills, Training and Experience: The post holder is required to be a Registered Nurse with substantial experience in the management of long term conditions, managing complex needs and holding advanced clinical assessment skills. The post requires the completion of the HEAB 358 Advancing Practice in Long Term Conditions Management module or the equivalent. The post holder should be an independent prescriber or working towards this qualification
Autonomous Clinical Practice: To take a comprehensive history, perform a systematic physical examination and establish baseline data to inform the development of a comprehensive care plan. Analyse signs and symptoms, laboratory tests, investigations and other measures of function in formulating a diagnosis. Provide evidence-based treatment plans based on sound clinical decision making, including the unique presentation of illness and response to treatment of elderly people and those with chronic disease. Collaborate with GP/Hospital Consultant to plan and implement treatment for acute illness/injury/chronic illness as required, using skills in nurse prescribing and medicines management. Monitor indicators of chronic disease, anticipating possible decline and proactively managing this to enhance well-being and promote independence. Plan interventions in light of patients’ express wishes and goals of care, facilitating discussion with the family and significant others. Ensure a robust process is in place to review care and treatment plans Take an active role in auditing and monitoring all components of care delivery. Review and develop clinical competency as required to support clinical practice, participating in ongoing personal development. Ensure all clinical records are kept in line with NMC guidelines.
Care Co-Ordination: Integrate care across all care settings; preventing duplication, fragmentation and delay occurring as patients move between care settings. Build relationships across professional and organisational boundaries, breaking down barriers and smoothing the patient’s journey. Negotiate with other professionals in all settings to provide care in the most appropriate and least invasive manner possible. Participate as a key member of the multidisciplinary team through development of collaborative and innovative practice.
Communication: Establish the dynamic process of understanding, reflecting, active listening and checking understanding, thus developing a therapeutic relationship with patients and their carers. Enable and support patients as active partners in the care planning process for present and future needs. Dissemination of information throughout the multidisciplinary team, taking into account the patient’s right of confidentiality.
Education: Utilise communication skills and knowledge to promote patients and families abilities to make
JD No: 201-19-314 informed decisions and participate in care planning. Empower patients and carers to evaluate possible treatment options as disease progresses and evaluate the relative benefits and burdens of these treatment options. Participate in the development of the teams’ knowledge about disease, disease processes and treatments. Play an active role in disseminating knowledge about chronic disease and its management within primary care, mentoring students as required and developing education for other primary care colleagues. Provide and create learning opportunities in the clinical setting that support the wider primary care team. Continue to develop own expert practice. Critically evaluate research and integrate theory into practice.
Leadership/Management: Contribute to the development of policies, procedures and guidelines ensuring they are implemented and monitored. Participate in the appraisal process, providing feedback on performance. Contribute to the recruitment and selection process. Act with colleagues to identify clinical development needs within the service. Act as an advocate at all times for both patients and the service. Play an active role in raising public awareness of the needs of people with chronic disease, in particular, older people.
Professional: Work within the NMC Code of Conduct. Remain updated and ensure that clinical practice is evidence based. Have a personal development plan and professional portfolio.
Freedom to Act: The post is a clinically autonomous one and the post holder is expected to manage their caseload and the care of their patients independently recognising the limits of their knowledge and experience and seeking help and support appropriately
Working Conditions • Based within the DN Team, but working mainly in patient’s homes. • Carrying light cases and other equipment. • Some computer based work and data inputting. • Car driving. • Not required to wear uniform. • Expected to deal with difficult situations on a regular basis. • Working in patients own homes
JD No: 201-19-314 Additional Information Code of Conduct The post holder is required to comply with all relevant Code of Conducts for the role, including the Trusts Code of Conduct. All staff are required to support the Trust’s commitment to developing and delivering excellent customer service by treating patients their carers, families, friends, visitors and staff with professionalism, dignity and respect. All staff are expected to behave in a professional manner and not to bring the Trust into disrepute.
Confidentiality and Data Protection Act All NHS employees have a duty to maintain confidentiality under both common law and the Data Protection Act 1998. Service users and staff have a right to expect that any information, whether personal or commercial, held by the Trust will be treated in a confidential manner. All employees of Cornwall Partnership NHS Foundation Trust must not, without prior permission, disclose any information regarding patients or staff.
Safeguarding Children and Vulnerable Adults All employees of Cornwall Partnership NHS Foundation Trust must be familiar with and adhere to the Trust’s safeguarding policies and procedures.
Personal Development All employees are required to undertake statutory and essential training as directed by the Trust. This will be monitored through the supervision and appraisal process which is in place for all staff to participate in.
Risk Management and Health and Safety All employees of Cornwall Partnership NHS Foundation Trust are required to make positive efforts to maintain their own personal safety and that of others. You are reminded of your responsibilities for health and safety at work under the Health and Safety At Work Act 1974 as amended and associated legislation. These include the duty to take reasonable care for the health and safety of yourself and of others in your work activities or omissions, and to co-operate with your employer in the discharge of its statutory duties. It is also essential that precautions advised by Management, Occupational Health, Risk & Safety Services, etc. are adhered to for your own protection.
Infection Prevention and Control All staff, collectively and individually, has a duty of care in following best practice in adherence to guidelines which is a fundamental requirement in underpinning the management of infection control.
Location/Mobility In accordance with the Trust’s requirements, all staff are required to undertake work and alternative duties as reasonably directed at variable locations in the event of, and for the duration of a significant internal incident, major incident or pandemic. You may be required to work at or from any additional location as determined by the Trust. You may also be required to travel between Trust premises for the performance of your duties.
Equal Opportunities The aim of the Trust’s policy is to ensure that no job applicant or employee is discriminated against either directly or indirectly on the grounds of race, creed, sex, marital status, disability, age, nationality, ethnic or national origins. The Trust commits itself to promote equal opportunities and will keep under review its policies, procedures and practices, to ensure that all users and providers of its services are treated according to their needs.
JD No: 201-19-314 Review of the Job Description This is a generic job description and is intended as an outline of the general area of activities. It may be amended in light of the changing needs of the organisation, in which case it will be reviewed.
Rehabilitation of Offenders Act The Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 is applicable to this post. Therefore should you be offered the post it will be subject to a Disclosure & Barring Service check satisfactory to the Trust. You will therefore be required to declare all criminal convictions, cautions, reprimands and warnings that would not be filtered in line with current guidance
The Trust operates a no smoking policy. Employees are not permitted to smoke anywhere in the premises of the Trust or when outside on official business. Staff must be mindful of public perception and therefore must not smoke whilst travelling in Trust identified vehicles or when can be identified as a member of CFT staff.
JD No: 201-19-314 Person Specification
Job Title Community Matron
Salary Band Band 7
Division/Service Line Adult Community Services
Department Integrated Care
Role Requirement Essential Desirable Education and Qualifications Registered Nurse Relevant post registration qualification e.g. specialist practitioner qualification (District Nursing) or specialist gerontology/care of long term conditions. MSc Nurse Practitioner qualification or equivalent
Extended and Supplementary Prescribing Qualification or equivalent Experience Previous relevant experience of working with patients with long- term chronic conditions Skills and Aptitude Caseload management ability Relevant developed clinical expertise and knowledge in caring for patients with chronic long term conditions Basic keyboard skills
Training Willingness and ability to undertake required specialist clinical training Personal Qualities/Disposition Proven written and oral communication skills including ability to deal with challenging and sensitive situations Proven ability to work on own and in partnership with other care providers. Self-motivated and self-disciplined.
JD No: 201-19-314 Ability to deal with emotionally challenging clinical situations Commitment to client centred, non-discriminatory practice. Proven sensitivity to the needs of patients, relatives carers and other care providers Awareness of the impact of the role of the Community Matron on the wider care agenda Other Demonstrates evidence of Trust “CARE” values Disclosure and Barring Service check satisfactory to the Trust Occupational health clearance satisfactory to the Trust
Holds full valid UK driving licence.
Community - Will need to use own car for work. (business use insurance is essential if claiming travel expenses for use of car) Ability to undertake Moving & Handling Procedures. Knowledge of Primary Care responsibilities.
JD No: 201-19-314