About this role
Job summary
Are you caring, compassionate and committed to delivering patient-centred care? An exciting opportunity has arisen for a nurse working as a band 6 or 7, who are looking for a new challenge or to progress to a Guided Care Matron. In Hillingdon we are transforming our model of case management as part of the North West London - Integrated Care model. You will work as part of a Care Connection Team (CCT) in Hillingdon, providing anticipatory care to patients to prevent escalation of their health and or social care needs, thereby reducing the risk of emergency hospital admissions.
Main duties of the job
The service works with patients over the age of 18 years with one more or of the following conditions; COPD, Stroke, Cardio Vascular Disease, Dementia, Social Isolation and Diabetes Mellitus. You will work to develop care plans for the patients on the CCT caseload, and proactively seek to identify at risk patients. You will be part of a once weekly huddle meeting with each of your CCT's, to discuss patients on your caseload and formulate their care plans. Where appropriate, you will make referrals to key stakeholders such as other community services e.g. district nurses, geriatrician, social services and third sector.
About us
The distance nurses travel each day is considerable and you will need to use a motor vehicle to carry out domiciliary visits. You will work autonomously to provide a full range of services predominantly to house bound patients including care homes and supported living, and will be skilled in carrying out Holistic assessments. The role also involves managerial aspects such as attending key meetings and supervision of junior staff such as Healthcare Support Workers, Senior Administrative Co-ordinators and Student nurses.
Job description
Job responsibilities
The GCM will work closely with GPs to proactively identify patients (aged 18+) with high risk complex needs. They will provide a proactive, holistic approach to managing patients with long-term conditions that is centered on primary care and the prevention of avoidable hospital admissions. The focus will be on providing comprehensive assessments, individualized care plans and coordination for complex patients in their usual place of residence including care homes. The GCM will enable the patient, carers/care home staff and families to understand their disease or condition, how to recognize early symptoms and proactively manage their care decisions.
The GCM will work as part of a multi- disciplinary team and will develop care plans for the patients on the Care Connection Team (CCT) caseload, supported by the CCT. GCMs will attend once or twice weekly huddles with the CCT to discuss patients on their caseload and formulate care plans. Where appropriate, referrals will be made to key stakeholders such as other community services e.g. district nurses, geriatrician, social services and third sector. The distance nurses travel each day is considerable and the GCM nurses use of their own car to carry out their domiciliary visits. The GCM works autonomously to provide a full range of services predominantly to house bound patients including residential and nursing homes and will be skilled in carrying out Holistic assessments.
Person Specification
Education and Qualifications
Essential
- RGN: Adult nurse
- Evidence of relevant Continuous Professional Development
- Non- Medical Prescribing Qualification or willing to undertake within 12months of appointment
- Advanced Assessment Skills/ Nurse Practitioner Qualification/ Community Matron qualification or willing to undertake within 6months of appointment.
- BSc or equivalent experience Assessor/Mentor
- Numeracy skills required for the safe administration of medicines
Desirable
- Mentorship Qualification
Experience
Essential
- Previous experience as a Band 6/7 nurse working in the community or primary care setting
Desirable
- Experience of working in A&E, ITU, or other equivalent acute medicine speciality
Skills and Knowledge
Essential
- Able to communicate with the multi-disciplinary team, present cases, take note of actions, update others in the team and use handover effectively. Speaking face to face but also by telephone and writing letters and reports.
- Maintaining accurate, timely, concise and legible clinical records both electronic and handwritten which adhere to the CNWL policies.
- Manage others and contribute to the management of the team
- Contribute to the culture of the team and play a role in making it inclusive, kind and hard working
- Able to talk to people about sensitive issues in a supportive manner but also challenge others assertively where necessary
Desirable
- Expertise in particular skills and evidence of how you developed them and use them in your current role
Other
Essential
- Access to Car or other motor vehicle for use for work purposes
- Able to work efficiently in the community
- Full UK licence holder
- Able and willing to work in partnership with service users, their friends and family as well as other health care professionals
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details
Employer name
Central and North West London NHS Foundation Trust
Address
Hillingdon
Various sites
UB8 1QG
United Kingdom
Employer's website
https://www.cnwl.nhs.uk/work (Opens in a new tab)