About this role
Job summary
We are seeking a motivated & dynamic Hospital at Home Community Matron to join our Neighbourhood Teams within the Barnsley Physical Health & Wellbeing Care Group
This role is central to delivering Hospital at Home pathways, working alongside Urgent Community Response Crisis & Virtual Ward services, supporting acutely unwell patients in their own homes or place of residence with consultant oversight & MDT support
You will also provide cross-cover to support proactive neighbourhood care for patients with complex co-morbidities, alongside contributing to Ageing Well services & multidisciplinary clinics. This is an exciting opportunity to join a growing service aligned to national priorities and community-based care transformation
You will provide clinical leadership, deliver high-quality holistic care & support admission avoidance through effective assessment, treatment & coordination of care. Working collaboratively across primary, secondary & social care, you will help ensure safe, effective patient pathways from triage to discharge.
Service delivery operates between 08:00 and 18:00, 365 days per year.
All employees of the Trust are strongly encouraged to have their up-to-date flu vaccination to protect staff and patients.
At the time of advertising, this role does meet the minimum requirements set by UK Visas and Immigration to sponsor candidates to work in the UK. We look forward to receiving your application.
Main duties of the job
Key Responsibilities
Oversee & deliver high-quality, holistic patient care, ensuring individual needs are met within the home environment Support admission avoidance initiatives by identifying & implementing effective community-based care strategies Provide clinical leadership & expertise to help shape & develop evolving, integrated community services Promote innovative, patient-centred approaches that enhance care delivery & outcomes within the community Main Duties
Actively contribute to admission avoidance by managing patients safely at home, including assessment, treatment & onboarding to virtual ward pathways where appropriate Reduce unnecessary hospital admissions by coordinating timely interventions, linking with Same Day Emergency Care & mobilising the wider multidisciplinary team (MDT). Work collaboratively across primary, secondary & community care services, maintaining strong partnership working to deliver seamless patient care Utilise non-medical prescribing skills to assess, prescribe & manage treatments, ensuring effective & timely clinical interventions Where required, manage a caseload of patients with complex, long-term conditions, ensuring continuity, quality & proactive care delivery
This role requires strong clinical expertise, leadership and a proactive, adaptable approach to support high-quality care & meet the changing needs of the community.
Cherie Webb/Lesley Cooper
[email protected]/[email protected]
01226644387/07833048059
About us
We are a specialist NHS Foundation Trust that provides community, mental health and learning disability services for the people of Barnsley, Calderdale, Kirklees and Wakefield. We also provide low and medium secure services and are the lead for the west Yorkshire secure provider collaborative.
Our mission is to help people reach their potential and live well in their communities, we do this by providing high-quality care in the right place at the right time. We employ staff in both clinical and non-clinical services who work hard to make a difference to the lives of service users, families and carers.
We encourage and welcome applications from all protected characteristic groups, we value diversity and want our workforce to be reflective of our communities.
Being a foundation Trust means were accountable to our members, who can have a say in how were run. Around 14,300 local people (including staff) are members of our Trust.
Join us and you will be one of over 4,500 staff committed to supporting and improving the mental, physical and social needs of the thousands of people we meet and help each year.
We are committed to safeguarding and promoting the welfare of children, young people and vulnerable adults and expects all colleagues and volunteers to share this commitment.
We do reserve to right to close vacancy before the advertised closing date if necessary, so please apply as soon as possible.
Job description Job responsibilities
JOB SUMMARY
The role of the Case Manager/ Community Matron is:
To provide systems leadership at a neighbourhood level for managers, specialist nurses and staff within a primary care setting.
Work effectively in an integrated partnership way with primary care, secondary care, social care, the independent and voluntary sector
Through patient involvement, brokering care across partnerships, whilst leading and promoting the principles of multidisciplinary team working, to support the achievement of better health outcomes
To provide a high quality, comprehensive and accessible community nursing service to housebound patients
Undertake complex holistic assessments using advanced clinical examination and assessment skills that encompass all aspects of an individuals needs.
Act as keyworker, liaising and working collaboratively with other professionals to co-ordinate care, preventing duplication, fragmentation and ensuring the effective deployment of resources
Undertaken line management responsibilities of the District Nurse and Assistant Community Matron roles.
KEY RESULT AREAS
1.1 Clinical Care
Proactively manage a caseload of patients with long term conditions who have complex needs, increasing and decreasing input into a patient care as required and discharging from the caseload as appropriate in line with the Community Nursing Service Operating Framework. Undertake the keyworker role, liaising and working collaboratively with other professionals to co-ordinate care, preventing duplication, fragmentation and ensuring the effective deployment of resources. Actively case find using data bases and risk stratification tools to actively seek out patients who will benefit from clinical case management techniques to avoid unplanned hospital admissions and reduce the length of hospital stays by facilitating a timely discharge Undertaken complex holistic assessments using advanced clinical examination and assessment skills that encompass all aspects of an individuals needs in conjunction with the individual and their family. Use self-management and joint care planning principles to care delivery that promote the resilience, enhance well-being and maintain independence To provide evidence based care plans based on sound clinical decision making using the knowledge of the unique presentation of long term conditions, negotiated with the person. To initiate and lead medicines management reviews, independently prescribing medicines and appliances where appropriate and within scope of practice. Use expert knowledge to promote healthy lifestyles and self-management of long term conditions Prevent unplanned hospital admissions through intensive clinical management and health and social care support at home. Reducing the length of stay of unplanned hospital admissions through communication and coordination of care with secondary and primary care To help individuals and their families to plan for and improve end of life care, ensuring their choices are reflected in personalisation care plans. Communicate effectively using higher level communication skills at all levels within the organisation, to a variety of health and social care professionals, individuals and their families. Challenge practice, systems and policies in an objective and constructive manner Use high level communication skills to negotiate care plans and establish collaborative partnerships with patients and carers Support the patient to develop a range of self-management strategies to enable them to be independent. Actively promote health and self-care, disease prevention and the self- management of acute and/or long term conditions, applying the principles of making every contact count in clinical practice Maintain contact with the individual if admitted to hospital, providing information about home circumstances to hospital staff and ensuring that discharge of the patient is rapid, planned and safe Utilise nursing metrics to provide high quality advanced nursing care Visible role model for the National Nursing Strategy and the values within Compassion in Care and the 10 commitments to nursing
For full job description, please see attached supporting documents.
We are aware that an increasing number of applicants are using AI technology to generate responses on NHS Job application forms. Over reliance on AI-generated content in application forms is strongly discouraged and we will conduct a thorough screening process before selecting candidates to progress to the next stage. If you are using AI to enhance your application, please disclose this in your NHS Jobs application form.
Person Specification
Personal Attributes Essential
Ability to work on own initiative Able to negotiate and influence Reliable and flexible Enthusiastic and highly motivated
Qualifications Essential
Registered Nurse Level 1 First Degree Mentorship Qualification Independent prescriber or willingness to undertake Post Graduate Certificate in Advanced Clinical Practice Masters Degree or equivalent experience
Desirable
Qualification as Community Specialist Practitioner (District Nursing) Palliative Care qualification
Training Essential
Motivational Interviewing/ Behaviour Change Leadership and Management. Venepuncture or be prepared to complete the training required
Desirable
Specialist courses appropriate to Long Term Conditions. E.g. CHD, Diabetes, Respiratory conditions
Experience Essential
Substantial post registration experience and able to demonstrate relevant effective learning from this experience Demonstrable leadership experience Experience of working as an autonomous practitioner Experience in management of Long term Conditions including palliative care. Evidence of working effectively in an integrated and partnership way with a range of professionals and agencies. Evidence of innovative practice.
Desirable
Experience of undertaking investigations/significant event audits
Special Knowledge/Skills Essential
Ability to undertake advanced clinical practice and examination skills independently that encompasses all aspects of the patients needs Skilled in care pathway planning, promotion of health and self-care, disease prevention and the management of acute or long-term conditions. Ability to lead and participating in multi-professional/agency meetings and strategies Awareness of and ability to contribute to national, local, strategic and operational policy developments. Evidence of developing, delivering and evaluating training packages for individuals and groups in a variety of settings Ability to undertake quality assurance measures, including research and audit. Excellent communication and interpersonal skills Ability to motivate staff and work across organisations and professional boundaries Demonstrate an understanding of clinical governance Demonstrate good IT skills
Physical Attributes Essential
Ability to undertake the duties and demands of the post. A satisfactory sickness record over the previous 2 years (subject to the need to act with fairness and equality of opportunity, particularly where the sickness is related to a disability and/or pregnancy). A Current driving licence and access to a car during the working day is essential (reasonable adjustments will be considered for any applicants who are unable to drive due to a disability)
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.
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 South West Yorkshire Partnership NHS Trust
Address Kendray Hospital
Doncaster Road
Barnsley
S Yorkshire
S70 3RD
United Kingdom
Employer's website https://www.southwestyorkshire.nhs.uk (Opens in a new tab)