Community Matron

• Proactively managing a caseload of patients with complex needs and coordinating their care.
• Developing personalised management and care plans in partnership with patients, families and carers.
• Identifying deterioration or changes in a patient's condition and supporting timely intervention to reduce the risk of avoidable hospital admission.
• Supporting patients following discharge from hospital and working with colleagues to promote safe, coordinated care within the community.
• Working collaboratively with GPs, community services, acute services, social care and other members of the multidisciplinary team.
• Supporting patients and carers to understand and manage long-term conditions, promoting independence, self-management and informed decision-making.
• Making appropriate referrals and coordinating input from other health, social care and voluntary sector services according to individual patient needs.
• Providing clinical leadership, advice and support to colleagues and contributing to the ongoing development of high-quality community services.

• Identify people at increased risk of deterioration, decline in health or wellbeing, or unnecessary hospital admission.
• Undertake comprehensive and holistic assessments, considering physical, psychological and social needs as well as the needs of carers.
• Develop individualised, patient-centred care plans in partnership with patients and those supporting them.
• Use advanced clinical assessment and decision-making skills to recognise changes in condition and initiate appropriate interventions.
• Interpret clinical information and assessment findings to inform decisions about treatment, care and onward referral.
• Maintain responsibility for the proactive management and coordination of an identified caseload.
• Promote early recognition of exacerbation or deterioration and timely intervention to improve patient outcomes and reduce avoidable hospital admission.

• Provide specialist assessment and management for people living with frailty, multiple long-term conditions and complex health and social care needs.
• Promote independence, enable self-management and support people to remain safely within their usual place of residence wherever clinically appropriate.
• Work proactively rather than waiting for an acute deterioration in the patient's condition.
• Provide patients and carers with information and education to support understanding and management of long-term conditions.
• Ensure personalised care planning reflects what matters to the individual, their goals and their changing clinical needs.

• Identify opportunities for early intervention to prevent avoidable deterioration and hospital attendance or admission, and work alongside CSH Virtual Ward referring appropriate patients in for admission avoidance
• Coordinate care across organisational and professional boundaries.
• Work closely with primary care, community services, acute care, social care, mental health, voluntary organisations and other relevant services.
• Support safe and coordinated transitions of care between hospital and community settings.
• Contribute to multidisciplinary discussions and ensure patients receive coordinated, timely interventions.
• Act as an effective clinical link between services to support seamless care.

• Work autonomously and exercise professional judgement when assessing and managing patients with complex needs.
• Recognise clinical deterioration and take appropriate action, including escalating or referring to other services where required.
• Review and evaluate care interventions, changing the management plan in response to the individual's condition or circumstances.
• Make appropriate onward referrals and coordinate specialist input according to individual need.
• Maintain accurate, timely and comprehensive clinical documentation.

• Work collaboratively with the wider Frailty Hub multidisciplinary team.
• Build effective relationships with GPs, community nursing, therapy services, pharmacy, mental health, social care and voluntary-sector colleagues.
• Participate actively in MDT meetings and complex case discussions.
• Ensure effective communication between professionals, patients and carers.
• Promote a coordinated approach that reduces fragmentation and duplication of care.

• Provide clinical leadership and act as a source of specialist advice within the Frailty Hub.
• Promote high standards of evidence-based, person-centred care.
• Support colleagues through clinical advice, supervision, coaching and shared learning.
• Contribute to service improvement and the continued development of integrated frailty services.
• Promote a positive culture of learning, professional development and multidisciplinary working.
• Maintain professional registration and practice within the appropriate professional code, organisational policies and scope of practice.

Essential

• 1st level registered nurse
• Qualification equivalent to level 7 / PGdip / Masters level
• NMP qualification or working towards
• Mentorship qualification
• Clinical Supervisor

Essential

• Significant post-registration clinical experience, including experience caring for people with frailty, complex needs and/or multiple long-term conditions.
• Experience of undertaking holistic assessment and developing individualised, patient-centred care plans.
• Experience of managing patients at risk of deterioration or avoidable hospital admission.
• Experience of working autonomously and making clinical decisions within professional scope of practice.
• Experience of coordinating complex patient care across services.
• Experience of multidisciplinary and multi-agency working.
• Experience of supporting patients and carers to understand and manage long-term conditions.
• Experience of providing clinical leadership, advice and support to colleagues.
• The CSH role specifically identifies proactive management of patients at high risk of admission, holistic nursing assessment incorporating physical, psychological and social needs, and coordinated case management as key responsibilities.
• Knowledge and skills
• Strong knowledge and understanding of frailty and the management of complex long-term conditions.
• Excellent clinical assessment and clinical decision-making skills.
• Ability to recognise deterioration and take appropriate action.
• Ability to prioritise and manage a complex caseload effectively.
• Ability to work independently while contributing effectively to the wider multidisciplinary team.
• Excellent communication and interpersonal skills, including the ability to communicate effectively with patients, carers and professionals across organisational boundaries.
• Ability to develop and maintain effective working relationships with primary care, community services, social care, mental health and other partner organisations.
• Commitment to personalised care, promoting independence and supporting patients to remain safely within their usual place of residence wherever appropriate.
• Good organisational, prioritisation and time-management skills.
• Ability to maintain clear, accurate and contemporaneous clinical records.

Desirable

• Ability to work across the required community/neighbourhood footprint.
• Able to work flexibly in accordance with service requirements.
• Enhanced DBS clearance as required for the post.