Community Matron (Annex 21)

Detailed job description and main responsibilities

Advertising date 18th August 2025
Closing date 5th September, 2025
Shortlisting 8th September, 2025
Interview date 22d September, 2025

KEY DUTIES

• Maximise independence by supporting people with long term conditions and highly complex needs to remain in their own homes as appropriate, by utilising and commissioning available resources
• Undertake clinical assessment and diagnosis and provide treatment for patients within the defined group.
• Link with existing services to facilitate early discharge from hospital and prevent re-admission.
• Develop Partnerships and joint working within the local health and social care economy.
• Work collaboratively across organisation boundaries to support the effective and co-ordinated provision of social care and health care services.
• Be aware of and adhere to, the Professional bodies Standards for administration of Medicines Act 1992, and the Misuse of Drugs Act 1971.
• Challenge professional and organisational boundaries to ensure that the Case Management role is focused on meeting the needs of service users, thus promoting continuity of high quality patient centred health and social care.
• Acts as an advocate and champion for patients in a variety of forums and professional groups and challenges attitudes and behaviour.
• Act as a role model so that patients receive the most effective care possible through:
• Encouraging optimum management of long term conditions to ensure that the patient is functioning at the most independent level possible.
• Acting in patients’ interests at all times.
• Make, implement and communicate changes to clinical practice as necessary in relation to case management

CLINICAL & PROFESSIONAL RESPONSIBILITIES

Conduct a comprehensive health and social care assessment, utilising any current information in order to develop an individualised plan of care for patients within a defined group. This will include:  

• Review of health assessment including medical history.
• Physical examination.
• Assessment and review of medication.
• Prescribing in conjunction with management plans.
• Making referrals for diagnostic tests.
• Functional /cognitive assessment.
• Assessment of social care need

Develop, monitor and manage the plan of care in collaboration with the primary health and social care team and others through:

• Application of clinical knowledge about long term conditions.
• Analysis of symptoms and data.
• Identification of risk factors associated with exacerbation of patient’s condition.
• Recognition and management of early signs and symptoms of acute illness.
• Involving patients and carers in the development of the care plan and ensuring that their views and abilities are reflected.
• Documentation of progress and continuous reassessment
• Referral and investigation.
• To be responsible for maintaining competence in clinical and diagnostic skills required to manage patients.
• Set up and actively participates in case review to evaluate the outcomes of care plans including social care needs.
• Co-ordinate care and treatment to avoid fragmentation, duplication and delay, in the least intensive setting appropriate to the patient’s needs by:
• Prioritisation and co-ordination of multiple health and social care needs.
• Referrals to specialist services.
• Ensuring effective communication and sharing of appropriate. information amongst professionals to avoid conflicting treatments.
• Integration across health and social care (including voluntary sector and housing).
• Identifying deficiencies in service provision and addressing these as appropriate (i.e. through commissioning services for individuals).
• Understanding and working through entitlements to social care and necessary financial assessments.
• Lead the process of identifying their caseload through interpretation of the information available on the health needs of the locality in which they are based.
• Participate in the development of case management across the Trust.
• Provide clinical leadership and mentoring to those staff developing into a case management role.
• Contributing to the development of policy and services to reflect the needs of the patient caseload.
•  Liaise with patients and carers, community and specialist nursing and other health professional, GPs, acute colleagues, social care colleagues and the voluntary/charitable and non-NHS sector

TEACHING & TRAINING RESPONSIBILITIES

• Promote formal and informal training to pre and post registration health and social care professionals in relation to integrated working and long term conditions and provide mentorship and teaching to others developing a case management function.
• Participate in the induction of new staff.
• Provide education, advice and support to health and social care staff, people with long term conditions and their carers; in both community and acute settings.
• Maintain up to date knowledge and competence in line with professional and service requirements and demonstrate critical thinking, decision making and reflective skills to ensure own professional development

LEADERSHIP AND MANAGEMENT RESPONSIBILITIES

• Manage the complex clinical and social care interventions of individuals within an identified patient group on an ongoing basis.
• Undertake risk assessment in relation to individuals within the client group
• Monitor and respond to the development of changing clinical and social situations with the identified
• Patient group without recourse to others where possible
• Ensure the safe management of care and service delivery
• Line manage a defined team of staff; including performing appraisal, personal development reviews and the application of staff management procedures
• Provide clinical support to complete complaints, investigations and staff development
• Contribute effectively to service developments
• Act as a role model by demonstrating excellent communication and listening skills with patients, relatives and staff
• Promote effective team working
• Participate in recruitment and selection of staff as required
• Actively market and promote the role of the community matron
• Provide an effective leadership role in contributing to resolving own service issues pertaining to clinical governance agendas and shared governance within the Trust e.g. maintaining standards, risk management, clinical audit and research, standard setting, benchmarking, evidence based practice, etc.
• Provide leadership to nursing and HCA staff with regard to training and development ensuring the delivery of consistently high quality care.

RESEARCH & DEVELOPMENT, QUALITY AND SERVICE IMPROVEMENTS

• Participate in research and audit relating to long term conditions management
• Develop and implement policies and strategies in line with evidence based practice e.g. NICE/DoH and in partnership with other clinical teams.
• Be involved in identification, development and implementation of relevant policy/guidelines to aid future management by the MDT e.g. clinical pathways
• Assess the effectiveness of care delivery through self and peer review, bench marking, formal evaluation and consideration of patient responses.

PERSONAL ATTRIBUTES

• Develop good working relationships with all staff and other members of the MDT, other departments within the trust and external bodies.
• Act in accordance with professional guidance/Code of Professional Conduct

SAFEGUARDING RESPONSIBILITIES

• Comply with Trust Safeguarding Adult and Children’s Policy and standard operating procedures to safeguard vulnerable adults/children up to 18 years throughout the Trust, fulfilling your role as defined in these documents.
• Liaise with all relevant professionals (including Police and Social Services) in relation to safeguarding work undertaken by your Clinicians.  Type any medical reports as requested by the Clinician, Nurse or other Medical staff.  Arrange multi-professional meetings regarding adult/child protection cases.  Minute multi-professional meetings as necessary.
• Provide administrative support for the Named Consultant and Named Nurse for Safeguarding
• Know about the range of physical abuse, emotional abuse, neglect and sexual abuse.
• Be able to recognise signs of abuse appropriate to role and what action to take.
• Know what to do if concerned that a patient is being abused.
• Know about the Trust’s local policies/procedures.
• Understand the importance of sharing information, how it can help and the dangers of not sharing information.
• Be able to recognise signs of abuse as this relates to their role. E.g. observe inappropriate interactions, an unusually quiet and withdrawn patient etc.
• Be able to seek advice and report concerns, ensuring that they are listened to.