Neighbourhood Nursing

Job overview

Our Community Matron’s for complex care focus on our most complex patients in the Neighbourhood Nursing caseloads requiring in-depth care, support and co-ordination of different services . You will work with the Neighbourhood Nurses and be at the centre of care, pulling in all the resources required to co-ordinate the care for these patients in community. You will also work alongside the Multi Disciplinary Team to ensure the patients have the care provided to prevent hospital admissions, prevent deterioration and promote independence and health education. This is a fantastic opportunity to really make a difference 
This is a great opportunity to build relationships with our acute and primary care colleagues and help to prevent hospital admission as you will be in contact with referring hospitals and GP’s to cover patients within Southwark and Lambeth areas. 
If you are experienced, clinically expert with a wide range of clinical skill and would like work with our community nursing teams providing advanced nursing care, then we would like to hear from you.

Closing date: 2nd June 2024 at Midnight 

Proposed interview date: 15th June 2024

Main duties of the job

Our community matrons act as case managers and are a single point of contact for care, support or as advanced nurse practitioners providing a variety of tasks and responsibilities, including:

Carrying out physical examinations. Deciding on and carrying out treatment, including the prescribing medicines, or refer patients to an appropriate specialist. Using their expert knowledge and clinical judgement to identify the potential diagnosis and where appropriate make a final diagnosis. Using their extensive practice experience to plan and provide skilled and competent care that meets patients' health and social care needs, involving other members of the healthcare team as appropriate. Ensuring the provision of continuity of care, including follow-up visits. Assessing and evaluating, with patients, the effectiveness of the treatment and care provided and make changes as needed. Working independently, although often as part of a healthcare team. Providing leadership. Making sure that each patient's treatment and care is based on best practice. Seeing patients in their own home and in other community settings. Working as part of multi-professional and multi-agency teams. Providing supervision, education and support to members of the community nursing team.

Working for our organisation

Guy’s and St Thomas’ NHS Foundation Trust comprises five of the UK’s best known hospitals – Guy’s, St Thomas’, Evelina London Children’s Hospital, Royal Brompton and Harefield – as well as community services in Lambeth and Southwark, all with a long history of high quality care, clinical excellence, research and innovation.

You will have the opportunity to further develop and enhance your skills with the support and training available by working alongside experienced nurses and specialists. We have a supportive culture to encourage each other to strive to be the best within our daily practice. Our feedback as a team reflects this.

Working with us you will have access to numerous benefits:

Mobile devices for personal protection whilst in practice, allowing you to work more flexibly. Opportunity to apply for training and mentorship programs on all grades of nursing staff. Access to our partners Kings College London for Masters level education opportunities. Financial, health and wellbeing support.

Detailed job description and main responsibilities

Duties and Responsibilities

To work with and alongside neighbourhood nurses in the team to teach and foster confidence in the care of complex vulnerable patients with a focus on sound assessment skills and care planning. To clinically cover and lead the service over a seven day service period on a rotational basis with other colleagues. To undertake holistic assessments of a person living with multiple, complex long-term conditions using advanced level clinical skills. To review and interpret clinical and diagnostic parameters requesting tests and investigations as necessary to form a picture of the disease progress. To provide comprehensive advanced nursing care, including disease treatment, prescribing, palliation and end of life care to a high standard. To carry out basic assessments of mental health, identifying and assess deterioration in cognitive function and refer to specialist services as appropriate. Support the team in carrying out mental capacity assessment and making best interest decisions. To anticipate possible deterioration and establish pro-active personalised care plans to enhance well being and maintain independence. To take a lead on initiating medicines management reviews as part of the case management package. To facilitate clients, carers, families in using a range of self-care and self management strategies, to enable them to act upon early warning signs of complications or deterioration. To lead complex care coordination and proactively case manage people with complex health and social care needs. To participate in Community Multidisciplinary Team meetings and attend GP meetings with neighbourhood nurses teaching and role modelling case presentation and clinical discussion. To implement and operate within relevant national and local clinical guidance and policies , non medical prescribing, record keeping, infection control, vulnerable adult. To participate in own peer review and clinical supervision. To ensure that own data entry is timely and that own activity is accurately reflected. To support members of the team in data entry and use of clinical IT systems and resources. To maintain and update knowledge and skills and undertake continuing education in accordance with personal and service needs within a framework of a personal development plan. To use evidence based practice to develop and maintain a high quality clinically effective and cost-effective service. GSTT is committed to developing new ways of working through the application of new technology. As a clinical member of staff in one of our clinical teams you are required to use a tablet or laptop as part of your clinical practice. It is our expectation that you make full use of mobile technology to maximise the benefits to patients and the effective delivery of our service. The post holder must use Skyguard or other personal protective equipment as determined by the service to ensure safety in general and to protect lone workers in particular.

Communications

To support staff in developing effective relationships with GP practices. To be an integral part of the community nursing team utilising other services and skills to get the best possible outcome for the patient. To utilize the links with other agencies and services to facilitate appropriate care packages and provide information for clients that focus on promoting independence, self care and wellness and keep people out of hospital. To provide concise feedback to the team and other partners, sharing information where appropriate. Support team to utilise communications and information sharing through the Local Care Record, EPR and in the use of mobile IT.

Staff Management

To deputise in the operational management of the community nursing team in the absence of the Clinical Nurse Lead and to provide frontline management to the community nursing team as appropriate. To be clinically expert and act as an effective role model. To demonstrate a focus on quality and standards to ensure that the neighbourhood nursing team is firmly focused on quality, standards and excellent patient experience. To provide clinical leadership to the nursing team in relation to long-term conditions and in the care of complex cases. To lead & facilitate MDT meetings, case conferences & other key meetings. Provide regular professional supervision for staff caring for people with complex needs and long term conditions and give verbal and written feedback to ensure high standards of competence and care. Hold others to account for the delivery of care to this client group along with the Locality Nurse Coach / Manager. To participate in efficiency and productivity work. To develop outcomes that demonstrate the value of the service. To champion and lead change.

Education training & mentorship

To provide clinical training and education to all staff within the nursing team and across GSTT as necessary working in partnership with the Practice Development team. Participate in, and plan, induction programmes for new staff. Provide practice assessment and supervision and plan learning and assessment programmes as appropriate to the needs of all students and others on community placements. To provide specialist supervision for the nursing team and around complex case management and long-term conditions. To facilitate clinical supervision for other nurses within the GSTT.

Service Development

To work across GSTT in the development of strategy, policy and practice around long term conditions. To work with the Locality Nurse Coach / Manager and clinical nurse lead, to implement strategy and policy relating complex care in the nursing team and across GSTT. To initiate and influence the development of policies, procedures and guidelines relevant to people with complex needs ensuring they are implemented and monitored. To identify areas for improvement and practice development, work with others across the locality and GSTT to develop and implement them.

Financial and physical resources

To utilise available resources effectively and support team to the do the same. Utilise appropriate guidelines to guide prescribing (eg Non medical prescribing policy). Ensure clinical equipment is calibrated and maintained.

Research and Development

To participate in, teach and support the neighbourhood nursing team in audit, benchmarking and improvement activity. To monitor the impact of the Community nursing role on clinical and cost effectiveness using a range of audit techniques. To collect data as necessary. To develop and inform the development of quality and performance indicators for the neighbourhood nursing service To work with managers and the nursing team to monitor the quality of nursing services offered.

Person specification

Values and behaviour

Essential criteria

Values and behaviour

Experience

Essential criteria

Substantial experience working as a senior practitioner in a team. Experience of teaching and assessing Experience of interagency and collaborative working. Experience of clinical audit, benchmarking and evaluation of services.

Desirable criteria

Experience of working in or with primary care

Skills&Personal Qualities

Essential criteria

Well-developed advanced assessment skills. Ability to demonstrate evidence based care and decision making that is responsive to the needs of clients and carers and negotiated in partnership with them. Ability to work as an autonomous practitioner being responsible and accountable for choices made. Excellent organisational and time management skills and ability to facilitate these skills in others. Excellent interpersonal and negotiation skills with an ability to adopt a number of ways to influence diverse parties. Ability to lead and implement successful change management.

Desirable criteria

Car Driver

Qualifications/Education

Essential criteria

RN (General Adult) Education to 1st degree level or equivalent. Evidence of post registration education relating to the care of older people and long term conditions Teaching certificate ( ENB 998/997) or equivalent mentorship training. Advanced assessment, long term conditions Nurse formulary prescriber Independent prescribing module successfully completed or willingness to undertake on taking up post.

Desirable criteria

Masters level study

Guy’s and St Thomas’ celebrates, respects and values the diversity of its staff and patients. We review our policies, procedures and practices to ensure that all employees, patients and carers are treated equitable according to their needs. We are actively committed to ensuring that no one who applies for a job, works or study’s at the Trust, or accesses our services is discriminated against on the grounds of race, ethnicity, nationality, disability, religion or belief, age, gender identity , gender reassignment, sexual orientation, pregnancy and maternity/paternity, or marital/civil partnership.

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