Job overview

The Community Matron is a pivotal member of the Primary Health Care Team and develops professional relationships with medical colleagues, other health professionals, Social Services, voluntary agencies, secondary care hospitals, community hospitals and liaison staff, to enhance the service and care pathway provided to patients who have complex needs and their families due to the presence of complex care, working independently exploring all avenues to support patients with complex needs and chronic disease including forming effective communication networks across organisations to achieve patient focused goals. 

To provide holistic nursing assessment, high quality care, support and information to patients and carers with the aim of maintaining patients in their own homes, enabling them to enjoy maximum independence and optimum quality of care. To actively participate in the planning and discharge of complex patients from secondary to primary care. To provide specialist clinical advice to the multi-disciplinary team. 

You will work towards setting up, implementing and evaluating the Community Matron role supporting patients with complex needs. This will inform and develop Torbay and South Devon NHS foundation Trust provider service management approach to the care of complex patient and support people to remain in their own home.

Main duties of the job

•          Anticipate care needs and collaborate with key stakeholders to develop appropriate care plans, referring on to other services or professionals as appropriate.
•          To carry out specialist and shared complex nursing assessments, to include CHC, medication review, prescribing and palliative care. To work as an autonomous practitioner in the planning and implementation of nursing treatment plans.
•          To provide initial and on-going assessment of nursing needs of patients and carers in the community. When planning a program of care, physical, social and emotional cultural factors are taken into consideration and suitably qualified staff used to facilitate the level of care agreed.
•          Build on a network that can be used to streamline care pathways for the caseload of patients.

Working for our organisation