Community Matron - Shires Health Care

Community Matron

Band

Agenda for Change Band 7 or 8a – depending on qualifications & experience

Base / Location

Shires Health Care, 18 Main Street, Shirebrook, Mansfield, Notts, NG20 8DG

Accountable to

GP Partners & Practice Manager

Responsible for

Patients with complex, long-term conditions; leadership, supervision and coordination of multidisciplinary care

Job Purpose

To provide proactive case management to patients with complex needs who may have one or more unstable long-term conditions; a recent fall; a recent unplanned hospital admission; cognitive impairment, dementia and/or depression; multiple contacts with health and social care services; or who are identified as significantly frail. The post holder will report to the CST Lead GP where appropriate.

The Community Matron will manage a caseload of a defined ‘high-risk’ population within the Primary Care setting, delivering a holistic, patient-centred approach and holding overall responsibility for the coordination and management of patients’ health and social care needs. Care will be delivered in line with national and local priorities, organisational policies and procedures, and in accordance with the Nursing and Midwifery Council (NMC) Code.

The post holder will work collaboratively with GPs, practice and district nurses, adult social care, medicines management teams, Allied Health Professionals, mental health services, acute and community providers, and the voluntary sector. They will lead and facilitate a coordinated, multidisciplinary case management approach across primary and secondary care for people most vulnerable to, and at high risk of, avoidable hospital admission. The role will actively support patient choice, improve quality of life, promote self-management, and ensure early intervention through proactive care delivered in the least intensive setting possible.

Service Aim

The overall aim of the service is to reduce inappropriate hospital admissions, facilitate early discharge from secondary care, promote improved health and medicines management, and enhance the quality of care for people with complex needs and long-term conditions. The Community Matron will lead the coordination of a holistic case management model for patients with complex needs, including those with chronic diseases who are at high risk of deterioration.

The role incorporates case finding, advanced clinical assessment, extended clinical practice and prescribing with the aim of improving patients’ understanding of, and ability to self-manage, their long-term conditions and thereby improve quality of life. Patients and carers will be actively involved in care delivery through education, evidence-based advice, and support to promote independence and self-care.

Key Responsibilities

Communication and Partnership Working

· Build and maintain effective working relationships with GPs, community nursing teams, adult social care, mental health services, acute and community hospital colleagues, therapists, and voluntary sector partners.

· Interpret complex clinical and non-clinical information to formulate and recommend appropriate courses of action, including medication reviews.

· Ensure timely, accurate, and effective communication with all relevant professionals regarding patient care and changes in treatment or management plans, utilising electronic patient record systems and assessment tools.

· Actively participate in and contribute to multidisciplinary team (MDT) meetings, including proactive care planning, frailty management, and population health management.

· Use a range of advanced communication skills to convey complex or sensitive information and overcome barriers to understanding.

· Act as an advocate for patients and carers, ensuring that individual needs, wishes, and preferences remain central to care planning.

· Embrace digital technology and innovative ways of working to support communication across services, while maintaining information governance standards.

Patient Care, Safety, and Quality

· Identify and proactively manage patients at high risk of avoidable hospital admission through anticipatory care, early recognition of deterioration, and timely intervention.

· Manage, prioritise, and regularly review a complex caseload, acting as lead clinician where required.

· Make rapid, autonomous clinical decisions, escalating to the Clinical Lead, GP, adult social care, or safeguarding services as appropriate.

· Undertake advanced clinical assessments, including physical examination of body systems, and interpret diagnostic findings to inform care and treatment decisions.

· Deliver personalised, anticipatory, and advanced care planning, including end-of-life care, chronic disease management, and frailty support.

· Work in partnership with acute and community teams to facilitate safe discharge from hospital and prevent readmission.

· Prescribe and recommend aids, equipment, and treatments in line with scope of practice and patient need.

· Work within multi-agency safeguarding policies to ensure the protection of vulnerable adults.

· Maintain accurate, timely, and confidential clinical records in line with organisational and information governance requirements.

Leadership, Education, and Development

· Act as a professional role model, providing clinical leadership, supervision, and specialist advice to colleagues, students, and new staff.

· Contribute to service development, quality improvement initiatives, and integrated working across community services.

· Participate in clinical audit, service evaluation, and the implementation of improvement actions.

· Maintain responsibility for own continuing professional development, appraisal, revalidation, and mandatory training in line with NMC and organisational requirements.

· As a non-medical prescriber, practice within national and local protocols, maintaining competence through CPD and revalidation.

Professional, Organisational, and Governance Responsibilities

· Plan and prioritise workload to meet service demands while ensuring patient safety and quality of care.

· Comply with organisational policies, including those relating to confidentiality, data protection, health and safety, infection prevention and control, equality, and diversity.

· Participate in risk assessment, incident reporting, clinical supervision, and research or audit activities as required.

· Travel independently across the locality to undertake home visits, attend meetings, and support integrated service delivery.

Role Differentiation: Band 7 vs Band 8a

Band 7 – Community Matron

· Manages a defined caseload of high-risk patients with complex long-term conditions and frailty.

· Works autonomously within agreed clinical pathways and escalates complex or high-risk decisions to the Senior Community Matron / Clinical Lead.

· Leads day-to-day case management and MDT coordination at PCN /CST level.

· Contributes to service development, audit, and quality improvement initiatives.

· Provides clinical supervision and mentorship to junior staff and students.

Band 8a – Senior / Advanced Community Matron

· Provides strategic clinical leadership across one or more PCNs or neighbourhoods.

· Manages highly complex cases and provides expert clinical oversight for Band 7 Community Matrons.

· Leads service development, transformation, and implementation of new models of care aligned to ICB priorities.

· Influences system-wide pathways for frailty, long-term conditions, admission avoidance, and integrated care.

· Leads audit, evaluation, and research activity and translates evidence into practice.

· Holds advanced clinical practice credentials (ACP/MSc level) and independent prescribing.

Knowledge and Skills Framework (KSF) Outline

Core Dimensions (All Bands)

· Communication (Core 1): Advanced communication with patients, carers, and professionals; complex and sensitive discussions.

· Personal & People Development (Core 2): CPD, supervision, appraisal, and development of others.

· Health, Safety & Security (Core 3): Risk management, safeguarding, infection prevention and control.

· Service Improvement (Core 4): Audit, quality improvement, service development.

· Quality (Core 5): Evidence-based practice, patient safety, clinical governance.

· Equality & Diversity (Core 6): Inclusive, person-centred care.

Derby and Derbyshire ICB – PCN / Neighbourhood Alignment

The Community Matron role is aligned to the Derby and Derbyshire Integrated Care Board neighbourhood model, working at Place and PCN level to support proactive, coordinated care for populations with the greatest need.

Key alignment includes: - Working as part of PCN-aligned neighbourhood teams, supporting delivery of anticipatory care, frailty pathways, and admission avoidance. - Active participation in PCN MDTs, including proactive care and review personalised care and support plans. - Use of population health management and risk stratification tools to identify and manage high-risk cohorts. - Collaboration with Derbyshire Community Health Services, Primary Care, Adult Social Care, Mental Health Services, and the Voluntary,. - Supporting ICB priorities around reducing health inequalities, improving outcomes for people with long-term conditions, and delivering care closer to home.

Person Specification

Qualifications

Essential - Registered Nurse (Adult) with current NMC registration - Degree in Nursing or equivalent - Evidence of continuing professional development

Desirable - Master’s level study or working towards MSc / ACP qualification - Independent / Non-Medical Prescribing qualification

Experience

Essential - Significant post-registration experience in a community setting - Experience managing patients with complex, long-term conditions and frailty - MDT and inter-agency working experience - Clinical leadership or supervision experience

Desirable - Case management and admission avoidance experience - Service development or quality improvement experience

Skills and Attributes

· Advanced clinical assessment and decision-making skills

· Ability to work autonomously and manage clinical risk

· Strong leadership, communication, and organisational skills

· Commitment to patient-centred, integrated care