Job overview
West Suffolk Foundation Trust is recruiting to the Matron role within Bury Rural and the surrounding Integrated Neighbourhood Teams (INTs). While the aim of reducing hospital admissions remains a priority, the role of the Matron will evolve through the introduction of a new and exciting Care Management Service.
This service will operate within a GP-led multidisciplinary team (MDT) across the INT, supporting patient assessment and ensuring individuals are appropriately signposted to the most suitable services for their ongoing care. This will be achieved through regular MDT meetings.
This INT team is one of a total of six INT teams. The other INT localities are based in Mildenhall/Brandon, Bury Rural, Haverhill, Sudbury and Newmarket.
If you really enjoy supporting patients with long term conditions and those patients who need support with complex health and social issues? If so, then you will be well suited to this role.
Do you also love working with a multidisciplinary team to optimise patient outcomes? Well, the INT accommodation 'Hubs' are the base for a wide range of other health professionals and agencies including Adult Social Care, social prescribers, GPs, police and mental health team members. Colocation and great relationships with these colleagues means we are able to work together, in a fully integrated way, to ensure the best care is delivered to the patients within our localities.
Main duties of the job
KEY TASKS:
Assessment and Treatment Planning:
- The ability to assess physiological and psychological functioning when there are complex and undifferentiated abnormalities, diseases and disorders using evidenced based advanced nursing knowledge and develop monitor and review related treatment plans e.g. clinical history taking and examination, diagnosis, treatment planning, arranging tests, investigations and prescribing.
- Understanding of and advanced knowledge of pharmacodynamics and pharmacokinetics when treating varying conditions and communicating to patients and carers the complexity of side effects and contra indications. This involves interacting using a variety of communication methods. Case managing complex cases to avoid unnecessary admission, reduce length of hospital stay and support independent living at home
Detailed job description and main responsibilities
JOB PURPOSE:
- To co-ordinate care provision through a case-management approach for a defined high risk patient group with complex long-term conditions (such as COPD, diabetes and CHD) with the aim of preventing unnecessary hospital admissions and facilitating timely discharge.
- To provide the highest standard of clinical care by using advanced skills and expert knowledge to holistically assess needs and instigate and provide clinical treatments based on evidence-based practice.
- To participate in the delivery of educational programmes to patients, carers and Health & Social Care workers that promote self care principles.
- To develop and promote robust multidisciplinary working across the wider Health and social Care sectors to ensure integrated services and support networks for patients.
- To monitor the quality of care provision and to identify and promote areas for service development.
Person specification
Personal Qualities
Essential
- To be adaptable, innovative and creative in pursuit of efficient and effective patient centred services
- High level of ability to reflect on and critically appraise own practice and performance
- Ability to travel to rural locations
Skills & Abilities
Essential
- Able to effectively communicate highly complex information both verbally and in writing
- High level of skill in developing and maintaining working relationships
- Sound knowledge of IT skills
- High level of presentation and training skills
- Experience of mentoring Students
- Advanced clinical assessment skills
- Experience of history taking and physical examination
- Experience of working autonomously
- Experience of working with people with long term conditions
- Ability to lead service development and practice improvement
Desirable
- Prior use of System 1
- Palliative Care/end of life experience
- Knowledge of mental health conditions
Experience & Knowledge
Essential
- Experience of assessing and providing care to people with LTC’s
- Experience of change management and implementing in practice
- Experience of teaching others
- Experience of receiving and delivering clinical supervision
- Experience of delivering evidence-based care
- Extensive post-registration clinical experience at minimum of Band 6 (AfC) or equivalent
- Knowledge of clinical governance and application to practice and service delivery
- Evidence of a high level of clinical skills and expertise
- Knowledge of case management principles and admission avoidance strategies
- Knowledge and understanding of professional and ethical issues
- Demonstrate a knowledge of health and safety legislation for self and others
- Demonstrable experience of autonomous clinical practice
- Experience of coordinating complex programmes of care
- Experience of implementing service improvements and managing change
Desirable
- Knowledge of National Initiatives in relation to people with Long Term Conditions
- Experience of Case Management
- Understanding of quality and outcome measures and relevance to service delivery
- Knowledge of research and audit processes
Education & Qualification
Essential
- Level 1 Registered Nurse
- First Level Degree or equivalent
- Current MNC registration
- Relevant post registration qualification eg Specialist Community Practitioner or Nurse Practitioner
- Evidence of continuing professional development
- Commitment to study at Masters Level
- Independent Nurse Prescriber or prepared to work towards
Desirable
- Masters level study or evidence of working at Masters level
- Independent Non Medical Prescriber
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Applying for this NHS job
This advert is for Community Matron Bury Rural INT with West Suffolk NHS Foundation Trust in Bury St Edmunds, East of England, England. It is listed as a Band 7 Nurse (adult and children) role. The advertised salary is £49,387 - £56,515 per annum pro rata. The contract type is Permanent. The application deadline is 31 Jul 2026.
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