Job overview

This post is part time 28.75 hours per week.

The Complex Care at Home Matron/Clinical Case Manager assumes the role of an autonomous Clinical Practitioner, responsible for overseeing the care of their assigned patients. This entails triaging, planning, managing, and coordinating intricate care and treatment requirements within the confines of patients’ homes.

Complex Care at Home is an established and innovative complex case management service that currently serves Gloucester, Cheltenham, and the Forest of Dean localities, with an aim to roll out across countywide.

The service collaborates closely with acute settings, community teams,

social services and primary care to identify and support patients who

would benefit from a case management approach.

Through a collaborative approach, the team works with patients

families, and carers, employing a coaching methodology to facilitate

problem-solving and empower self-management. 

 Each patient is assigned to the Complex Care at Home Team for a

specific period before being appropriately discharged.

Main duties of the job

As a member of the Complex Care at Home Multidisciplinary Team, they proactively manage patients with long-term conditions and at risk of deterioration, including those with frailty. The Community Matron/Clinical Case Manager provides comprehensive and specialised support to patients, carers, and families, enabling them to lead fulfilling lives alongside their conditions. They employ motivational interviewing and health coaching to establish therapeutic relationships, thereby mitigating unplanned hospital admissions. This proactive strategy fosters improved health outcomes. The Community Matron/Clinical Case Manager works closely with primary and secondary care services, including Physical and Mental Health, as well as statutory and non-statutory agencies. This collaborative approach enables the development of personalised care plans, consistently advocating for the ‘What matters to you?’ principle.

Working for our organisation

We have a skilled and dedicated workforce of over 5000 colleagues working in a diverse range of services over 55 sites and within people’s homes. We strive to enable a welcoming workplace culture that builds and celebrates civility, inclusivity and diversity, while providing a sense of belonging and trust.

Annual staff surveys, regular Pulse surveys and other engagement opportunities provide our people with lots of opportunity to tell us about their experiences of working with us.  In the latest staff survey, 61% of colleagues gave us their views.  It was great to hear that:

• 72% of colleagues would recommend the Trust as a place to work, ranking us 1st for Provider Trusts in the South West region on this question.
• 76% would recommend the standard of care provided in our services if a friend or relative needed treatment, also ranking us 1st in the South West region.
• 81% said that care of patients and service users is the Trust’s priority, compared with an average in comparable NHS Trusts in England of 64%.

This high-level overview shows we are in a healthy position, with higher scores than average for comparable organisations, alongside a great response rate, indicating good staff engagement.  However, we also know we have plenty of room for improvement in many areas. To that end, we continue to prioritise and invest in our commitment to genuinely becoming a Great Place to Work with consistent top-quartile performance in the annual staff survey and Pulse surveys.