Clinical Practice/Leadership To identify, assess and signpost patients with complex long term conditions and nursing needs within the allocated caseload in conjunction with General Practitioners, physicians within the acute sector, other lead clinicians and social care colleagues. To develop personalised management plans including self-care strategies to meet patients complex health and nursing needs. To lead the introduction and use of assisted technical nursing treatments utilising robust evidence base to meet effective long term conditions management, and avoidance of unnecessary hospital admission for patients on the allocated caseload. To prescribe, administer, monitor and review medications using the locally agreed medicines management formulary where applicable for patients with long term conditions on the caseload in ensuring such approaches are consistent with Your Healthcare's policies, procedures and standards and ensure compliance with all appropriate legislation. To support patients with complex disease management who have repeated active hospital admissions to develop their knowledge and understanding about their health and wellbeing to enable self-management within individual abilities and to recognise deterioration in a timely manner. To provide clinical practice advice, training and professional support to the community nursing team. To ensure that supplies and associated equipment are available to support the achievement of clinical management plans. To make independent referrals for diagnostic tests and/or opinions and care which requires free, open and informed discussion at all levels from consultants to GPs and specialist services. To contribute actively through data collection and analysis towards the effective management of service delivery and development within the organisation. To ensure that the community matron service is integrated with the district nursing teams and to offer clinical advice on the care of patients with complex needs as appropriate. To work autonomously and as a member of the multi-disciplinary team, developing and maintaining effective working relationships with other agencies including acute, primary and voluntary sectors. To manage a caseload and the care of patients independently whilst simultaneously recognising the limits of your knowledge and experience and seeking support appropriately. To work flexibly to meet service requirements which may include evening and weekend working. Personal and People Development To provide an effective learning environment and mentorship for staff, and for students in training ensuring their experience meets their learning needs. To participate in multidisciplinary team meetings to facilitate case management reviews and ensure critical learning that informs current and future care pathway development. To participate in appraisal and clinical supervision as part of the learning culture within Your Healthcare. To ensure own personal development through clinical supervision, appraisal and personal development plan, taking responsibility for own training and learning, reflection and professional registration requirements. Support the locality manager and community nursing team in the recruitment and retention of staff in the team. To provide leadership and professional support for the community nursing teams involved in receiving referrals of long term condition patients. As an independent prescriber participate in professional development that supports on-going personal development and ensures accountability and safety in prescribing decisions. Service Development To ensure that robust monitoring systems are in place to identify any required improvements to the quality of the patient experience and that clinical and care standards are maintained in line with organisational policies. To contribute actively and have a comprehensive understanding of national and local policy for older people and for people with long term conditions. To have a comprehensive understanding of safeguarding adults and specifically Protecting adults at risk: London multi-agency policy and procedures to safeguard vulnerable adults from abuse and the Kingston safeguarding adults local protocol. To ensure that the Mental Capacity Act is implemented as part of the on-going assessment and treatment processes for people who are case managed. This will include supporting the assessment of capacity and best interest decision making as appropriate. Participate in policy reviews and ensure dissemination to all team members. Undertake significant event reviews and complaint investigations including the development of action plans and reflective practice. To proactively contribute to the development of care pathways across acute/primary and community care that deliver continued improvement in community service provision. Quality To participate in the training and education of qualified and unqualified staff in gaining knowledge and experience and the maintenance of fundamental nursing skills. To ensure that records are kept up to date and evaluated to safeguard patients confidentiality by being aware of legal and ethical responsibilities. To ensure adherence to Your Healthcare Clinical Governance requirements, NICE guidelines and professional codes of conduct. To ensure that the Care Quality Commissions Core Standards are maintained and appropriate evidence is provided to contribute to Your Healthcare's registration. To identify and carry out appropriate audits as identified and agreed by the Adult Services Governance Sub-Group and included in the annual quality/audit calendar. Communication and working relationships To ensure accurate and contemporaneous records are kept and collect/collate data as required by the service and the YH policy/protocol in accordance with NMC guidelines. To identify patient groups by the use of case management tools and collate evidence of admission avoidance and reduction of secondary care use. To liaise with other disciplines and statutory and voluntary agencies to ensure that patient centred care is delivered in a manner acceptable to the patient, recognising individual cultures and beliefs. To act as a representative of Your Healthcare, communicating policy, procedures and standards in relation to care delivery and case management. To work collaboratively with internal teams and external agencies.