PCN Proactive Care Matron/ACP

Cross Gates Primary Care Ltd; Leeds; On-site; GBP 37,000 - 41,000; Part time

Job summary

Cross Gates Primary Care Ltd is recruiting a PCN Proactive Care Matron to deliver high-quality, person-centred care for patients with frailty and complex long-term conditions across East Leeds. The post involves autonomous clinical practice, assessment, prescribing and care planning within our proactive care team.

The role focuses on preventing hospital admissions, supporting independence and working with care homes, patients’ homes and community settings. Travel across East Leeds is expected.

Qualifications

• Registered NMC or HCPC professional.
• Master's degree in Advanced Clinical Practice (or equivalent).
• Advanced clinical assessment qualification.
• Postgraduate qualification in frailty, older people, long-term conditions or related field.

Responsibilities

• Deliver advanced clinical assessment, examination, diagnosis, treatment and prescribing for complex health needs.
• Undertake planned and urgent home visits and proactive frailty reviews.
• Develop and review personalised care plans and escalation plans with patients and carers.
• Support prevention, medicines optimisation and self-management initiatives.
• Utilise population health tools and dashboards to identify patients for proactive intervention.
• Collaborate with MDTs including primary care, community services and voluntary sector.

Skills

Advanced clinical assessment

Autonomous decision-making

Frailty & multimorbidity

Population health management

Communication across MDTs

Microsoft 365

Education

Master's degree in Advanced Clinical Practice (or equivalent)

Advanced clinical assessment qualification

Tools

Microsoft 365

Job description

Are you passionate about making a real difference to the lives of people living with frailty, complex health needs and long-term conditions? We are looking for a compassionate and experienced Proactive Care Matron/ACP to join our friendly and supportive Proactive Care Team at Cross Gates Primary Care Network. This is a unique opportunity to work proactively with patients who would benefit most from coordinated, personalised care, helping them stay well, maintain their independence and avoid unnecessary hospital admissions. If you enjoy building relationships, working collaboratively and delivering truly person-centred care, this is a role where you can make a lasting impact every day.

Main duties of the job

Working across care homes, patients' homes and community settings, you will support people with complex health and social care needs through comprehensive assessment, personalised care planning and partnership working. The role involves working closely with patients, carers and a wide range of health, social care and voluntary sector colleagues to ensure individuals receive the right care at the right time. You will also contribute to service development, quality improvement initiatives and the ongoing growth of our proactive care programme across the local population.

About us

Cross Gates Primary Care Network brings together Colton Mill and The Grange Medical Centre, Keystone GP Partnership and Family Doctors, serving around 33,000 patients across East Leeds. We are proud of our collaborative and inclusive culture, where colleagues support one another, share expertise and are united by a commitment to delivering outstanding patient care. Our multidisciplinary teams work closely with community services, social care, mental health providers and voluntary organisations to provide truly joined-up care. We value innovation, professional development and wellbeing, offering an environment where people are encouraged to contribute ideas, develop their careers and feel part of a team that genuinely makes a difference to local communities.

Job responsibilities

Job Title: PCN Proactive Care Matron

Band: Equivalent to NHS Agenda for Change Band 8a

Hours: Part-TimeEmployer: Cross Gates Primary Care Ltd

Base: Across Cross Gates Primary Care Network practices and community settings throughout East Leeds, including care homes and patients' homes.

Job Summary

The PCN Proactive Care Matron will be a senior autonomous clinician working within our established Proactive Care Team to deliver high-quality, person-centred care for patients at greatest risk of deterioration, avoidable hospital admission and loss of independence. The role focuses on supporting people living with frailty, multiple long-term conditions, complex health and social care needs, and residents of care homes.

Working across care homes, patients' homes and community settings, the postholder will provide advanced clinical assessment, diagnosis, treatment, prescribing and care planning, ensuring patients receive coordinated, proactive support that helps them remain as independent and well as possible.

Main Responsibilities

• Deliver advanced clinical assessment, examination, diagnosis, treatment and prescribing for people with complex or deteriorating health needs.
• Undertake planned and urgent home visits, care home ward rounds and proactive frailty reviews.
• Develop and review personalised care plans, anticipatory care plans and treatment escalation plans in partnership with patients, carers and multidisciplinary team colleagues.
• Support prevention, medicines optimisation, self-management and admission avoidance initiatives.
• Use population health management tools, proactive care dashboards and clinical intelligence to identify patients who would benefit from proactive intervention.
• Participate in multidisciplinary team meetings and work collaboratively with primary care, community services, mental health teams, social care, housing services and voluntary sector organisations.
• Contribute to vaccination programmes for care home residents, housebound patients and proactive care cohorts.
• Support quality improvement, clinical audit, service evaluation and ongoing development of proactive care services.
• Provide advice, support and learning opportunities for colleagues within the multidisciplinary team.

About the Service

Cross Gates Primary Care Network brings together Colton Mill and The Grange Medical Centre, Keystone GP Partnership and Family Doctors, serving approximately 33,000 patients across six sites in East Leeds. The Proactive Care Team works collaboratively with GPs, Advanced Clinical Practitioners, community providers, mental health services, geriatric medicine, specialist teams, Adult Social Care, housing services and voluntary sector partners to deliver integrated neighbourhood care.

Professional Standards and Governance

The postholder will be expected to maintain the highest standards of confidentiality, safeguarding, information governance, equality and diversity, health and safety, and professional accountability. Regular travel between practices, care homes and patients' homes across East Leeds will be required.

Person Specification

Knowledge and Skills

• Advanced clinical assessment, clinical reasoning and autonomous decision-making skills.
• Knowledge of frailty, multimorbidity and management of complex patient needs.
• Knowledge of population health management, health inequalities and wider determinants of health.
• Knowledge of clinical governance, safeguarding and risk management.
• Excellent communication skills and ability to work across multidisciplinary teams.
• Strong digital skills, including use of clinical systems and Microsoft 365.
• Knowledge of proactive care frameworks and community-based models of care.

Experience

• Advanced clinical practice experience.
• Experience managing complex patients autonomously.
• Experience working with frailty and older people.
• Experience of home visits and/or care home reviews.
• Experience of personalised care planning.
• Experience of multidisciplinary working.
• Experience of quality improvement, audit or service evaluation.
• Experience working within Primary Care Networks and/or integrated neighbourhood teams.
• Experience of population health management, risk stratification or proactive care cohort identification.

Qualifications

• Registered NMC or HCPC professional.
• Master's degree in Advanced Clinical Practice (or equivalent).
• Advanced clinical assessment qualification.
• Evidence of ongoing professional development.
• Postgraduate qualification in frailty, older people, long-term conditions, palliative care or a related field.

Disclosure and Barring Service Check

This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.

£36,817 to £41,440 a yearEquivalent to AFC band 8a