PCN Proactive Care Matron/ACP

NHS Jobs; Leeds; On-site; GBP 40,000 - 60,000; Part time

Job summary

Cross Gates Primary Care Network is seeking a PCN Proactive Care Matron (Band 8a) to lead proactive, person-centred care for patients at greatest risk of deterioration across East Leeds, including care homes and patients' homes.

The post holder will deliver advanced clinical assessment, diagnosis, treatment and prescribing, develop care plans, and work with GPs, community teams and housing services to prevent hospital admissions and support independence.

Qualifications

• Senior autonomous clinician delivering advanced clinical assessment, diagnosis, treatment and prescribing for complex health needs.
• Developing and reviewing personalised care plans and escalation plans with patients and multidisciplinary teams.
• Supporting prevention, medicines optimisation and admission avoidance initiatives.

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.

Skills

Autonomous clinician

Advanced clinical assessment

Care home & community care

Frailty management

Tools

Proactive care dashboards

Job description

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.