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Surrey Downs Health & Care

Working across organisational boundaries and as an integral part of the Surrey Downs Health and Care, the integrated health and care team is responsible for providing rapid access, enhanced, short term health and care support for people who would otherwise need emergency hospital admission as well for as those medically stable to return home from an acute hospital but requiring enhanced short term support as one stage in their on-going care pathway. The services aim to support people living as independently as possible by offering rapid multidisciplinary assessment and support at times of crisis.

The rapid response function provides assessment within 2 hours of referral and a short-term intervention to mitigate the risk of a hospital admission by providing service users with a short-term, high intensity package of care in the person’s own home as an alternative to hospital admission. Where admission has been unavoidable the team provide hospital in-reach with multidisciplinary discharge planning (community assessment, reablement, and support packages) to facilitate an early discharge from hospital and support people to return to their own homes as quickly as possible. Where on-going support is required the service provides on- going home based rehabilitation pathways and community bed based care.

Our service provide a 7 day / week service from 8am to 8pm working across both the community and hospital settings. Staff are required to work flexibly over the week covering, on average, one weekend within a four week roster period.

Surrey Downs Health and Care deliver care closer to people’s own communities through our Primary Care Networks, Community Hospitals, Specialist Services and our innovative partnership of local NHS organisations.

Surrey Downs Health and Care has a track record of providing person centered care that goes beyond organisational boundaries to do what is best for the individual. This partnership includes :

• The three GP federations GP Health Partners, Dorking Health Care and Surrey Medical Network representing practices that operate in the Surrey Downs area
• Epsom and St Helier’s University Hospitals NHS Trust
• Surrey Council County

Historically, there have been boundary lines between the organisations that provide care to people in their homes, in GP surgeries and in hospitals, but we have always been united in our mission to provide great care to the people who need us.

It’s on those grounds that the Surrey Downs Health and Care was formed – we want local people to receive the care that they need in the right environment. By bringing together our expertise, we can improve patient care and enable local people to access the right support, care and treatment more easily than ever before.

In bringing this partnership together, we are working to the same set of values that will translate into better care for our residents.

• Provide a clinical triage / assessment with inbound referrals and assign the appropriate urgency (i.e. 2 hr Rapid Response) and determine the best clinician to undertake the visit from their multi-disciplinary team.
• Support annual Learning Disability or Serious Mental Illness Health checks.
• Care coordination – both clinical and administrative, managing patient caseloads and offering proactive support (i.e. frequent attenders; support for cancer patients; CVD remote monitoring and support; blood pressure monitoring etc). i.e. Accept referrals from practices to proactively manage and support patients diagnosed with cancer, patients at risk of CVD and will act as a ‘step down’ from the Social prescriber / mental health team as appropriate to manage frequent attenders who have been discharged from their care with management plans in place.
• Anticipatory care – liaising with both primary, secondary and community teams to support the reduction of admission for patients with ambulatory care sensitive conditions and closing the hypertension diagnosis gap
• Enhanced Health in Care Homes – proactive and targeted visits for specific cohorts of patients
• To support the co-ordination with the delivery of all housebound annual vaccinations.
• Support and manage a small team of non-clinical care co-ordinators to support delivery of duties.
• Demonstrate clinical expertise and act as a professional role model to all co owners, both internal and external on behalf of SDHC, working as part of an integrated team taking the lead and developing services in line with the needs of the patient
• Treat all patients as individuals, respecting their privacy and dignity at all times
• Investigate and diagnose an unwell individual as part of the long term conditions clinical management
• Involving, supporting, informing and educating family / carers
• Promote the health of patients and the provision of support and advice
• Be responsible for planning cover, appropriate staffing and skill mix ensuring adequate cover when supporting community nursing teams or community matrons
• Provide specialist knowledge and advice to influence the SDHC strategic agenda
• Maintain clear and comprehensive, signed and contemporaneous records according to procedures
• Identify workforce planning issues and actively participate in the recruitment, selection and retention of clinical staff
• Provide support and an appropriate learning environment for both pre and post registration students as required
• Be responsible for ensuring that policies and procedures and standards of care, are adhered to at all times
• To work with other community matrons to ensure consistency of approach and share practice development
• Participate in research and development opportunities as appropriate
• Provide assistance with the resolution of complaints within the clinical specialty, or sphere of responsibility
• Have the ability to negotiate and work effectively across all agencies for the maximum effectiveness of care
• Undertake physical and social assessments and examinations and initiate appropriate diagnostics
• To work autonomously
• Help individuals with LTC to change their behaviour to reduce the risk of complications and improve their quality of life To work collaboratively with other specialist nurses and multidisciplinary teams such as GP’s, Community Nurses, Social Care and Voluntary Services
• Contribute to the development of Integrated care in the community
• Be aware of and act upon when necessary, procedures that are in place to protect vulnerable individuals
• Lead and implement the SDHC Clinical Governance Strategy within your practice area, facilitating and instigating clinical audit and monitoring of care
• Lead and implement the SDHC Risk Management Strategy within your practice area, ensuring that all processes are adhered to
• Maintain own professional and clinical integrity in line with NMC guidelines
• Undertake any other such duties as may be required from time to time as are consistent with the responsibilities of the post
• Be responsible for individual timely data entry and responsible for the corporate teams data entry
• Co-owners are employed to work within SDHC localities and may be reasonably requested to move base temporarily or on a more permanent basis, as requested by service needs
• To undertake clinical supervision and appropriate training for the role.

• 1st level registration with relevant post registration experience
• Evidence of continued professional development, with courses relevant to area of work
• Evidence of team management

• Management qualification
• Relevant Specialist courses

• Experienced mentor at pre and post registration level
• Previous experience of team management and multidisciplinary working

• Specialist knowledge

• IT skills and timely data entry
• Ability to assess and deliver, evaluate and benchmark quality care
• Critical analysis skills

• Project management skills

• Car owner with clean UK License
• Well organised
• Innovative and flexible

Please ensure that you have read the job description and person specification and that your supporting statement reflects these, as your application will be assessed and scored against these criteria.

You will be required to provide 3 years of employment / educational history. We do not accept references from personal email addresses such as Hotmail, Gmail etc. therefore please ensure you are providing professional working email addresses within your application form. If you are unable to provide professional email addresses and are invited to an interview, please ensure you advise the interviewers of this - otherwise, this may delay your pre-employment checks.

In order to streamline recruitment within our Trust, we reserve the right to expire vacancies prior to the advertised closing date once we have received a sufficient number of applications.

You will only be contacted via e‑mail / SMS if you are successfully shortlisted for this post. Please ensure that you check your Trac registered e‑mail regularly.

We are committed to safeguarding children and adults who are at risk of abuse. As such, if this post will have access to children or vulnerable adults, you will be required to undertake an Enhanced Disclosure and Barring Service check. However, all employees have a responsibility for safeguarding children and vulnerable adults in the course of their duties and for ensuring that they are aware of the specific duties relating to their role.

You must have appropriate UK professional registration.

This post is subject to the Rehabilitation of Offenders Act 1974 (Exceptions) Order 1975 (Amendment) (England and Wales) Order 2020 and it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service.

Name Nicole Smith Job title Operational Manager Email address Telephone number 07387139290