Community Matron

Job summary

We have an exciting opportunity for an experienced, motivated and compassionate clinician to join our Community Matron Service at CSH Surrey, based at Thames Medical Hub Walton Hospital

As a Community Matron, you will play a key role in providing proactive, personalised care to people living with frailty, complex health needs and long-term conditions. Working within our community services, you will support patients to remain as well and independent as possible in their own homes, helping to prevent avoidable hospital admissions and supporting safe and timely discharge from hospital.

We are looking for an experienced clinician who enjoys working autonomously while also being an integral part of a wider multidisciplinary team. You will need excellent clinical assessment, decision-making and communication skills, together with a genuine commitment to delivering high-quality, person-centred care.

This is an excellent opportunity to join a supportive community service where you can use your clinical expertise to make a real difference to patients, their families and carers.

Please note that Visa sponsorship is not available for this position. Candidates must possess valid UK right-to-work documentation.

Interviews will be held between 2nd to 6th November 2026.

Main duties of the job

As a Community Matron, you will provide proactive clinical assessment, care planning and case management for patients with complex health needs, frailty and/or multiple long-term conditions

Your main responsibilities will include:Undertaking comprehensive, holistic clinical assessments and identifying patients' individual health and care needs.

• Proactively managing a caseload of patients with complex needs and coordinating their care.
• Developing personalised management and care plans in partnership with patients, families and carers.
• Identifying deterioration or changes in a patient's condition and supporting timely intervention to reduce the risk of avoidable hospital admission.
• Supporting patients following discharge from hospital and working with colleagues to promote safe, coordinated care within the community.
• Working collaboratively with GPs, community services, acute services, social care and other members of the multidisciplinary team.
• Supporting patients and carers to understand and manage long-term conditions, promoting independence, self-management and informed decision-making.
• Making appropriate referrals and coordinating input from other health, social care and voluntary sector services according to individual patient needs.
• Providing clinical leadership, advice and support to colleagues and contributing to the ongoing development of high-quality community services.

About us

CSH Surrey are part of the NHS and are Surrey's longest established NHS community services provider, so our employees get NHS pay and pensions, and also receive the Fringe High-Cost Allowance of 5%.

Our staff enjoy excellent training and development opportunities, including the care certificate, apprenticeships, numeracy and literacy courses, access to the Nursing Associate programme, and a wide variety of management and leadership courses and programmes.

We CARE about our staff though through our values of Compassion, Accountability, Respect and Excellence. Our active employee council called The Voice, elect employee representatives to ensure colleagues' voices are heard at Board level. CSH is a diverse organisation, if you are a passionate, person-focused individual then apply to join CSH Surrey today!

We welcome candidates from all backgrounds who meet the essential criteria of the job you are applying for and if you require any reasonable adjustments, please contact the named individual for this advert, or our recruitment team.

Job responsibilities

Job Purpose

The Frailty Hub Matron will deliver expert clinical care, support and advice to people living with frailty, complex health needs and long-term conditions.

The post holder will work as an integral member of the multidisciplinary team, working closely with GPs, community nursing, social care, mental health services, medicines management and the voluntary sector.

The post holder will lead and facilitate a patient-focused, coordinated case-management approach for people who are vulnerable or at high risk of an unnecessary hospital admission, enabling them to maintain their health, wellbeing and independence wherever possible.

Main Duties and ResponsibilitiesAdvanced clinical assessment and case management

• Identify people at increased risk of deterioration, decline in health or wellbeing, or unnecessary hospital admission.
• Undertake comprehensive and holistic assessments, considering physical, psychological and social needs as well as the needs of carers.
• Develop individualised, patient-centred care plans in partnership with patients and those supporting them.
• Use advanced clinical assessment and decision-making skills to recognise changes in condition and initiate appropriate interventions.
• Interpret clinical information and assessment findings to inform decisions about treatment, care and onward referral.
• Maintain responsibility for the proactive management and coordination of an identified caseload.
• Promote early recognition of exacerbation or deterioration and timely intervention to improve patient outcomes and reduce avoidable hospital admission.

Frailty and proactive care

• Provide specialist assessment and management for people living with frailty, multiple long-term conditions and complex health and social care needs.
• Promote independence, enable self-management and support people to remain safely within their usual place of residence wherever clinically appropriate.
• Work proactively rather than waiting for an acute deterioration in the patient's condition.
• Provide patients and carers with information and education to support understanding and management of long-term conditions.
• Ensure personalised care planning reflects what matters to the individual, their goals and their changing clinical needs.

The wider CSH Surrey locality hub model describes a strong proactive offer aimed at coordinating preventative services and helping people maintain wellbeing and independence.

Admission avoidance and integrated working

• Identify opportunities for early intervention to prevent avoidable deterioration and hospital attendance or admission, and work alongside CSH Virtual Ward referring appropriate patients in for admission avoidance
• Coordinate care across organisational and professional boundaries.
• Work closely with primary care, community services, acute care, social care, mental health, voluntary organisations and other relevant services.
• Support safe and coordinated transitions of care between hospital and community settings.
• Contribute to multidisciplinary discussions and ensure patients receive coordinated, timely interventions.
• Act as an effective clinical link between services to support seamless care.

Clinical decision-making

• Work autonomously and exercise professional judgement when assessing and managing patients with complex needs.
• Recognise clinical deterioration and take appropriate action, including escalating or referring to other services where required.
• Review and evaluate care interventions, changing the management plan in response to the individual's condition or circumstances.
• Make appropriate onward referrals and coordinate specialist input according to individual need.
• Maintain accurate, timely and comprehensive clinical documentation.

Multidisciplinary team working

• Work collaboratively with the wider Frailty Hub multidisciplinary team.
• Build effective relationships with GPs, community nursing, therapy services, pharmacy, mental health, social care and voluntary-sector colleagues.
• Participate actively in MDT meetings and complex case discussions.
• Ensure effective communication between professionals, patients and carers.
• Promote a coordinated approach that reduces fragmentation and duplication of care.

Leadership and professional responsibilities

• Provide clinical leadership and act as a source of specialist advice within the Frailty Hub.
• Promote high standards of evidence-based, person-centred care.
• Support colleagues through clinical advice, supervision, coaching and shared learning.
• Contribute to service improvement and the continued development of integrated frailty services.
• Promote a positive culture of learning, professional development and multidisciplinary working.
• Maintain professional registration and practice within the appropriate professional code, organisational policies and scope of practice.

Key focus of the role

The Frailty Hub Matron will be expected to bring together advanced clinical practice, proactive frailty management and care coordination, with the overarching aim of:

identifying deterioration early coordinating timely interventions supporting independence preventing avoidable hospital attendance/admission providing joined-up care around the patient.

Person specification

Qualifications

Essential

• 1st level registered nurse
• Qualification equivalent to level 7 / PGdip / Masters level
• NMP qualification or working towards
• Mentorship qualification
• Clinical Supervisor

Desirable

• Non medical prescribing

Experience

Essential

• Significant post-registration clinical experience, including experience caring for people with frailty, complex needs and/or multiple long-term conditions.
• Experience of undertaking holistic assessment and developing individualised, patient-centred care plans.
• Experience of managing patients at risk of deterioration or avoidable hospital admission.
• Experience of working autonomously and making clinical decisions within professional scope of practice.
• Experience of coordinating complex patient care across services.
• Experience of multidisciplinary and multi-agency working.
• Experience of supporting patients and carers to understand and manage long-term conditions.
• Experience of providing clinical leadership, advice and support to colleagues.
• The CSH role specifically identifies proactive management of patients at high risk of admission, holistic nursing assessment incorporating physical, psychological and social needs, and coordinated case management as key responsibilities.
• Knowledge and skills
• Strong knowledge and understanding of frailty and the management of complex long-term conditions.
• Excellent clinical assessment and clinical decision-making skills.
• Ability to recognise deterioration and take appropriate action.
• Ability to prioritise and manage a complex caseload effectively.
• Ability to work independently while contributing effectively to the wider multidisciplinary team.
• Excellent communication and interpersonal skills, including the ability to communicate effectively with patients, carers and professionals across organisational boundaries.
• Ability to develop and maintain effective working relationships with primary care, community services, social care, mental health and other partner organisations.
• Commitment to personalised care, promoting independence and supporting patients to remain safely within their usual place of residence wherever appropriate.
• Good organisational, prioritisation and time-management skills.
• Ability to maintain clear, accurate and contemporaneous clinical records.
• The existing CSH Frailty model involves multidisciplinary working across areas including GPs, community nursing, social care, mental health, medicines management and voluntary-sector services.
• Leadership and personal qualities
• Ability to provide clinical leadership and act as a positive role model.
• Ability to support, develop and share knowledge with colleagues.
• Able to work collaboratively and influence effective patient care across professional and organisational boundaries.
• Demonstrates a compassionate and person-centred approach.
• Adaptable and able to respond effectively to changing patient and service needs.
• Commitment to continuous improvement and high-quality care.
• Able to work effectively both independently and as part of a team.

Desirable

• Ability to work across the required community/neighbourhood footprint.
• Able to work flexibly in accordance with service requirements.
• Enhanced DBS clearance as required for the post.