Community Matrons

Community matrons are experienced and skilled nurses who use case management techniques with patients who meet criteria denoting very high intensity use of healthcare.

The community matron role combines traditional nursing care with aspects of the medical model – but also combines ‘generalist’ and ‘specialist’ skills. This enables community matrons to develop advanced knowledge and skills, and to work in a highly autonomous way to deliver proactive and holistic patient care:

  • Combine high level assessment of physical, mental and social care needs
  • Enable each patient to have a personalised care plan based on their needs preferences and choices
  • Provide clinical care and health promoting interventions – including teaching patients and carers about warning signs of complications or crisis
  • Improve patients ability to function and their quality of life
  • Help patients and their carers plan for the future
  • Increase choice for patients
  • Review medication and prescribe medicines via independent and supplementary prescribing arrangements
  • Build partnerships with other professionals, including secondary care clinicians and social services, to ensure all patient needs are met
  • Enable patients to remain in their homes and communities
  • Liaise with a range of secondary care services
  • Help to prevent unnecessary admissions to hospital
  • Reduce length of stay of hospital patients
  • Integrate all elements of care
  • Support effective primary care
  • Improve end of life care
  • Support patients families

The team

The team consists of one clinical leader, 20 community matrons who are all trained highly skilled nurses and one health care support assistant who has received training to perform advanced support.

Who do we work with?

The community matron team works with patients in their own homes with complex long term health conditions.

What happens during the home visit?

The community matron will carry out an holistic assessment of your health and social care needs and will support you to develop a personalised plan of care. This may include physical assessment and examinations.

Where are we based?

West Acklam Clinic
Guisborough Primary Care Hospital

When are we available?

The community matron service currently operates between the hours of 9am and 5pm Monday to Friday.

Community matron contact numbers

  • Middlesbrough – 01642 368000
  • Eston – 01642 511604
  • Guisborough – 01287 284130
  • East Cleveland – 01287 655010