A new exciting opportunity has arisen for a Team Leader role for the Assertive Outreach function of the Bentley House Community Mental Health Hub. We are looking for an experienced Mental Health Nurse/Occupational Therapist/Social Worker to join our dynamic team. The post holder will work with adults in the community with severe and enduring mental illness who are at risk of disengaging with the service. The post holder will oversee the staff working with this client group, and facilitate collaborative work with the wider team.
The role is suitable for a qualified clinician with experience working in the community. Applicants should have strong clinical and risk management skills, and be able to work flexibly.
The post holder will work as a Team Leader with duties including:
Manage a complex caseload of patients with SMI and dual diagnosis, and have oversight of patients receiving assertive outreach interventions
To offer patients assertive and intensive time-limited support with the aim of building engagement, stabilising risk and preventing crisis.
Work collaboratively with the consultants, CMHH MDT and Psychotropic Clinic.
To coordinate referrals and transfers of care between teams
Be responsible for the supervision of staff
Chair clinical and team meetings as appropriate
To assist the team to be compliant with KPI and monitor electronic records
Commitment from the team to develop you by offering in-house development sessions
Free access to our Staff and Wellbeing service to ensure that you are always looking after yourself
Commitment to career mapping to ensure continuous professional development including opportunities within the Trust
On and off-site shadowing opportunities , including HTT, Psych Liaison and many more
Local nursing, social work or OT forums run by one of the senior leads
An opportunity to work with a friendly, dynamic, passionate and diverse team who are committed to looking after each other as well as their patients
Regular training opportunities including Trauma Informed Approach
MAIN DUTIES AND RESPONSIBILITIES
1. Assertive Outreach Delivery
Provide intensive outreach in line with the SOP:
First 3 months: minimum 3 contact attempts per week, aiming for 1–2 successful contacts.
Next 3 months: minimum 2 contact attempts per week.
Deliver flexible contact through home visits, community meetings, phone calls, texts, and occasional evening/weekend availability.
Maintain a “no discharge for DNA” approach, using persistent and creative engagement strategies.
Build strong therapeutic relationships through empathy, reliability, and trauma‑informed practice.
Provide continuity and consistency as the allocated Assertive Outreach named worker.
2. Clinical Responsibilities
Complete and update care plans , risk assessments , and safety plans in line with Trust policy.
Conduct frequent dynamic risk assessments and escalate concerns promptly.
Lead on transition planning back to routine CMHH care.
Ensure timely documentation of all contact attempts, outcomes, and risk assessments.
Work collaboratively with the Hub named worker where this is a separate role.
Deliver meaningful intervention
Use therapeutic engagement to support patients to engage.
Supervision of Assertive outreach staff
To hold a case load of 10-15 patients.
3. Holistic Support & Multi‑Agency Working
Address mental health and physical health
Liaise with other partners regarding identified needs e.g. drug and alcohol services, social care, housing teams, and voluntary sector partners.
Support individuals to access practical help such as housing applications, benefits, and community resources.
Involve families and carers (with consent) to strengthen support networks.
4. In‑Reach to Inpatient Wards
Provide continuity of care during hospital admissions.
Attend inpatient wards to maintain engagement and support discharge planning.
Ensure safe and coordinated transition back to community services.
5. MDT Working & Communication
Participate in MDT meetings and AO huddles.
Share updates, escalate concerns, and contribute to joint care planning.
Maintain strong links with crisis services, inpatient teams, and external agencies.
Promote reflective practice and collaborative working within the team.
6. Training, Supervision & Professional Development
Maintain professional registration and adhere to relevant legislation (MHA, MCA, Care Act).
Participate in clinical supervision, reflective practice, and mandatory training.
Contribute to team learning, including sharing specialist knowledge related to your profession.
Support students or trainees where appropriate.
To participate in training relevant to post.
7. Management of Resources
Work within CNWL policies including lone working, safeguarding, risk management, and health & safety.
Ensure accurate and timely record‑keeping.
Contribute to monitoring caseloads, contact frequency, and clinical review processes.
Use Trust systems (e.g., Tableau disengagement dashboards) to support identification of risk patterns.
8. Research, Audit & Service Development
Contribute to audits, service evaluation, and quality improvement initiatives.
Ensure practice is evidence‑based and aligned with the Assertive Outreach SOP.
Participate in the development of the AO model and wider CMHH pathways.
Recording caseload activity on system one and ensuring accurate recording
To report on team performance in terms of patient feedback and productivity and DNA rates.
9. Building and Maintaining Relationships with Local Community
Work collaboratively with community organisations, primary care, and voluntary sector partners.
Support individuals to access community resources that promote stability and recovery.
Maintain strong links with other CNWL community and inpatient teams.
10. General
Abide by legal requirements and the professional code of conduct for your discipline.
Undertake any other duties relevant to the post as requested by senior managers.
Promote equality, diversity, and inclusion in all aspects of practice.
RIDING CLAUSE
This job description is an outline of the postholder’s duties and responsibilities. It is not exhaustive and may be amended to meet the changing needs of the service.
