Assertive Outreach Team Leader

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 12 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 traumainformed 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 & MultiAgency 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. InReach 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 recordkeeping. • 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 evidencebased 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 postholders duties and responsibilities. It is not exhaustive and may be amended to meet the changing needs of the service. Job description Job responsibilities 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 12 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 traumainformed 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 & MultiAgency 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. InReach 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 recordkeeping. • 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 evidencebased 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 postholders duties and responsibilities. It is not exhaustive and may be amended to meet the changing needs of the service.