Assertive Outreach Team Leader

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 or 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.

Main duties of the job

• Manage a complex caseload of patients with SMI and dual diagnosis, and have oversight of patients receiving assertive outreach interventions.
• 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.
• Coordinate referrals and transfers of care between teams.
• Be responsible for the supervision of staff.
• Chair clinical and team meetings as appropriate.
• Assist the team to be compliant with KPI and monitor electronic records.

Working for our organisation

• 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.

Detailed job description and main responsibilities

Main Duties and Responsibilities

• 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.

Clinical Responsibilities

• Complete and update care plans, risk assessments and safety plans in line with Trust policy.
• Conduct frequent dynamic risk assessments and escalated 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.
• Supervise Assertive outreach staff.
• Hold a case load of 10‑15 patients.

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.

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.

MDT Working & Communication

• Participate in MDT meetings and AO huddles.
• Share updates, escalated 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.

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.
• Participate in training relevant to post.

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.

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.
• Record caseload activity on system one and ensure accurate recording.
• Report on team performance in terms of patient feedback, productivity and DNA rates.

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.

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.

Person Specification

Qualifications

• Relevant diploma or degree in Mental Health Nursing, OT or Social Work.
• Registration with NMC, HCPC or Social Work England.
• Relevant post‑basic training for all disciplines.
• Mentorship qualification relevant to professions.
• Management training.

Experience

• Significant years post‑qualifying experience at Band 6 level.
• Experience working with a complex and high‑risk caseload of patients with SMI in the community.
• Assessing health and social needs and formulating care plans to reflect those needs.
• Working in a multi‑cultural environment.
• Experience working with individuals with substance misuse.
• Experience working in a multidisciplinary team.
• Practical experience of providing high quality care and exceeding expectations.
• Demonstrated understanding of safeguarding children and adult practices and procedures.
• Experience providing supervision to junior staff.
• Evidence of continuing professional development.
• Budgetary management.

Skills / Abilities

• Ability to chair regular MDT meetings with strong leadership skills.
• Highly proactive and responsive to day‑to‑day demands of working in a busy CMHT.
• Experience of using a range of therapeutic skills and psychosocial interventions.
• Strong clinical and risk assessment skills.
• Able to build constructive relationships with warmth and empathy using good communication skills.
• Ability to succinctly formulate clinical intervention including signposting to other community services.
• Teaching and delivering group or individual presentations.
• Experience of policy development, strategic planning and clinical governance development resulting in change‑management projects or programmes.
• Knowledge of Mental Health Act 1983, Care Act 2014, Mental Capacity Act 2015.
• Risk assessment and management.
• Highly skilled in IT applications such as Excel and Word.
• Knowledge of new developments in social care and allied health professions.
• Ability to embrace and manage change effectively and sensitively within the team and the wider organisation.
• Proficient in utilising Tableau to monitor team and individual performance.

Other

• Willingness to undertake further training and professional development.
• Possession of a valid driving licence.
• Able to recognise signs of stress in self and others.