Central and North West London NHS Foundation Trust
Assertive Outreach worker (Qualified)
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Job Overview
An exciting opportunity for an experienced Registered Mental Health Nurse (RMN) to join a developing Assertive Outreach pathway within the Westminster Community Mental Health Hub. The role focuses on engaging adults with severe mental illness (SMI) who are at risk of disengagement, with the aim of stabilising care, reducing risk, and preventing crisis.
The successful candidate will be an enthusiastic, proactive, and highly organised mental health professional, capable of delivering high-quality, evidence-based nursing care. They will demonstrate strong skills in assessment, care planning, and treatment, with a commitment to supporting individuals with complex mental health needs within a community setting.
Main Duties of the Job
The Assertive Outreach Worker will deliver time-limited and intensive support to adults with severe mental illness (SMI) who are at risk of disengaging from care. This role will involve delivering person-centred care, including assessment, care planning, risk management, and therapeutic interventions to individuals with complex needs.
The service will be delivered in close collaboration with colleagues from partner agencies. Therefore, the ability to work both independently and as part of a multidisciplinary team is essential.
The postholder will:
- Provide assertive, flexible, and persistent outreach, including home visits, community-based contacts, and phone/text engagement
- Act as a consistent keyworker, building therapeutic relationships with individuals who find it difficult to engage with services.
- Work within a stepped 6-month model of intensive support, transition, and reintegration into routine CMHH care.
- Deliver holistic, person-centred interventions addressing mental health, physical health, housing, substance use, and social needs.
- Work collaboratively with the CMHH MDT, crisis services, inpatient wards, and external agencies to ensure continuity of care and safe transitions.
This role requires strong clinical skills, excellent risk management, and the ability to work autonomously in the community.
Working for Our Organisation
You will be in a friendly and supportive environment, where we encourage personal and professional development.
You will be based within the Community Mental Health Hub within a large multi-disciplinary team.
There is access to in-house and Trust wide training to support you in developing clinical and leadership skills.
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We have community mental health hubs based in the North (Woodfield Road) and South (Nightingale place) of the borough. The team will work across both sites dependent on need.
Detailed Job Description and Main Responsibilities
Core Function
- Maintain accurate clinical records, care plans, and reports
- Supervise Band 4 staff
- Work both autonomously and collaboratively
You will act as a dedicated Assertive Outreach keyworker, holding a small caseload (10–15 patients) and delivering intensive, time-limited support over a structured 6-month model:
First 3 months: high-intensity engagement (≥3 contact attempts/week)
Next 3 months: step-down and transition phase (≥2 attempts/week)
Focus on reintegrating patients into routine CMHH care
Key Responsibilities
Outreach & Engagement
- Deliver assertive, flexible, and persistent outreach (home visits, community contacts, phone/text)
- Maintain a “no discharge for DNA” approach
- Build strong therapeutic relationships using empathy and trauma-informed care
Clinical Care
- Provide comprehensive mental health nursing care, including:
- Assessment and formulation
- Care planning and treatment
- Evidence-based interventions (e.g. CBT-informed approaches)
- Address holistic needs: mental and physical health, housing, substance use, and social factors
Risk Management
- Conduct robust initial and ongoing risk assessments
- Manage and escalate risk appropriately
- Work within Mental Health Act (MHA), Mental Capacity Act (MCA), and safeguarding frameworks
Care Coordination & MDT Working
- Collaborate closely with:
- CMHH multidisciplinary team (MDT)
- Crisis services and inpatient wards
- Statutory and voluntary agencies
- Coordinate interagency care plans and safe transitions
- Lead on step-down and discharge planning
Documentation & Leadership
Essential Key Skills & Requirements
- Registered Mental Health Nurse (RMN) with post-registration experience
- Strong skills in:
- Assessment, care planning, and therapeutic engagement
- Risk assessment and management
- MDT and interagency working
- Knowledge of MHA, MCA, NICE guidelines, and safeguarding
- Ability to prioritise workload and work independently
- Excellent communication, empathy, and resilience
Desirable
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- Non-medical prescribing
- Clinical skills (e.g. venepuncture, ECG)
- Experience working at Band 6 level
- Experience delivering evidence-based intervention
- Use therapeutic engagement to support patients to engage.
- Supervision of band 4 support staff
- To hold caseload of 10-15 patients
Person Specification
Qualifications
Essential Criteria
- Current Professional Qualification in either mental health nursing, social work, or occupational therapy.
- Registration must be live with professional body
- Evidence of post registration training and CPD.
Desirable Criteria
- Training in Psychosocial Interventions
- Other relevant training, e.g. psychosocial interventions
- Non-medical Prescriber
- Counselling qualification
- Venepuncture qualification
- ECG application qualification
Experience
Essential Criteria
- Substantial post-registration experience
- Experience of working in multidisciplinary mental health team with clients with acute/severe and enduring mental health problems
Desirable Criteria
- Work with clients with acute/severe and enduring mental health problems who are homeless/rootless
- Work with people experiencing mental health crisis.
- Supervision of students and junior staff.
- Audit and research; Teaching; Working with people who use substances
Skills and Knowledge
Essential Criteria
- Excellent verbal and written communication skills, including report writing and presentations / IT skills.
- Ability to assess, plan, implement, and evaluate a comprehensive care plans for the identified client group, using a wide range of resources.
- Able to develop a comprehensive programme of intervention and support for the identified client group and their families
- Skills in risk assessment and management.
- Can demonstrate understanding of psychosis and its impact on service users and carers
- Knowledge of current legislation and guidance applicable to this client group.
- Can demonstrate understanding of the needs of diverse groups, e.g. residents of inner city; black and minority ethnic groups, and skills in engaging with them.
- Skills in psychosocial interventions
Desirable Criteria
- Skills in leadership: ability to motivate others, use initiative, and manage change.
- Basic counselling and group work skills
- Dual diagnosis or experience working in substance misuse services
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