Discharge and Community Liaison Social Worker

Job Description

The post holder provides specialist social work support to older adults with functional mental health needs admitted to MHSOP inpatient wards. As a key member of the MDT, the post holder leads on social care assessment, care planning, and discharge coordination, ensuring safe, timely, and person-centred transitions from hospital to community settings.

Using a strengths-based and recovery-focused approach, the post holder promotes independence, wellbeing, choice, dignity, and least restrictive practice while safeguarding vulnerable adults. Acting as a key link between inpatient and community services, they work collaboratively with service users, carers, and partner agencies to coordinate discharge arrangements, overcome barriers to discharge, and secure sustainable outcomes.

Key Responsibilities:

• Provide advice and advocacy to service users, carers, and families.
• Lead discharge planning from admission, coordinating safe, timely discharges by identifying and addressing barriers and arranging appropriate support, including domiciliary care, residential and nursing placements, supported living, reablement, equipment, and Section 117 aftercare.
• Undertake Carer Assessments, Care Act Assessments, Mental Capacity Assessments, and contribute to Best Interests decision-making.
• Promote safeguarding practice, undertake safeguarding enquiries where required, and contribute to risk assessment and management that balances protection, independence, and least restrictive practice.
• Provide professional advice to multidisciplinary colleagues on social care legislation, safeguarding, NHS Continuing Healthcare, ordinary residence, and charging responsibilities.
• Represent social work within MDT meetings, ward rounds, and discharge forums, advocating for the rights, wishes, and wellbeing of service users and carers.
• Maintain accurate records and statutory documentation.
• Contribute to quality improvement, audits, and integrated working.
• Participate in supervision and continuing professional development.
• Support students and newly qualified staff.
• Comply with Trust policies, procedures, and professional standards.