Assertive Outreach Team Leader

Job overview

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.

Main duties of the job

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

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.
• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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

• Assertive Outreach Delivery
• Clinical Responsibilities
• Holistic Support & Multi‑Agency Working
• In‑Reach to Inpatient Wards
• MDT Working & Communication
• Training, Supervision & Professional Development
• Management of Resources
• Research, Audit & Service Development
• Building and Maintaining Relationships with Local Community
• General

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.