Assertive Outreach worker (Qualified)

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.

Detailed job description and main responsibilities

• Maintain accurate clinical records, care plans, and reports Supervise Band 4 staff Work both autonomously and collaboratively Core function 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   Key skills & requirements Essential 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 Non-medical prescribing Clinical skills (e.g. venepuncture, ECG) Experience working at Band 6 level Experience delivering evidence-based intervention
• Maintain accurate clinical records, care plans, and reports
• Supervise Band 4 staff
• Work both autonomously and collaboratively Core function 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
• 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
• 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
• Provide comprehensive mental health nursing care, including: Assessment and formulation Care planning and treatment Evidence-based interventions (e.g. CBT-informed approaches)
• 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
• 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
• Collaborate closely with: CMHH multidisciplinary team (MDT) Crisis services and inpatient wards Statutory and voluntary agencies
• 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
• 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
• 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
• 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 case load of 10-15 patients