Assertive Outreach (Community Psychiatric Nurse)
Job Description
Job summary
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. The role is central to stabilising engagement, reducing risk, and preventing crisis escalation, in line with the Assertive Outreach Standard Operating Procedure.
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.
The role requires strong clinical skills, excellent risk management, and the ability to work autonomously in the community.
Main duties of the job
Assertive Outreach Delivery
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 AO keyworker.
About us
In this development post, you will be provided additional supervision and support as well as community specific training. You will be working in a team that prides itself on promoting innovation and working to the highest standards of clinical care as evidenced by the services ongoing Quality Improvement Projects. Commitment from the team to develop you as a practitioner by offering coaching, supervision development, reflective practice and in-house development sessions
Job responsibilities
Clinical Responsibilities
- 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 CMHH Care Coordinator where this is a separate role.
- Deliver meaningful intervention
- Use therapeutic engagement to support patients to engage.
- Supervision of band 4 support staff
- To hold case load of 10-15 patients.
Holistic Support & MultiAgency Working
- Address mental health, physical health, housing, finances, substance use, and social needs.
- Liaise with 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.
InReach 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 daily zoning/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.
Person Specification
Qualifications
Essential
- Registered Nurse qualification with current NMC registration or equivalent Allied Health Professional with current professional registration.
Desirable
- Educated to Masters level or equivalent
- Post Graduate management training/qualification
Experience
Essential
- Substantial Experience of working in the community mental health
- Working with other stakeholders. LA/ICB and inpatient staff.
- Experience of working with complex and high risk patients with SMI
- Experience in working with patients who have dual diagnosis/ patients who use drug and alcohol
- Demonstrable experience in safeguarding children /adult practice and procedures.
- Experience of supervision of junior staff
- Proven experience of managing a multi-disciplinary team including senior managers and clinicians.
- Experience of working within statutory and other regulatory frameworks within which health and social care services operate and translating these at an operational level
Desirable
- Teaching and delivering group/individual presentations
- Experience of policy development and strategic planning and clinical governance development resulting in change management projects/programmes.
- Ability to negotiate complex contracts with the approval of the Senior Manager
Knowledge
Essential
- Understands & promotes equality, diversity and human rights in accordance with legislation, policy and procedures
- Understanding of confidentiality in the workplace
Other
Desirable
- Full UK Driving License/Car Driver
Key Skills and Abilities
Desirable
- Ability to develop & maintain high standards of communication both orally and in writing with people about difficult matters & / in difficult situations
- Ability to prioritise & plan own workload to meet deadlines & competing demands
- Ability to negotiate and influence where appropriate
- Excellent interpersonal skills
- Excellent analytical and judgment skills.
Disclosure and Barring Service Check
This post is subject to the Rehabilitation of Offenders Act (Exceptions Order) 1975 and as such it will be necessary for a submission for Disclosure to be made to the Disclosure and Barring Service (formerly known as CRB) to check for any previous criminal convictions.
Certificate of Sponsorship
Applications from job seekers who require current Skilled worker sponsorship to work in the UK are welcome and will be considered alongside all other applications. For further information visit the UK Visas and Immigration website (Opens in a new tab).
From 6 April 2017, skilled worker applicants, applying for entry clearance into the UK, have had to present a criminal record certificate from each country they have resided continuously or cumulatively for 12 months or more in the past 10 years. Adult dependants (over 18 years old) are also subject to this requirement. Guidance can be found here Criminal records checks for overseas applicants (Opens in a new tab).
UK Registration
Applicants must have current UK professional registration. For further information please see NHS Careers website (opens in a new window).
Employer details
Employer name
Central and North West London NHS Foundation Trust
Address
Bentley House Harrow
15-21 Headstone Drive
Harrow
HA3 5QX
United Kingdom
