Job responsibilities
This role is focussed on providing appropriate, effective interventions and treatments to people with severe and enduring mental health needs, and their carers (including friends and relatives) and their supporters in the community, enabling and assisting them to meet daily health, social care and wellbeing needs, in line with personal recovery goals, and facilitating engagement with mainstream services. The post holder will also provide clinical leadership and supervision to team members.
Always under the framework of Your Team, Your Conversation, Your Plan. The post holder will be responsible for the ongoing assessment, planning delivery and review of activities and interventions against identified health, social care and wellbeing needs, acting as key worker for a defined group of service users. The role will also require undertaking and delivering specific health or social care assessments and interventions, including identified service users on other caseloads. This maybe either on a one to one basis, or as part of a group activity. Some regular out of hours working maybe required. recommendations for care and treatment within and across multiple care pathways.
Day to day leadership and support, will be provided by AWP managers, in conjunction with key contacts in primary care, such as a PCN GP Mentor. Access to senior clinical advice from the multi-disciplinary team at AWP will be available to support effective, clinical decision- making.
Description of the duties
To undertake the full range of activities required to deliver ongoing comprehensive mental health assessment for service users with severe and enduring mental health needs living in the community and in a range of settings. This will include:
a. The use of standardised assessment tools, i.e. the Cluster Allocation Support Tool (CAST), KGV
b. Recovery Star
c. History, strengths and aspirations
d. Mental state
e. Impact of culture and diversity
f. Functional needs
g. The needs of family and carer
h. Evaluation of risk
i. Physical health
j. Complicating factors
k. The interventions and treatments required to enable positive change.
l. Social care needs
m. Safeguarding and public protection
n. Capacity under the Mental Capacity Act
To be responsible for developing delivering and reviewing comprehensive and complex treatment programmes using appropriate frameworks in line with evidencebased practice, including strategies to manage risk for service users with complex needs and carers, bringing in other resources as required.
To act as Key worker for service users with the most complex needs, also providing defined interventions to individuals on other workers caseloads.
To plan, deliver and evaluate defined, specialist therapeutic interventions as indicated in the assessment process, in line with personal recovery plans, including to service users who maybe on other caseloads. This might include:
a. Individual or group therapeutic intervention
b. Psychological treatments such as CBT, DBT approaches, family interventions
c. Psychosocial interventions
d. Motivational and coping enhancement strategies.
e. Medication management
f. Interventions under the Mental Health Act,
To deliver a range of defined activities/interventions to improve the carers ability to support the service user and to enable them in their relationship with the service user.
To develop and maintain good partnership working with other services throughout all treatment episodes, including regular liaison within Primary Health Care Team, inpatient and intensive services, day services, voluntary sector and with nominated carers/advocates.
In collaboration with service users and carers, to be responsible for facilitating the development of complex comprehensive crisis plans, rapid access plans, advance statements etc, involving other agencies such as primary care etc where appropriate.
To personally build and lead others to build, hope inspiring relationships with service users, which acknowledge the personal journey of each person, and focus on strengths and aspirations to allow the creation of meaningful personal recovery plans.
To be responsible for maintaining own workload, as well as planning the workload of others, on a day to day basis, ensuring that time is prioritised effectively, utilising of electronic resources such as diaries/scheduling.
To be responsible for the protection of individuals from abuse and harm in line with local safeguarding policies and procedures, including working with others in the planning development and review of protection plans, ensuring the appropriate sharing of information.
Coordinating and undertaking protective interventions which maybe required in the protection of others, as outlined in the protection plan, taking individual action where indicated.
Personally and leading others to collaboratively and sensitively work with individuals,with a range of mental health needs to develop skills to manage their own health, in accordance with their personal recovery plan, by actively promoting and using approaches which are affirming, build onstrengths, identify past positive experiences and success, and use small steps to move towards the persons goal.
Undertake active clinical leadership and supervision within the team, covering for the manager and colleagues as required.
To maintain the single health and social care record, ensuring both paper and electronic records are kept up to date in accordance with professional and organisational standards.
Report and record within agreed timeframes, all activity relating to information reporting and performance requirements.
To participate in management, caseload and clinical supervision in accordance with trust policy.
To provide mentoring/training for others in relevant practice areas, according to professional requirements, taking a collaborative approach to practice development and evidence-based care. Specifically this means providing a safe and effective learning environment for the mentoring and supervising of students , participating in their learning objectives and assessments
Demonstrate responsibility for developing own practice in line with professional qualifications and for contributing to the development of others, by making use of and providing, effective feedback, supervision, coaching and appraisal.
Monitor and maintain health, safety and security of self and others, undertaking assessments and taking appropriate action where required.
Develop own knowledge and practice, and contribute to the development of others, making use of available feedback, supervision and appraisal to identify appropriate areas of development for this work role, taking responsibility for accessing identified learning and training opportunities.
Lead, maintain and participate in practices which enable effective team working.
To participate in on call rotas as required.
To participate in local arrangements in order to ensure consistent care to service users across the local geography.
Communications and Working Relationships
Services Users and Carers
Health and social care teams
Primary care
Third sector/voluntary agencies
Community groups and local authority provision
Other statutory agencies
Most challenging part of this role
Individually, and through leadership and supervision to co-ordinate the care of individuals within an individual and across a wider defined caseload, to develop increasing skill and confidence with a wide range of health, social care and wellbeing needs, setting priorities and working in community based settings. To contribute to the development of a culture where the personal and positive aspirations of service users are the primary focus of the Wellbeing plan, while developing and maintaining individual skills in delivering a range of therapeutic interventions. This must be achieved whilst respecting the dimensions of personal choice, diversity and culture and the benefits which these bring to the therapeutic relationship.
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