Go back Central and North West London NHS Foundation Trust
Mental Health – Integrated Discharge Team Social Worker
The closing date is 30 July 2025
The post holder will sit organisationally within the Urgent and Emergency Care pathway of Inpatient Services and be present on the inpatient wards within a defined geographical area working with an identified caseload to enable effective discharge planning.
As this is a patient facing role the post holder will need to be on-site daily to meet with Patients individually or in small groups and attend MDT/White Boardrounds.The post holder will need to have 2 years experience as a qualified social worker and experience of working with people with mental health social needs either in the community or in-patient settings.
Main duties of the job
The post holder will work in a targeted way to achieve the best pathway out of hospital, maximizing independence and choice for the individual and working in a solution focused way to ensure that once ready, there are no barriers in place to effect patients discharge's.The post holder will use the strengths based social model of care when carrying out their duties with a home first as standard practice and all other pathway being discussed as part of the multidisciplinary team.The post holder will work with individuals, families and carers, community services, housing and social care departments, third sector organisations, and other relevant agencies/parties to ensure smooth transition to the community from hospital.The post holder will work with individuals identified through their attendance and participation at Daily Whiteboard Meetings and Weekly Bed Management/Patient Flow Meetings, Weekly Clinically Ready for Discharge (CRFD) meetings and MDT/Professional meetings as required.
About us
OUR VALUES
Compassion: Our staff will be led by compassion and embody the values of care outlined in our Staff Charter.
Respect: We will respect and value the diversity of our patients, service users and staff, to create a respectful and inclusive environment, which recognises the uniqueness of each individual.
Empowerment: We will involve, inform and empower our patients, service users, carers and their families to take an active role in the management of their illness and adopt recovery principles. We will ensure our staff receive appropriate direction and support, to enable them to develop and grow.
Partnership: We will work closely with our many partners to ensure that our combined efforts are focused on achieving the best possible outcomes for the people we serve.
The successful applicant may have contact with patients or service users. As an NHS Trust we strongly encourage and support vaccination as this remains the best way to protect yourself, your family, your colleagues and of course patients and service users when working on our healthcare settings.
Job responsibilities
The post holder will coordinate the DTOC (and pre-DTOC) list for the Borough and attend the weekly DTOC meeting as a matter of routine to update on progress and highlight any potential blocks that they have been unable to resolve.
* Using strengths based social work practice tomanage a specific caseload of individuals who are inpatients and patients on HTT caseload and have potential barriers to discharge identified early on, in their inpatient stay or admission to HTT. Pre-empt and resolve arising barriers to discharge and length of stay.
* Ensure that patient care is provided in the most appropriate care setting to ensure effective and efficient treatment and that there is a clear and robust discharge plan. This will involve attendance on wards for specific discussions including White Board meetings, CPA meetings and s117 discharge planning meetings.
* Attend the weekly bed management meetings and take an active role in challenging delays in discharge.
* Develop positive working relationships with key stakeholders, including local commissioners (health & local authority)
* To develop effective relationships with housing providers, tenancy support teams and benefit agencies specific to the Borough.
* Verification of purpose of admission and expected length of stay for all new admissions to the hospital. Ensure ward staff have identified an Expected Date of Discharge (EDD) and identify likely pathway out of hospital early during their inpatient stay.
* Ensure that tenancies are maintained whilst in hospital and that independence is maximised on discharge.
Person Specification
Education / Qualifications
* Social Work Qualification
* Current HCPC Registration.
* Evidence of continuing professional development.
* Professional Expertise
Experience
* Working with people presenting in mental health crisis and their families/carers
* Multi-agency working/working across service interfaces
* Experience of applying legislation in practice including Care Act, MCA and s117
* Experience of using strengths based approaches to support individuals to maximise independence and achieve their goals
* Experience of presenting cases to funding panels.
* Experience of working with housing and specialist service
* Experience of working to deadlines
* Experience of safeguarding adults at risk and children
Skills & Abilities
* Communicating (oral and written) complex/highly technical and clinically sensitive information to clients, their families, carers and other professional colleagues both within and outside the NHS.
* Able to meet the service needs for mobility across the geographical area covered
* Able to recognise and respect the values of diverse perspectives
* Able to demonstrate commitment to high quality care and service provision
* Demonstrate the ability to liaise effectively with other agencies, both statutory and non-statutory
* Able to build and maintain relationships with a diverse group of colleagues, service users and partners to increase understanding
* Demonstrates the ability to empower the team to create solutions
* Ability to prioritise workload and ensure all documentation is current and up-to-date
* Evidenced based strengths based social work interventions relevant to the service
* Knowledge of key issues relating to developments in adult mental health services at a local and national level
* Knowledge and understanding of funding panel processes
* Possess extensive knowledge of the mental health legislative framework for health and social care
* Expert knowledge of Mental Health Act, Care Act, Mental Capacity Act including Court of Protection, Homelessness Reduction Act and Housing legislation.
* Use of SystmOne
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.
Central and North West London NHS Foundation Trust
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