Discharge and Community Liaison Social WorkerNHS

Job summary

The post holderprovides specialist social work support to older adults with functional mental health needs admitted to MHSOP inpatient wards. As a key member of the MDT, the post holder leads on social care assessment, care planning and discharge coordination, ensuring safe, timely and person-centred transitions from hospital to community settings.

Using a strengths-based and recovery-focused approach, the post holder promotes independence, wellbeing, choice, dignity and least restrictive practice while safeguarding vulnerable adults. Acting as a key link between inpatient and community services, they work collaboratively with service users, carers and partner agencies to coordinate discharge arrangements, overcome barriers to discharge and secure sustainable outcomes.

The role includes care coordination, risk management, advocacy, safeguarding, professional consultation and maintaining accurate records. Through effective partnership working and social work leadership, the post holder contributes to reducing delayed discharges and improving recovery-focused outcomes for older adults.

Main duties of the job

Provide advice and advocacy to service users, carers and families. Lead discharge planning from admission, coordinating safe, timely and discharges by identifying and addressing barriers and arranging appropriate support, including domiciliary care, residential and nursing placements, supported living, reablement, equipment and Section 117 aftercare.

Undertake Carer Assessments, Care Act Assessments, Mental Capacity Assessments and contribute to Best Interests decision-making. Promote safeguarding practice, undertake safeguarding enquiries where required, and contribute to risk assessment and management that balances protection, independence and least restrictive practice.

Provide professional advice to multidisciplinary colleagues on social care legislation, safeguarding, NHS Continuing Healthcare, ordinary residence and charging responsibilities. Represent social work within MDT meetings, ward rounds and discharge forums, advocating for the rights, wishes and wellbeing of service users and carers.

Maintain accurate records and statutory documentation, contribute to quality improvement, audits and integrated working, participate in supervision and continuing professional development, support students and newly qualified staff and comply with Trust policies, procedures and professional standards.

Job description

The Discharge and Community Liaison Social Worker is a specialist practitioner within Mental Health Services for Older People (MHSOP) inpatient services, providing expert social work assessment, intervention and discharge coordination for older adults with functional mental health needs. Working as an integral member of the multidisciplinary team, the post holder will lead on the social care aspects of admission, care planning and discharge, ensuring safe, timely and person-centred transitions from hospital to community settings. The role promotes recovery, independence, wellbeing and social inclusion through strengths-based practice while upholding the principles of the Care Act 2014, Mental Capacity Act 2005, Mental Health Act 1983, safeguarding legislation and least restrictive practice.

The post holder will undertake comprehensive Care Act assessments and reviews, determine eligibility for care and support, complete Carer Assessments, provide information and advice, and coordinate social care interventions required to support discharge and longer-term community living. They will undertake Mental Capacity Assessments relating to accommodation, care and support arrangements where appropriate and contribute to Best Interests decision-making processes to ensure that individuals' rights, wishes and preferences are promoted.

Acting as the key link between inpatient wards, Adult Care Services, community mental health teams, housing services, care providers, residential and nursing homes, voluntary sector organisations and other partner agencies, the post holder will coordinate and facilitate effective discharge pathways, identify and resolve barriers to discharge, and ensure continuity of care across health and social care systems. This includes arranging appropriate packages of care, Section 117 aftercare services, residential and nursing placements, supported living arrangements and community-based support to achieve positive and sustainable outcomes.

The post holder will exercise delegated adult social care responsibilities on behalf of Hertfordshire County Council under the Section 75 Partnership Agreement and act as a champion for social care within inpatient services. They will provide specialist advice and guidance to colleagues on relevant legislation, policy and best practice, including safeguarding, NHS Continuing Healthcare, ordinary residence, charging arrangements and statutory social care responsibilities. The role includes undertaking safeguarding enquiries where required, contributing to safeguarding plans and supporting risk management approaches that balance protection with personalisation, independence and positive risk-taking.

The post holder will maintain accurate and timely records, prepare professional reports and assessments, participate in supervision and continuing professional development, maintain Social Work England registration and contribute to the development of high-quality social work practice within the service. They may provide supervision, mentoring and support to newly qualified social workers and other social care staff and contribute to workforce development initiatives, including ASYE support. The role also supports service improvement and integrated working across health and social care systems to ensure older adults receive coordinated, recovery-focused and legally compliant support throughout their care journey.

About us

Hertfordshire Partnership University NHS Foundation Trust are one of just five mental health trusts to achieve an overall rating of 'Outstanding' from theCare Quality Commission.

Our family of over 4,500 members of staff provide health and social care for people with mental ill health, physical ill health and learning disabilities across Hertfordshire, Buckinghamshire, Essex and Norfolk, delivering these services within the community and several inpatient settings. Everything is underpinned by choice, independence and equality, with our Trust values embedded throughout:

Welcoming. Kind. Positive. Respectful. Professional.