Job Overview
Be part of an exciting new initiative in Brent – the Older Adult Urgent Care, Flow & Frailty Service – designed to transform care for older adults with complex mental health needs, frailty, and dementia. As a Band 6 Mental Health Specialist Practitioner, you will play a pivotal role delivering specialist input across community settings, supporting individuals without a requirement for routine hospital-based working. You will work closely with emergency departments, care homes, community teams, primary care, and voluntary sector partners to ensure timely, preventative, and person-centred support that makes a meaningful difference to patients and their families. Your focus will be on coordination, clinical decision-making, and proactive intervention to help individuals access the right care at the right time. In this innovative service, you will contribute to care planning, early intervention, and crisis prevention, supporting safe discharge pathways and ongoing community-based care. You will provide guidance to Band 4 colleagues and work collaboratively with carers, families, and partner organisations to enhance the patient experience. Your work will be instrumental in reducing avoidable hospital admissions, improving system flow, and strengthening integrated, community-based support for older adults in Brent. This is a unique opportunity to be at the forefront of a new, transformative service, shaping how mental health care is delivered for older adults in the borough.
Working for our organisation
Joining CNWL means becoming part of a leading mental health and community health organisation that is committed to delivering high-quality, person-centred care. In the Brent Older Adults Mental Health Service, you will work within a supportive, multidisciplinary team focused on improving outcomes for older adults with complex mental health and frailty needs. CNWL values innovation, professional development, and collaborative working. You will have the opportunity to work across community, care home, and home settings, contribute to integrated neighbourhood initiatives, and help shape preventative, high-quality mental health services. The Trust provides access to professional supervision, reflective practice, and continuous learning opportunities, ensuring that you can develop your skills while making a real difference to the lives of older adults and their carers in Brent.
Main Duties of the Job
Key Responsibilities
Clinical Responsibilities
- Undertake holistic assessments of older adults and people living with dementia across physical, cognitive, functional, emotional and social domains in patients’ homes, care homes and community settings.
- Provide timely response including triage, de‑escalation, medication review and clinical decision‑making to prevent escalation and hospital admission.
- Assess, plan, implement and evaluate evidence‑based interventions and personalised care plans that promote independence, recovery and self‑management.
- Identify and manage risks associated with frailty and mental health, including falls, delirium, polypharmacy, cognitive impairment, depression, psychosis, anxiety, self‑harm risk and carer strain.
- Monitor medication compliance and side effects, maintaining up‑to‑date pharmacological knowledge relevant to older adults and people living with dementia.
- Contribute to Comprehensive Geriatric Assessment (CGA)‑informed care planning, ensuring mental health is integrated into holistic frailty management.
- Support safe discharge planning and continuity of care through proactive follow‑up and coordination with neighbourhood partners to prevent readmission.
- Participate in duty systems including triage and allocation of referrals based on urgency and complexity.
- Maintain accurate, timely documentation and contribute to audit, data collection and service evaluation.
Integrated Neighbourhood & Admission Avoidance Responsibilities
- Participate in Integrated Neighbourhood Team (INT) meetings and multidisciplinary forums, contributing specialist assessment, risk formulation and preventative planning.
- Provide proactive case management for high‑risk individuals identified through neighbourhood risk stratification or frequent attender data.
- Deliver rapid response assessments within agreed timeframes to prevent avoidable Emergency Department attendance.
- Support care homes and primary care colleagues with specialist advice to reduce emergency presentations.
- Implement short‑term stabilisation and safety‑netting arrangements to prevent crisis escalation.
- Contribute to digital‑enabled follow‑up and remote monitoring to support continuity of care.
- Lead and implement evidence‑based cognitive and social interventions to support people living well with dementia, provide guidance to colleagues on strategies to reduce the risk of progression in individuals with mild cognitive impairment, and evaluate outcomes to inform care planning and service development.
Person Specification
Education
Essential criteria
- Registered Nurse (Mental Health) with current NMC registration
- Mentorship/Practice Supervisor or Practice Assessor training
- Willingness to undertake further specialist training as required
Desirable criteria
- Postgraduate qualification in frailty, older adult mental health or community health
- Leadership or management training
- Frailty‑specific training (e.g., CGA, dementia care, falls prevention)
Experience
Essential criteria
- Significant post‑registration experience in community nursing, frailty, older adults, or long‑term condition management
- Experience supervising or supporting junior staff, HCAs, or students
- Experience conducting holistic assessments and developing person‑centred care plans
Desirable criteria
- Experience in leadership or coordination within community or frailty services.
- Experience in care home liaison or hospital discharge pathways.
- Experience leading small projects, audits or service improvements.
- Experience delivering frailty education or training to others.
Knowledge
Essential criteria
- Strong understanding of frailty, ageing, multimorbidity, cognitive decline, delirium and polypharmacy
- Knowledge of safeguarding, Mental Capacity Act and DoLS
- Understanding of risk assessment, clinical governance and quality improvement.
- Awareness of long‑term condition management and prevention of avoidable admissions
Desirable criteria
- Knowledge of local community frailty pathways and integrated care systems
- Awareness of national frailty frameworks and best practice guidance
- Knowledge of digital frailty tools or remote monitoring technologies
- Understanding of care home regulatory frameworks
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