Job summary
Being responsible for a caseload of children and young people on the dynamic support register within the North East London specialist children care and support team .
The post holder will provide care coordination and act as the key worker across health, social care and voluntary sectors to manage the care and support of children and young people in North East London.
The post holder will ensure that children and young people is at the centre of holistic care planning across organisations such as health, social care and the voluntary sector. This way of working is a better, more coordinated way of providing care and support for children and young people who are risk and governance (RAG)-rated as red and amber on the dynamic support register in North East London and requires people with commitment and passion for working with children and young people.
The post holder will ensure that there is a coordinated multi-agency plan in place to support patients on their caseloads. All involved, including the person and the carer, will design care plans together to keep the person well for as long as possible and achieve outcomes they identify.
The Case Manager role offers a new and exciting opportunity to become part of the whole systems workforce; bringing together health and social care expertise to deliver real change for how care is delivered in North East London.
Main duties of the job
Provide direct case coordination while also supporting the business, operational, and governance requirements of the Keyworking service including:
- Service Delivery & Case Management: Manage a caseload of children and young people on the DSR; Coordinate multi-agency care across health, social care, education, and voluntary sectors; Ensure care plans are co-produced with children, families, and professionals, keeping the young person central; Proactively manage cases to reduce reliance on crisis/emergency care and support timely discharge from hospital.
- Operational Business Support: Maintain accurate, up-to-date records; Produce reports to evidence service activity and outcomes; Assist with the referral management process.
- Governance, Quality & Risk Management: Ensure safe, effective practice in line with Trust policies, professional codes, and safeguarding frameworks; Contribute to audits, service research, and outcome monitoring; Support infection prevention and control standards and participate in risk management; Highlight unmet needs, service trends, and risks.
- Partnership & Stakeholder Support: Work collaboratively with GPs, local authority, schools, voluntary sector, carers, and families; Act as a central point of coordination for professionals to ensure integrated care; Support user and carer engagement in service development; Nurture internal and external networks to strengthen service delivery and integrated pathways.
About us
Our Values 2025 - 2030
Working with our colleagues, patients and carers we have co-produced three new values that we aim to embed within our culture here at NELFT.
They are:We are kind.We are respectful.We work together with our communities.
These three values help us to strive to provide the best care by the best people.
Starting with NELFTNELFT place a great deal of importance on new starters being properly welcomed and inducted into the Trust. All new starters will join the Trust on the first Monday of each month and will undertake a comprehensive induction of up to two weeks which will include mandatory training, systems training and the allocation of equipment. As part of the process new starters will have the opportunity to also meet the executive team, senior managers, and attend a number of drop-in sessions focusing on engagement, health and wellbeing and key processes. The induction will be held at our head office in Rainham, Essex.
Probationary Period This post will be subject to a probationary period.
High Cost Area Supplement - Outer London
This post also attracts payment for High Cost Area Supplement of 15%of the basic salary (minimum payment of £4,714 and a maximum payment of £5,941 - per annum, pro rata for part time).
Job description
Job responsibilities
1. Undertaking case management function for children and young people on the dynamic support register and to ensure their health and social care needs are supported effectively.
2. Be responsible for a caseload on the dynamic support register (DSR) list.
3. Provide robust case management approaches of care to MDT discussions and proactively ensure all elements of patient care on their case load is in place.
4. Initiating and providing appropriate key working, support pan and holistic interventions to improve quality of life with partner agencies.
5. Developing a personal care plan in partnership with the patient, carers, relatives and health and social care professionals that includes preventative measures and anticipates future requirements.
6. Proactively case manage patient to ensure less reliance on emergency and crisis care.
7. Update patient records and inform other professionals of changes in condition.
8. Support patients under the key working model and care, (education) and treatment reviews (C(E)TRs).
9. Share up to date, accurate information with patients (and their family members and carers as directed) about their care and outcomes, signpost and direct patients appropriately.
10. Work with family members and carers as directed by the patient in a collaborative and compassionate way.
11. Assist in the coordination of all services the patient is receiving.
12. Work collaboratively with all professionals, carers and relatives.
13. Work in partnership with the patients GP and other health and social care professionals to mobilise resources as needed.
14. Ensure a team approach across the primary and community health care team.
15. Proactively and regularly monitor the patients care and support, by telephone or in person.
16. Maintain responsibility if the patient is admitted to hospital, provide baseline health data to support integrated care and facilitate timely discharge.
17. Work with colleagues as the programme and role develops to share knowledge and learning, particularly around social/voluntary aspects of care.
18. Ensure the patient remains at the centre of care and outcomes.
19. Operates effectively in a flexible and demanding environment, proactively engaging with a broad range of health and social care colleagues.
20. Ensure collaboration is prioritised and works in partnership to achieve the best outcome for patients across the whole system.
21. Committed to working and engaging constructively with internal and external stakeholders on a range of complex issues.
22. Nurtures key relationships and maintains networks internally and externally, including national networks.
23. Link with managers and members of other functions, to address inter-dependencies and ensure alignment.
24. Works with primary care to support patients to make decisions about their care and access services as required.
25. Work with patients and colleagues in a reflective way to test and adapt approaches.
26. To engage with a wide range of stakeholders, including users and carers in the mental health care agenda and those under the dynamic support registers.
27. To effectively and appropriately planning care and support including signposting, key working and care navigation.
28. To ensure the use of RIO and ICAN databases, producing reports/figures/statistics/ performance/flow rates and data on patients outcomes
29. To conduct agreed service research and generate appropriate reports and audits on RIO and ICAN to ensure user standards are delivered.
30. To ensure service users and carers are fully engaged in the development and delivery of the service. This will include supporting the development of user led self-help groups for a range of mental and physical health problems.
31. Deliver safe practice that reduces risk for service users, carers and staff, and improves people`s experience of the service and leads to better mental and physical health outcomes.
32. To be an integral part of the referral management process, to support and manage the delivery of the single point of access referral process.
33. To ensure that trends in need, service use and unmet needs are collated and conveyed to the relevant parties and to work with the service to develop strategies to meet address any unmet need.
34. To develop and maintain effective partnership between the service staff, schools, local authority teams and partner agencies.Please see the attached job description and person specification for more information about this role and working at North East London NHS Foundation Trust. We encourage you to refer to this when completing your application.Use of AIPlease see attached document regarding acceptable use of AIduring the recruitment process.
Job description
Job responsibilities
1. Undertaking case management function for children and young people on the dynamic support register and to ensure their health and social care needs are supported effectively.
2. Be responsible for a caseload on the dynamic support register (DSR) list.
3. Provide robust case management approaches of care to MDT discussions and proactively ensure all elements of patient care on their case load is in place.
4. Initiating and providing appropriate key working, support pan and holistic interventions to improve quality of life with partner agencies.
5. Developing a personal care plan in partnership with the patient, carers, relatives and health and social care professionals that includes preventative measures and anticipates future requirements.
6. Proactively case manage patient to ensure less reliance on emergency and crisis care.
7. Update patient records and inform other professionals of changes in condition.
8. Support patients under the key working model and care, (education) and treatment reviews (C(E)TRs).
9. Share up to date, accurate information with patients (and their family members and carers as directed) about their care and outcomes, signpost and direct patients appropriately.
10. Work with family members and carers as directed by the patient in a collaborative and compassionate way.
11. Assist in the coordination of all services the patient is receiving.
12. Work collaboratively with all professionals, carers and relatives.
13. Work in partnership with the patients GP and other health and social care professionals to mobilise resources as needed.
14. Ensure a team approach across the primary and community health care team.
15. Proactively and regularly monitor the patients care and support, by telephone or in person.
16. Maintain responsibility if the patient is admitted to hospital, provide baseline health data to support integrated care and facilitate timely discharge.
17. Work with colleagues as the programme and role develops to share knowledge and learning, particularly around social/voluntary aspects of care.
18. Ensure the patient remains at the centre of care and outcomes.
19. Operates effectively in a flexible and demanding environment, proactively engaging with a broad range of health and social care colleagues.
20. Ensure collaboration is prioritised and works in partnership to achieve the best outcome for patients across the whole system.
21. Committed to working and engaging constructively with internal and external stakeholders on a range of complex issues.
22. Nurtures key relationships and maintains networks internally and externally, including national networks.
23. Link with managers and members of other functions, to address inter-dependencies and ensure alignment.
24. Works with primary care to support patients to make decisions about their care and access services as required.
25. Work with patients and colleagues in a reflective way to test and adapt approaches.
26. To engage with a wide range of stakeholders, including users and carers in the mental health care agenda and those under the dynamic support registers.
27. To effectively and appropriately planning care and support including signposting, key working and care navigation.
28. To ensure the use of RIO and ICAN databases, producing reports/figures/statistics/ performance/flow rates and data on patients outcomes
29. To conduct agreed service research and generate appropriate reports and audits on RIO and ICAN to ensure user standards are delivered.
30. To ensure service users and carers are fully engaged in the development and delivery of the service. This will include supporting the development of user led self-help groups for a range of mental and physical health problems.
31. Deliver safe practice that reduces risk for service users, carers and staff, and improves people`s experience of the service and leads to better mental and physical health outcomes.
32. To be an integral part of the referral management process, to support and manage the delivery of the single point of access referral process.
33. To ensure that trends in need, service use and unmet needs are collated and conveyed to the relevant parties and to work with the service to develop strategies to meet address any unmet need.
34. To develop and maintain effective partnership between the service staff, schools, local authority teams and partner agencies.Please see the attached job description and person specification for more information about this role and working at North East London NHS Foundation Trust. We encourage you to refer to this when completing your application.Use of AIPlease see attached document regarding acceptable use of AIduring the recruitment process.
Person Specification
Qualifications
Essential
- Evidence of Study at Degree Level or equivalent
- Previously worked in similar position within the public or health sector
Desirable
- Registered Nurse (RMN Mental Health, LD, RGN) or AHP or Dip SW, CSS or CQSW
- Masters or equivalent experiences
Experience
Essential
- Extensive experience of working with young people with complex, acute mental health, ASD or LD needs and behaviours that challenge
- Knowledge and understanding of the issues facing Children and young people who may need care and support
- Understanding of the background to and aims of current healthcare policy in London and nationally on DSR and key working and appreciate the implications of this on engagement
- Understanding of risk assessment and management within community setting
- Understanding of the social care and voluntary sector landscape
Knowledge
Essential
- Able to provide and receive highly complex, sensitive or contentious information, negotiate with stakeholders on difficult and complex issues, and present complex and sensitive information to large and influential groups
- Able to negotiate on complex issues including performance and change in order to achieve good outcomes for patients
Desirable
- Physical Health assessment
Skills
Essential
- Ability to facilitate positive multi-disciplinary working relationships across all service areas
- Ability to problem solve and to respond to sudden unexpected demands
- Experience of care navigation and understanding of the local services available for Children and Young People
Person Specification
Qualifications
Essential
- Evidence of Study at Degree Level or equivalent
- Previously worked in similar position within the public or health sector
Desirable
- Registered Nurse (RMN Mental Health, LD, RGN) or AHP or Dip SW, CSS or CQSW
- Masters or equivalent experiences
Experience
Essential
- Extensive experience of working with young people with complex, acute mental health, ASD or LD needs and behaviours that challenge
- Knowledge and understanding of the issues facing Children and young people who may need care and support
- Understanding of the background to and aims of current healthcare policy in London and nationally on DSR and key working and appreciate the implications of this on engagement
- Understanding of risk assessment and management within community setting
- Understanding of the social care and voluntary sector landscape
Knowledge
Essential
- Able to provide and receive highly complex, sensitive or contentious information, negotiate with stakeholders on difficult and complex issues, and present complex and sensitive information to large and influential groups
- Able to negotiate on complex issues including performance and change in order to achieve good outcomes for patients
Desirable
- Physical Health assessment
Skills
Essential
- Ability to facilitate positive multi-disciplinary working relationships across all service areas
- Ability to problem solve and to respond to sudden unexpected demands
- Experience of care navigation and understanding of the local services available for Children and Young People
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.
