To make contact with patients recently discharged from hospital who are not allocated a keyworker but have an open referral to the HUB (3 day follow up). As a member of the multidisciplinary team to be responsible for the assessment of need and the planning, implementation and evaluation of treatment plans incorporating a network of community services and resources. To offer both individual and specialist group treatments and to deliver direct care, according to individual treatment plans and in response to identified need. To monitor and evaluate effectiveness of all intervention at regular intervals. To offer active involvement to service-users, their families and other significant persons in care planning and management. To contribute to the maintenance of positive contacts between the service and the families/carers of service users and to encourage their active participation in plans offering carers assessment and intervention as needed. To have an awareness and recognition of the impact of race and culture in mental healthcare provision and to ensure the service users views are taken into account as far as possible and enable the service users to establish their own goals when planning individual programmes. To maintain up to date written and electronic records of all interventions, to record information and write reports as necessary. To use the integrated mental health services documentation in line with the local policies. To take a lead in team meetings, to participate in clinical meetings and to lead where necessary handover of care to all staff involved in care. This should include support and guidance to junior staff, ensuring that the nursing contribution is professional and systematically applied. To ensure other parts of the mental health services are promptly informed of known service users accessing the Team. To maintain a good network of communications through out the services. To ensure that risk is systematically assessed and managed in accordance to Trust Policy. To ensure, through good clinical practices, that all aspects of the Mental Health Act 2007 and the NHS and Community Care Act 1990 are being adhered to. To ensure the requirements of all current legislation are observed. To participate in medication management Rota if required. To Participate in delivery of Group interventions