Community Health Care : Our Approach

We have developed a clinical framework for adults with complex needs, mirroring the rehabilitation typically provided in a hospital setting, but uniquely, we offer this within a home environment.  This framework demonstrates our commitment to delivering a community health care service at an exceptional level, ensuring individuals receive quality clinical input in the comfort of their own homes.

The focus of our approach is to provide the least restrictive package of support possible. Our hope is that as each individual makes progress and settles into the community we may see a reduction in staffing hours, and therefore the cost of the package, over time.

Our approach to care exceeds the expectations of national guidance such as Building the Right Support and the White Paper ‘People at the Heart of Care, Adult Social Care Reform’ (December 2021).

Our results show that within two years of receiving support from Gray Healthcare, a third of the individuals in our care will either continue to be supported by us but on a reduced package of care, be well enough to live independently or with some element of support from their local community team.  However, because some of the individuals we support have particularly complex needs, they may consistently require high levels of support throughout their lives.

Community Health Care : Our Clinical Framework

Our Multi-Disciplinary Team (MDT) provide support and clinical intervention underpinned by our clinical framework to adults with complex needs within their own homes.

All the people we support are engaged by our clinical team in accordance with their assessed level of need.

The majority of those we support have a minimum of five hours clinical engagement per week. Others may receive more, dependent upon their specific needs.

Everyone, irrespective of their role, receives training in Positive Behaviour Support, Trauma-informed Care and PROACT-SCIPr-UK ®.

There are five key drivers to our clinical framework. Click on each section of the model to find out more.

 

Trauma-informed Care
Health and Wellbeing
Co-production
Positive Behaviour Support
Research and innovation
You, your recovery and your future

Our Multi-Disciplinary Team

We are clinically informed and have intentionally brought together professionals with the expertise in the specialisms we have identified as being key to successfully supporting individuals with complex needs in a community setting.  Our clinical support is delivered in line with the assessed needs of those we support. Our national Multi-Disciplinary Team (MDT) is led by our Clinical Director.

Trauma-informed Care

In 2022 we committed to embedding trauma informed principles to our service and practice.

We are raising awareness and understanding about the wider impact of trauma (and adversity), the need to prevent re-traumatisation, while promoting potential paths of recovery.  The trauma informed approach also recognises the need to guard against vicarious trauma and the importance of the health and well-being of all.

Guided by six core principles of safety, trust, choice, collaboration, empowerment and inclusivity, we aim to create safe environments of healing and recovery.

Ultimately, the trauma informed approach values the person and recognises that any symptoms may be linked to traumatic, adverse life experiences, rather than a deficit, fault, or disorder, so changes the focus from:

‘What’s wrong with you?’ to ‘What has happened to you?’

You can read more about trauma informed care, here.

Health and Wellbeing

We ensure people have access to:

  • Reasonable adjustments to access mainstream services.
  • A team who are trained to recognise when the people we support are unwell.
  • A hospital passport and health action plan.
  • Annual health checks, flu immunisations and medication reviews.
  • A team trained in the use of the National Early Warning Score (NEWS2).
  • Medication oversight, including working within the STOMP guidelines and monitoring of side effects via the use of LUNSERS.
  • Access to our Multi-Disciplinary Team to provide health promotion advice and education.

This collaborative, whole team approach to support shows our commitment to coordinating care for adults with complex care needs.

Co-production

Co-production has a direct and enhancing correlation to trauma informed principles and aligns with our values of being collaborative, inspiring, innovative, honest and transparent.

We believe people who use services are best placed to know what works in improving the service we provide, facilitating recovery and enhancing quality of life and well-being.

The World Health Organisation’s Declaration of Alma Ata states that ‘people have a right and duty to participate individually and collectively in the planning and implementation of their health care (WHO, 1978).

We welcome, encourage and engage people we support, and others in their support network to:

  • develop person-centred clinical and support plans from in-reach to ongoing review.
  • design and develop person-centred training for staff.
  • contribute lived experience to induction training development.
  • voice preferences in the recruitment process.
  • voice views, opinions and preferences to support staff, managers and clinical staff.
  • complete annual surveys/questionnaires.
  • attend workshops.
  • contribute articles, art and other content to our internal newsletter.
  • consider advocacy.

Positive Behaviour Support

Gray Healthcare has embedded Positive Behaviour Support throughout the organisation to ensure that the quality of life of people we support is at the forefront of our treatment.  We recognise the importance of empowering the people we support to have choice and control within their lives and to be supported proactively to achieve their goals.  By promoting independent living skills development, social inclusion and by providing opportunities for those we support, we can increase wellbeing and quality of life for those receiving our support.

We provide training in PROACT-SCIPr-UK ® to all staff throughout the organisation. This approach is underpinned by the values and evidence base of Positive Behaviour Support and therefore provides a stable foundation of positive and proactive working with a focus on therapeutic intervention and least restrictive practices and is affiliated with the British Institute of Learning Disabilities (BILD).

Read more about Positive Behaviour Support.

Research and innovation

We have embedded an education and training system that is evidence based and underpinned by research and evidence. We will build the capability and capacity of our current workforce to embrace and engage actively with research and innovation.

By integrating research into our approach, we ensure that our methods for coordinating care for adults with complex care needs remain at the forefront of industry standards, always aiming to provide the best possible outcomes for those receiving our support.

 

Meet our National Multi-Disciplinary Team (MDT)

Led by our Clinical Director, Neil Berrington, our multi-disciplinary team have the skills, knowledge, and experience to enable those we support to live their best lives.

Our Clinical Outcomes

Our Multi-Disciplinary Team uses a suite of outcome measures underpinned by a robust evidence base to monitor and evaluate the therapeutic interventions and to evidence the progress made by the people we support. These outcome measures focus on meeting health and wellbeing needs, building new skills and quality of life.  We work collaboratively to empower the people we support and evidence a reduction in support needs, increased independence with daily living skills and meaningful engagement with their local communities.

Our annual outcomes report highlights and evidences areas where the people we support have achieved success with their goals.  Many of the people we support have experienced ‘placement breakdown’ historically but have now achieved success in maintaining their life in their own homes.  These results not only reflect the effectiveness of our community health care services but also underscore our success in positively transforming lives through clinically informed care in the community.

 

‘Families told us they saw positive changes in their family members since discharge from long-term care, for example, being involved in activities again, showing a sense of humour, reading, going out and spending time with siblings and relatives.’

(Care Quality Commission)