Many of the people we support have experienced failed community placements in the past and have found themselves readmitted to hospitals again and again. Our clinically-informed framework means that we can deliver ongoing multi-disciplinary clinical support to people with complex needs in their own homes following discharge from hospital. To further reduce the likelihood of another failed community placement, we have also created a bespoke and robust referral and assessment process. Details of each stage of this process are detailed below.
We encourage the people we support to access and actively engage with their local communities as part of their recovery journey. All our packages of support are reviewed by our in-house Multi-Disciplinary Team to ensure we have mitigated any risks to provide the exact level of support required by each individual at the start of their journey with us. We know that our approach works – a third of the people we support require less support than when they started receiving our support (usually within the first two years).
We accept referrals from Integrated Care Boards (ICBs) and Local Authority (LA) commissioners as well as social workers, care co-ordinators and case managers.
If you would like to see examples of how we have moved people towards independence, take a look at our case studies.
Referral
On receiving a referral, one of our lead clinicians first undertakes a desk top review of the current situation and evaluates the risks. If we believe we can support the individual being referred and enable that person to live their best life, we will forward some costings and an initial outline of the package plan to the referrer.
Assessment
A member of our clinical lead will undertake a face-to-face assessment with the individual in their current setting. We look at the individual’s presentation and behaviours and assess whether we can keep the person feeling safe in a bespoke supported living setting. We explore what has happened in the past and determine what we can do differently.
Solution identified
Taking into account all the information we have gathered during the assessment, we identify exactly what needs to be in place for each individual. We determine how we will safely manage risk and behaviours that are perceived to be challenging, and we present our bespoke supported living and clinically-informed solution to the referring team.
Package of support and clinical input identified
We create a bespoke support package for each individual. We include in each package of support the weekly hours of clinical support each individual will need from our Multi-Disciplinary Team (MDT). We also establish the level of staffing hours required and the skill set of staff that we need to recruit. We look at where the individual is going to live and consider the bespoke training our new team will need.
Property
Every element of our packages of support are tailored for each individual. This includes property. We work closely with the referring team to help secure a property for each individual in their preferred geographical area and close to their friends and family.
If needed we can offer advice on property adaptations.
Team Recruitment
We recruit a new team of support workers to exclusively support each individual in their own home. We look for team members with relevant work experience and who collectively share common interests with the person they will be supporting. We want the people we support to be happy with the team we recruit so we involve them throughout the entire recruitment process. Each team of support workers is managed by a dedicated Community Support Manager who oversees the package the care and works closely with the wider community care team.
Staff Training
We provide bespoke training tailored to the specific needs of each individual.
All staff members, including our central support teams, receive training on PROACT-SCIPr-UK ®, Trauma-Informed Care and Positive Behaviour Support.
In-reach
We build a programme of in-reach into every package of support. This involves members of our team visiting the individual in their current setting and meeting the family and the existing care team. It is during these regular visits that our team can strengthen their relationship with the individual in a familiar setting and make sure that nothing has been overlooked in terms of planning for a successful transition.