Transforming Care at Home
Many of the individuals we support have experienced multiple placement breakdowns or have undergone long periods of hospitalisation. Some may have a forensic history or be subject to a legal framework. All of them require a minimum of 1:1 support 24/7 at the beginning of their support package, but we are equipped to provide support up to 3:1, 24/7.
In summary, if you consider the most complex individual on your list – someone whom others have found difficult to support – there is a strong possibility that we can assist them in building a life in their ‘forever’ home.
We accept referrals from across England and Wales, and we welcome referrals from Integrated Care Boards (ICBs), local authority (LA) commissioners, social workers, care co-ordinators and case managers.
We also welcome individuals funded through direct payments and are part of various local authority and ICB frameworks nationally.
Occasionally ,following our thorough assessment, we may determine that certain adults are not yet ready to transition to a home of their own. In such cases, our team is happy to offer advice and collaborate with the existing care team to determine what steps are needed to prepare someone for a successful discharge in the future.
The Gray Healthcare Difference
Our clinically-informed approach bridges the gap between hospital and standard community care and is built around a single move into an individual’s ‘forever’ home. We design a bespoke package of support that includes clinical support mirroring that received in a hospital, but delivered within a home setting, and a team recruited and trained on the individual’s specific needs. We start to gradually reduce our package of support as the individual improves.
Once an individual no longer needs our intensive level of support, we can step back completely enabling a lower complexity provider to take over or for the person to live independently. Crucially, as the individual holds their own tenancy, they do not have to leave the stability of their ‘forever’ home.
Getting it right from the start
Though our experience, we have learnt that when the right support and strategies are in place from the beginning, we can create a stable and nurturing environment that greatly reduces the risk of future placement breakdowns.
The following model illustrates the six key components that together enable us to achieve our goal of ‘bringing healthcare home’ for the highly complex people we support.
Clinically-informed framework
The people we support need ongoing clinical support following discharge from hospital. To support their ongoing journey, we include dedicated clinical hours in every package of support, ensuring individuals have consistent access to the support they need as they transition and rebuild their lives.
Our clinical framework is delivered by our national Multi-Disciplinary Team comprising experts in the key foundations of: Trauma-Informed Care, Positive Behaviour Support (PBS), co-production and PROACT-SCIPr-UK®.
Dedicated teams
Each person we support is supported by a dedicated team, carefully recruited and trained to meet their unique needs and experiences. In addition to specific training, our teams also receive training in Trauma-Informed Care, Positive Behaviour Support (PBS), PROACT-SCIPr-UK®, National Early Warning Score (NEWS2) and Wellness Recovery Action Plan (WRAP).
Property
Our approach is based around one single, supported move into a ‘forever’ home. Support is centred around the individual, and not the service, ensuring each person has genuine choice over where they live, rather than being limited to where there are available vacancies. Our property team work closely with the individual, their families and referrers to identify suitable homes in the chosen area. They are on hand to secure the preferred property, advise on property modifications and to help with paperwork associated with the property, for example, registering the individual for housing benefit or social housing. The tenancy remains separate from the support provision, ensuring the person can stay in their ‘forever’ home even if support provision changes.
Clinical Assessment
Our detailed clinical assessment process enables us to meticulously plan how to safely support each individual so they can live the life they want in a community of their choice. As part of our assessment, we look at the individual’s presentation and behaviours on a day-to-day basis. We explore what has happened during past placements and why these may have broken down to determine what we can do differently to prevent this from happening again.
In-reach programme
To ensure that the move into the community goes as smoothly as possible, 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 current 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 move into their new home.
Positive risk taking
While some individuals will always require significant support to live in the community, we strive to promote independence and enable people to live their best lives. We encourage positive, well-considered risks that foster personal growth, ensuring that the people we support feel safe, empowered and supported at every stage.
Delivering positive outcomes
In March 2025, we published our latest Clinical Outcomes Report. This year, we continued to support adults with similar complexity while further reducing overall package hours compared to last year. Notably, about one third of those we support achieve this reduction within two years of starting our services.
However, providing a completely tailored package of support for each person is not something we can deliver overnight. Recruiting the best teams and training them to our exacting standards and to the individual’s needs before they start to work with us can take a little time. For this reason we are unable to accept emergency referrals.
Still unsure if we can support any individual you might have in mind?
To make it easier to see how we can help, we have created some pen pictures of people we support, highlighting their needs and experiences at the time they were referred to us. Do any remind you of someone you are looking to place? If so, please do get in touch.
Michael, 54
Michael is living with schizophrenia and has been known to services for over 20 years following a significant deterioration in his condition in his 30s. At times he experiences a lot of fear and often is worried that others want to hurt him; he can become distressed and angry as a result. At other times he can have difficulties in attending to his personal needs and in undertaking everyday activities.
Habib, 32
Habib has acquired a diagnosis of treatment resistant paranoid schizophrenia. Habib has historically chosen not to engage with services and has used non-prescribed substances to help manage distress and cope with life. He was homeless for many years and experienced sexual and physical abuse and exploitation before being arrested for drug offences.
Dom, 24
Dom has been given a diagnosis of a severe learning disability and is non-speaking. Staff have found it challenging to work with Dom; to understand and meet his needs. Frustration can lead him to hit, kick and shout out and restraint is often used. Dom has been continuously in hospital for four years on extended discharge.
Kate, 43
Kate has acquired a diagnosis of bipolar disorder and co-existing conditions. She disagrees with her diagnoses and can decline her medication. Trust and relationships are difficult as she has experienced both physical and emotional trauma. Due to risks, Kate was admitted to hospital several years ago where there has been an increase in self-harm and anger and agitation towards staff.
Have any other questions about our packages of support?
Make a referral
We accept referrals from across England and Wales. You can contact our central referral team by telephone, email or by completing our online enquiry form. Refer someone today to our supported living for adults with complex needs, and we’ll see how we can start providing them with the support they need.
0330 123 123 9referrals@grayhealthcare.comgrayhc@nhs.net