Coming Home Implementation: report from the Working Group on Complex Care and Delayed Discharge

Appendix One

Dynamic Support Register: Draft Guidance

1. Including Someone on the Register

To decide whether a person should be added to the Register, discussions should take place across the HSCP Learning Disability Team at a multidisciplinary team meeting. Using risk screening criteria, the team will agree if the person should be added to the Register and at what level of priority.

Local procedures may differ, but these meetings should be chaired by a senior member of the HSCP Learning Disability Team and should typically include all relevant disciplines from the Learning Disability Team including social workers. Senior representatives from the HSCP commissioning team and from local housing may also be required.

Once a person has been placed on the Register, a lead must be allocated to the case if there is not already one allocated, and a multidisciplinary discussion must be held within 2 weeks. The group should agree on the lead worker; this should be the professional best placed to support the overall co-ordination of the resulting action plan.

2. Levels of Priority on the Register

There are two levels within the Register; red, which is high risk, and amber, which is moderate risk, but still requires monitoring. Individuals can be moved between levels if their circumstances change or there is progression in the planning process.

Red: High Risk

People who will be included in the red section of the Register are as follows:

• Anyone with a learning disability in a NHS learning disability or mental health bed, whether delayed or not
• Anyone in an unsuitable out-of-area placement, defined as one where any of the following applies:
  • The person and/or their family did not choose to be there
  • Very poor inspection grades in the most recent report, indicating concerns at quality standards within the service
  • Where Adult Support and Protection or safeguarding issues have been raised in relation to the service as a whole
  • Where there is escalating use of restrictive practices, particularly physical restraint, seclusion or any use of prone/supine restraint or intramuscular medication
  • Where there are concerns about the person's human rights
  • Where the individual, their family members, or the HSCP have significant concerns about the placement
• Anyone who is at risk of their support breaking down or ending, either support provided by family carers, or by a social care service provider, or a school placement.

For those who are in the red section, there must be a multidisciplinary discussion, every two weeks. These meetings will focus on reviewing and updating a detailed personal action plan. For those in hospital, or unsuitable out-of-area placements, or whose residential school placement is within 12 months of ending, this review will address the following:

• Progress towards accessing suitable accommodation
• Progress in relation to financing the support package
• Identification of a suitable provider
• Timescales for the above
• The support plan in the person's current placement
• Any issues or concerns, e.g. use of restraint, high levels of challenging behaviour, serious risk factors.

For those at risk of service breakdown, this will address changes needed to the support plan to sustain their support. This may include the following:

• Crisis plan, particularly around high levels of behavioural challenges
• Potential for use of out-of-hours support
• Referral to specialist support teams, e.g. Positive Behaviour Support Team/Additional Support Team/inpatient services (depending on operational procedures locally)
• Contract compliance conversations with social care provider if appropriate
• Additional short-term financial support agreed if required, e.g. for respite care for family carers, for additional staff into a provider, for specialist training for staff teams etc.

Amber: Moderate Risk

The amber level of the Register is a monitoring phase, which ensures that people are not lost sight of once immediate crises are past. The information from those in the amber level should be of benefit to HSCPs to aid strategic planning and to inform commissioning. These cases require less intensive input from the support team and will be discussed monthly by the HSCP Learning Disability Team.

People who will be included in the amber section are as follows:

• Those who have left hospital or an out-of-area placement within the last 6 months.
• Those at risk of placement breakdown, but where their action plan has been implemented to the extent that their risk has reduced to amber.
• Those in poor placements, but where there has been sufficient reassurance that quality issues are being addressed.
• Those who mental or physical health is declining to an extent that their placement may begin to be under threat.
• Those who are placed out-of-area, anywhere, whose support has not been reviewed within the past 6 months.

3. Coming off the Register

Individuals will be judged able to come off the Register when one of the following standards can be met:

• The individual is more than 6 months discharged from hospital or other placement and is judged to be settled and no longer at risk.
• The service where the person is living has improved considerably and would no longer be considered a poor, inappropriate or institutionalised service.