1. INTENSIVE SUPPORT TEAM A New Way Forward

2. PREVIOUS SITUATION The average length of stay for a person in an Assessment and Treatment Unit was up to 18 months. What did this mean for the person and their family? Possibly a reassurance that the person is receiving treatment and may recover, however the person may be placed in a unit in the other side of Surrey. With no direct bus links, this may be difficult for some people to visit their relative. The person often becomes reliant on the service and transitions are difficult. Benefits can be affected and placements may be stopped. Difficult to work with the CCG and SS to facilitate timely discharge.

3. DRIVERS FOR CHANGE LOCAL DRIVERS Persons experience Families experience and feedback A desire to work in a person centred way to achieve the best possible care for the person. Commissioning Intentions Meeting NHS England requirements NATIONAL DRIVERS Winterbourne View Transforming Care Programme 2012 Positive and Safe Initiative Confidential Inquiry into Premature Deaths of People with LD 2013 NHS England National Plan - 2015

4. HOW DID WE START TO IMPLEMENT CHANGE Formed strong alliances with the Commissioners Introduced a new transition package which includes teaching the staff in the new home using an all about me power point presentation Follow the person through into the community and step down our support over an agreed time period of up to three months Benchmarked our services against other country wide services

5. HOW DID WE START TO IMPLEMENT CHANGE Detailed discussions with families and individuals using the Triangle of Care Model Consultation Paper Remodelling of LD Health Services Closure of Bramdean, remodelling of the CTPLD and setting up the New Intensive Support Team October 2015 Consultation with commissioners Staff Training to adapt to new ways of working Developed our current service to be an outstanding service.

6. WHERE ARE WE NOW OUR AT&S UNIT Received a Gold Award for Positive and Safe Champions in the Care Awards. Two Silver Awards for Leader and Care Support Worker of the year. ACCREDITED THROUGH AIMS FANTASTIC INTERACTIONS NOTED BY THE CQC 100% EFFECTIVE DISCHARGES NO FAILED PLACEMENTS POSITIVE COMMENTS RECEIVED BY THE CTR PANEL re PAPERWORK ROBUST MDT WORKING TO INCLUDE CCG and CTPLD

7. WHAT NEXT Moving the AT&S to Epsom changing its function to a Crisis Service Developing our service with the support of the MDT to ensure it offers a calm and therapeutic environment using a calm zone with an interactive screen and furniture designed by the OT and myself. Strengthening our working relationship with the CTPLD to support the persons journey. Developing One Person One Plan to ensure information is captured. Working to provide an integrated Intensive Support Team to provide 24/7 support to people with learning disabilities and complex mental health needs/behaviour that challenges living in the community.

8. Direction of travel Unified model incorporating the current CTPLDs, Liaison Services, a new Intensive Support Service which also staffs the Intensive Support beds at the newly sited April Cottage. Figure 1 Proposed Care Pathway Primary Care Annual Health Checks Health Action Plans Screening Primary Care Liaison nurses Mainstream Health Services Acute Liaison nurses Prison Liaison nurses CTPLD Supporting Mainstream Specialist Assessment and Formulation Specialist Clinical Therapeutic Support Quality Assurance Intensive Support Team Preventing Crises and Admissions Intensive Support Beds

9. OpenReferral?SPAOpenReferral?SPA Intensive Support Team (IST) CTPLDCTPLD Screening for IST Telephon e Mainstream MH Services 2 people (1 qualified) RAG rate Risk assessed Initial care plan Early Next Day MDT Initial formulation RAG rate Decide re admission / further work E.g. further asst, observations, medical review, discharge planning, set timescales, feedback to commissioners Admit to IST Bed Discharge to home Day assessment IST Support to prevent admission Further assessment Follow up Interventions Guidelines Training Placement e.g. pop-up / respite 2 weeks NotISTNotIST Review Staffing Needed Discharge & Support Transfers to CTPLD Needs Mainstream Within Hours Home Visit for Initial Assessment Out of Hours Max 4 Hours Review Staffing

10. BENEFITS OF USING THE IST There will be three elements of the model that are interconnected -the CTPLD -the IST enabling people to remain at home where possible -the IST beds the CTPLD will identify people most at risk of an LD inpatient admission and will hold a risk register which will document those at risk and changing needs.

11. BENEFITS OF USING THE IST They will work with the family/providers to ensure the person has a positive behaviour support plan in place to include crisis and contingency. They will join with the IST to provide a more intensive approach when required. The person should move seamlessly between the services And the joint working will encourage shared learning and increased understanding of the persons needs. The combined team will aim to avoid an admission where possible.

12. Any Questions