Community-based care and learning disabilities: providing the right support, care and housing

Rachael Byrne (Home Group): Not that we are working on. Primarily our focus has been on developing approaches for people who have funding, but the services available are not fit for purpose.

Helen Hassell (Expert by Experience): Community integration using link workers and social prescribing.

Rachael: Depending on commissioners’ requirements, we have models where we are purchasing properties for customers aligned with their specific requirements, primarily single-person occupancy or with a loved one/family member if that is requested. We then deliver the wraparound support to achieve the life that they want.

Helen: Person-centred planning!

Rachael: Our approach to this is two-fold. For our own services we have two separate business units, one for housing and one for care. Issues around tenancy are managed separately with an independent team, though there is a co-ordinated approach to support. If any customer wished to remain in their tenancy and change their support provider, this becomes very simple as their tenancy remains unaffected.

In addition, we deliver, in some circumstances, a housing-only offer with other care providers delivering the care and vice versa.

Rachael: Large service charges generally reflect the following:

• additional housing management requirements (that have been excluded from support budgets)

• higher levels of maintenance (either response times or frequency)

• costs associated with significant adaptations or therapeutic/risk requirements made to the building.

Rachael: Use and promotion of independent advocates is crucial. Even where families are part of the circle of support, there is more work we can do to ensure the person’s voice is heard. Families are too frequently seen as ‘difficult’ when in fact they have had traumatic journeys to the point when they engage with any particular service. Recognising this and understanding their perspective is central to gaining their trust and engaging in meaningful dialogue.

Helen: Listen to the individual. Look at staff who have great relationships with them and are good at personalised care and support.

Rachael: We are currently developing an approach to working with people and their families at home, aimed at 15 to 20-year olds specifically.

Rachael: There is emerging evidence that Covid-19 has had a disproportionate impact on people with a learning disability and we will be monitoring analysis and research identifying the causes behind this.

Rachael: There has been much criticism of the day-care model as it has traditionally resulted in focusing on activities put on in the centre reducing choice and social inclusion.

We use our LIFE support practice model to work with customers to identify their aspirations, motivations and interests and then support them to access this through existing community provision. This includes football, restaurants, pubs, music and other leisure activities. Obviously, this can result in a higher need for one-to-one hours, but the outcome on increasing confidence, happiness and ultimately independence is both an ethical and financial argument for this model.

Helen: Personal health budgets.

Rachael: Home Group include parents in the development and delivery of services as central partners in supporting a customer of whatever age. Obviously where the customer has capacity, they have the right to choose who and what is communicated, and we respect this.

Helen: Very good question! Staff are adult qualified not children qualified, and not used to dealing with families.

Rachael: Our transforming care services are built on a psychologically informed environment model. This means that we prioritise understanding the emotional and mental wellbeing needs of our customers. We respond to behaviours that challenge through a positive behavioural support framework, without judgement, seeking to understand the function of that behaviour. Offending behaviour falls within this framework as does any other behaviour that is challenging. This is our baseline. Services that work specifically with customers who have forensic history may differ is in three ways.

First, the team that is working around the customer will need specialist psychological leadership and expert advice, guidance, reflective practice and psychological formulation regarding each customer’s psychological care. This translates into practice/treatment that addresses specific risk behaviours and alleviates associated distress. CBT-based models also enable teams to reflect on internal experiences, teaching them to notice and articulate beliefs about situations, others’ motives and their own behavioural urges.

Second, though related, customers with forensic histories may present active risks to the community. So forensic services need to balance supporting customer aspirations and using the least restrictive practice with protecting the community. This involves specialist risk assessment and management plans, created internally or in partnership with statutory agencies. Partnership is also needed with statutory services to share crisis plans and co-ordinate responses to heightened risk.

Finally, customers with forensic histories may have additional legal restrictions and monitoring requirements. This, combined with issues around mental capacity and the Mental Health Act, can make enabling transition into the community a complex legal process. Exceptional partnership-working with statutory provision is required to enable this process to have a positive outcome resulting in an individual being transitioned into the community.