Bespoke Packages and Transforming Care

Many people leaving in-patient services display challenging behaviour and have complex health and social needs. Often, fitting into an existing service is simply not appropriate.

A bespoke service is one which is developed around the person’s individual needs, rather than, for example; relying on the availability of a bed in a residential or  supported living service. 

• Housing - A house, bungalow or flat that is suitable for the person’s needs e.g., right location & number of rooms, parking etc.– it may need adaptations to make it safe
   
• Support team – A team of support workers who are recruited and trained specifically to meet the person’s needs and deliver their care. The service is designed around the individual’s needs and wishes using person-centred planning and support.
   
• Specialist input - To meet the person’s complex needs ongoing input from specialists such as Psychologists, Psychiatrists or Speech & Language Therapists may be required. This may be provided via the support provider, the local Community Learning Disability Team, or Intensive Support Service or in some instances purchased from the independent market using a Personal Budget

Bespoke services are delivered in accommodation chosen specifically for the person.

The first step is to agree what the person’s housing needs are. This should be written down in a document called a “housing specification”.

The care co-ordinator should create this with input from the person, their family, current provider, and Multi-Disciplinary Team. The specification should clearly set out everything that the person will need in their new home. It should consider things such as:

• Living arrangements e.g., individual or shared
• Type of property e.g., flat, bungalow, detached, semi-detached
• Location
• Size
• Design and adaptations
• Décor and furnishing
• Assistive technology which would need to be incorporated e.g., lighting sensors, alarms
• Security and risk management (and whether this impacts on design and adaptations.)

There are pros and cons to different housing options.

The right option should be agreed between the person, commissioner, Multi-Disciplinary Team, and their family.

The most common options are:

• Living in the family home, with necessary adaptations undertaken and staff working in the home
• Renting from a social landlord (social housing)
• Renting from a private landlord
• Home ownership (there are a variety of options and schemes available)

If a suitable house is not available, creative solutions must be considered. For example, a house could be purchased and then rented to an individual through a registered housing provider or alternatively a bespoke property can be built based on individual needs.

Capital funding is available to Clinical Commissioning Groups and Local Authorities through the Transforming Care programme to expand the housing options available to people with learning disabilities and autism who display behaviour that challenges, details are available in “Building the Right Home”.

Registered housing providers (also known as social landlords) are organisations  which own and manage social housing. They are normally either councils or Housing Associations.

Sometimes, organisations act as both a care and a housing provider. 

The housing provider will find and supply the accommodation in line with the housing specification and provide all the duties of a social landlord.

The provider will normally have a tenant handbook with information about rights and responsibilities. If the person displays challenging behaviour, it is important to establish who will be paying for any repairs caused by this behaviour. This might be  the commissioner, care provider, housing provider, tenant, or a combination of  these.
For more information about renting through a social landlord, see the Citizen’s Advice Bureau’s factsheet
For more information on all aspects of house planning, including funding, see the Challenging Behaviour Foundation’s ‘Planning Your House’ Information Pack'

Individuals with complex needs require skilled support tailored to their individual needs. This is usually put in place by the commissioner appointing a care provider to deliver a package of support. Alternatively, the commissioner can provide the individual or individual’s representative with a Personal Health Budget which they can use of employ a team of staff to provide support

A care provider will:

• Undertake an assessment to decide if they can meet the person’s needs
• Work with the hospital staff, the multi-disciplinary team (MDT) and the person (in line with any relevant capacity assessments) and their family to create a person-centred care and support plan. They should also develop a transition plan detailing how the person will be supported through the discharge process (e.g., Through visits to the new local area, spending time with new staff, using pictures and social stories.)
• Recruit a staff team which is in line with the person’s care and support plan involving the person and their family in the recruitment process
• Identify and work with the housing provider to ensure that support will be delivered in the right environment
• Provide care in line with the care and support plan to ensure the person has a range of meaningful activities to take part in and is enabled to build friendships and relationships (and attend regular, person-centred reviews at a frequency determined by the MDT)
• Provide the person and their family with a clear point of contact e.g., team leader/ manager

For more information about what you should look for in a service, and what questions to ask, see the Challenging Behaviour Foundation’s pamphlet on ‘Well matched and Skilled Staff.’

A personal health budget is an amount of money to support the person’s needs  which is planned and agreed between the person (or a representative such as a family carer) and the local Clinical Commissioning Group (CCG). A personal health budget is available to people receiving NHS Continuing Healthcare funding. 
A personal health budget allows the budget holder to either purchase services from one or more care providers or to directly employ staff themselves. Together with the CCG, a care plan is developed to set out how the budget will be spent. The care plan should be regularly reviewed.

It is important that people with learning disabilities and behaviour that challenges and/or mental health problems have ongoing access to specialist input to provide support such as an individualised Positive Behaviour Support plan. This is often vital to ensure the person’s needs are met and they are not re-admitted to hospital. 
Depending on the person’s needs they may need input from a range of specialists including Psychologist, Psychiatrist, Speech and Language Therapist, Occupational Therapist and Learning Disability Nurse. 
Depending on the person’s needs and the services that are available locally there are different solutions to achieve this:

• The care provider can include access to specialist input as part of the care package. The provider employs specialist staff to provide input as set out in the care plan.
• The person accesses support from the local NHS Community Learning Disability Team or Intensive Support Service. Provision varies around the country, whilst some areas provide excellent services, other areas are not able to meet the needs of their local population and are missing key professionals or have long waiting lists and are not able to respond to changing needs.

Where specialist input it not available from the local NHS team it may be possible for the commissioner to purchase services from independent specialists or for the individual or their representative to use a Personal Budget to buy in the support that is required.

The earlier that the different elements of a bespoke package of support can be identified, the better. Guidance states that discharge planning should begin as soon as the person is admitted to an inpatient unit. 
The commissioner should develop and oversee a discharge plan which sets out everything which needs to happen as part of discharge. This plan should be like a project plan and should be detailed with clear timeframes. 
Note - care and housing providers can be searched for alongside each other. It is not necessary to wait for one to be found before looking for the other. Some providers offer both care and housing services.

A bespoke package of support is likely to take between 6-12 months to put in place. 

If the search for a care or housing provider is not being discussed, or is slow, you 
can help by:

• Requesting an assessment of need or Continuing Healthcare Assessment and a “pen picture” (summary of the person’s needs) which can be shared with providers
• Requesting a housing specification
• Asking for a discharge plan to be created at a meeting such as a Care & Treatment Review or CPA or write to the care co-ordinator or commissioner about this
• Ask for a list of providers who have been contacted, then research and suggest others. Contact Mencap for details of any local providers included in the Transforming Care ‘Provider Taskforce.’
• Ask for a list of housing options that have been considered, then research and suggest other solutions.
• Seek specialist legal advice

For top tips on wider discharge planning – see the Mencap, Challenging Behaviour 
Foundation and Respond guide Meeting the Challenge Guide 6 ‘Planning A Successful Discharge'.