Topic One: Enhanced Care Service (ECS) Guest speakers: Caroline Kirby - Interim Lead Complex Needs Commissioner, Angie Simmons - Team Leader, Enhanced Care Service (ECS), Ted Page - Behavioural Nurse Specialist (ECS) and Rachel Barrett – Expert by Experience, Speakeasy Now The presentation reflects on good practice around avoiding hospital admission in Worcestershire who have developed an enhanced care service working proactively in the community. Topic Two: Strategic resettlement, personalisation at scale and pace Guest speaker: Pól Toner, Head of Improvement, NHS England The presentation considers Strategic Resettlement, which is part of the Improvement and Enablement function of the Learning Disability Programme. It is being put in place to support the delivery of a transformational change to close inpatient services and develop the appropriate scale of personalised community care for people with a learning disability and/or autism who display behaviour that challenges, as set out in Building the Right Support. The function provides additional support to local systems to accelerate discharges where appropriate, focusing specifically on patients with the most complex needs and a long length of stay (over 5 years).

1. www.england.nhs.uk
Learning Disabilities:
Share and Learn Webinar
24 November 2016
Topic One:
Enhanced Care Service (ECS)
Caroline Kirby, Angie Simmons,
Ted Page and Rachel Barrett,
Worcestershire TCP
Topic Two:
Strategic resettlement,
personalisation at scale and pace
Pól Toner, Head of Improvement, NHS England
#improvingLD @NHSEnglandSI

2. Worcestershire TCP
Collaborative working and patient
experience
Presented by
Caroline Kirby – Interim Lead Complex Needs Commissioner
Angie Simmons – Team Leader, Enhanced care Service (ECS)
Ted Page – Behavioural Nurse Specialist ECS
Rachel Barrett – Expert by Experience, Speakeasy Now

3. Caroline – Interim Lead Complex Needs Commissioner and Programme Lead for TCP
Angie – Team Leader, Enhanced Care Service (ECS)
Ted – Behavioural Nurse Specialist, ECS
Rachel – Expert by Experience, Speakeasy Now – Lead Expert by Experience for local
TCP
Introductions:

4. Painting the picture of LD Services
within Worcestershire
• Commissioning – LD Health and Social Care is integrated and led by the County
Council
• Community Learning Disability Teams – 4 Locality Teams across the County,
each team has LD Nurses, Behavioural Nurse Specialists, Social Workers, SALT,
OT, Psychologists, Psychiatrists and Physiotherapists
• ECS are a small Team of LD Nurses and Support Workers
• Speakeasy Now are a team of people with learning disabilities who are experts
by experience. They have become integral to developing and transforming
services in Worcestershire by attending CCG Care & Treatment Reviews and co-
presenting TCP Highlight Reports to our Executive Board

5. Community Provision
• Worcestershire closed all the LD hospitals in 2009, developing Community Teams
to manage individuals in their own homes
• We have a range of domiciliary, supported living and residential provision across
the county
• We are currently developing the market to ensure that we have a wider range of
providers to meet the needs, manage and understand the presenting risks,
working towards sustainable provision for individuals stepping down from locked
and secure hospitals

6. Enhanced Care Service (ECS)
• The ECS was developed in 2014
• Working with people with a primary diagnosis of LD, autism and/or a co-
morbidity of MH conditions
• The ECS are a small team of experienced LD Nurses and Support Workers
• The ECS work across the county to prevent hospital admission and support
Worcestershire patients stepping-down from locked and secure units and
returning to Worcestershire
• The ECS work alongside the Community Learning Disability Teams, where many
of the referrals are received

7. ECS involvement in Care &
Treatment Reviews (CTR)
• The ECS attend Care & Treatment Reviews for all Worcestershire patients in
locked and secure hospitals
• This has enabled them to gain an understanding of patients and become involved
with developing relapse plans and Positive Behavioural Support Plans at the
earliest opportunity
• The ECS lead on delivering Positive Behavioural Support to Community Teams,
providers and carers; supporting successful discharge within our communities
• The ECS have become an integral part of the transition for patients

8. Case Studies
We wanted to share three case studies to demonstrate the pro-active work of the
ECS. The Case Studies represent:
• Patient 1 - has been successfully discharged from locked rehab following many
years of secure and locked services. The ECS have supported the patient during
the transition period
• Patient 2 - lives with an elderly carer in the family home. The ECS have
supported the patient in the community during medication review and changes
• Patient 3 – prevent a hospital admission, whilst supporting the provider to
manage a transition to a temporary service and the return

9. Case Study 1
Pen Picture:
• 28 year old male
• He has a mild learning disability
• He has a diagnosis of Autism
• He is very ritualistic and suffers with anxiety
• There are complex family dynamics
• There is a long history of placement breakdowns
• He has spent a number of years in locked accommodation
Brief History:
• Admitted to hospital following a placement breakdown linked to his obsessive behaviours
which could no longer be managed in community
• Structured environment and MDT approach met his needs
• Discharged into community which broke down in 11 days so readmitted
• Enhanced Care Service involved to support community and hospital to discharge

10. Support Given:
• Regular visits to develop relationship
• Attended CTR
• Collaborative working with MDT to support in identifying care provider to meet his needs
• Recommendations around building modifications
• Staff training with identified provider
• Work closely with family
• Regular visits once discharged (16 weeks)
Outcomes:
• Links remain open with provider
• Has now lived in community for 18 months
• Incidents continue to decrease
• He has recently been on holiday for a week with staff
• Has progressed within setting into flat with access to own kitchen

11. Case Study 2
Pen Picture:
• A 47 year old gentleman
• Learning Disabilities/Bi-Polar/Stress Anxiety Disorder/Kidney Failure
• Lived at home with elder carer receiving 1:1 from domiciliary support for day provision
• The gentleman had been receiving Lithium therapy for many years but needed to change
medication due to his deterioration in health. As such psychiatry had planned a phased
medication review to omit lithium before introducing new therapy regime
Support given:
• ECS maintained close liaison with psychiatry to monitor each stage within the medication
review and report back any side effects or concerns
• A Positive Behaviour plan and support plans was devised and reviewed during the stages
of the phase reduction. Also monitoring forms were distributed
• Hands on support was given in the interim whilst additional domiciliary support was
sought, with an agency who could provide 2:1 and out of hours support and weekends
during this period

12. Support given:
• Reintroduced respite with hands on support
• Referrals was also made to the wider MDT to support other health needs.
• Training was given to staff to ensure a consistent approach was maintained amongst new
and current staff.
• Daily contact with family for advice and monitoring.
Outcome:
• New medication regime successfully introduced.
• Hospital admission avoided.
• Individual was able to remain at home with mother and within a familiar environment.
• Incidence of behaviours of concern stabilised

13. Case Study 3
Pen Picture:
• 22 year old male
• He has a diagnosis of moderate learning disability and autistic spectrum disorder
• Communication and sensory needs mean he requires full MDT input
• Doesn’t cope well with living with others and has historically required very specialist provision
• Has experienced placement breakdown in the past
• Complex routines so skilled staff team to work with him
• Has epilepsy and associated undiagnosed physical health needs
Brief history:
• He was living in a stand alone single occupancy community bungalow which suited his needs
• He was suspected as being in pain and was unhappy but unable to communicate needs
• Physical assessments were not possible in community setting
• Placement was breaking down and aggressive outbursts increasing when ECS became
involved
• Hospital placement not seen as option due to complex needs

14. Support given:
• Intensive input given in community
• Liaison with potential providers to co-ordinate a move to somewhere that could meet his needs
• He moved to a specialist college overseen by a learning disability hospital where he had input
from required professionals
• Worked closely with Worcestershire and provider to keep existing placement available which is
close to family
• Training given to existing staff team and building modifications recommended
• Co-ordinated transition out of specialist college back to community when assessments had
been complete
• Robust relapse planning put in place
Outcome:
• Has now been back living in community for 6 months
• He does not appear to be experiencing any pain and his mood is very stable
• There have not been any incidents since his return
• He is close to family and is now visiting them more regularly
• He has recently been on holiday with staff to the sea side
• He is taking part in new and varied activities on a daily basis

15. Rachel – Speakeasy Now
Collaborative working to deliver the TCP has become essential and Rachel will share
her personal view of her experiences and shared learning of our journey so far

16. I was asked to be on the Transforming Care Board because I have
been involved in Care and Treatment Reviews so I have an
understanding of transforming care
Transforming care is about getting people out of locked hospitals
and getting people out who are in the NHS beds criminal justice
system. It is more difficult for people to come out of the criminal
justice system as a Judge needs to agree they would be okay to
come out

17. There have been 2 Pre-Admission CTRs that I have been involved
in and we stopped someone getting sent to a locked hospital
when they didn’t need to by having me involved as I gave an
independent view
I would like to feedback how pleased I have been to see that in
each review, the person being reviewed has been central to the
review and their needs and wishes have been taken on board
I am pleased that steps have been put in place for people to
move back into the community as soon as possible even though
there may be delays due to MoJ needing to make the final
decision

18. It’s been good where instead of having everyone in the room
together for the review, staff come in individually to give their
thoughts on progress of the person and whether they feel they
are ready to move on.
This showed whether staff knew the person and whether they
feel they are working as a team.
I feel more confident at being able to ask questions especially in
a smaller group.
I have been telling other members of Speakeasy Now about
how the TCP works so they can see what Worcestershire is
doing to support people to come out of locked hospitals and
not going in unless it’s needed for a short assessment period.

19. Thank you for listening
We welcome any questions

20. www.england.nhs.uk
Learning Disabilities:
Share and Learn Webinar
24 November 2016
Strategic resettlement,
personalisation at scale and pace
Pól Toner, Head of Improvement,
NHS England
#improvingLD @NHSEnglandSI

21. STRATEGIC RESETTLEMENT
TRANSFORMING CARE PROGRAMME
“
People with a learning disability and/or autism have the right to the same
opportunities as anyone else to live satisfying and valued lives and to be treated
with dignity and respect. They should expect, as people without a learning disability
or autism expect, to live in their own homes, to develop and maintain positive
relationships and to get the support they need to be healthy, safe and an active part
of society.”
Building the Right Support

22. STRATEGIC RESETTLEMENT – PURPOSE
• The aim of strategic resettlement is to support discharges and
a safe repatriation of patients with the most complex needs
• The main focus is on patients with a long length of stay (over
4.5 years)
• A safe resettlement of patients
• Accelerating discharges of patients with a long LoS are one of
the main programme priorities

23. PATIENTS WITH A LONG LENGTH OF STAY – KEY FIGURES*
• 880 inpatients have a total length of stay exceeding 5 years – this is
more than 30% of the total inpatient list
• 250 patients have been in hospital for more than 10 years and 115
patients for more than 20
• Two thirds of patients with LoS over 5 years reside in general and
low secure settings
• There have been no significant changes in the proportion of
patients with a long LoS since the Assuring Transformation data
collection started in March 2015
• This cohort is therefore a key programme priority
* Suppressed Assuring Transformation data as at 31.08.2016

24. STRATEGIC RESETTLEMENT – APPROACH AND
PROGRESS TO DATE
• Resettlement work to date – London and the South Region,
North established and Midlands and east work underway
• Dedicated regional functions are being set up to lead the
work
• Central team provides support to mobilise and coordinate a
safe resettlement of patients across the regions and unpick
system issues, i.e. legal technical support, expert clinicians,
practical experience and financial modelling
• Additional capacity and expert support may also be provided
through a CSU call-off contract – live in December 2016

25. STRATEGIC RESETTLEMENT – KEY ACTIONS
BEING TAKEN
• Clear discharge trajectories are being agreed for patients
whose length of stay exceeds 4.5 years
• Strategic resettlement functions provide further support to case
management
• Care and Treatment Reviews are being prioritised for patients
with a long length of stay who have not had a review in the last
6 months
• A common framework and tools are being used to support
local systems, such as combined Discharge Standards and a
12 point discharge checklist

26. 12 POINT DISCHARGE CHECKLIST
26
Key to Position on Discharge:
Stage
Named
Respons
ibility
Deadline
Date
Stage description - what should be happening? Who/what can help?
1) Patient in active
treatment, commence
discharge planning
Timescales
to be agreed
Person-centred plan to be developed if not in place (or updated):
• Support plan for future to be developed- what support does the
individual need to keep them and others safe and enable them
to live a good life in the community
• Home identification form to be completed and discussions on
what type of housing arrangements (e.g. tenancy/shared
ownership etc)
• Person-centred specification developed based on above
Community care
coordinator/Social worker
Family and person
PCP facilitator
Community providers and
team need to be involved
2) Patient identified ready
for discharge -
Specification Outline
Required
• CTR completed
• Discharge date or target discharge date confirmed
CTR panel and leads for
actions
3) Capacity Assessment
Required
• Tendering of the specification /identification of the right care
and support
• Panel/decision on care and support providers (involving the
person and family/those who know the person best)
• Plan for community team support agreed (e.g. community
nurse, psychology, GP) and for handover between hospital and
community (e.g. identifying responsible clinician in community)
and EHCP if CYP
Commissioner/Social worker
Community care
coordinator/Community
team/Local Authority
Local authority
4) Risk Assessment
Required
5) Specification Complete
6) Procurement Process
Required
Funding assessments completed including continuing health
care and social care funding.
• Include options for personal budgets
Commissioners/Social
worker
7) Placement & Provider
Identified
• Identification of housing (involving the person & family/people
who know best)
• Visits from person, family and professionals to assess and
advise on any adaptations
• Housing agreements signed (e.g. tenancy)
• Adaptations/changes to house take place
• Recruitment and training of care staff (involving the individual
and family/those who know the person best)
Community care
coordinator/Support provider
/Housing officer
Community or inpatient
team member (E.g. OT)

27. 12 POINT DISCHARGE CHECKLIST - CONTINUED
27
Key to Position on Discharge:
Stage
Named
Responsib
ility
Deadline
Date
Stage description - what should be happening? Who/what can help?
8) Funding Request
Required
As applicable Case manager
9) Legal Requirement
Application in Progress:
(DOLS,COP,MHT,MHA,BI
etc)
Legal frameworks applied (throughout admission
period and in preparation for discharge) including
MCA; DOLs; MHA – relevant preparations for
discharge - ensuring human rights are upheld
Responsible clinician
(RC)/Approved mental
health professional/Social
worker/Advocate
Case manager
10) Awaiting outcome of
Legal Process
Pursuing and awaiting the outcome Responsible clinician
(RC)/Approved mental
health professional/Social
worker/Advocate
11) Transition planned
and underway
• Leaving Hospital transition plan agreed and
underway, including leave arrangements and funding
for new staff to shadow, individual to visit new home.
• A discharge meeting (usually a CPA) is held- ensure
contingency and follow up plans in place including how
extra help can be sought
(CTR may be helpful to ensure discharge package is
robust)
• Consent for recording individual on at risk of
admission register on discharge
Hospital discharge
facilitator/Community care
coordinator
Agreed lead clinician for
ongoing support
12) Patient discharged
• Follow up review meetings planned – dates agreed-
first meeting within four weeks
• Follow up contact (CPA follow up) should take place
within 1 week of discharge
Agreed lead clinician for
ongoing support

28. NATIONAL, REGIONAL AND TCPs
• National strategic direction and support
• Regional:
Teams being established with clear remit and deliverables
Supporting DCO and TCP functions
Ensuring TCP and local capacity and working that through
Ensuring all the basics are in place
 Ensuring every person is mapped onto 12 point discharge
checklist and prioritising 4.5 year plus cohort

29. ESSENTIALLY
• Know all your patients
• In particular focus on 4.5 year plus cohort
• How many are coming home:
 When?
 What are their needs?
Housing
Care
Specialist health
General health and social care support

30. DISCUSSION
• Care needs mapping
 Who, what and when?
• Housing
 What, where and when?
• What is strategic and how can you plan for that?
 Scale and pace
• And what is person centred?
 Needs, hopes and aspirations

31. www.england.nhs.uk/learningdisabilities
Questions?

32. www.england.nhs.uk
Date Topic Guest speaker
26 Jan 2017 Workforce
Employing expert by experience
in commissioning
Lisa Proctor, Health
Education England
Sharon Jeffreys, South
West Lincolnshire CCG
23 Feb 2017 Housing
Launch of CTR Policy
Amy Swan, NHS England
Anne Webster, NHS
England
30 Mar 2017 To be confirmed To be confirmed
Learning Disabilities: Share & Learn Webinar Programme
#improvingLD @NHSEnglandSI