To support an intensive rehabilitation approach and personalisation, new personalised integrated offers have been developed, and will be continue to evolve as learning develops.This will enable a growing menu of support and access to less restrictive environments to all people eligible for support.
The key elements of the service offer as identified within the model are as follows:
**what does it actually do?**
An integrated assessment was co-produced by partners in 2013. This will be used together with the FACE (Functional Analysis and Care Environment) documentation that is being developed by Lambeth Council. It is hoped this will be in use from ………. FACE replaces the previous documentation FACS (Fair Access to Care). The new FACE is Care Act compliant and replaces the previous FACS (Fair Access to Care) documentation.
A resource allocation system for mental health in relation to this however has not been agreed. The IPSA will therefore set up a working group to review all documentation, take forward and develop resource allocation development in conjunction with the Council, and consider the best way of working together to ensure a joined up approach. This will also consider IT interfaces, and how staff/users will gain access to one recovery and support plan.Learning from the Living Well Network will be applied)
Integrated Alliance Rehabilitation Team
An Alliance Rehabilitation Team made up of a team of nurses, psychiatrists, occupational therapists, social workers and support workers who will work closely with you, your family, ward staff and staff where you live around your support.
The team can meet with you to help develop the skills and knowledge to support your recovery and to live more independently. For example:
- Planning your support the way you would like it
- Developing cooking, cleaning, and budgeting skills
- Identifying support to help you take your medication safely
- Helping you to explore employment, education and training opportunities
- Supporting you to meet new people and reconnect with family and friends
- Doing more leisure/recreational activities
- Exploring the best housing options available to meet your needs
Personalised planning approach
A personalisation pilot is taking place to apply a person-centred planning approach. This will pilot will initially work with 20 people who are in residential, in-patient or working with the Alliance Rehabilitation Team in the community. The pilot will involve working closely with people, their families, carers and support professionals to develop a greater understanding of what is ‘important to’ and ‘important for the person’.
This is a seven bed supported living service with staff on site. 24 hour support and dedicated clinical and medical in-reach support will be provided for intensive rehabilitation work with people so that they can leave inpatient facilities as soon as possible. The facility can also be used in admission avoidance. The expected length of stay is anticipated as 6-9 months. A service specification is currently being drafted and will be available from May 2015
This provides 9 fully furnished, flats, each compromising of an open-plan bedroom/kitchenette/living area and separate bathroom.
The flats provide highly personalised support aimed at helping people to recover, stay well and move successfully on to more independent living. Rehabilitation will be supported by community participation, supporting people to access a range of social, leisure, education, training and employment resources, but also to attend appointments, maintain contact with key formal and informal support networks and manage the various activities needed to live independently. The expected length of stay is anticipated as 9-18 months
The service provides the following support:
8.00am-2.00pm On-site support
2.00pm-5.00pm Choice based flexi support
5.00pm-11.00pm On-site support
11.00pm-8.00am On-site waking night support
Additional 1:1 support can be topped up by personal budgets. The accommodation becomes available for use from 1st April 2015.
Due to learning so far, the service will be used as a respite facility at a reduced cost of £50 per week (2015/6) to support flow.
- 20 new flats purchased via social finance from Thames Reach:
A portfolio of twenty studio and one-bed contained flats will be sourced throughout Lambeth and bought on the open market. These will be purchased through the Thames Reach BriL (Brokerage & Resettlement in Lambeth) project throughout the next year with the first already identified and the purchase moving towards completion by April 2015. Prospective people who are eligible will be given choice around where they live in the borough with emphasis on ensuring appropriate and accessible support to community networks with maximising opportunities for meaningful activities, volunteering and work. There may be a period of joint working with the Alliance Rehabilitation Team to support people in transition. For some people who enter the service from a residential care setting, the Alliance Rehabilitation will maintain ongoing support though these are envisaged as a long-term resettlement option. A draft specification is embedded below.
IPSA Providers together with commissioners will also use their expert knowledge and connections to:
- Engage with other voluntary sector providers and landlords to leverage a greater housing supply across all sectors, including the private rented sector. This may involve adaptation of existing accommodation or services to be able to flexibly respond to need.
- Be able to renegotiate existing placement costs where people are receiving appropriate support
- Implement and negotiate a core and flexi approach with existing and new providers to maximise choice and stimulate more personalised support
- Ensure resources and opportunities from the Living Well Network and Adult Mental Health Services are maximised to support people within IPSA, notably peer support, access to universal services such as the Home Treatment Team.
- Further develop the market in relation to supporting existing partners to develop the personal assistant market
- Work more closely with Older People’s Commissioners to jointly develop solutions to support people appropriately
- Enable compliance with the Care Act in assessment of need for people using the service and their carers.
To implement the above ways of working will necessitate significant culture change. A workforce development programme will be drafted. Staff will also have full access to the Assessment, Action and Planning sessions developed by the Living Well Network, and learning opportunities via the Adult Mental Health (AMH) Redesign. This shall ensure the development of a common workforce training strategy.