Bespoke support for people with learning disabilities and autistic people: Michelle and iDirect, Wiltshire

Before I moved to my own home, I was in a hospital. I was the youngest and sometimes felt other people were given more time, which didn’t make me feel calm or safe all the time. Now I’m living in my own home I feel so much more independent and happier in myself”.

Michelle, Wiltshire

A referral to support Michelle was circulated to a number of provider organisations. iDirect put in a bid to support Michelle, who is based in Wiltshire.

iDirect were successful with their bid and have been working with Michelle since July 2020. There was a long transition period before she moved into her own home in February 2021. Michelle has a diagnosis of mild learning disability and ADHD. In Michelle’s story, it was not appropriate to link in with her family, due to childhood trauma issues she was still experiencing.

Due to the trauma Michelle experienced, the provider is seeking therapeutic support for Michelle. Michelle had experienced a lot of change and disruption in her life- moving in and out of foster care, followed by child placement, residential care and eventually being sectioned under the Mental Health Act. She then moved from a traditional adult mental health unit to a specialist hospital setting for people with mental health and additional needs.

It came to light that people were staying there for up to five years without any plan to move on. Michelle was one of the people identified to be discharged. When Michelle’s transition plan commenced, her trauma triggers meant that it took a long time to establish trusting relationships.

Staff from the provider initially started working in the background, observing Michelle, having conversations and small interactions. Over time this built up and Michelle began to trust the staff who were visiting her in hospital. From there, the team started to plan about life for Michelle outside of the hospital setting. They reviewed existing paperwork from the hospital setting. The plan included identifying suitable accommodation for Michelle.

The transition visits from hospital commenced, but they were taking place during COVID-19 lockdown, and staff were wearing full PPE which made it more difficult to establish trust and safety. It was difficult to find private landlords willing to rent properties to people with additional needs and a risk history. Local authority properties were in short supply, and not necessarily meeting Michelle’s requirements.

After a lot of time searching, a suitable property was identified. iDirect shared the option with Michelle, using a social story. Michelle engaged positively and gave consent to plan for a move to this property. iDirect was prepared to act as guarantor for the property, but still found the process difficult. The property was in a village with local amenities. There was a supermarket, cafe, hairdressers, GP surgery etc. Michelle had established good relationships with her staff at the hospital, so starting to work alongside new staff was a risk for her. 

Michelle moved out into her new house in February 2020. She was involved in choosing her own furniture, fixtures and fittings and how she wanted the property to be decorated. She accessed online shopping, and created an Amazon wish list to identify things she would like to buy for her property. 

Michelle’s funding was provided via an individual service fund (ISF) arrangement with the provider. (Michelle received joint health and social care funding) which was built around the plan to step-down from hospital. The ISF was agreed as the funding model once the contract to provide support had been agreed. The ISF arrangement and budget was developed into a proposal which went to panel. It also incorporated a set-up budget for the home. iDirect were also able to build in a robust training budget into the ISF arrangement so that bespoke training could be provided to Michelle’s new staff team.

Having a vehicle was important, so a vehicle budget was included in the ISF as well. Michelle had high staffing needs, so 2:1 support was included in budget.

Michelle’s relationship with her family was difficult, so the provider organisation was aware of the need to support the rebuilding of those relationships. Michelle craves the relationships she sees others having with their parents. Family therapy was also built into the ISF budget along with funding for some personal therapy for her. This would be quite a lengthy process to arrange in order for Michelle to engage comfortably. By using the ISF model, the provider was able to build everything around Michelle’s specific needs.

Recruiting for staff prior to Michelle’s discharge was a challenge. To use agency staffing would have presented a high risk for placement breakdown. iDirect needed to stagger the timing of starting Michelle’s new staff at the right time so they weren’t a financial burden to the organisation. The provider set up a seven-day induction for staff which was built around Michelle. They provided mandatory core training. A senior trainer from the organisation played a major part in the transition process so that Michelle and staff could have a positive transition together.

The senior trainer got to know Michelle really well and had a good understanding of her. He then incorporated this knowledge and insight into the induction process for the staff team.

When Michelle moved into her home, she had an incident which lasted eight hours on her first night, but the staff team were prepared for responding positively to this. It has not been repeated. She does still show behaviours, but they are always for short amounts of time and staff are able to respond positively. The staff team have been committed to the process of helping Michelle to settle in the community, and their resilience has reinforced Michelle’s trust and feeling of safety.

Since moving in, Michelle has progressed really well. She’s now accessing new places. She has been able to access her hometown which previously she was terrified about. She’s able to visit her Nan, and sometimes meets her in the local town. Their relationship has developed really positively. She has visited Wales and is very proud of this! Michelle used to be quite reluctant to walk anywhere but now walks regularly. She loves going shopping. Previously, Michelle used to ask staff to go shopping for her whereas now she is very independent and keen to do her own shopping with support from staff.

In previous settings Michelle’s anxiety and behaviours constantly escalated which resulted in her being sectioned. Now, she still shows anxiety but the staff team are able to de-escalate and support her without it going further. Michelle is now talking about wanting to go to college next year! Michelle’s team attend regular multidisciplinary (MDT) meetings. Her advocate, financial deputy, and therapists also attend. At the meetings they discuss goals and outcomes. During the meetings they reflect on areas of support which may need to change. Quarterly outcomes focused reviews are held. Six outcome areas are set by the commissioners. iDirect report back against the outcomes. Michelle is joint-funded by the clinical commissioning group (CCG) and local authority under 117 aftercare.

It has worked really well. Private rental funding was put into the ISF arrangement for the first two years (rather than housing benefit), which is coming to an end. The provider is now looking for an alternative property, where Michelle can have her own tenancy.

IDirect had regular contact with Wiltshire CCG (the main commissioners for Michelle’s support) throughout the process. They were having bi-monthly or monthly meetings where they discussed progress, discharge plans, transition, housing etc. Set agenda items were agreed which would be reported against each time they met together.

Although she did not have any direct family involvement, Michelle had the involvement of an advocate who had worked with her for years and had seen her through various placements. The advocate was very supportive and positive in engaging with the process. She’s extremely proud of how far Michelle has come on in terms of achievements and resilience. Many other members of the MDT had known her for years. Other members of the MDT were apprehensive about the plans.

In terms of wraparound support for Michelle and her support team from local community teams, Michelle can access her local GP services but struggles to access the dentist due to trust and anxiety issues. Michelle has a Community DoLS authorisation in place (which the local authority is leading on), to enable staff to physically intervene, as Michelle does occasionally present with ligature risks and other risky behaviours.  

iDirect has ensured there are capacity assessments and risk management plans in place around Michelle’s behaviour support. Michelle has consented to staff using low/medium physical intervention to help her stay safe when needed. Michelle has fluctuating capacity depending on her arousal levels. Michelle has a community ld nurse and a community psychologist who are part of her MDT. However, they don’t have the capacity to provide the level of therapeutic input Michelle requires and iDirect is considering whether it needs to explore private therapeutic options due to the time needed to build a safe relationship with Michelle. This could be more costly.

In terms of the funding arrangements, the ISF arrangement was not prescribed within the initial tender specification which was circulated to providers; but iDirect worked closely with another organisation to develop a good life plan for Michelle, and the planning work evolved into a discussion with the commissioners about what the funding might look like in order for the plan to work well. The ISF arrangement became the obvious mechanism for enabling the creative plan and budget which had been designed bespoke for Michelle. The provider reflected that when developing support for people with complex needs it’s really helpful to have an open and flexible approach to commissioning.

Internal training was provided to staff supporting Michelle including physical intervention, trauma and behavioural training. Low arousal approaches and trauma-informed support training was also provided during staff induction.

A major key to success is promoting and enabling a good transition, which is well funded, mapped out and co-ordinated, well planned, and having all parties in agreement with the plan. The provider reflected the importance of establishing a good relationship with the person prior to discharge. Emergency discharges should not happen- this sets it up to fail and causes more trauma, which impacts the person further.

As a provider, iDirect has received an overall Outstanding rating in their CQC inspection, reflecting its outstanding commitment to outcomes and personalised support for the people it works alongside.