Care pathway

First Referral

There is a clear referral, assessment, transition and placement procedure at CTS. Within this procedure, referring agencies fill in a CTS referral form. Once this is received the referral is discussed and, if suitable, an assessment carried out. CTS may require further information for the assessment that they will request before the placement progresses. During this phase, we will contact local external services as appropriate in order to gain a shared understanding of outcome, expectations, risks and contingency planning.

Assessment Phase

At the assessment phase, consent will be sought from the individual for the assessment, and where the person lacks consent, a best interest assessment will be completed. The assessment will be carried out by at least one of our Clinical Team members, and where possible, a Manager. The assessment will look at many sources of information including talking with the individual, their family, professionals involved and gathering any previous information available. Once the pre-placement assessment has occurred and agreed as appropriate by the Clinical Team and Registered Manager, the individual’s care needs will be identified using Person Centred Planning in collaboration with as many stakeholders as necessary.

Positive Behavioural Support Plan and Risk Assessments

Every person who uses our service will have Positive Behavioural Support Plans, Risk Assessments and Management Plans. These will include Care Plans that focus on the needs and wishes of the individual.

The positive behaviour support plans will be based on an assessment of the individual’s social, physical, emotional, psychological and behavioural needs. This plan will include all the care plans and comprehensive risk assessments and management strategies. This plan will be developed in collaboration with the individual, their family, and all relevant professionals and agencies involved in their care.

The process of gathering information and revising care and risk management plans is a dynamic and fluid process and it is therefore an on-going activity throughout the individual’s stay with us. Evidenced based risk assessments and risk management plans will be completed and agreed prior to the placement and will be revised regularly with the expertise of the senior clinical management team members.

Each individual will have a care plan that looks at their capacity to consent to the care and treatment they receive. This is to ensure that any individual who may lack capacity in this area is assessed appropriately and any deprivations of liberty are considered. Where it is suspected that a new referral may have issues around deprivation of liberty, we will ensure that the best interest assessment is completed and appropriate Deprivation of Liberty applications are completed for the supervisory body. All care plans will take note of checking whether they are providing the least restrictive practice for the individual concerned.

Individual key worker

Once we have all agreed that CTS can provide the right place at the right time for an individual, and that the home is the right service, the individual will be allocated a ‘key worker’. This is a named senior support worker, who is the first point of contact for the individual. They are able to offer help and advice and are responsible for looking after the individual’s needs, being an advocate for them, communicating any problems to the wider multidisciplinary team, and helping the individual communicate their feelings and ideas. We encourage active engagement from the people who use our service by placing them at the centre of the care package.

Continued assessment

Once a fee has been agreed, a transition plan is planned and a transition team is put in place. Even though transition commences, it is still possible for CTS to decline the referral if information comes to light that deems it inappropriate. The assessment process carries on through the transition so positive behaviour support plans and risk management plans can be updated and all relevant information about risk can be acted upon if necessary. Individual needs are continually reviewed during this stage and this continues once the individual has started receiving care formally from our service.

Positive behaviour support plan

Every person who uses our service will receive a personalised positive behaviour support plan that is developed by placing them at the centre of their care and support. These plans will be based around their needs and risks and will incorporate family views and wishes where possible, and where this is not possible the possibility of an advocate will be explored. Following on from these care and support plans, there will be named outcomes identified for each person who uses our service and an audit will be carried out on the satisfaction of the individuals care from the perspective of the individual themselves, their family and professionals involved in their care/support.

Review and assessment

Once the individual has officially completed a transition period, a further period of assessment will occur lasting 12 weeks. This is a ‘settling in period’. This initial assessment period may be extended over 24 weeks if necessary. In this time relevant outcome measures and any revisions to risk assessments will be completed. A multi-disciplinary review of the Care Plans, Positive Behaviour Support Plans, Risk Management plans and Person Centred Planning will be held within the first 3 – 6 months.

Our assessment and review of the individuals needs carries on throughout the care pathway with regular clinical reviews led by senior managers. These reviews provide quality assurance for the positive behaviour support plans, risk assessments and risk management plans as part of our clinical governance.

We review each placement carefully and a considerable review is completed before deciding whether specific individuals might live together in a shared living arrangement.  Great care will be taken to ensure compatibility for individuals who may be living together taking into account the risks identified.

Ensuring the right care at the right time

We believe that every person who enters residential and community based care should have their needs and risks continually reviewed to ensure they are receiving the right care at the right time. If it is agreed that the individuals needs have changed and they no longer require the level of care provided we will work in partnership with the individual, their family and all agencies involved to move the individual onto the right place.

We strive to deliver a responsive service that identifies a potential move on plan from the time of placement and at each review thereafter. The pathway for the individual should be identified at the earliest stage. When the person is ready for moving on into environments that have less paid staff, we will collaborate with external agencies to work on a transition plan.