Aneurin Bevan University Health Board – Housing and Mental Health Support Analysis
Final Report
April 2019
Housing and Mental Health Mapping Analysis
Contents
1. Introduction 3
2. Context 3
3. Executive summary 5
4. Methodology 7
5. Current services, good practice and innovation in Gwent – the base line 8
6. Findings – key issues for stakeholders 29
7. Examples of good practice and innovation in housing and mental health – national 58
8. Recommendations for a strategic programme 65
Appendix 1 – Project Steering Group membership 69
Appendix 2 – Stakeholders and contributors to the research 70
Appendix 3 – Documents reviewed 73
Appendix 4 – Service mapping 75
Appendix 5: Horizon Scan of innovative and good practice services 88
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1. INTRODUCTION 1.1 This housing and mental health support analysis was commissioned by the Aneurin Bevan University Health Board (ABUHB) in January 2019. The Board and its partners in Housing, Public Health, Supporting People formed a steering group (membership listed as Appendix 1) to oversee the project, meeting fortnightly with Campbell Tickell throughout the project’s duration. 1.2 The analysis has set out to provide a baseline assessment of Housing and Housing Related Support Services for adults with mental health issues, aged 18+ across the Gwent area (Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen). The key objectives of this study are: 1) To identify the key issues for all stakeholders and describe possible solutions; 2) To map all current housing related mental health support available within health, social care, housing (statutory, registered social landlords and Supporting People) and the third sector; 3) To identify examples of good practice and innovation locally and across the UK that could inform possible solutions; 4) To organise and facilitate an event with key stakeholders to develop a strategic programme of work to take forward the findings of this study. 1.3 We have received support and co-operation from a range of individuals and organisations across Gwent throughout the project and we would like to thank all the contributors and participants in consultation events and meetings for their time and their contributions to this report.
2. CONTEXT 2.1 The operating environment for housing and mental health provision is challenging, with increasing homelessness, insecure housing, financial pressures, and the impact of welfare reform on people leading to increased demands on mental health services. Homelessness and poor housing multiply the impact of underlying inequalities and have a long-term impact on peoples physical and mental health. 2.2 The long-term economic squeeze and its impact on public services has also resulted in a dearth of resources for preventative services, the lack of which further increases demand on the mental health system.
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2.3 A recent report from NHS providers1 in England highlighted the fact that socio- economic pressures on people are creating additional demands on and pressures for mental health service providers, with many now increasingly involved in supporting patients to address these issues in addition to their mental health needs. The issues referred to in that report will also be familiar to providers in Gwent and are illustrated below:
2.4 ABUHB has made significant steps in looking to address these pressures and demands on the mental health system in Gwent. Partnerships have been established with housing and Supporting People and Public Health colleagues and joint working is increasing at the strategic level, with regional Boards and at a practical level where housing and support providers and statutory partners are keen to do more.
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3. EXECUTIVE SUMMARY
Lived experience quotes:
“I don’t feel like I can sort anything out until I have somewhere to live” “Hardest part is the nights and early mornings, especially when I can’t sleep and I’m having terrible dreams”.
3.1 The current system is failing some of the most vulnerable homeless people, who often struggle with the rules and conditions, stress, and lack of security in hostels, and who need higher levels of support as a result of poor mental health, substance misuse, physical or learning disabilities or a history of offending. 3.2 At the same time, the lack of appropriate, affordable housing with the right support across Gwent is a major barrier to recovery for many people who are ready to move forward on their recovery journey, whether that be by leaving acute hospital care, specialist services, residential care, or supported accommodation. 3.3 In addition, while the stresses associated with the social determinants of health increase amongst service users, preventative services that could alleviate some of these negative impacts on people’s mental wellbeing have been reduced through cuts to public spending arising from the economic squeeze since 2009. Front line services find themselves frequently working with a level of people’s mental distress that they know is preventable. 3.4 Our recommendations bring together the information gathered through service mapping, stakeholder interviews and two workshops conducted with stakeholders in summary these are: 1) Establish a mental health and housing pathway (or pathways) across Gwent based on mapping the journey’s into and out services for: a) Homeless/rough sleepers and those with complex needs related to homelessness b) People requiring ‘step-down’ services from high to low care and support and through to independent living c) People who are housed and in crisis or at risk of losing their housing as a result of mental health issues d) Young people in transition from children’s to adult services
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e) Offenders with forensic history or with mental health issues – in particular consider prison in-reach housing and mental health advice and support to access services 2) Identify the mental health offer to Housing First services for people with complex needs who are not able to benefit from a housing pathway approach and look to develop a Housing First Model across Gwent. 3) Consider how NHS Estates planning can be influenced to address some of the housing needs of people with mental health issues. 4) Work with private sector landlords to improve access to good quality secure private rented sector housing for people with mental health issues – building on existing initiatives. 5) Work with partners to address the impact of welfare reform e.g. through financial inclusion services, advice and assistance. 6) Agree information sharing protocols with partners across the pathway/pathways. 7) Commission a Gwent wide hospital discharge service that includes Housing Advice Workers, by bringing together and expanding existing provision. 8) Commission crisis support services based on a ‘recovery café’ model. 9) Build on dual diagnosis services. 10) Identify a mental health and housing pathway champion within ABUHB who can take oversight responsibility for: • maintenance and continuous development of the service mapping carried out as part of this project • building pathway access and exit routes, • joint working arrangements with partners across social care and housing 11) Work with social care colleagues to pool budgets for S117 service users and ensure that social care colleagues and mental health care managers are incorporated into the mental health and housing pathway(s).
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4. METHODOLOGY 4.1 Our methodology has consisted of: a) A review of key strategic documents (listed in Appendix 3); b) Document and web-based research and collation of existing lists of provision to map current housing and housing related support services for people with mental health. This has resulted in a spread-sheet based database of provision. A word version is attached as Appendix 4); c) Face to face and telephone interviews with 30 stakeholders (see Appendix 2 for those interviewed); d) Face to face interviews with 30 people with lived experience of mental health and housing issues. Meetings were held with people who use Torfaen and Blaenau Gwent Mind services, Gofal supported housing, Monmouthshire Housing Options, the Olive Branch (a drop-in day service in Newport) and people who are currently in St Cadoc’s hospital in Pillmawr Ward (re-hab, low secure ward for men). These meetings resulted in creation of 30 case studies – six of which have been included in this report. The full set of 30 case studies are provided as a separate digest. e) A Horizon Scan of new models, examples of innovation and good practice, based on desk top research, consultants’ own knowledge and information gathered via stakeholder interviews; f) Workshop meetings with key stakeholders: • A half-day ‘reality check’ event with 32 stakeholders conducted in February 2019; • A second Programme event with 36 stakeholders to agree a strategic programme of work based on the findings of this study, conducted in March 2019; g) A report setting out our findings (this study).
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5. CURRENT SERVICES, GOOD PRACTICE AND INNOVATION IN GWENT – THE BASE LINE
5.1 This section of the report sets out a description of the range of mental health and housing services mapped and identifies local examples of good practice. We have defined services for inclusion based on either having specialist mental health workers or being a designated mental health service. 5.2 To ensure that the mapping focusses appropriately and does not become too generic we have excluded services that support people with a mental health issues alongside other issues e.g. some single homeless services work predominantly with homeless clients and many of these have a mental health issue, but there is no specialist mental health input included in the service. Child and Adolescent Mental Health Services (CAMHS) and Older Adults’ Mental Health Services are also beyond the scope of this exercise. 5.3 The inforgraphic below is a summary of the services mapped between January and March 2019. The services included are also set out as Appendix 4 of this report. Accompanying this report is an excel mapping spreadsheet of the services mapped.
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5.4 The diagram below identifies the range of areas and stakeholders that intersect with mental health and housing issues.
National Crisis Prison and Response Housing Probation Options Service Advice and Police Support
Community Tenancy Rehabilitation Sustainment
Substance Mental Supported Misuse Health and Housing Housing Social Care Specialist Packages Housing
Community Mental Housing First Health
Hospital Primary Care Social Social Isolation Prescribers
Supporting People Mental Health Services 5.5 Across the Gwent region 874 people are supported through specific/dedicated Supporting People (SP) funded Mental Health services. Managing accommodation, managing money, feeling safe and being mentally healthy continue to be the key areas that people approaching all Supporting People funded services require help and support with. 5.6 The table below outlines the number of people who use Supporting People funded services who achieved mental health outcomes over 1 year across all SP services:
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Mentally Healthy Outcomes Data Jul 17 - Jun Positive Outcome Achieved 2018
Blaenau Gwent 239 Caerphilly 479 Monmouthshire 487 Newport 646 Torfaen 408 Gwent 2259 5.7 Floating Support is a key programme for supporting people with mental health to move on from more institutionalised settings, out of homelessness, move on from supported housing and into community housing as well as tenancy sustainment and homeless prevention. 5.8 As stated in 5.2 above there are also a range of SP services that provide support to people with mental health issues that are invaluable in terms of prevention and escalation that have not been mapped. We recognise that the services mapped in this report are underpinned by a range of non-specialist provision that is providing a much needed safety net and preventing the escalation of mental health issues and as such contributes to this map of specific mental health services. 5.9 From April 2019 the Housing Support Grant, (encompassing Supporting People (SP), Homelessness Prevention and Rent Smart Wales Enforcement) will apply to all local authorities across Wales. Detailed guidance for the grants will be developed including a new outcomes framework. Development and implementation of the Housing Support Grant is the key priority for the Gwent Regional Collaborative Committee (RCC) in 2019. 5.10 A total of £3.5m will be spent across Gwent on Supported housing and floating support services in 2018/9:
Local Authority Projected spend to 31/03/19 at 03/01/19 Blaenau Gwent 598,785.96 Caerphilly 963,000 Monmouthshire 322,200 Newport 896,365.45 Torfaen 727,542 Gwent 3,507,893.41
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5.11 In 2018/2019 Supporting People teams across Gwent contributed £936,442 of funding towards specialist posts working within the five Gwent Housing Solutions teams enabling them to deliver against the prevention duties required under the Housing (Wales) Act 2014. 5.12 All five local authorities operate a Gateway to manage referrals into Supporting People services. 5.13 In the Gwent Regional Service User Consultation survey in 2018, conducted as part of the Gwent Supporting People Inclusive and Strategic Needs Planning Framework, mental health was clearly the most important area for respondents. It was chosen as one of the top 5 services needed by 87% of the respondents. 5.14 As part of the development of the Torfaen Homelessness Strategy, people who have experienced homelessness were asked what they believed were the most important issues in preventing and resolving their situation. Respondents cited access to social housing, affordable private rents, immediate access to housing when homeless and support with mental health issues as priority areas.
Blaenau Gwent 5.15 Blaenau Gwent spends 23% of Supporting People funding on mental health services. The authority has 94 units of SP funded mental health services (543 total). Of these 76 are floating support and 18 are accommodation-based. Providers are increasingly feeding back that people are presenting with more complex needs and chaotic lifestyles and it is increasingly difficult to meet demand with the current supply in services. Mental health continues to be the highest main need identified. 5.16 Supported Housing: Gofal support 7 people at Miles Richards House 24hr (sleep in) and Mon-Fri, 9-5 provide support to 5 people at Garfield House. The Hollies also provide Supported Housing of 6 units with Office Cover (Mon-Fri, 9-5). All supported housing is for a two-year duration. A 24-hour supported accommodation service (jointly funded by SP and Adult Social Services) for people with mental health issues was recently remodelled into an SP service as the tenants only had housing related support needs. 5.17 Floating Support: Gofal provide Floating Support to 66 people at any one time and Adults Services Information Advice and Assistance (IAA) Team provide 10 Units. Both services are available Mon-Fri, 9-5. All services can be delivered for up to two years. People can also receive floating support from Torfaen and Blaenau Gwent Mind, although this is based in Torfaen.
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Local good practice A Mental Health Support Worker is to be based within the Housing Solutions Team to ensure a speedy and specialist response in times of crisis. They identify and assess accommodation and support needs as well as increasing awareness and knowledge of mental health matters to staff within the team.
Caerphilly 5.18 Caerphilly spends 15% of its SP budget on mental health services. 5.19 Supported Housing: There are a total of 24 units of supported housing in the Caerphilly council area. Gofal has two supported housing schemes in Caerphilly offering accommodation and support to 16 people. This includes 8 self-contained flats at Ty Oborne providing 24-hour (sleep in after 8pm) 8 self-contained flats at Ty Short (staff support 8am – 8pm). Ty Short work closely with SP and Social Care and take referrals of people stepping down from forensic wards. The schemes support people with varying levels of need and has a hub and cluster approach. 5.20 Home from Home provide 8 Supported Housing units (support 8am – 6pm). Tenants also have care arrangements in place. 5.21 Supported Tenancies: Jubilee House is a block of 4 flats where clients get floating support only (Monday – Sunday with support provided by Gofal). 5.22 Floating Support: There are 460 hours of floating support available per week in Caerphilly. Gofal Caerphilly Tenancy Support Team are commissioned to deliver 350 hours of floating support per week. Mind provide 35 hours of floating support and work closely with Cornerstone (rough sleeper service). Reach provide 75 hours per week. All floating support is available Mon – Fri 9am - 5pm 5.23 Shared Lives is a Former Adult placement scheme that provides support for older people, people with mental health issues and substance misuse issues, single people and vulnerable families.
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Local good practice Caerphilly recently expanded their mental health services by introducing a new dedicated Mental Health Community Worker based in the North of the borough. In addition, there will be a Mental Health Worker to focus on homeless people with mental health issues.
A dedicated support worker from Gofal works with Homelessness/Housing Advice colleagues for those who have identified vulnerability around mental health when completing their housing/homelessness application form; this will be available to those not currently in receipt of support services. The worker will also be present at the night shelter to deliver support to those who are homeless and disadvantaged through mental health issues.
Caerphilly has crisis workers based within mental health floating support teams, available to all service users, not just those with a diagnosed mental health condition.
A dedicated worker from Mind assists the rough sleepers’ floating support service, delivering direct support within an individual or group environment. They offer support for all individuals while in the night shelter, and follow through when they’ve moved on.
New members of social services staff are offered a slot of time to consider how SP fits within their daily job as part of their induction.
Monmouthshire 5.24 Monmouthshire commission their Supporting People services on a generic basis. However there are two specific mental health housing related support services with Monmouthshire Mind. 5.25 Supported Housing: Monmouthshire Mind has supported accommodation for 24 people (Mon – Fri 9am -5pm support) in shared housing. 5.26 Floating Support: Monmouthshire Mind provides 21 units of support Mon–Fri 9am – 5pm.
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Newport 5.27 Newport Spends 14% of its SP budget on mental health services. The Council has 76 units of supported housing for people with mental health issues across six services. 5.28 Supported Housing: 11 units provide 24-hour on-site cover and are supported by Newport City Council (9 in Newport and 2 out-of-county). Gateway Support & Care have 35 units at Brynderwen, Caerau and Chepstow Road. D McIntyre provides supported housing to 4 people at Station Road. L Pressley supports 10 people at Dewsland Park and Caerleon Road. West Park & Bryngwyn have 10 units and S White has 6 units at The Whitehouse. All non-24-hour service also provide on-call support out of office hours. The service duration is needs led across all services including un- time limited stays for all supported housing, except those delivered by Gateway Support and Care. 5.29 Floating Support: Newport Mind supports 80 people through Floating Support, Reach Newid supports 45 people, and Solas provides floating support to 13 people.
Local good practice Gofal provides a Hospital to Home floating support service for 15 people, for a duration of 12 weeks.
5.30 One of Newport Supporting People’s priorities, is for a specialist supported housing scheme for women with additional support needs, e.g. mental health and substance misuse. The Wales Domestic Abuse Modernisation Project also identified the need for a similar scheme in south Gwent. The need for crisis/emergency accommodation for people with occasional mental health episodes and dual diagnosis and/or forensic mental health issues has been recognised for some time. Additionally a Crisis House has been identified as a priority for a number of years but this provision is now being led by ABUHB. 5.31 There are more than 1,300 units of floating support in Newport; approximately one third of these are generic, and the need for additional floating support schemes for specific client groups has been identified including, in mental health, a floating support service for people with forensic mental health issues, which could be developed on a cross-authority basis.
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Torfaen 5.32 Torfaen Supporting People spends 21% of its SP budget on mental health services and has identified mental health as a priority. The Council is re-tendering their provision in 19/20 and intends to create additional capacity in floating support services’ temporary provision. The Council is reviewing a mental health and housing surgeries pilot and want to expand their vulnerable males service. 5.33 Supported Housing: Torfaen has 16 units of supported housing delivered by Torfaen and Blaenau Gwent Mind and 3 units of accommodation and support provided by Home from Home. 5.34 Floating Support: Gofal supports 54 people for up to 2 years. Torfaen & Blaenau Gwent Mind provide floating support to 79 people, including 8 specifically for vulnerable males who are experiencing homelessness or at risk, for up to two years, and the Short-Term Empowerment Project (STEP) supports 10 people for a 12-week duration. 5.35 Mental Health and Housing Surgeries: Torfaen & Blaenau Gwent Mind are also funded by Supporting People to deliver mental health and housing drop in surgeries for around 40 people Mon- Fri (various times). 213 people accessed the mental health and housing surgeries during April to October 2018.
Local good practice A Mental Health Liaison Officer is located within the housing solutions team and provides a vital link between health and housing, supporting those with a mental health and housing need navigate homelessness processes and systems.
In 2018, Torfaen Supporting People piloted a Young Person’s Mental Health Liaison Officer located within the Torfaen Young Person’s Support Service to assist in meeting the housing support needs of young people with mental health issues.
Torfaen trialled a ‘drop in’ model of generic and mental health services to enable an immediate access approach to services.
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Rhian and Trevor both struggle to manage their mental health and have spent several years between them on the streets and in homeless hostels. They met in a hostel, fell in love and now support each other to better manage their mental health. Both now have their own flats, but Trevor is staying with Rhian now to support her as she is currently having significant problems with anxiety.
Trevor was diagnosed with schizophrenic disorder at 18. He has struggled to find a course of medication that works for him and has previously had issues with substance misuse. Rhian has experienced anxiety and depression since she was a teenager. She had a psychotic breakdown in 2011 which resulted in her losing custody of her son, at which point she went into hospital and was sectioned.
Rhian spent six years without fixed accommodation. She was often on the streets but could not sleep there. She once went 50 days without sleeping properly, as she had nowhere to go at night. At one point she did manage to move into a shared house but this broke down. After this she was homeless for another three months, during which time she damaged her feet. Trevor has also spent time on the streets. He has settled accommodation at the moment but struggles to stay on top of rent particularly as his housing benefit is not paid directly to his landlord. He often has to choose between using the money for rent, or food.
Both have also had difficulties in accessing support from mental health services. Rhian previously had support, but now that she has her flat that support has stopped. Trevor feels he is stigmatised because of his previous drug use and that staff now don’t trust his motives when he requests changes to his medication.
Although they are both now in settled accommodation, they struggle to live independently. They struggle to remember how to cook basic meals and would like more support with daily living skills. They would like to move in together officially but expect they will face difficulties in arranging this with the council.
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Other Supporting People Services 5.36 Homeless services across Gwent provide housing related support to people who have mental health issues and include agencies such as The Wallich, Cornerstone, Gwalia, United Welsh, Reach and Llamau Ltd. 5.37 Solas Cymru, the Newport-based homelessness provider, has a 32 unit hostel (Clarence Place) that caters for a number of people who have dual diagnosis of mental health and substance misuse. Professional mental health workers from the CMHT visit the project on a regular basis to support some tenants in their recovery. Solas also has two other hostels (Albert Street with 25 units and Clifton Place with 29 units) both cater for homeless people with a variety of support needs including mental health and complex needs. 5.38 Shared Lives: Individuals using adult placement services can be supported in carers’ homes. Placements are available in the six local authority areas of Blaenau Gwent, Caerphilly, Merthyr Tydfil, Monmouthshire, Newport and Torfaen.
Local good practice Caerphilly Council runs a regular Rough Sleepers meeting that is multi- agency and includes Police, support providers Community Mental Health Team, Gwent Specialist Substance Misuse Service and Cornerstone.
Housing Options, Advice and Assistance 5.39 Housing Options services are delivered by the local authority. They fulfil the statutory role of advice and assistance for homeless people in their county. As part of the assessment the Housing Options provide Personal Housing Plans (PHP). 5.40 The Housing Options team also support people to access the Common Housing Register for social rented housing in each authority. In Newport, Home Options is delivered by Newport City Homes. 5.41 The Housing Options team also support people to access private sector accommodation.
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Social Landlords – Tenancy Sustainment and Homeless Prevention 5.42 Housing Associations reach people facing some of the biggest health inequalities and provide preventive support services to help people maximise their independence and reduce demand on traditional health and care services. 5.43 The table below lists the social landlords in the Gwent area with a breakdown of the local authorities in which they have housing stock:
Blaenau Caerphilly Monmouth Newport Torfaen Gwent shire
Aelwyd HA X X Bron Afon X Cadwyn HA X
Caerphilly X Homes Charter Housing X X X X Derwen Cymru X X X Elim HA X Hafod HA X X Linc Cymru HA X X X X Melin Homes X X X X Monmouthshire X Housing Association Newport City X Homes Seren Living X Tai Calon X Community Housing United Welsh X X X X Wales & West X HA
5.44 Housing associations are involved in initiatives and support programmes, many of which have a mental health dimension. 5.45 The following example is directed specifically for older people (over 55) in Gwent. It is highlighted here however as a model of good practice in prevention of social isolation and loneliness for people with mental health issues.
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Local good practice Mental Health Foundation, Melin Homes, Derwen Cymru, Newport City Homes and United Welsh Standing Together deliver a joint project to reduce loneliness and isolation amongst older residents. Big Lottery Wales grant of over £350,000 - delivering help to boost emotional health and community connections for older people. Standing Together will create 30 facilitated peer support groups to improve the wellbeing of 450 residents over the age of 55 in retirement housing across south East Wales. There is a staff team of four to train and support 60 volunteers who will enable the groups to continue and be run by residents themselves once the three- year project ends.
5.46 Some examples of landlord initiatives that support mental health and tenancy sustainment are: • Bron Afon (Torfaen) have Families First funded staff (6) (plus 2 core funded) with an emphasis on prevention of tenancy breakdown and reducing the need for high level intervention e.g. children at risk of going into care. The support provided gives families more confidence to manage their home. The service also provides employment and training, parenting courses and support with attending school. • Charter Housing Prevention by Intervention - Settlement team. This team provides move in support and a 6-week settlement plan. Tenants have an initial visit in week 1 and again after 6 weeks. Where a tenant is at risk of losing their tenancy or in crisis the team carry out assessment and action plan to prevent tenancy breakdown.
Local good practice In One Place is a collaborative programme launched in Gwent in 2014 as a collaborative vehicle to deliver projects that were needed from a health or social care perspective. This includes improving the provision of high- quality accommodation and care to people with Continuing Care needs.
The membership is ABUHB, the five Local Authorities, and nine Housing Associations - Bron Afon, Linc, Melin Homes, Monmouthshire Housing Association, Newport City Homes, Newport Housing Trust, Seren Group, Tai Calon and United Welsh. The initiative has resulted in several housing
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schemes being developed that support people with complex needs - mental health issues, learning disabilities, and young people moving from children’s services into adult care.
Challenges ahead include developing a Gwent-wide strategy that steps up the activity to meet needs in a planned way and is able to promote further recovery as people move on from Continuing Care funding under Section 117 aftercare arrangements. In One Place has broken down some key barriers, paved the way, and got people talking to each other, and achieved positive outcomes by housing a number of people who would otherwise have been living in “out of area” placements.
Private Sector Housing 5.47 A number of local authorities provide private sector landlord schemes such as Bond Schemes and Rent in Advance (e.g. Monmouthshire Council has partnered with Solas Cymru to deliver their scheme) and private sector landlord liaison such as Monmouthshire & Torfaen Landlord Hub and Newport Landlord Forum. Rent Smart Wales process landlord registrations and grant licences to landlords and agents. While these services are not specifically targeted at mental health clients, good quality private rented sector accommodation does have a role to play in supporting access to housing for people with mental health issues.
Police
Local good practice Gwent Police have five Mental Health Practitioners based in the control room (4 trained social workers 1 CPN) plus a supervisor. Originally this was a pilot of just one and as it has proved successful it was expanded. The Mental Health Practitioners cover 8am – 2am Sunday to Thursday and until 4am on Fri & Sat. The posts are funded by the Police and Crime Commissioner
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Gwent Mental Health Services
Hospital Services 5.48 Carn-y-Cefn Ward at Blaneau Gwent, Ysbyty Aneurin Bevan has 11 beds. It is a mental health acute unit providing assessment and treatment for individuals suffering from acute mental illness, between the ages of 16-65. This involves a multi- disciplinary approach consisting of medical, nursing, social services, occupational therapy and psychology staff. 5.49 Ty Cyfannol Ward at Caerphilly Ysbyty Ystrad Fawr has 22 beds for acute mental health. Ty Cyfannol provides recovery focused care for patients with wide ranging mental health issues, between the age of 18 and 65 who are registered with a GP practice within the Caerphilly County Borough. 5.50 Talygarn provides mental health services for residents of the Torfaen borough. The service comprises of an inpatient ward, which provides 22 beds for adults aged 16 to 65 who are suffering from an acute mental illness. 5.51 Adferiad Ward (22 beds) covers Newport and Lower Monmouthshire for people with acute mental health issues.
Specialist Hospital Mental Health Services (Tier 3) 5.52 Ty Skirrid (Forensic ward for 12 men) and Lindisfarne (2 step down beds) are rehabilitation services at Maindiff Court Hospital in Monmouthshire. The wards’ focus is on social and psychological intervention with an emphasis on community re- integration as many of the clients have previously been in prisons or secure accommodation. 5.53 Belle Vue ward for 6 women diagnosed with Personality Disorder and Pillmawr Ward for 12 men are locked rehabilitation wards. Pillmawr Ward also supports North Lodge, a 3-bed step-down house on site. Beechwood Psychiatric Intensive Care Unit at St Cadoc’s Hospital has 9 beds. There is a further 2/3-bed step down house (South Lodge) at St Cadoc’s.
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Community Mental Health
Local good practice Adult Community Mental Health Team in Newport has an early intervention Housing Worker
5.54 Eleven multidisciplinary Community Mental Health Teams (CMHTs) provide mental health services for people between 16 and 64 years. Each team covers a specific geographical area. Each Local Authority has at least one CMHT. 5.55 A variety of services are provided which include: • outpatient clinics; • group work (e.g. anxiety management, carer support, relaxation therapy etc.); • day treatment; • specialist psychological interventions (e.g. family therapy); and • liaison psychiatry. 5.56 A range of other Community Services are also provided by clinical staff, including Community Psychiatric Nurses, Community Occupational Therapists and Clinical Psychologists. Clinic and group sessions are provided at various locations within the catchment area. 5.57 Assertive Outreach is delivered for people who need more intensive outreach than other services can offer. Up to about 20 people are supported at one time but this varies. 5.58 Community Mental Health Teams include Community Forensic, Personality Disorder, and Eating Disorders, and Veterans Tier 2 services. 5.59 The Early Intervention Service (EIS) in Risca, Caerphilly is a Community Health service for people aged 14-35 who have either experienced a first episode of psychosis, or those deemed to be ‘at risk’ of developing psychosis. This supports around 120 people. It is a Tier 2 service including care-coordinators and team leader, psychologist and psychiatrist and works closely with four workers from Hafal. It has a practice lead and three recovery workers. 5.60 Gwent Crisis Resolution and Home Treatment are currently a combined service for people experiencing a mental health crisis and people receiving home treatment available from 8.30am-12 midnight 7 days per week. There are three teams that
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cover the Gwent area. A change programme is underway to split its two functions, which will provide a more consistent service to people receiving Home Treatment, and to increase cover to 24 hrs.
Local good practice Community Psychiatric Nurses are based in some GP practices in Gwent
Care Navigation (additional mental health services at GP surgeries) relieves pressure, saves GP time, gets people to the right help. They make the links to housing for issues such as rent arrears.
5.61 ABUHB has a Road to Wellbeing initiative to help people manage stress and improve mental wellbeing. ‘Stress Control’ and ‘Activate your life’ courses are for people with lower level depression/anxiety. There is a range of self-help resources, including links to online CBT websites and mindfulness apps, online bookshelf of downloadable Self-Help guides.
Substance Misuse Health Services 5.62 Gwent Specialist Substance Misuse Service (GSSMS) is provided from 11 locations around Gwent. A consultant psychiatrist works alongside the service. GSSMS provides specialist help and treatment for people experiencing problems with a wide range of drugs and alcohol issues across Gwent. The service provides in-patient alcohol detoxification, assessment and diagnosis of Alcohol Related Brain Damage, joint working with Gwent Drug and Alcohol Service (GDAS), specialist advice and consultation, screening and vaccination for Blood Borne Viruses, harm reduction, Needle Exchange facility in Newport, specialist antenatal clinics, talking therapies, occupational health advice and clinic for ABUHB staff. 5.63 GDAS is a third sector provider commissioned by the Area Partnership Board and PCC to provide support to people with substance misuse issues and includes a Registered Mental Health Nurse in the team.
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Hospital Discharge 5.64 There are two hospital discharge services operating in Caerphilly and Newport.
Local good practice Caerphilly Council has a jointly funded Hospital Discharge post between SP and Adult Social Care. The post holder is based within Ty Cyfannol, the acute inpatient unit within Ystrad Fawr hospital.
Gofal is commissioned to provide a Hospital to Home scheme based at St Cadoc’s.
Step Down 5.65 There are several services that are described as step up (hospital prevention) or step down (move on from hospital to prepare for independent living). The model of delivery is varied.
Local good practice Brynteg Road, Blaenau Gwent opened in 2016 and has 24 hr supported flats providing step down support. The project was an ABUHB and Thrive/United Welsh initiative and instigated via In One Place, for people requiring NHS Continuing Care. There are 5 self-contained flats, and a 24 hour dedicated staff team for people with complex and challenging behaviour.
Liberty Care provides step down from hospital accommodation and support for people with mental health issues requiring S117 aftercare and support around 40 people. The service is needs led and 24 hours waking nights. It is a Supported living model including high care. Housing arrangements vary. Liberty is a local private sector provider that only operates across Gwent, working to recovery principles. The model is housing and registered domiciliary care. Liberty Care has a clinical lead, a qualified clinical psychologist in house who acts as internal consultant. The team works on intervention.
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The CARIAD scheme started in 2014 using Integrated Care Funding from Welsh Government. CARIAD is a collaboration between Linc Cymru, United Welsh, Aneurin Bevan University Health Board and Blaenau Gwent Social Services to deliver several step up / step down intermediate care units within residential care, sheltered and Extra Care schemes throughout Blaenau Gwent. CARIAD stands for Collaborative Assessment Reducing Interventions, Admissions and Delayed transfers of care. Its reablement and rehabilitative focus promotes both prevention and early intervention.
5.66 Provided by Priory Group, Ty Ffynu is a four-bedded community residential home providing step-down care for both male and females suffering from complex mental illness. Elysium Care, Ederyn near Pontypool provide a mental health hospital "step down" for 19 men. Referrals are taken from outside Gwent.
Care Homes with Nursing 5.67 Shaws Healthcare deliver Maes Y Dderwen 24 hour waking nursing care and Cwm Celyn. Cwmcelyn Nursing Home is made up of four units, each of which is dedicated to particular care packages, including nursing care, dementia, respite stays and for people with schizophrenia.
Residential Care 5.68 There are eight residential care home services in Gwent, provided by four different providers.
Local good practice Tŷ Anwen is 16 bed registered care home provided by Gwalia (part of Pobl). It is located in Bedwas, Caerphilly and aims to provide recovery- orientated rehabilitation within a person-centred framework. Support is available for up to 16 individuals with serious and enduring mental illness. The service uses a combination of the Recovery Philosophy and a Relational Security framework to inform boundaried therapeutic processes. They work with other co-occurring symptoms such as substance misuse, personality disorder or other health issues.
5.69 Ocean Community Services has four Registered Care Home services across Caerphilly and Newport.
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• Hudson House in Caerphilly provides support to 8 people with severe or enduring mental illness and personality disorder; 24 hours sleeping nights. Clients have often stepped down from secure hospital. • The Glen, Newport is for 5 people with a diagnosed mental health need, learning disability and personality disorder and people with a forensic history. 24 hours waking nights. • Caerau Manor also in Newport provides residential care to 9 women with personality disorders. Referrals are from medium, low secure and locked rehabilitation from within the NHS or private sectors or from people in the community. • Wentwood Court, Newport provides residential care to 14 people including referrals from medium, low secure and locked rehabilitation services as well as the community 5.70 Elysium provides residential care at Ty Gwyn Hall in Abergavenny, Monmouthshire for 34 people with mental health issues. Llanthewy House is a care home in Newport supporting 7 people with mental health, learning disability and younger adults. Enable Care Services has Ty Gwernen Care Home in Blackwood, Caerphilly for 6 people with mental health issues.
Advocacy 5.71 Newid Project provides advocacy for young people (16-25) and their carers. The service is low intensity trauma-based intervention, intensive advocacy, group work, peer work and online hubs for carers. 5.72 Dewis CIL runs a Gwent wide advocacy service for adults 18+ and young people 16- 18 in transition. They also run “Let’s Talk” groups in Newport, and Caerphilly (North & South). 5.73 Advocacy Support Cymru runs the Independent Mental Health Advocacy service available to any in patient in psychiatric hospital both formal and informal, patients with a mental health diagnosis in general hospital and patients in the community on a Community Treatment Order or Guardianship Order.
Training 5.74 Mental Health First Aid training is provided by Mind. The course aims to increase the knowledge and confidence of delegates to enable them to provide first aid and support for people experiencing a mental health problem.
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5.75 Blaenau Gwent and Caerphilly Social Care Workforce Development run ‘Supporting people with compulsive and hoarding behaviours’ for Social Workers and Home Care staff.
Other 5.76 There are also a range of community support services including the Dewis meet and greet group, drop-in services at the Olive Branch and others. These services while not part of the mental health landscape are important in supporting individual’s recovery journey and foster community links that can prevent mental health deterioration. The importance of services that encourage social connections, such as social prescribing, and their capacity to reduce mental health distress, loneliness, depression are increasingly seen as important contributors to individual’s wellbeing. Linked to this is the recognition of the importance of supporting carers, particularly when the person they are caring for is experiencing a mental health crisis.
Developing Services 5.77 A number of services that are currently in development have also been identified and details are included below.
Local good practice Pobl Group has recently applied for Trailblazer funding to deliver a Housing First service across Gwent for people with complex need. Properties will be provided by Pobl Group and other social housing providers including Bron Afon, Melin Homes, Linc Cymru and Newport City Homes. The Wallich will provide support and accommodation from the private sector for 5 people. The scheme will support 5 people in each local authority of Caerphilly, Monmouthshire, Torfaen and Blaenau Gwent and 15 in Newport.
5.78 ABUHB is leading on the development of a Crisis House. The project will prevent unnecessary hospital admissions for people who are in existing housing. It will help to prevent tenancy breakdown and homelessness by providing a safe place to stay on a short-term basis. 5.79 ‘Sanctuary’ provision is also currently being discussed for development. This not a housing initiative but will provide a safe space providing emotional support and respite at times of crisis.
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5.80 Caerphilly Supporting People team is leading on the development of an eight-bed supported housing scheme in the south of their borough, we understand this will be complex needs domestic abuse provision. Newport and Torfaen will be contributing revenue funding to this scheme in 2019/20. 5.81 Social landlords seek to make some of their existing stock available for supported housing. One example of this is Hill Crest in Caerphilly owned by Charter Housing which is being explored for Intermediate Care Funding.
6. FINDINGS – KEY ISSUES FOR STAKEHOLDERS AND GAPS 6.1 We know that poor mental health can make it harder to cope with housing problems, while being homeless or having problems in your home can make your mental health worse. This report has identified many examples where system pressures, un-co-ordinated transition points, a lack of resources and lack of multi- agency work has led to fragmentation in responses to people’s housing and mental health needs. We have also however found many examples of good practice. 6.2 Mental health specialist SP services are well mapped due to the Gwent wide overview of Supporting People. It has however been difficult to gauge how the local networks do and don’t work. For example when a mental health provider offers wellbeing services or floating support and accommodation services, on the same patch there may be signs of better integration, however links between more generic provision and health services may well be more disparate and random. 6.3 The key issues identified through the stakeholder interviews and the two workshop events include: • A lack of available suitable affordable rented housing • A difficulty in homeless people and rough sleepers being able to access support to address barriers to housing they encounter such as previous arrears, eviction for anti-social behaviour • A need for more tenancy sustainment support and floating support to enable people to retain their existing housing • A need to address the effects of welfare reform and financial exclusion • A need to address move on from supported housing so that access to available services can be improved rather than remain ‘silted up’ • Access to mental health services for offenders needs to be improved
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• Support to enable quicker hospital discharge needs to be established across Gwent • Support and respite in times of crisis needs to be improved • Services that support individuals with complex needs (related to rough sleeping, offending, drugs/alcohol abuse and mental health) such as Housing First need to be promoted and mental health support embedded within these • A process for better co-ordination of transition from children’s to adults mental health services is needed, including training for managing a tenancy for young people in transition • While there were a number of examples of good joint-working, stakeholders felt that there was still room for improvement e.g. through joint training and information sharing as well as better pathway co-ordination. 6.4 This section of the report addresses each of the above areas, setting out stakeholders views, the key findings for each section are summarised below each section. 6.5 The Gwent Regional Partnership Board, set up following the 2014 Social Services and Wellbeing (Wales) Act to promote integrated care and community wellbeing, operates five thematic partnerships, one of which is the Learning Disability and Mental Health Partnership. This Board leads at the strategic level on the coordination of activity and resources. 6.6 Local Authorities in Gwent continue to face significant cuts. Newport Council has cut £40m from its budget to date and must make further cuts. As a consequence of cuts some authorities are cutting social workers posts. The Regional Partnership Board has secured funding for a programme of transformation. That transformation programme needs to be joined up and focused simultaneously on health, housing and social care transformation.
Lack of available suitable, affordable rented housing 6.7 Over one million people rent their homes in Wales. Although the availability of affordable housing differs slightly across the five Gwent local authorities, almost all the stakeholders we spoke to emphasise the lack of supply of suitable, affordable housing. Some said this was partly due to a changing housing market and house price increases, especially in Newport (since the abolition of bridge toll fees). Housing can also be a particularly difficult issue in more affluent areas in Gwent. This has made it increasingly difficult for people with mental health issues to access
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decent affordable housing and has put increased pressures on Housing Options and Homeless Services. 6.8 Stakeholders also told us that there is not enough one-bedroom accommodation available in both the private rented and social housing sectors. “The only one-bed flats that might become available tend to be in the worst areas … areas that perpetuate the complex issues.” 6.9 Not all affordable housing is appropriate. The rural locations of much of the affordable housing increases the isolation of people with mental health issues. Whilst shared accommodation may be a suitable option for people to combat isolation, there is also a lack of this type of accommodation and shared accommodation is not suitable for many people with mental health issues. “Isolation makes my mental health worse”. 6.10 Housing strategies don’t particularly reference mental health. Local authorities say that this is beginning to change, but that there is still some way to go. For example, they stated that they had invited health representatives to meetings and consultations, but that no one had attended.
Social Housing
“Social housing people are good, and really want to make a difference; they make an effort and it works both ways”. 6.11 At the stakeholder consultation event in February 2019, one of the more problematic barriers to housing identified was the long waiting times for social housing (10 people felt this was a top 3 priority/issue). This can be further exacerbated by the wait for mental health assessment when applying for social housing. 6.12 Stakeholders tell us that there is a difference between the way mental health is assessed by Common Housing Register Assessment Officers (for banding for social housing) and the Homeless Options Team (for homelessness assessment) and this is being examined. All five local authorities in Gwent operate Common Housing Registers. Choice based lettings schemes such as Homeseeker ask if a person needs support. Pre-tenancy assessments also aim to make sure people are tenancy ready. 6.13 Some concerns were raised about the lack of awareness/inconsistency across housing organisations to appropriately refer into mental health services.
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Private Sector 6.14 In 2017, 14% of all dwellings were estimated to be privately rented across Wales. Stakeholders identified that there is scope in private rented sector (PRS) but there was also some concern regarding quality, insecurity of tenure and affordability. Some stakeholders we interviewed also expressed concern that it has also become much more difficult to access the PRS as demand from working professionals is edging out people on low incomes. Local Housing Allowance is not in line with private tenancy rents and there are problems accessing private sector tenancies advertised a ‘DSS not accepted’.
Lucy is 25 and lives with her young daughter. She experienced severe postnatal depression and was sectioned under the Mental Health Act. She continues to experience general depression and anxiety. She has just moved into social housing after having significant issues with her previous private landlord. The property she had been living in was in a terrible state; it had substantial mould problems, an unsafe garden and was unsuitable for a young child. Despite raising these issues with the landlord nothing was done to resolve these problems. The condition of her private sector accommodation caused Lucy’s mental health to deteriorate. She began to isolate herself, refusing to leave the house or answer the door. She stopped contacting her landlord which removed any chance of improvements being made to the property. It was only with support from a support worker that her situation improved. The support worker contacted her landlord on Lucy’s behalf and helped her to apply for council housing through the Homeseeker website. Lucy has seen an improvement in her mental health since moving into a new council house.
6.15 Some of the people with lived experience of mental health and difficulties accessing housing told us that the reluctance to let to people in receipt of benefits was still a common barrier for them in getting into PRS housing. 6.16 Recently, research was commissioned by Tyfu Tai Cymru (a housing policy project managed by the Chartered Institute of Housing Cymru) and Tai Pawb indicated some discrimination against people with mental health issues. They cited for example evidence of letting agents putting the phone down when a support worker called on behalf of someone they were supporting. The report identified actions to improve the provision of mental health support for tenants and landlords in the PRS.
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6.17 Recommendations from the report are: • Provision of better information for landlords and letting agents about local and national mental health support; • Re-licencing through Rent Smart - landlords to complete a module on mental health; • Representatives from the PRS to be included in governance of the SP programme; • Crisis/emergency housing related support provided for people with mental health problems in the private rented sector, to support tenants to stay in their own homes; • The Welsh Government should explore and address instances of discrimination against people trying to access and sustain PRS housing; • Collection of data on the tenure in which floating support services are provided - Supporting People monitoring systems to include tenure; and • Services should be shaped with the expertise and insights of tenants living with mental health problems in the PRS. 6.18 Local authorities recognise the importance of the PRS in providing affordable housing and most have developed initiatives to improve access such as bond schemes and schemes to access the PRS for temporary housing for people who are homeless. One council told us they are looking at working better with private landlords such as improving security of tenure by asking landlords to agree to 5-year tenancies.
Mark had a private rented flat in Monmouth but he lost the stairwell key. The Letting Agent wouldn’t give him access to get in to get the money he needed to pay for a new key. He said the Letting Agent was hostile and very unprofessional. He felt the letting agent deliberately caused a drama and his mental health spiralled from there. Rent was being covered by housing benefit but he had no access and was stopped as he didn’t have access. This experience meant that he was “Never going through an estate agent again in my life”.
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Summary of gaps – Affordable housing • Lack of available, truly affordable housing – although this is not a Gwent specific issue and some stakeholders felt it was so basic it did not need including, we think that it is a fundamental constraint that can’t be ignored. • Lack of one-bedroom flats. • Work to access private rented sector accommodation and training for private landlords was required.
Homelessness 6.19 The lack of truly affordable housing is having an impact on homelessness. 6.20 Stakeholders told us that often there were inappropriate admissions to hospital due to ‘chronic’ homelessness or rough sleeping. This often peaks during night or in the winter months. Where the homeless person has exhausted all routes ward staff tell us they have to admit to hospital or face the decision to discharge out to the streets. Finding accommodation at night time is very challenging. A night shelter may be used to immediately resolve the problem but often it is full and not always appropriate.
“Some people have burnt bridges and are left abandoned and stuck in hospital. Very frustrating.” 6.21 Gwent Police told us of the distress they see due to homelessness. They told us of suicide calls from street homeless people and problems with offending due to having nowhere to stay. 6.22 There are often short-term admissions to hospital of people who are street homeless, with no diagnosis and no immediate risk of harm to themselves or other people. 6.23 Homelessness rules mean that for the authority to have a duty to accommodate a person, they need to be in a priority group. New homeless rules have meant that people with an offending history do not have priority for housing unless they can prove vulnerability. The burden of proof on vulnerability can be challenging and homeless offenders are most likely to need verification via a GP. Several stakeholders told us that the need for an offender to get a mental health diagnosis in order to be considered as priority homeless has increased across Gwent. 6.24 For many homeless people the existence of former tenant arrears or eviction due to anti-social behaviour is a barrier to affordable housing. Applicants with former
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arrears will be expected to pay rent of consecutive payments or a percentage of the total debt before being considered for some social housing.
Local good practice Torfaen Council are undertaking a pilot with customers in temporary accommodation to provide pre-tenancy assessment, what people need to do to access permanent accommodation and to work with people around how the tenancy failed, how it happened and how to resolve in future
6.25 Some stakeholders suggested that prison in-reach could be more effective in planning for housing and mental health treatment on release. They also suggested that connections with the community could be made more effectively through such services. 6.26 The need for emergency housing is met by a range of services including temporary housing for people who are statutory homeless, Bed & Breakfast, hostel accommodation or people may get a bed in a night shelter. Summary of gaps – Homelessness • The degree of homelessness is growing – Sofa surfing and rough sleepers are increasing. And there is increasing lone female and couple homelessness, this has grown over the last 10 years. • Torfaen SP identified a need for additional capacity for vulnerable males who are homeless, of no fixed abode (NFA) or rough sleeping. • There is a gap in emergency and crisis housing responses to people who do not have homelessness priority and to whom the council does not owe a duty. The only night time provision is night shelters. • There is a need for crisis/drop-in support provision to alleviate the wait for floating support (via SP). Some Supporting People programmes are commissioning crisis drop-in support to alleviate waits for floating support. For those that do not do this consideration should be given to how floating support waiting lists are managed. • Having a clinical diagnosis provides evidence of vulnerability when being considered priority homeless and for social housing banding. Many of the people with lived experience we spoke to do not have a formal diagnosis but have experience of poor mental health often due to trauma or adverse childhood experiences. There are barriers to receiving a diagnosis including stigma, lack of
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awareness of services or insight into condition, old diagnosis, not being registered with a GP. As a result there is a risk that some people who are vulnerable due to mental health will not receive prioritisation for housing.
Maintaining Independent Living and Preventing Homelessness 6.27 Stakeholders told us of the need to be better at preventing tenancy breakdowns that arise as a result of a crisis in mental health. 6.28 Poor mental health can prevent a person from coping with the day to day of managing a tenancy. This can include simple things like not opening letters due to anxiety about what the letter might say, or making it difficult getting to appointments. Some people lack the life skills to maintain the responsibility of a tenancy or have unrealistic expectations. 6.29 Floating support is a key programme of support that can help people with mental health issues in social and private sector tenancies.
“When I was a CPN I had people on my caseload struggling to maintain housing and (SP provider) were fabulous, got involved early, and 9/10 times were able to secure the tenancy then follow through. They made such a difference.” 6.30 Floating support to move on from supported housing is valued and needed to help support independent living. Accessing floating support to maintain tenancies in a timely manner was cited by a number of stakeholders as a challenge.
Local good practice Homeless prevention across social and private sector tenancies can be reinforced by early intervention especially with rent arrears. Melin Homes have not evicted anyone because of rent arrears in the last two years. They have established an Income and Inclusion team including recovery officers and provide support with money advice, energy advice and support into employment. They have supported 44 people into employment. Melin also offer free counselling and CBT services to tenants across Newport, Torfaen, Blaenau Gwent, Monmouthshire and Powys.
Due to an increased demand from non-priority, single people, a current floating support service has been remodelled and will work closely with existing street homeless service. The worker will also be present at the
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night shelter to deliver support to those who are homeless and disadvantaged through mental health issues.
6.31 People also lose tenancies due to anti-social behaviour which may from time to time be linked to mental health. Some people struggle with neighbours which can cause conflict. Mediation can help with neighbour disputes. 6.32 Concern was raised by some stakeholders about the disengagement of statutory services once a person is accommodated. 6.33 In 2017, about 670 hoarders (78 in South East Wales) were known to Welsh fire services and estimates suggest up to 5% of the population could have the disorder.2 The Bron Afon service for hoarders is the only service of this nature in Torfaen or in Gwent. They report that demand by tenants and partners outweighs capacity and current resources. There is also a service, The Attic Project, run by Care and Repair Newport that assists older people to organise and/or dispose of their possessions so that they can either ‘down-size’ or live in their homes more safely.
Local good practice Bron Afon have a decluttering service. The service improves the condition of the property and is the ‘tool to get in the door’. Tenants are also supported to engage in wider services – support is at the heart
Impact of Welfare Reform and Financial Exclusion
Successive UK Government welfare reforms will take over £1 billion annually out of the pockets of low-income households in Wales by 2020/21. They have a disproportionate impact in areas of Wales that have suffered from long term industrial decline.3 6.34 The impact of welfare reform was seen by stakeholders as a key problem in accessing and maintaining housing. The Shared Accommodation Rate of Local Housing Allowance to under 35-year olds was most commonly identified as
2 https://www.bbc.co.uk/news/uk-wales-42410983 3 The homelessness monitor: Wales 2017 (Crisis) Aneurin Bevan University Health Board April 2019 37 of 111
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especially damaging. We were told of the additional stress faced by people when claiming Universal Credit. The stress can be caused by the requirement to log in to online journals, the level of identification required, the need to have an address to have a bank account to get paid and delays in receiving benefit. These are systemic issues with Universal Credit rather than Gwent specific issues however the need for support to manage former tenant arrears, debt, and the reliance on charity to support people in dealing with debts as well the need for support to improve budgeting was highlighted with the researchers.
Summary of gaps – Maintaining independent living and addressing financial exclusion • There is a need for more floating support and tenancy sustainment support including specialist support regarding finances, budgeting to maintain a tenancy and deal with Universal Credit related issues.
Supported Housing 6.35 As described above in section 5, across all Supporting People funded services there is a very broad range of need catered for from those with diagnosed mental health conditions through to general mental wellbeing support. 6.36 Stakeholders told us that there are some great services but some expressed frustration that people can’t get a supported housing tenancy when they need it. Some felt that supply is skewed towards long term services, that referral routes are not always clear, and the availability differs across the authorities. 6.37 This paints a picture of ‘silted up’ accommodation, meaning there is limited or no turnover so pathways into and out of services do not work as effectively as they could. Move on from supported housing is difficult as a result of the lack of available affordable housing. Some providers (e.g. Newport Mind) are buying properties to help combat this. Some stakeholders also reported a lack of availability of floating support as a barrier to helping people to move people on. 6.38 We understand that the NHS Estates Plan is being developed. We believe this is an important opportunity to identify development opportunities for affordable and supported/specialist housing to address some of the gaps identified in this report.
Diane is 38 years old and has four children who live with their father. She grew up with depression and has a history of self-harm but as a child was prevented from accessing services by her abusive father. Although she believes she has Bi-Polar Disorder, she has never been diagnosed and has not had a
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formal diagnosis because she says doesn’t want the label. She is being treated by her GP and takes anti-depressant medication.
The relationship with her partner was breaking down and became violent. In May 2018, she took an overdose and was admitted to Royal Gwent Hospital. It wasn’t safe for her to return home and she sought refuge. However, she was unable to get a place in a refuge as providers felt she was too high risk because of the suicide attempt.
Diane was accommodated in a homeless hostel in Gwent and soon offered a flat which she moved into. But things didn’t go well. “I felt I had to accept the flat. I was isolated and broke. I couldn’t cope on my own.” She was offered floating support, but she didn’t hear anything from the support provider for the first month. She had been given a grant to help her to buy furniture for the flat. This only covered the cost of a cooker and a washing machine. She had no bed and slept on the floor. Diane said the floating support worker often didn’t keep appointments. Diane says it wasn’t the support worker’s fault. “They didn’t have enough staff and they couldn’t cope”. Eventually, Diane was referred to supported housing as it was clear she was not coping on her own.
She is now living in shared, supported housing with three other women. Diane said it is hard to live in shared housing especially because they all have mental health issues, but she does feel that her support provider has “made me so much stronger”. She has also made a close friend where she lives.
Although Diane is not ready to move on into her own tenancy yet, she feels the support she is getting will help her to live independently. She has a new relationship and is thinking about her future career. She has a degree, digital media skills and says she would like to be a fire fighter.
Summary of gaps – Supported Housing and specialist accommodation • Stakeholders identified the lack of suitable housing with support and supporting people providers report increased demand. • There is a need for supported housing for dual diagnosis. Newport reported a need for a small number of dual diagnosis and personality disorder housing (NHS, SP, NCC) • Stakeholders suggested that both specialist step-down accommodation for people with forensic history from hospital and more supported housing places for offenders are required.
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• There is a need for support for women with complex needs including experience of domestic violence, and those who may have children and mental health needs. • There is a lack of safe step-down accommodation from acute services and hospital wards, a need to look at opportunities for people to learn life skills, including tenancy sustainment. This provision needs to be in the community and include transition houses that support the move on to independent living. This would need excellent risk management, high tolerance, knowledge/experience of what to do, and access to mental health expertise - s/c flats would always be better, although some people may not want to live alone. • Blaenau Gwent Community Mental Health Team has identified the need for more move-on accommodation with support for people moving out of 24 hour supported housing schemes. • Newport needs mapping day identified gaps in provision of supported flats for people with enduring mental health difficulties, a lack of supported housing and the need for a move-on 24-hour supported accommodation unit for acute mental health • Torfaen Supporting People identified the need for additional capacity for existing provision. One stakeholder commented that there was very little available in Torfaen and Monmouthshire. • No ‘Supporting People’ premises in the area specifically for young persons. Current focus is on homelessness in general.
Access to Mental Health Services 6.39 Discussions with stakeholders identified problems for tenants gaining access to mental health services. Barriers included: • long waiting times for talking therapies and Community Mental Health Team support; • rurality and transport issues (CMHT say that a Monmouthshire visit can take 45 min or more and in a crisis, this can need 2 members of staff); • moving areas and transferring between health services.
“It’s about trust” - often people don’t trust services as they have been turned down before. 6.40 Delays in accessing health services for prison leavers were consistently reported. If a person is experiencing mental health crisis or ill health on release, they may require
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quick access to mental health services (often for medication). Trying to find a GP practice that will accept people leaving prison is difficult. Although if someone has significantly been in service in the past mental health services will see or send someone out without requiring referral from the GP.
‘A lot get released on Friday - some must wait until Monday for medication’. 6.41 Registration with GP surgeries is essential to access mental health services. This can be problematic for homeless people. The first contact with GP is vital to understanding need/issue and many people feel a short (7-minute) conversation is not long enough. 6.42 Some barriers that may be improved by better joint working included: • Lack of availability of information sharing between health services; • Some health professionals are resistant to engage/collaborate with housing/third sector/social care; and • Lack of knowledge of services available. 6.43 Access to hospital mental health care is difficult as the threshold for admission is increased. A particular challenge cited by stakeholders was that of getting access to mental health treatment when the person is considered below the level of needing to be ‘sectioned’ but is heading for a crisis. 6.44 More generally some stakeholders felt the condition of the NHS buildings (hospital wards/clinics) is a big issue in that they are not conducive to providing Psychologically Informed Environments. Summary of gaps – mental health services • Not enough forensic support offered for people in the community. • Mental health and drug related problems are being over looked. • Gap in Crisis responses and options for alternatives to hospital admission. Gwent Regional Supporting People Strategy identified Crisis House and Sanctuary provision which is currently being developed by ABUHB / and the Mental Health and Learning Disability Partnership with SP working closely to ensure clear referral pathways are in place for anyone requiring housing related support after accessing these services. • Structured clinical management, an addition to CMHT, a small team that will help the CMHT manage more intensively in community, with resource to provide supportive framework around the person.
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• More good practice in primary care such as for ‘enhanced GP services’ and Mental Health workers in GP surgeries are needed. • A clear process for offender registration with a GP is needed as they are the only route into to Mental Health services.
Hospital Discharge 6.45 Hospital discharge can be problematic if the patient is homeless. Where the local authority has a duty to accommodate the person, options are limited. Homeless inpatients are most likely to be offered temporary, shared and hostel accommodation where available (although a lack of emergency accommodation has also been reported). 6.46 Where there is no duty to accommodate, the options are more limited. Some people may not be able to access social housing. Reasons include previous stays in B&B or temporary housing which have gone wrong, they may have a history of arson, or be considered too high risk for supported housing. There is a need to develop solutions for this cohort of people. One option could be Housing First, another approach could be development of specific provision for high risk individuals with staff skilled in dynamic risk assessment and staffed by multi-disciplinary teams involving psychiatric support, working within a trauma and psychologically informed approach. “There is no safety net, and these are the most vulnerable people”. 6.47 Several stakeholders cited examples of people being discharged from hospital and given a tent. One health stakeholder told us that a patient was discharged and homeless and to address her housing needs she would accompany men home and by doing this she had put herself in very vulnerable situations. 6.48 A barrier to solving a patient’s homelessness can be that adequate plans are not made at an appropriate time. Discharge planning should begin from when the individual is admitted rather than being left until they are ready to leave. While there are some hospital discharge services, coverage across Gwent is patchy and stakeholders suggested that a Gwent wide hospital discharge service should be commissioned with the inclusion of Housing Advice Workers to identify suitable housing prior to discharge. 6.49 Forensic wards and acute wards struggle to find adequate move on from discharge into step down and other supported housing provision. We spoke to one man who had been assessed by a Mental Health Tribunal as able to move on from the secure ward but there was nowhere for him to go. Several stakeholders told us there is a gap in meeting social care need for people coming out of hospitals.
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Alan is 47 and is currently a patient in a secure forensic ward. He was diagnosed with schizophrenia in 1999 and has had substance misuse issues in the past. Alan has a history of unsettled accommodation including rough sleeping, sofa surfing, stays in hotels and temporary housing. His last settled accommodation was is a housing association tenancy, but he was evicted due to anti-social behavior and problems arising from his substance misuse. He spent 6 months in prison and transferred to hospital due to deteriorating mental health, where he has been for 9 months. Alan feels ready to leave hospital. A recent Mental Health Tribunal assessed him as being fit to leave if he had somewhere to live. He would like to move into housing where he could receive 9-5 support but has been told that he might not be eligible for this and Adult Social Care would not refer him there. Now he feels stuck; he was due to have another tribunal in a couple of days but didn’t have anywhere sorted where he could move. A Housing Association has been to the ward to discuss his options and suggested that he could get into supported accommodation for over-55s, but he would have to bid for a place. He didn’t have much hope that they would be able to arrange a place for him. Finding somewhere to move to has made him feel anxious.
6.50 There is some evidence of people losing accommodation due to a long stay in hospital although this was not seen as a significant problem in Gwent. One stakeholder acknowledged that occasionally patients can accrue arrears when they thought that they had ended their tenancy, but it had in fact carried on leaving them with huge debts. However, concern was expressed that people who stay in hospital for long periods of time often have a poor level of independent living skills.
Summary of Gaps - Hospital Discharge • There is a lack of Gwent wide hospital discharge provision that can address discharge to homelessness. • Discharge planning needs to start from an early enough stage to reduce delays when individuals are ready to leave a hospital setting.
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Crisis 6.51 Stakeholders told us that high level services are often ‘silted up’. This can result in the use of expensive out of area, or in area services. 6.52 Gwent Police told us that a significant amount of police time was involved in responding to crisis situations and mental health issues. Recent BBC research estimated about 40% of police time is spent on mental health. During the day the Crisis Resolution Home Treatment Team guarantee a visit in 4 hours but in the meantime the police often must stay with person and wait for team to arrive. Crisis Resolution Home Treatment Team only operates until midnight. Tal Y Garn, Pontypool will take out of hours admissions. Summary of Gaps - Crisis • There is a lack of crisis accommodation and services such as ‘recovery café’ - out of hours support available at night and at weekends for people in distress.
Complex Need 6.53 Complex need was identified as a top priority by more people than for any other single issue at the stakeholder events. 6.54 Stakeholders from all agencies told us they struggle to meet the increasing demand for people with complex need. A social landlord spoke of the sheer complexity and volume, including an increase in light touch and poor levels of mental health support within generic housing provision. 6.55 Blaenau Gwent Supporting People providers fed back that people are presenting with more complex needs and chaotic lifestyles. Mental Health continues to be the highest main need identified. Blaenau Gwent Community Mental Health Team has also identified the needs of service users moving into 24 hour supported accommodation have become more complex. Torfaen Supporting People identified a gap in services for those with multiple vulnerabilities (e.g. substance misuse / offending) alongside mental health issues. 6.56 The term complex need can mean several different things to different agencies. For the purpose of this report complex need will be defined as a person who is socially excluded and has a range of all or some life experiences such as repeat homelessness, sofa surfing and rough sleeping, mental health problems, history of substance misuse, offending, domestic abuse, living in care, adverse childhood experiences and deprivation.
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Sam is ‘street homeless’ and has been living in a tent under a bridge in Newport for the last 6 months. He hasn’t had settled accommodation for over 12 years. He has had issues with his mental health since he was a teenager, having a particularly bad time with depression in his late teens. He has been using drugs partly to self-medicate for his mental health, but he knows that this is only making things worse in the long run. Sam is not currently receiving support from anywhere and has not accepted support in the past. He has been in contact with the council about housing, but nothing came of it and Sam felt they just wanted him out. He doesn’t see his GP even though he has abscesses on his legs which needs treatment. Sam now feels as though he has hit rock bottom and that he is in a place where he would accept support. He expects he will go to prison and thinks that it might help him as he will get a roof over his head, food, and access to support. He hopes that there will be support in prison to help him sort out his future and housing. If Sam manages to improve his situation, he would like to build on his experiences to help other people and to support people to move on from homelessness and drug addictions.
Most women on the unit - at least 50% will have had major drug issues. I worked with one woman who had been addicted to heroin for ten years and homeless for much of that time, selling herself for money for drugs. 6.57 One support provider told us that dual diagnosis is now the ‘prevalent condition’ of their service users. Whilst mental health is identified as the lead need people most often also have substance misuse issues and low-level learning disability or autism. Spice and strong cannabis are reported to be having a massive effect on people’s mental health. 6.58 Feedback indicated that having the dual problem of drug or alcohol addiction as well as mental health issues can create barriers to accessing services. This is in part due to identifying alcohol and substance misuse versus mental health diagnosis. “How do we know which was first? We need to treat both not pushing back and forth”. 6.59 One stakeholder told us Gwent Specialist Substance Misuse Service (GSSMS) has good follow up and experts who understand and provide a good service to service users and support public protection.
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6.60 The 2009 Lord Bradley Report indicated that 90% of prison population have mental health issues (wildly out of step with general population). 6.61 The multi-agency panel and safety planning approach of MAPPA (high risk offenders) was seen by many as a useful and productive way of finding solutions for people with offending history and housing need. If someone is initially sentenced and then go into hospital, the hospital will contact National Prison and Probation Service (NPPS). If a section is completed before release the person will go back to prison. If on release a licence period is attached the person would have to have contact with NPPS and the person would be routed through to the MAPPA service. Hospitals can refer in to MAPPA, but this does not appear to have happened for some time. 6.62 NPPS told us of demand from single white male offenders from deprived communities such as Blaenau Gwent. Some parts of Torfaen and Caerphilly and Newport also have pockets of high deprivation. 6.63 A stakeholder highlighted the lack of understanding of the transgender experience of mental health. NPPS have recently issued guidance on offering service to transgender people
“A lot of the people I work with show levels of aggression and high levels of risk. We work with homeless people, who can be very resourceful in some ways, e.g. sofas, acquaintances – but clients often lack bigger insight into their situation – people have different insights, different abilities. Some feel they can go on for ever with it.” 6.64 Many of the people with complex need are not able to manage within a pathway or in shared accommodation and would benefit from a Housing First approach.
From the housing perspective, housing has often complained about “being left holding the baby”. Support must wrap around the person otherwise they end up in the revolving door. I am aware of one person who has been in and out of hospital for ten years with no sign of an end to it. Housing First would be the right thing for that person 6.65 Gwent Community Health Council are about to start a project talking to street homeless people and people at risk. This work will provide a useful source of information for future service planning purposes. Summary of Gaps – Complex Need • A dual diagnosis regional project previously identified - requires scoping work with Health to review if it is still a regional priority – we endorse the view that it is.
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• Housing First is a gap. The building block to deal with mental health problems is stable housing. Health needs to be at the Housing First table as it needs ‘buy in’ of all stakeholders to be successful. • More Autism Spectrum Disorder provision required. Asperger’s is often undiagnosed, increasingly better understood but services struggle and often goes hand in hand with personality disorder and other mental health issues. It may be an important “overlooked” dual diagnosis group.
Recovery 6.66 Stakeholders are clearly committed to delivering person centred services that are trauma informed and recovery focused. Services want independence for people and aim to work towards this. 6.67 Many of the stakeholders we interviewed had attended training on Psychologically Informed Environments (PIE) and were implementing good practice.
Local good practice Pobl Group use motivational interview techniques and all managers go on Psychologically Informed Environment & ACES training. “We attend Path training delivered by Cymorth Cymru”
6.68 Some felt that things still needed to move on and spoke of “old school” thinking that means that people stay in services too long. “People can feel all hope is lost, you have to keep thinking of recovery, but you can feel stuck. Sometimes I can’t imagine what the solution is”. 6.69 One person said they like to think they work to a recovery focused approach but that this approach can get stuck if it is not supported by wider systems. “I was so struck by a visit to the Cardiff project. Really trauma informed, the team can understand why people (clients) do what they do, what’s behind it. A world away from what we see here”.
I asked patients in the wards about where they want to live when they leave... the process too often was to “seek a placement” without even consulting the person, then find something…and it would not be located anywhere near where the person wanted to be
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6.70 Front line staff can also benefit greatly from a psychologically informed approach. Staff can be young, inexperienced and feel overwhelmed by the range of issues that some clients are facing. They sometimes don’t have skills or resilience to deal with some of the issues. Basic training on mental health, trauma, and risk management, are vital. Embedding psychological support into teams can be one way of building staff resilience and capability. This support can provide clinical support to de-brief and capacity build teams to manage increasingly difficult mental health issues. 6.71 One stakeholder reported that the recovery word is around but not really to the fore in the Partnership Board discussions and doesn’t feel like a key issue. 6.72 Many of the support providers and social landlords are adopting and train in Psychologically Informed Environments (PIE). Many are planning to do more e.g. within housing management such as looking at warnings, taking a more restorative approach to resolve anti-social behaviour.
Local good practice At Bron Afon Housing Association, a psychologist provides case support and consultations for complex cases, providing advice and specialist support to staff. The Psychologist supports home visits and risk plans and delivers specific training for team such as attachments, risk formulation and hoarding.
Young People 6.73 Our research with stakeholders found that there is limited availability of housing for young people, in their area of choice and housing that is available is often poor quality or in bad condition. 6.74 Some said that the benefits system was a key barrier, particularly the under 35 rule which restricts the amount of money available to shared accommodation rates in the private sector. Shared accommodation is hard to find and is not always ideal for people with mental health issues. 6.75 Stakeholders also highlighted the difficulties for young people with mental health issues in maintaining tenancies. They described vulnerable young people without the basic skills (e.g. shopping, cooking, budgeting) required to live independently. Lack of engagement with services from young people was also highlighted as a problem. More support for families was also cited as being needed to bolster parenting skills.
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6.76 There are complexities for young people going through the transition from child to adult services. Registration requirements mean that young people face the upheaval of being required to move where the provider is registered for Children’s services but not Adult services. Researchers were told about a provider who adapted their registration to dual registration. It was recognised that this provider has an excellent understanding of need and a well embedded value base. 6.77 Some stakeholders felt that difficulties occurred where LA’s source very high cost services (often out of area) when young person is within Children’s Services which are unsustainable in Adult Services. One stakeholder referred to the huge culture change in moving from Children’s to Adult Services. In addition, foster placements out of area could be problematic as there is a lack of infrastructure around the young person when they are ‘repatriated’ at 18. 6.78 There are however a number of examples of good practice. The Early Intervention Service (EIS) told us about a young person that they had started to work with at the age of 14. Through collaborative working the transition to adult services was a success resulting in the young person now being settled in their own accommodation. They emphasised the benefits of early engagement, joint working and joint planning between Child and Adolescent Mental Health Services (CAMHS) and EIS – however it was noted that EIS is limited to young people in crisis. 6.79 ABUHB are considering the employment of a Transitions Worker for children with complex needs (transitioning to adults) who has housing skills, we would endorse this approach. Summary of gaps – Young People • Nightstop emergency accommodation is needed to avoid homelessness. • There is a lack of specialised housing for young people (general housing not suitable e.g. ligature risks, non-adapted) • A ‘Preparation House’ would help to prepare the young person for independent living. • Young single girls – mental health low resilience – medication not the answer. Broken, chaotic backgrounds • Young males with substance misuse issues. “We have had to send people to Cardiff before now as there is nothing in this area”.
Joint Working
We can’t expect people to be stable when we’re not joined up.
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Multi-agency working isn’t working so well 6.80 Stakeholders highlighted time and again the need for good multi-agency working, and vital to this was agreed protocols around information sharing. It was felt that concerns about data, GDPR and customer confidentiality can be a barrier to joint working. A lack of information and understanding about what agencies do and are responsible for was consistently highlighted.
People don’t understand different parts of their own organisation let alone other organisations’ issues. 6.81 The Adult Social Care sector across Gwent has a key role in delivering and commissioning services to maintain independent living, preventing homelessness and combatting loneliness and social isolation and maintaining mental wellbeing. But stakeholders express frustration that where the need is ‘care’, thresholds are high, and it becomes unclear how to access and who pays for some services e.g. medication prompting and domiciliary care packages.
“We already have good multi-agency working, although social care can be clunky, due to the information systems they have to use, but in terms of day to day, multi-agency work happens. Geography may be tricky but there is much willingness to make things work” (Community Nurse)
“An individual Social Worker, helping a person with a housing problem, may or may not have a working relationship with a landlord. The individual may either be completely new, or already in the system. Typically, Social Workers do know who they need to talk to, on a basic level, and individuals are supported in some way, but the solutions search is challenging. Good solutions and good practice exist but are inconsistent.”
Main barriers are attitudes, people not wanting change. Projects can succeed in one place and fail in others depending on the attitudes of the people round the table. 6.82 Stakeholders also cited tensions between Social Care and Health where it was felt there can be friction when people move from S117 into the community and this impacts on social care. While some stakeholders confirmed this tension hadn’t delayed placements it was felt that pooled budgets and better joint working would help. 6.83 Some support providers felt that the Intermediate Care Fund was difficult to access and it would be an opportunity to fund work focused on inclusion and community networks for people with mental health issues. For example Gofal Food Coop and
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Tarragon Gardens promote a community spirit and combat loneliness and social isolation.
Local good practice Gwent Mental Health Consortium provide a wide range of services across Gwent for individuals, families and carers and act as a single point of access for the health board, GP's and local authorities. The consortium partners include Inside Out Cymru (Arts and Mental Health charity), Torfaen and Blaenau Gwent Mind, Caerphilly Mind, Hafal, Newport Mind and Mind Monmouthshire. Growing Space are the lead charity for the consortium who provide real work skills, and a support network for adults with mental ill health.
6.84 Multi stakeholder panel meetings were a positive approach to finding solutions for people with complex needs. S115 (Crime and Disorder Act 1998) permits the disclosure of personal information where there is clear public interest to do so. (See also Information Sharing Agreement - South East Wales Public Protection services). S115 meetings are often police led meetings, but other agencies can call a S115 meeting. Concern was expressed that S115 meetings are too frequently attended by people who do not have authority to make decisions. This holds things up and prevents quick and appropriate responses. It was noted that these meetings are rarely attended by health professionals. 6.85 The MAPPA meetings are considered an effective way of finding solutions for high risk offenders often who also have mental health needs. WISDOM is a recent pilot for high risk Domestic Violence perpetrators. 6.86 The Criminal Justice Liaison Service based in the custody unit has a small team including a CPN and they assess mental health when people come into custody. It was felt the service would benefit from housing support. Summary of gaps – Joint Working • A culture change is required to create a person-centred system. • The In One Place project is a collaborative vehicle to deliver projects from a health or social care perspective, it has initially focussed on Continuing Health Care (CHC) and housing. This is a joint working initiative to build on. • Planning is not effective. New developments can take at least 3 years. “Health struggle to visualise where they need to be in three years”.
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• Each of the five LA’s is different. It’s a challenge and a minefield to NHS. E.g. each has its own way of accessing housing • Funding access complicated and needs to be more joined up and with more user led initiatives. There’s a need for more joint funded projects – more collaborative approaches. • Need more approaches that are community development focused. Opportunities to reduce isolation build social capital and support people in the community with improving and maintaining wellbeing. • Activities for carers – increase in support groups for carers. • There is an opportunity to review/join up social prescribers/community connectors/IAA • Information sharing agreement is very good and useful – enables us to talk within the room. Pathways 6.87 There is no single mental health pathway or set of pathways that addressed the journey from a person needing support to access and navigate through the housing and mental health service they need. There is no lack of recognition of the problem and agencies are trying to do their best, but the processes are not transparent or well-known across the board. Mapping of services and clarity about access routes, the criteria for moving through services and the routes through to independence and community support can help to prevent a haphazard system. 6.88 Stakeholders have repeatedly told us the importance of multi-agency working and given many examples which are highlighted in this report of housing, clinical and social care services working together to achieve positive outcomes. 6.89 But in some cases, knowledge of referral routes is poor and too dependent on personal relationships. We have set out below a recommended approach to developing a Pathway: 6.90 An integrated Mental Health and Housing Pathway between housing, health and social care can contribute to improvements in quality and cost savings to commissioners and funders. The Pathway is a whole system approach which is focused on users being able to do more themselves and to have more control over decisions as well as partnerships to create innovative service models. An effective pathway relies on a shared understanding of what a journey through services might look like, and what the goal of that journey is.
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6.91 The Pathway should set out what should happen when things go wrong and determine routes of people new to services and not engaging in services.
• From homelessness to settled housing • When there is a threat of homelessness or risk of losing a tenancy • From hospital (including secure) to settled housing • From prison to settled housing • From children’s mental health and care services to settled housing
Service Pathway Review Response
Crisis Response Homeless to Settled Housing Options Need Housing Common Housing Register Advice/Support/ Advocacy At Risk of Supported Housing Agreed Outcomes Homelessness Floating Support Specialist Accommodation Housing First Co Produced Models From Hospital to Primary Care Settled Housing Social Inclusion Process Map for Hospital timely move on From Prison to Settled Community M H Housing Psychological Therapy Recovery, trauma Care Informed, PIE Substance Misuse Children MH to Multi Disciplinary Settled Housing Probation/CRC Social Prescribers Approaches
6.92 The Pathway should be recovery focused, trauma informed, and within Psychologically Informed Environments. Services should take a multi-agency approach and be co located across organisations where required e.g. DWP/housing/mental health. 6.93 Prevention of homelessness, of out of area placements and inappropriate hospital admission are key outcomes across the Mental Health and Housing Pathway. 6.94 The Pathway should identify :
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• routes and access to services at times of crisis including Mental Health Crisis and Emergency Housing need. • the provision of specialist (e.g. step down, registered care, Intermediate Care and supported accommodation-based provision including 24 hour and non 24 hours cover, duration of service (short or long term, drop in etc) and arrangements for clinical, psychological, social care and housing related support. • the range of options for non-accommodation-based support and community- based provision including advice and assistance, social prescribing, criminal justice, substance misuse, social care, clinical and third sector service provision. • provision for complex need (it is a recommendation that Housing Frist model is adopted to meet complex need) • where multi-agency s115 Mental Health and Housing Panels are required on the Pathway to find housing solutions to complex cases • the quantity of accommodation and non-accommodation-based services required to meet need • the role of multi-speciality providers • the role of the Supporting People Gateway • Options for services to build on existing schemes or remodel where required. • The requirement for systems information sharing throughout the Pathway. • process maps/visual representations of the Pathway - what leads where, so that teams can see where they fit in. 6.95 The Pathway would require strategic planning and oversight. The most likely place for this to sit would be with Gwent Health, Housing and Social Care Operations Board. A Pathway approach would also require a ‘Champion’ to coordinate the operational development of the Pathway in Gwent, to liaise with landlords, adult social care and local authority housing, third sector, support providers and local authority housing and homelessness departments. 6.96 Intelligence to inform the strategic planning of the Pathway would need to include: • Mapping – continue to improve and update the mapping data within this report • A Needs Assessment for mental health and housing across Gwent is required to inform future planning. • Data collection – improve data collection to inform planning. For example, the number of people in hospital service who have unsettled housing, the number of people on housing waiting lists who have an identified mental health need. 6.97 For illustration a Homeless Pathway could look like this:
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6.98 How the Pathways could benefit our lived experience case studies
Lived Experience Pathway Rhian and Trevor have spent several Long history of homelessness. Complex years between them on the streets and Need in homeless hostels. Rhian spent six years without fixed accommodation. Homeless to Settled Housing Pathway She was often on the streets but could • Appropriate emergency housing for not sleep there. She once went 50 days street homeless without sleeping properly, as she had • Access to appropriate service for nowhere to go at night. complex need
Rhian did manage to move into a History of entrenched homelessness, shared house, but this broke down. rough sleeping and at risk of losing Rhian previously had support, but now tenancy again. No independent living that she has her flat that support has skills. They want to live together stopped. Both now have their own flats, but Trevor is staying with Rhian to Tenancy Sustainment Pathway support her. He struggles to stay on top • Housing Advice of rent and often must choose between • Access to tenancy sustainment using the money for rent or food. They Support - Floating Support struggle to live independently. They struggle to remember how to cook
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basic meals and would like more • Neither currently have any support support with daily living skills. They to manage their housing and not would like to move in together officially coping but expect they will face difficulties in • Access to ‘tenancy training’ arranging this with the council. • Access to social inclusion services • Access to psychological therapies
Trevor was diagnosed with Reliance on GP for mental health support schizophrenic disorder at 18. He has and substance misuse management. struggled to find a course of medication Trust issues due to substance misuse that works for him and has previously had issues with substance misuse. Both Tenancy Sustainment Pathway have also had difficulties in accessing • Access to Early Intervention in support from mental health services. Psychosis Trevor feels he is stigmatised because • Access to a Homeless Pathway would of his previous drug use and that staff have identified need earlier now don’t trust his motives when he • Access to community mental health requests changes to his medication. services • Self Help • Access to Substance Misuse Services Rhian has experienced anxiety and Crisis in Mental Health depression since she was a teenager. She had a psychotic break in 2011 Tenancy Sustainment Pathway which resulted in her losing custody of • Crisis prevention her son, at which point she went into • Access to Crisis Support – e.g. hospital and was sectioned. Sanctuary or Cris House Or if hospital admission / section most appropriate
Hospital to Settled Housing Pathway • Access to acute health services • Access to community mental health services • Access to supported housing and specialist housing • Access to social care and Families First
Lived Experience Pathway Alan,47 a patient in a secure forensic Alan is stuck in a secure hospital and not ward and has been for 9 months. Prior able to move out. to that he was 6 months in prison. He Hospital to Settled Housing Pathway
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was diagnosed with schizophrenia and • Access to step down or specialist has had substance misuse issues. service A recent Mental Health Tribunal • Access supported housing assessed him as being fit to leave if he • Access to Forensic community had somewhere to live. mental health services Alan feels ready to leave hospital. He • Access to Housing Options feels stuck. He didn’t have much hope • Probation services that they would be able to arrange a place for him. Alan has a history of unsettled Homeless to Settled Housing Pathway accommodation including rough • Appropriate emergency housing for sleeping, sofa surfing, stays in hotels street homeless and temporary housing. • Access to appropriate service for complex need His last settled accommodation was is a Tenancy Sustainment Pathway housing association tenancy, but he • Access to Substance Misuse Services was evicted due to anti-social • Social Landlord tenancy behaviour and problems arising from sustainment (Eviction prevention) his substance misuse. and social inclusion • Floating Support • Self Help He would like to move into housing Hospital to Settled Housing Pathway where he could receive 9-5 support but • Access to complex need services has been told that he might not be • Access to Common Housing Register eligible for this and Adult Social Care • Hospital Discharge to Home would not refer him there. A Housing • Access to community mental health Association has been to the ward to • Access to care discuss his options and suggested that • Access to social inclusion services he could get into supported and community connectors accommodation for over-55s, but he would have to bid for a place.
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7. EXAMPLES OF GOOD PRACTICE AND INNOVATION IN HOUSING AND MENTAL HEALTH – NATIONAL
7.1 The brief for the national Horizon Scan is to identify examples of good practice and innovation elsewhere in Wales and the UK. Campbell Tickell used desktop research and drew on our knowledge and networks to collate examples that cover a range of mental health needs and health and housing service models. As the Gwent research and consultation progressed, the horizon scan has focused on18 varied examples that could offer transferable innovative solutions for ABUHB and Gwent. 7.2 The examples have been described in full at Appendix 5. We hope this will help ABUHB and partners to find solutions to specific issues. Although some examples (e.g. those in big cities) are not obviously transferable, they have been chosen because they have relevant features that could inspire ideas in Gwent. 7.3 The following table lists the examples that we fully describe in Appendix 5, under eight themes: 1. 24/7 Integrated Teams and “Step Down” Care: Forensic schemes
2. 24-Hour supported “step-down” schemes
3. Pathway models
4. Housing First
5. Accommodation for single homeless people in Psychologically Informed Environments (PIE)
6. Crisis Houses and “Sanctuary”, “Recovery café” models
7. Helping people leave hospital models
8. Early Intervention in Psychosis.
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Summary of National Horizon Scan - examples and rationale for their inclusion
Theme Examples given in Appendix 5, and rationale for their inclusion
1 24/7 Integrated St Andrew’s, Maidstone, Kent: Choice Support and Kent and Teams and “Step Medway NHS and Social Care Partnership Trust Down” Care: Nine self-contained flats intensively supported in partnership Forensic schemes with the hospital Forensic Unit. The building is on the edge of a hospital site, originally owned by the hospital. ABUHB may have land on which it could consider developing such a scheme. Tabard scheme, Look Ahead: a forensic 3-way partnership: Housing, NHS, and London Borough of Tower Hamlets Large former hostel, near central London, developed into 19 flats, in close partnership with the NHS Trust and Local Authority. A detailed evaluation is available, which outlines the principles and successful ways of working with this complex client group. There is a key element of step down within the service – 7 flats that each have with their own entrance to the street.
2 24-Hour Vale of Glamorgan Integrated Dispersed Housing Scheme: supported “step- Newydd HA, Gofal, NHS Intensive Recovery and Integration down” schemes (IRIS) Team, Vale of Glamorgan Council A strong example of innovative practice in Wales, involving Supporting People, nearby and in similar environment to parts of Gwent. An evaluation has been completed. The service makes creative use of intensive floating support in dispersed accommodation with clinical partnership geared to housing, and the combined support covers 24 hours. Care & support plus model - Tile House, One Housing Group and Camden & Islington Mental Health NHS Trust High level 24 hour waking mental health support from a housing provider that has built 14 carefully designed grouped flats with communal facilities, for this specific purpose.
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Significant, dedicated clinical input, and a close housing/NHS partnership. Works with people who would otherwise be in hospital and has dramatically reduced their length of stay when admitted. A detailed evaluation is available. Richmond Fellowship, Tameside 24hr Supported Housing (Greater Manchester) Three dispersed 24 hour staffed blocks of housing, one shared, two grouped flats, including one block for women only. Included due to housing mix and women’s service. Not researched in detail but could be a worthwhile contact.
3 Pathway models Suffolk Mental Health Supported Housing Pathway: County Council, NHS, four specialist third sector mental health /housing support providers This example describes a longstanding pooled LA/NHS budget for housing and mental health across a large County. Partners offer support levels from 24 hrs to floating. There is a County wide gateway and regular Section 117 Panel. Lewisham Supported Accommodation Pathway: Local Authority and nine different supported housing providers This user-friendly system is run by Lewisham Council, pulling together existing services to provide a coherent framework for individual pathways for homeless people with complex needs. The service includes a specific mental health pathway and a simple website with details/photos of all supported properties in the pathway. The concept appears transferable. Progression together model: Together for Mental Wellbeing A detailed practical example of how one mental health provider, who ran a number of long-established adult care homes with an indefinite length of stay, transformed these to offer a structured recovery pathway, for people with high support needs. Evaluation available. This example could stimulate consideration of the future of existing “long-stay” or “needs led stay” provision in Gwent, some, but not all of which is SP funded.
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4 Housing First Housing First, Anglesey: The Wallich The Wallich like many “homelessness charities” is increasingly developing its offer on mental health. This was the first Housing First scheme in Wales and now has a depth of positive data on outcomes. Their latest report stood out because they must be developing some close NHS partnership work; their new mental health- focused expansion in Anglesey incudes an arrangement to support people moving from secure NHS settings.
5 Accommodation SHP Southampton Row Service, Camden, London for single Campbell Tickell’s research identified an appetite across Gwent homeless people for promoting psychologically informed and trauma informed and ways of working with people who have complex needs. Psychologically Informed This new service in central London, to accommodate people, Environments who have been sleeping rough for a long period in a (PIE) remodelled former hostel building, is offered by a homelessness charity that has embraced the principles of Appendix 5 gives Psychologically Informed Environments across the whole of its a weblink to the operation. influential Homeless Link Guide to Creating Psychologically Informed Environments.
6 Crisis Houses and Crisis House: Cardiff: Gofal “Sanctuary”, Well documented information is available on this long- “Recovery café” established Crisis Housing in neighbouring Cardiff, operated by models Gofal, the mental health provider that is also well established While these across Gwent. It will be important for ABUHB to take up models do not learning opportunities from crisis house providers, as the Crisis offer housing House model is by no means universal and is evolving solutions directly, nationally. they have a key Richmond Fellowship (RF): Crisis houses, Lancashire part to play in preventing
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escalation of RF operates 8 crisis houses across England in partnership with mental health NHS Mental Health Trusts and others and collates and issues and evaluates data about many aspects of their operation. The hospital Appendix gives a link to a recent conference presentation admissions and giving details of exactly how the crisis houses work and key supporting data about who uses them and their impact. people to cope, Northamptonshire dispersed, part time crisis cafes: MIND including with difficult housing The “Sanctuary or Recovery Café” concept is spreading and is situations. starting to demonstrate impressive preventive outcomes. This example of part-time sessions delivered by a single third sector provider (Northamptonshire MIND) across a large County could be transferable to Gwent and appears to have potential to “bolt on” to existing “wellness” services. Recovery Cafes, South West London Two services, provided by two specialist charities, each offering evening/weekend support in dedicated premises 365 days a year. Both are commissioned by the local Mental Health NHS Trust, and information on the web gives useful detail on how the model runs day to day, the partnerships, and views of people who use the services.
7 Helping people “HAWK”: Look Ahead Housing and Care and South London leave hospital and the Maudsley NHS Trust models Housing and Advice Workers (HAWK) offering housing advice This section to patients in mental health wards n Croydon. A highly opens with successful pilot was quickly extended. reference and a Greater Manchester Mental Health Trust housing advice, with link to a 2015 third sector providers evaluation by Homeless of 52 Included as an example of a similar service to the Look Ahead Department of scheme, spread over a wider area (Greater Manchester) and Health (England) involving several third sector providers. funded hospital Horton (Bradford) intermediate care: Respite accommodation discharge pilots for people discharged from hospital who are homeless Included partly because of its key NHS partnership with primary care: a specialised primary care GP practice which as a social enterprise specialising in care for people who are
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homeless. Whilst this is not specifically a mental health service, the links between homelessness and mental ill-health are clear and it is therefore likely that the GP practice will have specialist mental health skills. The scheme is highly innovative hospital discharge accommodation - intermediate care - 16 short-stay (weeks, not months) newbuild studio flats with 24-hour support. Provided by a West Yorkshire based specialised housing association with a social inclusion purpose. Whilst this model may not be transferable to Gwent, it highlights the notion that excellent GP services to homeless people could have a preventive role in enabling housing providers to offer short term intermediate care for people who are homeless and need to leave hospital mental health wards.
8 Early Newcastle: Mental Health Concern Intervention in This small-scale service (4 dispersed housing units) offering Psychosis intensive, specialised support to young people referred by the Early Intervention in Psychosis team, often with substance misuse issues, is unusual and heavily oversubscribed. The Newport ABUHB Early Intervention Service has emphasised the importance of safe, suitable housing options for young people recovering from their first episode, and their concern at the lack of such housing options in Gwent and the consequential negative impacts on their clients’ recovery plans.
Horizon Scan for Good Practice: Summary of key features 7.4 Although each model presented in this horizon scan has its differences, common features emerge which support their success. These are: • An individualised recovery approach; • Integration across different support providers, including clinical services; • Multi-agency working, collaboration between health providers and housing providers in particular; • Non-judgemental, understanding approaches from support providers, with peer support particularly beneficial; • Close links with local housing providers to support move-on; • Interlinked ‘tiers’ of support, moving from high to low intensity;
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• Where possible, a continuation of support from the same team across these tiers; • Carefully designed buildings; • Specific staff training, integrated across services where appropriate; and • 24/7 staff support as part of the pathway including preparatory work in an existing residential care setting.
Good practice
Look Ahead Housing and Care learning points:
Treat the service as an extension of your own service
Recruit specialists, and train and equip them with knowledge of mental health issues, substance misuse/harm minimisation, support planning, lone working, health and safety, dealing with challenging behaviour, and adult and child safeguarding
Build trust, work in partnership, promote and achieve joint respect – mutual respect – between clinical and housing staff
Appreciate that housing is an area of expertise that NHS staff can have difficulty navigating
Engage the service’s stakeholders in the commissioning and design of the service
Agree clear outcome measures at the outset in order to enable easier evaluation, which should be both quantitative and qualitative, and include the service’s impact on patients’ length of stay, as well as financial savings.
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8. RECOMMENDATIONS FOR A STRATEGIC PROGRAMME
Coordinate effective multi-agency working to deliver a Mental Health and Housing Pathway 8.1 Ownership and oversight of the Pathway should be with Gwent Health, Housing and Social Care Strategic Partnership. 8.2 Improve intelligence to inform the strategic planning of the Pathway: (a) Mapping – continue to improve and update the mapping data within this report (b) Aneurin Bevan UHB and Public Health Wales to undertake a Needs Assessment for mental health across Gwent to inform future planning. (c) Data collection – improve data collection to inform planning. For example, the number of people in hospital service who have unsettled housing, the number of people on housing waiting lists who have an identified mental health need. 8.3 Employ a Housing Specialist at ABUHB to coordinate the operational development of the Mental Health and Housing Pathway in Gwent. The role is to liaise with landlords, adult social care and local authority housing, third sector, support providers and homelessness departments. 8.4 The Pathway should consider what should happen when things go wrong and determine routes of people new to services and not engaging in services? • From homelessness to settled housing • When there is a threat of homelessness or risk of losing a tenancy 8.5 And cover points of transition: • from hospital (including secure tier 3) to settled housing • from prison to settled housing • from children’s mental health and care services to settled housing 8.6 The Pathway will identify routes and access to services at times of crisis including Mental Health Crisis and Emergency Housing Crisis. 8.7 It is a recommendation that complex need is met through the delivery of the Housing First model across Gwent. 8.8 The Pathway should consider the provision of specialist accommodation-based provision including 24 hour and non 24 hours cover, duration of service (short or long term, drop in etc) and arrangements for clinical, psychological, social care and housing related support.
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8.9 The Pathway should cover the range of options for non-accommodation-based support and community-based provision including advice and assistance, social prescribing, criminal justice, substance misuse, social care, clinical and third sector service provision. 8.10 Options for services should build on existing schemes or remodel where required. 8.11 Consider where multi-agency s115 Mental Health and Housing Panels are required on the Pathway to find housing solutions to complex cases. 8.12 The Pathway should be recovery focused, trauma informed, and within Psychologically informed environments. Prevention of homelessness, and inappropriate hospital admission are key objectives. Services should take a multi- agency approach and be co located across organisations where required e.g. DWP/housing/mental health. 8.13 Assess requirement for systems information sharing throughout the Pathway. 8.14 Agree joint outcomes across the Mental Health and Housing Pathway. 8.15 It would be helpful to have process maps/visual representations of the Pathway, - what leads where, so that teams can see where they fit in.
From Homelessness to Settled Housing 8.16 Improve the availability of affordable housing for people with mental health issues through effective utilisation of NHS Estates. Input into forthcoming Estates Plan. 8.17 Housing Needs Assessment and Strategies should refer to Mental Health Housing Need. The Mental Health, Housing and Social Care Partnership Board should coordinate Health and Social Care response and involvement in Housing Needs Assessment. 8.18 Develop a multi-disciplinary Housing First service for people with complex need. Consider care pathways for homeless people with complex needs coupled with issues around mental health, offending or addictions. 8.19 Community Mental Health support in each Housing Options Team to support the assessment of ‘vulnerability’ when being considered if the person is a priority and owed a duty to accommodate. 8.20 Improve routes into treatment for rough sleepers with links between homeless and health assertive outreach. 8.21 Review the response to emergency housing need from people who are mentally unwell and are homeless.
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8.22 Promote training on mental health and the availability of services with homelessness front line staff.
When there is a threat of homelessness or risk of losing a tenancy 8.23 Floating Support is a key plank of the Gwent offer of support to: • maintain a tenancy and prevent homelessness; • move on through the Pathway; and • Resettlement after a period of homelessness/prison/care/hospital. 8.24 Review mental health needs of people in floating support defined under other needs groups and ensure these services are well connected with mental health and social care services to deliver mental wellbeing outcomes. 8.25 Map tenancy support services for each social landlord and include in the Pathway. 8.26 Earlier engagement via housing associations with homeless cases (prior to being housed) to support pre-tenancy. 8.27 Map provision of housing, social care and health support for Hoarding and highlight gaps. 8.28 Review/join up social prescribers, community connectors and IAA. 8.29 Promote housing training with health and social care staff. 8.30 Mental health practice in GP surgeries. 8.31 Collaborate with the social housing and third sector to deliver ‘Sanctuary’ and ‘Crisis House’ provision to deal with crisis.
From Hospital to Settled Housing 8.32 Improve housing outcomes for people discharged from hospital through a Hospital Discharge Service across all second and third tier mental health wards across Gwent. 8.33 Develop specific supported/housing/step down service for effective and timely discharge from secure wards including Forensics and Personality Disorder. 8.34 Joint funding of initiatives across health, housing and social care. Pooled resources for S117 cases. 8.35 Consider extending scope of Housing First to move on from acute wards. 8.36 (Forensics/arson??) Some service models include multi-disciplinary teams e.g. psychiatrists, social workers, primary health providers, occupational therapist,
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children's workers, therapeutic counselling, access to work - provide direct clinical/psychological support.
From Prison to Settled Housing 8.37 Provide timely mental health diagnosis and assessment for people who are moving from prison.
From Child and Adolescent Mental Health Services to Settled Housing 8.38 Employ ‘Housing Officer’ specific to young people transitioning from children’s services (CAMHS and Care). The Housing Officer would have in-depth specialist knowledge of services available and the issues of this client group and to prevent homelessness. 8.39 Consider model of specialist housing (accommodation based, and non- accommodation based) provision for young people in between the stages of being an inpatient and community. Such as training flats. 8.40 Joint funding of initiatives across health, housing and social care. Pooled resources for S117 cases.
Helen Woods, Daphne Ingham, Annie Field, Liz Zacharias March 2019
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APPENDIX 1 – PROJECT STEERING GROUP MEMBERSHIP Senior nurse for Newport adult mental health secondary care Senior nurse for Torfaen Adult Mental Health secondary care Principal Public Health Officer Regional Development Co-ordinator for Supporting People Housing Strategy and Development Manager Divisional Director for the Mental Health & Learning Disability division; Chair of Mental Health & Learning Disability Strategic Partnership Head of Partnership, Development & Integration Mental Health & Learning Disability Division Administrative support
Telephone 020 8830 6777 Recruitment 020 3434 0990 [email protected] www.campbelltickell.com @CampbellTickel1
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APPENDIX 2 – STAKEHOLDERS AND CONTRIBUTORS TO THE RESEARCH
Attendees at February 8th stakeholder consultation event
No. Organisation Job title 1 Gwent Police Mental Health Liaison Officer Office of the Police and Crime 2 Commissioner for Gwent Policy Officer 3 Gofal Project Co-ordinator Patient and Public Engagement/Monitoring and 4 Community Health Council Scrutiny Officer 5 United Welsh Head of Specialist Housing 6 Gateway Support and Care Trainee Manager 7 Gateway Support and Care Manager 8 Torfaen County Borough Council Housing Access Manager 9 Monmouthshire County Council Housing Strategy 10 Gwent Supporting People Regional Dev Co-ordinator 11 Bron Afon Housing Young People and Families Manager 12 Hafal County Manager 13 Newport City Homes Sustaining Communities Team Leader 14 ABUHB - Primary Care Team Lead and Operational Manager 15 Caerphilly County Borough Council Housing Strategy Officer 16 ABUHB Head of Partnership and Development 17 Torfaen County Borough Council Team Lead Blaenau Gwent County Borough 18 Council Service Manager 19 ABUHB Senior Nurse 20 ABUHB Seconded Senior Nurse 21 ABUHB Senior Nurse 22 ABUHB New Projects and Performance CHC 23 Caerphilly County Borough Council Service Manager 24 Newport City Council Supporting People Manager 25 ABUHB Community Psych Nurse 26 CAMHS - ABUHB Forensic Lead for Gwent - ANP Lead Commissioner Social Care and Health, 27 Monmouthshire County Council Supporting People Lead 28 Tai Pawb Open Doors Project Manager 29 Monmouthshire County Council Housing Support Officer 30 Newport City Council Senior Practitioner - Social Worker 31 Monmouthshire County Council Housing Support 32 Monmouthshire County Council Housing Support
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Attendees at March 13th stakeholder consultation event
No. Organisation Job title 1 Monmouthshire County Council Lead Commissioner 2 Monmouthshire Housing Association Wellbeing Support Manager 3 The Wallich (Blaenau Gwent and Torfaen) Prep worker 4 Gwent Supporting People Regional Development Co-ordinator 5 Newport City Council Supporting People Manager 6 Tai Pawb Open Doors Project Manager 7 Gwent Regional Partnership Team Policy and Project Officer 8 The Wallich Area Manager Newport City Council, Community Mental 9 Health Team Student Social Worker 10 The Wallich Research Co-ordinator 11 Gateway Support and Care Trainee Manager 12 Gateway Support and Care Registered Manager 13 Monmouthshire Housing Association CEO 14 Pobl Area Manager 15 Newport City Council Strategy and Development Manager 16 Linc Cymru Independent Living Manager 17 ABUHB Operations Manager PCMMSS 18 ABUHB Projects and Performance Manager LDMH 19 ABGPMT Principal Public Health Practitioner 20 ABUHB Programme Manager 21 NCC APB Lead (Substance Misuse) 22 Caerphilly County Borough Council Housing Strategy Officer 23 Newport City Homes Sustaining Communities Team Leader 24 Caerphilly County Borough Council Housing Solutions Manager 25 AB Community Health Council PPE/Monitoring and Scrutiny Officer 26 Melin Homes Independent Living Service Manager 27 Newport City Homes Sustainable Communities Manager 28 Gwent Regional Partnership Team Regional Partnership Team Service Manager 29 Hafal EIP Lead All Wales 30 Caerphilly County Borough Council Contracts Monitoring Commissioning Officer 31 Caerphilly County Borough Council Team Lead CMHT 32 Caerphilly County Borough Council Monitoring Officer 33 Monmouthshire County Council Strategy and Policy Officer 34 Bron Afon Housing Young People and Families Manager 35 ABUHB MHLD Project Manager 36 Gwent Police Gwent Police Mental Health Triage Manager
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Individual meetings and telephone interviews with Stakeholders 1. Angela Lee, Regional Development Co-ordinator, Gwent Supporting People 2. Rachael Lewis Torfaen Supporting People 3. Jerome Fanfare, Charter Housing 4. ABUHB Ward Managers Meeting 5. CHC Transition Group 6. Gwent Regional Collaborative Committee (SP) 7. Gwent Health, Housing and Social Care Operational Group Meeting 8. Representatives from Gofal (Chris Haynes and Nicole Webber) 9. Ceri Meloy, Tai Pawb 10. Monmouthshire housing representatives (Sarah Ridley and Ian Jones) 11. Amanda Williams, Inspector, Gwent Police 12. Simon Rose, Newport City Council 13. Mind representatives: Jill Lawton, Caerphilly Mind, Bernadette Kelly, Mind Monmouthshire. Denise Suckling, Torfaen and Blaenau Gwent Mind 14. Lisa Meredith, Regional Substance Misuse Coordinator, Newport City Council 15. Nigel Spacey, National Prisons and Probation Service 16. Justin Wigmore, Melin Homes 17. Diana Binding Assistant CE Wales Community Rehabilitation Company 18. Lisa Charles, Bron Afon 19. Harry McKeown, Pobl Group 20. Alex Osmond, The Wallich 21. Jo Lewis-Jones, Performance & Projects Manager, ABUHB 22. Bob Colter, Consultant Clinical Psychologist, Gwylfa, ABUHB 23. Sara Newnes, Head of Public Engagement, Community Health Council 24. James Harris, Strategic Director People, Newport Council 25. Candice Illidge, Community MH Nurse, Torfaen Assertive Outreach Team, ABUHB 26. Andrew Price, North Gwent Crisis Resolution & Home Treatment Manager, ABUHB 27. Susie Gurner, Acting Senior Mental Health Nurse, Caerphilly Community Metal Health Team, ABUHB 28. Gary Lewis, Manager, Head Office, Liberty Care 29. Amanda Biddle, Team Leader, Early Intervention in Psychosis, ABUHB 30. Steve Woods, Monmouthshire Social Services, Professional Team Lead for Social Work, Monmouthshire Adult Community Mental Health Teams.
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APPENDIX 3 – DOCUMENTS REVIEWED Document, date of document, no of pages 1 NATIONAL STRATEGIES AND INFORMATION (WALES, AND WIDER UK WHERE RELEVANT) 1.1 Summary-2012 10 year plan: Together for Mental Health. 42 pages 1.2 Full document- 2012 10 year plan as above 1.3 Together for Mental Health Delivery Plan 2016-19, 37 pages 1.4 2016 Mental Health in Wales: Fundamental Facts: 20 pages, published Mental Health Foundation 1.5 2017 Wales national prosperity strategy 1.6 Jan 2018-Parliamentary Review NHS and Social Care Wales 1.7 A Healthier Wales: Our Plan for Health and Social Care 1.8 Dec 2018 Review of Mental Health Act (England and Wales) 1.9 Integrated Care Fund 2018 Guidance 1.10 Report on a review of the Eating Disorders Framework for Wales 2 REGIONAL: GWENT MENTAL HEALTH AND OTHER STRATEGIES 2.1 Together for Mental Health in Gwent: 2012 Strategy. Spans 2012-17. 44 pages. 2.2 A Review of the 2012 – 2017 Gwent Mental Health Strategy. 2018. 154 pages 2.3 Together for mental health in Gwent: commissioning consultation doc. 2015. 17 pages 2.4 ABUHB 2019-22 Divisional Plan: Mental Health and Learning Disabilities. 59 pages 2.5 Summary: Population Needs Assessment Greater Gwent Health Social Care and Wellbeing Partnership 2017. 5 pages 2.6 Population Needs Assessment Greater Gwent Health Social Care and Wellbeing Partnership full report 2017. 51 pages 2.7 Information Sharing Agreement, South East Wales Public Protection Services 3 SUPPORTING PEOPLE DOCUMENTS 3.1 Regional Strategic Plan 2017-20 – 2018-19 Annual Update, 42 pages 3.2 Blaenau Gwent SP LCP update 2018-21. 29 pages 3.3 Caerphilly SP LCP 2018-21: Planning for the future. 32 pages 3.4 Client Group Factsheet – Mental Health Issues January 2019. 9 pages 3.5 Easy Read – Regional Strategic Plan Annual Update 2019-20. 12 pages 3.6 Gwent SP Regional Strategic Plan Update 2019-20. 36 pages 3.7 Newport LCP 2018 draft. 31 pages 3.8 ABUHB _ SP and mental health document, 13 pages 3.9 Monmouthshire SP LCP 2015-18, 26 pages. 3.10 Torfaen Supporting People Local Commissioning Plan 2019/20 and Annual Update Report 2018/19, 17 pages 3.11 2018/19 Annual Update / Regional Strategic Plan 2017-2020 3.12 Newport Directory of Supporting People Services 3.13 Torfaen Supporting People Directory of Services
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Document, date of document, no of pages 4 HOMELESSNESS DOCUMENTS 4.1 Gwent Homelessness Strategy 2018-22 (regional Action Plan) 17 pages 4.2 As above- 1-page infographic 4.3 Homelessness contacts – 2 pages- saved emails 4.4a Caerphilly Action Plan – Gwent Homelessness strategy 2018-22, 26 pages 4.4b As above, in Welsh 4.5a Torfaen Homeless Action Plan Nov 2018, 26 pages 4.5b As above, in Welsh 5 LOCAL AUTHORITY HOUSING STRATEGY AND GENERAL INFORMATION 5.1 LHMA 2018-2023 final draft 5.2 Housing Needs Strategy Summary 5.3 From Newport - Housing Association addresses/contacts
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APPENDIX 4 – SERVICE MAPPING Gwent-wide services
No. of people Provider Target Client No. Service name Service Type at any Boroughs Organisation Group one time Activate Your ABUHB Advice and Mental 1 Life Signposting Health All Adult ABUHB Community Acute Mental Community Health Health Mental Health 2 Team All Assertive ABUHB Community People who Outreach Health need more intensive outreach than other services can 3 offer All Beechwood ABUHB Hospital Acute Mental 9 Psychiatric Health Intensive Care 4 Unit All Belle Vue ABUHB Hospital Personality 6 5 Disorder All Community ABUHB Community Forensic Forensic Health 6 All Dewis CIL Dewis Advocacy Mental 7 Health All Early ABUHB Community 14- 120 Intervention Health 35 Psychosis 8 Service EIS) All Eating ABUHB Community Acute Mental 9 Disorders Health Health All Gwent Mental Inside Out Other Mental Health Cymru Health Consortium community wellbeing services - member Inside 10 Out Cymru All
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No. of people Provider Target Client No. Service name Service Type at any Boroughs Organisation Group one time Gwent ABUHB Advice and Substance Specialist Signposting Misuse Substance Misuse Service 11 All Lindisfarne ABUHB Hospital Step Down 2 12 All Newid Project NYAS Advocacy young persons (16- 25) and their 13 carers All North Lodge ABUHB Step Down Acute Mental 3 14 Health All Personality ABUHB Community Personality 15 Disorder Health Disorder All 16 Pillmawr Ward ABUHB Hospital Forensic 12 All Primary Care ABUHB Self Help Mental Mental Health Promotion Health Support 17 Services All Road to Well ABUHB Advice and 18 Being Signposting All Seren Living Seren Living Letting Generic 19 Letting Agency Agency All Shared Lives Ategi Shared Lives Broad range of support 20 needs All South Lodge ABUHB Step Down Acute Mental 3 21 Health All Supported Liberty Care Independent People with 40 Living Living mental health issues requiring S117 22 aftercare All The Lighthouse Taff Housing Hospital Older People Project, Gwent Association Discharge 23 Service All
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No. of people Provider Target Client No. Service name Service Type at any Boroughs Organisation Group one time The Welfare The Wallich Other Homeless Vehicle people 24 All Ty Skirrid ABUHB Hospital Forensic 12 25 All Up4It Hafal Self Help Young People 26 Promotion 14 - 25 All Veterans’ NHS ABUHB Community Acute Mental 27 Wales Health Health All Changing MIND - Other Young people Minds - young Monmouthshire, with mental people in Newport, health issues Newport, transition (14- Torfaen aged 14-25 Torfaen and 28 25) Monmouthshire Crisis ABUHB Community Mental Torfaen, Resolution and Health Health Crisis Blaenau Gwent Home and 29 treatment Monmouthshire
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Newport
No. of people Provider No. Service name Service Type Target Client Group at any Organisation one time Adferiad Ward ABUHB Hospital Acute Mental Health 22 (also covers 1 Monmouthshire) Albert Street SOLAS Supported Homeless inc mental 25 2 Housing health Caerau Manor Ocean Community Residential Care Women with 9 3 Services personality disorders Clarence Place SOLAS Hostel Dual Diagnosis, 32 homeless and mental 4 health Clifton Place SOLAS Supported Complex Needs 29 5 Housing Dewsland L Pressley Supported Mental Health 10 Park/Caerleon Housing (enduring) 6 Road (Accomm) Gateway Support Gateway Support Supported Mental Health 35 7 and Care and care Housing (including enduring) Gwent Mental Growing Space Other Mental Health Health Consortium community wellbeing services 8 - Growing Space Gwent Mental Hafal Self Help Health Promotion Consortium community wellbeing services -Newport structured 9 recovery courses Hospital to Home Gofal Hospital Mental Health 15 10 Discharge Service Housing Options Newport City Housing Options Homeless and 11 Newport Homes Service Threatened Homeless IA&A Newport City Community Mental Health 12 Council Connectors
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No. of people Provider No. Service name Service Type Target Client Group at any Organisation one time Llanthewy House Mrs S James Residential Care Mental Health, Learning 7 Disability, Younger 13 Adults Manor Lodge Accomplish Group Residential Care Acquired Brain Injuries, 7 Learning Disabilities, 14 Mental Health Newport Council Newport Council Supported Mental Health 9 15 Supported Living Housing Newport MIND Newport MIND Floating Support Mental Health 16+ 64 16 Floating Support Newport MIND Newport MIND Supported Mental Health 18+ 16 Supported Housing 17 Housing Olive Branch Drop In Day 18 Service Out-of county Newport Council Supported Mental Health 2 19 supported living Housing Pobl Bond Pobl Housing Access to Private Generic 20 Scheme Group Sector Housing Prevention by Pobl Group Tenancy Support Social housing tenants Intervention to Social Housing 21 tenants Reach: Newid Reach Floating Support Mental Health 45 22 Floating Support Reene Court Abbeyfield Nursing Care 16 23 Nursing Home Home Station Rd D McIntyre Supported Enduring Mental Health 4 (Accommodation) Housing - Single men only 24 Tenancy Support Newport Mind Advice and Mental Health 25 Drop In Service Signposting The Glen Ocean Community Residential Care Diagnosed mental 5 Services health needs, learning disability and 26 personality disorder The Whitehouse Sally White Supported Enduring Mental Health 6 27 Housing Wentwood Court Ocean Community Residential Care Learning disability and 14 28 Services mental health issues
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No. of people Provider No. Service name Service Type Target Client Group at any Organisation one time West Park & West Park & Supported Enduring Mental Health 10 Bryngwyn (2 Bryngwyn Ltd Housing 29 shared houses)
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Torfaen
No. of Target people No. Service name Provider Organisation Service Type Client at any Group one time Gwent Mental Health Torfaen & Blaenau Advice and Mental Consortium community Gwent Mind Signposting Health wellbeing services - member Torfaen & Blaenau Gwent Mind (also covers Blaenau 1 Gwent) Gwent Mental Health Torfaen & Blaenau Counselling Mental Consortium community Gwent Mind Health wellbeing services - member Torfaen & Blaenau Gwent Mind: Counselling (also covers 2 Blaenau Gwent) Gwent Mental Health Torfaen & Blaenau Self Help Promotion Mental Consortium community Gwent Mind Health wellbeing services - member Torfaen & Blaenau Gwent Mind: Self help promotion and courses (also covers 3 Blaenau Gwent) Talygarn Ward (also ABUHB Hospital Acute 22 covers Monmouthshire) Mental 4 Health Care Navigation British Red Cross Advice and Mental 5 Signposting Health Care Navigation - Torfaen County Social Prescribing Mental 6 Borough Council Health Care Navigation - Torfaen Torfaen County Community Mental 7 Community Connectors Borough Council Connectors Health Gofal Floating Support Gofal Floating Support Mental 54 Health 8 Gwalia floating support Gwalia Floating Support Generic na service 9 Gwent Mental Health Torfaen & Blaenau Advice and People Consortium community Gwent Mind Signposting with 10 wellbeing services - mental
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No. of Target people No. Service name Provider Organisation Service Type Client at any Group one time member Torfaen & health and Blaenau Gwent Mind housing issues Gwent Mental Health Torfaen & Blaenau Floating Support People 10 Consortium community Gwent Mind with wellbeing services - mental member Torfaen & health and Blaenau Gwent Mind: housing 11 STEP 12 week support issues Gwent Mental Health Torfaen & Blaenau Floating Support Mental 8 Consortium community Gwent Mind Health- wellbeing services - Vulnerable member Torfaen & Males Blaenau Gwent Mind: Young Vulnerable Males 12 service Gwent Mental Health Hafal Community Mental Consortium community Connectors Health wellbeing services - 13 Torfaen recovery service Home From Home Helen Reynolds Supported Housing Severe and 3 enduring 14 MH The Hollies The Hollies Supported Housing Mental 6 15 Health Torfaen & Blaenau Gwent Torfaen & Blaenau Floating Support Mental 71 16 Mind - Floating Support Gwent Mind Health Torfaen Housing Options Torfaen County Housing Options Homeless Borough Council Service and Threatened 17 Homeless Torfaen IAA Team Torfaen Council Floating Support Mental 10 18 Floating Support Health
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Blaenau Gwent
No. of Provider people at No. Service name Service Type Target Client Group Organisation any one time Gwent Mental Health Torfaen & Blaenau Advice and Mental Health Consortium Gwent Mind Signposting community wellbeing services - member Torfaen & Blaenau 1 Gwent Mind Gwent Mental Health Torfaen & Blaenau Counselling Mental Health Consortium Gwent Mind community wellbeing services - member Torfaen & Blaenau Gwent Mind: 2 Counselling Gwent Mental Health Torfaen & Blaenau Self Help Mental Health Consortium Gwent Mind Promotion community wellbeing services - member Torfaen & Blaenau Gwent Mind: Self help 3 promotion and courses Blaenau Gwent The Wallich Floating Support People at risk of na Floating Support homelessness
4 Brynteg Road Thrive@United Supported People leaving acute 5 5 Welsh Housing care Cariad Linc Cymru, United Hospital Generic - Hospital Welsh, Aneurin Discharge Service Discharge Bevan University Health Board and Blaenau Gwent 6 Social Services 7 Carn-y-Cefn Ward ABUHB Hospital Acute Mental Health 11 Cwm Celyn Shaw Healthcare Residential Care Complex needs, 24 including nursing care, dementia, respite stays and people with 8 schizophrenia
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No. of Provider people at No. Service name Service Type Target Client Group Organisation any one time Floating Support Gofal Floating Support Mental Health 66 9 (Blaenau Gwent) Garfield House Gofal Supported Mental Health 5 Housing
10 Gwent Mental Health Hafal Other Mental Health Consortium community wellbeing services -Blaenau Gwent recovery programme and 11 resource centre Housing Advice Centre Blaenau County Housing Options Homeless and Borough Council Service Threatened 12 Homeless Maes-y-dderwen Shaw Healthcare Residential Care Nursing, respite, 24 dementia care and people with 13 schizophrenia Miles Richards House Gofal Supported Mental Health 7 14 Housing
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Caerphilly
No. of Provider people at No. Service name Service Type Target Client Group Organisation any one time Solas Floating SOLAS Floating Support Young People 16 - 25 na Support (also covers 1 Monmouthshire) ALP Supported ALP Supported Living Supported Learning disability and 10 2 Living Services Ltd Housing mental health issues Caerphilly Caerphilly County Housing Options Homeless and 3 Housing Options Borough Council Service Threatened Homeless Gofal Floating Gofal Floating Support Mental Health 4 Support Gwent Mental Hafal Other Mental Health Health Consortium community wellbeing services - Caerphilly Recovery 5 Programme Gwent Mental Caerphilly Mind Advice and Mental Health Health Signposting Consortium community wellbeing services 6 -Caerphilly Mind Home from Home Home from Home Supported Mental Health 8 7 Housing Hudson House Ocean Community Residential Care Severe or enduring 8 Services mental illness and 8 personality disorder 9 Jubilee House Gofal Floating Support Mental Health 4 Mind Floating Caerphilly Mind Floating Support Mental Health 10 Support Reach Reach Floating Floating Support Mental Health 11 Support Ty Anwen Gwalia Residential Care People with a diagnosed 16 and enduring mental 12 illness Ty Cyfannol Ward ABUHB Hospital Acute Mental Health 22 13
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Ty Gwernen Care Enable Care Services Residential Care Mental health issues 6 14 Home Ty Oborne Gofal Supported Mental Health 8 15 (Accommodation) Housing Ty Short Gofal Supported Mental Health 8 16 (Accommodation) Housing Pathways to Gofal Other Mental Health 60 17 Employment
Monmouthshire
No. of Provider people at No. Service name Service Type Target Client Group Organisation any one time Adferiad Ward (also ABUHB Hospital Acute Mental Health 22 1 covers Newport) Solas Floating SOLAS Floating Support Young People 16 - 25 na Support (also covers 2 Monmouthshire) Talygarn Ward (also ABUHB Hospital Acute Mental Health 22 3 covers Torfaen) Ederyn Elysium Residential Care Mental Health "step 19 4 down" - men. Gwent Mental Monmouthshire Self Help Mental Health Health Consortium MIND Promotion community wellbeing services - Monmouthshire 5 courses and groups Gwent Mental Monmouthshire Advice and Mental Health Health Consortium MIND Signposting community wellbeing services - Monmouthshire welfare benefits 6 advice Gwent Mental Hafal Other carers and families - Health Consortium people with MH issues community wellbeing services - Monmouthshire 7 carer support Mind Supported Monmouthshire Supported Mental Health 24 8 Living Mind Housing
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Monmouthshire Monmouthshire Housing Options Homeless and 9 County Council County Council Service Threatened Homeless Monmouthshire Monmouthshire Floating Support Mental Health 21 Mind Floating Mind 10 Support 11 Ty Gwyn Hall Elysium Residential Care Mental Health 34
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APPENDIX 5: HORIZON SCAN OF INNOVATIVE AND GOOD PRACTICE SERVICES Introduction 1.1 This Appendix is a comprehensive report of the national Horizon Scan exercise carried out by Campbell Tickell to identify examples of good practice in mental health and housing from elsewhere, both in Wales and the rest of the UK. The scope of this research has been refined as the Gwent research has progressed, to focus on areas that emerged as potential priorities for further development in Gwent. Section XX of the main Report provides a summary of this “Horizon Scan” with comments on each service model described here. Section XX also provides an analysis of key features that occur across many of the good practice models described. 1.2 In the course of our Gwent research, Campbell Tickell found many good practice examples within the region, and have made reference to a selection of these throughout the main report.
24/7 Integrated Teams and Step Down Care: Forensic schemes 1.3 These are high level schemes for “forensic” clients in the formal sense who may have have committed a crime serious enough to result in detention in a secure hospital, as opposed to the far larger numbers of people with mental health problems who are ex-offenders.
St Andrew’s, Maidstone, Kent: Choice Support and Kent and Medway NHS and Social Care Partnership Trust The Beeches (commonly known as St Andrew’s), is a converted Victorian house providing nine self-contained one bedroom flats for people leaving secure care. The house is on the edge of the NHS Trust’s hospital site, near the secure provision, yet is also near the centre of the town (Barming). Tenants, with Assured Shorthold tenancies, pay their own bills, buy their own furniture, and are responsible for cleaning. The model of support is designed to enable people to move on within two years, although this is flexible. Choice Support provides 24-hour waking and sleeping support, with a minimum of two staff members on site at any time. Staff provide emotional and practical support, co-produce ‘goal plans’ with tenants, and facilitate group activities to nurture a sense of community, responsibility and social progression. Staff encourage tenants to engage with the local community and enrol for learning, volunteering and paid work opportunities. Clinical support is delivered by staff from the nearby forensic psychiatry service operated by Kent and Medway NHS and Social Care Partnership Trust, the Trevor Gibbens Unit (TGU). Client
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contact with consultant psychiatrists varies, from weekly or fortnightly to less frequently where appropriate. Choice Support owns the property and recoups income for the tenancies from housing benefit. There is no ‘block contract’ in place; spot-contracts are negotiated on an individual basis. Choice Support is therefore able to assess and accept tenants who are appropriate and suggest alternatives for those not deemed to be ready to enter the service. Where people are assessed and not yet ready for the move, Choice Support will keep in touch and over time assess their progression in order to be able to offer a service when they are ready. Clinical services are provided ‘in kind’ by the TGU. Choice Support has an excellent relationship with the TGU, with • Bi-monthly meetings to ensure that each tenant’s needs are met by their care plan • Accurate information sharing • Reciprocal training sessions Around18 months after opening, two of nine tenants were almost one year ahead of schedule in preparing to have their own home in the community by joining the housing list. A tenant’s perspective “When I first came to St Andrew’s (The Beeches), I found it hard. I was lonely and I didn’t look at it as my home, just another institution. I had a few blips along the way. I was caught with drugs and alcohol. I admitted it and have since received support to help me stop from making the same mistakes. I am monitored daily, I have random drug and alcohol testing, I am encouraged to join in with activities and generally encouraged to share my everyday life experiences instead of isolating myself…..I am encouraged to build on my relationships with my family members and enjoy the freedom to spend three nights a week at my family home. I don’t go home every week but it is nice to know I can. At this time in my life I feel no aggression or paranoia and feel I am able to stay away from drugs. I would say I am content….I am still fighting my diagnosis but accept I need support. I am looking forward to moving on with my life and putting the bad things behind me… St Andrew’s has given me the beginning to getting my life back and taking it in the right direction”. References – https://www.choicesupport.org.uk/stories/forensic-mental-health-st-andrews https://www.nhsconfed.org/-/media/Confederation/Files/Networks/MentalHealth/Mental- Health-Network--Innovation-in-housing-care-and-support.PDF
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Tabard scheme, Look Ahead: a forensic 3-way partnership: Housing, NHS, Social Services A Look Ahead service, opened in 2014 and delivered in partnership with East London NHS Foundation Trust (ELFT) and the London Borough of Tower Hamlets. This description draws on the evaluation by HACT (Housing Associations Charitable Trust), completed in autumn 2017. https://www.hact.org.uk/sites/default/files/uploads/Housing%20and%20health/0249-24PP- TabardServices-Full%20Report.pdf Tabard Forensic Service provides vital components in the London Borough of Tower Hamlets’ (LBTH) wider forensic pathway, supporting service-users with complex histories and high levels of risk to step-down from secure mental health inpatient services to live in the community. • Intensive accommodation-based support to 19 men aged 18-74, with serious and enduring mental health needs and offending histories. • Building: 19 self-contained flats on one site, converted from a former hostel. 12 are high- support flats with a communal entrance and facilities. 7 are a low-support “stepdown” option, each with their own front door to the street. Security features include CCTV and screened walkways and a landscaped garden. This design encourages interaction and socialising, including with staff, to strengthen therapeutic relationships. • A comprehensive medication management service supports residents to comply with medication and progress towards self-management.
• Staff undergo a bespoke training package, and receive clinical supervision from ELFT clinicians to manage the unique challenges and risks. • Look Ahead’s co-produced person-centred approach enables residents to shape their support, improve their engagement and prepare for independence. • Look Ahead’s psychologically-informed risk management model, See Think Act, ensures well-trained staff identify and respond to emerging risks at an early stage. • Clinical supervision is usually delivered by a consultant psychiatrist, and on a case-by- case basis can include psychologist input to support the team to implement particular interventions or approaches to manage challenging behaviour. • On-site drug and alcohol screening to support resident compliance with Ministry of Justice restrictions. “Tabard Forensic Service staff are good at communicating consistently with transparency and immediacy.” Forensic social worker, ELFT
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What the service achieves for individuals The HACT evaluation highlighted four key outcome areas for residents that reflect the success of the service and the partnership with ELFT and other stakeholders: Meaningful activity, Medication support, Substance misuse, and Move-on rates. The evaluation details outcomes and benefits for the wider health and social care system and provides a detailed set of figures that demonstrate significant value for money and cost savings.
24-Hour supported “step-down” schemes
Vale of Glamorgan Integrated Dispersed Housing Scheme Overview: This enhanced, remodelled Floating Support service is for six people in dispersed accommodation, who have higher level mental health needs and are “stepping down” from higher levels of care. In 2016, of the 6 clients, 5 were in accommodation, one waiting and five were men, one woman. There were three Gofal staff dedicated to the project. The IRIS team had a total of nine staff (for their whole portfolio of work). At the core of the model is the joint work between social landlord Newydd, specialist mental health floating support provider Gofal, and the IRIS team, which has strong partnerships with Housing Associations and third sector providers, with the support is provided jointly by Gofal and the Health Board Intensive Rehabilitation and Integration Service (IRIS) team, offering nurse-led services 7 days a week. The scheme was set up as a pilot, and has been identified by the Welsh Government as a model of good practice. The Welsh Government’s 2016 evaluation gives perspectives from the partnership on future risks and suitability, as well as a full picture of how it worked in 2016. The evaluation is here https://gov.wales/statistics-and-research/evaluation-vale-glamorgan- dispersed-housing-scheme/?lang=en The housing model is Floating Support to people living in six dispersed housing units provided by Newydd Housing Association. If and when support is no longer required tenants stay in their accommodation with a permanent tenancy. The core membership of the original 4-agency group became a project steering group with representatives of the four organisations playing a role. The four agencies are • Newydd (social Landlord) • Gofal (Specialist mental health support provider) • Cardiff and Vale University Health Board (IRIS team) • Vale of Glamorgan Council Supporting People (Funding the Gofal team).
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Referral routes: people known to the IRIS team from their shared supported accommodation service; via the Gofal presence on some Cardiff psychiatric wards; Community Mental Health Team care co-ordinators; Clinical Psychiatric Nurses. IRIS and Gofal carry out joint assessments, including risk. Gofal usesthe Mental Health Recovery Star. Work with the person begins while they are waiting for suitable accommodation, which can be a protracted and frustrating period. Contact details: Sarah Wills, Project Co-ordinator, Gofal, [email protected] Outcomes and evidence of success: Extracts from a 2018 joint presentation:
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Care & support plus model - Tile House, One Housing Group and Camden & Islington Mental Health NHS Trust The “Care & Support Plus” model is a form of supported housing designed for people with a high level of mental health support needs. Successful schemes are often jointly delivered by a housing provider in conjunction with a local NHS Foundation Trust and in some cases the local authority as well. Key features: • Tile House is newbuild accommodation: 15 high quality, fully furnished self-contained flats, with communal areas that are used as informal settings for workshops and group sessions. Carefully designed safety features include CCTV, airlock doors and front facing office staff. • Tile house is staffed 24/7 by one Housing Group’s support team, working conjunction wth NHS clinical staff. Each person has a designated key worker. • In-house clinical support: a care coordinator 2.5 days a week, and support from an occupational therapist and a psychologist. Without such support, these service users may have required hospitalisation for their clinical support needs. One Housing’s own evaluation after the first 2 years (2012-2014)4 showed positive outcomes for service users – people better able to manage their mental and physical health, substance misuse, and finances, more in control of their decisions and choices, more engaged in activities, and more prepared for move-on. In terms of hospital admissions, whist the number of admissions, compared to the last 2 years before moving in, was similar, there were far shorter stays in hospital, down from an average of 317 days in the preceding two years to 81. The high level of on-site support seen as preventing 23 further potential admissions. 1. Moves towards independence: two customers had planned moves, and eight were ready to move on to lower support and awaiting suitable accommodation. 2. Cost savings: Calculated at £21,298 per placement per annum, saving the social care budget over £1million over 5 years and the system overall £443,964 per annum. The evaluation identified some limitations, including difficulties in ensuring that service users are able to self-medicate (seen as a prerequisite for moves to lower level support).
4 Available here: http://www.contactconsulting.co.uk/wp-content/uploads/2015/02/Integration-that- Works-One-Support-Tile-House-Evauation.pdf Aneurin Bevan University Health Board April 2019 93 of 111
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Richmond Fellowship, Tameside 24hr Supported Housing (Greater Manchester) This brief outline describes a mix of 24-hour supported shared and self-contained housing on three sites in one Local Authority area, Tameside in Greater Manchester, one of which is for women only. Richmond Fellowship (RF) is a mental health specialist provider working across England whose aim is to help individuals on their recovery journey so they are able to move on to more independent living within the community. The three 24hr supported housing schemes in the Tameside area are: • Manchester Road – Available to men and women. 12 individual rooms in the main building with shared communal facilities, including living room, dining room, kitchen and bathrooms, plus four self-contained flats on site, • Maple House – 13 self-contained flats, available to men and women, plus a communal lounge, kitchen and dining area, and • Boston Bank House – Five self-contained flats for women only. There is also a communal lounge, kitchen and conservatory area. https://www.richmondfellowship.org.uk/greater-manchester/tamside-24hr-supported-housing/
Pathway models These are examples of schemes where health, social care and housing agencies work together to plan, develop and link the operation of services at different levels of support, that provide personalised recovery “pathways” towards greater independence.
Suffolk Mental Health Supported Housing Pathway Suffolk is a large county with rural areas, and notable towns and ports. The County Council, responsible for social care and the NHS commissioning bodies have a pooled mental health supported housing budget of £2.43m. It is known to the CT team that this pooled budget has been operating for many years, and will incorporate funds that would previously have been allocated via the Supporting People programme. The County Council runs a single application process for supported housing. Several of the supported housing schemes in the mental health pathway are 24-hour staffed, are purpose built grouped 1-bed self-contained flats (around 6-8 units), purpose developed by
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housing associations, with a design that allows for the shared and staff accommodation to become an additional flat should these facilities not be required at a future date. The slide presentation (see link below) emphasises recovery and move-on, lists all the providers and schemes, and outlines the process and pathway. Across the County there are 250 “beds” of various support levels across all areas, some with 24 hour support, some with waking nights, and others with floating support and/or a personal care package. A multi agency “Mental Health EAT Panel” makes funding decisions for individual patients, where funding is not already agreed through standard contracting and commissioning. The panel reviews funding decisions on all new packages after 3 months and established packages 6 monthly; criteria are S117 aftercare or clinical exceptionality, defined as follows: • How is this patient significantly different from the population of patients with similar clinical circumstances who would not normally be offered this treatment? • Is this patient likely to gain significantly more benefit from this treatment than would be expected from other patients with the same condition who are not currently offered it? There are four different providers: MIND, Julian Support, Richmond Fellowship and Home Group. Included are two assessment beds for up to 3 months; three respite beds; three admission prevention (gate kept by home treatment team); and one homelessness bed. The aim of these services is to enable people to recover, sustain that recovery, be socially included, and develop/ maintain independent living skills. Pooled Fund: Total Supported Housing £2,436,706, comprising £1,515,389 from Suffolk County Council and £921,317 from the NHS. Reference and contacts: November 2018 regional Housing Learning and Improvement Network (LIN) meeting, joint County and District Councils and NHS presentation, available at https://www.housinglin.org.uk/Events/Eastern-Region-Housing-LIN-ADASS-Meeting/
Lewisham Supported Accommodation Pathway A Local Authority and nine different supported housing providers collaborate in Lewisham to help place people in accommodation that, as part of the partnership, can prevent homelessness and offer an individualised housing and support pathway. There is a simple and user friendly website, The pathway is run by the Lewisham Council’s SHIP (Single Homeless Intervention and Prevention Team) which is a centralised assessment and referral service, responsible for
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preventing homelessness and placing vulnerable single homeless people with support needs into supported accommodation. Clients must have a local connection with Lewisham. It is one of three Pathways: Mental Health, Vulnerable Adults, and Young People aged 16-24. The three Pathways are a number of housing-related support services that support clients to achieve independent living, offering a range of accommodation and support levels. There are three stages to each Pathway: Assessment, Specialist, and Move Through. Each stage provides a different level of support, with different lengths of maximum stays. Nine different supported accommodation services are delivered by a range of providers. Details are shown on the website. Each supported housing provision offers a specific level of support, given in a comprehensive table and indicated on each accommodation profile page. There is a dedicated website at https://www.lewishamsupportedhousing.org/lewisham- pathways
Progression together model: Together for Mental Wellbeing This example describes a pathway that stems from the historical provision of care homes for adults with mental health issues by the charity Together for Mental Wellbeing (TMW). TMW has transformed several of its registered residential care homes for people with complex mental health needs into personalised accommodation-based support. The model provides a personalised pathway from hospitals/secure settings to independent accommodation within the local community. This self-directed support is designed to help individuals eventually transition into independent living in the community. People within this pathway have a variety of complex mental health needs. For those service users who participated in the MHF evaluation, the age range was 19-59 with a mean age of 39. The model consists of both ‘core’ and ‘flexi’ elements, which include: 3. Peer support; 4. Psychological therapies; and 5. A recovery voucher system; people plan and book specific activities or time with staff to meet goals within their recovery plans, which helps prepare for using personal budgets.
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A pilot with several care homes allowed TMW to assess the strengths and address the weaknesses of the model. A three-year independent evaluation of five services was undertaken by the Mental Health Foundation (MHF).5 The model unfolds in three stages over a two-and-a-half-year timeframe: Stage 1 (between 0 and 12–18 months) is an intensive phase of recovery and support within a residential care environment; Stage 2 (6 -12 months) helps people to prepare for independence, identify suitable move-on accommodation, and start to address the needs, fears, risks and goals associated with moving, and Stage 3 is support provided to 6 individuals once they have moved on to independent living, for up to 6 weeks, with flexibility to provide longer term support if needed. Key elements of the model include 6. Staged pathway of support, using the Recovery Star approach. People must meet all of their goals before moving on to the next stage 7. Increasing levels of responsibility: supported to direct one’s own support and recovery 8. Good access to clinical care, 9. Conjoined approach: staff work closely with all agencies involved in an individual’s care, 10. Specialist staff training: to equip staff to support people with complex needs, and 11. Incorporation of peer support. The MHF report found that all participants reported that they had developed new skills; several moved on to greater independence, including at least one who had been in the service for 60 months; general wellbeing measures for participants increased from below average for the general population, to above average, and participants showed increased levels of exercise, health eating, stress management, and social interactions, and had better relationships with health professionals. The cost comparison analysis (undertaken in 2014) was somewhat inconclusive, and the MHF report includes tables showing more in-depth cost comparisons.
5 Available here: https://www.mentalhealth.org.uk/publications/progression-together-report Aneurin Bevan University Health Board April 2019 97 of 111
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Newcastle Collaborative Housing Pathway: Consortium led by Mental Health Concern The Collaborative Housing Pathway is delivered by a consortium of four third sector agencies in the Newcastle area providing accommodation services to people aged over 18 with severe and enduring mental health issues. They are all part of the same contract, with the consortium led by the charity Mental Health Concern. The providers have a single point of referral system hosted by Newcastle City Council, which ensures that all potential service users are directed to the appropriate service. This information is based on a 2014 report. Campbell Tickell is aware that the service continues to operate. Changes in local authority commissioning intentions brought the need for a more joined up pathway across mental health housing services. Most of the properties used pre-dated the establishment of the partnership and are in a range of designs, allowing allows for people to be offered appropriate forms of accommodation within the available supply according to their needs. The pathway was commissioned by Adult Social Care, which funds the support element. Additional management income is generated through entitlement to housing benefits or personal contributions. The model does not have NHS funding. There is no overall evaluation of this model, but it was included in the Housing LIN report of innovative practice. Key elements include Individualised person-centred approaches and planning, delivered through 68 units across several tiers of accommodation in the pathway. The units are: 12. ISOS Housing and Richmond Fellowship: low level supported accommodation, 3-6 hours of support per user each week (38 Units) 13. Mental Health Matters: medium to intensive level accommodation, 6–9 hours per week support (17 Units) 14. Mental Health Concern: high level need support (clinical led), over 9 hours support per week and an RMN keyworker per tenant (13 Units). People are matched with the correct level of support through the collaborative approach, which builds in inter-agency support and user step-up and step-down, reducing the complexities associated with involving external providers in moves towards independence. Such moves are assisted by strong links with local housing providers.
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Positive move-on is a measurement of recovery across the pathway, with rates varying across the provider patch. Each recorded a minimum of 2 to 3 service users moving in each 12-month period. The Housing LIN report found that this model reduced costs in the health and social care economy.
Housing First a. Housing First is an internationally evidence-based approach, which uses independent, stable housing as a platform to enable individuals with multiple and complex needs to begin recovery and move away from homelessness. The approach and evidence base of its effectiveness is currently growing in popularity in the UK. b. Housing First works on the premise that, rather than expecting a person currently living on the streets to go through several steps to reach independence, they should instead be offered an independent tenancy first with no prerequisites for access and they should receive intensive and assertive support. c. The Welsh Government is promoting Housing First, allocating £700k to fund projects already identified across Wales, from the £30m Welsh Government ministers have promised to spend tackling homelessness and rough sleeping in 2018 and 2019. In Gwent, Pobl is progressing a Gwent-wide Housing First development.
Housing First, Anglesey: The Wallich Overview and mental health aspects: The Wallich has run the Anglesey Housing First Project, the first in Wales, since 2013. The approach is trauma-informed and follows a therapeutic model of support, enhanced by creative interventions provided by The Wallich’s participation and progression department. The Anglesey service has recently developed specialist mental health capacity, having been commissioned in April 2018 to support an extra five people with mental health issues facilitating discharge from the secure mental health unit (employing an additional Senior Support Worker), and in November 2018 was commissioned to support further five people into step-down accommodation with a lead support need of mental health. These recent initiatives can be assumed to be the result of significant work developing mental health partnerships with NHS hospital provision. The Wallich is one of many homelessness providers across the UK who are prioritising developing their mental health expertise, sometimes in response to the need and desire to provide a timely, more therapeutic offer when local NHS services are unable to respond. The Housing First initiative can also be a vehicle for improved joint working and collaboration.
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Housing model: On average in 2017 it took the service 26 days to house someone in their own independent accommodation. Clients choose where on the island they want to live and the team works with private rental landlords to access housing. “The Wallich will always try their hardest to help me and any issues I’ve got.” (Client feedback) People who use the service: Housing First Anglesey was set up as a pilot in 2013 to meet the identified need of 25 people who were regularly sleeping rough and/or experiencing repeat homelessness on the island. Of 151 people supported since then 22% were rough sleepers, 40% sofa surfers and 38% in temporary accommodation and at risk of homelessness. At the end of 2018, the service was supporting 25 people. of these 60% were in accommodation, 20% in bed & Breakfast and 20% sofa-surfing. Staffing: Project Coordinator, Senior Support Worker(s), Support Workers, volunteers. Cover incudes on-call at night Outcomes and evidence of success: Over the first 5 years 74% of the 151 people supported have successfully secured and maintained accommodation including 51% still in their original accommodation. 11 people found paid employment, 5 people started volunteering and one is in education. “It feels as though I have a road to follow to recovery, which I never had before.” (Client feedback example) Contact: The Wallich Housing First Anglesey, Park Mount, Glanhwfa Road, Llangefni, LL77 7EY 01248 725910 / [email protected]
Accommodation for single homeless people in Psychologically Informed Environments (PIE) PIE, referenced elsewhere in this report, is increasingly being adopted by teams that work with homeless people who have complex needs. The influential 2015 Guide produced by Homeless Link6 summarises a Psychologically Informed Environment (PIE) as “... one that takes into account the psychological makeup – the thinking, emotions, personalities and past experience - of its participants in the way that it operates.. it’s an approach to supporting people out of homelessness, in particular those who have experienced complex trauma3 or are diagnosed with a personality disorder. It also considers
6 https://www.homeless.org.uk/sites/default/files/site- attachments/Creating%20a%20Psychologically%20Informed%20Environment%20-%202015.pdf
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the psychological needs of staff: developing skills and knowledge, increasing motivation, job satisfaction and resilience.” The Department of Communities and Local Government England published a 2012 Good practice Guide, which states that: “Training all staff within an agreed framework, or combination of frameworks, will help them work more effectively with clients experiencing complex trauma. This approach will help clients who often behave chaotically to gain an understanding of their behaviour, take responsibility for themselves and develop negotiated, positive relationships. This in turn will help them move away from a street lifestyle and rough sleeping.”
SHP Southampton Row Service, Camden, London: This example is a recently opened homelessness scheme that adopted the PIE approach from the outset, as part of an organisation-wide programme. Single Homeless Project (SHP) is a London-wide charity working to prevent homelessness and help vulnerable and socially excluded people to transform their lives. Up to 600 people live in SHP hostels and supported housing at any one time. Each hostel specialises in meeting one of four priority needs: mental health, substance misuse, offending or the needs of vulnerable young people, including those leaving care. “Some of the people we work with are trapped in a spiral of offending. Without the right support and financial help when they come out of prison, many ex-offenders find themselves turning back to crime to get by. There’s also a strong link between offending and homelessness, with one in six prisoners reporting being homeless before they are taken into custody”. (SHP website)7 SHP opened the Southampton Row service in October 2017, remodelled from a previous hostel to form 21-bed accommodation service for adult men who are ex-offenders with very complex needs. Residents are entrenched rough sleepers, who are taking the first steps out of homelessness. They may in the past been excluded from the mainstream accommodation pathway a number of times. All staff have been trained in Psychologically Informed Environments (PIE), ensuring that our hostel-based work takes account of the persistent effects of adversity or trauma on clients, and their resulting psychological and emotional needs. SHP’s in-house clinical psychologist is embedded in the team. Reference: https://www.shp.org.uk/
7 https://www.shp.org.uk/offending Aneurin Bevan University Health Board April 2019 101 of 111
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Crisis Houses and “Sanctuary”, “Recovery café” models The national MIND website lists some examples of Crisis and Sanctuary models at https://www.mind.org.uk/information-support/guides-to-support-and-services/crisis- services/crisis-houses/#.XI3_Ynd2v4s
Crisis House: Cardiff: Gofal Overview: Coed Arian Community Crisis House was established in August 2006 and remains unique in Wales, providing an alternative to acute hospital admission for those who have reached a point of mental health crisis. Working in partnership with Cardiff and Vale University Health Board, the service has shown that it prevents hospital admission, facilitates early discharge from hospital, and is an effective broker of other community services and resources. At the date of an early evaluation, the house provided short-term (up to seven days) intensive 24-hour, specialist mental health support, working in collaboration with the crisis teams. The evaluation noted that the house had experienced peaks and troughs in occupancy, and that this offered an opportunity when occupancy was low to work flexible e.g. By extending the length of stay, or offering a “step down” facility to a person leaving hospital. Direct contact with Gofal is recommended to explore how the service has progressed in recent years. The Crisis House is an ‘ordinary’ house on a residential street, with no external signs of being associated with mental health services. Here are 4 individual bedrooms, and communal living areas. The service is supported by appropriate medical intervention from the Cardiff and the Vale of Glamorgan NHS Trust Crisis Teams., and both statutory and voluntary sector partners work together to support the positive reintegration of individuals back into the wider community and to offer advocacy on behalf of individuals to access to a range of services and mainstream community activities. The Crisis House is available to residents of Cardiff and Vale of Glamorgan who are assessed by the local Crisis Intervention and Home Treatment Teams as needing additional support to avoid admission to hospital. Staffing: A team of 7 mental health support workers and a Project Co-ordinator, offering an holistic support package that considers the individual’s housing, employment, educational, physical and social and emotional needs. Funding is by Cardiff and Vale of Glamorgan Local Health Boards, originally assisted by the Big Lottery.
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Outcomes and evidence of success “During 2013, 80% of people referred to our Crisis House were supported to manage their mental health crisis and successfully return home. “The remaining 20% were supported to access hospital in a planned way”. (Gofal website, 2019) A leaving pack identifies options open to people once they return home, e.g. day services, education, employment, voluntary work, and access to talking therapies, and includes a personalised summary of health management strategies which proved effective during the person’s stay. 75% of service users surveyed rated the leaving pack ‘excellent’. A peron who used the service is quoted on Gofal’s website: “The Crisis House does exactly what it says on the tin. The Crisis House and Crisis Team work perfectly together. It gives me total rest and rest for my brain. When I’ve left I feel positive about the future but return home to face the wolves. It’s a lack of community support that causes me problems.”
[1] 2008: http://www.gofal.org.uk/uploads/Policy_documents/Gofal_reports/crisis-house- english.pdf
Richmond Fellowship(RF): Crisis houses, Lancashire RF operates two Crisis Houses in Lancashire, 1 six bed, 1 five bed, in partnership with the Lancashire Care NHS Trust (the provider of NHS Mental Health services) and Lancashire County Council (Responsible for social care). RF acquired the two houses using their own capital resources, and revenue is jointly funded by the NHS Trust and the Council. The houses each provide: • Rapid access, up to 10 days stay • House 1: 311 placements may 2017-Oct 2018 • House 2: 100 placements April –Oct 2018 • 24 hours staffing, trained recovery workers, not clinical; a WRAP - Wellness Recovery Action Plan – is developed with each person using the service on Day 1. • Menu of 1-2-1 interventions incudes mindfulness, mood dairies, worry charts, Emotional thermometer, distress tolerance, taking back control, confidence mind maps. Sleep hygiene, problem development, healthy relationships • Group and peer support: Food & Mood, Relaxation, Managing Anxiety, Thinking Patterns, Emotional Jenga, Good Sleep Practice, Music & Mood.
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Some data: • 27% of people presented at A&E • 30% of referrers said otherwise people would have had to be admitted • 39% suicidal ideation, 32% live alone, 66% are women, 26% have caring responsibility; 11% no diagnosis, 40% in touch with CMHT, 20% personality disorder diagnosis This link is to a recent to RF presentation on how their crisis house services operate, who uses the services, the offer to people, and outcomes achieved. The presentation features the Lancashire examples. https://www.northern-consortium.org.uk/wp-content/uploads/files/Mental-Health-and- Housing-conference/Crisis%20and%20Avoiding%20Unnecessary%20Hospital%20Admission%20- %20Sue%20Moore,%20Joe%20Redmond,%20Tanya%20Samuels.pdf RF contact: [email protected]
Northamptonshire dispersed, part time crisis cafes: MIND Below is the NHS Trust website’s summary Crisis Cafes provided by MIND in Northamptonshire, operating limited hours in part time evening venues across a whole County Council area. The link to this information is http://www.ketteringmind.org.uk/support-services/crisis-cafe/
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Recovery Cafes, South West London Overview: Two open access Recovery Cafés were launched in 2017 in South West London, commissioned and funded by South West London and St George's Mental Health Trust to support individuals in mental health crisis to reduce their immediate anxiety, formulate individual plans to support their mental health and thereby reduce the likelihood of requiring assistance from local accident and emergency services. A welcoming, friendly and non- stigmatising environment offers food, activities and quiet spaces to cater for each individual need. The cafés aim to assist attendees in making practical plans with the ultimate goal of preventing a reoccurrence of such mental health crises. Opening hours are 365 days, from 6pm – 11pm (Mon-Fri) and 12 noon – 11pm (Sat / Sun & bank holidays). Both providers are charities already present in the area who have with significant expertise in mental health and complex needs. Hestia is a charity for adults in crisis: “We support adults and children in crisis across London. We campaign and advocate nationally on the issues that affect them.” CDARS is a charity committed to improving the lives of vulnerable people and those with complex needs arising from the ill-effects of addiction to alcohol, drugs and other psychosocial conditions. Partnership working with the NHS Mental Health Trust is intrinsic to the service. Further partnerships include the Hestia service and The Listening Place, a London based charity offering face-to-face support for people who feel that life is no longer worth living. People who use the service are those who feel they may be moving towards, or are currently experiencing a mental health crisis, aged 18 and over, from South West London (Kingston, Merton, Sutton, Richmond and Wandsworth). The service is free and there is no requirement to pre-book an appointment. Some exclusions: Adults with dementia, children or adolescents, people exhibiting violent or aggressive behaviour, and people under the influence of drugs/ alcohol. Non-South West London residents will not be refused entry, but will be offered of short term support and signposting back to appropriate local Services. It was reported in 2017 that the Recovery Cafe in Tooting served over 135 people since it was launched 3 months earlier. Staffing: The provider staff are supported on site by The Listening Place, the local Home Treatment Teams, volunteers and peer champions. CDARS: http://www.sunshinerecoverycafe.org/ Hestia: https://www.hestia.org/news/hestia-launches-recovery-cafe
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Helping people leave hospital models
Hospital Discharge for people who are homeless: Homeless LInk Evaluation Homeless Link’s comprehensive 2015 evaluation of the Department of Health Hospital Discharge funded projects studied 52 projects in total. The different models of provision described by projects were grouped into nine typologies, and the evaluation made a number of good practice recommendations. The study can be found at https://www.homeless.org.uk/sites/default/files/site- attachments/Evaluation%20of%20the%20Homeless%20Hospital%20Discharge%20Fund%20FINAL. pdf Two of the examples below are mental health-specific, where third sector providers are working with Mental Health NHS provider Trusts. The third (the Bradford example) offers short stay self- contained accommodation to a more generic homeless client group. This example was included in the above Homeless Link study.
“HAWKS”: Look Ahead Housing and Care and South London and the Maudley NHS Trust In partnership with South London and Maudsley (SLAM) NHS Foundation Trust, Look Ahead’s team of specialist Housing and Advice Workers (HAWKS) offer housing advice to patients directly on the wards at Bethlem Hospital in Croydon. This enables them not only to leave hospital but also to move on to a safe environment where they can continue to make progress. • Pilot launched in February 2017; by October 2018 more than 200 patients in Croydon had been supported with housing, enabling them hospital quicker. Expanded March 2018 to 3 more hospitals. • On average, one in four patients admitted and discharged in pilot were referred to HAWK. Quotes from a clinical perspective: • “I cannot overemphasise the value of having a HAWK specialist available to us. Housing issues with mental health are vastly complex and require inter-working between multiple agencies… • "Expecting clinical staff to do this in addition to our current duties would not only reduce clinical engagement, but put a further strain on resources… [The HAWK service] it’s worth its weight in gold, should be continued and spread to other parts of the trust.” Ward manager.
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• “The HAWK team made a big difference in terms of getting patients with housing issues discharged earlier… it’s been a significant part in keeping patient flow going and reducing private overspill.” Consultant psychiatrist. The scheme was described, with key learning points, in an NHS Confederation document on October 2018, available here. https://www.nhsconfed.org/resources/2018/10/helping-to- address-delayed-discharges-in-south-london.
Greater Manchester Mental Health Trust housing advice, with third sector providers The Trust’s website describes a comprehensive Housing Advice Service that ensures that service users with an identified accommodation need, before or during admission, are screened and helped with housing and complex discharge issues. • Integrated part of service provision • Housing Advisors at each inpatient site • Available to all inpatients of adult working age who have accommodation needs during their inpatient episode • Integrated approach with Community Mental Health, Assertive Outreach and Early Intervention teams and others, e.g. substance misuse services and learning disabilities • Relationships with third sector, DWP, court liaison and probation • Works with homeless services in order to avoid wherever possible a homeless presentation. Links with street homeless support agencies, temporary accommodation and frontline hostels, to navigate a pathway to a more stable housing situation. “The discharge planning approach is fundamental to preventing homelessness and ensures that the S117 aftercare provisions are delivered. This can only happen when appropriate and stable accommodation is secured for inpatients.” Further information: https://www.gmmh.nhs.uk/housing-advice-service
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Horton (Bradford) intermediate care: Respite accommodation for people discharged from hospital who are homeless Bradford Respite Intermediate Care Support Service (BRICSS) is a home from hospital scheme for people who are homeless or living in unsuitable accommodation and are being discharged from hospital. This intermediate care facility provided respite accommodation for vulnerable patients on discharge from hospital, aiming to support patients who need continuing medical care or have unsuitable or no accommodation and so would otherwise have a prolonged stay in hospital or be discharged onto the streets. Patients are cared for in a dedicated facility containing 14 fully furnished studio flats with laundry facilities. Run in partnership with Bevan Healthcare, which is a GP practice, a social enterprise that specialises in healthcare for homeless people, the scheme provides 24/7 staffed, short-term, temporary accommodation. A ‘Pathway’ team is based in hospitals to identify clients who may benefit from the care offered by BRICSS. The service is staffed by a team of resettlement and housing officers and by a GP and nurse who perform a ward round twice a week. Staff provide an integrated, holistic service of medical and social care including long term medicine management, nutritional meals, housing assistance, and benefits help. In the first 3 months, the facility housed 16 patients for an average of 3.3 weeks each. A cost analysis of just 5 of these patients revealed that their most recent experience with health services had cost the NHS £208,000 through re-admission and prolonged hospital stays, money which could have been saved if the BRICSS team had been involved earlier. Furthermore, staff ensured that every patient discharged from BRICSS had a discharge plan in place and suitable accommodation to move into. https://hortonhousing.co.uk/get-support/bradford-respite-intermediate-care-support-service/ https://hortonhousing.co.uk/wp-content/uploads/2017/04/BRICSS.pdf
Early Intervention in Psychosis
Newcastle: Mental Health Concern Overview: Established since 2010 and provided by the charity Mental Health Concern (MHC), this service runs four dispersed self-contained individual flats intensively supported by the provider in partnership with the statutory Early Intervention in Psychosis (EIP) team, run by Northumberland, Tyne and Wear NHS Trust.
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People using the service are predominantly diagnosed with psychosis and “dual diagnosis” (drugs and alcohol.) The service uses holistic care and support plans and risk management using the GRiST model. With an average length of stay of 14 months, and 2 people moving on successfully in each 12 month period, the service receives far more referrals than it can accommodate. The four dispersed flats are all within one locality and accessible to a staff base just outside of the centre of Newcastle. Each flat is fully furnished and modern in design and layout. They are leased by MHC from Your Homes Newcastle (City Council Arm’s Length Management Organisation) and managed by MHC; tenure is Licence Agreements. Its location is important to its success with the organisation managing to implement a “core” facility and culture into a “dispersed” design similar to a hub and spoke. Partnerships: Other agencies involved include statutory EIP team, GPs, social services, housing and substance misuse services. People who use the service are aged 18-35, around 75% male and 25% female, with a predominant diagnosis of psychosis and dual diagnosis (drugs/alcohol), experiencing their first episode of psychosis. Staffing: MHC staff roles include RMN nurse manager and an RMN clinical lead plus community support workers. MHC provides all staff with on-going supervision and appraisal processes can include clinical supervision and Continuous Professional Development. Referrals: Although the early intervention model falls within the Council’s Supported housing Gateway, nominating rights remain with the NHS statutory Early Intervention in Psychosis (EIP) Team. Although ey attempt to maintain a “waiting list” this is often futile as referral need is often immediate. Funding: Health, adult social care and housing benefit. Outcomes and evidence of success The intensity of the support and care tails off during the person’s stay. For most, this is limited eventually to monitoring and signposting activities. The team and the person then work on a plan to move on. Some people move on into the lesser supported environments, some back to families and others access mainstream housing options. For a small number this may lead to further inpatient care or community rehabilitation; as this is often the person’s first episode of mental illness and engagement with services, their symptoms may need more clinical interventions. http://www.mentalhealthconcern.org/our-services/housing-with-care-support/newcastle-early- intervention-in-psychosis/
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Telephone 020 8830 6777 Recruitment 020 3434 0990 [email protected] www.campbelltickell.com @CampbellTickel1
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