See answers to previous information requests

We are currently undertaking a service development and pathway review in relation to community-based open rehabilitation and step-down provision for adults with mental health needs, neurodevelopmental conditions, learning disabilities and complex psychosocial presentations.

1. Current Demand and Placement Need
• Does your organisation currently commission or utilise open rehabilitation or step-down rehabilitation services from independent providers: We are not sure exactly what is meant by "open rehab or step down rehab". We commission some specialist MH providers such as places which specialise in eating disorder or in comorbid substance misuse, some times this is step down from hospital into other support. We want our community providers to be reablement focussed. Our NHS provider trust has a MH rehab service and we have in house MH OT social care reablement.
• Approximately how many individuals are currently placed within open rehabilitation or community rehabilitation settings: Probably less than 5 in adult mental health
• What are the most common presenting needs requiring this type of placement: Substance misuse and eating disorder

2. Hospital Discharge and Delayed Transfer Pressures
Approximately how many individuals are currently experiencing delayed discharge from:
• Acute mental health wards: 1
• Rehabilitation wards: 1
• PICU or low secure settings: 0
• Specialist autism or learning disability services: 0
• What are the most common barriers to discharge: History of antisocial behaviour and substance misuse - sometimes combined with neurodiverse diagnoses (ASD)

3. Out-of-Area Placements
• Does your organisation currently place individuals outside of its local area for rehabilitation or step-down support: Rehabilitation is provided by NHS provider trust. Unclear again what is deemed to be step-down support. However we do place people outside of local area for supported living and long-term residential placements.
If yes:
• Approximately what proportion of placements are out-of-area: On average 37% of placements are out of area. However, many of these placements are still local to WBC. It is rare that individuals are placed at a significant distance unless there is a specific request from the individual (i.e. a request to be close to family)
• What are the primary reasons for out-of-area placements: Unable to meet need within the borough
• Is reducing out-of-area placements a current strategic objective: Yes - attempts are always made to keep individuals within the borough as long as their Care Act or S117 needs can be fully met

4. Service User Cohorts
• What service user groups are currently most difficult to place within community rehabilitation settings: In MH- people with comorbid neurodiversity, substance misuse or antisocial behaviour/forensic history
Are there identified gaps in provision for individuals with:
• Autism: Please view our Market Position Statement: https://www.wokingham.gov.uk/care-and-support-adults/support-services-and-assessments/strategies-supporting-adults/adult-social-care-market-position-statement-mps
• Learning disabilities: Please view our Market Position Statement: https://www.wokingham.gov.uk/care-and-support-adults/support-services-and-assessments/strategies-supporting-adults/adult-social-care-market-position-statement-mps
• Dual diagnosis: Yes- supported living or res care providers able to support people with dual diagnosis and work closely with substance misuse services and support people not ready/able for total abstinence
• Personality disorder: Yes but low numbers
• Complex trauma: Yes but low numbers
• Forensic histories: Yes but low numbers
• Behaviour that challenges: Yes but low numbers

5. Current Provider Market and Sufficiency
• Does your organisation currently identify a shortage of rehabilitation or step-down placements: Rehabilitation is provided by NHS provider trust. Community based placements (residential and supported living) can be limited for some more complex presentations (people with comorbid neurodiversity, substance misuse or antisocial behaviour/forensic history) or those available might be in locations which are unsuitable for those we're trying to place
• Are there specific rehabilitation models or service types currently required but limited in availability: Residential settings for those with mental health difficulties and difficulties abstaining from substance misuse, with some antisocial behaviour. Settings where a tenancy is not required (where individuals have fluctuating capacity and unable to sign) but support-wise they would benefit from supported living as opposed to residential care
• Does your organisation have a current rehabilitation, mental health, or accommodation sufficiency strategy? If so, please provide a copy or link where available: No not in relation to rehabilitation and step-down provision for adults with mental health needs, neurodevelopmental conditions, learning disabilities and complex psychosocial presentations.

6. Placement Models and Support Levels
• What support levels are most commonly commissioned: Supported living is most commonly commissioned for our population
• 24-hour staffed rehabilitation: Provided via NHS provider trust
• Waking-night support: Often included for some individuals in supported living
• Positive Behaviour Support models: Not aware of any providers explicitly using Positive Behaviour Support (PBS) - more commonly used in LD and ASD settings
• Transitional or move-on support: Mental Health OT Reablement is commonly used to review placements with highest level of support to assess if this level of support is still needed and to role model to providers how to enhance individuals' independence. Supported living environments with self-contained flats and 24 hour background support are commonly used and sought after
• What are the most common referral pathways into these services: Often after a hospital admission (sometimes as part of S117 aftercare planning) or where continuing to reside with families is no longer viable.

7. Spend and Commissioning
• What was the approximate total spend on independent rehabilitation or step-down placements in the last financial year: We spent approximately £2.5 million on supported living (£2 million) and residential placements (~£500K) in the last financial year
How are such services typically commissioned?
• Framework agreements: Yes
• Spot purchasing: Yes
• Approved provider lists: No
• Block contracts: Yes

8. Quality and Outcomes
• What are the most important factors considered when sourcing rehabilitation placements: Rehabilitation placements are arranged via NHS provider trust
• What outcomes are considered most important when evaluating placement success: In terms of supported living /residential placements - Providers willingness to work with MH colleagues to best support individuals and reduce support in line with need/increase also where appropriate. Effective communication about any concerns/incidents. Individuals and their families feedback being positive. If supported living, good separation of tenancy and care. Environments well maintained. Robust management of individual's risks alongside risks of the population as a whole. Good quality of care and staff maintaining professional boundaries. Sufficient staffing levels to be able to consistently deliver care without disruption. Good CQC ratings, where relevant.
• What are the most common reasons for placement breakdown: Poor separation of tenancy and care. Poor communication across staff team and with ASC and NHS colleagues. Lack of willingness to flex support according to need (i.e. reduce hours where people gain independence). Lack of robust management of risks. Poor maintenance of environments. Lack of professional boundaries. Inability to fully staff rotas and therefore deliver hours of care to clients. Care quality & safeguarding concerns.

9. Commissioning Contacts
Please provide the structure or generic contact details for the teams responsible for:
• Rehabilitation commissioning:Operational Commissioning team; operationalcommissioningteam@wokingham.gov.uk
• Complex mental health commissioning: Operational Commissioning team; operationalcommissioningteam@wokingham.gov.uk
• Learning disability/autism commissioning: Operational Commissioning team; operationalcommissioningteam@wokingham.gov.uk
• Hospital discharge pathways: Operational Commissioning team; operationalcommissioningteam@wokingham.gov.uk