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The South London Mental Health and Community Partnership (SLP), Complex Care Programme is introducing new community rehabilitation service for service users in SLAM NHS Foundation Trust boroughs – Croydon, Lewisham and Southwark. The new community-based supporting living accommodation, delivered by SIG Penrose, and sited in Lewisham, is due to go live in April 2024.
What is the community rehabilitation service?
The service shall offer specialist intensive rehabilitation for a period of up to nine months to support people who require more enhanced intervention than that offered by commissioned community services.
The service shall enable people to receive a community-based, specialist intensive rehabilitation offer for a period of up to nine months. The service shall support discharge from acute wards and avoid admission into inpatient rehabilitation. It will also strengthen the level of care and support for service users requiring rehabilitation after their discharge, supporting people to step down to less supported accommodation.
This is a supported living service delivered in partnership with SIG Penrose, a voluntary and community sector (VCS) specialist mental health provider, with clinical in-reach provided by SLAM, to deliver an integrated and rehabilitation focused model of care. The service is delivered by SIG Penrose, in partnership with a dedicated clinical team provided by the Trust, including psychiatry (0.4 whole time equivalent (WTE), occupational therapy (1.0 WTE), psychology (0.5 WTE), and complimented by a substance use/dual diagnosis worker provided as part of SIG Penrose core staffing (0.6 WTE).
What support will the service provide?
SIG Penrose shall ensure the service is appropriately staffed to deliver 24-hour waking night support at both properties.
The support service delivered by SIG Penrose is not registered with the CQC to deliver personal care or any other regulated activity.
SIG Penrose Mental Health Recovery Workers will work in close partnership with the SLaM clinical MDT to ensure that support is person-centred and focuses on individual strengths, interests and personal recovery goals. The service will work intensively to identify and co-produce rehabilitation goals with individuals, building motivation and community engagement, including maintaining and building links with services in each resident’s home borough. The service will deliver support to meet needs and build independence across a range of activities of daily living.
Where is the service?
The service will be offered through two properties (eight and six bedrooms), located in Lewisham. Properties are a short distance from one another and in close proximity to Bellingham and Catford Bridge train stations.
What is expected of care co-ordinators if the person is accepted?
The service will have a dedicated consultant psychiatrist who will work closely with the community mental health team Responsible Clinician.
When a person is accepted into the project, they will retain their Care Coordinator in order to maintain links with their home borough. This is because the service has a maximum 9-month length of stay and the expectation is that people will return to their originating borough.
Care Coordinators are required to fulfil the same role as usual for individuals under their care, working closely in partnership with the clinical MDT offered within the community rehab service, and taking the lead on driving the move on process.
Care Coordinators remain responsible for:
- Undertaking all standard care coordination functions
- Working as an integral member of the rehabilitation MDT
- Attending monthly reviews at the community rehabilitation service
- Attending discharge planning meetings
- Regular liaison with SIG Penrose keyworker and service manager
- Ensuring timely referrals are made for Care Act assessments, and chasing up referrals
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Contact the service
Email: slm-tr.complexcarespa@nhs.net - Conditions: Community Rehabilitation Service
Other essential information
Eligibility criteria
The service will only be open to those service users supported by SLAM NHS Foundation Trust, serving the boroughs of Croydon, Lewisham and Southwark only (Lambeth has its own local community rehabilitation arrangements).
The service is for people with severe mental illness, with a primary mental health need (high and complex needs), and dual health needs, between the age of 18-65, assessed to require intensive and integrated rehabilitation in the community. Dual needs may include, without limitation:
- Substance misuse
- Complex Emotional Needs
- Mild learning disability
- Challenging behaviour
- Physical disabilities and additional health needs (where these can be safely met)
- Autistic spectrum conditions
It will be suitable for people:
- Who previously would have been considered for inpatient rehabilitation but do not need to be in an inpatient setting.
- Who are currently in an NHS or private inpatient rehabilitation setting who could complete their rehabilitation journey in the community
- Who are currently in an acute setting, ready to be discharged but who require a higher level of supported accommodation with intensive clinical support than is currently available
Referrals
Referrals can be made by a professional within the team responsible for a person’s care. Individuals referred will typically be an inpatient on an acute ward or within an inpatient rehabilitation setting.
People can be referred through the SLP Complex Care Single Point of Access (SPA) which can be contacted via slm-tr.complexcarespa@nhs.net
Please complete South London Partnership Complex Care Referral Form [docx] 348KB
If deemed a suitable referral by the Complex Care Programme SPA (Single Point of Access) Panel, the person will be assessed within a seven-day period of presentation jointly by a member of SIG Penrose and the SLaM clinical team in-reaching to the service. Following assessment and discussion with the person and care co-ordinator, an initial personalised rehabilitation recovery support plan will be coproduced – this will emphasise the person’s goals, strengths, and recognise their connections with friends and family. The plan will be centred around the person accessing services in their home borough so that contact is maintained.
The care co-ordinator must also present the individual to their local borough placement funding panel, as despite the service being funded health, the local authority will need to agree to the plan and accept responsibility for any social care eligible needs on discharge. This will remove any barriers for the person to be rehoused in their home borough.
If accepted, the person may view the service, and a move-in date be agreed.
If the person is not deemed suitable, a rehabilitation opinion will be given to guide the referrer on how best to support the individual.
More info
Who are the main contacts to gain further information?
| Partner | Name/Role | Contact Details |
|---|---|---|
| SLP Complex Care Programme |
Bronwyn Dewing, Senior Programme Manager
Christina Kyriakidou, Clinical Director |
|
| SIG Penrose | Angela Henry, Director of Service and Support | angela.henry@socialinterestgroup.org.uk |
Does the person need capacity to sign a tenancy?
The person will be required to sign an occupancy agreement (License Agreement) so must have mental capacity to make this decision.
Will people who have independent accommodation be excluded?
It is recognised that wherever possible people should be given the opportunity to maintain their independent accommodation and to return home. A person’s suitability for the community rehabilitation service will need be reviewed and assessed on a case-by-case basis.
How is medication stored and managed?
SIG Penrose staff will prompt and supervise individuals with prescribed regular and PRN medication. SIG Penrose will provide lockable medication cabinets in each client’s room.
The service will work to gradually increase independence with medication with clinical oversight. The service is not registered with the Care Quality Commission, and staff will not store or administer medication.
Will support be provided to attend appointments such as GP/hospital appointments?
Yes, unless person requires regular/high frequency of appointments which may pose a problem due to staffing levels. The service will do everything feasible to accommodate.
If a person cannot adequately meet nutritional needs/prepare meals, what are the options?
The suitability of a person for this service and their level of need will be determined by a person-centred assessment undertaken by community rehabilitation clinicians and SIG Penrose. Individuals unable to meet their nutritional needs can in theory be assessed under the Care Act for an additional package of care to meet this need. SIG Penrose and the clinical MDT will work with individuals to build up their functional and independent living skills, including meal preparation, and all options shall be considered before making a determination on an individual’s suitability for the service.
If client readmitted to hospital, will their room be kept open?
SIG Penrose will work closely with clinical MDT to understand the nature of admission; anticipated length of admission, and if person will be suitable to return. Decisions will made on a case-by-case basis.
Policy on drugs and alcohol?
No alcohol or drugs are allowed on-site. The service will work closely in partnership with any individual breaching this policy to support person-centred de-escalation and management, including the offer of support from the substance use/dual diagnosis worker. Evidence of breaches will lead to written warnings which may escalate to eviction.
Do admissions need to be on a Monday?
No. SIG Penrose shall issue License Agreements for this service which do not specify a Monday start date.
What is expected of care co-ordinators if the person is accepted?
The service will have a dedicated consultant psychiatrist who will become the Responsible Clinician.
When a person is accepted into the project, they will retain their Care Coordinator in order to maintain links with their home borough. This is because the service has a maximum 9-month length of stay and the expectation is that people will return to their originating borough.
Care Coordinators are required to fulfil the same role as usual for individuals under their care, working closely in partnership with the clinical MDT offered within the community rehab service, and taking the lead on driving the move on process.
Care Coordinators remain responsible for:
o Undertaking all standard care coordination functions
o Working as an integral member of the rehabilitation MDT
o Attending monthly reviews at the community rehabilitation service
o Attending discharge planning meetings
o Regular liaison with SIG Penrose keyworker and service manager
o Ensuring timely referrals are made for Care Act assessments, and chasing up referrals
Will the person need to change their GP?
Wherever possible the person will retain their GP. This decision however will be made on a person-by-person basis, dependent on the wishes and needs of the individual, factoring in practical considerations.
Clozapine Clinic and Depot Medication
Where a person is prescribed Clozapine, a decision will be made as to whether they will continue to access the Clozapine clinic in their home borough, or if they can temporarily transfer to a local Clozapine Clinic in Lewisham. People who are on depot anti-psychotic medication will be able to continue to access their depot in their home borough via their Care Coordinator/depot clinic.
What happens if the person relapses in their mental health?
Due to the intensity of the clinical offer, it is expected that admission can be planned if mental health relapse occurs.
Local arrangements in place regarding those who are within the area of Lewisham shall remain. It is best practice for the responsible local social services authority (LSSA) to carry out planned assessments under the MHA 1983 for people known to them to whom they hold a duty. If the out-of-area LA AMHP team is unable for good reason to complete the assessment, then under S13(1) of the Mental Health Act the legal responsibility lies with London Borough of Lewisham. There must not be a delay to AMHP support due to disagreements over responsibility.
In the event of an emergency MHA being required out of hours in Lewisham, the resident will be assessed by the Lewisham Emergency Duty Team.
Access to Home Treatment Team
If required, residents of the community rehabilitation service can be referred to the Lewisham Home Treatment Team.
