The Vulnerable People’s service has worked in partnership with Castell Care and Wales and West Housing Association to plan and develop a unique model of care to meet the needs of vulnerable young adults leaving care or who are living chaotic lives in the community. This continues with the focus of ‘recovery’ and housing plays a key role in supporting and encouraging people to develop the skills necessary to live independently in their community. This means that people can move away from residential care and learn how to manage everyday activities that most people take for granted, such as personal care and household tasks, managing their money and building links with others and participating in their communities.

The Project will provide one shared living house for four young people and seven individual flats for other vulnerable people. The flats will be part of a newly built housing estate in Abergele. Individuals will receive tailored support from Castell Care in order to develop their independent living skills and to help them maintain their tenancies. This Project gives those young people the opportunity to move out of foster and residential care to start their development journey which will ultimately lead to successful independent living.

The Supporting People Programme Grant, which is a fund to deliver accommodation related support services to help people to achieve or sustain independent living in their community, has been used by the service to initiate this exciting development. We have been working very closely with the Housing Association to identify which of our service users would benefit the most from this scheme so that the moves goes smoothly once the flats are ready in the summer.

Kickstart is not about doing things for people. It’s about helping people to understand that things can be different. It is about supporting people to find their way, understand that they can have goals and that they can be achieved. Kickstart will help people realise they do have a future, that it can be different from today and it will enable them to find their own way while accompanying them on their journey. The service will be there for them when they need to talk and staff will listen to what they have to say with a strong focus on helping them build or rebuild their life to achieve what they want. Most of all it’s about not giving up on people or allowing them to give up on themselves.

Voluntary Organisations, also known as the ‘Third Sector’, have always had a close relationship with Social Services and we contract with particular groups to deliver certain aspects of support to our service users. Often, people prefer to engage with voluntary groups for ongoing support rather than remain in public sector services and we wanted to provide an onward service that enhanced and complemented the work of our Community Mental Health Teams.

In 2014 we began to review our contracts for people with mental health issues and support for carers of adults with mental health issues, as they were due to end in March 2016.  It is important that we make sure that all our services are fit for purpose and offer the most effective and valuable support to our service users. Research tells us that the best way to help people manage their mental health problems better and gain control over their lives is an approach called ‘recovery’. This does not mean recovery in the same way as someone fully recovers from a physical illness but does offer hope and ‘the belief that it is possible for someone to regain a meaningful life, despite serious mental illness.’ [1]

With this in mind, we began to design a new service that would be delivered by the third sector for ongoing support to those people with mental health issues. To help us with our ideas we involved our Participation Team who spoke to people currently receiving services to find out what has been the most beneficial and made the biggest difference to their lives. The end result is a new service called ‘Recovery Compass’, which will be delivered by Aberconwy Mind from April 2016. Everyone who goes on the ‘Recovery Compass’ will receive a ‘Wellness Recovery Action Plan’ or WRAP, which is the individual’s plan entirely tailored to their needs and ambitions for the future. The eight key points on the compass are: Participation, Peer Support, Employability, Coaching, Social Interaction, Social Therapies, Learning and Achieving, Information and Advice.

For some service users their experience of the ‘recovery compass’ will be having some information and advice about their condition and the best ways to manage it or signposting to other groups more suited to them. For others it will be joining in activities with others that help their physical and mental wellbeing or being part of a peer group that provides support to others in a similar situation. Some individuals will utilise all the services as part of the compass, which will offer opportunities to learn new skills that can lead on to work experience and employment. Whichever aspects of the Recovery Compass are important to the service user, the main aim is to go beyond managing symptoms but to allow people to increase or maintain their own wellbeing, including them in their communities and giving opportunities to contribute and participate in society.

[1]  https://www.mentalhealth.org.uk

As a newly established service within Social Care, the Vulnerable People team was designed to help the most vulnerable in our society to regain or maintain their independence and wellbeing and making sure that a greater number of people with needs are supported in a range of ways. Those people with complex, challenging and chaotic lives are often more vulnerable than those who fit into the traditional  services and as a consequence of limited support they often look inappropriately to the emergency services such as Police or Fire service or the Ambulance service for their help. The team itself has minimum access to a care budget and therefore the members of the team are reliant on themselves as a social work and OT resource to address the needs of the clients. They are particularly creative and make strong links with third sector organisations to enable their clients to access the universal services available in the community.

Although this is a new and developing service a number of case studies have been recorded demonstrating the benefits and positive impacts the team are having:

• A young man was referred to the service from his family as he was using cannabis and getting in trouble with the police, there were lots of issues at home with aggression towards his family. The worker did some motivational interviewing and worked with him to develop an outcome focussed assessment and care plan. As a result of this work the young man’s Mum wrote a letter of thanks to the team saying the approach has had 100% positive affect on her son and she has been very grateful for the intervention which has meant that her son can remain at home with family.
• Another young man was in trouble with the police and potentially facing a jail term. The team began working with him and at his court case the barrister stated that it was directly the interventions put in place by the Vulnerable People team that meant that this young man avoided a prison sentence.

The team are also developing processes and mechanisms to enhance the service:

1. The Vulnerable People’s team have piloted the new integrated assessment process [1] in preparation for the implementation of the Social Care and Well Being Act. This gave practitioners the opportunity to embed the principles of person centred outcome focussed assessment and care for vulnerable young people.
2.  The team manager has also introduced a new robust risk assessment to ensure that staff consider their own health and safety when working with clients who pose a risk to themselves and others.
3. As the team has developed and listened to the needs of service users they also felt that the introduction of a wellness recovery action plan (WRAP) would be of benefit. Through working in partnership with the PARIS team [2] we have made it easier for staff to create a smooth transfer for Care Leavers, to an Adult social worker, with their individual plan in place.

[1] As mentioned on page 8.

[2] The PARIS system is used to store records and information about the people who use the services provided by Conwy’s social services department.