Interim National Care Service Advisory Board: Advice to Scottish Ministers and Council Leaders - Coming Home

Annex A

Case Study 1: John*

Situation

John is young a man in his thirties, who has a complex learning disability, autism spectrum disorder and epilepsy. Since childhood, John has been supported in many settings away from his family home. His longest placement was a residential school in England, where he lived for 9 years. Whilst this physical environment worked well for John, he had limited interaction with his family. This resulted in John being extremely isolated, and regularly displaying high levels of distress. Following his school years, John returned to Scotland to be closer to his family, but he was unable to sustain suitable support settings within his local community. Multiple service breakdowns led to John being admitted to an Assessment and Treatment Unit (ATU) where he stayed for 6 years.

Background

At the Assessment and Treatment Unit, John was supported by a large team of NHS professionals twenty-four hours a day. John would often display behaviours that challenged as a result of him demonstrating his distress. In order to minimise physical harm to both John and his support team, a PaMoVA de-escalating technique was used. This included the use of supine restraint requiring up to 6 staff members at a time.

The extended length of John’s stay at the Assessment and Treatment Unit was due to his continuously increasing levels of challenging behaviour, and associated high levels of supine restraint interventions. The professionals supporting John, however, recognised that the Unit environment did not meet John’s needs and was contributing to his distress, and escalating behaviours. South Lanarkshire University Health & Social Care Partnership (the Partnership) met with Enable to explore whether it would be operationally and financially possible to support John within his local community. An alternative placement had been identified in Wales, but given John’s previous negative experience of living away from his family, the Partnership wanted to look at what could reasonably be done more locally before committing to another residential out of area placement for him.

Transition

Enable was awarded the contract to support John to transition into his new specially adapted home in South Lanarkshire in July 2018. The transition involved working within a large multi-disciplinary team from:

• NHS Greater Glasgow & Clyde
• NHS Lanarkshire
• South Lanarkshire University Health and Social Care Partnership
• Enable

This complex discharge was sponsored at Chief Executive and Chief Officer level across all agencies involved. Day-to-day leadership was provided by the NHS Clinical Director for Learning Disability.

Fundamental to the success of John’s transition was shaping his support in line with Enable’s PA Model. This included John recruiting his own self-directed team of Personal Assistants. The personal assistant model was the most effective model to ensure success for John’s transition. Enable quickly recognised, however, that the standard rate of pay that was funded by the Partnership for John’s personal assistants within this model was not fit for purpose, given the level of support complexities and associated training requirements involved. Enable worked constructively with the Partnership to increase the funding arrangements so that people with the necessary skills, experience and resilience could be recruited and retained for John’s team. This resulted in an initial 10% salary enhancement being funded by the Partnership and applied to John’s team of Personal Assistants beyond the standard funded rate of pay, which is typically set at the real Living Wage for the social care workforce in Scotland.

The transition period took place over 18 months and involved many phases:

1) John’s new dedicated team observing John’s support being delivered in the Assessment and Treatment Unit by NHS staff

2) the new team providing John’s support directly in the Assessment and Treatment Unit under clinical supervision

3) providing John’s support in his new home ‘on pass’ for three months

4) providing John’s ongoing support in his new home independently

This transition at point of discharge was widely recognised as exceptional in the Scottish and broader context. The Clinical Director confirmed this was the “most complex hospital discharge” they had achieved to date.

Outcomes

John has now successfully sustained his own community living arrangements for over 6 years. Since leaving hospital, John has benefited across many aspects of his life:

• the parameters of John’s challenging behaviour have reduced
• his support has become less restrictive
• the risk factors within his support have reduced
• his informal “Quality-of-Life” indicators have improved.

John now walks in his local community when he chooses, enjoys daily outings in his van, and regularly interacts with his family and loved ones. Enable is now working with Dr Brody Patterson – a leading learning disability and mental health nurse with a specialism in behaviour distress – to consider options to implement further reductions in support that would be appropriate and proportionate for John in continuing to live a fulfilling life in the home and community of his choice.

*The individual’s name has been changed for the purpose of this case study.

Case study 2: David*

Situation

In July 2025, Enable was contacted by a partner authority about a crisis situation which had emerged for a young man, David. David had been living in a low security forensic hospital ward under a Compulsion Order for six months. When Enable was contacted, the Compulsion Order only had 48 hours remaining on it. This meant the legal power to keep David in hospital was about to end. It was not an option for David to continue to be supported in this hospital setting. The local authority had not managed to find suitable accommodation or support for David. This created significant risk.

Background

David is a young man who has experienced significant trauma in his life. He was removed from his parents’ care as a child and moved between multiple foster placements, time with extended family, and out of area placements.

In early adulthood, David was supported within 24-hour supported accommodation provided by another organisation. During this time he committed an offence that led to him being admitted to the forensic hospital under the Compulsion Order.

As the Compulsion Order was now ending, David was at risk of being discharged from hospital into homeless accommodation without appropriate care planning. David has complex needs associated with autism, learning disability and trauma, and he would have been extremely vulnerable in this situation.

Transition

Enable attended an emergency meeting at the hospital with senior social work and nursing professionals. Enable identified vacant accommodation available within a larger tenancy where it already provided support. This was assessed as fit for purpose for David.

A needs assessment confirmed that David would need a robust support package in the community, This included 2 to 1 support, 24-hours a day. This required a total staff team of 10 Personal Assistants. Enable worked collaboratively with colleagues in health, social work and regulators to expedite a transition planning process.

The transition was phased into three parts

1) initial transfer from hospital with emergency staffing in place

2) mobilisation of the PA Model of self-directed support with a bespoke team of personal assistants recruited with and by David to deliver his ongoing support in a way that he chooses

3) ongoing assessment of needs to review and adjust the support needed to help David with independence and integration within his local community.

At the point of transfer, David had been supported by hospital staff who knew him well, and understood his communication needs. As part of the transition, Enable secured commitment from existing hospital staff to undertake outreach work post-discharge as part of David’s emergency staffing team. This team was further supplemented by existing personal assistants within Enable who were considered a good match for David through this change process.

This approach provided David with familiar staff within his new environment. The hospital staff were able to support the development of David’s remaining team of personal assistants in his new home.

Outcomes

David has settled well into his new home and is getting to know his new team of personal assistants. He had not been out in the community for 18 months while under the care of his previous provider or while in hospital. The identified outcome for David now is for him to access his local community through a planned outing with his staff. This continues to inform his ongoing support planning.

*The individual’s name has been changed for the purpose of this case study.