Getting Out of Hospital


Beyond Limits predominantly plan with and then support people with learning disabilities and mental health needs who have had to spend often very long periods of time in Assessment & Treatment Units and Specialist Hospitals. We help people get put a service together that works for them using Individual Health Budgets (IHB), which involves a home of their own and a team matched to them (shared hobbies, interests, temperament etc.) or in other words a team that they like being with!
The process from start to when the person settles into their own home can be long and complicated so we have put together this fact sheet to help our teams understand what others do and what they need to do in the planning and transition process.
Arrange and facilitate a service design meeting
This then forms a tender or can be used to RAS the Individual Health Budget
Arrange and facilitate a working policy meeting (to form the care plan with the provider/PA’s providing the support)
Ensure Court of Protection Deputy is necessary at least 6 months before housing is needed.
Look into any savings etc. that may be able to be used for more bespoke housing options.
From Service Design – team specification for advert and job spec and how family/person want to be involved in recruitment, housing specification, hopes and dreams for targets, natural and AT support requirements, next step actions, family role. 
The working policy forms the starting doc to be worked on during transition by the team getting to know the person. It is done in a way that all known safety issues are discussed and plans formed with the multi-agency, family and person to agree robust support especially when things are not going well.
The costings need to include transition costs (period of time for staff to work alongside the person, travel expenses and accommodation expenses)
Work out team hours, and make up of team.
Decide with person and family who will interview and how. Sometimes the Hospital will not let then attend so we have used video and the person coming up with questions. We also always send photos of interviewed candidates if family and us first interview.
Write advert with person/family based on ‘what people love about the person from the service design’ and a bit of the behaviours
Advertise roles in paper to start and our website – but when they move locally in shops too
Send the application forms to family for comments and selection and arrange interviews/initial meetings.
If person not able to come to interviews arrange how they can be involved (e.g. thinking up questions, getting the candidates filmed answering questions)
Interview with family/person. Team selected on ‘match’ over experience. Shared hobbies and interests. Experience needed for team leader though.
Once team have been employed they have a full Induction here and get to know service design and working policy.
We hire a house/accommodation near to the hospital and agree with the Hospital for our staff to start to shadow the person and team there.
Need to develop a working relationship with Hospital. Although they have been involved with service design and working policy so know what we are all about.
Arrange visits and shadowing. Support to complete daily notes, shadow as much as possible at different times of the day and night and ensuring they have knowledge of medication, seizures (if relevant), behaviours and routines.
If people are on certain sections of the mental health act that involve the Ministry of Justice agreeing to the discharge arrangements then a plan involving them must be started as soon as a Service Design is being arranged. The Ministry of Justice will not agree a discharge if they are not assured of public safety. Their agreement is also reliant on housing being suitable to the person so this will mean planning the housing in conjunction with everyone involved. 
Locate GP surgery, dentist, opticians, podiatrist, local Hospital, eye infirmary and all relevant health related services and make referrals where appropriate. Obtain ID for the person – may require passport photos, letter from Care Coordinator.
Work out bus routes, start to look at local neighbourhood and identify key people and places, start to introduce arrival to local shops etc (all positives). Look for opportunities linked to the person’s assets in the locality – ways to contribute and give back.
Explore job and education opportunities. Think of ways to involve neighbours in arrival, garden party, BBQ, offers of cat feeding when on holidays etc.
When first starting service design process look at savings and whether there are any that can be used for house deposit or shared ownership. Also make sure if there is any issues with capacity to sign a tenancy or get a mortgage that the court of protection application is put in for (this can take up to 6 months). Get person on housing register with local council. Complete housing specification based on service design information.

If money then shared ownership or buying a house through a Trust will ensure the greatest security of tenure. If shared ownership is an option then this process should be started as soon after service design as possible as it takes time (as long as it takes to set up a mortgage and buy a house from the open market).

Use housing specification from the service design to search for an appropriate house.

Search for appropriate housing with those involved (remember to involve OT if any adaptations and care coordinator) and find a house, view house and a joint agreement should be made on suitability. Always involve person and/or family in the search. Houses cannot be bid on until there is someone in place who can sign the tenancy. Bid on a house through Council process, or arrange private rental or shared ownership arrangement.

Once tenancy is agreed, a meeting with Landlord to go through tenancy agreement is needed. They may want to understand the support package before agreeing a tenancy so the person should be away of this. The Landlord should be aware it is their duty to provide a tenancy in a format understandable to the person if they have capacity to understand a tenancy. There are many easy read versions and the Housing & Support Alliance are a good source of information if the Landlord is struggling. All info on support needed with a person’s tenancy should be included in their working policy.
Establish who the supplier of utilities are, when the bills start from (record readings on meters) and where shut off points are for the following: Electric, Gas, Water. Ensure the person has the best deal for utilities in conjunction with their Deputy if they have one.

If there are issues around fire or arson ensure that the fire prevention team are involved at service design stage and can advise on any fire prevention systems and escape plans that may be needed. 

If any restrictive practices are needed – alarms, sprinkler systems, sensors etc. ensure best interest meetings agree before installation.


Ensure you have up to date information on benefit entitlements (some may have been suspended for the person whilst in Hospital) and knowledge of what can be claimed.

Ensure all benefits are applied for that are applicable.


Ensure a plan is in place with person and appointee/families (where necessary) regarding budget (living expenses and bills etc.) that can be put in place as soon as they move. It should include all income and outgoing monies.

Ensure arrangements for staff food and drink are agreed with person and recorded in working policy both for whilst at home and out and about.

Set up bank arrangements for any support funds needed getting all team staff signatures.

Ensure a Hospital passport is put together and epilepsy or other health related plan (if appropriate) has been completed. There will also need to be a contingency/crisis plan developed with the community team, and any arrangements agreed and recorded about Guardianship or Community treatment or MAPPA arrangements and that the relevant police or other services have information about their roles on their communication systems.

Make an Introduction to GP and learning disabilities liaison nurse at local acute Hospital. If the person will frequent A&E a meeting should be arranged with a Consultant form A&E so that there is a joint agreement on how we all work together to manage admissions. The plan with A&E should extent to hospital admissions as well as sometimes the plan stops at A&E and people are treated differently when in the actual hospital. If ambulance travel is also used then they too need to be aware of plans (and have a plan on their communication system) to limit admissions (this is vital especially for people with personality disorder type diagnosis).

Inform the GP of the person’s intentions to register within their surgery as you may need to obtain ID and ensure medication is ordered and is ready to collect when the person arrives at their new home. Ensure the pharmacist is instructed to provide blister packs if required. Obtain any relevant aids of support e.g.: seizure bed alarm, iPad, sensors.

Write up a Police passport and contact police and meet with local community liaison officer. Support the team in understanding the passport so they can advise police if they arrive at the house.
Establish where the person will be taken if arrested under s136 e.g.: local psychiatric in-patient unit or whether they will be returning the person to their own home. Establish knowledge of an appropriate adult and support the team to understand their responsibilities and limitation’s.

Ensure any health and safety systems are in place: carbon monoxide alarms and fire extinguishers, blankets and means of escape.

Ensure team are aware of the mental capacity act and undertake these before the person, or soon after the person moves to their home so that you do not start off over-supporting a person:
·       Tenancy assessment
·       Medication Capacity Assessments
·       Financial Capacity Assessments
·       Capacity Assessments for other areas

As the Individual Health Budget Project Beyond Limits is part of in Plymouth enters its second year, I have started to meet and work with some families who have different views from those we met in year one. These families don’t want their relative to move out of the Specialist Hospital setting they are in despite them being hundreds of miles from home. 

This is not to say that these families are not just as passionate about their relatives, nor do they love them any less, and they still only want what they feel is best for them. These families have just been so profoundly affected by the lack of support, failed services and rejection by the systems that were meant to protect and help them and their relative in the past that all trust, hope and optimism for the future has disappeared and they are very scared of any change. It has been truly humbling to listen to the heartache and mental stress these families and their relatives have been through trying to make things work when they lived more locally, and for them to still take part in planning for the future. 

I took two of these family members in my car on the 750 mile round-trip to do a service design meeting for their relative. These trips are very useful (about the only thing about someone living so far from home) for getting to know people and listening to their story as 14 hours in a car makes or breaks relationships! 

They were grateful for the lift as their usual journey four times a year takes 24 hours round-trip on a bus. They have been making the trip for over 8 years now and have had to make it into a mini-break as it is too far to do in a day (paying for travel and accommodation themselves). They don’t want things to change  and would rather make these trips than bear the consequences of another placement in the community for their relative. 

One of the family members summed up how they felt about their relative being in a Specialist Hospital, and wanting them to remain there as; ‘he is not hurting, he is not hurting anyone else and no one is hurting him’. I found this statement very profound but could not blame them for wanting so little for their son after hearing the catalogue of disasters, poor support, and heartbreaking decisions they had been forced to make, including sending him away, when he lived nearer home and things went wrong. They are also both retired and could not imagine how they would cope with the worry and involvement they used to have to give, as they were always called to help out, when things went wrong. And they can’t imagine, nor have any faith in, it not going wrong again. 

All this makes me both angry and sad on two counts, not with the family but with the systems that I have been a part of in the past,  which enables this situation to ever exist. 

Firstly, we do families a great disservice when discharge planning is not started on the day that their relative is admitted into Hospital. This enables families to gradually fall into a false sense of security that their relative may be able to remain in the Hospital environment long term. No one would blame them for this hope, when for perhaps the first time in years they are able to breathe a sigh of relief that they don’t have to worry for a while and can get a semblance of life back, but then weeks become months and soon the years roll by and their relative is still in Hospital 

Secondly, if a person is admitted for assessment and treatment surely the Hospital should be made (through commissioners) to give detailed plans of what is to be ‘assessed’ and ‘treated’ and a timescale for release? Treatment is surely a short-term thing so I wonder what is still being ‘treated’ after 8 years. Should they not then be held accountable if the treatment is not successful in the timescale? These are questions I have yet to get a good answer to. Interestingly the Specialist Hospitals that have engaged most proactively with us on this project have been those where the person has been there for less than a year as they are keen for the person to move on. 

The expense of someone living away from their community is immense in all senses of the word; emotionally, treatment costs, costs of visiting and professional visits and reviews plus the costs of transition back home which should not be underestimated. When are we going to learn to spend time getting it right first time, and not giving up on people in their local communities?

Current Vacancies - Please note that some of the people that we support specifically need their teams to be Drivers

We are looking for a Part Time Support Workers  for Laura who is arty, generous and great company. She also finds life difficult at times. Laura has an established team in place. If you are interested in the above post please contact us. 
We have vacancies for the following:
·         Support Workers Part Time £15,450 pro-rata
All posts involve evening and weekend work as well as sleep overs.
If you are interested in any of the above posts please contact us on 01752 546 449 or e-mail for an application pack or an informal conversation.

Note:  A DBS Check will be requested in the event of being offered a position with Beyond Limits, the cost of which will be to the employee, however, this will be returned after completion of probation period (6 months).
Ref:  Laura0614
Closing Date: 17th July 2014

This position has a “genuine” occupational requirement” covered under the Sex Discrimination Act 1975 and therefore only applications from females is requested.

Laura Team Descriptors

Staff should be:

ü  Women
ü  Don’t take things personally
ü  Caring and give lots of their time
ü  Calm and able to talk things through
ü  Able to cope with spontaneity
ü  Fun and energetic
ü  Keep to their word
ü  Protective and interested in Laura
ü  Tactile
ü  Go the extra mile
ü  Have clear boundaries and keep to them
ü  Firm and assertive
ü  Think on their feet and be flexible
ü  Problem solving and strong
ü  Resilient
ü  Able to give information and give space for a decision
ü  More of a night owl than up with the larks!
ü  Like dancing and going to Bingo and pubs
ü  Can stand up to people in Laura’s life she finds it difficult to say no to, and give her the confidence that she is right to. Good at team work
ü  Have a consistent team approach
ü  Open minded
ü  Able to prove a sound value base for their practice
ü  Aware of their own and others safety
ü  Able to appear confident even if they are not
ü  Comfortable with taking risks
ü  ‘Thick’ skinned
ü  Have patience
ü  Commitment and ‘staying power’
ü  Not intimidated easily
ü  Ability to see Laura’s behaviours in terms of her life experience and not her the person

*        Bossy or hard faced
*        Keep pushing things
*        Not be upset if plans change often
*        Not be upset by swearing and raised voices
*        Not be fazed by emotional ups and downs
*        Strong minded

*        Rigid thinkers


This job description is a statement of the core duties of a support worker. Every individual will have additional duties for her support worker specified in her Service Design and Working Policy.


To the Team Leader and Service Leader of Laura’s team and to Laura.



Health & Social Care Diploma level 2 (or willing to work towards)



To provide 24 hour support which may include un-sociable hours, weekends, bank holidays and sleep in duties

Role Specification

To provide whatever help and encouragement is required by Laura to take control of her life.  It is likely that to achieve this, the person receiving support will require support from a number of different people, including friends, family, professionals.  It will therefore be necessary for the support worker to respect and work co-operatively with others enabling Laura to live in her own home within her local community, based on the individual’s preferences/needs within the framework of her Service Design and Working Policy. 

Main responsibilities

To work as a member of a small support team for Laura. To facilitate good quality services for Laura by contributing to creative planning and person centred approaches to ensure that Laura’s life moves in the direction they choose. The team must ensure that the service is as invisible as possible within Laura’s life.

  1. If required lead Laura’s working policy process in partnership with the Team Leader, her team and members of her circle of support.

  1. To continually seek to provide support in ways which utilise natural supports for Laura.

  1. To at all times communicate respectfully and appropriately to, with and about Laura.

  1. Communicate regularly with members of the team and attend regular team meetings.

  1. Act as an advocate for Laura where appropriate.

  1. To recognise and respect at all times that you are a guest in Laura’s home.

  1. To be actively involved in developing Laura’s service design and working policy and follow it whilst helping her.

  1. To provide support to Laura to live in her own home and to have a lifestyle which she chooses.

  1. Promote Laura’s health and well-being by supporting Laura to ensure her primary healthcare needs are met by accessing appropriate facilities for medical, dental, optical treatment etc.

  1. Ensure Laura’s medication is handled, administered, recorded and stored in accordance with Beyond Limits’ Policies and Procedures.

  1. To help Laura with the choices she needs to make in her day to day life, by using a balanced approach which emphasises advice and encouragement rather than making decisions on her behalf.

  1. To help Laura stay safe and well while she lives in her own home. Assisting Laura to participate fully in the community by developing a range of valued activities outside her home, promoting real choice by giving opportunities to try different options.

  1. Assisting Laura to maintain and develop a range of relationships within the community including friends, neighbours and other social contact.

  1. To work with Laura to help her cope with her feelings and relationships, assist her in managing the practicalities of daily living and to access other support systems in the community.

  1. To help Laura with all areas of budgeting and in maintaining her household and ensuring that her financial obligations are met.

  1. To treat Laura, at all times, as an adult and unique individual, recognising her rights to choose, dignity, individuality, sexual preference, love, friendship and respect.

  1. To work with the Laura to find and develop employment opportunities, and to support her secure and sustain employment.


1.  To help Laura monitor her mental and physical health and encourage her to take appropriate action to safeguard and maintain her health e.g. calling a doctor or professional help if she is unwell.

2.  To help Laura develop and maintain her relationships with neighbours, friends and family by providing encouragement, guidance and organisational support where needed.

3.  To work with the other team members to find, secure and maintain employment. To support Laura at her place of work and assist them to become a consciences employee.

4.  To help Laura organise and develop new work and recreational activities; to try new experiences, meet new people and broaden her hobbies and interests.

5.  To work with Laura to develop her existing skills and to learn new skills.

6.  To communicate respectfully with the other members of Laura’s support team with Laura’s interests uppermost in mind.

7.  To plan ahead with Laura for times when other members of the support team are absent.

8.  To seek continually, to provide support in ways which utilise appropriate natural supports for Laura i.e. family, friends, colleagues, neighbours etc.

9.  To seek continually, ways to ensure that Laura retains and enhances her power and control over her own life.

10.To, at all times, talk respectfully to and about Laura, recognising that she is an adult and that she has individual rights.

11.Specific support work will include: Assist and support Laura to:-

·      Be a successful householder
·      Maximise income through benefits
·      Assist in claiming and receiving benefits
·      Budgeting and paying bills, saving etc.
·      Assisting in access to welfare rights
·      Purchasing items for the home - home furnishings
·      Domestic support - shopping cooking etc.
·      Take care of her personal care needs, e.g. cleaning, bathing etc.
·      Plan for her future and solve problems that are worrying her
·      Make new friends and socialise
·      Help find, support and sustain work

12. To implement the organisations Equal Opportunities Policy.

13. Duties may vary from time to time as agreed by Beyond Limits.

Team Duties

  1. To communicate effectively with other team members, participating constructively in team meetings, contributing to and putting into effect decisions made in respect of Laura’s working policy.

  1. To give and receive constructive feedback.

  1. Support other members of the team in her work.

  1. To provide written records/reports as required.

  1. To maintain Laura’s household finances as required and as per Beyond Limits Policies and Procedures.

  1. To participate in relevant opportunities for training and development and attend all mandatory Training.

  1. To maintain confidentiality in respect of Laura, employees and the organisation.

  1. To ensure that all Beyond Limits principles/policies are strictly observed and adhered to at all times.

Additional duties of a Live-in Carer

This should be read in conjunction with the Core Support Worker job description and the Specific list of duties for the individual.

1          To enable the individual to live safely in her own home

2          To ensure that Laura feels fully at home in her own home and that the home reflects her tastes, preferences and lifestyles

3          To ensure that anyone who needs to enter the home to offer support can get access to the home

4          To ensure that the contents of the home belonging to Laura and the home are protected from abuse and damage and that all necessary measures are taken to reduce the risk of theft

5          To build good relationships with neighbours and local people

6          To ensure that any household bills are paid

7          To safeguard the fabric of the house and avoid any actions which might undermine the home or its contents


Senior Support Worker
Part Time, Relief & 
Waking Night Support Workers

The team is coming together but there are still a few positions to fill in my dream team! Do you fit the bill?


Howard says: "I need my team to support me 24/7 to live independently in my own home in kingsbridge after my stroke and subsequent, now partial, locked in syndrome." Visit to read my story. 
  • Full Time Senior Support Worker
    (37.5hrs pw) £16,995 per annum
  • Full & Part Time Support Workers
    £15,450 per annum pro rata
  • Relief Support Workers
    £7.73 per hour
  • Waking Night Support Workers
    £8.24 per hour
  • (All posts will be required also do Waking Nights)

I want my team to be…
  • Quick to pick up on my needs (know me really well)
  • Young thinking or of a young age
  • Be happy, bubbly, positive and have a sense of humour similar to me (witty and a dry sense of humour)
  • Like a laugh and a joke
  • Not be concerned about posters of half-naked women 
  • Put a big effort into their work
  • More like friends
  • Loud and confident but calm in approach
  • Same hobbies and interests
  • Patient
  • Like sport
  • Enjoy a challenge
  • Put me first
  • Have knowledge of technology and gadgets (be able to fix it when it goes wrong)
  • Like gaming and poker
  • Speak up for me
  • Be a driver
  • Not talk about me 
  • Like animals 
  • Can step back when I want them to
  • Don’t take my comments to heart 
  • Willing to travel abroad and go off on breaks away
  • House proud and clean
  • Able to cook and prepare food to feed me
  • Give me the ‘kick’ I need sometimes  when things are tough
  • Relaxed and easy going
  • Lots of ‘get up and go’

My team must not be…

  • Talk for me instead of letting me talk for myself
  • Think they know what I need
  • People who see me as a job and not a person
  • Too serious, negative and moaners
  • Pushy people that take decisions away from me
  • Not interested in me
  • Nursing oriented seeing my  health needs above my other needs
  • Not flexible and rigid thinkers
  • Someone who likes to go to bed early
  • Aversion to gambling
  • Aversion to scary movies and laddish posters and films

More info and forms...

All relevant training will be given. DBS check will be required for successful applicants. If you would like to apply to be on my team and you live in the South Hams.

Please request an application pack by contacting Jo Sly

Download: HW Application Form

Download: HW Senior Support Worker job description

Download: HW Core Support Worker job description

Download: HW Night Support Worker job description