Breakthrough Case Management

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. People's needs assessments fed into the skills required of the bespoke staff team before care was commenced. Staff had completed a high level of specialist training tailored to individuals which provided them with the expertise to assess, monitor and support people with their complex needs. The service worked very closely with other health and social care professionals and lawyers involved in people's care to ensure they received a high level of care and support. Secure online feedback was shared regularly including videos which enabled health partners to see how people were progressing and if treatment/exercises were effective. Staff supported people and their families in a very person-centred way, tailored to individual complex needs and preferences to ensure they lived their best lives following life changing events. There were many examples of how excellent care and support had resulted in improvements for peoples' quality of life. Staff meticulously followed specialist health professional programmes to great effect.

There were very robust and high-quality governance systems in place to assess and monitor the service provided, with regular detailed reports also sent to the fee payers, (commissioners and lawyers). People's views were extremely valued and used to drive improvement. As a growing service, the two directors had worked hard to ensure the service remained one with a personal touch. They knew people well and supported staff in navigating complex family dynamics and emotions to promote the best outcomes for people. There was a complaints procedure in place. Care assessment and planning records were extremely detailed to enable close monitoring of peoples' care, progress and future planning individual to them.

Risks in people's daily lives were assessed and mitigated with a focus on positive risk taking. Staff were

provided with safeguarding training, adults and children, and understood how to keep people safe. Recruitment of staff was bespoke to each persons' care management package and completed safely with peoples' involvement. There were sufficient staff numbers and flexibility to provide the care and support required by people to meet their needs. People were supported to take their medicines safely, where this was required. Infection control procedures were in place.

People were matched with bespoke staff teams suitable to meet each individuals' needs before the service started. Staff were very caring and compassionate and knew people extremely well, often building up close, long-term relationships sharing common ground. People's rights to dignity, independence and privacy were promoted and respected. People's choices were always sought, valued and used to plan their care as well as staff offering up ideas and creative ways to enhance life quality and opportunities. The values and culture of the service focussed on striving to achieve the best quality of life for people. This included being pro-active and using innovation, research and accessing specialist health professionals for people's benefit.