Dynamic Support Register

When someone is referred to Staffordshire and Stoke on Trent DSR, the DSR team helps to make sure that all the right services are working together as effectively as possible. The DSR is there to help everyone share information and understand what is happening so the person gets the right support.

If the person is under 25 when referred to the DSR, the Learning Disability and Autism Keyworker team will look at the person’s circumstances to see if they think they can help. If the Keyworker Team think their service would be useful, they will make contact with the person, their parent or carer to describe what they can offer and to see if they would like their input.

Important to know:

• The DSR does not give direct help or respond to emergencies.
• It can’t help people skip waiting lists.
• It’s not the right service if the main problem is getting an Education, Health & Care Plan (EHCP)

DSR information leaflet

Easy read formats

• DSR easy read photosymbols grid
• DSR easy read symbols grid

Consent leaflets

• Childrens consent form 
• Adult consent form 

DSR Rating Tool: Decision Making Flow Chart

• RAG ratings on the DSR refer to the risk of admission to a mental health hospital (not any other types of risks).   
• RAG ratings are very likely to change over time as people’s circumstances change. 
• RAG ratings changing over time is part of the “dynamic” nature of the DSR.  For example, RAG rating may change as people are referred into services, as interventions and other supports are introduced, and as situations change over time.
• Any proposed changes in RAG ratings should always be discussed with the person on the DSR, and their families and carers (as appropriate).
• It is important to note that people’s support packages and how seriously their needs are viewed by professionals do not reduce if a RAG rating on the DSR goes down.

For a referral to be accepted it is essential that:

1. The person has capacity to give informed consent, or
2. A best interest decision has been made on their behalf if they don’t have capacity, or
3. An appropriate person with parental responsibility has consented for the person to be included in the DSR.

It is important all relevant information about the DSR is given to the person themselves, people with parental responsibility and services that support them when referral decisions are being made.

Consent also needs to be renewed on an annual basis and when a young person turns 18. Consent renewal needs to be done in a timely manner. If it is not renewed within 4 weeks of becoming overdue, the person will need to be removed from the DSR and a new referral made if necessary. People will be sent reminders about the need to renew their consent if they want to remain on the DSR during this four-week period.

Information about the DSR is available in various formats (including easy read) to help the person to understand, retain and weigh up information about the DSR and to be able to give informed consent. Consent can be withdrawn at any time.

If a person is assessed as not having the capacity to give informed consent, a best interest decision can be made under the Mental Capacity Act to be added on the DSR.

It is important to know that deciding not to join the register will not affect the person’s current support.

Consent forms

The following forms support the recording of consent. These forms will not be uploaded to the DSR, however consent must be gained prior to be added on DSR. Professionals may upload these or similar consent forms to their clinical systems.

• Childrens consent form 
• Adult consent form 

The information held on the DSR will be:

• Name
• Date of birth
• Where you live
• NHS number
• Demographic information
• Key professional involvement, their names and contact details.
• Current issues that can lead to a mental health hospital admission or placement breakdown
• Reason for referral

If you are a professional working with someone who you think would benefit from being included on the DSR, please discuss this with the person and/or their families (when appropriate) rather than encouraging the person (or the family) to make a self-referral. When someone is already open to a service, a professional referral is far more appropriate than asking a person, or their family members, to self-refer. Login or register to make a referral and link for the platform DSR platform Login or Account Registration

The DSR is not a clinical or intervention service. As such, it is not appropriate for professionals to make a referral to the DSR and then to subsequently discharge from their own service.

• Once professionals make a referral to the register, they remain responsible for ensuring the personal details on the referral are accurate and updated over time. 
• This includes ensuring that changes of address or contact details are updated, and the RAG rating (for risk of admission or placement breakdown) is reviewed on a regular basis in collaboration with the person or their parent/carer,
• There should also be a regular brief update in the “updates” box on the referral page to reflect the current risk of admission and summarise any significant changes in need prior to the Thursday tracking meetings.  Updates should be provided to the register by referring professional a minimum of fortnightly for people rated as Red and Amber and monthly for people rated Green on the register.

The DSR team do not have access to other clinical systems, so it’s important all information required is added to the platform including contact information for the service user, any parent/carers and any other paid carers and details of all the professionals involved. It is very important there is accurate contact information for the person and/or parent carers to enable the DSR team to renew consent when required.

If you discharge a person or cease your involvement with a person you have referred to the DSR for any other reason, please contact the DSR team so we can re-allocate the person to an appropriate professional.

If you need help for yourself or someone you know, you can register a referral at Staffordshire and Stoke-on-Trent DSR :: Dynamic Support Register (staffordshireandstokeontrent.nhs.uk). Please only include the brief list of information requested in your referral. 

Alternatively:

• Email us at dynamicsupportregister@mpft.nhs.uk (please only email us your name, postcode and an email address and phone number). We will use this information to get back in touch with you. Please do not send us lots of detailed clinical information at first contact - this is not needed to make a self-referral.

or

• Call us at 01785 550291 and leave your name, contact number and postcode and we will contact you to discuss the referral and next steps.

If you already have professionals involved in your care you can ask them to submit a DSR referral on your behalf. We understand that it can be difficult to make contact with further services when things are not going well or you are supporting someone in a time of crisis, so we aim to make these processes as simple as possible. 

Remember, if you or the person you’re talking about needs help right away from doctors, nurses, or emergency services, please contact these emergency numbers for help.

If you need mental health support, you can also call 111 and select option 2.

The DSR Team is not the right service to help in an emergency. We work from 9am to 5pm, Monday to Friday (not bank holidays).

What happens after you make a referral?

If you contact the DSR for yourself or someone close to you, here’s what will happen next:

1. We’ll contact you within 5 working days to ask more questions to help understand what you need. This will help us manage your request better.
2. The information you tell us will be discussed in our DSR meetings, which happen every two weeks on Thursdays. These meetings include key people from healthcare, social care and education. There will be a discussion about your current needs, how risky your situation is, and what kind of help is available.
3. If there are high risks, we might need to arrange a meeting with you after we have spoken to other professionals. (Please also refer to meetings information in the drop down)

If you have made a self-referral which has been accepted on to the DSR, the professionals involved should ensure you are kept informed of any developments as a result of discussions and meetings you may not be included in.  

The professionals involved should also discuss your thoughts on any proposed changes to RAG ratings.

If you would like an update on what is happening with your referral direct from the DSR team, please email us on dynamicsupportregister@mpft.nhs.uk and a member of the team will be in touch.

• Tracking Meetings - These meetings work best when someone is already known to at least one of the key local LD&A services. Meetings are held fortnightly on Thursdays. It is a professionals only meeting over MS Teams. Many representatives from a variety of health, social care and SEND and education services attend these to generate discussion and support decision making.
• Meetings by Exception (MbE) - Happen on an individual basis.  Organised and chaired by the DSR Leads. These meetings are for individuals who are on the DSR but don’t currently have support from any key local LD&A Services; or when there are significant concerns or differences of opinion between services. The person on the DSR and parent/carers (where appropriate) are invited to MbEs, alongside professionals.  Usually over MS Teams. If support is needed to access a meeting once arranged, please contact the team to discuss this.

The organisations that have signed up to work together on the DSR are:

• Midlands Partnership University NHS Foundation Trust:

Support people in South Staffordshire with learning disabilities, autism, and mental health issues.

• North Staffordshire Combined Healthcare NHS Trust:

Support people in North Staffordshire and Stoke on Trent with learning disabilities, autism, and mental health issues.

• Staffordshire County Council:

Support social care needs and education in Staffordshire.

• Stoke-on-Trent City Council:

Support social care needs and education in Stoke-on-Trent.

All these agencies have agreed to share information through the DSR. They will only share information that is important, right for the situation, and follow the rules about sharing information.

The DSR will keep adapting to meet the needs of NHS England and in response to feedback from everyone who has contact with the DSR.

If you have used the DSR, your feedback on the service is very valuable to us.

There are several different ways to share feedback.

Friends and Family Test - is an online questionnai9re which asks 5 questions about your experience, and 8 optional questions about you. To complete this, please select the dynamic support register (DSR) from this drop down menu.

If you have a compliment or concern about the DSR team, please contact the Customer Services team (formerly known as Patient Advice and Liaison Service (PALS)) at MPFT. You can do this via their website.