Dynamic Support Register

Dynamic Support Register

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1 July 2022

Dynamic Support Register

The Dynamic Support Register (DSR) aims to bring people together who are involved in supporting local children, young people and adults with learning disabilities and/or autism. With the aim to ensure that they (and those important to them) receive robust, timely, proactive monitoring, intervention and support.

Where all agencies and services involved in commissioning and delivering care and support for people with a learning disability and/or autism in Staffordshire and Stoke-on-Trent work together to develop a comprehensive and proactive digital database. To help identify people at most need of support to reduce the likelihood of unnecessary or inappropriate admission to mental health or specialist hospitals.

With close links to the Transforming Care Programme, the DSR will provide a collaborative forum for communication where a person’s support needs can be reviewed and issues escalated where appropriate.

Who will be included on the dynamic support register?

The DSR is for everyone with a learning disability and/or autism (whatever their age), regular meetings will focus on people who are most at risk of hospital admission or placement breakdown. Inappropriate hospital admissions can be related to placement breakdown therefore it is important to ensure the right level support is identified.

Appropriate referrals will be for people who when faced with difficult challenges in their lives can or are presenting as a risk to themselves or others that could lead to an admission to specialist / inpatient services.

For a referral to be accepted a person must either have capacity to give informed consent or where capacity is lacking at the time of referral, a best interest decision has been made. Where appropriate a person with Parental Responsibility can consent to inclusion of a child or young person. The DSR team will be proactive in responding to requests for information to help a person understand, retain and weigh up information about this decision. 

Not consenting to inclusion on the DSR will not affect a person’s current support.

What are the benefits of the dynamic support register?

Prior to the DSR different agencies, services and teams hold there own information about people who they are trying to support. By developing a single register which has input from all those involved in supporting each individual, it will be easier to make sure people get the right support at the right time in the community and help to avoid inappropriate hospital admission wherever possible.

People who are included on the register will be proactively reviewed to identify as early as possible whether any additional support is needed.

Information from these reviews will also be used to identify key themes, trends and service gaps. This information will not use person identifiable data but it will help to plan and develop future services.

For 0-25years included in the register, a referral can be made to the Key Working Service if this additional support would be of benefit.

What agencies and organisations are involved?

Currently the key agencies and services who will collaborate and communicate through the DSR are:

  • Midlands Partnership NHS Foundation Trust (Learning Disability, Autism and Mental Health Services)
  • North Staffordshire Combined Healthcare NHS Trust (Learning Disability, Autism and Mental Health Services)
  • Staffordshire County Council (Social Care and Education)
  • Stoke-on-Trent City Council (Social Care and Education)

Each agency has signed up to the DSR information sharing agreement. This agreement stipulates that the agencies will share information that is relevant, appropriate and proportionate in line with information governance policy.

Evolution of the DSR will continue in line with NHS England’s requirements and will become increasingly inclusive.

What information will the register hold?

The information held on the DSR will be the minimum required to facilitate high quality communication of needs and actions, including;

  • Name
  • Date of birth
  • Place of residency
  • NHS number
  • Key professional involvement, their names and contact details
  • Current issues that relate to risk of admission and the risk of escalation
  • What has been tried that could mitigate risk (including positive strategies to improve a person’s quality of life, increasing life opportunities and self-esteem)
  • What could be useful to further reduce risks
  • Action plan moving forwards including recommendations for current and potential future service involvement

Information for professionals

For a referral to be accepted it is essential that the person has capacity to give informed consent, a best interest decision has been made on behalf a person who lacks capacity or where appropriate a person with parental responsibility has consented to inclusion on behalf of a child or young person. It is therefore important that all relevant information about the DSR is made available to the person themselves, people with parental responsibility and agencies when referral decisions are being made.

Information about the DSR is available in various formats to ensure that it is provided in a way that maximises a person’s ability to understand, retain and weigh up information about this decision to be able to give informed consent. Consent, once given, can be withdrawn at any time.

If a person is assessed as not having the capacity to give informed consent (and no one holds parental responsibility, or a court of protection appointed personal welfare deputyship), a best interest decision can be made under the Mental Capacity Act for inclusion on the DSR.

It is important to know that not consenting to join the register will not affect the person’s current support. Although the benefit of inclusion on the DSR will be the multi-agency collaboration and communication, scrutiny of the current support provided and the potential to access other appropriate agencies as part of the DSR process.

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