Ep7: Yes to supporting people with complex mental health needs
In this episode of Yes to You, the Lifeways social care podcast, our host Paul is joined by Richard Cunningham, Service Development Director for SIL, Lifeways’ mental health specialist. Richard and Paul discuss how SIL supports people severely affected by mental ill health, how its self-contained flat schemes work, and how SIL works in partnerships with local authorities.
Ep7: Yes to supporting people with complex mental health needs
PC Paul Crompton
RC Richard Cunningham
PC Hello, and welcome to Yes to You, the Lifeways podcast. Lifeways is the UK’s largest team of support professionals who provide support for adults in the community. I’m Paul Crompton, marketing and communications manager and podcast host and I’m speaking to Richard Cunningham, service development director at SIL which operates 24 supported living services across the country.
SIL is part of Lifeways. Each of these SIL services supports adults living in the community who are severely affected by mental ill health. Many have come from secure facilities or long stay hospitals. Prior to SIL, Richard has a long background in working with homeless or at-risk people. Richard, welcome to Yes to You.
RC Morning, Paul, thank you very much indeed.
PC Great, let’s get started and let’s start simple. How would you describe SIL in one sentence?
RC So SIL basically, as you’ve already said, we’re an organisation who provides supported living, so that’s basically, we have flats we operate in partnership with an RSL, which is a social landlord, and we provide support for individuals there 24/7. So a typical service would have say, 12 to 16 flats, each individual living there would have their own tenancy. They could come and go as they please but on-site we have a team of mental health support staff supported by a well-trained manager and deputy and by our quality and practice team.
And their job is to basically provide support, to help individuals develop the skills to grow in confidence and their ability to live with greater independence. What we’re trying to do, really, is help people become accustomed to living back in the community and how they can keep themselves well, healthy, etc. But also, above all, realise the kind of things they want to do, ambitions in terms of developing social networks, friendship groups, hobbies.
And ultimately, ideally, we want to help people move on from us, get jobs, have family, anything, really. The sky’s the limit, really. It’s what these individuals want to do. So our role, really, is to, or our support worker’s role is to walk alongside these individuals, not to lord it over them in any way, but to help them understand and develop their own capabilities, basically, and to, ideally, live more fulfilling lives.
PC In our context, what does being severely affected by mental ill health mean or coming from secure facilities or long stay hospitals?
RC Our target audience is, so to speak, the people we’re looking to really reach out to and try and provide support to, are individuals who’d been in hospital maybe for a considerable period of time, who’ve been, as you said, severely affected by mental ill health, they’ve had long periods of mental unwellness.
These are individuals who may also have been by virtue of their mental ill health, they may have come into contact with the criminal justice system. They may have been involved in crimes as a result of, that have been linked to their mental ill health. And as such, these are individuals for whom there may be a sense that your more traditional support in the community isn’t really sufficient.
And I think one of the interesting things I always felt when I came to work in mental health was having come from a homelessness background where there was an awful lot of work looking at pathways, looking at how to prepare people to go back into the community, and an awful lot of effort was put in as result of various government policies around trying to effectively get people off the streets. What was strange and a bit surprising to me was actually the fact that these pathways didn’t really seem to exist so clearly in the world of mental health, really.
So SIL as an organisation set out to try and address some of those disparities, really, looking to see if we could provide a form of support that would be able to support people who perhaps had more profound illnesses, who had these risks, possibly, attached to them by virtue of having been through the MHA pathway and so on.
And this was as much about our ability to support them as about us being able to give the confidence to commissioners and so on that we have the competence and skills to support these individuals properly. Because it’s not always just about necessarily supporting the individual and helping them to stay well in the community.
It’s also about potentially being able to spot when people are becoming less well and being able, therefore, take effective action to ensure that other agencies are brought together so that the individual receives correct treatment, etc., and any potential risk that might have been posed by them becoming unwell, a relapse into previous offending behaviour, for example, can be averted, really.
So that is kind of what we set out to do, really. But it was more driven by a realisation that a large group of individuals who were almost being underserved by the current mental health pathways and were stuck in hospital and various placements because it wasn’t seen that there was the right kind of support and provision out there.
So we set out to become experts in what we do, to become really competent in supporting individuals, helping them to achieve their goals and aspirations, but also in helping to create the right kind of environments and non-physical structures around them that would keep them save, but also keep the wider community safe and secure as well.
PC So if I’m someone that’s supported by SIL, what makes my life different living at SIL or being supported by SIL as opposed to, let’s say, being supported by many other providers that may be out there?
RC We’re a recovery-based organisation, so we’re very much driven by hope and the belief that individuals can develop the skills to enjoy a greater level of independence and independent living and more fulfilling lives.
I think where we differ is we’ve really set out to understand what makes our individuals tick and to make sure that our staff teams are trained and supported to understand who they’re working with. And to do so in a way that’s empowering and person-centred.
But above all, we spend a lot of time developing our assessment process, so that when people come to us and referred to us, we spend a lot of time getting to understand them. Talking to them directly but talking to those people around them. Families, care teams, etc., to understand what’s making the individual tick to understand the context.
For example, we have a lot of individuals who come to us with significant histories that involve the Ministry of Justice, offending behaviour, etc. For example, we have something in the region of 33% of our residents or the people we support, have a fire-setting history or a conviction for arson, if you want it in more blatant terms. And obviously, that poses quite a significant issue for housing providers in the community and so on.
What we do is really to try to understand the individual and above all, understand the context in which certain things may have happened. Were they ill at the time? What were some of the potential triggering factors? What are the things we need to look out for in the future to help keep this individual safe? And above all, what we need to do if someone starts to become unwell? Who do we need to involve in terms of pulling things back together again, basically, and making sure that we can get help to that individual quickly?
So we spend a lot of time developing our assessments so that we understand people, we understand what it is they want, we understand their histories, we understand how we can help them stay well. And we spend of lot of time training our staff to be able to understand that as well. To be able to understand the recovery plans and risk assessments that are put together as part of our assessment processes.
And through our quality and practice team, which is a team of peripatetic mental health professionals, so we have mental health nurses, social workers, OTEs and so on who support our teams through training, reflective practice and supervisions to understand and to put into effect the plans that we’re developing with individuals to support them.
And I think that’s where we’re successful. We really do understand who’s coming to us. We understand how they want to be supported and how best we can support them. And above all, we have the ability to understand what it is we need to do to help keep them well.
PC So people we support at SIL have their own tenancies, but how does this fit in with them receiving support? In other words, who pays what?
RC Yes, as you said, our schemes are generally between 12 and 16 self-contained flats. We run these in partnership with a housing association and individuals do have their own tenancies. And that’s part of the deal, basically. When people come to us, we want them to have their own high-quality accommodation because, actually, I see that very much as being part of that road to recovery.
We have developed some really attractive services and part of it, really, is to inspire hope in individuals. The idea that when they cross the threshold and they get the keys to their house, this really marks a red line where everything that went before was before, and actually, this is a whole new horizon.
There’s hope here, so people will walk into their flats, and they are beautiful flats, and my hope is, in the words of the Loreal advert, that they’ll look at that and say, I’m worth this, really. It’s the idea of reflecting back to people that they’re worth this flat and so on and that, actually, life could offer opportunities to them, really.
So yes, everyone has their own tenancy and effectively, that’s paid through housing benefits, so it’s paid through people’s benefits, allowances and so on. And that money is paid to the housing association, it doesn’t come to us.
And basically, we provide the support within the services. We have a staff hub there, sleeping facilities, and that’s paid through contracts with health and social care.
PC Right, so in this particular case, so in the case of people who are supported by SIL, the tenancy is in a sense linked to the support that they receive. So, for example, the person we support wouldn’t move across town to like, let’s say a house somewhere and then we would deliver support there. How does that work?
RC No, I mean, that is a model, obviously. In general, it’s called floating support where you have a support team visiting someone’s home and so on. I mean, in our instance, individuals are coming to us, very often, from long stay hospital placements, residential care, etc. The support is very much tied to the accommodation and the idea basically is that people will stay in the scheme for a period of time, receive support and then at a point where they feel ready to move on, they’ll move on to hopefully further independent accommodation elsewhere.
Our support doesn’t necessarily go outside of that setting. I mean, I say that on occasion we have delivered some elements of support and as I speak, actually, we’re also experimenting with delivering support in the community as part of a step-down project from our service, Moor House, in Hereford.
We were invited there by the local authority to provide support to six independent tenancies in the community, three of which are occupied by former tenants of ours, but three are also individuals coming from another setting. So that is a bit of a new venture for us. But traditionally, our support is tied to the services that we run in conjunction with our housing association partners.
PC Right. I think I remember writing about the case of an individual who has moved into one of those Hereford services and essentially, in my understanding, the council or the local authority had built or had been involved in the construction of the different properties. So how did that work?
RC It was a really great opportunity and kind of lovely. I mean, one of the hardest things of all is finding people move-on accommodation, really. When people come to us, one of the most difficult things, yes, as we know, generally, housing is an issue for a huge part of society. So people are moving on, they’re waiting on housing lists, etc., or possibly going to the private renting sector.
But, I mean, this was a great opportunity, really, in that the strategic housing planner officer for Hereford County Council had working with one of their local providers, Connexus Housing Association, who were developing a mixed tenure estate just inside Hereford.
As part of that development, she had negotiated that six houses, and they are, they’re one-bedroom houses, so it’s quite an unusual thing. You don’t often see one-bedroom houses, but they are over two floors, they have a garden, they come with a garden shed.
Basically, she’d secured six of these for individuals with histories of complex mental health problems and so on to move out into the community, really. And we were lucky enough to get three of our chaps into the scheme as well as being offered the opportunity to run the support there as well. So it’s been in its early days, we’ve been doing it for the last two and a half months, but so far, I have to say, working in conjunction with local mental health and social service teams, it’s been a great success.
We had a really interesting meeting the other day just catching up on the first two and a half months, and I think everyone concerned just said how successful it’s been, really, and the chaps and girls who’ve moved in are so far very happy. So it’s something that I’m keen to see us do more of, really.
Because one of the things I’ve always felt is that having done resettlement when I was in a different part of my life many years ago, you can see people drop off a bit of cliff edge when they move from one provider to the next. So certainly, the ability for us to follow the three guys from Moor House into the community and keep that consistent support going has been good for them and it’s been, actually, really enjoyable for us.
PC Is there a support threshold at SIL? So, for example, are there people whose needs would be lower or people who we wouldn’t support because they wouldn’t be at our level? Are there people whose needs are more severe than we could support?
RC Part of our assessment process is to ascertain whether we can genuinely support somebody. Now part of that might be saying actually, the level of support we provide is too much, this individual doesn’t need to come to, effectively, a residential setting. I mean, they have their own flats, but they are in a community with support on-site and we might say that that’s too much. That could, in fact, be debilitating for somebody.
At the other end of the scale, yes, there’d be people who may not be quite ready yet to come. And we try to be a very optimistic organisation, looking for how we can support people rather than why we shouldn’t support people, which is why, as I said before, we have 30% of the individuals have a fire-setting history.
A further 30% of people come from the MHA with a history of offences that put them in the MHA pathway. Significant numbers of people with offences that include violence, assault, murder, etc.
We try to be optimistic but there are certain things that will say individuals may not be necessarily ready for us, so that would be part of the assessment. There’s no hard and fast rule on that. As I say, we look to include everybody, but it’s a question about looking at their history, looking at current behaviours.
A very simple one might be, has this person had unescorted leave if they’ve been in hospital? And if they haven’t had unescorted leave then possibly that’s something that needs to happen before they start considering the step-down process.
This is also very much about where they see they’re at as well, really. So if someone’s not showing an awareness or a desire to engage with services and so on, possibly it’s not quite the right time for them. So I would say there’s no hard and fast criteria for exclusion. What we try to do is include everybody, but it is very much about that holistic assessment process that tries to help us understand how we would support somebody. What the risks might be and how we would mitigate those risks.
PC Can you think of any really positive examples of how SIL has made someone’s life better, perhaps even helped transform it?
RC Well, I think there are a number. I mean, you mentioned the chap you wrote about the other day and it’s a lovely story there. But the one that sticks in my mind was someone who came to us very early on in our, we set out, I think I’ll use the word journey, I’ll punch myself for that later.
But years ago, a young lady came to us in our service in Exeter and she’d had a very lengthy history of inpatient admissions. She had a diagnosis of, I think, EUPD and she engaged in a lot of self-harming behaviour. She used to swallow things. I mean, you mentioned at the start of this, your fear of swallowing the teaspoon. Well, she used to swallow things like toothbrushes and so on.
PC Just cut in here so, to our listeners, we had a quick debate before the recording of this podcast about whether or not you make a cup of tea and leave the teaspoon in the cup. And as you probably gather, I’m not of that persuasion but Richard is. And also, just to clarify, when you say EUPD, you’re referring to Emotionally Unstable Personality Disorder, formerly known as Borderline Personality Disorder, is that right?
RC That’s correct, Paul, and yes, the listeners will realise that I am much more of a risk-taker than Paul is and I’m not too worried if that spoon is sticking in my eye. I see that as the risk worth taking for that cup of tea although possibly, I’d be wiser to take it out and avoid any kind of injury in the first place. But yes, you’re quite right, Paul, Personality Disorder.
So this young lady had this lengthy history, had come to us. It’s fair to say, I think, she’d experienced a great deal as a result of her illnesses and so on. However, with us, and remarkably quickly, she’d started to turn a corner. And it’s a shame, she sent a letter to the manager of the scheme recently which I was looking for because I’ve managed to lose it somehow, I don’t know.
But it was really touching, particularly early on, because it made us feel like we were actually doing the things we’d set out to do. And basically, recounted how she felt when she came to SIL and then the changes. And one of the interesting things which she said, the point I realised that the only person who can really drive the change was me. And that’s absolutely correct.
We can’t make people do things and it is not in our power to make people do things. But what we can do is create the right environment where people can feel that they’re developing the skills and above all, developing the confidence to do things for themselves.
And that, for me, was the bit that stood out in her letter. And she’d moved on and to the best of my knowledge is still living happily. I mean, she’s going to university, she moved in with her boyfriend who, I think, we’d known whilst at the service and so on and been very supportive. But basically, wrote to say that SIL had a really positive impact on her life and her ability to move forward.
Yes, no, just lovely, the fact that this a young woman getting on with life, doing things, living the life we’d all hope for our children would lead. Go to university, having a partner, having a home and just doing stuff and not in and out of hospital and not swallowing toothbrushes and so on and hurting herself.
PC And how long had this individual lived at SIL?
RC Actually, it all happened rather quickly, really, which I attribute to her skills rather than… I think it’s about the support we gave her, but I think it’s also about, I’d met her, and she was a resourceful, intelligent young woman, basically. So I will say you can’t say it was all down to us, I think it was also down to her, but she was with us for about nine months, I think, before moving on.
So quite a profound change, really, so one that I think we can justifiably take some credit for alongside her, which we would do with all the people we support, basically. It’s not just us, it’s us working with them and them working with us.
PC And I’m going to guess that the average, not that we can really say there’s an average, but if we had to tot it all up, the average person who is supported by SIL probably lives in a SIL service a bit longer than nine months, is that right?
RC We work and plan from day one for people to move on. What we do say is ours is not permanent accommodation and so on, but obviously we want people to treat it as their home. And the way I’ve always explained it to others, and this goes back also to my days in homelessness, running a programme for the government that was refurbishing or redeveloping hostel facilities, is we want to create environments that are really attractive and inspire hope in individuals and we’ve been very successful doing that.
Very often the criticism comes, but they won’t want to move on because actually, very often, what’s out in the community isn’t as good. And my retort to that has always been, and I still hold it, is that the house I grew up in was much nicer than the house that I then move into because my father was relatively well-off, and it was home and all the rest of it and I didn’t have to pay the bills.
But ultimately, as much as I loved my dad, I was happy to move on because it was my own place and so on and I didn’t have dad, I didn’t have to make excuses when I came home half-cut from the pub and so on. So the reality is, ultimately we don’t want to be living with mum and dad, as lovely as the house might be.
So people will always move on when they feel it’s the right time for them to do so because they want to spread their wings and get out and enjoy their independence. So I’m confident that the quality of accommodation is not a bar. So I’d say we support people for as long as they feel it’s necessary.
Ironically, there used to be a standard support length of time in the old days of supporting people and so on which was about, I think if I remember rightly, 18 months and by that stage, you must have affected change, people must be moving on. That was always a bit of a nonsense, but you had to set a bar somewhere. You had to set a target somewhere, I believe, or I suppose. Ironically, that seems to be roughly how long people stay with us, about 18 to 22 months.
PC And very lastly, can you think of anything you’ve learnt while at SIL that you really feel is worth sharing with commissioners, funders or family members or individuals who we might support?
RC Yes, there is. I mean, as I said earlier on, we set out to become experts in what we do and I think one of the things that’s important also is recognise, as an organisation, as I said before, we see ourselves as working alongside the people we support, recognising them as experts in their experience as well, really. So it’s very much a partnership.
Yes, I want to kind of reflect. Interestingly, Adam, in his podcast the other day was reflecting on sometimes that some of the tensions you might get with commissioning environments and so on. And I think one of the things particularly, as we move into a new phase in the NHS with integrated care systems and so on, and again, the words like partnership and so on going on, it is to emphasise that, I think, we achieve our successes when we work in partnership with people.
And that means working in partnership with the individuals we support but also with our colleagues in health and social care and with families and significant others of the people we support and so on. And with other wider partners such as the police, emergency services and so on, community services.
That’s when we’re really successful, so we’re supporting people in the community and actually, we can only do that by creating invisible but structures around them that help the individual feel safe themselves and so on.
And so I would say the thing I’ve learnt is to recognise that everyone in the room brings with them expertise and if we did that and looked at things more as partnerships going forward, then probably, we’d all benefit.
PC Right, and thanks for partnering with me to produce this podcast, Richard. It’s been a real pleasure to speak to you.
RC Well, cheers, Paul. It’s been, as always, a pleasure to speak to you. I hope it made sense.
PC Absolutely. And thanks to you, the listener, for tuning in to this episode of Yes to You. If you want to know more about SIL and the work SIL does, please web search for S I L and Lifeways. We’ll be releasing new episodes all about adult supported and residential living every month, so if you haven’t already, please do subscribe to this podcast. See you next time.