Team Around the Person Meetings guide for professionals

Contents

• Referrals and initiation process
• Frequency of meetings
• Attendance
• Health professionals
• Mental capacity
• The role of the Surrey Adults Matter Steering Group

Referrals and initiation of process

Surrey Adults Matter (SAM) is an approach to tackling multiple disadvantages in Surrey. This involves asking professionals to refer clients they may be working with that are experiencing multiple disadvantage to one of two SAM partnership leads, who can facilitate a holistic view of what is working well for the client, what is not working so well and to form a multi-agency action plan with them, the client, the client's family or carers and the wider local workforce.

Adults referred will have achieved a score on the New Directions Team (NDT) assessment included in the referral form that demonstrates complex needs associated with; homelessness or risk of homelessness; mental health; substance misuse; criminal justice involvement and domestic abuse.

Quadrant Panels involving local partners then consider and if appropriate agree to accept a referral, after which the SAM partnership leads will invite the referrer, the client, any family member, or advocate the client would like to be present - plus all professionals who are working with the client or whose expertise might be needed, to a Team Around the Person (TAP) Meeting.

These meetings are conducted online as this both enables greater engagement, ensuring partners and agencies do not need to travel to attend, whilst also obviously making it a more environmentally friendly approach. Clients are able to join on their own devices, with help from a support worker or lead professional. Clients may not always be invited to a first meeting but in subsequent meetings can choose to attend all or part of a meeting and be on or off screen as they wish. If a client specifically requests a face-to-face meeting, this can be accommodated also.

Frequency of meetings

Meetings will be held according to the needs of the client and so frequency varies significantly. Some clients have a lot going on and may require robust risk management plans and specialist professional input and may need weekly meetings. Other clients, particularly after having some of the initial meetings may be supported with less frequent 6 weekly meetings. An underlying principle however is being as flexible as possible to meet the needs of the clients and professionals involved and, on this basis, urgent meetings can also be held at short notice.

Attendance

Clients may have a range of professionals supporting them at any given time. The Team Around the Person group may change according to any new services the client might be involved with or agencies and professionals that start working with them at any given time, such as a new accommodation provider.

A typical but not exclusive membership might include:

• Social Housing representative
• Probation Officer
• Drug and alcohol support
• Adult Social Care
• Police
• Health
• Accommodation provider
• Client
• Client's advocate / family member or support worker to ensure their voice is heard.

Many clients being supported by the SAM approach are not always close with family members and it is important to have their consent to invite anyone even if they have named them as next of kin.

Health professionals

With the SAM approach, partnership leads work closely with colleagues in Surrey and Borders Partnership NHS Trust and substance misuse social care teams especially around receiving treatment and suspected alcohol related cognitive impairment. Alcohol liaison teams to TAP meetings as well as Consultant Psychiatrists; Psychologists; Hospital staff and GPs where appropriate.

If a client is detained under the Mental Health Act in a local hospital setting, the ward rounds will be utilised in place of a TAP meeting and relevant professionals will be asked to join this virtually until the client is discharged. If partners are invited to attend a TAP meeting, it is important this is accepted as soon as possible Or if unable to attend for any reason a delegate is provided. If this is not possible an update should be provided to the SAM partnership lead prior to the meeting so that information is available to inform discussion.

Mental capacity

If during a TAP meeting, there is concern regarding an adult's capacity to make decisions, the partners on the TAP will decide if a referral for a mental capacity assessment is needed in respect of a client's ability to make decisions regarding their care, treatment, or residence. This may be via adult social care and best interests' decision-making processes, DoLS or medical consultant opinion. Legal advice will be sought accordingly, and any information received shared with the TAP as appropriate.

The role of the SAM Steering Group

The SAM Steering Group meets quarterly and is co-chaired by the Director of Public Health; the chair of the Surrey Chief Housing Officers group and a representative of the Office of the Police and Crime Commissioner (OPCC).

The Senior SAM Partnership and Programme manager presents quarterly data at this meeting that is shared with all Strategic Leads in the membership group. The anonymised information and data links individual issues being experienced with service and system implications and includes emerging trends and themes per Quadrant area. There is also a quarterly report with case examples of work being undertaken. It is in this forum that any particular concerns might be raised where there is a difficulty in achieving a desired outcome in a particular case. Cases escalated in this way are then resolved through the involvement of the partners in attendance as part of the meeting or through subsequent follow up with relevant individuals and organisations.
There is a live risk and issues log that is used to track progress of matters arising which includes any specific escalated issues when this occurs.

Key learning is disseminated through this group and fed through the Changing Futures Programme to the front-line Bridge the Gap Workers commissioned to provide trauma informed outreach. The expectation is that Steering Group members also disseminate learning and information through their own teams as representatives of their organisation and / or team.

The SAM partnership leads attend agency team meetings by request to look at the SAM process and any key learning or themes.

If there are any strategic or more significant resource issues that the steering group is not able to address directly, these can be escalated to the Prevention and Wider Determinants of Health Delivery Board and / or Health and Well Being Board as appropriate, via the Chair of the Steering Group and in consultation with Surrey Safeguarding Adults Board (SSAB) as necessary.