Dynamic Support Pathway

The Joined Up Care Derbyshire Dynamic Support Pathway (DSP) brings together the services who provide help and support to children, young people and adults with a learning disability, autism or both, who are struggling with their health and wellbeing whilst living in the community, with the key focus being on prevention, early identification and early intervention.

What is the aim of the Dynamic Support Pathway?
The purpose of the Dynamic Support Pathway (DSP) is to make sure that people with learning disabilities and/or autism, and their carers receive good and timely support, and respond quickly to any problems and concerns which may lead to a crisis.

The DSP provides a place where agencies communicate and work together to develop an action plan to support people using various levels of multi-agency coordination and review. The DSP also helps to connect people to appropriate services.

In Derby and Derbyshire, all agencies and services that care for people with learning disabilities and/or autism use a digital database, called the Dynamic Support Register (DSR). The DSR helps identify those who need support the most, so they don’t have to go to a mental health hospital, if this is not the best thing for them.

The DSP uses a rating system to show the different levels of risk. The ratings are:

Red: For people who are at high risk of going into hospital straight away

Amber: For people who are at high risk of going into hospital if they do not get the right care and treatment soon

Green: For people who are having their risks managed well at home

Blue: For people who are already in hospital

Ratings help determine the person’s needs and makes sure that they get the right care and treatment, such as:

Going to hospital if appropriate

Extra support at home to avoid unnecessary hospital admissions. For example, having
NHS England » Care (Education) and Treatment Reviews or a referral to a keyworking team from 0 to 25 years old.
Who is the Dynamic Support Pathway for?
The pathway is for children, young people, and adults of any age with a diagnosis of learning disability and/or autism who are:

experiencing a difficult time with where they live or with their current care and support.

needing extra support to live a healthy, safe and fulfilling life in the community and not go to hospital if they do not need to.

being discharged from a LD/AMH hospital bed.

experiencing mental ill health, an unmet need, and/or behaviours described as ‘challenging’.
What are the benefits of the Dynamic Support Pathway?

The Dynamic Support Register (DSR) brings together information from different agencies, services, and teams that help people. Before the DSR, each service had their own information. With the DSR, everyone’s information is in one place.

This makes it easier to make sure people get the right help at the right time in their community. This can help to avoid going to a mental health hospital when it’s not necessary.

People on the DSR will be checked regularly to see if they need any extra help. This way, we can find out early on if someone needs more support.

For children and young people up to the age of 25 who are on the DSR and need more support, a referral can be made to the Derby & Derbyshire keyworking team who will get in touch with them and offer to their help and support.
Referral information

For a referral to be accepted it is essential that:

The person has capacity to give informed consent or;

A best interest decision has been made on behalf of them if they don’t have capacity.

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

Information about the DSR is available in various formats to ensure that the person is able to understand, retain and weigh up information about this decision to be able to give informed consent. Consent can be withdrawn at any time. They will be supported with this.

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 not consenting to join the register will not affect the person’s current care and support from services.

The benefit to be included on the DSR will be:

Multi-agency collaboration and communication.

Scrutiny of the current support provided.

Potential to access other appropriate agencies as part of the DSR process.
Consent

Dynamic Support Pathway rating tool

The MDT supporting the individual will be required to discuss and agree the risk rating (below) based on the individual’s current situation using professional and clinical judgement and RAG rate them Red, Amber, or Green.

Red

Individual in a crisis situation and at risk of hospital admission

Amber

Wellbeing is deteriorating – at risk of crisis if action not taken quickly potential hospital admission

Green

Individuals whose wellbeing has settled and are no longer requiring DSP meetings

Confidentiality

The information held on the DSR will be:

Name

Date of birth

Where you live

NHS number

Key professional involvement, their names and contact details.

Current issues that can lead to a hospital admission.

What has been tried that could help (including positive strategies to improve a person’s quality of life, increasing life opportunities and self-esteem).

What could be useful to reduce risks further.

An action plan moving forwards including recommendations for current and potential future services

All documentation and data relating to the DSP is stored securely, according to regulations within the Data Protection Act (2018) and General Data Protection Regulations (GDPR).
Dynamic Support Pathway resources & templates

DSP SOP - guidance notes for professionals

docx, 86.19 KB

Download

DSP guidance notes for individuals, families and carers

docx, 313.24 KB

Download

DSP consent form

docx, 42.73 KB

Download

DSP consent form - easy read

docx, 179.87 KB

Download

DSP first meeting template

docx, 329.81 KB

Download

Follow up MDT template

docx, 328.06 KB

Download

DSP post discharge meeting template

docx, 331.35 KB

Download

DSP referral form

docx, 149.40 KB

Download
Derby and Derbyshire Keyworking Service

Derby and Derbyshire Keyworking Service

The Keyworking service in Derby and Derbyshire provides dedicated keyworkers for children and young people with a learning disability and/or autism and who at risk of being admitted into a mental health inpatient setting.

The service if for Children and Young People up to 25 years old with a learning disability and/or who are autistic and who are on the Dynamic Support Register (DSR)

The Keyworking service in Derby and Derbyshire is provided by Affinity Trust – more information can be found by following the link below:

Derbyshire Keyworker service | Affinity Trust

Referrals

Professional referrals:

Referral forms can be found here.

Email completed referrals to dhcft.ndpat@nhs.net These emails should be password protected and passwords forwarded in a separate email.

The DSR team does not provide an emergency crisis response services and work 9am – 5pm Monday to Friday.

Please note that if you, or the person you are referring needs an urgent or immediate response from mental health, physical health or other emergency service please look here.

Dynamic Support Pathway

Referrals

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