We develop a support plan which includes person centred thinking tools with people we support and people who know them well. These identify staffing and routine needs, outcomes and preferences. After this, we aim to hold a planning day to develop a path with the person and people who know them well and agree the initial transition plan, which is a detailed document that sits alongside the support plan and covers everything for the team about how best to support them.

Once the service is in place, we have regular reviews to gather views from the individual we support, and people close to them to see if we are doing what we promised in the first place? If we don’t, we acknowledge, improve our processes, and carry on.

Like any of us, the people we support have their ups and downs. Sometimes they express their emotions in a challenging manner and sometimes it is subtle, but we know there is a sense of purpose to their behaviour. Times like these are not easy for the individuals and us but we stick together and see it through. We organise meetings and involve those they trust, including their friends, relatives and other professionals and discuss and move on.