Personalised Services that Bring People Home

Building bridges from hospital to community care through safe transitions for autistic people, people with a learning disability and multiple needs.

Our Community Transition Support (CTS) is developed to directly support people with multiple needs in complex situations to transition safely from institutionalised settings to community living. The CTS service is designed to meet the specific care requirements, considering the person’s needs and life aspirations.

Upon release, we work hand-in-hand with care providers to offer ongoing support, identify potential challenges proactively, and minimise the risk of hospital readmission.

Our teams remain in close communication with the person and their care providers until they are stable and ready to move to long-term care with a trusted healthcare provider.

Proven Process that Drives Positive Outcomes

Every year, the Mental Health Act is used to sanction thousands of people, whether they have a formal mental health diagnosis or not. Committed to reducing delayed hospital discharges and readmissions, we work collaboratively to support people regain their lives in the community.

A provider reaches out for support

We receive a referral along with a care plan

We form a team of support workers based on the individual’s unique needs

The team is briefed thoroughly before starting the transition

We begin providing support

When crises arise, we stand by people. Not just to manage the immediate risks, but to build stronger, lasting solutions that prevent restrictive and costly interventions.

The CTS Team and Multidisciplinary Support

Our CTS team, trained by PBSuk in Positive Behavioural Support, adopts a proactive and person-centred approach.

We develop tailored plans while collaborating with our multidisciplinary team, led by a Behavioural Analyst. To provide a seamless transition to community care and implement sustainable and practical strategies, we first offer intense support that is gradually reduced.

Our care teams include:

Community Mental Health Nursing

Registered Mental Health Nurses

Experienced Support Team

Positive Behaviour Support

Occupational Therapy

Multimedia and Communication Specialists

Success Stories in Community Transition Services

Real-life stories showcasing the difference a bridging support creates.

I chose to work in care because I wanted to do something that would directly impact positive changes in vulnerable people and people who need support.

Donald Aderorho

Healthcare Assistant

I always want to make sure we give an individual the very best care and treat them like family.

Charles Akwomagbe

Healthcare Assistant

I have been able to make a positive impact in the lives of others by teaching/introducing skills, activities, and professional bonds that help people to be better individuals than we met them.