13 - 2025-12-10 IJB - Coming Home Report
North Lanarkshire Council · 10 December 2025
Back to Health and Social Care Integration Joint Board — 10 December 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 13 SUBJECT: Coming Home Implementation TO: Integration Joint Board Lead Officer for Report: Diane Fraser, Chief Officer Adult Social Work Services Author(s) of Report Andrea Breen, Senior Social Work Manager, Adult Social Work Claire Leslie, Service Manager, Adult Social Work DATE: 10 December 2025 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☐ Reviewed By: ☐ Endorsed By: ☐
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2 3. RECOMMENDATIONS The Integration Joint Board to note the following 1. To note the current progress to implement the recommendations from the Coming Home Report 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES Introduction This report provides an update to the Integration Joint Board (IJB) on the requirements of the Coming Home programme and North Lanarkshire’s progress. The work is aligned with the Scottish Government’s Coming Home Implementation Report (2022), which set out a national ambition to reduce delayed discharges and inappropriate out- of-area placements for adults with learning disabilities and complex care needs. The report emphasised the importance of visibility, accountability, and rights-based approaches, and introduced mechanisms such as the Dynamic Support Register, National Support Panel, and Peer Support Network to drive improvement across Health and Social Care Partnerships. This report focuses specifically on individuals identified as high risk through the Dynamic Support Register (DSR). And outlines key developments and emerging challenges in improving outcomes for people with complex and neurodivergent needs. The purpose of this report is to: Update the IJB on current DSR data, including the increase in individuals rated RED due to hospitalisation or risk of support breakdown. Highlight systemic barriers and emerging risk factors impacting service delivery and outcomes. Ensure alignment with national policy and the Coming Home vision of enabling individuals to live in their own homes, with care tailored to their unique needs. The Dynamic Support Register (DSR) is a tool introduced as part of the Scottish Government’s Coming Home Implementation Report (2022) to help Health and Social Care Partnerships Yes ☐ No ☐ N/A ☒
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3 identify and monitor individuals with learning disabilities and complex needs who are at risk of poor outcomes due to inappropriate placements, delayed discharges, or support breakdowns. This work is governed by Health Important Scotland and collated and shared Nationally. NSC Partnerships submit the Dynamic Support Register quarterly to inform the National Picture. There are currently 15 people in hospital on the local Dynamic Support Register, there are 2 people who are at risk of breakdown, and 4 people with enhanced monitoring. There is no one inappropriately placed out of area whilst 14 people are appropriately placed out of area and 16 people have been removed from the register. North Lanarkshire Health and Social Care Partnership (NLHSCP) has made notable progress in tackling delayed discharges and reassessing out-of-area placements through the Coming Home Implementation Plan. Supported by £1.1 million from the Community Living Change Fund, a temporary specialist team was established to work in close collaboration with allocated social workers. This initiative enhanced coordinated care management and prioritised discharge planning for individuals whose circumstances had previously stalled. Background In 2018, the Scottish Government initiated a national focus on reducing inappropriate out-of- area placements and delayed hospital discharges for people with learning disabilities and complex care needs. This report concluded that all adults with learning disabilities, including those with complex needs, should experience meaningful and fulfilled lives closer to home and this was to be achieved by 2024. It led to the Coming Home Implementation Report (2022), which set out a joint ambition with COSLA to ensure that individuals are supported to live in their own communities, with care tailored to their needs and rights respected. A key milestone was set for March 2024, by which time significant reductions in out-of-area placements and hospital delays were expected. To support this ambition, the report introduced three core mechanisms: Dynamic Support Registers (DSRs) to improve visibility and local case management A National Support Panel to provide oversight and challenge A Peer Support Network to share best practice across partnerships North Lanarkshire HSCP Position and Progress North Lanarkshire has actively engaged with the Coming Home agenda and established a local DSR to monitor individuals at risk. This was to improve the monitoring of those at risk of hospital admission or living in inappropriate placements. Since the establishment of the dynamic risk register an oversight group has been established to monitor the position in North Lanarkshire. The dynamic support register reviews and monitors those people who are delayed in hospital, out of area placements and those at risk of their placements breaking down. As a consequence of the dynamic support register our
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4 local information highlights that the age group at risk is 17-18 year old. In addition, 3 of the 31 individuals on the dynamic risk register have been delayed in hospital for over 10 years. Current and future demand The strategic group have worked closely together to analyse the information and consider the current and future demands. An increasing number of young adults in North Lanarkshire, particularly those with autism, are presenting with significant behavioural dysregulation. This dysregulation is not associated with a recognised physical or mental health diagnosis, which creates barriers to accessing appropriate support through conventional service pathways. Families frequently report feeling overwhelmed and unsupported, struggling to manage behaviours at home. These challenges often escalate into crisis situations, resulting in hospital admissions or placements in residential schools. Such placements are often unsuitable and misaligned with the principles of the Coming Home agenda. This trend highlights a gap in current service provision for neurodivergent individuals whose needs fall outside conventional diagnostic categories. It highlights the need for, flexible, rights- based support models tailored to neurodivergent profile, enhanced early intervention and crisis prevention strategies as well as workforce development to build capacity in supporting complex behavioural needs. The Coming Home Implementation Plan emphasises supporting individuals to live in their own homes with care that reflects their unique needs. Addressing the evolving needs of neuro divergent younger adults is essential to achieving this vision and reducing reliance on institutional or out-of-area placements. Several individuals in North Lanarkshire remain in hospital settings despite being clinically ready for discharge, often due to complex needs, limited provider availability, or unresolved professional disagreements. While the Coming Home Implementation Plan and Community Living Change Fund have supported progress, systemic barriers persist. The graph below shows the estimated cost for individuals currently in hospital Community Living Change Fund £100,000 £1,000,000 £500,000 £250,000 £190,000 £370,000 £500,000 £400,000 £500,000 £1,000,000 £400,000 £200,000 £30,000 £50,000 £50,000 £0 £200,000 £400,000 £600,000 £800,000 £1,000,000 £1,200,000 A B C D E F G H I J K L M N O Individuals on the Dynamic Support Register Total Estimated Cost - £5,540,000
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5 The Scottish Government provided a non-recurring Community Living Change Fund £1.1m to support delivery of local implementation with North Lanarkshire. This was non-recurring funding to support the implementation of Coming Home recommendations in local areas. The primary aim of the Community Living Change Fund was to support local implementation of the Scottish Government’s Coming Home recommendations. Specifically, to reduce delayed discharges for adults with learning disabilities and complex care needs, reduce out of area placements to ensure people can remain closer to home, build on provider flexibility and workforce skills to offer the right support for complex care at home, enable right based care models and develop suitable housing solutions. In North Lanarkshire, the fund (approximately £1.1 million) was used to create a temporary specialist team and enhance two independent providers within the commissioning framework. These interventions improved discharge planning, reduced hospital readmissions, and demonstrated more flexible, skilled approaches to care. However, the funding was non- recurring, so while short-term improvements were achieved, sustainability remains a challenge without ongoing investment. Insights from these interventions must now be embedded into ongoing practice to ensure sustainability. The Partnership continues to collaborate with local housing colleagues and framework providers to develop long-term housing solutions, including purpose-built accommodation offering independent tenancies and personalised care. Despite progress, challenges remain—particularly in securing appropriate housing, addressing workforce capacity, and managing risks of support breakdown. Increasing demands on clinical services and financial pressures further impact the delivery of person- centred care. North Lanarkshire Council faces significant operational and strategic implications as a result of the current DSR profile. The number of individuals delayed in hospital reflects both systemic pressures and gaps in community-based support. This not only impacts individual wellbeing and rights but also places strain on acute services and local budgets. Supporting people closer to home remains a core priority. However, achieving this requires targeted investment, improved provider matching, and enhanced workforce capability. The current challenges highlight the need for a coordinated response that strengthens local capacity, embeds preventative practice, and ensures timely transitions from hospital to appropriate community settings. Through the focused work undertaken it has been possible to gather information on emerging themes and risks which are outlined below. Emerging Themes and Risk Factors 1. Support Breakdown Without Clinical Diagnosis A growing number of younger adults with autism are experiencing dysregulation not linked to a defined physical or mental health condition. Families report exhaustion, lack of meaningful support, and an inability to manage behaviours at home, leading to crisis situations and, in some cases, hospital or residential school admissions. 2.Developing a enabling approach which is person centred, and outcome focused.
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6 Focusing on assessment which promotes an enabling approach that supports early intervention when someone is discharged or at risk of admission. Discharge planning from the point of admission is necessary which is underpinned by strong multidisciplinary working is essential. People in North Lanarkshire have access to a range of community, health and social care supports. The commissioning framework is unique and does provide a range of flexibility. At present their framework has expanded to approximately 84 providers, offering support across the full spectrum of social work needs. While this expansion has increased choice, it is recognised that not all providers have the skilled workforce or infrastructure to support those individuals with complex care needs. It is essential that individuals and their families are engaged in identifying their support and suitability is prioritised over availability. This ensures that right care is provided to individuals who require a more tailored and nuanced approach—where provider expertise, flexibility, and a deep understanding of neurodivergent and complex needs is necessary. Alongside this, we have identified a pressing need for development to reduce the risk of support breakdown. Individuals with complex needs—particularly those whose dysregulation is not linked to a diagnosed physical or mental health condition—require providers who can deliver consistent, responsive, and relationship-based support. This is necessary to prevent carer breakdown. Addressing this gap is essential to achieving the core vision of the Health and Social Care Partnership: that everyone should be supported to live in their own home, with care tailored to their unique needs and built around natural supports. Realising this vision will require recurrent training and reflective practice for staff involved in assessment and care management, ensuring decisions are informed by a deeper understanding of complexity and neurodivergence. 3. Housing Appropriate housing is key to successful planning. While housing mechanisms are generally effective, individuals with complex needs require intensive coordination. Close working with NLC Housing Service colleagues, Enterprise and Communities, Registered Social Landlords is required to source housing. There is ongoing collaboration to identify appropriate housing provision including new build. 4. Children and Families: Early Indicators of Systemic Risk The rise in children and young people entering residential schools due to breakdowns in community support is concerning. Many young people present with complex needs linked to autism or neurodivergence, often without a formal diagnosis. These cases correlate with family strain and caregiving challenges. Early education settings, health visitors, and GPs are critical touchpoints for identifying emerging needs. Equipping these professionals with tools, training, and escalation pathways is essential to enable preventative intervention and continuity planning.
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7 There is a clear need for earlier, proactive intervention—at or before diagnosis—through universal services. Supporting caregivers with education, emotional support, and practical strategies can strengthen family resilience, improve outcomes, and reduce crisis-driven transitions. This aligns with a rights-based, whole-family model of care, offering the best opportunity for children and adults to thrive within their communities. Financial Planning Implications: Rising numbers on the DSR and persistent hospital delays signal growing demand for complex care services. Sustained investment is needed to expand local capacity, strengthen provider capability, and develop scalable, community-based support models. 15 individuals who are in hospital will require varying levels of support. The anticipated financial implications is estimated to cost approximately £5.5 million. Workforce The wider health and social work/ care workforce across the system including those supporting the Coming Home agenda is working to capacity supporting people with a range of clinical and social care needs. Staffing levels are beginning to stabilise following a prolonged period of instability, the teams require support to manage the complexity of this work. To support complex discharges there is a requirement for an appropriately skilled and resilient workforce that will strengthen service delivery but also reduce the risk of placement breakdowns and improve outcomes for individuals and families. Conclusion North Lanarkshire has made notable strides under the Coming Home agenda, especially in reducing inappropriate placements and delayed discharges. The DSR has improved visibility and accountability, enabling targeted interventions and supports collaborative working. To meet national ambitions, continued investment, strengthened partnerships, and integration of learning into long-term practice are essential. 7. IMPLICATIONS: NATIONAL OUTCOMES This work contributes directly to several National Health and Wellbeing Outcomes, particularly those focused on enabling individuals to live independently in their communities, improving the quality of life for people who use services, and ensuring that care is person-centred and rights based. The Coming Home agenda supports a shift away from institutional settings toward sustainable, community-based models of care.
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8 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☐ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☐ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☐ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☐ Health and Social Care Services contribute to reducing health inequalities ☐ People who use Health and Social Care Services are safe from harm ☐ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☐ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☐ 7.2 ASSOCIATED MEASURE(S) Progress will continue to be monitored through the DSR, with regular updates provided to the IJB. Key indicators include reductions in delayed discharges, improved transitions from hospital to home, and increased stability in community placements. 7.3 FINANCIAL The implementation of the Coming Home agenda has been supported by the Community Living Change Fund, with £1.1 million allocated to North Lanarkshire HSCP. While this has enabled short-term improvements, ongoing financial pressures and increasing demand for complex care services present sustainability challenges Anticipated future demand for complex care services driven by rising numbers on the DSR and increasing hospital delays will require sustained financial investment to expand local capacity, enhance provider capability, and ensure long-term viability of community-based support models. This paper has been reviewed by Finance:
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9 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Choose an item. 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☐ Involve stakeholders in the development work aimed at achieving the national outcomes ☐ Provide stakeholders with information on how to get involved ☐ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☐ Measure how well we involve community stakeholders in the planning, design and delivery of our services ☐ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☐ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings ☐ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff ☐ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership ENGAGEMENT & PARTICIPATION Yes ☐ No ☐ N/A ☐
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10 Ongoing engagement with individuals, families, advocacy services, and provider organisations is central to the Coming Home approach. Participation mechanisms are being strengthened to ensure that service users have a meaningful voice in planning and decision-making. The Coming Home agenda is underpinned by a commitment to reducing inequalities and promoting rights-based care. EQIA and Fairer Scotland assessments will be completed to ensure that strategic decisions reflect the needs of all individuals, particularly those with complex and neurodivergent profiles. 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: The Coming Home agenda is underpinned by a commitment to reducing inequalities and promoting rights-based care. EQIA and Fairer Scotland assessments will be completed as we progress with this agenda, to ensure that strategic decisions reflect the needs of all individuals, particularly those with complex and neurodivergent profiles 8. BACKGROUND PAPERS 9. APPENDICES Please include a glossary of terms if not already included. Yes ☐ No ☐ N/A ☒ Yes / Date added ☐ No ☒ N/A ☐
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11 Diane Fraser CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following;Andrea Breen, Senior Manager BreenA@northlan.gov.uk
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12 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed