Information for Families working with a Keyworker

The Keyworker will ensure the young person’s voice is heard. They will identify blockages and challenges in the system, and aid in seeking alternative placements and/or seeking additional support to improve their quality of life, emotional and mental wellbeing.

The Keyworker service aims to:

Support and empower children, young people and their families to navigate the system
Develop and sustain effective, positive working relationships with children, parents and/or carers; sitting alongside them during times of uncertainty.
Work across systems and services to ensure these respond to needs when required

The Keyworker’s Role

Navigate and Coordinate the system and Multi-Disciplinary Team (MDT)
Coordinate support at home and in the community
Promote best practice approaches to support children and young people with a learning disability and/or Autism
Provide flexible, person-centred planning
Ensure the young person is involved in the development of their support
Representing the views and opinions of the young person to ensure their voice is heard

What to expect

When a young person has been identified as either amber or red on the Dynamic Support Register (DSR) then they will be referred to our service. This means that they are at risk of hospital admission or have experienced a breakdown in support. Once referred, we must gain consent before Keyworking can start.

A Keyworker will be matched to the Young Person. This Keyworker will then get in touch with the young person/family (our main point of contact), followed by the surrounding MDT and begin to gather information to better understand the person and to gain key insight into how we can support them.

Some of the things they will do are:

Streamline and coordinate assessments
Review and collate information about the young person, identifying any gaps in their support which need to be addressed
Develop a personalised plan which will identify the young person’s goals and aspirations, alongside how to achieve them.

The first visit – What we need to know about you

The Keyworker will then arrange an initial visit. This will be just a chat in a place where the young person feels comfortable.

This meeting will help the keyworker understand the young person’s story and how they have arrived at crisis, with the aim of developing relationships and as a result be able to represent the child or young person and their family, carers or advocate in discussions around the provision of support, services and interventions.

The Keyworker will also develop effective strategic partnerships with the organisations involved in providing support to the young person, which may include children’s health, social care, education, school and adult services.

The second visit – Planning for change

During this visit, the Keyworker will start working with the young person to create their personalised plan and develop ideas for SMART goals (Specific, Measurable, Achievable, Relevant, and Time-Bound).

They will also be able to signpost the family to other services or sources of support to meet the young person’s needs.

Visits will continue as the Keyworker works closely with the young person and their network of support to improve their quality of life, build confidence, work towards goals, aspirations and independence, and develop skills and knowledge.

While part of the purpose of the keyworker is to prevent admission to an inpatient setting, if this is not possible, the keyworker will facilitate transitions to ensure the minimum stay, providing support, advice and practical input as required.

Step down – Setting up for success

The keyworker will keep track of the young person’s progress to gauge ongoing support requirements, representing them and their family in discussions around their provisions of support. They will continue to work with the young person to prevent re-admission or risk of admission, helping the young person and their family to access appropriate ongoing support to enable the Keyworker to step down, once the young person is more stable.

Working together for a successful outcome

Keyworking is focused on getting the correct support in place for families and young people during a very challenging period of their lives. To have the best chance of positive change, families and their keyworker need to work together. So, to best support this;

Honesty and transparency from the family and keyworker help to build a strong and healthy relationship.

Open communication and willingness to work together.

Both family and keyworker should always aim to be punctual. Sometimes appointments might need to be cancelled or amended however keeping continuity and structure in place will help the young person adapt and maintain relationship.

Expectations – Do’s and Don’ts

What we will do

A Keyworker is somebody who will visit the young person, set goals and help them develop positively.
They will take the time to get to know the young person, speak with the family, and be an advocate.
They are human rights focused, working with families to get the correct support, and will professionally challenge when support does not meet the young person’s needs.
The keyworker will listen to parents, help them to explore the effects that their child’s diagnoses has on their day to day life.
They will advise parents or carers how to navigate the CYP system and understand their rights and choices
The keyworker is available 9am – 5pm Monday to Friday but will provide flexibility to effectively support and this will be negotiated with the young person and family.

What we won’t do

The keyworker is not a support service – meaning we will not take responsibility for the young person's support needs during visits.
We are not crisis support and don’t offer out-of-hours services
The keyworker is not the lead professional

Family Support Worker

As well as a Keyworker offering support to the young person, we may offer a Family Support worker to work with the family or carers. The role of the Family Support worker is to;

Help families in need of practical or emotional support, particularly when difficulties arise around parenting and the wellbeing of children, young people.
Engage with close family members/carers of CYP and support to improve parent/carers & families’ lived experience so that they can increase the skills, confidence and abilities of all family members to live their daily lives in a positive and safe way, that they feel listened to, informed and involved.
Will be supporting the families in a range of settings: their homes, in the community, and in liaison with their short breaks setting, their school and mental health services
To support parents/carers to understand, navigate, signposting and engaging to other services i.e. parents/carers forums, family support groups, learning programmes, short break provision, professionals through education, Health and Social care to ensure they are working together and providing the quality support to each child and young person.

Working with young people within a hospital setting

If the young person is admitted whilst the Keyworker is involved, then the Keyworker will carry on supporting them by

Ensuring they can effectively access the support required whilst in hospital by identifying any areas which might be a barrier for the young person
Co-ordinating and pulling professionals together around the young person
Being a link to the community and following the person through the process of being in hospital
Being involved in all meetings and ensure CYP and parents voices are heard and advocated for throughout the process
Keeping regular contact with the young person. This maybe via face to face visits or phone contact
Helping to secure a robust discharge plan to ensure the right wrap around support is in place to aid their discharge back into the community

If the young person is already an inpatient when allocated a Keyworker, then the Keyworker will contact the young person and visit them in hospital. They will follow similar processes on meeting the young person.