My Team Around Me (MTAM)

(Names been changed for the purpose of this case study.)

Steve is a well-known character to Cornwall's street-attached community. Steve came to Cornwall to attend rehab around 12 years ago, but after a series of events, relapsed and return to his lifestyle of living on the streets, triggering multi-agency support. Over the past 12 years, Steve has lived in many of the supported accommodations on offer, as well as periods in temporary accommodation, cold weather provisions and housing first approaches. Steve has had many spells in prison for acquisitive crimes and has also been the victim of some serious assaults including head injuries and broken bones. He is a frequent attender at hospital, with his ageing body not recovering as it once did; he now has diagnoses of COPD, cirrhosis of the liver, as well as poorly-healing wounds and broken bones.

Steve is well known to services for people with complex needs, and during a recent MDT someone said "we have all known [Steve] for years, but his situation never seems to change and we are still discussing the same risks. How do we make it different this time?” He was soon accepted onto the My Team Around Me pilot project. Steve entered accommodation with a formal tenancy where he has his own front door, is responsible for his own bills and, most importantly, has a dynamic team working with him at the centre of his care plan. 

Steve has attend multiple safeguarding conferences online over the years, but has struggled to engage over a screen, has got easily agitated and had to leave early due to alcohol withdrawal. After a period of the MTAM team getting to know each other and making some initial plans, Steve was invited to the meeting. Reasonable adjustments were put in place to facilitate his attendance, including for him to be able to visualise the care around him and understand the united approach. The MTAM took place over lunchtime in a meeting room where Steve lived; all practitioners involved in his care  were invited and everyone reinforced the plan throughout the week ahead of the meeting. 

Steve joined the meeting happily and was glad to see that everyone had come along to see him. We gave him a space to talk about his experiences, what he thinks is going well and what he wanted going forward. When discussing housing options for the future, Steve made it clear he wants a bungalow with a garden so he can get a dog, but aside from this had no firm desires. When we probed further, it came to light that for years Steve had such limited options for housing, he never considered that this could be possible so didn't know what to ask for. Steve told us that he wants more support, but the most important aspect of this is having good relationships with his workers, who come to see him regularly as opposed to an over the phone arrangement, or when they have a form to complete. 

Steve thanked everyone for attending, stating that seeing everyone together made him realise how many people are supporting him and, most importantly, gave him optimism for the future. 

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Do you have a story arising from an MTAM MDT you attend? Your experiences - the triumphs, challenges, and everything in between - could inspire and support fellow practitioners and help build better practice. If you have a story, email tim.huntley@cornwall.gov.uk to discuss sharing your case study.