The DSR (Dynamic Support Register) and CETRs (Care Education and Treatment Reviews)

The Dynamic Support Register or DSR is a local list for children and young people with autism and/or learning disabilities who are a risk to themselves or have behaviours that challenge. As a result of this combination they:

• may be at risk of being admitted into a hospital setting or

• may not be able to stay safe at home / or in their current placement in the community.

The information held on the Dynamic Support Register will be shared with a small group of lead professionals from relevant Social Care, Education, and Health Services. Together these professionals review the children and young people on the register to think about when more support might be needed.

Being on the DSR may mean a Care, Education and Treatment Review (CETR) would be a helpful next step.

Children and young people on the DSR will be placed in different priority categories according to their current risk level. In some situations, a referral for a CETR may be sent by a Care Coordinator or other professional as the next best step, but the child or young person and parent or carer are asked for their consent before a review is arranged.

Families can also self-refer to the DSR.

If you are on the Dynamic Support Register, your care will be discussed by senior people working in relevant services. This may include:

• Clinical Psychologists and or Psychiatrists from CAMHS or an Adult Mental Health Service Manager
• An Educational Psychologist
• Senior Education Health and Care Plan Coordinator or an officer from the Education Inclusion and Safeguarding Service.
• A Social Care Service Manager from Disabled Children’s Services.

Information for the DSR may include:

• Name, Date of Birth, NHS number
• Diagnosis of autism and/or learning disability
• A brief summary of why enhanced support might be required
• Names of teams involved in your care

All information is kept electronically on a separate file system.

Only a limited number of staff in NHS North East London Integrated Care Board (NEL ICB) can access the DSR.

Your details will be removed from the register and all files deleted 12 months after you have stopped being on the register.

You can ask for your details to be removed at any time by contacting your Care Coordinator or by emailing the following address: nelondonicb.candhcetr@nhs.net

If you think your child or young person is at risk of admission to an in-patient mental health unit also known as a tier 4 mental health service, you can sign up to be on the DSR.

If the MDT (Multi-disciplinary Team) support network suggests that your child or young person needs additional support to keep them in the community you or they can sign up to the DSR.

There are 2 ways to be added to the DSR.

1. Professional referral: Your Care Coordinator or other professionals involved in your care can request a young person be added to the register. They will need your consent before any information is added to the register.

Download DSR consent form at the bottom of this page.

1. Self–referral: Alternatively, If you feel a child or young person is at risk of a hospital admission you can also self-refer to be added to the Dynamic Support Register. Any self-referrals will be considered in monthly DSR meetings. Families will be informed whether their child or young person has been placed on the register.

Please complete the Dynamic Support Register Consent Form (Word doc download)

If you live in the City of London and are registered with a Tower Hamlets GP you will get referred to the Tower Hamlets Dynamic Support Register, for more information on how to do this and contact details please use the following link: Tower Hamlets Local Offer :: Providers / Dynamic Support Register (localoffertowerhamlets.co.uk)

Online self-referral
Please use the following Dynamic Support Register self-referral form or please contact nelondonicb.candhcetr@nhs.net for more information.

Children and young people on the Dynamic Support Register will be RAG-rated. This is a bit like a traffic light system. It is based on the level of risk of admission and or their need for more support.

• Green for people who are having their risks/needs managed well at home.
• Amber for people who are at risk of going in to hospital if they do not get the right care and treatment soon.
• Red for people who are at high risk of going into hospital straight away.
• Blue for people who are already in hospital.

When assessing the level of risk/need for each child or young person we consider:

• Any significant life events
• Mental/physical health
• Admission history
• Transition between children’s and adult’s services
• Education provision including residential or specialist provision
• Presenting challenging behaviours
• Changes in support staff
• Contact with the criminal justice system
• Alcohol consumption/misuse
• Recent crises involving accessing either A&E or emergency social care

The register is called dynamic (active or changing) because it reflects the changing needs of the person and their situation. This means the rag rating can change regularly, based on the changing needs of the child or young person.

If the risk is thought to be Amber or Red, then the family and professionals might discuss and agree if a Care Education Treatment Review (CETR) meeting would be helpful.

The NEL (North East London) Keyworking Service

When on the dynamic support register, you may be offered support from the NEL (North East London) Keyworking Service. The aim of the Keyworking Service is:

• To ensure children, young people and their family's voices are heard and represented and they have the right support from services at the right time.
• To either avoid admission or reduce the length of stay in a specialist hospital and help improve the experiences and outcomes.

A Care Education and Treatment Review (CETR) is a meeting about a child or young person who has a learning disability and/or autism and displays behaviours that may mean that they are a risk to themselves.

This, in turn, could result in them being either at risk of being admitted to, or mean they are currently already in an in-patient (psychiatric) service.

Any inpatient admission should be based on very clear reasons why certain needs can only be met in hospital. Inpatient services should not be used due to a lack of local services and support. The aim of a CETR is to avoid admission wherever possible or to plan a discharge from an admission.

The CETR review will look at 4 areas:

1. Is the person safe?
2. Are they getting good care now?
3. What are their care plans for the future? This includes their educational needs and related support provision.
4. Can care and treatment be provided in the community?

A Care, Education and Treatment Review (CETR) is a meeting to find out if all
aspects of your care and treatment are as good as they can be.

When a CETR takes place, it looks at what is good and what could be better.

The CETR is an opportunity to review and better understand:

• How to help improve the quality-of-care people receive within the community
• How to reduce the amount of time people spend in hospital.
• Help to find solutions for problems that are stopping them from leaving hospital.
• Help people stay in their homes and community with extra support.
• Empower people to be in control of their care and treatment and involved in decision-making.
• Brings health, education, and social care teams together to work collaboratively for the benefit of the child or young person.

If your child or young person meets the criteria for the DSR and you think they are at risk of admission to an in-patient mental health unit also known as a Tier 4 mental health pr psychiatric service, you can sign up to be on the DSR and requests a CETR.

If the MDT (Multi-disciplinary Team) support network is suggesting that your child or young person needs additional support to keep them in the community you or they can sign up to the DSR and request a CETR.

There are three different types of CETR.

1. Community CETR: This will take place when a child or young person currently living in the community is at risk of being admitted to hospital or where there may be a placement breakdown if in a residential care setting.
2. Post–admission CETR: This will take place if no community CETR took place pre-admission and will be within 10 working days.
3. In-patient CETR: This will take place If a person has had a community CETR and is still admitted to hospital, they should have a repeat review within 6 weeks if they remain an inpatient.

The CETR panel has a Chairperson and also two independent panel members: a Clinical Expert and Expert by Experience (someone who has lived experience of learning disabilities and/or autism).

If you are happy to meet the panel, they will speak to you to understand what you think about your care, and whether this could be improved. You can bring someone with you, like a family member or advocate.

They will also talk to people in your care network from health, education and social care and will look at some of your files.

The chair will then draw up actions and recommendations from the day’s discussions which will be shared with the family.

The CETR panel is different from the DSR panel and independent of the Multi-Disciplinary Team (MDT) of services directly involved in providing care for the child or young person.

The CETRs are led by health services. A CETR will bring together a network of professionals responsible for providing services to the child or young person. Representatives from health, social care, and education should all be involved. The aim of a CETR is to bring a person-centered and individualised approach to the treatment of the child or young person and to address barriers to their progress.

People from relevant services who are working with your child or young person and attend their CETR may include:

• Parents and carers of the child or young person
• The young person themselves if they are able.
• Family advocate
• CAMHS Clinician
• School SENCo
• EHC Plan Coordinator
• Social Worker

The CETR panel will separately meet and speak with the family and or the young person. They can speak with the young person separately if this is helpful.

If the family and young person wish the advocate can be present for these discussions.

If you require advocacy support please e-mail nelondonicb.candhcetr@nhs.net who will refer you to the right person in the service that provides advocacy.

Will someone with financial decision-making power be at the meeting to agree to packages of support?

No. The CETR provides recommendations, these will then need to be discussed by individual teams and the usual funding allocation process would be followed.

The CETR officer can follow up to see whether these have been actioned.

Anyone can request a CETR with the child or young person’s consent. If this is not possible due to their age or if they are assessed as lacking capacity, consent can be given by their parent, carer or guardian.

You may make this request if your child or young person has had frequent admissions to hospital because they have a learning disability and/or autism and displays behaviours that may mean that they are a risk to themselves. This in-turn could result in them being either at-risk of being admitted to, or mean they are currently already in, an in-patient (psychiatric) service.

If you are on the DSR and find there are blockages in your care and support you can request a CETR and an independent panel will review your situation. This is so that any barriers to staying in the community can be considered and overcome.

Professional Referral for a CETR
To request a CETR, either speak to your social worker or health professional lead who will discuss this with you and escalate your request.

Self-referral for CETR
Alternatively, you can self-refer for a CETR by using the following form:
Care, Education and Treatment Review Self-Referral Form

If you need support to complete this form and process please email: nelondonicb.candhcetr@nhs.net

Please first ensure you have completed the consent form.
CETR consent form (word doc download)

We can offer an advocacy service to help support you in a CETR and to ensure that your views are heard. Please read the following section for more information about this service.

During the CETR process, you will be offered an advocate. If you wish to have an advocate, they will meet with you before the CETR panel meets with you.

The advocate will help you to express and capture your thoughts and feelings, including what is working and not working in all areas of your care and education and what you want for the future.

The advocate will meet with you, in a way that best suits you. They will also ensure the panel is aware of what support you need to engage in the CETR meeting. The advocate, if appropriate, can also speak to your family members or supporters.

The advocate will also be present on the Panel meeting day that you will attend, to ensure your views and wishes are heard and understood. This can be a person from the SEND Information Advice and Support service. In Hackney, this is the SEND Information, Advice, and Support Service SENDIAGS.

A CETR will bring together a network of professionals responsible for providing services to the child or young person. Representatives from health, social care, and education should all be involved. The aim of a CETR is to bring a person-centered and individualised approach to the child or young person’s treatment and address barriers to their progress.

Information shared at the meeting will be unique to the child or young person and their situation. However, most CETRs follow a similar agenda which you can find an example of here. (Word doc download)

The child or young person will be asked to share their views (in a way that is best for them) and where appropriate attend the review themselves.

Parents and carers are also able to share their views prior to the CETR or within the review itself. The child or young person can bring family members, carers and/or anyone else they feel comfortable with to their review for example the advocate if they have chosen to use one.

The chairperson attending the CETR will write up recommendations based on their findings from the meeting and these will be sent to and or shared with parents or carers.

The CETR action plan will reflect the discussion with parents, carers and the child or young person. This is where the most suitable support options will be identified. Recommendations based on the findings and discussion in the review meeting may be made for services to implement.

To ensure there is a tell-it-once approach the same version of the CETR action plan will be circulated to the network and families.

The CETR coordinator will contact services to follow up on the action plan and ensure that what was discussed and agreed at the review is being implemented.

Each action point will have a person assigned from the network of professionals who is responsible for carrying it out.

Recommendations will also be reviewed in monthly DSR meetings and relevant network meetings, the ICB (Integrated Care Board) team will liaise with those identified to deliver recommendations.

Families are also encouraged to liaise with their care coordinators for any feedback or concern relating to recommendations from their CETR.

Is there a quarter or half-yearly review meeting?
Network meetings take place throughout the year but a further CETR may be called when it is needed. Network meetings are held by Care Coordinators. If a further CETR is required you can request the same panel members from your previous CETR to attend.’

Who holds the case and liaises with parents?
The CETR Project Support Officer holds the responsibility for arranging CETRs, specialist keyworkers will also be available to support the child or young person and their families from September 2023 to further understand the CETR process and follow up on recommendations.

The advocate from SENDIAGS and/or the Care Coordinator or Keyworking officer can help parent-carers and young people understand their CETR Outcome Action Plan and how it enables access to support.

Specialist Key working support will be available from September 2023.

The CETR outcome action plan can be discussed at the monthly DSR meetings. If families disagree with any of the actions, they can contact their care co-ordinator who can escalate this with the CETR Project Support Officer.

Usually, families are welcome to attend the feedback session at the end of the CETR where they can raise concerns.

Care Package disagreements support.

The advocate can help parents and young people unpick the package from the care coordinator if they do not agree with the interventions. For example, if PBS (Positive Behaviour Support) was not requested and/or considered the most appropriate way forward.

If parents, carers, or Young People are not in agreement with any intervention, in any area, the advocate should record this. Their role is to draw these issues out when gaining the views of the young person and family.

Disagreements and Complaints

Families are encouraged to discuss any complaints or disagreements with the CETR process and outcomes with their Care Coordinators.

Alternatively, they can contact nelondonicb.candhcetr@nhs.net