HUB Model –Staff Guide
We acknowledge and appreciate the support of the EVE participants and staff who took part in an engagement process and were so generous with their time and feedback.
v2, 2025
TABLE OF CONTENTS
1. Introduction to the HUB Model .......................................................
2. What is the HUB Programme .........................................................
2.2 Programme Delivery .....................................................................
2.3 Breakdown of empowering opportunities & key Elements of the HUB
2.3.1. Discovery Phase .......................................................................
2.3.2 Life Skills (LS) ............................................................................
2.3.3 Transition Planning ....................................................................
2.3.4 Community Access & Training for Continued Health (CATCH)..
2.3.5 Participant Alliance through the HUB (PATH) ...........................
2.3.6 LINK ...........................................................................................
2.4 Additional Features of the HUB ....................................................
2.5 Programme Timeframe .................................................................
3. The Programme Approach Summary .............................................
3.1 Staff Role ......................................................................................
3 2 Participant Profile
3.3 Task Analysis ...............................................................................
3.4 Programme Deliverables ..............................................................
The HUB programme seeks to enhance community development, supporting adults who experience mental health difficulties, autistic adults and adults with an intellectual disability to access mainstream services. The ultimate goal is to foster well-being, social inclusion, and personal goal achievement.
The HUB services are person-centred, and participants will be supported to exercise choice and control over the supports and services they receive and build their capability to be self-directing, making informed decisions in their lives in line with Assisted DecisionMaking (ADM) and using a human rights-based approach.
The programme will operate using a hub and spokes model in which the centre will act as a hub to form active and dynamic relationships (spokes) with different community-based services and resources, an example of which is depicted below
2. What is the HUB Programme
What it is: The HUB programme is a person-led service which supports the individual to meet their goals at their own pace
The HUB is comprised of a number of empowering opportunities & key elements:
Discovery - An individual will start the programme & work through a Discovery Phase where the individual and staff get to know one another A staff member is assigned as a participants’ key worker. This key worker will then support the individual to develop their initial Personal Profile. This in turn will support the individual to develop their first PersonCentred Plan (PCP).
Life Skills - Tailored programme is matched to the individual based on their PCP goals. The programme of need is continually updated via feedback, key worker meetings and updated PCP goals
Life skill sessions can be offered on site, off site or a blend of both.
Transition Planning - This process starts when the individual walks in the door It is informed via key worker meetings & PCPs The last six months is dedicated to working on an agreed progression/exit plan.
CATCH - Identifying what is in the community, what supports can be offered to whom, by whom and when
PATH - Co-produced & peer-led group work to meet identified need, e.g. young adult groups, cinema clubs, Connect Café, men’s sheds etc.
LINK - Individuals can link back into the centre in a number of ways, e g dedicated short courses or for LINK sessions via CATCH to get information on what is happening in the local community by way of courses, groups etc
How it is delivered: The HUB programme is delivered through a range of individual and/or group support and activities that respond to the needs and goals of individual participants
Once an individual is supported to develop their Personal Profile, their key worker will support the individual to develop their first PCP This PCP will identify goals that will need to be broken down into steps and stages These steps and stages may include goals that require the individual to attend some sessions to develop their skills or knowledge in certain aspects, they may include an individual to be supported to make links with local colleges for emolument on courses, to be supported to access the community to identify meaningful opportunities for an individual etc
Individualised Support: Because everyone’s journey is different, there is no ‘one size fits all’ solution The HUB model is person-led using person-centred thinking tools. It takes account of the individual’s needs and works with the individual to plan and support them to achieve their individual goals A person-led approach focuses on the individual, not the service This means: ·respecting where the individual is at now, their journey, dreams and goals ·matching the services and support with the person’s needs ·working in partnership with the individual, families/supporters to ascertain the person’s capacities and strengths
The Support it Offers: The HUB model offers a wide range of supports to improve the individual's wellbeing, from advice and planning to practical support with daily living skills. It can support the individual with:
budgeting & financial planning
transition planning
behavioural & emotional supports via Slánú
assistance with the co-ordination of external support needs, e g housing
assistance, educational support etc.
support for daily living
budgeting assistance
leisure & recreational
community participation
healthy lifestyle planning
social skills development
coaching & mentoring
peer-support
individual or group-based activities
employment, training & education
development of a Recovery Action Plan
Offering Choice: The HUB model supports choice and control for all service users It ensures that all an individual’s needs and goals are unique and recognises that the individual is an expert in their own wellbeing. This approach will securely place them at the centre of the service they receive and be supported across all areas of their lives into their communities, where the objective is to empower individuals to realise their goals and ambitions. The programme outline will be determined by the needs of the participants…their service, their way!
A Person-Led Approach: Person-centred, confidence-building and a 'fun' social aspect to programme development are essential to the success or failure of a programme. Participants in any group need to want to participate in a programme; this can be achieved by innovative programme development and paying attention to the voice of each participant in the group.
Skills Development: The other aspect to programme development will concentrate on developing the skills of individuals in the group so that they can participate in their communities, to the extent that they wish to do so. Links with mainstream agencies/programmes/activities will encourage participation in services and refine delivery of existing programmes.
Community integration: Community integration will be a key component of this programme. The HUB stresses getting participants out into the community to complete meaningful, life enhancing activities. The amount of time spent in the community should be monitored The goal is to support service users to spend more time in the community the longer they access the programme, dependent on individual needs and abilities. The programme will provide opportunities for community activities and centre-based activities Full community integration, or participation in society, is the ultimate goal of rehabilitation. Community integration is defined by three main areas: employment or other productive activity, independent living, and social activity The HUB programme should provide opportunities in the following community integration domains: Housing, Employment, Education, Health, Leisure/Recreation, Spirituality, Citizenship, Social Roles, Peer Support, and Self-Determination. This can be achieved through developing local connections and linking with local statutory and voluntary service providers and support networks based in the participant’s local community. To achieve these local connections staff and participants will need to lead a process of Community & Network Mapping which will discover and continuously update the resources available.
4. Deliver
Ensuring Quality: A primary consideration of the service will be the development of a quality person-centred systematic programme, which will be trauma-informed and will provide a safe and supportive environment, offering sensitivity to participant experiences, providing opportunities and encouragement, and ensuring participants can lead both the direction and pacing of their programme Participants will be offered an opportunity to develop a Recovery Action Plan using the Recovery Context Inventory (RCI) This, in turn can be integrated into the person’s PCP
There is a need to liaise with vocational training and employment agencies alongside developing/coordinating training and support programmes to facilitate recovery and re-employment. Joint working between the centre and the participants’ supporters (Relationship Circle), which may include multidisciplinary/support teams, family and friends, is key to a successful HUB programme.
Staff can deliver support from the centre or out in the community The HUB can offer online/hybrid activities and Outreach / In reach support, where a staff member can work with the person over the phone or via Teams.
2.2 Programme Delivery
The programme will use a semi-structured approach with activities occurring during the day, based on need A diagram outlining a sample day’s schedule/timetable is presented below for illustrative purposes. For example, as we can see John is taking part in an external ‘Silver Surfer’ course in his local library from 10am until 11am. He returns to the HUB to take part in a Communications session at 11 15am until 12.30pm, he has some lunch and then, via the PATH module, he takes parts in a social and recreational visit to the museum as part of programme
There will be several activities available based on a timetable. Each participant will access activities as per their individual timetable These activities can be derived from the individuals’ goals as set in their PCP. External activities (via the CATCH module) will be facilitated alongside individualised key worker meetings, and a selection of centre/alternative HUB-based activities are offered for those who are not engaged externally.
Each staff member will facilitate skill sessions/projects along with activity sessions, both centre-based and community-based External instructors, e g ETB, VEC, sessional instructor etc., where feasible, can run programmes internally on various days alongside the other activities. Participants will be encouraged to access external, e g ETB, VEC or other community-based provision, where possible, as part of the community integration segment of the programme.
2.3 Breakdown of empowering opportunities & key Elements of the HUB
2.3.1 Discovery Phase
The Discovery Phase in the context of the HUB occurs when the person starts on the programme Whilst the timeframe for this will vary person to person, we estimate that this phase can extend for up to 17 weeks or more, if required. It offers the individual the opportunity to get to know the programme, get to know the staff, service users and also provides dedicated time for the individual and their key worker to get to know each other. It provides individuals with the skills, knowledge, and motivation to gain access to, understand, appraise and apply information to make effective decisions about progressing through the programme, about community inclusion and how to take appropriate action to achieve their individual goals. Spending 1-1 time with the person will give staff the opportunity to find out more about the personand the things that matter to them
The process of the Discovery Phase involves gathering information, using a person-centered approach, to guide the development of a customised programme for the individual The benefit of this aspect of the programme is that efforts focus on the individual’s abilities and the things they do well It provides the key worker with a way of focusing on the individual’s strengths and interests in a way that is both positive and empowering.
The structure of the Discovery phase is broken down into five distinct areas (as depicted in the image on pg. 10.)
1. Learn 2 Develop
3. Deliver
4 Refine
5. Progress
Learning starts on day one and looks at the areas of: commencing induction, being assigned a key worker, taking part in key worker discussions, looking at who might make up a person’s Relationship Circle and going through what a Personal Profile is, what it looks like and the information that goes into this document This aspect of the Discovery Phase would take approximately 4 weeks but will be person-led and the duration may vary.
The Develop section looks at building up the key worker relationship and taking part in key worker meetings where the individual can set initial goals, make a draft of a Personal Profile, which will be further added to as we go through this process, and taking part in activities within the programme with other participants. Again, this will be personled, and the duration of this section could be two to four weeks.
The Deliver section of the Discovery Phase looks at refining the Personal Profile, supporting individuals to choose goals which are meaningful to them, informed by keyworker discussions, developing an initial programme and taking part in activities/sessions, e.g. selfadvocacy, goal setting, managing
stress, communication skills, decisionmaking, understanding emotions, problem-solving skills, personal empowerment, lifestyle balance, mindfulness, community inclusion etc. This section may take up to six weeks to complete and is person-led.
The Refine section looks at agreeing and finalising the individuals’ Personal Profile and their Person-Centred Plan (PCP), taking part in sessions (as above) and giving feedback on learning to date This section may take up to four weeks to complete and is person-led.
The Progress section looks at agreeing the individual’s timetable (based on goals derived from their Personal Profile and Person-Centred Plan), co-designing their programme, and agreeing the resources and supports needed. The entire process can take up to 17 weeks to complete but may be longer as this is a person-led process.
2.3.2 Life Skills (LS)
The Life Skills Programme is designed to support participants, at their individual pace, to develop the skills needed to live independently in the community. Semistructured / co-facilitated activities address the specific needs of participants through targeted group or 1-1 programmes These are based on goals set by the individual at key worker meetings and person-centred planning meetings They also provide the added value of participant involvement in the service through peer-support and peer learning. The structured programme elements aim to support the social and living skills of participants through a variety of group activities in a safe, peersupported environment where participants feel accepted.
Some of the core life skills offered may include:
1.Personal Development – Core element (examples below)
Self-Advocacy
Communication Skills
Managing Emotions
Managing Stress
Personal Empowerment
Decision-Making
Goal-Setting
Developing assertiveness skills
Problem-Solving
2. Home cooking, which may include:
Shopping for groceries
Preparing nutritious, well-balanced meals
Accurately managing a budget
3. Numeracy & Literacy
4. Independent Living Skills
5. Mindfulness
6. Wellness Recovery Action Planning (WRAP®)
7. Recovery Planning in Action
8. Smoking Cessation
9. Communicating and working with health and medical professionals
As well as developing specific skills, participants are encouraged to explore aspects of themselves through participation in a range of creative pursuits, e g music, drama and writing groups, and art and craft activities both within the centre and within the community
Participants are encouraged to build on their strengths to support and/or increase their involvement in community activities. The programme will be flexible enough to accommodate transitional periods during which a participant may test moving out of the programme with the knowledge that it is still available to them should the need arise. Transition planning is woven throughout the programme with a view to enhancing opportunities for the individual, then they are ready to leave the service, i.e. before two years, at two years or during a period of agreed extension to provide the necessary supports to transition.
Programme activities will also include those to support participants in their recovery, fostering new goals and ambitions, and coping with challenges using a range of supports and resources. These activities may be provided through WRAP® or by EVE Slánú, the Primary Care Team or jointly with community and/or support teams, individually or in groups, where possible.
How will this look in the day-to-day HUB service:
Timetabling: Individuals, once they have completed the Discovery Phase, will have an individualised daily/weekly schedule or timetable of events (including core Personal Development modules), activities, sessions and 1-1 meetings. This process is person-led via their person-centred plan and the SMART goals set out in this plan.
Planning: Planning and scheduling will be key here as staff will need to factor in time to have 1-1 meetings with individuals, time to link in community connections etc. and also to deliver some of the core and identified group sessions being run throughout the week. For this reason, an individual staff daily/weekly schedule will also be required and will be key to this process.
Material Development: Staff will need to factor in time to develop a session plan with supporting materials / resources, e.g. personal development, life skills etc. that they will facilitate The plan and supporting resource materials will vary based on session duration and topic Some sessions may be of a shorter duration, e.g. 4 weeks and may be more practical or conversational style, which will need less materials developed. Others may be longer in duration and may need more materials. These will need to be saved on the shared drive where the Quality Assurance department and Regional Manager can access and review on a regular basis
Delivery: These sessions can be peerled, co-facilitated and/or facilitator led. The sessions are not academic in nature, they are centred on life experience. The sessions can be a combination of lived and professional experience It is important to note that staff are not expected to be the ‘expert’, knowledge can, and should, come from everyone.
Short Courses: Our Life Skills sessions can be open to everyone, individuals from the community and HUB alike They can be held onsite and/or off-site, where needed. We welcome each individual's valuable perspective and provide the opportunity to join a community of people with shared values
Partnership Working: Partnerships can be extremely valuable here, e g Healthy Food Made Easy, ETB tutors, Sessional tutors etc , in opening the HUB to community but also allowing HUB service users the opportunity to engage in activities we organise in community venues with individuals from the community, e g connect café events, yoga in the park, community art workshops in the library etc.
While the sessions offered can be diverse, they all have the common goal of providing individuals with the knowledge and tools to find the most meaning, confidence and enjoyment in day-to-day life.
2.3.3 Transition Planning
Both moving on from the HUB programme and engaging in community activities whilst attending the HUB should be seen as a process and not something that can be addressed in a single event. Transition planning is woven throughout the HUB model via the goals individuals set at key worker meetings, at personcentred plans and moving from the Discovery phase into other elements of the HUB
Transition planning is key to ensure the individual doesn’t get ‘stuck’ in the programme/service. It enables the key worker and the individual to identify key supports in an effective time frame before progressing onto other services, employment or education at the end of the HUB programme. The key worker needs to work with the individual to decide if additional supports are needed based on the person’s goals
To ensure transition planning is interwoven throughout the programme, the following supports are necessary:
1.Early preparation - Be clear at the start what the duration of the programme is and when the person will be due to exit.
2 Key worker is in place
3.A formal planning process is in place - Person-centred planning and key worker meetings occur which have SMART goals identified.
4 Good communication is essential
5.Empower, encourage and enable the individual to self-manage - Where necessary, support people to take increasing responsibility for decisionmaking gradually and ensure the individuals relationship circle/circle of support are included, where they wish
6 Be person-led at all times
7.Evaluation and feedback is key
2.3.4 Community Access & Training for Continued Health (CATCH)
The CATCH programme is a blended model (i e some activities take place on site and some in off-site community setting) approach, tailored to assist participants by helping them connect with exciting recreational and educational opportunities in the community The programme is more than community participation, it focuses on developing skills that promote meaningful community integration and on abilities that allow individuals to become more self-reliant
Some of the areas of focus include: learning and practicing self-advocacy skills, pursuing educational opportunities, participating in social recreational activities, becoming aware of the community, participating in volunteer work, exploring work opportunities, and learning about personal safety etc.
Involvement in leisure activities, recreation, and life skills development offers additional possibilities for success in everyday life. The CATCH programme supports individuals in achieving a greater quality of life, sense of well-being, and meaningful community inclusion. Participants are encouraged to develop positive connections and resources so that they can be part of a community in which they feel included and valued In order to support people in their wellness journey real progress on community inclusion means a commitment to ensuring all the people we support have many opportunities to fully
participate in the community, and to actively create communities that seek out and welcome the participation of everyone.
Full meaningful community inclusion is when individuals have the same opportunities as everyone else to create a home, develop relationships with families and friends, find a job or complete education, discover communities of people with similar interests, or explore recreational or cultural opportunities.
Each person should have the: opportunity to work toward community inclusion, even if someone else believes that they are not yet ‘ready’ for community participation. power to make their own decisions about what community inclusion means to them, to choose the supports that will help them achieve their goals, and to identify the best ways to manage any risks that may be involved (self-determined goals etc )
chance to pursue participation in areas that are important to them rather than being restricted to what is available or believed to be important by society
To support community inclusion, the individual needs to be an active participant Active involvement begins with individuals identifying for them what is missing, what needs to be retained and/or what they would like to further develop in terms of community inclusion Staff need to work with participants to get to know an individual’s needs and wants, as well as increasing knowledge of the resources available in the community There is no right path and no right approach
With multiple paths and avenues available, it can be hard to know where to start. What may work for one individual does not work for another There may be religious, cultural, personal and family beliefs which influence decisions Some influences may emphasise independence while others promote interdependence As a result, we have developed a Community Mapping and Networking guide that details a stepby-step process that can be followed
Please note that when developing the timetable, the CATCH name will not appear on it, but it will be the activity that you are completing that falls under the heading of CATCH, e.g. Feet on the Street (community mapping), employment research, social media production for events, newsletter development – anything that identifies community, employment, education etc.
2.3.5 Participant Alliance through
PATH is a forum for various clubs and activities that occur within the HUB which are ideally peer-led, but which can be cofacilitated or staff facilitated and/or external tutor/guest speaker led. What ultimately makes a successful alliance is that it is flexible to meet the needs of the participants, it is social in nature and it nurtures and supports the individual We know from research that the following are key to the success of any alliance or club: The relaxed, informal nature of the clubs
The participants’ active involvement in the running of their own club/alliance Outings and social occasions
Each club differs and the format for the group varies. What goes on in the alliance is led by the participants Checking in with the participants is essential Some of the following elements may happen:
Small group discussion/general conversation
Large group discussion/general conversation
Activities (e g exercise, music)
Cup of tea/coffee Outings to local places of interest
Group-based, participant-led peer activities aim to assist individuals to increase connection with community and others, increase social supports, decrease social isolation and support skill development and achievement of individual goals through group processes.
Peer-to-peer learning occurs when participants engage in collaborative learning, where they learn from one another, not a facilitator or staff member Some benefits of PATH include engagement in fun activities, enjoying the social interaction that comes from the activity, involvement in organising and leading group activities (particularly where there are peer led activities).
Examples of such alliances that are facilitated via the HUB are special interest/hobby groups, support groups, e.g. mental health engagement, social activities groups, collaborative project groups, rep committees, sport groups, senior living groups, discussion groups, walk and talk group, youth group etc
Please note that when developing the timetable, the PATH name will not appear on it, but it will be the activity that you are completing that fall under the heading of PATH, e.g. Connect Café, local hobby group, i e book club, knitting group etc.
An overview of the Connect Café is given overleaf
The groups can initially be supported by a staff member and/or peer-support worker, but these supports can be tapered off once the groups get up and going Payment for activities will be funded by participants, and positive risk-taking must be encouraged, e g going to the coffee shop, cinema or supermarket without support.
Positive risk-taking empowers people to discover new experiences, sources of joy and fulfilment, and a sense of meaning. The strategy includes taking carefully reviewed risks to provide positive outcomes for the people we support and focusing on what people can and already do This ensures we are applying a human rights-based approach to our programmes and services
2.3.6 LINK
The LINK programme, which is for those participants who have completed their HUB programme, emphasises social and recreational activities to promote peer networks and reduce community isolation It aims to provide an opportunity for past participants to maintain a connection with the HUB by offering opportunities to attend for specific events/occasions (maximum two halfdays per week, e g Monday morning and Thursday afternoon) without requiring formal commitment It is anticipated that the LINK could offer an ongoing source of connection and support in past participants’ lives and its informal nature lends itself to innovation, creativity, peersupport and experimentation
The LINK programme can take two forms: 1. Dedicated short courses 2. LINK module
Dedicated short courses: Individuals who access other services, community groups, partnerships links, past participants etc. can express an interest and submit their names for attendance on specific courses run within the HUB when places/slots become available These individuals will need to complete an application form and have support available to them from an external person, for example, a community nurse etc
Link Session: Activities are centre and/or community based, e.g. coffee and chat, community update meeting, social group etc. Where possible and of interest, individuals should be supported to engage with existing community groups, e.g. book clubs, cinema clubs, library activities, forum groups etc
The LINK module may be used by past participants as a way of continuing contact with the service, even though they are accessing other services or participating in the community in other ways, such as through employment. It can also act as a pathway to participate in more structured programmes within the community, and where appropriate, participants will be assisted in making this move.
Staff should support participants to explore engagement in other community activities in order that the LINK doesn’t become the sole activity
Process: Participants, prior to exiting the HUB programme will be invited to complete a contact form and, where provided, the information on this form will be used to contact participants when any LINK activities are being offered To access these supports, former HUB participants will be contacted via the Outreach/CATCH element of the HUB when any activities are being arranged and/or short courses/information sessions are available.
For individuals who never attended a programme in the HUB or attended a number of years ago, these activities can still be accessed through a nominated member of the clinical team and community networks/links with the HUB, who can offer additional supports. These individuals will need to complete an application form and submit it to the centre. Programme flyers will be available on a periodic basis and will be circulated to all networks/links for dissemination to all service users If an individual would like to attend a particular short course, they can contact the centre to book a place If there is no available place, the individual’s name will be kept on a shortlist for cancellations and/or the next time the course is being run. Once an individual contacts the centre their contact details are kept on file in the outreach programme and they will be sent notices on upcoming events etc
2.4 Additional Features of the HUB
agreed period of absence, (e g after two days of no attendance or contact)
This is important in supporting participants who may be experiencing difficulties in accessing the centre or a participant who is too unwell to attend the programme, and assists them in maintaining links with the service.
In Reach
Similar to the Outreach system, participants who cannot physically be present can phone the HUB and/or their key worker to assist with support needs This can also assist with community support needs, to discuss any concerns, to have a key worker meeting if they cannot physically attend etc. This is important in supporting participants who may be experiencing difficulties in accessing the centre or a participant who is too unwell to attend the programme, and assists them in maintaining links with the service
2.5 Programme Timeframe
The programme is person-led so each individuals timeframe may vary depending on their individual support needs, attendance, and goal attainment, for example Funding for some services may stipulate a two-year duration with additional time, if needed, to meet individual need.
The individual will participate on an agreed frequency of days per week The first three months, or longer, depending on the individual, will be the Discovery phase. During this time, the individual will develop a personal plan, goals etc and their remaining time will be made up of time in the HUB / community
Internal evaluations will take place every 17 weeks to assess the impact of the programme and make changes as required. The focus will be on progression to more mainstream or community settings. Where a participant has used support tools such as the Recovery Context Inventory, keyworkers can work with participants using goals identified to support participation in their community.
If for any reason attendance is not maintained over a period of time the participant will be invited to a meeting with centre manager / keyworker to explore reasons for disengagement and may be exited from the programme, should they no long want to attend Should the individual wish to re-attend the HUB programme, they will need to reapply. Waiting lists may be in place dependent on numbers within the centre
3. The Programme Approach Summary
The overall approach to the programme will be purposeful and collaborative
Principles underpinning delivery:
Keyworkers should encourage and support participants in taking action based on self-determined choice All approaches will be determined in a collaborative fashion and participant input will be at the forefront at all times.
Person-centred planning and key working will be key processes to this model. Government Policy, as outlined in ‘Sharing the Vision’, is that our mental health services should be recovery-oriented and reflect the user’s unique situation. The development and revision of personcentred planning is a key step taken to ensure this. Proper care/personcentred planning is another essential and indispensable component of a modern mental health service which supports recovery
Operational:
A breakfast / morning meeting, where applicable, will outline the day’s activities, events and/or modules based on the current timetable. It will also note any unforeseen changes to the current timetable, which will be clearly marked on a number of boards (i e Timetable, Calendar of Events etc.) throughout the centre.
Within the HUB model, a PCP will be carried out each 17 weeks. Short modules can be delivered throughout each quarter by a staff member, for example, there may be two five-week sessions (Healthy Food Made Easy and Recovery Planning in Action),
followed by a six-week session (Managing Emotions)
Staff members, alongside their manager, will develop their individual schedules/timetables which will encompass their 1-1 meetings, session delivery, community networking, 1-1 support, linking in with supporters etc. to progress goals
PCP completion can be weaved throughout the 17 weeks (e g between weeks 9-12 – must be completed by week 12 to give time for timetable and work plan development).
Key worker meetings to occur monthly and goals will be reviewed at these meetings.
A Person-Centred Review and achievement meeting will be facilitated annual for each individual to share their achievements and progression with their supporters.
3.1 Staff Role:
The focus of the HUB programme is providing the service user with support, activities and community opportunities that help him/her to live as independently as they can and be a part of their own community to the best of their ability. There is no ‘one size’ that fits all Every staff member will come to this service model with their own unique set of skills and abilities
The main role of the staff member is to: act as a key worker; support individual choice; provide a safe environment; be responsible for the day-to-day running of the programme;
assist the individual to integrate into the community; and deliver/facilitate programmes/learning sessions and monitor, evaluate & review same, including supporting the individual with their annual PersonCentred Review
Supporting effective community integration for participants requires staff to engage with each individual honouring their right to self-determination and to exercise choice in their decisions (Ref: HUB Framework Guide for information on Assisted Decision Making and Will and Preference). It means that independence rather than dependence is promoted, but also that they facilitate access to peer, friendship, family, and professional supports if the participant wishes. It means that support is provided, as much as possible, to support community integration and reduce the reliance on centre-based activities/programmes. It means that the use of mainstream resources is promoted whenever possible and the barriers that limit opportunities for participants from using these resources are addressed.
3.3 Task Analysis
To achieve this person-led, goal-driven programme approach, the following will need to be achieved:
Programme
Develop & implement an individual timetable of activities based on the Person-Centred Plan and Personal Profile for each individual
Carry out community & network mapping
Identify and attain necessary/appropriate programme funding/resources
Identify and develop resources required for programme delivery
Implement programme
Create external community links
Carry out key worker meetings
PCP
Assist the individual with the development of their relationship circle
Have a Personal Profile in place for each individual
Develop and review individual PCP’s / Recovery Action Plans
Maintain links with the participant’s support team (family and friends where relevant and with prior consent) and external key workers as necessary
Support each individual to facilitate their annual Person-Centred Review.
Evaluation
Maintain records & Activity Tracker
Carry out quarterly participant evaluations
Carry out quarterly review meetings with management
Develop an annual service plan and annual report
Carry out annual H&S checklists & self-audit assessments
Participate in system reviews, EASI Tool, quality system audits and external monitoring.
The programme will be reviewed annually or as required, based on participant or programme need.
Internal evaluations will take place every 17 weeks to assess the impact of the programme and make changes as required. EASI Tool focus group sessions can be built in here.
The programme will be monitored regularly with health & safety self-audit checklists, quality systems audits, system reviews, records and participant evaluations
Communication is key and staff meetings should be held frequently.
Participant review meetings should occur weekly to allow a free flow of information to all staff in relation to support needs, individual concerns etc.
provide good support in the way that the person wants. It looks at a number of areas, as follows:
4.Programme Management
What people Appreciate about me -
This section is a list of the individual’s positive qualities
4.1 Person-Centred
Planning
What is Important to me - This section describes what really matters to the individual. The people, places, routines, and aspects of their life that reflect who they are, and what is important to them
The individuals’ personal profile can be continually updated as needed by the individual and their keyworker at key worker meetings, PCP meetings and PCP Reviews.
4.1.2 Person-Centred Plans
How to Support me - This section is what others need to know or do to support the individual to be at their best.
Person Centred Planning has been used in EVE for many years and is about planning with the individual, rather than for them – the individual leads out on this process It’s an approach that considers what’s important to them now, what they want for the future and the support required to get them there. This can be achieved with a team or circle of people to support them, including supporters and professionals.
During the Discovery Phase, the individual will complete their initial PCP based on discussions with individuals and using the goals set by them, their schedule/timetable will be developed Further PCP meetings will occur every four months. The PCP will also be guided by the participant’s key working meetings, WRAP® plan and Recovery Plan (RCI), where relevant
4.1.3 Recovery Plans
Participants will be given the option of completing a Recovery Action Plan during the Discovery Phase. Key workers can support the individual to complete their Recovery Action Plan if they wish. Key workers must give the participant sufficient time to complete their recovery plan prior to their next PCP meeting in order for some or all of their recovery goals to be incorporated into their PCP.
A Person-Centred Review uses person centred thinking approaches to explore what is happening from the person and other people’s perspectives The review looks at what’s working and not working, what’s important to the person now and in the future and agrees outcomes for change.
This review meeting occurs annually, it is facilitated by the key worker The individual and the people in their relationship circle/circle of support are at the meeting The aim of the review meeting is to review progress and plan for the future
A review meeting following a personcentred approach will:
Ensure that everyone, including the person, has an opportunity to have their say
Ensure there is a clear record of agreed actions
Encourage people to add to each other’s comments
The Implementation of the Interim Standards involves self-evaluation The purpose of self-evaluation is to explore and reflect with all stakeholders (people using the service, staff and management) and to report on the effectiveness and quality of the supports being provided under New Directions.
Evaluation, Action and Service
Improvement (EASI) is a self-evaluation process by each service and is a fundamental part of continuous quality improvement process and key to the delivery of the New Directions policy. The aim of the EASI process is to produce a constructive report which will help each service to maintain and improve the quality of its services and supports under New Directions.
Each centre will continually review their EASI Tool and action plan and update and submit to the National Office for November of each year.
! The National Framework for Person-Centred Planning is an important part of New Directions Training for the above is mandatory for all staff working in our HUBs and can be found on HSeLanD. Additional training on the development of Personal Profiles and Person-Centred Reviews has been delivered to all staff.
Please refer to EVE’s Person-Centred Planning Standard Operational Procedure document for more information on these processes
A process needs to be agreed and implemented to review progress and give feedback by the participants, staff and managers throughout the year.
In 2021, there were a number of webinars developed to support service providers to continue to implement the EASI continuous quality improvement process, these are available on HSeLanD It is mandatory for all staff to complete the training and watch the webinars for the EASI Tool.
External monitoring is scheduled for implementation in 2026 and will focus on individual’s person-centred plan outcomes and progression
4.3 Quality Assurance (QA) Audits
Governance provides a framework which ensures that organisations are accountable and have systems in place for continuous quality improvement to safeguard high standards of service provision The QA Audit (along with the EASI Tool etc.) is in place to meet this requirement
The self-assessment can measure and assess the progress of all EVE centres Upon completion, EVE will be able to more accurately understand a centre’s stage of development and any supports required. The information gathered at each centre assessment will form the body of a ‘Self-Assessment Report’, which will highlight recommendations that each centre and the relevant management and support function in EVE can work on together to strengthen the
4.4 Record Retention
4.5 Social Payments
5.1 Programme Overview: 53. Programme Details:
The HUB programme is designed to support individuals with intellectual disabilities, mental health difficulties and/or autistic people. It is a person-led and traumainformed programme using a universal design approach. It focuses on community integration, personal development, and recovery. Activities are tailored to individual needs and goals, encouraging curiosity and hope.
The programme operates through a hub-and-spokes model, connecting participants to community resources Key components include Discovery Phase, Life Skills, CATCH, PATH, LINK with Transition Planning interwoven throughout.
5.2 Objectives:
Empower individuals using a strengths-based approach. Encourage active citizenship and community participation. Create an environment supportive of recovery.
Bridge the gap between the programme and the community
Maximize independence and social inclusion
5.5 Timeframe & Methodology
Timetables developed from the PCPs – individual supports/needs Evaluations every 17 weeks to assess impact and progress. Person-Centred Plans every six months
Recovery Action Plans available to align with personal goals
5.6 Staff Roles:
Act as key workers, supporting choice and community integration. Deliver educational sessions and facilitate skill development Engage with community resources and promote participant autonomy
5.7 Record Retention & Social Payments
Records are maintained securely as per EVE Record Retention Protocols. Social activity payments as outlined in the EVE Community Activities Protocols.
6. Conclusion
The focus of the HUB programme is to provide the participant with support, activities and community opportunities that help him/her to live as independently as they can and be a part of their own community to the best of their ability. The recovery-oriented HUB programme will facilitate the needs of participants, as required, through a community integration focus and recovery approach which adopts the attitudes of hope, respect and empathy towards people with mental health difficulties, intellectual disability, and autistic people (where relevant)
The programme will operate using a HUB and Spokes model in which the centre will act as a hub to form active and dynamic relationships (spokes) with different community-based services and resources, as depicted below.
The centre/staff will help facilitate and assist participants to form support systems and to fully participate in community living Community-based activities will run alongside those of centre-based activities over a 39-hour week (pro rata based on personal need and agreed hours)
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