Keyworking service

The Surrey Keyworking Service is a newly formed team who are passionate about listening to children, young people and their families living in Surrey, and we aim to ensure local health, education and social care teams work together in a holistic and joined-up way to put the right support in place at the right time. By working in partnership with other agencies to offer a joined-up approach to supporting families, the Keyworking Service helps services to work more closely together to manage a person's support needs effectively and ensure positive outcomes in the community.

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What is the keyworking service?

The NHS Long Term Plan includes a commitment to provide a designated keyworker for every child or young person with learning disability, autism, or both, with the most complex needs.

Autism and learning disability keyworkers support children, young people and families to help avoid unnecessary admissions to mental health hospitals. They work with children or young people who are at risk of mental health hospital admission or are in inpatient settings. Keyworkers make sure that these children, young people, and families get the right support at the right time.

You can find out more about keyworking services nationally on the NHS England webpage Children and young people keyworkers (NHS England).

You may also wish to view our Privacy Policy 

Who is the keyworking service for?

Surrey's Keyworking Service support children and young people aged 5 to 25 years old with a learning disability and or autism who are Surrey residents and are on the Dynamic Support Register (DSR).

A Dynamic Support Register (DSR) is a list of people with a learning disability and/ or autistic people who need support. People on the Dynamic Support Register are at risk of going into hospital if they do not get the right care and treatment in the community. It helps health and care staff understand the type of support a person with a learning disability and/ or an autistic person needs to stay well at home. Surrey Heartlands Integrated Care Board manages the Dynamic Support Register for those living in Surrey.

Priority referrals to the service for Keyworker support will be provided to children and young people who are already inpatients or are at risk of being admitted to a Mental Health setting. Keyworkers will work closely with the child, young person and family alongside other agencies involved to try and prevent this happening or will remain involved to try to make any hospital stay as short as possible and endeavour to facilitate a smooth as possible discharge whilst ensuring the right support is available in the community.

Who can have a keyworker?

You can have a keyworker if you meet all following criteria.

  • You have a diagnosis of autism, learning disability or both.
  • You are 5 to 25 years old.
  • You are at risk of hospital admission or currently in hospital.
  • You are on the Dynamic Support Register. Priority referrals are those who are at an immediate risk of admission to a mental health hospital and those who are currently in inpatient services.
  • You live in Surrey.

How can a keyworker help?

A keyworker can help in many ways, including:

  • Acting as the main point of contact for children, young people and their families.
  • Building and maintaining positive relationships with the child, young person and their family/carers during the supportive period, with the aim of avoiding admission or facilitating discharge and strengthening links with relevant services.
  • Working on behalf of the child, young person and their family/carers towards unblocking challenges and barriers.
  • Ensuring the child/young person has a clear, personalised plan to promote their development.
  • Providing continuity of care for the child/young person, working across systems and services to ensure they respond and react to their needs as required.
  • Ensuring recommendations from Care (Education) and Treatment Reviews are completed in a timely manner

Feedback about Surrey keyworkers

We have been receiving lovely feedback from the young people, families and professionals we are working with about the ways in which keyworkers have been able to help.

Just a quick message to say well done – [YP] has really benefitted from your support and the network also seem to be working together fabulously too

Feedback from a practitioner

Very supportive and accommodating with mine and my family’s needs. The path was a big thing that’s positively impacted us and helped someone (me) who can find it really hard to look to the future positively.”

Feedback from a young person

The service was a great support to not just our child but to us all as a family, we knew we only had to ask and they would do their best to help or signpost us to where we needed to go for help.  [Keyworker] was really good at explaining the processes we were going through and how different services interacted with each other.

Feedback from a parent

Information for Families and Carers

The Keyworking team have compiled some helpful resources that families and carers of individuals with a diagnosis of autism and/or learning disability may find useful.

  • Parent toolkit | Ambitious about Autism
  • Family relationships - a guide for parents and carers
  • Spoon Theory & Autism | EdPsychEd
  • Cygnet Parent Programme is a support programme for parents and carers of children and young people aged 15-18, with a diagnosis of autism.
  • R;pple is an innovative online interceptive tool designed to ensure more help and support is provided to individuals conducting searches related to self-harm or suicide. You can install R;pple for free and provide and extra layer of safety for children and young people online.
  • Hope Box - A hope box goes by a lot of names: crisis box, emergency box, self-soothe box, happy box. You can call it anything that makes you feel comfortable. The idea behind this box is that it is filled with things that can help you to feel better. When you’re feeling upset, anxious, or experiencing thoughts of suicide then you can use the box as a way to feel better.

  • Action for Carers provide help for carers across Surrey. Young carers, adult carers and professionals who work with carers. Some of the support they can provide includes giving information, support, advocacy, help with benefits, and workshops/training. We also provide social activities, to give carers a break from their caring role.
  • The National Autistic Society is the UKs leading charity for autistic people and their families. Their website has a wealth of resources with dedicated areas for Families of autistic people.
  • Turn2us is a national charity that provides practical information and support for people facing income shocks and financial insecurity. Amongst other resources, their site includes a helpful benefit calculator.
  • Mind, the mental health charity. Mind are there to make sure no one has to face a mental health problem alone.
  • Hope Box - A hope box goes by a lot of names: crisis box, emergency box, self-soothe box, happy box. You can call it anything that makes you feel comfortable. The idea behind this box is that it is filled with things that can help you to feel better. When you’re feeling upset, anxious, or experiencing thoughts of suicide then you can use the box as a way to feel better.
  • Hub of Hope is the only directory of its kind in the UK that brings local, national, peer, community, charity, private and NHS mental health support services together in one place.  It is free to use and available on desktop and from the App Store and Play Store.
  • The CYP Haven is a safe space for children and young people aged ten to 18 to go to talk about worries and mental health in a confidential, friendly and supportive environment.

What is an EHC plan?

An Education, Health and Care Plan (EHCP) is a legal document for children and young people up to the age of 25 years. It describes and outlines the child or young person’s special educational needs and support they require.

What is an ECHNA?

An Education Health Care Needs Assessment (ECHNA) is the assessment completed to determine if an EHC plan is required. If the child or young person has significant and long-term special educational needs or a disability that ordinary provision is unable to support, then the education provider or parent can request an ECHNA.

For more information on EHC plans and ECHNAs in Surrey, visit the Education, Health and Care (EHC) plans – advice for parents and carers page.

Information for young people

If you’re struggling to make sense of your autism diagnosis, the Ambitious about Autism Charity has videos from different individuals who have been diagnosed with autism in childhood, teenage years and adulthood.

Making sense of your autism diagnosis | Ambitious about Autism

If you need some help understanding the words and phrases used by health and social care, here is a Jargon Buster produced by Think Local Act Personal (a government funded partnership).

  • The National Autistic Society is the UKs leading charity for autistic people and their families. Their website has a wealth of resources with dedicated areas for Autistic adults
  • Surrey County Council have five Autism Friendly Community Groups across Surrey. These groups welcome, support and value autistic people, families, carers and friends.
  • The CYP Haven is a safe space for children and young people aged ten to 18 to go to talk about worries and mental health in a confidential, friendly and supportive environment.

Social Stories

What is a social story? A social story explains a situation by breaking it down to help you understand it better. With the use of pictures and short sentences.

Speak to your Keyworker, Care Co-ordinator or Social Worker about creating a social story if you are finding it hard to understand something.

Communication passport/ profile

A Communication Passport/ profile is personalised to you. It lets you share key information about yourself, your communication style and your needs. It can be shared with anyone. This might be hospital staff, friends, family and teachers.

You can download a communication passport/ profile from the My Compass website.

Hosptial/ health passport

A Hospital/Health Passport is about you and your health needs. It also has other information personalised to you, such as your likes, dislikes, interests, how you communicate and any reasonable adjustments you might need.

You can download a hospital/ health passport template from the Mencap website.

  • Hope Box - A hope box goes by a lot of names: crisis box, emergency box, self-soothe box, happy box. You can call it anything that makes you feel comfortable. The idea behind this box is that it is filled with things that can help you to feel better. When you’re feeling upset, anxious, or experiencing thoughts of suicide then you can use the box as a way to feel better.
  • Hub of Hope is the only directory of its kind in the UK that brings local, national, peer, community, charity, private and NHS mental health support services together in one place. Tens of thousands of services are listed on the Hub of Hope, with numbers growing every day. It is free to use and available on desktop and from the App Store and Play Store.

Information for practitioners

All referrals to the Keyworking Service must be made via the Dynamic Support Register (DSR). For more information, contact Surrey Keyworking Service at keyworkingservice@surreycc.gov.uk.

If you would like to speak to someone in the Keyworking Service about a young person you’re working with or to find out more about the Keyworking Service, please contact us at keyworkingservice@surreycc.gov.uk.

What is an Education, Health and Care (EHC) plan?

An Education, Health and Care (EHC) plan is a legal document for children and young people up to the age of 25 years. It describes and outlines the child or young person’s special educational needs and support they require.

What is an Education Health Care Needs Assessment (ECHNA)?

An Education Health Care Needs Assessment (ECHNA) is the assessment completed to determine if an EHC plan is required.

If the child or young person has significant and long-term special educational needs or a disability that ordinary provision is unable to support, then the education provider or parent can request an ECHNA.

For more information, visit the Education Health and Care plan section.

Social Stories

Social stories are short descriptions of a particular situation, event or activity, which include specific information about what to expect in that situation and why.

  • They can be very useful for someone who is in a heightened state, as this may mean they will struggle to digest or retain large quantities of information.
  • They can help a person to cope with changes to routine and unexpected or distressing events (e.g. change of staff or a legal process that will affect them).
  • They can also be used as a behavioural strategy (e.g. what to do when angry, how to cope with obsessions, how to use de-escalation strategies when in meltdown).

Here are some examples of social stories that the team have used for some of the young people we work with:

Communication passport/ profile

A communication passport/ profile is a person-centred tool, used to help an individual share key information about themselves, their communication style and their needs.

You can download a communication passport/ profile from the My Compass website.

Hospital/ health passport

A hospital/ health passport is about the individual and their health needs. It also includes personalised information, such as their likes, dislikes, interests, how they communicate and any reasonable adjustments they might need.

You can download a hospital/ health passport template from the Mencap website.

PATH

A PATH is a person-centred approach that focuses on an individual’s dreams for the future and what it would take to be travelling towards this. A step-by-step big picture planning activity will be completed to show the individuals dreams and the possible and positive milestones that can be achieved within an agreed and realistic period, which is usually one year.

Below is a video showing the path drawing process. Consent to share has been given by young person.

  • Hope Box - A hope box goes by a lot of names: crisis box, emergency box, self-soothe box, happy box. You can call it anything that makes you feel comfortable. The idea behind this box is that it is filled with things that can help you to feel better. When you’re feeling upset, anxious, or experiencing thoughts of suicide then you can use the box as a way to feel better.
  • Hub of Hope is the only directory of its kind in the UK that brings local, national, peer, community, charity, private and NHS mental health support services together in one place. Tens of thousands of services are listed on the Hub of Hope, with numbers growing every day. It is free to use and available on desktop and from the App Store and Play Store.
  • The CYP Haven is a safe space for children and young people aged ten to 18 to go to talk about worries and mental health in a confidential, friendly and supportive environment.

An explanation of the PATH process

Further information

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