Transition spotlight: Gwen moves out of county

Gwendolyn, age five, is supported by our Children’s Complex Care (CCC) team. She was born with spina bifida and vocal cord palsy. This means she is wheelchair dependent and is PEG fed. Up until recently, she also required tracheostomy care, and regular, invasive ventilation for sleep apnoea.

We have been supporting Gwen since her hospital discharge when she was six months old. We deliver nightly ventilation care that supports Gwen to breathe. This also means her parents receive overnight respite so they can continue to work.

Image of Gwen smiling. She has a white t-shirt on and she has a tracheostomy in her neck.

Making a move

In May 2021, Gwen’s family decided to move to Redhill, Surrey. The family were moving out of county as they’d outgrown the space in their previous home and wanted to be closer to their family and friends network. Yet it was unclear if we could continue to deliver care to Gwen and her family.

Gwen and her parents had built a good relationship with our team who had successfully managed to provide them with consistent, quality care and they didn’t want this put at risk. They asked if we could continue to support Gwen after they moved. That’s when work began to ensure care could continue.

Becoming CCG approved

We liaised extensively with the Clinical Commissioning Group (CCG) in Surrey, where Gwen was moving to. CCGs are groups of practices that are responsible for the provision and planning of healthcare services for local people in their area.

After some initial discussions and application, Surrey CCG felt we could provide a high-quality care service in their borough. They added us to their approved provider list so we could continue to support Gwen.

Parents and child with complex care needs supported by a healthcare assistant during transition.

Overcoming transition barriers

As with all transitions, we had to overcome several obstacles to ensure the process was smooth with little impact on Gwen and her family.

Collaborating with two CCGs

The transition involved input from two CCGs. This was initially a little challenging as each CCG has its own processes and way of working. We spent time understanding each CCG process, working with both boroughs to develop clear communication channels. This ensured everyone was kept up to date with key milestones and collaboration could work seamlessly throughout the transition.


The next challenge was around staffing. The house Gwen was moving to was harder for healthcare assistants to reach than her previous home. Transport links weren’t as accessible and there were limited parking facilitates available.

To overcome this, we gave Gwen’s existing staff team increased travel allowances so consistency in care provision could be maintained. This gave us time to recruit locally in the new location. Once recruited, staff members received an intensive training programme, accompanied by shadow shifts, to ensure they had the bespoke skills required to support Gwen’s needs.

Hannah Eastwood, Clinical Nurse Manager in the Children’s Complex Care team, said, “Having the good existing relationship with Gwen and her family was vital in helping us deliver continuity of care. Gwen is very aware of what’s going on and who delivers her care. So being able to retain the same provider and staff made a real difference.”

Temporary accommodation

We were also able to be very adaptable throughout the process. This was especially true when Gwen’s family were housed in temporary accommodation during the transition before moving into their new home. Our team completed thorough risk assessments in a timely manner, ensuring temporary equipment was safe to manage. This enabled Gwen’s family to receive the support they needed without any hassle.

Hannah Eastwood, Clinical Nurse Manager, discussing the transition said, "It required a lot of flexibility but made the process easier for the family at a stressful time, which is what really counts." Image of Hannah in a purple circular ladder frame.

Ensuring Gwen’s smooth transition

Part of the transitioning Gwen’s care to a new borough involved an interim period. During this time, we delivered joint care alongside the Surrey Children’s Community Nursing Team (CCNT).

The interim period included additional training for staff on new equipment, regular shadow shifts, and third-party oversight and input into care plans. This was done to ensure a safe handover between teams and to demonstrate our clinical ability.

After a few weeks, Surrey CCG reviewed the set-up. They were impressed by the quality of our care delivery and how effective our clinical governance was. As a result, they instructed us to manage Gwen’s care package independently and granted us complete clinical oversight.

Gwen’s mum Jenny was really pleased with the transitional support we offered, commenting, “for us, there was no change, it was such a smooth transition. Our Clinical Nurse Manager Hannah took all the stress away and managed the whole process for us.”

"From the outset, we've been so impressed with the quality assurance and professionalism of the Children's Complex Care Team. We value your honesty, transparency and openness. Our experience to date has been fantastic!" said Senior Clinical Case Manager, Surrey Heartlands CCG.

Gwen continues to make progress

Gwen has been well clinically for some time now, thanks to the great quality care we provide. Recently, she had her tracheostomy out and has learnt to talk! This is great news as it means she’s moved from wet circuit ventilation overnight, to dry circuit ventilation. The main difference with this is that wet circuits filter, heat and provide moisture via a machine-led humidifier. Whereas with the dry ventilation she has now, Gwen is able to do this herself!

Gwen loves her additional healthcare assistants. In fact, she likes them so much, we’ve began assisting the family with their morning routine! This has allowed further person-centred care and interaction with Gwen while she is awake, supporting her to develop her social skills as she grows.

Jenny, Gwen’s mum said, “The carers we have are really interactive with Gwen and she knows that they’re there to keep her safe. That shows me they’re doing everything I want them to with my child and the fact she feels so comfortable around them says a lot.”

We’re excited to continue supporting Gwen to be the happy, healthy and strong little girl she has become!

"I was worried about what the move might mean for Gwen's care package, buit I can't fault the support we had from Children's Complex Care" said Jenny, Gwen's Mum. Image of Gwen on the right in  a wheelchair. She's wearing a white t-shirt with a pink, yellow and blue tutu.

Looking for transition support? Get in touch!

We are experts in delivering smooth care and support transitions. Whether your child or young person is making the jump to adult services, requires out of county support or even if you’re looking for a new care provider, we can help.

Contact our friendly team today. Call 0207 407 7704email or fill in our quick form to find out how we could support you with your child or young person’s transition.

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