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Guiding Light project

The Guiding Light project supports a small group of women who are affected by violence and multiple disadvantage. The definition of multiple disadvantage used by the 'Making Every Adult Matter' (MEAM) approach includes needs around housing, substance misuse, mental health, and involvement in the criminal justice system. You can find out more about the MEAM approach further down the page.

Who we work with


The project works with women who:

  • live in Middlesbrough
  • are 18 and over
  • feel excluded from support services
  • are affected by:
    • domestic abuse and / or sexual violence
    • sexual exploitation and / or sex working
    • housing issues and / or homelessness
    • substance use
    • mental health needs

The Guiding Light project works alongside existing support and professionals, and involves working directly with women to understand the challenges they're facing and what they would like to achieve.

What is MEAM?


The Guiding Light project is a local service using the MEAM (Making Every Adult Matter) approach.

The MEAM approach helps local areas design and deliver better coordinated services for people experiencing multiple disadvantage. It has seven core principles:

  1. Partnership co-production and vision - the right people at the table, a culture of co-production, a shared understanding of the problem and a vision for change
  2. Consistency in selecting a caseload - agreeing a clear referral and selection process
  3. Coordination for clients and services - the practical resource to link individuals to existing services and to get engagement from local agencies
  4. Flexible responses from services - ensuring flexible responses from all statutory and voluntary agencies
  5. Service improvement and workforce development - seeking continuous improvement in local services
  6. Measurement of success - a commitment to measuring social and economic outcomes
  7. Sustainability and systems change - making sure that the results of interventions are sustainable, through changes to systems

The exact way in which the principles are applied will depend on needs in that area.



To be eligible for referral to the Guiding Light project, clients must:

  • be female, aged 18 or over, and live in Middlesbrough
  • have been working with professionals or services for 3 months or more
  • be experiencing barriers to change, and have difficulty engaging with services and / or systems which do not work for them
  • be affected by multiple disadvantage, in 3 or more of the following areas:
    • domestic abuse and / or sexual violence
    • sexual exploitation and / or sex working
    • housing issues and / or homelessness
    • substance use
    • mental health needs

For a copy of the referral form, call 01642 354124 or email guidinglightproject@middlesbrough.gov.uk.

Once the lead worker has made a referral, a meeting will be arranged to discuss what the client is having difficulty with, what they want to happen next, and how to move forward.

How we can help


The Guiding Light project offers:

  • direct support, like home visits alongside the client's social worker / lead worker
  • relationship building to understand the client's needs and wishes
  • support to help the client access services and attend multi-agency meetings

Support can continue until barriers are removed, or the client feels better supported and is engaged with services in a meaningful way.

Frequently asked questions

What is Making Every Adult Matter (MEAM)?


MEAM is a national approach focussed on addressing multiple disadvantage and system change effectively. MEAM supports local areas to coordinate statutory and voluntary agencies to better meet the needs of those experiencing multiple disadvantage by addressing system barriers at operational and strategic level. The MEAM approach aims to improve the wellbeing of people affected by multiple disadvantage, reduce costs to public services, and design and deliver better interventions at a local level.

Why this approach?


Middlesbrough Council expressed interest in the MEAM approach after learning from needs assessments carried out in 2017/2018. These found a need for a more coordinated response to women who are affected by violence and multiple disadvantage, and who consistently fall through the gaps in service provision.

Our aims are to:

  • work closely with a small group of women affected by violence and multiple disadvantage
  • develop an operational partnership with representation from statutory and voluntary partners
  • use the partnership to identify and address system barriers
  • develop a strategic partnership
  • take system issues to the strategic partnership to find flexible solutions
  • escalate system barriers to the Community Safety Partnership where needed

Who is involved in MEAM?


MEAM is a partnership of national charities including Clinks, Homeless Link, Mind, and associate member Collective Voice. The MEAM approach is currently used in 31 areas nationally, with over 1,300 frontline organisations involved. This gives us access to shared learning from across the country - frontline practitioners meet monthly, with oversight from MEAM's Head of Partnerships, Networks, and Training, Anna Suswillo.

In Middlesbrough, MEAM sits in the Adult Social Care department. Key partners in the council include the Head of Specialist and Lifelong Services (Ruth Musicka), the Domestic Abuse and Sexual Violence Lead (Claire Moore), the Homelessness Lead (Debra Cochrane), a Public Health Advanced Practitioner (Rachel Burns), and the dedicated MEAM Coordinator (Kelly Mendum).

The MEAM Coordinator's role

The MEAM Coordinator oversees the Guiding Light project operational partnership. System barriers will be highlighted at operational partnership meetings, and escalated to the strategic partnership with the hope that barriers can be broken down with flexible solutions for our clients.

The MEAM Coordinator will receive the NDT assessment tool referrals (see below) and arrange an initial meeting with the referrer and client where possible. Key objectives in the initial meetings will be for the MEAM Coordinator to develop a trusting and professional relationship with the client. This will be done by creating effective boundaries, and using a person-centred approach to understand the client's goals and wishes.

The MEAM Coordinator will work with professionals and people with lived experience to engage clients in the community, and support them to attend appointments and / or meetings, where system barriers have been identified. To achieve a coordinated and partnership-based approach, the MEAM Coordinator will arrange and attend case conferences, safeguarding meetings, and High Risk Adults Panel (HRAP) meetings. This will allow for better information sharing, and prevent duplication and conflicting actions.

When the client's wishes have been established and appropriate actions have been identified, the MEAM Coordinator will work with the existing partnership and wider services in Middlesbrough to overcome system barriers. They will prepare the 'Team Around Me' template for the operational partnership meetings, draw on the attendees' shared knowledge to develop actions to address system barriers, and escalate to the Community Safety Partnership if needed.

Who will you work with?


Women aged 18 or over, who live in Middlesbrough, and who are affected by violence and multiple disadvantage. We intend to focus on women who have consistently engaged and disengaged from services, and who are unable to engage at a meaningful level due to system barriers.

What is the referral process?


We accept referrals from any frontline services. Referrals are made using the NDT assessment tool. Please email guidinglightproject@middlesbrough.gov.uk for both a copy of the referral form, and the referral guidance, which you'll need to read first.

For professionals and services with access to the CDP, referrals can be made using the built-in NDT assessment tool. The tool is designed to be used as a conversation and potential referrals should be completed as such, using the criteria as prompts. Please read the guidance before making a referral, as inappropriate referrals will not be accepted, although we will provide feedback. You must get consent from the client before making the referral.

If we accept the referral, we'll arrange a meeting with the referrer and the MEAM Coordinator, as well as the service user (where possible).

An agreement and commitment to work with the service user will be made at the next operational partnership meeting.

How many women will you work with?


Due to the intensive work involved, our caseload will be between 5 and 10 women.

How long will you work with an individual for?


The MEAM approach encourages the use of trauma-informed practice, as well as moving away from performance-driven working. Because of this, we will not set timescales for how long individuals can access support for.

How is this different from what other professionals are doing?


The Guiding Light project tries to work in a different way to existing services and professionals. There's a focus on collaboration and involving experienced experts. We also focus on the client's goals, rather than the goals of the service or professional. We emphasise relationship building and flexibility - the MEAM coordinator spends time with clients to understand what their needs and wishes are, then feeds this back to the operational group. This will be done by using the 'Team Around Me' template at meetings to lead discussions on system barriers.

The operational partnership includes partners from statutory services, third sector services, and experts by experience. It gives all professionals a seat around the table, and gives the client a full picture.

The Guiding Light project does not try to replace any existing support. We'll work with any client, regardless of their engagement with frontline services, but will not replace any of those services. Instead, we'll help clients to access services by overcoming system barriers. By identifying these barriers, the MEAM Coordinator will build up links with services and help them to adapt their processes to better suit the client's needs. This then results in system change.

Finally the Guiding Light project will operate differently from statutory and third sector partners by moving away from key performance indicators (KPIs) and timescales. Instead we'll focus on qualitative work and supporting clients until they feel the work is complete.

How will you know when the work is complete?


We hope that clients will be living in appropriate accommodation, and accessing support services which meet their needs. However, there are no set timescales for this to happen, and these outcomes are dependent on the client's wishes.

Some of the core aims of the Guiding Light Project are as follows (although they are open to change depending on the a client's needs):

  1. Clients feel involved in decision-making, and can influence change via the strategic and operational partnerships.
  2. Clients feel that the barriers to accessing services have been reduced.
  3. The partnership identifies barriers and agrees solutions at an individual, operational, or strategic level.
  4. The partnership has increased understanding of women affected by violence and multiple disadvantage, and their needs.

How will information be stored and used?


Information will be stored on the core CDP system and Adult Social Care LAS system / Objective. The initial information gathered on the NDT assessment tool will be discussed at the operational partnership meeting so it's important that clients understand this when they agree to a referral.

We're currently creating an information sharing agreement which all partners must agree to.

What is the Guiding Light operational partnership's focus for 2023?


We've agreed a new format for the Guiding Light operational partnership meetings. This is based on feedback from the group about the best way to facilitate open discussions, as well as the need to get buy-in from partners.

The 'Team Around Me' template for each individual will be shared with the partnership before the monthly meeting. We hope this will give partners time to think about updates since the last meeting, provide background for the upcoming discussions, and make conversation easier and more natural while meetings are being conducted online.

We're also setting aside time in the monthly meeting to discuss system barriers. These issues do not have to involve the Guiding Light client group directly, they could be affecting vulnerable women with complex needs in the wider Middlesbrough community. This will hopefully benefit both our partners and our client group by promoting change on a larger scale.

The partnership has discussed and agreed on the following focus areas for 2023:

  • the voice of women
  • addressing issues around women's trust of, and engagement with, the police
  • barriers to accommodation

If you want more information about the Guiding Light project, you can call 01642 354124 or email guidinglightproject@middlesbrough.gov.uk.

To find out more about the Making Every Adult Matter (MEAM) approach, visit the MEAM website.