Meeting documents

            Meeting: Health Scrutiny Sub-Committee (County Hall, Durham - Committee Room 1b - 11/03/2008 10:00:00 AM)

                  Item: A4 Looking at the Future of Residential Care in County Durham

         

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To view all graphs please refer to PDF attachment.
Report of Head of Overview and Scrutiny

Purpose

To present for information the JHOSC working group report on the Future of Residential Care in County Durham.

Information

The primary focus for the JHOSC working group was to look at a policy of
reprovision within the context of Cabinet’s decision in October 2006 not to close
homes.

The JHOSC working group recommendations are in two parts:
A) General Recommendations
B) Specific Recommendations for each home

Report attached.

The report will be presented to Durham County Councils Cabinet on Tuesday 20 March 2008.

Recommendation

1) That the JHOSC note the report and agree the recommendations.
2) That Overview and Scrutiny (OS) receive an update on progress in 6 months time as part of the systematic review process of OS recommendations.

Contact: Feisal Jassat Tel: 0191 383 3506 E-Mail: feisal.jassat@durham.gov.uk

SECTION	PAGE
Foreword by Councillor Norman Wade	5
Executive Summary	6
Durham County Councils Decision on “Investing in Modern Services for Older People” October 2006	9
Joint Health Overview And Scrutiny Committee (JHOSC) Working Group: Project Terms of Reference/Approach/ Reporting Membership of the Working Group/ Methodology/ Witness List	13
Location of Our Homes	17
What is the policy context and national drivers for the future of Residential Care? What role does the Commission for Social Care Inspection (CSCI) have with this Agenda?	19 20
What is the Durham County Council Vision for supporting older people to live independently? What principles drive the Vision for the Future of Residential Care?	21
What do we want to see in place to meet the needs of older people in our communities?	24
What are our commissioning arrangements to support older people?	28

Are we making the best use of resources and providing value for money? Do we know what the demographic trends a\re and what are the implications for service delivery? Is the stock we own fit for purpose? What do we know about the stock?	30
Technological Advances To Support People To Live Independently	37
What role and responsibilities do public sector partners have in delivering Residential Care, namely the County Council and District Councils? What is the eligibility criteria? What are the legal implications associated with this role?	39
What do we mean by reprovision? What models of reprovison exist?	43
What opportunities exist for partnership working with other public sector providers for example the NHS? What are the views of partner agencies with regard to our existing provision?	46
Role of the Independent Sector in providing Residential Care	52
How effective is our marketing strategy to promote our residential care facilities?	54
What are the views of the staff, carers and users of the service? Are there staffing implications we need to consider?	56
In House Care Homes Options Appraisal	60
Recommendations	85
PROJECT PLAN APPENDIX 1
AGE CONCERN DURHAM COUNTY REPORT ON THE VIEWS OF USERS AND CARERS APPENDIX 2

FOREWORD BY COUNCILLOR NORMAN WADE

CHAIRMAN OF THE JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE

JANUARY 2008

The future of residential care was always going to be a thorny issue. This is an emotive subject as it impacts directly on the quality of life of our older people, their families and their carers. The task, handed to the Joint Health Overview and Scrutiny committee, from the Executive of Durham County Council, has been challenging but not insurmountable. A challenge that we responded to through an approach we take in overview and scrutiny, that is about being

clear about outcomes for people, the evidence, and what people tell us about what they want. The outcome, captured in this report, is set of recommendations that the Executive need to consider when making a decision on the future of residential care.

In the final analysis the question we all asked ourselves when looking at future care options for older people, the benchmark if you like, was would I put my parents in such a care facility? Does it meet the gold standard?

The report before you deals with the issues and concludes with some important recommendations for the future of residential care. Older people want to live independently in their own homes and be supported to live independently for as long as possible. This is clear.

I would like to extend my thanks to Cllr John Priestley who began this review and my district council colleagues who participated in it.


Norman Wade
January 2008




DURHAM COUNTY COUNCIL
JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE

LOOKING AT THE FUTURE OF RESIDENTIAL CARE

EXECUTIVE SUMMARY

Investing in Modern Services for Older People (IMSOP)

The County Council’s initial strategy for Investing in Modern Services for
Older People (December 2001) involved two phases.
Phase 1(September 2004) involved the closure of 12 of the County Council
Care homes and the development of 6 Extra Care Housing Schemes. A
further 4 homes were earmarked for closure in phase 2 to be achieved by
March 2006. Before embarking on the second phase a review led by Peter
Fletcher Associates considered the housing, care, and support needs of older
people in Durham. The Peter Fletcher report then followed a period of
consultation on the strategy with major stakeholders.

In December 2005 Cabinet considered the outcome from this consultation and
in January 2006 then considered the future direction of in-house residential
care services for older people which proposed the expansion of phase 2 to
include the possible closure and reprovision of all County Council care
homes.

In October 2006 Cabinet decided “proposals for closure as set out in the
report be not taken forward”

Overview and Scrutiny

The primary focus for the Joint Health Overview and Scrutiny Committee
(JHOSC) working group was to look at a policy of reprovision within the
context of Cabinet’s decision. The emphasis being delivery of a higher
quality service rather than closure.

The Evidence

Government Policy on social care places significant emphasis on the need
to achieve transformation of social care by working across boundaries, to
include services such as housing, benefits, leisure, transport and health; and
with partners from private, voluntary and community organisations “to harness
the capacity of the whole system”.

In line with this thinking the County Council will need to develop a strategy
for care informed by a number of key principles that deal with reprovison
whilst supporting people to live independently in their own homes. The
evidence suggests that people want choice, flexibility , information, and
value for money .
People are living longer and it is estimated that over the next 20 years the very old population will increase by two thirds. People are entering care later in life and overall there has been an increase in the number of over 85 year olds in residential care with a corresponding decrease in the number of 75-84 year olds in residential care. That said County Durham has the second highest number of permanent admissions of older people to residential, nursing and EMI beds per 10,000 of the 65 +population with an average occupancy level of 76%.It is worth noting that the numbers of people receiving domiciliary services has increased and there has also been a significant increase in the number of people receiving day care over the last 5 years. There has also been a significant uplift in the number of hours purchased for home care. County Durham is performing well with a 36% target for home care surpassing the Government target .Home care supports people to live independently in their own homes.
The implementation of Telecare services can help older and vulnerable people who wish to stay in their own homes, remain healthy and safe and have as much control of their own lives as possible.

The overall budget for in house provision in 2007/08 is approximately £8.2M.
Durham County Council homes have been graded according to national minimum standards coming out as 3 and 4 (Grade 1 being good).The cost of new build to highest standards for all homes is estimated to be around £42M.

Reprovion (for example extra care, intermediate care,) would require the co-operation of the Primary Care Trust, other partners (e.g. registered Social Landlords) and the joint commissioning of services. Partnership approaches in responding to the whole system is fundamental.

The views of users and carers suggest that issues that would make them consider moving into a home are most likely to be maintaining their house (physically and financially). They want access to affordable personal care, home maintenance and information and advice services.

OPTIONS APPRAISAL

An options appraisal for each of the twelve homes concludes the report making recommendations to remodel our homes in two phases informed by a feasibility study and business case for each home.
Phase 1: with a focus on Manor House Annfield Plain, Lynwood House Lanchester, Grampian House Peterlee, East Green West Auckland and Feryemount Ferryhill.
Phase 2: Cheveley House,Glendale House,Hackworth House,Mendip House,Newtown House,Shafto House and Stansfield House

RECOMMENDATIONS

Recommendations fall into 2 categories ,general and specific, that reflect the evidence in the report.
Durham County Councils Decision on “Investing in Modern Services for Older People” October 2006

Durham County Council’s Cabinet (October 2006) considered a report of the Corporate Director, Adult and Community Services about the outcome of formal consultation on the proposal to close three County Council residential care homes for older people: Hackworth House, (Shildon), Lynwood House, (Lanchester), and East Green, (West Auckland).

Cabinet agreed at that meeting that the proposals for closure as set out in
the report not be taken forward and the homes be retained.

Cabinet also tasked a member working group to examine all alternative
methods of management, marketing, investment needs and revenue
costs. The member working group met over a four month period (between
December 2006 and March 2007) suggesting a vision and strategy to guide
future direction .The approach built upon the Cabinet decision not to close the
existing homes and to ensure that the local authority retained a strong
commitment to good public sector services.

This time limited piece of work was handed over to the Overview and Scrutiny
function in the County Council with a request to build on and conclude
discussions regarding the future of residential care in County Durham.
(see page 14 - What is Durham County Councils vision for supporting older
people to live independently? What principles drive the vision for the future
of residential care?

Investing in Modern Services for Older People (IMSOP)

The County Council’s initial strategy for Investing in Modern Services for
Older People (IMSOP) agreed in December 2001, involved two phases. The
first phase was completed by September 2004 and involved the closure of 12
of the County Council care homes and the development of 6 Extra Care
Housing Schemes. A further 4 homes were earmarked for closure in phase 2
to be achieved by March 2006. The County Council homes identified for
closure in phase 2 were Wellfield House (Murton), Hackworth House
(Shildon), East Green (West Auckland), and Lynwood House in Lanchester.

Before embarking on the second phase of the improvement programme it was felt advisable to take stock and review the current position. To assist with this Peter Fletcher Associates were engaged to update the earlier work undertaken for the County Council in mapping out the housing, care, and support needs of older people in Durham. The Peter Fletcher report was reported to Cabinet in September 2005 and there then followed a period of consultation on the strategy with major stakeholders. A further report was submitted to Cabinet on the 22nd December 2005 giving information from this consultation.

A presentation was made to Cabinet on the 26th January 2006 regarding the future direction of in-house residential care services for older people which proposed the expansion of phase 2 to include the possible closure and reprovision of all County Council care homes. This proposal was rejected following subsequent discussion in Labour Group. A further report was presented to Cabinet on the 23rd March 2006 where it was agreed to close Wellfield House, as no residents remained there at that time, and to initiate a process of consultation in relation to the possibility of closing Hackworth House, Lynwood House, and East Green.

The reasons for proposing the closure of the County Council Care Homes were:
· An over-supply of care home places in Durham both in relation to County Council homes and those owned and managed by the private sector.
· Value for money considerations, specifically the cost difference between County Council care homes and Independent Sector care homes.
· The impact of legal standards relating to County Council care homes, the cost of repairs and maintenance.
· Older people wanting to stay in a home of their own for as long as possible and the Council needing to direct resources to enable them to do so.
· Older Peoples right to choose their care home and an under-occupancy in Council homes. Durham County Council’s Decision on Investing in Modern Services for Older People - Outcome of Consultation Regarding Proposed Closure of Care Homes [Key Decision SHSC/A&CS/04/06]

Cabinet considered a report (October 2006) on the outcome of formal consultation on the proposal to close three County Council residential care homes for older people at Hackworth House, (Shildon), Lynwood House, (Lanchester), and East Green, (West Auckland). The report recommended the closure of the three homes.

The Cabinet Portfolio holder for Adult and Community Services, moved that the three residential homes should not be closed because of the following factors:

· The weight of evidence against closures and the concerns expressed about the impact upon residents and families;
· The risk of a legal challenge having consulted and been provided with clear view that the retention of the homes is preferred option;
· The risk attached to a long protracted trade union dispute and a further challenge from employees for disregarding the findings;
· The fear that a monopoly/private market may result in a reduction in standard provision and higher costs for users;
· The desire for partnership working and local solutions for communities;
· The impact of the pending Local Government White Paper and the thrust for more collaborative working arrangements;
· The view that, whilst two health trusts agreed with the broad principal of closure, they expressed concerns that such changes could not take place prior to local area agreements and understanding about the gaps within service provision;
· The recognition of the high quality provision of care within the public sector that currently exists;
· The demographic changes and extent of the increases in the number of 85 year old plus residents over the next 15 years, which indicate an overall average increase of 81.6 %;
· The difficulties surrounding home care services and the need for radical reform and the problems associated with recruitment, retention and salary levels.

Cabinet Resolved:

1. That the proposals for closure as set out in the Report be not taken forward.

2. That the homes be retained and a working group be set up to examine all alternative methods of management, marketing and investment needs and revenue costs.
(See page 14 - the outcome from the working group commissioned by Cabinet).




THE JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE (JHOSC)
WORKING GROUP:

Looking at the Future of Residential Care in County Durham

The remit of the JHOSC working was informed directly by the decision that
Cabinet took to keep residential care homes open.

The focus of the overview and scrutiny review was also informed by the
outcome from the time limited member working group that met to consider a
vision and strategy for the future of residential care in County Durham .
(See page 14 :- What Is Durham County Council’s Vision For Supporting Older People To Live Independently? What Principles Drive The Vision For The Future Of Residential Care?)

The primary focus for the JHOSC working group was to look at a policy of
reprovision within the context of Cabinet’s decision. The emphasis was to be on re-provision with a higher quality service rather than closure.

The JHOSC working group agreed to look at the following issues within this
context :-

· What is the policy context and the national drivers for the future of residential care?
· What role does the Commission for Social Care Inspection play with this agenda?
· What is Durham County Council’s vision for supporting older people to live independently; what principles drive the vision for the future of residential care? What are our commissioning arrangements to support older people.
· What do we want to see in place to meet the needs of older people in our communities?
· Do we know what the demographic trends are and what are the implications for service delivery?
· Are we making the best use of resources and providing value for money? What funding do we have available (capital and revenue) to support reprovision?
· Is the stock we own fit for purpose? What do we know about the stock?
· What role and responsibilities do public sector partners have in delivering residential care namely the County Council and District Councils?
· What is the eligibility criteria? What are the legal implications associated with this role?
· What do we mean by reprovision? What models of reprovison exist?
· Can we identify examples of good practice in other local authority areas that can inform how best to deal with reprovision, for example extra care schemes?
· What opportunities exist for partnership working with other public sector providers, for example the NHS?
· What are the views of partner agencies with regard to our existing provision?
· What is the role of the independent sector in providing residential care? What is our relationship with them?
· What are the views of the staff, carers and users of the service? Are there staffing implications we need to consider?
· How effective is our marketing strategy to promote our residential care facilities? Membership of the Working Group

The working group took its membership from the JHOSC. Each District Council was represented by one member. County Council members who had a care home in their electoral division were not invited to join the group as standing members because of potential conflicts of interest, but were invited to give evidence as appropriate.

The following County Council and District Council councillors were involved:

Durham County Council
Councillors Bell, Carroll, Chaplow, Hunter, Mason, Nicholls, Porter, Priestley, Simmons, Stelling, Stradling, Trippett and Wade.

Chester le Street District Council
Councillor Armstrong

Derwentside District Council
Councillor Agnew

Durham City Council
Councillor Smith

Easington District Council
Councillor Campbell

Sedgefield Borough Council
Councillor Crosby

Teesdale District Council
Councillor Cooke

Wear Valley District Council
Councillor Todd

Approach

The Working Group agreed to take evidence from key witnesses involved directly and indirectly with residential care. It also agreed to receive correspondence, organise visits, meet with relevant parties to ensure members fully understood and considered the evidence on this matter before reaching any conclusions or making any recommendations.

Reporting

The Working Group agreed to report, in the first instance, to the Joint Health Overview and Scrutiny Committee on its findings, then to Corporate Management Team (DCC) and Cabinet (DCC) with its recommendations requesting Cabinet to respond to these recommendations via an action plan.

Methodology

A detailed project plan for the Working Group is attached. (See Appendix 1). The plan in effect is a scoping document that identifies who was invited to the meetings and the nature of the evidence the JHOSC working group received.

Witness List (In Order of Appearance)

Lesley Tickell Head of Adult Care (DCC)
Marion Usher Divisional Commissioning Manager (DCC)
Teresa Brown Service Manager - Community Care Services (DCC)
Nick Whitton Head of Adult Commissioning (DCC)
Jeff Garfoot Head of Service - Strategic Finance & Business Support (DCC)
Peter Appleton Head of Planning and Performance (DCC)
Ken Pearson Head of Corporate Estates (DCC)
Geraldine Waugh Divisional Commissioning Manager (DCC)
Alan Hodgson Director of Customer Services (DCC)
Colette Longbottom Assistant Head of Legal Services (DCC)
Cameron Ward Director of Commissioning County Durham PCT
Anthony Prudhoe Assistant Director of Commissioning County Durham PCT
Michael Laing Chief Executive of Wear Valley District Council
Martin Knowles, Chief Executive Three Rivers Housing
Geoff Wade Chair Independent Sector provider
Richard Proud Information to the Public Team Adult and Community (DCC)
Linda Lindsey Information to the Public Team Adult and Community (DCC)

Visits

The following visits were undertaken during the course of the project:

· Older People’s Services Gateshead (The Members who had attended the visit commented on the excellent services commissioned for older people by Gateshead Borough Council).

· County Council Residential Care Homes: Feryemount House, Hackworth House and Grampian House.
· Extra Care Homes: Sycamore Lodge and Appleton Lodge



County Council provided Homes



THE POLICY CONTEXT AND NATIONAL DRIVERS FOR THE FUTURE OF RESIDENTIAL CARE. The Government White Paper, “Our Health, Our Care, Our Say: A New Direction for Community Services” presents an ambitious vision in which health and social care are closely integrated, community based, and focussed on maintaining the health, well-being and independence of service users. It signals future priorities and directions for health and social care with four main goals.

· Better prevention and early intervention
· More choice and a stronger voice for individuals and communities in how services are planned and provided
· Tackling inequalities and improving access to services
· More support for people with long-term needs and their carers

A key policy direction which the government believes will assist in achieving these goals is:
Recently (January 2008), the Department of Health (DH) issued information to support the “transformation of social care” agenda, signalled in the DH’s social care Green Paper, “Independence, Well-being and Choice” (2005) in line with “Our health, Our care, Our say: A new Direction for Community Services”.

The vision for social care services proposed is that of “personalisation” including a strategic shift towards early intervention and prevention. Personalisation is taken to mean “every person across the spectrum of need, having choice and control over the shape of his or her support, in the most appropriate setting”.

An important emphasis in the document is on the need to achieve transformation of social care by working across boundaries, to include services such as housing, benefits, leisure, transport and health; and with partners from private, voluntary and community organisations “to harness the capacity of the whole system”.

The approach is intended to range from support for those with emerging needs, to enabling people to maintain their independence and to supporting those with high-level complex needs. The new Joint Strategic Needs Assessments, the Local Performance Framework and Local Area Agreements are seen as fundamental to achieving the vision.

Government thinking for the “transformation of social care” considers a number of changes in society that, together, present a case for change. These include:

· demographic changes - the increasing numbers of older people and therefore of dementia associated with extreme old age; people with learning disabilities and severely disabled children living longer; changes in the numbers and availability of voluntary carers;
· changes in expectation - people wishing to live independently at home with a greater emphasis on dignity, respect and control over their own lives ;
· an emphasis in policy and a desire among service users for a shift in services towards wellbeing and prevention, rather than relying on intervention at the point of crisis.
WHAT ROLE DOES THE COMMISSION FOR SOCIAL CARE INSPECTION (CSCI) HAVE WITH THIS AGENDA?

The Commission for Social Care and Inspection (CSCI) is the body responsible for monitoring the performance of Adult and Community Services. It is also responsible for registration and regulation and prescribes national minimum standards for residential care homes. They also produce data in relation to compliance with minimum standards of care for every home.

CSCI also inspect homes and are moving towards a risk based inspection regime. Therefore if an establishment is rated as 3 stars it will only receive a key inspection once in every 3 years. The balance between regulation and commissioning is shifting and therefore the County Council will be expected to pay more attention to its commissioning.

Note: The Commission for Social Care Inspection (CSCI) Annual Performance Rating Assessment for Durham County Council Adult’s Social Services (06/07) overall judgement for “Delivering on Outcomes” is ‘Good’ with a 2 star rating.(Cabinet report 24 January 2008).

RECOMMENDATION The JHOSC working group note the emphasis placed upon working across boundaries to harness the capacity of the whole system in government policy. The JHOSC working group welcome Local Area Agreements and Joint Strategic Needs Assessment (JSNA) as important mechanisms to enable this to happen.

WHAT IS DURHAM COUNTY COUNCIL’S VISION FOR SUPPORTING OLDER PEOPLE TO LIVE INDEPENDENTLY? WHAT PRINCIPLES DRIVE THE VISION FOR THE FUTURE OF RESIDENTIAL CARE? Following the Cabinet decision in October 2006, a member working group met
in line with Cabinet’s request to examine all alternative methods of
management, marketing, investment needs and revenue costs.

The group was chaired by the then Cabinet member with responsibility for
Adult and Community services. All members having a residential care home
in their electoral division were invited to join the group. The chair of the Joint
Health Overview and Scrutiny committee (JHOSC) attended as an
observer. The member working group was supported by the then Head of
Adult Services, with support from legal services. Information was also
provided from other services as required, for example Estates Division of Corporate Services.

The group met on 4 occasions between December 2006 and March 2007. In addition to these meetings the Leader of the Council, chair of the working group and lead officer visited Gateshead Social Services Department early in January 2007 to determine how they had assessed similar issues now being faced in Durham. Visits also took place within County Durham to aid understanding on issues and options relevant to this work. The homes visited included a traditional local authority residential care facility, an adapted home specialising in intermediate care, an extra care scheme developed in partnership with Hanover Housing Association and a private sector home.

Finally, an open seminar was held for all members of the County Council on the 7th March 2007 to share preliminary findings as part of an open process designed to engage members in formulating an effective vision and strategy.

Important Considerations from the Member Task Group

Focus on Re-Provision Rather Than Closure:-
The lessons from Gateshead indicated that they successfully re-provided 12 local authority homes with five new extra care schemes developed in partnership with a housing association and 1 intermediate care facility in an adapted home. The focus on re-provision rather than closure meant that the changes received support from staff, trade unions and public. Other important developments included the council building bungalows and a new sheltered accommodation scheme as part of a whole system approach covering housing and care, thereby offering greater choice to the public within an overall regeneration programme.

Extra Care Is Better than Traditional Residential Care For Many People:-
The lessons from Durham included confirmation that extra care is better than traditional residential care for many people. A previous report from Peter Fletcher (Cabinet, September 2005) suggested more of this type of accommodation will be needed in future, particularly 2 bedroom and self purchase units.

Strong Partnership Working Across Health And Social Care:-
Members also noted the important outcomes for many people being achieved via intermediate care, the strong partnership working across health and social care and its ability to maintain people's independence. The local authority currently have a “market niche” with this service and more is likely to be needed in future because of hospital stays reducing and people's desire to retain their independence to live at home. It was also noted that the private sector has developed some new builds offering high-quality provision.

Standard of Independent Sector Homes (Grade):-
As part of fee negotiations with the independent sector an independent company, GLP, were commissioned to grade the homes based on physical standards. Grade 1 homes meet the latest building standards, including en- suite facilities and wider corridors and grade 4 the poorer quality homes.
GLP findings indicate that of the 104 independent sector homes in County Durham:

· Grade 1 = 21
· Grade 2 = 39
· Grade 3 = 39
· Grade 4 = 6

The local authority homes (Durham County Council provided) are graded as follows:

· Grade 3 = 6
· Grade 4 = 6 Funding Challenges:-
Members also considered the funding challenges specifically regarding capital and revenue relating to the homes.

a) Capital:
Observations from Gateshead and Durham clearly confirmed that new build is superior and investing in adapting buildings is costly and undesirable. It cannot achieve the standards or quality of new builds and risks reducing occupancy further, thereby increasing unit costs, making homes uneconomic.

Previous reports referring to the estimated cost to upgrade local authority homes were challenged in the light of the GLP findings. Concern was also noted that any estimates of rebuilding were based upon desktop exercises and time-limited, i.e. building costs can increase and decrease. Members were also aware that there were many options available for accessing alternative finance to mitigate any estimated building costs, including housing grants, joint ventures with housing associations and other providers, sale of land to generate investment etc.

b) Revenue:
It was noted that the revenue costs of the local authority provision are higher than those in the independent sector. Some contributory reasons include the local authority paying higher wages.

Proposed vision for the next 40 years:-
An early conclusion from the group was that after Cabinets decision not to close home it was necessary to restate a vision for their future. The vision needed to be in line with the County Council wanting “to provide high quality local services and public sector care.”

The group agreed that the model of care should be based on:

· Additional extra care schemes developed in partnership with others. (Peter Fletcher’s report, and observations in Gateshead and Durham confirming this as a positive way forward).
· A North and a South Centre of excellence for intermediate care. The observation of Grampian House and awareness of future need indicate this to be an essential development for future services.
· More housing and care options, including the development of bungalows, sheltered accommodation and tele-care within a wider regeneration/sustainable communities initiative shared across all agencies.

Underpinning principles:-
The vision needed to be underpinned by a number of fundamental principles to deliver on this agenda:

· To support older people to live independently in their own homes.
· To invest in new builds rather than major adaptations of existing homes. This will ensure available funding is used wisely to develop homes that are fit for the future.
· To proactively undertake market testing to identify suitable partners to achieve our vision. This will provide an opportunity for members to select partners who share common aspirations and ensure best value is achieved.
· To make changes incrementally, thereby allowing time for single status and partnership options to mature.
· To seek to expand extra care facilities across the county to ensure that we are well equipped to respond to the changing demographic and service needs to help people to maintain their independence.
· To re-model staffing in the remaining homes based on the need to achieve best value and savings associated with medium-term financial planning strategies to provide more flexibility for managers and enable exploration of new initiatives such as pooled arrangements for staffing the homes.
· To explore the merits of registering LA homes for Elderly Mentally Ill care in response to emerging demand and budget implications. Proposed Next Steps:-
That the work of the member working group be taken forward by the Overview and Scrutiny function in the County Council.

WHAT DO WE WANT TO SEE IN PLACE TO MEET THE NEEDS OF OLDER PEOPLE IN OUR COMMUNITIES?

Introduction

Older people are the main users of the NHS. CSCI research suggests that two thirds of general and acute hospital beds are occupied by people aged 65 and over. Of care home residents, 72% are immobile or reliant on assistance, 62% are confused and forgetful and 24% are confused, immobile and incontinent. Older people in healthcare, especially those with complex needs, are dependent on others for many, if not all of their basic needs, such as food, personal care and medication. They may have, or feel that they have, little or no control over what happens to them.

The government’s agenda for public service reform includes creating the levers and mechanisms whereby people can participate in shaping and securing the services they want in order to achieve their aspirations.

Place-Shaping

Community Leaders will need to ask what the nature and variety of supply means for the type of place the local council represents. The “place-shaping” agenda described by Sir Michael Lyons (Securing Good Care for Older people March 2006) implies the need to ask such questions as: “What sort of area is this in which to grow old? To live as a disabled person? Can a person meet their expectations in this area? Is it a place with many options and opportunities?" In seeking to develop their areas as good places in which to grow old, the council will need to guard against the emergence of a widespread two-tier market, where those with resources buy “good” and “excellent” services, whilst those who access provision paid for by councils have to make do with lower-quality services. This means that councils will need to engage in long-term relationships with a wide variety of providers of social care to provide not just the minimum standard but strive to provide a gold standard.

The overall vision is that the State should empower citizens to shape their own lives and the services they receive... “In some instances the best way of empowering users is to give them direct involvement in the commissioning of the services they receive.” (“Building on Progress: Public Services”, Cabinet Office, 2007.)

Too often, however, there are a limited range of services available and offered to people, with an overwhelming emphasis on institutional care. The emphasis must be about supporting people to live independently in their homes, with an appropriate level of support.

People’s Choice

The County Council is expected to adhere to a directive on people’s choice on where they want to receive their care. The Department of Health requires the County Council to offer choice to service users. Service users may choose not to be cared for by the authority. People may choose the independent sector. It was stated that many incoming residents have properties to dispose of and will be paying for their own care. They are aware that local authority homes are more expensive than the independent sector when making a choice of a residential home.

People have a choice to stay at home or go into care. They have a choice of County Council homes or the private sector. The County Council will try to support people to live at home where possible. It is worth noting that whilst the number of elderly is rising, the numbers entering residential care are decreasing because we are managing to keep more people at home.

As part of the Choice agenda, County Durham has a mixed care economy which ranges from fully funded public services, residential care fully funded by private individuals, people staying in their home or extra care developments. The County Council has provided a full menu of services, in conjunction with its partners and stakeholders, which offer rehabilitation, support in community hospitals, extra care schemes, intermediate care, sheltered accommodation and community villages. There is also a rising demand for Elderly Mentally Ill (EMI) care.

Key Principles

As a way forward, the evidence suggests that the County Council should develop a strategy for care informed by the following key principles:

· Refer to re-provide and not close
· Support people to live independently in their own homes
· Invest in new build not just adaptations.
· Proactively seek partnerships to fund our ambitions.
· Focus on extra care and intermediate
· Consider registering for EMI care.
· Implement incremental change to allow for unitary and partnership options to mature.
· Re-model staffing in remaining homes based on the need to achieve best value.

What Do People Want?

CSCI believes that councils need to pay more attention to what people say about the qualities that are important to them in the services they receive. Its recent report, “Real Choices, Real Voices” highlighted what people said matters most to them. This is the order of importance that people put things in:

· choice
· flexibility
· information
· being like other people and making their own choices
· respect and being heard
· fairness and non-discrimination
· cost and value
· safety.

People’s expectations of their quality of life (both younger people with disabilities and people who are due to retire in the foreseeable future) are unlikely to be the same as the quality of life or care standards of those who are retired.

Furthermore, once people have experienced managing and controlling their own services, through direct payments and individual budgets, they are unlikely to accept a return to a traditional “menu” of prescribed options that they have previously experienced. What needs to emerge is a new model of care that offers more than a simplistic choice between “independence” and residential care.

At the same time councils have to develop strategic commissioning for the whole community, working with local communities to identify what people want from social care services and ensuring there is sufficient supply of those services - care, support and infrastructure - to meet local needs.

CONCLUSION

The County Council should develop strategic commissioning for the whole community, working with local communities to identify what people want from social care services and ensuring there is sufficient supply of those services - care, support and infrastructure - to meet local needs and taking into account:

· choice
· flexibility
· information
· being like other people and making their own choices
· respect and being heard
· fairness and non-discrimination
· cost and value
· safety.

RECOMMENDATION

The JHOSC working group recommend that the new unitary council for County Durham recognises and plans for the place shaping agenda with regard to the needs of older people in line with Sir Michael Lyons thinking on this subject.

That the County Council give consideration to an Older Peoples strategy that reflects key themes to do with what people want underpinned by the principle of supporting people to live independently in their own home.

WHAT ARE OUR COMMISSIONING ARRANGEMENTS TO SUPPORT OLDER PEOPLE? What Is Commissioning? “Commissioning is at the heart of effective social care. It offers an opportunity to transform people’s lives through better services - it is not about procedures and processes”. (Denise Platt, Chair of CSCI) Commissioning must define outcomes for people. The starting point for both commissioners and providers should be effective engagement with people who use social care services or might use these services in the future. This should not just be about listening to people’s views, but about giving them information about what the options are, and sometimes raising their expectations. People often ‘choose’ residential care because they don’t know about all the community services that could help them. The Commission for Social Care Inspection has given some attention to the role of commissioning in developing new models of care. Its most recent publication, Safe as Houses? What drives investment in social care? published at the end of September 2007, considers the relationship between councils, providers and investors in developing the social care market for older people. Previously, it has published Relentless Optimism: Creative Commissioning for Personalised Care. Commissioning is the process of translating aspirations and need into timely and quality services for users which meet their needs, promote their independence, provide choice, are cost-effective, and support the whole community. Commissioning is distinct from contracting, which is about the formal agreements between commissioners and service providers that determine the service specification, service volumes, costs and how services will be procured. It is also separate from purchasing, which is about arrangements for the procurement of services to meet the needs of individual people identified in their care plans. Councils need to commission services for all those living within their boundaries, including those who pay for their own care and those whose voices are not heard. The commissioning role of local councils is crucial for the future. Directors of Adult Social Services will need to know the future social care needs of people in their areas, identify how people would prefer those needs to be met and estimate how the council might purchases directly so as to provide the maximum flexibility and choice for service users, while ensuring that they are getting value for public money. The future will be a very different world from the current one of limited options of (mainly) domiciliary care and care homes. Councils will have to find ways, in their commissioning activity, of “aggregating infinity” - the sum of everyone’s choices and preferences. This means that they will need to signal to providers, either individually or collectively, the need to offer a very wide variety of services - tailored to individual choices - with a clear tariff of costs and charges. It is possible that many older people will live in their own homes or in assisted living facilities longer before possibly moving into a care home. This can be supported by greater imaginative commissioning of assistive technologies - anything from enabling people to remain independent longer by monitoring when they take medication and reminding them to do so, to something as simple as being able to open and close blinds electronically from a bed. CSCI in its publication Relentless Optimism: Creative Commissioning for Personalised Care promotes commissioning of a wide range of services that are personalised at the point of delivery. For instance, home care organisations could supply several services. Some people may choose to have a meals-on-wheels service from a care organisation which offers to arrange delivery of meals from local restaurants or pubs, to a whole suite of additional services, such as trips to go out shopping, arranging holidays or chiropody. Commissioning for outcomes raises key issues about structures and institutions. Many people currently attending day centres might prefer to go to a park, cinema, pub or job instead, particularly if they knew the component costs of transport, activities, lunch, and so on. The route to well-being may therefore not be via existing services set up by councils for people with social care needs, but by ensuring that mainstream services cater properly for everyone. The Council will need to consider if their information systems are adequate to allow them to review regularly the choices that people make, to see what trends are emerging and to assess the implications for social care and other services. They will need to consider how they can use all available information, including inspection information, on how local services meet national improvement standards. The Role Of Elected Members in Commissioning Elected members have a key role to play in shaping a council’s commissioning strategy. Executive members make policy on a wide range of central issues - the level of priority given to social care, the contribution of social care to the corporate agenda, the share of the corporate budget to be given to social care, the role of in-house service provision and the balance with independent sector provision, the extent and pace of change, the development of the local economy. Members of scrutiny committees also have an important function in keeping the relative priority of social care within the council’s agenda under review, making recommendations on strategic priorities, monitoring performance and undertaking inquiries into areas of particular concern. CONCLUSION The commissioning role of local councils is crucial for the future. Commissioning must define outcomes for people. Councils should drive the ‘place shaping’ agenda for older people, considering all aspects of what makes an area good for older people to live in, not just social care. While it is important that commissioning should remain a local responsibility, assisting with the development of the skills and capacity needed to undertake this effectively should be supported nationally. The Commissioning Framework for Health and Wellbeing describes many mechanisms, such as the Joint Strategic Needs Assessment, which will contribute to better commissioning. It also proposes better training for commissioners, which will be essential if councils are to enhance their capacity in this area. RECOMMENDATION The JHOSC working group note the important role elected members have with shaping a commissioning strategy that should focus on outcomes for people.

ARE WE MAKING THE BEST USE OF RESOURCES AND PROVIDING VALUE FOR MONEY?

DO WE KNOW WHAT THE DEMOGRAPHIC TRENDS ARE AND WHAT ARE THE IMPLICATIONS FOR SERVICE DELIVERY?

IS THE STOCK WE OWN FIT FOR PURPOSE?
WHAT DO WE KNOW ABOUT THE STOCK? Demographic Trends, Property Stock and Financial Issues

Demographic Trends

· It is estimated that over the next 20 years the very old population will increase by two thirds.

· The 65+ population in County Durham is expected to rise by 22.5% (19342 people) between 2006 and 2016.

· Chester le Street & Durham will experience the highest increase in this period of 31.1% (2821 people) and 30% (4013 people) respectively.
· Easington will experience the lowest increase at 14.1% (2346 people).

· The 75+ Population in County Durham is expected to rise by 20.3% (7922 people) between 2006 and 2016.

· Chester le Street and Durham will again experience the largest increase at 35.8% (1367 people) and 20.2% (1195 people) respectively.
· Wear Valley will experience the lowest increase at 16.6% (873 people).

· The 85+ population in County Durham is expected to rise by 38.9% (3616 people) between 2006-2016.

· Sedgefield and Easington will experience the highest increase at 52.1% (850 people) and 50.1% (839 people) respectively.

· Wear Valley will experience the lowest increase of 25.4% (365 people).

Domiciliary Services

The numbers of people receiving domiciliary services has increased whilst the number of people placed in residential, nursing or EMI placements has fallen significantly.

Durham’s domiciliary in-house market share is lower than the North East average (2006), IPF average (2007) and England average (2007). Durham has a low level of in-house domiciliary care, although has a high level of domiciliary provision overall and performance is very good for indicator PAF C28 ‘Numbers of older people in receipt of intensive home care’

The number of people being helped to live at home has increased by 113% from 2002/03 to 2006/07. This is in line with national trends.

Permanent Admissions
County Durham has the second highest number of permanent admissions of older people to residential, nursing and EMI beds per 10,000 of the 65 +population compared to the IPF cluster with only Northumberland County Council having a higher number of admissions.

The actual number of clients being admitted to residential, nursing and EMI beds is falling and is expected to level out and will then increase with the general uplift in the population of older people.

The average age at permanent admission has been increasing and is currently 85.6 with people being admitted to residential care only when they need to be. As a consequence, the average length of stay in a residential placement is shorter as people die.

Population trends show a significant increase in the EMI population with the number of permanent EMI residential admissions increasing. This is in comparison with a decrease in the overall number of residential admissions.
There is likely to be an increase in demand for the provision of EMI places and for intermediate care. .

Home Care Hours
There has been a significant uplift in the number of hours purchased for home care. The Government target for intensive home care as a percentage is 34% of overall activity. County Durham is performing well at 36% surpassing the Government target and in our IPF cluster County Durham is the best performer.

Residential Care
Overall there has been an increase in the number of over 85 year olds in residential care with a corresponding decrease in the number of 75-84 year olds in residential care. There has also been a significant increase in the number of people receiving day care over the last 5 years. This includes a 48% increase in the number of over 85 year olds in receipt of day care. There are no national comparisons for Day Care.

The level of bed occupancy within the private sector is approximately 81% and the level of in house occupancy is approximately 76%.

Durham’s in-house market share is higher than the North East average (2006) though lower than the IPF average for 2007. Durham’s performance against indicator PAF C72 ‘Number of admissions of older people’ was very good in 2006/7.

CONCLUSION

Evidence suggests that home care makes economic sense and enables people to live independently in their own homes.
The market in County Durham is well developed and tends to respond to any need as it arises.

RECOMMENDATION

The JHOSC working group would like to remind Durham County Council’s Executive of the importance of home care in supporting people to live independently; and that any strategy for Older People must recognise the importance of community and social support networks that support to people to live independently.

Financial Issues/Value for Money How longer-term care should be funded has been a controversial issue for over 30 years, with reforms suggested over the years. It has once again become a pressing political issue, with the growing pressures on social care and the major demographic changes we are facing. Its importance was highlighted by the government's announcement in the comprehensive spending review that they will produce a green paper setting out options for a future reformed system sometime in 2008, which would identify the key issues and explore options for reform. Future Of Funding Long-Term Care Caring Choices is an initiative run by a coalition of 15 organisations from across the long-term care system, led by the King’s Fund, Joseph Rowntree Foundation, Help the Aged and Age Concern. They carried out a nine-month consultation on the future of funding long-term care which involved over 700 people with experience of the long-term care system as users, carers, providers and researchers. The Future of Care Funding: time for a change report (January 2008) is timely and will clearly be influential, given the nature of the organisations that came together to produce it. There are issues raised in the report that will be challenging for local government, as well as for central government. The paper suggests that there may be a need to impose national eligibility requirements on local authorities to reduce local variability, even if there is not going to be a nationally assessed and funded system, where eligibility depends on a formula linking need to funding. The authors conclude: "while there are many ways to design a new funding system for long-term care, acceptance of a new settlement depends most of all on creating a fair and visible method of sharing the costs between state and individual, being clear-cut in what it promises and funding it adequately to meet these commitments. In short, tomorrow’s older people will be willing to contribute to an equitable system for funding care, as long as it ‘does what it says on the tin’." County Council Budget For In-House Provision The overall budget for in house provision in 2007/08 is approximately £8.2M. The average occupancy level is 76% with around 272 beds out of 356 being utilised. It is expected that estimated costs will rise following the implementation of job evaluation. If 90% occupancy can be achieved in-house then the unit cost per bed will fall. The capacity within the private sector has continued to increase with new (60/70 bed) homes being opened on a regular basis. Each time a home of this size is opened it increases overall capacity by 1½ %. The over-supply of places has placed the County Council in a stronger position when negotiating fees. During price negotiations with the private sector, the County Council negotiated fees based upon 18.9 care hours per week per client. The rate paid to the private sector for residential care is based upon four different rates which reflect the environmental quality of the home: § Grade 1 (100% compliant with National Minimum Standards with reference to new build homes) £411 § Grade 2 (75% to 99.9% compliant) £399.50 § Grade 3 (55% to 74.99% compliant) £382.50 § Grade 4 (less than 55% compliant) £372 PriceWaterhouseCoopers (PWC) have carried out an exercise to determine the number of care hours provided per client in all residential homes in the County. The results of the survey indicated that averages of 18.9 hours care were provided for each occupied bed for non-EMI and 22.52 hours for EMI. The County Council favoured adopting the Rowntree Efficient Model of care hours of 18 and 20 for non-EMI and EMI and the final negotiated levels were 18.265 and 20.975 respectively, upon which the fees were based. In terms of comparison of unit costs the County Council’s costs are higher than those of the private sector. The majority of costs are for staffing with the remainder going towards provisions and the repair maintenance of homes. The independent sector generally only pays the minimum wage with no enhancements for weekend working, whereas County Council staff get paid time and a half for Saturday and double time for a Sunday. In response to questions about levels of sickness, use of agency staff and paying higher wages it was explained that the independent sector have advantages as they have staff on casual basis or on temporary contracts. They will have a core of permanent staff and will bring in casual staff when there is a demand. They will only use agency staff if they need qualified nurses. The majority of independent sector staff are not on fixed hours contracts. If there is under occupancy hours will be reduced. County Council staff have 37 hour contracts and they also receive enhancements when on annual leave or off sick. Level of Occupancy People are being supported to stay in their own homes for as long as is possible. Therefore, the numbers per 1000 population requiring residential care will continue to fall before the trend bottoms out. The County Council’s level of occupancy is very similar to that of the private sector. It should be noted that there is an oversupply of places. Establishment	Capacity	Possible Bed Days	Actual Bed Days	April 07-Dec 07
NORTH
Stanfield House	21	5775	5340	92.47%
Mendip House	28	7700	6912	89.77%
Manor House	26	7150	6148	85.99%
Cheveley House	36	9900	8471	85.57%
Lynwood House	33	9075	5675	62.53%
EASINGTON
Grampian House	19	5225	3726	71.31%
Glendale House	28	7700	4881	63.39%
SOUTH
Newtown House	28	7700	6214	80.70%
Feryemount	29	7975	6375	79.94%
Shafto House	30	8250	6562	79.54%
Hackworth House	40	11000	7634	69.40%
East Green	39	10725	7380	68.81%
TOTAL	357	98175	75318	76.72%

Nationally some authorities have no homes at all, whilst others have more homes than County Durham.

Cost of New Build

It would be possible to upgrade some of the homes and this would be dependent upon a cost benefit analysis.

The cost of new build to highest standards for all homes is estimated to be around £42M. (Durham County Council Residential Care Homes Property report February 2007).

At the present time £6M over 3 years is available for capital investment.
On average each home requires £1 million investment for general repair and upgrade.

To upgrade existing homes would probably be a false economy as the homes would not meet national minimum standards. To meet the full CSCI standard will cost approximately £3.5m per home.

A way forward would be to rebuild with partners and to have a mixture of provision. Evidence suggests that the unit cost provision for extra care and home care services are significantly lower than for placements in residential care.



Property
Review of Property Stock

GLP (a consultancy) were contracted to carry out a review of property stock similar to the exercise carried out on private sector homes. The process ‘grades’ homes based upon the extent that they meet National Minimum Standards in relation to the quality of the build environment. Grade 1 homes meet the latest building standards including en suite facilities and wider corridors and grade 4 the poorer quality homes. The results are detailed below:
Private Sector County Council
Grade 1 21 0
Grade 2 39 0
Grade 3 39 6
Grade 4 6 6
Total 105 12

The key issues for County Council stock in relation to standards are:
· en-suite provision
· the size of rooms
· door widths.

Durham County Council Residential Care Homes Property report February 2007suggests that:
· The homes could be demolished and sites re-developed should there be demand for beds in the area. This would incur significant costs (estimated £3.5 million per home).
· The local authority has the opportunity to reconfigure existing buildings. Not all buildings lend themselves to reconfiguration and the overall condition of certain homes may indicate that investment in reconfiguration is unviable.
· Reconfiguration within the existing footprint will reduce the overall bed numbers and this could, in turn, impact detrimentally on unit costs.
Comments were made about the following homes:
· Lynwood House - there are significant concerns in respect of investing in the fabric of this property. The flat roof design is not ideal and there is significant cracking of internal walls. An economic decision must therefore be made before investing in the fabric of the building.
· Hackworth House - the size of rooms is limited and reconfiguring the home is not a viable prospect.
· Newtown House - Upgrade opportunities are limited with a major refurbishment carried out in 1998. Further information was also provided about the impact of reconfiguration on the number of rooms and the likely revised grade. This will reduce the number of available rooms though not all of them will be en-suite on the completion of reconfiguration.

CONCLUSIONS
· People are living longer.
· Support for people to live independently in their own homes is an important policy driver.
· The cost of in house care compared to the Independent sector is more. There are a number of reasons, staff costs are one.
· Opportunities to explore joint venture arrangements to deliver care through other means are worth considering. A way forward would be to rebuild with partners and to have a mixture of provision .
· The evidence suggests that Extra Care gives value for money.
· The cost of rebuilding is significant.
· Evidence suggests that the unit cost provision for extra care and home care services are significantly lower than for placements in residential care.
· To upgrade existing homes may be a false economy as the homes would not meet national minimum standards.
TECHNOLOGICAL ADVANCES TO SUPPORT PEOPLE TO LIVE INDEPENDENTLY

The Telecare Strategy is an important development in helping to respond to the challenges of the 21st century, which include significant demographic change and increasing public expectations for convenience, choice and customer service.

It is clear that most older and vulnerable people wish to stay in their own homes, remain healthy and safe and have as much control of their own lives as possible. The implementation of Telecare services can help to meet those aspirations, by helping to give vulnerable people the confidence to live their lives in a way they want - independently, but knowing that help is at hand if they need it.

Durham has gained a reputation as one of the pacesetters for successfully using new technology in social care settings in England. By working across partner agencies in health, housing and social care, it has been possible to develop and validate services which have been proven to help improve outcomes for vulnerable people.

The Government has also demonstrated its commitment to this programme, by releasing a 2 year grant to help all local authorities. This injection of resources will help local agencies to transform the way that technology is used within health and social care services.

The aim is to develop a robust, fair and equitable service across the County with a vision to :

‘To help to promote independence, choice and quality of life for our service users and to support a higher number of people in their own homes or in a supported housing setting by developing a structure with which to deliver an integrated, mainstream and equitable service across County Durham.’

The Government has recognised the potential of telecare and in July 2004 announced the release of the Preventative Technology Grant which aims to increase the number of people who can benefit from telecare services. The £80m grant has been allocated over two years from April 2006 as their commitment to modernising and transforming care services provided by local authorities and the NHS.

The Preventative Technology Grant will be managed locally by Partnership Boards to ensure that it is used to develop the most appropriate and effective services to meet local demand. Durham County Council will remain responsible for the use of the grant and therefore request that Partnership Boards sign up to this strategy and its implementation plan and provide regular reports for Durham County Council to monitor and review progress.

The scope of this strategy is limited to telecare at this stage, but the policy group will continue to meet to address any issues arising, review the strategy and look at how we continue to develop more holistic services encompassing telehealth, telemedicine, electronic assistive technology (EAT) and the use of information and communication technology (ICT).

The major percentage of the Preventative Technology Grant is being used to mainstream telecare with Older People’s Services and People with a Physical Disability. However, 20% of the grant has been allocated to pilot and develop work with People with a Learning Disability and Children with a Disability, continuing Durham’s approach to being visionary and proactive in this area.

The use of telecare has already been established in our Extra Care schemes in the County and has proved to be very effective, both in terms of quality of life for tenants and in saving health and social care agencies money.

One of the projects being undertaken is ‘VITAL’. It is a German lead EU (6th Framework) project involving 4 different partner countries. DurhamNet are participating in the project.

The objective of VITAL is to develop a set of assistive technologies to provide remote assistance to elderly users. The project presents a different concept of remote assistance that differs from traditional schemes. It aims not only to provide basic needs but also has the aim of significantly increasing the quality of life of the average elderly user. VITAL is designed to deliver advice, assistance information, education, entertainment and inter-personal communications to the users.

A technology project in the Stanley area is based around the secondary school. Computers have been deployed to several hundred family homes as part of an educational improvement project. The current cable based broadband delivered via BT is being replaced by wireless based broadband (Wi-max). This will allow greater bandwidth and the delivery of cable type TV services and allow the deployment of interactive TV services. Tenants of Derwentside Homes will be able to communicate directly with the company when they need assistance. The homes involved in the project will be converted to wireless broadband and pilot projects will be undertaken. It is hoped to deploy wireless broadband for all of County Durham to enable access to the next generation of broadband.

CONCLUSIONS

Welcome this development.

RECOMMENDATION

The JHOSC working group recommend that Durham County Councils Executive consider the impact of the Telecare Strategy ,reviewing its effectiveness and pitfalls with a view to supporting its implementation across the whole system.

WHAT ROLE AND RESPONSIBILITIES DO PUBLIC SECTOR PARTNERS HAVE IN DELIVERING RESIDENTIAL CARE NAMELY COUNTY COUNCIL, DISTRICT COUNCILS? WHAT IS THE ELIGIBILITY CRITERIA? WHAT ARE THE LEGAL IMPLICATIONS ASSOCIATED WITH THIS ROLE? Legislative Requirements The social services function lies with the County Council whilst the Secretary of State is responsible for providing health services. There is an interface between the County Council and the health service when they jointly commission services for users. National Assistance Act 1948 The National Assistance Act is the act that relates to residential accommodation. There are many different Acts empowering or obliging local authorities to provide services e.g. home help and welfare services. The key Act for adults is the National Assistance Act 1948 Section 21 which states that: Local Authorities “Shall make arrangements for providing residential accommodation” for persons aged 18 or over who by reason of · Age · Illness · Disability · Or any other circumstances · Are in need of care and attention which is not otherwise available to them. Section 21 of the Act does not apply to those people who are not ordinarily resident in the County, to those who are excluded from benefits because of their immigration status, or those whose need of care and attention only arises because they are destitute and for providing for health needs that should be covered by NHS continuing health care. This final area is a contentious issue as Councils are not responsible for health services but for social care. Whilst this might include personal care and physical care, it does not include areas where the primary need is health care. Residential accommodation has traditionally been seen as “care home” provision. There have been a number of legal cases which have clarified that this can include other forms of provision e.g. · R v Newham LBC ex p Medical Foundation for the care of Victims of Torture and Others - need was met by bed and breakfast · R v Bristol CC ex p Penfold - need was met by providing the tenancy of a council house. Residential care under the 1948 Act can be broadly defined, but could be just somewhere to live without ancillary services. This issue was covered by Lord Justice Hale in R (Wahid) v Tower Hamlets LBC [2002]. This referred to: “…small groups of people with learning disabilities who are able to live in ordinary houses with intensive social services support; or single people with severe mental illnesses who will not receive the regular medication and community psychiatric nursing they need unless they have somewhere to live.” Independence Well-Being and Choice The Independence, Well-Being and Choice agenda has made it clear that there is a greater promotion of independence and less emphasis on residential care. However, the meeting of assessed needs is likely to produce some cases where a care home is the only realistic way to ensure safety. If an authority decided not to provide or arrange for residential provision in all cases then this would be a decision likely to be the subject of a legal challenge. It was initially expected that Councils would provide care homes. However the 1989 White Paper “Caring for People” introduced a market element as part of the community care reforms. The Government made it clear that Councils would engage with a “flourishing independent sector” which would be provided alongside quality public service provision. Social Services were seen as “enabling agencies” to help people to decide where they would be cared for. This was made clear when Councils were initially required to spend 85% of special transitional grant on non-local authority services. The initial guidance from the government was that Council’s should still make some direct provision. However in the case R v Wandsworth LBC ex p Beckwith the House of Lords decided that, provided there is sufficient residential provision in a Council’s area, there is no obligation on it to provide its own homes and that the guidance produced by the government was “simply wrong”. Some Council’s have decided that they will not provide any of their own homes and all provision will be commissioned from the independent sector. National Health Service and Community Care Act 1990 The National Heath Service and Community Care Act 1990, deals with assessment for community care services ( as provided for under different acts) and planning for their provision. Those services are ones covered by different acts of which the National Assistance Act is one. To decide whether a person is eligible for care, an assessment is carried out under the National Health Service and Community Care Act 1990 section 47. Section 47 states that: · (1)…where it appears to a local authority that any person for whom they may provide or arrange for the provision of community care services may be in need of any such services, the authority:- · (a) shall carry out an assessment of his needs for those services; and · (b) having regard to the results of that assessment, shall then decide whether his needs call for the provision by them of any such services. When taking the results of an assessment into account in deciding whether to meet needs, Councils can take resources into account. In R v Gloucestershire CC ex p Barry the courts accepted that local authorities have finite resources. What a council cannot do is decide on resource grounds not to meet a need it has already identified as on it should meet. To ensure that Council’ s achieve fairness and consistency when balancing needs and resources, the document “Fair Access to Care Services” 2002 was published. Council’s now have to use an eligibility framework to describe the circumstances which make needs eligible for help. The framework is based on the impact of the needs in factors that are key to maintaining an individual’s independence over time. The framework has obligatory categories: Categories (simplified) · Critical (examples only: life is or will be threatened: significant health problems have or will develop) · Substantial (example only: is or will be only partial choice and control over immediate environment) · Moderate (example only: an inability to carry our several personal care or domestic routines) · Low (example only: inability to carry out 1or 2 routines) The guidance allows Councils to decide how far up needs must be on the framework before resources are used to meet them. Once that is done Council’s: · Assess “presenting needs”; · Do an analysis of risk to the user; · Compare the risks to the framework. If the needs fall into one or more of the risks that a Council has decided to meet then they must meet them. Human Rights Act 1998 Resources are not the only deciding factor. Under the Human Rights Act 1998, a Council could be challenged if a resource led decision clashed with human rights. For example if an authority refused to fund a package other than residential care for someone who wanted to stay at home with family or setting the line of eligibility so high that the life or health of service users are threatened. Therefore the Council will not be meeting statutory obligations. Local Authority and Social Services Act 1970 When the Government issues a letter of guidance under Section 7 of the Local Authority and Social Services Act 1970, it has to be followed by authorities. Failure to do so will lead to a legal challenge. The guidance issued in LAC (2004) 20 relates to the choice of accommodation. If an individual expresses a preference for a home, the council must comply provided: · It is suitable for their assessed needs. · It would not cost more than it would usually expect to pay for someone with those needs. · The accommodation is available. · The provider is willing to provide on the Council’s usual terms and conditions. Therefore an individual can choose the independent sector, providing it fits the above criteria, they cannot be made to use a local authority home. Questions Q. Could we be challenged because the costs of our homes are higher than the independent sector? It is an area which some Social Services Departments are concerned about. So far few of the independent sector legal challenges against councils have been successful and haven't been specifically on this point. So far the successful councils in litigation have had strategies that have enabled them to meet their statutory obligations, Q. Would it be legal to enter a partnership with a particular independent sector provider? The social care market is very complex. The authority should not enter a partnership arrangement with a particular provider until they have a defined strategy, the partnership meets it and has been properly procured. Failure to do so could result in a legal challenge. Q. Where is the dividing line/definition for residential care? The District Council can use their housing function to meet need if the client does not require ancillary services. Q. In relation to people returning to the UK, is there any mechanism to ensure that people/families who have intentionally deprived themselves of their property/resources contribute to the cost of their care? The authority must do an assessment of needs but this does not mean that the care is provided for free. If they fall within the financial criteria they will be required to contribute to the cost of care. The authority can look to the family who has property which used to belong to the service user if they have evidence that the service users have intentionally deprived themselves of resources/property in order to avoid paying for their care. Q. Is there a time limit on the need to act on a request for an assessment? The authority has teams of social workers and occupational therapists who will undertake an assessment and decide the level of care that is needed. If the person involved is in hospital the authority will have to act quickly to avoid any financial penalties for delayed discharge. WHAT DO WE MEAN BY REPROVISION? WHAT MODELS OF REPROVISON EXIST? Re-provision Overview The Working Group was advised that within the care homes model there are at least four different categories. The County Council’s homes only deal with people who have residential care needs. To move into other types of care would require the co-operation of the Primary Care Trust and the joint commissioning of services. Care home provision is seen as long stay provision even though the length of time is going down because people are entering care later in life. Short Term Care This is where people are admitted to a care home for a short period or temporary stay. This might be for a number of reasons: · You may need to consider a stay in a care home following an admission to hospital and until you are independent enough to return home; · In order to prevent an unnecessary admission to hospital. Intermediate Care Intermediate Care is aimed at preventing unplanned admissions to hospital, or unnecessarily prolonged hospital stays if hospitalisation has been needed. These services will help you recover faster and maximise your independence and are free for a maximum of six weeks depending on your assessed needs. Intermediate Care Teams include Social Workers, Nurses and Therapists and the services they provide include, supported hospital discharge, crisis response, residential and mobile rehabilitation, and home care support, as well as residential and day services. Extra Care Extra Care offers older people an alternative to moving into a care home by providing specially designed housing and 24 hour care and support. Moving into Extra Care is like moving house, rather than a move into residential care. Tenants in Extra Care have their own flat in a specially designed housing complex with 24 hour care and support available on-site. Tenants are encouraged to furnish their flats to their own tastes. All tenants have a tenancy agreement and pay rent to the Housing Association who owns the scheme. Extra Care enables tenants to maintain their privacy and independence whilst knowing that support and companionship is available. Extra Care can give you: § Your own home § A self contained flat with a bedroom, lounge, kitchen and bathroom with a level entry shower § Full central heating § An emergency alarm link § Flats suitable for people who use a wheelchair and there are lifts to the upper floors § Personal care and support to meet your assessed needs. Communal facilities include: § Lounge § Launderette § Access to a local shop § Guest Suite § A laundry and cleaning service if and when required § Restaurant § A hair and beauty salon § Landscaped gardens § 24 hour support available § Security with CCTV and intercoms § Social events and activities available for those who wish to take part. § Extra Care schemes in County Durham: § Charles Dickens Lodge, Barnard Castle § Chester View, Ouston, Chester-le-Street § Harbour Lodge, Seaham § Maple Court, Consett § Southfield Lodge, Crook § Sycamore Lodge, Spennymoor § The Orchards, Brandon § Appleton Lodge, Spennymoor (specialist scheme for people with memory problems). There are various models of Extra Care. Some of the County Council schemes are operated in conjunction with partners or a landlord and there are also schemes operated by the independent sector. There are also different ways that the housing management and domiciliary care support is provided. At Appleton Lodge, for example, the County Council does not provide any services directly. Residential Care Homes In a residential home the emphasis is on providing personal care and support, such as help with washing and dressing. If there is a limited need for nursing care in a residential care home this is usually provided by the Community Nursing Service, who would visit the home to see you. All residential homes are inspected once a year by the Commission for Social Care Inspection to make sure homes keep to the national minimum standards set by the Care Standards Act 2000. Supported Housing The non-residential models are often referred to as supported housing and most people occupy the property they live in under a licence or tenancy. In the non residential models, all types of tenure exist or are being developed in the intermediate housing market and include shared ownership schemes and lease schemes and not just people who are renting. Extra Care and Independent Supported Living have similar features and vary only in the level of support in the accommodation. Sheltered Housing Sheltered housing is a group of unfurnished self-contained homes specially designed for the elderly. The aim is to provide independent secure accommodation with additional social and domestic facilities. Residents enjoy the opportunity of living independently in their own self-contained flat whilst also being part of a small secure community. Intercom systems ensure residents' homes are secure and only invited guests can gain access. Scheme Managers maintain daily contact with the residents to check their well being. Underlying Principles that will inform overall CONCLUSIONS It should be noted that in developing any of the above there are : · Financial considerations - the revenue considerations in addition to the capital considerations. It was pointed out that Extra Care schemes are funded differently for revenue purposes than those of residential care. · Operational considerations - this includes dual running i.e. keeping two homes open while residents transfer from the old building into the new building and will also include an issue about unused capacity. There will also be substantial staffing issues to be resolved. · Property considerations - the sites have different values and some are physically joined with other complexes. WHAT OPPORTUNITIES EXIST FOR PARTNERSHIP WORKING WITH OTHER PUBLIC SECTOR PROVIDERS FOR EXAMPLE THE NHS? WHAT ARE THE VIEWS OF PARTNER AGENCIES WITH REGARD TO OUR EXISTING PROVISION? Opportunities for Partnership Working The Working Group received information from Anthony Prudhoe County Durham Primary Care Trust on joint commissioning; Michael Laing Chief Executive Wear Valley District Council on the strategic housing role; Martin Knowles, Chief Executive Officer and Chris Reed, Head of Care and Support at Three Rivers Housing. Primary Care Trust (PCT) The role of the Primary Care Trust (PCT) is to engage with the local population to improve health and well-being and to commission a comprehensive and equitable range of high quality responsive and efficient services, within allocated resources. It is also directly responsible for providing high quality responsive and efficient services where this gives best value. As the leader of the local NHS, the PCT works in partnership to support all of the people of County Durham to live healthier and longer lives and is working to eliminate the health gap between the best and the worst off. The PCT also works to ensure residents have control and choice of excellent services that are safe, effective and give good value. The Mission Statement of the PCT is ‘Your health, your choice, your say, our commitment’. The PCT’s strategic themes are as follows: · Focus upon improving health and well being · Shifting the balance from treatment to prevention · Focus on services not buildings · ‘Separation’ of commissioning and provision · Levelling up across the county · Partnership and involvement · Support and develop a workforce which is fit for purpose · Provide a locally based flexible healthcare service · Develop a choice of providers in each care sector · Achieve and exceed national targets as milestones towards real service and health improvements The PCT’s strategic vision is about helping people to live independently in their own homes. This will be achieved through a shift in the system towards prevention and community based care. Therefore the focus will move away from hospital based care to community based care. The PCT wants to encourage and help people to take responsibility for their own lifestyles and to aim for a healthy and fulfilling old age. This will be a challenge and the PCT will have to start working with people at an earlier age to help them take control over their life. The PCT supports choice and giving people more say over decisions that affect their daily lives but will provide care for those with high levels of needs. The outcomes that the PCT and its partners want to achieve are improved health and emotional well-being with an improved quality of life. They want people to make a positive contribution and give them choice and control to do this. To do this people need to be free from discrimination and have economic well being. The PCT is working with the County Council and District Councils to ensure people have access to benefits and other experiences. Health, social care and other partners are working together to build on existing good practice to further develop intermediate care and community services. This will ensure that more people are supported with rehabilitation, home adaptations, domiciliary care and support for carers rather than long term placements in residential and nursing care. Strengthened intermediate care services will provide safe and effective alternatives to acute hospital admissions for many people which will help them get better and move back into their own homes. Health, social care and other partners are also working together through joint strategic needs assessments and integrated workforce planning. This will enable residents to have a better integrated service delivery and will also help to develop more capacity through a wider range of service providers to secure value for money and improved access to community health and care services. We will know we have made a difference when people are helped to remain healthy and independent and have real choices and greater access to a range of support. This will involve services being delivered to people near where they live and integrated and built around the needs of individuals. This will require that more resources are invested in prevention and community health and social care than in secondary care. Strategic Housing There are strong and productive working relationships between strategic housing authorities and the County Council. These have developed significantly since the creation of the adult and community service and the appointment of senior staff. These working relationships have led to an improved position on:- · strategic planning e.g. provision for older and vulnerable people is now a priority in the sub-regional housing strategy , · work has been done on coordinating disabled facilities grants to link with adult care and Districts have increased budgets, · a nationally recognised improvement in community alarm provision · the inclusion of bungalows and sheltered schemes in service planning · involvement of the PCT · the impact of extra care schemes · using housing associations to provide solutions e.g. Care and Repair A joint approach to commissioning is being developed in line with national guidelines but in a way that is sensitive to the position in County Durham The joint housing market assessment work presents some very interesting analysis:- · an ageing population who prefer to stay at home, · a preference for home ownership and/or 2 bed bungalows, · an over-provision of the one bedroom bungalows and 'traditional' sheltered schemes, · increasing capital costs of modernisation, · evidence of population decline being reversed in some areas, e.g. Wear Valley, and Durham City , · over provision in the residential care home sector. Housing authorities are able to help the County Council in the following ways: · By giving residents a choice. They have told us that they do not want to go into residential care and they would prefer to stay in their own home. If this is not possible they would prefer to move into a two bedroom bungalow. · By maximising the investment coming into the County. After health and social care ,housing takes up the majority of public expenditure. We need to ensure that substantial amounts of investment for the region are coming into County Durham. It is essential that housing authorities, housing associations, ALMO’s, the PCT and Adult and Community services are working together on this. · By linking up at a strategic and operational level. This may be one of the benefits of local government reorganisation. Improvement in services will be achieved through the sub regional housing strategy. The strategy has services for older people as a priority. The strategy states that older people want to remain in their own home. The strategy outlines that there is over-provision in the County of one bedroom bungalows. These are using up resources which should be reinvested into new provision of two bedroom bungalows which are adapted to wheelchair standard. District Councils should be using their strategic housing role and using Section 106 agreements to lever in investment. Examples were provided of recent developments where developers had provided two bedroom bungalows as part of larger developments. In addition District Councils should be using their strategic housing role to influence the Arms Length Maintenance Organisation (ALMO) to invest in modernising the existing housing stock. As an example it was explained that Wear Valley DC had received an investment of £27M. A quarter of existing housing stock is bungalows. As part of the modernisation this involves installing flat floor showers, low level light switches and other adaptations. District Councils also need to encourage private developers to provide supported housing which people can buy on leasehold terms. Another area which could be improved is around home improvement agencies, the disabled facilities grant and community equipment. The current service is not sufficiently streamlined but the establishment of a unitary authority should help improve this service. The Housing Strategy for County Durham, developed by Durham Housing and the Neighbourhoods Partnership Board (a partnership of local authorities, housing organisations and other stakeholders), has as its vision to “make your home in Durham a great place to live”. The strategy’s main aim is to have a strong and supportive housing market. In order to deliver on this it has as its focus objectives looking at regeneration and the rejuvenation of housing markets; delivery of quality and choice; improvement and maintenance of existing housing and meeting specific social and community needs. It is this latter object that supports older people to be supported to live in their home for as long as possible. CONCLUSION · Older people want to remain in their own home. · There is over-provision in the County of one bedroom bungalows. These are using up resources which should be reinvested into new provision of two bedroom bungalows which are adapted to wheelchair standard. · DCC to take an active role in the partnership/note Unitary Local government opportunity. RECOMMENDATION · The JHOSC working group recommend that the new unitary council for County Durham, in its role as a strategic housing authority, continue to work in a partnership context to respond to the needs of an ageing population working across boundaries, “to harness the capacity of the whole system”.

Registered Social Landlord (RSL)

Overall, extra care is a good alternative to residential care. RSL’s provide good extra care models. They also have a good range of services that provide preventative measures. It is no surprise that people want to stay independent as long as they can and that this is reflected in national and local studies. The evidence suggests that people want to receive practical support to achieve this aim. Going into care is rarely by choice. The resources that are necessary to maintain some one in care are hugely different from maintaining someone in supported housing. Sheltered housing has appeal if it is well run. Extra care and bungalows are people’s first preference.

50+ is older
There are lot of definitions but contemporary thinking indicates that 50+ is older. Services need to be designed to meet a wide range of needs and be able to meet what people will require in the future. The scale of this issue will be enormous with an ageing population.

A range of preventative measures will need to be implemented that will ensure that people do not require acute care if they are offered support. This will help reduce the burden on acute care. Sometimes they may only require advice or help to make benefit applications. Sometimes there is a lack of engagement with older people preferring to take advice from friends and family. There is a need to provide them with good advice. Poverty is a major issue in the north east with benefit take up being low in some areas. This leads to poor health and fuel poverty and impacts on people’s ability to live independently.

Three Rivers Housing

Three Rivers Housing provides care and repair schemes to five of the County’s District Councils. This is beneficial to older people by being able to provide adaptations which enable them to stay at home. They are also able to provide handyman services for property repairs.

Three Rivers Housing has provided sheltered schemes which give support appropriate to peoples needs. They have also provided new high quality, low cost, self contained accommodation which is very energy efficient.

Three Rivers Housing is about providing a flexible approach to on-site care and is community based. There have been attempts to re-model sheltered accommodation into extra care but not all have been successful as they have not provided sufficient services. Some extra care schemes also provide registered bed spaces particularly where they are dealing with EMI. There may well be challenges to be faced by placing many people in one location who in the future then go onto develop complex care needs.

Extra care can also be very expensive to provide because of the capital and resource needs for one site. Extra care does not deal with all needs such as those with learning difficulties who are now living much longer lives. It has not been able to use Extra Care to help those with drug or alcohol problems.

Extra care however provides flexibility that residential care is not always able to provide. A move to extra care is seen as a positive move while a move to registered care is often seen as the final move. Extra care is community based and promotes independence and has financial benefits for the tenants.

There is a place for registered care in the continuum of care. In future it will be needed for mainly acute needs and for pre or post hospital intervention. It is also good in providing short term interventions such as helping to recuperate from illness and for respite care. It was pointed out that registered care has its background and culture in the NHS and is not seen as being able to empower residents. Therefore there is a need to look at new models of working.

In future, residential care may need to be remodelled to provide a short term ‘hotel’ role. Even where there are long term residents, it does not mean that they lose their independence.

It is essential to involve older people in re-design - they will tell you want they want. The point was made to the Working Group that we must work to empower families, peers and relatives as they are usually the main carer and understand the needs of their loved ones.

Evidence suggests that making adaptations to existing homes such as the provision of grab rails, adapted kitchens and providing wheelchair access will be cheaper in the longer term than providing residential care.

CONCLUSIONS

· There are major regeneration schemes being delivered in the north east region. It is important for County Durham local authorities to act as a sub region in order to attract investment into the County.

· It will be difficult to plan for 20 to 30 years in the future. The main issue is choice and making provision to enable people to remain independent.
· In order to achieve transformation of social care we need to work across boundaries, to include services such as housing, benefits, leisure, transport and health; and with partners from private, voluntary and community organisations “to harness the capacity of the whole system”.
· Making adaptations to existing homes such as the provision of grab rails, adapted kitchens and providing wheelchair access will be cheaper in the longer term than providing residential care.

ROLE OF THE INDEPENDENT SECTOR IN PROVIDING RESIDENTIAL CARE

The Working Group received information from the Chair of the Care Association.

There has been extensive debate on residential care. The number of beds has been falling as providers have adapted to the changing legislation and improvements in standards.

The corporate providers of residential care are continuing to build and buy new homes. This is based on demographic trends which indicate that the number of people over the age of 85 will increase from 1.2 million to 5 million by 2071.

Some local authorities are now approaching care providers and are commissioning them to build and operate residential care homes on their behalf. It was suggested that local authority run care homes cost between 33% and 50% more to run than those operated by the Independent sector.
That said there is a future role for residential care as it will not be possible to care for large numbers of frail older people in their own homes. This will require the format of residential care to change and evolve to meet new circumstances. There is potentially a demand for additional facilities for dementia and challenging behaviour as the numbers of people affected increases.

Staff Considerations

There is a legal requirement that 50% of staff must be trained to NVQ level 2, (this is to increase to 70%). In addition managers must have the manager’s award. All staff must have received other statutory training i.e. health and safety etc. It is also recognised that some care providers will only provide the legal minimum of trained staff. European Care provides dementia training for all staff. CRB checks are usually completed in 3 to 4 weeks. A POVA (protection of vulnerable adults) check can be completed in 24 hours. Staff with a POVA check need to work under supervision. All staff receive training about dementia so that they are able to manage residents with this condition.

Multi-Care/Provision

Separate units may be provided within an establishment, particularly recent new build homes. Therefore, when a resident’s physical and mental condition deteriorates they do not have to move home. Through care planning they are able to offer different levels of care. This also gives the company flexibility in how staff are deployed and are able to provide cover for staff absences.

The model of extra care is good in that people are provided with their own private accommodation in a supportive environment. However, there are likely to be difficulties particularly if people have secure tenancies/legal rights. Older people can deteriorate very quickly and a situation could potentially arise where a number of residents within an extra care setting developed severe physical disabilities or dementia/challenging behaviour. This will present difficulties in staffing and managing an extra care unit as these people may need 24 hour care. Costs will increase and extra care units may become economically unviable. In a residential care home which offers multi-care, there are economies of scale and sufficient trained staff to deal with different care levels

Inspection

All residential homes ,including those run by the Independent sector, are subject to inspection by CSCI. There are two types of inspection. The announced inspection which can take 2/3 days and is very thorough; and the unannounced inspection when CSCI can arrive at any time often on night shift. CSCI now star rate homes using a traffic light system. Homes which are green will not be inspected for another year. Homes marked as amber could be re-inspected in 3-6 months time. Homes assessed as red are inspected regularly until such time as they have improved.

The local authority is entitled to inspect a home where they have placed a resident to ensure that the contract is being operated correctly.

CONCLUSIONS

· Residential care needs to change and evolve to meet new circumstances.
· There is potentially a demand for additional facilities for dementia and challenging behaviour as the numbers of people affected increases.

RECOMMENDATION

The JHOSC working group recommend that in negotiation of contracts with the Independent sector consideration is given to staff development and staff training in delivering standards of care identified in the contract.

Members note the potential increase with dementia and challenging behaviours in the future and ask Durham County Councils Executive to note these long term conditions within an ageing population.

HOW EFFECTIVE IS OUR MARKETING STRATEGY TO PROMOTE OUR RESIDENTIAL CARE FACILITIES? In May 2005, the Office of Fair Trading (OFT) issued a report, Care homes for older people in the UK: A market study which was based on a one-year study prompted by a ’super-complaint’ from the consumer organisation Which? on behalf of the Social Policy Ageing Information Network (SPAIN). The study investigated consumer choice, transparency of price information and contracts. It made a number of recommendations to central government and devolved administrations, local authorities, care home regulators and care homes. In summary, the recommendations were: · people considering a care home need comprehensive, understandable and easily available information · local authorities should provide assistance to people who self-fund their care placements as well as those who are supported by the state · fees should be transparent and contracts should be fair and easily available · access to complaints should be improved. The government and CSCI support the direction of the OFT report, indicating that it is in line with proposals in the adult social care Green Paper, Independence, Wellbeing and Choice and CSCI’s role in modernising inspection and improvement. What are we doing in Durham County Council then? The Working Group received evidence from the Information to the Public Team , Adult and Community Services on the publications produced to inform the public of the options available to them. Here are two examples:-

One of the publications produced is entitled ‘Choosing a New Place to Live’. This is aimed at older people who think they may need to move out of their present home, or at families who are looking for accommodation for a parent or relative to help them make the right choice of accommodation.

The objective of the publication is to inform residents about care home options that are available in the region. There is also advice and information on how to choose the right home and the right type of care, i.e. do you need a residential care home, extra care or nursing care? The publication also provides legal and funding information. This should help ensure that people are aware of care rules around costs and funding and do not choose a home which is inappropriate to their long term needs.

Consideration is being given to providing a directory or a separate listing of homes with key information on third party top up fees and extra services such as entertainment and whether a home is available within council funding limits.

It is hoped that the brochure will stand out, so that people will want to read it and consider their options before they need to make any decisions. It is also being designed to make it easy to read and use.

The brochure will have to be self-funding in order that sufficient copies can be printed to reach as many people as possible. To do this in the future advertising will be allowed. Care homes which contract with the County Council will be given the opportunity to advertise in the brochure. In addition, other companies who provide related services will be allowed to advertise. This will include companies who help people to reorganise their finances to enable them to fund their care package. Advertising will be restricted to reputable companies.

The sister publication ‘A Guide to Services for Older People’ is a much broader publication, covering services such as meals on wheels, day care etc. It tells people what services are available in County Durham. It will signpost people to the brochure ‘Choosing a New Place to Live’.

In relation to the marketing of County Council care homes, the brochure provides information on all the options open to them and explains the benefits of having an assessment of needs and a financial assessment from a trained member of staff before contracting with an independent sector home.

CONCLUSION

· The publication may help to form part of the marketing strategy for DCC Care homes by:-
- Informing and educating people about all the options available to them
- Explaining the benefits of having an assessment of need and a financial assessment before contracting with a private home.


RECOMMENDATION

The JHOSC working group recommend that Durham County Councils Executive build on the work already in place to inform and educate people about all the care options available to them by investing in a marketing strategy for this purpose.

WHAT ARE THE VIEWS OF THE STAFF, CARERS AND USERS OF THE SERVICE? Users and Carers Views regarding the future of Residential Care. A county-wide survey seeking to gather the views of users and carers was undertaken by Age Concern Durham County between Nov-Dec 2007 on behalf of Durham County Council’s Joint Health Overview and Scrutiny Committee. The JHOSC are mindful that a number of information gathering/consultation exercises have taken place over the years. In fact Age Concern Durham County and Durham County Council have a significant amount of information on the needs of older people. However, the JHOSC felt that a “snap shot” of user and carer views would enhance the overview and scrutiny exercise. The aim of the survey was to enable older people and their carers to express their views and aspirations about future residential and care services for older people in County Durham. The information to be used by the JHOSC working group in its consideration for the future planning of residential care provision in support of Durham County Council’s thinking on policy and practice relating to residential care provision for older people. (A copy of the report is attached - Appendix 2). The research involved 126 older people across County Durham who require varying levels of support and care. The sample group comprised those currently living independently, residents of extra care homes and residential care provision (including residents of an EMI unit):- · 80 older people currently living independently · 14 Residents in 3 Durham County Council extra-care homes · 29 Residents in 5 Durham County Council residential care homes · 3 Residents in 1 private care home which also provides EMI support. Individual questionnaires were used to enable individuals to comment on how existing care provision meets their needs and identify their priorities and aspirations in relation to their future care. Focus groups were also held. The project was directed and undertaken by experienced managers with Age Concern Durham County. The survey concluded that older people would like to remain independent and stay in their own home for as long as possible. The top 3 factors that would force them to move are most likely to be a garden too big to maintain, difficulty climbing stairs and difficulty in maintaining their house (physically and financially). They particularly highlight the need for access to affordable personal care, home maintenance and information and advice services. The majority of older people (89%) would prefer to have support or assistance that will help them live independently at home, rather than move into alternative accommodation. Only 10% of people said they would consider moving in with a member of their family. The majority of older people identified that their priorities for assistance are around practical support, particularly personal care, property maintenance, information and advice and foot care. If older people have to move into an extra care or residential care home, their priorities are to be able to afford their own en-suite room large enough to take some personal effects. They would also prefer to stay close to family and friends. In general, extra care was slightly more likely to meet older people’s expectations than residential care homes. Older people currently in extra care homes are also more aware of the cost of their accommodation and personal care in a way that residential care receivers were not. This could be indicative of the higher level of independence and awareness of those in extra care, and/or because they are more informed and involved with the delivery of their care packages. Older people in extra care highlighted how the facilities enable them to live as independently as their health allows. They value the care assistance that supports this independence and provides healthy meals, although some are unhappy at the limited food choices presented to them. They were more critical of problems with timely personal care than those in residential care. Respondents in extra care highlighted the impact of staff shortages that requires them to wait for someone to take them to the toilet or leaves them to do their exercises on their own. One respondent challenged the complex system that means individuals wait up to 24 hours for prescribed medication. Systems may need reviewing to ensure care services are available when needed and medicines obtained as quickly as possible. Extra care have en-suite rooms. However, some residents pointed out that they only had a shower cubicle and those requiring a bath (especially those requiring assistance) have to use communal facilities. There may be a need for mixed en-suite provision to provide baths instead of showers in some rooms. There is a high level of social interaction and participation in activities in both extra care and residential homes. However, residents in extra care were more critical about the range of activities available to them. Older men felt they were being discriminated against; card-making, crafts and bingo were seen as gender stereotyping because of the higher levels of women residents. They have requested a wider range of activities. Higher levels of residents in extra care homes go on trips and holidays than those in residential care. However, both extra care and residential care home respondents sent out a loud request for assistance with care and transport to enable them to go on trips and holidays. Elderly mentally ill patients (EMI) are particularly vulnerable. They are more passive receivers of care provision than others in extra care or residential care homes. Consultation with older people in EMI units involved referring to their care plans in addition to talking with them. They may be confused and unable to communicate their needs or aspirations and rely on care staff to deliver their care packages. CONCLUSION Nine recommendations have been identified as a result of this report. They are: · Provide clear information about the cost of care and the options available to older people ; · Ensure older people can have their own en-suite room that is large enough to accommodate some personal effects; · Encourage older people to visit the care home as much as they need to before moving in. Those who had come once a week for a few weeks were much happier because they knew what to expect. · Provide advocacy services to enable those who have a grievance to be involved in finding the solution. · Make sure all residents know where to go and who to ask for information. · Avoid perceptions of gender stereotyping by identifying alternative activities that can engage older men. · Investigate programmes of care assistance and travel that can enable older people to go on trips and holidays if they wish. · Review the system for obtaining prescribed medication in care homes. · All respondents praised the care staff but were concerned about staff shortages. Staff Views regarding the future of Residential Care. The JHOSC were keen to ensure that staff working in our residential care homes had the opportunity to share their views about the how they saw the future of residential care. Residential care managers were invited to share the views of their teams and themselves. Two responded. Key messages include: · Intermediate Care - is a very worthwhile service which Durham County Council establishments do well. Dedicated units for Intermediate Care would be more beneficial to the service. However Assessment Beds are needed in homes where Intermediate Care has not been identified. Assessment Beds can be implemented within current resources, the only work to be done is to change the registration of the home with CSCI. · Investment in Day Centre provision would support Older People to remain at home. · Dedicated staff should be employed for the sole purpose of rehabilitation and empowerment for the client group. At this point in time the units are integrated into residential establishments and not all staff feel comfortable encouraging clients to be more independent, they have a great problem in separating care from empowerment. · There needs to be clear definition of the term Extra Care i.e. does it mean Residential or Supported Living. · In the interests of staff and clients involved in any future plans it would be useful for them to be consulted and to be kept informed of any progress. · The benefits of using in-house provision while refurbishment is taking place, i.e. the use of vacancies in units in the same area whereby staff and clients could remain together and this would not inconvenience relatives/visitors. Most importantly the clients will enjoy the same high standard of care while waiting for their new home to be completed. RECOMMENDATION The JHOSC working group recommend that Durham County Councils Executive consider the nine recommendations in this section of the report (informed by the survey of work undertaken on behalf of the JHOSC working group by Age Concern County Durham) ,when planning for reprovison care options.

OPTIONS APPRAISAL for IN-HOUSE CARE HOMES

Members of the working group considered at length an options appraisal for each of the twelve homes with a view to making recommendations to Cabinet on what should happen to them in the light of evidence received thus far. We have capacity in our 12 homes to accommodate 357 people. The latest occupancy rate for the period 1st April 2007 - 31st December 2007 is 76.72% and has remained relatively unchanged from last years occupancy (2006/07) rate of 76.74%

What follows is an analysis of:-

· current description, performance and future demand
· options with cost implications
· property and risk implications

Included in this section are specific recommendations for each of our homes.

The recommendations relate to either the first phase (Phase 1) of remodelling (dependant on a feasibility study leading to a business case); and a second phase (Phase 2) to follow as soon it is financially viable to do so.

The costs for remodelling of homes set out below are not based on detailed estimates. (All figures are taken from the Property Services Report of February 2007).

HOMES TO BE CONSIDERED IN PHASE 1 (PENDING FEASIBILITY STUDY AND BUSINESS CASE FOR EACH)

Name	Preferred Option
Manor House	Re-model as extra-care in partnership with Derwentside homes
Lynwood House	Re-model as North Centre for Intermediate care or, subject to Member agreement, dispose of land to a developer who will re-provide in accordance with locally perceived needs
Grampian House	Retain and re-model as Centre for Intermediate Care
East Green - West Auckland	Re-model as Centre for Intermediate Care for Wear Valley/Teesdale
Ferymount - Ferryhill	Re-model into Intermediate care/short stay/respite and Day care facility

Manor House, Annfield Plain

This is a 28 bedded home, of which 8 beds are for intermediate care. Occupancy is 79.12% and is 79.2% for intermediate care. There is also a day service, with 20 places available daily, 7 days per week. Occupancy of this service is 61%. The building is combined with 36 flats which house tenants of Derwentside Homes. There are a total of twenty two independent sector homes in Derwentside. Eleven of these homes are registered for nursing care and, out of these, six offer EMI care. Of the remaining eleven residential care homes, six offer EMI care.

Options

(a) The District Council and Derwentside Homes are reviewing their sheltered housing scheme on the same site and would be interested in an extra care development. There is currently one extra care facility in Derwentside, in Consett, so the site in Annfield Plain would best be developed differently, i.e. to include older people with mental health needs. A floating support or resource centre could be included in this development as the whole site is quite large.

(b) Retain the home for permanent residents but expand it to include EMI residents, which could offset cost of in-house care. However the area is well provided for this group already in the independent sector
Risks

(a) No capital available for extra care
(b) Local Government Review
(c) Unit costs of in-house provider

Property - This property was purpose built in a joint venture with the District Council and offers accommodation for the PCT. Any changes to the site would be subject to a three way agreement. In terms of alternative sites, there is not much available in the area. There is a detached playing field nearby which may be suitable.

RECOMMENDATION: (a) The Working Group note the options and suggests that Manor House, Annfield Plain be included in Phase 1 and be re-modelled as an extra-care scheme in partnership with Derwentside homes. (Phase 1 to go ahead as soon as is possible informed by a feasibility study and supported by a detailed business case). (b) Members note that it is still unknown if Derwentside District Council could access capital for an Extra Care building. However, this is a promising prospect because the District Council is keen on such a development on that site and it would be a good partnership development. (c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on: · Redecoration · Flooring, Furnishings · Minor Improvements The cost for doing this is estimated at £37,100

Lynwood House, Lanchester

This is a 33 bedded home, of which 10 beds tend to be used for short stay, or respite care. Four of the residents have a learning disability. The occupancy rate for this home is 61%, the lowest of all homes in the most recent figures. Lynwood House is the only care home in Lanchester and there is considerable public support to retain such a facility (preferably a redesigned one).

Options
(a) The Lanchester Partnership, comprising of the Parish Council, Mental Health Care (a local care home charitable provider), the local hospice and a local GP practice, are extremely interested in this site. Their plan is to reprovide both the local hospice and a mental health care home for older people (both currently at Maiden Law) on the site as they have to move from their present site. The local GP practice also needs to move to a bigger location if the site is large enough for all. The Partnership have capital available, are willing to buy or lease the land, and to accommodate any current residents from Lynwood House. The present building would have to be demolished. The plan is unable to proceed because of advice from Legal and procurement colleagues who have indicated that legally it cannot proceed while members have made a decision to retain all their homes, and that even if this were overcome, a full tendering process would be required for the site. In order to proceed with the plan, Members would need to agree that the home be re-provided and the site offered to external bidders.
(b) Develop as intermediate care, short stay facility for the North. The site is considered the best location among all these in the North, since is relatively near to both Durham and Chester le Street. It is however possible that some people, particularly east of Durham might not wish to travel there. A new intermediate care facility should include provision for older people with mental health needs, where there is currently no service.
Cost: Backlog £621,490.

(c) Retain as long stay care home, but under occupancy is likely to continue.
Cost: £1,577,850 to up-date

NOTE: Rebuild costs are estimated at £3,296,520

Property - This one of the largest residential home sites being over 2 acres in size. There is some debate about whether the site could be used for residential development.

RECOMMENDATION:

(a) The Working group note the options and suggests that, Lynwood House, Lanchester be included in Phase 1 and be re-modelled as a North Centre for Intermediate care or, subject to Member agreement, that the land be disposed of to a developer who will re-provide in accordance with locally perceived needs.
(Phase 1 to go ahead as soon as is possible informed by a feasibility study and supported by a detailed business case).

(b) Members note that the Lanchester Partnership, comprising the Parish Council, Mental Health Care (a local care home charitable provider), the local hospice and a local GP practice, are extremely interested in this site. It is suggested that the proposals for Lynwood House, Lanchester should be fast-tracked with an early report to Cabinet and that an early indication should be given to the Lanchester Partnership about the County Councils position on this matter.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on :
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £33,500

Grampian House, Peterlee

This is a 20 bedded home and has a day service with 20 places available daily. It is registered to accept adults over the age of 18 years rather than specifically older people as it also provides an intermediate care service.
The home also accommodates the Intermediate Care Team. Performance shows occupancy at approximately 74%. There are no other care homes in Easington locality providing intermediate care services there is sufficient provision of residential care by the independent sector.

Options

(a) This care home be maintained and remodelled into a Centre of Excellence - providing exclusively intermediate care and short stay assessment
(b) Day services are relocated to other locations so that intermediate care day therapy sessions may be operated from the current day centre accommodation.
(c) Staffing levels are reviewed to allow for 20 beds to be used for the new service delivery and delivery of intermediate care to older people with mental health issues.
(d) Consideration is given in longer term to adapting one “wing” of care home to provide more appropriate facilities for younger people.

An extensive amount of money has recently been spent on this home to refurbish and redesign the accommodation (£365,000 from Neighbourhood Renewal Fund, £28,000 from Performance Fund + approx £20,000 from DCC)

Risks

(a) Co Durham PCT does not engage in joint commissioning/does not have necessary funding.
(b) Previous promises to current residents to remain at Grampian House until their care needs can no longer be met will need to be honoured or negotiated.
(c) Dissatisfaction of day service clients to relocation needs to be managed.
(d) Lack of staff to provide safe service for 20 beds will reduce occupancy and raise unit costs.
(e) Younger people will not accept admission due to lack of appropriate facilities.
(f) Services for older people with mental health issues deter other people from admission - needs to be incorporated via use of “separate” facilities.

Property - There is a site available in Peterlee that could accommodate a new development

Costs
a) Backlog £150,400
b) Up-date £1,150,240
c) Re-build £3,081,800

RECOMMENDATION:

(a) The Working Group note the options and suggests that Grampian House, be included in Phase 1, is retained and re-modelled as Centre for Intermediate Care.
(Phase 1 to go ahead as soon as is possible informed by a feasibility study and supported by a detailed business case).

(b) Members note that Grampian is a shining example of partnership working and integrated service delivery, and a model that the County Council should build upon and invest in within County Durham. (c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £23,850

East Green, West Auckland

This is a 39 bedded home with 8 beds identified for intermediate care in a dedicated unit. Performance shows occupancy at 74% which is 4% lower than the local independent sector market. There are fifteen independent sector care homes in Wear Valley and Teesdale. Within the Bishop Auckland area there are nine independent sector homes.

Options

(a) It is suggested that this home be remodelled (new build) into a resource centre for Wear Valley/Teesdale offering intermediate care, short stay beds, respite beds, day care, drop in, including a facility for respite with dementia.

(b) Alternatively the existing building could be adapted to meet the different needs. The building design as it exists would need to be altered.

Risks

(a) No capital available to replace/upgrade
(b) Decommissioning if home is to be redesigned
(c) Building not suitable for alteration/too expensive

Property - There is no obvious alternative site.

Costs:

a) Backlog £933,840
b) Re-furbish £1737,640
c) Re-build £3,070,800
d) Cleared site valued at £270,000




RECOMMENDATION:

(a) The Working Group note the options and suggests that East Green, West Auckland be included in Phase 1 of any development as soon as it is financially possible to be re-modelled as a Centre for Intermediate Care for Wear Valley/Teesdale.
(Phase 1 to go ahead as soon as is possible informed by a feasibility study and supported by a detailed business case).

(b) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £49,640

Feryemount, Ferryhill

This is a 29 bedded home with 9 of those beds being used for the delivery of intermediate care. Occupancy for this financial year is 81%. Utilisation of the intermediate care beds is 80% which is very good given the nature of intermediate care. There are thirteen independent sector care homes in Sedgefield with two in Ferryhill, 1 in Chilton and 1 in West Cornforth. The Chilton Care home has a unit for people with dementia and Appleton Lodge offers Extra Care in Spennymoor for people with memory problems.

Options

(a) The use of this home should be expanded for intermediate/respite and short stay beds and includes a focus for Intermediate Care for people with dementia. The SHARP team could be re-accommodated into the building which would improve efficiency.

(b) The alternative is to continue with its present use.

Risks

(a) Residents and families may not support the development
(b) Capital may be required to remodel the home.
(c) Unit costs may increase if beds are used differently
(d) CSCI minimum standards may not be achievable

Property - There is no obvious site in Ferryhill. The current building occupies the entire site.

Costs

a) Backlog £158,050
b) Re-furbish £1,094,850
c) Re-build £3,053,359




RECOMMENDATION:

(a) The Working Group note the options and suggests that Feryemount be included in Phase 1 of any development as soon as it is financially possible to be re-modelled into Intermediate care/short stay/respite and Day care facility.
(Phase 1 to go ahead as soon as is possible informed by a feasibility study and supported by a detailed business case).

(b) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £37,000

HOMES TO BE CONSIDERED IN PHASE 2 (WHEN IT IS FINACIALLY VIABLE, INFORMED BY FEASIBILITY STUDY and SUPPORTED BY A BUSINESS CASE FOR EACH HOME) Stansfield House, Stanley

This is a 21 bedded home. Until 2006 the Mental Health Trust occupied another 12 bedded wing of the home, but withdrew to reprovide services elsewhere. These beds are not included in the figures, but there is considerable empty space in the home. There are a total of 22 independent sector homes in Derwentside. Eleven of these homes are registered for nursing care and, out of these, six offer EMI care. Six of the remaining eleven residential care homes offer EMI care.

Options

Retain as a care home or develop to include beds for EMI residents. However, there are significant numbers of such beds in the independent sector. Costs
a) Backlog £204,750.
b) Up-date £1,134,350.
c) Rebuild £3,043,810,
d) Site value £270,000

Risks

(a) Unit costs
(b) Numbers of other beds in the area

Property - This is a very small site of just over 1/2 an acre and there is not much scope to expand the building. In terms of alternative sites, there is an option of a one stop shop on Front Street, which could be developed to provide residential care. There is also a small site at East Stanley and two other sites at Annfield Plain and the Kings Head playing fields.

RECOMMENDATION:

(a) The Working Group note the options and suggest that Stansfield House, Stanley be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) Members note that no potential partners have been identified to progress on the options and suggest that this home continues to provide existing services.

(c) That planned maintenance work be undertaken with any health and safety issues in the home addressed.

(d) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £54,080

Glendale House, Blackhall

This is a 28 bedded home and has a day service with 8 places available daily. 20 beds are identified for long stay residents with 8 being targeted to respite care. In addition there is a day service funded via a Service Level Contract with Alzheimer’s Society for 20 places daily. Performance shows occupancy at approximately 62% which is lower than the local market. There are seventeen residential care homes in the Easington locality. Within the Blackhall area there are eleven residential care homes which include five homes with EMI provision included, which allow for older people to be cared for as their needs increase/change.

Options

(a) Remodel (new build) into EMI Extra Care and develop floating support for local area - this option would enable older people with mental health issues to retain their independence within a supported environment. There is no such facility within the Easington locality. Surrounding Glendale House are a number of bungalows and a sheltered housing complex. There is easy access to local shops and amenities. Work could be done with Easington District Council /East Durham Homes to develop a “village” support service.

(b) Adapt to different needs. The market has identified over-capacity in all care areas in Easington, however there is a rise in EMI demand. With additional training DCC staff could provide this care within a specific unit in Glendale House, thus creating a new market base and also ensuring that people did not need to be transferred if their mental health declined.

(c) Additional use could be made by remodelling the upper floor (which has a poor lay-out) to provide day services on a larger scale and all residential care would be relocated to the ground floor, thus enabling more flexible use of the care staff. This option would be sustainable in the short/medium term, but Glendale House does not meet the current CSCI guidelines for care homes. These changes may result in less staffing requirements.

Risks

(a) No capital available for Extra Care development.
(b) TU/staff opposition to change in duties.
(c) Unit cost impacts
(d) Building not suitable/too costly for remodelling.

Property - There are no obvious alternative sites available in Blackhall

Costs -
a) Backlog £193,600
b) Re-furbishment £1,152,650
c) Re-build £3,073,800
d) Cleared site value £510,000
RECOMMENDATION:

(a) The Working Group note the options and suggests that Glendale House be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) That this home continues to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £76,970

Newton House, Stanhope

This is a 28 (however 3 beds are currently decommissioned) bedded home with an adjoining day centre that has capacity for 10 attendees, 62 service users on the register and has 95% attendance. There are also 8 bungalows in the grounds accommodating older and disabled people who occasionally receive support from the Home and Care Line. Performance data shows occupancy at 72% for this financial year (including 3 beds decommissioned). Consequently occupancy of the 25 beds will be higher. There is one other home in the town of Stanhope with 25 beds. The next nearest care home is in Tow Law.

Options

(a) Newtown House is in a prime location in terms of meeting strategic need. The home enables the most dependent people to remain in Upper Weardale. The first option would be to replace Newtown House with a new build extra care scheme on the same site. The building of a new scheme would compliment the specially adapted bungalows and should also include, within the development, a new day care facility. The inclusion of a small number of units for people with dementia should also be considered

(b) Consideration is given to the development of part of the home into a unit for people with dementia. Currently people who need specialist care have to travel to Tow Law, Willington or Bishop Auckland. This would need to be subject to a building feasibility study.

Risks

(a) Opposition from residents and family if home was decommissioned
(b) No capital available for development.
(c) TU/Staff opposition to change in duties.
(d) Planning permission
(e) Unable to secure a partner

Property - There are no alternative sites in Stanhope. The existing building is in a conservation area and any changes could be problematic.

Timescale

Option 1 - 24 months
Option 2 - 12 months

RECOMMENDATION:

(a) The Working Group note the options and suggests that Newton House, Stanhope be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) That this home continues to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £66,700

Shafto House, Newton Aycliffe

This is a 30 bedded home in the centre of Newton Aycliffe. The home also has a day unit with 10 places per day which has 35 people on the books and 85% attendance. Occupancy for this financial year which is at 80% which is 2% lower than the total independent sector average for Sedgefield. There are thirteen independent sector care homes in Sedgefield with five of those homes in Newton Aycliffe (including Greenfields House which is currently not commissioned but may be refurbished/rebuilt in the future). Three of those homes accommodate older people with dementia.

Options

(a) Remodel (new build) into an extra care scheme. There is local commissioning evidence to support the development of an extra care scheme in Newton Aycliffe. The nearest existing scheme is in Spennymoor which is often considered too far away from Newton Aycliffe to be an option for older people

The development of an Extra Care scheme could be undertaken in partnership with Sedgefield Borough council and a Registered Social Landlord to maximise the access to Housing Revenue Grant.

(b) Adapt to meet different needs. There is direct competition in the locality for standard residential, nursing and dementia care with all remaining homes either Grade 1 or 2. This to some extent limits the options for this home and the commissioning ‘intelligence’ would suggest the need for a small number of crisis beds in the locality.

Risks

(a) Residents/families not supporting redevelopment
(b) Unable to secure a partner
(c) No capital available
(d) TU/staff opposition to changes in duties
(e) Site not suitable for redevelopment
(f) Costs

Property - Alternative sites are available in the area at Elmfield School which is being demolished. There is also space at the former Avenue School or at Aycliffe Centre for Children.

Costs:
a) Backlog £158,900
b) Re-furbish £1,170,500
c) Re-build £3,284,000
d) Site value £380,000


RECOMMENDATION:

(a) The Working Group note the options and suggests that Shafto House
be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) That this home continues to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £74,900

Hackworth House, Shildon

This is a 40 bedded home with a 8 place day centre offering a 5 day service, 2 days for dementia care and 3 for general older persons. There are 20 people on the ‘books’ and 75% utilisation. The home has an average occupancy of 67% for this financial year, which is significantly lower than the independent sector average. There are thirteen care homes in the Sedgefield district with two new builds in Shildon. Both new builds offer dementia services alongside general residential and nursing.

Options

(a) Remodel into a smaller, highly specialised dementia unit with a maximum of 16 units (two units of eight). This development should be considered in partnership with the Mental Health Trust and potentially use health act flexibilities to enable nursing care to be provided.

There should be consideration to the development of a specialist day unit on site and interest was expressed by the adjacent GP practice to develop a new build surgery also on the site.

(b) Upgrade building and continue to offer standard residential care with potentially lower number of beds - subject to feasibility

Risks

(a) Decommissioning of the existing building
(b) Failure to secure interest of partners
(c) Capital availability
(d) Unit cost would increase with the reduction of units
(e) Increased revenue costs

Property - There is a potential alternative site in the centre of the town which is leased to the Town Council. There is also another site close to the town in the neighbouring settlement of Eldon.

The Working Group was advised that there were further financial issues which will need to be considered and these are detailed later in the report.

Costs

a) Backlog £926,500
b) Re-furb £1,870,440
c) Re-build £3,080,700
d) Site value £480,000
RECOMMENDATION:

(a) The Working Group note the options and suggests that Hackworth House be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) That this home continues to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £85,600

Mendip House, Chester le Street

This is a 28 bedded home, which has 20 places for permanent residents and 8 intermediate care beds. The home is popular and occupancy is high at 96.87%. The occupancy rate for intermediate care is 52%. There are a total of eleven independent sector residential care homes in Chester le Street. Four of those homes offer nursing care, and one of these also offers EMI care. Five of the remaining seven residential homes offer EMI care.

Options

(a) Mendip House is popular and is high occupancy, so one option is to retain it as a residential care home and carry out repair/maintenance work.
Cost: £142,270 backlog figure
(b) Intermediate short term and respite care would be better provided in a single unit for the North where staff could be dedicated to this type of service. This requires different training and skills in rehabilitation work. Mendip House could provide this facility, although it might not be well used by people from the East of Durham or Consett areas.
Cost: £1,069,400 up-date internal environment

(c) The prevalence of dementia is rising and additional payments are currently paid to the independent sector for this type of care. Staff could be trained in this type of care and this could partly justify the additional cost of the in-house service. The building might need upgrading for EMI care.
Cost: As above assuming no additional costs associated with change of use

Risks

(a) There is over-provision of beds in the area, particularly beds for EMI care, and independent sector providers would see in-house provision of this type of care as a threat
(b) Location as a single intermediate strategy respite care centre for the North is not ideal and risks not being fully utilised
(c) PCT might not agree to jointly commission and fund and intermediate care relies on adequate therapy input (PCT responsibility)

Property - Some land will be shortly available adjoining Hermitage school. This land will be put for sale jointly with the District Council. There is little land availability in the Chester le Street area.


RECOMMENDATION:

(a) The Working Group note the options and suggests that Mendip House be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) Members note that no potential partners have been identified to progress on the options and suggest that this home will continue to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £29,760

Cheveley House, Belmont

This is a 36 bedded home of which 8 beds are used for intermediate care. The home is popular and occupancy is high at 99.22%. The occupancy rate for intermediate care is 62%. There are a total of eleven independent sector care homes in Durham District. Only three of these homes are in close proximity to Cheveley House. Seven homes offer nursing care, of which three also offer EMI care. Two of the remaining four homes offer EMI care.

Options

(a) Cheveley House is popular, has limited competition in the immediate vicinity and has high occupancy, so one option is to retain it as a residential care home and undertake repairs/maintenance work.
(b) The prevalence of dementia is rising and additional payments are currently paid to the independent sector for this type of care. Staff could be trained in this type of care and this could partly justify the additional cost of the in-house service. The building might need to be upgraded for EMI care. (c) Remodel (new build) into EMI Extra Care Facility with floating support available in people’s own homes. This option would enable older people with mental health problems to be supported in tenancies. There is currently one extra care scheme in Durham but it is in the West of the district, is oversubscribed and does not cater for mental health problems.
Costs: Major capital costs but site worth £1.7m

Cheveley is not considered as a desirable location for an intermediate/short stay/respite care centre for the North because its location at the extremity of Durham would not encourage Derwentside or Chester le Street residents to use this facility.

Risks

(a) No capital available for extra care
(b) Local Government Re-organisation getting in the way of remodelling
(c) District Council may not co-operate
(d) Unit costs if in-house provider
(e) Building/site unsuitable

Property - Additional land will be required for an Extra Care Scheme. There is no land in the immediate area, although there is land available in Gilesgate and in Newton Hall.

RECOMMENDATION:

(a) The Working Group note the options and suggests that Cheveley House be included in Phase 2 of any development namely when it is financially viable to consider, informed by feasibility study and supported by a business case.

(b) Members note that no potential partners have been identified to progress on the options and suggest that this home will continue to provide existing services.

(c) Members note that a minor improvement in house residential care programme (planned programme for maintenance and repair) is planned for focusing on:
· Redecoration
· Flooring, Furnishings
· Minor Improvements
The cost for doing this is estimated at £79,146

DURHAM COUNTY COUNCIL JOINT HEALTH OVERVIEW AND SCRUTINY COMMITTEE LOOKING AT THE FUTURE OF RESIDENTIAL CARE RECOMMENDATIONS GENERAL RECOMMENDATIONS 1. THE POLICY CONTEXT AND NATIONAL DRIVERS FOR THE FUTURE OF RESIDENTIAL CARE. RECOMMENDATION The JHOSC working group note the emphasis placed upon working across boundaries to harness the capacity of the whole system in government policy. The JHOSC working group welcome Local Area Agreements and Joint Strategic Needs Assessment (JSNA) as important mechanisms to enable this to happen.

2. WHAT DO WE WANT TO SEE IN PLACE TO MEET THE NEEDS OF OLDER PEOPLE IN OUR COMMUNITIES?

RECOMMENDATION

The JHOSC working group recommend that the new unitary council for County Durham recognises and plans for the place shaping agenda with regard to the needs of older people in line with Sir Michael Lyons thinking on this subject.

That the County Council give consideration to an Older Peoples strategy that reflects key themes to do with what people want underpinned by the principle of supporting people to live independently in their own home.

3. WHAT ARE OUR COMMISSIONING ARRANGEMENTS TO SUPPORT OLDER PEOPLE? RECOMMENDATION The JHOSC working group note the important role elected members have with shaping a commissioning strategy that should focus on outcomes for people.

4. SUPPORTING PEOPLE TO LIVE INDEPENDENTLY

RECOMMENDATION

The JHOSC working group would like to remind Durham County Council’s Executive of the importance of home care in supporting people to live independently; and that any strategy for Older People must recognise the importance of community and social support networks that support to people to live independently.

5. SUPPORTING PEOPLE TO LIVE INDEPENDENTLY RECOMMENDATION The JHOSC working group recommend that Durham County Councils Executive consider reprovision (extra care, intermediate care, sheltered housing, other housing provision), rather than just residential care, as a significant option in responding to the future of residential care needs.

6. TECHNOLOGICAL ADVANCES TO SUPPORT PEOPLE TO LIVE INDEPENDENTLY

RECOMMENDATION

The JHOSC working group recommend that Durham County Councils Executive consider the impact of the Telecare Strategy ,reviewing its effectiveness and pitfalls with a view to supporting its implementation across the whole system.

7. WHAT OPPORTUNITIES EXIST FOR PARTNERSHIP WORKING WITH OTHER PUBLIC SECTOR PROVIDERS FOR EXAMPLE THE NHS? RECOMMENDATION The JHOSC working group recommend that the new unitary council for County Durham, in its role as a strategic housing authority, continue to work in a partnership context to respond to the needs of an ageing population working across boundaries, “to harness the capacity of the whole system”.

8. ROLE OF THE INDEPENDENT SECTOR IN PROVIDING RESIDENTIAL CARE

RECOMMENDATION

The JHOSC working group recommend that in negotiation of contracts with the Independent sector consideration is given to staff development and staff training in delivering standards of care identified in the contract.

Members note the potential increase with dementia and challenging behaviours in the future and ask Durham County Councils Executive to note these long term conditions within an ageing population.

9. HOW EFFECTIVE IS OUR MARKETING STRATEGY TO PROMOTE OUR RESIDENTIAL CARE FACILITIES? RECOMMENDATION The JHOSC working group recommend that Durham County Councils Executive build on the work already in place to inform and educate people about all the care options available to them by investing in a marketing strategy for this purpose.

10. WHAT ARE THE VIEWS OF THE STAFF, CARERS AND USERS OF THE SERVICE?


RECOMMENDATION

The JHOSC working group recommend that Durham County Councils Executive consider the nine recommendations in this section of the report (informed by the survey of work undertaken on behalf of the JHOSC working group by Age Concern County Durham) ,when planning for reprovison.

SPECIFIC RECOMMENDATIONS PHASE 1 Name	Preferred Option
Manor House	Re-model as extra-care in partnership with Derwentside homes
Lynwood House	Re-model as North Centre for Intermediate care or, subject to Member agreement, dispose of land to a developer who will re-provide in accordance with locally perceived needs
Grampian House	Retain and re-model as Centre for Intermediate Care
East Green - West Auckland	Re-model as Centre for Intermediate Care for Wear Valley/Teesdale
Ferymount - Ferryhill	Re-model into Intermediate care/short stay/respite and Day care facility

PHASE 2

The JHOSC Working Group also recommend that all of the remaining seven homes be included in Phase 2 when it is considered financially viable to do so and when partners have been identified to support re-modelling opportunities in line with the thrust of this report. Phase 2 included seven homes: · Cheveley House · Glendale House · Hackworth House · Mendip House · Newtown House · Shafto House · Stansfield House

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© “Looking to the Future” Age Concern Durham County, January 2008



1 Executive Summary ……………………………………………………3

2 Introduction ……………………………………………………………...5

3 Older people currently living independently ………………………6

3.1 Summary 6
3.2 Reasons why older people may move from their home 7
3.3 Preferred care options 7
3.4 What would make it easier for older people to live independently 8
3.5 What factors would influence choice of extra care or care home 8


4 Older people living in extra care homes …………………………..10

4.1 Summary 10
4.2 Expectations and care 11
4.3 Social interaction and participation 13
4.4 Access to information and personal care 14


5 Older people living in residential care homes ……………………16

5.1 Summary 16
5.2 Expectations and care 17
5.3 Social interaction and participation 19
5.4 Access to information and personal care 21


6 Conclusion and recommendations ………………………………...22

APPENDIX: Questionnaires used in the consultation ……………..……24


1. Executive Summary

2. Introduction
· 80 older people currently living independently
· 14 Residents in 3 Durham County Council extra-care homes
· 29 Residents in 5 Durham County Council residential care homes
· 3 Residents in 1 private care home which also provides EMI support
3. Older people currently living independently

3.1 Summary

3.2 Reasons why older people may move from their home

1. Garden too big to maintain 56%
2. Experiencing difficulty with stairs 51%
3. House too difficult / expensive to maintain 46%
4. Move nearer to local amenities 43%
5. Better access to public / voluntary transport 29%
6. Move closer to family 26%
7. Move to a safer / quieter neighbourhood 25%

3.3 Preferred care options
The preferred care options were:

· Stay in their own home with carer support 82.5%
· Sheltered accommodation would be considered by 37.5%
· Extra care home 26%
· Residential care 20%
· Live with a family member 10%
3.4 What would make it easier for older people to live independently
1. Help with personal care
2. Maintaining your property
3. Information and advice (where to go to access services)
4. Foot care
5. Heavy housework (laundry, cleaning)
6. Advocacy help
7. Light housework (dusting, tidying)
8. Assistance or advice with money matters
9. Preparing meals
10. Shopping
11. Changing light bulbs, moving furniture etc

3.5 What factors would influence choice of extra care or residential care home
1. Own room (with own bathroom)
2. Own room large enough to take some personal effects
3. Cost
4. Close to family and friends
5. Care assistance
6. Friendliness of staff
7. Activities
8. Access to computers
9. Tea making facilities
10. Own television / radio
11. Privacy



4. Older people living in extra care homes
4.1 Summary
4.2 Expectations and care

· Overall, 59% of residents felt ‘very happy’ that the extra care home had met their expectations with 6% stating the home had not met their expectations (see fig. 2).


· The majority of residents were ‘very happy’ (59%) or ‘happy’ (35%) that they were involved in how their care package was delivered. However, 6% felt ‘unhappy’ with their involvement.

· The majority of respondents were ‘very happy’ (59%) or ‘happy’ (35%) that the facilities allowed them to live an independent life.

· The majority of residents were ‘very happy’ (59%) with the way in which their dietary needs were being met. However, 12% were ‘unhappy’ with 6% being ‘very unhappy’ with the food provided.
· The majority of respondents (94%) were happy that their faith and cultural needs were being met.

· All respondents were ‘very happy’ that their visitors were made welcome.
· 100% of respondents were ‘happy’ or ‘very happy’ that their personal dignity was being respected. · 100% of respondents were ‘happy’ or ‘very happy’ with the extra care home’s environment.

· All respondents have their own bathrooms. However, one extra care home respondent required a bath with care assistance in one of the home’s communal bathroom because only a shower was provided in his en-suite room. As a result, this respondent stated they did not have their own bathroom. 4.3 Social interaction and participation

· 70% of respondents were very happy or happy with their participation in activities in the home · 64% of residents in extra care have the opportunity to go on trips although some choose not to go on them. However, other residents reported that they were unhappy that they could not go on trips because of health care needs.

· 47% of residents reported that they had the opportunity to go on holiday. However, 53% were unhappy that they could not go on holiday because of their health and the need for care assistance.
“Suggestions for activities are not acted on” · 70% feel that the activities are relevant to them, although 30% were ‘unhappy’ with the activities available.
· 82% felt that they were able to suggest other activities to the staff, and most residents were aware of how the social committees operated in their home.

· Most residents of extra care homes (94%) socialise with other residents

· All respondents in extra care were able to have their own television or radio.

4.4 Access to information and personal care

· 82% of residents said they knew where to go if they needed help and 94% said they knew who to ask. However, 18% said they did not know where to go for information and 6% did not know who to ask.

· 88% of respondents said they received the personal care they needed, however 12% said they were unhappy with the level of personal care.

· 71% were ‘very happy’ that they received timely personal care, however 18% were only ‘happy’ and 12% were ‘unhappy’. No-one was ‘very unhappy’.



· Respondents praised the care workers, but were critical about staff shortages and the systems in place. · The majority of respondents (94%) received visitors.

5. Older people living in residential care homes
5.1 Summary

5.2 Expectations and care

· Each resident had their own story of how they had come to the residential care home. Some had chosen to move, some wanted the security, and others did not want to move but were placed in residential care because of physical or mental health care needs that could not be met by their families or other care provision.

· The majority of residents were ‘very happy’ (52%) or ‘happy’ (38%) that the home had met their expectations. Those who had been to the home previously for respite or weekly visits felt they had particularly known what to expect. For some, residential care was an environment they needed to adapt to (see fig 4).


· Most people were ‘very happy’ (35%) or ‘happy’ (52%) that they were involved in how their care package was delivered. However, 10% were not sure whether they were involved (see fig. 5). Respondents who are involved in the delivery of their care packages commented that it can be challenging.

· Older people with mental health problems found it harder to discuss their views or aspirations. They were also less likely to know if they were involved in the delivery of their care package.

· 86% of respondents were happy that the facilities enabled them to live an independent life.
· All respondents were happy that their dietary needs were being met
· All respondents were happy that their faith and cultural needs were being met

· All respondents were happy that their personal dignity was respected

“There are laundry problems - I get someone else's underwear”. · All respondents were happy that their visitors were made welcome

· All respondents were happy with their surroundings

· Only the private residential care home provided en-suite rooms. Residents in council managed care homes accessed communal bathrooms.

5.3 Social Interaction and participation

· The majority of respondents participate in activities in the residential home.
· However, 7% were ‘unhappy’ with their level of participation.

· Some respondents said they go on trips or holidays with family members. Others participate in trips arranged by the care home. However, 48% of respondents are ‘unhappy’ that they do not go out on trips and 62% are ‘unhappy’ that they do not go on holiday. Some reported that they had not been on holiday since they entered the care home.

· Many respondents reported that their health makes it difficult to go on trips or holidays.
· 29% felt that the activities are not relevant to them.
· 79% of respondents feel able to suggest other activities to the staff. · Older people with mental health problems were less likely to suggest other activities to the staff and appear to be more passive receivers of entertainment provided by the home.
· 93% of respondents said they were ‘very happy’ or ‘happy’ with how they socialise with other residents

· The majority of residents have a television or radio in their room.

5.4 Access to information and personal care

· The majority of residents said they knew where to go for information and who to ask. However, 3% said they were unsure.

“I do not know who anyone is in order to ask for information or help”.
· All respondents were happy that they received personal care they needed

· 94% of respondents were happy that they received personal care when they needed it

· The majority of residents received at least one visitor. EMI respondents were less likely to receive visitors.

6. Conclusion and Recommendations

Recommendations

· Provide clear information about the cost of care and the options available to older people

· Ensure older people can have their own en-suite room that is large enough to accommodate some personal effects.

· Encourage older people to visit the care home as much as they need to before moving in. Those who had come once a week for a few weeks were much happier because they knew what to expect.

· Provide advocacy services to enable those who have a grievance to be involved in finding the solution.

· Make sure all residents know where to go and who to ask for information.

· Avoid perceptions of gender stereotyping by identifying alternative activities that can engage older men.

· Investigate programmes of care assistance and travel that can enable older people to go on trips and holidays if they wish.

· Review the system for obtaining prescribed medication in care homes.

· All respondents praised the care staff but were concerned about staff shortages. Their concern needs to be addressed.

















 Item 4_ii_.pdf;
 REPORT on the Future of Res Care 30 Jan 2008 Item 4 _i_.pdf;
 item 4.pdf