Contact: Claire Bruin ext 7219

1 Summary

1.1 The review of residential services for people with learning disabilities and disabled people has included residential, nursing homes and adult placements for adults aged between 18 and 64 years, provided by in-house and independent sector providers. The independent sector includes voluntary, not for profit and private providers.

1.2 Short stay/respite services have not been included in this review, as they have been considered within the Best Value review on support to carers.

1.3 The review has included the following activities:

· An analysis of the costs of different types of service provision.

· Comparison of the costs of in-house and independent sector provision

· Comparison of Hampshire's performance against other local authorities

· Questionnaires sent to relatives of people resident in homes

· Meetings with care managers and team managers across Hampshire

· Meetings with staff working in in-house services

· Meetings with some relatives of people living in in-house services

· Visits by review team members to the five in-house services and sixteen independent sector providers

· Consultation with individual residents living in the services visited, and where permission was given, with their relatives.

1.4 Consultation provided the following messages:

1.4.1 Relatives - High levels of satisfaction, but concern about staff turnover, leading to lack of continuity and poor communication. Strong views regarding the permanency of in-house placements and issues around communication of developments that may impact on the lives of their relatives.

1.4.2 Service Users - high levels of satisfaction, where users were able to express an opinion. For people with complex needs, who would find it difficult to express an opinion verbally, members of the team spent a day with individuals to sample their day-to-day experience, and gather information on their perceived satisfaction, and the service quality.

1.4.3 Care Managers - A mix of quality with some more institutional services; Concerns over staff turnover; Potential to co-ordinate purchasing power across the county.

1.4.4 Adult Placement Officers - A valued scheme that needed greater co-ordination and clearer direction.

1.5 Comparison

1.5.1 The performance against Performance Assessment Indicators for the unit cost of residential places has remained constant for disabilities, with a good rating, while the rating for learning disabilities has dropped from good to poor.

1.5.2 The average unit costs of in-house services compare favourably with the independent sector based on the level of analysis that was included in the review.

1.6 Competition

1.6.1 There is a mixed market providing services for both client groups although the residential market is much smaller for disabled people, with independent living and Direct Payments having a very strong presence in Hampshire. Supported living is a growth area for people with learning disabilities but will not replace residential services and there is a need to develop both types of service to support people to remain in Hampshire.

1.7 Challenge

1.7.1 There is clearly a need to develop services that maximise independence and choice, to fit with national agendas. Independent and supported living are models of service that support this agenda.

1.7.2 Residential services have the potential to maximise independence, choice and involvement within the limits imposed by registration. The use of a benchmarking tool has the potential to be of value in the reviewing and monitoring of services but needs further work. The benchmarking tool piloted during this review asked Services to provide evidence on how they support service users in relation to a number of key "life elements". These life elements are those identified in the DOH Guidance "Best Value Reviews of Learning Disability Services for Adults - A Framework for Applying Person Centred Principles", and are issues which support rights, independence, choice and inclusion.

1.8 Outcomes

1.8.1 In the options (see section 8) adult placement, in-house services and the independent sector have been considered separately. To each part of the market, the same three options have been applied: remove the service from the market i.e. stop purchasing or providing; take no action to change the current purchasing or provision; take action to change the current way of purchasing or providing.

1.8.2 Following presentation to members on 31 May 2002, the third option i.e. take action to change the current way of purchasing or providing, was supported and a detailed action plan requested. The action plan is set out in Appendix A.

1.8.3 The key outcomes that are expected to be achieved through the implementation of the action plan are:

· A strengthening of the Adult Placement Scheme with a mix of registered care and Supported Living.

· Flexible use of vacancies in in-house services.

· Options appraisals carried out for all in-house services in response to the standards set by the National Care Standards Commission.

· Joint working with NHS colleagues and providers to identify gaps in services and progress new service developments within Hampshire.

· Purchasing co-ordinated across the County, to ensure most effective use of resources.

· Collaborative approach to providing appropriate services for people with health and social care needs, within the framework of the Continuing Care Eligibility Criteria.

· Increased number of Supported Living arrangements.

· Use of benchmarking tool for comparison of residential services.

2 The Service under Review

2.1 The review of residential services for people with learning disabilities and disabled people includes residential and nursing homes and adult placement. Residential services include in-house and independent sector provision. Within this report, residential will be taken to include all three types of service unless otherwise indicated. The services under review cater for a wide range of needs in a variety of settings and in homes of differing size.

2.2 Short stay/respite services have been considered in the Best Value review on support for carers, even though four of the in-house services provide short stays as well as permanent provision.

2.3 The budget for long stay residential services in 2001/2 are shown below - these figures for Learning Disabilities are estimated because of the mix of long stay and short stay in some in-house provision. The figures for Physical Disabilities still include Short Stay. The income for purchased services in the learning disability budget includes £12 million transferred from Health Authorities under Section 28A of the National Health Service Act 1977.

2.4 The table below shows the long stay budget for 2001/2 as a percentage of the total budgets for learning disability and physical disability. This shows clearly the much higher percentage of spend on residential services in learning disability compared with physical disability. This reflects the number of disabled people living in their own homes, supported through direct payments or purchased domiciliary support, an agenda that has more recently been adopted within the learning disability sector.

2.5 The table below show the number (and percentage) of places purchased in the independent sector and the long stay places in in-house services.

2.6 The breakdown of the places in the in-house services is shown below, with the number of short stay places, for information.

2.7 The vast majority of the market for residential services is in the independent sector for both client groups. Residential providers either provide the building and the staff or they work with housing associations (or Registered Social Landlords) to provide the building, while they provide the staff. The former arrangement is most common in the private sector and adult placement, while in the not-for-profit sector we have actively moved to the latter arrangement.

3 The Review Process

3.1 The outline project brief presented to the Policy Review Committee on 21 September 2001 specified the goals and objectives shown below:

· Goals

· To carry out a fundamental review of residential and accommodation services by July 2002 in order to meet current and future needs effectively, efficiently and economically.

· To provide residential services that maximise independence in partnership with other agencies and organisations and in accordance with national agendas (e.g. National Service Frameworks, new care standards)

· Objectives

· To identify the current and future demand for residential services

· To implement effective, efficient and economic methods of service delivery

· To evaluate the financial performance of services in appropriate comparison with other Authorities and other organisations

· To review and clarify quality standards taking account of stakeholder views

· To measure performance against these quality standards and identify options for addressing potential shortfalls

3.2 The review has included the following activities:

· An analysis of the costs of different types of service provision, grouping services together that cater for particular needs, as far as this is possible

· Comparison of the costs of in-house and independent sector provision, by aligning in-house services with similar services in the independent sector

· Comparison of Hampshire's performance against other local authorities, including our performance under the Social Services Inspectorate's Performance Assessment Framework

· Questionnaires sent to all known relatives of people resident in homes, to elicit level of satisfaction with the service and the extent to which needs were being met

· Meetings with care managers and team managers across Hampshire to gather information on the quality of services

· Meetings with staff working in in-house services to discuss the best value process

· Meetings with some relatives of people living in in-house services

· Attendance at two full day countywide meetings of adult placement officers, who were discussing the future development of the service

· Visits by review team members to the five in-house services and sixteen independent sector providers. The visits were used to gather information on care practice using a questionnaire that had been sent ahead of the visits and to shadow or interview (as appropriate) one resident to gain an insight into their view of the service. A questionnaire was also completed with the relatives of the resident, where this was acceptable.

4 Consultation

4.1 The key messages from the consultations undertaken within the review are set out below:

4.1.1 A short questionnaire was sent to all known relatives of people living in residential homes, asking them to rate their level of satisfaction with the service and to what extent it was meeting the needs of their relative. In total, 912 questionnaires were sent out and 431 (47%) were returned. The returns provided information on 168 providers. Of these providers, 55 (32.7%) were given the highest rating (4) on satisfaction and on meeting the needs of the person living there. A further 51 (30.4%) of providers were given ratings of 3 and/or 4 on the two questions and 62 providers (36.9%) received ratings of 3 and below to the two questions. Just 7 (4.2%) of providers were given the lowest rating of 1 for one or both of the questions. From the comments made on the questionnaire and from follow up contact with 54 relatives, high turnover of staff and the subsequent use of agency staff were raised as concerns. This led to a lack of continuity of care and breakdown in communication with relatives. The importance of the role of the home manager was also highlighted in so far as the manager strongly influences the culture of the home and the quality of communication with relatives. The majority of responses relating to adult placement were very positive, with relatives valuing the "home from home" style of this sort of provision.

4.1.2 Consultation with care managers and team managers elicited information on 46 providers, which ranged from very positive to concerns about the institutional style of some provision and the difficulty of finding services locally that can appropriately meet individual needs. The choice is particularly restricted for the physically disabled. The potential to increase the purchasing power of the County Council by co-ordinating across the county, where different areas make placements with the same provider, was discussed, with particular reference to the private sector. Concerns were also made regarding staff turnover and the use of agency staff, with the issues of consistency and communication being identified again.

4.1.3 Meetings have begun with relatives groups for in-house services and feedback thus far has highlighted the strong view that the placements are permanent and that changes should not be introduced that might threaten that situation. Issues have been raised on the communication of developments that may impact on in-house services and confidence needs to be built through open communication with relatives about the national and local agendas and the potential impact on in-house services.

4.1.4 A member of the review team joined two full day meetings for Adult Placement Officers from across the county who were meeting under a new management arrangement that has centralised the adult placement scheme. The value of the adult placement scheme for people who wanted this style of service was recognised, echoing the views of relatives. The scheme has recently lacked co-ordination and a sense of direction and the need to restate the purpose of the scheme and actively promote it was discussed.

4.1.5 During the visits to 16 services, including the 5 in-house services, 2 adult placement carers and 9 other independent sector providers, team members spent time with service users and where agreement was gained, also undertook a telephone questionnaire with a relative of the service user. Findings from these visits are discussed in the section on Challenge as they were used to look more closely at services that were perceived as good quality by relatives and care managers.

5 Comparison

5.1 Information from the Social Services Inspectorate's Performance Assessment Framework (PAF) has been used to compare the performance of Hampshire County Council against other local authorities, as detailed below. A detailed analysis of the cost of different types of residential services was planned in the scoping of the review. Unfortunately, it has not been possible to categorise services is as detailed a way as was proposed because the information is not readily available and the mix of people served by providers makes it difficult to define clear categories. A less detailed analysis has therefore been used, within the resources available to the review, the results of which are set out below.

5.1.1 The PAF results for Hampshire, within the comparator group of Shire counties, from 1999/2000 and 2000/01 are shown in the tables below:

1999/2000

N.B. In 1999/2000 B14 did not include placements funded by income from Health i.e. money transferred under Section 28A of the NHS Act 1977.

2000/2001

N.B. in 2000/2001 B14 did include placements funded by income from Health i.e. money transferred under Section 28A of the NHS Act 1977. CIPFA also changed the formula by which overheads were allocated to services.

(It is tacitly accepted within the SSI that the Shire comparator for costs is misleading and that a better cost comparator are other SE Region authorities who have similar supply problems, leading to increased costs of provision.)

5.1.2 The performance on learning disability has worsened from 1999/2000 to 2000/2001, with the Section 28A transfers being included and with the impact of significant movement of individuals from residential care into supported living schemes. The development of supported living has given opportunities for people who were in the lower end of the residential market (based on cost) to move on, thereby raising the average weekly cost of those remaining in residential care. However, if compared to Local Authorities on the outskirts of London e.g. Surrey, where local authorities are operating in the same economic environment as Hampshire, then our performance on B14 would have been rated "good" - see table below:

2000/2001

5.1.3 An extract taken from the National Statistics publication 2000/2001 detailing the number of supported residents shows Hampshire's performance against counties in the South East (see Appendix). The percentage of residential and nursing placements for people with learning disabilities is 14.1%, against a South East rate of 14.7% and a South East Shire rate of 14.6%. Kent is notably low, at 8.8%, while Surrey is high, at 20.9%.

5.1.4 The PAF performance on physical disability has continued to be rated "good" in both 1999/2000 and 2000/2001, which reflects the relatively stable position in residential placements across these two years.

5.1.5 The success within Hampshire of supporting physically disabled people in their own homes, through direct payments and purchased domiciliary care, is reflected in the extract from the National Statistics publication 2000/2001. The percentage of residential and nursing placements in Hampshire is 3.8%, against a South East rate of 4.4% and a South East Shire rate of 4.5%. Kent is also low, at 3.5%, while Surrey is high, at 5.1%.

5.2 The unit costs for the in-house services, in 2000/2001 are shown below, with the budgeted cost, assuming 100% occupancy and the actual cost with actual occupancy, based on expenditure and usage. The third column of figures shows the unit cost with capital charges and overheads for the County Council - some caution should be attached to these figures, as there is further work to be done on this type of unit cost. It should be noted that when purchasing in the independent sector, the cost is for the placement and is not based on the number of beds occupied throughout the year. This contributes to making direct comparisons between the unit costs produced for in-house services and the costs of purchased services difficult. However, the unit costs in the table below will be considered against the analysis of costs in 5.3.

5.3

* Improved budgetary control significantly reduced the Actual Costs for Upton Grey Close in 2001/2002.

5.4 Given the limitations described above, the following information has been drawn from an analysis of all residential placements being purchased and provided in September 2001 i.e. 1,197.

5.4.1 Learning Disability

5.4.2 This shows the wide ranges of costs for residential services for people with learning disabilities, which reflect the wide range of needs that are catered for within the residential sector. The in-house services, which cater for a mix of people, some of whom present challenges to the service and some of whom have additional physical disabilities or sensory impairments, are not unreasonably priced.

5.4.3 Physical Disability

5.4.4 Again, this shows a wide range of costs, with both residential and nursing homes costs being reflected at the lower and higher ends. The annual unit cost of the in-house service is in the upper half of costs, but this is a reflection of low occupancy raising the unit cost, rather than the needs of the people living there being particularly high.

6 Competition

6.1 Learning Disability

6.1.1 The vast majority of residential services for people with learning disabilities are in the independent sector, with only 4% being provided through in-house services. This reflects the position in other local authorities e.g. Surrey and Essex, where policies to move away from in-house provision have been implemented. The independent sector market consists of the adult placement scheme, not-for-profit organisations and the private sector. Adult placement officers support the adult placement scheme and the not-for-profit sector has developed in response to tendering for services to reprovide for in-house services and long stay hospitals. In contrast, the private sector has developed as individual providers have chosen to open more services, often focusing on a particular niche in the market, with the confidence that if the local social services department does not purchase the service, other authorities will do so.

6.1.2 There continue to be gaps in the local market and there is opportunity to work with both the not-for-profit and private sectors to address these gaps. There is also the potential to co-ordinate purchasing discussions with providers that serve people from across the county - this is particularly relevant for the private sector.

6.1.3 The adult placement scheme commands a particular niche in the market, at the lower level of need, offering an alternative to traditional registered homes that cater for similar levels of need. It is a service valued by those people using it and under the National Care Standards Commission could offer supported tenancies as well as the current registered option.

6.1.4 Consideration has been given to the role of the in-house services in the market place. Recent experiences of using in-house services to resolve accommodation needs for a number of people for whom there were no local alternatives available in supported living, have shown the value of retaining a small amount of local authority provision in the residential market. For these people, it is anticipated that they will move on to supported living as soon as it is arranged. People who have been living in in-house services for some years, regard them as their permanent home and there will need to be a balance of respecting their wish to remain where they are and ensuring that they are aware of other opportunities, in case they wish to move at some time in the future. People who have moved into one service more recently are using it until alternative accommodation is available and they can move into a supported living situation. This latter function could be expanded to provide medium term stability, whilst appropriate services are developed locally for people, individually or with friends.

6.1.5 The impact of the requirement on in-house services to register with the National Care Standards Commission needs to be considered as it is expected that changes will be required in some services to meet the new standards. The extent of any changes required to meet the standards will impact on the future viability of each service. It is planned for this work to be undertaken over the next three months.

6.2 Physical Disability

6.2.1 As with learning disabilities, the majority of residential services for disabled people are in the independent sector, with 6% being provided through in-house services. There is a greater focus for independent living supported by Direct Payments, with Hampshire leading nationally. The level of residential purchasing is therefore relatively low and the choice of provision, locally, somewhat limited.

6.2.2 The adult placement scheme caters for a very small number of disabled people but with the opportunity under the National Care Standards Commission to offer supported tenancies, this may be an area of the market that could be expanded.

6.2.3 The one in-house service provides both a rehabilitation service and a short stay/respite service that do not fit well together with all residents sharing communal areas. The relationship between rehabilitation in hospital and the rehabilitation offered in this service need to work together to provide a more streamlined service to disabled people. Discussion with health colleagues on how best to link services, with a possible focus on intermediary care would be worthwhile.

6.2.4 This service has also had to register with the National Care Standards Commission and will be included in the work being undertaken in learning disability services to identify the changes required and the options available.

7 Challenge

7.1 The fit of the residential model of service with national agendas for people with disabilities and disabled people has been considered. For both groups, independence and choice, including the right to choose where and with whom you live are central. The White Paper for people with learning disabilities, Valuing People, places a strong emphasis on supported living where people have a tenancy and are supported through agencies that work into the person's home (sometimes providing support over a 24 hour period). For disabled people in Hampshire, there is a clear focus on supporting people in their own homes, wherever this is possible, with many people using Direct Payments to take control of their care package. The continued development of supported living and Direct Payments will provide real alternatives to residential services, but it is dependent on the availability of housing. Close working with Housing Departments and Registered Social Landlords is vital to open up more opportunities.

7.2 In contrast to supported living, residential care does not provide the same degree of independence and choice. However, residential services will continue to play a significant role, in order to ensure that people have this as an option, should this be their preferred way of having their needs met. It must also be recognised that there may be difficulty in identifying sufficient suitable housing for all the people that require accommodation and support,

7.3 Despite the limitations on residential services, a good provider can work to maximise independence and choice and actively involve residents in the running of the home and support participation in the local community. The visits that were undertaken within the review were used to check out the results of a questionnaire sent to providers prior to the visit, from the perspective of the visitor, the resident(s) and their relative(s). The questionnaire was based on guidance from the Department of Health on carrying out Best Value Reviews on services for people with leaning disabilities and was applicable to disabled people, too.

7.4 The questionnaire was designed to provide us with a tool for benchmarking services, to be used by care managers when reviewing services and in contract monitoring. Further detailed analysis needs to be undertaken to establish the benchmark(s) for the mix of services that were visited and agree exactly how this is used. The services visited included in-house services, adult placement and private and not-for-profit providers, some of which provided specialist services e.g. services for people with learning disabilities who challenge.

7.5 The team of visitors came together to discuss the visits and the performance of the services. The services were chosen from the services that were considered to be amongst the best by relatives and care managers and the general impression from the visits was that the providers were working hard to maximise independence, choice and involvement. This view was based on the discussions with managers and staff during visits, the experience of visitors spending time with (and shadowing) residents and from interviews with residents and relatives.

8 Options

8.1 In developing the options for residential services for people with learning disability and disabled people, the approach used has been to look at the market in three parts - adult placement, in-house services and the independent sector - and to identify the impact of taking the following action for each market sector:

· Removing each type of service from the market

· Taking no action to change the way of purchasing or providing services

· Taking action to change the way of purchasing or providing services.

8.2 These options need to be considered alongside the continued commitment to increase the level of independent or supported living available across Hampshire.

8.3 The options are set out in the tables below. The preferred option is to take a proactive approach to residential services for all three parts of the market and take action to change purchasing and provision and to expand the points in the options tables into a detailed action plan.

8.4

8.5 Options for Adult Placement

8.6 Options for In-house services

8.7 Options for the Independent sector (excluding Adult Placement)

Section 100 D - Local Government Act 1972 - Background Documents

The Following documents disclose facts or matters on which this report, or an important part of it, is based and has been relied upon to a material extent in the preparation of this report.

NB the list excludes:

1. Published works

2. Documents which disclose exempt of confidential information as defined in the Act.

1

Action Plan: Residential Review - Adult Placement

Action Plan: Residential Review - Adult Placement

Action Plan: Residential Review - In-house

Action Plan: Residential Review - In-house

Action Plan: Residential Review - In-House

Action Plan: Residential Review - Independent Sector

Action Plan : Residential Review - Independent Sector

Action Plan: Residential Review - Independent Sector