1 Summary

The following decisions are sought.

1.1 That the strategy and action plan for developing capacity and the quality of residential-based care for older people with dementia in Hampshire, is adopted.

2 Reason(s)

2.1 The County Council has made providing effective services for older people one of its four priority areas, with a particular focus on care at home and the quality of life for all older people. This strategy links directly with Corporate Aims one and five, "Maximising life opportunities" and "Improving services", through a clear focus on developing the quality of services provided and seeking to ensure that appropriate services are available to meet the needs of older people with dementia in future years.

3 Other options considered and rejected

3.1 Findings from an analysis of national policy and practice, local and national research, performance data and fieldwork associated with this study have been used to develop this approach.

3.2 The strategy must be considered in conjunction with other key commissioning objectives for services for older people focussed on delivering care at home and developing alternative housing options. The focus has been on ensuring a range of choices are available to older people and their carers when considering care options.

4 Conflicts of Interest declared by the decision-maker or other Executive Member consulted

4.1 None

5 Dispensation granted by the Standards Committee

5.1 None

6 Reason(s) for the matter being dealt with if urgent

Not applicable

Approved by: Date of decision:

Councillor Felicity Hindson

1

1.1 Summary

1.2 Background

1.2.1 The Strategy for the Provision of Long Term Residential and Nursing Care for People with Dementia in Hampshire (Attached ) aims to ensure that older people with dementia in Hampshire have access to high quality residential and nursing home services which meet their identified individual needs. An analysis of current demand and supply of this type of care is contained within the strategy, plus a discussion of future need. Two key issues emerge:

1.2.2 The lack of provision to meet current and future need and stabilising the market to secure specialist services for the future.

1.2.3 The quality of services and the lack of clear standards for specialist dementia care.

1.3 Links to Corporate Strategy

1.3.1 The County Council has made providing effective services for older people one of its four Cabinet priority areas, with a particular focus on care at home and the quality of life for all older people. This strategy links directly with the Corporate Aims of, "Maximising life Opportunities" and "Improving Services" through having a clear focus on developing the quality of services provided and seeking to ensure that appropriate services are available to meet the needs of older people with dementia in future years.

1.3.2 The strategy must be considered in conjunction with other key commissioning objectives for services for older people focussed on delivering care at home and developing alternative housing options.

1.3.3 Informal carers play a crucial role in providing care at home. Support for carers is a priority and a range of service developments are underway, including consideration of further expansion of the Alzheimer's Café model.

1.3 Developing the strategy

1.3.1 Findings from an analysis of national policy and practice, local and national research, performance data and fieldwork associated with this study, including:

1.3.1.1 direct work with older residents with dementia regarding the quality of care

1.3.1.2 a workshop involving commissioners and providers of residential based services, the National Commission for Social Care and Social Services Inspectorate (as they were known at the time) and Dementia Voice, the Dementia Services Development Centre for the South West, were used to develop this approach.

1.4 Person Centred Care

1.4.1 The strategy supports the provision of a social model of care, focussing on communication, interaction and an enabling social environment. Care provision is person centred and maintaining individual well-being is a major objective.

1.4 Race Impact Assessment

1.4.1 Research findings need to be taken on board when implementing the strategy and planning services for the future.

1.5 Recommendations within the strategy (Strategy attached.)

1.5.1 To tackle the issues outlined above the following recommendations are made:

1.6 Building Capacity

1.6.1 The strategy seeks to focus efforts on the development of specialist residential care services.(Strategy, para 17.2)

1.6.2 The focus of residential-based provision for older people whose needs are associated primarily with the presence of dementia, should be services provided in a residential setting (Strategy, para 16.1)

1.6.3 Where, at the time of placement, an individual also has high nursing needs or is very physically dependent, a nursing home placement may be a more appropriate way of meeting their needs. The nursing home would need to be registered to care for people with dementia and would need to take account of the needs of people with dementia in its staffing skill mix training provided. (Strategy, para 16.1)

1.6.4 Where appropriate, current more generic independent sector providers of residential care for older people are to be encouraged and offered support to change to more specialist residential provision. (Strategy, para 17) Incentives to be offered include:

1.6.4.1 Possible block contracts

1.6.4.2 Support with staff training (financial support and assistance in accessing appropriate training, through identified training grants and partnership training post.)

1.6.4.3 Dedicated support to homes from health professionals with specialist skills

1.6.4.4 An additional fee band with a higher fee for providing a specialist service (introduced in April 2003)

1.6.4.5 Development of a Dementia Care Forum for information exchange and support to providers of dementia care

1.6.5 Review and reconfiguration of in-house residential capacity will be undertaken to provide more specialist provision (Strategy, para 17.8)

1.6.6 The development of specialist home-based services and housing options will continue and planning will consider integrated models with residential/ nursing home care.

1.6.7 Plans will be produced centrally to secure improved management information relating to older people with mental health needs. When available this information will inform local planning. (Strategy para 11.6)

1.6.8 The new HCC nursing homes will provide additional nursing home capacity for older people with dementia. (Strategy, para 13.1)

1.7 Ensuring the Quality of Services

1.7.1 A service specification will be used to indicate the nature of the residential service which Hampshire Social Services wishes to purchase for older people with dementia. This will be linked with the additional OPMH payment for residential care. Support, as outlined above, will be given to providers to assist with implementing the service specification. (Strategy, para 15.3)

1.7.2 The specification is for residential care provision, but the care practice elements are equally applicable in a nursing home setting. The section on philosophy of care, underpinning values and care practice performance indicators will form part of the supporting policies and procedures for the new Nursing Care Investment Strategy homes. (Strategy, para 15.3)

1.7.3 Quality assurance mechanisms related to the specification will be determined at local level (Strategy, para 15.3)

1.7.4 In order to:

1.7.4.1 share good practice

1.7.4.2 identify training opportunities across agencies and sectors

1.7.4.3 further develop the quality of care

a Discussion Forum for providers and commissioners of residential and nursing home care for older people with dementia will be developed, initially covering the whole of Hampshire, but with a view to possibly developing more local for a in the future.(Strategy, para 19.2)

1.8 Financial Impact

1.8.1 The HCC nursing home capacity proposed for people with dementia has been costed and will be funded as part of the ENHANCE strategy.

1.8.2 Some of the cost of an enhanced rate for placements meeting the dementia criteria was recognised as an additional allocation of £586, 200 to residential budgets in 03/04 with the additional band being introduced to the Hampshire fee levels in April 2005 for EMH placements in the independent sector. Further funding requirement has been absorbed in the gross of £28.8m and through reductions in standard residential placements and some placements, which would otherwise have needed to be made in more expensive NH placements, now coming within the new fee band.

1.8.3 Consideration of new block contracts to secure independent sector capacity would be arranged to gain possible cost advantage within the independent sector, whilst sharing risks.

1.8.4 Reconfiguring of in-house residential capacity for more specialist provision is currently being funded from within the gross budget of £17.9m.

1.8.5 The independent sector training grant supports delivery of training for this sector and dementia care remains a priority within training plans. This is an important component of the strategy.

1.8.6 Other developments are also being funded from within the current base budget or through securing funding from other sources, as indicated, PCTs and the workforce development confederation. If successful these initial projects will need to be fully costed for potential wider implementation.

1.9 Action Plan (See Appendix 1 for full plan)

1.9.1 Local plans will be developed at Area level, in conjunction with key stakeholders, to support the further development of specialist residential care for people with dementia, including:

1.9.1.1 Determination of local capacity requirements

1.9.1.2 Redesignation of beds in local authority homes

1.9.1.3 Mechanisms for assuring the quality of provision

1.9.1.4 Dedicated support to homes from health professionals with specialist skills

1.9.2 In conjunction with the Training Commissioning Team, training opportunities for the independent sector in relation to dementia care training will be explored.

1.9.3 In conjunction with health colleagues, further investigation and evaluation of processes in determining the Registered Nursing Care Contribution when older people have mental health needs will be carried out across the county.

1.9.4 Opportunities for joint workforce planning with colleagues from the independent sector and health will be explored.

1.10 Current Progress

1.10.1 Consultation on the strategy has been underway since January 2004 and included:

1.10.1.1 Local Implementation Teams in all 7 PCT areas.

1.10.1.2 Hampshire Care Association representative

1.10.1.3 The Commission for Social Care Inspection

1.10.1.4 Local branches of the Alzheimer's Society

1.10.1.5 Age Concern Hampshire

1.10.1.6 Specialist Older People's Mental Health Trusts

1.10.1.7 All stakeholders support the recommendations

1.10.2 The Service Specification has been agreed.(See Appendix 2)

1.10.3 The Dementia Care Forum for providers of residential-based care for older people with dementia is established and has met on 2 occasions since April 2004

1.10.4 A £50 premium on top of the residential fee was introduced in April 2003 for all new residential placements of older people with mental health needs.

1.10.5 Funding has been secured for independent sector training with dementia care training a priority. The Dementia Care Forum is linked with the development of the Independent Sector Training Strategy.

1.10.6 Primary Care Trusts and Older People's Mental Health (OPMH) Trusts are committed to moving forward with a partnership approach to implementing the strategy and progress has been made in a number of localities regarding securing health support for residential based care. Eg. in Andover an OPMH nurse has recently been appointed to support care homes in the locality and in Basingstoke a bid has been made for Workforce Development Confederation funding for such a post.

1.10.7 Some independent sector providers have come forward regarding extensions and new build. Consideration is being given to block contracts.

1.10.8 In some areas beds in in-house services have been redesignated as specialist beds in order to meet identified need.

1.10.9 In-house services are committed to implementing the service specification in both nursing and residential care homes.

1.10.10 A major training programme has been instigated for in-house services to support implementation.

1.10.11 Progress has been made on securing improved management information:

1.10.12 There is now a data base of homes registered to provide care for older people with dementia, but this needs manually updating

1.10.13 A mechanism for collecting activity data for OPMH has been identified but needs securing in the new SWIFT system.

1.11 Outstanding Issues

1.11.1 Securing dedicated support to homes from specialist health professionals in the current health economy context will be challenging.

1.11.2 Implementing the Service Specification in the independent sector requires considerable work. Development requirements are:

1.11.2.1 Explicit quality monitoring mechanisms

1.11.2.2 Mechanisms for aggregating quality information for strategic use

1.11.3 Actions identified in the Race Equality Impact Analysis being delivered

1.11.4 Information for service users and their relatives/carers regarding specialist services

2.0 RECOMMENDATIONS

2.1 That the strategy and action plan for developing capacity and the quality of residential-based care for older people with dementia in Hampshire, is adopted.

2.2 That a further report is presented to Social Care Executive in six months time to outline progress on the action plan.

Section 100 D - Local Government Act 1972 - Background Documents

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

The Commissioning Plan for Services for Older People, 2003-2006

The Best Value Review of Residential and Nursing Home Care for Older People in Hampshire, 2002

The Nursing Care Investment Strategy, 2002-2003

NB the list excludes:

1. Published works

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

APPENDIX 1, ACTION PLAN

SPECIALIST OPMH RESIDENTIAL CARE: Additional notes

Consideration will be given to the whole proposed service. Discretion may be applied to individual aspects whereby the quality of the whole is evidently satisfactory.

Principles - In normal circumstances an integral expectation of a placement is that it will be the Resident's permanent home. Consideration should be given to the provider's previous and current record and expertise in providing terminal care. Also relevant will be the working relationships established with key health care professionals.

Accommodation - Account will be taken of the essential limitations of non-purpose built buildings.

Security arrangements -Evidence will be sought of sensitive planning, careful consideration and appropriate interventions, which minimise the avoidable risks but maintain the fullest rights possible for individuals. The aim is to achieve the least restrictive environment possible, compatible with the safety of individual users.

Expectations/Permissible use of restraint and/or removal of civil rights: In general terms many potential risks can be avoided by adequate observation of users by staff and/or by staff diverting the user's attention to some other activity. Where this is insufficient, advice should be sought from appropriate specialists/professionals.

Physical restraint should only be considered in the most exceptional circumstances when it is intended to achieve the protection of the user. It should never be used as a convenient means of control, nor as a means of overcoming staff shortages.

There must be a clear written procedure on the use of restraint. This should include the circumstances where this may be permissible/appropriate, who should authorise this, who should be informed, and how it is recorded, monitored and managed.

A person who likes to walk should not be denied access to the outside world; he/she should be aided by planned regular escorted walks.

Staffing

4i. Staff Complement

· The minimum number of staff available at any time in each home will be agreed between the NCSC, SSD and the home. This will depend on the number of residents, the assessed needs of the service users and on the size and layout of the building.

· Providers will also be expected to provide a staff complement based on the following hourly calculation: 20 care hours per resident per week. These hours are purely care hours and do not include management hours, domestic hours or hours associated with training. They also do not take account of annual leave or sickness.

· Night staff will also be agreed on a home by home basis in line with National Care Standards and the particular needs of residents.

· The above are minimum requirements; at all times there is a responsibility to top up to meet increased levels of assessed need.

· The staff group should have appropriate skills, gender, ethnic and age mix reflecting residents needs and preferences.

· the use of agency staff is not encouraged - continuity of care is particularly important. Agency staff should also meet the requirements below re experience and training

· Where there is a separate unit for people with dementia, to maintain continuity of care a substantial core of staff must be designated to work primarily in the unit.

· Volunteers must not be used to supplement staffing levels, their role is recognised as important, but should be supervised

4ii Staff Selection and Training

· Supervisory staff should have a minimum of 3 years experience working with older people, including one year OPMH experience - or equivalent transferable skills.

Care staff should have 1 year's experience of working with older people and a preference for working with people with dementia.

NVQs - recommendations regarding awards and unit selection.(Further discussions to take place with Training Commissioning)

Further specialist training programmes must include:

- Dementia and Mental Health awareness

- Communicating with people with Dementia.

- Providing activities for people with dementia

- Understanding challenging behaviour

- Adult Protection

- Ethical issues:

_ Capacity and Consent,(Including decision-making frameworks and Advance Directives)

_ Medication

_ Restraint

2 APPENDIX 2

3 SPECIFICATION FOR SPECIALIST RESIDENTIAL CARE FOR OLDER PEOPLE WITH DEMENTIA

4 Philosophy of Person Centred Care

There is a culture of care that views dementia primarily as a disability, the degree of this disability depends, to a large extent, on the quality of the care and social contact with others. Care Workers possess the most reliable, valid and relevant knowledge, and are skilled and insightful practitioners. The culture of person-centredness extends to all individuals in the care environment, encompassing all members and levels of staff. All so-called problem behaviours are viewed as attempts to communicate a need, and Care Workers aim to understand the meaning behind the behaviour so as to engage with any need that is not being met. In this person-centred care environment, there is a clear and accurate view of individuals' abilities, tastes, interests, values and forms of spirituality.

5 Value Framework *

5.1 Maximising Personal Control

I continue to be in control of as much of my life as is possible for me.

5.1.1 Enabling Choice

I have opportunities to make real and informed choices when I want and am able to do so.

5.1.2 Respecting Dignity

I am known, respected and valued as a unique individual in meaningful relationships with others.

5.1.3 Preserving Continuity

I receive reliable help to maintain my links with both my past and my present

5.1.4 Promoting Equity

I am not discriminated against because I have dementia or for any other reason and I receive a fair share of good quality and appropriate services.

Taken from:

"The Person, the Community and Dementia-Developing a Value Framework"

Sylvia Cox, Irene Anderson, Sally Dick, Jean Elgar

Dementia Services Development Centre, university of Stirlin

Additional note re: eating well for Older People with Dementia

Nutritional Assessment Within the first week of admission a new resident should be weighed and their food and fluid needs assessed. These needs should be reviewed regularly. A specific review after one month is useful as by then the resident will be better known to the staff. Particular attention should be paid to the resident's energy needs (i.e. the calorie requirements). Efforts should be made to find out about any special dietary needs, food preferences and religious or cultural requirements. This information should be sought from family and friends as well as from the individuals themselves, preferably before they move into the home. This information should be part of the care plan and regularly updated.

Weight checks The home should have weighing scales, preferably sitting scales. Each resident should be weighed once a month and the weight recorded in the care plan. Any resident with a weight gain or loss in excess of 3kg should be referred to a health care professional for assessment.

Choice and availability of food and drink Older people with dementia need a healthy, balanced diet in common with the general population and other older people. Food and nutrition should therefore be seen as an essential, integral part of the care plan. All foods served should be attractive, appetising and appropriate to the needs of the residents. These might include finger foods and textured soft foods as well as more conventional meals. If pureed foods are served, particular care should be given to ensure that they look and taste appetising. Care staff should be able to offer food and drinks for residents whenever required. Snacks and drinks - such as sandwiches, fresh fruit, biscuits, tea, milky drinks, fruit juices and water - should be available all day and during the night.

Fluid Staff should be aware that an adequate fluid intake is essential to prevent dehydration and constipation, which can lead to further confusional states. Residents should be encouraged to drink 1.5 litres (8-10) cups of fluid a day. Staff should be aware that limiting fluid does not reduce problems associated with incontinence.

Help with eating Where necessary, speech and language therapist and occupational therapists should be consulted to ensure that appropriate assistance is offered in helping residents to eat and drink. Oral hygiene should be checked regularly and help given with brushing teeth and gums.

A useful reference is Eating Well for Older People with Dementia published by VOICES and available from VOICES, Beechwood House, Wyllyotts Close, Potters Bar, Herts. EN6 2HN, £12.95 incl. P&P

STRATEGY FOR THE PROVISION OF LONG TERM RESIDENTIAL AND NURSING HOME CARE FOR OLDER PEOPLE WITH DEMENTIA IN HAMPSHIRE

1.0 INTRODUCTION

1.1 One of the key objectives in the Commissioning Plan for Services for Older

People 2003-2006¹ is to refocus provision of long term residential-based care. The plan identifies gaps in the provision of both specialist nursing and residential care for older people with mental health needs (OPMH), primarily dementia, and issues about the nature and quality of some services.

1.2 This strategy is intended to address these issues specifically for people with

dementia.

1.3 At this stage in time it does not cover services for those people with early onset

dementia ie those under age 65, whose needs can be very different to the very elderly. It also does not cover residential care specifically for older people with functional mental health needs, again their needs can be different, but recognises that many older people with dementia also have a range of functional mental illness.

1.4 There are significant commissioning gaps in relation to provision of such

services, but consideration of these groups will be completed as a next step.

2.0 AIM

2.1 To ensure that older people with dementia in Hampshire have access to high

quality residential and nursing home services which meet their identified individual needs and that in achieving this, the resources available are used to their best effect.

3.0 THE CONTEXT:

RELATED NATIONAL AND LOCAL POLICIES AND OBJECTIVES

The objectives of this strategy have been derived in the context of the major

documents listed in Appendix 1.

3.1 Care at Home

The Governments' modernisation agenda ensures that national and local policy objectives focus on building services around people, on maintaining independence and supporting older people in their own homes wherever possible. Providing effective services for older people, is one of the four priority areas for Hampshire County Council for 2003/04, with a particular focus on providing care at home and on the quality of life for all older people.

3.2 This strategy acknowledges the overarching objective of supporting older people

in their own homes for as long as possible, but recognises that, though there are measures in place to achieve a shift to providing more housing based alternatives and supporting more intensive care at home, there is likely to still be a need for residential and nursing home provision. As dependency and levels of risk increase, it becomes more difficult to sustain care for people at home, both in terms of the financial cost of care provision and the strains and stresses placed on informal carers, who bear the brunt of meeting needs. It is important for a range of choice of services to be available to meet a range of need.

3.3 Though residential respite services are not the main focus of this strategy, as it

is largely concerned with the provision of long term care, it is important to note that in providing more intensive care at home, informal carers have a significant part to play. Respite care services, both in the home and in residential settings are crucial in assisting them and offering them a break. A range of short stay beds need to be available in specialist homes for people with dementia, not only for social services placements and self-funders, but also for fully NHS funded continuing care packages.

3.4 Whole Systems Health and Social Care Issues

Planning for social care services for older people cannot take place in a vacuum and it is essential that a partnership approach is maintained where all parts of the "system" of care, which impact so significantly on one another, are considered together. This is reflected in both the C.C. Corporate Aims and SSD objectives listed in the appendix. The following are of particular importance to this strategy.

3.5 Delayed Transfers of Care

Central Government is placing high priority in performance terms on tackling Delayed Transfers of Care (DTC) from, and preventing unnecessary admissions to, acute hospital settings. Local Authorities are to be fined for social care delays from Jan '04. A major factor in DTC is the lack of availability of residential and nursing home placements and a significant proportion of these waits are for specialist placements for people with dementia.

3.6 Intermediate and Interim care

Significant new service developments in intermediate and interim care have been achieved over recent years, with the aim of reducing DTCs and unnecessary admissions to hospital. Across Hampshire there has been limited development of such services for older people with mental health needs (OPMH). There is currently inconclusive evidence supporting the development of residential models of this type of care. In the South East of Hampshire we are about to commence a new in-house residential OPMH intermediate care service in conjunction with Primary Care Trust (PCT) partners and an evaluation of this and other intermediate care services around the county is underway which will inform future planning.

3.7 Primary Care Trusts as Joint Commissioners of Nursing Home Care

Following the introduction of the Registered Nursing Care Contribution the PCTs now share the responsibility for commissioning nursing home services for older people with dementia. Over time they are developing the infrastructure to support this. PCTs have to determine the banding level for the Registered Nursing Care Contribution and issues have been highlighted around the county regarding differential practice in relation to how mental health needs are taken into account in making this determination. There also appear to be differences in terms of whether and how specialist OPMH services are involved in this process.

3.8 The National Service Framework (NSF) for Older People and Audit

Commission Report Forget-Me-Not

In common with the governments overall modernisation agenda, the NSF promotes services built around the needs of older people, enabling them to make choices about their care.

3.9 Standard 7 in the NSF and the Audit Commission document, Forget-Me-Not,

highlight the need for staff in specialist mental health services to provide

support to and training for residential and nursing homes. Forget-Me-Not points

out that a high proportion of emergency admissions to acute beds in specialist

services come from residential and nursing homes who are no longer able to

cope with residents needs. It suggests that where sufficient support is available,

emergency admissions will be reduced.

3.10 It further highlights how important meaningful activities are in maintaining

individual well-being and local authorities are expected to ensure, as part of

their contracting processes, that sufficient account is taken of this element of

service.

3.11 Care Practice Issues

Best Practice

Nationally best practice in dementia care has been developing apace over the

last 10 years and there is a move towards more social rather than medical

models of care. Dementia is seen as a disability and part of the role of

caregivers is to minimise the effects of the disabling factors associated with

dementia. It is also recognised that the social environment in which the person

with dementia has to live has a major impact on the progress of the disease. ²

The quality of interactions with caregivers can have a huge impact on the

stress, anxiety and frustration experienced by people coping with

the disabling effects of the disease. There is much research and literature

available now to support the provision of person-centred models, which show

an understanding of this specialist area of care.

3.12 In-House Specialist Model of Care

Locally a model of care that takes account of individual's cognitive ability and

emotional needs has been developed for in-house specialist dementia

residential services. This was evaluated and proved to be very effective in

raising levels of well-being in residents, reducing the need for medication and

intervention from Community Psychiatric Nurses and relatives noted real

differences in residents mood and abilities. A major training programme is

underway and the model is being rolled out across the county.

4.0 CURRENT SERVICE PROFILE

The following SWOT table summarises the current position.

4.1 STRENGTHS AND WEAKNESES OF CURRENT POSITION

4.2 Priorities for the strategy are to show how

· the quality of provision can be further developed

· The market can be stabilised and specialist provision can be secured for the future.

5.0 QUALITY OF PROVISION

5.1 The National Care Standards (2001) and the Care Home Regulations define

minimum standards and thus minimum quality requirements for residential and

nursing home care. They outline the legal requirements, inspection regime,

standards for the physical environment and care practices, number and

qualifications of care staff and management arrangements.

5.2 There is a new registration category for care homes providing a service for older

people with dementia (DE E), however, there are no dementia specific standards, rather generic standards, which require a degree of interpretation in relation to caring for this care group. This can lead to confusion and inconsistencies in approach.

5.3 In terms of contracting arrangements with the independent sector, Hampshire

County Council Social Services Department currently uses the National Care Standards to specify minimum requirements regarding the quality of care provided. Some local authorities have additional requirements over and above the national standards which further define minimum standards and outcomes expected from providers of specialist services.

5.4 Findings from Recent Studies of Quality of Provision in Hampshire

Few studies have been carried out specifically regarding the quality of care home provision for older people with dementia in Hampshire.

5.5 Of particular relevance were a ground breaking consultation exercise with older

residents with dementia carried out in 2002 and a follow up workshop held in

May 2003, plus a national study of carer's views conducted by the Alzheimer's

Society and including carers from Hampshire.(See appendix 2 for more details)

5.6 The following points summarise key findings.

Positive views were expressed about:

· The physical environment of homes

· The quality of assistance given

· The quality of food provided

· The quality of the interaction between residents and the staff in homes

The following quality issues were highlighted:

5.7 Care Practices

The need:

· to consider residents emotional well-being and mental health needs, as well as practical personal care needs, and plan to maintain or achieve increased levels of well-being

· to identify specialist care practices

· for programmes of purposeful and relevant activities for residents built from individual needs and preferences.

· for reduction in the use of drugs for controlling behaviour

· for clarity in relation to the use of restraint

5.8 Staffing and Support

The need for:

· additional staffing levels in homes, skilled staff and availability of specialist training

· more dementia specific training for NCSC Inspectors

· better involvement, communication and consultation with relatives

· improved health care and more effective involvement of GPs

5.9 Environment

· The need for environments which allow freedom of movement and adequate access to other people, tasks and objects

5.10 Service Planning

· The need for closer liaison between Commissioners, the Care Standards Commission and providers of care

5.11 These issues will be considered in the broader debate about procurement

solutions and will also be addressed in the Action Plan

6.0 SUPPLY OF SERVICES

6.1 Appendix 3 shows the number of potential beds available registered to provide care for older people with dementia (ie DE(E) category ), by SSD Area. This shows a county total of 2336 residential beds and 1228 nursing and dual registered beds in 35 nursing and dual registered homes and 121 residential homes. ³

6.2 Currently around 7% of these beds are provided by the local authority, those

local authority beds listed are purely specialist beds for people with dementia. All local authority beds are actually registered for older people with dementia, in recognition that many older people currently resident in non-specialist beds have a degree of dementia and many people develop problems once they have become residents, however, only the 250 beds are seen as "specialist" beds providing a service for those older people who are more disabled due to dementia.

6.3 All other beds are independently provided. Many of these are also registered to

provide care for other groups as well. It is not possible to identify the exact numbers of beds currently occupied by people with dementia. Thus numbers shown are merely potential beds.

6.4 As can be seen from the table, SSD Areas where there appear to be

comparatively low numbers of potential specialist residential beds per estimated

head of older population with dementia are:

Basingstoke, Alton/Aldershot, Andover/Winchester, Havant/Petersfield

6.5 SSD Areas where there are comparatively low numbers of potential specialist

nursing beds are:

Fareham/Gosport, Havant/Petersfield, New Forest

6.6 Basingstoke appears to be comparatively low overall, closely followed by Havant

and Petersfield.

6.7 Self funders

There are high numbers of self-funders in Hampshire, which have an impact on

beds available to the local authority. The Hampshire Care Association

newsletter quotes the Dec 2002 DOH census of nursing homes as identifying

45.7% of self funders in nursing home beds in Hampshire, with particularly high

proportions in the New Forest and Mid Hants PCT areas.

6.8 Instability in Market

There has been great instability in the care home market with heavy losses in

beds over recent years. See appendix 4

6.9 Figures for '03-'04 are suggesting a continued, though slowing, loss of smaller

residential homes, but some stabilisation of nursing home losses, with planning

permission being sought for new build or extensions to existing properties,

though this is largely for the privately funded end of the market.

6.10 Anecdotal evidence suggests that a significant proportion of losses have

occurred in homes providing care for older people with mental health needs,

though data on this is not available. Anecdotal evidence also suggests that a

number of homes have also deregistered and no longer provide care for older

people with mental health needs, as this is seen as a more demanding and

costly service. According to the local National Care Standards Commission,

deregistration does not actually seem to have been as significant a trend over

the last year.

6.11 The factors associated with bed loses need to be considered in identifying

solutions. A clear distinction needs to be drawn between the following, since

different policy responses will be required for each scenario:

_ Closures due to declining need/demand for residential-based care

_ Closures for other reasons such as:

- Land prices

- Implementation of the new National Care Standards

- Difficulties in the recruitment of staff (care staff and nursing)

- Fee levels

- Size of home⁴

In the Hampshire context for OPMH services, the latter list best describes the

current situation. SSD activity in relation to placements in nursing and, for very

dependent people, in residential homes has increased over recent years, due

in a large part to demographic changes, and it has become progressively more

difficult to find beds.

7.0 FINANCIAL INFORMATION

7.1 Current Fees

Fees paid by HSSD for residential based care are in the middle range for SE

authorities. The following table shows the increases in fees paid by HSSD over

the last 3 years, including the Registered Nursing Care Contribution for 03/04.

7.2 Price Escalation

Over the last year or so there has been a particular escalation in the price of care to the local authority, especially that of nursing home care. This is due to increasing costs to home owners eg due to the National Care Standards and additional staffing costs (Employment Act, European Directives, Minimum Wage), but also reflects the decline in numbers of residential and nursing home beds available for Hants SSD to purchase over the last couple of years, and the increasing pressure to manage Delayed Transfers of Care. There are significant numbers of beds that are not available at the Hampshire rate. This lead to increased third party top-up payments being required to secure places in homes of choice and additional pressures on care managers when seeking placements.

7.3 Performance Assessment Framework Indicator B13, Average Gross

Weekly Expenditure per Person on Supporting Older People in Residential and Nursing Care

For 2002-2003 this indicator was £361 for Hampshire, which is regarded by the Government as an acceptable level of funding. The average for shire counties was £351 and for Hampshire comparator group was £358. Neighbouring authorities to the north and east of Hampshire have higher values.

(NB this data relates to generic care for older people and is not specific to older people with mental health needs)

8.0 DEMAND FOR SERVICES

8.1 ACTIVITY

Hampshire Social Services currently has around 10,750 service users over 65 years of age at the end Aug '03. Operational estimates suggest 50% of these have a degree of mental health need, largely dementia.

8.2 Appendix 5 shows Hampshire Social Services Department activity data for long

term placements of older people in residential and nursing home care. The

following table shows the trends for current residents at different fee band rates

for all long-term older people's residential services from Oct '00 to Sept '03(ie

not just for people with dementia)⁵

Derived from HSSD Community Care Statistics (See appendix 6)

8.3 Numbers of very dependent current residents, including those on the OPMH

rate, peaked in July '02 and have reduced slightly and remained relatively

steady throughout the latter months of '02 and through '03. Nursing home

placements continue to rise.

8.4 Those placed on the standard residential care rate are being significantly

reduced as efforts to support more people at home bear fruit. This is a key

commissioning objective and budgets for the current year were adjusted to

reflect this commissioning intention.

8.5 There are problems in identifying Social Services Department activity specifically

re older people with dementia, as data collection is currently focused more

generically on the broader category of "older people". Generic data for older

people must be used instead, plus estimated proportions for OPMH. Steps must

be taken to ensure more accurate data is available for future planning

purposes.

8.6 Operational estimates indicate that most older people with dementia are placed

at the very dependent rate in residential care or in nursing care. The activity

information above would therefore mean that over the last three years there has

been an increase in demand for long-term residential based care for people with

dementia.

8.7 Admissions to long term care and proportions of intensive home care to

residential care provision

Performance Assessment Framework data shows that the number of long stay

admissions of older people to residential care per 10,000 of the population in

Hampshire is low compared to national averages, though it should be noted that

there is a relatively higher proportion of self-funders than in some other parts of

the country.

It also shows that Intensive Home Care as a proportion of Intensive Home and

Residential Care has increased from 17.3% in April 2001/March 2002 to 23.9%

as a current average (Dec '02-Nov '03), reflecting the policy of enabling older

people to remain in their own homes wherever possible.

8.8 Delayed Transfers of Care (DTC)

Data has only recently started to be collected systematically specifically

regarding DTC for older people with mental health needs. Operational

experience has shown that there are significant numbers of people waiting in

hospital beds for OPMH residential or nursing home places.

9.0 NEED

Appendix 7 shows the current estimates of older people in Hampshire who have

dementia. There are around 16, 594 people with dementia over the age of 65.

By far the largest proportion is of those over 85 years of age.

9.1 In terms of the 3 yr planning period covered by this report, it can be seen that

there is a predicted 5.9% increase in the numbers of people over 65 with dementia. By far the biggest increase in age cohort is for those over 85 years, where numbers of older people with dementia in Hampshire are predicted to increase by around 829 additional people, an increase of 11.8% on figures that are already high. The prevalence indicator used reflects a level of dementia where people are likely to require some degree of assistance to overcome disabilities associated with the disease. People aged 85 and over are also more likely to have other long term and disabling conditions, thus the demand for services is likely to increase significantly over the next few years.

10.0 SUMMARY OF CURRENT CAPACITY

· Pressures are experienced in all SSD areas when seeking placements for older people with dementia.

· There is limited choice available and vacancies may be some distance from a person's former home.

· Though the market has stabilised to some extent over the last year, there is still some risk of further closures and limited entry to the specialist dementia care, DE (E), part of the market.

· Activity has significantly increased in relation to very dependent and nursing home placements over the last three years and, given predicted population increases, demand for services is likely to continue to rise.

· In the context of seeking to minimise delayed transfers of care from hospital, availability and choice of placements is crucial

11.0 FUTURE CAPACITY REQUIREMENTS

11.1 There are significant difficulties in predicting future demand for services.

Factors that need to be considered in conjunction with predicted population

increases are:

· Changing patterns of need and dependency⁶,

for example there will be changes in people's expectations and medical advances such as new anti-dementia drugs.

· Patterns of other services provided.

These currently differ and have a significant impact on current demand.⁷

Changes in service configurations in the future will therefore also be

significant.

· The shift to more home-based care

In recognition of older peoples preferences, an overarching objective in

commissioning is to provide more home based services. Some of the current

pressures in finding beds will be compensated for by the development of

housing based alternatives and specialist domiciliary care services.

· The continuum of care between residential and nursing home care. In determining capacity requirements for residential and nursing home placements it is first necessary to have a view on what individual needs are best met in what settings. This is currently open to interpretation.

11.2 Insufficient data is available to accurately predict how much the different

factors affecting supply and demand will influence future OPMH bed requirements. It is necessary to plan for a high degree of flexibility in provision and an ability to identify and respond quickly and positively to changes in circumstances as they arise. This requires sound management information and close communication between strategic and operational staff.

11.3 Significant work has already been carried out to identify nursing home bed

requirements as part of the planning for the Nursing Care Investment Strategy⁸. A number of other possible scenarios specifically for people with dementia have been considered:

· Identifying average bed ratios to people with dementia across the county and showing how these could be maintained given predicted increases in population

· Showing proportions of people with dementia currently placed in long term care and what capacity requirements in 2006 would be if these proportions remained the same, given the increase in population. See Appendix 8

11.4 It must be noted that these do not take account of current pressures or further

losses in the care home market and merely reflect increases in population and

patterns of provision.

11.5 Key stakeholders now need to consider current pressures at local level and

determine local future capacity requirements.

11.6 Recommendations

· Plans should be developed centrally which identify how management information related to older people with dementia can be improved for the future

· Key stakeholders will consider current pressures at local level and determine local future capacity requirements. Once available, the additional management information above can assist in this process.