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Community development and Self-directed Support/Models of Health and Social Care delivery

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This space is for everyone interested in learning about, and sharing examples of, great health and social care practice which places the community at its heart.

DTAS Study Trip[edit | edit source]

The following examples were provided by a study trip led by DTAS

Fall of Dochart Retirement Home[edit | edit source]

The care home was previously run by a private company who made the decision to close due to the unsustainability of the service. Proposals emerged for the home to be converted into a hostel which would have meant the loss of a vital service in the community. Recent bad weather was a reminder of the importance of maintain this service as care organisations couldn’t get in to the local area so it is vital to have services in the locality.

John MacPherson, Chair of the Community Council, lead a community effort to buy the care home and subsequently maintain the service in the local area. The four main funders for this were the Land Fund, Rural Challenge Fund, Forth Valley Health Board and Stirling Council. The current board of the Retirement Home noted the importance of the council’s support and that they were fortunate to have such a supportive council – with the Council sitting on the Board for the first few years. In addition to the local authority support, the community of Killin were also very supportive and involved in the process.

The running of the care home is very participative, with residents and their families involved in meetings, trainings and decisions about the service. The emphasis is on the care home being a ‘home away from home’. Residents are therefore involved in decisions (such as re-decoration choices, food menus and activities). There is also relationship with the local school and residents are able to attend balance and strength classes which take place nearby. Attempts are made to keep married couples together, with two double rooms available, which is not the case within other services. The culture of the home is active, personalised and fun.

Sustainability remains a key concern for the home and the Board. Dochart Retirement home requires a 95% occupancy rate in order to stay sustainable (which means one room free no more than 6 months of the year). Other burdens in terms of finances has been increased pay for sleepover staff which has impacted the number of staff the home can employ overnight. As a result, Dochart have now developed ‘on call carers’ as a way around this where individuals are paid for four hours per night but are on call for ten hours. They do not have to stay in the home, but they have to be two minutes away.

The board highlighted that the Home is very much governed by council rates. Previously all rooms were charged at the same rate but due to financial pressures (including living wage and sleepover pay, as above) private rooms are now charged at a higher rate. The money received from the council has declined over the years which has made this distinction in pricing structures a necessity.

For staff, the home tries to recruit locally from the community and currently employ 15 staff who work across three daily shifts. Training helps to maintain staff as they feel part of something, staff are also involved in board meetings, staff meetings. Residents are also very local. However, residents from outside of the local authority area are able to stay in the care home and this involves other councils paying Stirling Council to use the service.

Barriers[edit | edit source]

 Sustainability of the service  Sustainability of the board – people have been on the board since the outset which has given a continuity and maintained skills within the organisation. However, there are issues with young talent coming onto the board. People have less time to volunteer and being on the board is a big responsibility, given that they own the care home  There still exists a need for care at home services. The Board are interested in this but unclear about options as to how to facilitate this.

Why did this work?[edit | edit source]

 Strong community leadership and the process led by the community  Continuity of leadership enabling learning and understanding to be maintained  Integration is working well in the area and the home has good relationships with service providers, district nurses, GPs and hospitals.  Local donations and legacy donations – the Care home have received two large legacy donations and regular donations amount to around £5000-10000 every year. This makes the home sustainable and contributed to reserves. If a similar model was to be adopted in a disadvantaged area, sustainability could be threatened by a lack of donations.

Tomatin – Strathdearn Community Developments[edit | edit source]

The local area suffered from shrinking of care services and the loss of the district nurse. The area also has an ageing demographic. While Tomatin is only 15 minutes to Inverness, none of the care providers cover Tomtin. Recognising this as an issue, Strathdearn Community Developments decided to find a solution.

Existing care provider did not pay for travel between which, when coupled with low pay, made caring for clients in Tomatin financially unfeasible for carers (and providers). Prior to the opening of this service, the community relied on relatives and friends providing unpaid caring hours (which will have had an impact on women’s economic participation in the area). Strathdearn Community Developments took the decision to work with a care provider, registered with the Care Inspectorate, to recruit in the local area. They work with Highland Home Carers who host the community care organisation’s staff and handles training.

This model operated through the following process:

Initial assessment of individual  agreement of budget  paid to Highland Home Carers  pay carers from community caring When advertising and recruiting locally, the organisation looked at the soft factors of why people might and to work in the area. Subsequently, one full time coordinator (on a fulltime contract) was hired with six part time carers employed on zero-hour contracts. At present, they have six clients. Zero hour contracts mean some hours are difficult to cover due to people being able to choose when to work. There is capacity for the organisation to cover a variety of needs, such as disability, but at present the clients are elderly individuals in the community as there is no demand for a wider service. The staff are flexible on their timings and will use their discretion to be able to take people to coffee mornings and pick up on the way back. They deliver a flexible, tailored service. This programme benefited from ‘pump prime’ whereby the organisation put money in before they had clients so that they would be prepared when clients arose. It is the Tomatin logo on the care uniforms that has been designed by the carers so the organisation is very much rooted in the community. For this project, funding was received through money received from windfarms but there is a need to make the project sustainable in the longer term once this money ceases. Also noted that windfarm money can't be used for services that the council deliver, but you can add value to existing services. The community are in the process of building a new resilience centre which will include a sports centre, new hall and a base/hub for carers. They will also be opening a community café which hopes to capitalise on the lack of facilitates at the nearby Tomatin distillery. There is also a local community shop.

Why did this work?

 Well-developed community infrastructure (community council, charitable trust and development trust) with active members.  A retired GP is the chairman of Strathdearn Community Developments so strong medical knowledge and insight into the process of care, the workings of the health board etc were very important.  Able to recruit from the local community using local knowledge of why people would want to be employed in the community.

Barriers and problems

 Need to pump prime the service so that the organisation is ready to provide for clients when the need arises. Waiting for clients to emerge before hiring and training staff would mean a delay and individuals subsequently having to receive care elsewhere.  Zero hour contracts mean some hours are difficult to cover due to people being able to choose when to work.

Highland Home Carers[edit | edit source]

Stephen Pennington is CEO of Highland Home Carers which has existed since 1994 and been employee-owned since 2004. The organisation is 100% employee-owned so everyone has the same share. HHC have 500+ employers who deliver care at home and independent living services. The organisation has three elected directors and three executive directors. The format means that employees don’t have to buy shares as they have a share incentive plan. The community teams, such as Strathdearn carers, are also part of the community ownership.

The transferral of social care responsibility to the health and social care partnership from the local authority has been coupled with a single, fair tariff for a standard hour of care including mileage (£18.59).

As a local authority area, Highland also has responsibility zones (one provider in each area which doesn’t happen elsewhere) and there is no procurement process which means that price isn’t driven down. This is also a way to drive better standards as providers across the area work as a ‘cartel’, working together to keep high standards and resisting changes which might hinder quality (see 15 minute visits below).

Highland Home Carers acknowledge that registration is a barrier for communities so this is why they are willing to operate within this model. In terms of coting, it costs £2500 for a single registration and an organisation requires a registered manager with a qualification. There is also a time implication as it takes months to facilitate and complete a registration. On one occasion, a project similar to Strathdearn Community Developments did subsequently go on to register themselves after effectively ‘testing’ the provision through this model.

Highland Home Carers are also trying to develop into other, harder to reach areas and as they move into new areas, they have to satisfy the care inspectorate that they are responsible.

Highland Home Carers are able to put money in from the outset because they can claim money back from admin payments.

For this to work, a human rights based approach must be the starting point and moving beyond care and services being done to people. There is a commitment to no 15 minute visits, and the care is delivered via 30 minute or one hour visits. With providers working together, this means that they are able to collectively vote against 15 minute visits. Questions from the other DTAS members around how it works to be an ISF manager. You don't have to register with the care inspectorate to do this. So this could be a good option for community organisations. ON the other hand, if you deliver care, you have to be registered. With option 2, you are able to purchase services as long as they meet your agreed outcomes. Self-directed support Within this model, Highland Home Carers are committed to all care being delivered under SDS Option two. Under SDS option two, an individual is assessed and subsequently allocated a budget. This budget is then given to Highland Home Carers to manage. In situations such as Strathdearn, the local organisation will advise the client on how to use the budget. This utilises Individual Service Funds as the model of payments and payment management. The budget is paid to the organisation four weeks in advance.

Option two provides additional financial resources when compared with option one, With option one, individuals are paid less money as there is an assumption that they will be gaining assistance from family members so will have less overheads.

Boleskine Community Care[edit | edit source]

A further example of Highland Home Carers operating as a ISF Fund manager and broker organisation is Boleskine Community Care. One of the individuals involved in this project is a former local council and the community is actively involved in the delivery and design of care. In addition to care delivery, the organisation also has a handyman service and community transport.

This couldn’t have been done without self-directed support and strong leadership. This is also firmly community-led with the community identifying the need for care, the communities finding people to be careers, putting them on the HHC pay roll and handling registration and training etc.

The organisation design their own uniform so that carers wear the name “Boleskine Community Care” rather than Highland Home Carers. In general, Highland Home Carers have responsibility but the care is managed locally.

Individuals receiving care are able to choose how to use their hours. For example, hours have been used to clear snow, chop wood and stack wood, take to GP appointments and take people’s dogs for walks. Boleskine Community Care do not just focus on physical needs but look at broader health and wellbeing.

Barriers[edit | edit source]

 Regulators don’t understand the concept of the community teams model and ask questions such as ‘how do you know who you are working with?’ Problems with the trust required in these models.  Highland Home Carers had tried to operate in Lismore but the Argyll and Bute Council operate in a different way which made it too difficult. As Argyll and Bute hadn't worked out option 2, they decided to do this through option 3. Implies this might be difficult to replicate elsewhere where the particular circumstances of Highland do not exist?  Other Councils have spoken to Highland Home Carers and Highland council about this model but decided to go down the procurement route at the last minute. This is seen as a dramatic departure from previous models.  Individuals are not being told about the various options, in particular option 2 which means there is a lack of understanding.  Other providers do not want to take on the additional responsibility of managing budgets or other community organisations.  Need for greater public awareness. Highland Home Carers recommended this should be achieved through Councillors, MSPs and a public campaign. What is the role of communities and DTAS members to promote self-directed support?  If the demographics of a particular area mean that there are very few young people, it may be difficult to recruit carers.

What helped?[edit | edit source]

 Transferral of social care responsibility and budgets to the health and social care partnership from the local authority. Highland Council had acknowledged that internal provision should be stopped and were also willing to let-go of the control of the procurement process.  Good relationship between the community and the provider is vital.  The impact of integration is key as it would have been impossible to adopt this model without integration  This has to be community-led, not just delivered in the community, meaning that the community has to be actively involved in the design and the delivery of care  Need to get past the jargon of ‘social care’ and associated legislation so that self-directed support can be easily understood by communities. Also need to ensure that people know their rights.  Highland Home Carers will only operate through option 2 which helps to root personalisation and self-directedness into the process.  Providers working together so that they can vote against 15 minute visits etc  Being employee owned has been a big part of the success as this has an ethos of investing in communities, community people and working hard for their own community. This is not essential, but a corner of the jigsaw.

Braemar Care Initiative[edit | edit source]

The starting point for the emergence of Braemar Care Initiative was a community meeting in a village hall. This means the process is rooted in the community and is led by the community. Population of Braemar is around 500 but, like other rural villages, the population is ageing.

While the original ambition was to have a local group with directly employed carers, the necessary regulation meant that this was too difficult and, presumably, expensive. The barriers to setting up as a care organisation themselves were the registration and regulatory requirements. The group also felt that the demand for care would be too variable to be able to sustain a stand-alone care service.

For their first client, Braemar used Cornerstone as a broker under self-directed support option two. However, there were some perceived problems with Cornerstone as the broker due to there being no induction training for carers.

Subsequently, due to these issues, the group have since changed to use the health and social care partnership as the broker. This operated along the Highland Home Carers and Strathdearn Community Developments example with the local authority being registered with the care inspectorate and formally hosting staff on behalf of the community. The local authority have been flexible in allowing the newly-recruited carers to only work in this particular area.

Within Braemar, there were no private providers, only self-directed support or the local authority. This means, when the health and social care partnership are unable to recruit, there is no care service in the area. The local authority had previously tried to hire carers in this area but had been unsuccessful. However, the local recruitment process by Braemar Care Initiative has been successful.

The community have very recently employed a coordinator who will assign carers and try to promote the service and the role is funded until December 2018. So far, 12 people have indicated that they are interested in caring in the community and others have said they would be willing to volunteer in the service. The carers are employed on zero-hour contracts which enables them to do self- directed support and private work on the side.

Volunteers will do less formal care such as making cups of tea, doing shopping. It is hoped that this will also work as a gentle introduction to caring as a profession and will also get individuals used to receiving some care. These carers will only be allocated care patients within Braemar and it is the intention that carers will have a base within the local GP surgery.

To establish this programme, they received funding from the Robertson Trust, LEADER, Economic and Development Fund and the Health and Social care Partnership. The group mentioned that they had applied from other funds but been unsuccessful – so applying for funding is something of a process. A key question asked by funders when applying for funding is how will you ensure the programme is sustainable. This is a key question for services of this nature.

Some concerns about how much control the community will have against the health and social care partnership. It is the hope that the local authority will build-up trust in Braemer as they build expertise and pass on responsibility to the community. Appears from these early discussions that all of these patients will be option 3 patients which might limit personalisation. Alternative approaches would be to replicate the Strathdearn Community Care.

Currently have the potential for 3 or 4 clients but, at present, are not delivering care to anyone. However, they are looking to be ready to take on clients when they arise – hence the early recruitment of a client. Without such preparation it would be time consuming to put in the necessary work to get to a point where they could provide care. If they were to wait for the next self-directed support client, there would be no training until employed and no employment until client.

There is a human rights angle to this work as couples and families are being split up so that they can receive care in facilities. For this reason, their work will not be limited to elderly services but vulnerable people in the community too.

Why did this work?[edit | edit source]

 “You need people to come in and have the same dream”  It’s vital to have people involved who have a background in health and social care  Aberdeenshire Health and Social Care Partnership is very supportive and gave money to create the steering group.  The community felt passionately about care in their community  The group have a very strong relationship with the local GP which enable joined-up care and sharing of information  Relationship with the manager of the Health and Social Care Partnership is crucial and having representatives on the board from a health and social care background enable the navigation through this complex landscape.  The group have linked into pre-existing groups in the community such as Lunch Clubs where they were able to link-in to people on a fortnightly basis. Also discussed opportunities to link to care and repair and time banking.

Barriers[edit | edit source]

 Difficulties associated with understanding self-directed support and the options available to communities  Low levels of understanding of self-directed support in the community and general public  Problems with insurance around what volunteers can do e.g. unable to change a lightbulb which can limit the impact  Registrations and regulation – time and cost  It can be very time consuming to find the correct model for your area and you have to work through various options as there is no one-size-fits-all model for community-led care initiatives.  Reliance on zero-hours contracts as recruitment model.  Difficulties associated with remaining sustainable and providing the sustainability when applying for funding.  Health and social care partnership involvement may limit personalisation due to reliance on option 3. Also unclear how the relationship will work in practice which may limit the control enjoyed by the community.

What would help?[edit | edit source]

 A couple of strong examples of community-led health initiatives which can be pointed to when you speak to your Health and Social Care Partnership  The group noted that a network to share information and bring people together to discuss what worked and what didn’t work would be helpful. It was unclear about how people share information in this area  The group noted that being able to share information and knowledge would be of real assistance.