NOVEMBER 2003
BEST VALUE REVIEW
OF SERVICES FOR
OLDER PEOPLE IN
WEST SUSSEX:
DAY CARE
FULL REPORT
Project Director: Anna Coss, Head of Strategic Commissioning
and Performance
Project Manager: Alison Tuck, Scrutiny and Review Group
Working Group Leader and Author of Report: Mary Sinclair,
Strategic Commissioning and Performance Manager
NOVEMBER 2003
Company, activities, a meal and ‘to
get away from the same four walls’.
BVR Services for Older People: Day Care. (Service user survey
Spring 2003: main reasons for attendance at a day care centre.)
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NOVEMBER 2003
CONTENTS
SUMMARY
Recommendations for the Project Steering Group
Principles
Risk Analysis
Gap Analysis
Options
Strategic Performance Improvement Plan
FULL AND DETAILED REPORT
1.
2.
3.
4.
5.
6.
Introduction
Background
Methodology and limitations
The in-house day care service: the current position
What do people think of the service? (Consultation)
How does the service stand up to examination
(Challenge)
7. How does the service compare? (Comparison)
8. Is the service fit for the future? (Competition)
9. Vision into action (Areas/Primary Care Teams)
Appendices
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NOVEMBER 2003
Recommendations for Project Steering Group
The Best Value Review Group looking at day care for older people
present the following report to the Project Steering Group on 6
October 2003 and make the following recommendations to the
group:
• The Best Value Review is accepted by members of the
Project Steering Group
• The document is then published and shared with
stakeholders
• The Performance Improvement Plan forms the basis for
action
• An update on progress is made available to members in
one year’s time
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NOVEMBER 2003
BEST VALUE REVIEW OF SERVICES FOR
OLDER PEOPLE IN WEST SUSSEX: DAY CARE
Executive Summary, Conclusions & Recommendations
The central purpose of best value is to make a real and positive difference to the
service people receive from their local authority. The Best Value Review (BVR)
process looked in detail at the service provided, seeking an understanding of the
current position and ensuring that actions will drive improvements. Action plans
will need to be clear and have challenging targets and take a long-term view which
involves stakeholders and ensures a good quality sustainable service for
vulnerable people of West Sussex.
The BVR researched day care within West Sussex concentrating primarily on the
in-house provision which offers a service both to older people and to people of
working age. During the course of the review it was clear that day care forms only
a small part of a range of day services the majority of which happen in the local
community. The working group suggested that day services should be an
umbrella term that includes daytime activities and day care. The following
definitions were therefore used as part of the review:
Daytime activities are broadly those that happen in the community, that
support people who have lower level needs. Such activities might include
formal and informal settings, centres run by voluntary organisations, drop in
centres, luncheon clubs, social clubs, education and leisure facilities, cafes and
pubs. In addition it may include respite in the home or in another carer's home.
Such activities may, or may not, involve staff or volunteers.
Day care implies therefore that there is a specific need that would not be met
by daytime activities. A care plan would clearly state the individuals need and
how this would be met through short term, intensive programmes such as
intermediate care and rehabilitation. Some individuals would need specialist
day care as part of a programme of ongoing support.
Wherever possible the role of day care would be to support individuals to move
into socially inclusive daytime activities. Where ongoing day care is the assessed
need there should still be opportunities to create meaningful links with ordinary day
time activities and this should be built into the care plan.
Four key objectives were agreed for the BVR and below is a summary of the
conclusions against each together with key recommendations:
1.To review the need, availability, accessibility,
effectiveness and cost of day care.
The BVR working group focused in depth on the twelve in-house day centres: six
larger multi purpose and six smaller centres. Information was also collected from
other sources which included voluntary organisations, housing, education,
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NOVEMBER 2003
libraries, direct payments, day hospitals, in-house residential homes and other
local authorities (LAs).
The outcome of the benchmarking exercise with other LAs showed that most have
either reviewed or are in the process of reviewing their day services. There is a
recognition that in modernising services, promoting independence and social
inclusion there needs to be a greater understanding of the full range of day
activities rather than a more limited focus on day care.
The working group researched the views of the five Areas/PCTs:
•
•
•
•
•
Western
Coastal
Crawley
Mid Sussex
Horsham
Research of the Area/PCTs included gathering information about the current
services, the gaps and service development for the future. It was clear that an
overall vision of day services was necessary but given the different composition of
each Area/PCT 'the one model fits all' approach would not be appropriate
Important issues raised about access to services included the need to have
knowledge of resources available and efficient transport systems. ICIS provide
quarterly resource information which is available to all WSSCS help desks and
social workers. This information will soon be available fortnightly on the Intranet to
a wider audience which should include day centres. Information, including leaflets
is also available from a number of different voluntary organisations. Other
organisations including Age Concern provide information and advice. Transport is
a source of dissatisfaction for service users, the day centre managers and other
professionals. More reliable, flexible and user sensitive services need to be
designed to respond appropriately to modern daytime needs. Links also need to
be made with the range of alternative transport provision in the community.
The effectiveness of day care services is more accurately measured if certain tools
are in place such as standards, procedures and care plans. Currently the day
centres are not subject to regulation by the National Care Standards Commission
and therefore are not working to national standards. The quality of care plans and
reviews are not consistent and there is an absence of day care procedures and
national performance indicators specific to day services.
A survey of day care service users showed that what people valued most from
attendance at a day centre was expressed as being company, activities, a meal
and to get away from the same four walls. The importance for example of activities
as part of a rehabilitation programme was acknowledged. However, the BVR
working group would suggest that opportunities for greater community integration
are offered by voluntary and other organisations in a variety of ordinary daytime
activities. In some instances service users attended in-house day care and a
range of other community activities. It therefore seemed that there was duplication
of services and that not everyone attending the day centres needed care.
The BVR working group needed to consider the cost of providing day care. The
benchmarking exercise with other LAs repeated the findings of the BVR Home
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NOVEMBER 2003
Care which illustrated the difficulties in drawing cost comparisons given some LAs
do not know their unit cost and others appeared to calculate it in different ways,
the range was from £7.60 to £30.00. As part of the BVR a unit cost was
established which averaged across the twelve in-house centres as £47.10 per
week. A unit cost for the independent sector (three voluntary and one private
sector organisations) was calculated as £25.95. As with the LAs, some caution is
required given some organisations also provide drop in, lunches and specific
interest groups which means attendance is difficult to predict and record.
Nevertheless the cost effectiveness of the in-house service needs to be
questioned if a number of people are attending for day care when their needs
might best be met by alternative day time activities in their local community. It is
therefore also important to ensure the grants to other organisations are being used
in a way that supports a modern day service.
Key recommendations:
1.1
1.2
1.3
1.4
1.5
A clear vision for a modern day service which includes
daytime activities and day care is agreed and promoted.
Areas and PCTs implement plans for day services in
accordance with local need.
Awareness is raised about the information provided by ICIS
and other voluntary organisations to help desks and day
centres.
A plan is devised together with the Transport Co-ordination
Unit which reflects the recommendations of the BVR and
ensures an approach to the management of transport which
includes local, community transport and supports a modern
day service.
To draw up standards and procedures specifically for day
care in preparation for the introduction of National Minimum
Standards and local performance indicators.
To review grants to ensure those used for daytime activities
and day care are consistent with the vision for a modern day
service.
2. To analyse and evaluate services in order to determine
how services match service users current and future
needs.
The message throughout the review was that service users want company,
activities, a meal and to get away from the same four walls. It became obvious
that this could be provided in a number of different more socially inclusive ways,
particularly where there was not a care need and not necessarily within the inhouse day care centres.
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NOVEMBER 2003
The working group found a huge range of ordinary activities in the community.
Such daytime activities support people in the community, promote independence
and prevent or delay the need for higher-level services. Most people access these
services independently, some need advice and, or, support to access activities.
Given that some individuals may be attending day care when their needs would
best be met in a more socially inclusive way and that others may need different
levels of support, the future use of the in-house day centres within WSSCS need
to be re considered. The BVR working group suggest that day care needs to
address the current and future needs of the following groups:
•
Time limited day care for those returning home from hospital or requiring
rehabilitation, with a view to accessing daytime activities, in partnership with
other agencies in particular health.
•
The needs of those who require ongoing services can be met in a number
of ways which might include residential homes, specialist smaller centres,
smaller units within larger centres, care at home or in another carer's home,
out reach work and resource centres.
It has been agreed that the principles for a modern day service are applicable to all
service user groups. Reviews undertaken in respect of older people with mental
health needs, people with learning difficulties and people with physical
impairments need to be integrated into any proposed action for day services, given
that a proportion of people attending in-house day care are under 65 with a range
of impairments. Similarly in meeting the needs of carers for respite and more
flexible services the findings of the BVR of Carers need to be included.
Key recommendations:
2.1 That the daytime needs of individuals attending in-house day
care are reviewed.
2.2 That the future use of all in-house day care centres is
reviewed in the light of the need to provide time limited
programmes and longer-term support, in partnership with other
agencies and the specific needs of each area.
• Also referred to in key recommendation 1.2
2.3 In recognition that the principles of a modern day service can
apply to all service user groups links need to be made at a local
level with other reviews to ensure a consistent overall approach
that is sensitive to service user and carer needs:
• Service plan for older people with mental health needs
• Modernising day services for people with learning
difficulties
• Strategy for people with a physical impairment.
• The BVR of Carers
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NOVEMBER 2003
3. To ensure that in each area/PCT there is a range of day
care that is:
• Accessible
• Cost effective
• Sensitive to the needs of older people including those
with mental health needs
• Friendly, welcoming and within a stimulating
environment
• Therapeutic and maintaining maximum independence.
There is a need for an overarching vision and direction for day services to ensure
general cohesion. However, the BVR working group recognised from the outset
that 'one model fits all' was not appropriate. Therefore information was collected
from all Areas/PCTs that would help to inform the range of day services that
should be available including:
•
•
•
•
Current day care resources
Area/PCT view of current resources
Current/planned developments
Vision of day service for the future
Each Area/PCT is different in terms of the population, the needs of the local
community and the resources available. Some will continue to wish to use
buildings working with other partners to provide services, for some the focus may
be on specific groups and for others an integrated approach will be the best way
forward.
The main issues raised in respect of accessibility to services were information and
transport. For some people it will also mean access to advice about benefits and
other entitlements, as there may be costs attached to certain alternative daytime
activities and day care. Knowing what is available and can be accessed will
enable imaginative packages to be drawn up that include a range of different
options that are sensitive to individual need.
Providing low-level services within the in-house day centres is not believed to be
cost effective, particularly where these could be provided in different ways in
ordinary community settings. The focus of day care should be on more intensive
care provided in partnership with other agencies for example, promoting health
and social care on discharge from hospital or as part of rehabilitation programme.
Services which are purposeful, therapeutic and promote and maintain
independence, therefore preventing or delaying admission to residential care, can
be cost effective. Such changes to the role and function of day care centres imply
a need to review the number/location of day centres and managers required, the
roles and responsibilities and training needs of managers and staff, particularly in
relation to out reach work and supporting intensive therapeutic programmes.
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NOVEMBER 2003
The BVR working group found that the in-house day centres aim to provide
services that are sensitive to need, friendly and welcoming. Indeed in surveys
service users are generally satisfied with their day care and would be reluctant to
change. However, for many people there are a number of alternative ways of
meeting what service users want from day care in more socially inclusive
environments.
In the surveys and discussions, carers asked for respite, more flexible services, a
move away from traditional services, smaller units or care in another carers home.
A modern day service needs to listen to these views involving people at the
planning stage. The needs and wishes of carers are important and recognised by
the BVR working group which linked with the BVR of Carers being undertaken at
the same time.
The modern plan for day services is less dependent on bricks and mortar with a
greater emphasis on community support and development and working in
partnership with other agencies. For this reason, it is important for each Area to
review the range of in-house provision. The provision varies considerably and for
some Areas there may an opportunity to disinvest in order to reinvest; the main
drive being to promote greater use of daytime activities in the community. Areas
with more than one centre would seem to have the greatest potential for
exploration of options, which could include amalgamation of centres or transferring
a service into the community.
A criticism throughout the BVR has been that buildings are empty at weekends
and during the evenings. The best use of buildings needs to be considered in
order to provide appropriate levels of support, flexible services and a greater
sense of inclusion within local communities. This could imply a more imaginative
use of the building together with other organisations for example, a shop within a
shop and Daily Living Centres and create greater opportunities for more flexible
opening times as requested by carers, service users, various organisations and
other stakeholders. Day care within the residential homes that are to be
transferred to an independent provider needs to complement the modern day
service. Local forums of interested organisations would assist the Areas/PCTs to
identify gaps and how best to maximise accessible, flexible, cost effective services
that promote and maintain independence.
Key recommendations :
3.1 A review of numbers/ location of buildings, to include, for
example, amalgamation or transfer, together with a review of
manager numbers, management and staff structures and tasks in
order to identify the skills and training required to meet the needs
of a modern day service.
3.2 Existing local forums of in-house, voluntary organisations,
health and housing, private sector and other agencies to include
day service providers.
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NOVEMBER 2003
3.3 Areas to agree the future use of day services within the
residential homes that are being transferred and consider with
housing the use of sheltered accommodation.
3.4 Maximum use of day care buildings, where appropriate, by
other organisations needs to be part of the modern day service.
4. To develop a strategy and action plan to achieve these
aims.
The BVR working group examined options for a modern day service which
included:
•
•
•
•
Do nothing/ maintain the status quo
Withdraw/outsource
Total in-house service
Market development
The working group concluded that the market development option would be
recommended as being most likely to provide a modern service. Developing the
market requires knowledge of what is available, where the gaps are and how these
might be addressed. The option gives greatest opportunity to work in cooperation
and collaboratively with other organisations providing a spectrum of day services
to meet the current and future needs of service users and carers. (see
Consideration of Options)
The BVR working group suggested the following vision:
A modernised day service will provide a range of flexible, community based
services in partnership with other organisations to promote and maintain
peoples independence.
The strategy is set out in the BVR full report and the implementation plan is
outlined in the performance improvement plan. The purpose will be to ensure Best
Value is achieved through the ability to make a real difference to the lives of
service users and their carers. An important key element will be how the
recommendations are led, implemented and monitored.
The BVR addressed the objectives using the four C’s of consult, compare,
challenge and compete. The full report describes the current in-house service, the
strengths and weaknesses and the action that will be needed to achieve the
recommendations of this review. The performance improvement plan implies a
huge piece of work that needs to be undertaken. The market development
approach will create a framework for improvement and modernisation of day
services that will address the current and future needs of service users and carers.
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NOVEMBER 2003
Key recommendations
4.1 The Head of Adult Services and the Head of Commissioning
and Performance will ensure that an operational performance
improvement plan is confirmed, agreed and implemented.
4.2 That the progress of the plan is regularly monitored and a
report is given to elected members at Select Committee in twelve
months time.
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NOVEMBER 2003
Principles For A Modern Day Service
•
A modern day service will have a clear vision and purpose which will i nclude
a clear definition of daytime activities and day care.
•
The modern day service will address the spectrum of service user and
carer need including prevention, time limited intermediate care and
rehabilitation programmes and longer term support with the view to
helping people to live at home.
•
A high level of co-operation and collaboration in planning and operating day
services will exist with partner agencies.
•
Opportunities for access to socially inclusive daytime activities within local
communities will be maximised through the availability of up to date
information and the development of local facilities.
•
Day care, which will involve a range of providers, will be targeted on those
people with high level needs both short and longer term with outcomes
clearly stated in care plans.
•
Training programmes for staff working in day centres will address the need
for a mix of skills, focusing on maximising independence, including
rehabilitation, specialists needs and outreach work.
•
Grants made for daytime activities to organisations will be consistent with
the principles of the modern day service and will be monitored and
reviewed.
•
Transport provision will be subject to eligibility criteria and advice given on
options, including community transport, where alternative arrangements
need to be made.
•
Maximum use of day care buildings, where appropriate, will be made to
ensure greater flexibility, good links with local communities and increased
opportunities for both local people and those attending for day care and
their carers.
•
The modern day service will ensure that there is continuous improvement
that takes into account developments across service user groups,
outcomes of reviews and national and local principles.
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NOVEMBER 2003
Risk Analysis
Risk is defined by the Audit Commission (Worth the Risk) July 2001, as the
threat that an event or action will adversely affect the organisation’s ability to
achieve its objectives or to successfully execute its strategies. Risk
management is a process of evaluating and addressing the impact of risk in a
cost effective way. It requires staff and managers with appropriate skills to
identify and assess the potential for risks.
The BVR showed that the main risks are in not being able to respond to the
need for a modern day service that recognises a spectrum of need that is
required now and for the future:
•
•
•
•
•
•
•
•
•
•
•
•
Lack of vision and unclear purpose
Opportunities to work in partnership not fully utilised
Potential difficulties in the future of meeting the needs of more
dependent older people
Absence of standards and procedures resulting in difficulty in measuring
efficiency and being National Minimum Standards compliant in the future
Low profile resulting in the part services can play in meeting
Performance Indicators in helping people to live at home and support
carers not being fully recognised.
Traditional services which can be socially exclusive and create
dependency
Over reliance on bricks and mortar
Inability to provide flexible services
Duplication of services and wasted resources
Communication across and between services and organisations
A number of service plans and strategies for service user groups that
may not be linked and may be in opposition
Building blocks to support a modern day service not yet in place.
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NOVEMBER 2003
Gap Analysis
The BVR working group identified the following gaps which need to be
addressed:
•
•
•
•
•
•
•
•
•
•
•
•
An overall vision for a modern day service
A long term strategy and implementation plan
A strategy that sets out how a spectrum of low to higher level need can
best be met.
Flexible services that promote independence and support the needs of
carers
Focus on local, community based and socially i nclusive provision
Joint day services forums in each Area/PCT with both in-house and
other organisations.
The specific needs of certain groups including older people with a
functional mental health need, younger people with dementia, older
people with learning difficulties, younger people with a physical disability
and older people with a sensory impairment
Work and educational opportunities
Regular use of alternative provision and opportunities for joint working,
such as education. libraries, home visitors and leisure activities
Future use of day facilities in in-house residential homes when they
transfer to the independent sector
Realistic change programme
Absence of integrated services
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NOVEMBER 2003
Consideration of Options.
DO NOTHING/ MAINTAIN THE
STATUS QUO
Advantage
• No change for service users
and staff
Disadvantage
• Perpetuates the place for life
and the possibility of
dependence
• Socially exclusive service
• Static, traditional services
• Use of buildings and
partnerships not maximised
• Does not address the need for
greater flexibility
• Lack of recognition of the
important part day care might
play in assisting people to stay
in their own homes and to meet
PAF targets
Justification
Doing nothing as part of BVR and the
need for continuous improvement is
not an option.
Against national and local principles
and desire to modernise services
WITHDRAW/OUTSOURCE
Advantage
• WSSCS would concentrate on
commissioning only.
• Buildings can be disposed of/
staff redeployed as part of
organisational change
• Possible financial efficiencies
Disadvantage
• At behest of market
• Market currently not sufficiently
mature
• TUPE regulations could make
this option costly and take time
to achieve thus reducing
financial efficiencies
• Reacting quickly to new
directives and agreeing new
initiatives with a range of
providers could be difficult.
• Move away from mixed
economy
Justification
Not in line with national principle i.e. to
create a mixed economy.
Starfish/ ADSS Report suggests
outsourcing may not achieve savings.
TOTAL IN-HOUSE SERVICE
Advantage
• Retains management control
Disadvantage
• Stigma of statutory service for
some people
• Lack of capacity to innovate,
develop new services
• No focus: all things to all people
• Waste of finite resources
MARKET DEVELOPMENT
Advantage
•
•
•
•
Best use of available resources
Opportunity to work with
partners, to promote socially
inclusive daytime activities.
Greater opportunity to work in
partnership with other
organisations promoting good
health and social care.
Opportunity for provision of
more services to keep people at
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NOVEMBER 2003
Justification
Against nationa l principles to promote
a flourishing independent sector within
a mixed economy.
No evidence found of LAs that have
fully retained a service.
Difficulties in rural areas
Does not address flexibility or need for
alternatives to day care
home and assist early
discharge from hospital.
• Opportunity to work with
partners creating specialist
services and ensuring gaps in
service are addressed
• Co-operative and collaborative
working make further change
and flexibility more possible
Disadvantage
• Change programme including
consideration of staff roles and
responsibilities
• Reviews for service users that
may result in alternative day
time activities and loss of
friendship groups
• Time needs to be invested in
selling the idea, ensuring
resources are known and
market stimulated where
necessary
• May require pump priming to
get alternatives off the ground
and investment in training and
equipment.
Justification
Improvements can begin immediately
Clear vision for day services
Targeted service with clearer roles for
different organisations
Recognition that day services are not
the responsibility of one agency
CONSIDERD TO BE THE
PREFERRED OPTION
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NOVEMBER 2003
BEST VALUE REVIEW (DAY CARE) STRATEGIC PERFORMANCE IMPROVEMENT PLAN
RECOMMENDATION OUTCOME
STRATEGIC LEAD
CONSTRAINTS/ TIMESCALE
COMMENTS
1.1 Communicate vision for
day services which includes
day care and day time
activities implemented locally
within Areas/PCTs together
with other partners
1.2 Information provided to
Areas by ICIS, Age Concern,
libraries and other
organisations to be available
to the public, help desks, day
centres and link with call
centres
Awareness and
understanding of
vision
Head of Adult Services /Area
Managers
Involvement of key
managers throughout
the BVR process.
March 2004
Better information
about options
available
Area Managers/ Business
Managers/ SDM Older
People
May 2004
1.3 Transport Co-ordination
Unit to work with Areas to
begin to develop a reliable
and flexible transport system
which also links with
community transport options.
A transport system
which supports a
modern day
service
Area managers/ /Transport
Co-ordination unit
Work in progress on
information strategy.
ICIS will provide
information on a more
regular basis.
Build on information
available e.g. VSLDOs
and CCIs
Recent reorganisation
of transport services.
Difficulties in driver
recruitment.
Capacity issue.
November 2004
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NOVEMBER 2003
RECOMMENDATION OUTCOME
STRATEGIC LEAD
CONSTRAINTS/ TIMESCALE
COMMENTS
1.4 Standards, procedures
and local performance
indicators to be established
Services are
measurable and
ready to meet the
National Minimum
Standards.
Head of Adult Services/ Area
Managers/Strategic
Commissioning and
Performance
1.5 Review grants to
voluntary organisations for
day and information services
2.1 Review needs of
individuals attending inhouse day care centres
Consistent, modern Area Managers/ Deputy
day services
Head of
Commissioning/VSLDOs
Service users are
Head of Adult Services/ Area
receiving
Managers
appropriate
services
Continuous
Head of Adult Services and
improvement is
Head of Commissioning
ensured
Management
information systems
need to be developed.
Links to be made with
work undertaken in
residential/home care.
Awaiting draft national
standards.
Potential to disinvest
and reinvest according
to local need.
Capacity issue.
Requirement to
undertake reviews
under FACS
Cost and quality to be
constantly monitored
Readiness of market to
respond.
Links made as part of
BVR.
Possible overlaps and
or gaps between
services
2.2 Continue to review day
services and options for
change over the next five
years
2.3 Links to be made locally
with other work being
undertaken i.e. service plan
for OPMH, modernising day
services for people with
learning difficulties, strategy
for people with a physical
A consistent overall Head of Adult Services and
approach to the
Head of Commissioning
delivery of modern
day services for all
service users
November 2004
Ongoing
July 2004
Ongoing 2008
Annual meetings
2004/5/6/7/8
Ongoing
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NOVEMBER 2003
RECOMMENDATION OUTCOME
impairment and the BVR of
Carers
3.1 Review of numbers
/location of buildings
including
amalgamation/transfer and
manager/ staff structures,
tasks and training.
3.2 Existing local forums of
in-house, voluntary
organisations, private sector,
health, housing and other
agencies to include day
service providers
3.3 Agreement of future use
of day care within residential
homes.
3.4 Maximise, where
appropriate, use of day
centre buildings together with
STRATEGIC LEAD
CONSTRAINTS/ TIMESCALE
COMMENTS
Less dependence
on building based
services and
greater emphasis
on community
based activities.
Appropriate skill
mix
Resources and
need for
development
identified
Head of Adult Services/ Head Capacity issue.
of Resources/ Head of
Possible links with
Commissioning
Budget Review
November 2004
Area Managers
Build on existing
forums. Capacity issue
for some Areas.
November 2004
Ensure day care
within residential
homes is part of
the modern day
service
Greater opportunity
for flexibility and
use of buildings by
Area Managers/ Contracts/
Shaw Homes/
Provision for day care
September 2004
in residential homes
subject to National
Minimum Standards,
possible restrictions.
Opportunity to create
November 2004
revenue.
Ongoing
Issues re security, care
Area Managers
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NOVEMBER 2003
RECOMMENDATION OUTCOME
STRATEGIC LEAD
CONSTRAINTS/ TIMESCALE
COMMENTS
other organisations
local community
taking, transport and
weekend working
4.1 Confirm, agree and
implement the
recommendations in the
performance improvement
plan
4.2 Progress of the
performance improvement
plan is monitored and
reported to elected members
in twelve months time.
Best value and
continuous
improvement
Head of Adult Services and
Head of Commissioning
November 2003
Action taken,
monitored and
revised as
necessary
Head of Adult Services and
Head of Commissioning
December 2004
N.B. Process of implementation will be driven locally. A detailed action plan with defined tasks, individual timescales and milestones will
be developed within Areas to deliver this strategic overall plan.
21
NOVEMBER 2003
BEST VALUE REVIEW OF SERVICES FOR
OLDER PEOPLE IN WEST SUSSEX: DAY CARE
Full Report
1. Introduction
The central purpose of West Sussex Social and Caring Services (WSSCS) is to
make a real and positive difference to the services that local people receive.
The Local Government Act 1999 places a duty on every council to deliver best
value services which take into account clear standards of cost and quality by
the most economic, efficient and effective means. Since April 2002, over a fiveyear period all Local Authorities have been required to review their services
against the Best Value Framework which comprises the four following drivers:
Challenge
Compare
Consult
Compete
A Best Value Review (BVR) recognises the importance of continuous
improvement. The process involves looking in detail at the service provided,
understanding the current position, having clear and challenging targets and
ensuring that actions will drive improvements. It is important to have a longterm view that involves a wide range of stakeholders including those
responsible for delivering the service, carers and the service users.
The BVR working group included membership from a number of departments
and organisations (Appendix 1). The group drew up a scoping report which
was agreed with the Project Team and was approved by the Project Steering
Group in January 2003. It was agreed that the following objectives would be
incorporated in the review:
A. To review the need, availability, accessibility, effectiveness and cost of
day services
B. To analyse and evaluate services in order to determine how services
match service users current and future needs.
C. To ensure that in each Area/PCT there is a range of day care that is:
• Accessible
• Cost effective
• Sensitive to the needs of older people including those with mental
health needs
• Friendly, welcoming and within a stimulating environment
• Therapeutic and maintaining maximum independence
22
NOVEMBER 2003
D. To develop a strategy and action plan to achieve these aims.
In order to undertake the task, recommend a strategy and produce a
performance improvement plan, information was gathered about the in-house
service. Using the four C’s of challenge, compare, consult and compete the
following questions were addressed:
•
•
•
•
What do people think of the service?
How does the service stand up to examination?
How does the service compare?
Is the service fit for the future?
Best Value was regarded as a helpful framework which would assist WSSCS
gain a better understanding of the in-house day care service and the views of a
range of stakeholders in order to improve services and link these improvements
to performance management arrangements. It was also regarded as an
effective way of addressing the national drivers including the Government’s
Modernisation Agenda and the National Service Framework for Older People.
The review focused primarily on the twelve in-house day centres; six-multi
purpose and six smaller day centres. The review also considered the
independent sector organisations where there are Service and Funding
Agreements, day care in residential homes, other LAs and a range of formal
and informal day services in the community. Information was collected about
services for older people with mental health needs, physical disabilities and
learning difficulties. The BVR was undertaken alongside the BVR of Carers.
The purpose of the BVR was to make a real and positive difference to the
services people receive and to support maximum opportunity for people to
retain and maintain independence.
2. Background
2.1 Day care for older people
Since the 1930’s the number of people over 65 has more than doubled. By
2025 the expectation is that the number of people over 80 will increase by
about a half and the number of people over 90 will double. Currently one in five
of the population is over 65 and it is anticipated that this will have grown to one
in four by 2020. The profound changes in demography and the age structure
will have far reaching political, economic and social consequences.
West Sussex is a large rural county with a population of approximately 763,000
and a higher than average proportion of older people. In 2001 there were an
estimated 151,600 older people (over 65 years of age) living in the county. The
increase in the next decade is estimated to be a further 9,800 of people over
65.
The West Sussex Five Year Plan (1998 to 2002) referred to:
23
NOVEMBER 2003
We need to review the current Day Services provision in the county to make
sure it responds flexibly to meet needs.
It also stated the need to further develop specialist services, especially for older
people with dementia and older people with mental health needs. It was
recognised that more support for carers was required especially through respite
care provision.
The aims over the 5 year period were stated as:
Ensure that services are as accessible as possible
Making services available as locally as possible particularly in rural areas.
Modernising Social Services (DOH 1998) set out the blueprint for future social
services provision. It confirmed that the needs of service users should be at
the centre of the way councils arrange and provide services. In the introduction
to Strong Local Leadership – Quality Public Services DLTR 2001, reference is
made to a vision of a modern social services department which:
Delivers flexible services to meet users and carers need and expectations at
times when they require them
Makes best use of resources delivering best value
The historical roots of day care for older people are multiple and diverse. Much
of the policy literature is characterised by debate and definitional refinements
which attempt to clarify the distinction between day care, day services, day
hospitals, luncheon clubs and social clubs. Under the terms of the definition of
day care it is possible to find a permutation of:
•
•
•
•
location from purpose built centres to hospitals to residential homes to
church halls,
service provider from statutory social services to health and housing to
voluntary organisation and private sector,
intensity of access from a few hours to several days a week,
variation in purpose from social stimulation to care and assessment to
rehabilitation and therapy and to respite for carers.
2.2 National and local principles and strategic intentions
Day services were established in this country in the 1950’s beginning with day
hospitals which increased during the 60’s and 70’s and expanded with the
introduction of day centres in the statutory and independent sector in the 70’s.
In the 1980’s day centres primarily included: NHS day hospitals, (older people
and older people with mental health needs), SSD community based day
centres, day care in residential homes and community based centres run by
voluntary organisations. In the late 1980’s and 1990’s newer types of day care
emerged which included resource centres and day centres.
24
NOVEMBER 2003
Policy changes in the 1990’s focused on community care and a greater
diversity of day care. The NHS and Community Care Act stressed the need to:
Promote the development of domiciliary, day and respite services to enable
people to live in their own homes wherever feasible and sensible
To ensure that service providers make practical support for carers a high
priority
To make proper assessment of need and good case management the
cornerstone of high quality care
In the 1990s day care expanded and there was greater commissioning of
services from the independent sector. However, Warburton and McCracken
1999 (An evidence based perspective from the Department of Health on the
impact of the 1993 reforms on the care of frail elderly people) referred to
expansion of the independent sector having only been achieved “to some
extent”
Day care for older people with mental health problems was a specific area of
service development and innovation in the 1990’s. Bacon and Lambkin noted a
sharpening of boundaries between providers with statutory SSDs focusing on
those with greatest needs, voluntary organisations catering for social day care,
and NHS agencies providing rehabilitation and treatment. (Bacon V and
Lambkin C 1997. The relationship between the delivery of day care services for
older people and design of day unit premises.)
Modernising Social Services 1998 points out that changes in the 1990’s:
Concentrated largely on structure and on process, rather than outcomes.
There is little reference to day care but there is an emphasis on intermediate
care services, an implication being that this might be expected to include day
services.
Definitions about care can still be service driven and concentrate on doing
things for people according to what is available, rather than tailoring services to
the needs of individuals and their carers and encouraging those who are helped
to do things for themselves
The broad aims of social care for older people are
• Promoting independence,
• Prevention and rehabilitation
• Coordinated services
• Individualised care
The Royal Commission on Long Term Care 1999 stressed the importance of
social inclusion:
A more positive and inclusive climate should be created and nurtured, so
ensuring the development of more opportunities which can be taken by older
people
25
NOVEMBER 2003
Little reference is made to day care and when it is mentioned it tends to be an
acknowledgement of its existence and then as a type of break for carers. It
needs to be recognised that service users, carers, service providers and
commissioners may all have different perspectives about the purpose of day
care and the extent to which it is achieving its objectives.
The needs of service users and those of carers can be in conflict. Stevenson O
and Pasloe P 1993 (Community Care and Empowerment) wrote:
In the case of older service users, day centres put carers interests first,
whereas they did not do this for carers of adults with disabilities.
If the most frequent reason for providing day care is to give respite to the carer
then the service must be equally measured by the ability to meets the needs of
the person who is being cared for. It should also be acknowledged that older
people do not have a need for day care per se. In the BVR survey the needs
were expressed as:
Company, activities, a meal and to get away from the same four walls
Traditional assessment of older people has been criticised for being overly
functionally oriented, deficit focused and service led to the exclusion of the
individuality of the person. An innovative way of working with people has been
person centred planning which is most developed in the field of learning
difficulty.
The National Service Framework for Older People, which was published in
March 2001, sets out new national standards and models of care for older
people living at home, in residential care or in hospital. It focuses on
eliminating age discrimination, providing person centred care with older people
being treated as individuals with respect and dignity and promoting older
people’s health and independence as a means of improving quality of life
3. Methodology and limitations
3.1 Methodology
The review used the Best Value framework comprising of the four C’s of
consult, challenge, compare and compete.
Information gathering for the review included:
•
•
•
•
•
•
•
•
Data collection exercises
Statistical information
Surveys
Questionnaires
Focus groups
Stakeholders groups
Meetings
Interviews: free flowing, semi structured and structured
26
NOVEMBER 2003
•
•
•
•
•
Telephone contact
Visits to other LAs
BVR summaries from other LAs
Literature review
Internet
Evidence files containing details of reports, consultations, surveys, meetings
and benchmarking documentation are available for a more detailed study.
3.2 Limitations
The following issues were outside the scope of this report, however they are
being addressed within the context of the BVR of Services to Older People.
•
•
Care management
Commissioning
4. The in-house day care service: the current position
4.1 Day care in WSSCS
Day Care is often described as any organised activity that takes people out of
their home during the day. Reference is made to day care being for vulnerable
people to enable them to continue to live at home. Mention is also made to the
role of day care in providing support to carers. The fact that day care can take
place in different environments such as the individual’s own home or in the
home of a carer or as part of Direct Payments is not usually stated.
Day services are often regarded as an intermediate service between
residential/nursing care and occasional support in the community. A wide range
of services are found under the heading of day services. The traditional view is
one of a centre to which users must travel to receive a service. Reasons for
attending day care frequently include:
•
•
•
•
For companionship and social stimulation
For rehabilitation and the teaching of new skills and social skills
For positive experiences and new achievements
For promoting independence, social integration and employment.
While traditional day care has been an important resource for users and their
carers, it has attracted regular criticism. In a recent review (Scottish Executive
2000) users comment that what is provided is boring and lacking in direction.
Users want skilled and focused help with their specific problem or disability,
they want friendship, social contact, something interesting to do, to maintain or
improve their continued capacity for a n independent life. Traditional services
may hold people back from achieving their independence.
One of the disadvantages of traditional services based in buildings is that they
tend to encourage a mentality of routine and predictability.
27
NOVEMBER 2003
Day care sho uld be seen as promoting the ordinary life. However, comments by
carers and professionals suggest that large centres may encourage
dependency:
Day care becomes, paradoxically, a place where progress is suspended, not
promoted.
The NHS and Community Care Act 1990 intended needs led rather than
service led packages designed to meet the needs of both carers and service
users. Day care was seen as part of a package of support. The emphasis
now is on greater joint planning, provision or purchasing of day services by
health, SSD and voluntary organisations. The Health Act 1999 gave specific
powers to facilitate partnership working between health, social services and
housing authorities including pooled budgets, lead commissioning and
integrated care service providers. The NHS Plan proposed a single assessment
process for health and social care by April 2002. Fair Access to Care refers to
greater consistency in assessment procedures.
The SSI in 1992 drew the conclusion that day services had developed in a
piecemeal way and that services:
•
•
•
Were not integrated into coherent local planning between agencies
Do not reach those most in need
Have not been fully exploited to the extent of their potential
The SSI suggested that:
•
•
•
Day services are more than just day centres. They embrace the full
range of facilities and services available to and in the wider community
People will need assistance and encouragement to use alternative
services
Development is not the responsibility of one agency, it requires a coordinated and collaborative approach
A modern approach would suggest that the way forward for service
development is to be found in the creation of strategic alliances with health on
the one hand, to provide a continuum of services to targeted vulnerable
individuals and with education, housing, voluntary organisations and leisure
services on the other, to develop and provide support for older people to
access local amenities, community centre activities and adult education
classes.
4.2 PEST analysis: external factors
The working group undertook a PEST analysis (Appendix 2) in order to look at
the political, economic, social and technological factors that influence the
current functioning and future planning for day care.
The PEST analysis highlighted a number of issues that need to be addressed
as part of any future strategy including the Modernisation Agenda, increasing
28
NOVEMBER 2003
number of older people, budget constraints, higher dependency, rural areas
and transport.
4.3 SWOT analysis: internal factors
The SWOT a nalysis examined the strengths, weaknesses, opportunities and
threats to the in-house day service.
The working group drew up an initial SWOT at the first meeting in December
2002 and also managers of day centres were asked to complete the exercise
with their staff groups. In June 2003 the working group revisited and revised
the SWOT in order to more accurately reflect the groups findings. (Appendix 3)
Strengths and opportunities were considered to be the building blocks.
Strengths included:
• Social interaction, learning opportunities, maintaining/ promoting
independence and preventing/ delaying admission to residential care
Opportunities included:
• BVR, vision and strategy for day care, modernised service and ability to
respond to the local community.
The weaknesses and threats were seen as challenges to be overcome.
Weaknesses included:
• Institutionalisation, lack of flexibility, large buildings and catchment
areas, tension between range of need, nothing to move on to and
absence of a strategy.
Threats included:
• BVR, budgetary constraints, different charging arrangements across
organisations and change.
4.4 Financial information
4.4.1 Unit cost
A report by the Starfish London ADSS Benchmarking Club (The Elusive Costs
of Home Care. Are in-house providers really more expensive than private
contractors? 2002) advises caution when comparing unit costs with other LAs
and the independent sector. In particular the author suggests that unit costs
cannot be used as a reliable indicator of the potential savings that might be
realised by externalising a service.
They identified a number of key components of unit costs that need to be
carefully considered. Some of these would appear to apply equally to day care
services:
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NOVEMBER 2003
ISSUE
1. Many local authorities use
sample weeks to estimate
annual service volumes
2. Many local authorities fail to
add a fair proportion of
Management and Support Costs
to the external provider
POSSIBLE EFFECT
With seasonal fluctuations this can
produce a very unreliable annual
figure
The costs apportioned to the external
provider are understated resulting in
artificially lower unit cost.
Source: BVR Home Care August 2002
Funding is an issue, day care centres are susceptible to the problems of all
group-based provision: costs tend to be averaged out over the user population.
This masks the need for variation in support given and makes cost per
individual sensitive to changes in volume and demand. Day centre managers
refer to the higher dependency and the greater need for personal care,
sometimes involving two staff at any one time. The latter has an impact in
terms of occupancy and consequently on the unit cost. Equally the inability of
the transport service to provide sufficient transport places has an impact.
The BVR working group considered the financial aspects of the service. It was
acknowledged that Best Value is not about finding the cheapest way of
providing services; the aim is to achieve best quality outcomes within budget
costs. Thus although the costs associated with a service are important they
cannot alone satisfy the whole systems approach inherent in Best Value.
However, services operate within tight budget confines and therefore cost must
play an important part in determining what services can be delivered.
It is important to understand the nature of the activity in order to analyse
costings. In this way the non-financial information becomes equally important.
It needs to be recognised that the unit costs are not especially useful on their
own unless they are considered in conjunction with the underlying strategy,
management structure and demographic and geographic information.
Obtaining unit costs on a comparable basis from other LAs proved difficult. As
part of the comparison exercise a survey of LAs was undertaken. The range
was from £7.60 to £30.00. Unit costs were not available for all LAs; one quoted
a particularly high cost and in the feedback asked for the cost to be removed,
as it was clearly wrong. Given the West Sussex figures, averaged across all
twelve in-house day care per day are £9.42 and per week are £47.10
respectively, an assumption might be made that some had quoted a weekly
cost and others a daily cost.
In Spring 2003 the information collected indicated the following for week
commencing 3 February 2003, based on actual occupancy were:
Unit Costs
Day Centre
Rowans
Chestnuts
Maidenbower
Glebelands
Direct Unit Cost
Weekly £s
41.82
58.03
49.48
34.65
Direct Unit Cost
Daily £s
8.36
11.61
9.90
6.93
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NOVEMBER 2003
Day Centre
Laurels
Grange
Chanctonbury
Pulborough
East Grinstead
Harwood House
Henfield
Judith Adams
Direct Unit Cost
Weekly £s
41.05
42.58
75.69
69.21
71.12
48.86
40.02
35.23
Direct Unit Cost
Daily £s
8.21
8.52
15.14
13.84
14.22
9.77
8.00
7.05
Source: FS July 2003
Key to Unit Costings
Type of Unit Costings
Total Direct
With Area Overheads
With Social and Caring Services
Headquarters Overheads
With Central Dept. Overheads
Description
Managers, staff, building and
premises, meals, occupancy,
transport, income
As above with a proportion of Area
Overheads
As above with a proportion of Social
and Caring Services Headquarters
Overheads
As above with proportion of Central
Overheads
Source FS April 2003
4.4.2. Proportion of social service adult budget spent on day care
LAs surveyed were asked what proportion of the social services budget was
being spent on day care. The range was 0.86 to 12%. The proportion of the
WSSCS Adult Services spend in 2002/2003 was 5.55% on in-house day
centres plus 1% on independent day centre placements.
Proportion of Adult Service budget spend on services for adults.
Provider
Home Care
Residential Care
Day Care
£s
£s
£s
In-house
19,041,000
47,265,000
5,107,000
Other
£s
6,582,000
Source FS 2002/2003 July 2003
4.4.3 Day Care budgets
The total budget for the twelve day centres in 2002/2003 was £4,320,650. The
highest proportion was spent on the following:
53.7% (£2,320,000) was spent on staff pay, superannuation, National
Insurance and staff additions
11.1% (£480,200) was spent on transport
6.74% (£291,300) was spent on property.
Transport costs were highest in the larger centres where there were more
individuals and consequently greater transport needs. However there were
variations as follows:
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NOVEMBER 2003
Transport expenditure.
Day Care Centre
Actual expenditure on
transport 2002/2003 £s
Maidenbower
Glebelands
Grange
Laurels
Chestnuts
Rowans
67,267
54,438
46,586
55,764
49,077
41,688
Proportion of budget
2002/2003
12.64%
15.28%
11.12%
11.14%
9.49%
8.85%
Source: FS 2002/2003 July 2003
The variations are explained by catchment area. Some centres cover extensive
areas which may also include other Area/PCTs
Similarly property expenditure also varied:
Property expenditure:
Day Care Centre
Actual expenditure
2002/2003 £s
Proportion of budget
2002/2003
Grange
Maidenbower
Glebelands
Rowans
Chestnuts
Laurels
66,701
48,158
39,208
24,246
19,104
14,986
15.92%
9.05%
11.00%
5.15%
3.69%
2.99%
Source FS July 2003
In terms of ownership of property and restrictions, or not, on use there is some
variation. In some instances the building and land is owned by WSCC, in
others there are arrangements which are shared with District or Borough
Councils and there are also rental agreements. In addition, some day care is
stand-alone and in others the building is shared by one or more services.
4.4.4 Grants to other organisations.
Payments of £340,000 under the heading elderly (agency) include independent
agency costs (£133,000) plus block payments to Sussex Health Care and the
Salvation Army (£207,000). Included in the £6,582,000 (Other Adult Services)
is £470,000 spent on voluntary organisations including daytime activities such
as luncheon clubs and social clubs. In addition expenditure of £476, 613 from
the Carers Grant is planned for this financial year. The money will be spent on
short-term breaks for adults which will be mainly sessional rather than overnight
care. A further £108,266 will be used to extend the services that Crossroads
and Alzheimers Society provide.
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NOVEMBER 2003
4.4.5 Charging
Over the last ten years it has become more common nationally for day care to
be charged for. How charges are made and what for varies. Guidance from the
Government (DOH 2001) recommends that all councils must ensure that
service users net incomes are not reduced below the basic levels of Income
Support
LAs surveyed were asked what charges they made for day care. These ranged
from a charge of about £2 for a meal and £2 for transport to means testing.
In WSSCS there is a single charge covering non-residential care services. This
is worked out on an individual basis by a welfare benefits adviser who visits the
service user at their home. For most people the charge is a contribution
towards the full cost of the services provided.
The income from day care only is difficult to establish, as the current system
does not allow for non-residential income to be split between home care and
day care services.
Charging is an issue that was raised by a number of people:
•
•
•
•
•
•
Some people pay nothing and query why they do not pay even for the
meal
The high cost might put people off, and those who really need this facility
will be even more vulnerable
When people need to move on (voluntary organisation) they may not do
so because the cost is higher in social services
It is confusing because health does not charge but social services do.
There are particular difficulties for people who attend different types of
day care
If people do not pay they do not feel any sense of ownership.
4.5 The shape of the service
The review of the WSSCS in-house day care service is one part of a wider BVR
process, which examines services for older people. The day care service
provided in Spring 2003, a total of 2036 places; 1481 in multi purpose centres
and 555 in smaller centres. The majority of people attending receive one or
two days a week. This may be complemented by other services such as home
care or respite care and in addition a number of people attend other day
services both informal and formal. Most of the in-house day centres,
particularly the larger multipurpose centres, provide a service both to older
people and to those under 65 with a variety of disabilities. The total ratio of
under 65’s being 34% (47% in multi purpose centres and 18% in smaller
centres) and therefore as part of the BVR reference was made to the needs of
the wider groups
A survey of all in-house day centres was undertaken in Spring 2003 in order to
understand the shape of the services provided by WSSCS and use as part of
the benchmarking exercise with other LAs. Where appropriate, comparison
33
NOVEMBER 2003
was also made with a day care survey undertaken by day centre managers in
2001.
4.5.1 Service availability, attendance, number of days and age range
Day Centre Audit 2001
Opening
times
Planned
attendance
Actual
No. of
days
Age range
Attendance
Mon to Fri
8 to 5
Most
service
users
attend 10
to 4
Average on
register 73%
Average
actual
attendance
63%
Majority
attend one
day
Most are
over 65
Source DC Survey 2001
Day Centre Audit 2003
Opening
times
Planned
attendance
Actual
No. of
days
Age range
Attendance
As 2001
Average on
register 73%
Average
actual
attendance
55%
86%: one
or two
days;
44%:one
day;
42%: two
days and
2%: 5 days
71% are
over 65
years.
Source: DC. Survey 2003
The survey in 2003 showed that there appeared to be the same number of
people on the register but that actual attendance had reduced by about 8%.
The number of people attending for more than one day may have increased.
In some centres managers said that the eligibility criteria had had an impact
and accounted for fewer admissions. Generally the planned and actual
attendance is lower in the multipurpose centres than in the smaller centres. The
range being from 31% to 80%
4.5.2 People receiving other day services
The survey of the in-house day centres suggested that many people attending
the centres were in receipt of other services. In addition some individuals
appear to be receiving day care in different settings, for example, both a
voluntary organisation and day centre. The implication was that some people
might be attending the day centres when in fact they could consider o ther
ordinary facilities in the community. A suggestion was that sometimes people
are being assisted to ‘fill up their week’ rather than needing a service that can
only be delivered through day care.
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NOVEMBER 2003
At the other end of the scale people in need of a number of days care, for
example, to support a carer or enable them to continue living at home might
receive care in a number of different places. A person with moderate dementia
was receiving services from a multi purpose day centre, a day hospital and at
the weekends in a residential establishment. All had different charging and
transport arrangements as well as the different daily programmes. The
potential exists for both duplication and confusion
4.5.3 Reasons for attendance
Findings from the Audits of 2001 and 2003 and the benchmarking exercise with
LAs were:
Day Care Audit
2001
Mental
physical/well
being
Social contact
Stimulation
Respite for
carers
Day care Audit
2003
LA Survey 2003
Preventative
Rehabilitation
Social contact
Stimulation
Respite for
carers
Personal care
Enable people to
live at home
Daily living
activities
Support people to remain in their
own homes
Promote and maintain independence
Rehabilitation
Intermediate care
Prevent social isolation
Respite for carers
Assist with personal care
Access to food, security and
stimulation
Prevent admission to long term care
Protection for those with mental
health needs
Monitoring
Source: DC Audits 2001 and 2003, Benchmarking survey April 2003
4.5.4 Non-take up of service
In the 2001 audit the figure quoted for nontakeup of service was 20%.
The reasons were considered to be either because the assessment was
inadequate or the service may not offer what the individual wants/needs.
Cambridgeshire looked at low attendance. Common reasons were:
•
•
•
•
Service users are kept on attendance list indefinitely when they are ill or
in hospital
Lack of staffing
SSD teams not always notified of vacancies
New referrals may only attend once and then takes weeks to make up
their minds whether or not they will continue attending.
In the benchmarking exercise with other LAs, the reasons given included:
•
•
•
•
•
Service not what they want
May have preconceptions and prefer to stay at home
Lack of motivation/reluctance to leave own home
Not available at the right times
Delay in being allocated a place.
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NOVEMBER 2003
•
•
Transport
Changes in personal circumstances
As part of the BVR a small survey was undertaken of individuals who had either
been offered a place and not taken it up or had started and finished after the
first day. Reasons included:
•
•
•
•
•
•
Too many older people
Journey too long
Activities not suitable
Building too confusing.
Prefer support in the home
Not needed
Most day centres offer a pre admission visit and, or an introduction day. Follow
up of non-attendees vary according to whether or not a social worker is still
involved. If the latter applies then the social worker is notified and will advise
the day centre.
4.5.5 Other services
The 2003 survey listed other services in addition to day care used by service
users including:
•
•
•
•
•
•
Home care
Meals on Wheels
District Nurse
Chiropody
Community Psychiatric Nurse
Respite care
Brace (1990 Day Care for Older People in London. West Lothian Social Work
HQ) suggests that the services most used by day care users were home care
and district nurse. Where day care was offered alongside other services there
was a lack of integration into an overall package of managed care.
The audit commission (Integrated Services for Older People Oct 31 2002),
referred to the fact that services for older people must work together if they are
to meet the needs of older people. The report pointed to the fact that too often
individuals receive a disjointed and confused response when they need help or
advice. In the BVR survey it was clear that information is not routinely given to
day centres, for example about changed circumstances, and may not be
passed on by social workers and home care.
4.6 Human resources
4.6.1 Day Care staffing structures
The 2001 audit listed the regular duties staff were expected to undertake. It
referred to differences between drivers and instructors duties. In some centres
they were required to undertake personal care in others they were not.
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NOVEMBER 2003
Managers have pointed out that the roles need to be reviewed in order to
respond to current and proposed change. The 2003 audit highlighted the
different staffing establishment between centres in both hours and composition.
The modernisation of the service would suggest greater flexibility; it is difficult to
meet the changing needs if roles are either very different or rigidly adhered to,
and there is a need to agree a staffing formula for day centres.
4.7 Training
Studies have shown (C Clark ed. Adult Day Services and Social Inclusion.
Better Days 2000. Jessica Kingsley Publishers London) that while the majority
of staff in day hospital have professional qualifications, audits of staff in LA and
voluntary organisation day care show that the proportion of staff with
professional qualifications is low. Very few have access to NVQ programmes.
Modernising Social Services stresses that people who receive social care
should have an assurance that staff are sufficiently trained and skilled for the
work that they are doing. Staff should feel included in a framework that
recognises their commitment, assures high quality training standards and
oversees standards of practice. People should have confidence in WSSCS
knowing that the day care service works to clear and acceptable standards.
There are specific TOPSS requirements (Training Organisation for Personal
Social Services) and in addition, given that day care will be subject to
inspection at a later point by the National Standards Commission, preparation
should to meet the NVQ targets should begin.
Service users attending for day care in the future are likely to be frailer and
more dependent. Staff will require the skills to provide care, working alongside
professionals from other organisations, which takes account of the impact of
the users disabilities without losing the social contact and companionship which
are valued by the older people themselves. Similarly if people are to be
assisted in moving on to or back into ordinary activities this will require different
thinking and new skills.
The recent emphasis on ensuring staff who are part of the Residential Homes
transfer are properly qualified as required by the National Minimum Standards
and the current programme for home care staff, had meant that training for day
care staff has not been a priority. However, NVQ programmes are now
available to day care staff. There are particular difficulties in smaller day
centres in releasing staff. Some centres have undertaken mandatory training
in-house which has meant closing the centre for the day.
4.8 Information technology and management information systems
All day centres now have access to a computer. In some centres there are
additional PCs and service users also have access to PCs and instruction. In
other centres service users may go to a local college to learn skills. The level
of expertise and the training needs of staff vary considerably. The use of
information technology will have increasing importance both for managers and
staff and for service users and their carers. If day centres are to work with
individuals helping them to move into ordinary activities they will require access
to databases such as ICIS with up to date information about resources.
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NOVEMBER 2003
There are a number of procedure manuals in WSSCS, for example Health and
Safety and Personnel but there is no procedure manual specifically for day
care. Some mangers have devised their own information records. In
preparation for registration by the National Care Standards Commission it will
be necessary to undertake this work.
4.9 Service Level Agreement
WSSCS expect that the independent sector where part of a Service Funding
Agreement will have a contract and service specification. If the in-house day
care service is to be regarded as part of a spectrum of services then it should
have such agreements with their local Areas. This would assist everyone
involved to be clear about the overall purpose of the day care provided.
4.10 Performance indicators
The aim of Best Value is to achieve continuous improvement in performance
and excellence in services, ensuring that the needs of service users and carers
are central. To successfully deliver continuous improvement it is essential to
have a robust framework in place and important that this framework is
understood and owned by everyone.
An important question that needs to be asked about day care is does it reduce
the need for institutional care? Carer and professional judgement (Hampshire
BVR) would suggest that this is the case and that there may be a correlation
between the PAF indicators. However, in the survey of other LAs, only 24%
said that they had PIs in place.
Work is currently being undertaken within WSSCS on developing information
tools for day care. It is beginning to be appreciated that day services, in the
broadest sense, have a contribution to make to all performance indicators that
are about helping people to live at home, keeping people out of residential care
and supporting carers. In this way day services have an important role to play
in the continuum of services for older people.
Information on attendance at day centres is now being collected. In the future
the new management information systems will carry additional information
about the voluntary and private sector. It will then be possible to have an
overview of different day care facilities attended by individuals and assist care
managers when reviewing packages of care.
4.11 Managing the performance
4.11.1 Quality
The white paper Caring for People 1989 set out the responsibilities for
monitoring and reviewing. The intention being that SSDs would monitor
independent sector provision and ensure quality was specified and monitored
through contracts
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NOVEMBER 2003
The first document to give a high profile to service standards was Homes are
for Living In (DOH/SSI); this was endorsed by the SSI 1992 guidance on day
care for people with long-term mental health problems
Proposals for the reform of quality systems are mainly approached from a
national perspective through the Best Value approach, performance indicators,
the NSF for Older People (2001) and through regulations, inspections and
improved training. A National Care Standards Commission was established
under the Care Standards Commission Act 2000 to regulate services and
enforce new minimum standards. Implementation of the standards for day care
is anticipated to be 2007.
There are no specific in-house standards for day care. Some work was
undertaken two years ago together with the Learning Difficulty service to begin
to set some standards. This was not implemented. Day centres need to
prepare for the National Minimum Standards and would benefit from working
alongside colleagues in home care who are in the process of implementing the
domiciliary care standards.
4.11.2 Quality assurance
As part of the 2003 audit with day centre managers and in the benchmarking
exercise with other LAs both were asked how they assured quality.
Quality Assurance.
Day care Audit 2003
Stakeholder’s questionnaires
Day centre reviews
Observations
Client committee
Complaints and compliments
Carer and user forums
LA Survey 2003
Six monthly satisfaction
questionnaires
Annual Carers questionnaires
Annual Quality assurance process
Monitoring of external contracts only
Source: DC Audit 2003 and benchmarking survey 2003
4.12 Modern ways of working
National and local principles imply that a modern way of working requires a
move away from traditional services which can encourage dependency and a
move toward ordinary activities in the community which maximise opportunities
for social inclusion and promote and support independence. Some day centre
managers were able to give examples of where they had been able to support
individuals to move on from the day centres into community activities.
One multi purpose day centre has a Community Opportunity group which has
been very successful. Managers have noted however that when people are
settled into such activities they may not want to sever their links entirely.
Assisting people to move on requires dedicated outreach time.
Modern ways of working would need to be part of a change programme that
assists and supports individuals to appreciate the reasons and benefits for
different approaches and alternatives to day care.
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NOVEMBER 2003
As part of the BVR some of the models seen both within and outside WSCC
included:
•
•
•
•
•
•
•
Mobile day care in sheltered accommodation
Joint planning a nd working with other organisations
Healthy Living Centres and Daily Living Centres
Creative links with voluntary organisations and housing, sharing staff and
assisting with equipment
Culturally sensitive services
Links with Education/ life long learning a nd libraries
Local initiatives using village shops and church clubs
4.13 Specialist services
4.13.1 People with learning difficulties
The audit in 2003 showed that 20% of those under 65 attending day centres,
primarily the multi purpose centres, had a learning difficulty. 3% of the over 65’s
had a learning difficulty. The percentage of people over 65 attending the
specialist centres for people with learning difficulties is believed to be small.
The learning difficulty service is currently undertaking a programme of day
service modernisation. Many of the themes that had emerged in the BVR are
similar. Discussions were held with managers within the service highlighted the
following points:
The main areas of concern in meeting the daytime occupation for older people
with learning difficulties include:
• Those whose needs are not being met through current day services
• Those who choose not to attend a day centre and have no meaningful
occupation during the day
• Those who age early and may require an early link to services for older
people
A specification for day services would include:
•
•
•
•
Support to find employment/ voluntary work
Activities
Opportunities for social contact
Access to community activities
The intention is that day services will be modernised and the person centred
approach will inform how the needs of older people with learning difficulties can
be met in the future. The growing number of older people with learning
difficulties will mean that a range of support and opportunities will need to be
identified.
Day centre managers in the twelve centres had different views as to whether
the needs of people with learning difficulties currently attending day care
centres are being appropriately met. Where dedicated time was given to
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NOVEMBER 2003
supporting people and assisting their integration the benefits were more
obvious. In other centres difficulties in integration were indicated. In one centre
successful work has been undertaken in helping people to move into alternative
daytime activities. The funding of a staff network from the Learning Difficulties
Development Fund is being considered as means of looking at the issues of
ageing and support best practice.
4.13.2 People with physical impairment and sensory impairment
The highest proportion of people of all age groups attending day care have a
physical disability, 43% of under 65’s and 57% of over 65’s. Generally there is
insufficient focus on the needs of older people with a sensory impairment.
In the under 65 age group, the majority attend for one or two days per week. It
can therefore be queried as to how important this facility is to the individuals
given day care represents just a small part of their lives. However, it is noted
that some people have been attending for many years. One has attended for
nineteen years, thirty-three for nine years and nineteen for five years.
A vision for future services will be included in the forthcoming strategy for
people with a physical impairment. There will be a focus on greater social
inclusion, on work or work environments which could include voluntary work,
educational opportunities and generally the provision of purposeful activity.
It is important to ensure that there is an awareness of alternatives that are
available such as Workability and Direct Payments.
The new strategy together with the introduction of the National Service
Framework for people with long -term conditions in 2004 should give this service
a higher profile and promote greater partnership working.
4.13.3 Older people with mental health needs
Health, WSSCS and the independent sector provide day care for older people
with mental health needs. Day care therefore happens in hospital wards,
multipurpose centres, smaller day centres, specialist centres, travelling day
hospitals and in residential homes. Services vary according to where they
happen, the needs of individuals, staffing numbers and skills. They range from
a sitting service providing support to carers, to specialist services which may
include assessment and therapy.
In some day hospitals and day centres separate days are set aside for those
with functional and those with organic problems, there may also be separate
days for frail older people and those with mental health needs. Specialist day
care facilities are provided at East Tyne, a residential home that will become a
resource centre. All twelve in-house day care centres offer a service to people
with mental health needs. The audit 2003 found that 30% of over 65's
attending day care have mental health problems.
Particula r consultation exercises were undertaken and detail is included in
Chapter 5.
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NOVEMBER 2003
4.13.4 Integration or segregation?
There are different views about the benefits or otherwise of integrated services.
The multi purpose centres were set up to provide services for people over 18
with different disabilities. The current picture in terms of the integration of over
and under 65’s is mixed:
Attendance at day centres: under and over 65.
Centre
Maidenbower
Laurels
Rowans
Chestnuts
Glebelands
Grange
Judith Adams
Chanctonbury
Henfield
Pulborough
East Grinstead
Harwood House
Under 65
Over 65
45%
23%
54%
19%
50%
26%
11%
12%
2%
0%
34%
28%
55%
77%
46%
81%
50%
74%
77%
88%
98%
100%
66%
72%
Source: Audit 2003
In the benchmarking survey of other LAs, most do not provide or had stopped
providing integrated services. One was still providing a service for all under
65’s but was moving away form this to concentrate on intermediate care;
another said there had been difficulties in providing services in rural areas
which might result in some integration. In a neighbouring LA that was not part
of the survey, one multi purpose centre was offering time limited services to
people of all ages with the view to being rehabilitated back into the community.
Service user views vary, for some younger people there were disadvantages in
being with a mainly older group and some older people found the noise created
by younger people difficult to tolerate. In the specialist centres for learning
difficulties this is also an issue. There can be particular difficulties in integrating
frail older people with older people with mental health needs. Conversely
advantages were expressed by some in being able to mix with other
generations and to assist less able people.
In some day centres separate areas or specific days for certain groups have
been set up. The issue for the future, given the different needs of local
communities within Area/PCTs will be to decide, based on need and local
facilities how best to arrange services. A crucial issue will be determining
whether there is a need for care and if so whether this is a time limited service
that will enable the person to move into ordinary activities or there is a need for
longer-term support
It is important to create links between other service reviews including people
with learning difficulties, people with physical disabilities, older people with
mental health needs and the BVR Carers.
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NOVEMBER 2003
4.14 Transport
The need to meet the transport requirements of a growing population of older
people is vital to the success of the Government’s commitment to sustainable
mobility and people’s own mobility and ability to retain a high quality of life as
their income, health and mobility level change.
Older people are major users of public transport. Transport provides an
essential link to friends, family and the wider community - a vital lifeline to
maintaining independence. Research has shown that a lack of mobility can
prevent older people from participating in social activities and lead to low
morale, depression and loneliness. People living in rural areas and those with
sensory disabilities were more likely to be constrained by transport difficulties
than other groups, while people over 80 are more likely to attribute their
constraints to personal mobility and sensory problems. It can also impact on
others such as carers, social care and health agencies.
Transport arrangements caused dissatisfaction for both service users and
managers of day centres and issues were raised in most meetings:
•
•
•
•
•
•
•
•
Unreliable transport
Relief drivers not knowing the routes
People having to stay on transport too long, especially in rural areas
Lack of flexibility and availability
Insufficient places on transport
Restricted driver hours
Dual role of some drivers who are also care assistants
Lack of escorts
The newly formed Transport Co-ordination Unit is currently considering how
best to deliver services for the future. Possible options being:
1. To manage the transport from the day centres. The advantage being
that there is a sense of ownership and drivers may have more flexible
roles. The disadvantage being that a county overview of transport
capacity is not available and buses may be idle when they could be used
by other centres.
2. To manage the transport form the day centres but with stronger focus on
local community provision, alternatives available and using transport to
maximum capacity across the Area.
3. To manage and co-ordinate the transport centrally. The advantage
being that managers would cease to spend time scheduling and finding
replacement drivers and a county overview of transport would be
achieved. The disadvantage being that driver roles may be more rigid
and the success of the service rests with the coordinator.
4.15 Cross cutting issues
West Sussex County Council Strategy set priorities for the period 2001 to 2005.
Those that are particularly relevant to day care include:
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NOVEMBER 2003
•
•
•
Caring for those most in need in the community
Preventing crime and investing in public safety
Promoting a strong and diverse economy.
These have been reaffirmed in the Mid Term Review.
4.15.1 Sustainability
Sustainability is about ensuring the actions and decisions taken today
guarantee a better quality of life for everyone, whether economic, social or
environmental, now and in the future.
Day services have a role to play in supporting people to maintain independence
and, or, to learn new skills to continue to live in the community.
4.15.2 Social inclusion
The social inclusion strategy for West Sussex identifies minority groups which
include vulnerable people potentially at risk from exclusion from services and
from society generally.
Day care has an important part to play in improving life for people who are
vulnerable and may become socially excluded. It has been argued that
traditional day care which tends to deal with relatively powerless and socially
excluded groups, needs to be replaced by a broader range of day services
imbued with a philosophy of social inclusion. (Adult Day Services and Social
Inclusion. Better Days. Edited by Chris Clark. Jessica Kingsley Publishers.
London and Philadelphia 2001)
Taking people out of their normal environment and providing segregated
services may contribute to the social exclusion. Bacon and Lambkin 1997
suggest that for day services to be integrated into the community they need to
be in or near to buildings that are used by the general public and to promote
links with the local community. This creates a particular difficulty for some day
centres and for day hospitals. (The relationship between the delivery of day
care services for older people and the design of day unit premises. Ageing and
Society 17)
In discussion with carers as part of the BVR. It was suggested that our day care
services are traditional, inward looking and may be institutions. Throughout the
BVR the working group became increasingly aware of the range of
opportunities in the community for people to participate in ordinary activities
and the potential to promote daytime activities.
4.15.3 Caring for those in need in the community
A WSSCS aim is to help people to continue to live independently and to provide
security for those who need care or support. The prime role for day care is to
support people to live in their own homes, to promote and maintain
independence thereby preventing unnecessary admission to long-term care.
This needs to be alongside a range of daytime activities, which support social
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NOVEMBER 2003
inclusion in partnership with, for example, voluntary organisations, health and
housing, education, libraries and leisure facilities.
4.15.4 Preventing crime and investing in public safety
Many older people live alone or with elderly partners. Day services, both day
time activities and day car, can play an important part in helping to ensure
people can live safely in the community and have access to crime prevention
and local neighbourhood networks.
4.15.5 Learning County
Life Long learning is an important part of Government policy although much of
the emphasis is on employment the government also recognises that some
older people may lack the confidence or resources to participate in learning
activities. Probably the best known is the University of the Third Age (U3A),
which recognises that older people have the skills to organise their own
autonomous groups
Day services play an important part in helping people to access educational
opportunities.
4.15.6 Equity
The WSCC strategy sets out the overall aim for 2001 to 2005 as being to:
Seek to promote the overall well being of the communities we serve and
improve the quality of life of local people
There is a commitment to achieve this through targeting and promoting social
inclusion and equality of opportunity. The West Sussex inclusion strategy
includes:
•
•
•
Customer focus
Policies and initiatives targeted on the right priorities and in the right
areas
A multi disciplinary approach as the preferred way of progressing our
attempts to reduce social exclusion and promote social inclusion.
WSCC has recently published a Race Equality Scheme and has identified
Equality Officers within each service unit. All LAs have a duty to ensure staff
receive training. WSCC has an equal opportunities employment policy and is
committed to providing equality of opportunity and to eliminating unwarranted
and inappropriate discrimination
4.15.7 E government
The intention of WSCC is that by 2005 citizens of West Sussex should where
feasible be able to access information electronically.
The use of information technology is increasingly important. In the in house
day centres access to and skills to use information technology varies. There is
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NOVEMBER 2003
potential for important developments at centres and in educational facilities in
the community for service users, carers and staff.
IT 2 Eat based in Rotherham, South Yorkshire provides IT support, information
and advice on diet and health to people over 55 with mobility problems. The
project is in partnership with Age Concern, the local PCT, social services and
the library service. IT2 Eat means that they can explore the option of using
online shopping which gives them the power to choose their own goods.
Advice is also given on diet and nutrition. IT 2 Eat works with people in their
own homes and in day centres, lunch clubs and GP surgeries. Demand for the
service is far outstripping supply and older people in Rotherham are dispelling
the stereotype that suggests older people are fearful of new technology.
Instead they are using it to enrich their lives.
KEY FINDINGS
The number of people over 65 is set to increase. The profound changes
in demography and age structure will have far reaching political,
economic and social consequences.
Nationally day care has developed in a piecemeal way. It does not have a
clear vision, is not integrated into planning with other organisations and
does not reach those most in need
Individuals attending day care may not have a care need and may also be
accessing a range of ordinary daytime activities the community.
Those individuals with higher level needs needing more than one or two
days care per week may have a package which includes attendance at
different day care centres
Working in a modern way, which promotes independence and an ordinary
life, can require new skills both in outreach and working in partnership
with a range organisations.
5. What do people think of the service? Consultation with
stakeholders
The intention of this section is to summarise the consultation exercises that
have been undertaken. The process enabled the BVR working group to gain a
better understanding of the views of stakeholders and the action required to
bring about improvement.
Exercises undertaken prior to the BVR and by other LAs were included.
Research included individual interviews, focus groups, team meetings, postal
questionnaires, confidential questionnaire and stakeholders meetings. Regular
meetings were held with Day Centre Managers to ensure that staff teams were
kept informed.
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NOVEMBER 2003
5.1 Survey undertaken with service users currently attending day care
centres. Spring 2003
119 service users responded to the q uestionnaire. There were 84 individual
responses and three group responses (groups of 8,12 and 15)
Questions and headline responses were as follows:
What is good about day care?
• Company
• Activities/stimulation
• Get away from the same four walls
• Meal
•
What is not so good about day care?
•
•
•
•
Insufficient staff
Inflexible hours, not enough days
Transport problems
Lack of understanding of care needs
Do we need day care? If yes, what improvements could we make? If no,
what might the alternatives be?
•
•
•
More/different activities
More staff
More flexible hours/days including weekends
5.2 Confidential questionnaire of service users attending multi purpose
day centres.
A confidential survey of five multi purpose day centres is currently being
undertaken by West Sussex Disability Network.
5.3 Review of one multipurpose day centre. Summer 2001 (service users).
Focus group of older people:
The review included a focus group of older people attending this multipurpose
day centre.
Participants were positive about services. They regarded the day centre
primarily as a place where they could socialise, be occupied and receive
emotional support. They requested more information about a range of
subjects including holidays, trips out, home care and cleaning services.
They saw the centre as a place for disabled people who will not get any better
and thought they would be attending the centre indefinitely. One expressed a
fear that they might be asked to leave when they got better but said this had
never happened.
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NOVEMBER 2003
5.4 Postal survey of carers undertaken in Spring 2003
A questionnaire was included with a newsletter sent to Carers. 83 carers
responded:
Questions and headline responses were as follows:
As a carer, what support would you find most helpful during the day?
•
•
•
•
Respite in the home
More help in the home including check visits
More flexible arrangements, longer/shorter days
Company, activities, outings, walks for the person cared for
How might this best be provided?
•
•
At home
At a day centre
When would you want help?
•
•
•
More days including weekends
Flexible arrangements
Respite
What activities/ care would the person you care for most benefit from
during the day?
•
•
Activities
Company
Please comment on any support you are receiving whether or not this is
meeting your needs and how this might be improved
•
•
•
More days
Respite
Greater flexibility
5.5 Meeting held with the Carers Network Spring 2003
The purpose of the meeting was to give information about the BVR of day
care, the process and progress made. A discussion was then held in order
to obtain peoples views about the current and future services.
Main headlines were:
•
•
Huge day centres are impersonal and institutional. Small centres and
residential units are more personal.
Large centres are often isolated and therefore not integrated into the
community,
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NOVEMBER 2003
•
•
•
•
•
•
•
Day centres can be a step to death, people ‘stuffed in ‘ and out of the
way
Same people, same furniture, same activities can be very boring.
Centres need to be more dynamic
Carers caring in their own home worth pursuing.
Large centres with lots of older people can be depressing for younger
people
Needs of younger people who have had strokes needs to be addressed
Carers need to know that the person that they care for comes back
better
It can be beneficial for carers and the cared for to attend all or part of the
day together.
5.6 Review of one multi purpose day centre. Summer 2001 (carers).
Focus group of carers
The day centre was seen as primarily offering a break from the person that they
cared for. Some group members felt they would like more feedback from the
centre on progress being made by the person that they cared for. They would
like to be involved through regular meetings with other carers and recent social
activities were seen as examples of being able to do this. But at the same time
acknowledged that they were very busy and not always able to attend the entire
meeting.
5.7 Survey of volunteers working in the in-house and independent sector
day care centres. Spring 2003
A total of 48 people (25% i ndependent sector, 75% in-house) participated in the
survey. Mindful of the fact that volunteers were working with both older and
younger people and that for some organisations older is regarded as over 60
this was reflected in the questions
Questions and headline responses were as follows:
What is good about day care for adults over 60 years of age?
•
•
•
•
•
•
Company
Meal
Activities/stimulation
Help/personal care
Respite for carer
Away from the same four walls
What is good about day care for adults under 60 years of age?
•
•
•
•
Company
Activities/stimulation
Respite for carers
Meal
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NOVEMBER 2003
What is not so good about day care for adults over 60 years of age?
•
•
•
Insufficient care staff
Insufficient individual attention
Some do not take advantage of resources
What is not so good about day care for adults under 60 years of age?
•
•
•
Could stop younger people from working
May not wish to mix with older people
Most would not normally attend a day centre
Do you think day care is needed? If so please state why
•
•
•
•
•
Company
Get away from same four walls
Respite for carers
Meal
Activities
Could there be any improvements to the present service provided? If so
please specify:
•
•
•
•
More money
More staff and volunteers
More space for wheelchairs/walking aids
Outings
Could day care be provided in a d ifferent way? If so, please specify
•
•
Day care could be provided by others e.g. independent sector
More care in the home
5.8 Review of one multi purpose day centre. Summer 2001 (volunteers).
Focus group of volunteers
There were expressions of not being involved, feeling that they just walked in
and were ‘given a job to do’ They wanted to be more involved and given a clear
role and task to do.
5.9 Individual interviews and small group discussions:
Interviews and small group discussions were held with 21 individuals employed
in different settings which included health, housing, voluntary groups and
WSSCS and other LAs. Main points arising from discussion included:
•
•
•
•
There may be no output from day care (except death)
Centres work hard but with the wrong people.
There is an overestimation of bricks and mortar
Is the ratio of staff to service users and the skill mix right?
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NOVEMBER 2003
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Difficult to understand roles i.e. care assistant/instructor
There should be sufficient staff with a mix of skills in order to provide
meaningful activities
How are managers managed, do they work to objectives, do they
know what they should be achieving?
Confusion as to who to refer where for what service. There is no
clear pathway
The criteria should allow for some manager discretion about which
days people should attend. There are too many rules and regulations
More intensive short-term service may not be linked to other centres
that can follow on with the treatment.
No sense of being able to move on, back and between centres as
needs change
Physical environment and equipment, intensive care/rehabilitation
could be health funded. The voluntary sector could be responsible for
the social aspect.
Who decides the capacity for the day centre in the first place and
who are they for?
Need to consider the needs of those who fall within preventative
services, people who do not want to be clients but may want to drop
in.
Change in day centre attendees, generally older and frailer and less
able to participate in certain activities. Medical rather than social
care is becoming a dominant factor
There is less involvement in activities by staff and there is continual
references to staff shortages
Need to evaluate activities in line with the changes.
Travelling especially for those in rural areas may put some potential
clients off
Evidence of good partnership working across organisations
Accessing services in the first place can be difficult. It can take a
long time to get an assessment
There may be a stigma attached to attending day centres
Volunteers are getting older and difficult to recruit
Some communities, e.g. villages, look after their own
5.10 Stakeholders meeting. Summer 2003
The meeting included service users and carers, district / borough councils,
voluntary organisations, independent sector, health, elected members,
volunteers, staff and managers from WSSCS.
The questions and headline responses were as follows:
How well do our current services meet people’s needs?
•
•
•
•
Ask people who have stopped attending
Need to be more flexible
Low attendance may mean people ‘vote with their feet’
Need to look at occupancy from a different perspective e.g. dependency
levels
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NOVEMBER 2003
•
BVRs take a long time, too much talking, not enough action.
Views on integrated services (all ages and disabilities)
•
•
•
•
People with learning difficulties need specialist services
There is a need for short term intensive services then access to normal
community services
Those with high dependency needs should be in specialist groups
Multi purpose day centres do not work because there are too many
different needs to cater for
What are the gaps?
•
•
•
•
Meeting the range of need e.g. older people with mental health needs
and people with learning difficulties
Insufficient integration of different organisations
Different approaches in different areas
Strain on home care if day centre users not able to attend
Examples of developments and good practice
•
•
•
Mobile day care, luncheon clubs
Volunteer drivers
Library service and housebound delivery service.
What do we want in the future?
•
•
•
•
•
Flexibility
Improvement in services
More services working together
Transport issues addressed
Value for money
5.11 Staff focus group. Spring 2003
A focus group was held with staff, headlines included:
•
•
•
•
•
•
•
•
•
Staff not always kept informed of what is happening
Service users who are attending day care can be maintained in their own
homes for longer
Our centre has not changed structurally but the client groups have. Our
centre is not secure enough now
Transport can be a problem. Numbers of seats restrict number of
attendees
Problems with changes of drivers and not knowing the routes
Staffing levels are insufficient to care for more highly dependent
Need more home care involvement to assist with personal care
Should we be more flexible and offer split days?
Luncheon clubs could be a means of integrating people into the
community
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NOVEMBER 2003
•
•
Age Concern have set up social care groups in local community centres
for those who just need to socialise.
There are training issues e.g. NVQ and specialist training on dementia
and mental health
5.12 Arun Local Planning Group Workshop Spring 2003
The workshop, which looked at staying at home and practical help at home,
concluded that there are many good services already in existence but that gaps
and duplication are rife:
Issues raised with reference to gaps in service included:
• Health promotion, healthy active living
• Stop start funding to voluntary organisations
• Practical help at home (shopping, gardening, cleaning, washing)
• 24-hour services
• Access to transport and rehabilitation
5.13 Meeting with NHS Health and Social Care Trust. Spring 2003
The meeting focused specifically on older people with mental health needs
Questions and issues highlighted included:
Gaps in service
•
•
•
•
•
•
•
Seven day a week care, 24 hour service and out reach.
Escorts on transport, many people need reminding and encouragement
to attend day centres
Flexible services which recognise people’s changing need
Facilities for those with early on set dementia
Separate facilities for those with functional and organic problems
Services not rigidly fixed at over/under 65 they should address the needs
of each individual.
Difference in resources: north of the county poorly resourced
Improvements required
•
•
•
•
•
•
Jointly planned services
Day hospitals and day centres with different but complementary
functions
Opportunity to pass back and forward along the spectrum of care in
different settings according to need
Charging needs to be addressed
Appropriate forms of transport
Different ways of providing services e.g. in a carers home
Vision of day service for the future
•
•
•
Network of different facilities across the county
Small day care units with care closer to home
Graduate clubs run by volunteers
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NOVEMBER 2003
•
•
Fully joined up approach, agencies working together
Care pathways for each individual
5.14 Meetings with the five Areas/PCTs. Spring/summer 2003
The working group linked with the five Areas/PCTs. During consultation the
following issues included:
•
•
•
•
•
•
•
•
•
•
•
•
Day care lacks a vision
There is a wide range of community activities
Staff working in multipurpose centres need to be multi skilled
Home care tends to be more successful in promoting independence
More services are required for older people with mental health needs
Day care at the weekend and luncheon clubs could save home care
assistant time and be cost effective
Can we reshape what we buy?
Residential, day care and home care need to work together
There is a need for more rehab, therapies and appropriate resources
Social support can be offered by voluntary organisations
Transport can be a real issue. Need to explore alternatives such as own
transport arrangements, taxi, Dial a Ride
The end of a programme needs to be carefully planned so that people
do not feel abandoned.
5.15 Black and ethnic minorities groups Spring 2002
The National Service Framework for Older People 2001 and the Race
Relations (Amendment) Act 2000 aim to improve the standards of care for older
people, providing them with services that are free from discrimination.
The SSI report of services for older people in West Sussex in May 2001
referred to:
The lack of understanding of the needs of people from ethnic minority
communities. WSCC needs to develop a clear analysis of the needs of these
communities. This should help them understand the take up of services and
manage the necessary changes in culture as service users from these
communities become included.
The BVR of home care worked with the Crawley area to consult with a number
of different groups, individuals and staff. During the consultation it was clear
that there was little awareness of home care. It was suggested that the LA
might not be offering the services that people want. There was consistent
reference to transport, day care and grants and the need for action. The
exercise was not repeated however; an update of the current situation was
requested from Crawley. In addition to ongoing work there are a number of
recent developments, particularly with the Sikh and Hindu groups. A carers
support group, two days per week, now offers 20 places respite for carers at
Maidenbower multi purpose day centre.
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5.16 People living in rural areas May 2002
In West Sussex 30% live in rural areas of which 30% live in small towns of over
3000 with the remainder living in villages, hamlets and isolated dwellings (1991
Census) The Rural Development Commission showed that the population of
rural areas tends to be older and there tends to be a larger proportion of those
over 65 whose need for social care support is greater than that of younger
people.
The BVR of home care considered the need of older people living in rural
areas. This exercise was not repeated, however it was evident both from this
exercise and discussion, themes emerging from the BVR of day care that the
geographic isolation of many rural communities may mean that even the
smallest communities present service users and their carers with considerable
difficulty in accessing services. Equally those who support them often have a
problem getting services to service users in their own homes.
The issues emerging throughout the BVR supported previous views as follows:
•
•
•
•
Lack of choice
Less accessible services
Higher costs in providing services
Transport problems
The issue of transport has a substantial impact on older people living in rural
areas and their ability to access services and facilities.
5.17 Support at home: a study by the Scottish Executive, central research
unit
An investigation of the needs of older people over the age of 75 found that
almost one third felt they needed help with some aspect of daily living. Social
isolation, type of housing and other environmental factors affected what people
felt they needed. Lack of knowledge about services and how to access them
was a major reason for needs not being met.
KEY FINDINGS
•
Service users request company, activities, a meal and to get away
from the same four walls
•
Some service users see the day centre as a place for disabled
people who will not get better. Others may hope they do not get
asked to leave once they are better
•
Carers request respite, not necessarily in a day centre, flexible
arrangements, company and activities for the person that they care
for.
•
Huge day centres can be impersonal and institutional. Same
people, same activities can be very boring
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NOVEMBER 2003
•
Volunteers believe that day care offers company, a meal, activities,
to get away from the same four walls and respite for carers
•
Volunteers want to be involved and given clear roles and tasks
•
There is no clear vision for day services and no care pathways.
Routes in and out of day care are confusing
•
The ability to identify a range of daytime activities as part of
preventative services is important
•
Services for older people with mental health needs should be 7
days a week, 24 hours a day with separate provision for those with
functional and organic problems
•
There are a number of transport issues. Travelling, especially in
rural areas can put service users off.
6. How does the service stand up to examination? Challenging
the Best Value Process.
The intention of this section is to describe how the BVR day care process was
challenged. A challenge was to consider whether or not WSSCS should
provide the day care service, if so how it should be provided in order to ensure
continuous improvement. The options considered are illustrated in Chapter 8.
The groups that challenged were therefore concerned that the work undertaken
covered key points and was thorough.
6. 1 Groups that challenged
The BVR was challenged throughout the process by a number of groups which
included the Project Team, the Challenge Panel and the Project Steering
Group. Membership of the various groups was wide ranging and included
elected members, carers and service users, officers, staff and representatives
from partner organisations including the private and voluntary sector, housing
and health. The BVR was discussed in a number of different forums which
included meetings with Areas/PCTs, managers and frontline staff and team
meetings with the commissioning and performance team and the adult
management team. Various consultation exercises were used as an opportunity
to provide a challenge and fresh thinking. The BVR group also identified a
critical friend who was a carer representative.
6. 2 The Challenge Panel
It was agreed that the Policy and Development Group for Older People, which
has a wide representation, would act as a Challenge Panel. Two service users
from a day centre were also asked to attend the group specifically for this item.
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NOVEMBER 2003
Issues raised included:
•
•
•
•
•
•
Addressing the need for adequate staff cover
Residential homes
SWOT analysis
Better use of bricks and mortar
Clarification of percentage of budget spend on day care by other LAs
The need for preventative services
6.3 Project Team
The Project Team which consisted of officers from WSSCS, Finance,
Management Audit and Scrutiny and Review met approximately six weekly:
Issues raised included:
•
•
•
•
•
•
•
•
Rewording and agreeing the scoping report
Reference to day care offered by homes to be transferred to be included
Care management colleagues to be invited to attend the working group
Need to consider other opportunities for day time activities including, for
example, joint working with education and libraries
An understanding of the spend on day care including the unit cost and
options.
The need for help desks to have comprehensive information on available
options
WSSCS needs to manage the market to get best use of investment.
The need for a clear vision for day services
6. 4 Project Steering Group
The group chaired by the Cabinet Member has representation from elected
members, officers, carers and service user organisations, health and voluntary
organisations. The group approved the scoping report in January 2003.
Issues raised at meetings included:
•
•
•
•
•
•
•
Visit to a Daily Living Centre
Need for benefits and advice to be available at day centres
Possibility of consultation fatigue
Time delay in implementing recommendations from BVR
Clarity about purpose of day care required
Needs led rather than service led services
Importance of partnership
6.5 A stakeholders meeting
This meeting gave those present the opportunity to challenge the process and
included representatives from service users and carers, district/borough
councils, voluntary organisations, health, elected members, managers and
staff.
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NOVEMBER 2003
Issues that challenged included:
•
•
•
•
•
•
•
The need to find out why people stop attending day care
Look at occupancy from a different perspective
Details about any waiting lists
Social services should have details about gaps
Concern that if current service users lose their place at a day centre they
may lose social contacts built up over the years and it may put more
strain on home care if people say at home.
Need to talk to Learning Difficulty team
Imposed change on volunteers could mean we lose them.
KEY FINDINGS
A number of different groups including the Project Steerin g Group and
the Project Team have challenged the BVR process.
The Policy and Development Group for Older People acted as a challenge
panel and a representative of carers acted as a critical friend
The stakeholders meeting and other groups have also been used as
opportunities for challenge
7. How does the service compare? Comparison with other LAs
7.1 Benchmarking exercise
The intention of this section is to give an overview of the contacts made with
other LAs as part of the benchmarking exercise.
The working group chose to compare the in-house service with other LAs. The
purpose of the exercise was to identify the possibility of efficiencies by looking
at processes, which help deliver better performance and outcomes. It was also
important to identify themes, developments planned and models of good
practice.
A questionnaire was devised and sent to 55 other authorities, county councils
and a sample of unitary / borough authorities who had received two or more
stars. The following LAs responded:
•
•
•
•
•
•
•
•
•
•
•
Brighton and Hove City Council
Calderdale Metropolitan Borough Council
Cheshire County Council
Cumbria County Council
Hampshire County Council
Hertfordshire County Council
Lancashire County Council
Leicestershire County Council
London Borough of Southwark
Northamptonshire County Council
Nottingham City Council
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NOVEMBER 2003
•
•
•
•
•
Oxfordshire County Council
Sefton Council
Shropshire County Council
Staffordshire County Council
Suffolk County Council
Findings were as follows:
7.1.1 Who provides day care?
The proportion of day care provided by social services varied from 20% to 90%
with an average of 62%. A high proportion of day care was provided by
voluntary organisations, with significant amounts being provided by the private
sector and health
The proportion for WSSCS was approximately 50%
7.1.2 Do you provide integrated services (all ages/disabilities)?
The survey did not reveal current models of integrated services similar to the
WSSCS multi purpose centres. Some LAs referred to integration for older
people, frail older people and people with mental health needs. There were
some examples of integrated care for under 65’s but generally a move way
from this model. One LA referred to moving toward a non integrated approach
to focus on rehabilitation for younger people with a physical disability, given that
younger disabled are resistant to integration with older people
WSSCS has 6 multi purpose day centres providing services for people
over 18 with a range of different disabilities. In addition most of the
smaller centres also provide services to younger people. The proportion
of over 65’s is 71% (44% to 100%) and under 65’s is 29% (range 0% to
56%).
7.1.3 Main purpose of day care
•
•
•
•
•
•
•
Support people to live in their own homes
Social stimulation and prevention of social exc lusion and isolation
Respite for carers
Care and support
Prevention
Monitoring
Safe environment
WSSCS also includes rehabilitation, personal care and daily living
activities.
7.1.4 Occupancy
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There were variations in the occupancy from 60% to 90%. However it needs to
be noted that it was not evident whether this was the planned or actual
attendance. Reasons for low occupancy were not given
WSSCS occupancy, planned attendance (Feb 2003) was 73%. Attendance
was higher in the smaller centres.
7.1.5 Non take up of service
Reason for not taking up a place or ceasing early included:
•
•
•
•
•
•
•
•
Service user refusal
Service not what they want
Prefer to remain at home
Lack of motivation.
Not available at the right time
Delay in being allocated a place
High dependency
Transport difficulties
WSSCS reasons given were similar
7.1.6 Proportion of social services budget spent on day care
This varied from 0.86% to 12%
WSSCS spend in 2002/2003 was 5.43% of the Adult Services budget.
7.1.7 Unit cost
Not all LAs responded to this question.
Those who did showed that the variation was 7.60 to 30.0
Responses varied from being cheaper, to more expensive to varying according
to nature of service.
WSSCS average unit cost is £47.10 weekly and £9.daily.
7.1.8 Grants to voluntary organisations
•
About 81% of LAs were providing grants for day care. This figure may
be greater given 13% were unable to respond.
WSSCS spend in 2002/2003 on grants, in the Areas, was £470,000
including a high proportion on daytime activities.
7.1.9 Opening times
The standard day was from 8.30 to 5, with the shortest day being 10 to 3.30.
The majority offered a service at weekends or had plans to do so. Where plans
were not in place reasons for not providing a service included trying it but no
take up and too costly. However there was a general view of the need to be
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more flexible. 35% were providing day care in the evening and 29%in the early
morning.
WSSCS opening times vary between 8 and 5, generally service users
arrive at 10 and leave at 4.
7.1.10 Transport provision
66% LAs provide in-house transport and 33% provide mixed transport which
included dial a ride, private taxis, Red Cross, clients own transport
All WSSCS day centres provide in-house transport, there is some use of
taxis and other transport including service users own arrangements
7.1.11 Escorts
47% of LAs routinely provided escorts and 35% sometimes offer this service
WSSCS do not routinely provide escorts. Home care provides this
service on occasions.
7.1.12 Standards and specifications
53% of LAs have standards and specifications in place.
WSSCS do not have standards in place. Some work has been undertaken
but this has not been implemented
7.1.13 Consultation with service users and carers
59% of LAs responded that they had undertaken surveys. These included
• Satisfaction questionnaires
• Carer’s questionnaires
• Annually through Quality Assurance process
• Monitoring of contracts
WSSCS undertake discussion groups, surveys, carers meetings and
focus groups, has newsletters and suggestion boxes
7.1.14 Common themes from consultation
The 59% of LAs listed these as:
•
•
•
•
•
•
High satisfaction rates although more flexible hours were seen as
desirable. 30% wanted more days per week
More opportunity to go on outings and to participate in community
activities
Extra days to support carers
Local day care
Early morning, evening and weekend service
Timely transport
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•
Involvement in care planning
WSSCS service user surveys suggest overall satisfaction. Main reasons
for attendance included company, activities, a meal and to get away from
the same four walls. A friendly atmosphere is also important. Carers
request respite, not necessarily in a day centre, and greater flexibility in
terms of when day care happens and for how long.
7.1.15 Performance indicators
Most LAs (69%) had no performance indicators for day care only 24% said that
there were PIs currently in place.
WSSCS has recently agreed that PIs that refer to help to live at home,
support for carers and preventing admission to residential care are
relevant and information will be collected.
7.1.16 Opportunities for working in partnership
LAs listed the following examples:
•
•
•
•
•
•
•
•
•
•
•
•
Mobile service in partnership with housing
Working with health staff on specialist dementia services
Sponsoring Age Concern to provide community day services
Partnerships with health and voluntary organisations
Joint planning with NSF team
Project management with extra care sheltered housing
Multi disciplinary assessments
SLAs with voluntary organisations for assessments of specific groups
e.g. sensory impairment
Visits by District Nurses to provide services to service users
Outreach support with other organisations to enable people to access
ordinary activities
Block contracts with private and voluntary organisations to produce a
mixed economy of service provisions
Joint centres with health, housing and voluntary sector
WSSCS works in partnership with a number of agencies in different
settings. Future opportunities include greater working with health,
housing, and education, libraries, leisure and the private and voluntary
sector in creating a spectrum of day services.
7.1.17 Ethnic minority groups
Most LAs were undertaking work which included:
•
•
•
•
•
Specific groups
Grant funding
Interpretation and translation services
Specialist day care
Day centres in local community buildings
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•
Residential home offering day care and respite service.
WSSCS is involved in the majority of the above. There are specific
projects and developments in Crawley
7.1.18 Staff recruitment and retention
Given the national difficulties in recruiting and retaining staff, LAs were asked if
they were experiencing problems and if so what these were:
• Competition from other organisations
• Ageing workforce
WSSCS has experienced the same issues. Drivers, cooks and domestics
can be difficult to recruit. There has also been little interest from ethnic
minority groups.
7.1.19 Charging for day care
65% of LAs make a charge for day care
Charging arrangements varied:
•
•
•
•
Means tested, if user receives home care and day care, the day care
component is free apart from meal and transport charges.
Attendance, meal plus transport
One charge for refreshment/lunch
Transport and a meal
WSSCS make a single charge for non-residential services which is
worked out on an individual basis
7.1.20 Developments and initiatives for the future
Most LAs gave examples of developments and initiatives and these included:
• Link workers schemes
• Sheltered housing mobile schemes
• Integrated day care with health
• Healthy Living schemes
• Closer integration of day hospitals and day care to avoid duplication
• Primary care centres/one stop shops
• Larger centres replaced by smaller, more local services
• Specific services for minority ethnic groups and older learning disabled
• Specialist care services e.g. rehab and respite
• Day centres developed with Age Concern in rural areas as part of
prevention strategy
• Voluntary organisations to provide social, traditional day care. Greater
emphasis on independence and enablement
• Development of services outside weekend and outside normal hours
linked to 24 hour managed services.
7.2 LAs that have undertaken BVR of day care
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Examples of recent BVRs included Cambridgeshire and Hampshire. Findings
included:
7.2.1 Cambridgeshire:
•
•
•
•
•
•
•
•
•
Purpose of day care: prevention, companionship, stimulation, respite,
personal care, meals and safety
Variety of provision but little choice of day centre
Insufficient specialist provision for those with mental health needs
Few preventative services given the eligibility criteria and need to focus
on high level needs
Unit cost estimated, including transport to be £23
Service developed in a piecemeal way
Need to increase occupancy.
Need consistency of quality across all centres
Need more flexible day care
7.2.2 Hampshire:
•
•
•
•
•
•
•
•
•
Purpose of day care: prevention of deterioration, maintenance,
prevention of social isolation, carer support /enablement
Inconsistent services across the county
Mixed economy with SSD as main providers
Average unit cost for SSD £29.35 (£15.93 to £47.05). Independent
sector £18.21
Would wish to survey service users who withdraw
Changes in day care will have a knock on effect for other services such
as residential and home care
Need to develop more meaningful measures of performance linked to
PAF indicators
Piloting more flexible day care hours
Need to improve transport reliability
7. 3 International
Europe, America and Australia are reviewing day services recognising that day
services will be required for an increasing number of older people. The
American model seems to be most advanced and includes planning for
different life events including retirement, disability and death. Access to
Internet shopping and advice and information on services such as gardening,
household repairs together with health promotion is available.
7. 4 Follow up from the survey of LAs
•
Telephone calls and visits were made to some LAs
•
A visit was made to Brighton and Hove to discuss the mobile day service
in sheltered accommodation units
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NOVEMBER 2003
•
Two visits were made to East Sussex. The first to a multi purpose
centre offering a time limited service and the second to a resource
centre for older people with mental health needs.
•
Telephone contact was made to Cumbria to discuss their business unit.
However, given they are undergoing a review and this call was
premature
•
Telephone contact was made with Northampton, Southwark and Sefton
to clarify information given as part of the survey
•
The DOVE Daily Living Centre at Portsmouth was visited.
7. 5 Independent Organisations
The working group considered six independent day centres in the independent
sector where Service and Funding Agreements are in place. These included
two voluntary organisations and a private sector provider.
Findings indicated that:
•
•
•
•
•
•
•
•
The purpose of day care is generally regarded as promotion of well
being, respite for carers and to offer social and organised activities to
isolated people.
Opening hours range from 8.30 to 4.30
Some centres were open for five days, others for part of the week
Lunches, drop in facilities and special activities were often offered in
addition to core services
Primary disability is elderly frail and physical disability with some older
people with mental health needs
Reasons for attendance were respite, prevent isolation and social
stimulation
People were often in receipt of other services which included home care,
help at home, other day care, social club, day hospital and rehab. Unit
Some people who develop a greater need for care are reluctant to move
into statutory day care. One reason being given is that of an increased
charge.
7.6 Residential homes
Traditionally the policy in WSSCS has been that individuals who are living in
residential care are not eligible for a place in a day care unit. This was based
on the need to ensure sufficient places for those living in the community who
without such support might not be able to continue to do so and the expectation
that the homes are required, as part of registration, to provide social and
recreational activities.
In July 2003, there were over 30 people attending in-house day care from,
mainly in-house, residential homes. All day centres were mindful of the policy
and one third did not provide places. The remainder provided places either
because of historic reasons e.g. a group of individuals who had transferred
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from a day centre that had closed within the home that they were resident and
following a closure of a hospital. In addition specific reasons contained in care
plans were given. Attendance varied from transitional, supporting someone to
settle into a residential home to much longer term, in some instances ten years.
About 50% of the in-house day centres provide ongoing support to those in
respite care if there is seen to be a good reason.
Given the policy seems to vary a more consistent approach would be fairer.
7.7 Models of good practice
In addition to the models listed others identified included:
.
• Home from Home is intended to extend home based services for people
with dementia across Suffolk and was developed by Age Concern. Host
carers are salaried Age Concern staff
• Homeshare in Sutton though not focusing on people with dementia is
comparable to the Suffolk scheme. The scheme serves vulnerable older
people for whom the standard day care is ‘inappropriate’, it offers
companionship with two or three people in a domestic environment and it
depends on volunteers both as ‘home sharers’ and as drivers who are paid
expenses.
• A similar home share scheme in Ipswich has developed a pattern of two
to three days a week day care for people at risk of being admitted to longterm care. Home carers are self-employed.
• Rosebank, a residential home in the west of Scotland includes a unit
which supports people with dementia at home, through day care and respite
and offers advice, support and counselling to carers as well as older people.
Day care is offered in units of two hours, available flexibly throughout the
day from 5am to 11pm
• SADSA (South Ayrshire Dementia Support Association) is a voluntary
organisation that supports people with moderate to severe dementia. It
provides individually tailored support (day centre attendance, home
support), intensive service (365 days of the year, users averaging four days
a week); it provides collaboration and partnership through its funding mix, by
having seconded salaried workers as well as project workers.
•
East Sussex, as part of a pilot project, offers time limited day care
programmes to assist people to move into ordinary daytime activities in the
community. Transport is used flexibly to provide support for people to move
into ordinary activities and is developing more local services that are socially
inclusive.
•
Direct payments being used to provide personal assistant time to support
people to participate in activities outside the home. The aim of Direct
Payments is generally to give individuals greater flexibility and cost
effectiveness in the way their personal assistance is managed. Currently a
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small number of people are using personal assistant time to access
activities outside the home. There are others where there is not an
assessed need for day care who use the Direct Payment to enable them to
access shops, colleges and other community facilities.
•
Some LAs are setting up databases with details of the range of resources
available in the community. ICIS provides information to all Area offices in
West Sussex on a quarterly basis; this information will shortly be available
on the Intranet and updated fortnightly. Age Concern provides a range of
information including regularly updated fact sheets which can be displayed
in day and Area offices.
•
Link workers are being used in different settings to help people find
alternatives to day care and to move on from day care into more socially
inclusive settings.
•
Carers short breaks are being funded in West Sussex through the Carers
Special Grant. The range of part or fully funded schemes includes those for
older people with dementia, black and ethnic minority groups, older people
in isolated or rural areas and older frail people.
•
Libraries offer a range of advice and information. In partnership with the
County Library and WSSCS Arts Development Officer a reading project is
being set up. Libraries also offer services to housebound people.
•
Disability Living Centres as stand alone or part of other community facilities
including day centres. A stand-alone centre in Portsmouth offers advice
and an information service on housing and equipment for people with
disabilities.
•
Adult Education offers a number of opportunities. There are a range of
classes that could be accessed and assistance can be given to individuals,
groups and staff to ensure they know what is available. In addition for those
who cannot attend ordinary Adult Education Centres there is potential for
teaching within day centres that could also be opened up to members of the
local community.
•
Community Craft Instructors provide a range of classes, often supported by
volunteers, for groups in the community.
KEY FINDINGS
Most local authorities are not providing multi purpose day centres
Purpose of day centres varies from prevention, support to live in own
home, rehabilitation and respite for carers
Unit costs quoted vary from 7.60 to 30.0, the proportion of budget
spend varies from 0.86% to 12% and the majority of LAs are using
grants to provide additional day services.
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Standard opening times of centres are generally 8.30 to 5, with the
shortest day being 10 to 3.30. Most are providing or looking to provide
more flexible opening hours
Common themes from consultation include high satisfaction although
some would like more flexible hours, extra days to support carers,
local day care and involvement in care planning.
LAs were generally using opportunities to work in partnership with
other organisations
Most LAs were addressing the needs of ethnic minority groups
Developments for the future include link workers, mobile day care,
closer integration of day care and day hospitals, smaller local centres,
intermediate care and rehabilitation with an emphasis on
independence and reablement.
Day care internationally is being reviewed; the American model
includes planning for life events and access to advice and information
Comparison with the independent sector indicated that the low level
service are also being offered to some service users attending inhouse day care and therefore there is the potential for duplication
8. Is the service fit for the future? Competition with other
providers.
The intention of this section is to draw together the work undertaken throughout
the BVR and illustrate how this influenced the conclusions drawn and
recommendations made.
8.1 Addressing the themes
The working group set out the emerging themes and considered whether or not
they were relevant and if so how they might best be met:
ISSUE
1. Why people attend day care
Service users highlight company,
activities, meal and to get away from the
same four walls
HOW ADDRESSED
Decision re: care or day time
activities
Information on community
Carers request respite, not necessarily in a activities needs to be up to date
day centre.
and available to help desks,
assessors, the public and day
centres.
Explore options to meet need for
day time activity
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ISSUE
HOW ADDRESSED
Care management process to
test eligibility and review ongoing
need
Joint planning with stakeholders
including other organisations
Specific service and funding
agreements (SFAs) for day care
and agreement re how this
applies to existing service users
2. Large buildings/institutions
Large buildings may be viewed as
institutions creating dependency and
difficulty in moving on
Promote social inclusion using
ordinary activities.
Traditional day care can be seen as boring
and lacking in focus
Consider other options such as
residential homes, Direct
Payments, smaller units or care
in carers home
Use larger buildings to create
smaller spaces
Work with other organisations
promoting intermediate care and
rehabilitation thus maximising the
space.
Encourage other organisations
(shop within a shop) to use the
building both during the day, and
at weekends/ evenings.
3. Partnership working
Day care should be more than a day care
centre; it should embrace a full range of
facilities and services that are available to
the wider community.
Development of services is not just the
responsibility of one agency. It requires a
collaborati ve and co-ordinated approach,
working with a range of agencies.
4. Occupancy
Occupancy in the in-house centres
showed low planned attendance and
actual attendance.
People generally attend for one or two
Maximum use of partnerships
both as part of daytime activities
and day care
Working with health, housing,
voluntary organisations, private
sector, education and leisure
Alternative ways of setting
occupancy levels which take
account of dependency levels,
transport and building, nature of
intervention and outcomes need
to be introduced.
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ISSUE
HOW ADDRESSED
days.
Clarity about the purpose of day
care and care pathways
5. Availability of service
Carers and service users request
flexibility: longer/shorter days, early
morning/later evening, weekend and extra
days.
6. Area/PCT variations
Area/PCTs vary in population, levels of
dependency, resources etc.
Urban models may not necessarily
translate well into rural communities.
One size fits all is not appropriate.
Access to services which are
flexible need to be set up. Such
services could be in residential
establishments, day care, Direct
Payments and as part of day
time activities in collaboration
with health, housing and
voluntary organisations and the
private sector
Overarching WSSCS vision with
consistency achieved through
standard setting and monitoring
Variations in services delivered in
Areas/PCTs in line with specific
needs of local communities.
Areas/PCTs using existing
meeting structures to devise local
and implementation plan
7. Integrated/ specialist provision
Care for all age groups and disabilities
under one roof rarely happens in other
LAs. Where it has happened LAs are
tending to move toward more specialist
provision or offering certain days to
specific groups
Particular attention needs to be give n to
certain groups including:
Older people with mental health needs,
particularly functional illnesses, people
with sensory disabilities and older people
with learning difficulties
8. Vision/ direction and positioning
Most LAs are in the process of reviewing
their day care. Generally and historically
there is a lack of strategic direction.
Range of purpose indicates being all
things to all people
Work being undertaken on the
BVR needs to be in conjunction
with the strategy for people with
physical disabilities, valuing
people and modernising day
services and the service plan for
older people with mental health
needs.
Create vision and strategic
direction
Utilise facilities appropriately in
line with vision and principles
Ensure care management
process in place and review
regularly.
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ISSUE
HOW ADDRESSED
Review grants to ensure service
commissioned meets changed
need
9. Transport
A number of transport issues including:
availability, reliability flexibility, too long
journeys and lack of escort
New structure and arrangements
for transport service currently
being devised. Links to be made
with this BVR
Criteria for use of transport
needs to be agreed and
alternative transport explored at
assessment stage
Information on meeting cost of
new arrangement available via
benefits advice or at assessment
stage.
10. Financial/ performance
management
Unit cost variation between LAs, different
ways of calculating costs.
Unit cost needs to be reviewed
annually
Charging varies between organisations
and causes confusion or may be the
reason for people not wishing to attend/
move on
Charging needs to be
transparent
Little attention given to monitoring day
care performance and the role it can play
in contributing to keeping people at home.
Preparation for the
implementation of the National
Minimum Standards (2007)
through the introduction of draft
standards and a procedure
manual needs to commence.
Lack of standard and procedures specific
to day care
PI information being collected
8.2 Comparison with others
The section on comparison describes how WSSCS compares with others in
particular other LAs but also those independent organisation where SFAs exist
8.3 SWOT and PEST analysis
The working group also considered the analysis undertaken and described in
Appendix 2 and Appendix 3
8.4 Models of good practice
The working group had begun to identify good practice. The group were also
aware of the range of daytime activities available as part of the collection of
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information from Areas/PCTs. In addition it was clear that there are a range of
agencies and individuals who wish to build on and develop new initiatives that
would increase the opportunities available to people requiring assistance during
the day.
8.5 Strategic target for WSSCS
An important strategic target for WSSCS is:
A reduction in the use of residential care in favour of community based services
such as home care and day care
The main aim being to help people remain living independently and to provide
security for those who need care or support.
8.6 National and local principles
The working group were mindful of the national and local principles that would
have an influence on direction which included:
•
•
•
•
•
•
•
•
•
Partnerships
Prevention
Rehabilitation
Intermediate care
Whole systems approach
Meeting targets
Seamless services
Social inclusion
Modernisation agenda
8.7 Day services
The term day care is loosely applied in a number of settings where people are
out of their usual home setting. What people actually receive varies
considerably. In the consultation exercise with service users it was clear that
the main reasons wanting day care were:
Company, activities, a meal and to get away from the same four walls
People may attend a number of different venues to receive ‘day care’ in the
same week. Services therefore may be duplicated and the services for many
people provided by WSSCS may be the same as that provided by, for instance
in a social centre or a luncheon club.
There is little question that as people become older their networks become
weaker with fewer surviving relatives and friends. Isolation and loneliness can
lead to depression, loss of social skills and greater dependence. Thus the
value of preventative strategies that maintain independence need recognition.
This does not mean that isolated and lonely people are necessarily in need of
care that can only be met by attendance at a day care centre. There are a
range of daytime activities which can include local social clubs, drop in centres,
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leisure centres, education centres, café, pubs, luncheon clubs and voluntary
organisations
Meanwhile people who wish to continue living at home may need higher levels
of support to regain or to learn new skills. The aim being through intensive,
time limited programmes to integrate people back into ordinary daytime
activities and support their wish to continue living at home.
In addition, there are and will continue to be people who require longer term
care to support them and their carers to enable them to live at home.
8.8 Day services, daytime activities or day care?
The working group suggested that day services is an umbrella term that
includes day time activities and day care:
Daytime activities are broadly those that happen in the community, that
support people who have lower level needs. Such activities might inc lude
formal and informal settings, centres run by voluntary organisations, drop in
centres, luncheon clubs, social clubs, education and leisure facilities, cafes and
pubs. In addition it may include Direct Payments, activities and respite in the
home or i n another carers home. Such activities may, or may not, involve staff
or volunteers.
Day care implies therefore that there is a specific need that would not be met
by daytime activities. A care plan would clearly state the individuals need and
how this would be met through short term, intensive programmes such as
intermediate care and rehabilitation. Some individual’s need would be for
specialist day care as part of a longer programme of ongoing support.
Wherever possible the role of day care would be to support individuals to move
into socially inclusive daytime activities. Where day care in the longer term is
the appropriate need, opportunities to create meaningful links with ordinary
activities need to be built into the care plan.
8. 9 What would a modern service look like?
Daytime activities are for some people about prevention, maintaining skills and
stopping or delaying deterioration. Generally, there will be an expectation that
individuals would be given information, advice and where necessary support, to
participate in ordinary, local activities.
Day care, in partnership with other agencies, particularly health, would provide
care that is time limited, intensive, rehabilitative, part of intermediate care
programmes and will aim to support people to move on and into ordinary day
time activities. Some individuals will need support to move from the day care
into such activities.
People requiring longer-term day care would benefit from specialist services in
partnership with other agencies. Suc h care might be in smaller units in the
community, in residential homes, parts of larger units, on specified days or in
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small group settings in a carer home. Service providers could include WSSCS,
health, voluntary organisations, carers, Direct Payments and the private sector.
8.10 What are the benefits?
The benefits would be social inclusion, local facilities, intensive programmes of
care when required, larger range of services, less duplication, greater use of
partnership to enable more seamless services, regular and more dynamic use
of buildings and the potential for cost effectiveness. Above all a more focused,
flexible service that is tailored to meet individual need. Such services would
help maintain independence, prevent unnecessary admission to hospital or
residential care, support hospital discharge and offer support to help people to
live at home.
8.11 Consideration of options
Using the issues described in 8.1 to 8.10, the working group considered four
options; the pros and cons of each and which option seemed most appropriate.
The following options were considered:
•
•
•
•
Do nothing/ maintain the status quo
Withdraw / outsource day care
Total in-house service
Market development
DO NOTHING/ MAINTAIN THE
STATUS QUO
Advantage
• No change for service users
and staff
Disadvantage
• Perpetuates the place for life
and the possibility of
dependence
• Socially exclusive service
• Static, traditional services
• Use of buildings and
partnerships not maximised
• Does not address the need for
greater flexibility
• Lack of recognition of the
important part day care might
play in assisting people to stay
in their own homes and to meet
PAF targets
Justification
Doing nothing as part of BVR and the
WITHDRAW/OUTSOURCE
Advantage
• WSSCS would concentrate on
commissioning only.
• Buildings can be disposed of/
staff redeployed as part of
organisational change
• Possible financial efficiencies
Disadvantage
• At behest of market
• Market currently not sufficiently
mature
• TUPE regulations could make
this option costly and take time
to achieve, reducing financial
efficiencies
• Reacting quickly to new
directives and agreeing new
initiatives with a range of
providers could be difficult.
• Move away from mixed
economy
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need for continuous improvement is
not an option.
Against national and local principles
and desire to modernise services
Justification
Not in line with national principle i.e. to
create a mixed economy.
Starfish/ ADSS Report suggests
outsourcing may not achieve savings.
TOTAL IN-HOUSE SERVICE
Advantage
• Retains management control
Disadvantage
• Stigma of statutory service for
some people
• Lack of capacity to innovate,
develop new services
• No focus: all things to all people
• Waste of finite resources
Justification
Against national principles to promote
a flourishing independent sector within
a mixed economy.
No evidence found of LAs that have
fully retained a service.
Difficulties in rural areas
Does not address flexibility or need for
alternatives to day care
MARKET DEVELOPMENT
Advantage
•
•
•
•
•
•
Best use of available resources
Opportunity to work with
partners to promote socially
inclusive daytime activities.
Greater opportunity to work in
partnership with other
organisations promoting good
health and social care.
Opportunity for provision of
more services to keep people at
home and assist early
discharge from hospital.
Opportunity to work with
partners creating specialist
services and ensuring gaps in
service are addressed
Co-operative and collaborative
working make further change
and flexibility more possible
Disadvantage
• Change programme including
consideration of staff roles and
responsibilities
• Reviews for service users that
may result in alternative day
time activities and loss of
friendship groups
• Time needs to be invested in
selling the idea, ensuring
resources are known and
market stimulated where
necessary
• May require pump priming to
get alternatives off the ground
and investment in training and
equipment.
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Justification
Improvements can begin immediately
Clear vision for day services
Targeted service with clearer roles for
different organisations
Recognition that day services are not
the responsibility of one agency
CONSIDERD TO BE THE
PREFERRED OPTION
8.12 The preferred option
The working group proposed that it would recommend that the following are
not considered to be options:
•
•
•
Do nothing / maintain the status quo
Withdraw / outsource
Total in-house service
The working group concluded that the market development model would be
recommended as the option most likely to provide a modern day service.
8.13 Funding the modern day service
There is no additional money therefore any changes need to be funded through
the current financial envelope for in-house day care, SFAs and grants for day
care. Issues that would need to be addressed would include:
•
•
•
•
•
•
•
•
Strong, clear vision for day services that ensures an understanding of
the important part that services play in supporting people to live in the
community
Thorough knowledge of local day service market to ensure the most
creative use is made of existing daytime activities, day care and the
avoidance of duplication.
Market development where there are gaps in daytime activities and day
care.
Support to organisations to establish/develop further activities and
services
Support to individuals and their carers in identifying and accessing
appropriate activities/services
Greater partnership working with health, housing, libraries, education
and voluntary and private sector.
Better use of buildings by different organisations both during the day and
out of hours
Greater flexibility for instance in terms of when day time activities and
day care are available, staff roles and responsibilities and use of
buildings
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The model depends on and will benefit from current knowledge of the range of
activities and services available, flexibility, in terms of a range of imaginative
packages, activities and services, partnership with other agencies, less
dependence on buildings but also more creative use of buildings.
More targeted day services may mean that number of people receiving day
care at any one time, as it is now delivered will reduce. However, the number
of people benefiting given the throughput should increase. The changed
direction would give the opportunity to recycle time and energy into supporting
new and exciting daytime activities and more dynamic day care.
8.14 The fit between the overall vision and the Areas/PCTs
The working group researched the Areas/PCTs in order to gain an impression
of:
•
How well current services meet the needs of the Areas/PCT
•
How well day services meet targets e.g. delayed discharge, prevention of
admission to residential care and support to carers?
•
Examples of developments and good practice.
•
Opportunities for agencies working together to provide day services
•
Vision for the future service
Information collection included detail about services available in each
Area/PCT. For the evidence files information is available about each area,
which includes:
•
•
•
•
•
Description of Area/PCT
Current provision
Area/PCT view of current resources
Current / planned development
Vision for the future
KEY FINDINGS
A strategic target for WSSCS is a reduction in the use of residential care
in favour of community based services such as home care and day care.
National and local principles that have an influence on future service
direction include partnerships, prevention, intermediate care,
rehabilitation and social inclusion.
Company, activities, a meal and to get way from the same four walls are
main reasons given by service users for attendance. Often these can be
met by ordinary daytime activities in a socially inclusive way rather than
by more traditional day care.
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Attending a day care centre should imply that there is a specific need for
care. Such care may be time limited and intensive enabling people to
return to ordinary activities or for some it may be longer term.
Do nothing/ maintain the status quo, withdraw/outsource day care or a
total in-house service are not recommended as options for a future day
service.
The preferred option would be market development. This model would
enable collaborative and cooperative working with a range of partners
and would be recommended as the option most likely to provide a
modern day service.
9. Vision into action: Areas/PCTs
The recommended option for the future is a market development model. This
recognises that people need a spectrum of care which, under the umbrella term
day services, would include day time activities in ordinary local settings and day
care which is either time limited and focused or for some people may be longer
term. The ability to develop the range of community activities further, to assist
people to access more socially inclusive opportunities and to work in greater
partnership with other agencies providing flexible services that meet the needs
of service users and their carers takes time to achieve. Equally the Areas and
PCTs have different needs and resources available to them at this point in time.
It was clear to BVR working group from the outset that one model fits all was
not appropriate for a modern day service.
9.1 Coastal
Coastal Area covers the three major towns of Shoreham, Worthing and
Littlehampton and has a population of approximately 230,000. There are a high
number of over 65’s along the coastal strip, with one of the highest over 85
populations in the country; Worthing has the highest per capita in the UK. The
population are largely situated within the three major towns, and it is therefore
mainly an urban area, though there are a few parishes which are remote from
good public transport such as Clapham and Findon. Whilst the elderly
population are generally of above average affluence there are parishes which
are amongst the most deprived in the country including Heene and Central
wards in Worthing and Wick in Littlehampton.
Current resources show that there are a wide range of social, lunch and activity
clubs for older people across the Coastal area. Though it is likely that the links
could be improved by the evolution of the Coastal help desks, greater use of
VSLDOs as a liaison point and ensuring the connections with the Health
enhancements remain strong.
In the independent sector, Guild Care has important centres at Methold House
and the Lovett Centre. Currently they are developing a Healthy Living Centre
which offers scope fo r improving the range of day support.
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Arun district council runs the Tamarisk day centre which offers a five day a
week service to the over 50's. Adur is heavily reliant on voluntary sector clubs
to support Glebelands.
WSSCS has three multi purpose day centres, Rowans, Laurels and
Glebelands. Currently, in line with other in-house day centres there is a very
static occupancy with few people moving on from the centres. The former day
centre at Parkview for older people with mental health needs is now a part of
East Tyne. Contribution to the modernisation agenda and targets is currently
relatively small. Potential links with intermediate care and the promotion of
independence seem high. Overall the range of activities and response to
varied service user groups is good, but each centre tries to be all things to all
people without focus. Links with other service, particularly health, for older
people could be stronger.
Current developments include the strategy for older people with mental health
needs and the reprovision of the Ridings and Birchfield and proposal for a
resource centre at East Tyne which will include day care, links with Guild Care
healthy living centre proposals and an intermediate care strategy.
The model for the future is likely to include a spectrum of services to meet the
full range of need, clear focus based on targeted intervention and promotion of
independence, multipurpose day centre at the heart of the intermediate care
strategy and clear role for day hospitals with care pathways with day centres
based on the single assessment process. The Area/PCT recognise the
importance of actively promoting and linking with voluntary groups and
independent sector providing for lower / medium level of need and of linkage
between services along the spectrum and enabling service user to access them
flexibly.
9.2 Crawley
Crawley Borough Council area covers a population of approximately 100,000.
The Area is not co-terminus with the Crawley PCT which covers parts of
Surrey, Charlwood and Horley, a nd represents a population of approximately
110,000 to 120,000
Historically there has been an under investment in community health and social
care services to meet the needs of older people. The main gaps are the level
of community nurses and mental health services for older people e.g., there is
no CMHT. The gaps are significant given that the Area/PCT anticipate a
significant increase in the number of people aged 65 and over. The Health
Improvement Plan also identifies a higher than national, and county, average of
certain illness associated with ageing, including dementia. Improvements to
ensure targets set in the Performance Assessment Framework and the NSF for
older people are required.
WSSCS day care provision includes one multipurpose daycentre,
Maidenbower. Day care is also available in three residential homes Burleys
Wood, Little Paddocks and Barley House. These homes will be transferring at
the end of this year to the independent sector.
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The current developments include the Crawley intermediate care team which
focuses on avoiding admission to hospital and timely, safe and effective
discharge from hospital. Work to integrate the role of rehabilitation and
recuperation within this team is underway. It is anticipated that Maidenbower
will play a significant part in maintaining and promoting independence in people
identified by the intermediate care team. The work will be time limited and
outcome focused, working in partnership with health and social care.
Services for people with dementia have increased three fold in the last three
years. A review of existing services and plans for the development of more
specialist service will be held with the independent sector provider of the
transferred homes once the provider has been identified. Other developments
being considered include the need for carer’s respite, a drop in facility for
service users and flexible hours, evenings and weekends.
The overall focus of the service will be increasingly to work in partnership with
health and other agencies to give a strong community commitment. Specialist
services will be offered to support people to live at home taking account of the
changing population of Crawley.
Services will include community rehabilitation working closely with the Crawley
Intermediate Care Team; dementia services and the development of a care
suite at Maidenbower; a short break service for carers, one of which will be
specifically for carers within the black ethnic population and community
outreach services.
The main aim for Maidenbower will be to focus on intensive, time limited
intervention where appropriate and offer sign posting to other services within
Crawley as appropriate.
9.3 Horsham
Horsham Social and Caring Services provide services to the rural villages of
Henfield, Steyning, Storrington, Pulborough and Billingshurst and extends to
Partridge Green, Southwater, Broadbridge Heath and Horsham town including
Rudgwick, Rusper and Slinfold. This is co-terminus with the areas served by
Horsham district council and also the majority of Horsham and Chanctonbury
PCT.
Current population is approximately 122,000 and is projected to rise to 129,000
by 2011. By 2006, 23% of the population will be over 60 and 8.3% aged 75
plus with the highest percentage of people living in Storrington, Sullington and
West Chiltington.
WSSCS have four smaller day centres, one in Horsham and three in the
villages. There is also a 10 place day centre for people with dementia in one of
the residential homes that will be transferring to the independent sector. The
area also has eight day centres/clubs supported by the voluntary sector. In
addition WSSCS purchase 10 places in a private sector home in Billingshurst.
Within Horsham hospital there is a small day service for 10 to 12 people
providing short-term rehabilitation. There are also a large number of
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lunch/social clubs, two extra care schemes, home visiting schemes, community
transport and self-help groups.
There is increasing demand for services for older people with mental health
needs. It is becoming increasingly difficult to meet the needs of older people
with more advanced stages of dementia.
A Day Care Operational Group has been set up following a review of day
services in the Horsham Area in 2001. This is a valuable forum for sharing
good practice. Other good practice examples include, voluntary sector day care
grant funded by WSSCS linked to sheltered housing which has established a
range of community links; a club which runs in a sheltered housing scheme to
support people in early stages of dementia and their carers and a voluntary
sector day centre in a housing complex which supports very frail, older people.
There is a commitment to work closely with partner agencies. There is in
addition to links created with sheltered housing the opportunity to work with the
PCT to enhance the rehabilitation service and increase work on falls
prevention. The local vision is to provide day services, as opposed to day care,
which can be flexible enough to provide either a one off service, bathing,
educational opportunity, hot meal or a fully structured day in an appropriate
setting. The local services will focus on a range of need, including mental
health and be supportive to carers.
9.4 Mid Sussex
Mid Sussex Area/PCT serve a population of approximately 136,000 people
mainly living in the towns of Haywards Heath, Burgess Hill, East Grinstead and
Hassocks. There is a large rural area consisting of a number of smaller villages
and communities. The elderly population, 20,750, is predicted to significantly
increase over the next decade and are of above average affluence. Generally
Mid Sussex in not a deprived area, however there are areas of deprivation e.g.
Bentswood, Haywards Heath and Victoria, Burgess Hill. Historically there has
been little social services investment in day care, however, the strengths of Mid
Sussex include its mix of arrangements, the affluent area and the fact the
voluntary sector is very active.
Current day care provision includes one WSSCS day centre at East Grinstead
which accommodates up to 90 people a week. 34% attending are under 65
and 66% over 65. The highest proportion have mental health needs. There
are plans to relocate to a new and larger site extending the occupancy to 40 to
50 people. WSCC also own a Victorian building, the Yews, which
accommodates 30 voluntary groups. The purpose of the Yews is to provide a
community resource rather than day care. There is also day hospital provision
at the Princess Royal hospital and East Grinstead and specialist provision for
older people with mental health needs at Princess Royal.
There are 20 places at Blackthorns residential home for older people with
mental health needs. The home will be transferring to the independent sector at
the end of the year; the minimum future requirements are for 20 places.
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Mid Sussex has a number of day centres which are run by the Salvation Army
and Age Concern in Burgess Hill, Hayward Heath, Hassocks and East
Grinstead. There are a large number of luncheon clubs, social clubs, church
groups, meeting places and community facilities. Mid Sussex spend on grants
to voluntary organisations in 2002/2003 (all age groups) was 189,904 the
highest proportion being spent on daytime activities for older people.
The view of current provision is that day care lacks a vision and tends to be
more about respite, drop in and socialisation. The new day care centre at East
Grinstead will provide an exciting opportunity but will require joint planning with
local partners to secure the right focus in meeting local need. There is a wide
range of daytime activities within the community with good links with sheltered
accommodation including extra care
Gaps in service include the need for a seven-day a week service for older
people with mental health needs. In East Grinstead the absence of specialist
facilities mean that services cannot be provided early enough and there tend to
be more crisis management. There is also a need for improved service
provision for those with functional mental health needs, more sitting services
and services for ‘younger old people’ (60+).
Current developments include the intermediate care strategy, partnership
working, plans for the new East Grinstead day centre, luncheon clubs in
sheltered accommodation and four new short break schemes to support carers.
The options for the Yews in partnership with local stakeholders will continue to
be reviewed in the context of local community services.
The model for the future will mean a clear vision for day services that ensures
services are linked to an overall prevention strategy as well as supporting those
people with high care needs. Day care will be time limited and purposeful
including intermediate care and rehabilitation in partnership with other agencies
and longer-term specialist support for some people. The important role that
day services play in supporting carers, opportunities for work and employment
related activities and adult learning opportunities would be recognised. The
intention will be to develop integrated, socially inclusive, flexible and local
services in partnership with other agencies.
9.5 Western
Western Area/PCT serve a population of 212,000 people living in Chichester,
the Manhood Peninsula, Bognor Regis, Arundel, the five villages and the area
north of the downs including Midhurst and Petworth.
The view of current resources is that in order to improve services and target the
most vulnerable people, there should be a focus on partnership working to
provide intermediate care to support hospital discharge and avoid admission
within a social care/ health care integrated service. Services should be
smaller, more local and may be provided in a mobile form in rural parts of the
community.
Provision includes two larger multi purpose day centres, the Chestnuts and the
Grange and a smaller centre, Judith Adams. The PCT provide day services at
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St Richards and Bognor War Memorial hospital. There are day places in five
residential homes, four of which are transferring to the independent sector.
Arun District Council run a day centre in Aldwick. In addition there are
numerous luncheon and social clubs, particularly in the urban areas of
Chichester and Bognor Regis.
Developments are in progress at the Chestnuts multi purpose centre to provide
a service for older people with dementia. A further development is planned to
provide intermediate care for older people with an integrated health and social
care team. These developments will be rolled out to other parts of Western
Area. The intention is also to develop small specialist services in Arundel,
Selsey and north of the downs.
Gaps in service include the lack of a link worker to develop and support
community groups and co-ordinate local transport and small, local, flexible,
seven day a weekday services. There is a need for stronger links between
other services such as home care and clear care pathways.
The model for the future is stated as one where the Area and PCT work in
partnership to provide intermediate care and rehabilitation in integrated teams
which are time limited and where specialist day services are provided to
vulnerable people. There would be a range of community daytime activities to
support older people’s need for social interaction and stimulation. In this way
the Area/PCT will work together to provide day care to those with the highest
need and support the community to develop day time activities for older people
in order to live full and healthy lives in their own homes in the community.
END
Please refer to the first section of this report for the
Executive Summary, Conclusions and
Recommendations
.
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GLOSSARY
Best Value
A framework to help local councils
to improve the way that they deliver
services to the public in terms of
cost and quality
Care management
The process of assessing individual
need and arranging packages of
care to meet those needs
Four C’s
The four C’s used to review
services: consult, challenge,
compare and compete
Independent sector
Includes both voluntary
organisations and private agencies
which provide services
Market development
Making the best use of available
resources and working with partner
organisations to address the gaps
and increase the range of options
that can assist people to continue
to live in the community
National Care Standards Commission
An independent, non government
public body which regulates social
and health care services previously
regulated by local councils and
Health Authorities. At a future point
day care will be expected to
conform to the National Minimum
Standards.
Performance Improvement Plan
The improvement process formally
starts after the Best Value Review
has been completed and the
recommendations have been
approved. The plan is reviewed and
if it does not achieve the intended
outcome it is revised and the new
actions proposed
Policy and Development Group
A multi agency, strategic policy,
consultation group chaired by an
elected member. The group
referred to in the report is the PDG
for older people which acted as a
challenge panel throughout the
BVR
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APPENDICES
Appendix 1: Membership of BVR Working Group
Appendix 2: PEST analysis
Appendix 3: SWOT analysis
Appendix 4: Summary of Key Points and Issues Raised
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APPENDIX 1
BVR DAY CARE WORKING GROUP MEMBERS
NAME
ORGANISATION/ROLE
Alison Tuck
Project manager (Scrutiny and Review
Unit)
Mary Sinclair
Strategic Commissioning and
Performance Manager/ Working
Group Leader WSSCS
Martin Sherred
Service Manager WSSCS
Jenny Daniels
Service Manager WSSCS
Jennie Reed
Day Centre Manager WSSCS
Veronica James
Age Concern
Lesley Strong
Mid Sussex PCT
Jill King/ Sarah Grant
Western PCT
David Richardson
Unison
Claire Hellyer
Financial Services
Susanne Sanger
Management Audit
Sharon Plank
Service Manager WSSCS
Regular links were made with individuals and smaller working groups
including service users, carers, Personnel Services, Contracts, Training
and Development, Information Section, Care Management, staff,
managers, Areas/PCTs and partner agencies.
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APPENDIX 2
PEST ANALYSIS: DAY CARE SERVICE
POLITICAL
ECONOMIC
NHS and Community Care Act 1990
Best Value
Mixed economy
Unit cost
Joint review 1998
Market share
WSCC 5 year plan 1998
Ageing population
Health Act 1999
Alternatives to residential care
Modernising Social Services 1999
TOPSS agenda
Direct Payments
Budget constraints
Performance framework
Government settlements
Human Rights
Large rural areas
National Service Framework
FACS 2002
Care Trust
Best Value Review 2003
SOCIAL
Ageing population
TECHNOLOGICAL
Absence of adequate information
systems
Increased expectations
Insufficient hardware
Demography
Few communication aids
Core competencies
Training needs
High employment
Older workforce
Large rural areas
Transport access
Integration of different groups
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APPENDIX 3
SWOT ANALYSIS: DAY CARE SERVICE
STRENGTHS
•
•
•
•
•
•
•
•
•
Social interaction
Reduces isolation
Meal
Prevents/ delays admission to
residential care
Maintains/promotes independence
Diverse in line with community
needs
Staff with skills, experience and
expertise
Learning opportunities
Monitoring/ reviewing care
programmes
WEAKNESSES
•
•
•
•
•
•
•
•
•
•
•
•
•
OPPORTUNITIES
•
•
•
•
•
•
•
•
•
•
BVR Day Care
Vision and strategy for day care
Higher profile for day care
services
Modernised services
Greater flexibility i.e. hours
Better access to ordinary services
Clearer access to services
Needs led services
Equity
Responsive to local community
Institutionalisation/ dependency
Lack of flexibility
Transport limitations
Large buildings and catchments
areas
Tension between range of need
Labels people
Insufficient resources e.g. staff
and equipment
Absence of day care strategy
Difficulties in access into and
between services
Lack of care plan/ purpose for
attendance
Generally low occupancy levels
Nothing to move on to
Gaps in provision/ imbalance in
provision
THREATS
•
•
•
•
•
•
•
•
BVR of day care
Budgetary constraints
Same pot of money/ no new
money
Charging across different
organisations
Inequity
Political issues
Changes for services users and
carers
Changes for staff
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APPENDIX 4
A SUMMARY OF KEY POINTS AND ISSUES RAISED
1. The Best Value Review (BVR) of day care is part of a wider BVR, which
examines services for older people in West Sussex. The prime purpose of
the BVR was to make a real and positive difference to the day service that
people receive.
2. The working group gathered information for the BVR under the headings
of consult, compare, challenge and compete.
2.1 Consult
2.1.1The BVR working group designed a consultation process that included
a cross section of stakeholders. Exercises undertaken prior to the BVR and
information from other sources was included.
2.1.2 Monthly meetings were held with managers of the twelve in-house day
centres to gather and share information. The expectation was that
managers would ensure that staff were kept informed of the progress of the
BVR.
2.1.3Main reasons for attendance at the day care centres were expressed
by service users as being company, activities, a meal and to get away from
the same four walls
2.1.4Carers wanted respite although not necessarily in a day centre and
greater flexibility of days and hours.
2.1.5Transport issues were raised at most meetings. Travelling especially
in rural areas where the journey may be long was seen as a reason for nonattendance.
2.1.6Services for older people with mental health needs should be seven
days a week. Separate provision for those with functional and organic health
needs were requested.
2.1.7Day services lack a vision. There are no clear care pathways and
routes in and out of day care can be confusing.
2.1.8The ability to identify socially inclusive daytime activities as a of part of
preventative services is important
2.2 Challenge
2.2.1 The work of the BVR working group was challenged throughout by a
number of different groups with a cross section of stakeholders.
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2.2.2 A challenge panel was established as part of the Policy and
Development Group for Older People. A critical friend who was a carer
representative was identified.
2.2.3 Opportunities for challenge by other meetings with stakeholders were
also used.
2.3 Compare
2.3.1 In order to compare the in-house day care service a benchmarking
exercise was undertaken with other LAs. Most LAs had either completed or
were in the process of undertaking reviews of their day care service.
2.3.2 Most LAs are not providing multi-purpose day centres. The focus of
day care is targeted and moving toward people that are more dependent
and have specific care needs.
2.3.3Common themes arising from consultations in other LAs included high
satisfaction although some service users and carers requested more flexible
hours, extra days, local day care and involvement in care planning.
2.3.4 Developments included link workers supporting people to access
ordinary activities in the community, mobile day care in sheltered
accommodation, closer integration of day hospital and day care, smaller,
local centres, intermediate care and rehabilitation with an emphasis on
independence and reablement.
2.3.5 Comparison with the independent sector indicated that for some
people the services could be very similar to that provided in a statutory day
care centre. There are service users who attend day care when there may
not be a specific care need.
2.4 Compete
2.4.1A strategic target for WSSCS is a reduction in the use of residential
care in favour of community based services that include home care and day
care
2.4.2National and local principles have an influence on future service
direction. These include partnerships, prevention, intermediate care,
rehabilitation and social inclusion.
2.4.3Options considered by the BVR working group for the future day
service included do nothing, withdraw, total in-house service and market
development.
2.4.4The recommendation was market development as this was regarded
as being the most likely option to achieve a modern day service.
2.4.5A modern day service would include daytime activities and day care.
The focus would be on maximising the range of resources in the community
to ensure social inclusion. Where a care need is identified this would either
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be very specific and time limited e.g. intermediate care or rehabilitation, or
for some a longer term specialist facility.
3.The success of the modern day service depends on good information and
market management, community development and out reach, appropriate
training and working in partnership with a range of organisations.
4.Areas/PCTs have different demographic and resource issues and will wish
to consider how to implement the change in their area. One model fits all is
not appropriate for a modern day service that seeks to meet the needs of
service users and carers within their local communities.
5.The modern day service approach emphasises the range of opportunities
that already exist from pub, café, social club, educational facility, leisure
centre, luncheon club, library, church group, voluntary organisation, libraries
and the potential for maximising social inclusion. The model looks outward
and away from buildings. Where buildings are used the facilities need to be
dynamic and flexible, there may for instance be specialist provision and
equipment, shops within a shop and a variety of different community
facilities
6.Longer term provision may be provided by different organisations and
need also be dynamic and flexible maximising opportunities for participation
in ordinary activities wherever possible.
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