Cyngor Sir
CEREDIGION
Adran y
Gwasanaethau
Cymdeithasol
Department of
Social
Services
CEREDIGION
County Council
The Ceredigion Strategy
for
Older People
Ceredigion
Adran y Gwasanaethau Cymdeithasol
Social Services Department
August 2004
CONTENTS
1. Introduction
2.
3.
Background preparation
4.
3.
4.
Current position –
Assessment and Analysis of Need
5.
Audit of existing provision by way of
Summary analysis of the current
Service system for older people
7.
5.
Carers Development Plan 2004/05
15.
6.
Objective and Targets for Programme
23.
Building Block 1
Engagement and partnership with older
people - Real Listening and involvement
23.
Building Block 2
Enabling self-help culture to underpin
the vision
23.
Building Block 3
Develop whole system approach
24.
Building Block 4
Rebalancing the accommodation system
25.
Building Block 5
The hospital/community interface
26.
Building Block 6
Integrating services at a local level
27.
Building Block 7
Partnership and commissioning
29.
7.
Diagnostic Structure
29.
8.
Proposals for next stage
30.
Appendix –
Framework for whole systems working
31.
2
All Wales Strategy for Older People: Final Development Plans
THE CEREDIGION STRATEGY FOR OLDER PEOPLE
August 2004
1.
INTRODUCTION
Ceredigion’s Strategy for Older people is currently based upon its Accommodation Care & Support
Strategy for Older People.
The County Council had already embarked on a strategic approach to services for older people
firstly in response to local challenges around accommodation and secondly following
recommendations arising out of the Joint Review. Both the Cabinet and thereafter a group of cross
party leaders/members gave support to this approach.
Chief Officers of all partner agencies as well as the Cabinet have endorsed the strategy itself and it
has also been agreed to aim to use the document as a core common planning tool across
agencies.
The plan was approved by the Ceredigion County Council Cabinet on the 25th March 2003.
Following a report from the Audit Commission review of Delayed Transfers of Care in December it
was agreed by the interagency heads of service that this should form the overarching strategy for
this area of operation. Arising from the analysis of Ceredigion’s needs four themed targets were
identified namely:

Engaging older people as partners and developing an older people focused vision.

Rebalancing the accommodation system and services.

Developing a joined up approach at a locality level.

Building a stronger partnership approach to strategy development and commissioning
services across health, social services, housing and more widely to tackle capacity issues
and develop an approach to service and system redesign.
The Health Social Care & Well Being Strategy Group is becoming the County’s integrated planning
group. It includes all the main stakeholder agency heads and is chaired by the Chief Executive with
significant input from the Director of Social Services. This group has been gaining increased
maturity and has already drawn from the Older Person’s Strategy for its model of analysis. This
basis should provide a structural seed bed in which Ceredigion’s Older Person’s Strategy can be
embedded, and thereby implemented across the Social Care economy but can continue to evolve
and develop.
In summary, our wish is to implement a strategy which addresses the changing expectations of
older people, based on a vision for growing older in Ceredigion and including the place of older
people as citizens. In essence we wish to:

Get the foundations right for the long haul.

Adopt a partnership approach which engages both older people and other agencies and
sectors (such as the health service and the independent sector) in the development of the
strategy, based on a recognition that older people want joined up (whole system) solutions.

Get a joined up agreement on the changes needed.

To implement real changes that makes a difference to real lives.
3
2.
BACKGROUND PREPARATION
In preparing the ground there has been:

An analysis of existing data, including background demographic and health data; policy,
performance and service reports; financial information; and national reports from the Welsh
Assembly and other sources.

A process of telephone or face to face interviews with a range of stakeholders in order to
understand better how the current service system works and the issues that need to be
addressed.

Discussions with and visits to a number of providers of direct services including hospitals
(both community hospitals and the general hospital); residential homes; sheltered housing
schemes; Age Concern, Care & Repair and the Home Improvement Agency.

Specific meetings/workshops on Supporting People; and capital finance for new
housing/hospital developments for older people.

A full day development workshop with over 50 people, including older people. This enabled
us to feedback on findings so far and to develop ideas for action.

Further feedback on what is good about growing older in Ceredigion upon which to build;
and what are the areas for improvement.

The Involvement of stakeholders in planning the next stage of work by working on 4
themes:




analysis of a range of documents, including background demographic and health data;
policy, performance and service reports;
financial information;
and national reports from the Welsh Assembly and other sources.
4
3.
CURRENT POSITION - ASSESSMENT & ANALYSIS OF NEED
Ceredigion Local Health Board and Ceredigion County Council are jointly developing a Health,
Social Care and Well-being Strategy for the County.
(Detailed information on the Needs Assessment is contained in a separate document of reference,
“On the State of Health, Social Care And Well-Being in Ceredigion”– A preliminary technical needs
assessment, November 2003)
Older People in Ceredigion

The county has the highest relative population growth in Wales and 22% of the population are
pensioners (and growing, especially 85+ and from incomers to the County) – the 3rd highest
area in Wales. Outward migration of the young and inward migration of older people leaves
what is an ageing population isolated from family networks and with fewer young people.

There are variations in the proportion of the older population across the County – from 16.5%
in the north to 26.7% in the south.

Ceredigion has the highest life expectancy of all areas in Wales

The County has a lower than average level of long-term limiting illness (but the student
population may distort this figure).

There is a high % of older people aged 75+ living alone. The number of older people from
minority ethnic groups is very low.
Health and well being indicators for Ceredigion overall

There are a number of issues related to poor housing conditions – a higher than average % of
unfit dwellings; households lacking amenities; pre 1919 properties. Ceredigion has the highest
percentage of homes in Wales without central heating (16%). The county has the highest
percentage of homes owned outright (70%). There is however a lack of affordable,
accessible, well-designed Social Housing.
Income/Poverty
The whole of Ceredigion is an Objective One area. This means that the overall Gross Domestic
Product (GDP) of the county is less than 75% of the European Union average. There are few
opportunities for local employment and with low wages and the lack of affordable housing, young
people tend to migrate out of Ceredigion. This has implications for balanced age structure and for
intergenerational work.

There are lower than average levels of crime. Ceredigion has the lowest level of recorded
crime in England and Wales but incidences of violent crime, alcohol misuse and drug
trafficking are increasing.

There is a very high road traffic accident casualty rate. It records highest hospital episode
rates for serious accidental injury in Wales.

There is a higher than average level of social capital (measured by the proportion of people
voting and a higher than average level of civic engagement but declining) and a relatively high
number of community organisations. A declining proportion of young people undermines
social cohesion. There has been an increased provision of community centre/village hall
facilities for multipurpose community use.
5

Ceredigion has the second lowest population density in Wales, and this makes it difficult to
deliver services across a large thinly populated area. This can result in a negative impact for
people living in isolated areas; and highlights the key importance of rural transport links.
There is a need for the systematic and creative use of modern telecommunication.

There is a lower than average level of geographical access to the County. This means that it
is hard to attract certain services because of the distance of Ceredigion from other parts of the
UK and it reflects the poor transport system leading to the county from other parts of Wales
and the UK.

The quality of the physical environment is seen as high
Disease
Main causes of death are coronary heart disease, cancers, stroke, respiratory diseases and
trauma. Main causes of premature (under 75 years of age) death are cancers, coronary heart
disease, and stroke and trauma. The main cancers causing death are lung, breast and large
bowel. Ceredigion has the lowest suicide rate in Wales, however, there is a year on year increase
in suicide in women.
North Ceredigion, centred on Aberystwyth, tends to fare better than the rest of the county and
South Ceredigion, centred on Cardigan, tends to fare worse. The hotspot wards i.e. those, which
have two or more health and well-being scores (as measured in the Welsh Index of Multiple
Deprivation) in the most deprived quintile (20%) in Wales are Tregaron, Llangeitho, Capel Dewi,
Llanwenog, Llanarth, Llanfihangel Ystrad, Ciliau Aeron, New Quay, Ceulanamaesmawr, Penbryn,
Troedyraur, Beulah and Aberystwyth South.
Economy
The county has a significantly smaller proportion of small manufacturers as employers than other
parts of Wales. Recruitment to jobs is difficult partly because of low wages, relative costliness of
housing etc and because of geographical isolation. The impact of an ageing population on both the
availability of staff and the needs of the care services to recruit suitably qualified staff in the future
will be significant.
Services for Carers
2.6% of the population provide informal care for more than 50 hours per week - 10.4% of the
population are informal carers.
Secondary Care Sector
Inadequate development of specialisation because of the very low catchment population of the
general hospital and resultant lack of critical mass e.g. no Consultant Rheumatologist and no
Stroke Physician.
6
4.
AUDIT OF EXISTING PROVISION BY WAY OF SUMMARY
ANALYSIS OF THE CURRENT SERVICE SYSTEM FOR OLDER PEOPLE
The analysis focuses on:

Corporate Issues.

Services: the hospital system; rehabilitation; primary care; mental health; social care; the
housing and accommodation system; prevention and active ageing; and community support
and self help.

Engaging older people.

Partnership working, strategy and commissioning.

Growing older in Ceredigion.
Corporate Issues

The County Council has formally accepted the local Strategic document but there is a need
to implement its implications across other Departments and the relevant strategic theme.

Need to re launch the strategy within the Authority and across partner agencies
Hospital system

There are pressures around Accident & Emergency; & delayed transfers of care (hospital
discharges) and these are being successfully addressed.

There have been issues around developing effective discharge processes between hospital
and community based services. Much progress has been made with the interagency Delayed
Transfers of Care group.

Plans are being developed to reconfigure the community hospital services at Tregaron and
Cardigan – but as yet there is no shared strategy across the three agencies to help health
look outside hospital walls and into the area of primary care.

There is evidence to suggest that we should bring together hospital & community
Occupational Therapists.

There is a need to strengthen and further develop alternatives to hospital admission.
Rehabilitation

Adref yn Saff has been developed as a 6-week hospital based re-ablement scheme, jointly by
health and social services.

An Intermediate care strategy is being developed in partnership across agencies and will be
going out next month to relevant stakeholders. An Occupational therapy pilot is in place to
move the culture of the Home Care service from “dependency” to “enabling”.

A Falls clinic developed by Health jointly is at an advanced stage.

An Osteoporosis service has been established as a prevention service by health with across
agency support. Work is currently underway in residential care with related, accurate and
timely drug administration. There is also a protector trial within a residential home.

In partnership with housing/sheltered housing a report has been undertaken of property &
tenants dependency levels. Work is in progress on changes to warden arrangements but
much remains to be done in the longer term
7
Primary care

The key issues are the development of stronger community based support systems for GPs
to refer to instead of using the hospital and long-term care systems, and the potential to
influence outcomes expected of GPs through the new GP contracting structure. Provision of
step up/step down places has been made.

Good links are developing between health and social services on a locality basis. Social
work & community staff are based in GP surgeries at Lampeter and Borth and at community
hospital sites at Cardigan & Aberaeron.

Further work is needed to develop the district nurse/home care interface. Two pilots have
taken place: one successful and one although unsuccessful is proving to be a useful learning
experience.

Joint work is taking place with the Human Resources department of the Hospital Trust on the
shape of the future workforce
Mental Health

There is recognition from health and the County Council that services for older people with
dementia and mental health problems are under developed. A separate strategic plan has
been in place and a new residential service is at an advanced stage of commissioning.

Nursing/residential home and supported housing places.

Specialist home care.

Day care.

The role of the Alzheimer’s Society Information, education & voluntary sector support has
been developed.

There is a need to develop Memory clinics & promote early diagnosis.

Following from this there is a need to link primary care more closely with other communitybased services for older people with mental health problems and an increased usage of
assistive technology.
Social care
Identified areas of shortfall in Ceredigion’s 2002/2003 Strategy Document and our progress:

In 2002/2003 Social Services Performance Indicators, in comparison with other Welsh
authorities, have shown: a higher than average number of delayed transfers of care for social
care reasons, use of residential care and nursing homes; a slightly lower than average level
of respite care and rate of older people aged 65+ helped to live at home.

Action on both these fronts has improved considerably. We have shown a month-by-month
reduction in delays and although this figure will rise again, our long-term plan includes
increasing capacity which will kick in during 2005/2006.

On the respite care performance and numbers of older people helped to live at home, we
have moved into the upper quartile of Welsh Authorities.

We do need to join up strategy and service systems to ‘enable’ more older people to be
supported at home – linking with health, housing, community based services, and transport.
This has already occurred for the Health Social Care & Well Being Strategy but is a target for
2004/2005
8

Development areas had been identified in the 2002/03 programme as:

The Carers Strategy - Considerable progress has been made here (See submission and
progress reports).

Prevention - Work is in progress here on a partnership basis particularly in the areas of
Home Safety (Care & Repair) and Assistive Technology (Care & Repair work in progress
on pilot site).

Hospital admission and discharge - to be reviewed.

Intermediate care - Joint draft strategy and agreed elements of good practice from
2003/04 onwards.

Unified Assessment Process - Considerable progress in this area

There are key pressures around: staff recruitment; specialist skills; STET and time and
resources to plan and implement change but there is clear evidence of progress.

Recruitment and retention of personnel in Homecare has become a central challenge and is
beginning to impact negatively upon hospital discharge arrangements.
The accommodation system

There has been pressure on the nursing and residential care system around fee levels and
potential shortage of places in some areas.
Action: Clear progress on these fronts. Increased fee levels compare well with other Welsh
Authorities.

The role of sheltered housing needs developing to provide a real choice for older people
between general housing and residential care. In order to offer a ‘home for life’ there is a
need to address both physical standards in some schemes and service models, including the
role of sheltered housing wardens.
Action: We are in the initial stages of re-engineering Supported Living arrangements and are
wrestling with agreement on a shared corporate model.

Extra Care-need to find creative capital funding solutions that may lie in the ‘For Sale’ & ‘For
Rent’ area.

There is a need to develop ‘floating support’ services for older people in general housing,
making use of the potential provided by the introduction of Supporting People.

The potential of using community alarm services and new technology as support services for
older people in the community are undeveloped.

Further work is needed to develop a more joined up Care and Repair and adaptations service
for older people.

There appears to be very limited capital available from public sector sources to rebalance the
accommodation system, apart from health funding for community hospitals. The level of
revenue funding for support services to be converted into Supporting People funding is also
currently at a very low level.
Set out below are tables that have been prepared to show the current provision in different parts of
the accommodation system, together with day services. There may be some inaccuracy in the
figures.
9
Accommodation provision
This information will be used as the basis for assessing the desired future configuration of the
accommodation system in the County. The tables show some clear gaps and imbalances in the
current system, for example the lack of nursing home places for people with dementia; and the lack
of sheltered housing in the Tregaron area.
Table 1: General Hospital, community hospital and nursing home places
General
Medicine
Hospital
81
29
0
0
25
135
Districts
Aberystwyth
Tregaron
Aberaeron
Llandysul & Lampeter
Cardigan
Totals
Nursing Home
OP
RMNB
68
0
0
29
25
122
0
0
0
0
0
0
Table 2: Residential care places
Residential
Private
Ord
EMI
Districts
Aberystwyth
Tregaron
Aberaeron
Llandysul & Lampeter
Cardigan
Totals
*2 Respite
*4 Assessment
90
5
21
53
41
210
LA
1
0
0
0
0
1
Ord
EMI
Perm Respite Perm Respite
56
5
10
*6
13
2
0
0
28
2
0
0
44
2
8
0
31
1
0
0
172
12
18
0
Table 3: Sheltered housing places
Districts
Aberystwyth
Tregaron
Aberaeron
Llandysul & Lampeter
Cardigan
Totals
Sheltered
RSL
LA
Units
32
133
0
0
0
54
0
52
35
92
67
331
10
Table 4: Day services (day hospital, day centres and luncheon clubs
Districts
Aberystwyth
Tregaron
Aberaeron
Llandysul & Lampeter
Cardigan
Totals
* Day Hospital
Day
Lunch
Centre
Club
*1
4
1
1
0
2
2
2
1
2
5
11
Prevention and active ageing

There is recognition by both Social Services and the Local Health Board as to the
importance of services that promote active ageing and prevent decline.

There is a range of preventative services provided by Age Concern: information &
advice; income maximisation; befriending; lunch clubs; exercise; home cleaning;
shopping; nail cutting; day centres; gardening; insurance. Some of these services
receive health and/or social service funding.

The services that have been developed reflect the services that older people say they
want to remain living independently in the community.

Based on information provided by Age Concern, there appears to be potential for
volunteer recruitment in the County, as long as the infrastructure funding is provided to
train and support volunteers and fund their travel and expenses.
Action: To appraise current Service Level Agreements with Age Concern

The Local Health Trust has developed the infrastructure for a Falls Clinic. Within the
Intermediate Care Strategy there will be a proposal to develop a community based Falls
Prevention Service.
Regeneration, Community support and self-help

Given the rural nature of Ceredigion, how far do local communities support their older
people locally, or older people provide support to each other? This is asked as a
question at this stage, but came out in the development workshop as a key issue to
address in a strategy given the geographical difficulties of providing support services to
rural communities. The need was identified to link the Older People's Strategy into the
wider Community Strategy for Ceredigion, and to ensure that older people's issues are a
visible part of social regeneration and community well-being for the County.
Action: This is included as a target for 04/05.
11
Partnership working, strategy and commissioning
The absence of a joined up strategy between health and social services housing and the wider
service agenda in relation to older people, has been recognised as a need. In response a
mechanism for providing a platform for this has been established.

Across the board there is eagerness to breakdown barriers and build better working
relationships.

There needs to be an under-pinning structure to support the good relationships that exist.

There has been strong feedback from across the spectrum desirous of building a more
joined up system which puts older people at the centre.

There was a willingness of people to move beyond their own way of doing things –
people centred not organisation or service centred. Most people mentioned a “user
centred approach” as one of the key changes required.
The November 2003 development workshop included a number of senior staff from the County
Council, as well as senior staff and non Executive members from the health sector, and
independent sector representatives, who supported the principle of setting up a strategic planning
structure to underpin the development of a joined up strategy for older people in the County.
Action:
In 2003/2004 an across agency “Holding group” was established that became a Health, Social
Care & Wellbeing Strategic Planning Board. It will be necessary to confirm this as the strategic
group into which all across agency developments are agreed & ratified.
Locality Working
The group work at the development workshop also identified the lack of, and need for a locality
approach within the county, to enable services – both formal and informal - to work in a more
effective and joined up way. This has been confirmed as an emerging theme within the Health
Social Care & Well Being Strategy.
Conclusions
There is much that is positive on which to build.
Set out below are just a few examples of service developments going on in the County, which
reflect cross sector and multi-disciplinary working.
Examples of cross-sector initiatives:

Adref yn Saff collaboration between health and social services.

Use of sheltered housing for day care and additional support.

Growing examples of co-location of staff – in surgeries and community bases.

Joint working across health, social services and the voluntary sector on day care.

Joint Equipment Store.
There is recognition and awareness of the service and funding areas that need addressing, but
also a need to fine up a clear view of how to get there.
There is also support for a whole system approach, in line with The Strategy for Older People in
Wales, and the need for a cross sector strategic planning and commissioning mechanism to deliver
joined up change.
12
In addition, there is support for engaging older people and developing an older people centred
strategy that promotes health and well being in older age rather than a traditional service led
strategy.
Within the National Strategy there are a number of pegs to lever in a range of other resources –
from rural regeneration to transport, to lifelong learning to the National Service Framework (NSF)
and intermediate care, to name but a few. Now that the Older Persons Strategy Co-ordinator is in
post we can, together with the building blocks of an engagement approach with older people and a
partnership whole systems approach, ensure the co-ordination of resources and tap into newer
funding sources.
Consultation with older people
A full day development workshop with over 50 people, including older people, to:

Feedback on findings so far and ideas for action

Get further feedback on what is good about growing older in Ceredigion on which to build
and on what areas need improvement

Involve stakeholders in planning the next stage of work by working on 4 themes:




Engaging older people as partners and developing an older people focused
vision
Rebalancing the accommodation system and services
Developing a joined up approach at a locality level
Building a stronger partnership approach to strategy development and
commissioning services across health, social services, housing and more widely
to tackle capacity issues and develop an approach to service and system
redesign
Age Concern runs regular focus groups in order to consult older people on their issues and
priorities. The outcomes from these groups feed into the planning which Age Concern undertakes
in terms of prioritising the development of new or additional services to meet older people’s needs
and aspirations. This work has developed to include a County wide Involving Older People Forum
workshop and The Rehearsal for Reality theatre which enables older volunteers to use theatre
techniques to demonstrate the real issues identified by older people. This is portrayed in a short
piece of theatre to a mixed audience including planners and policy makers. The audience are
encouraged to participate in sharing ideas on existing and potential solutions. (See separate Age
Concern Engagement Strategy document).
Growing older in Ceredigion
As part of the development workshop on 19 November 2003 participants were asked to identify
what was good about ‘growing older in Ceredigion’ (the strengths) and what were the areas for
improvement (the weaknesses).
The write-up from the Groups is given below. This represented a valuable insight into the views of
a range of stakeholders. It provides a basis to build on the strengths and to address the areas for
improvement. Below are highlighted some key areas that can inform the development of the
strategy.
13
Key points from Appendix 1
Strengths








Nice place to live
Access to primary care
Voluntary provision
Growing voice for older people
Joint working
Socialisation opportunities
Free bus journeys
Lifelong learning
Areas for improvement









Diverse housing provision
Intermediate care
Isolation of older people and services
Transport
Aspects of health provision
Communication/joint working
Lack of service choice
Limits of lifelong learning
Downside of volunteering unless it is
handled right
However there had been no formal engagement models with older people in the county.
Action:
This was a target for 03/04 and the funding of a specific post under a partnership arrangement with
Age Concern has been implemented
The health service and the local authority also undertake consultation on specific issues or plans,
mainly as required by government. However, these consultations, and the structures that underpin
them such as the Health Alliance, are often not older people specific, nor do they start from the
older person’s perspective.
Action:
To link the Older People's Strategy into the wider Health Social Care & Well Being strategies for
Ceredigion, and to ensure that older people's issues are a visible part of Health, Community Safety
and Transport strategies
14
5. CARERS
THEME
Valuing
Older
People
Strategic
Objective:
Development Plan 2004/05
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
MONITORING &
EVALUATION
PERSON
RESPONSIBLE
Person in post.
Plan in place
Implementation
of plan in
progress
Director Age
Concern
Six monthly
reporting.
& SLA
Age
Concern
Coordinator
Appointed
Telephone Club
worker
Volunteer
support
Clients input
Feedback /
Evaluation
Director Age
Concern
Six monthly
reporting.
& SLA
£
To enhance
engagement
&
Participation;
this is also a
priority within
Ceredigion’s
strategic
strategy
Telephone Club
To engage with
those who are
isolated by
rurality,
transport
difficulties, low
income,
language
barriers.
Year 1
03/04
Year 2
04/05
Establish
an across
County
framework
To provide
core coordination
16k to Ceredigion Age
Concern
SLA with
Age
Concern
Agreement on
Involving
People
post
To include
isolated
(rural),
disadvantaged
groups
(disability)
older people
in
consultation
£
Tel 30 2 per
month
Phone, hire
Staffing
Appointed
Telephone
Club
worker
Volunteer
support
Clients
input
Feedback/
Evaluation
£1,440.00
£218.00
£2,880.00
£4,538.00
Year
3
05/06
Age
Concern
Coordinator
15
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
MONITORING &
EVALUATION
PERSON
RESPONSIBLE
Three
organised
forums per year
in main towns.
Potential to
evolve steering
groups to
manage
forums.
Director Age
Concern
Six monthly
reporting.
& SLA
Age
Concern
Coordinator
Events to
take
place
An event to
include details
on Health,
Finances,
Community
care etc
Director Age
Concern
Six monthly
reporting.
& SLA
Age
Concern
Coordinator
Events to
take
place
Target day
centres and
other groups
and clubs with
high
populations of
older people.
Age Concern
Co-ordinator
£
Year 1
03/04
Fora
Open meetings
involving all
sectors focusing
on topical issues
Information
Giving Event
Theatre Forum
To allow open,
tangible, public
meetings
inviting all
sector
representatives,
held in highly
populated areas
throughout the
county to
discuss topical
issues
To provide
information on
general and
topical issues
related to older
people.
Venues x 3
Facilities
Materials
Mailouts
Expenses
Management/
Staffing
To take issues
and allow
interaction
within day
centres and
clubs across
Ceredigion
Training
Room hire
Travel expenses
Materials
Performance
Value
Venue
Facilities
Mailouts
Expenses
Staffing
£180.00 For a in
£150.00 place
£175.00
£ 75.00
£150.00
£1,500.00
£2,230.00
£180.00
£150.00
£75.00
£150.00
£72.00
£627.00
£500.00
£216.00
£500.00
£500.00
£200.00
£1916.00
Year 2
04/05
Year
3
05/06
16
THEME
Valuing
Older
People
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
MONITORING &
EVALUATION
£
Year 1
03/04
Attendance at
existing fora
Consultation
with Older
Peoples
Champion
Newsletter to
link in with the
Health Social
Care & Well
Being
newsletter
Year 2
04/05
PERSON
RESPONSIBLE
Year 3
05/06
To
acknowledge
interests, and
discussions
beyond those
selected for
consultation.
To enable
participation
through
existing
familiar
channels
To maintain
corporate
involvement
Within existing budgets
To
determine
nos. of
informal
events
To actively
attend meetings
of existing older
peoples forums,
senior citizens
clubs, groups
across
Ceredigion.
Age Concern
Co-ordinator
Within existing budget
One
meeting
per year
Director Age
Concern
Director
Age
Concern
To enable the
sharing of
information,
an alternative
form of
communication. An
opportunity
for feedback
on the
Strategy for
Older People
Staff
Materials
Mailout
Publisher
Alternative
sources
First issue
04/05
Recorded
meetings with
Older Persons
Champion
Newsletter in
print and
inclusive of
viewpoints
Director Age
Concern
Director
Age
Concern
£3,000.00
£400.00
£600.00
£150.00
£400.00
£4,550.00
17
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
MONITORING &
EVALUATION
PERSON
RESPONSI
BLE
Service
Manager
Older
People
Older
Persons
Strategy
Coordinator
£
Year 1
03/04
CARERS
Year 2
04/05
Year 3
05/06
Maintenance of
Consultation
Group
SS mainstream budget
Continuation
Regularity of
meetings
A.D. Adult
Services
Elevating
Strategy on a
Corporate basis
SS mainstream budget
Links to
Corporate
Management team
Links to
Corporate
strategies
Renegotiate
with the
existing
Organisations
Engagement with
Highways
Property &
Works
Strategy in
place
Observable
higher profile
on a corporate
basis
Evidence
Inclusion
within
Corporate
Amendments to
SLA’s
Older Persons
Strategy Coordinator
Heads of
Service
Organisations.
Inclusion of
particular
needs of Older
People within
the strategy
Service
Manager Older
People
Older Persons
S.C. in
conjunction with
Transport
Strategy leads
OPSC
Continue to
fund Age
Concern; CAB;
and CAVO &
WRVS
Maintenance
and extension
of volunteering
opportunities
SS mainstream budget
To engage with
the Community
Transport
Strategy
To help develop
a better
community
transport
system
To underpin
Carer’s Special
Grant Scheme
Plan
Mainstream budget
Developing
Carers Strategy
Mainstream budget
04/05
Manag
-ement
Team
18
TOOLSDESCRIPTION
AIMS
SPENDING
PROPOSALS
TARGET DATE
MILESTONES
MONITORING
&
EVALUATION
Observable
higher profile
on a
corporate
basis
OPSC &
assistant
Director (SS)
PERSON
RESPONSIBLE
£
Strategic ThemeChanging Society
This is not to be a
targeted theme
within Ceredigion’s
Older Person’s
Strategy for
2004/05 other than
a part of the
department’s drive
to bring it to the
fore as part of the
corporate agenda
Strategic ThemeLiving Longer &
Healthier Lives
For 2004/05 This
is to remain as part
of the
department’s
engagement with
its partner
agencies in work
that is already
ongoing
Year 1
03/04
Skills of Older
Persons
Strategy Coordinator
Continuation of
its promotion at
a corporate
level within
leisure learning,
personnel and
IT & economic
development
Engagement
with the
progress and
advancement of
the Health
Social Care &
Well being
Strategy
Intermediate
Care
Developments
SS budget
Year 2
Year 3
04/05
05/06
Corporate
engagement
Intermediate
Care coordinator in
post
19
TOOLS-
AIMS
DESCRIPTION
SPENDING
PROPOSALS
TARGET
DATE
MILESTONES
MONITORING
&
EVALUATION
PERSON
RESPONSIBLE
Consultant
Nurse for
Older People
Ceredigion &
Mid Wales
Trust
Dr. Hugh
Chadderton
N/A
N/A
N/A
£
Year 1
03/04
Knowledge
Base
Strategic Theme:
Coping with
Increasing
Dependency:
Housing Social
Care & Health
Unified
Assessment;
Carers Strategy;
National minimum
standards
These are reported
upon elsewhere
and monitored
separately by the
Assembly
Good
progress has
been made in
each of these
areas as
validated by
WAG
Inspection
reports
Support for
the ongoing
Falls Clinic
development
To establish
the base level
local role and
work being
undertaken
within the LA
in this area of
Health
Promotion
Imputed Costs -use
of LA facilities
N/A
N/A
Mainstream budget
Year 2
Year 3
04/05
05/06
Local Health
target
Establish
baseline of
resources
N/A
N/A
N/A
20
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
£
Strategic
Theme: Coping
with Increasing
Dependency:
Housing Social
Care & Health
Local Strategic
Aim:Rebalancing
the
Accommodatio
n System
(Rationale
explained
below in the
document
Partnership
with Housing
Dept. &
Supporting
People
Year 1
03/04
Year 2
04/05
MONITORING
&
EVALUATION
PERSON
RESPON
-SIBLE
Year 3
05/06
04/05
Restructuring
of Warden’s
terms &
Conditions
Provide better
support within
Sheltered
Housing
£35000 Mainstream Budget
and onwards
03 04
Night & week
end care
To enable
people to stay
in their own
home
£26000 standby allowance
Jan 05
New job
description
terms &
conditions
being
implementted
Appointment of
staff
Housing
Officer/
Direct
Services
Manager
Direct
Services
Manager/
Housing
Officer
Housing
Officer/
Direct
Services
Manager
Direct
Services
Project
Development
Manager
21
TOOLSDESCRIPTION
AIMS
SPENDING PROPOSALS
TARGET DATE
MILESTONES
£
Year 1
03/04
Year 2
04/05
Year 3
05/06
Technical
Officer in
Post
Consultancy
engaged
Equipment
purchased
Completed
Project
Board
Service
Manager
Older People
Housing/
SS
Assistant
Director &
Consultants
Pilot Assistive
Technology
project
To enable
people to stay
in their own
home
£26000 (04 05)
Dec 04
Sheltered
Housing
Tenants &
Property survey
To inform
strategic
approach
Mainstream budget and
imputed costs
03/04
MONITORING
&
EVALUATION
PERSON
RESPON
-SIBLE
22
6.
OBJECTIVES & TARGETS FOR PROGRAMME
This section of the report sets out the building blocks for developing a whole system strategy for
older people in Ceredigion, with an initial focus on accommodation, care and support.
Set out below are a number of building blocks with proposed action proposals for next steps for
each building block. The building blocks are:
1.
2.
3.
4.
5.
6.
7.
Engagement and partnership with older people
Culture to underpin the vision
Whole system planning framework
Rebalancing the accommodation system
The hospital/community interface
Integrating services at a local level
Partnership and Commissioning
The building blocks and action plan proposals were approved by the Ceredigion County Council
Cabinet at its meeting on 25th March 2003.
BUILDING BLOCK 1
Engagement and partnership with older people - Real Listening and Involvement


Engage older people as partners to develop an older people focused vision – a joined up
strategy locally with older people. Older people will need support to develop an
engagement mode.
Older people can link into existing consultation frameworks such as the Health Alliance,
and contribute to everything from hospital admission and discharge processes to falls
strategies.
Actions implemented:


Appointment of Older people’s Champions within the County Council at Executive
Member level, and in Health
Commissioning and funding of Age Concern to work with older people to develop and
support a Senior Voice “Cwlwm” (Forum), as the basis for engagement with the wider
older population
Actions in progress:

Set up County level partnership vehicle between older people and the council and
other agencies (using BGOP advice)
BUILDING BLOCK 2
Enabling a self-help culture to underpin the vision

Citizen culture: Recognising the RIGHTS of older people to solve their own problems and
define their own well-being outcomes, free from age discrimination

Focusing on health promotion and active ageing

Supporting older people with the information and tools and contacts to problem solve

Developing the Carers Strategy to promote self help and family support

Further develop the system of direct payments for older people
23

Promoting volunteering, employment and life long learning initiatives

Service Culture: ‘enabling’ service culture across agencies/professions – proper risk
assessment & not over professionalising
Action in progress:

A programme of citizenship to tackle age discrimination and build intergenerational
links to be agreed during 2004

Developing active ageing and health promotion plans in conjunction with partner
agencies as part of Health, Social Care & Wellbeing.

Develop a Carers Strategy to enable older people and their carers to live as
independently as possible

Expansion of direct payments system for older people

Build broader partnerships within the County Council to promote the Strategy for Older
People
Actions planned:

Develop information strategy to provide older people with the information and access
to advice to enable them to: maximise income to address poverty and have greater
information and choice about the services available, including those that they can
purchase themselves such as equipment and simple adaptations. An effective
information strategy for older people will help to drive the culture change required.
Engage potential partners such as the Pensions Agency in the process; link the work on
Unified Assessment to the work in information.
Actions not yet initiated:

Development of a cross sector training plan to create the ‘enabling’ service culture
change in line with the strategy

To address discrimination in employment for people over 50

Looking at the potential to draw in a range of funding sources, including regeneration
funding, to support the active involvement of older people, and to improve access to
services

Promote the active involvement of older people through volunteering, employment and
life long learning.
BUILDING BLOCK 3
Develop whole system approach
There is a need to find a conceptual model to build ONE whole system approach and make people
feel a part of it – from hospital consultant to home care worker to sheltered housing warden to tutor
in life-long learning.
Example of Whole systems planning framework
Level 1 - citizenship, inclusion and engagement
Level 2 - prevention and minimum intervention
Level 3 - intensive time limited interventions
24
Level 4 - community based ongoing health and social care support
Level 5 - hospital, residential and nursing home care
We are using this framework to map current services at both strategic and locality levels for each of
the 5 levels, and then to develop plans to change the balance of future services between the levels.
The goal is to shift the culture and resources from levels 4 and 5, and into levels 1, 2, and 3.
An active example of the framework is set out in Appendix 2.
Action that has taken place:

The County Council and partner agencies have affirmed the framework for integrated
working as a strategic and local planning tool.
Further action required:

Reaffirmation within the new structure (Health Social Care &Wellbeing (HSC&W)
Strategic Planning Board) in order to develop a commitment to using whole systems
planning across the accommodation and wider service system.
BUILDING BLOCK 4
Rebalancing the accommodation system

Develop work programme to rebalance the accommodation system; address specialist
needs and link housing more closely into the wider system to support people at home.
Accommodation and services: the framework to shift the focus of long term care

Developing a re-ablement culture in long-term care settings

Re-configuring the long-term care map



Greater interest in housing based solutions/services
Offering more choice and tenure options:
a) Extra care housing as alternative to residential care
b) Reshaping sheltered stock / service
c) Intermediate care and rehabilitation
d) Services for people with dementia
Meeting the needs of older people in ordinary housing across all tenures, through:





Community alarms and new technology
Action on housing renewal to tackle non decent homes
Adaptations and handyperson services
Home energy initiatives to tackle energy poverty and the resultant health
consequences
Rural housing markets
Action in progress

Rebalancing the specialist accommodation system.

Refocusing the sheltered housing service to support an ageing population within a ‘home
for life’ model. This has been by way of modernisation & updating of existing role of
Wardens in Sheltered Housing.

Provision of 24 hour care cover pilot within an area of Sheltered Housing.
25

There has been a buildings survey of existing sheltered housing as to how far the
accommodation needs upgrading to meet increasing levels of frailty.

There has also been a survey of dependency levels amongst tenants of Ceredigion’s
existing sheltered Housing units.

Submission of plans to the Welsh Assembly Government for integrated Social & Health
Care & Community Hospital facilities in two areas of Ceredigion. To include Extra Care and
additional nursing home capacity

Plans are at an advanced stage in commissioning:



Specialist accommodation scheme for people with dementia together with additional
nursing care home capacity in order to stabilise the care home sector market.
An “across agency” intermediate care workshop has taken place, facilitated by WAG
change agents and a draft multi agency Intermediate Care Strategy has been
developed. In partnership with the LHB and the NHS Trust. Step up step down
places in existing care homes in both the independent and local Authority sector have
been established across the County
Pilot scheme is being established to develop the role of the community alarm service
and new technology to help support older people in the community. Funding is
agreed and project board in place.
Actions planned

Discussions with private sector to develop extra care housing for sale & rent

Fast tracking of minor equipment and adaptations via telephone assessment by our Contact
Centre.
BUILDING BLOCK 5
The hospital / community interface

Address the pressures around hospital admission and delayed transfers of care, through:

Developing a “whole systems” approach to discharge

Mapping the whole process

Building better links between various services

Better information about roles

Better information about the availability of services

Developing Intermediate Care

Developing a locality team approach with flexible roles to help address some of the
geographical issues

Making use of existing service bases (either residential care or sheltered) to provide
a platform for developing these services

Develop initiatives to link primary care more closely as part of the local service system,
building on initiatives such as the one in Lampeter and using the potential of the new GP
contracting structure to build shared outcome aims at a local level.
Action:
A structure for whole systems planning has taken shape. Viz., Strategic Partnership Board; that
overarches the HSC&W Project Team and sits alongside the Local Health Board Commissioning
26
group, (chaired by the Director of Social Services) and sitting beneath this is the Emergency
Pressures and Joint Working Action Group. It incorporates the monitoring of initiatives such as
Flexibilities and Intermediate Care and Delayed Transfers of Care ( Structure is illustrated below)
Working (“cross discipline”) groups have successfully tracked current pathways leading to delayed
transfers of care. Blocks have been removed and longer term solutions created.
Actions planned:

This relates to the whole systems planning framework in building block 3 and to promoting
ways of elongating the early phases of older age reflected in levels 1 and 2, thereby
reducing pressure on the hospital and long-term care systems

To develop a specific action plan focused on effective community support, avoidance of
hospital admission and promotion of early discharge as these relate to the NSF for older
people.
BUILDING BLOCK 6
Integrating services at a local level

Need to implement a structure of service as postulated in the HSC&W Plan. Social Care
and community health services in each of between three and six localities within Ceredigion
falls under the umbrella of one integrated single management structure.

Geography – Need to further develop this approach and encourage a bottom up ‘locality,’
as well as county approach. This will be built around active ageing, prevention and
community support, as well as health and care. Communities first area could be targeted.
Resources and forecasted growth in demand will not allow for solely a professional ‘service
led’ approach

Need to learn how to stimulate & enable the local approach with older people as
partners?

Capacity building and community development required to develop practical services to
deliver social inclusion and tackle inequalities

Need to legitimise culture of joined up work, trade ideas and resources, and enable
decision making at a local level

Need to Identify 2 areas in the county to develop locality pilots as part of the County’s
Community Plan, and with regard to the regeneration areas in the County
Action:
 Emergency pressures and Joint working group have successfully promoted the trading of
ideas and legitimised a culture of joined up working at that level at the Social Care&
Hospital interface. This process needs to continue to be embedded.

The draft Health Social Care & Wellbeing strategy has identified a specifically integrated
and singly managed cross-agency service as being the model that is fit to meet the future
Health and Social Care needs of an ageing population.
Actions proposed at a future date:
Identify one area to develop local pilots integrated and singly managed:

Consider how initiatives can be supported by way of generic community support
workers
27

Providing senior level leadership and mentoring of each pilot and giving local staff the
permissions to take decisions and trade


Securing funding from a wide range of sources, including rural regeneration funds
Mapping local services, both formal and non formal

Setting up cross sector local stakeholder group to agree local action plan built around
expressed needs and priorities of older people - to include issues such as community
safety, rural transport, housing, barriers to employment for people over 50, practical
services, local facilities such as Post Offices as community resources, as well as health and
social care

Engaging older people as partners in community regeneration through the Communities
First programme

Working with community organisations such as Age Concern to ensure that the focus is on
Active Ageing and prevention and not just services to vulnerable older people
An example of a locality pilot is given in Appendix 4
BUILDING BLOCK 7
Partnership and commissioning

The need for a cross sector strategic planning and commissioning structure has already
received senior level support at the development workshop on 19 November together with a
model for a possible structure. This has been further developed and implemented and is
reproduced on the next page.

Such a structure is in line with the requirements of The National Assembly for Wales for
Local Health Boards and local authorities for the preparation of Joint Strategies for Health,
Social Care and Well-being. The structure has been used for this purpose. It will become
the managing and monitoring structure for Ceredigion’s Strategy for Older People and in
fulfilment of our expectation for a 10 year action plan that will require a range of agencies
and sectors to plan and commission services together for the benefit of the older population
in their area. This is in line with the emerging Community Plan

The strategic commissioning group that has already been established may also
assist in the delivery of the Primary Care Strategy and oversee the development of
specific priorities within the county such as reablement, rehabilitation and
intermediate care, as well as the NSF for Older People.
Action that has Taken Place

Established the Health, Social Care and Well-being Partnership
Action for 04 / 05

To secure sign up to enable this group to act as a Strategic Commissioning Board

To get Strategic Commissioning Board to take ownership of this strategy and the future
work programme

To get Strategic Commissioning Board to take on a wider leadership role within the
County Council and partner agencies to broaden ownership of this initial strategy and to
use this plan to address the wider agenda set out in The Strategy for Older People in
Wales, which has been incorporated into these action proposals
28
7. Diagnostic Structure
PEMBROKESHIRE &
DERWEN NHS TRUST
LOCAL HEALTH BOARD
CEREDIGION AND MID
WALES NHS TRUST
COMMUNITY PLAN
HOUSING
CONSULTATION
GROUP
Health
Social Care
and
POOLED
RESOURCES
Well being
REGENERATION
Emergency
Pressures
and
INTER AGENCY
STRATEGY GROUP
Joint
Chief Officers
Working
Project Team
OLDER PERSONS
STRATEGY AND
ACTION
OLDER
PERSONS
FORUMS
Advisory Group
MENTAL HEALTH
DIRECTORATE
PLANNING MATTERS
FLEXIBILITY, EMERGENCY
PRESSURES &
INTERMEDIATE CARE
GROUPS
(DELAYED TRANSFERS OF
CARE)
29
8.
PROPOSALS FOR NEXT STAGE
Planning work to continue our action on:

Building the engagement model with older people (building block 1)

Enabling self help culture to underpin the vision (building block 2)

The hospital/community interface (building block 5)
1)
It is intended to link into the hospital/community interface work (building block 5) in so far as
it relates to work on the other building blocks. In particular, there is potential to undertake work
linking primary care to other community based services, and intermediate care and rehabilitation as
part of the locality pilot work (building block 6)
2)
Work will also begin on establishing the links with other strategies, both locally and
nationally, to ensure that the local work maximises the potential to draw on the widest possible
ownership and resources both within the County and in relation to national funding sources.
Examples here are the potential to continue to draw down funding specifically related to the
National Strategy for Older people in Wales, Supporting People funding, capital funding for housing
based developments from the Welsh Assembly and rural regeneration funding.
Undertaking direct development work with local partners:

Rebalancing the accommodation system (building block 4)

Developing the whole system framework and the joined up planning and commissioning
approach (building blocks 3 and 7)
Prepare the ground for:

Developing the locality pilots (building block 6)
30
Appendix – Framework for whole system working
(Note - the model is illustrative and will need to be further developed into countywide and locality versions
- many of the strategies go across more than one level)
Level
Strategy and Elements
Development areas/action points
Principles
1. Citizenship,
inclusion and
engagement,
active ageing
Active
Ageing
Strategy – to
enable the
older people
to enjoy
later life and
be as fit,
active and
healthy as
possible
When I’m
64……and
more
Health,
Social Care
and Wellbeing
Strategy
Housing
strategy









Physical activity
Leisure and learning
Removing barriers and challenging ageism
Encouraging volunteering
Access to information
Pre-retirement education
Supporting older people’s organisations
Engaging older people in decision making
Transport


Active ageing/ageing well - health, diet,
exercise
Anti poverty

Accessible housing and lifetime homes






Timescales
Outcomes
Milestones
Engagement strategy - county wide and local –
Tref a Bro
Development of life time homes
Community transport to help older people stay
active
Accessible lifelong learning opportunities.
Computer and Internet access to all.
Training and skills development for the above.
31
Level
Strategy and
Principles
2. Prevention
and minimum
intervention
Strategy for Older
People; Housing
strategy; Unified
Assessment
Process
Community
Safety Strategy
Supporting
People Strategy
Elements









Proposed Carers’
Strategy –
Elements
Joint Carers’
Strategy with
Health, Local
Health Board,
Voluntary Sector,
Carers
Ceredigion and
Carers’ Alliance
Vulnerable Adult
Protection Policy
and Procedures




Befriending/good neighbour schemes
Practical services - shopping and cleaning
Luncheon clubs and day clubs
Adaptations and Home Improvement
agencies
Community alarm services
Purpose designed housing for older people
Role of community/neighbourhood
wardens
Home safety and security - all workers
(including nurses) going into the home
assessing risks from falls, damp, security
Services for black and minority ethnic older
people
Telecare Pilot Projects – Managing risk
with minimum intervention but immediate
response
Technical Officer appointed in Care and
Repair.
Services of external consultant
commissioned.
Protection of Vulnerable Adults from
abuse. Joint procedures with Police and
Health.
Development areas/action points


Greater investment in prevention
Use of community alarm service

Invest in information, leisure, training
employment opportunities for carers
supporting their health and wellbeing
through identified areas in assessment
Pilot Strategy commenced September 2004

Theatre Forum to raise awareness amongst
older people. Information leaflet for the public.
Timescales
Outcomes
Milestones
Joint
Carers’
Strategy in
place by
December
2005
April 2005
32
Level
Strategy and
Principles
Elements
Development areas/action points
3. Intensive
time limited
interventions
intermediate
care
4.
Community
based
ongoing/longterm health,
care and
support
services
Intermediate care
and mental health
strategies


 Strengthening the intermediate care
infrastructure in the community
 Use of housing based models for step up and
step down schemes
 Creating a reablement/ablement approach in
home care and community nursing.
 Changing commission patterns for services
into the home
 Development of specialist housing and
support services
 Development of extra care housing
5. Hospital
and
institutional
care

Housing strategy
Unified
Assessment
Process
Health, Social
Care and Wellbeing Strategy


Unified
Assessment
Process – Joint
Action Plan




Emergency/rapid response services
Step up and step down schemes and
community based beds/flats using
sheltered housing settings
Community based resource centres
Sheltered and very sheltered housing
Specialist domiciliary, day care and
supported housing for people with
dementia
Integrated locality health, care and
housing support services
More flexible use of residential places
Short stay rehab/reablement in sheltered
or extra care services.
Assessment and Fair Access to Care,
addressing the prevention agenda
 Long- stay residential and nursing home
care
 Continuing care beds
 Main elements to be in place for older people
by April 2005
 Proportionate assessment focussing on risk
to independence and person centred
planning
 Reduction of emergency and long stay
admissions
 Developing the independent sector market to
meet changing need
Timescales
Outcomes
Milestones
Outcome
milestones
April 2005
33