Adult social care - winter preparedness plan: 2021-22

Working in partnership across health and social care organisations and unpaid carers

The strategic priorities set out in this Plan will be reviewed and monitored on a regular basis. Stakeholders from across the adult social care sector will continue to review, monitor and support implementation of the Plan through the Pandemic Response Adult Social Care Group (PRASCG). A System Response Group (SRG) has also been established, comprised of strategic leaders from across the Health and Social Care system, to provide strategic oversight of pressures across the system and to consider collective response and action at a national level. The Social Care GOLD group continues to meets twice weekly to assess system pressures and address emerging issues. It is chaired by Scottish Government and has representation from across local government, IJBs, and wider delivery partners.

The Clinical and Professional Advisory Group for Adult Social Care (CPAG) will continue to provide clinical and professional advice and guidance to support the social care sector during the pandemic. Our response to COVID-19 has benefited from dynamic and collaborative expert professional advice across social care. As we emerge from the pandemic, in addition to continuing to provide COVID support, CPAG's role will expand to provide a multidisciplinary perspective and voice in a range of social care reforms including the establishment of a National Care Service.

National Oversight

• System Response Group
• Resilience Meetings
• Weekly NHS-SG Meetings
• Social Care GOLD Command

Local Monitoring

• Local Health Board Bronze, Silver, Gold Command
• HSCP Bronze, Silver, Gold Command
• Health Board and HSCP Local Resilience and Operational Plans

Multi-disciplinary teams (MDTs) within health and social care will continue to play a critical role in keeping people well and independent and delivering the right care at home or in the community to prevent unnecessary hospital admission through accessing a range of health, social care and other community services. MDTs are made up of a range of professionals from across healthcare services, social work and social care. The aim of the healthcare framework for care homes is to enable a more nationally consistent approach to MDT working, recognising differences in local context.

We are providing recurring funding to support the strengthening of Multi-Disciplinary Working across the health and social care system to support discharge from hospital and to ensure that people can be cared for as close to home as possible, reducing avoidable admissions to hospital. This includes up to £15 million for recruitment of support staff and £20 million to enhance MDTs this year and recurring.

These MDTs should support with social work and care assessment, hospital-to-home and rapid response in the community. MDTs may encompass:

• integrated assessment teams to discharge people from hospital with care and support in place, working in partnership with unpaid carers;
• enabling additional resources for social work to support complex assessments, reviews and rehabilitation, as well as AWI work;
• ensuring that people at home or in care homes have the most effective care and that care is responsive to changing needs;
• rapid-response community MDTs to facilitate diversion away from GPs, Out of Hours services (OOH) and the Scottish Ambulance Service (SAS) into the community; and,
• scaling up Hospital at Home to prevent or avoid admissions.

Assurance and support to care homes to ensure the safety and wellbeing of residents will remain a high priority as the pandemic continues. The Care Inspectorate will continue to work collaboratively with services, member organisations and national stakeholders to support and drive quality improvement through:

• timely correspondence from the Care Inspectorate chief executive to care homes highlighting the key themes and trends from inspections and good practice noted;
• timely information presented to CPAG;
• the development of a series of COVID-19 winter webinars to support the care sector; and
• strategic development work with stakeholders such as Scottish Care.

The Scottish Government will continue to support the Care Inspectorate's assurance and improvement activity during the winter months, including examining further ways to share good practice and information within the care sector. We will also continue to assess the progress with the recommendations made in the root cause analysis report and continue to learn through reflecting on progress and importantly hearing from those in the sector.

The Turas Care Management – Safety Huddle Tool was developed as part of the response to the COVID-19 pandemic. The tool has made available, for the first time, a standardised data set on each adult care home in Scotland. One year on since the launch of the huddle tool, with response rates remaining high, we recognise the ongoing commitment of providers and local partnerships to the tool. The huddle tool continues to provide – in one place – key data and information to allow for early warning, escalation and timely intervention. The need for consistent and timely data has not gone away, and for that reason, making sure the huddle tool is being proactively used by all local partners to record, analyse and act upon information must continue to be a priority. The tool will be an important resource throughout the autumn/winter period for providers and as part of the enhanced clinical and professional oversight arrangements that remain in place. The Scottish Government will continue to provide support and training on the use of the tool as well as working with the sector to develop it further, and work with wider stakeholders to reduce the burden of data capture as much as possible.

A refreshed Digital Health and Care Strategy will set out the strategic approach to support digital in social care. As part of winter planning we will also:

• Continue to provide connectivity support and data packages for devices for a further year and we will extend the digital training and leadership package available to residents and professionals.
• Continue to roll out Near Me video consulting into our care homes and wider social care, facilitating Near Me social work reviews, duty social work and out of hours early adopters as appropriate.
• Support telecare providers with new guidance to support contingency planning for telecare services over the winter period. This will include supporting proactive telecare, remote working where appropriate and contingency when adverse weather or the pandemic are disrupting installation and responder services.
• Work with Alzheimer Scotland to increase uptake of the Purple Alert app for people with dementia if they are missing. We will also consider further innovative approaches to lifestyle monitoring that will support enhanced wellbeing from home.
• Continue to implement the Care Home Assessment Tool (CHAT) to support assessment and decision making.

Links to training, funding and guidance for working in partnership

• A resource for team leaders in health and care settings.
• https://www.gov.scot/collections/adults-with-incapacity-forms-and-guidance/
• Delivering social care in a changing climate (climatexchange.org.uk)
• Dementia, mobility, respiratory & breathlessness, mental health and communication
• https://lms.learn.sssc.uk.com/
• https://www.badges.sssc.uk.com/
• https://learn.sssc.uk.com/cyber/s