Recommendations on The Future of Residential Care for Older People in Scotland

Part 1: People, Places and Personalisation

There has been much progress in bringing a more person-centred approach to health and social care services in recent years. Within an NHS context, new standards in patient safety and patients' rights have been introduced, alongside on-going person-centred work associated with the NHS Quality Strategy. Local government and social care providers in the third and independent sectors have likewise been on a similar journey for some time.

Personalisation is about empowerment, it is about rebalancing power relationships, and it is about co-producing solutions that allow individuals to improve their lives. And importantly, it has to be available to all.

This work has recently developed a focus around Self-Directed Support (SDS), with the 2013 Act enshrining the right of the individual with eligible support needs to exercise control over their support. SDS is an approach designed to bring about independence and choice for people with care or support needs. It involves identifying a budget for an individual's support and puts them in control of how that budget is invested to meet agreed outcomes. This can include taking a direct payment in lieu of services. The practical application of the use of Direct Payments in care homes will shortly be tested by a small number of local authorities - and this is a development that the Task Force welcomes.

The implementation of SDS will require a shift towards outcomes-based assessment and review. Recent developments within this field include the creation and gradual roll-out of 'Talking Points', which is an outcomes-focused assessment process designed to put the individual in control of their support arrangements. Work undertaken by Scottish Borders Council, JIT and a number of independent sector providers demonstrated that this approach is just as applicable to residential settings as to care at home. However, its success requires strong leadership, a commitment to cultural change and the pursuit of personalised care. In a similar vein, 'My Home Life'⁴ is a collaborative movement focused on personalising practice within care homes for older people. It identifies best practice in care homes for older people in the 21st century and has a particular focus on personalisation.

While these are two good examples of personalisation initiatives in care homes, the consensus among key parties, such as the Mental Welfare Commission and the Scottish Human Rights Commission, is that there is much work to be done before personalisation becomes an embedded principle in the sector.^5,6 New developments around guardianship and the embedding of the Mental Health Act are seen as high priorities to further the Personalisation agenda.

The optimisation of personalised service arrangements will require reform in a number of areas:

Finance and Funding

• Greater transparency in the fee rate attached to care within a grouped living arrangement, separating out the cost of care, rent, board and recreation;
• Consideration of the conditions of residence, ranging from tenancy or owner occupier models through to residency agreements; and
• Greater control over personal budgets and income sources such as DWP benefits.

Care and Support

• Enhanced individual leverage to control the care package, based on individually identified outcomes and goals;
• Normalisation of healthcare arrangements - accessible GP, nursing and other specialist input as required;
• Greater control over the 'who-what-where-how-when' of care delivery; and
• Greater opportunity to involve unpaid carers in support arrangements.

Daily Living

• The normalisation of daily living arrangements, including expanded opportunities to choose to live with a spouse, partner or friend;
• Greater opportunities for life outside of the home; and
• Greater control and choice over recreation and physical activities.

From the perspective of engendering a personalised approach, we advocate an approach which would allow an individual to build a matrix of support with the relevant input from family and providers, which offers the right balance between residential and home life. It would mean enhanced access to care at the right times in the right way.

In our view, the features of a more personalised care arrangement will be differentially expressed depending on the structure of the residential or grouped living model. In general, three types of accommodation will be at the heart of the development of the residential sector over the next period: an evolution and expansion of the extra-care housing sector; a residential sector focused on rehabilitation and prevention (step-down / step-up care); and a smaller, more specialised residential sector focused on delivering high quality 24-hour care for people with substantial care needs.

At the same time, the separation of 'hotel costs' (accommodation and living costs) and care costs presents some challenges for providers, for example, in relation to workforce and more general financial planning, as the type and level of provision required in the medium to long-term is driven by individuals' choices and therefore harder to predict and plan for. Furthermore, the question of responsibility for the health and safety of external staff coming into the residence also arises, along with issues as varied as adult protection, regulation and insurance. The Task Force believes that the best way to test the practical application of these recommendations is through pilot activity.