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

Part 5: Conclusion and Recommendations

The Residential Care Task Force is pleased to provide the following recommendations to help shape the future of residential care in Scotland:

Strategic outcomes and priorities for adult residential care for the next 20 years

• The development of the residential sector over the next period should see expansion in three directions: an evolution and expansion of the extra-care housing sector; a growth in the residential sector focused on rehabilitation and prevention (step-up / step-down care); and a smaller, more specialised residential sector focused on delivering high quality 24-hour care for people with substantial care needs. We anticipate that in some areas, single facilities or hubs might provide all of these service types.
• The implementation strategy which will be developed by the Scottish Government and COSLA must be linked to the on-going review of the National Care Standards to ensure that the reforms being recommended here are supported in the new standards.

Personalisation

• People living in grouped care arrangements should be able to exercise choice and control over their care, support and daily living arrangements. This will involve practical work through a proof of concept project, and will also require the Scottish Government and COSLA to carry out further policy development work.
• The Scottish Government, COSLA and ADSW should make sure that arrangements are in place to support well-informed decision-making for people considering residential care or supported housing. This will require effective information and advice being given to older people around the options that are available to them under the SDS legislation.
• Outcomes-based assessment and review within residential settings should become standard practice, learning from the initial 'Talking Points' pilot work undertaken in Scottish Borders.

Residency, Tenancy and Tenure

• The Scottish Government, Care Inspectorate, COSLA, CCPS and Scottish Care should ensure that people are able to access the right type of tenure. For some, particularly within extra-care housing arrangements, this will mean an opportunity to enter into a tenancy or ownership arrangement; for others, it may mean a more flexible residency agreement. Further work on developing a tenancy-based model will benefit from a pilot project and discussion about possible reforms in regulatory practice.
• The definition of housing support within secondary legislation should be revised by the Scottish Government to allow for more flexible service design and registration.
• The Care Inspectorate and Scottish Government should ensure that registered care home services can add to their functions (e.g. day care/respite; laundry; meals; activities) to provide an outreach service to non-residents in the local community.

Capacity planning

• Investment in improving existing care accommodation and building future capacity should be managed through a coordinated planning and commissioning process at local partnership level. This should also seek to address the location and distribution of care home provision within a local area.
• Work should be undertaken by COSLA, CCPS, Scottish Care and the Scottish Government, along with local partners, to audit the physical infrastructure of the care home estate, to provide a sense of what type of future investment is required.
• Commissioners and developers should ensure that new builds should focus on 'person-centred' design, developing accommodation that is supportive of the care needs of residents/tenants.
• Further work should be carried out by local partnerships to determine the desired mix of accommodation across the housing with care and care home spectrum. This will require a comparison of the ranges of need and cost to help better understand the comparative costs between residential care and housing with support.
• A national workforce planning tool for the care home sector should be developed by SSSC, NES and other relevant partners.

Commissioning

• A collaborative approach should be taken in the commissioning process, with providers themselves fully involved in the planning of future provision. Strategic commissioning plans should be based on a joint strategic needs assessment in order to plan future capacity.
• Partnerships should produce a Market Facilitation Plan to direct future care home supply. This should be incorporated in Joint Strategic Commissioning Plans, which should clearly state the number and the type of services required.
• Commissioning partnerships may want to explore new procurement methodologies, which would offer greater control over quality and capacity of provision in the market. For example, the commissioning partnership could enact preferences around quality, capacity and type of service by selecting 'preferred providers' through a tender process. Commissioning partnerships should take care to ensure that any such developments are consistent with the choice directives.
• The Scottish Government, COSLA, Scottish Care and CCPS should review partnerships' commissioning levers within five years to ensure that local markets are responding to commissioning plans.
• Dependency tools, such as the Indicator of Relative Need (IoRN), should be promoted by the Scottish Government, Scottish Care, CCPS and ADSW in order to obtain a better understanding of the needs of current care home residents to inform the alternative uses described above.
• Local partnerships should develop volunteering and carers' roles in support of people that live in care homes. The Care Inspectorate should devise new protocols and toolkit materials to support the involvement of volunteers and unpaid carers in care home environments.
• Joint Strategic Commissioning Plans should include, as part of their needs analysis, a scoping of the workforce issues in the care home sector in their partnership. This scoping should include an analysis of skills and training requirements and gaps, issues of recruitment challenge and gaps and opportunities for role and career development.
• The workforce should be adequately trained by employers to respond to the increasing levels of dementia seen in residential care home settings, by ensuring that the good practice set out in Promoting Excellence is enshrined in a formal qualification.
• Providers should enter into dialogue with the Care Inspectorate and Health Improvement Scotland about the innovations they want to take forward within their care homes or housing with support service. This might include discussion about developing care homes as community assets, but which continue to safeguard the safety and privacy of care home residents.
• The Scottish Government should work with professional bodies and education providers to ensure that nurses, GPs, Social Workers and AHPs in training experience high quality learning placements in the care home sector.
• Local partnerships should make effective links across community care and all health services (primary, community and acute settings, including mental health) to maximise the available support and expertise to care home residents and to the people who care for them in the home.
• It is recommended that Heath and Social Care Partnerships scope out the potential opportunity to rationalise health and social care expenditure on older people with highly complex long-term care needs.

Managing Risk

• A compulsory risk register should be devised by COSLA, ADSW, Scottish Government CCPS and Scottish Care to provide an early warning system for care providers experiencing challenges to the continuity of care - and an associated ladder of intervention for public authorities to co-produce solutions for exit or redesign of struggling services.
• The Scottish Government should consider further revising and simplifying the regulation of care, to enhance openness and support service improvement.
• Research should be commissioned by SSSC and NES on the level of burn-out experienced by staff in care home settings, and models of supervision and support also developed to address this.

Care Home Governance and Quality Assurance

• The Scottish Government, COSLA, CCPS and Scottish Care should undertake policy development work to underpin a system of community engagement boards for care homes, to ensure greater continuity between the needs of the local community and the management of the service.
• The Care Inspectorate should undertake further work to establish if there are additional risks to continuity of care as a result of the separation of property owning companies from operating companies in relation to care home provision.

Fee structure and funding

• The Scottish Government, COSLA, CCPS and Scottish Care should undertake work to ensure that charging arrangements are transparent and stratified. Accommodation, hotel, care, and leisure and recreation costs should be separated.
• Modelling work should be undertaken to ascertain the cost effect of raising capital limits in Scotland, both in terms of public funds, and the possible regression effect on households of the current limits and potential changes. This work should be remitted to the CRAG Review Group with subsequent recommendations put to Scottish Ministers and COSLA.
• The Free Personal and Nursing Care contributions should be reviewed by the Scottish Government to more accurately reflect the costs of personal and nursing care in a residential setting.
• Financial modelling should be undertaken by COSLA, CCPS, Scottish Care, the Scottish Government and other relevant stakeholders to establish the costs of implementing a national commitment to pay the Living Wage in the care sector. This would support a national debate on appropriate payment and reward in caring as a career.