LONDON BOROUGH OF RICHMOND UPON THAMES

CABINET

DATE: 24 JANUARY 2011

REPORT OF: CABINET MEMBER FOR ADULT SERVICES HEALTH AND HOUSING

LEAD OFFICER:

DIRECTOR OF ADULT AND COMMUNITY SERVICES

SUBJECT: CHANGES TO ADULT SOCIAL CARE SERVICES

WARDS: ALL

KEY DECISION?: YES

IF YES, IN FORWARD PLAN?: YES

For general release 1. PURPOSE OF THE REPORT 1.1 For Cabinet to note the responses received to the public consultation

on proposed changes to the Borough’s Adult Social Care Services. 1.2 For Cabinet to make decisions on the proposals relating to the Self

Directed Support (SDS) Contributions Policy, changes to the eligibility criteria for Adult Social Care and re-configuration of day services.

EXECUTIVE SUMMARY

1.3 The Council carried out a public consultation exercise on proposed changes to the Borough’s Adult Social Care services. The key messages from this consultation were that people generally understood why the Council was making changes. Whilst some people were supportive of the Council in prioritising its resources on those with higher support needs and requiring people who could afford it to pay for their care, there was also considerable concern expressed as to how the changes would impact on some service users, in particular the most vulnerable such as those suffering from dementia that use one of the Council’s day centres at Tangley Hall. This report summarises the responses received and includes recommendations which take account of the views expressed during consultation.

Adult Social Care accounts for over 40% of the council’s total budget, and in the current economic climate, savings in this service must be identified. The proposals set out in this report enable the council to achieve savings in the order of £1m, whilst ensuring that the most vulnerable continue to receive support. In relation to day services, the proposals will mean a change of venue for some people but current

levels of service will be protected. The changes will put these services on a sustainable footing for the future and will provide an opportunity to build further on existing good practice, creating two centres of excellence as part of the borough’s developing range of support for older people.

2. RECOMMENDATIONS That Cabinet: 2.1 Note the responses received to the public consultation on proposed

changes to Adult Social Care Services. 2.2 Approve the revised Self Directed Support Contributions Policy as set

out in Appendix 1 to this report with effect from 1 April 2011. 2.3 Approve the changes to the staffing establishment as set out in

paragraph 8.5 2.4 Change the eligibility criteria for Adult Social Care Services to stop

providing services to new people assessed with Moderate needs from April 2011, but continue to provide services to existing service users with Moderate needs.

2.5 Agree to reconfigure the Council’s Intensive Day Care Centres for Older

People so that services are provided on two sites (Sheen Lane and Ham) and services currently provided at Twickenham and Tangley Hall Day Centres are closed in accordance with the timescales set out in paragraph 6.10.

2.6 Approve the capital expenditure for building improvements for the

Intensive Day Care Centres as set out in paragraph 8.3.

3. DETAIL 3.1 Richmond upon Thames council has been consulting on three proposals to

changes in Adult Social Care:

1) Changes to the Self Directed Support (SDS) Contributions Policy (the way the Council charges for Adult Social Care), so that where people are able to afford it, they contribute more to the cost of their support. The main changes proposed are the removal of the maximum weekly contribution which applies to people paying for their care services as well as the inclusion of income from disability-related benefits when assessing someone’s ability to pay.

2) Changes to how people qualify for Adult Social Care (eligibility criteria) to raise the threshold for social care services so the Council will no longer provide services to people with Moderate needs and will only provide services to people with Substantial and Critical needs as defined in the Putting People First: Guidance on Eligibility Criteria for Adult Social Care, England 2010, which replaces the 2002 Fair Access to Care Services guidance on eligibility criteria.

3) Intensive Day Care Centres. To close two of the Borough’s four intensive day care centres for older people at Tangley Hall and Twickenham and to focus intensive day centre provision at the two remaining centres at Ham and Sheen Lane. Current levels of service will be maintained and people currently attending Tangley Hall and Twickenham will have the option to attend services at Sheen Lane or Ham, or to have their needs met in a different way.

3.2 On 19 October, a letter and questionnaire was sent to 2,077 people,

comprising Adult Social Care service users and their carers. They were asked to comment on each proposal. A number of voluntary organisations were also consulted and invited to comment on the proposals and two public consultation meetings were held. In relation to the day services proposals, eight meetings were held with service users and their carers. Approximately 300 people attended the various meetings held during the consultation period.

3.3 Consultation feedback was gathered and collated via the following methods:

• Paper questionnaires • Online via a web questionnaire for each proposal • Requesting a council officer to complete the form face-to-face in their

home • Providing feedback over the phone • Writing a letter or email feedback to the consultation address • Residents could also write to their MP, councillor or council staff to

raise their concerns

3.4 The proposals were considered by the Health Housing and Adult Services Overview and Scrutiny Committee on 25 October and in relation to the day care services proposals an Intensive Day Care Centres Scrutiny Task Group was established to look at alternative options to the proposed changes which would deliver the same level of saving.

3.5 This report sets out some of the key themes emerging from the consultation as well as information on how the Council plans to address any issues or concerns. Key themes are defined as those that are strongest or occurring the most e.g. views expressed by a number of service users, carers and voluntary organisations. The main themes and the Council’s response for each proposal is outlined in the following sections of this report. A summary of alternative options suggested during the consultation period is provided in Appendix 2. Case study examples showing the potential impact on service users affected by these changes are included in Appendix 3.

3.6 The overall themes gained from the consultation are outlined below:

• A general acceptance that in this current financial climate, cuts are inevitable and it is important for these to be applied fairly.

• Richmond upon Thames is a high performing council which also has a high Council Tax and it should not be lowering standards to be in line with other councils.

• Many people responded that Adult Social Care should not bear the same level of cuts compared to other areas of the Council.

• The impact on family carers was a key concern, as many felt that less funding would mean less support and therefore more burden on carers to bridge this gap.

3.7 General responses to the consultation themes are that:

• Whilst it is recognised that Richmond is a high performing council with high standards and good quality services, the poor financial settlement from Central Government means that the Council has to consider cuts across all areas of spend. Unfortunately, the Council cannot fully protect Adult Social Services from budget reductions as this accounts for 42% of the Council’s budget.

• Richmond has been out of step with many other councils as it has been more generous in both its contribution and eligibility policies. Compared to most other councils Richmond Upon Thames provides services to people with lower levels of need and people that receive services contribute less towards the cost of their services.

• The Council is committed to providing services to the most vulnerable and to maintaining high quality services that meet the needs of these vulnerable people. However, in this current financial climate it is considered that people that can afford to do so will make a contribution towards the cost of their services.

• The council will continue to provide support to carers, through a carers assessment, carers payments and a range of specialist carers support through the voluntary sector. A new carer’s information directory has recently been published.

4. Changes to the SDS Contributions Policy 4.1 Two separate proposals related to the SDS Contributions Policy (Appendix 1)

were proposed which would generate additional income of £700,000 per annum, taking into account the additional costs of administering the policy. This policy determines how much someone has to contribute towards the cost of non-residential care and support services. Removal of Maximum Contribution Level. This proposal would mean that where someone is financially assessed as “able to pay for their care”, they would have to pay the full cost and would no longer receive a subsidy from the Council, whereas under the current policy the Council meets the cost of everyone’s care and support where this cost exceeds £320 per week. Initially this proposal would not apply to existing service users that currently pay £320 per week. Taking Disability-related benefits into account when assessing contributions. The Council’s current Contributions Policy ignores disability-related benefits when assessing a person’s income. Richmond upon Thames is believed to be the only Council in England to do this. The proposal is that disability–related benefits are taken into account when assessing someone’s

ability to pay towards their care. A disregard of £20 per week will be applied to people in receipt of disability-related benefits to enable them to cover their disability-related costs which are not being covered by their Personal Budget. The financial assessment process also takes into account a person’s housing costs and also ensures a minimum personal allowance for general living costs of (£171.69 per week for a single person aged over 60, £262.12 per week for a couple aged over 60 and £120.44 per week for a single person aged under 60, based on annual rates set by the Government).

4.2 A summary of themes following the consultation is provided below with responses: Theme: Many people found the proposals difficult to understand, in particular, how they would work and how they would be affected. Service users and their carers were anxious to know as soon as possible how much they would be required to contribute towards care and support costs so that they could make plans to address any necessary changes. Response: A contributions helpline is in place to advise people about how they will be individually affected. Individual financial assessments will be carried out during February and March in order to notify all service users of their revised contribution before any changes take affect. Public information, including information leaflets and web-based information is being made available to service users and their carers. Theme: Many felt that any increased contribution towards social care costs would impact greatly on service users’ quality of life. In particular, people felt that their social life would be greatly impacted as this would be the first area they would stop spending money on. Response: All service users will be offered access to help and advice on how to claim welfare benefits to help maximise their income.

Theme: There was general support for abolishing the maximum weekly amount that service users are asked to contribute towards their care. Many felt that if someone can afford to pay for their own care then the Council should not be contributing towards this. The important thing was that those that need care are receiving services. There was also an acceptance from some service users and carers that they would have to pay more for their care in this current financial climate. Response: The Council will ensure that existing service users who pay the maximum contribution of £320 per week are protected so that they do not experience large increases in their contributions. The Council will continue to provide care and support to those with assessed eligible needs. Theme: Younger adults with a long term disability that prevents them from being able to work would not have the same opportunity to save money from employment and are therefore more reliant on benefits and public funding to support their care needs. Response: All service users will be offered access to help and advice on how to claim welfare benefits to help maximise their income. When calculating someone’s contribution, the Council ensures that everyone has sufficient money for their housing costs, Council Tax, disability-related expenditure and also a Personal Allowance of £171.69 per week for a single person (Pension Credit rate) or £144.23 per week (Income Support rate) or £262.13 per week for a couple.

Theme: Some people felt that applying a ‘flat rate’ was unfair, particularly for those receiving higher rate DLA. Various individuals felt there should be an individual assessment rather than a ‘flat rate’. Response: It is felt that most disability-related costs covered by disability benefits relate to care and support needs being met from someone’s Personal Budget and therefore it is fair for people to use these benefits to contribute towards the cost of their care. Whilst a flat rate disregard of benefits of £20 per week is being applied, a review process is available where someone wishes for their individual circumstances to be taken into account. Carrying out detailed individual Disability Related Expenditure assessments would be costly and intrusive to service users.

4.3 When the Department of Health’s Fairer Charging Statutory Guidance was first published in 2003, the Council revised its charging policy, moving away from flat rate charges. At the same time, a decision was taken to disregard income from disability benefits to minimise the cost of financial assessments and to remove the need to carry out intrusive assessments about individuals’ disability-related costs. The Council also introduced a more generous capital limit before applying full cost charges. The Council has subsequently revised its policy, most recently in 2008 to adapt it for Self Directed Support and Personal Budgets in line with Fairer Contributions Guidance. Over time the Council’s Policy has become more out of step with other Councils, with a more generous financial assessment process with regard to the following aspects, compared with other councils:

• A high capital limit of £35,000 before full cost charges apply, compared to

most other councils where this is £23,250 • A relatively generous maximum weekly contribution of £320 per week,

whereas many councils have no weekly maximum for those assessed as able to pay for their own care

• Richmond Upon Thames is believed to be the only council in England which applies a disregard of 100% to disability-related benefits

4.4 A recent survey of other councils confirmed that Richmond’s policy is out of

step with the national and London position. With regard to the maximum weekly contribution, Richmond Upon Thames’ maximum contribution of £320 in 2010/11 is lower than that in two thirds of other London Boroughs. In relation to the disregard of disability-related benefits, Richmond Upon Thames is believed to be the only council in England to do this and this is evidenced by a survey with responses from 75 Local Authorities. Also in setting a high capital limit of £35,000 for non-residential care services, Richmond continues to help minimise the impact of people’s savings being eroded.

4.5 In the course of developing the revised Contributions Policy and consulting

with service users, carers and voluntary sector organisations, alternatives were considered and these are set out in Appendix 2.

4.6 In formulating the proposal to assess income from disability-related benefits,

consideration was given to introducing detailed individual Disability Related Expenditure (DRE) assessments, however it is considered that these assessments would be intrusive and the cost of administering the financial assessment process would be prohibitive. The introduction of detailed DRE

assessments would go against the Council’s general approach to reducing assessment processes and introducing leaner processes for assessment and administration.

4.7 A flat rate disregard of £20 per week of disability benefits has been set to take

account of a person’s disability related costs. This level has been set taking into account standard rates used by other councils and this rate is considered to be in line with standard rates used by other councils. In addition certain disability benefits and income will not be included when assessing someone’s income as follows:

• All Income (earnings) from employment • Disability Living Allowance - Mobility Component • Income from the Independent Living Fund (ILF) • War Pensioner’s Mobility supplement • Disabled Persons Tax Credit • Winter fuel payments • Social Fund Payments • £10 per week of War Disability Pension • £10 per week of War Widows Pension

4.8 During the consultation process, some people responded with a view that the

standard disregard of £20 per week applied to disability-related benefits would be insufficient to cover some people’s disability-related costs. The Council’s view is that where someone has assessed eligible care and support needs, many of these disability-related costs are met from the Personal Budget and therefore these costs would not also need to be taken into account in the financial assessment process. Also, the proposals include a Review Process so that individual disability-related costs can be taken into account.

4.9 The £20 per week disregard of disability-related benefits is intended to cover

costs such as additional laundry costs due to a disability, wheelchair/scooter running costs, special clothing and special dietary needs. Where someone is eligible for a higher rate of Attendance Allowance or Disability Living Allowance, they are also likely to have a higher level of care needs, reflected in the level of their Personal Budget. It is therefore considered reasonable that someone with a higher rate of benefit makes a higher contribution from their benefit towards their care and support.

4.10 The Council recognises that in the current financial climate, it is no longer

possible to offer a more generous policy than other councils. The proposed way forward, therefore, is to remove the maximum weekly contribution level for those financially assessed to pay from 1 April 2011. As it was felt, however, that this would result in excessive increases for a small number of existing service users (24 people), a phased approach to implementation is being applied. The change in policy with regard to the maximum weekly contribution will not be applied to those service users who currently pay £320 per week. In these circumstances a revised contribution of £335 per week will apply from 1 April 2011 and the position will be reviewed in April 2012.

4.11 To further minimise the impact of the removal of the maximum contribution

level, the charges set for the Council’s intensive day care services will be maintained at the current levels for the next two years. This also addresses

feedback during the consultation process that some service users have been deterred from using the Intensive Day Care Centres due to the increased charges for this service.

4.12 It is proposed to include income from disability-related benefits in the financial

assessment for all service users from 1 April 2011 and to apply a standard disregard of disability benefits of £20 per week to cover disability-related costs. In order to ensure that individual circumstances are taken into account, a Review Process is being put in place as set out in Appendix 1 paragraph 8.

4.13 Work will commence in February to carry out revised financial assessments

for all existing service users and to provide written notification to individuals. In addition a Charging Helpline is in place for any service users and their carers who wish to enquire about their individual circumstances. Suggestions for implementing the policy were received during the consultation process and these have helped shape the way changes are implemented. These are also set out in Appendix 2.

4.14 In conclusion, feedback received during the consultation process has been

taken into account in formulating the SDS Contributions Policy. The revised policy will generate net additional income of £700k per annum and will enable the Council to continue providing care services in the context of increasing demand. Cabinet is recommended to approve the revised policy, included in Appendix 1.

5. Changes to the way people qualify for Adult Social Care services (eligibility criteria)

5.1 Richmond Upon Thames has seen an unprecedented increase in demand for

Adult Social Care services with 10% growth over the last two years and 28% over the last four years, resulting in a budget pressure of £2m. Councils are permitted to take available resources into account when setting their eligibility for Adult Social Care services, based on the Department of Health (DH) eligibility framework. The four categories set by DH are: Critical, Substantial, Moderate and Low. Richmond currently provides services to people with ‘Moderate’ needs at a cost of approx £0.5m per annum. The proposal is to stop providing services to people with Moderate needs from April 2011.

5.2 Richmond Upon Thames has been generous and out of step with most other

councils in providing services to people with Moderate needs. Most other councils in England only provide services to people with Critical and Substantial needs and some councils have provided this level of service for many years. In London, Richmond is one of only five London Boroughs to provide services to people with Moderate needs and all these boroughs are currently reviewing this position for 2011/12. With its poor level of Central Government funding and significant demand pressures, the Council can no longer afford to continue providing services to people with Moderate needs. Changing the eligibility criteria would enable the Council to focus its limited resources on the most vulnerable residents. This proposal would generate a saving of £50k per annum, although a longer term saving from reduced care management staffing would also be possible if services were only provided to people with Critical and Substantial needs.

5.3 A summary of themes following the consultation is provided below with responses:

Theme: Some people not directly affected by this proposal felt it was right that those with a higher level of social care needs would continue to receive services and be protected from these efficiencies. Response: The proposal supports this view. The Council has made a commitment to provide services to the most vulnerable people in the community. Theme: Concern that raising eligibility will cause those with Moderate needs to quickly deteriorate into having substantial needs, particularly those people currently receiving services, therefore not providing savings for social care and having cost implications for the health service. Response: The Council is aware that people can deteriorate quickly and when assessing needs will take into account if people’s needs will deteriorate into ‘substantial’ within 3 months. Services will be provided in that scenario. The Council intends to develop an early Intervention and Preventative Strategy in partnership with health which sets out the services that the council will commission through the use of existing resources that people not directly supported by the council can access. Theme: FACS definitions were thought to be ambiguous and many people felt that these allowed care workers to apply bandings in a subjective manner, meaning that different care workers assessing the same person could come to different conclusions regarding bandings. People wanted more consistency around the way FACS banding would be applied. Response: The Council is committed to ensuring a consistent approach when assessing needs and that the bandings are fairly applied. Consistency is currently ensured through effective management of the assessment process. To ensure a more thorough approach, the application of FACS criteria will be discussed on a regular basis at the Department’s social work practice forum and any issues arising from inconsistency or poor practice will be briefed to staff. Theme: Carers felt that they are best placed in advising on which FACS banding is most appropriate as they have a day-to-day view of the person’s care needs that an assessor paying a one-off visit may not get. It was also felt that input from health, particularly a GP, should be taken into account when assessing which FACS band people fall into. Response: Where possible the council always involves family members, carers and health professionals in the assessment. Information from those involved with our service users is invaluable to provide an accurate picture of the person’s needs. Theme: Support from voluntary organisations was seen as crucial in providing those with Moderate needs with help if they can no longer receive services directly from the council. There was concern that the voluntary sector would not be able to cope with the demand placed on it. Response: The council is moving to a commissioning approach to voluntary sector services for Adult Social Care, commencing in 2012.. The Council will ensure that the voluntary sector provide services that meet a range of needs, including services for people with Moderate needs.

Theme: Respondents made a variety of suggestions for services that people with Moderate needs would require if the council no longer directly provided services for people. The suggestions were: § Meals § Equipment, telecare and small adaptations to peoples homes § Cleaning, shopping and gardening § Support with employment or education § Information and advice § Social and day opportunities and transport Some people suggested services provided by health as being important for those with Moderate needs, such as chiropody and physiotherapy. Response: Services such as meals, telecare, equipment, small adaptations, employment support and information and advice will be available to new people who currently meet the Moderate band criteria. Services provided by the voluntary sector will also be available to them. Before April, details of the services available to people with Moderate needs will be published, setting out how these can be accessed and whether the services are free or chargeable.

5.4 Some carers were concerned that if services are withdrawn for existing

service users with Moderate needs this may cause their needs to escalate and become Substantial. Data provided through the Equalities Impact Needs Assessment showed that 73% of current service users have had services for over a year and it is recognised that many service users and carers will have become reliant and dependent on these services. Consequently it is proposed that existing people assessed with Moderate needs who are receiving services to meet those needs, will not have their services withdrawn and the changes to eligibility will only apply to new service users from April 2011. It should be noted that service users with Moderate needs will still be subject to an annual review of their Personal Budget and a reassessment of their needs.

5.5 In conclusion, specific feedback received during the consultation process about the impact on current service users has been taken into account in recommending changes in the council’s eligibility criteria. Cabinet is recommended to approve changes which mean the Council will meet the needs of new services users who have Substantial and Critical needs only, to apply from 1 April 2011.

6. Changes to intensive day care services for older people, closing two of

the Borough’s four intensive day care centres at Tangley Hall and Twickenham

6.1 The proposal in relation to day care was to close two of the Borough’s four

intensive day care centres at Tangley Hall and Twickenham. Over the last three years the four day care centres have overall not been used to full capacity, with unoccupied spaces and staff who could be supporting more people. If the proposal were to go ahead, the day care centres at Ham and Sheen Lane would continue to provide intensive day care services to those who choose to attend from Tangley Hall and Twickenham respectively.

In the three months since this consultation commenced, numbers attending all 4 services have decreased from 148 to 141 with numbers on register at Tangley Hall down from 41 to 36.

6.2 This proposal came about in order to achieve the following objectives:

• To make intensive day care services sustainable and viable in the short and long term.

• To make savings of £315,000 per annum, once the proposals are fully implemented.

• To maintain current service levels and quality of service, i.e. to ensure that all service users currently accessing intensive day care services can continue to do so.

Whilst the proposals were not originally conceived with the purpose of creating centres of excellence, in the early part of the consultation feedback suggested that the Council could build on the objective of maintaining service levels and also improve the quality of service through developing best practice models for care of older people and dementia care. The outcome will therefore be two specialist centres of excellence in day care, one for the physically frail and one for dementia sufferers which shall provide specialist and personalised services that support people in maintaining their independence within the available resources.

6.3 Background to the proposal and why this recommendation is made

Appendix 6 provides further detail on the background to the proposal. In summary, the proposal came about as a result both of Stage 1 of an ongoing review of day services, started at the beginning of 2010, as well as the Council’s Budget Review which was instigated in June 2010. Both reviews established that the status quo was not sustainable due to the under-use of day services as a whole, over a three period, and that there was the potential to make significant savings. The Council therefore considered the best way to move forward in making the services sustainable and viable whilst making savings and importantly ensuring that current service levels were maintained (i.e. ensure that all service users currently accessing intensive day care services can continue to do so). The proposal would make significant savings, would ensure that service levels are maintained, makes best use of the Council’s existing portfolio of buildings as well as providing the opportunity to develop two Centres of Excellence for day services within the borough. This development is in the context of improving services in the borough for older people across Adult Social Care and health, and in particular for people with dementia, as described by the Mental Health Joint Commissioning Strategy for Older People. Intensive Day Care Services are one part of a network of support for older people in the borough – development of these services therefore forms part of our broader strategy aiming to care for and support older people with both physical frailty and dementia across the full range of need.

6.4 Consultation

A total of 218 people have completed a questionnaire about the day centre proposals, of which; 61% understood why this change was being made, 25% did not understand why this change was being made, and the remaining 14% were unsure why the change was being made.

6.5 The proposal to reconfigure intensive day care services received the most attention before, during and after the consultation process from the public (including service users, existing and previous carers, and interested local residents), the voluntary sector and members. In particular, by far the strongest concern raised on all areas of the consultation was about the proposed closure of Tangley Hall Day Centre.

6.6 A summary of themes following the consultation is provided below with

responses: Theme: There were significant concerns regarding the potential for extended journey times for those currently attending Tangley Hall and Twickenham who under this proposal would move to Ham and Sheen Lane respectively. Response: It is understood and recognised that transport is a significant factor to be addressed. Work has been undertaken to address this through our transport modelling. Projections based on current attendance and estimates of future attendance indicate that average journey times will reduce with the proposed closure of Tangley Hall and Twickenham Day Centres. When it is clear specifically who will travel to the reconfigured day centres there will be greater clarity on routes and journey times. Details of the transport modelling information can be found at Appendix 4. Theme: People were generally resistant towards change and wanted reassurance that staff and activities that were familiar to them at their current day centre would continue, this was particularly important for users with dementia who would not cope so well with changes to their routine. Response: Wherever possible, it is intended that staff will remain with the service users they currently support and maintain the same key working arrangements, which means that the Council will encourage staff currently working at Twickenham to move to Sheen Lane, and staff currently working at Tangley Hall to move to Ham. A period of staff consultation and appointments to posts will commence as soon as decisions are made about service changes. However, as a result of this proposal there will be some changes with regards the level of staffing, for example a reduction in assistant managers / managers, ancillary staff and front line support staff. The Council will ensure that existing service users’ favourite activities continued in the ‘new’ centre. In addition, service users will have the opportunity to try new activities. The change process will be managed carefully, with staff at the day centres working with all service users (and their carers) on an individual basis to look at the future, and how they would like their support needs to be met. This will include looking at alternative options for those who do not want to move centres as well as transport arrangements. The transition between centres, for service users who were moving, will be managed on an individual basis. Theme: The demand for day services was queried, with some suggesting that day centres are being under utilised due to an increase in the cost of day care. In addition, some individuals pointed out that Tangley Hall is close to full capacity and queried whether the reason other centres are under utilised is due to a lower quality of service compared to the excellent service received at Tangley Hall. Furthermore, other residents acknowledged that centres are being under utilised and therefore understood why this was being targeted as an area to make cost savings. Response: The Local Authority believes that demand has dropped for a number of reasons, including:

• The introduction of self directed support and the allocation of personal budgets to individuals has meant that service users and their carers have had more choice about the way in which their needs are met, and are therefore not choosing to attend day care.

• The charge for day care has increased, so where previously service users could attend multiple days, the number of days accessed is now in line with the needs of the individual, and have therefore reduced overall. It is also proposed that the charges for day services are frozen at current levels until April 2013.

• Demand was looked at across the centres, as they are managed as one service and therefore need to be considered as a whole in order to come up with a proposal for how the service could be made sustainable for the long term, whilst maintaining current service levels and meeting the needs of older people with physically frailty and dementia across the borough. Whilst Tangley Hall continues to be used to near full capacity, the Council is aware that there is no longer a service user waiting list for Tangley Hall (which suggests that demand for these types of services has reduced).

Theme: Concerns that the Council had not considered alternative options to the proposal put forward and the view that the Council should delay proposed changes and do more work on other possible options, including working with the voluntary sector and use of volunteers before implementing changes. Response: Consideration of the options put forward by the Task Group and as set by the Health Housing and Adult Services Overview and Scrutiny Committee is included in Appendix 2 to this report. Theme: Some respondents questioned why the two centres proposed to remain open are both on one side of the river Response: An ideal model would have been for one of the services to be located on the west side of the borough. The proposal for both centres to be on one side of the river came about due to the Local Authority’s intention to use the best facilities available for the remaining two centres. The centres at Ham and Sheen Lane are large enough and have the right facilities for the increased numbers who would be attending (as a result of combining four existing centres into two). Theme: There were positive reactions from many at Ham and Sheen Lane towards new users attending their day centre, which would give the centres a lively atmosphere and allow everyone to make new friends. Respondents were also positive about the opportunity to develop ‘thriving’ community based services which provide excellent quality care and work in partnership with the NHS and voluntary sector. Response: The proposal supports an objective of creating two centres of excellence for intensive day services in the borough, with one specialising in supporting people with dementia, and the other in supporting the physically frail. The aim is that both centres will be financially viable and sustainable.

6.7 Health, Housing and Adult Services Overview and Scrutiny Committee

At the Health, Housing and Adult Services Overview & Scrutiny Committee on 11 November 2010 a decision was made to convene a short term Task Group to consider in more detail the proposal to reconfigure the four day centres to two remaining centres. In particular, the Task Group was tasked with

attempting to identify the same savings (as would be generated by the existing proposal) through other means.

The Task Group included cross party membership and met on five occasions in November and December 2010. A number of witnesses were called to give evidence, including staff of the Local Authority, and voluntary sector partners.

A report was drafted based on the findings of the Task Group, which included 17 recommendations. All but one of these recommendations were agreed, with some wording changes, by an extraordinary meeting of the Health, Housing and Adult Services Overview and Scrutiny Committee on 6 January 2011. A report from Overview and Scrutiny Committee is also on the agenda for this Cabinet meeting, (Item 9a) which describes the recommendations of the Task Group.

The short term nature of the Task Group meant that the four members of the group were limited as to the information they could consider and the range of witnesses they could call on. In addition, the group did not have the advice of a social care expert or financial expertise (in relation to estimating potential savings associated with the recommendations made) and there was no time for the Task Group to ‘test out’ emerging proposals. The Task Group report is welcomed and has been listened to, looking carefully at all concerns raised and recommendations made.

Overall, there is a shared vision between the proposals put forward for consultation and in the Task Group’s recommendations – to maintain and improve the quality and range of services for those with the highest levels of need and provide a comprehensive range of day services for older people across the borough. However, the Task Group proposed a different process to achieve our shared objective, suggesting that the review of intensive day services should be delayed and take place as part of a wider review of all day service provision, whilst the proposition put to consultation involved a staged approach, with the review of intensive day services to be completed as a first stage of a phased approach to the older peoples day services changes. It is agreed that the voluntary sector have an important role to play in taking the consultation recommendations forward, but that it is important to put intensive day service onto a sustainable footing before taking forward the wider review of the voluntary sector role as part of the move from grant giving to commissioning the voluntary sector. Feedback from some carers is that the voluntary sector would not be able to meet the needs of those with the highest support needs especially those with dementia. Our work so far supports the view that the voluntary sector services do not currently provide the necessary specialist skills and that there remains a need for specialist centres for those with the highest level of need. As part of the move towards becoming a commissioning council, these services might in the longer term be provided by the voluntary sector, but services meet to be put on a sustainable footing before any outsourcing or different model of delivery can be considered. Aspects of the Task Group report will help to inform work going forward and some of the recommendations, for example about Intensive day centre staff supporting current frail older users to access social day care will be pursued However, the delayed and wider review is not considered to present a “better

way” forward. The response to each of the Task Group recommendations is attached as Appendix 5 to this report.

At the meeting of the Overview and Scrutiny Committee on 25 October, the Committee recommended that an independent opinion should be sought from a psycho-geriatrician on the suitability of the services at Ham and Tangley Hall for people with dementia. In the first instance, a visit was arranged with a local psycho-geriatrician, which subsequently did not go ahead. The Mental Health Trust subsequently recommended an independent Consultant Psychologist with experience in the NHS of working with older people with dementia and in particular, experience of relocating older people with dementia to different residential settings. Due to the tight timescale for an initial report (an initial report was tabled at the Overview and Scrutiny meeting of 6 January) the Psychologist was unable to visit the centres. Instead a report was produced and presented to the Overview and Scrutiny Committee which provided advice on: • ‘the best way to manage a move of people with dementia from one day

care setting to another, including the potential impacts of the move, and protective factors that should be put in place to minimise these impacts

• What makes a building suitable for day service user by people with dementia’

This report is attached as Appendix 7 to this report.

6.8 Alternatives considered

Throughout the consultation process a range of alternatives have been suggested to the proposal to close two centres. These alternatives can broadly be grouped into three categories:

• Alternatives which close different centres to those proposed • Alternatives which look to generate additional income • Alternatives which look to delay decision making and bring Stage 1 and 2

of the day centre review together to consider the viability of the voluntary sector taking over delivery of intensive day care services.

Some alternatives proposed have involved more than one of the approaches above.

Each alternative suggested has been considered in detail. Some financial analysis has been included where appropriate. Full financial analysis has not been undertaken for those alternatives where initial analysis indicated that the alternative would not fulfil either of the following criteria: • To achieve per annum savings of £315,000 • To maintain current service levels Analysis of these alternatives can be found attached at Appendix 2.

Analysis of these suggestions indicates that no alternative proposal has been put forward that achieves the required savings as well as maintaining service levels in the same way as the proposal made to close Tangley Hall and Twickenham centres and relocate the services to Ham and Sheen Lane centres respectively.

6.9 Impacts of the change and planned action

The key concerns and questions in relation to the proposal have been the following: • That transporting existing users of Tangley Hall and Twickenham Day

Centres to Ham and Sheen Lane Day Centres respectively would increase journey times, making them too long for many service users, and thus meaning that they are not able or willing to transfer to the other centre.

• That the change process, in particular for older people with a diagnosis of dementia, will have a significant negative impact

• That the building at Ham does not offer the same homely environment as provided at Tangley Hall, therefore making the impact of the change more considerable

• What are the alternatives for people who do not wish to move to ‘new’ centres, for any of the reasons outlined above?

Transport Prior to, during, and after the consultation period, work has been underway on the proposed transport model. This proposed model includes the continued use of all seven existing vehicles (currently split across the four centres), and a clustering system, whereby service users are grouped according to their resident location in the borough. The concerns of anyone living closer to the day centre they currently use than the new one proposed for them are fully recognised and understood. Modelling has shown however that average journey times to the reconfigured services will be less than for the current day centre services, although a small number of service users will face significantly longer journey times. In view of the concern over the combined effect of a change of venue for people with dementia , and the time spent on the bus it is proposed to offer the option of a taxi to current users of Tangley Hall who would face a significant increase in journey times. Once it is known exactly who chooses to attend Ham and Sheen day centres and requires transport there will be greater clarity on journey times. Further information on this model can be found at Appendix 4.

The change process

The report prepared by Dr Sara Turner, Consultant Psychologist (Appendix 7) provided some advice on the best way to manage a move of people with dementia from day care setting to another, including the potential impacts of the move, and protective factors that should be put in place to minimise these impacts. This advice (page 3-4 of Dr Turner’s report) would be followed for each service users moving from Tangley Hall to Ham. In particular: • Each individual will be reviewed prior to the move, with detailed

discussion to take place, in partnership with carers, on the best way to prepare for the move, and how to manage the move itself

• Existing staff where possible will transfer with the service users they currently work with, ensuring continuity of care

• Maintenance of activities and routines

The recommended longer transition period for Tangley Hall service users (the move to take place by in September 2011) will allow for careful planning to take place, which will be particularly important for older people with a diagnosis of dementia. Building Design for dementia Dr Turner’s report also referred to ‘what makes a building suitable for day service use by people with dementia’ as well as indicating that the change from a smaller building to a larger one is an additional risk factor in the change process. As Dr Turner refers to, there is considerable literature and guidance available on the best practice in building design for use by people with a diagnosis of dementia. Her report refers to some of the resources available and some design elements that can be used. This report recommends that further guidance is taken on building design for dementia, in relation to the building at Ham, and that changes are made where possible by September 2011 to ensure it is fit for purpose for use by older people with a diagnosis of dementia, and in particular that changes are made which reduce the impact of the change for those service users moving from Tangley Hall Centre. This may include but would not be limited to: • Installation of familiar furniture and decorations and creation of cosy,

homely space in the side rooms in particular. This may include a room which is used initially by Tangley Hall service users only.

• Features to assist wayfinding, including: o colour contrast between rooms and between grabrails and

walls, doors and walls etc o use of landmarks o signage (using both words and pictures)

• Ensuring glare of sunlight and loud or sudden noise is kept to a minimum • Removal of visual clutter (apart from landmarks etc) • Creation of a wandering path which does not have an end point, can be

supervised by staff unobtrusively and offers access to a range of activity areas

• Creation of a sensory garden which forms part of the wandering path described above

Alternatives to daycare For those service users who despite the protective factors described above, choose not to move to the ‘new’ day centre there are a range of alternative options which could be considered, in partnership with a Social Worker, carers, and potentially an external support organisation. Any alternatives would be considered in relation to the service users’ individual needs, and the outcomes as described in their support plan, as well as in relation to their Personal Budget (where eligible for a Personal Budget). Alternatives include: • Provision of home care • Provision of a Personal Assistant (providing homecare and/or support to

access the community)

• Attendance at Homelink, potentially with outreach support of worker/s from the Intensive Day Care Service

• Attendance at a voluntary sector run Social Day centre (for the physically frail) with outreach support of worker/s from the Intensive Day Care Service

• Attendance at an Intensive Day Care service in a neighbouring borough • Potential for day attendance at a residential/nursing care home Further development of these alternatives where required would be undertaken if the recommendation is agreed, and on an individual basis dependent on personal preferences and needs.

Case studies of examples of existing service users with needs eligible for day care attendance, but whose needs are met through alternative provision can be found at Appendix 3.

6.10 Recommendation

In conclusion, the council has listened to the reasons why people were concerned about proposed day care changes, in particular concerns raised about transport provision, continuity of care, continuity of activities and service improvement, and these have been addressed in the proposals now put forward for approval.

This report recommends that Cabinet proceed with the proposal to reconfigure the four existing Intensive Day Care Centres to a remaining two, and that Twickenham and Tangley Hall Intensive Day Care Centres are closed.

However it is recommended that the closure of Tangley Hall is delayed until September 2011. This phased approach will allow for suitable adaptations to be made to the centre at Ham (see 6.9), as well as allowing for a full, person-centred transitional approach to the move, on an individual basis (see 6.9) as recommended by the independent clinical psychologist. Advice and measures suggested by the psychologist will be used to inform the transition process and enhance the environment at Ham Day Centre. If this recommendation is taken forward, no new referrals will be made to Twickenham and Tangley Hall Day Centres. Finally, this recommendation is made in the context of the Council’s aim to improve and enhance existing local good practice in the provision of care and support for older people and in particular older people with dementia, through the creation of two day centres in the borough which are financially sustainable and viable and provide excellent care and support, as part of a network of care and support provided by the Local Authority in partnership with the NHS and the private and voluntary sectors.

7. CONSULTATION AND ENGAGEMENT

7.1 A period of public consultation was carried out from 19 October until 10 December with service users, carers, voluntary organisations and interested residents. 2,077 questionnaires were distributed and 372 individual responses received.

7.2 In addition, 19 public meetings were hosted by the Council, at day centres and by voluntary sector organisations, of which there were approximately 300 attendees.

7.3 Of the 279 questionnaire responders providing personal information; 47% were users of care services, 40% were carers, 3% responded on behalf of an organisation or group, 2% were staff members of a health or social care organisation, with the remaining 8% being ‘other’. ‘Other’ responders tended to be people who would not be directly affected by the cuts, but included family, friends and neighbours of service users as well as interested residents who felt these cuts may affect them in the future should they required social care services.

7.4 Most respondents understood why the proposals were being put forward, with 63% understanding why the maximum contribution proposal had been suggested, 58% understanding why the disability-related benefits proposal had been suggested, 60% understanding why the changes to how you qualify for social care had been proposed, and 61% understanding why the day centre proposals was put forward.

7.5 A lower proportion of service users and carers understood why the proposals had been put forward, compared to responses from staff members and organisations and groups, where understanding of these proposals was high.

7.6 The proposals were considered by the Health Housing and Overview and Scrutiny Committee at a special meeting on 25 October. In addition, an Intensive Day Services Scrutiny Task Group was established to look at the proposals in relation to day care services.

7.7 Under the Council’s Petition Scheme, the Council received a petition opposing the proposed closure of Tangley Hall Day Centre and merger with Ham Day Centre. This petition was debated at Full Council on 23 November.

8. FINANCE AND EFFICIENCY IMPLICATIONS

8.1 The proposals considered in this report will contribute annual net revenue

savings to the Adult and Community Services budget of £1.065m, once fully implemented as follows:

Proposal Total

Saving £000

SDS Contributions Policy 700 Eligibility Criteria 50 Day Services 315 TOTAL 1,065

8.2 The savings figures above do not include potential redundancy costs arising

from changes to staffing at the Intensive Day Care Centres, estimated at between £50 and £100K which will be funded from the Council’s Invest to Save Fund. Final costs will be known once the final staffing structure is agreed, consultation carried out with staff and recruitment and selection to posts in the new structure is carried out.

8.3 Capital works will be undertaken to ensure the buildings at Sheen Lane and

Ham Day Centres fully meet requirements to operate as Centres of Excellence. This includes minor building improvement works at both centres and landscaping works at Ham Day Centre. Funding for this work will be identified in the 2011/12 budget.

8.4 The Council will consider alternative uses for the buildings currently occupied

by the Tangley Hall and Twickenham Day Centres as part of its Asset Management Strategy. These buildings are both leased by the Council.

8.5 The proposal to implement the revised SDS Contributions Policy will require

additional 3 FTE financial assessment staff at Scale 5/6 to deal with an additional 1,000 people likely to pay a contribution under the new policy. The cost of the new posts, estimated at £96k will need to be built into the 2011/12 revenue budget and these costs have been taken into account in delivering a net saving of £700k. Staffing levels will be reviewed once the policy has been fully implemented to seek efficiencies where possible.

8.6 In response to concerns raised in consultation, a number of delays and

adjustments have been made to proposals; phasing the closure of Tangley Hall, offering taxis to some service users and the protection on change of eligibility for existing services users. The potential impact of this will be managed within the overall budget.

9. POLICY IMPLICATIONS/CONSIDERATIONS 9.1 The Adult Social Care Consultation was carried out within the Local Strategic

Partnership’s agreed Community Engagement Framework.

9.2 All three proposals fit within the Council’s overall Adult Social Care framework – Personalisation and Self Directed Support.

9.3 The intensive day care proposal was made with reference to the Mental

Health Joint Commissioning for Older People, 2010. 10. RISK ASSESSMENT

10.1 The risks of these proposals have been taken into account and mitigating controls have been put in place. The major risks are outlined below:

• Financial assessments of individuals will need to be carried out in a timely

manner so that service users are notified of their increased contribution. Delays will cause anxiety to service users and could result in a reduced level of income being collected. Additional resources have been identified to carry out financial assessments during February and March to mitigate against this risk.

• One of the risks identified is that by withdrawing services from those with Moderate needs, this may cause needs to become Substantial. It is proposed that services for existing service users with Moderate needs will not be withdrawn and the changes to eligibility apply only to new service users from April 2011.

• The main risks in relation to Day Services are ensuring careful transition and planning for service users and carers affected and ensuring that suitable transport arrangements are in put in place. Recommendations made by Dr

Sara Turner are being implemented to mitigate the potential impact of people with dementia being moved to another day centre. Detailed transport planning has been carried out to assess the impact on service users.

11. EQUALITY IMPACT/CONSIDERATIONS 11.1 Equalities Impact Needs Assessments (EINA) have been completed for all

three proposals. The full EINAs are published on the Council’s website. 11.2 The corporate EINA model was used to evaluate the equalities impact of the

proposals. Information was gathered from the Adult Social Care information system on those that would be affected by the proposals, as well as considering information collected throughout the period of public consultation. A number of issues were identified through analysis of this information and as a result a number of mitigating proposals have been put forward.

11.3 In relation to the SDS Contributions Policy, mitigating actions are being taken

to address potential equality impacts identified in the EINA as follows: • Clear information will be made available on the new policy and individual

notification of contributions following a financial assessment. Information will be made available in accessible formats, where required.

• Access to welfare benefits advice and assistance with completion of financial assessment forms will be made available through Richmond AID and Age Concern Richmond Upon Thames, commissioned to provide these services.

• Different Personal Allowances will be set to take account of age-related differences in state welfare benefits.

• A Review Process is in place to fairly take account of individuals’ Disability Related Expenditure.

• A phased approach to implementation is being taken for a small number of service users who currently pay £320 per week to avoid them facing excessive increases. People who currently contribute £320 per week will not be subject to the maximum contribution being removed until April 2012 at the earliest.

• To minimise the impact of changes on people affected by both proposals to day services and the Contributions Policy, it is being proposed to freeze day service charges for two years. This will also minimise the potential impact of people reducing their attendance at day service due to the charges for these services.

11.4 In relation to the changes to the eligibility criteria the following impact has

been identified with associated mitigating actions: • Consultation findings show that this proposal may have a greater impact

on people with Moderate needs that receive services as they have become dependent on the support they receive. Data analysed for the EINA shows 73% of services have been in place for more than over a year.

• The proposal has been changed to only apply to new service users from April 2011; therefore there will be no impact for the 174 people currently receiving services who have Moderate needs.

• An analysis of data on current service users with Moderate needs was carried out to gain an understanding of the types of people that will be affected in the future by this change in policy. People from black and minority ethnic groups are not adversely affected by this change

compared to the general borough population. There is a higher proportion of older people affected which is expected given the high incidence of disability with age and the higher proportion of older people receiving social care services.

• There are no individuals with Moderate needs currently attending any of the Intensive Day Care Centres.

• Consistent application of eligibility criteria across client and disability groups will be ensured by using the Social Work Practice Forum to discuss cases and disseminate learning to all staff.

• Information gathered through the consultation process about services needed for people with Moderate needs will inform the Council’s future commissioning approach and the requirement for BME and disability related services for people with Moderate needs will be taken into account.

11.5 In relation to the day care proposal the following impacts were identified, with

associated mitigating actions: • The impact of the change may be felt more by those aged over 90 (20%

of existing service users). This impact will be mitigated through a personalised and carefully managed change process, involving existing day centre staff.

• All service users will have an individual review to gain individual preferences regarding transport, activities, meals, personal care, cultural and faith preferences to ensure all needs are being met.

• Those with dementia and physically frailty (all service users) may find changes to transport arrangements difficult. This will be mitigated through minimising changes to journey times and length, and through continued provision of known drivers and escorts throughout and after the change happens.

• It is recognised that people with dementia will have more difficulty adjusting to a longer journey time. If the journey to Ham will be significantly longer than the journey to Tangley Hall, the service user will be offered a taxi service.

• Individual needs related to faith and ethnicity which are currently met through specific activities will continue to be met in the remaining two centres.

• Individual needs related to gender will continue to be met in the remaining two centres, including personal care.

• To minimize the impact of changes on people affected by both proposals to day services and the Contributions Policy, it is being proposed to freeze day service charges for two years. This will also minimize the potential impact of people reducing their attendance at day service due to the charges for these services.

12. LEGAL IMPLICATIONS 12.1 The Council may provide community care services to carers and adults with

needs arising from physical, sensory, learning or cognitive disabilities or mental health. Councils are required to use the eligibility framework set by the Department of Health and to follow guidance for setting and reviewing eligibility criteria. In setting and reviewing eligibility criteria, the Council should take into account their resources, local expectations, local costs and agreements with the local NHS and other agencies. The review of eligibility criteria should be done in line with the usual budget cycle or when there are

major changes with significant resource implications. Councils are required to consult service users, carers and appropriate local agencies and organisations about their eligibility criteria.

12.2 The proposal to raise the eligibility criteria for social services from Moderate

to substantial and critical needs, enables the Council to prioritise social care needs that are considered to have substantial and critical consequences for independence and well-being ahead of needs with Moderate consequences.

12.3 Section 17 of the Health and Social Services and Social Security

Adjudications Act 1983 permits Councils to make a reasonable charge for non-residential care services. Section 17 also gives service users the right to ask the Council for a review of the charge which has been assessed, if they consider that their means are insufficient for them to pay the charge. Councils are required to consult service users and carers about charging policies and changes that would result in significant increases in charges.

12.4 Councils are required to set charges based on the Department of Health -

Fairer Charging guidance. The level of charges should not reduce the service user’s income below basic levels of income support plus a buffer of 25%.The Council may take into account disability benefits as income when setting its charging policy but assessments of the service user’s ability to pay should take full account of any disability-related expenditure.

12.5 The proposals in the report include changes to intensive day care services for

older people. The Council is required to consult on proposals to close day care centres and to act fairly.

13. ENVIRONMENTAL STATEMENT

13.1 The Environmental impacts of the proposed changes to day care include the

following: • Potential for increased distance travelled for a number of users could

result in a negative environmental impact from greater use of fuel. • Reducing the number of centres would create a positive

environmental impact through reduced use of heating, lighting etc.

13.2 No environmental impacts have been identified for the proposed changes to the SDS Contributions Policy and Eligibility Criteria.

14. BACKGROUND DOCUMENTS:

Equalities Impact Needs Assessments: • Changes to the SDS Contributions Policy • Changes to the way people qualify for social care (eligibility criteria) • Intensive Day Care Services for Older People

Adult Social Care Consultation Key Themes Report December 2010 Department of Health Fairer Charging Guidance 2003 Department of Health Fairer Contributions Guidance 2010

15. CONTACTS

Cllr Nicola Urquhart Cabinet Member for Adult Services, Health and Housing Cllr.NUrquhart@richmond.gov.uk Cathy Kerr Director of Adult and Community Services Cathy.Kerr@richmond.gov.uk 020 8891 7360 Jeremy DeSouza Head of Finance Adult and Community Services J.Desouza@richmond.gov.uk 020 8831 6311

Brian Castle Assistant Director Community Services Operations B.Castle@richmond.gov.uk 020 8891 7482

Appendix 1

Self Directed Support Contributions Policy

DRAFT SUBJECT

TO CABINET APPROVAL

Self Directed Support Contributions Policy 1 General Principles 1.1 Self Directed Support gives people choice and control over how their needs

are met by giving them control of a Personal Budget. The Council provides Personal Budgets to meet assessed eligible care and support needs. Eligible service users can choose a Direct Payment to arrange their own services or they can ask the Council to ‘manage’ their Personal Budget, where the Council will make arrangements for their care services from their Personal Budget. Under SDS, service users pay a single means-tested contribution towards the cost of their care and support (Personal Budget). The contribution is calculated according to a Financial Assessment.

1.2 The general principles underpinning the SDS Contributions Policy are as

follows:

Fairness: the policy will be applied consistently to everyone, regardless of how they are getting their services, so that everyone is treated fairly and equitably Ability to pay: everyone will be asked to contribute towards the cost of their social care based on their means. In support of this principle everyone will be offered a financial assessment of their individual circumstances and be left with a basic level of protected income. Reasonableness: no one will be asked to pay more than is reasonable. Maximising benefit entitlements: to ensure everyone is receiving all the welfare benefits to which they are entitled and are not missing out, everyone will be offered a welfare benefits check as part of their financial assessment. Transparency and clarity: the policy will be set out in a clear and straightforward way so that everyone can understand how their contributions (if any) have been calculated, will know what their contributions might be at an early stage, and be able to judge whether or not the policy has been applied in accordance with its underpinning principles. This new system is intended for people to know up front what money they are entitled to from the Council for their support and how much they will have to contribute themselves. Choice and Control: the policy will support the overarching aim of Self Directed Support which is to allow people to have more choice and control over their care and support arrangements. A single means tested contribution towards someone’s Personal Budget, instead of individual service based charges, support this overall aim. Compliance with statutory duties: the policy will be developed and applied in way that is fully consistent with legislation and the requirements set out in national guidance on fairer contributions.

1.3 Councils have discretionary power to charge adults who receive

non‐residential social care services under Section 17 of the Health and Social Services and Social Security Adjudication Act 1983. Section 7 of the

Local Authority Social Services Act 1970 gives the Secretary of State the authority to issue guidance on how councils should exercise this power.

1.4 The Financial Assessment will be based on the Council’s published SDS

Contributions Policy set out in this document. The Financial Assessment is based on the Department of Health’s Fairer Contributions Guidance and Fairer Charging Guidance. In specific cases where clarification is needed about capital and non-earnings income, the Council will follow guidance set out in the Department of Health’s Charging for Residential Accommodation Guide (CRAG).

1.5 Where someone does not provide their financial details for the purposes of a

financial assessment they will have to pay the full cost for their care services. 1.6 The Council will provide written information about the Contributions Policy to

service users when they first contact the Council for an assessment of needs. From the initial contact assessment, where it is likely that someone will need ongoing care services, arrangements will be made for a financial assessment to be conducted in parallel with the needs assessment.

1.7 The Council will endeavour to notify service users of their likely contribution at

an early stage while they are preparing their Support Plan. This will ensure that service users know their contribution before they agree to receiving any care and support arrangements from the Council. Where someone is not entitled to financial support from the Council towards the cost of care and support, they will be usually be offered information and advice on how to arrange their own care.

1.8 Where there is a delay in completing a financial assessment, resulting from

someone failing to provide complete, accurate and timely information, the Council will seek to recover back-dated contributions from the start date of care services.

1.9 Service users choosing to take their Personal Budget as a cash equivalent

(Direct Payment) will receive a payment less their assessed contribution. 1.10 People suffering from Creuzfeldt Jacob Disease (CJD) are exempt from

paying contributions towards their care. 1.11 The following are exempt from charges:

• Continuing NHS healthcare services • After care services under S117 of the Mental Health Act 1983.

Certain people are exempt from paying contributions towards their care. This mainly

applies to the following:

• People entitled to Continuing NHS healthcare • People receiving after care services under S117 of the Mental Health

Act. Such people, however, may also be in receipt of other chargeable services

• People suffering from Creuzfeldt Jacob Disease (CJD)

2, How Contributions are Calculated

2.1 Following the completion of the financial assessment form, an assessment of a person’s financial circumstances is carried out to determine the level of contributions towards the cost of their care. This is also known as a person’s available income.

2.2 The assessed contribution is the lower amount of either available income or someone’s Personal Budget. No one is asked to pay more than the amount or their Personal Budget or ‘available income’. The contributions are calculated as follows:

Calculation See Paragraph Below

A Income 4 Plus: B Capital Tariff Income 5 Minus: C Housing Costs 6 D Disability Related Costs 7 E Personal Allowances 9 F Available Income G Personal Budget H Contribution

The elements of this calculation are explained in more detail below.

3. Capital Limit 3.1 There is a capital limit of £35,000 before full cost charges apply. Anyone with

capital exceeding £35,000 will not be eligible for Council funding and will be usually offered information and advice to make their own care and support arrangements. Where someone lacks capacity to do this, the Council will arrange care and support and the service user will be required to pay the full cost of their care and support services.

4. Income 4.1 Income is money someone has coming in on a regular basis. Examples

include the following:

• Welfare benefits • Employment and Support Allowance • State retirement pension • Occupational and private pensions • Industrial Injury Benefit • Endowments from a life insurance policy • Rental income from a property

4.2 Certain types of income are ignored when calculating the level of

contributions as follows:

• Income (earnings) from employment • Disability Living Allowance - Mobility Component

• War Pensioner’s Mobility supplement • War Widow supplementary Pension • Working Families Tax Credit • Child Tax Credit • Child Benefit • Disabled Persons Tax Credit • Winter fuel payments • Social Fund Payments • £10 per week of War Disability Pension • £10 per week of War Widows Pension • Christmas Bonus paid with Benefits • Pension Credit Savings Credit • Ex gratia payments made to former Far Eastern POWs and payments

under the Vaccine Damage Payment scheme • Partner’s income, including earnings • 50% of the occupational pension or private pension (couples only) • Interest on savings • Income from the Independent Living Fund (ILF)

5. Capital Tariff 5.1 Savings below £14,250 are not taken into account when assessing the level

of contribution. A capital tariff of £1 is applied for every £250 held above the lower capital limit of £14,250. This means that someone with savings of £15,000 would have a capital tariff applied of £3 per week (i.e. £14,250 is ignored, £750 divided by £250 = £3 capital tariff)

Capital/Savings £0 ‐ £14,250 This will be not be taken into account in

the financial assessment.

£14,250 ‐ £34,999 This is taken into account in full to calculate tariff income. Tariff income is calculated at a rate of £1 for every £250 or part thereof on capital between £14,250 and £23,250.

Over £35,000 Not eligible for funding from the Council and required to pay the maximum contribution towards the cost of care.

5.2 The following items are taken into account as capital:

• Savings held in a bank, building society, post office or other savings

account • Premium Bonds • Bonds, stocks and shares • property owned, excluding the main home where you live

5.3 The capital value of a person’s home will not normally be taken into account

in the financial assessment where they continue to occupy this as their home/dwelling. The capital value of any other property owned or part-owned

will be regarded as capital. All decisions about the treatment of property will be made following the CRAG provisions, Section 7.

5.4 The above list is only a guide and it does not cover all the possible types of capital income.

6. Housing Costs 6.1 Certain housing costs (net of Housing Benefit or Council Tax Benefit) are

taken into account when assessing someone’s ability to pay, based on Fairer Contributions Guidance as follows:

• Rent (net of Housing Benefit) • Mortgage Payments (net of income support or pension credit

assistance) • Service charges • Council Tax (net of Council Tax Benefit) • Careline Charges

7. Disability Related Costs 7.1 When carrying out a financial assessment, the Council will take into account

income from disability-related benefits. In order to take account of someone’s disability-related expenditure (DRE) needs, the financial assessment will disregard £20 per week from disability-related benefit income.

7.2 The disregard of disability benefits of £20 per week is intended to cover the

following:

• Special dietary needs • Wheelchair/electric scooter costs • Laundry • Special clothing

7.3 The following disability-related benefits will be taken into account in the

financial assessment process

• Severe Disability Premium of Income Support • Attendance Allowance • Disability Living Allowance (care component) • Severe Disablement Allowance

7.4 Generally it is considered that other disability-related costs are likely to relate

to care and support needs and therefore these will be met from the Personal Budget. In exceptional cases, where someone has DRE needs in excess of £20 per week, they can request an individual review of their circumstances. The Financial Assessment Review Process is set out below.

8. Financial Assessment Review Process 8.1 Service Users have the right to request a review of their contribution towards

their Personal Budget, as determined by the Financial Assessment for the reasons set out below:

• incorrect dates or amounts have been used • the contribution is incorrectly calculated

• there is additional income and/or expenditure which was not included in the financial circumstances form

• costs in respect of a service user’s disability are higher than the disregard of disability benefit income given by the Council and are not being met from the Personal Budget

• there are exceptional personal circumstances concerning the service user’s financial situation, which mean they believe it is unreasonable to pay the assessed contribution

8.2 The service user can make the request by telephone or in writing to the Adult

and Community Services Finance Team. The individual circumstances will be reviewed and a decision will be communicated in writing to the service user within 2 weeks.

8.3 If the request for review is in relation to Disability Related Expenditure, it

should be made in writing to the Adult and Community Services Finance Team. The Service User should give details of any exceptional costs relating to their disability.

8.4 If the service user remains dissatisfied with the outcome of the financial

assessment review, they can use the Council’s Adult Services Complaints Procedure.

9. Personal Allowances 9.1 When assessing someone’s ability to contribute towards the cost of their care

and support, the Council gives each person a personal allowance. This ensures that the person will always be left with enough money to pay for basic household expenditure items and general living expenses. Where someone receives Disability Benefits an additional allowance will be made (see paragraph 7 above).

9.2 The Government set the level of Personal Allowance, linked to state benefits,

allowing a buffer of 25% more than the standard rate of Income Support or Pension Credit Guarantee Credit.

9.3 In 2011/12 these allowances are as follows:

• Pension Credit Guarantee Credit £171.69 per week for a single person

• Pension Credit Guarantee Credit £262.12 per week for a couple • Income Support £120.44 per week for a single person

9.4 Different allowances will be calculated for families taking into account specific

benefits and premium benefit payments, where applicable. 9.5 General living expenses are classed as every day costs which people are

expected to pay for themselves or using their state benefits. Examples of this expenditure include:

• Food • Water • Heating and Lighting • Telephone and Broadband

• TV Licence and TV Subscriptions • Insurance • Clothing • Repairs and Maintenance • Gardening • Credit Card/Loan re-payments

9.6 Where a service user’s income is below the current rate of Income Support

plus 25% they will not be required to contribute towards their Personal Budget.

10. Personal Budget 10.1 Following an assessment of need or Self Directed Support assessment, if you

have eligible care and support needs you will be allocated a Personal Budget. This represents the cost of meeting your care and support needs before your contribution. No one is asked to contribute more than the amount of their Personal Budget.

10.2 Contributions will be applied to 100% of the value of someone’s Personal

Budget. There will be no upper weekly limit on contributions. 10.3 Where an existing service user (at the date of this policy being approved)

pays a contribution of £320, their contribution will be capped at £335 per week and the removal of the upper weekly limit on contributions will not apply to them, unless they experience a change in their assessed care needs, whereby they will also be subject a revised financial assessment.

10.4 Under Self Directed Support, the Council will set (usually on an annual basis)

prices for its in-house care services. These prices will apply to people using their Personal Budget on Council run services e.g. intensive day care centres. The pricing mechanism is used to determine whether the Council seeks to provide an element of subsidy for specific services in line with its commissioning intentions.

11. Independent Living Fund (ILF) 11.1 The Council’s SDS Contributions Policy will not apply to the proportion of care

services funded by the Independent Living Fund (ILF). Where someone is entitled to claim ILF, the Council will take this into account when funding their care and support. The ILF has its own charging policy which will apply to their element of funding which generally takes into account 50% of the Higher Rate of Disability Living Allowance.

11.2 Where a service user is in receipt of Independent Living Fund (ILF) monies,

income from disability-related benefits will be taken into account in the Council’s financial assessment, however the proportion of benefit income deducted by the ILF under their own charging policy will be taken into account as an expense. This means that service users in receipt of ILF will not have benefits taken into account under two charging policies.

12. Couples 12.1 The financial assessment will aim to take into account people’s circumstances

and treat people fairly where they are married, have a partner or civil partner. 12.2 The Council will carry out a financial assessment which produces the most

favourable result for the service user. Charges should not reduce a couple’s joint income to less than the couple’s Income Support rate, plus 25%. Financial assessments for couples take into account both persons savings, income and household expenses.

12.3 Where someone and their spouse, partner or civil partner have joint savings,

only half will be taken into account in the financial assessment, unless evidence is available to the contrary.

12.4 50% of the occupational pension or private pension will be ignored when

assessing income for couples. 12.5 A partner’s income, including earnings, will be ignored in the financial

assessment. 13. Non Residential Care Services 13.1 Service user contributions for all non-residential care services will be based

on the Self Directed Support Contributions Policy except the following services:

• Home care reablement services (where there are no charges for up to 6 weeks)

• Community Meals (including meals at home and day centre meals, where flat rate charges apply)

• Services provided directly to carers e.g. Carers Direct Payments • Daily Living Equipment and Minor Adaptations • Telecare and Careline Services where separate flat rate charges

apply • Housing rents for supported living services and the Adult Placement

Scheme, where separate rent charges apply • Food/Utility charges for supported living services, where flat rate

charges apply • Universal services provided free of charge which include information

and advice, support planning and brokerage, employment advice and support services.

13.2 Previously the Council provided some people with specific services under the

Chronically Sick and Disabled Persons Act e.g. payment of telephone rental costs. Under SDS, the Council assesses someone’s eligible needs and provides a Personal Budget to meet those needs. Where someone is provided with telephone rental payments, this will form part of their Personal Budget and will be subject to personal contributions as part of the financial assessment.

14. Residential and Nursing Care 14.1 Contributions for residential or nursing care in a registered care home, will be

based on a financial assessment according to the department of Health’s

Charging for Residential Accommodation Guide (CRAG) rules. This policy does not cover the details elements of CRAG, however some aspects are included to clarify areas where Richmond has an agreed policy.

14.2 Where a service user owns or jointly owns a property and also meets the

criteria for a Deferred Payment, they can request a Deferred Payment of care home fees from the Council. This means that the payment of care home fees can be delayed until the sale of the property. Where a request for a Deferred Payment is granted, the service user will enter into a Deferred Payment agreement with the Council and consent to the placing of a legal charge (mortgage) to be registered against the property until the payment of care home fees has been made. The Council can only agree a deferred payment in respect of a jointly owned property if all co- owners sign an agreement to a legal charge being placed on the property. Full details are contained in the Council’s Deferred Payments Policy. The Council reserves the right to refuse a Deferred Payment where there are other means available to the service user to fund their own care home fees or where there is insufficient equity held in the property to cover the care home fees. Interest will be charged after 56 days when the Deferred Payment Agreement has ended at 1% above Barclay’s Bank Standard Base Rate.

14.3 The value of any property owned by someone in a care home would normally

be taken into account in the calculation of how much they should pay towards the cost of their care, unless it is occupied by a spouse or partner or a relative who is under 18 or 60 or over years of age.

14.4 Contributions for short term/temporary admissions to care homes, excluding

respite/short breaks for carers, will be based on a financial assessment using CRAG rules.

14.5 The Council will assess someone’s eligible care needs and offer a Personal

Budget to meet those needs. Where this assessed need is met by residential or nursing care in a registered care home, the maximum value of the Personal Budget will be based on the Council’s ‘usual rate’ for residential or nursing care. Where a service user chooses a more expensive care home, where their needs can also be met in another home at the Council rate, the Council will fund up to the value of its usual rate and enter into a third party top up agreement with family members for the shortfall in care home fees.

14.6 The Council has legal powers under Section 22 of the Health and Social

Security and Social Services Adjudications Act 1983 to place a unilateral charge against property owned by someone placed in a care home. A unilateral charge will be place on properties where the Council has not been able to obtain payment for care home fees. In these cases, interest will be charged at 3% above the Barclays Bank base rate after the date of the end of the care home placement.

15. Usual Rate for Care Homes 15.1 The Council’s ‘usual rate’ for care homes fees is based on the following:

• Rates agreed annually with the Council’s care home providers • The current rate applicable to the Council’s Private Finance Initiative

(PFI) care homes contract which is £632 per week in 2011/12

• The ‘usual rate’ paid by the host borough for care homes outside the Borough of Richmond Upon Thames

15.2 Charges will not apply to the first 6 weeks of intermediate care in a care home

setting i.e. Intermediate care beds at Greville House. Charges will apply for the first 6 weeks of residential or nursing care in a care home.

15.3 Charges will not apply to after care services under S117 of the Mental Health

Act. Care services that are not arranged under section 117 are chargeable. 16. Application to Court of Protection for immediate release of funds 16.1 Where someone has sufficient means to be self-funding, but does not have

access to funds, the service user’s next of kin or family members will need to initiate a request to the Court of Protection to grant a stand alone order to immediately release funds to settle care home fees. In order to arrange this, the Court will require the relevant application forms and fees (currently a fee of £400 and forms COP 1 and COP3). A full application to the Court of Protection will still need to be made to appoint a Deputy to manage the remainder of the person’s affairs. This procedure should be used when a service user has a family member able and willing to act for them.

16.2 Where no suitable person can be identified, the Council will take up the role of

Deputy, following a recommendation from the Care Management Team. 17. Deprivation of Capital 17.1 If a person has deprived himself of capital or an asset in order to reduce their

personal contribution towards the cost of their care and support, this will be treated as if the person still possesses the asset. The question of deprivation of capital should only be considered when the person ceases to possess capital which would otherwise have been taken into account. If a person knowingly reduces their capital in order to reduce their contributions (for example by excessive spending or gifting), this will be taken into account in the assessment and the contribution may be calculated as if that person still holds the capital that has been disposed of.

17.2 The Council will only consider questions of deprivation of capital when the

person ceases to possess capital which would otherwise have been taken into account.

17.3 Ownership: The Council will decide from available evidence whether the

person owned the capital and if applicable the timing of a disposal prior to the provision of care services.

17.4 Has deprivation occurred?

It is up to the Individual to prove that they no longer have a resource. Failure to do so will result in the Council treating the person as if they still possess the actual capital. Examples of acceptable evidence of disposal of capital would include:

• A trust deed • Deed of gift • Receipts for expenditure

• Proof that debts have been repaid. 18. Collection of Contributions 18.1 Where a person receives a Direct Payment to pay for their support any

contribution payable will be deducted before payment is made i.e. they will receive a net payment.

18.2 Where services are arranged by the Council as part of a ‘Council managed’

Personal Budget, an invoice will be issued on a calendar month basis in arrears. Settlement terms for each invoice will be strictly 28 days from the date of the invoice. Payment should be made by Direct Debit, although alternative methods will be offered in exceptional circumstances.

19. Recovery action 19.1 Recovery action will be taken where non payment of contributions occurs.

Follow up reminders and recovery action will be taken on all outstanding unpaid invoices. All cases requiring legal action will be presented to the Head of Finance (Adult and Community Services) for approval to proceed.

19.2 The Council will, at all times require users to pay the assessed charge. The

overall approach will be to obtain current compliance while at the same time working with any individuals experiencing difficulty in making payment. While an individual’s personal circumstances will be considered with sensitivity, in fairness to those people who pay their assessed contributions and to reduce the burden on local Council Tax payers, non‐payment will need to be handled in a business like manner in line with the Council’s overall debt recovery policy.

19.3 Where any person is found to be providing false information or providing

incomplete details of their finances, action will be taken as set out in Richmond’s Anti-Fraud Policy.

20. Variation to Planned Services and Contributions 20.1 The contribution will be assessed based on the agreed Personal Budget and

Support Plan. Contributions will be calculated on the basis of planned service provision and applied on a weekly basis.

20.2 Variations to planned service will occur from time to time for a variety of

reasons. For example where a person is unwell or is away visiting relatives and does not require their care and support in a particular week. This does not automatically mean that the weekly service contribution will be reduced.

20.3 A reduction of the assessed weekly contribution will only be considered if:

• Someone has given reasonable notice of absence e.g. due to holidays, planned hospital stay, etc,

• Someone has been admitted to hospital or short term care in an emergency.

20.4 Where a planned service is not delivered e.g. home care as it is not required

on a particular day, in most cases the service user will be expected to pay their assessed weekly contribution. It may be possible to arrange with care

providers for care to be provided at other times in lieu of missed visits. For day care services, service users are still charged for planned attendances even if they do not attend on particular days. Where someone cannot attend on their usual day due to a centre being closed, the attendance can be changed to an alternative day, therefore the contribution will still be collected. In addition the contributions set out in this policy for day care services do not reflect the full cost of providing the services concerned which remain subsidised.

20.5 If an adjustment is required to contributions, service users will need to notify

the Adult and Community Services Finance Team to arrange the adjustment. The agreed amount of contribution will need to be paid and where appropriate, an adjustment will be made on the invoice for the following month.

20.6 Where someone receives residential respite care in a care home, this is

charged in the same way as other non-residential services. The contribution will be based on the cost of the respite care service, divided over 52 weeks e.g. someone receiving 6 weeks of respite care during the year as part of their Personal Budget will make a small contribution each week towards this cost, instead of paying more in the weeks when they receive the respite care service.

21. Annual Revisions and Change of Circumstances 21.1 An annual revision will be undertaken to calculate a revised financial

assessment and contribution taking into account changes in pensions and benefit rates as well as other changes in financial circumstances.

21.2 Service users remain responsible for notifying the Council of changes in their

financial circumstances. Where changes in circumstances come to light retrospectively, the Council will request any backdated contributions to be made.

Appendix 2

Alternatives Considered and Suggestions Made During the Consultation Process

Overarching suggestions for implementation: § There is a need for an Equalities Impact Needs Assessment (EINA) to be carried

out and made public so that people can be confident that they are not being disproportionately affected by the proposals.

§ The council should consider the broader impacts of presenting these proposals

and conducting this consultation exercise on those with mental health problems, who this may cause considerable anxiety and stress leading to a deterioration in their mental health.

§ It was suggested that proposals should be piloted prior to implementation, in

order to measure the impact of the proposals which would help in planning for when the proposals are fully implemented.

§ Risk assessments should be carried out regarding the wider implications of the

proposals, such as for those with mental health problems that would not be able to cope with the anxiety caused by changes to their finances and services.

§ The SDS process should be reviewed in light of making efficiency savings in

order to see if there can be reductions in routine audit expenditure from personal budgets or ways of simplifying systems to determine what can be purchased through personal budgets.

SDS Contributions Policy Alternative 1 - Carry out detailed individual Disability Related Expenditure (DRE) assessments, instead of a flat rate disregard for benefits of £20 per week. Examples of individual costs:

• heating costs • water use that exceeds standard rates • high volume laundry • food/shopping costs that are high due to disability • equipment/Telecare/bedding costs related to disability

Could this proposal work? • Many councils use this approach to Fairer Contributions financial assessments, so

this proposal is possible, however it would be very costly to administer. It would also require a detailed and intrusive assessment process which would not fit with the general approach being taken to reduce the complexity and cost of assessment processes. It would result in increased expenditure for the Council. .

Summary • The financial assessment process would cost approximately £200k , a very high

proportion of the increased income generated • The overall savings target of £700k would not be achieved and there would be a

need to make further savings • The current proposal includes a review process whereby individual’s

circumstances will be reviewed where they feel £20 per week does not cover their disability-related costs.

Alternative 2 - Carry out detailed individual DRE assessments using a points-based questionnaire, instead of a flat rate disregard for benefits of £20 per week. Percentage disregard would be allowed depending on answers to DRE questionnaire (similar principle to RAS questionnaire). People with higher levels of DRE would be required to submit evidence of this expenditure. Could this proposal work? • This proposal would be very costly and bureaucratic to administer, including

additional costs of visiting staff to help people complete the questionnaire and processing staff.

Summary • This proposal would result in significant amount of increased expenditure and

appear to be contrary to the general principles of simplifying assessment processes.

Alternative 3 - Use a sliding scale for the disregard applied to benefit income, instead of a flat rate disregard of £20 per week. This would mean, for example, that someone on the lower rate of Attendance Allowance £49.30 would have a £13 disregard applied to their benefit income in the financial assessment and someone with the Higher Rate £73.60 would have a £20 disregard. Could this proposal work? • This proposal would work and possibly generate slightly more income from service

users on the lower and middle rates of DLA who would have a higher disregard applied to their benefit income. Whilst this proposal seems fairer to people, it is less generous than the original to people on the lower and middle rates of DLA.

Summary • This proposal has been discounted as it adds further complexity to the proposed

policy and will mean that people on lower benefit rates will have to pay more than the current proposal. Applying a higher disregard than £20 for people on the Higher Benefit rates would not achieve the required level of income.

Alternative 4 - Apply a standard % disregard of disability benefit income of 50% of service users’ disability benefits. The amount disregarded as income from someone’s disability-related benefits will be higher for those assessed as having higher needs, less for those assessed as lower need. This would mean a disregard of £9.77 per week for low, £24.65 for middle and £36.80 for high rate DLA, instead of proposed flat rate of £20 per week. Could this proposal work? • This proposal could work, however, in most cases it allows a more generous

disregard than the current proposal and would therefore result in a lower amount of income generated. Allowing a variable disregard based on the rate of benefits assumes that service users will incur many disability-related costs which will not be met from the person’s Personal Budget. Local experience shows that many disability related costs relate to health and social care services, therefore these are met by the NHS or provided by the Council through a Personal Budget. In addition to the disregard of benefits all service users are left with a Personal Allowance for general living costs and housing costs are taken into account.

Summary • This proposal has been discounted as it adds further complexity to the proposed

policy and will mean that people on lower benefit rates will have to pay more than the current proposal. Applying a higher disregard than £20 for people on the Higher Benefit rates would not achieve the required level of income.

Alternative 5 - Reduce the administrative costs of monitoring how people have spent their Direct Payment/Personal Budget Could this proposal work? • New light-touch monitoring processes were introduced for Direct Payments in 2010

so that Care Managers review spending while reviewing someone’s care needs. The Whole System Re-design of care management has achieved a reduction of 15 FTE posts and the Financial Management Review has reduced posts associated with processing transactions within ACS Finance. The dedicated resource for financial monitoring of Direct Payments is less than 1 FTE and there is not potential for savings in this area.

Summary • This alternative does not relate to the Contributions Policy and it has been

discounted as it would not generate any budget savings and could cost more if the Council stopped recovering surplus unspent Direct Payments.

SDS contributions policy – suggestions for implementation: § Many suggested having an appeals process in place for those who feel they can

not afford the care they need. It was also highlighted that whilst essential to have an appeals procedure some groups such as PLD service users or those with dementia would be less likely to use an appeals process, and therefore more likely to end up with insufficient money. It may also be inappropriate for those with M.E. who may not have the energy to appeal and whereby the appeals process may in fact be detrimental to their health and well-being.

§ Consideration should be given to crises that may be caused as a result of

proposal implementation such as safeguarding issues, hospitalisation and emergency respite.

§ Some groups such as those with dementia may require financial and legal advice

in order to maximise the funds available to them. § Information and advice provided to those no longer subsidised should be

strengthened in collaboration with service users. § Invest in high quality, independent community based support planning and

brokerage that can give financial advice, help people build social networks and give information on alternative care options.

Eligibility criteria –suggestions for implementation: § It would be useful to make information about services received by those with

Moderate needs available, in order that carers and the voluntary sector can be better prepared to step in and bridge this gap in services.

§ An impact assessment of these changes on carers would help ensure better systems to identify carers and signpost for assistance.

§ Those with MS or M.E. and therefore fluctuating needs need responsive services

in times or relapse or sudden deterioration to help maintain independence and reduce the long-term cost to council.

§ The council should work with health and the voluntary sector to review

preventative activities first and put a strategy in place before implementing the proposal.

§ A complaints procedure could be put in place and communicated to service users

to allow them to challenge decisions around eligibility for social care. § Investment in befriending services and voluntary care groups would allow

increased monitoring of those with Moderate needs. Intensive Day Care Services The following alternatives proposed have been suggested and are being considered. Alternative 1 - Opening Ham to service users in Kingston, thus generating income equal to or in excess of £134,000. This alternative would involve keeping all centres open with the exception of Twickenham (those service users would go to Sheen Lane as per the current proposal). Could this proposal work? • Initial discussions have taken place with Kingston - indicating that there could be

some interest for those living near the border with Richmond (near Ham). • No indication however that the numbers would be the minimum of 9 additional

service users per day required (equalling c.13-15 individual new users as most users attend on average 2-3 days per week) and therefore sufficient to generate the required income.

• In addition, if this additional number of service users were to attend, it would take the service ‘over capacity’ (based on current attendance) and therefore would mean a need for more staff, and therefore increased expenditure.

Alternative 2 - Increase Charges to Intensive Day Care Service, i.e. charging service users the true direct unit cost for the services (£78 per day) rather than the current subsidised charge of £58 per day including £10 for transport. Could this proposal work? • Whilst increasing the charge to self funders would create an additional ‘real’

income stream, increasing the charge to those with personal budgets, due to the accounting system currently in place for day care, would not increase the income into the service

• Increasing the charge may well mean that many self funders and individuals with personal budgets would not be able to afford as many days as currently purchased, thus reducing the overall usage of the service further, and therefore increasing the unit cost yet more

• Feedback from the consultation indicates that many service users and carers (attending both the physically frail and dementia services) feel the unit cost charged is already too high, and would not support a further increase

Alternative 3 - Mixed use of Sheen Lane or Ham through a split week or sessional use • Keeping two centres open, namely Tangley Hall and one other centre (Sheen

Lane or Ham) which would cater for all other service users • Attendance at Sheen Lane or Ham would be split across days, to avoid mixed

usage on the same day, as this is strongly discouraged by best practice due to the negative impact in particular on the physically frail service users without a diagnosis of dementia

• Or attendance at Sheen Lane or Ham would be split on a daily basis (i.e. sessional use)

Could this proposal work? • The proposal involving split usage on a weekly basis would be unlikely to work

due to associated capacity issues which would be likely to arise at Sheen Lane or Ham Day Centres as the numbers of days that could be accessed at the centre would be capped to a maximum of 2 or 3 (dependent on how many days used for each service user group). Currently, 39% (or 43 service users) of service users accessing Ham, Sheen Lane and Twickenham purchase 3 days or more. 20% of service users currently attending Ham, Sheen Lane and Twickenham (22 service users) attend for 4 days or more.

• The proposal involving sessional usage (split daily usage) would also represent a reduced service for most service users. Currently the vast majority (95%) of service users attend for full days. Arriving earlier and leaving earlier (e.g. 8-1), or arriving later and leaving later (e.g. 1-6) would disrupt current homecare arrangements as well as informal carer routines for all of those people, and would represent a reduced service. Transport costs would also be likely to rise, due to the need for significantly earlier pick ups and later drop offs at the end of the day.

• Both proposals would therefore mean not fulfilling the commitment to maintaining current service levels.

• Additional one-off capital receipts could be created from closure of Ham or Sheen Lane rather than Tangley Hall (more likely in the case of Ham, as Sheen Lane occupies the same building as other Council services). However, the value of these receipts is unknown at this time.

Alternative 4 - Mixed use of Ham or Sheen Lane through adaptation of the building • Adapting the centre at Ham for mixed use for both service users with dementia and

the physically frail • This would involve one off capital costs to split the centre at Ham or Sheen Lane

into two separate centres. • Tangley Hall would remain open and continue in its current use as a dementia

centre • Ham or Sheen Lane would accommodate both the physically frail (borough wide)

and dementia clients (Richmond side of the river) • Sheen Lane or Ham and Twickenham centres would close Could this proposal work? Ham: A further detailed proposal has been received in relation to the possibility of using the centre at Ham for all service users, excepting those service users accessing Tangley Hall Day Centre, through splitting the site into two centres. The following provides a brief summary of the Council’s response to this proposal: • The proposal may have a negative impact on current users of Sheen Lane,

Twickenham and Ham Day Centres who would have access to less flexible space

than would be the case under the Council’s proposal. Further capital investment (in addition to the investment required to split the centre) would be required to recreate the specialist facilities currently provided at Sheen Lane.

• The proposal would continue to split dementia services across the borough making the joint working with the NHS and voluntary sector as described as part of the Centre of Excellence model more difficult to achieve.

• Financial analysis of the savings outlined in the proposal has indicated that they could not be of the magnitude described due to a range of factors.

Sheen Lane • The building, whilst large, is only part used by intensive day care at present. The

remainder of the building accommodates the library and a community hall. The layout of the accommodation at Sheen Lane does not currently lend itself therefore to being split into two centres.

Alongside this proposal, suggestion has also been made that for those physically frail service users who do not want to access the one remaining centre, provision could be made at the Access Project to accommodate them. The Access Project currently provides for younger physically disabled adults, and is therefore not currently suitable for older people. The service would need considerable change to accommodate a new group. This kind of change (i.e. adapting the service to work with an older service user group) would not be in keeping with the overall strategy of the physically disabled service which is away from a building based service towards support into employment/skills development and community based support. Alternative 5 - Extend Tangley Hall in order for it to accommodate more service users (i.e. all dementia service users borough wide) Could this proposal work? • This proposal would incur significant capital costs and disruption at the site for a

prolonged period. • Tangley Hall (at the far end of the borough) is not in a suitable location to be the

single centre for dementia • Other centres in the borough are already of a size required Alternative 6 - Use of Kneller Road site for dementia centre Could this proposal work? • The Kneller Road site is currently used by the Access Project (for younger

physically disabled people), EMAG and Age Concern • The building is large enough to accommodate current service users with dementia

accessing both Tangley Hall and Ham. • However, this would need to be a longer term plan – as the Access Project itself

would need to move/become more community based and Age Concern and EMAG would need to move (potentially to Twickenham).

• It would also involve change for a larger number of service users (all those currently attending Ham, Tangley Hall, Twickenham and the Access Project).

• It would however mean shorter journey times for current Tangley Hall service users, thus addressing one of the key concerns with the current proposal.

• This plan could only be progressed from 2012-13 Alternative 7 - Income generation through advertising to self funders and to ‘unknown’ dementia sufferers through GPs etc

Could this Proposal work? • Currently the centres are open to self funders but access to the service is via Care

Management assessment. • To make the service more attractive and accessible to self funders the referral

pathway would need to adapt to allow for centre staff to assess eligibility for access to the service. This could potentially increase numbers accessing the service.

• This longer term plan should be considered whatever the outcome of the current proposals, in tandem with work to make the centres more attractive and accessible to all as specialist centres of excellence.

Alternative 8 - Voluntary sector to take over running of one or more centres Could this proposal work? • This proposal could involve the voluntary sector taking on delivery of Intensive Day

Care Services – either wholesale, or in parts. • The Council’s longer term plan for in house services needs to consider

externalisation, in line with progressing towards becoming a Commissioning Authority, as referred to above. However, when developing social enterprises and other community led service models, the guidance is clear that the services need to be fit for purpose and efficient before being externalised – transferring a liability to an external organisation will represent a risk to both the external organisation, and to the Council.

• Closer working with the voluntary sector, including in particular the Alzheimer’s Society for dementia sufferers would be very positive, and could be supported through a centre of excellence model.

Alternative 9 - Short term, smaller scale savings in year one, through reduction in staffing (one manager overseeing two centres) and other staff in line with current attendance (this option could be combined with many of the options above which would involve a significant time delay due to need for further consultation/development work etc) Could this proposal work? • There is potential for some smaller scale savings to be achieved in year 1 (2011-

12) through reduction in management (to 2 managers overseeing all four centres) and some reduction in support staff. However, the staff reductions could not be to the scale proposed through reduction to two centres.

• The £100k target for year 1 could potentially be achieved through these smaller efficiencies but these would be limited and would not create the £315,000 savings required in the longer term.

Appendix 3 Case Studies to Illustrate the Impact of Proposals The case studies shown below shows examples of the impact of the changes on service users for the following:

• SDS Contributions Policy • Changes to the Eligibility Criteria • Changes to the Council’s Intensive Day Care Services for Older People

SDS Contributions Policy Case Studies Case Study One – A married person in receipt of Higher Rate Attendance Allowance

Mr A has a Personal Budget of £190.00 per week. He uses this to purchase home care and 1 day at a Council Intensive Day Care Centre. Mr A is married and his wife does not receive any care services. He has savings of £20,500, but no occupational pension. The first £14,250 of savings is ignored and a capital tariff of £25 per week is applied to the remainder of these savings, £1 per £250 held. He is also entitled to the higher rate of Attendance Allowance. Under the previous Contributions Policy he would have not made any contribution towards his care services. Under the new policy he will make a contribution of £24.69 per week.

Calculation £ State Pension 102.15 Attendance Allowance 73.60 A Total Income 175.75 Plus: B Capital Tariff Income 25.00 Minus: C Housing Costs – Council Tax 25.00 D Disability Related Costs 20.00 E Personal Allowances 131.06 F Available Income 24.69 = A + B - C - D - E G Personal Budget 190.00 H Weekly Contribution 24.69 = Lower of F or G

Case Study Two - A single person who is not in receipt of disability benefits

Mrs B has a Personal Budget of £190.00 per week. She uses this to purchase home care and 1 day at a Council Intensive Day Care Centre. Mrs B has savings of £25,500 and a small occupational pension. The first £14,250 of savings are ignored and a capital tariff of £45 per week is applied to the remainder of these savings, £1 per £250 held. Mrs B is not currently in receipt of any disability benefits and is assessed a single person.

Under the previous Contributions Policy she would have not made any contribution towards her care services, as her available income is insufficient, taking into account the personal allowance given. Under the new policy she will still not have to make any contribution, however she may be entitled to receive Attendance Allowance and could be helped to do this by Age Concern’s Welfare Benefits Advice. She would still be better off by £20.00 per week. Her contribution would either £27.76 per week or £52.06 per week depending on whether she is entitled to claim the higher or lower rate of Attendance Allowance.

Calculation £ State Pension 102.15 Occupational Pension 29.00 Other Income 19.00 A Total Income 150.15 Plus: B Capital Tariff Income 45.00 Minus: C Housing Costs – Council Tax 25.00 D Disability Related Costs 0.00 E Personal Allowances 171.69 F Available Income -1.54 = A + B - C - D - E G Personal Budget 190.00 H Weekly Contribution 0.00 = Lower of F or G

Case Study Three - Someone who does not qualify for Council funding

Mr C has assessed care needs which would give a Personal Budget of £300.00 per week. He chooses a Direct Payment to arrange his own care. Mr C has savings of £26,500 and an occupational pension. The first £14,250 of savings are ignored and a capital tariff of £49 per week is applied to the remainder of these savings, £1 per £250 held. Mr C is currently in receipt of Attendance Allowance at the higher rate and he is assessed as a single person. Under the previous Contributions Policy he would have not received any funding from the Council and he would have to pay the full cost of his care services, as his available income exceeds the cost of his Personal Budget. Under the new policy he will be unaffected.

Calculation £ State Pension 102.15 Attendance Allowance 73.60 Occupational Pension 192.00 Other Income 175.00 A Total Income 542.75 Plus: B Capital Tariff Income 49.00 Minus: C Housing Costs – Council Tax 28.39 D Disability Related Costs 20.00 E Personal Allowances 171.69 F Available Income 371.67 = A + B - C - D - E

G Personal Budget 300.00 H Weekly Contribution 300.00 = Lower of F or G

Case Study Four - Someone who does not wish to disclose their financial details

Mr D has a Personal Budget of £280.00 per week. He uses this to purchase home care and 3 days at a Council Intensive Day Care Centre. Mr D has chosen not to disclose details of his income or savings to the Council, so he will not receive funding from the Council and will have to arrange his own care, unless he is unable to do so, in which case the Council will arrange his care services and he will be charged the full cost. Under the previous Contributions Policy he would have not received any funding from the Council and he would have to pay the full cost of his care services. Under the new policy he will be unaffected.

Calculation £ State Pension Attendance Allowance Occupational Pension Other Income A Total Income Not

disclosed

Plus: B Capital Tariff Income Minus: C Housing Costs – Council Tax D Disability Related Costs E Personal Allowances F Available Income = A + B - C - D - E G Personal Budget 280.00 H Weekly Contribution 280.00 = Lower of F or G

Case Study Five - An existing service user who is currently assessed to pay the maximum contribution of £320 per week

Mr E has a Personal Budget of £450.00 per week. He uses this to purchase home care and 2 days at a Council Intensive Day Care Centre. Mr E has savings of £29,000 and an occupational pension. The first £14,250 of savings is ignored and a capital tariff of £59 per week is applied to the remainder of these savings, £1 per £250 held. Mr E receives the Higher Rate of Attendance Allowance and is assessed as a single person. Under the previous Contributions Policy he would have had to pay the maximum weekly contribution of £320 per week. As Mr E is an existing service user paying £320 per week, his contribution will be increased to £335 per week.

If Mr E were a new service user, he would have to contribute £423.06 per week as this is the amount of his available weekly income and the maximum weekly contribution is being removed.

Calculation £ State Pension 102.15 Attendance Allowance 73.60 Occupational Pension 400.00 A Total Income 575.75 Plus: B Capital Tariff Income 59.00 Minus: C Housing Costs – Council Tax 20.00 D Disability Related Costs 20.00 E Personal Allowances 171.69 F Available Income 423.06 = A + B - C - D - E G Personal Budget 450.00 H Weekly Contribution 335.00 = Max Contribution for Existing

Service Users who currently pay £320

Case Study Six - Someone assessed to pay the full amount of their available income

Miss G has a Personal Budget of £450.00 per week. She uses this to have a Direct Payment to arrange her own care. Miss G has savings of £26,000 and an occupational pension. The first £14,250 of savings is ignored and a capital tariff of £47 per week is applied to the remainder of these savings, £1 per £250 held. Miss G receives the Higher Rate of Attendance Allowance and is assessed as a single person. Under the previous Contributions Policy she would have had to pay the maximum weekly contribution of £320 per week. As Miss G is a new service user, her contribution will be £369.67 per week as this is the amount of her available weekly income.

Calculation £ State Pension 102.15 Attendance Allowance 73.60 Occupational Pension 192.00 Other Income 175.00 A Total Income 542.75 Plus: B Capital Tariff Income 47.00 Minus: C Housing Costs – Council Tax 28.39 D Disability Related Costs 20.00 E Personal Allowances 171.69 F Available Income 369.67 = A + B - C - D - E G Personal Budget 450.00 H Weekly Contribution 369.67 = Lower of F or G

Case Study Seven - Someone receiving Independent Living Fund contributions

Mr H (younger adult) has a Personal Budget of £500 per week and receives funding from the Independent Living Fund (ILF) to pay for some of his care costs. He uses this to have a Direct Payment to arrange his own care. ILF offered to contribute £154.49; cost to council is £500.00. Mr H has savings of £2,500. As the first £14,250 of savings is ignored, no capital tariff is applied to his savings. Mr H receives the Higher Rate of Disability Living Allowance (DLA) – Care Component, however ILF require him to contribute 50% of his DLA towards his ILF payment. Under the previous Contributions Policy he would not have had to make any contribution and this will remain unchanged under the new policy.

Calculation £ Income Support 31.72 Disability Living Allowance 73.60 A Total Income 105.32 Plus: B Capital Tariff Income 0.00 Minus: C Housing Costs: Service

Charge 3.39

D Disability Related Costs 56.80 includes DLA deduction of £36.80 from ILF

E Personal Allowances 120.44 F Available Income -75.31 = A + B - C - D - E G Personal Budget 500.00 H Weekly Contribution 0.00 = Lower of F or G

Case Study Eight - Someone whose contribution equals the full cost of their service

Mr Z has a Personal Budget of £30 per week. He uses this to have a Direct Payment to arrange his own care. Mr H has savings of £2,500. As the first £14,250 of savings is ignored, no capital tariff is applied to his savings. Mr H receives the Higher Rate of Disability Living Allowance (DLA) – Care Component. Under the previous Contributions Policy he would not have had to make any contribution but under the new policy he needs to contribute dependant on his out goings.

Calculation £ Income Support 164.35 Disability Living Allowance 73.60 A Total Income 237.95 Plus: B Capital Tariff Income 0.00 Minus: C Housing Costs 3.39 D Disability Related Costs 20.00 E Personal Allowances 120.44 F Available Income 94.12 = A + B - C - D - E G Personal Budget 30.00 H Weekly Contribution 30.00 = Lower of F or G

Eligibility Criteria Case Studies The case studies below set out the services that have been provided by the council for people with Moderate needs and the services that could be provided when the changes in eligibility criteria are implemented for people with Moderate needs Case Studies One and Two – Same level of service provided Case Study One - Mrs F is 73 and recently moved from her family home to sheltered accommodation. Her husband who has dementia now lives in the flat next door. Mrs F is low in mood and forgetful for which she takes medication. Mrs F will frequently miss meals if not prompted and is prone to neglect her personal hygiene. On assessment her needs for domestic and personal care were judged to be moderate but with a likelihood that her needs would increase in the foreseeable future. She receives a daily visit to prompt her to take medication and to prepare a meal and one visit a week to help with domestic tasks. • Current Service - Home care 5 hours per week • Future Service - As her needs have been assessed to increase to substantial

within the foreseeable future (3 months) she would receive the same services Case Study Two - Ms G is a 90 year old woman who was admitted to Hospital after collapsing at hairdressers. Prior to admission Ms G was highly independent and on discharge was considered to require short term support to resettle at home. • Current Service – Support from the Intermediate Care team and meals were

provided for two weeks only. • Future Service – Will be the same. Support from the Intermediate care service

and meals at home will still be offered when we stop providing services for people with Moderate needs.

Case Study Three- Services provided through Voluntary sector and provided in a different way Ms V lives alone, but keeps in contact with friends and family using the telephone. She has restricted use of both arms and poor eye sight. She is able to dress herself, manage her personal care and strip wash independently but she cannot use the bath without help.

Ms V is able to shop locally everyday and pick up a few small items. She cannot manage large items of shopping. She prepares her own meals and manages all household/domestic tasks • Current service - Ms V has a paid carer who provides assistance twice a week for

2 hours. The carer helps her to have a bath and does any additional shopping that is required.

• Future service - There are a number of options. For bathing, it is possible to

provide equipment to help Mrs V bath alone. For shopping services, she can be referred to the voluntary sector, such as Neighbourhood groups, that can help with transporting shopping or putting her in touch via a buddy system to other people in her community who may be able to help. This would have a positive impact of getting Mrs V involved in her local community. Alternatively it could be recommended to Mrs V that she occasionally uses a home shopping service for heavy shopping from the local supermarkets.

Day Services Case Studies Case study One - Supporting someone to move from Tangley Hall to a Centre of Excellence at Ham Background: Mr J is a senior member of the community living. He is 89 years of age and lives with his 80 year old wife in their own home. He has a diagnosis of vascular dementia, which is defined as moderate to severe. He is physically quite able and is independent with all personal care. He attends Tangley Hall Day Centre 3 times a week and participates in activities such as chess, listening to music, watching TV along with the social aspects of having lunch at the Centre. He has formed a friendship with Mr B, who attends Tangley on every Monday. His wife reports since he started receiving support at the Intensive day Centre 2 years ago he is much calmer at home. In addition Mrs J benefits from respite in caring for him, using the opportunity to visit her granddaughter in Kingston and attend other social events. Mr J can become agitated in unfamiliar environments or when inactive for long periods. When travelling on a bus he will frequently attempt to get off at what he believes is his bus stop, even if it is not. When he is prevented from doing so he can become challenging. Transition Plan: In this situation promoting stimulating activities and encouraging his established friendship with Mr B are key to enable Mr J to enjoying his life, as well as ensuring Mrs J retains the opportunity for respite and time to be free from caring responsibilities. Mr J would benefit from additional activities so periods of inactivity do not lead to periods of difficulty for him and the others around him. The Centre of Excellence to be developed at Ham will enable this. The day care support worker (Miss P) would meet with the carer (Mrs. J) and involve Mr J as far as possible, to discuss and agree a plan for both transport and day care arrangements, that support his needs. Miss P will agree the journey start time with Mrs J and set out how long the journey will take. If the journey will be significantly longer than the current journey to current service then a taxi will be offered. In preparation for the move, they would also arrange a number of visits to the Ham Centre, accompanied by Mrs J and Ms P to show Mr P around and allow him a chance to become familiar with the new place.

Ham will ensure that the activities that Mr J currently enjoys will continue and they will ensure that Mr J is supported to maintain his friendship with Mr B. New services will also be offered to both Mr and Mrs J, including a chance for Mrs J to share and discuss issues with people in a similar position through the Caring Café, enable access to specialist health services such as support from Community Psychiatric Nurse for Mr J. As a developing Centre of Excellence for Intensive Day Care, Ham will have greater opportunities through its size as a large centre. There will be more choice of activities which can be run simultaneously, more expertise on site from a skilled and diverse group of skilled staff and the availability of discussions with others, including drop-ins from social workers, health staff and voluntary agencies and support groups. Case study Two - Person with dementia with services other than Day care Background: Mr. V is a senior member of the community currently residing alone in warden-assisted accommodation. He is 75 years of age. He has a cognitive impairment as a result of strokes and whilst he has not been formally diagnosed, his symptoms are consistent with vascular dementia. There are some issues in that his behaviour can be challenging to others, but he is supported to have control of this and be more settled. He is unable to communicate verbally as a result of expressive dysphasia but can communicate through body language and signs; something which requires people to get to know him. Meeting Identified Support Needs: Mr V currently receives a Direct Payment which he uses to employ a Personal Assistant (PA) who assists him with his personal care as well as domestic tasks. Mr V had declined to attend a day service, and through the assessment process (with the support of his daughter) it became clear that Mr V would feel uncomfortable in a Day Centre as he is unable to communicate verbally. This would have been both a source of frustration and anxiety and would no doubt have led to Mr V being seen as challenging when in fact he was doing no more than exercising his right to self determination and choice. The provision of a Direct Payment has opened up a range of new opportunities to Mr V, and has avoided him being labelled as “challenging” with the consequential need for unnecessary formal behavioural interventions. Through his support plan social stimulation through focussed activities which he chooses were identified as important. Using a Direct Payment to employ a PA with whom he has developed a good rapport has been key to meeting his needs, reducing anxiety and promoting his own choices. The PA assists Mr. V to engage in activities such as reading the newspaper with him, supporting him on short walks and simple tasks around his home. In addition this has allowed Mr V’s daughter to be able to provide informal support and protect the importance of their relationship. Had day services been the only option then clearly Mr V’s circumstances would have been very different.

Appendix 4 Transport Modelling on the Day Centre Reconfiguration

1. As of 12 October 12 2010 there were 148 different clients attending the four day centres. Of those 134 were transported by the Council’s transport service, Richmond Transport Services (RTS), in specially adapted buses. Modelling was done by looking at current attendees of the four centres using RTS buses and changing the routes to help get people to the centres at Sheen and Ham i.e. post closure of Twickenham and Tangley Hall. Reducing the number of day centres whilst retaining the seven buses allows for people to be collected more easily in clusters or neighbourhoods and it has showed reducing journey times on average for the clients across the four day centres. It should be noted that journey times can only be indicative until the exact list of names (and addresses) of those choosing to attend Ham and Sheen is known. If people leave or are added to the route it changes and could affect the journey time for everyone on the route. Journey times though for some clients currently attending Twickenham could be increased significantly, but only one person appeared to have a likely journey time of over ninety minutes. In detail current journey times for Ham clients range between 60 to 90 minutes; for Sheen clients between 31 and 79 minutes; for Twickenham clients between 30 and 100 minutes, and for Tangley Hall between 30 minutes and 120 to 130 minutes. If Tangley Hall and Twickenham closed the estimated longest journey times would be: for current Tangley Hall users 68 minutes; current Twickenham users between 83 and 95 minutes, for Sheen between 36 minutes and 50 minutes, and for current Ham users between 45 and 62 minutes.

2. Letters and comments at the formal consultation meetings showed that there is great concern for the service users currently attending Tangley Hall and the effects of a move to Ham in general, but particularly around journey times. A snapshot of current journey times to Tangley Hall taken on Tuesday 12 October 2010, showed that one service user living in Whitton had a journey time of 132 minutes, and two others over 90 minutes, (the maximum in the Service Level Agreement with RTS). The service provided in that 12 October 2010 snapshot was for the majority of service users at Tangley Hall, (although only ten actually travelled in that bus), on that day and since early October RTS has utilised some vehicle downtime to operate a “mop-up” bus for a few Tangley Hall clients. In the morning a vehicle coming back across Kingston Bridge after taking Special Educational Needs (SEN) children to school is now able to pick up 3 or 4 clients and take them to Tangley Hall. Similarly, in the evening falling numbers at Twickenham Day Centre have meant a bus became available to take home for 3 or 4 Tangley Hall clients at no extra cost. A further snapshot from week days in January 2011, all indicated that current average journey times are likely to reduce in the reconfigured service. As at 12 January 2011, the total number of service users at the four day centres had fallen to 141 and, of those, 127 are transported by RTS. The total number of users attending Tangley Hall dropped from 41 to 36 between 12 October 2010 and 12 January 2011, and numbers transported by RTS from 36 to 31. This illustrates the decline in day centre attendance in general, but also the changing nature of transport routes.

Because of the changing numbers of service users and the concerns around current and future journey times for Tangley Hall clients, more analysis has been done of current journeys. The tracker sheets for Wednesday 5 January 2011 to Tuesday 11 January 2011 show that the morning journey times are generally longer than the afternoons, and on Sunday, Monday and the Tuesday one client was on the bus for over two hours. Wednesday 5 January was the only morning when the bus to Tangley Hall took less than 90 minutes. On the afternoon of Saturday 8 January 2011 the return journey home was 125 minutes, (longer than any morning), but on no other day was there a journey time over two hours, although on Wednesday and Thursday there were total journey times of 92 and 91 minutes, (both above the SLA target). The “mop up” bus afternoon times never exceeded 39 minutes in the 5-11 January period. Unfortunately, the morning mop up bus does not have a tracker device but officers are confident that journey times were not excessive.

3. The modelling using the cluster arrangements to Ham and Sheen was based on knowledge of traffic speeds across the borough and the best use of vehicles to adjust to the two venues (instead of the four). There had been an assumption (based on work for an efficiency review of accessible transport in 2008) that the average stoppage time to pick up and drop off clients to Tangley Hall was 8 minutes, but recent analysis also using the tracking device has shown it is currently about 5 minutes. In recognition of the fact that some current Tangley Hall users will choose not to move to Ham day centre, a model was used with four clients, (all of whom have expressed reluctance to switch to Ham), so that RTS would only be transporting 75% of current numbers. None of the four current Tangley Hall users omitted in the model have the longest journey time. By applying an average 4 minutes stoppage time, the model showed that no-one would have a journey time of over 60 minutes to Ham, and if 5 minutes stoppage time applied the longer journey time would be 68 minutes.

Short “Dummy” Runs to Ham, Twickenham and Sheen for Current Tangley Hall Users

4. Because of concerns about journey times for clients currently attending

Tangley Hall travelling to Ham empty buses were driven on the three proposed routes stopping for five minutes at each address. The cluster covering the Whitton area with six clients took 83 minutes. Thus with 5 minutes pick up time the journey time for the first client would have been 83 minutes. For the Whitton cluster the second client’s journey time was 69 minutes with all the other journey times being less than an hour. The second bus collected five service users from the Twickenham area and the journey time from the first address was 64 minutes with all the others clearly being less than an hour. The third bus stopped at addresses in Hampton and Teddington, (those clustered closest to Tangley Hall), and the journey time from the first address to Ham Day centre was 80 minutes the second address 60 minutes and the other three clearly being less than an hour. All the “dummy” runs took place on 13 January 2011 using all the addresses of clients usually collated on a Thursday and arrived at the first address at 8.30 am, and so faced the rush hour traffic.

The dummy runs confirm that average transport times under the new cluster transport arrangements to Ham would lead to reduce average journey times and an end to excessive journey times currently experienced by a small number of clients.

Help to Reduce the Effects of Change

5. Although modelling shows the journey times would be reduced for most clients with the reconfigured day service, given the concern over the combined effect of a change of venue from Tangley Hall and the time spent on the bus, it is proposed to offer the option of a taxi to any current service user of Tangley Hall who would face a significant increase in journey times.

Appendix 5 Response to Recommendations by the IDCC Task Group Summary Points

• The recommendations made in the report would not generate the £315,000

savings required and further work would need to be carried out to verify the savings figures in the Task Group report.

• The report does not reflect the feedback given by all witnesses • Some of the suggestions made would incur additional costs, or make no

savings, and are not evidenced to improve services Strategic Vision • The Council supports the strategic vision for IDCCs as described by the Task

Group and want to work towards enhancing the provision whilst making it sustainable in the long term, and generating savings in the short term

• Whilst demographic changes may increase the overall demand for Adult Social Care it cannot be assumed that the demand for day services will increase – the personalisation agenda is allowing people to choose how they receive their support – this may not always involve day services, and as preferences change between generations over time, changing choices may become more marked

• The centres are currently open to older people, whether self funders or in receipt of Local Authority funded care. Access to the services is based on need due to the level of support provided and the cost of providing this support.

• In house Day Centres in Richmond upon Thames previously did provide to a wider variety of need – but the Council moved away from this approach, with the voluntary sector now providing social centre type services, in part funded through the Grants Programme with the Council providing to the highest level of need through the specialist services provided at the IDCCs.

• The support provided to those with a higher level of need is different to those whose needs are low, or who are accessing services purely for socialisation. Mixing the services can therefore be problematic and detract from the intensive level of care needed by some service users, in order for them to maintain their independence.

Recommendation 1: That cabinet defer the decision relating to proposed closures of Intensive Day Care Centres in order that a longer term strategy for the IDCCs can be developed. This strategy should seek to work in partnership with the voluntary sector to expand and enhance the services that are available to frail older people and those with dementia and their carers. Through developing a longer term strategy it is hoped that current unmet need for older people who would benefit from expanded day care provision would be addressed.

Response: The work completed thus far represents a Stage 1 review of all day services, including both the intensive day care services and voluntary sector services provided in the borough. The Stage 1 review did focus on the intensive day care services, and how they could be made financially viable and sustainable due in part to the need for the Council to make significant savings in the short term. However, the review did also look ahead, towards the longer term future. Work has already commenced on looking at the wider offer, through two meetings held with the

voluntary sector including initial discussion on the role they play going forward. This will link directly with the move towards commissioning local voluntary sector services from 2012 onwards, away from the current grant programme. The next stage of the day care review will also link closely with both the Council’s direction of travel as a Commissioning Authority, as described in the Cabinet paper of 8th November 2010 as well as the development of Social Enterprise in the borough, as described in the Cabinet paper of 6th December 2010. The Council will be carefully considering how day services are managed in the future, as part of its overall portfolio of in house care services. With the potential for creation of a social enterprise or for the services to become voluntary sector run in the future, it is essential that the services become fit for purpose and financially viable in the short term. The work completed to date has indicated that in their current position, externalisation of the services would not be possible without placing significant risk on both the Council, and the new or existing external organisation. Creation of two centres of excellence which are self sustaining, attractive and valuable community resources will ensure the future of intensive day care services in Richmond upon Thames, however they are managed going forward.

Recommendation 2: That Cabinet be encouraged to continue to work closely with Scrutiny in any future developments of Intensive Day Care Centres. Response: The Council welcomes the involvement of Scrutiny in stage 2 of the review. Short Term Savings

• Immediate savings could be made from the establishment, estimated to

generate the £100k indicated for Year 1 (2011-2012). The potential savings referred to in relation to Assistant Manager posts, alongside others, have been factored into the proposed £315,000 saving.

• The estimated savings associated with centralised services across the Council have been included as part of the Council’s budget review under other spend areas, and therefore cannot be ‘counted twice’.

Recommendation 3: That officer’s work with the IDCC Managers to look at potential savings that could be made in current running costs. Recommendation 4: That the IDCC Managers are more actively involved in the current and future proposals for the IDCCs. Response: The Intensive Day Centre Managers were involved at an earlier stage of the review, but more recently, due to the sensitivity of the proposal made were not involved in detail at this stage. The group Manager (who oversees all four centres) and Head of Care Provision have been involved throughout the process. Intermediate Term Savings • Moving Elleray Hall Day Centre to the building at Twickenham, would by

necessity involve the closure of the intensive day care service at the centre, beyond limited access from some service users to the ‘Elleray Service’ with support from IDCC staff (outreach) as already suggested as an alternative option for those not wanting to move to Sheen Lane. This suggestion is therefore no different to the current proposal, beyond the move of Elleray Hall, which could be

considered anyway, dependent on the building at Twickenham becoming available.

• Service users with higher level needs accessing Linden Hall and/or Meadows Hall also fits with the Council’s current proposal, and would only generate savings if the Intensive Centre at Twickenham were closed.

• The offer of Homelink opening an additional day for more severe dementia sufferers has already been discussed with officers and would be an alternative for existing Tangley Hall service users.

• The possibility of Homelink or a consortium taking over the running of Tangley Hall in its current form is complex and would need to consider TUPE of existing staff with LA terms and conditions and associated costs (therefore making running the service more cheaply difficult).

Recommendation 5: That alternative ways of keeping Twickenham IDCC are explored with a view to creating a centre for a wider group of clients, but still providing support for people with a high level of physical need, through working in partnership with the voluntary sector. Response: Maintaining the service at Twickenham, even if it were to cater to a wider range of needs, in partnership with the voluntary sector would not make the savings required and would not mean an improved service. If the IDCC were to close, the Council would consider the best future use of the building, which could involve use by the voluntary sector Recommendation 6: That transferring the running of Tangley Hall either by outsourcing it through commissioning to a suitable organisation such as Homelink, with much lower running costs or by running it in partnership with the voluntary sector be investigated. Response: Continuing the intensive service as is at Tangley Hall but run by the voluntary sector would involve TUPE of staff, which would make the cost efficiencies associated with the service at Homelink (for example) which uses paid staff/volunteer mix very difficult to achieve. The Council believes that externalisation of the services should happen when it is fit for purpose and efficient, and that a range of options should be considered, including development of social enterprise.

Transport • The work undertaken on how transport would be configured to support the

current proposal is described at Appendix 4 of this report Recommendation 7: That a review of the transport system takes place with a view to developing a more cost effective efficient service, this should include outsourcing the service, the use of volunteer organisations and looking at alternative models elsewhere. Response: Transport is an expensive service to provide, officers agree that there may be more cost efficient and better ways of transporting service users to and from the centres. This will all be considered as Stage 2 of the review.

Meals • Apetito tendered for the meals contract on the assumption that 23,000 meals

would be purchased per annum. The current numbers purchased are significantly lower than this and therefore the price per meal is now over £8. The

number of meals is lower than expected due to the occupancy rates at the centres.

Recommendation 8: That the contract with Apetito be re-looked at and the potential to produce the meals using IDCC staff be explored with a view to both saving money and improving the quality of the meals. Response: The contract with Apetito is for a duration of three years, and will end in 2012. Officers have looked at the possibility of producing the meals in house, but this would involve terminating the contract and consideration of TUPE issues involving the existing Apetito staff. Options for future provision after the current contact has ended will be explored.

Management Costs

Recommendation 9: That Adult Social Care review the management structure for the IDCCs with a view to flattening the management structure and increasing the responsibilities of the IDCC managers. Response: Savings could be made through reducing the number of managers as included in the current proposal. This proposal is made at a time when other changes are being made in the in house care service; for example changes to management arrangements in residential care services . Once all these changes have been made, there will be a review of the senior management structure needed for this service in the future. Revenue Generation • The unit cost of the services is £58 per day (including transport), whilst still being

subsidised by the Council. This unit cost is linked in part to the occupancy levels at the centres. Making the services more efficient, through reducing the number of buildings used will reduce the costs of delivering the services, and increase the overall occupancy levels.

Recommendation 10: That the IDCCs are more actively promoted to potential users and their carers and their profile is raised with health and social care professionals so clients are give more choice.

Response: The IDCCs are promoted, with work undertaken recently in producing new information leaflets etc. We will explore opportunities to promote the service further but under the Council’s proposal, there would already be capacity to take additional referrals. Recommendation 11: That officers make contact with neighbouring local authorities to ascertain the level of demand there might be from non-Richmond residents. Response: Initial contact has already been made with some neighbouring local authorities, indicating that there may be some interest, although this is likely to be limited Recommendation 12: That the borough works with the voluntary sector and NHS colleagues to look at the provision of places for people with functional mental illness. Response: The provision of support for older people with functional mental illness will be considered as part of Stage 2 of the review.

Consultation • The local voluntary sector were written to directly by the Council at the beginning

of the consultation and were invited to comment via the questionnaire. In addition, the sector was encouraged to invite Council Officers to their own meetings to explain the proposals and gain feedback. As a result Council Officers attended 9 meetings held by the voluntary sector which considered all three proposals.

• In addition, two meetings have been held with the voluntary sector involved in the provision of social day care and neighbourhood care in September and November to discuss the proposal and to look at the broader development of day services locally. All voluntary sector providers of daycare and neighbourhood care were invited to these meetings.

Recommendation 13: That the borough makes note of the disappointment expressed by some representatives of the voluntary sector about their lack of inclusion in the consultation. Response: The Council does not accept that the voluntary sector were not included in the consultation, for the reasons described above. The Council will continue to engage with the voluntary sector throughout Stage 2 of the process and in the implementation of the proposal if agreed. Dementia Care Strategy • Creating a new service at Barnes Hospital in partnership with the NHS for more

intensive and Moderate clients with dementia and mental health problems would create additional costs for the local authority without closure or move to Barnes of services already provided. Joint working would be possible at the centre at Ham.

Recommendation 14: That the Dementia Care Strategy be re-visited with our NHS and voluntary sector partners and the potential for expanding the range of services locally, particularly for the early and moderate stages of dementia, in the IDCCs be investigated. Response: The future of dementia services in the borough and how the Dementia Strategy is responded to locally across health and social care is being considered carefully by NHS Richmond, South West London St Georges Mental Health Trust and the Council through the implementation of the Mental Health Joint Commissioning Strategy for Older People, which was published and agreed by Cabinet in March 2010. The vision of a centre of excellence for dementia in the borough, at Ham, would involve close working with the NHS and voluntary sector partners.

Recommendation 15: The review of the IDCCs presents an opportunity to address the needs of these client groups more holistically and those of vulnerable older people whose needs are not being picked up sufficiently i.e. those with functional mental illness. The Task Group would like to see the service reviewed in this light in partnership with the NHS and the voluntary sector.

Response: The day services review is considering the needs of the full range of service user groups holistically, and will be involving the NHS and continuing to involve the voluntary sector as the work progresses. Working with our Partners • The Council does not yet have a clear indication of how the additional monies

from the DH will be distributed, and what this will mean on a local level. 2008 Review of Community Day Care Centres Recommendation 17: That the 2008 Review of Community Day Care Centres be re-visited and the proposals put forward for developing the day centres be re-evaluated.

Response: The work undertaken in putting together this proposal led directly from the 2008 review of day services. However, the more recent work looked in considerably more detail at the patterns of demand for the services, as well as benefitting from reviewing the impact of the introduction of self directed support and a new charging regime, which has meant a change in both demand and patterns of usage.

Appendix 6 Background to the day services proposal Work on reviewing the borough’s full range of day services, both in house intensive day care and the broader offer provided by the voluntary sector began at the start of 2010, and was instigated in order to: • revisit the recommendations of the 2008 review in the context of changing

demand and usage of services (in particular the in house intensive day care services)

• look at how the services could be improved both individually and as a collective (i.e. to ensure that the full spectrum of needs are met)

• begin to consider the future management and organisational arrangements for the Council’s in house care provision

• and in the context of the need to make efficiency savings across all of Adult Social Care

Since the work on the review began, the administration of the Council has changed and a new national coalition government has been elected. The new administration instigated a full Budget Review in June 2010. The intention of the review was that all areas of the Council’s budget should be considered for efficiency savings. At that time, the analysis work undertaken on the in house intensive day care services indicated that overall for the period 2007/08 to 2009/10, the centres have consistently, and increasingly, not been used to full capacity (73% occupancy at Q1 of 07-08 and 66% occupancy at Q4 of 09-10). Occupancy levels at the centres have varied, with Tangley Hall having the highest occupancy levels (over the three year period described, nearly always at over 80% occupancy) but with the lowest number of places (15 per day) and elimination in the waiting list held over the same period. When considering the Budget Review, and the need for the Council to make substantial savings over the next three years, it became clear that continuing to run four centres, which are collectively under-used, was not sustainable or financially viable going forward. Having established that the status quo was not sustainable, and that there was the potential to make significant savings, which could contribute to the Council’s overall Budget Review, the Council considered the best way to move forward in making the services sustainable and viable whilst making savings and importantly ensuring that current service levels were maintained (i.e. ensure that all service users currently accessing intensive day care services can continue to do so). When considering the existing portfolio of buildings, and the nature of the services (i.e. two existing services for the physically frail, and two for dementia sufferers), it is proposed that the number of centres should reduce from four to two. The proposal will involve all service users currently accessing Tangley Hall and Ham Day Centres accessing a new dementia service at Ham, and all service users currently accessing Twickenham and Sheen Lane Day Centres accessing a new service for the physically frail at Sheen Lane. The centres at Ham and Sheen Lane are proposed to remain open because: • Sheen Lane has physical capacity for 50 service users (and therefore space for

all existing users of Sheen Lane and Twickenham) and has a range of facilities

well suited to intensive day care for the physically frail including an Aids for Daily Living room and adapted kitchen for service users to re-learn skills and a safe and secure garden. The facilities are located on one floor, and are in the same building as the library, as well as being next door to two of the Borough’s four health and social care locality teams.

• Ham has physical capacity for 50 service users (and therefore space for all

existing users of Ham and Tangley Hall). Ham also has a large and secure garden which could be adapted further to make it a therapeutic experience for dementia sufferers (see 6.9). The building is designed around a large central space which is bright and airy. Three smaller side rooms can create a cosier feel. The space is flexible and with some minor work (see 6.9) could form a suitable therapeutic environment, meeting the needs of both dementia sufferers who need a cosy, home-like environment, as well as those for whom wandering with purpose is important.

As work developed on Stage 1 of the review, and in response to one of the original aims of the review (i.e. to improve local services) it became clear that through reconfiguring existing provision, there was an opportunity to develop two ‘Centres of Excellence’ in the borough, one for dementia and one for the physically frail, which work in partnership with the NHS and the voluntary sector which would provide specialist and personalised services that support older people in maintaining their independence. Whilst the “Centre for Excellence” model was not cited as an initial aim of the proposed changes some of the early consultation feedback supported this view, in particular in relation to the potential of the building at Ham. It was identified that through consolidating services onto two sites the potential for this development will be enhanced (as compared to the current location of the services over four sites) through: • Greater number of staff on one site, therefore providing flexibility around

activities and therapeutic interventions provided • Focus in terms of any capital spend on building development or improvement • Focus for partnership working with the NHS and voluntary sector The core component of the centres will continue to be the intensive day care service which, providing to the highest level of need. This service will be clearly defined and will be made available to FACS eligible service users, both those whose care is funded by the Local Authority, and those who fund their own care. In addition to this core service, the buildings provide the opportunity to expand partnership working with Hounslow and Richmond Community Healthcare and South-West London St George’s Mental Health Trust (in the case of the dementia service at Ham). In particular, in relation to older people’s mental health services there could be the opportunity to expand the existing outreach service and explore the potential for links with streams of work contributing to the implementation of the Mental Health Joint Commissioning Strategy for Older People. In particular the building and service at Ham could integrate more closely with development work around information, advice and early diagnosis of dementia and the development of a memory assessment service. This could further be enhanced at Ham by developing closer partnership working with the voluntary sector, and the Alzheimer’s Society in particular. There could be potential for development of drop in services, provision of information and advice and

support for carers, including potential relocation and expansion of the Caring Café. The Ham Centre will also provide a weekend service. Finally, focusing services on two sites could create enhanced opportunities around the recruitment of volunteers. The inclusion of volunteers working in the service alongside, and supported by, trained intensive day care staff could further enhance the range of activities provided and ensure the full integration of the services into the local community. Work in developing these centres of excellence will commence prior to the proposed change in services, and will form part of Stage 2 of the review which has already commenced. In addition to the development of the centres of excellence model, Stage 2 of the day services review is considering the wider day services offer in more detail, including importantly voluntary sector provision. From 2012/13, these services will be commissioned, providing an opportunity to ensure that funded services are meeting the full range of local needs in a way that is attractive to local older people.

Finally, Stage 2 of the day care review will also link closely with both the Council’s direction of travel as a Commissioning Authority, as described in the Cabinet paper of 8 November 2010 as well as the development of Social Enterprise in the borough, as described in the Cabinet paper of 6 December 2010. The Council will be carefully considering how in-house day services are managed in the future, as part of its overall portfolio of in house care services. With the potential for creation of a social enterprise or for the services to become voluntary sector run in the future, it is essential that the services become fit for purpose and financially viable in the short term. The work completed to date has indicated that in their current position, externalisation of the services would not be possible without placing significant risk on both the Council, and the new or existing external organisation. Creation of two centres of excellence which are self sustaining, attractive and valuable community resources will ensure the future of intensive day care services in Richmond upon Thames, however they are managed going forward.