Choice re Care/Support Provision

I am the Direct Payments Co-ordinator for Wolverhampton City Council and have been asked to respond to your email request below.

Unfortunately we have had no referrals to date for older people in Extra Care Schemes. However, should we get any I will try and remember to pass on the details.

Janine Tye

We are currently in the process of transferring from a "spot purchased"
home care service supplied by several independent care suppliers, to 3 area-based block contracts, to stabilise what was a fractured/ piecemeal home care market. This was done through negotiation with all the suppliers, the vast majority of whom agreed that this form of approach was necessary for stability.

The issue of choice was brought up in this situation the argument is that
the service user still has the right of choice of who tends to their
individual needs and can ask for a different worker but not a different
supplier.
In the transfer process the opportunity for people to opt for a "Direct Payment" has been raised as an alternative, so in effect they still have an "alternative supplier" in that, with the help of the support service, they can organise their own care. We are monitoring up take closely!

Steve Thomas
Planning and Implementation Officer
Social Services Department
Hartlepool Borough Council
Civic Centre
Hartlepool
Tel (01429) 284296
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In Liverpool our initial thinking around this has been pretty simplistic but i think has moved us in the right direction:

a) direction on choice only applies to care home services and even then with certain restrictions. specifically the choice is limited to service availability and the provider operating to the authorities terms and conditions. moves towards more sophisticated purchasing of care services, particularly in the home/dom care feild, via tendering etc has targetted investment on a reducing provider base.

b) so long as the tenant is enabled to make an informed choice at the front end, ie as part of the assessment process for extra care, by the provision of clear info that the care is provided by agency x and part of the charge (levied whether or not service is recd) then weve assumed were on solid ground. if tenant then decides to not allow provider x to support them, that is their call but:
they are refusing service and will continue to be charged whilst living in scheme.


Paul Clitheroe
Group Manager Strategic Commissioning
Liverpool City Council.
Supported Living & Community Safety Portfolio
Millennium House. 60 Victoria Street. Liverpool. L1 7JQ.
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re Q 1 this is indeed a difficult one because total choice exercised by a number of people in an ECH scheme could completely undermine the ability for a single care provider to provide the care in an Ex care scheme and also the consistency in the care providers .
However the legislation says that people must have the choice so the way to deal with it in my view is to ensure that the care providers commissioned to work in the scheme provide high quality, reliable care and that people are actively encouraged to use them.
Where people have wanted to keep their existing carers when moving in to a scheme we have spent time explaining the reasons why they need to change carers and the need for consistency in the care provision. So far this has worked well in our first scheme in the city but if someone did insist on keeping their external carers we feel we would have to go with that and work with the individual to get them to change their position.
Alternatively the external worker could be recruited, part time or full time by the extra care provider company but this could be undermining for their managers and cause disruption to care provision for the external company, so no easy answers I'm afraid.
I expect that preventing choice could be subject to a challenge at some point so we try to do everything we can to persuade people moving in to the scheme about the benefits of one care company providing the care.
In other Ex care schemes (private) I am aware that the choice is offered but if people decide to exercise this the developers have refused to allow the external company staff use of any of the communal equipment (e.g. hoists and baths, i.e. equipment that is not inside the persons flat, this is done on the grounds of health and safety and training)

Angela Rowland
Project Manager Extra Care Housing
Sheffield City Council
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It is quite a big issue to hope to resolve sensibly by e mail but what might help is to look at the same debate which has been going on in the learning disability field for about 7-8 years as the move to independent supported living has taken place.
In case you are not aware there is a major test case involving CSCI and a care provider company called Alternative Futures proceeding at present. Briefly they deregistered care homes and granted tenancies through an associated landlord company. The then NCSC argued not properly deregistered because of a variety of issues including were these proper tenancies (legal capacity issues which are similar to problems of granting tenancies to older people with dementia) and was there choice of care provider-the issue raised by your enquirer.
AF appealed but lost the appeal. The appeal tribunal put considerable stress on the choice of care provider point in deciding if the service was registered or not.
There is no further appeal route but AF have recently been given approval by a judge for a judicial review. Our view which you will find some reference to on Housing Options web site is that the tribunal took too little account of years of housing law and cases almost ignoring the point that someones own home should not be registerable -the judge seems to have a similar opinion advising AF and CSCI to seek further advice from a land law specialist.

Nigel King
Director of Housing & Support Partnership
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Unfortunately I cannot offer example of direct payments in extra care.
However the issue of choice in care provider within extra care (when there is a dedicated, perhaps contracted team, in place) has been considered by us but not driven by particular objection or challenge. Our issue is that the on-site team is configured to deliver flexible support and an independence-promoting ethos and (we believe) the best option for service users.
We support our line of thought with a monitoring process which involves 1:1 interviews of service users and we respond to any issues raised. I feel that the choice element is also about the way in which the care is delivered as well as who provides it.
I know this isn't definitive but our `bottom line' would be to allow another provider to provide the care if sufficient justification was offered.

John Hazelhurst
Planning & Commissioning Officer
Tameside & Glossop Primary Care Trust
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I am taking the pragmatic approach to this one - we make absolutely certain at the point of offer of housing that the choice of housing is also a choice of care provider - and that it is highly unlikely that they will be able to make a different choice of care provider if they accept the tenancy. Indeed this would be extremely difficult to do with the advent of generic teams with the specialist skills needed for my Dementia projects.

We are applying this to our not yet opened Dementia extra care schemes and our former res care - now Extra Care - scheme.

As for a legal challenge - - - - - not daring to think about it !!

Lynne Redfern
Manager
Sheltered Housing & Older Persons Services
Mercury House
Belmont, Durham, DH1 1TW
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Concerning Q1, I do not believe that we (local authority SSDs) have any requirement to offer choice concerning Home Care providers (the Choice Directive only applies to Care Home placements). In Shropshire we have introduced zone providers whereby contractually a named home care provider has first call on all our requests for home care services in each specified geographical zone. Only for specialist services or in exceptional circumstances such as serious unresolvable difficulties of a service user with a particular provider would we go to a different one. Advantages should be a more consistent service, less picking and choosing by providers and better recruitment, training and retention of carers. Also, subject to availability, all our short term Intermediate Care home care goes to our inhouse service before transfer onto the appropriate zone provider.

We have v little v Sheltered housing as yet in Shropshire but I think that acceptance, choosing to go to such a scheme would include accepting the care provision if this was tied into the scheme with a particular scheme.

Q2. I don't think we have relevant DP experience.

Derek Manger
District Manager
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We thought that we were going to have difficulties with regulators when they were NCSC. After discussion with all partners we decided to take a firm hand with the inspectors and point out that older people have made the choice to move into the service knowing that there is a dedicated staff team and knowing who the provider or the service is, (in our case this is usually the same RSL as the Landlord although we have schemes where care and support is provided by SCS Homecare in 1 case another RSL).
Further to this we have always been clear that if a tenant did want to bring in their own care and support they could so do. Out of our, now, 19 schemes this has only happened twice over about a 10 year period. On both occasions it was felt by the assessors that the desire for change came as much - if not more - from families than from the tenant. Having said that the switch was made. On one occasion it lasted for about 6 weeks and in the other case about 4 months.

Judith Hawkshaw
Housing Champion & Partnership Manager
Suffolk County Council
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Tenants would have choice in the same way as they would in the community especially given that Soc Servs are now going down the route of locality based commissioning i.e. discrete providers for each geographic area. We have to start somewhere and providing the 24 hour dom care on site is managed (as it would have to be) in the same way as any other provider, a service user can technically request a change of provider  (so perhaps not all risk is limited), but on the whole in my experience those are generally happy with the team on site based approach. Its just a case of ensuring that this team is really perceived as and delivered as a Dom Care Team.

Siân Walker
Director of Care & Support
Devon Community Housing Society
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Service users do have the right to refuse the service and actively have to sign up for it, they are given choice over the unit (within reason) as some units can not manage particular care needs.
Therefore we see it that they have exercised their choice. Service users also have some involvement in the allocation of their key worker and their views are recorded and actioned or written reasons why they can not be actioned are given.
The process of deciding on an extra care scheme has several elements to it, the intro leaflet, visiting the scheme or a scheme, discussing their care needs with their care manager and the possible solutions, meeting the housing person and scheme manager who ensure the person wants the service. Given the number of steps (which often start to happen before the referral is made, there are several points when service users can decide against moving). The service is accepted as a package!
I am sure it could be challenged but I feel as long as there are several steps which service users can opt out at then there is choice and the care management role is to assist the person to work out the + and  of any or all of their option.

Ian Buchan
Service Manager
Community Based Services
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My understanding was that the means by which extra care schemes are not deemed registerable establishments are exactly that they allow the tenant the choice of who crosses their threshold to deliver care. The 2002 DoH Supported Housing and Care Homes Guidance document has, I believe, two
important parts:

"Provision of personal care within these schemes would usually be expected to lead to registration as a domiciliary care agency."

"In the case of extra care housing or supported housing, possession of an assured tenancy will generally mean that a person has a right to deny entry to other people, including any care workers, without this having an effect on their right to occupy the dwelling."

This has obvious implications for commissioners and budget holders in that there must always be both the contractual and budgetary flexibility build in to allow the choice of alternative providers should the tenant wish - failure to do so may (if found out by CSCI) lead to the establishment becoming registerable as a care home.

We are in the process of developing our first scheme, so if it transpires from other input, that my understanding is incorrect, I would be very interested.

Ray Keane
Strategic Commissioner (Older People, Physical Disability and Sensory Needs)
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There are a number of ways of trying to ensure that you can demonstrate degrees of choice in this matter.

1. Ensure there is a clear method of selection for the care provider. This may or may not be the housing provider but the process should be transparent.
2. Include residents of schemes in selection/tender process (not easy if it is a new scheme).
3. Ensure that there is a method of explaining that people can change provider if they are dissatisfied (probably part of the complaints procedure).
4. Ensure that the benefits of an "on-site" team are fully understood by all, including CSCI; e.g. responsive, knowledgeable, known staff, greater permanence of response etc.. (This is a new area for many inspectors and my experience with Housing 21 was that inspectors needed re-assurance that
some policies were in place to deal with this issue if it arose).
5. You may also need to be clear about the levels of choice available within the community. In many places there is none anyway!

I don't yet know of any DP's being made at any extra care schemes, others may. However I would imagine that they would not be dissimilar to schemes elsewhere in that the individual was able to exercise choice of provider, which, I suppose, could include family members if they met those criteria.

Nigel Walker
Lead - Better Commissioning Learning & Improvement Network
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There is no definitive answer about choice of care and support provider in extra care. Decisions will be local and based on inspectors views. Inspectors can challenge choice and can have their decisions challenged.

Denise Gillie
Specialist Housing Advisor
Department of Health
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This discussion forum has been very helpful and it is encouraging to know other people are facing similar difficulties. I am indebted to Heather Christiansen of Southampton City Council for her guidance and support.

I have been involved in a newly built joint extra care 40 bed housing scheme here in Hastings for the last 2 years. I have been investigating a complaint by a user of the extra care scheme which involves her being unhappy with the service being offered by the care provider and wanting to change to another provider.

This potentially has the potential to de-stabilise the whole funding balance of the scheme and therefore we need to address urgently how we will respond.

Unfortunately I think we not as explicit as we could have been at the beginning of this new scheme with regard to acceptance of the care provider as part of the tenancy and that leaves us open to challenge.

I am seeking a compromise with this user and am hoping alongside our partner agencies to ensure that all other existing tenants and new tenants are informed that as part of their acceptance of their tenancy agreement they 'accept' the chosen service provider of care.

I will post further when this issue has been resolved.

We currently have no users on Direct Payments within the scheme.

In my previous employment in North Yorkshire this was an issue. The outcome, as far as I recall required a number of approaches.

Firstly there was the choice the older person had in choosing the particular home. This home is available and this is the main care team. Do you want to choose this home? A choice.

Secondly the home based team was costed and set in place at minimum requirements levels knowing that additional support would be required. The home acts as base for home care for the local community so fluctuations in hours are built in!

For the older person if you are unhappy with the care provided as part of the care package you now have a number of choices:
if a self funder you can buy care as and where you wish as one dependent on the LA we can arrange alternatives if we have not been able to satisfy your unhappiness with our service, or you can use
direct payments.
Note: under Direct payments legislation and guidance, if the older person is entitled to a service and wants that service outside the LA provision, or as part of the provision, then we must seek to meet that demand. The alternative may be that the LA is brought before judicial review for fettering its discretion.

Seamus Breen
Health and Social Care Change Agent Team
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I think there is a potential problem balancing customer choice (i.e. to receive direct payments) and economies of scale in funding a staff team to deliver on site in arguably all types of supported housing provision. I would share your argument that if a customer chooses to move to say for example in an extra care scheme, then it is implied that they have made a choice to receive the support available.
This however would rule out the availability of direct payments to many services where the staffing complement is based on number of households x support required. The SP Commissioning Body may wish to take a decision otherwise and pay for a customer to receive their own choice of support in a service that already has support staff in place, but this would of course come at an additional cost.
In Suffolk we have just completed out first DP for a customer living on their own, and believe this right and appropriate, but I believe there are potentially high costs that could be incurred in administrating this service which the ODPM would have to consider. For example, 100 customers at £200 each = admin cost of £20,000.
This doesn't answer your question on customer choice, but I guess shares the debate.

Jayne Hellowell
Head of Supporting People Suffolk
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My view is why over complicate the issue and make it more difficult to manage and more costly. Older people choose to live in ExtraCare. They have chosen the facilities and in house staff.. This can be reviewed with all residents of the scheme via the best value framework.

Sue Lock
Wulvern Housing Ltd [log in to view email address]

I don't think there is a problem. The choice directive applies to choice of residential placements not to choice of domiciliary care providers. If someone moves in to extra care housing then they do so in the knowledge that the care is delivered by an agreed provider (same as they do with landlord provided supporting people).
If an individual wanted Direct Payments to pay for their own care then they would not accept extra care housing as that does not offer this option. Those most in need who need the 24 hour access to care generally go into EC housing as an alternative to residential care. Direct Payments would not be available to pay for that either. Don't know if this interpretation helps...

Jacqui Maguire
Divisional Manager
Older Peoples Services
Social Care, Housing and Health Directorate
Halton Borough Council
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Interesting to note that we are not alone in some of the dilemmas that extra care housing gives us. In our organisation, we have taken the view that "choice" is being promoted at the point of considering the service ie that extra care housing is per se providing a new choice for older people.

- as the query implies, we have agreed that it will be difficult to sustain an on-site care team if choice about care provider is given to each individual tenant ; and from a mgt point of view, it would be difficult to monitor the services of potentially many different providers within one scheme.

- this said, I appreciate that this does not sit very well with direct payments etc but if someone wants to use an alternative care provider by exercising their direct payments right, then we would have to manage that.

- and we don't force tenants to use our chosen care provider in the circumstances where they have an assessed care need but "informal" care arrangements already in place (e.g. spouse or family). We respect that (and so far that has not had an impact upon sustainability of care provider team) as most people are happy to have the care arrangements made for them.

- However, we do promote the service as flexible and responsive so in theory, in our circumstance, if the demand for the care team reduced (at that point in time as tenants exercise choice) then the core team should be able to be reduced to reflect that , then increased again if and when demand increases.

- choice is probably most practically promote from a practical day -to-day point of view as to that tenants individual package of care and how they want to receive that.

Sue Lewis
Head of Supported Housing Services
Pennine Housing 2000
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Direct payments
I looked fairly extensively some months ago at the use of direct payment in extra care housing. I came to the conclusion that whilst a good method of payment for an individual in an isolated situation, it would not be sufficient to cover the overheads associated with an extra care scheme. If anybody has made it work I would be interested to hear from them.

Maureen Sim
Director of Care Services
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