INTRODUCTION

The future potential of Sheltered Housing focuses on the provision of health and social care support to create 'a home for life':

	increasingly extra ‑ care/very sheltered/cat 2½ schemes are being developed
	increasingly social services and health authorities are planning joint commissioning and co‑ordinated service delivery
	Best Value review and the Supporting People programmes also promote these developments

Whilst discussions take place at a national level between ministries and quangos involved, and at the local level between care providing agencies, little seems to be done to involve the recipients of care and support, and, in particular residents of sheltered housing

	yet advocacy bodies (eg: Age Concern, Help the Aged etc) repeatedly call for such involvement
	and government policy and pronouncements (eg: The National Service Frameworks and various charters) prescribe user involvement and choice
	currently, uncertainty about the charging policy in Supporting People and the sizing of the 'pot' to be available in April 2003 has dissuaded housing landlords from involving residents in the likely outcomes of the programme

In our own previous Workshops, we have on many occasions discussed residents' participation in:

	the provision of social and leisure activity within their scheme (they should be pro‑actively involved, with the Scheme Manager acting as a facilitator)
	housing management issues (eg: the job description and work practices of the Scheme Manager, the services to be embraced within rent or service charges)

We have not previously discussed residents' participation in health and social care issues; residents continue to be viewed as passive recipients of care. Why should this continue to be so?

Support and care provision is very personal and individual;

we do not age uniformly but develop different needs; we have different resources to cope with these needs ‑ personality, family and social networks, incomes. Assessments are individual and lead to specific care packages. Hitherto, social services, health workers, care agencies have almost invariably dealt with clients individually; (hence the frequent observation that six different care workers enter the scheme daily to support six different residents)

our care needs are highly personal issues; often we are reluctant to discuss them with others; rightly we expect privacy in our own affairs and confidentially from those to whom we disclose them

But residents have a collective interest in ensuring that their own scheme (and others provided with the same management structure) is, as far as is possible, a 'home for life'; that as they grow more frail and dependent support will be available to enable them, if they so wish, to continue to live in the scheme rather than move to a residential care or nursing home (such a move not only has financial implications but signals a marked loss of independence).

Residents ought therefore to have a say in the type and level of support and care available within their scheme and the manner of its provision

What input might residents, therefore make?

	they may articulate the needs with they experience as they age
	they may be more pro‑active in suggesting how these needs might be met
	they may monitor and evaluate services provided to ensure that a high quality of life is maintained and that no resident is, without good reason, unwillingly obliged to leave the scheme

Over 100 participants attended the Workshop, well over a quarter of them being Sheltered Housing residents, with the majority of the remainder being scheme or line managers.

In the morning session two projects were presented at length together with a third brief presentation. The first of these described a large scheme offering a wide range of care and support services, with substantial resident participation; the second described a Best Value exercise; the third, shorter, presentation outlined resident participation in the move towards extra‑care provision.

PRESENTATIONS

"Empowerment : Myth or Reality" ‑ Angela Bradford, Assistant Director The ExtraCare Charitable Trust, assisted by Derek Chawner and Joyce Bough, residents of Berryhill Village ‑ a scheme of nearly 150 units in Stoke‑on‑Trent

The Extra Care Charitable Trust evolved 15 years ago from Coventry Churches HA; it is a Coventry based organisation working in the Midlands to provide various levels of support within a housing environment, though it also manages, today, some nursing homes. Currently the Trust has 37 schemes, accommodating some 1200 older people, employing a similar number of staff and involving 1000 volunteer helpers. The Trust's philosophy is to offer services, up to the levels provided within residential care and nursing homes, to older people in their own accommodation so that they don't experience the trauma of moving as their needs increase, usually marked by loss of independence. The provision of care and support is backed with a wide programme of activities enabling residents to contribute to the life of the scheme. A feature of ExtraCare developments is the pre-planning that takes place before the opening of a scheme. From a data base of over 9000 interested potential residents, workshops and consultation days are set up in the selected localities (400 people attended a recent day in Northampton). These events explore perceived needs, embracing design features, activities welcomed, preferred tenure (at Warrington both rented and leasehold properties are included) and the levels of care and support sought.

Such pre-planning involves all aspects of provision of the type of meals to be provided and their cost, the charges to be levied for various activities, the charges of purchased domestic services. At Berryhill Village, for instance, many of the activities were already ongoing before the residents moved into their new home.

The vision of the residents of what they expect from their scheme is co-ordinated with those of other providers - Social Services, Health and Housing 

Five levels of support are identified: from a minimal need of domestic support to the equivalent of nursing care. All flats within a scheme can meet all levels of support ‑ one does not need to move if one's support needs change. Flexibility enables a person to move both upwards and downwards in support level; close collaboration exists with social services

Berryhill Village has a staff of 30 embracing care and support tasks, housekeeping and catering administration. Also included are a well‑being advisor, fitness instructor and volunteer co‑ordinator. The aim is to involve all residents in the management of the Village; 'street' meetings are held monthly

The Well‑being Centre, including chiropodist, optician, dentist, is available both for residents and also older people in the neighbourhood

At Berryhill Village, a well being advisor has been engaged from fund raising events; it is hoped that the PCT will finance the continuance of the project. The advisor offers annual screening to identify health risks. In recent months it was found that 20 Berryhill Village residents had diabetes ‑ but none knew about blood testing or dietary needs; a special interest group has been developed which has resulted in all those residents achieving acceptable blood glucose levels. Similarly those with raised blood pressure, urinary infections etc have been identified and supported. These support groups also serve an important social function

Those residents with the lower levels of support needs are able to access specialist staff at all times

Angela provided two case studies of residents who came to Berryhill Village after very serious acute illnesses or surgery but who, through the support and activity provided, achieved much greater levels of independence

Each of the speakers emphasised the wide range of care and activities available to residents. Any support plan is designed with the full agreement of the resident and reviewed monthly, 3 or 6 monthly. Residents are strongly encouraged to set goals for themselves (eg: to walk without a frame within the month). The Village offers them opportunities to achieve their goals

The ExtraCare Schemes demonstrate that, within a sizeable community a wide and flexible array of support services and activities can be offered. Individuals have a wide range of choices open to them. Collectively they can oversee this range of choices to ensure that it meets most of their needs

"A Different Kettle of Fish"  Sharon Mitchell, Business Review Manager, Atlantic Housing Group

Sharon Mitchell described the approach to Best Value adopted by Eastleigh HA, in partnership with Fernhill Care Ltd, as part of a Housing Corporation BV Pilot in March 1999 Labels, such as Investors in People, Quality Assurance, Charter Mark, Crystal Mark are used as symbols of quality in the workplace. The label Best Value connotes of the 4C's: Challenge, Comparison, Consultation and Competition. One must see Best Value as an integral part of the process of service provision ‑ not an add‑on extra What is extra‑care? It encompasses frail older tenants, some of whom need relatively little support, whilst others need higher levels of care and support to maintain their independence. This project involved 117 tenants in two higher schemes. Extra‑care aims to promote independence, dignity and choice and to provide a home for as long as is wanted. Support is provided on site for 24 hours a day. Quality is assured through employment of staff with NVQ levels 2 or 3; all are already employed, with no casual employees. Care is bulk purchased through a contract established via social services. Individually tailored care packages can include washing and dressing, toileting and bathing, food preparation and medication and tailored to meet individual needs This is a very different type of service from that usually subject to review ‑ eg: property maintenance and repair. It is a 'soft' service in which exact quantitative measurement is difficult; it is based on personal relationships; performance indicators are not well established and there is little or no comparative baseline information. In a fiercely competitive market , information is tightly guarded and it is difficult for tenants to make an input. There is a large number of stakeholders involved in providing and using extra-care services Who are the stakeholders and how might they be involved? This project's strategy aimed to support and facilitate the ir involvement, recognising their complexity. A range of involvement options must be adaptive and flexible, maximising the linkages to wider tenant participation and community involvement A matrix was devised which mapped the power and interest of the several stakeholders. One need not spend much time involving quadrant A but one must target one's resources to those in quadrant D

Mapping Power and Interest

	z
At
	A (minimal effort)	B (keep informed)
	Opticians	Meals on Wheels
	Chiropodist	Social Groups
	Dentist	Disabled Aids
	Undertaker	College
	Church	Community Service
	Police
	c (keep satisfied)	D (key players)
	Tenants Consultative Group	Health - OT, CPNs, Gps
	Tenants Forum	Social Services
	Unison	Tenants
	GMB	Advocates
		Staff
		Board Members
		Borough Council
		Mental Health

To amplify: Different Stakeholders may be involved in different ways

... For Example ...

		Direct Service User
	0	Test approach with Volunteers
	0	Role for Advocacy
	0	Development needs: self esteem, confidence, trust
	0	Issues: gratuitous nature, will people be open
e	0	Block Purchase Care - Key Buyer
	6	Contractual Relationship
	0	Effective Use of Time
	0	Demonstrate Benefits
		Linkages with wider BV Agenda
		Targeted Involvement

Other agencies and community groups need to be embraced ‑ eg: Help the Aged, Association for the Deaf, Cancer Relief, MacMillan Fund etc

There are obstacles in involving some stakeholders in the partnership. Frail older people are often unable to participate fully and wider views must be incorporated through proxies. The very number of stakeholders produces problems

A variety of formal and informal techniques of involvement were used in the project. 40% of the tenants took part in one to one interviews; three small groups were established and 14% of tenants took part in focus groups. An Advisory Board embraced key players; outside organisations formed a Consumer Panel. Scheme Staff could not be used as interviewers but they were made to feel comfortable with the process and were encouraged to cite obstacles to development, opportunities for improvements

What Worked? Front end planning took time but provided a focus for the project. Stakeholders, especially the tenants, drove the process. Good practice was shared and linkages maximised. Family members and carers acted as advocates

In semi structured interviews people were asked to rank what issues they felt to be important, and these were then compared with satisfaction levels 

Focusing on What Matters

Performance / Importance Matrix

	Care	Staff	Control & Independence	Safety / Security	Keeping Informed	Choice	Flat	Cost of Living
Performance	%	%	%	%	%	%	%	%
Very Good	77	85	83	75	28	34	72	34
Fairly Good	11	11	11	19	30	17	17	26
Neither Good / Bad	2	2	2	0	9	15	4	6
Fairly Poor	2	0	0	2	13	4	2	0
Very Poor	-	0	0	0	6	9	0	0
No opinion / No reply	9	2	2	4	15	21	4	34

 

1st	2nd	3rd	4th	5th	6th
Importance

 A series of Soft Pi's was developed

	Having a say about the level of care and keep they get Feeling that staff listen to their views
	Staff always knock and wait for an answer
	There is security of tenure
	Information provided is clear and easy to understand