Scottish Government

Chapter 8 Stirling Council and NHS Forth Valley partnership

This chapter, together with chapter 5, covers all the issues for the Stirling partnership. It follows the model as set out in appendix 1.

8.1 Person centred care

Stirling was working to improve the joint process for assessment and care management but there were weaknesses in the processes at all stages, including the allocation of resources for care packages. There was a strong focus generally on enabling well being and self care in the Stirling partnership and there were positive initiatives to promote health and well being in later life. The experience of people receiving services needed to be taken into account more fully when delivering and developing services. The range of methods to ensure information about services, such as leaflets, needed to be improved. The partnership's performance was evaluated as adequate.

8.1.1 Assessment and care management

Jointly agreed and documented assessment processes

Multi-disciplinary assessments should be undertaken following a jointly agreed and documented assessment process, and in partnership with other agencies where required. In Stirling the single shared assessment ( SSA) process underwent a substantial review in 2006, and an action plan was agreed to improve the process. The Stirling SSA Strategic Implementation Group Action Plan 2006-09 was specific, measurable, attainable, realistic and had a time frame attached to it explaining in detail what had to be in place to work towards a single shared assessment process.

An innovative pilot to promote and extend the use of SSAs by health and other staff in order to access more services was about to be implemented in one of the rural areas of Stirling. Stirling expected the extent and scope of SSAs to develop following the implementation of the e-Care information sharing infrastructure, which is being led by the Scottish Government and is due to be delivered in early 2008. IoRN (a national tool for assessing the dependency levels of individuals) data was not being gathered in the Stirling partnership, which was awaiting IT development capacity to include this. Stirling managers thought that the situation would improve once the new IT system was available.

The acute health sector had unified patient case records, with SSA documentation being used in some areas. The unified case record had a trigger list for involving internal colleagues and external agencies. There was a range of guidance notes, forms and documentations to support joint working. A full SSA process had been agreed for two services, mobile emergency care service ( MECS) and rapid response.

During file reading, we found that assessments of community care needs were on most, but not all files. There was evidence of multi-agency working in most cases and in two thirds of applicable cases there were clearly stated roles and responsibilities for each agency. However, many of the assessments were for services rather than being a comprehensive assessment of individuals' needs.

Our staff survey showed that just over half of respondents thought that SSAs were undertaken by the relevant professionals. In discussions with us, social work staff made it clear that they thought that that the Action Plan was at an early stage of implementation with much activity still to be done in making sure staff were informed and fully involved in its implementation. They also said that health staff did not like undertaking SSAs, because of the volume of paperwork involved. Some Stirling managers told us that the local SSA group appeared not to have been very effective of late. Social work and health staff were continuing to use different forms to collect information, with little effort appearing to be made to share information and thus reduce the number of times people had a full assessment completed.

Stirling social work staff were committed to the SSA process in enabling people to live independently and to working together to achieve this. However, difficulties arose in the division of assessment and resourcing roles. Field work staff completed assessments and all proposed care plans were scrutinised in order to complete a 'sizing' exercise and decide on the level and kind of service to be provided. In exceptional circumstances, care plans went to a resource panel for a decision to make on the level and kind of service provided. This process created time delays which social work staff, users and carers described as frustrating.

Our service user survey showed that only 23% of older people had seen a written assessment of their needs whilst 77% had not. Representatives of the private and voluntary providers felt that generally it took a considerable length of time for an assessment to begin, unless the case was urgent.

We found limited evidence during the file reading and fieldwork of joint working in undertaking or sharing assessments between health and social work or the use of a single SSA format agreed by health and social work. We were concerned about the quality of assessments. We comment on this and make a Forth Valley-wide recommendation in chapter 5.

Assessment of cultural and ethnic needs

Culturally sensitive systems should be in place to identify and assess the needs of groups and individuals who have particular needs or preferences within the population. Stirling told us that their assessment process fully included the minority preferences and needs of individuals. Partners had diversity training programmes and IT based training packages including race equality and diversity. The council's Community Services employed an ethnic minority advisor who worked across all council services but also worked closely with care management and health staff, both for individual referrals and assessments and for specialist general advice. Staff also had access to the council's Language Line.

Needs of carers are identified and assessed

The Stirling carers strategy had been jointly developed following a full consultation exercise with carers, which was managed by the Stirling partnership for carers. This document, called Together We Care 2006-2009 was a user friendly document and had a clear action plan. Together the council, NHS Forth Valley and Carers Centre had also developed a new way forward for carers assessments.

Less than half of carers in the survey had been informed of their right to carers assessments. In most cases they had been informed by a social worker or a Carers Centre representative. Only 26% had had their needs assessed. Of those who had had a carers assessment, most said that the assessment had helped them a lot, or had partly helped them. Five out of eight respondents had received a copy of their assessment. As a result of the carers assessment, two out of eight respondents had received support services for themselves, whilst three out of eight respondents had received additional services for the person they cared for. These figures show the value of carers assessments.

In the file reading, about half of the cases had a carer and were therefore considered applicable cases. In just over half of these applicable cases, the carers in Stirling had been offered information on the support needs of the older person they cared for. There was an assessment of the carers needs on file in only 7% of applicable cases. However, there was other evidence on files that carers needs had been identified more often than an actual carers assessment was undertaken.

We met with some carers who expressed concern about accessing information and services. They felt it was 'trial and error' with some professionals providing relevant information and others not. They thought that there were long delays both in undertaking assessments and starting services. For example, they said there was a waiting list for the day care service. However, managers informed us that, of people waiting, the majority had alternative services in place such as home care and respite. We set out carers views more fully in the next section of this chapter.

Some providers said that the needs of carers were not taken into account and there was a lack of information and support for carers. However, we recognise that carers could directly access support services funded by the council, such as the Carers Centre, Crossroads Town and Townbreak which also undertook assessment and screening.

Prevention of inappropriate admission to hospital

Stirling identified a range of joint initiatives that have been put in place over the last two years (involving social work services, NHS primary care and acute hospitals) to reduce hospital admissions, including the following:

• The CARE service which provided rehabilitation at home (for approximately four weeks), step up and step down rehabilitation in rural and city areas in council care homes, including three care home beds available for crisis situations which were fully used.
• Continued development of the rapid response service which will result in services being available at home from approximately 6.45 am to 11 pm. This service will facilitate early supported discharge. The crisis care service offered up to 72 hours service and was used for people who had a short term acute illness which had led to deterioration in ability.
• A considerable amount of work had been undertaken by the falls prevention group, which had not met regularly but had just been reconvened.

Most council staff in the survey agreed that multi-agency services were successful in preventing inappropriate hospital admissions, although less than half of health staff agreed.

Screening and initial assessment for unscheduled or planned hospital care

For older people being admitted for unscheduled or planned hospital care, a prompt initial screening and initial assessment should be completed within agreed timescales. This should include a review of both health and social care needs.

A comprehensive assessment process had been developed as part of the new rapid response protocols. This allowed for a full assessment to be completed at the point of admission to hospital either to prevent unscheduled hospital admission or facilitate quick supportive discharge. The Fast Track team in the hospitals was widely considered to be very effective.

The file reading showed that most of those who had been admitted to hospital during the last 12 months had been admitted once only. The majority of admissions were unplanned.

Overall the service users in our survey thought the results in relation to their admission to hospital were fairly positive, although a lower proportion of users in Stirling said that the help they needed was in place at the time they were ready to leave hospital compared to respondents in the other council areas. As with the other partnerships, a few said that their hospital stay could have been prevented if they had had better support at home.

Jointly agreed care planning processes

There should be jointly agreed care planning processes which document goals and outcomes agreed with each older person and record whether these were achieved. Care plans were not kept on the electronic system in Stirling. There had been a major fire in the council building, which was the centre for all the operational care management and home care functions, shortly before the inspection, so there were no care plans on the paper files for us to inspect as part of the file reading exercise. Following the fieldwork we asked to see some care plans which had been completed after the fire.

Stirling managers told us that care planning which clearly set out the desired outcomes for older people was at an early developmental stage. However, they said that the new rapid response service had clearly agreed protocols and documentation to support goal setting and outcome measures.

We found little evidence of any systematic completion and/or sharing of care plans with service users or carers. Only one third of users in the survey had been given a clear plan of the services they receive, which was lower than for the two other partnerships. Of the eight older people we interviewed during the fieldwork, only two had a copy of their care plan, and two others recalled signing their care plan but had not been given a copy. Some of the documents we saw which were called care plans were home care plans, as opposed to full care plans.

Less than half of staff responding to the staff survey said that care or treatment plans were regularly reviewed on a multi-agency basis. We saw little evidence of reviews having taken place regularly. We were concerned about the effectiveness of care planning in Stirling and we make fuller comments and a recommendation about this in chapter 5.

Discharge planning

Discharges, transfers and/or significant changes of accommodation should be planned in partnership with older people, their carers and other agencies as required and arrangements put in place to meet assessed health and social care needs.

The partnership managers said that professionals worked well in partnership to complete assessments of people who were to be discharged. Social workers, residential staff and ward staff and therapists contributed to the identification of individuals who could be maintained and supported at home or transferred for rehabilitation in care homes with additional rehabilitation from the CARE team.

Therapists from the CARE team arranged the deployment of some equipment and council OTs handled home adaptations. Formal weekly review meetings, which included professionals, older people and carers, ensured arrangements were put in place that matched assessed needs. Although we were told that discharge planning meetings and case conferences took place, these did not seem to happen on a routine basis.

As part of the review of care management services, a full review of hospital social worker services had been completed. Specific hospital based services were to be established from April 2007, with the expectation these would provide stronger support for discharge and transfer planning. The council's care managers took the lead for the majority of cases with complex care arrangements for older people being discharged from hospital. Health colleagues led where professionals were more actively involved, for example, from CMHT(E).

Although most (79%) service users in the Forth Valley surveys said the help they needed was in place at the time they were ready to leave hospital, those in Stirling were less positive (67%).

Less than half of carers from our survey said they were involved in planning when the person they cared for was discharged from hospital, and a third were asked prior to discharge if they were willing and able to provide care. Most carers of older people in the survey said that they had received specific information on treatment and medicine prior to discharge, mostly from hospital staff. Less than half of the carers said that the person they cared for had received assessments of their needs prior to being discharged from hospital with one third feeling that they had sufficient information on services and support available prior to discharge from hospital.

Less than half the staff in the survey thought that multi-agency discharge arrangements met the needs of older people. In support of that, we found that in practice multi-agency discharge planning varied considerably.

Assessment of the ability of older people to manage their medication safely

In all settings there should be effective assessment of the ability of older people to manage their own medication safely, with provision made for those in need of support, supervision and monitoring in relation to administration of medicines. The approach to the ability of older people to manage their medication in Stirling appeared to be patchy. There was some good guidance and practice such as a guide to the council policies and procedures and a self-medication assessment tool for people who could self-medicate. The documentation used by the CARE team therapists included a pharmacy screening tool, which was used to determine the need for input by the team's pharmacist.

Medication procedures and self medication procedures existed within care home settings. There were medication guidelines for home support services, care managers, and health partners making it clear that home care staff should only give verbal prompts without having to check that the older person has taken their medication.

In-patient nursing staff and CMHT(E) nursing staff worked with families and carers to identify tools to support older people to self-medicate, for example dosette boxes. A community pharmacist, as a member of the Development and Implementation Group for older people's services, had a remit to explore the issue of medication management and prompting in community based services. There were plans to establish a partnership group to develop a protocol for the self-administration of medicines.

The majority of staff in the survey said that there was effective assessment of the ability of older people to manage their own medication safely regardless of setting. However, in the fieldwork staff told us there was considerable uncertainty about the extent to which staff could prompt or administer medication and there was inconsistency in what staff actually did. We make a recommendation about this in chapter 5 in the section on medication.

Older people are provided with full information about their condition

Stirling partnership identified a range of ways in which older people were provided with information about their condition and any treatment or care they required, and their right to consent to treatment. These included nursing staff in community and in-patient settings providing information verbally and in written form. Community care staff also provided information through the assessment process.

There were advocacy leaflets and partnership funding of an Alzheimer Scotland information officer post, with the organisation providing a full range of information on the condition as well as a phone information line.

Of the people interviewed during the fieldwork, most said they had been consulted about their care and, where appropriate, their carers had been as well. Most of carers in the survey said they had received specific information on treatments and medicines prior to the person they cared for being discharged from hospital, mostly from hospital staff.

Accessing personal information

Older people should be informed about how to access their personal information, and about their rights to determine how their personal information is shared and protected. NHS Forth Valley and Stirling Council participated in the Forth Valley data sharing partnership with the other council partners, police and fire service. The Forth Valley information sharing protocols, November 2006, provided thorough guidance. The leaflet on Sharing information and giving consent; a guide for service users was helpful. The NHS Forth Valley staff also provided all new patients with a helpful leaflet Confidentiality and your health records. In addition, the NHS Forth Valley carers information strategy contained advice on this issue.

Two thirds of staff in the survey thought that older people, and with their consent, carers were informed about how the older person's personal information was recorded and used, how to access their personal information and about their rights to determine how their information was shared and protected. Staff across the partnership attended mandatory training in data protection and confidentiality, which covered consent and information sharing.

However, older people and carers told us they were not routinely informed about how to access their personal information, and about their rights to determine how their personal information is shared and protected. We think more emphasis should be put on this issue by managers because it appears that while procedures and training are sound they are not being followed through by staff when working with older people.

8.1.2. Experience of older people and carers when accessing and using services

Systems to obtain feedback from people who use services

Systems should be in place in to obtain feedback about the experience of people when accessing and using health and social care services. The partnership gave us some examples, such as Stirling Council's survey in 1999 as part of its review of its care homes. It also carried out surveys on shopping and housing services, in particular 30 individual older people's reviews for Supporting People services. The majority of these individuals expressed positive views about the services they received. Two older people were members of the Development and Implementation Group for older people's services and shared their views on experiences of using both health and social work services.

Feedback had shown a high level of satisfaction with rehabilitation at home services. GP practices were required to undertake patient surveys to meet the requirement of the patient experience indicators in the QOF. There was a jointly agreed job description for an older people's development worker post, for which joint funding was being sought. The post holder was expected to focus on engagement of older people.

The council's talkback system and complaints procedure provided general opportunities for older people and carer feedback. There was a joint protocol for the investigation of multi-agency complaints drawn up between Stirling and NHS Forth Valley, which also had a complaint and patient relations service. Half of users in the survey said they would feel comfortable about making a complaint if they were unhappy about the service they received from health or social work services, but only one quarter knew who to contact to do this.

The partnership managers were clear that they could not rely on current processes and complaints procedures and needed to obtain the views of older people receiving services more proactively and systematically.

Systems to obtain feedback from carers

There were many ways that the partnership used to obtain feedback. There was a Partnership for Carers group which was chaired by the PRT Carers Centre and involved the council and NHS Forth Valley. The group had a monitoring role in the implementation of the carers strategy as well as providing a forum for constructive dialogue between carers and statutory agencies. The Stirling partnership Strategy for Carers, called 'Together We Care 2006-2009', was a well written and user friendly document informed by positive consultation. The Centre, whilst undertaking carers' assessments, could also provide feedback to the partnership.

As a result of carers feedback the council's residential and day services had opened a rural care initiative in the Callander health centre, as a joint venture with health, and was actively seeking to expand the provision further to meet local needs.

NHS Forth Valley and the council had formal complaints systems and could be contacted by carers to express their views about their experiences of accessing health services and the standard of services received. The staff survey showed that two thirds agreed that systems are in place to obtain feedback from carers.

However, managers told us they were clear they needed to obtain the views of carers about services more proactively and systematically.

Older people are enabled and supported to make decisions

Forth Valley traditionally had a very positive approach to advocacy and invested considerable resources in advocacy services. It had the highest percentage spend per head of population on independent advocacy in Scotland in 2003-04. In response to Scottish Government guidance and implementation of the new Mental Health Act, the councils and NHS Forth Valley had acted both independently and in partnership to commission independent advocacy services. NHS Forth Valley had a five year service level agreement with Forth Valley Advocacy to provide independent advocacy to mental health and older people. Stirling Council funded one post in Forth Valley Advocacy specifically for an older people's worker.

Advocacy workers prioritised those with dementia or communication difficulties. Older people had the option of accessing a professional advocacy worker or they could be partnered with a volunteer advocate. Almost all staff in the survey thought that older people were enabled and supported to make decisions throughout their care or treatment, although NHS staff were more likely to disagree. All the older people we interviewed said they were supported to make decisions throughout their care experience.

Direct Payments constitute another way of enabling and promoting choice to people who require services. All the councils had information leaflets and procedures in place to promote Direct Payments, but take up was still relatively low. Although one reason cited was that older people did not want to have the responsibility for the administration of these, we believe much could still be done to improve the take up. In 2007, Clackmannanshire had 32 service users (all care groups) using Direct Payments, Falkirk had 61 and Stirling had 37. These figures need to be considered in relation to the size of the population.

8.1.3. Enabling well being and self care

Agencies collaborate to promote and maintain health and independence

The Joint Health Improvement Plan ( JHIP), 2004-2008, for Stirling CHP provided partners with the strategic direction for promoting health and well being in later life. Older people had participated in the development of this plan. The work involved in promoting healthy ageing had received international recognition at a recent WHO conference. This approach was well embedded in the Community Planning structure, with the Health and Wellbeing Group leading on the delivery of key health improvement actions.

The life expectancy and healthy life expectancy for men and women in Stirling is above the Forth Valley and Scottish averages, both at birth and at 65 years. On average, women in Stirling are expected to have about two more years more of healthy life (10.4 years), compared to the Scottish average of 8.8 years, while men in Stirling are expected to have about three (9.5 years) more compared to the Scottish average of 7.6 years. This figure is related to a number of factors such as relative affluence of the local population, as well as health and social work services.

We met with a wide range of representatives involved in promoting health and well being within the older people population in Stirling and were impressed their positive approach and certainty about the value of their work. There was a range of initiatives including:

• 'Walk around Stirling' funded a co-ordinator providing volunteer-led walks which successfully involved approximately 150 people, largely older people, who regularly walked each week.
• 'Moving aboot' training was being delivered to care home staff and day care centre staff to provide activity programmes for frail older people.
• A retired volunteer was providing a handy person service to older people across Stirling with priority given to home safety issues. The intention was to link this development with the telecare developments and the falls prevention programme (which involved persuading older people not to wear 'sloppy slippers').
• The Sensory Centre provided direct support to people with sensory impairments in Falkirk and Stirling. We met 10 profoundly deaf older people from across Forth Valley who spoke positively of meeting every week as a group and communicating in their first language, BSL.

Joint action to support older people's capacity for self care and self management

The current focus in the NHS in Scotland on action to support people with long term conditions in order to increase their capacity for self care and self management was still in the early stages in Forth Valley, but an anticipatory care pilot was being initiated.

Partnership services included the CARE team and the joint loan equipment service ( JLES). NHS Forth Valley community nursing and the council were considering improved methods of meeting the needs of those who were terminally ill, in particular improving palliative and end of life care. Some staff were to be offered Liverpool care pathway training to support this way of working.

8.1.4 Access to services

Information for older people, carers and the public about services

The partnership informed us that there was a good range of information for older people, carers and the public on services provided by the NHS, the local authority, voluntary organisations and care providers. We found that it was patchy and needed to be reviewed and improved.

There were no council leaflets setting out all services for older people. There was a range of information on specific services, for example leaflets on home care, rapid response service and residential care, which provided basic information, including eligibility criteria. A Forth Valley partnership leaflet Moving from hospital to a care home was clearly written and easy to understand, although it was only in English with no signposting to other formats or languages.

There was a range of joint directories of services, community care directory and mental health directories, which were developed involving service users. The Community Care Directory of Services, 2005-06, whilst thorough, did not dedicate specific sections to older people. The council had a section devoted to older people within their website, but it was not easy to find.

There were a number of general advocacy leaflets. The partnership funded an Alzheimer Scotland information officer post and the organisation provided a full range of information about dementia services as well as a telephone information line. Some providers thought there was little information available about access to services.

In the service user survey, only 31% of users said that they found it easy to obtain clear information and 39% disagreed. (The Forth Valley figure was 49%). Almost all carers responding to the survey were not informed of their right to a carers assessment when the person they cared for was admitted to hospital.

Comprehensive information should be provided in all relevant languages and formats and Stirling Council had a contract with a local company to provide interpretation and translation services as well as the translation of information for minority ethnic languages. Within NHS Forth Valley, interpretation and translation flow charts were provided to each department and the relevant procedures were highlighted as part of new staff induction training.

Information leaflets were written in English with signposting to other languages or formats, which was helpful. Both organisations thought it was appropriate to access interpretation and translation facilities when needed, rather than to try to provide a wide range of leaflets in minority languages because of the low numbers of minority groups. Two thirds of Stirling staff in the staff survey answered positively when asked if they felt comprehensive information was provided in all relevant languages and formats.

Most staff in the survey believed that information was available to older people, carers and the public on services provided by NHS Forth Valley and the council. This was in marked contrast to responses from service users and carers. The discrepancy between what staff perceived to be easily available information and what service users and carers told us, as well as our own experience in trying to obtain information about services for older people, leads us to suggest that information must be made more accessible.

Systems to determine eligibility and priority

In health and social care there should be systems to determine eligibility and priority which are transparent, fair and equitable. It is commendable that Stirling Council had published eligibility criteria for assessments which were applied to new referrals and gave priority to hospital discharges. There were jointly developed eligibility criteria for the rapid response and rehabilitation at home models to ensure consistency of access.

Whilst these systems for determining eligibility and priority were transparent and fair staff said that they had concerns about their implementation. They said there was a lack of consistency between front line staff and their area manager, or when it was involved, the resource panel, in using these criteria. Staff said that this could result in disparity between recommendations made and resources allocated. Senior managers informed us that 'some staff may have viewed all of their cases as a priority, while their area manager may have reached a different view'. We think that Stirling needs to consider the issue of the implementation of their eligibility criteria with a degree of urgency.

The council also had difficulties in making sure that social care was delivered equitably between rural and urban areas, as home care could be particularly difficult to access in rural areas.

Managers told us that there was a range of creative solutions and flexible and joint working within the rural areas to meet local needs. Home support services and MECS ensured access to all areas in poor weather via the use of four wheel drive vehicles.

Health and social work services sought to ensure there were no barriers to accessing health and social care services. The three ethnic minority lunch clubs (for the Chinese, Indian, and Pakistani communities) were primarily for older people but also provided services to any socially excluded members of these communities. The sensory impairment service provided interpretation and translation services for people with sensory impairments or limited English proficiency. Telephone interpreting service and face to face interpreting services were available across all services.

Access to specialist services

There were several specialist services available to older people in the Stirling partnership so that they could be cared for in a manner that reflected their individual needs. These included the Forth Valley-wide arrangements for deaf blind communicators who were available to support individuals via the sign language interpretation service. Other examples included the provision of advocacy services and provision of specialist information and support services from Alzheimer Scotland.

The NHS Forth Valley continence advisory service provided advice and information across Forth Valley. It was available through the community care and health mainstream processes, although during the fieldwork some social care staff and carers we met were confused about how to access this service. Stirling Council residential and day services also ensured a continence service advisor worked with service users who required the service.

Emergency referrals to the NHS disability service were seen within three working days. There was a waiting list of up to eight weeks for non-urgent referrals, although telephone or letter contact might take place to provide support. The CMHT(E), the day hospital and community rehabilitation service all had both open referral and GP referral systems in place.

The people we interviewed during the fieldwork felt that their requirements were met and they were treated with respect when accessing the specialist services.

Multi-disciplinary rehabilitation for older people

There was good access to multi-disciplinary rehabilitation for older people who required it. A range of rehabilitation services were being provided in hospital settings and in individuals' homes, depending on needs. Staff worked well across the GORU (geriatric orthopaedic rehabilitation unit) and the CARE (community assessment and rehabilitation for elderly people) team. This provided continuity of care and avoided duplication of assessment and treatment.

Developments made since the rehabilitation service was established included the introduction of rehabilitation units in Falkirk and Clackmannanshire as well, thus confirming the need for the service and the value of having a co-ordinated and focused approach to rehabilitation.

Essential equipment is delivered to older people within agreed timescales

Essential and urgently required equipment was generally available and delivered to older people within agreed timescales. The JLES had been established since 1987 as a partnership between NHS Forth Valley and the council. Although initially each agency had funded appropriate equipment separately, access to equipment had been extended to include a wider range of staff with agreed competencies, since implementation of the Joint Future recommendations relating to SSA. OT staff in acute services and community nurses could access some council funded equipment through the joint arrangements. Stirling Council also operated a local 'buffer store' of equipment to enable speedy delivery of standard pieces of equipment at the time of initial assessments.

Emergency and out of hours delivery of essential equipment was available to prevent inappropriate hospital admission. Impressive work had been undertaken by the NHS head occupational therapist over the last five years to manage and monitor the waiting lists for specialist items of equipment. Clinical guidelines, protocols and priority tools had been developed to support the appropriate assessment for provision of equipment.

The majority of staff agreed that people received the required equipment and that it was delivered on time.

8.2 Key outcomes for older people and their carers

Positive outcomes for older people and their carers form a key indicator of effective collaboration between agencies. The evidence in Stirling in relation to outcomes for older people and their carers was mixed. Some older people and carers said they were satisfied with their services. Most had concerns about aspects of the services they received, and did not believe that they always ensured positive outcomes for older people. For example, they said that health and social work staff did not always respond quickly to significant changes in their situation, and that the help they got did not always help them to remain at home. The service users survey was the least positive of the three partnerships' surveys. The partnership's performance was evaluated as weak.

We evaluated outcomes for people who use services and their carers by considering a range of information, including service user and carer surveys, interviews, focus groups, and evidence from file reading. We also agreed with the partnerships a core set of published performance data, such as levels of delayed discharges and amount of home care hours provided by the councils. Some of this information was proxy for the more robust set of National Outcome measures which is being developed.

Core data set for evaluating outcomes for older people and carers

We used exactly the same performance indicators for 2005-06 for the three partnerships on four key areas relating to outcomes for people and carers, as set out below.

Overall, Stirling performed very poorly on the level of home care service provided and therefore on the balance of care. It also performed poorly on some of the other core performance indicators, but it performed well on the level of respite for carers and day care services.

1. Supporting more people at home as an alternative to residential and nursing care. This is often known as the balance of care between home based care and long term care, including NHS continuing care beds and care homes.

Long term residential care in Stirling was consistent with the pattern in Scotland. In March 2006 there were 571 older people in care homes. This represents a rate per thousand of people over 65 years of 40.0. The average for Scotland was 39.8. There are 3.3 (rate per thousand) occupied NHS continuing care beds in Stirling. The average figure for Scotland was 2.7.

However, the level of home care is problematic. There were 49.7 (rate per thousand of over 65s) who received home care in Stirling. The average figure for Scotland was 68.2. The total hours of home care provided (rate per thousand of over 65s) was 284. Stirling ranked 29 out of 30 councils in Scotland. Moreover, 22.7% of home care service users got care in the evenings and or overnight. Stirling ranked 21 out of 31 councils in Scotland on this. In relation to home care at the weekends, 54.9% of over 65s received this service. Stirling ranked 17 out of 31 councils in Scotland.

Seven (rate per thousand of over 65s) home care service users in Stirling received more than 10 hours home care. The average figure was 17 for Scotland. Intensive home care as a percentage of all long term care was 18% in Stirling. The average figure for Scotland was 30%. In relation to older people receiving less than 10 hours home care per week, the rate for Stirling was 39.1, while the national average was 51.3.

2. Assisting people to lead independent lives through reducing inappropriate hospital admissions, reducing time spent inappropriately in hospital and enabling supported and faster discharges from hospital.

There were 12 delayed discharges of over 6 weeks in March 2006, and this figure had been reduced to six by May 2007, much to the partnership's credit.

3. Ensuring people receive an improved quality of care through faster access to services and better quality services.

The average time taken to provide a community care service from first identification of need to first service provision was 26 days in Stirling. The average figure for Scotland was 20 days.

4. Better involvement of and support for carers.

The number of overnight respite nights provided (rate per thousand of over 65s) was 457. This was very positive as the average figure for Scotland was 342. The rate for day care places for older people in Stirling was also positive - 19.3 against a national average of 8.8. The number of older people attending day care services (rate per thousand of over 65s) was 21.7 against a Scottish average of 14.3.

The views of older people on outcomes for themselves

The evidence in Stirling in relation to outcomes for older people and their carers was mixed. Many of the older people and carers, for example those we interviewed, said they were satisfied with their services, and that the quality of the help they got was excellent or good. However, most people had concerns about some aspects of the services. These included their belief that health and social work staff did not respond quickly to significant changes in their situation, that the help they received did not always help them to remain at home, and that they did not think the charges they had to pay were fair. (We recognise that Stirling followed the CoSLA charging policy.)

Several concerns were expressed to us about the setting up of large care packages. For example, one person who had very severe disabilities told us that he was promised more care before he was discharged from hospital than he actually received. He needed two members of staff at any time help him transfer. Stirling Council had a policy, based on a committee decision, of normally allowing around 25 hours of home care per week, except in exceptional cases, for example where an alternative care arrangement, such as a care home placement is not available. He was told that he could only get a maximum of twelve and a half hours care per week since two workers were needed at the same time. He said that the care manager who did the initial assessment recommended more care hours, but this was rejected. The restriction placed a considerable burden on his wife, although she said that eventually they had 'grown accustomed' to the care arrangements. Moreover, the individual could not obtain day care locally as Stirling Council had no centres for people who needed to use a hoist. We comment on the allocation of services later in the report.

Everyone we interviewed said both they and their carers were involved in the arrangements for their hospital discharge, although one individual said that not all of the services were in place when she was discharged: 'It was quite frightening to go through an experience like this at a very horrendous time. We got nothing on paper. It was not clear who was responsible for what. We had no one point of contact. We should have had something in writing.'

However, some of the people we interviewed said that the help they received helped them to feel part of the community. One of them was very positive about the benefit he got from mainstream services such as free travel. He said: 'I travel all over Scotland in my disability scooter. I get free travel. Meals on wheels did not suit as I had to be at home to get the food.'

All of the people we interviewed said they were treated with respect by council staff and NHS community staff. Some people said they were not treated with respect by hospital staff. Half of the people we interviewed said they would be comfortable making a complaint.

The service user questionnaires showed that the way that people felt about services was in line with the other partnerships, but they were much less positive about some key aspects of services. For example, only about half agreed when asked if health and social work services staff had helped them feel safer and able to lead a more independent life. When asked if health and social work staff had helped service users to feel that they were a part of their community - again respondents in Stirling were least positive, with only 37% agreeing.

Respondents were less positive than in the other two council areas about whether the help they needed was in place at the time they were ready to leave hospital. Responses in Stirling were negative about whether it was easy to get clear information on the range of services available to help them (31% agreed but 39% disagreed). Older people were notably less positive than in the other two areas with under half agreeing that services provided by the health and social work staff were well organised and co-ordinated, or that health and social work staff responded quickly when there was an important change in their circumstances. Only about 60% said they received help at the time they needed it.

Views of carers on outcomes for older people

Carers were, on the whole, less satisfied than service users in Stirling, and also less satisfied than carers in the other two partnerships. In the survey of carers, carers in Stirling responded negatively to statements about social work staff providing them with practical support, and about health and social work staff working together to provide them with practical support. They were also less positive than other respondents about health and social work services responding promptly when there was a crisis. However, carers in Stirling were more positive than other carers about health professionals providing them with practical support.

Carers were forthright in expressing their views about services in a meeting with us. They were very positive about the support they got from the Stirling PRT Carers Centre. Many had had a carers self assessment undertaken with Carers Centre staff, using a template developed jointly by the Carers Centre and council staff. They said this type of carers assessment had been very helpful to them. One said: 'The Carers Centre has been invaluable. Things started to happen after I got a carers assessment. Before that I got passed from pillar to post.'

Most of the carers felt that services in Stirling were not as good as in other areas. One said: 'You can get in Falkirk when you can't get in Stirling. They all get the same funding and they all have the same duty of care. If it's Stirling you will not get anything.'

The carers said there was difficulty getting a home care service in Stirling, especially in rural parts of the council. Another concern, which we heard from a number of sources, was that service users had to accept services at unreasonable times of day to suit the needs of the service provider. Some carers also said there were problems in obtaining services such as respite or equipment.

Carers said that they believed that the problems lay at senior and middle manager level. One said: 'It's not the front line staff; it's the people above who are sitting on things. They have a fixation about budgets. I was able to bypass the blockage. Not all of the people have the energy to do this. It's quite a battle to get results. '

We thought that the views held by this group of carers reflected the issues identified for the Stirling partnership, such as problems in obtaining home care, as well as delays and limitations on services.

Views of staff on outcomes for older people

Staff questionnaires showed that staff thought that positive outcomes in relation to independence, developing skills, isolation, and safety were being achieved. Most respondents agreed that multi-agency services were successful, in keeping older people safe, in helping them to lead less isolated lives and in helping older people to develop their skills and abilities to the full. Almost all thought that multi-agency services are successful in helping older people live as independent a life as possible. Most respondents agreed that multi-agency services are successful in preventing inappropriate hospital admissions.

Evidence from file reading

The council case files showed that the objectives set out in the care or treatment plans had been or were in the process of being achieved in 76% of cases - the average figure for Forth Valley overall was 93%.

In view of all the evidence, we make a recommendation that Stirling Council must review the way that services are provided and take steps to improve outcomes for service users and carers.

8.3 Whole systems approach

The partnership's understanding of the whole systems approach was not well developed in Stirling. There was not a high level of services to support people in their own homes, although there were examples of integrated services which had developed largely as part of early supported discharges. Joint strategic planning and commissioning needed to be developed and this needed to take place at the level of the partnership, as well as Forth Valley wide.

Improvements had been made on delayed discharges, but performance on other indicators was mixed. Repeat emergency admissions were low, but performance against the national target for intensive home care was poor. Systems were not yet in place for fully aligned budgets or joint financial management of older people's services. The partnership's performance was evaluated as weak.

8.3.1 Range and quality of community based services

A whole system approach to delivering services

The partnership's understanding of the whole systems approach was not well developed. The 2005-06 JPIAF evaluation statement found the partnership's performance on the comparative whole systems indicator to be below average. The partnership showed extensive slippage on services between years, which impacted on the already low levels of services at the year end. It was performing well on repeat emergency admissions, but less so on discharges. Its balance of care was very dependent on care homes and to a lesser extent on long stay beds. The partnership was found to be making steady progress on its understanding of the holistic approach. It provided a very limited analysis of the drivers of individual indicators and their interaction, and the direction of travel was not very clear, giving a sense of being static. Local improvement targets were reasonable but did not really impact on the balance of care.

Our discussions with front line and middle managers suggested that whole systems thinking was not yet well embedded at key levels within health and social work. We found some examples of good collaborative practice, and these are commented on more fully below.

In the staff survey, more than half (62%) agreed that a whole systems approach was taken to services for older people. This was marginally lower than the response for the other two councils or for NHS staff across Forth Valley.

Broad range of quality services

There was not a high level of services to support people in their own homes, although there were some examples of integrated services which had developed largely as part of early supported discharges.

In chapter 5, we described the reconfiguration of NHS services in Forth Valley, designed to bring about fundamental shifts from acute to primary care and community health services, in line with the national policy. Alongside this, the balance of long term care provision, including NHS continuing care beds, required to shift more towards intensive care at home.

Delayed discharges (over six weeks) peaked in Stirling at July 2002, when the numbers of delayed discharges reached 30. This was followed by a marked improvement to July 2003, when discharges fell to 16. The partnership failed to achieve its local improvement targets on delayed discharges in March 2006. However, in the latest JPIAF submission, for March 2007, delayed discharges (over 6 weeks) had been reduced to six. The rate of delayed discharges in Stirling was above the Scottish average in January 2005, but has shown a steady downward trend in line with the rest of Scotland.

Stirling's rate of two or more emergency admissions for patients aged over 65 was at the Forth Valley average, and below the Scottish rate. Bed days for patients with two or more emergency admissions, were also below the Scottish rate, and fluctuating just under the Forth Valley average. This success was attributed by the partnership to step-up, step-down, rehabilitation and respite care initiatives.

In looking at the balance of care we use some of the data already considered in the previous section for outcomes for individuals and their carers, but here we consider the trends in service provision. Stirling compared unfavourably with its neighbouring authorities and with Scotland in terms of overall rates of home care for older people, as well as intensive home care. In March 2006, 49.7 per thousand older people received a home care service, compared with a rate of 68.2 for Scotland. The rate of people receiving intensive home care (7 per thousand) was less than half the rate for Scotland (17 per thousand). Provision of intensive care (10+ hours per week) barely increased in the two years prior to the inspection, and stood at 18% of all long term care. This was approximately half the national target of 30%.

We were concerned that in Stirling, levels of home care and care home placements were decreasing, against a backcloth of significant increases in very frail older people and people with dementia and reducing hospital provision. For example, the total home care hours, provided as a rate per 1,000 population of older people aged over 65 years dropped from 350.4 in 2003-04 to 291.8 in 2004-05 and again in 2005-06 to 281.4, and in 2006-07 improved to 354.3, a marginal increase. The most recent JPIAF return by the partnership to the Scottish Government showed that for March 2007, placements in care homes reduced by 5% and the number receiving intensive home care was almost static.

However, we noted that Stirling had developed a mobile personal care service in 2002. It began with the bathing service which helped facilitate early discharge from individuals as older people did not have to wait for bathing equipment to be in place prior to discharge. Mobile personal care which covered all of the council area, operating from 6.30 a.m to 11.30 p.m, had been in place since 2005.

In Stirling, the evidence we received in the fieldwork from front line staff and managers, senior medical clinicians, service users, carers and providers, suggested that social work, health and housing services were generally disjointed and communicated poorly with each other, rather than operating jointly to achieve a whole systems approach. Community care services were perceived as very thin on the ground, with shortages and waiting lists for most services, and particular problems of coverage in rural areas. This was a consistent theme, well reflected in the words of one senior health professional: 'If you need a care home place in Stirling, you might be lucky, but if you need care services at home, you can forget it. Older people in Stirling get a very bad deal.'

The evidence from the staff survey was however more positive, for example about half of all staff agreed that the quality of service offered to older people by multi-agency services had improved over the last year. Stirling Council staff were more positive (62%) and all NHS staff least positive (only 16% agreed.)

We found evidence of some joint and integrated services in the form of individual projects. These included rapid response services and joint rehabilitation delivered from two redesigned local authority care homes. The hospital based CARE team provided an outreach rehabilitation services for people in their own homes and in community settings, and had close links with GP practices, community nurses, and social work teams.

The rapid response service had initially focused on early supported discharges but had been restructured to broaden the focus to include prevention of admission. The restructured service was due to be relaunched in June 2007. Other partnership projects under development included health care staff directly accessing social care resources in the rural area, and step-up/step-down rehabilitation in two council care homes. An initial review of dementia services had been undertaken, although further work on this was not scheduled to take place until 2008.

Over the last four years there had been a significant increase in the number of day care resources in Stirling, three of which were jointly set up by health and social work. About 220 people per week received a service. Day centre provision in the grounds of Strathendrick care home, established four years ago, was a joint venture. A support group instigated by carers was run from 3-5 pm one day a month within the centre. Stirling Council residential and day services had introduced a carer's support group offering support to families and carers of people with dementia who attended day care. There was also a stroke carer's support group.

Service commissioning

The Stirling partnership had signed up to the Forth Valley-wide Joint Commissioning Statement of Intent. The draft Joint Commissioning Framework was accepted in so far as it set the direction for travel, but required further work and refinement before it would provide a full strategy for joint commissioning. The balance between service commissioning at Forth Valley and individual partnership levels had still to be worked out.

Managers identified the need to reconfigure some existing services in order to achieve a greater balance of care and indicated that the provision of sheltered/more supportive styles of housing for older people would be a significant challenge. Stirling had a comparatively low level of extra care housing. There was, however, a sense that little would move forward in Stirling in advance of a Forth Valley-wide strategy being concluded.

We considered that in parallel with work on a Forth Valley-wide joint commissioning strategy, it was imperative that the Stirling partnership demonstrated leadership in tackling service commissioning for the Stirling area. Early and vigorous action was needed to identify redesign and service development priorities and to accelerate the pace and direction of change in order to improve the balance of care for older people. The partnership should agree clear local priorities, targets and timescales for change in older people's service, and harmonise these with the emerging Forth Valley-wide strategy.

We have noted in chapter 5 that the overarching financial plan for older people's services in Forth Valley needs to be set out. NHS Forth Valley and Stirling Council also needed to develop a joint local financial plan for older people's services. As with Clackmannanshire and Falkirk, this needed to take account of the Forth Valley-wide financial framework. In Stirling's case, it also needed to specifically address whether sufficient council resources were available to support an appropriate and equitable range and quality of care for older people and people with dementia.

We heard that Stirling had a higher proportion of older people who paid for their home care service or care home place (although they might also be eligible for free personal care payments as well), but we did not consider that this diminished the council's responsibility to ensure an adequate level of provision for its older citizens, delivered in partnership with the NHS and other agencies.

In discussion with senior managers in the council, it was apparent that the social work services need to resolve practical issues around specifying services and contracting these from the independent sector, such as the use of block contracts. In these areas, they appeared to be much less well advanced than neighbouring councils, and many other parts of Scotland. This is a significant concern, given the scale of the commissioning challenges the council faced.

The group of providers we met considered that services were not always suitably planned and co-ordinated between agencies. Examples included allocating a day care resource without corresponding practical arrangements being put in place, for example sufficient assistance with dressing, or transport arrangements. Providers also commented that Stirling had a low uptake of direct payments and in some cases, potential claimants were actively discouraged by council staff. Providers said that access to urban services was easier than rural services and they cross-subsidised rural clients by providing services in both areas at the same price, despite the differential in costs to them.

8.3.2 Planning, policy development and partnerships

Strategic planning is informed by a whole systems approach

As with service commissioning, there was not a strong sense that strategic planning was well informed by a whole systems approach. Within Stirling, a strong shared vision of a whole systems approach to older people's services was not apparent at all levels in the partnership. There were no recent joint strategic plans for older people which set out the vision or joint objectives, and we did not find evidence of joint action to set SMART objectives, action plans and timescales. An action plan for Better Outcomes for Older People⁵ had been produced, but this was a joint position statement rather than a strategic plan.

We recognise that Stirling is a relatively small partnership and had capacity issues in relation to committing resources to strategic planning and commissioning of services. Nevertheless, we consider that this is an essential next stage if the partnership is to begin to address the many challenges it faces in implementing national policy and improving community health and care services for older people.

We were told by managers that partnership working was effective at Forth Valley level in agreeing a joint vision for older people's services, agreeing joint plans for managing delayed discharges, and reaching agreement to develop joint commissioning plans. We have noted earlier in the report that the intention behind the recent reconfiguration of planning structures in Forth Valley was to streamline Forth Valley-wide planning and ensure that the majority of planning at CHP level.

Partnership working at local authority and CHP level was considered to have been most effective in agreeing joint local improvement targets ( LITS) and in putting in place local services such as rapid response and joint rehabilitation services.

The current local planning structure in Stirling was the Development and Implementation Group for older people's services. We observed this group to be well attended, bringing together a range of planning and operation managers from the local authority, the CHP lead nurse and clinical nurse manager, together with representatives of service users and the voluntary sector. Our observation of a meeting of this group suggested that it came together mainly for discussion and information sharing rather than to drive forward a strategic agenda.

Senior council managers told us that a Stirling geographical data mapping workshop had been held with Forth Valley GIS (Geographical Information Services) to explore how geographical data mapping can enhance future planning and reporting issues. Regular management information is presented to the JLES Management Group to inform operational and strategic decision making.

Managers in the Stirling partnership considered that there was good involvement with voluntary and provider organisations. The Stirling carers strategy had been jointly developed following a full consultation exercise with carers, which was managed by the Stirling partnership for carers. This document, called 'Together we care 2006-2009', was a user friendly document and had a clear action plan. However, some comments made by stakeholders, other than carers, suggested that generally involvement was patchy.

The CHP's Public Partnership Forum ( PPF) brought together a range of stakeholders, including the voluntary sector. There was a carers strategy group and a housing strategy group, both of which brought together a range of stakeholders and gave them the opportunity to participate in and influence joint planning.

Implementation of joint vision, policies and strategies

In the staff survey, exactly half the staff felt that the vision for older people's services was set out in comprehensive, joint strategic plans, strategic objectives and measurable outcomes. This was higher than the response for the other two councils and for NHS Forth Valley staff. A similarly positive response was obtained when staff were asked if there were effective partnerships which focused on delivering key policies and plans for older people and included all relevant stakeholders. Here only 2% (1 member of staff) disagreed - much fewer than in the other councils or NHS Forth Valley.

We also received information about the North West locality group within the CHP structure. Older people had been identified as a priority for this group during 2006-07, and minutes of meetings showed evidence of whole systems thinking and good local joint working on the older people's agenda on a range of issues, including palliative care, dementia, rapid response, access to services and the interface between partners and the acute hospital. This group involved social work staff, GPs and primary care staff.

During fieldwork, front line managers and staff were not clear about whether there was any overarching shared vision for older people's services. They did not think that there was a coherent set of joint plans in the form of a strategy for older people, objectives and timescales beyond the performance indicators set out in the JPIAF.

We think that the production of written plans and local commissioning strategies for older people would assist staff, managers and other stakeholders to understand and have confidence in the strategic direction for the service and the performance required to deliver this.

8.3.3 Financial and resources management

Financial planning

Stirling Council's budgeted resources for community care services were £20.0 million for 2006-07. (We were not provided with figures for older people's services.) The NHS Forth Valley budget was £8.2 million for the Stirling area. The council spent £1373 per adult over 65 in 2005-06 which was less than the average figure of £1504 for Scotland.

As was the case in the other two partnerships, financial plans were prepared by each partner individually and were not yet driven by policies and service plans agreed by the partners. Therefore, the annual budgets were largely incrementally driven. In addition, the officers that we met advised us that they were aware that much work was needed to align services and budgets. At the time of our inspection, almost two months into the financial year, the aligned budgets had not been identified and agreed for 2007-08 and there were no joint financial plans available for 2008-09 and 2009-10.

Financial management

As was the case with the other two partnerships in Forth Valley, budgets were aligned rather than pooled, and therefore each partner was responsible for its own financial control. The financial monitoring reports submitted to the CHP Committee included only NHS Forth Valley financial information. Therefore the committee did not receive the full financial data for all older people's services within its area. NHS Forth Valley managers advised us that the financial reports submitted to the CHP Committee were in an agreed format to facilitate understanding of the respective CHP's position and, in summary form, of the other two CHPs and NHS Forth Valley as a whole.

However, we are of the opinion that there is room for improvement in the clarity and accuracy of the financial reports submitted to the CHP Committee. The content of the reports should be reviewed to ensure that the financial information provided is robust, complete and commensurate with the committee's role and remit. NHS Forth Valley accepted that the reporting needed to improve and there was enthusiasm to expand and encapsulate the appropriate information from all the partners.

Each partner produced its own budgetary control information for its own officers on a monthly basis and regular meetings were held between managers and budget holders to discuss budgetary control issues. Cost centres were set up where older people's services costs could readily be coded, but analysis work was necessary where these costs could not be readily identified within a particular cost centre.

The partnership had no capital budget of its own. Capital requirements were minimal and had to be bid for to the council and to NHS Forth Valley under their normal capital planning procedures. Although the partners operated separate capital plans, joint discussions were held in advance of the capital plans being finalised.

We make recommendations about financial planning and management in chapter 5.

8.4 Delivery and management of services

Day to day planning and resource management were adequately undertaken and monitored at a local level. Staff found the decision making processes for care packages difficult to use to get the best results for older people as they found them cumbersome and unresponsive. Procedures for the risk management of vulnerable adults were in place. Management and support of staff relied on formal channels for conveying information and staff did not feel committed to or involved in decision making about the future direction of travel for services. Joint performance management and continuous improvement was not yet systematically used. The partnership's performance was evaluated as adequate.

8.4.1 Joint operational management

There were some activities in both service delivery and service developments where managers had opportunities to agree service models, and pilots. For example, there was a Joint Future Management Team but it appeared to focus on strategic issues rather than day to day jointly managing operational issues.

There were examples of joint operational management and delivery of services, for example in relation to day care services in Callander and the jointly funded rehabilitation services at Strathendrick and Allan Lodge. Funding from the council was used to support Crossroads West Stirlingshire to ensure it had sufficient funds for health staff to access services. There was direct access for staff of up to £500 of service for an individual from Care and Repair. Palliative care both in hospital and in the community was also effective and much appreciated by families. The CMHT(E) supported people with dementia well, particularly where there was limited community support available. Referrals to the team were increasing instead of people being admitted to hospital as had happened in the past.

There was limited collaboration between health and social work operational managers. They did not present to us as working effectively together in responding to the challenges facing the partnership. This meant that effective management of services and resources across the whole system of care was not as effective as it could have been. Managers and services seemed largely to operate in parallel rather than in a joint way. There was a notable exception to this.

The SSA Group in Stirling was taking forward a pilot in West Stirlingshire whereby community nurses would have access to MECS, occupational therapy, rapid response service, up to 12 hours home care per week, day care and designated rehabilitation care home beds, for people over 65 years through the completion of one agreed assessment form.

Waiting lists for services

We were concerned about the long waiting lists for services and assessments. In 2005-06, numbers on waiting lists for complex assessments were 95, for standard assessments 68, for care home placements 21, and for home support services 30. We were also advised that the waiting times for services could be considerable - about 8 weeks. JPIAF returns for waiting times for single shared assessments showed that the time intervals between initial contact and start of service as an average of 22 days for older people without dementia, with 45% of people waiting over 28 days. For older people with dementia, time intervals were much longer. In the cases read during the file reading, 16% of people were waiting for services in Forth Valley overall, but in Stirling 27% were waiting.

In 2006, the average time taken to provide a community care service from first identification of need to first service provision was 26 days. The average figure for Scotland was 20 days. Many health professionals considered that older people received a poorer service from Stirling Council than elsewhere in Forth Valley, especially for home care. A community nurse said: 'Staff, patients and carers are all suffering in Stirling unless a care home is the answer and even that involves long delays.'

Health and social work services scrutinised and reported on some waiting lists more intensively than others. For example, in relation to delayed discharges, reports were produced monthly, detailing the reasons for waiting times, such as waiting for care home places, home support services and completion of community care assessments. The Forth Valley Delayed Discharge Steering Group monitored these reports at its monthly meetings. At a meeting of the group which we attended, we saw the senior health manager, the General Manager, Medicine and Rehabilitation Unit, work very constructively and positively towards enabling action to be taken to reduce delayed discharges. Waiting lists and pressures in community health services are reported to the CHP and through it, to the NHS Board. Service volume and pressures in relation to waiting lists for community care services were reported to the council committees.

Joint mechanisms for operational management

There were a limited number of mechanisms for jointly managing workloads and allocation of services and resources in line with the partnership's agreed priorities.

For example, the Joint Home Support Resource Panel met weekly and agreed priorities for allocation of available resources, such as rehabilitation at home and home care. The discharge liaison co-ordinator attended the panel meetings to participate in the allocation of resources. We were told by staff that this panel was overly bureaucratic and was, in effect, used as a delaying tactic to ration scarce resources. Senior managers said that applications to the panel were often inappropriate or poorly completed. We think that more attention should be given to providing a feedback loop to staff, if this is the case.

The Delayed Discharge Steering Group had given considerable impetus to the issue of delayed discharges across Forth Valley, for example £1.8 million had been allocated for a variety of projects or service developments which the group was monitoring. Although there had been some difficulty in specifically evidencing that the projects had impacted on admissions and discharges, the group had agreed that the projects were to continue.

In April 2006, there were 20 delayed discharges (seven above target) over six weeks. Of these 15 were awaiting assessments and five were awaiting placement. In Stirling the reasons for delayed discharges continued to be a combination of waiting for community care assessments and care home placements. However, the council was taking steps to improve its efficiency effectiveness of providing services to older people. By June 2007, the partnership had six delayed discharges.

At the time of the fieldwork, the council had just implemented a restructuring of the community care teams into short term and long term teams in order to address the waiting lists for community care assessments. There was a high proportion of OTs (about 60%) in the short term team in order to ensure rapid and effective throughput of the high volume of requests for equipment. The long term team would undertake care management with individuals needing complex care packages. It was anticipated that this new arrangement would be successful in reducing the waiting lists for assessments and services. The council had also restructured its rapid response service in order to improve its capacity to respond to urgent need in order to prevent inappropriate admission and to support early discharge from hospital.

There is, however, a major issue about how effectively the council can support joint working when it has real difficulties sourcing enough home care services, either from its own in-house service or through independent providers. The commissioning issue is covered in the section covering the whole systems approach. In relation to the impact this limitation has on operational practices, Stirling Council had a policy that care packages should not exceed 25 hours per week, unless there was an assessed need for a higher level of care. There are two issues here.

One is that, as mentioned earlier in this chapter, we were told by senior managers that some staff were applying for inappropriately high levels of care packages. We note that there was no feedback loop to staff and their assessments were not being reviewed in relation to their appropriateness. Secondly, we were told by staff, service users and carers that if one older person needed two staff members for handling and lifting in their home, then the number of home care hours proposed in the assessment would be routinely halved. This would usually mean that someone assessed as needing 24 hours per week would receive 12 hours. We were told by managers that that this is not so, as this would be unacceptable practice because it could place frail older people at risk. Nevertheless, senior managers should take immediate steps to improve general understanding of the process. We make a recommendation, Forth Valley-wide number 5, about care planning in chapter 5 which covers this issue.

8.4.2 Risk management and accountability

This section deals with risk management and accountability specifically in relation to inter-agency working regarding individuals. Organisational risk management issues were not covered in this inspection. Inter-disciplinary arrangements for the protection of adults at risk should be in place. These should include a fully implemented inter-agency policy and procedure for the reporting and management of abuse of vulnerable older people. Staff generally should be aware of these and confident in using them.

Arrangements

The Forth Valley Vulnerable Adults Steering Group met quarterly, and a comprehensive Forth Valley adult protection policy and framework were in place. There were local customised procedures within Stirling and a system for preventing financial abuse was being developed.

Joint training for managers and some practitioners took place in May 2006 on a Forth Valley-wide basis, involving the three councils, police and health. Training for staff was being rolled out across Forth Valley. It would be reinforced by the council's on-going care management training. Other arrangements included the 'Message in a bottle scheme' and quarterly statistical reports on adults at risk.

Accountability for risk management

The accountability for risk management and monitoring of risk assessments was undertaken through multi-disciplinary protection of vulnerable adults ( POVA) case conferences, supervision, assessment, the care programme approach ( CPA), care management processes and case file audits.

Deciding on the appropriate balance between risk management and the right of people to make their own decisions is a complex process. Stirling worked through their person centred care planning to ensure there was a balance between an individual's self determination and risk management.

There appeared to be a mixed level of awareness about adult protection issues in Forth Valley. One service user told us that she had been inappropriately accommodated in a care home for one year for her safety, following Stirling's adult abuse procedure, because housing services were unable to offer her alternative accommodation. Some staff in Stirling were concerned that training for them had not been made available sooner, and they told us that they lacked confidence about handling vulnerable adult cases.

Case file reading showed that there were up to date risk assessments in 48% of the applicable cases in Stirling CHP, and in 28% of the applicable cases in Stirling Council. There was evidence that multi-agency partners' views had informed the risk assessment in the majority of the CHP cases, but in less than half of the council cases. There was an up to date risk management plan or equivalent on file in all the applicable Stirling CHP cases but in only 67% of Stirling Council's applicable cases.

8.4.3 Management and support of staff

Joint training and staff development

There were many joint development and training opportunities which had been set up as part of the Joint Future programme and these were being further developed, such as the partnership development programme which was open to all staff employed by the council and NHS Forth Valley. The Management Certificate programme was also open to managers, such as those of integrated teams and community care managers. The updated Joint Future Training Plan for 2006-07 set out all the joint training and development activity undertaken or planned, including that for SSA and care management, adults with incapacity, and the Mental Health Care and Treatment Act, 2002.

Managers said that all community nursing staff and social work staff had supervision, professional support and opportunities for development, which were identified through regular development reviews. They also had personal development plans.

The surveys of Stirling Council and all health staff showed that the majority agreed that they were given time to undertake professional development and that their team regularly evaluated its work and took appropriate action for improvement. There was less agreement about the annual appraisal or staff review system with 48% of Stirling Council staff, but only 32% of Forth Valley health staff, agreeing it helped them improve the way they did their work. We note that the council did not have an agreed appraisal system and that this might have affected the response of staff. Our expectation is that all managers should be carrying out annual appraisals or performance reviews, in line with good practice and to assist in professional development.

Health and social work staff were able to access information they required to carry out their duties and responsibilities through formal information sharing arrangements such as team meetings, locality meetings, and websites. Relevant information about individual patients and service users, such as minutes of care planning meetings and reviews, was also circulated. There was also single agency information. For example, NHS Forth Valley had a comprehensive discharge manual for staff which included guidance on the role of the discharge co-ordinator, the discharge planning pathway, assessment of ability of an older person's ability to take their medication, rehabilitation services, and policy on choice of care home.

Effective communication between staff

Stirling partnership managers saw communication between health and social work staff taking place mainly through formal channels and groups such as the North West Forth Valley Locality Partnership, the Delayed Discharge Steering Group, CHP meetings, Forth Valley Sensory Centre Board, the resource panel and trade union meetings. There was also joint training, for example for the single shared assessment process. Formal awareness sessions were planned as part of the roll out of the telecare bid, and joint work had taken place on new developments such as the restructuring of the rapid response service and housing for older people.

Managers thought that better outcomes for older people resulted from these methods of communication. They had not developed clear strategies for improving communication between health and social work staff, largely because they did not perceive there to be any reasons for doing so. We were advised by many of the staff whom we saw that communication between staff on the front line was good.

However, staff also said that there were significant issues about how well they were kept informed by managers about service issues and new developments, since staff did not necessarily participate in many of the formal groups. The staff survey showed that just over half of Stirling council respondents but only 38% of NHS Forth Valley respondents thought that there were policies, developed in partnership with other agencies which guide, monitor and improve the way that staff communicate and engage with each other and older people, carers and the public.

Staff support and morale

There appeared to be a mixed picture in relation to staff support and morale. The survey of social work staff demonstrated that social work staff were positive about the services they provided, the capacity for improvement and the leadership provided by senior managers. Staff in the health service survey, which covered all NHS Forth Valley staff, were much less positive.

For example, under half of all staff agreed that the quality of service offered to older people by multi-agency services had improved over the last year but Stirling staff were most positive (62%) and all NHS staff least positive (only 16% agreed). NHS staff also gave negative responses to the questions about feeling valued by managers (54% of Stirling council staff and 39% of NHS staff), receiving feedback about the quality of their work (64% and 32%), annual appraisal system (48% and 32%) and policies on communication and engagement (55% and 38%). They were also less positive than council staff on several other statements, such as joint leadership of change (45% and 30%).

Both health and social work staff were positive about many aspects of joint working such as information for the public, guidance on eligibility for council services, that assessments were person centred and there was sound access to advocacy. In particular, staff were positive about the role of multi-agency services in successfully enabling people to live more independently and safely.

During the fieldwork, we gained the impression that the situation was more mixed than demonstrated in the staff survey. We were told by many people that the morale of social work staff in Stirling had been low for a long time. This was said to be for a number of reasons such as the perceived bureaucracy in getting care packages approved and the unresponsive style of the senior managers. However, although managers were concerned that staff had been displaced from their usual workplace in Drummond House because of the very serious fire there, staff did not tell us this was a problem.

The council had just implemented a restructuring of the community care teams into short term and long term teams in order to address the waiting lists for community care assessments. Staff in the community care teams seemed largely happy with the new arrangements, stating that the responsible manager understood their issues, had taken time to think through the changes and to involve them. Another positive factor quoted to us was the strong peer support amongst front line social work staff.

We acknowledge that, at the time of the inspection, there were significant changes taking place in NHS Forth Valley, for example, the development of the new acute hospital and community hospitals, together with changes in the role of community nurses and heath visitors.

We think that the senior managers should consider these messages and take action to support staff more proactively. We make a recommendation about health staff in chapter 5.

8.4.4 Performance management and continuous improvement

Joint performance reporting

This is undertaken through the Scottish Government's reporting mechanism, the Joint Performance Information and Assessment Framework ( JPIAF). This contains annual returns by partnerships on performance indicators based on four national outcomes. They are underpinned by Local Improvement Targets ( LITS), which are set by the partners themselves to measure progress and improvement.

The Scottish Government rated the partnership's performance in 2005-06 as requiring improvement.

1. The Scottish Government stated that improvement was required in the progress of the partnership on single shared assessments ( JPIAF 6).

2. It judged that steady progress was being made in cross-agency access to services ( JPIAF 8).

3. The whole system working indicator ( JPIAF 10) was evaluated as below average on the comparative model, but making steady progress on understanding the holistic approach. Their balance of care was very dependent on care homes and to a lesser extent on NHS long stays beds.

4. For JPIAF 11, the progress on the existing LITS was rated as falling well short, and the new targets were evaluated as insufficient. In particular, information was lacking on SSA, rapid response services, and reducing emergency admissions. The intensive home care was well below the local target of 28.8%. However, the partnership was close to meeting its target on delayed discharges. It also more than met its target to provide respite to older people in their own homes, in order to support carers.

Although the lead in Forth Valley for developing a joint performance management framework lay with Clackmannanshire, the CHP was developing a local Performance Management Framework. This will cover national, Board and local priorities and outcomes, including general outcomes around shifting the balance of care, management of long term conditions, anticipatory care and specific outcomes such as targets for multiple emergency admissions. A paper by the Stirling CHP General Manager on the development of performance management system of the CHP's services was presented to the CHP Committee in March 2007.

Use of joint performance management information

The NHS Forth Valley Chief Executive was very focused on the use of performance information, such as SPARRA health data, to drive improvements in services. We saw a powerful and comprehensive presentation on information about emergency admissions at a Forth Valley-wide meeting, which was considering how the partners could work together to improve the delayed discharge situation. We fully endorse this approach.

However, the staff survey showed that only 37% of staff thought that multi-agency services for older people performed well against service targets. Only a third of staff thought that services performed well against national and local indicators and benchmarks. High proportions of respondents ticked the 'neither agree nor disagree' option. Our impression was that managers, while conscious of performance management information, did not promote the understanding or use of it with staff.

Continuous improvement

The partnership said it was positive in its use of performance information and that they could demonstrate positive outcomes and targets met, such as waiting times for assessment, the delivery of care packages and other services. However, joint performance management appeared to be focused on the JPIAF indicators and LITS, rather than on driving continuous improvement at all levels. For example, Stirling had not set itself a standard or targets for completion of assessments following the introduction of the new community care teams which were designed to speed up the completion of assessments.

There was a helpful joint protocol for the investigation of complaints, which was agreed by NHS Forth Valley and Stirling Council, dated 2004. Staff told us they did not know of any examples of complaints being used to review service quality. However, there was a number of ways in which individuals could make known their concerns, for example through the Carers Centre (which was jointly funded), the Joint Dementia Initiative, and advocacy services.

There were several existing standards for services which were single agency standards with partnership elements, such as the ISO Quality Standards in residential and day care standards, national assessment and care management standards, Clinical Effectiveness Standards and Supporting People services. There were a few joint standards such as that a joint assessment should be carried out by the care home rehabilitation service within 24 hours.

There were several examples of joint developments which have led to successful improvements in health and care services in the last two years, such as the rehabilitation in care homes service, which allowed speedy discharge from hospital and a period of structured rehabilitation provided jointly by social care and health therapy staff. A joint development group was in place to take forward development of the telecare/telemedicine services across the area, with Scottish Government funding to support the purchase of the hardware.

Other examples were the joint services for older people with dementia. Alzheimer Scotland provided specialist day care at weekends in rural areas. There was a dementia liaison nurse who assisted staff in care homes to understand how to best work with older people with dementia. There was joint development of services through the Dementia Collaborative, for example the work being undertaken on integrated care pathways.

Benchmarking has been used effectively by NHS Forth Valley, for example, as part of its point prevalence studies in relation to its acute and community hospitals. A number of these have been undertaken, such as those on rehabilitation pathways and on the characteristics and needs of most patients in NHS Forth Valley beds. These studies have been used to inform healthcare strategy decisions and strategic capacity planning. They have also demonstrated key internal changes in the balance of care, over time.

The council did not appear to use benchmarking regularly as part of the process of continuous improvement, but the work which was undertaken in conjunction with the national Joint Improvement Team ( JIT) on joint commissioning involved considerable benchmarking for both health and social work services across Scotland. This was to be continued in the development of the joint commissioning plan in 2007.

Culturally sensitive services

The NHS Forth Valley-wide group called 'Fair for All' had three council representatives as well as community group representatives. This group supported the Central Scotland Chinese Association Big Lottery application to secure funding for support and advocacy on behalf of isolated groups including older Chinese people.

Equality and diversity training was being delivered to NHS Forth Valley staff and it included information about access to interpreting services for people with a sensory impairment or people with limited proficiency in English. Equality and Diversity Impact Assessments have been undertaken by NHS Forth Valley for a wide range of services such as A&E, the complaints procedure and food and nutrition in hospital.

The council delivered its own diversity training programme to staff, covering areas such as stereotyping in relation to age, gender, race and sexual orientation. Training also covers cross-cultural communication and access to professional interpreting and translation services to support people with a sensory impairment or people for whom English is not their first language.

Funding had been made available to three specific minority lunch clubs (Chinese, Indian and Pakistani communities). These were primarily for older people but will also provide a service to any member of these communities. It has also been agreed that they can be used by the partnership to publicise services, provide information or consult on specific service developments. These were helpful services but it appeared that the low level of ethnic minority groups had generally led to a low level of staff awareness of culturally sensitive services and the need for them.

8.5 Leadership and direction

Relationships between managers and staff at all levels across health and social work services were positive and there were some good services. The relatively low level of home care services was a key factor affecting the partnership's outcomes for older people and their carers. Services for older people were being provided by committed front line staff but opportunities to extend the balance of care towards greater home support was lacking in the partnership's strategic plans for older people's services. The funding for older people was relatively the lowest in Forth Valley in 2005-06. The partnership's performance was evaluated as adequate.

The Stirling partnership has not yet developed a clear joint vision of services for older people. Although the shift of focus from acute to primary health care was clearly set out in the Healthcare Strategy, the new acute hospital at Larbert had taken up considerable managerial time and effort to date, and there had been much less discussion about community health services. Managers felt this was changing, however, with a stronger relationship forming between some NHS Board and council senior managers.

Our impression was that the driving of developments remained at NHS Board level, rather than at the CHP level. We recognise that the role and remit of CHPs are evolving nationally, in different directions and at a different pace. The Chief Executive of NHS Forth Valley acknowledged that the Board was considering how to strengthen the role and remit of the CHPs and the CHP Committees, in order to promote partnership working at the local level. We did not observe strong joint operational leadership between senior managers in the council and the CHP, for example, in actively promoting collaborative or innovative ways of working.

Middle managers in the partnership were not clear about a joint vision, and expressed some frustration about timescales for concluding on new service models. For example, senior council managers talked about setting an objective of supporting older people to remain independent and in their own homes for longer - the average age on admission to residential care was 79 years and they would like to increase this to an average of 81 years. There were however no identified targets or actions identified in order to achieve this.

The council had a very strong track record of promoting healthy life styles, such as 'Walk around Stirling'. The Chief Executive stressed the importance of looking widely at all the factors and services, such as transport, which impacted on the quality of life for older people.

However, the performance data showed that Stirling performed poorly on the provision of specific services to enable people to be supported at home. Stirling Council home care was below the national average and the per capita spend on services for older people was the lowest across the Forth Valley in 2005-06. The council had prepared a report on the community care housing needs assessment of tenants and also those residing in residential care homes. There was recognition within the 36 broad recommendations of the importance of holding discussions with housing services in Stirling and separately with Communities Scotland in order to progress towards improved provision. However, the detailed housing needs assessment did not however appear to have been translated into effective planning in conjunction with Communities Scotland to develop extra care housing to enable people to remain within their own homes.

We recognise that the council faced a number of corporate challenges, including responding to Audit Scotland's Best Value Review and other inspections. It had therefore to balance the needs of older people against other competing corporate demands, such as road improvements. Nevertheless, we think that it should take action on the level and quality of services for older people.

Senior managers were aware that the council had not made a strong contribution to the development or functioning of the CHP. This was attributed to the relatively small size of the council (with only 22 elected members) and the range of responsibilities held by elected members. The changes following the elections (14 new members) presented both challenges such as informing members about the issues and opportunities to develop a more proactive way forward for services for older people.

The council has reported to Committee over several years about delayed hospital discharges and levels of home care provision. Against a background of competing demands for services across the council, it was not clear that the long standing difficulties in improving waiting times and approval of care packages for older people had been addressed by the council. However, during the financial year 2006-07, the council's Service Policy and Performance Committee received reports concerning the increasing pressures on home care services, equipment and adaptations, which were causing a budget deficit of £100,000. This was offset in part by a number of staff vacancies which were causing waiting lists for assessments and care packages to grow, thus making it difficult to reduce the numbers of those experiencing delayed discharge from hospital.

Senior managers in the council repeatedly described the difficulties which they had encountered in recruiting home carers, but did not appear to have taken proactive steps to engage with the independent or voluntary providers to commission services from them, particularly for the more remote rural areas. The partnership was committed to jointly agreeing plans for commissioning services, and had started in 2006 scoping its requirements through the work with the national Joint Improvement Team ( JIT) to achieve this.

However, it had not yet progressed this work, and remained unspecific about the current and projected levels of need and services, particularly in relation to the balance of care. Managers in the council demonstrated a tendency to be unclear in their analysis of need - they said that they were 'awash with data' - and to be uncertain about the way forward, for example in using contracting processes more effectively. The planning processes seemed protracted, and to be affected more by the extent of current demands than in the shaping of future services. There were, as yet, no sound strategic plans.

There was considerable frustration amongst clinicians within hospital services who had concluded over time that delayed discharges in Stirling had become accepted as a fact of life by the council, with no sense of appreciation about the poor outcomes for patients when discharge from hospital was delayed. As we have noted, significant progress has been made recently in reducing delayed discharges and it remained to be seen whether this could be sustained.

Representatives from the voluntary and private providers stated that the difficulties in providing services were not always taken into account at senior levels within the council. They quoted the example of the higher costs of providing services, especially home care, in rural parts of the Stirling area. Such view points had contributed to a belief that partnership approaches should be improved.

There had been some positive joint initiatives looking at the way forward for services in Stirling, such as a stakeholders' day called 'Patient focus - Public involvement' and also a joint CHP seminar with Stirling University on the needs of older people with dementia. However, health and social work staff were clear that there was a need for increased information sharing and discussion between managers and staff. They expressed a need for senior and middle managers to ensure that staff at all levels could be empowered and involved in problem solving of the very considerable challenges for services for older people which lay ahead.

Overall, it appeared that older people in Stirling were not able to access social work services as easily or as equitably in comparison with other areas in Forth Valley, or across Scotland. Nevertheless the partnership has achieved some improvements in areas of joint working, such as an increase in rehabilitation services, a reduction in the level of emergency admissions for older patients and the length of stay in acute hospitals, as well as the level of delayed discharges.

8.6 Capacity for improvement

Stirling partnership had made improvements to outcomes for older people and their carers such as a reduction in the number of delayed discharges. However, the partnership's performance was adversely affected by the low level and quality of some of the single-agency service provision such as home care. Although there was a strong focus on quality assurance and performance management in the health services, this was not seen in social work services. The joint leadership had not been as proactive or as innovative as it could have been. The partnership's capacity for improvement was evaluated as adequate.

The evaluation of capacity for improvement is based on three key factors:

• demonstrable improvements in outcomes for people who use services and their experiences,
• quality assurance and performance management, and
• effectiveness of leadership at all levels in health and social work services.

Both health and social work staff were highly motivated to work together to provide the best possible outcomes that were valued by older people and their carers. The partnership had made improvements to some of these outcomes, such as a reduction in the level of emergency admissions for older patients and the length of stay in acute hospitals, an increase in rehabilitation, as well as the level of delayed discharges. However, these improvements were in danger of not being maintained because of the council's approach to the provision of single-agency services, for example, the council's level of funding was relatively the lowest in Forth Valley. There was, at the start of the inspection, little recognition of the impact of this approach on improving the outcomes for older people through collaborative working. However, a determination to improve services emerged as the inspection progressed. Both the Chief Executive and the Director of Community Services stressed to the inspection team that they would ensure that services for older people were given significantly more attention, in order to improve outcomes for older people.

Although there was a strong focus on quality assurance and performance management in the health services, this was not seen in social work services. For example, community care teams had been restructured to improve the speed at which services were provided, which was very positive. But senior managers were not able to give us an idea of what was being targeted for improving times to undertake assessments. There was an absence of recognition of the importance of whole systems thinking in improving services. It was essential that a the partnership undertook its own scoping work on what was required in a whole systems approach to commissioning complementary health and social work services.

The joint leadership was not as proactive or as innovative as it could have been, and the issue of limited managerial capacity across the partnership was frequently raised with us. This is a very significant issue for this partnership. In order that real improvements can be implemented and sustained, the partnership will need to consider urgently how it strengthens leadership and management of services, both separately within the council and the CHP, and jointly within the partnership. One way of doing this would be to consider how Stirling partnership managers could work more collaboratively with those in the other Forth Valley partnerships. It would be helpful to share, on a national and Forth Valley-wide basis, ideas about how to develop and commission services more creatively as well as empowering staff more effectively.