Scottish Government

Summary of the Scoping Exercise

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Introduction

Aims of the Scoping Exercise

Methodology

Key Finding and Conclusions

Service Model

Service Delivery

Partnership

Performance (reporting & Monitoring)

Communication

Service User/Carer Involvement

Professional Support

Recommendations

Community Care aims to support people to live as independently as possible in their own homes. The timely and appropriate provision of housing adaptations for disabled people is a vital contributor to this aim.

New guidance on the provision of equipment and adaptations was launched in December 2009 by the Scottish Government. It aims to assist local authorities and their NHS partners to integrate their equipment and adaptation services within the wider context of community care.

This guidance was the first step in a series of actions to ensure the effective modernisation of equipment and adaptation services across Scotland. In addition to achieve this, one of the commitments in the new guidance was to research and develop national good practice guidelines for the provision of major housing adaptations for disabled people.

Adaptation services differ significantly across Scotland and in order to produce an effective good practice guide specific commitment was made to scope the variety of arrangements currently in operation for the provision of major adaptations. A scoping exercise was carried out which sought areas of good practice in the assessment for and provision of housing adaptations that could be tested for inclusion in the development of new innovative models for national consideration. It also focused on identifying areas for improvement in the provision of adaptations.

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The aims of the study were to:

• Engage all 32 Local Authorities in the scoping of current practice relating to the provision of adaptations
• Engage with respondents to confirm the key messages from the scoping exercise and identify areas for improvement and models of good practice
• Produce a report on the key outcomes of the scoping exercise with recommendations for long term sustainability, governance structures and processes for this service.

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The scoping exercise employed a range of quantitative and qualitative research methods.

32 local authorities were asked to complete a JIT questionnaire. This was used to obtain quantitative information to allow the creation of a data base. This contains data on the nature and availability of the following information related to the provision of major adaptations:

• Service Model
• Service Provision
• Partnership
• Performance (Reporting & Monitoring)
• Communication
• Service User/Carer Involvement
• Professional Support
• Good Practice/Innovation

The database has been designed to compare and analyse the information provided and to identify trends.

The qualitative element of the information sought was obtained during the visits to the authorities. Timescales were identified for the completion of the questionnaire and the return of related documentation. Those authorities that completed the questionnaires were contacted and visits arranged to discuss and expand their responses. The focus of these meetings was to confirm the information provided and establish an understanding of the current practice and trends across the authorities. Follow up interviews were also held with 2 local authorities to test good practice models previously identified during the visits.

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24 local authorities returned completed questionnaires, 23 visits were carried out and contact made via telephone with one further authority. This gave an overall response rate of 75%.

The quantitative results are detailed in the database for the 24 local authorities that engaged in this process. Data is supplied in percentage terms for the key questions posed.

The qualitative results are broken down into the sections used within the questionnaire to obtain the information related to the current practice of the authorities and draw conclusions.

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As anticipated there were a variety of different service models in operation across the 24 local authorities delivering assessment and provision of housing adaptations for disabled people. There exists a lack of strategic overview for adaptations across tenure. No local authority had identified a dedicated lead officer to drive the strategic provision of adaptations and generally provision was a shared responsibility across Social Work (SW), Local Authority Housing, Registered Social Landlords (RSL's), NHS and Care & Repair type organisations.

An adaptations service has essential links to other key corporate objectives within a local authority such as Local Housing Strategy, The Delivery Framework for Adult Rehabilitation and Single Outcome Agreements. It is therefore critical that the policy formation for the service brings together a wide partnership of all stakeholders. This is also in line with key actions on major adaptations in the guidance that state 'local protocols should be reviewed in line with the Housing Scotland Act 2006 and the new duties introduced from April 2009'.

It is essential that there is a strategic overview for adaptations across all tenure and the service is linked to mainstream community care provision in order to maximise whole system working and rebalance care. This is in line with the key actions in the guidance on assessment, that equipment and adaptations should be incorporated into mainstream community care services. In order to achieve this, local authorities should identify a named senior officer with accountability for delivering the strategic responsibility for the provision of major adaptations across tenure.

The national guidance on the provision of equipment and adaptations and the future Good Practice Guide for the Provision of Major Adaptations will provide a framework for local authorities to consider appointing a dedicated lead officer for coordinating provision across tenure.

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It was widely recognised across the local authorities screened in the scoping study that strategic planning across services and agencies should be improved and that there is a direct link with effective operational delivery across tenure. In most local authorities strategic forums where they existed were linked to individual tenures and interface with registered social landlords was minimal. Where no formal strategic framework existed for the provision of major adaptations service development often rests on the motivation of individual Team Leaders and is not coordinated.

Although funding of adaptations was linked to the budget setting cycle most local authorities did not link budget setting for adaptations with levels of unmet need or increased demographic demand and trends. Where local authorities had robust systems in place to do this then budgets were generally higher and waiting lists lower.

Joint information systems between NHS, SW and Housing were only available in 8.3% of areas. Although joint protocols existed for inter-agency access to equipment and minor adaptations these do not apply at present to major structural adaptations.

In relation to the high volume of referrals to SW for assistance only a very small number result in the provision of major adaptations. For example in one year a local authority received 6614 referrals for assistance with activities of daily living but surprisingly this only resulted in the provision of 463 major adaptations across tenure within the same timescale. It is clear from this data that within the overall referral rate it is only a very small number of people who require major adaptations. It is however this very small number of major adaptations that have the potential to create maximum confusion and negative outputs if not co-ordinated properly as delivery can involve many systems, agencies and sectors. Given the small number of adaptations required but the very high impact when things go wrong there is now an urgent need to address service improvement by using a whole system approach.

Customer Care standards should be agreed and published across tenure between partner agencies. These should include the following:

• Arrangements and criteria for the provision of service
• Timescale for the provision of service and access to clear information on timescales, waiting lists and other sources of help
• Arrangements for the monitoring of service outcomes
• Complaints procedure

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Duty of care, legislation and operational arrangements that underpin the current assessment and provision of adaptations mean that a wide variety of agencies may be involved and processes can be time consuming, fragmented and complicated by tenure. Partners often include SW, housing providers, building control, in-house or external architectural services, Care and Repair and legal services. Where there was lack of co-ordination amongst services and agencies it was obvious that there was also no cohesion for service users in the process.

It was also clear that there was a specific lack of equity and continuity between RSL's. It was also clear that there were issues with communication between local authorities and RSL's. There is an urgent need for all partnerships to promote inter-agency ownership, collaboration, cohesion and accountability across the system.

The scoping study has highlighted that where services work well agencies have already reviewed their systems and processes across tenure from referral to provision to create adaptation pathways that integrate appropriate functions across the whole system. This ensures a clear pathway of care and an integrated model of service delivery.

A wide range of key stakeholders should be included as part of any design or review of major adaptation services. This should include:

• Service Users
• Carers
• Housing personnel across all tenure
• Grants Officers
• Occupational Therapists
• Architects
• Building Control
• Building Contractors including in-house provision
• Legal Services
• Finance

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Current arrangements for adaptations span several services and agencies and it can be difficult for local authorities to provide robust data on timescale from assessment to provision for adaptations. Often performance information is not available because the intervention requires input from more than one service or agency and frequently robust performance data does not exist across tenure. This makes it impossible for local authorities to ensure equity of provision and also to manage performance across tenure.

The development of an integrated care pathway with robust customer care standards that focus on service user outcomes and performance review is critical.

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Most local authorities (91.7%) had a corporate communication strategy but did not specifically highlight this area of provision.

There were arrangements in place to ensure that information is available in a variety of formats but all stakeholders agreed that the availability of specific information for service users on provision of adaptations should be improved.

Publication of information should include access, criteria and processes and should be available in appropriate formats. Partnerships should consider if access to the adaptation process is clearly signposted.

Local authorities have a responsibility to ensure that they respond to equality and diversity legislation and that in doing so they recognise and minimise the problems that people from minority groups can face in accessing an adaptation service. Partnerships should consider if they have provided adequate training for staff in disability awareness, disability equality and diversity.

Integrated IT systems that provide all partners with ready access to information should be considered. Where partners do not have direct access to the same IT system other arrangements such as hand held computers and access to lead agency computers are possible and should be considered.

Local procedures should be in place to assist disabled applicants to obtain planning permission quickly and to resolve problems with planning permission where these arise.

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From the scoping exercise it can be reported that service users/carers are involved in determining the processes and or priorities for service provision in 45.8% of local authorities.

87.5% of local authorities had service user/carer feedback systems but there was little evidence that feedback questionnaires are part of a robust service improvement cycle linked to performance.

Although all stakeholders referred to ensuring staff are trained in person centred care there was limited evidence of systematic measurement tools in operation for quality of life outcomes. This is an area for service improvement and services will be required to move away from traditional methods of measuring throughput to focus on measures related to process and outcomes at an individual service user level. This will require stakeholders to develop real outcome measures that include quality and experience.

People who require major adaptations on the grounds of disability should be placed at the centre of service provision and service outcomes should be user focused. Performance management systems should evidence and reflect this shift.

All technical specifications/drawings should be shared with the disabled person (if appropriate their carer/s) and the OT prior to sign off. This will ensure that the person can make an informed consent on the adequacy of the proposed provision in accordance with their needs and aspirations.

Decision making should be transparent and shared with service users so that they are empowered to be in control of their own lives. Partnerships should ensure that they give disabled people and their carer's sufficient information to be able to make informed choices on the best solutions that are available for them and also to understand why it is sometimes not technically feasible or cost effective to carry out an adaptation.

Local authorities should also allow individuals to use the funding that is available flexibly towards an increased specification if they wish to contribute additional money. The only consideration in agreeing this type of request should be that the finished work safely meets the assessed needs of the disabled person.

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Training needs should be identified and resourced for inter-agency stakeholders to collaborate well together. All stakeholders should have access to integrated performance information about demand, throughput and outcomes to influence effective service delivery.

This scoping exercise highlighted that there is a need to establish a network for peer review, evidence sharing and good practice. It is recommended that a community of practice model is adopted for adaptations.

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Key Findings from this exercise highlighted where changes to existing procedures would bring consistency, equity and place service user focused outcomes at the centre of timeous adaptation service provision. The resulting recommendations from the analysis of data and questionnaires will be used to inform the development of a Good Practice Guide for the Provision of Major Adaptations that supports and informs the simplification of processes for access and provision of adaptations.

The result of the analysis of information gathered during the scoping exercise has established that there is an identified a need to improve adaptation services in 4 main areas:

• Strategic overview of Adaptation Services across tenures.
• Improved information for service users to make informed choices and exercise self management where appropriate.
• Improved interface across services to ensure an integrated care pathway for adaptations from assessment to provision.
• Improved service user focused outcomes and a robust system of performance monitoring.

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