Adult Social Care Assessment & care management In-house care services

Adult Social Care Assessment & care management In-house care services Service Plan 2015/16 Date 19/03/15 Final Directorate: Education Health and Social Care

1. Introduction Policy Context The Adult Social care Service helps to deliver the Council s strategic themes of Ambitious Cornwall, Partners working together, Healthier and safe communities & Being efficient, effective and innovative This is in the context of a significant National policy focus on integration with Health, including the Better Care Fund a new pooled budget for Cornwall of c. 46m in 15/16 & the locally agreed Living Well Blueprint for integrated care communities. Adult Social Care is subject to major policy change in 2015 and again in 2016 with the implementation of the Care Act, the most major legislative change for adult social care since the advent of community care. Part 1 of Care Act takes effect from April 2015. It requires significant changes in practice and carries significant delivery and financial risks. Local Picture All of this change is also in the context of changing need and demand for adult social care in Cornwall. Our demographics show a growing ageing population but there are significant inequalities in life expectancy between the richest and poorest in Cornwall. There are a growing number of people who are carers for family, friends and neighbours. People with some of the most complex disabilities are living longer. In general, people expect greater choice and control over how their care needs are met. At the same time resources for publically funded care services are scarce and the changing demographic position in Cornwall and improving economic position brings issues about a shrinking labour market to provide care workers. More work is needed to map needs and model demand for care services in Cornwall and this will be part of Public health s work as they update the Joint Strategic Needs Assessment and establish a new health & Wellbeing strategy for Cornwall. Adult Social Care in Cornwall started a service improvement journey in 2014/15 but there is still more to do. The latest position was reported to Scrutiny in January 2015 and the next phase of improvement activity is summarised in the objectives in this service plan. The service is still working through new management structures to be completed later in 2015. This service plan cannot be seen in isolation and links with 3 other service plans within EH&SC Directorate: o Children s Early Help, Psychology and Social Care for overview of strategic approach to adult safeguarding

o Commissioning, Performance and Improvement for adult social care commissioning priorities o Public health for work on prevention and strategic needs analysis, understanding of demand and evidence of effective interventions in support of adult social care commissioning 2. Purpose of the service plan The service plan outlines the outcomes to be delivered by both the assessment and care management service and the Council s in-house direct care delivery services that fall under the line management of the Head of Service. The plan clarifies the contribution and action required in the assessment and care management and in-house provider services areas to achieve the overall plans of 14.058m of savings in Adult social Care in 2015/16, as agreed in the Medium Term Financial Strategy. Over the next 12 month our key priority from the business plan will be: Corporate Business Plan EHSC Outcome 2: We will be achieving public health aims through a personalised care system in Adult Social Care. The below table details how ASC outcomes link to the Council Strategy: ASC Outcomes for 15/16 Ambitious Cornwall (hyperlink) 1 Engaging with our Communities (hyperlink) Partners working together (hyperlink) Greater access to essentials for living (hyperlink) 1 4 Driving the economy (hyperlink) Stewardship of Cornwall s assets (hyperlink) Healthier and safe Communities (hyperlink) Being efficient, effective, innovative (hyperlink) 1 2 3 4 5 6 7 8 9 1 2 3 5 6 7

8 9

3. Overall approach to how we will deliver a) Assessment & care management Adult Social Care is a statutory responsibility for the Council which importantly includes activity to safeguard vulnerable adults. It covers both assessment and care management responsibilities, which focus on individual members of the public, and the commissioning of activity and services to meet needs and to help manage demand for care, at an individual level and by looking at current and future needs in the wider population. The service receives approximately 48,000 contacts from the public each year through our Access Service. The service supports approximately 8,000 adults on an ongoing basis and approximately 2,000 carers. Our future model for adult social care is captured in the Living Well blueprint for integrated care communities.support for carers is threaded through the model. There is a strong focus on managing demand for care to help slow growth and avoid or delay the point at which someone may need long-term care and support. Our strategic approach to adult social care is themed as follows: - Prevention - Promoting easy access to information and advice - Promoting community inclusion and employment to improve independence and reduce social isolation - Ensuring effective reablement and crisis response, helping to avoid admission to hospital or a care home and to support timely hospital discharge enabling people to recover the maximum degree of independence possible - Delivering personalised long-term care and support with an emphasis on direct payments, housing solutions and helping people to stay in their own homes for as long as possible - Ensuring good quality end of life care with an emphasis on choice Our vision is for services that are: - Joined up between health and care - Where information about individual s needs is readily accessible so that people only tell their story once - Where the services available are tailored to people s needs and accessible seven days a week The assessment and care management function covers a number of statutory responsibilities, including undertaking Section 47 assessments of need and then supporting individuals in need and their carer/s by planning care that responds to any unmet eligible needs. The Council currently sets its eligibility threshold at

the level of meeting substantial and critical needs. A new national eligibility threshold is being introduced as part of the Care Act from April 2015. The service leads on safeguarding vulnerable adults. It also carries specific legal responsibilities in relation to Mental Health (largely delegated to Cornwall Partnership Foundation Trust (CPFT) via Council staff seconded to the organisation) and in relation to the Mental Capacity Act, including Deprivations of Liberty. Other important functions include assessment action and care planning in respect of avoiding admissions to and preventing delayed transfers of care from acute and community hospitals. The legislation that applies to Adult Social Care has been updated via the Care Act 2014. Work to deliver service improvement is being undertaken in that context and in preparation for new duties under the Act which come in to force from April 2015 and further responsibilities scheduled for April 2016. The integration of health and social care is an important theme running through the Act. The Act aims to strengthen a personalised approach to Adult Social Care that emphasises choice, control and promotes prevention, inclusion and wellbeing beyond social care. Approximately 120 full time equivalent assessment and care management staff are outposted to other organisations in Cornwall. This includes staff seconded to Cornwall Partnership Foundation Trust (CPFT) as highlighted above, staff seconded to Peninsula Community Health (PCH) (including those who provide the assessment and care management service in support of the discharge process from acute hospitals in Cornwall and Devon) and Occupational Therapy staff who are seconded to the integrated therapy team in PCH. Gaps in strategic commissioning in the past have meant that some of these arrangements have lacked clarity of purpose and some of the necessary governance controls are missing. As a result, practice standards, policy and policy changes were not implemented consistently. In some service areas significant delays in assessment handovers led to some clients receiving care packages they were not entitled to and major loss of income. This has largely been addressed in 2014/15 but the next phase of work on the management and staffing structure for assessment and care management will continue to resolve the problems. An interim management team was established in 14/15 and work implemented to support service improvements. Early action was taken to change line management reporting, grouping Adult Social Care services by function rather than care group to enable a consistent approach assessment and care management, in-house direct care delivery and strategic commissioning. The next step is to finalise a new management and staffing structure for assessment and care management, working on a locality basis, that helps to deliver the vision for integrated care communities.

There are still a number of areas of significant risk within the service as it currently operates. These include workforce gaps (particularly re a high number of vacancies for qualified social workers) which have impacted on the timeliness of assessments and completion of care planning work and the timeliness of work on adult safeguarding. Other risks include some remaining gaps in financial controls, information governance including poor data quality and inconsistent approaches to quality assurance and performance management. In order to focus on managing risk appropriately, the service is developing a new risk register and the main strategic risks are being added to the Directorate and Corporate Risk Registers. Activity to manage and reduce those risks is built in to this service plan. b) In-house direct care delivery The Council is still involved in direct delivery of a range of care services including: 16 Day centres STEPS reablement service 5 residential respite care homes The Community equipment service & Tremorvah industries A supported employment service During 14/15 temporary management arrangements were put in place to bring all of the provision, regardless of care group, under single leadership. This is working well to date as it enables an overview of all of the services. Our aim is to continue to improve the efficiency and effectiveness of the inhouse provision. Key areas of work in 2015/16 include: reviewing and restructuring management arrangements maintaining relevant registration with CQC for STEPS and residential respite, ensuring compliance with all care standards work to complete a set of quality assurance measures with common standards set and monitored for services, regardless of care group working with commissioners, continue modernisation of provision ensuring it fits with the overall model for adult social care Workforce challenges for in-house care services to address include achieving retention and recruitment of staff in a care labour market with low unemployement, that is increasingly competitive and where, as Cornwall s

economy grows, the number of job choices at the lower end of the wage scale are increasing. c) Financial position The service is a major part of the Council s annual revenue expenditure at 132.7m net per annum. Adult Social Care is means tested and charges apply. The contribution to meeting care costs through charges is 20.7m per annum. Income from the NHS through budget transfers and pooled budget arrangements contributes 63.1m per annum. A new pooled budget of nearly 50m in 15/16 is being created from existing funding as a result of the national Better Care Fund policy. One of the new initiatives that the fund will cover is the creation of a pooled budget approach to meeting the needs of some of our most complex clients who are currently funded in part by ASC and in part by the CCG. The financial information provided in Appendix 1 is an indicative budget position that was reflected within the November 2014 corporate budget report. There is now a need to review and realign the detailed budgets to the new directorate service areas, this will follow the initial Service Plan and has already started to ensure accurate budget setting and clarity on savings to be made in 15/16. See Appendix 1

4. What are we going to do? Outcome: 1. Improve timely access for the public to assessment and care management services including safeguarding adults Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: To establish a new locality-based structure for assessment and care management teams. This will provide the first step in aligning with NHS community health services and Primary Care to realise the vision of integrated care teams. Helps to deliver strategic themes of Ambitious Cornwall, Partners working together, Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes We will have an efficient and effective workforce and We will be achieving public health aims through a personalised care system in Adult Social Care Starts to put in to practice the Living Well Blueprint for integrated care communities MTFS saving CIA being developed Proposal for Phase 1 vision and management arrangements complete by end March 2015, to include clarity of approach to safeguarding across community teams Proposal for Phase 2 team structure complete by May 2015 Phase 1 implemented by July 2015 Phase 2 implemented by September 2015 Implement revised plans for sharing care records as part of Better Care Fund objectives for interoperability of client information systems Pressure on teams currently is leading to high numbers of people on waiting lists - mitigate through restructure Failure to structure staffing in a more effective way risks harm to the public through service failure and harm to staff through excessive workloads, high sickness absence mitigate through restructure

Measures Risk to service continuity from change programme - mitigate by use of change management tools No of people waiting for assessment No of people receiving a review Local targets and safeguarding performance measures

4. What are we going to do? Outcome: 2. An efficient and effective assessment and care management workforce that delivers confidently for the public Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: To put in place policies and processes which enable strong retention and recruitment of adult social care staff, particularly Social Workers, AMHPs and Occupational Therapists ( NB Links with Outcome 1 above on restructure of community teams) Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes of We will have an efficient and effective workforce and We will be achieving public health aims through a personalised care system in Adult Social Care CIA under development linked to outcome 1 above Cross reference with actions in Children s early help, Psychology and Social Care Services Service Plan for work on qualification and career pathway for Social Workers and AMHPs Continue current work on a rolling recruitment programme for social workers including new microsite etc. Evaluate impact of measures taken by Mrch 2016 Develop plan for OT recruitment by September 2015 New Quality Assurance and Performance Management system introduced for assessment and care management teams that helps to measure and supports the development of practice by June 2015 High levels of qualified staff vacancies risk poorer quality service to the public and put increasing workload pressure on remaining staff, risking higher turnover and higher sickness absence levels Inconsistent standards of practice between teams and specialist areas risk poorer quality service to the public Measures No of vacancies in establishment for Social Workers, AMHPs and Occupational Therapists, reduce % vacancies

Qualitative - Feedback from exit interviews when practitioners leave the organisation

4. What are we going to do? Outcome: 3. Fewer people delayed unnecessarily in hospital due to waits for assessment by adult social care Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: Measures Reduce reportable delays in discharge from hospitals due to waits for assessment by adult social care Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes We will have moved closer to a joined up public sector for Cornwall by 2016, Our services will be less reliant on the central government grant and We will have an efficient and effective workforce Helps to deliver Better Care Fund objective and contributes to achieving 1m incentive payment for Cornwall Council if reportable delays due to adult social care decrease by 25% in 2015/16 MTFS saving (additional income) Will need to be completed As part of work in Outcome 1, ensure review of efficiency and effectiveness of current staff team supporting acute hospital Mainstream current voluntary rota of additional assessment staff for Saturday and Sunday working to support hospitals and build 7 day cover in to new staffing structures Work with Peninsula Community Health to explore a trusted assessor model to streamline assessment activity for patients in community hospitals Poorer outcomes for individuals if they are delayed unnecessarily, including increased risk of loss of independence and poorer health outcomes mitigate by tackling reportable delays Failure to meet target results in loss of BCF incentive payment and 1m risk to council ASCOF Reportable delays measures Local Pledge Target = Zero reportable delays due to waits for adult social care assessment

4. What are we going to do? Outcome: 4. Implement part 1 of the Care Act so that the public receive assessment and care management services that are legally compliant & prepare for Part 2 Aim: Council Strategy / Business Plan or other priority? To ensure adult social care s assessment and care management function is compliant with the must do s in Part 1 of the Care Act and that we prepare for implementing Part 2 from April 2016. Helps to deliver strategic themes of Partners working together & Healthier and safe communities Helps to deliver business plan outcomes of We will have an efficient and effective workforce and We will be achieving public health aims through a personalised care system in Adult Social Care Cross reference to Council s Care Act Implementation plan Comprehensive Impact Assessment (CIA)? Actions / Milestones: Complete Improve information and advice available for the public, enhancing self-service approaches New eligibility criteria and updated approach to support planning Updated policy and practice for safeguarding Extend offer to carers for both assessment and support Ensure deferred payments option offered and available by choice to home-owning self-funders moving in to a care home Improve the promotion of advocacy services to people using assessment services and who are subject to safeguarding Ensure service contributes intelligence to updated quality monitoring system for commissioned care services helping to identify potential provider failure at an earlier stage Continue with work to prepare for Part 2 of Care Act implementation from April 2016 Risks: If services are not Care Act compliant risk of legal action, judicial review and associated costs

Measures Changes in threshold s for service may cause increase in demand beyond that predicted by government modelling, resulting in cost pressures and increasing waiting times for assessment services and care Qualitative continued self-assessment on progress and where possible comparing practice with other LAs e.g case audits to review application of eligibility criteria Monitor activity information to understand impact of change in legislation and to aid reporting to DH about financial impact

4. What are we going to do? Outcome: 5. Increase the number of people in control of their own care and support Aim: Council Strategy / Business Plan or other priority? To extend the coverage of Direct Payments and ensure growth in the number of people in receipt of care and support at home that have a personal budget Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes of We will have moved closer to a joined up public sector for Cornwall by 2016 and We will be achieving public health aims through a personalised care system in Adult Social Care Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: Measures N/A, continues current approach Continue to promote Direct Payments as an option for meeting care needs for all relevant clients and carers at assessment and review Set target for growth in number of clients with mental health needs who are able to benefit from a Direct payment Increase the number of carers benefitting from the 400 carers support grant each year Set target for improving coverage of personal budgets using the revised methodology for calculating the ASCOF indicator as agreed with the Department of Health in 2014/15 Explore option of integrated personal health and care budgets for the clients with complex needs whose care will be jointly funded through the Better Care Fund in 2015/16 ASCOF measures for No of people in receipt of a Direct Payment and No of people in receipt of a personal budget Local measure - No of people in receipt of 400 annual carers support grant

4. What are we going to do? Outcome: 6. Continue to bring adult social care budget under control Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: To further improve financial controls N/A Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcome of We will have an efficient and effective workforce Helps to secure MTFS Cross reference remaining actions from 2014/15 Improvement Plan including: New budget structure Updated scheme of delegation Financial refresher training for all budget managers Audit areas of discretion such as approval of higher levels of personal budgets and direct payments above those indicated by the RAS Risks: Measures Failure to deliver compromises care delivery to the public as more cuts in activity will need to be made quickly in order to bring budget back to balance Financial performance of service budget back in balance

4. What are we going to do? Outcome: 7. Implement new arrangements for Independent Living Fund Aim: Council Strategy / Business Plan or other priority? To implement the Government s changes to ILF which give Cornwall council responsibility to manage the Fund for the 170 service users in receipt of ILF. Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes of We will have moved closer to a joined up public sector for Cornwall by 2016 and We will be achieving public health aims through a personalised care system in Adult Social Care Comprehensive Impact Assessment (CIA)? Actions / Milestones: Will need to be completed Agree approach to involving service users and carers in new arrangements Agree policy and approach to ILF in the light of confirmation of the level of grant to be transferred. ( NB Principle of ring-fencing grant to existing recipients during year of transfer has been agreed as part of 15/16 budget setting) Review, update and communicate approach to charging given changes in how ILF contributions will have to be treated i.e no longer a disability related expenditure Ensure any necessary changes to MOSAIC Review existing ILF clients in Cornwall and update support plans Review financial assessments Set up additional direct payments to the 170 clients concerned Review ongoing arrangements in the light of further national announcements about changes to the level of grant allocation to the Council from 16/17 onwards Risks: High level of uncertainty about amount of grant to be transferred to Council in June 2015 for new arrangements.

Measures High level of uncertainty about future grant allocation Implementing ILF locally changes approach to and treatment of ILF and will mean changes for existing users. Individuals are already anxious about impact and changes risk higher levels of anxiety and impact on outcomes for individuals re established patterns of independent living. Survey ILF users before and after changes to measure impact.

4. What are we going to do? Outcome: 8. Ensure Financial Assessment process is fair, timely and income maximised Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: To further improve financial assessment process to ensure that assessments are fair, timely and that as a consequence customer satisfaction improves, complaints decrease and income is maximised. Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcome of We will have an efficient and effective workforce Helps to secure MTFS Already completed as part of charging policy changes in 2013/14. Will need to be updated as required Review current process end to end to check customer information and communication and efficiency and effectiveness of referrals from ASC to financial assessment service and timeliness to completion of assessment and implementation of charging Failure to deliver compromises care delivery to the public as dissatisfaction will persist and risk of more cuts in activity needing to be made quickly in order to bring budget back to balance Measures Number of complaints about financial assessments reduced by 10% from baseline in 14/15 Income target of a further 460k achieved Financial performance of service budget back in balance

Outcome: 9. Establish new joint funding arrangements for clients with complex needs and work to secure better outcomes for individual service users. Aim: Council Strategy / Business Plan or other priority? To implement the scheme for jointly funded clients with complex needs as part of the 15/16 Better Care Fund. Aim is to secure better outcomes for individuals and better value for money. Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcomes of We will have moved closer to a joined up public sector for Cornwall by 2016 and We will be achieving public health aims through a personalised care system in Adult Social Care Helps to deliver Better Care Fund objective and contributes to achieving 400k risk share payment for Cornwall Council. Comprehensive Impact Assessment (CIA)? Actions / Milestones: Will need to be completed Establish mechanism to involve service users or their advocates and carers in the project Establish new pooled budget within BCF Establish a shared policy for jointly funding and managing clients with complex needs Jointly review the 56 clients working with KCCG Establish existing outcomes Develop new support plans working with service users and carers that improve outcomes and value for money Introduce option of integrated personal health and care budgets as appropriate Risks: Measures Insufficient alternatives to current care arrangements that deliver improved outcomes available. Work closely with commissioning colleagues and providers including third sector throughout project to help mitigate risk Number of people in receipt of an integrated personal budget

Client and carer satisfaction with updated support plans and any changes to care arrangements Achievement of 400k cost improvement target

4. What are we going to do? Outcome: 10. In-house care services management restructure Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? To reduce the costs of the current management structure for our in-house care services by maximising economies of scale of working appropriately across the services not just in current structure divided by care group and service-type. Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcome of We will have an efficient and effective workforce Helps to secure MTFS Will need to be completed Actions / Milestones: Proposal for new structure by May 2015 Risks: Measures Changes implemented by August 2015 New arrangement in place Cost improvement target of 160k achieved

4. What are we going to do? Outcome: 11. In-house care services quality standards Aim: Council Strategy / Business Plan or other priority? Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: Measures Use management changes in Outcome 7 above to help improve consistency and quality of services N/A Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Set new operational standards for in-house care services, working with service users, carers and staff Update service user and carer involvement in service performance monitoring Without service standards services will remain variable and consequent risk to quality of delivery to the public. New service performance measures to include full compliance at all times with CQC registration standards as applicable

4. What are we going to do? Outcome: 12. Improve effectiveness and efficiency of STEPS reablement service Aim: Council Strategy / Business Plan or other priority? To reduce the unit costs of the STEPS service and to increase the number of people benefitting from reablement Helps to deliver strategic themes of Healthier and safe communities & Being efficient, effective and innovative Helps to deliver the business plan outcome of We will have an efficient and effective workforce Objective in Better Care Fund MTFS Comprehensive Impact Assessment (CIA)? Actions / Milestones: Risks: Measures Will need to be completed Work with colleagues in commissioning to review and improve current service arrangements ASCOF measure for reablement

Appendix 1 Financial Plan Adult Care & Support Summary Revised in Year for 14/15 m Growth Areas m Changes to Previous Savings Plans m Savings Plan for 15/16 m Virements m 2015/16 m Learning Disability Services Care Provision 47.216 0.000 0.000 0.000 0.000 47.216 LD Care Management Staffing 3.992 0.000 0.000 (0.003) 0.000 3.989 CaSS (Day Service + In house Respite) 6.145 0.000 0.000 0.000 0.000 6.145 Older People with Physical Disabilities Older People 41.084 0.000 0.000 0.000 0.000 41.084 Physical/Sensory Disabled 13.181 0.000 0.000 0.000 (0.005) 13.176 Older People Physical Disabilities 10.713 0.000 0.000 (0.010) 0.010 10.713 Tremorvah Industries 0.005 0.000 0.000 0.000 (0.005) 0.000 Adult Care & Support Pan Service (13.968) 8.775 11.512 (14.045) 0.000 (7.726) 108.369 8.775 11.512 (14.058) 0.000 114.598

Prepared by: Miriam Maddison Interim Lead Manager Adult Social Care Improvement Adult Social Care 11 June 2015 If you would like this information in another format please contact: Cornwall Council County Hall Treyew Road Truro TR1 3AY Telephone: 0300 1234 100 Email: enquiries@cornwall.gov.uk www.cornwall.gov.uk