A Joint Strategic Approach to Supporting People to Live Independently in Devon 2020 to 2025

Executive Summary

This strategy describes our vision for giving people a true choice in where they live.

It sets out how we will work in partnership to increase the range of housing and accommodation for all adults, including older people and young people approaching adulthood who receive or may receive health and care support during their lives to sustain and/or maximise their capacity for independent living.

It has been developed by Devon County Council and Devon’s Clinical Commissioning Group, in consultation with a range of partners. It is for the Devon County Council area.

The strategy includes all the types of homes that people might live in, temporarily or permanently during their lives; with mainstream housing at one end of a spectrum of intensity of support, housing with some levels of care and support in the middle and residential and nursing care at the highest end.

Introduction

A home is a critical foundation in all our lives, physically and psychologically, and is our primary location of care and support. Good quality housing and accommodation in the right place contributes to good health and wellbeing and cohesive communities. It opens up opportunities for people to live the independent life that is right for them.

Across Devon, accessible and quality housing options that support people with a range of needs to live in the community are limited. This includes adults of working age with mental health needs and/or disabilities[i], young people with health and care needs who are approaching adulthood, and older people with increasing frailties.

People tell us that they want more options in communities to help them to live with and/or be supported by their family and friends in their own homes. They want information to help them and their families/carers to plan for the future. People’s views have informed this strategy[ii] and we will continue to listen to and actively involve people in planning, shaping and reviewing support.

This strategy sets out our vision for giving people a true choice in where they live. It sets out how we will work in partnership to increase the range of housing and accommodation for people who receive or may receive adult health and care support during their lives to sustain and/or maximise their capacity for independent living.

To achieve the ambitions within this strategy, we will continue to develop effective partnerships with District Councils, the wider health and care system, the voluntary, community and independent sector, housing and care providers and people. The strategy aligns with national and local approaches across Devon and will fulfil the priorities in our Transforming Care Partnership Housing Plan[iii]. This strategy will inform planning in localities. It will be regularly reviewed and informed by future developments.

In this strategy, housing and accommodation means all types of homes that people who receive or may receive adult health and care support during their lives might live in, temporarily or permanently. It includes mainstream housing at one end of a spectrum of intensity of support, housing with variable levels of care and support in the middle and residential/nursing care at the highest end[iv].

[i] People with a learning disability, physical disability, autism and/or sensory needs.
[ii] Detailed feedback is set out in Appendix A.
[iii] Devon Transforming Care Partnership Housing Plan for people with complex needs.
[iv] Detailed definitions are set out in Appendix B.

Our vision

Our vision is for more people to live in their own homes in Devon and make informed and planned choices about where they live throughout their lives.

We want local people to drive the delivery of care, and health and wellbeing in communities across Devon so that people feel safe, healthy, connected and able to help themselves and each other.

People’s care and support needs change over time and so might the housing and accommodation that they choose to support them to live as independently as possible. We will increase the range of good quality homes across Devon and make it easier for people to remain in their current home or to move between different housing options to develop their independence. We will shift away from traditional residential care models.

Our housing pathway will inform local plans, offer real choice for people and ensure that moves are planned and appropriate. No person will move straight from their home on a long-term basis at a point of crisis or when discharged from hospital. We will promote the use of Technology Enabled Care and Support (TECS) and encourage appropriate infrastructure to promote self-care.

Wider health, care and housing context

This strategy sits within the overarching context of the Sustainability and Transformation Partnership (STP) for Devon. This includes the Care Act 2014, Devon County Council’s Promoting Independence Policy[i], Devon’s Sustainability and Transformation Partnership[ii], Transforming Care Partnership [iii], Joint Commissioning strategies, Market Position Statements, and Better for You, Better for Devon long term plan (currently in development).

The strategy aligns with District Council housing strategies and plans. It supports Healthy and Happy Communities, Devon’s Joint Health and Wellbeing Strategy 2020-2025, and the ‘healthy, safe, strong and sustainable communities’ priority on creating conditions for good health and wellbeing where we live, work and learn. The outcomes in this priority are to improve housing conditions, reduce homelessness and increase supply of appropriate housing; and create conditions for good health, physical activity and social interaction.

The Devon STP is working towards an Integrated Care System; to achieve equal chances for people living in Devon, Plymouth and Torbay to lead long healthy lives and to harness the value of partners tackling problems together. It will focus on creating the right social, economic, commercial and environmental conditions for health; access to homes that are safe, warm and stable, quality work and workplaces and reduce social isolation by establishing thriving communities for all.

The housing and accommodation strategy supports wider work to address health inequalities of people in Devon and sets out a more proactive approach to local partnership working to develop sustainable services for the future. There is much work already being delivered through local partnerships (for example through the Devon Safeguarding Adults Partnership) and real value in health, care and housing organisations working closely together locally.
[i] Promoting Independence Policy.
[ii] Sustainability and Transformation Plan 2016.
[iii] Source: Devon Transforming Care Partnership (2018). Devon TCP/learning disability/mental health housing plan 2018/19-2020/21

Where we are now

Housing is complex and there is no single organisation in control of housing or planning across Devon. Devon is a two-tier authority, with District Councils having responsibility for housing. Whilst housing policy is determined by central and local government, most housing and accommodation is delivered by the private sector operating in a market that is sensitive to macro-economic forces and changes in resources. This strategy needs to be sensitive to the fact that there is a market in provision and support people to make informed choices at the right time for them.

A rapidly expanding population and complexity of need

People are living longer in Devon with more complex needs. This includes young people moving into adulthood, people with disabilities living longer than their parents/carers and people over the age of 90 with increasing frailties. The table below shows the projected population in Devon to 2039 for all age groups.

In Devon, we have a rapidly expanding older population and a range of housing and accommodation that is at or near capacity. There are currently 200,271 people in the County who are over age 65. 3.4% of these live in care homes, increasing to 15.2% for over 85s.

According to the latest Census (2011), 38,626 people living in the county aged 18 to 64 have a disability. 78.6% of people with a learning disability live in their own home or with their family in Devon (compared to 77.4% England average) and 13.7% of people aged 18-64 in receipt of long term services with a disability were living in a care homes.

There are approximately 84,292 people aged 18-64 living in Devon who have a common mental health disorder. 61% of people who are in contact with mental health services on a Care Programme Approach live at home in Devon, compared to 58% England average. 11.7% of people receiving adult social care services live in care homes.

There are also increasing numbers of young people with disabilities and mental health needs who need to be supported as adults to live as independently as possible throughout their lives. Young people and their families/carers regularly tell us that their experience of transition from children to adult services could be improved.

Shortage of a range of housing and accommodation in the community

Across Devon, accessible housing and accommodation options that support people to live in the community are limited. Unsuitable and poor-quality housing can lead to an increase in people’s needs and reliance on statutory services. Without better housing in the communities in which people belong, the choice can lie between getting by in an unsuitable home or uprooting to an institutional home, often removed from familiar surroundings.

Barriers to housing and the indoor environment are a challenge for certain parts of Devon based on the Indices of Deprivation[ii]. The Living Environment is split into two sub-domains; indoors- quality of housing, and outdoors- measures of air quality and road traffic accidents. The maps show significantly higher levels of deprivation within the indoor sub-domain (quality of housing) and low levels of deprivation relating to the outdoor sub-domain (air quality and road traffic accidents).

1 in 8 Devon households are considered to experience fuel poverty and there are a number of small rural communities across Devon[iii]. More homes need to be built or adapted with the specific needs of people with disabilities, complex needs, people who engage in substance misuse, or older people with increasing frailty in mind.

There is limited flexibility within Supported Living, Extra Care Housing and Shared Lives schemes to meet people’s changing needs as they progress towards independence or as their independence reduces. Most Supported Living settings in Devon are multi-occupancy buildings with 24-hour care. Their location often reduces choice for people to remain close to their families and/or local connections, and if people do not want to share accommodation, there are limited community-based options.

Moves to residential and/or nursing care are usually triggered by a crisis, and even where they are planned, they are constrained by location, availability and tenure. People may be accommodated in care homes when they have the potential to live in less dependent settings. There are also not enough nursing homes to support older people with dementia.

Limited leverage in the market to develop supply and ensure fair price of care

Current provision is comprised of a mix of spot purchase and block contract arrangements with inconsistencies in contract terms and service provision being offered. There are limited ways to contract with new providers to the market and historic arrangements with no common monitoring or performance oversight. It is difficult to track spend and forecast need, and there is limited leverage in the housing market to ensure a fair price of care.

Housing and accommodation pathway not understood or used

Operational teams and housing providers tell us that the housing and accommodation pathway is not clear and is therefore not used. Alongside this, the housing and accommodation offer in Devon is often focused on age rather than need, which limits choice. Extra Care Housing is almost exclusively used for older people, with Supported Living and Shared Lives schemes aimed at working age adults.

People do not plan for independent living

Many people, including people with disabilities or long-term ill-health and their family/carers, make no plans for their future housing and accommodation needs. This can mean that people are admitted into care homes at a point of crisis when an earlier opportunity for more independent living might have been possible

Lack of collaboration at a local level to inform new developments

New homes and adaptations to existing homes offer opportunities to encourage healthier lifestyles, greater independence and access to community facilities. However, collaborative action is limited by gaps in understanding across health, care and housing organisations, meaning opportunities are missed. Local planners and providers tell us that they want to understand the types of housing and accommodation required to inform provision. We need to improve local collaboration, including through the Market Position Statement.

Working together to address homelessness

Homelessness is a significant issue in Devon, with average earnings below the national average and house prices over the national average. Nationally, Exeter has the 9th highest volume of rough sleepers and North Devon is in the top 50 areas with the highest rough sleeping[i]. Bringing together local resources has supported homeless people to recover their independence. We need to build on this and ensure that commissioning arrangements are informed by a local understanding of why people are homeless.

[i] Ministry of Housing, Communities and Local Government (2017) Rough sleeping in England: autumn 2016

Difficult to recruit health and care workers

Across Devon, it is difficult to recruit health and care workers to support people in housing and accommodation settings. The adult social care workforce is growing and has increased by 6% in the South West region since 2012. If the workforce grows proportionally to the projected number of people aged 65 and over, by 2035, in Devon it is estimated that approximately 30,000 care workers will be needed. This is more than double the current number of care workers in Devon which is approximately 13,500.

What we will do to achieve our vision

We will develop a clear housing pathway for people, communities, housing planners, providers and the wider health and care system. It will inform local plans, offer real choice and ensure that moves are planned, appropriate and support people to live as independently as possible.

Our approach will be multi-faceted and flexible as people’s needs and contexts change over the course of their lives. It will be based on how needs and goals can best be supported, rather than by age. It will also adhere to the principles of ‘Building the right support for people with a learning disability and/or autism who display behaviours that challenge’.

Working in partnership, we will work to ensure that people have timely access to information about their housing and accommodation needs. This includes current housing advice and support and reviews of a person’s care or support needs, including young people transitioning to adulthood.

To achieve our strategic intent and develop the housing and accommodation pathway, priority areas of focus are set out in the table below and described in more detail within this section of the strategy. They are supported by a detailed action plan.

Priorities

1. Build joint understanding of market towns and localities to inform development and increase opportunities for independent living.
2. Increase the supply of accessible homes through new developments or adaptations to existing homes.
3. Develop the housing market so that housing with support settings are more flexible, support a wider range of needs and a fair price of care.
4. Develop residential and nursing homes for people with only the most complex health and care needs and frailties.
5. Support recruitment and retention of the workforce through access to housing.

Priority One: Build joint understanding of market towns and localities to inform development and increase opportunities for independent living.

We will support communities and providers to have a shared knowledge of local housing and accommodation supply and demand, alongside other opportunities to support people to live independently. We will work together at a local level towards shared goals to develop the range of independent living and improve outcomes for people, such as social isolation and confidence to self-manage health needs.

To get there we will:

• Improve local information and data sharing across health, care and housing to understand how people are currently living in localities and the types of homes they want to live in, to shape future provision to help people achieve what matters to them. This includes supporting District Councils as they refresh their housing strategies.
• Be clear with housing planners and providers about the types of homes we need and where, including through the Market Position Statement.
• Improve information for people and their families/carers about how (with or without social care support) they can access housing and accommodation, information on understanding tenancies and negotiating splits of utility bills, etc.
• Create three designated housing leads whose role is to coordinate and share knowledge on housing, health and care across Devon.

Priority Two: Increase the supply of accessible homes through new developments or adaptations to existing homes.

We will increase the supply of general housing (new and existing stock) through improved health, care and housing collaboration at a local level, with District Councils, to share information, develop plans and deliver actions. New housing and community developments are ideal opportunities to create inclusive neighbourhoods that are accessible for all people.

To get there we will:

Through active involvement in the preparation of local housing plans we will:

• ensure that local assessments of housing need include the needs of people who require health and care support;
•  shape planning requirements for new developments and housing policies to provide more homes that meet accessibility standards;
• support Local Planning Authorities to ensure the built environment meets health and care needs and enables access to community facilities;
• encourage all new builds to be fitted with appropriate infrastructure to enable TECS to be easily incorporated within the home;
•  describe our requirements as part of negotiated agreements (section 106 agreements) between planners/developers to stimulate development of housing; and
• ensure planning applications for new developments are consistent with our strategic intentions and understood levels of need.
• Align work in communities with Primary Care Networks so people have access to a far broader range of alternatives to statutory interventions where appropriate.
• Promote the use of adaptations and technology enabled care and support (TECS) and home improvements.
• Make existing homes more adaptable, including through the Disabled Facilities Grant, sheltered, private, and rented accommodation, floating support arrangements and keyring schemes.
• Identify people whose health and or independence is at risk due to poor housing to target multi-agency support, including where appropriate, supporting a move to more suitable accommodation.
• Support multi-agency arrangements that address homelessness prevention and offer support with the additional challenges faced.

Priority Three: Develop the housing market so that housing with support settings are more flexible, support a wider range of needs and a fair price of care.

Develop Supported Living, Extra Care Housing and Shared Lives schemes, as part of the housing pathway, to be more flexible in the range of needs that they can support, support achievement of outcomes and be part of the community. Our approach will be informed by learning from supporting people in the Transforming Care Partnership cohort from hospital settings to greater independence within local communities.

To get there we will:

• Develop and implement a new ‘housing with support’ contracting framework to support people with a range of needs, achieve personalised outcomes (including use of TECS), ensure quality and be located in the right place.
• Create leverage in the market to ensure a fair price of care through a fairer pricing policy.
• Where we are unable to resolve pricing discussions, we will develop options to change the provider and consider direct care provision in this sector for people with complex needs.
• Develop options for where people want to share support that are not based within a house/building. For example, hub and spoke and ‘on call’ support.
• Progress a more flexible Shared Lives schemes offer to support people with high levels of needs as short-term respite and alternative to residential care, or to develop independent living skills.
• Work earlier with young people to understand needs and jointly commission housing that is part of the community to support their progression and prevent transition to residential care.
• Develop enhanced provider engagement and contract management infrastructure in localities to support our strategic approach.
• Develop short-term provision for people to avoid residential care placements at a time of crisis.
• Work across the STP to develop good quality housing and accommodation to support people with complex needs in communities (including through the Transforming Care Partnership and in accordance with NICE guidelines).
• Stimulate the development of and commission effective models of Supported Living, including Extra Care Housing, in areas where people want to live.

Priority Four: Develop residential and nursing homes for people with only the most complex health and care needs and frailties.

Whilst our aim is for people to live in their own homes, there will always be a need for some residential and nursing care for people with complex and/or intensive health and care needs[i]. We will encourage the development of residential and nursing homes in Devon that deliver high quality care for these people.

[i] NHSE (2016). Enhanced Health in care homes frameworks

To get there we will:

• Ensure residential and nursing homes deliver quality person-centred care to meet the needs of people with behaviours that challenge, with advanced dementia and those that are at the end of life.
• Work more closely with care homes to prevent admission to hospital and work with the acute hospitals to find appropriate settings for people on discharge from hospital.
•  Increase cost transparency and improve quality of care homes through our contracting vehicles.
•  Ensure high quality and safe care through robust contract management.
•  Support care homes, where appropriate, to develop a more community-based offer.
•  Work with people currently living in care homes who have the potential to live more independently, to consider alternative housing and accommodation that is based in the community and will better support them to achieve their goals.

Priority Five: Support recruitment and retention of the workforce through access to housing.

We will continue work with housing planners and providers to support potential health and care workers to be able to live and work in Devon, to improve recruitment and retention of this valuable workforce.

To get there we will:

• Explore with District Councils, through their housing and planning approaches, the options to widen access to affordable housing for health and social care workers where there is a relevant need.
• Work with partners to promote and target local and national schemes.
• Explore approaches in other Local Authorities and Health Care Trusts to understand good practice and initiatives.

How we will know if we have been successful

This strategy will be reviewed every year to understand the impact of our approach and to reframe plans accordingly. Our approach will evolve over time and we will continue to listen to the views of people and their families/carers as we progress to inform our work.

The impact measures, through which we will understand our impact, include:

• % of people who are in residential and/or nursing care
• % of people living independently (either in housing with care or mainstream housing
• Proportion of people who say that they feel safe and connected in their communities
• % of people who report good social contact
• Satisfaction of people and their families/carer
• Number of people who use adaptions/TECS to enable them to remain in their own home
• % new build properties constructed to M4(2) and M4(3b) standards
• Number of people waiting for Extra Care Housing

Appendix A: Learnings from people and their families / carers

We regularly listen to people with disabilities (learning disabilities, physical disabilities, sensory needs and/or autism) and older people. Their feedback is summarised below and informed this strategy. We will continue to listen to people and understand the impact of our approach.

Here is what people told us:

“I was able to choose where I live and I like living in Crediton”

“I want to know what options my son has to make the move to live independently”

I like living with people my own age”

“We don’t talk early enough for planning when parents die, it’s important to talk about options early on”

“It is not accessible and difficult to get what I need from the District Councils”

“I want a better house that is not cold and damp, I had to spend two night in a Premier Inn as the conditions are so poor”

“I am worried about whether my grown up child can live by themselves. I worry that they will be vulnerable”

“When my dad ended up in a Care Home due to his dementia, I wish I had known if there were alternative housing options such as supported living or extra care housing”

“Why do you have to be separated from your loved one? We have been married for 52 years and want to remain living together”

“If my parents had been given the support they needed in their own home after leaving hospital, I don’t think dad would have ended up in a care home”

“I want you to use the language that helps us accept help, you package everything as packages of care, support would have helped us”

I often do not have the same freedom, choice, dignity and control as other people at home.

I do not feel that I have been given a choice about where I could live or how I am supported. I want to understand how the location of where I live affects my access to transport, support networks and work so I can make informed choices.

I want transparency over money so I can get involved in choosing where I live and how I am supported.

I want to live with other people and to know these people well, for example, friends or a partner. I would like to live in a house, in a quiet area and with a garden. I would like the choice to have pets. I don’t always want to share the same living space with others.

I want my views and aspirations to be considered when decisions are made in my local area. I want to know whether my local area is doing as well as others.

I want to know how to connect with other people. I want the everyday services that I come into contact with to know how to make reasonable adjustments to include me and accept me as I am.

I want to be safe in my community and free from the risk of discrimination, hate crime and abuse.

I want autism to be included in local strategic needs assessments so that person centred local health, care and support services, based on good information about local needs, is available for people with autism.

I want to know that my family can get help and support when they need it.

I want to be supported through big life changes such as transition from school, getting older or when a person close to me dies. I need information about how housing changes at different stages in my life so I can plan.

Appendix B: Glossary

Type	Definition
Mainstream housing (or general needs housing)	Includes (privately owned or rented) general housing with no specialised features. Housing can be adapted homes to meet the needs of residents or designed to meet access and adaptability standards for people.
Age exclusive housing	Schemes or developments that cater exclusively for older people and may have communal facilities but do not provide any regular on-site support to residents.
Sheltered Housing (specialist housing)	Developments of self-contained homes, with support available via a full or part time manager whose job includes providing support and advice to residents. This enables residents to continue to live independently. Properties may be purchased or rented.
Extra Care Housing (specialist housing)	Developments that comprise self-contained homes with on-site care and support who can provide personal care and support to meet resident’s needs. Residents may be owners, part owners or tenants.  The homes have been designed with features and services available to enable self-care and independent living. Can be called housing with care.
Supported Living (or housing with care)	Arrangement whereby someone who has support from a “Care and Support” provider who already has or wants their own tenancy, is helped to live as independently and safely as possible. People who live in Supported Living arrangements can live in different settings:   ·        With other people with similar needs but have their own tenancy agreement and bedroom.  This provides both independence and companionships. ·        In their own in flat / house or bungalow, with their own tenancy but in close proximity to other people with similar needs. “Care and Support” providers visit to help residents live as independently and safely as possible.
Shared Lives schemes (within a family environment/ carer households)	The schemes (from age 16) match someone who needs care with an approved carer. The carer shares their family and community life and gives care and support to the person with care needs. Some people move in with their Shared Lives carer, while others are regular daytime visitors. Some combine daytime and overnight visits.   This offer supports people to be introduced to higher levels of independence, whilst remaining in a safe and protective family environment.
Residential Care Homes	Provides living accommodation and personal care for people who may not be able to live independently but aren’t yet in need of nursing care. Staff are available 24 hours a day, 7 days a week.
Nursing Care Homes	A nursing home, as distinct from a residential care home, provides medical care from a qualified nurse who is on site 24 hours a day 7 days a week.

Appendix C: References

[1] People with a learning disability, physical disability, autism and/or sensory needs.

[1] Detailed feedback is set out in Appendix A.

[1] Devon Transforming Care Partnership Housing Plan for people with complex needs.

[1] Detailed definitions are set out in Appendix B.

[1] Promoting Independence Policy

[1] Sustainability and Transformation Plan 2016

[1] Source: Devon Transforming Care Partnership (2018). Devon TCP/learning disability/mental health housing plan 2018/19-2020/21

[1] Kingstone et al., (2017) Is late-life dependency increasing or not? A comparison of the Cognitive Function and Ageing Studies (CFAS). The Lancet, 390(10102), pp.1676-1684; Public Health England (2017). Improving health through the home.

[1] Source: ASCOF 1G 2018/19

[1] Source: Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2014 (2016), NHS Digital

[1] Source: ASCOF 1H 2018-19.

[1] Public Health Directorate NHS Devon (2011). ‘Housing Health Needs Assessment 2011’. Alzheimer’s Society (2016). Factsheet: risk factors for dementia.

Equality and Human Rights Commissions (2018). Housing and disabled people: Britain’s hidden Crisis.

[1] 2019 The Indices of Deprivation Devon.

[1] Public Health Devon (2018). Joint Strategic Needs Assessment: Devon Overview 2018.

[1] Department for Communities and Local Government (2014). As cited in Government Office for Science (2014) Future of an ageing population:evidence review:. Equality and Human Rights Commissions (2018). Housing and disabled people: Britain’s hidden Crisis.

[1] Strutt and Parker (2017). Housing Futures: Platinum Generation. Sense (2018) When I’m Gone. Securing long-term care and support for disabled adults.

[1] Alzheimer’s Society 2009 -YouGov Poll for Alzheimer’s Society March 2013; Holland, C et al., (2015) Collaborative Research between Aston Research Centre for Healthy Ageing (ARCHA) and the Extra Care Charitable Trust, J and Provenzano, P. (2017) Six Steps to Managing Demand in Adult Social Care : A Performance Management Approach. Institute of Public Care. Oxford Brookes University, Oxford.

[1] Ministry of Housing, Communities and Local Government (2017) Rough sleeping in England: autumn 2016

[1] NHSE (2016). Enhanced Health in care homes frameworks