Your life, your well-being - A vision and strategy for adult social care 2018 2021 - Kent County Council
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Your life,
your well-being
A vision and strategy for adult social care 2018 - 2021
Kent County Council Adult Social Care and Health
Updated October 2018
Kent County Council Adult Social Care
Foreword
1. Foreword
at a glance
Strategy
Contents By: Graham Gibbens, Cabinet Member for Adult Social Care
and Public Health and Penny Southern, Corporate Director for
Adult Social Care and Health.
1. Foreword 2. Strategy at 3. Introduction 4. Our vision It is well known that as a society we are living
Introduction
a glance and strategic longer and, as a result, an increasing number
approach of people have complex needs and require the Graham Gibbens Penny Southern
to adult support of the health and social care system.
Page 3 Page 4 Page 5 social care This includes increasing numbers of young We are already working with our partners in
people with learning and physical disabilities developing new ways of doing things, with
who are moving from Children’s to Adult the aim of breaking down barriers between
Vision
Page 7 Services and often need high levels of support. organisations when they get in the way of
These developments are happening at the better care and support. This includes the
same time as a continued reduction in funding. NHS, and our vision and strategy is part of the
All the available information shows that this broader process of joining up health and social
reduction in funding is likely to continue. care under the NHS Five Year Forward View
and the development of Local Care, within the
Values
5. Our 6. Promoting 7. Promoting 8. Supporting This document sets out how we are going to Transformation and Sustainability Partnership
values and well-being independence independence respond to the changing environment with a for Kent and Medway.
principles new vision and strategy for adult social care.
It is a vision and strategy that builds on our Working much more closely with the NHS will
well-being
Promoting
past successes but firmly points to the future help to reduce unnecessary admissions to
Page 15 Page 16 Page 20 Page 23 in how we plan to work with our partners to hospital and mean those already in hospital
meet the challenges ahead. Our vision, to put it should be able to go back home as soon as
simply, is to ‘help people to improve or maintain they are ready. People will also be able to
their well-being and to live as independently receive their health and social care from one
independence independence
as possible’. Our strategy sets out the overall community place linked to their GP surgery.
Promoting
direction that we aim to follow in the coming People with more intense and complicated
years to achieve this vision. The aims and ongoing needs will have one professional
principles of the strategy are the basis on how who will lead on co-ordinating their care and
we develop and introduce new ways of doing build a team of support for the person. This
9. Supporting 10. Building 11. Ho we will things in the services we provide or arrange support will include a single assessment (rather
Supporting
carers blocks know we are to be provided. The measure of our success than several from different professionals) and
delivering the will be if we are able to deliver more person- enablement which helps people to become
strategy centred care and support, keep people safe more independent by gaining the ability to
and help people to have reasonable choice move around and do everyday tasks.
Page 27 Page 28 and control. We will make sure that there are
Page 35 enough care and support services available Finally, in designing and developing our
Supporting
working in partnership and make better use of services we will make the best use of 21st
Carers
our resources. century technology, including digital systems,
to share appropriate information between
The new vision and strategy is informed by partners and tools such as telecare and
the Care Act 2014. Under this Act we not telehealth to support those receiving health
This document is aimed at members of the county council, our staff, people who use our services, only have responsibilities towards adults with and social care.
Building
Blocks
carers, the wider public, providers, the voluntary sector, health services, schools and colleges, care and support needs and their carers, but
district councils and other public services. also a broader responsibility to support the The next three years are going to be very
prevention agenda and promote well-being . challenging, but we are committed to doing
This document is available in alternative formats and languages. Please call 03000 421553 This should help prevent some needs arising in all we can to provide the right level of care and
Text relay: 18001 03000 421553 for details or email alternativeformats@kent.gov.uk the first place or delay their development. support to those who need it.
Monitoring
2 Your life, your well-being Your life, your well-being 3
Kent County Council Adult Social Care
Foreword
2. Strategy at a glance 3. Introduction
at a glance
Strategy
What is the purpose of adult
Adult social care is there to support people (adults, young people social care?
Purpose and carers) who need help with daily living so they can live as
Introduction
independently as possible in the place of their choice.
Adult social care is there to support people
who need help with daily living so they can
Adult Social Care must address three gaps: live as independently as possible in the place
of their choice, within the resources available.
Context Efficiency and finance The care and support that adult social care
Vision
Quality of care commissions (arranges or provides) is based
Outcomes and well-being. on needs assessments of adults (including
carers and young people during transition)
who are supported using public money
Strategic outcomes or pay for their own services. The Adult
from our Strategic Strategic outcome 3: Older and vulnerable residents are safe and Social Care and Health Directorate also
Values
Statement supported with choices to live independently. holds delegated responsibilities for disabled
children’s services to provide statutory
functions for children and young people.
well-being
Promoting
Keeping people safe is an important part of
To help people to improve or maintain their well-being and live as the legal obligations we must meet, and we
Our vision for
independently as possible. take this very seriously.
adult social care
The main responsibilities of adult social care
independence independence
are set out in three main pieces of legislation;
Promoting
Over the last 10 years we have been the Care Act 2014, the Mental Health Act
Promoting well-being transforming adult social care in Kent, as can be 1983 and the Mental Capacity Act 2005. As
Achieving our vision Promoting independence seen from the timeline on page 6. the overarching piece of legislation, the Care
through three themes Supporting independence. Act 2014 lays down new responsibilities and
This strategy replaces the previous ‘Active extends existing responsibilities, including:
Supporting
Lives’ strategy. Its development took into
account the views of service users, providers promoting well-being;
and partners that had been gathered through protecting (safeguarding) adults at risk of
Protection (Safeguarding) our on-going discussions with these groups. abuse or neglect;
What will make Workforce The vision and aims set out in this document preventing the need for care and support;
it happen? Commissioning strongly link with and support ‘Increasing promoting integration of care and
Supporting
Integration and partnerships. Opportunities, Improving Outcomes: Kent support with health services;
Carers
County Council’s Strategic Statement 2015- providing information and advice; and
2020’ and the principles described in the promoting diversity and quality in
Person-centred care and Quality of care ‘Commissioning Success’ document. It is providing services.
support Integration important to understand that this strategy sits
Our values and
Supporting people to be safe Answering for what we do between the council-wide strategies and other
Building
Blocks
principles
Shared responsibility Best use of resources. specific social care group strategies such as By transition we mean the process where
Prevention the ‘Learning Disability Joint Commissioning young people with health or social care
Strategy’, the ‘Strategy for Adults with Autism in needs move from children’s services to
Kent’, ‘Sensory Strategy’, ‘Being Digital Strategy’ adult services.
and ‘Live Well Kent Principles for Mental Health’.
Monitoring
4 Your life, your well-being Your life, your well-being 5
Kent County Council Adult Social Care
Foreword
Updated ‘Your life, your well- 4. Our vision and strategic Strategic outcome: Older and vulnerable
at a glance
Strategy
being’, implementation of residents are safe and supported with
2018 the new operating model
approach to adult social care choices to live independently
and key commissioning October
programmes 2018 Supporting outcomes:
Those with long-term conditions are
Introduction
supported to manage their conditions
Commissioning October through access to good quality care and
2017 Success 2017 support
People with mental health issues and
dementia are assessed and treated earlier
and are supported to live well
Vision
Launch of Your life, More people receive quality care at home
2016 your well-being December avoiding unnecessary admissions to
2016 hospital and care homes
The health and social care system
work together to deliver high quality
Planning for community services
Values
delivering the August Residents have greater choice and control
2016 strategy for adult 2016 over the health and social care services
social care they receive.
well-being
Promoting
Strategic outcome – Kent communities
Vision for adult While we are proud of our past successes, feel the benefits of economic growth by
2016 social care May we believe that we must continue to do being in work, healthy and enjoying a good
2016 more to promote people’s ability to improve quality of life.
and maintain their health and well-being,
independence independence
live independently, and cope well with Supporting outcome:
Promoting
deteriorating conditions. We will carry on Physical and mental health is improved by
Strategic Statement ‘Increasing March putting the person at the centre of everything supporting people to take responsibility
2015 Opportunities, Improving 2015 we do, offering a timely and integrated for their own health and well-being.
Outcomes’ 2015 to after 2020 approach to care and support. In short, this
is based on the central idea of focusing on As well as supporting our wider outcomes,
Supporting
‘a life not a service’. We have decided to use the delivery of the vision and strategy will link
A Commissioning Framework for Kent this approach based on consistent feedback with the aims of our public-sector partners,
2014 County Council - Delivering better October that current models of support fit people into including district and borough councils. We will
outcomes for Kent residents through 2014 a narrow band of available services, whereas continue to work closely with these partners to
improved commissioning future support needs to be more personalised deliver our common aims to achieve the best
so people can achieve the outcomes that outcomes for the people of Kent. Our strategy
Supporting
June matter to them. for adult social care over the next three years
Carers
2014 & Adults 2012 & breaks our approach down into three themes,
2012 transformation March Our vision is ‘to help people to improve supported by four building blocks, as shown
phase 1/ phase 2 2014 or maintain their well-being and to live as in the image over the page. The three themes
independently as possible’. cover the whole range of services provided for
people with all kinds of social care and support
Building
Blocks
Published Active This vision supports the delivery of some needs, and their carers, throughout their adult
2007 Lives Strategy March of our overall outcomes, set out in our lives. Chapters 6, 7 and 8 explain our plans over
2007 to 2016 2007 Strategic Statement. In particular, it supports the next three years for each of the themes, and
the following: Chapter 10 describes the building blocks.
Monitoring
6 Your life, your well-being Your life, your well-being 7
Kent County Council Adult Social Care
Foreword
Help people to improve
or maintain their Four building blocks
at a glance
Strategy
well-being and to Through these models of care and support,
live as independently Promoting To deliver the vision and strategy there are our aim is to:
as possible. well-being important building blocks that must be in place.
They are: improve people’s experience and
promote their health and well-being;
Introduction
Making sure we provide effective end the current crisis-driven model of
Supporting management (with partners) to protect care;
Promoting independence adults at risk of neglect or abuse and making create a value-driven and outcome-
independence sure staff are well trained and confident to focused culture that nurtures
carry out their duties creativity and find new ways to meet
Developing a flexible workforce with the people’s needs;
Vision
right skills to work across organisational support people to access good-quality
Age 16-18 End of life boundaries, including having in place advice and information that allows them
suitable and smooth care pathways for to look after themselves;
people create the right conditions which allow
Commissioning and providing a range of people to find solutions that support their
flexible care and support services based on well-being outside of traditional service-
Values
a strong understanding about what people driven models of care and support;
need and what matters to them, setting encourage community development and
Promoting well-being are products designed to help people live the outcomes that need to be delivered, increase volunteering, befriending and
independently in their own homes and deciding which organisation is best good-neighbour schemes;
well-being
Promoting
This is delivered through services which aim to Our aim will always be to achieve the best placed to deliver them. This includes a new support carers in their vital role by
prevent, delay or reduce people’s need for social long-term solution for the person. approach to evaluating performance and providing advice and individually tailored
care or health support, by helping people to contract management support;
manage their own health and well-being. Supporting independence Improving the way we work with the provide flexible and responsive models
NHS through integrated commissioning of care and support, including long-term
independence independence
We will promote and build on people’s This is delivered through services for people and provision to promote the well-being care, that can increase and reduce in size
Promoting
strengths to help them look after who need ongoing support and aims to of adults with care and support needs, as needed;
themselves, stay independent and live a full maintain well-being and help people do as including carers to deliver the ambition of free professionals up from rules and
life within their community much as they can for themselves. The aim is effective and efficient co-commissioning. bureaucracy so they can ‘do the right
People will be able to make the best use of to meet people’s needs, keep them safe and thing’ and provide person-centred
available resources such as information and help them to live in their own homes, stay support that promotes well-being;
Supporting
advice and community support. connected to their communities and avoid Care pathways make use of digital technology and
unnecessary stays in hospitals or care homes. By this we mean an agreed plan for caring innovation in the delivery of care and
Promoting independence for and supporting people with a particular support for people of all ages and help
More people will receive care at home and health condition so they can move smoothly services address challenges; and
This involves providing targeted support that stay connected in their community, avoiding between services. It is based on evidence bring services together to make sure
aims to make the most of what people are able unnecessary stays in hospital and care about what works to treat and manage there is better communication and
Supporting
to do for themselves to reduce or delay their homes particular conditions. effective use of resources which will
Carers
need for care, and provide the best long-term We will change the way our services are create a comfortable experience
outcome for people. commissioned and delivered to be more for people.
focused on achieving better outcomes
They will have greater choice and control to for people.
lead healthier lives.
Building
Blocks
We use case studies to help explain the three Model of care
We will promote independence by themes. These show how people’s needs could A way of providing care based on a set of
providing targeted support and adaptations be met through better use of existing support beliefs and principles about what is right and
such as community equipment, enablement arrangements and new ways of doing things. works best.
and other assisted living technology, which
Monitoring
8 Your life, your well-being Your life, your well-being 9
Kent County Council Adult Social Care
Foreword
Prevention, support and managing the Organisational background is provided, where possible. The health and
at a glance
Strategy
move for young people into adulthood (efficiency and finance gap) social care workforce will increasingly work in a
flexible way across organisational boundaries to
We recognise the importance of managing the It is great news that people are now living deliver smoother care and support.
move to adulthood for disabled young people longer than ever. Nationally the number of
receiving care and support. This can apply up people aged over 60 is expected to pass the Provider background (quality of
Introduction
to the age of 25. Our strategic outcome for 20 million mark by 2030 and within Kent, by care gap)
children and young people is to make sure 2026, the number of people who are 65 or over
that they get the best start in life. So, it is vital is expected to increase by 43.4%. Improved Over 80% of our budget for adult social care
that we work with services for young people medical care and higher survival rates following is spent through the external market, with
to make sure they can have access to the illnesses and accidents also mean that we are many providers being Kent registered. The care
appropriate preventative and early intervention seeing significant increases in the numbers market is made up of around 500 providers of
Vision
services as well as having the right links with of people with complex needs, including the services in the public, private and voluntary
health, education and housing. Getting this number of younger people with long-term sectors, employing over 40,000 people. Given
right should mean that we will be able to help support needs. All of these changes are putting our position we have significant buying power,
young people to be with their families, until huge pressure on the adult social care system. which needs to be exercised rightly to ensure
they can live independently (which will depend we support and enable a sustainable care
on their development needs). National funding has not kept up with these economy.
Values
increases in demand, with significant reductions
Prevention in spending across services. In the last five years The continuing pressures on finances and
Any act that prevents or delays the need (since 2010) we have delivered over £433 million increasing demand, in terms of an ageing
for people to receive care and support by of savings, around £80 to £90million each year, population and an increasing complexity of
well-being
Promoting
keeping them well. so the percentage of our total budget which need, are causing significant challenges for the
is going on adult social care is rising. Where whole system. Some providers have not been and support in the home’ which will enable
Background possible, we have made savings by redesigning able to adapt their business in order to survive, providers to increasingly become part of a
services and passing funding to front-line others are reporting that they are struggling multi-disciplinary team.
Like all councils, we are working within severe services. If we do not change the way we to recruit, retain and develop staff to ensure
independence independence
financial restrictions as well as seeing increased deliver services, we cannot meet the current they have the right skills to deliver and maintain Like all local authorities, we have a duty under
Promoting
demand for services brought about in part by and future needs of local people within our high-quality outcome-based services. the Care Act to shape the local care market
changes to the population. We know that this existing budget. and to ensure that market is sustainable. As
will continue for at least the next three years. more people have control over their own care
We will measure our success by how well we Front-line Outcome based and support by being self-funders or through
manage to close three important gaps that Staff or services who have direct contact with Services focused around the individual’s personal budgets, our role is increasingly
Supporting
are central to everything that we do. These are people who need care and support. needs and their desired outcomes. focused on supporting providers to understand
shown in the image below. supply and meet demand.
So that we can keep providing the services As we move into delivering this strategy, we will
that people need, with reduced funding need to look at our relationship with our main Our relationship with the voluntary and
and increasing demand, we have become a partners to see how together we can deliver community sector is changing, as reflected
commissioning authority. This means examining what is needed in the most cost-effective way in our new Voluntary and Community Sector
Supporting
and reviewing the way we deliver services in including using new models of care that are Policy. We will work with providers to help them
Carers
partnership with the NHS, district and borough clearly based on outcomes. become more sustainable, including by moving
councils and the private and voluntary sector, long-standing grants to contracts.
and looking at new ways of working to make Work has already started with the NHS to jointly
sure that we develop the best services we can. commission and deliver a more integrated Personal background (outcomes and
This new approach involves working in a more service provision in the community including well-being gap)
Building
Blocks
joined-up way with our partners, including the discharge services. We will also be examining
NHS and providers of services. We will continue how the commissioning of NHS Continuing The Care Act makes very clear adult social care’s
to work with the people who use our services Healthcare and residential services could responsibilities for promoting the well-being
and their carers to produce changes in what be aligned. There is a new contract for ‘care of people with care and support needs in the
Monitoring
10 Your life, your well-being Your life, your well-being 11
Kent County Council Adult Social Care
Foreword
local area. This includes those who pay for their Outcomes for people are influenced by a Advice will also be available to support and
at a glance
Strategy
own care. Our commitment to promoting the number of factors including housing, education assist other staff on safeguarding matters
well-being of people in Kent is reflected in our and lifestyle choices, some of which fall within The Quality Improvement Function will
Strategic Statement and in the Commissioning our responsibilities in terms of public health. ensure providers take steps to improve
Success document. At the moment we know This is an area where we believe more needs their care where quality issues have been
that we do not always make the best use of to be done working with our health partners, identified. They work with providers to
Introduction
information about the benefits our services are district councils and local communities, to develop and monitor change and to make
bringing to all the people who use them so that reduce health inequalities. sure that these changes are sustained and
we can shape how services could be improved. contribute to improving outcomes for
people
Well-being is defined very broadly in the Care Health inequalities Older people and people with physical Social workers will work with clients for 12
Act and includes personal dignity, physical, The differences in health between different disabilities teams to 16 weeks to provide short term support
Vision
mental and emotional well-being, protection population groups, for example, people from where it is shown this will benefit them.
from abuse and neglect and control over less well-off backgrounds tend to suffer from The teams cover social work, safeguarding, This will be governed by the KCC Social
day-to-day life. We will continue to put the health problems more. promoting well-being, supporting Work Framework.
well-being of the person at the centre of independence and quality improvement.
everything we do. This means that we will listen The carers of people with care and support The promoting well-being function People with mental health needs
and respond to the views and issues that are needs (who might be family, friends or delivers information, advice, advocacy
Values
important to the person when working with neighbours), play an essential role in the well- and signposting to local services in the Our team, which support people with
them and use information more intelligently, being of the people they care for and we community with the aim of preventing, mental health needs work to a new
such as identifying people at most risk. recognise the important contribution that delaying or avoiding people from entering operating model that continues to deliver
they make to society. We know that carers social care or health systems, by helping services in partnership with Kent and
well-being
Promoting
We will also work with people who use our can experience significant negative effects on people to manage their own health and Medway Partnership Trust, whilst also
services to design them so that they meet their finances, health (physical, mental and well-being continuing to work with a range of other
their needs. This is known as co-production. emotional) and employment prospects as a The Supporting Independence teams partners
We see a person’s care and support as a shared result of their caring role. As part of this strategy work closely with health colleagues using The aims of the new delivery model are to
responsibility between the person (and their we will work with our partners to improve the integrated screening processes to give make sure that:
independence independence
carers and families) and public services and we lives of carers, as set out in Chapter 9. people a consistent journey through health • the person referred to a community
Promoting
will support people to take this responsibility as and social care services. There will be joint mental health team is seen by the right
far as they are able to. How we are putting the strategy into working in the discussion of cases and this professional at the right time;
practice will avoid duplication and ensure people are • there is no duplication of process;
given the right support by the right people • there are equal services for all people
This strategy explains our vision for adult social at the right time. In the longer term it is referred; and
Supporting
care over the next three years. We will deliver hoped providers can take on case holding • all professional groups are not expected
it by bringing together all our change and responsibilities with appropriate support to work outside their professional
improvement work into a single new operating from the Supporting Independence team accountabilities or eligibility criteria
model, which works across adult social care. Support will be targeted to help people Under the new delivery model, referral
to achieve the goals set in their care and screening is undertaken jointly by health
This new operating model looks at what people support plan. This will be done with service and social care staff, and assessments
Supporting
can do, and not just what they cannot do. providers who will become part of the ‘Local (whether health only, social care only or joint
Carers
This might be referred to as an asset based Care (see page 17) team’ (made up of various are carried out with the right professionals
approach. The ambitions in this strategy will be agencies and professionals) involved). Any joint assessments are
accomplished by working together with our There will be a dedicated safeguarding undertaken with a minimum of two
partner organisations using a shared approach function. Teams will take appropriate steps professionals to be present, one of whom
to deliver care and support. This approach (the in providing safeguarding, working with will be qualified
Building
Blocks
new operating model) is described here: partners to protect people at risk of abuse There are two duty systems (one health, one
or neglect. This dedicated function will work social care) which are co-located and run
to agreed time-scales for when the different alongside each other. Case responsibility
parts of their work should be completed under the model is determined by the main
Monitoring
12 Your life, your well-being Your life, your well-being 13
Kent County Council Adult Social Care
Foreword
needs of the individual; the lead professional We will develop plans to have the same 5. Our values and principles
at a glance
Strategy
could be a health worker, a social worker or processes across our service to speed up
joint management. referrals and avoid duplication. We look at These values and principles guide everything
meeting the right outcomes for people we do to provide care and support to adults
Adults with a learning disability using personalised support planning and their carers.
materials. We will ensure that we are
Introduction
Our teams which support adults with a working towards better outcomes for all Person-centred care and support
learning disability over the age of 26 years people we support irrespective of their care We provide care and support that is
are integrated with colleagues from Kent needs tailored to the person so they can achieve
Community Health Foundation Trust and We have made our job descriptions the things that matter most to them. This
Kent and Medway Partnership Trust, also consistent across the service so we have means putting the person at the centre
working with Clinical Commissioning the same and greater resources. Staff can of everything we do, supporting them to
Vision
Groups now be better matched to people who choose and control what care and support
The service is part of our Lifespan Pathway use services. Inspiring Lives have created they receive. We will treat every person with
that supports disabled children, young ‘champion roles’ in various areas, where team respect and dignity
people and adults over the age of 26 years members will become trained in things like Supporting people to be safe
who have lifelong complex disabilities. Its “positive risk” and “active support” to further Working with people to help them stay safe,
aim is to provide support that is seamless enable independence and allow everyone including managing the risks of harm, abuse Integration
Values
with continuity through transition periods in to have choice and control in their lives. We or neglect. This is central in everything we We aim to provide care that is ‘joined-up’
people’s lives are moving towards very highly trained staff do across organisations so that people do
The aim is that people with a learning who will be able to deliver bespoke support Shared responsibility not experience duplication of services or
disability in Kent get high quality, integrated to enable people (especially those who may Throughout a person’s care journey we delays in accessing support or fall between
well-being
Promoting
health and social care to support them to have complex behavioural needs), to have work with them and their carers to jointly the gaps. We are open to new ways of
live healthy, fulfilled and safe lives in their a greater level of stability in their everyday design their care and support in a way doing things and we make the most of the
community. The service is provided through lives and have more control. that encourages them to do as much for strengths of all our partner organisations
five area teams which follow the same themselves as possible, including taking – from the public, private, voluntary and
allocation processes so that the person is Principal Social Worker responsibility for their own health and well- community sectors
independence independence
seen by the right professional at the right being and working with family members Answering for what we do
Promoting
time with minimal duplication or delay Our Principal Social Worker will support us and carers We answer to the people we provide care
Should there be a breakdown in a person’s to have a greater focus on the quality of Prevention and support to, their carers and the whole
placement the service offers a complex care our practice. This will be delivered via the We work with our partners to provide advice community. We communicate clearly about
response within four hours to minimize the establishment of a Social Care Academy, and support to prevent problems getting our responsibilities and policies and we are
need for admission to specialist hospitals. incorporating the work of our Teaching worse. We aim to prevent, delay or reduce honest and open about our performance
Supporting
Teams also respond to safeguarding Partnership with Medway Council, The people’s need for social care by helping Best use of resources
concerns and will undertake all necessary University of Kent and Canterbury Christ them to maintain or improve their well- We make the most of the resources (money
safeguarding enquiries. Church University. We will be enhancing being and independence, or to cope better and our staff ) we have available to promote
our focus on quality by developing a quality with conditions which are gradually getting people’s well-being by focusing on the
In-house provision (KCC owned/ assurance framework to support us to worse outcomes they want to achieve, including
run services) measure and understand performance at Quality of care by influencing other organisations and the
Supporting
different levels. We maintain and improve the quality of community. We use information intelligently
Carers
The services that KCC directly manages are the care and support that people receive, to plan services that achieve outcomes in
now known as ‘Inspiring Lives’. We have no matter which organisation provides it, the most cost-effective way.
renamed our day services as ‘Community so that people receive the right support
Services’ with the expectation that the at the right time in the right place. We
provision will change to offer outcome constantly look for opportunities to make
Building
Blocks
focused activities that may not be restricted improvements to the ways that people
to 9 to 4, Monday to Friday access our services and the ways we
design and provide care and support, using
information and feedback about people’s
experiences
Monitoring
14 Your life, your well-being Your life, your well-being 15
Kent County Council Adult Social Care
Foreword
6. Promoting well-being At the same time as helping people to take
at a glance
Strategy
more responsibility for their own health and Local Care is about bringing together Social Prescribing
well-being, we need to strengthen communities primary, community, mental health and Information to help people access advice and
to support the vulnerable adults living in them. social care to offer more joined-up care in services to help them improve and manage
We need to support communities so they can people’s homes and local communities. their own health and reduce the risk of
better use their own assets and help each other. Local Care services are at the heart of our serious illness.
Introduction
future strategy. Local Care hubs are a cluster
How things are today of GP surgeries working together with
additional services as one to provide quick, We will continue to make sure information and
Although there are various sources of co-ordinated access to a wide range of advice is an important part of the development
support for people outside of the formal services including therapies close to or at of Local Care and local multi-disciplinary teams.
care system, it is not always easy to find out home. People will be able to get information about all
Vision
what is available locally and how to access the health and social care services and activities
it. Even GPs and other health and social care Local Care services are being developed in their local area and advice about living
professionals find it difficult keeping on top locally to reflect the needs in different areas healthily and planning for future care needs.
of all that is available in the community to of the county. The aim is to prevent ill health
support people’s well-being by helping people stay well, improve the We will make sure information and advice can
As a local authority we provide a range of access and quality of care, reduce avoidable be accessed through a variety of channels
Values
useful information and advice in a number demand on hospitals (for example A&E and formats, including, for example, advice
Providing the right response so people can of places. But currently the system is departments) and provide better support lines, drop-in services, websites and health
manage their own need for care and support broken up and it is not easy to access all in care homes. As a result they will help professionals. We will make sure that when
within their communities. of the information that a person may want to reduce avoidable hospital admissions people ask for information or support services,
well-being
Promoting
or need. This is based on feedback from and care home placements in the longer all agencies either hold the information needed
Many older and vulnerable adults are able people stating that they have not always term. They will be made up of the following or know how to get hold of it. Our ‘Being Digital’
to manage their care and support needs been told about support that exists in their typical services. Strategy describes how we would like to make
themselves and continue to live in their own communities. it possible for people to communicate with
homes and communities. However, to do this, GPs and paramedic practitioner services, us in ways that work best for them, this could
independence independence
they may need information and advice about How we want things to be in the future which will support home visiting for those be through; email, apps, online conferencing,
Promoting
the help that is available. This could include not able to go out instant messaging or virtual visits. The strategy
information on benefits, facilities available in the By 2021 we want to have developed, with our Integrated nursing and social care services is built around the five themes of People, Place,
community, aids they can buy to use at home partners, a wide-ranging information and including home care, community, district Practice, Product and Partnerships.
and outside, and advice on how to maintain advice system so that people can access all the and specialist nursing, physiotherapy,
or achieve a healthy lifestyle (what we can call information they need from wherever they ask occupational therapy, mental-health We will greatly improve the information
Supporting
‘well-being’ services). for support. We also want to have significantly services, urgent and crisis care and available to people who pay for their own care
developed the community and voluntary sector palliative (end-of-life) care and support (self-funders) so that they are fully aware of all
Through promoting well-being services we to make best use of community resources Out-of-hospital services such as the options available to them and know which
aim to prevent or delay people from entering and improve the range of support offered. We diagnostics tests and same-day treatment support is provided free of charge. This support
the formal social care and health system, by talk more about this in the integration and for minor illnesses and injuries includes assessment, enablement (helping
helping them to manage their own health partnerships section of the Building blocks Prescribing medicines people become more independent by gaining
Supporting
and well-being. Well-being services are based chapter in this strategy. Information and advice services to help the ability to move around and do everyday
Carers
in local communities and use local resources. with preventing health problems getting tasks), and some equipment. It also includes
They help to prevent the issues that lead to We will continue to make information and worse and promote good health information on what level of support people are
people needing formal care and support, such advice an important part of the development Support for carers in tackling their likely to receive if it was arranged by us.
as social isolation, falls and where the person’s of Local Care and local multi-disciplinary teams. different needs
carer is not able to cope. Access to good-quality People will be able to get information about all Access to voluntary and other We will expand the use of ‘care navigators’, or
Building
Blocks
information and advice will be the cornerstone the health and social care services and activities community services including through other forms of community worker that we
of our well-being services, helping people to in their local area and advice about living social prescribing. arrange using voluntary organisations. Care
identify and access the support that they want healthily and planning for future care needs. navigators give advice and information about
so they can keep on living fulfilled lives in their what services are available in a person’s area so
own homes.
Monitoring
16 Your life, your well-being Your life, your well-being 17
Kent County Council Adult Social Care
Foreword
that the person can choose to arrange the care
at a glance
Strategy
and support that best meet their needs. Their George’s story: As a result, George is given information
role is to help people manage their own health Promoting well-being in the future on joining a befriending group organised
and well-being by accessing local community- by Age UK as well as information on
based services, aids and equipment, benefits George is 87 and, since his wife died two joining his local University of the Third
and other sources of support. years ago, has been living on his own in Age. This is a self-help organisation for
Introduction
the house he had shared with her for the retired and semi-retired people providing
We will continue to expand the role of ‘trusted previous 40 years. leisure, educational and creative activities
assessor’. These are people who have been which holds all sorts of regular group
trained to assess whether a person could Over the last year he has started to put on activities, including teaching people
benefit from simple aids and equipment or weight as a result of not walking as much about using information technology to
adaptations and take full advantage of new as he used to when his wife was alive. keep in touch with relatives. George also
Vision
technology, to support qualified occupational This has also been due to the arthritis in gains information on arranging for the
therapists across health and social care. We his hips which has been slowly getting appropriate equipment to be installed in
recognise that getting the right aids, equipment worse (but is not yet bad enough to need a his bathroom, which helps him to keep
and technology can make a huge difference to hip replacement). clean and manage his other personal
a person’s ability to stay independent and safe. needs. He also gets information on a
George generally manages to look after scheme where a volunteer driver will take
Values
We will be looking at how medical and social himself, but getting in and out of the bath him, once a week, to see a friend who lives
care professionals can use social prescribing can sometimes be painful and he often feels about five miles away.
models more widely. An example of social lonely and isolated. He has a daughter and
prescribing could be GPs prescribing a course son but they both live over 100 miles away George is encouraged to see his GP who
well-being
Promoting
of exercise classes rather than, or as well as, and so only visit occasionally. His daughter advises him to go on a diet to lose weight.
medication for someone with mild depression worries that her father is becoming He also talks to the GP about his feelings
or anxiety. depressed. He doesn’t want to move from of isolation and it is agreed he should
his home or the area as he knows it very return to see him after two months of
Promoting well-being is also about well, it is within walking distance of several taking part in the above activities to see
independence independence
encouraging and supporting people to live shops and he does have some friends in the if he has improved. The GP is concerned
Promoting
healthy lives, which has benefits for the person area that he sees occasionally. that George may be becoming depressed
in the short term and can prevent a range of but decides to wait to see how the various
health problems in the longer term. Working encourage volunteering, befriending and George belongs to his local Neighbourhood activities help before deciding what to
with our partners, we will continue to promote good-neighbour schemes. Our focus will be Watch as do most people in his area. do next.
public-health campaigns and programmes that on strengthening communities, making use of Recently they have decided to add to
Supporting
encourage people to change their behaviour, other social support networks where necessary what they do by looking out for their more
such as taking more exercise, stopping smoking to improve the range of support offered. vulnerable members, including older
and attending health screenings that are people, like George, who live alone.
offered. Well-being is also influenced by wider
issues including housing, employment and The local council provided some training for
education, and we will continue to work with them and other local groups in recognising
Supporting
partners to make improvements in these areas signs of social isolation, dementia and other
Carers
that will promote well-being. problems among older people and also
where to go for information and advice to
Social isolation and loneliness can lead to ill help with these things. As a result, one of
health and we will be developing schemes George’s neighbours invites him for tea and
which help people get together for mutual suggests that he goes to or phones his GP
Building
Blocks
support, activity and fun. Keeping people practice which can access services across
connected helps to keep them well. We will health social care and the voluntary sector
work with the community and voluntary sector as part of Local Care.
to make best use of our combined resources,
Monitoring
18 Your life, your well-being Your life, your well-being 19Kent County Council Adult Social Care
Foreword
7. Promoting independence For several years we have provided telecare section on Supporting independence), but we
at a glance
Strategy
services to people we believe could benefit will provide much more targeted support for
Providing the right targeted action when it is from them. For most people this involves people at the crucial points when this is needed
needed and the right environment so people using personal alarms that are triggered in the future.
can care for themselves. when help is needed (for example, after
a fall, the bath being overfilled or the gas Care and support, whether it is only short
Introduction
Not everyone who needs support needs it all being left on). Telecare is an area of continual term or ongoing, will be co-ordinated by the
the time. Some people only need help for a innovation and we need to do more to Promoting Independence teams as part of Local
short period, either once or sometimes more make sure we are making best use of the Care and therefore integrated with support
often. This could be to help them get back on new technology becoming available from health and the voluntary sector (see box
their feet after an illness or operation, to help We have also tried to improve our referral, on page 17). The hubs will provide access to
them recover from a period of illness (physical assessment and review practice to increase equipment and assistive technology.
Vision
or mental) or, if they have a carer, to give that opportunities to make the most of a person’s
person a break from caring. independence at every stage that we have We will look to combine occupational therapy
contact with them. Rather than expecting services we and the NHS provide to improve
Some people may need adaptations to help a person to go on needing the same level access and remove the risk of duplication
them manage without the need for formal of support for the rest of their lives, we are and variation in assessments and services.
support. This could include grab rails in the encouraging our staff to consider ways to We will continue to develop the use of more
Values
bathroom or the more sophisticated telecare reduce people’s reliance on formal care and sophisticated telecare and other technology
services, for example to sense if someone has support. However, there is much more that and will work with professional organisations to
left the gas on or someone with dementia has we want to do. increase the range of equipment on offer.
gone missing from home.
well-being
Promoting
How we want things to be in the future We will work on the basis that ‘your own bed is
People with long-term conditions (mental or best’, and that in most cases people are more
physical) or disabilities may need training to By 2021 we want to have the systems and comfortable in their own homes and so recover
help them be as independent as possible so culture in place so that everyone we come into and get their independence back more quickly
they do not have to rely on formal care systems. contact with is helped to be as independent as if they can receive good-quality therapeutic
independence independence
possible and this will be an ongoing process. support at home. If we get this right, it will
Promoting
Our aim in promoting independence is to Enablement services are provided to reduce unnecessary stays in hospital and allow
increase the availability of this type of support respond intensively for a short period of time The starting point for all assessments will be people to leave hospital as soon as they are
and to target it more effectively, at the right to help a person get back their independence to consider, with the person and any carers, medically fit to do so.
time, before a person’s condition gets to or to make significant steps towards being as what their specific goals are, what is important
the point that they need ongoing, long- independent as possible. They can help with to them and what they would like to be doing We will try to increase independence when
Supporting
term support. physical problems, such as after an accident that they cannot do at the moment. The above we first make contact with a person and
or illness when a person might need help approach is supported by the Care Act which then continue to do this throughout the care
How things are today getting out of bed, washing, dressing and puts a person’s well-being at the heart of the journey. At every opportunity we will see if
so on. They can also help people suffering assessment. We will encourage people to there is more that we can do to help people
There are already services in place to provide from mental-health problems who need an make the best use of support from their own be independent. This will be done through
some of the short-term support needed intensive period of support to help them community, including voluntary organisations, assessing needs and responding to change.
Supporting
and to promote independence in the home. regain their confidence or ability to interact as explained in the chapter on Promoting While continuing to review the support we
Carers
This includes enablement services (both for with people and continue with what matters Well-being. provide in this way, we will also be sensitive to
those who have physical needs and those most to them such as work, study or family the fact that people need some certainty about
with a mental-health problem), which we life. Help could also include aids, equipment Having considered what is important to the help they will be given. Because of this,
currently provide to some people. However, and telecare. These services are available for a someone, we will work with them to help them we will make it clear that, while the aim of any
we need to significantly expand this type of specific period of time, which can vary from a be as independent as possible and reduce, support is to encourage independence and that
Building
Blocks
support few days to a number of weeks. where we are able, the need to rely on the some support might be short term, it can also
formal care sector. Clearly there will be some be increased when needed.
people who do need ongoing support and
we will provide this when needed (see the
Monitoring
20 Your life, your well-being Your life, your well-being 21Kent County Council Adult Social Care
Foreword
8. Supporting independence
at a glance
Strategy
Ben’s story: Towards the end of his time at college several
Promoting independence in the future meetings were held with Ben, his family and Providing effective ongoing support
the main professionals involved in his care.
Ben is 23 and lives with his parents who are Ben got a part-time paid job at the garden Supporting independence is the final part of
in their 60s. He has always lived with them centre. He used his personal budget for our strategic approach to adult social care and
Introduction
and has not had any experience of living short-term support from a support worker, is aimed at those who need ongoing care,
alone. who also helped him when he had to learn whether at home or in a residential setting. It
new tasks and went with him to a local club aims to meet people’s needs while allowing
Ben has fragile x syndrome (a genetic for all abilities on Saturdays. He has made them to live in their own homes where possible,
disorder linked to the x chromosome friends at work and now calls on his support stay connected to their communities and avoid
– one of the most common forms of worker less and less. unnecessary stays in hospitals or care homes.
Vision
inherited learning disability). He also has Supporting independence is delivered with
epilepsy, which is fairly well controlled with Ben has recently said he would like to live services that aim to maintain individual well-
medication. Fragile x syndrome affects Ben with friends in his own flat. He and his being and keep people safe, help people do
in several ways. parents are also keen that he moves into his as much as they can for themselves and allow
own place. Jane, Ben’s mother and carer, is people to live and be treated with dignity.
Ben has attention deficit disorder and this finding it increasingly tiring supporting Ben
Values
and his hyperactivity have affected his ability and she doesn’t like to leave him alone in the How things are today
to learn and hold on to information. While house for more than about an hour.
Ben can make himself understood, he gets We have a health and care system that is not
very irritable quickly and this sometimes Ben and his family have started to look at responsive enough. This can unintentionally
well-being
Promoting
leads to aggressive and inappropriate options for independent living, including lead to people becoming more dependent on
behaviour. He can travel on his own on living in a shared house with other people services than they need to be, which does not
some simple routes but easily gets lost if with learning disabilities and on-site support always lead to the best outcomes for them.
he doesn’t know the route well, or if the if needed. He is spending short periods in We are developing new models to provide
route changes. one of these units to see how he gets on, The system is not always flexible enough more independent living options in the
independence independence
which gives his parents a break. He has also to respond to changing needs, which can community, including Your Life Your Home
Promoting
Ben went to a special school until he was 19 gained new skills through support from the result in providing too much or not enough which aims to move adults with learning
and later a local college until age 21 where Kent Pathways Service. care disabilities out of residential care, and Shared
he was well-supported by the Additional In spite of the progress on joining up health Lives which provides supported placements
Needs Unit in the college. He managed to As a result of the support being offered to and social care services across Kent, there for adults with care and support needs within
get a certificate in basic computing and Ben, his mum’s situation as a carer has been are still areas where duplication of services a family home. At the moment these new
Supporting
also gardening which is something he really helped. Jane has been given a personal could be avoided, more information could models are helping a small number of people
enjoys. budget and can use this in a way which be shared and services could be better with ongoing care needs.
best meets her needs to ease the stress of designed to provide more effective care
He went to college for three days a week, caring. She has also joined a local carers’ We need greater choice and availability of Currently we spend about £7million a year
and on the other two days he used support group. other accommodation options rather than jointly with the NHS to provide support
some of his personal budget to pay for a long-term residential and nursing care. We for carers whose health and well-being is
Supporting
support worker to go with him to a local need to work with partners to develop other affected by their caring responsibilities. The
Carers
garden centre where he carried out work options such as Extra Care housing and assessments and services provided are good
experience. For the last six months of his specialist accommodation for people who quality but there are long waiting lists for
college course he walked to the garden have dementia some support such as sitting services to
centre himself and stayed there on his own Young people with disabilities and ongoing provide respite (a break from caring).
without his support worker. He was helped care needs can experience a lack of
Building
Blocks
to do this by having a GPS locater on his connection between children’s and adults’ How we want things to be in the future
wrist which would alert certain people if services as they grow up. We have started
he got lost on the journey to and from the to manage this by bringing together our We will always make sure that people who need
garden centre. services for disabled children and adults, but ongoing care and support receive it, while at
there is more to do the same time working with people to help
Monitoring
22 Your life, your well-being Your life, your well-being 23You can also read
