1. Care Home Strategic Commissioning Review
Clare Gilbert – Commissioning Lead

2. Purpose of Today’s Session
Make sure that that our understanding of care home services is correct
Get feedback on our proposals around the new model
Jointly shape key components of the specification including; Developing independence, Supporting Inclusivity, Connecting with Communities and Defining Outcomes
Informing Providers about the process of how to apply to become an Accredited Provider

3. Agenda 9.15 – 9.45 Arrivals and Refreshments 9.45 – 9.55 Introductions
Clare Gilbert
9.55 – 10.10
Scene Setting –Drivers for Change
Linda Sellars
10.10 – 10.20
Analysis
Caroline Keenan
10.20 – 10.30
Engagement
10.30 – 10.45
Table Discussion - Sense checking
10.45 – 11.05
The Model What is changing? What is staying the same?
Clare Gilbert,
Sharon Ribeiro, Gemma West
11.05 – 11.50
Table Discussions -
Promoting Independence, Being Inclusive, Being part of the community
11.50 – 12.00
Milestones and Markers
Nick Webster
12:00 – 12.10
Table Discussion - Milestones and Markers
12:10 – 12.30
How to become an Accredited Provider
Julie Herrod, Gemma West
12.30 – 12.35
Close

4. Better Lives Better Outcomes
Prevention: promoting healthy lifestyles and intervening early when people’s wellbeing is at risk to avoid crisis and loss of independence.
Community Connections: ensuring citizens are connected to the resources and support in their local neighbourhoods.
Independent Lives: supporting personal and community resilience, strengths and resources, reducing dependence on council funded support where possible.
Choice and Control: seeing the citizen in the driving seat, shaping solutions around the outcomes which matter for individuals.

6. The Vision A life outside statutory services where possible.
For citizens to live in their own home / own tenancy
For citizens to be well connected to their communities, have access to training, leisure & employment opportunities
One of the things we’ve done this year is to set out our new strategy Better Lives Better Outcomes is about the longer term plan for sustainable Adult Social Care
The title is all about being really clear about our commitment to improving lives. This isn’t about raising the bar of eligibility or rolling back. In times of financial challenge this is about making the very best of ALL the resources we have available to achieve the outcomes that matter for citizens. Our 4 founding pillars are unmovable: Prevention, Community Connections, Independent Lives and Choice and Control.
So we are explicit:
A life outside statutory services where possible. An independent life is a better life.
For citizens to live in their own home / own tenancy. Opening the door for increased independence.
For citizens to be well connected to their communities, have access to training, leisure & employment opportunities
This means change for all of us. But it also means building on what we know works and fixing what doesn’t. That means difficult and honest conversations but that’s the route to success in any partnership.
So thanks for joining us, and I’ll hand over to Linda and the team to take you through the morning.

7. Drivers for Strategic Commissioning Review
New contract required for April 2020
Working with health and County partners
NHS Long term Plan
Better Lives Better Outcomes
Outcome Focussed Approach
Movement from Residential to Care Support and Enablement
Movement from Residential to Block Funded (HRS) Accommodation
Reductions in numbers of older people being referred to residential care

8. Analysis How many citizens are we currently supporting?
Primary support reasons
Demographic profile
Geographic profile
What might we expect in terms of future need?
People aged 65 and over
People aged 18-64
Introduction – ten minutes – happy to take and questions as we go through
Purpose is to inform the ‘understand’ segment of the commissioning cycle
How many citizens are we currently supporting?
Just over 2,000 adult citizens supported in 2017 in either residential (84%) or nursing (16%) care
Primary support reasons
18% of those supported in residential care had a PSR of mental health, 19% had a PSR of LD and 63% had another PSR, which was mainly physical support (71% of all other PSRs)
13% of those supported in nursing care has a PSR of mental health, 10% had a PSR of LD and 77% had another PSR, which again was predominantly physical support (70% of all other PSRs)
Demographic profile

9. The majority of residential and nursing care citizens supported for reasons other than mental health and learning disability (predominantly physical support reasons) are aged 65 and older (86%, 1,131 citizens).
In contrast, citizens with a mental health or learning disability primary support reason are reasonably equally distributed by age.

10. Analysis How many citizens are we currently supporting?
Primary support reasons
Demographic profile
Geographic profile
What might we expect in terms of future need?
People aged 65 and over
People aged 18-64
Geographic profile
The majority of citizens in residential and nursing care supported by Nottingham City Council are placed within the Nottingham City boundary (66%, 1,322 citizens)
A slightly higher proportion of citizens in residential care are placed within the Nottingham City boundary (67%, 1,128 citizens) compared to nursing care citizens (59%, 194 citizens)

11. Future need in the 65 and older population
The population aged 65 and over will continue to increase
The proportions of the population that meet each of the four categories of dependency (independent, low, medium and high) will remain relatively unchanged
Conclusion: demand for care home places will rise, but not at the same rate as might be expected
The volumes of the 65 and over population within each category were estimated for 2025 and Estimates of care home places required were then based on the population projections and estimated levels of dependency. The study estimated that in 2035, 8.6% of the medium dependency population and 29.6% of the high dependency population would require a care home bed.
Despite an increase in the population aged 65 and over, the study predicted the proportions of the population that met each of the four categories of dependency would remain relatively unchanged. It was concluded that the demand for care home places would rise, but not at the same rate as the increase in the population.
Kingston et al., 2017

12. Projected population of 65 and over population by estimated level of dependency
+53%
+58%
The study’s estimates of dependency were applied to Nottingham City’s population and the projected increases to 2035
Results showed an increase in medium dependency of 58% (1,295 more citizens) and an increase in high dependency of 53% (1,113 more citizens)

13. Projected demand for residential and nursing home places in 65+ population
If the study’s estimates of the proportion of high and medium dependency populations that require a care home bed are applied to these projections (29.6% of high dependency people and 8.6% of medium dependency people), it can be estimated that 1,247 beds will be required for this population by 2035 to support 946 high dependency citizens and 301 medium dependency citizens.
In 2017, 1,500 citizens aged 65 and over were supported in residential and nursing care by Nottingham City Council (represented by the green line).
When compared with the current utilisation of residential and nursing care for the 65 and over cohort (the grey line), these estimates suggest we may have more clients in residential and nursing care than is necessary. If these estimates are correct, it ill not be until around 2035 that the level of demand will start to meet the current level of supply.
These findings are consistent with those reported by a recent diagnostic of adult social care in Nottingham City Council (Newton Europe, 2017).

14. Future need in the 18-64 population
Economic modelling study of social care demand for adults aged in England
Projected demand in five-year intervals between 2010 and 2030
Conclusion: adults aged receiving local authority funded residential and nursing care would increase by 25% between 2010 and 2030
Snell, Wittenberg, Fernandez, Comas-Herrera, & King (2011)
Estimates of future need in the population have been based on an economic modelling study of social care demand for adults aged in England (Snell, Wittenberg, Fernandez, Comas-Herrera, & King, 2011). The study focused on three types of disability:
Adults with a severe learning disability
Adults with a physical or sensory impairment
Adults with a mental health need / other
The study projected demand in five-year intervals between 2010 and It concluded that the volume of adults aged receiving local authority funded residential and nursing care would increase by 25% between 2010 and 2030.

15. Future need in the 18-64 population
Projected increases estimated in the study were applied to the Nottingham City population of adults aged in receipt of residential or nursing care in Percentage increases were adjusted to match the timeframe in order to suit the availability of local data. Results showed need in the year old population is estimated to increase by 15% between 2017 and 2030 (see Figure 16). By applying the projected increases to the current cohort’s geographical distribution prior to admission, it can be estimated that the greatest need will be located in Mapperley and St Ann’s (see Figure 17).
The Newton Europe diagnostic found there was opportunity to increase independence in 50% of citizens with a primary support reason of mental health or learning disability. This evidence suggests that whilst the population in need of support will increase, this increase will not necessarily result in an increase in residential and nursing care placements.

16. Engagement - Providers
Welcome the opportunity to work collaboratively with commissioners to develop innovative approaches
Want to know our plans and priorities
Changes in Need
Big changes in the past 5 years. Increasing complexity of clients
Challenges providing dementia and EoL care - cost and effect on other residents.
Health
Wide variation in support from local GP’s. Some very pleased with local provision but some really struggle with this.
Support (from District Nurses, Care home Team, Dementia Team) helps reduce unplanned hospital admissions. Training of staff valued.
Independence outcomes
Some homes showed a clear approach to setting and achieving outcomes. Other homes worked more traditionally - limiting role to keeping people safe and well
Assistive Technology
Some providers really valued and welcome AT. Some homes did not understand or recognise the potential benefits
Community Links
Many Providers make a big effort to make links with the local community and bring the community into their services
Moving On
Availability of properties can be challenging, especially city/County overlap. Bidding process.
Providers are keen to work collaboratively with commissioners and would welcome more of it. Keen to look at innovative approaches and development.
Useful to know about issues and plans in advance of tendering so they know how to direct long term planning and development.
All of the interviewees were using assistive technology to some extent. All were keen to further utilise this in the future.
Wide variation in experience of support from local GP’s. Some very pleased with local provision but some really struggle with this.
Seen a big change in the past 5 years. Increasing complexity of clients. People staying in their own home longer
Lots of support from other agencies (eg District Nurses, Care home Team, Dementia Team) helps to reduce unplanned admissions to hospitals. Training for staff is also key. Eg sepsis
Providers make a big effort to make links with the local community and bring the community into their services. Not necessarily reflected in commissioning/pricing.
Challenges providing dementia and end of life care in terms of cost and the effect on other residents.
Getting increased number of referrals for Huntingdon’s
The availability of properties can be a challenge, especially city/County overlap. Bidding process.

17. What Citizens Tell Us Need for choice and personal space
Remaining independent at home for as long as possible
Not being a ‘burden’ to relatives
What Citizens Tell Us
Need for choice and personal space
Fears about the cost.
Fear that I will be separated from my husband/wife
MYTH
“It’s not fair that I have to sell my home!”
“It is really important to have lots of interaction and links with the community when you are in care to keep you lively.”
“Going into care can be good and you can live with people your own age.”
“We are not ‘older people’ we are people who have just got older.”
What Citizens Tell Us:
They want to remain as independent at home for as long as possible
But also:
They don’t want to be a ‘burden’ to their relatives
It is really important to have lots of interaction and links with the community when you are in care to keep you lively
Going into care can be good and you can live with people your qwn age
We are not ’older people’ we are people who have just got older
Need choice and personal space
Worried about the cost. It’s not fair that I have to sell my home!
Myth: Fear that I will be separated from my husband/wife
In a local survey by Age UK, the number 1 concerns for residents was; Greater, Choice, Independence and Autonomy.
For carers, it was: More opportunity to improve and maintain health
Age UK (local survey)
Number 1 concern for residents: Greater, Choice, Independence and Autonomy.
Number 1 concern for carers: More opportunity to improve and maintain health

18. Quality in care homes summary: Healthwatch
Eight quality indicators:
Strong, visible management
Staff have time & skills to do their job
Good knowledge of each resident & how their needs may be changing
Varied programme of activities
Offer quality, choice and flexibility around mealtimes
Ensure residents can see health professionals such as GP’s & dentists regularly
Accommodate residents personal, cultural and lifestyle needs

19. What is staying the same?
 Accredited Provider List
 Joint Contract for City and CCG
 Quality Assurance process
 Key requirements in the specification

20. What will the changes mean for citizens?
Care homes
Citizens requiring support
Supported Living
Extra Care
Support in own home
A care home will continue to offer the best care for younger adults in these circumstances:-
When it’s not possible to place someone in his or her own accommodation right away, because the right accommodation or the right support is not yet available (interim stay for up to two years).
Emergencies where current care arrangements break down and a care home is the best short-term solution.
Citizens living at home with their family, but their level of need means the family requires a planned break from care.
Fewer older people will be going into care homes. Instead, they will be supported in their own homes or in supported accommodation such as Extra Care. Where a care home is the right option, citizens will be supported to maintain their independence and to be a part of their community.
For everyone else, care homes will no longer be seen as a home for life. This means that as well as stopping placing people in long-term residential care, we are working with people who live in care homes, and their families. We are looking to support people to move out of care homes and into their own tenancies in Supported Living, Extra Care, or to be supported in their own homes, where that’s the right option for them.
There can be times when a care home will continue to offer the best care for younger adults:
When it is not possible to place someone in his or her own accommodation right away, because the right accommodation or the right support is not yet available. In these circumstances, someone may need an interim stay in a care home for up to two years.
When there is an emergency where current care arrangements break down and a care home is the best short-term solution.
Where the citizen lives at home with their family, but because of their level of need, the family requires a planned break from care.

21. What will the changes mean for care homes?
Number of citizens with complex needs
Need for residential care homes
High quality care homes to support objectives
Adult Social Care Strategy
NHS Long Term Plan
Care homes will be required to:
Strengthen expectations around quality care, linked to a skilled and well supported workforce
Have clear, person-centred plans and approaches which support residents to enable them to do things for themselves and where possible to develop and strengthen skills for independence
Provide time-limited, interim care for working-age adults, and to work with the citizen and their families to support the transition to community-based support
Work with their local communities to bring benefits to both the lives of those living in the home and to the community
Provide emergency placements where this is compatible with current residents
Although the number of citizens with complex needs will continue to increase, given the commitment to support people to live more independent lives, the need for care homes will reduce.
However, we will continue to need high quality care homes who can work with health and social care colleagues to support the objectives of the Adult Social Care Strategy and the NHS Long Term Plan.
Care homes will be required to:
Strengthen expectations around quality care, linked to a skilled and well supported workforce
Have clear, person-centred plans and approaches which support residents to enable them to do things for themselves and where possible to develop and strengthen skills for independence
Provide time-limited, interim care for working-age adults, and to work with the citizen and their families to support the transition to community-based support
Work with their local communities to bring benefits to both the lives of those living in the home and to the community
Provide emergency placements where this is compatible with current residents

22. Health What is changing?
Focus on implementing the Enhanced Healthcare in Care Homes Framework (EHCH) across the service spec including:
NHS Mail
Reliable Wi-Fi and telephony within the home
Expectation to work with Commissioners to
implement and develop technological developments, including assistive technology
support care delivery
What is staying the same?
 Clear expectation of the care that a Nursing resident should receive
 Clear expectation of the skills staff are required to have to deliver CHC

23. Table Discussions On your tables please discuss these three topics
What do you currently do?
What works well?
What are the blocks and concerns?
Promoting Independence
Being Inclusive
Being Part of the Community

24. Setting Goals, Milestones, and Markers
Goals: what has been achieved by the end of the package of care
Milestones: key markers of achievements or changes
Markers: the steps from one Milestone to the next

25. Goals - Set by the social worker
July 2019
November 2019
The goal should be identified by the social worker at the point of commissioning.
To independently attend the local swimming group

26. Milestones: Set by the social worker and provider
Will independently get ready to go. (packed costume, towel, toiletries, money , bus pass)
Can get changed
independently
going in/coming
out of session
Can travel independently to/from the leisure centre
21st Sept 2019
11th Oct 2019
10th Aug 2019
5th July 2019
8th November 2019
To independently attend the local swimming group
The milestones to achieve the goals should be agreed by the social worker and the provider (as in the example above).

27. Markers: Set by the provider
Will independently get ready to go. (packed costume, towel, toiletries, money , bus pass)
Can get changed
independently
going in/coming
out of session
Can travel independently to/from the leisure centre
21st Sept 2019
11th Oct 2019
10th Aug 2019
5th July 2019
8th November 2019
To independently attend the local swimming group
The markers would be identified as the smaller steps required to meet the point from one milestone to the next.

28. Table Discussion
Feedback on proposal regarding Milestones and Markers

29. Accreditation process
An open Application Process is anticipated to commence September 2019.
An application form has been developed to ensure the accreditation process is not onerous. Many questions will be Yes and No answers.
Details of your organisation including current provision
Care Quality Commission registration
Health & Safety
Policies & Procedures
Safeguarding Vulnerable People
Business continuity plan
Equality & Diversity

30. Accreditation process
The process will be managed through the Due North Electronic Procurement System – Registration -
You will need to download the documents from the portal and follow the instructions carefully
All questions to go through the Due North system during the accreditation period
Applications will be scored according to the stated criteria. If successful, a contract will be issued. Take care when completing questions as some are “eliminate” questions
Return completed Application by the stated deadline through Due North

31. Accreditation process
The Accreditation will be open for duration of the contract (initially 5 years) and providers can join at any time
If unsuccessful, feedback will be provided on request
Opportunity to reapply if unsuccessful in the first instance provided that the reason for elimination has been ratified
There will be no guarantee of business
Citizen's choice
There will be NO contracting outside of the accredited list of providers

32. Accreditation process - CHC
As with the previous accreditation there will be an option to apply for Continuing Healthcare (CHC)
You will be asked if you are currently providing CHC via any contracts
You will be asked to explain in 500 words how you will meet the requirements of the CHC spec.
It is important that you answer this thoroughly as unacceptable answers will be returned via the Procurement Team.

33. Current Older Person Contract
In place since 2011
Out of date
Does not include new legislation e.g. Care Act 2014

34. New Contract
Aligning specification with the Nottingham City (in progress)
Use of NHS terms and conditions (same as City)
Aligning quality schedules

35. New process – Contract award
Contract awarded through Procontract procurement system
All care homes in Nottinghamshire will have to apply
City homes wanting County residents will have to apply
Process to commence October 2019.
Contact details: Gemma Shelton
Team Manager
Quality and Market Management Team

36. Next Steps Project timeline Status Do Develop New Specification
June-July 2019
Underway
CPSC for new Spec
July 2019
Develop Tender Documents
July-Aug 2019
To do
ITT
Sep-Oct 2019
Tender Marking
November 2019
Contract Issued
December 2019
Develop Implementation Plan
Implement System Changes for New Specification
Jan-March 2019
New Contracts Start
April 2020
Review
Build in review dates