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Chapter Four The Spectrum of housing and Support

4.1. This chapter will consider the spectrum of support services for older people including home care, sheltered and extra-care housing; the nature of these different forms of provision, the pros and cons of these services, as well as issues relating to delivery of services. The continuum of housing and support services is taken to include residential and nursing care by Parry and Thompson (2005), as illustrated in their Good Practice Guide to sheltered housing:

Figure 1: Housing-related support and personal and nursing care - the spectrum (Source: Parry & Thompson, 2005)

Assistance at Home

4.2. Since the widespread implementation of community care policies in the early 1990s there has been a wealth of research done on assistance at home, much of which includes an analysis of the implications of the policy for older people. It is not possible in the scope of this research to review all of this literature. However, it is the aim that the key issues will be identified, particularly as they relate to housing choices, and the implementation and availability of services.

4.3. There are three forms of support at home which can enable older people to remain in their original home (Parry and Thompson, 2005; Curtice et al, 2002; Quilgars, 2000; Douglas et al, 1998):

• Housing support
• Personal and nursing care
• Property and related services

These services are described briefly, and then discussed further below.

4.4. Housing support includes a range of tenancy and housing related tasks, such as assistance with budgeting and benefits, maintaining safety within the home, support with shopping and accessing other local services, and cleaning. This is now funded through Supporting People, and can be delivered to older people in all tenures. Individual needs assessments are carried out to assess what level of support is necessary, and how this should be provided. These assessments are conducted at the local level, and variations in conducting these assessments mean that the outcomes for the individual can vary significantly. Support can be delivered by the local authority or other independent or private contractors, but the local authority manages the overall budget. The use of care alarms and assistive technology to enable people to remain at home can also form part of this provision.

4.5. Personal and nursing care is funded, and generally delivered, through health or social services budgets, and can be contracted out to the voluntary or private sectors. It includes personal care tasks such as washing, dressing and, as with Supporting People, where the needs assessment indicates a need, this service is free, both at home and in residential settings. (This is different from England, and there are suggestions that this has avoided some distortion in funding and provision that are reported in England).

4.6. Property related services include :

• Care and Repair services (now available in all but one local authority - further discussion of these services is provided below).
• Handyperson schemes and garden maintenance services: the householder is responsible for paying for materials, but labour is provided free. Some RSLs also provide this service for their tenants.
• Equipment and Adaptations are crucial to enable many people to stay in their own homes. Occupational therapists assess older people on their needs, and can arrange for equipment and adaptations to be installed in private properties. Local authorities are expected to pay for the adaptation of properties through their private sector housing funds. However, shortages of funds may mean long delays in the delivery of funding, which may ultimately mean that the older person is unable to remain at home (Heywood and Smart, 1996). The Scottish Executive Health Department's review group have also identified the importance of the need to providing Equipment and Adaptations quickly, as the alternatives are often more costly (Scottish Executive, 2006d).
• The Scottish Executive's Central Heating Programme for older people and Warm Deal scheme for people on low incomes are also providing an important service for many older people experiencing fuel poverty and cold related health difficulties (Scottish Executive, 2005g).

Housing Support and Personal Care

4.7. There is considerable overlap between housing support and personal care. Services are often delivered as an integrated package, and particularly in the voluntary and not-for-profit sectors they may be delivered by a single member of staff. Social service departments also generally provide domiciliary care (Curtice et al, 2002). The varying needs of individual service users and the need for flexibility in service provision between service users means that coordination and integration of services is key to delivering effective services that enable people to remain at home (Office of Public Management, 1995; Lund and Foord, 1997).

4.8. The provision of housing support and personal and nursing care is not dependent on the tenure of the older person; these services are provided to people in their own home, in sheltered or extra-care housing, and in residential care, with provision dependent on circumstances and needs. Looking specifically at older people in mainstream housing, it has been found that many of those in need of support had not accessed social services; some were unaware of the availability of such services, and some tended not to approach social work departments, because they were unwilling to see themselves as being in need of support (MacDonald, 1999 - looked at older people aged 75+). This research also found that these people wanted to be able to make their own support arrangements.

4.9. Systems for direct payment of Supporting People funding are under development in Scotland, and this may enable some older people to make their own arrangements for support, and thus provide them with additional choices. However, this will be limited to those who have the capacity to take on the role of "support co-ordinator". There are suggestions that at present, some older people pay for this support themselves as they are unaware of their right to Supporting People services, or have not been assessed as being in need and choose to pay for it themselves.

4.10. Ensuring that older people are aware of the services available to them is also a particular challenge. Several researchers have identified that older people are unaware of the services available to them, and that this is a key constraint ( e.g. Oldman, 1990a; Age Concern Scotland, 1998; MacDonald, 1999; Wright, 2002). At its worst there was evidence of people who had entered residential care, but felt they would not have had to, if they had been aware of the supports available, particularly in relation to grants, equipment and adaptations (Clough et al, 2003). The provision of equipment and adaptations is discussed further below.

4.11. The level of support provided through housing and care services determines to a large extent the capacity of older people to stay at home. However, there is evidence that these services are being stretched in order to provide intensive support to enable more dependent older people to remain in their own home (Curtice et al, 2002; Netten et al, 2005), while also providing lower intensity support, important for preventing dependency (Joseph Rowntree Foundation, 1999). Research in South Gloucester found that clients were not being maintained in the community solely through high levels of formal care: they identified that social and psychological support from family and social networks provide the key motivation for continuing to remain at home (Stilwell and Kerslake, 2004).

4.12. Research relating to the availability of domiciliary support in Scotland suggests that this form of support is being targeted at a smaller number of more dependent service users, at the expense of its preventive role. The researchers suggest that the result is that some older people are moving into residential care, despite having higher levels of function than those provided with intensive services in the community (Curtice et al, 2002).

4.13. This is particularly significant, given findings that older people's self-respect and feelings of independence can be significantly improved by a feeling that they are in control of their home and housework (Lund and Foord, 1999; Quilgars, 2000). Low intensity support or care has also been found to have other positive impacts:

• reduce isolation and provide social contact, even if the support is oriented to practical tasks;
• improved sense of safety and comfort in the home;
• improved confidence and a more positive attitude to life.

4.14. Direct information on the capacity of low level support to stop service users from moving into residential care has not been identified from the literature, though there is strong service user support for this form of provision (Quilgars, 2000; Levenson et al, 2005). A recent review of the Supporting People programme in England made the assumption that "five per cent of older people currently receiving Supporting People services and living in very sheltered housing, sheltered housing and receiving floating support would have to move into more intensive forms of residential care if these services were removed" ( ODPM, 2005a). (This assumption was arrived at through discussion with the Department of Health, and relates to both low and high intensity support packages.)

4.15. Recent personal and domestic care statistics indicate that there may have been a change in the focussing of support on the clients in most need. The number of clients aged 65+ receiving care increased by 4,000 over the two years to 2002/3, to 34,300 (Audit Scotland, 2004b; more recent statistics are not comparable with these, so it is not possible to monitor change over time.). This has been accompanied by increases in the number of older people receiving care in the evening and at weekends.

4.16. These performance indicators show how local authorities have progressed in terms of their provision of flexible services, but do not provide information relating to the number of hours each client is receiving. Thus while support may be provided in a flexible manner, it is difficult to determine the distribution of low and high intensity support.

Property Based Services

Care and Repair Services

4.17. Care and Repair services across Scotland help older people and those with disabilities to maintain their home in decent repair. The Scottish Executive provides revenue funding for care and repair projects to local authorities through the Private Sector Housing Grant ( PSHG). Local authorities, NHS Trusts and other funding agencies contribute various levels of revenue funding to help deliver respective national and local priorities / targets.

4.18. Care and Repair services have been in existence in England and Scotland since the 1980s. However, there has been a renewed focus on the impact they can have on private sector housing stock since the Housing (Scotland) Act 2001. This came into force in October 2003, and gave local authorities increased responsibility for strategic development in private as well as social rented housing sectors.

4.19. In 2001 there was at least partial coverage in most local authority areas with Care and Repair services, with the exception of six (mostly rural) local authorities. These services are available to older people in owner occupied and private rented properties. They include facilitation of repairs and improvements, small repairs services, installation of equipment and adaptations, home security measures, and a register of reliable trades people. (Scottish Executive, 2002d)

4.20. The Scottish Executive's Housing Improvement Task Force examined the issue of care and repair, and identified a need for local authorities to provide services to assist home owners with the care and repair of their properties, based on "the principle that the form of assistance should be appropriate to the difficulty that the owner faces in carrying out works" (Housing Improvement Task Force, 2003). This report specifies that, while owners are responsible for the maintenance of their property, there should be mechanisms in place in all local authority areas to ensure that owners take on this responsibility. Where owners find this difficult (for example, older people), a 'Scheme of Assistance' should be available to assist them with this responsibility. It also recommended that national standards were implemented for the delivery of Care and Repair services.

4.21. Since this report, the Scottish Executive has issued standards and guidance that local authorities are required to work towards (Scottish Executive, 2004a). The standards cover fair access, service management, 'being an employer', joined up service delivery, and the provision of information and advice. There are also specific standards for service provision in relation to major repairs and adaptations, handyperson and small repair services, and home visits.

4.22. It is too early to tell what impact these improvements in legislation and standards will make on the delivery of services to older people. However, the signs of progress are evident in the fact that the coverage of Care and Repair services has improved, with Midlothian being the only local authority not to have this provision.

4.23. These services provide a key mechanism by which older people can remain in their own home. The Health Department's recent review (Scottish Executive 2006d) notes that care and repair is a major contributor to reducing delayed discharge and inappropriate admissions. They therefore play a significant strategic role, and the distribution of funding to these services, among others, will influence the decisions of older home owners, particularly those with limited incomes (Williams et al, 2001).

Equipment and Adaptations

4.24. The provision of equipment and adaptations impacts on the housing needs of older people at two critical times:

• Circumventing a need to move into alternative accommodation when frailty and ill health mean that the person's home is no longer fit for purpose, and is leading to a decline in physical or mental health and increased risk;
• Following a period of critical ill health and admission to hospital, equipment and adaptations can facilitate a move back home, rather than to alternative accommodation.

They are therefore seen as supporting the government's key aims of keeping people out of hospital, reducing strain on carers and promoting social inclusion. Occupational therapists from either social work departments or hospitals are responsible for doing home assessments, and identifying what equipment and adaptations are required in the home. Good practice guidance from Scottish Homes (1999) indicates that housing managers also have an important role to play in identifying and assessing need and maintaining completed adaptations in the social rented sector.

4.25. Home adaptations in particular are a highly effective way to improve the safety and quality of life for older people (Heywood, 2001). Minor adaptations (under £500) were often used to provide rails, ramps, over-bath showers and door entry systems. These were generally associated with a range of lasting positive consequences, such as feelings of safety and greater independence in bathing and toileting.

4.26. This research also identified that major adaptations (over £500) were associated with even more positive results for older people, and often transformed their lives. The works included extensions to the home, improved heating, stair lifts and adaptations to bathrooms. These led to major improvements in quality of life for both the recipient and their carer, with increased confidence, dignity, self respect and independence all noted by the research. Average satisfaction ratings for those aged 65+ were more than 9 out of 10.

4.27. Very few adaptations for older people were seen as unsuccessful, and the research therefore concluded that adaptations provided very good value for money. They also suggested that increasing funds for adaptations could come from a range of funding sources, as the positive effects are felt far beyond the housing department.

4.28. The research undertaken by Clough et al (2003) identified stairs as a particular issue for older people; 17% found internal stairs difficult to manage. The provision of stair lifts in particular was identified as a feature that some older people said would have been particularly useful for them (Audit Commission, 1998).

4.29. The recent review by the Health Department (Scottish Executive, 2006d) found that Equipment and Adaptations are cost effective alternatives to other care services. They quoted an example where the cost of home care while waiting for a stair lift to be installed (delay was caused by an inadequate Equipment and Adaptations budget) cost more than the stair lift itself. The findings of this review and previous research (Heywood and Smart, 1996) indicate that adequate funding for equipment and adaptations has been an issue for some time.

4.30. Good practice guides in adaptations (Scottish Homes, 1999; Scott et al, 2001) recommend the monitoring of adapted social rented properties, so that the properties can be suitably matched with the needs of future tenants. Databases of adapted properties in all tenures can improve access to information on properties that have been adapted (such as the Disabled Persons Housing Service in Lothian, Scott et al, 2001). It is advised that some adaptations can be re-used, where these involve the installation of equipment such as stair lifts. This could be applied across tenures, and, given the barrier that stairs can cause for older people, this creates potential for significant savings (Audit Commission, 1998).

Sheltered Housing

4.31. Sheltered housing schemes were initially introduced in the 1960s, and were a popular form of provision throughout the 1960s and 1970s. However, in the last twenty years the development and delivery of sheltered housing has changed more than any other form of housing (Foord, 2005). The characteristics of residents have also changed, along with the services provided, the staff, and the approach to facilitating independent living. However, it is interesting to note that the proportion of the older population living in sheltered and very sheltered accommodation has remained fairly static at around 5% since the 1980s (Clapham and Munro, 1990; Sumner, 2002).

4.32. The early sheltered housing schemes (and many later ones too) provided small units (often bedsits, though increasingly one bedroom flats), with shared facilities such as bathrooms (particularly in the early schemes) and residents lounge and laundry. This model also includes a resident scheme manager; the exact role of the scheme manager varied significantly between schemes, though the role of a 'good neighbour' able to respond to emergencies has been suggested as the original key function (Clapham and Munro, 1990). An emergency alarm for residents to call the scheme manager was also considered to be a key, popular feature of this traditional model.

4.33. As the residents in these original schemes became older, and housing expectations changed, issues with this form of provision started to emerge in the 1980s. The difficulties identified in the provision of sheltered housing are now well known. A review of the factors leading to difficulties with letting sheltered accommodation (in England and Wales, 1994-5) found that 92% of local authorities and 79% of large housing associations had encountered some difficulty in letting their stock. Furthermore, 8% of local authorities and 14% of housing associations found over half of their traditional sheltered housing units (Category 2 stock) difficult to let (Tinker et al, 1995). This research may now be somewhat dated, though the issues encountered have been reiterated since then. The various issues have been identified from a range of literature (Clapham and Munro, 1990; NFHA, 1994; Tinker et al, 1995; SFHA, 2005; Parry and Thompson, 2005):

• Size of properties was often identified as particularly problematic, with bedsits being the least popular, and single bedroom flats being increasingly seen as too small for older people, particularly couples and those being encouraged to down-size from larger social rented housing.
• Access difficulties, particularly where properties are on upper floor without lift access; wheelchair access can also be problematic. Guidance on the development of new sheltered housing in Scotland in 1980 specified that sheltered units should be on ground or first floor, unless a lift was provided (Scottish Development Department, 1980), and this was not revised with more accessible specifications until Housing for Varying Needs was introduced in 1998 (Pickles, 1998).
• The neighbourhoods in which sheltered schemes are located have changed significantly since their initial development, with the closing of local shops and services, and reductions in public transport. They may also now be in areas where other housing and social issues make them unpopular for all tenants, not just older people.
• The introduction of the European working time directive and other developments in human resources mean that the role of the scheme manager has had to change. This also reflects the changing client group that are living in sheltered housing.
• The increasing age of residents in sheltered schemes meant that the level of support available from the scheme manager was insufficient, and prior to the developments in widespread community care and support services, this was a significant issue.
• Some areas may have an over-provision of sheltered housing units.
• Where there have been difficulties of low demand, allocation policies have been implemented to try and bring in a wider mix of tenants. However, this has led to further difficulties, as people have accepted sheltered housing tenancies that they did not want, because they were in need of accommodation, and accepted the first offer, for fear of not being offered an alternative.
• Contradictions have also been identified within the traditional model of sheltered housing: that it can only work when a fair proportion of the residents are fairly independent, and do not particularly need its specialist facilities. This has led to allocation policies that are not based on the needs of residents, but on the needs of the scheme as a whole, or on the need to fill units (where low demand has become entrenched).
• In addition to these factors, the change in approach initially to the provision of services that enable people to remain in their own homes, and more recently in the emphasis on choice, has reduced overall demand for sheltered housing.

4.34. With greater understanding of the issues faced by sheltered housing schemes, and a requirement to cater for the needs of the increasingly elderly population of many sheltered schemes, the 1980s saw the diversification away from this traditional model. There has been an effort to identify the popular aspects of sheltered housing scheme, and adapt these into more flexible forms of provision to provide for the needs and expectations of older people (Tinker et al, 1995). This led to the development of very sheltered or extra-care schemes for those in need of more intensive support.

The Changing Role of the Scheme Manager

4.35. In particular, the role of the scheme manager or warden has changed, and continues to change. There are a number of aspects to the role that have changed, and the changes vary significantly from scheme to scheme.

4.36. A project established in 1997 aimed at highlighting the changes that were underway in sheltered housing, and the opportunities that this presented for partnership working between scheme managers and social care and health professionals (Hasler and Page, 1998). This encouraged many local authorities to review the role of their scheme managers, and to improve joint working practices.

4.37. The change in legislation and in staff expectations has led to a significant shift away from resident scheme managers (Parry and Thompson, 2005), and towards a system of duty managers, with a transfer to a community alarm scheme for over night. In some cases mobile scheme managers now cover a number of schemes, with a greater reliance placed on alarm systems for when they are not on site. While some managers are still residential, there is no longer an expectation that they will always be available to cover out of hours emergencies.

4.38. The role has also become increasingly professional, with an increase in the level of staff training and qualifications. It has also diversified into a range of different areas (Parry and Thompson, 2005; Hasler and Page, 1998; Scott et al, 2001):

• Tenancy and independent living support, both for residents and also for older people in the wider community on an outreach basis;
• Promotion and facilitation of social activities, including involvement with the wider community through opening up activities to other older people and their families, activities with local school children etc;
• Management of the housing stock in terms of maintenance, safety and tenancy issues;
• Promoting residents' involvement in service development and housing issues;
• Increased involvement in tenants' financial situation, with the provision of advice and assistance in relation to accessing benefits;
• They increasingly undertake joint working with social care and health services in relation to assessments of need, arrangements for hospital discharge, facilitating and monitoring the support that tenants receive from other agencies, and in some cases acting as care co-ordinator. The provision of additional support and personal care in sheltered housing schemes is increasingly common, and blurs the boundaries between sheltered and extra-care housing. The scheme manager can perform a useful role in monitoring and sometimes co-ordinating the input of social and health services.

4.39. The changing role of the scheme manager means that sheltered housing has more to offer residents, and makes it more distinct from floating support provided to those in general housing. However, the physical limitations of some sheltered housing schemes (in relation to unit size, stairs, and shared facilities) still cause problems for some providers.

Other Improvement Options

4.40. A range of options have been identified for difficult to let housing schemes (Clarke, 2004; Tinker et al, 1995; NFHA, 1994). These include refurbishment of the property, conversion of bedsits to one bedroom flats, installing lifts, and improving communal facilities. Some providers have also focused on marketing the advantages of their schemes, particularly following other improvements, although they not that this should not exaggerate the positives. The research by Tinker et al also found that broadening allocation procedures had been used to increase lettings, and while this had achieved its aim, it may have been at the expense of choice for the new residents (Clapham and Munro, 1990). More radical alternatives have also been suggested in this research: changing the use of the whole scheme (this could include a shift towards provision for older people with more intensive needs, or different groups all together), or disposal of the scheme. However, both these alternatives involve finding new homes for some if not all residents, and this can be problematic, particularly in rural areas where schemes are widely dispersed.

4.41. The option of diversifying the provision of support, in relation to the forms of care and support to residents, as well as extension of provision into the wider community have been tried with success ( NFHA, 1994). The expansion of service provision to include older people in the community has the advantage of increasing the scale of support services available, and also increasing diversity in the range of people attending activities provided on site. It may also serve to shift people's perceptions of sheltered housing.

Private sheltered and retirement housing

4.42. Since the 1980s there has been an increasing development of private sheltered and retirement housing. In Scotland, there are estimated to be 6,000 households (5.5%) in this sector (Fisk and Prida, 2004), with development starting in the mid 1980s (Edgar, 1987). In England the level of private provision has been estimated to be around 14% of all sheltered housing (Sumner, 2002; Dalley, 2001), and is increasing every year. Figures for 2004 indicate that 3,888 new retirement homes were built in England in 2004, of which 3,169 were warden assisted ( NHBC, 2005). With increases in home ownership in those approaching older age it is anticipated that this form of provision will become increasingly popular (Mills, 2004; Dalley, 2001).

4.43. The profile of sheltered housing in the private sector is generally to higher specification, with newer buildings, larger flats, and located in better neighbourhoods. As a result, they have not suffered from the low demand evident in the social rented sector (Dalley, 2001).

4.44. Research in Scotland found that the majority of private sheltered housing units were sold outright, with just 4% being available through shared ownership or shared equity schemes through registered social landlords (shared ownership properties were in schemes with other privately owned units) (Fisk and Prida, 2004). A further 2% were estimated to be privately rented.

4.45. Private sheltered schemes generally provide similar facilities to traditional sheltered housing schemes in the social rented sector. The focus is generally more on property maintenance than the provision of care and support (Joseph Rowntree Foundation, 2004; Netten et al, 2005). Almost all these schemes (around 95%) have scheme managers, with the majority (75%) having resident managers, with a social alarm service for when the manager is unavailable (99%). Communal facilities such as common room, laundry and guest bedrooms were also identified in the majority of private schemes. (Fisk and Prida, 2004).

4.46. In comparison with residents of social rented sheltered housing, the residents of private schemes have an older age profile, and have lower support and care needs. The trend is towards increases in age, and an increasing proportion of female owners. Satisfaction levels have also been found to be high, with surveys indicating that the move had improved quality of life, and many felt it was a 'good investment'. (Dalley, 2001).

4.47. Where dissatisfaction was expressed, it was generally identified in relation to similar concerns to those in the social rented sector; in particular, lack of enough space was often mentioned. Specific to owners were concerns over management and especially service charges. (Dalley, 2001).

4.48. One of the key differences between private and social rented sheltered housing lies in arrangements for the delivery of additional personal care. In private schemes this is generally managed by the individual or their family, with direct funding from Supporting People where eligible (Mills, 2004). Those within the social rented sector are more likely to have their care provided through social services, or contracted out by them, rather than through direct payments.

4.49. However, this situation is changing, with increases in the delivery of owner-occupied extra-care facilities (Netten et al, 2005).

4.50. Following the introduction of the Title Conditions (Scotland) Act 2003, owners of sheltered properties have the right to vote on certain aspects of their services, such as the scheme manager and social alarm service provider, according to the burdens of title. These votes are available only to the owner, not the resident. Therefore high proportions of private rented properties within one development could give landlords undue control over the services provided to residents. However, research found limited levels of private renting, and in dispersed developments. This therefore allayed concerns over the impact of the legislation on residents' rights to choice. (Fisk and Prida, 2004).

4.51. Over 90% of developments had adopted the Scottish Executive Code of Practice for owner occupied sheltered housing (Fisk and Prida, 2004). This sets out good practice in scheme management, such as the development of owners' associations, consultation on major repairs, and a full explanation of charges (Scottish Executive, 2000a). This then ensures that in the majority of schemes certain safeguards are in place, though these are significantly less than the level of accountability required of registered social landlords.

4.52. In many areas of England private sheltered housing schemes are now required to provide a number of 'affordable' housing units, similar to all other housing developments (Fynn and Auchincloss, 2003). This question has not yet arisen in Scotland, though the increase in provision of private sheltered accommodation and the development of national planning policy to deliver affordable housing (Scottish Executive, 2005h) mean that some planning authorities may have to develop policies to address this issue.

very sheltered and Extra-Care Housing

4.53. The identification of difficulties with existing sheltered housing in the 1980s, and the increasing frailty of the sheltered housing population led to the development of early forms of very sheltered and extra-care housing. This form of delivery has been both supported and influenced by developments in community care since the 1990s, with a focus on assisting people to remain in an environment that is as 'homely' as possible (Fletcher et al 1999). In 2001 there were 23,000 extra-care units in the UK, equivalent to 5% of all sheltered housing. Unfortunately there has been little research done on the provision of extra-care housing in Scotland to date, and the development of these schemes appears to have come somewhat later than schemes in England ( e.g. Godwin, 1987).

4.54. There is no single definition of extra-care or very sheltered housing in the literature (and it is occasionally referred to as 'supported housing' and 'assisted living'). The Scottish Executive uses definitions set out in their Supporting People Operational Guidance (Scottish Executive, 2002f). In this guidance, very sheltered housing and extra-care housing have similar definitions, including 24-hour care (extra-care) or wardens (very sheltered), and at least one meal a day in very sheltered housing, and a full meals service in extra-care. The most significant difference is in the separation of housing and care providers in very sheltered housing, such that full tenancy rights are maintained, whereas joint provision of care and housing in extra-care, such that residents have occupancy agreements rather than tenancies. In this report we have used the terms as they appear in the literature wherever possible, though the definitions used by the Scottish Executive are not universal, and there is some overlap in these terms within the literature.

A Supportive Environment

4.55. Extra-care and very sheltered housing provision aims to replicate the advantages of remaining at home or in sheltered housing (such as having your own front door, security of tenure, access to social networks and housing support as in sheltered housing) as well as the provision of flexible care. Informal care can be provided as at home, and spouses can remain together (Stilwell and Kerslake, 2004). Indeed relatives are often an important source of care and support, and contribute to the life of the scheme (Oldman, 2000). They have been likened to an alternative to residential care, though this alternative may not be realistic in all cases, and some commentators suggest that those with intensive support needs, and particularly those with sensory impairments, may not find the support and interaction enough (Brookes et al, 2003).

4.56. The main difference between traditional sheltered housing models and very sheltered housing is the provision of additional support services, including personal care (Brookes et al, 2003). The provision of a barrier-free environment and the provision of a meal or meals have also been identified as core aspects to this form of housing.

4.57. The flexibility of the level of support has also been identified as a key feature of very sheltered housing (Fletcher et al, 1999). In particular, the provision of care and support through one dedicated team, often based on-site, means that there is a much greater level of coordination in support. By comparison, the spot-purchasing of care and support in traditional sheltered schemes can lead to a patchwork of service providers and visiting support staff, with a single scheme manager who is unable (or not empowered) to monitor all comings and goings. However, the provision of care through one on-site team means that the residents have no choice in the management of their care, and only limited choice in who provides it (Lloyd, 2005). Some residents have been found to prefer to get a more flexible package of support from providers of their choice (Oldman, 2000).

4.58. In private extra-care schemes there may be more variation in who provides services, as some residents may be paying for their own support services, and so can choose external agencies. However, there is often a basic support service as part of the service charge, which can be topped up as appropriate (Riseborough and Porteus, 2003).

4.59. One key variable in extra-care housing schemes is whether the care provided is integrated with the housing ( i.e. provided by the same organisation), or separated (Brookes et al, 2003), as identified in the Scottish Executive's definitions (Scottish Executive, 2002f). Local authorities tend to provide integrated schemes (where they own the properties and provide care), while housing associations and particularly private schemes are often separated. However, Anchor Trust prefer to use an integrated model, with the housing and care services all managed by the scheme manager, as they consider this improves communication and clarity for residents and their families. Local authorities have often been resistant to facilitating this integration through their funding, preferring to either provide the care through their own in-house provision or contract it out to a third party, so they can maintain more control over this element (Brookes et al, 2003).

4.60. The average level of care provided in extra-care (from a survey of seven schemes managed by Hanover Housing Association in England) is 9.5 hours per week, which is slightly less than the 13 hour average for residential care (though this includes some additional activities) (Bartholomeou, 1999). This research also identified that social services generally considered extra-care provision to be a good value alternative to residential care, though this became questionable for those requiring particularly intensive support (20+ hours per week). Hanover Housing Association have identified a threshold of 11 hours a week, above which residential care becomes a more cost effective option (Booker et al, 2003) (though still not necessarily preferable for the individual). However, research undertaken for the Joseph Rowntree Foundation found that very sheltered housing is usually more expensive than residential care, when the full range costs are taken into account (Oldman, 2000).

4.61. The staff in extra-care facilities aim to support and enable the residents to do things for themselves. However, this can often take longer than doing the task for the resident, and staff require training to work effectively with residents (Riseborough and Porteus, 2003). There are therefore short term and on-going resource issues involved in the extra-care approach, though the prolonged independence achieved may reap resource rewards in the longer term.

Enhanced Physical Surroundings

4.62. Some extra-care schemes provide a range of other facilities, including social activities, assisted bathrooms, cleaning services and an on-site shop (found to be particularly popular) (Bartholomeou, 1999). Housing 21 has developed a number of units with facilities such as café, shop and hairdressers, which are open to the wider community, and they intend to extend this practice to more new schemes (Brookes et al, 2003).

4.63. Variations between very sheltered housing schemes have also been identified in relation to:

• The ownership and management of the scheme and their philosophy ( e.g. whether greater emphasis is placed on the building and its facilities or the care provided);
• The physical structure: whether it was purpose-built or conversion, the number of units on site and its location in relation to other facilities; the initial financing of the scheme.
• Some very sheltered units are part of wider schemes, with other sheltered units and/ or residential units alongside very sheltered units, though this is generally found most in local authority schemes. (Brookes et al, 2003)

4.64. In terms of purpose-built very sheltered housing, commissions for new-build at the end of the1990s (Fletcher et al, 1999) indicated that there was an increasing emphasis on:

• Flexible buildings, with clusters of flats creating smaller modules
• Higher space standards, and particular attention to the design of kitchens and bathrooms
• A proportion of two-bed flats
• Lift access
• Informal seating areas and communal lounges, as well as larger communal facilities for day centre or other activities
• Catering and dining facilities.

4.65. As with sheltered housing services, the importance of a good estate manager, who works closely with social services and other agencies, has been identified as key (Bartholomeou, 1999). Where care services are provided by a separate team, there is variation in the role of the scheme manager. In some cases they work alongside the care team, while in others they are responsible for managing the team (Lloyd, 2005).

Residents in Extra-care Schemes

4.66. Residents have generally expressed considerable satisfaction with very sheltered housing, particularly in relation to access to care, and provision of meals (Fletcher et al, 1999), though there are some criticisms. These have been identified in relation to staffing levels and location of schemes closer to community facilities (Bartholomeou, 1999). Other research identified dissatisfaction with provision of lifts, and with the provision of baths rather than showers (Fletcher et al, 1999).

4.67. The mix of residents' ages and abilities in extra-care/ very sheltered schemes has been identified as an important element in their success (Fletcher et al, 1999; Stilwell and Kerslake, 2004). It has therefore been suggested that extra-care is promoted as a preventive service, for those who wish to move before they develop intensive support needs. This would require the provision of enough units to accommodate people with a range of needs. (This has also been identified as an issue in alternative models of provision as well, as detailed in Chapter 6.) Without ensuring this range of provision, older people are likely to avoid moving to extra-care until their support needs are at such a level that residential care is the most likely option (Stilwell and Kerslake, 2004). Tension has therefore been identified between the aim for a balanced and active community and the operation of these schemes as alternatives to residential care. Allocation policies have been found to focus on dependency, not on social needs or aspirations; and this is likely to hamper the long-term vibrancy of the community (Oldman, 2000).

4.68. This situation resembles some of the difficulties that sheltered housing schemes encountered in the 1980s, when their increasingly frail and aging populations made them unattractive for more able older people. It begs the question as to how to manage allocations effectively, and how to make extra-care/ very sheltered schemes more attractive to the more able older people they need if they are to remain balanced and lively communities.

4.69. The delivery of a flexible service to a larger group of people as identified above would be a particular challenge for rural areas (Williams, 2001). In these areas the research suggests focusing funding on providing intensive home care packages, mobile wardens and befriending schemes as a more realistic way of helping older people stay in the community.

Cost-effective Provision

4.70. Larger schemes make the provision of care services more cost effective, though economies of scale can also be delivered through schemes with a mixture of sheltered and very sheltered units (Williams, 2001). The provision of support to all residents (whether public or privately funded) as well as others in the locality can also improve cost effectiveness, though this also provides contractual challenges for local authorities and care agencies (Lloyd, 2005).

4.71. The level of demand for very sheltered housing is high, and many schemes are over-subscribed. There are, however, suggestions that this may in part be due to the closure of residential homes and the view of some local authorities that very sheltered housing is a realistic alternative, though the researchers suggest that this may not be the most appropriate setting for more dependent older people (Brookes et al, 2003).

4.72. This finding is in line with current UK government practice to provide support for the development of new extra-care units, while reducing support for residential care. The government provided £87million between 2004-6 for local authorities in England to develop extra-care provision, and they are set to provide a further £60 million in 2006-8 (Leason, 2005).

Private Provision of Extra-care Housing

4.73. There are a growing number of private very sheltered housing developments, which provide enhanced care and support, as well as a range of communal facilities. In addition to the private development of very sheltered schemes, many housing associations and not-for-profit organisations also offer very sheltered units for leasehold and sale in England. There is little information available at present about the scale of this provision. However, it seems likely to constitute a small proportion of the market in Scotland, given the lower overall proportion of privately owned sheltered housing (Fisk and Prida, 2004). This is an area which may see significant expansion in the future.

Re-modelling Sheltered to Extra-care Housing

4.74. Many extra-care/ very sheltered schemes have developed out of traditional sheltered schemes, and this trend seems likely to continue. The period of transition can be crucial to the development of a fully integrated service. The experiences of the major specialist provider, Housing 21, in transforming sheltered to extra-care schemes has enabled Clarke (2004) to identify the key building blocks that facilitate this process:

• The development of a long-term business plan, which includes an analysis of the long-term needs of the local area, to ensure the long-term requirements for changes in provision. This could include an investigation of the options for provision of wider community facilities, such as meeting spaces, café, day care, shops, hairdressers, gyms and spa pools, IT facilities, and provision of intermediate care.
• Clarity on capital and revenue funding. Capital funding may be sourced from health as well as housing budgets, and from Private Finance Initiatives. Revenue funding can come from social services, health or Supporting People budgets.
• Involvement of residents is essential to gain their support for the changes. This should include discussions over the facilities to be provided, involvement in the design process, and in decisions over phasing and management of moving tenants during works.
• A clear design brief, which incorporates minimum mobility standards; staff facilities; design features that assist with orientation; provision of communal facilities, etc. In addition, each individual flat must meet the 'home for life' standard (or the 'homes for varying needs standards' in Scotland).
• Active inter-agency support and the use of experiences and committed consultants and contractors.

4.75. Other issues which should be considered early on in the re-modelling process include:

• Whether and how best to move residents during works;
• The phasing and timetable for works;
• Impact on revenue of a reduction in the number of units;
• Deciding whether to provide exclusively extra-care units, or to mix sheltered and extra-care provision;
• Deciding on and planning for provision of outreach facilities, respite and intermediate care;
• Use of technology, particularly for residents with particular needs;
• How best to meet the needs of older people from black and minority ethnic communities;
• The role that the scheme manger and staff and will play.

4.76. Despite the difficulties involved in re-modelling existing schemes, it is argued that there are significant benefits over new-build: the cost is significantly lower (around £30,000-£40,000 less per unit); the availability of the site is key, as suitable new-build sites can be very difficult to access; and they provide the chance for existing residents and the local community to develop a scheme and services that meet their own specific needs.

The Need for Consultation

4.77. Tinker et al (1995) highlight the importance of consultation for sheltered housing tenants, particularly when major changes are being proposed, whether they are physical works, allocation policy changes, or whole scheme changes. This is an issue that has been raised by a number of other researchers (Scott et al, 2001; Appleton, 2002; Cooper, 2005), and is highlighted in policy documents ( e.g. Scottish Executive, 2001c). The best results are achieved through a high level of consultation with tenants in the period running up to the change. If changes in the provision of care are being proposed, residents should be given considerable say over which agency should provide the service (Lloyd, 2005).

4.78. The need for ongoing communication with tenants can be achieved in a number of ways. Brooks et al (2004) evaluated four very sheltered housing schemes, and identified a number of methods of effective communication with tenants. In particular they highlighted the use of tenants' forums and consultative groups. Inviting tenants' relatives to join these groups was considered an effective way of including those with severe or multiple communication impairment. However, the report said that this mechanism was rarely used. Notice boards were also advocated as a means of improving communication, particularly through the use of photos of staff with clear labelling, as were scheme newsletters.

4.79. The scheme management should be open and responsive to the views of residents, and be willing to be flexible in response to their concerns. Communication should go two ways, if consultation is to be effective, though this was not always found to be the case (Brooks et al, 2004).

The Need for Partnership Working

4.80. The development of strong partnerships is important for every stage of the planning and delivery of sheltered and extra-care/ very sheltered housing. New provisioning should only be undertaken after thorough needs analysis and strategic planning of all forms of provision for older people. This requires the involvement of primary care trusts, social services, housing, Supporting People commissioners, and sometimes planning and regeneration teams (Riseborough and Porteus, 2003). The importance of good partnership working was identified above in relation to the re-modelling of sheltered housing schemes into extra-care, but it is equally important for new-build developments.

4.81. The commissioning of service providers, and particularly joint commissioning of health, personal care and housing support (for example), is only possible if effective partnership working arrangements are in place (Riseborough and Porteus, 2003; Fletcher et al, 1999). This form of commissioning provides considerable scope for the delivery of best value, and it is therefore important for agencies to determine how it can be achieved in each individual situation. This has been achieved in Liverpool through the development of the Liverpool Strategic Commissioning Board, with representatives from housing, social services, Supporting People, regeneration and primary care trusts. As well as these statutory bodies, it includes voluntary service providers, housing associations, Housing Corporation, Strategic Housing Partnership, and private sector providers of care homes and home care providers. This Board can plan effectively for both capital and revenue investment in a strategic way for all forms of supported housing provision (Riseborough and Porteus, 2003). ⁵

4.82. Effective delivery of services also relies heavily on joint working between staff from different professions. This was identified in relation to the role of the scheme manager, and includes other on-site staff, domiciliary, health and personal care staff (Hasler and Page, 1998). The wide variety in the working arrangements across schemes mean that roles, responsibilities and communication systems will be different for every scheme, and that good management is important for ensuring these are clearly identified (Parry and Thompson, 2005).

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