NHS Circular No: NHS MEL(1994)86

Env Circular No: Env 28/1994

SWSG Guidance Package, Index Ref F.16

Previous Circulars Cancelled/ NHS 1989(GEN)5

SW10/1988

14 September 1994

Dear Sir/Madam

COMMUNITY CARE ACCOMMODATION: PUBLIC AWARENESS AND LOCAL DISCUSSION

Summary

This Circular deals with the delivery of community care support services, including housing, for those discharged from long-stay hospital care and for those already in the community requiring additional support.

Introduction

1. This circular offers advice on the type and location of housing for those with community care needs; and gives practical guidance on ways of keeping the community informed about, and receptive to, community care housing developments and on the circumstances in which these might be helpful. This Circular replaces the guidance in Circulars NHS 1989(GEN)5 and SW10/1988, which are now withdrawn. It complements the guidance in the recently issued Circular Env 27/1994, SW7/1994, NHS MEL(1994)79 on Housing and Community Care. Like that Circular this guidance reflects the combined interests of health, social work and housing within The Scottish Office.

2. The issues that providers and managers of community care accommodation need to consider in the context of liaison with the local community apply across the board to all community care client groups. This Circular should therefore be taken as offering guidelines equally applicable to the full range of vulnerable people needing support, including older people, people with physical or learning disabilities, dementia sufferers, young people with special needs, people with mental health problems, people with alcohol and/or drug problems and people with HIV/AIDS. It is addressed to all the agencies involved in providing or purchasing community care support services - Health Boards, NHS Trusts, social work and housing authorities, Scottish Homes, housing associations, voluntary bodies and private providers.

3. The principles of care in the community are well established and accepted by practitioners. There is now a substantial body of guidance elaborating these principles. The practical implications of "normalisation" for the planning and delivery of a range of support services are of central importance. These services can no longer be designed around one particular model or set of assumptions about client requirements but must be capable of responding to a wide range of individual needs and wishes. The aim is to enable individuals with community care needs to lead as normal a life as possible, using mainstream services and living in their own homes or homely settings, either alone or with others of their choice.

4. In this context it is important to bear in mind that care in the community covers not only accommodation (whether mainstream, residential, adapted, very sheltered, sheltered, medium dependency or other) but also day care and domiciliary services and other related services. Indeed the whole range of resources available in the community, including social, recreational, educational, employment and community health services may need to be brought into play in providing appropriate support. If these services are to be effective in integrating and retaining individuals within the community, they need to be increasingly designed with the varying and evolving needs of individuals in mind.

5. NHS Circular No 1975(GEN)46 is concerned with the closure or change of use of Health Board premises providing any of the services available under the National Health Service Acts and includes procedures for consultation with local and other interests. Although proposals to establish community based facilities may involve the use of property transferred to NHS Trusts, the guidance in this Circular and in the 1975 Circular generally address different situations, especially in terms of scale.

Options for Accommodation

6. Local authorities are responsible for assessing peoples' care needs, including accommodation, and responding to these needs either by providing from within their own resources or purchasing services from the private and voluntary sectors. The availability of a range of suitable housing for those requiring community care is essential if their needs are to be properly met. There should be a general presumption in favour of people being able to exercise choice over the service they receive. This point is covered in the guidance circular SW05/1993 and the associated Social Work (Scotland) Act 1968 (Choice and Accommodation) Directions 1993. Providers should, therefore, be aware of the variety of needs of users and their carers and take their views into account when making development plans. Where there are obvious communication difficulties, a user's advocacy needs must be addressed.

7. It should not be assumed that the care in the community alternative to long term institutional care is necessarily accommodation in a "group home". The majority of community care users will be accommodated in mainstream housing, with adaptations, if necessary. A range of options exists from managed homes and hostels to core and cluster flats, supported landlady schemes and ordinary tenancies, some of which may be slightly adapted to suit particular needs. Some people will want to live alone; some will prefer to share accommodation with others; and for some a staffed care home will be the only way to provide an appropriate level of support outside hospital.

8. As a general principle, in considering the housing requirements of individuals with community care needs, the aim should be to ensure that the property into which they move is similar in character and appearance to other properties in the same area. If a property which is strikingly dissimilar to its neighbours is selected for community based housing, the aim of integrating its residents into the mainstream of the community may be frustrated. For this reason, large scale hostel type accommodation should generally be avoided. This type of accommodation is too institutional and therefore undesirable to community care. Generally, community care provision should be dispersed throughout communities; and concentrations, for example, close to local day hospitals or day centres, which might inhibit integration should be avoided. At the same time, properties selected for residential community care should where possible be located within easy reach of shops, local amenities, and good public transport links. Full account should also be taken of the wishes of the prospective resident in relation to the area into which he or she wishes to move. Regard should be had to the expertise of many housing associations and voluntary organisations working with other housing providers in providing accommodation for people with community care needs, often as part of a mixed needs project where housing is provided in one complex for people with varying needs and requirements.

9. It may be that the NHS Trust, the social work authority or a voluntary organisation itself already owns property; but this should not be the overriding consideration in deciding where to provide residential accommodation. Indeed it may well be that the buildings owned by a statutory or voluntary organisation may have, by virtue of architecture or local identification and history, over-much of an institutional feel and would therefore be inappropriate for those making the transition from hospital into the community.

Planning Considerations

10. Developments (including any material change of use) commissioned by a social work authority, housing provider, Health Board or NHS Trust, require planning permission the same way as developments by any other developer. The procedures for obtaining planning permission are set out in the Town and Country Planning (General Development Procedure) (Scotland) Order 1992. These procedures include notifying neighbours about the proposals before the application is submitted. The Town and Country Planning (General Permitted Development) (Scotland) Order 1992 grants general planning permissions (known as "permitted development") for a variety of minor developments which may be helpful in certain cases, eg for alterations or small extensions to houses. The planning authority will be able to provide any advice an authority may require on whether permitted development rights apply and on planning procedures generally. Authorities will also require to obtain listed building consent to demolish, alter or extend a listed building. The local housing authority will be able to advise on licensing schemes, or other regulations which would apply to housing for community care groups which may be classed as houses in multiple occupation.

11. Converting a family dwellinghouse to residential accommodation for not more than 5 residents (whether or not with disabilities or mental health problems), does not constitute a "change of use" for the purposes of the Town and Country Planning (Scotland) Act 1972 and so planning permission would not be required (although permission may still be needed for any physical alterations). However, the conversion of a family house to accommodate more than 5 residents, would constitute a change of use and require a planning application. Planning permission would also be needed to use a flat for residential accommodation regardless of the number of people it is to accommodate. Where there is any doubt about whether planning permission is required the planning authority should be consulted. The use of mainstream housing for community based developments for 5 residents or less may also obviate the need for extensive alterations which would otherwise require Building Control and Fire Officer consent.

12. Where a proposed development requires planning permission, the applicant is required to notify neighbours of the proposals before submitting the planning application to the planning authority. The fact that the development is to provide residential accommodation for community care does not give neighbours any more of a say in the process of determining the application than they would have in relation to development for any other purpose. The decision is entirely a matter for the planning authority, after taking account of any comments and other material considerations. Planning authorities must determine planning applications in accordance with the development plan for the area unless material considerations dictate otherwise.

Contact with the Local Community

13. There are many examples of the successful integration into the community of people with community care needs, often with positive local support; and the future lies in encouraging this approach. To achieve such integration requires sensitivity in discussing the issues, where appropriate, with others living in the area. In very many cases, the provision of support - through accommodation and other services - to enable individuals to resettle or remain in the community will be wholly uncontroversial. Indeed, the fact that accommodation is being provided in the context of an integrated programme of care will in many cases be invisible to local residents and neighbours. Although as a matter of principle proposals for such accommodation should never be concealed, elaborate information - exchange initiatives with the local community are unnecessary in such cases. They would also tend to undermine the principle of normalisation on which the policy of community care rests. The suggestions made in paragraphs 16 and 17 below are therefore offered for use in situations where, either because of the nature of the needs being catered for or because of the character of the neighbourhood, a possibility exists of local concerns arising from proposals for community care accommodation. It should perhaps be stressed that concerns may arise in any neighbourhood and cannot be linked to any particular socio-economic setting.

14. At the same time, and even in cases which may be contentious, it must be recognised that those leaving long stay hospital care or being supported in the community have the same rights as anyone else to choose where they stay; and these must not be eroded by a process of discussion with local residents which implies any right of veto. However local residents will be more likely to welcome and support such developments if provided with information at the right stage. It is important to stress that different approaches to the exchange of information with local residents may prove effective in different situations: the experience of bodies working in this field suggests that, whilst certain basic principles can be agreed, it is necessary to look at each project individually.

Publicising the Strategy

15. It is important to sustain efforts to inform the public not only about the broad principles of community care but also about the local effects of patient discharge programmes. The need to involve the community in a positive way in integrating individuals with needs for special support is particularly pressing in cases where a long stay hospital is being run down or is scheduled for closure. Patients may be transferred from the hospital to more than one housing authority area. A major issue of public education arises here. As lead agency for the provision of community care, social work authorities need to develop, with Health Boards, NHS Trusts and other planning partners, a programme of public education as part of their overall strategy. The objectives of such a programme would be to explain the thinking behind the transition to community care; to draw attention to the work that has been done in this field in recent decades; to publicise examples of successful developments; and to spell out the impact of the policy locally in the context of programmes for the discharge of long stay hospital patients and for the minimisation of hospital admissions. The programme might also describe the parts played by social work and housing authorities, Health Boards, NHS Trusts and voluntary bodies purchasing and providing community care; explain the way in which prospective residents prepare themselves for their move into the community; and make clear the range and types of support that can be provided to the residents both on the premises and through the whole range of community based services.

Inter-Agency Liaison

16. A programme of public education needs to be supplemented when plans are made for developments in particular localities - a district within a city, or a town or smaller settlement. The authority or agency which will be responsible for the development needs access to complete and up-to-date information about the location of existing special needs projects and facilities in the area before deciding on the precise area in which to focus its search for accommodation. Consultations amongst statutory authorities and with relevant voluntary bodies are therefore essential at this stage. Agreement should be reached amongst the relevant agencies involved on how consultation should be undertaken. It is also advisable for the agency contemplating a development to seek at this stage to make contact with community leaders and, in particular, to make its general plans known to any Community Councils in the area. Discussions at this stage should focus on the principles behind the development, on its supervision and management, and on the contribution which the community as a whole can make to the integration of the prospective residents. Whilst it will be for the body seeking to develop housing for people in the community to decide where it should concentrate its search, Community Councils may have useful information to offer on the suitability of certain neighbourhoods; and their views should be sought and taken into account. However, this should not be confused with a right of veto.

The Purchase of Specific Properties

17. When negotiations for the purchase of a specific property are underway, the body or agency responsible for the development should give careful consideration to the question of discussions and information exchange with the immediate neighbours of the development and with local residents in the vicinity of the development. This applies equally to tenants as well as to owner occupiers. Neighbours and other local residents have no right of veto on such developments, nor any say in the assessment process that determines who will be accommodated. It is however necessary for local people to have a clear understanding of such developments so as to dispel any misconceptions and to enhance the prospects for the full integration of the prospective residents. Various methods of giving information to neighbours and local residents have been tried: generally the preferred approach is for staff of the purchasing body or agency to introduce themselves to neighbours and to have informal discussions. The timing of the approach is important and can be difficult. Some bodies make a practice of visiting neighbours before the purchase is concluded; others open discussions after the purchase is concluded but before residents move in. Others again wait until work on the project is underway or until supervisory staff have moved in. No consensus has emerged about what works best: different approaches work in different situations. What is important is openness and a respect for all those involved.

18. The guiding principle, in approaching neighbours, should be to seek to enhance the prospects for the successful integration of the prospective residents. Research carried out in North America suggests that, whilst various approaches can work effectively in different situations, relatively low-key approaches, in which face-to-face discussions are held with selected individuals, seem to work better than high-profile approaches involving meetings with groups or public meetings. In all contacts with neighbours, however, it is important to make absolutely clear that "consultations" at this stage involve exchanging information and listening to views: they do not give local residents a right to choose their neighbours.

19. It is equally important to be clear about what neighbours can or should be told. The rights of the prospective residents to privacy and to confidentiality must be respected. Personal health information or other personal details about an individual prospective resident should not be released. It may be helpful however to indicate the general purposes for which the accommodation will be required. Neighbours cannot be given unequivocal guarantees that no problems will ever arise: difficulties may arise as they can do with any neighbour. Those responsible for managing the project should however offer information which may help to allay any fears or anxieties. In particular it is useful for neighbours to hear about an organisation's policy and practice in managing community care housing, and to have telephone numbers of people to contact if they have a complaint or an anxiety. It is important to bear in mind, too, that neighbourly concern, provided it is not intrusive, can be positive and beneficial to individuals with special needs. Neighbours can, and often do, provide advice and support in matters of daily living; they can help new residents make contacts in the local community; and good neighbours can be a source of reassurance to individuals with needs, as to any other resident.

20. The judgement as to how much information to give must always be made in light of the specific circumstances of the case. With certain types of accommodation, it may indeed be appropriate on occasion to give no information to neighbours. Where, for example, a project involves only 1 or 2 people in an unstaffed house, there may be no need or advantage to the residents in volunteering information about the nature of the accommodation.

21. It has been drawn to the Department's attention that, in the case of public sector housing, certain housing authorities make a practice of consulting with tenants' associations, Community Councils and others before new residential accommodation for community care is allocated. Some confusion over the nature of this consultation process has apparently arisen with local groups wrongly assuming that they have the right to veto special needs projects and objecting to what they see as "queue jumping". Housing providers should consider their procedures in these circumstances in the light of the guidance offered in this Circular.

22. Nothing that is said above about the need for local discussion should be seen as undermining the importance of siting residential accommodation in areas where adjustment to independent living can be facilitated. Any local objections should of course be responded to with openness and every effort should be made to resolve any conflict. Where conflicts arise, it is important that the framework for any discussions with objectors should be set by reference to what would be grounds for objection in planning terms.

Examples of Effective Practice

23. In recent years, a number of bodies involved in residential care developments have systematically examined various approaches to the involvement of neighbours and the wider community in housing projects. Some have developed guidelines for effective practice. The Scottish Office, in partnership with Scottish Homes, has recently awarded a 3 year contract to the Nuffield Centre for Community Care Studies at Glasgow University, to develop and manage on our behalf a database of good practice covering all aspects of community care. In time, the database will also include examples of effective practices in neighbour involvement and it is very important that organisations involved in this activity contribute to the database by nominating examples of practice. Further details about accessing the database or nominating examples of practice can be obtained from: The Database Manager, "Community Care Works", Nuffield Centre for Community Care Studies, University of Glasgow, 7 Lilybank Gardens, Glasgow, telephone: 041 330 4554.

Management of Community Care Accommodation

24. There is a clear responsibility on the managers of community care accommodation to ensure that the facilities are well run. They should ensure that there is a comprehensive and accessible system in place for dealing with complaints from the residents/tenants, from staff employed at the facility, and from members of the community. They should also seek to maintain positive and informal contacts with the community, using neighbourhood groups or Community Councils as appropriate, so as to maintain a clear understanding of the purpose of the project and to ease the passage into the community for people who may have lived in institutions for many years. This liaison may also provide them with useful feedback on their own performance as managers. It is important to recognise in this context that adjustments on the part of the managers, or the residents themselves, may well contribute to the overall objective of successful integration. What needs to develop is a mutual respect by residents and their neighbours for one another's values, lifestyle and need for privacy.

25. Social work departments, which are responsible for the inspection and registration of residential care homes, have a monitoring duty to ensure compliance with the standards they themselves have set. Although the criteria for the registration of nursing homes are set centrally, Health Boards are responsible for registering nursing homes and have a duty to ensure that statutory and local requirements are met.

26. In light of the foregoing and of their own experience, Health Boards, NHS Trusts, local authorities and voluntary organisations will wish to continue to develop their own agreed procedures for staff to follow in setting up and managing community care support services including accommodation. The successful implementation of this guidance will be significantly dependent upon the level of skills of the staff concerned, many of whom may be working in situations that are new to them. It will be necessary, therefore, for employing agencies to give attention to identifying staff training needs and the means of meeting them.

27. Any enquiries about this Circular should be made to Neil Rennick, Social Work Services Group, Room 52, James Craig Walk, Edinburgh EH1 3BA

(telephone 0131-244-5389).

Yours faithfully

GAVIN ANDERSON JOHN ALDRIDGE DAVID MIDDLETON

Social Work Services Group NHS Management Executive Housing Group