DD 7/96

SWSG Guidance Package, Index Ref: F1

March 1996

Chief Executive of Unitary Authorities

Copy to: Chief Social Work Officers/Directors of Social Work of

Unitary Authorities

Directors of Housing/Chief Housing Officers of Unitary Authorities

Chief Executives of NHS Trusts

General Managers, Health Boards

General Manager, Common Services Agency

General Manager, State Hospitals Board for Scotland

Chief Executive, Scottish Homes

Appropriate Professional and Voluntary Bodies

Association of Directors of Social Work

Convention of Scottish Local Authorities

Dear Colleague

GUIDANCE ON RESPITE CARE

Summary

1. The circular accompanying this letter sets out how the Government considers respite care services should be developed to assist both vulnerable people and relatives and friends who care for them.

Background

2. The Government’s commitment to assisting vulnerable people and those who care for them was set out in the White Paper "Caring for People". The NHS and Community Care Act 1990 provided the main legislative basis for implementation of its commitment. The first key objective set out in the White Paper involved promoting the development of respite care services. Subsequent surveys showed little evidence that local statutory agencies were addressing the issue. Local social work authorities and others have for some time invited The

Scottish Office to provide guidance on respite care. The Association of Directors of Social Work and the Care in the Community Scottish Working Group have been closely involved in the preparation of the Guidance. When in July 1995 we sought views on the draft guidance, over 100 statutory, professional and voluntary bodies in social work, health and housing commented. The attached guidance takes account of these views.

3. This guidance complements MEL(1996)22 on NHS Responsibility for Continuing Health Care which issued on 6 March 1996. While social work authorities will in many cases have the lead responsibility for arranging and funding respite care, health purchasers will continue to fund short-term health care where the patient’s health requires it. The respite care guidance will complement the forthcoming guidance on the provisions of the Carers (Recognition and Services) Act 1995.

4. In order to encourage the implementation and development of the principles in the guidance, we will be holding seminars during the summer of 1996 to promote the guidance. Purchasers and providers in social work, health and housing, service users and their carers will be invited to attend.

5. Health Boards will wish to bring the circular to the attention of General Practitioners.

Contact Point

6. Any enquiries about this Circular should be made to Sally Smith in Room 48C at the above address, telephone: 0131 244 3748.

GUIDANCE ON RESPITE CARE

Paragraph Contents

Summary

1 Introduction

4 Policy Context

8 Forms of Respite Care

13 Strategic Planning

18 Agency Responsibilities

25 Resources

28 Value for Money

30 Commissioning and Purchasing

33 Quality Assurance and Monitoring

38 Assessment and Care Management

40 Charging

46 Staffing and Training

50 Information

52 Good Practice

54 Action

ANNEX Indicators of Good Respite Care

RESPITE CARE

Summary

In its community care policy, the Government has made clear its concern for vulnerable people and the relatives and friends who care for them. This guidance sets out how effect should be given to its policies by putting in place arrangements to develop respite care services.

Introduction

1. This circular invites social work departments, health boards and housing authorities to develop the range of respite care services provided at their own hand and by other agencies by:

1.1 adopting a jointly agreed strategic approach to respite care;

1.2 resolving outstanding questions about agency roles and responsibilities, in the light of national guidance;

1.3 examining the use of current resources and committing resources to support service development;

1.4 ensuring that good quality respite care, suitably planned and organised, is an integral part of community care packages, wherever relevant;

1.5 providing information to the public specifically about respite care services.

2. The arrangements for the provision of respite care in Scotland have been examined extensively in recent years, initially, as reported in " [ "The Patchwork Quilt" A study of Respite Care Services in Scotland 1993, Meg Lindsay, Mary Kohls and Janet Colins ISBN 0-7480-0818-7.] The Patchwork Quilt" and, in Autumn 1994, in a survey by Social Work Services Group. Both these studies identified that while all agencies recognised the importance of respite care, its availability, quality and the arrangements under which it was provided varied substantially from area to area. Much of the content of this circular, therefore, arises from issues identified in these studies.

3. This circular primarily addresses the needs for respite care of adult groups. Separate guidance on children with special needs and their carers will be issued as part of wider guidance in the context of the implementation of the Children (Scotland) Act 1995.

Policy Context

4. The focus of the Government's community care policy is that people should, wherever possible, be looked after in their own home, or in homely settings. The Government recognise that respite care is an integral and central part of the range of health and social care services which ought to be available to persons with community care needs and also that demand for respite care is substantial. This is underpinned in the White Paper "Caring for People" which identified amongst its key objectives:

- promoting the development of domiciliary, day and respite services to enable people to live in their own homes wherever feasible and sensible;

- ensuring that service providers make practical support for carers a high priority.

The Government's support for the Carers (Recognition and Services) Act 1995 confirms its concern for carers. The Act will be implemented on 1 April 1996. Separate guidance will be issued on its provisions.

5. In funding the implementation of community care, the Government has made available to local authorities in successive settlements funding for the development of community based services, including respite provision. More specifically, the local government finance settlement includes provision for the development of respite care services. These and other substantial resources allowed for local authorities’ community care responsibilities and other social work functions are not ring-fenced. It is for each authority to determine its own expenditure priorities according to the care needs of the local population. See also paragraph 25.

6. The 1994 survey by SWSG confirmed the essence of "The Patchwork Quilt" and that the pattern of respite care remains patchy. In summary, while some improvements have been made:

- they were not (in most authorities) in the context of a fully developed strategic framework;

- the roles of the respective agencies remains unclear;

- little is known about either the aggregate needs for respite care or within individual care groups, in most areas; and

- the charging policies in some areas may inhibit the use of respite care and, accordingly, the outcomes for clients.

For these reasons The Scottish Office believes that there exists an urgent need for this policy guidance on respite care.

7. In the light of this guidance, renewed emphasis will be given centrally to ensuring that respite care features appropriately in service and other developments in which The Scottish Office has a role. For example, it would be reasonable to expect resource transfer negotiations to have regard to the changing balance of care including the need for respite care provision and short-term health care (respite). Also, the development of respite care will continue to be an important objective for projects seeking funding under the Mental Illness Specific Grant.

Forms of Respite Care

8. A number of documents have attempted to define or describe respite care. None of these, however, seems to encapsulate all the necessary requirements of a good service. We have, therefore, adapted others' efforts to create the definition below:

"Respite care is any service of limited duration which benefits a dependent person. The distinctive feature of respite care is that the break should be a positive experience for the cared for person and the carer (where there is one) in order to enhance the quality of their lives and to support their relationship. Respite care can be provided within or outwith an individual's home and may extend from a few hours to a few weeks."

9. The essential features of good respite provision are that it should be:

- needs-led

- responsive to clients’ and carers’ choices

- of good standard

- affordable

- accessible

- flexible.

These elements are described more fully in paragraph 32.

10. Respite care can take a number of forms. Traditionally it has been viewed in many quarters as a short break provided in a residential facility or similar settings, often to relieve a crisis. This is, however, a very limited view of a respite service. There are already a number of examples in Scotland of existing good quality and innovative respite services (see Patchwork Quilt Report) provided both within and outwith the individual's home. These include:-

- local authority or voluntary sector specialist residential units;

- home support services (eg from Crossroads);

- local authority and voluntary sector short breaks (eg Shared Care family based schemes);

- Befriending schemes;

- day care;

- provision within supported housing;

- holidays (with care and support) for users;

- arrangements where the carer and the dependent relative/friend remain together.

11. The role of the private and voluntary sectors is continuing to expand. For example, local authorities which have traditionally provided respite beds within their own residential care homes are now increasingly contracting with voluntary and private sector agencies to provide designated beds, to be used exclusively for respite purposes. There remains considerable scope for further innovation and development of new and flexible models of care and for the extension of particular models such as shared care to meet the needs of both users and carers to have a wide choice. Users and carers will each have ideas as to what form of respite best meets their needs and those needs may also change over time. The choices and needs of users and carers will not always correspond and this must be taken account of in assessments. There is particular value in carefully designed mixed packages of respite and day care. Provision should also take account of the varying needs between individuals and different user groups. Where there is a mix of respite and residential care, agencies should be sensitive to the needs of permanent residents and ensure that disruption of them is kept to a minimum.

12. Social Work authorities will in many cases have the lead responsibility for arranging and funding respite care. However, health purchasers should continue to arrange and fund short term care (respite) where the patient’s health needs require it, usually in a planned way but also to meet unforeseen circumstances. Relevant health purchasers in organising short term health care (respite) should relate to the health needs of the individual rather than the social needs of the carer(s), although relief for the carer(s) will of course be an important aspect of the health care. Social work authorities and health care purchasers should of course work together with housing partners to maximise the social benefits of these planned episodes of care. In addition, they should recognise that social respite care may require regular inputs from primary or secondary health care services.

Strategic Planning

13. Guidance on planning for community care is contained in:

- Circular SW1/91: introduced the requirement on local authorities to prepare and publish, in conjunction with their planning partners, community care plans every 3 years and to review them annually. It identifies the basis for joint planning, the process and the intended content of plans.

- Circular SW14/94: amended SW1/91 in respect of the content of plans. It reduces and reshapes their contents to make them more management tools, by focusing particularly on intended action.

- Circular SW13/94: requires local authorities to include in their plans a statement of their purchasing intentions.

- SWSG's letter of 2 February 1995: invites authorities to present information identifying (a) present levels of service; and (b) proposed levels of service to be provided by the new unitary authorities.

- Circular SWSG 21/95: invites the new unitary councils to develop new structures for joint planning in their area in the light of the reorganisation of local government. It calls for decisions to be made on the level at which joint planning will proceed and the substance of the joint planning structure.

- NHS MEL(1996)22: refines existing guidance on the responsibilities of the NHS in the organisation of continuing health care. The Annex refers to health purchasers continuing to arrange and fund short-term health care (respite) where the patient’s health needs require it.

14. The SWSG survey in 1994 highlighted the absence in most areas of a clear, strategic framework for the provision of respite care. Service developments have accordingly tended to be implemented incrementally rather than as part of a planned or systematic approach. Whilst many authorities have yet to develop a strategic approach to respite care, there are some valuable examples where such an approach has been taken forward jointly, usually by health boards and social work departments. These have included specific respite care strategies in some authorities. In others respite care needs have been identified systematically within user group and carer strategies as a whole. These have been helpful in developing a coherent approach which meets the differing needs for respite provision of user groups and their carers.

15. The prime task therefore is to ensure the adoption of a strategic approach within future community care plans and other strategic planning documents. Social work departments, health boards, housing authorities and other planning partners should apply the same principles to planning for respite care as already extend to strategies for individual care groups. They need to:

15.1 identify aggregate need for services (which may be derived from national or local studies or surveys, individual needs assessments etc). For example, one authority has done some useful localised surveys in this field which can be built on;

15.2 quantify the size and shape of current services, gaps and deficiencies;

15.3 identify the objectives of their strategy and their planning goals, and how they are to meet them over the planning period;

15.4 identify ways of increasing and monitoring the provision of the full range of respite care services.

15.5 Involve users, carers and providers in the development of strategies and their implementation.

16. These strategic statements should be incorporated in local health strategies, housing plans, community care plans, care group strategies etc when these documents are produced. The statements should be an integral part of community care plans for 1997-2000. Consultations on these should take place around the end of 1996. Respite is not an adjunct to continuing care services but part of the wider range of services. It will, therefore, be linked to related provision including day and domiciliary services, emergency support services and transport. Strategies should address the needs of different user groups and their carers, and the place of respite care within this wider range of support services.

17. The needs of carers should be considered, preferably in a separate section within community care plans in particular, but also within other strategic documents as relevant. These should be compiled on the basis set out in the previous paragraph and if possible, identify separately the needs of those caring for each user group, eg mental health, learning disabilities, older people, younger disabled people etc. Recent research and other work has highlighted the needs, often previously under-recognised, of young carers (under 16 years), the very elderly and those within ethnic minority groups. Respite care strategies should aim to assess local needs of all such groups and to promote specific initiatives to meet these, within mainstream and specialist services, as appropriate. From April 1996, the Carers (Recognition and Services) Act 1995 gives carers a statutory right to separate assessments of their needs.

Agency Responsibilities

18. Clarifying agency responsibility is one of the key objectives of community care policy generally. The need to do so extends equally to the provision of respite services, many of which (especially in the residential sector) have come to be provided, as the studies made clear, on the back of other services for clients. Social Work authorities, health boards and housing bodies have a joint responsibility therefore to plan and commission (where appropriate on a joint basis) a full range of services including respite care and, within that, to determine their respective roles. Services should be relevant and accessible to all sections of the community, and staff trained and equipped to provide appropriate assistance.

19. Social work departments have traditionally provided respite care in their own residential homes. Before 1993 DSS supported similar provision in the voluntary and, to a more limited extent, the private sectors; local authorities and voluntary sector agencies have provided respite support facilities in individuals' own homes. Social work authorities will have a continuing role to play in the provision and commissioning of services. The changing balance of care generally, particularly as between health and social work, will provide an opportunity for authorities to extend the scope of their commissioning role to influence and encourage innovations in service development. There is also scope to consider the joint commissioning of services which will be appropriate to many situations.

20. Health Boards' commissioning of short-term health care (respite) in most cases will relate to the health needs of the individual rather than the social needs of his or her carer. Moreover, as the NHS long-stay sector generally reduces in size to meet the assessed need under the community care policy, there will be a commensurate increase in the provision by local authorities of related services such as social respite care. Short-term care (respite) hitherto provided by the NHS for people whose needs are predominately for social care should, in future, be more appropriately commissioned by social work departments. As this develops, Health Boards and local authorities need to address these changes of responsibility in the same way as those governing long-stay care. They need to ensure:

20.1 that users and carers are consulted;

20.2 that changes are agreed, planned and monitored with other agencies;

20.3 that the pace of change is agreed;

20.4 that financial implications are properly addressed and resources transferred as appropriate;

20.5 that no change is introduced unilaterally.

21. Health Boards should therefore agree with local authorities their complementary responsibilities for short-term health care (respite) and social respite care, both planned and emergency. In particular, Health Boards should address the needs of:

21.1 people who have been assessed as having complex or intense health care needs and who require specialist clinical supervision during a period of short-term care;

21.2 people who require or could benefit from active rehabilitation during a period of short-term health care (respite);

21.3 people who are receiving a package of palliative care in their own homes but who would benefit from having a period of in-patient or day hospital care. In many cases, this will bring the added benefit of respite to the carer.

22. In making arrangements for this short-stay health care (respite), health service commissioners should pay careful attention to the wishes of patients and their carers drawing on the information available from the primary care health team. For many people with major or complex health needs who depend heavily on their carers whilst at home short-term care services are an essential part of the support network.

23. Housing bodies such as housing authorities, Scottish Homes, and housing associations, should also be involved in respite care. This usually occurs in two ways:-

23.1 Housing authorities may refer people to social work authorities for community care assessments, and to them and other care providers for provision of respite care for their tenants. This may be in the form of domiciliary respite care, but may also include the placing of tenants in respite care accommodation run by other housing providers, or by social care providers.

23.2 Housing authorities may provide respite care accommodation in supported or other housing. This will need a clear statement of the responsibilities of the housing and care providers (if these are different) and sound interagency co-operation (see "Community Care - The Housing Dimension" (August 1994, Env 27/98; SW7/94; NHS/MEL (1994/79)). In the case of housing associations, Scottish Homes would provide Housing Association Grant only where respite care accommodation is a small part (maximum 20%) of an integrated scheme designed to provide permanent accommodation. Respite care in supported housing may be made available for use by tenants of other housing providers in the social or private rented sectors, by nominees of care providers, or by people living in owner occupied houses.

24. In either role, housing bodies will need to cooperate closely with social work and health agencies. The arrangements for inter agency working will be affected by whether the housing provider is itself providing both the care and accommodation for respite care users, or whether the care is provided by a separate care provider. There should be a clear statement of the responsibilities of the housing and care providers involved in providing respite care (where these are different).

Resources

25. The Government has provided local authorities with significant resources to implement their community responsibilities, including the provision of respite care services. An additional £51m will be provided in 1996-97 for local authorities’ community care responsibilities arising from the 1990 Act. This brings to £292m the sum allowed for new community care expenditure in social work Grant Aided Expenditure for 1996-97. This includes the DSS transfer of £158.3m of which an element of £18m has been allowed to develop community-based social care services. It also includes £12m for service development of which £2.1m has specifically been included for respite care. The Mental Illness Specific Grant, totalling £18m in 1996-97, is available to provide new facilities including respite care for people with mental illness, dementia and head injuries. Local authorities will also have substantial resources of £371m for their continuing community care responsibilities which existed before the NHS and Continuing Care Act 1990. Authorities therefore have a total provision for community care of £662m in the 1996-97 Grant Aided Expenditure totals.

26. £18m Bridging Finance is again available this year towards the double running costs incurred by NHS Trusts as resources are transferred to local authorities and alternative services are developed in the community. The Resource Transfer arrangements from Health Boards to local authorities are intended to contribute towards the cost of providing community care services for those discharged from long-stay hospitals and those already in the community. In 1994-95, over £44m transferred. Respite care is one of the wide range of care services which can be supported from this source. Resources will continue to transfer from the health service to the local authorities reflecting the shift in responsibility set out in MEL(92)55 and confirmed in MEL(1996)22, "NHS Responsibility for Continuing Health Care".

27. This will result in two adjustments to short-term care services traditionally provided by the NHS. Firstly, responsibility for the provision of some short-term care will transfer in a planned way to community services. Again negotiations should take place between the Health Board and the local authority on the contribution that can be made by the former towards the cost of the replacement services. Secondly, the scope which the NHS now has to meet a local need for social respite care in the margins of its provision of long-stay care will reduce and will, in time, cease as services are re-provided and firmly established in the community. Health Boards and local authorities will need to take account of the total resources available and how they are currently deployed, in establishing what resources will be available for transfer. It is therefore in the interest of local authorities, Health Boards and the users of services and their carers that these changes of responsibility are transparent, and accompanied, where applicable, by an appropriate resource transfer. Other agencies in the community care field should also be made aware of any changes in responsibilities and resource transfers.

Value for Money

28. The demand for respite care is known to be high. Obtaining value for money is therefore one of the key factors in the provision of an effective service. Purchasers should identify the most cost-effective ways of deploying existing or additional resources to provide respite care.

29. Moreover, agencies need to have regard to the longer term value provided by respite care. Often it will not only be more appropriate to the needs of users and carers but also better value for money even although the cost of a short period of respite care may be higher than an equivalent period of long term care, or existing domiciliary services. Therefore, in deciding whether to provide respite care, and which respite care services to provide, agencies should consider long term as well as short term costs and benefits. In particular, respite care or, where appropriate, short-term health care (respite), by relieving the strain on carers, can delay or prevent permanent admission to long term care. Similarly, a mixture of short term residential respite care and domiciliary support may sometimes be more cost-effective than domiciliary support alone. The alternative to the provision of appropriate respite care may be a breakdown of a carer resulting in the need for additional health or social care not only for the user but also the carer.

Commissioning and Purchasing

30. Guidance to social work authorities on commissioning and purchasing all types of services were set out in SW19/1991. Agencies' purchasing arrangements have a considerable effect on the range of services available and the choice afforded to clients. This applies particularly to respite care. Some purchasing arrangements have constrained the development of respite provision. Social work authorities, Health Boards and housing authorities should be seeking to develop the range of providers of respite care to ensure that provision closely meets individuals' needs, offers good value and provides choice and quality of care. There are particular opportunities to encourage appropriate private and voluntary sector providers to diversify into respite care not only in residential but also domiciliary settings. To diversify, independent sector providers may require a degree of commitment either in terms of direct assistance in development (eg assistance using the Training Specific Grant) or in undertakings to purchase, or both. In the current absence of statutory regulation, local authorities have scope to impose standards on the independent domiciliary care sector via the community care contracting arrangements.

31. It may sometimes be appropriate, while taking account of the varying needs of user groups and individuals, to incorporate respite facilities into units providing long term care. This may be particularly relevant to small communities in remote areas and for some people eg dementia sufferers for whom continuity from respite to long term care may be important. For other people eg people with learning disabilities, it may be more appropriate to provide dedicated provision in order to avoid disruption to long term units and to focus on the specific requirements of those for whom respite is being provided.

32. To ensure an effective residential respite care service, local social work authorities should adopt a constructive approach to purchasing residential respite care which recognises that higher vacancy levels than for long term care may occur and be reflected in costs, has quality high on the agenda and provides for optimum use of the facility. Spot purchases (ie for one or a few identified users for specified periods as need arises) may appear to maximise flexibility in offering choice. However in practice, the opposite appears to be the case. As all the financial risk lies with the provider who has to hold open places against the possibility of purchases, this approach alone is unlikely to result in a reliable supply of respite care places or services. In addition, a scarce resource may be under-utilised and, more particularly, the concept of using a long term place for respite, when it happens to be vacant, is not generally consistent with good quality respite care. Block purchasing (ie commitment in advance to purchase places for an extended period for users not at that stage identified) has particular advantages in offering continuity of care for the user, better planned care and encouraging development of specialist facilities. The best service - together with a more equitable distribution of risk - can usually be achieved through the block purchase of provision, or a combination of block and spot purchasing.

Quality Assurance and Monitoring

33. The quality of all respite care services should be specified according to commonly agreed service principles and by performance standards which exemplify good practice in key areas. These must be as high as those for either permanent care establishments or intensive home-based provision. Local authorities are required, under Section 61 of the Social Work (Scotland) Act 1968 as principally amended by Registered Establishments (Scotland) Act 1987, to register establishments where the whole or a substantial part of an establishment’s function is to provide personal care, including assistance with physical and social needs, or support as part of a planned programme of care. SWSG has issued guidance to local authorities in respect of their registration and inspection functions and ADSW issued model guidelines on registration in 1988. A Scottish Office Working Group has been considering registration and inspection issues relating to residential care homes and is due to report by Easter 1996. Health Boards also carry a responsibility to register and inspect nursing homes under the Nursing Homes (Scotland) Act 1938. In 1993 SOHHD issued Model Guidelines for the Registration and Inspection of Nursing Homes. A Scottish Office Working Group is currently examining standards for nursing homes and will report later in 1996.

34. It has been the practice for local authorities to develop detailed standards of service provision for people in residential care as well as some day care services. It is important to ensure that standards are developed with the full involvement of users and carers and that they are consulted when the standards are reviewed. The standards should include quality of life, assessment, care planning, reviewing, physical/social environment, staff. The application of these standards is the subject of regular monitoring by Inspection Units which operate at arms length from the social work departments operational services.

35. Registration and inspection has made a significant contribution to the development of innovative and well-managed schemes and the local authorities should ensure that the regulation of respite care is sensitive to the needs of users as well as the aims and purposes of the establishment. The core values of the service must show commitment to the rights of the individual and his/her basic need for choice, autonomy and fulfilment, as well as personal privacy, personal rights, dignity and independence. A quality system should determine how well these principles are being met in service outcomes for users and their carers. This approach should apply to all services. Monitoring should incorporate the separate views of both users and carers on the quality of provision. The views of both are relevant to consideration of possible changes to service provision. The annex to this circular lists indicators of good respite care.

36. Where there is a mixing of users of short and long term care it will be necessary to ensure that account is taken of the impact which such an approach has on the nature and quality of provision. The level, deployment and management of staff, the nature of physical provision and the balance between short and long term users will be important considerations.

37. Providers should have systems which monitor the realisation of their aims and objectives. Monitoring should look at quality of life, the environment, staffing, care and management and administration. It should also examine the need for the service, unmet need and the characteristics of the users.

Assessment and Care Management

38. General guidance about assessment of the individual needs of adults for community care services and care management, is contained in Scottish Office Circular SW11/1991: HHD/DGM(1991)40 dated 17 September 1991. As with other community care services, respite care provision for individuals should follow an assessment of their needs and those of their carers. This should include the development of a care plan to identify what services are required and how they are to be provided. The Carers (Recognition and Services) Act which comes into effect on 1 April 1996 will give carers the right to request an assessment of their own needs. Local authorities will be required to consider the results when determining what support the people being cared for require. The views and distinct needs of users and carers, although these may not always be compatible, should be taken into account throughout the assessment and care management process. This should address, amongst other things an individual's social, religious, cultural, dietary and other requirements. Respite care will often be part of a wider package of support services provided on a continuing basis. While such arrangements will need to be kept under regular review, it should not be necessary to have a new assessment before every care episode.

39. A high quality care plan is central to the achievement of good standards. The care plan should take account of the likes and dislikes of the service user and the carer. Users require to have detailed care plans which are regularly reviewed in conjunction with them and their carers at home. The care plan should demonstrate harmony (of both approach and aims) between the respite and continuing models of care.

Charging

40. Under the Social Work (Scotland) Act 1968, as amended, separate charging arrangements apply for respite care provision in residential and non-residential settings. Social Work Departments have significant discretion on charging for respite care on both a residential and a non-residential basis. Charges are made to the user of the service, not their families.

41. For the first 8 weeks residence local authorities are not required to carry out a formal assessment of a person’s ability to contribute towards the cost of residential and nursing home care (see the National Assistance (Assessment of Resources) Regulations 1992). During that period the authority should only charge what it considers reasonable for the resident to pay having regard to the person's resources and financial obligations, particularly in respect of maintaining his or her own home. The basis for making any charge should be clear and made available.

42. After 8 weeks of continuous care an authority must carry out a formal financial assessment of ability to meet the full cost of accommodation taking account of the 1992 regulations. The charging rules require, however, that consideration should continue to be given to the temporary nature of the respite care stay, particularly the financial commitments concerning the dwelling normally occupied as the resident's home.

43. The charging arrangements set out in the above paragraphs would apply to accommodation purchased or provided under the Social Work (Scotland) Act, usually following a community care assessment. Charging for other respite care accommodation will vary according to the individual arrangements for its management and provision. When negotiating contracts with social work authorities, housing providers should make realistic estimates of the financial effects of voids in respite care accommodation, particularly where crisis respite care is provided.

44. Social work departments have discretionary powers to charge for non-residential care services which they provide or arrange. Section 87 of the Social Work (Scotland) Act 1968, as amended, requires that an authority should not charge more than an individual could reasonably afford to pay. The basis for making any charge should be clear and made readily available. The funding for the service should be agreed with the funder prior to the user availing of the service. The Scottish Office will shortly issue guidance on local authorities discretionary powers to charge for adult non-residential care services.

45. Cumbersome arrangements for assessment of ability to pay, and charging policies which discourage the use of effective respite services are not in the best interests of users, carers or providers or of local authorities' effective use of resources. Poor uptake of respite care and the subsequent heavier burden on carers may often result, in the long term, in an increased demand for more expensive services such as permanent residential care. When considering charging policies, it is necessary to have regard to the wider longer term effects. Local authorities are accordingly invited in terms of this circular to review their charging policies for respite care to ensure that they are equitable and consistent with the wider objectives of the community care policy.

Staffing and Training

46. Staff responsible for assessment, purchasing and care management need to be trained for the particular requirements of respite. Adequate budgetary arrangements should be made to ensure that the ongoing training needs of respite care staff whether employed by the local authority or an independent provider can be met. Assessment, purchasing and care management staff should have a wide knowledge of the range of services available and how these match assessed needs; this will include service development, matching and placing. They will require to take account of the wide and sometimes conflicting needs of service users and their carers, and particularly the support and reassurance which some carers will need if they are to accept and benefit from services which are offered.

47. Service providers including managerial staff, whether in residential or domiciliary settings should be suitably trained and supported for the specific requirements of providing a respite service. Staff will require skills of community development and personal counselling as well as expertise in staff recruitment and supporting users and carers. There will be common as well as separate training requirements for volunteers and paid staff; volunteer and paid staff require the same level of knowledge and skills where their roles or tasks are similar. Training will include developing specialist knowledge and skill in respect of users' specific needs, as well as induction in non-discriminatory practices. It is essential that all users are treated with equity and their cultural needs taken into account. Training should enable staff to integrate users of respite and long term care in a sensitive manner which meets the needs of both types of user. Health care advice will often be provided to care staff by the health professionals, often in consultation with the carer whose own knowledge is likely to be extensive. It is important that supervision is provided to ensure that staff follow locally specified procedures correctly. In some circumstances it may be necessary to augment the skills of staff by drawing on specialist staff with particular health care skills. This may involved negotiations between purchasers and providers both of primary and secondary health care and respite services.

48. More general training should include developing a sensitive awareness of the impact of respite on the user and the carer, and the necessity of effective preparation of them. Staff should recognise the difficulties experienced by many carers in attempting to disengage from their caring role and that carers may require help to accept respite care. Many carers find it difficult to accept that a short break with care and support may be appropriate for both user and carer. Respite care staff must recognise their role as a supportive adjunct to carers and that they require to work in active partnership with them. Care staff also need training in how to monitor and review user and carer satisfaction.

49. Care staff should receive regular supervision of a developmental nature which includes planned analyses of training needs and opportunities to participate in accredited schemes which lead to a suitable qualification.

Information

50. Social work authorities and their planning partners should have a co-ordinated information resource base as an aid to care planning. Information should be provided tailored to specific client groups and not only about respite care services in general. For users and carers to receive the full benefits that respite can offer they, staff (including the primary care health team) and other interested parties need to be informed about:

50.1 the purpose of respite and how it can help both carers and users;

50.2 what types of respite services are available and who they can help (for example, what client groups will benefit);

50.3 how to access the services, ie how users and carers can request assessments of their needs, how carers' assessments can be separate from those of users, and what the eligibility criteria are;

50.4 what the charging arrangements are for the various types of respite care and how individuals or carers will be assessed in terms of their ability to make contributions as appropriate;

50.5 how to obtain information on the detailed service types and individual providers; for this purpose authorities should have detailed lists available on request or may wish to include them within a general information leaflet;

50.6 how to complain.

51. Many carers see themselves as family and friends etc, but not as informal carers. More generally, many of those who require respite are often not aware of the possibilities and in many cases information can easily miss them. For these reasons social work authorities and others will wish to consider a number of approaches for advising the public of the benefits of respite care and the availability of services by for example:-

• literature - leaflets (also available in languages other than English), advertisements, local newspaper articles;

• roadshows, ie public meetings and exhibitions;

• video and audio tapes ; braille and large print translations are also available in languages other than English;

• involvement in the development of strategic thinking and planning generally, and in the development of operational matters such as the procedures for individual needs assessments;

• ongoing discussion with users and carers organisations and individuals;

• provision of translators for ethnic minority groups.

Good Practice

52. These are a number of examples of innovation and good practice in the development of respite care services but it would be impossible to list them in this Circular. However, it is essential that good practice is widely known and statutory and non-statutory agencies and individuals are invited to share information about good practice in the planning and delivery of respite services. The Scottish Office, in partnership with Scottish Homes, has commissioned the Nuffield Centre for Community Care Studies at Glasgow University to provide a database of good practice in all aspects of community care including respite. The Database ("Community Care Works") exists to support the sharing and networking of such information and service planners, practitioners, providers of care, users of services and their carers are encouraged to help to expand the network by nominating examples of good practice. Those who wish either to nominate good practice or access information currently held, you should contact the Database direct by telephoning 0141 330 4554.

53. Other professional bodies and networks will also be concerned to provide and support good practice, including Shared Care Scotland and the recently established Care Management Forum for local authority care management.

Action

54. Local authorities and their planning partners are invited to review the arrangements for respite care in their areas in the light of the guidance in this circular.

ANNEX

INDICATORS OF GOOD RESPITE CARE

Particular indicators of good respite care are that it:

55. Is needs-led: meeting the needs of both users and carers, who should be fully involved in designing packages of care.

56. Is planned: but flexible enough to accommodate emergency situations.

57. Is flexible: provides choice and meets an individuals' changing needs but is also predictable and reliable.

58. Forms part of a continuing programme of care: it is monitored and reviewed as part of that process.

59. Provides feedback to the carer on what has happened during respite and enables the carer to resume or, with suitable training and support, expand and optimise his or her caring role.

60. Takes account of the information and support the primary care health team can provide.

61. Is accessible: information about the range of services, eligibility criteria and their cost should be made available (see paragraphs 50 and 51).

62. Is provided in a range of settings: for example, residential care or nursing homes, supported housing, day care, an individual's own home or someone else's home, hospitals (including community hospitals).

63. Incorporates arrangements to ensure that both groups benefit where respite and long term users mix (eg in residential care and supported housing).

64. Provides value for money: in relation to other forms of support when viewed as part of a programme of care.

65. Is affordable: charges to users should not discourage the use of effective services (see paragraphs 40 to 45).

66. Has benefits for both users and carers.

67. Is a partnership: providers, users and carers should be at the heart of the design and delivery of services. The provider should elicit the views of consumers on a regular basis and inform them of their role in influencing the service. Feedback should be sought and geared to the abilities and interests of the service users, eg focus groups, one to one interviews, questionnaires, and representation on committees.