Wiltshire Independent Living Strategy 2022 to 2027

In 2019, Wiltshire Council launched the Good Lives Alliance of providers. The GLA has enabled greater transparency and consistency, particularly around costs. However, there are still challenges in the market's ability to meet people's complex needs in a way that is person-centred and empowering. As a result, too many people are placed in residential care, not getting the most enabling support, placed outside of Wiltshire away from family, friends and networks, or moving from one placement to another because of placement breakdown.

We need to mitigate our reliance on the independent sector by leading the way in providing housing and/or support for certain groups - for example, younger people or those with particularly complex needs - and demonstrating both the quality and value for money that we expect. We will use data to inform exactly what this market disruption will mean for us as a Council, and within the context of the BSW Partnership. Alongside this, we also need to manage performance and outcomes more effectively, and commission better accommodation and support in County.

Within the County, Wiltshire Council places people in a range of residential care homes specialising in mental healthcare and/or support for people with learning disabilities (including two nursing care homes) and a range of supported living for people with learning disabilities and/or autism spectrum conditions. Most provision is in and around the larger populations of Salisbury, Trowbridge, Chippenham, and Devizes.

Wiltshire Council is also growing its Shared Lives and Shared Days schemes. Shared Lives Wiltshire offers long-term and short-term matches, respite and home from hospital provision for people who need support. This includes people with mental health needs, autism spectrum conditions, learning disabilities, physical disabilities and older people. People sometimes use a shared lives scheme as a way of learning the skills they need to live independently and to help them put down roots in the area or community before moving into a place of their own.

In January 2021, joint NHS and social care funding was approved to pilot a new Intensive Enablement Service within the Council. The service provides time-limited enablement support which aims to build up people's independence and resilience, particularly for people at risk of hospital admission and/or for people being discharged from acute psychiatric hospital and/or rehab. We will share the lessons we learn from this new way of working and ensure that commissioned providers support people to become less dependent on long-term care.

The table below shows Care Quality Commission (CQC) inspection ratings for care homes in Wiltshire specialising in learning disabilities, autism spectrum conditions and/or mental health. CQC ratings in Wiltshire are broadly in line with national ratings with 89% of homes at Outstanding or Good (compared to 85% nationally in December 2021). The Council and ICB expect all providers to achieve 'good' as an overall rating from their CQC inspections. Where this is not achieved the Council and ICB expect the provider to develop an action plan with CQC that will result in a move towards 'good' or 'outstanding'.

In January 2022, there were 207 people with mental health conditions, learning disabilities and/or autism spectrum conditions placed out of County. 121 of those (58%) were placed in neighbouring Local Authority areas¹ and 86 were placed further afield. The average weekly cost of out of County residential and nursing care home placements was £1,856.70 (compared to £1,419.27 for residential and nursing care placements overall). The average weekly cost of out of County supported living was £1,269 (compared to £850.75 for supported living overall).

The median distance between a customer's home (where they lived before moving into the placement) and the placement itself is 52.5 miles.

Analysis undertaken in 2020 found that around half of Out of County placements were made because there was no available appropriate option in Wiltshire (for people with mental health needs, this was often because of a forensic history), a quarter were placed due to the person's and/or their family's choice, and for 20% no reason was given. This shows that current supply in Wiltshire does not consistently meet the needs of our residents.

Conversely, there is a similar number of non-Wiltshire residents in Wiltshire provision: 177 people placed by other Authorities live in Wiltshire placements. 170 of these are residential placements, and seven supported living. By far the biggest placing Authorities are Swindon (59) and London Boroughs (17 in total). Wiltshire is increasingly working with B&NES, Swindon and other Local Authorities in the South West region to ensure a joined-up approach to out of area placements.

Developing a mental health pathway

As stated above, there is no clear accommodation-based recovery pathway for people with mental health needs in Wiltshire. Practitioners are often unclear of the skills and limitations of particular services, and there is a lack of appropriate support in Wiltshire, especially for people with more complex needs (for example, forensic and offending histories, substance misuse, hoarding etc). This means that, in reality, residential care is often more recovery and move-on focused than supported living. Support needs to be flexible, adapting to a person's needs as they increase or decrease over time, so that people do not have to move home just because their needs have changed.

Research compiled by the Mental Health Foundation and Mental Health Provider Forum in 2016 focuses on how different types of supported housing can meet different types of need. Broadly, the report recommends a flexible model of support - from support which is intensive, 24 hour, 7 days a week, onsite and includes clinical health support such as psychology and occupational therapy, through that which is onsite during the day, to floating support which enables people to maintain independent tenancies - and a range of accommodation solutions, including purpose-built new-build accommodation, existing buildings re-developed to meet the needs of particular customer groups, and specialist housing providing shared and non-shared living, and general needs housing.

The report includes a Care Support Plus model of supported housing for people with complex mental health needs who might otherwise be in hospital or long-term residential care (see Appendix 4). This provides a strong rehab and recovery focus; self-contained accommodation with tenancy rights; building adapted to particular sensory or physical needs; safety features such as airlock doors and CCTV, but designed sensitively to ensure a non-institutional, homely feel, with shared lounge, space for socialising, regular activities etc. Key to the success of this model is the quality of the multi-disciplinary staff team (with higher levels and skill sets than would be usual), and a joint commissioning model where the NHS and Council have joint responsibility for funding and accountability.

Accommodation and support for people with complex and/or lower-level needs should both be designed around the needs of people. There is significant research that good-quality, modern accommodation, which is light, airy and well-maintained is a significant factor in good recovery and wellbeing. Where possible, people should enjoy tenancy rights and live in a home that combines privacy with space for socialising, learning skills etc. Again, safety features (such as wet rooms, sightlines for communal areas, non-intrusive CCTV) should be sensitively designed to make people feel safe, and this should be supported by robust risk assessments and protocols (again, undertaken sensitively in ways that feel social and inclusive). Where possible, communal outdoor space can be provided, such as gardens, allotments, space for ecotherapy etc².

This purpose-built accommodation should be staffed by staff who are experienced and skilled in supporting people with mental health needs. The service should prepare people to move onto independent tenancies by supporting them to manage money, form healthy, safe relationships, learn independent living skills, etc. The model of Psychologically Informed Environments embeds reflective practice and enables staff to understand, rather than bluntly react to, a person's behaviour or emotions. Commissioning arrangements must clarify the Council's requirements and expectations around the competencies of staff who will support people with complex needs.

People who have been supported in this way may be able to step down to independent tenancies. This will help people towards further independence by providing support with paying bills, attending appointments, accessing activities and services in the community, forming friendships and social groups. To do this effectively, staff will need to be experienced and skilled in supporting people with mental health needs and be able to build rapport, demonstrate empathy and form positive relationships. Employers, whether commissioned or in-house, will need to provide practical training - for example, around psychosis, medication, dual diagnosis, personality disorder, recovery model etc.

New developments

To develop new accommodation in Wiltshire, we must bear in mind that land is finite and often prohibitively expensive to buy. We must prioritise individuals or groups, so that when land becomes available for redevelopment, or when there is an opportunity to re-purpose buildings, we can start planning and delivering quickly. In order to achieve this, and particularly for groups of people who wish to live together in shared accommodation, we need to have a clear policy on how the risk of voids is managed.

Most people who do not wish to share will apply for housing via Homes4Wiltshire. Each person's needs and (where necessary) connection to Wiltshire will be assessed to determine eligibility for social housing. Prioritisation for housing depends on a variety of factors, including medical and/or social care needs. Once assessed as eligible, people can bid for and access housing as and when it becomes available. H4W advertises social rented homes, its own affordable homes and those owned by Registered Providers, as well as private landlords. Most of the Council's own housing is in the Salisbury area or south of the County, although it is expanding into other areas in the next few years. It is important that people who are ready to move are on the housing register and provide support for them to apply and bid when such support is required.

Multi-tenancies

There is a challenge in Wiltshire where a group of people want to share a property (for example, a three-bedroom family home) and potentially a joint package of support.

For a group of people wanting to share a property, some registered housing providers will not grant individual tenancies and some registered housing providers will not grant a multi-tenancy to a group of people who are not related, due to the risk of the multi-tenancy breaking down. Where the Council is the housing provider, multi-tenancy applications will be accepted - however, most of the Council's housing is in the south of the County. Whilst housing providers are responsible for their own allocations policies, this may mean that some properties will be overlooked even where such a group of people is in urgent housing need.

The Council has contacted local housing providers to clarify their allocations policies, so that it can manage expectations and make sure applicants are given clear information to help them understand where multi-tenancy applications for unrelated people may be rejected.

The Council will review its procedures, practices and the training given to housing and social care staff around how choice-based lettings work in relation to unrelated adults who want to apply to join the housing register together. Where unrelated adults who have not previously lived together choose to apply to join the housing register, we will discuss and confirm the limitations of any potential offer of accommodation as it will be extremely limited, and we need to ensure we do not raise expectations.

Adaptations and design features

Some people will require housing that has been adapted or designed to meet needs arising from a physical disability or sensory impairment. Such adaptations may include level access or ramps, wider doorways or turning circles to allow wheelchair accessibility, bathroom adaptations such as level-access shower or wet room, adapted kitchens with lowered units, stairlifts (in multi-level houses) etc. Where such properties already exist, people can access them via the standard bidding process. However, this strategy has identified a lack of accessible or adapted homes, particularly in certain areas of the County where there is a need.

The Council is in the process of reviewing how it acquires bespoke housing for people with disabilities and/or sensory needs (including needs relating to autism spectrum conditions). In the past, the Council has sometimes purchased specialist accommodation on the open market; however, whilst this has made the right property available, it has not always been possible to identify care providers to support the person in that property. The person has not been able to live in the property, and the Council is left with a property that may, in some instances, be difficult to re-let to another tenant.

The Council is exploring an alternative approach where it includes adapted housing within broader housing developments. All new homes built by the Council will be to a standard that is adaptable, albeit without the much-needed ground floor facilities to meet (say) wheelchair needs, and it may be possible to meet additional needs with a "pod" solution - like an addition to a new build, with the planning process allowing for the pods to be added as needed and the specification agreed to meet specific family needs (subject to limitations on the variances). The "pod" solution is intended for families with an individual with specific needs rather than for single person households, with the latter needing their accommodation needs to be met in a different way.

To support this approach, the Council, Registered Providers and commissioned social care providers need to work closely together to ensure a coordinated approach to sourcing housing and support, and to support people to manage tenancies and mitigate any risk of the breakdown of a tenancy. This tripartite working will be supported through the Homes4Wiltshire partnership and the Good Lives Alliance.

We will use the data we hold to develop a series of business cases and service specifications which, once created, will fill the gaps we currently have in Wiltshire. To build the right accommodation and provide the right care and support is likely to require a range of models and solutions - from direct provision to the establishment of strategic partnership with market leaders.

Registering the right support

When building, re-developing or de-registering specific schemes, we will work with providers to ensure that the principles of the CQC's registration guidance³ are applied. Whilst it is not the Council's policy generally to develop additional residential care, any such care should meet an identified local need and be focused on enablement; be co-designed by individuals and families; prioritise local people; be based near to communities and services which can be easily accessed. The Council supports CQC's move away from campus-style provision, where due to the scale of the scheme, person-centred care becomes difficult to deliver. Care homes and supported living should be small in scale, and usually be home to no more than six residents.

Principle of person-centred care, co-production, choice and control should also be at the heart of supported living services. Arrangements for a person's housing should be legally separate from care arrangements, and people should be able to choose who provides support to them. Whether a person is an owner or tenant, they should have control over their "front door" - in other words, have private space over which they decide who can enter and when and they have unrestricted access to every part of their home, apart from any co-tenants' private space. Accommodation and support provision should meet REACH standards⁴ and the Real Tenancy test⁵.

In the event of a provider choosing to change the registration of a service from residential care to supported living, there should be a demonstrable change in culture and feel for tenants and staff should be trained to support this.

¹ B&NES, Dorset, Hampshire, Oxfordshire, Somerset, South Gloucestershire, Swindon, West Berkshire

² See Mind, Feel better outside, feel better inside: ecotherapy for mental wellbeing, resilience and recovery for evidence of the effectiveness of ecotherapy.

³ Registering the right support, PDF 225KB (cqc.org.uk) (opens new window)

⁴ The Reach Standards practical guide (paradigm-uk.org) (opens new window)

⁵ The Real Tenancy Test (ndti.org.uk) (opens new window)