Wiltshire Independent Living Strategy 2022 to 2027

Our vision

This strategy aims to maximise the independence, choice, and control for people with a mental health condition, learning disability and/or autism spectrum condition (MH/LD/A) in Wiltshire by providing the right accommodation and support in the right place at the right time. This vision is underpinned by a need to ensure high quality and value for money.

Our focus in Wiltshire is to move away from residential care and ensure that we support people to live independently, with their own tenancy wherever possible. This means developing new supported accommodation and providing innovative and flexible care to enable people to live in the community.

The challenges we face

We currently face several challenges which stop us realising this vision:

• housing and care markets in Wiltshire provide limited quality and choice - we need a new approach to commissioning accommodation and support, including where appropriate intervening in the market, building new housing in the right places, providing support, and modelling good-practice
• there is a lack of focus on recovery - especially for people with mental health conditions. Through robust analysis of people's needs, we will develop business cases for new models of support which promote independence and recovery
• there is a lack of housing and care options in the right place - especially for people with learning disabilities and autism spectrum conditions. This leads to people sometimes having to move out of County, or to residential care, where a more independence-enhancing option closer to home might provide better outcomes. We will create more housing choices for people, including building where they are most needed
• housing and care provision is often not well aligned - through our commissioning functions, we will develop stronger relationships with and between housing and care providers. Internally, we will review our own processes to make sure these are clear and seamless
• the public do not always understand the options available - we will provide clear information to help people find accommodation and support which meet their needs.  Hearing from people with lived experience is at the heart of this strategy, and we will work with people and providers to co-produce new housing and support. We will also be clear about what is available and feasible and what is not, in order to manage expectations

The strategy identifies these challenges and sets out a plan of action as to how we can overcome them.

In the short-term (the next 12 months), we will:

• make sure our processes are clear to everybody, to ensure smooth pathways for housing and social care
• build on our needs analysis and agree new ways of delivering and commissioning the right housing and care
• establish arrangements for indemnifying housing providers if a person lacks capacity to sign a tenancy, to give housing market confidence
• explored the feasibility of deregistering residential care and be in the process of remodelling to supported living

In the medium-term (the next 2 to 3 years), we will have:

• recommissioned our framework of care and support providers (known as the Good Lives Alliance (GLA)
• fully implemented a dynamic system Provider Assessment and Market Management Solution (PAMMS) which will improve the collection and analysis of data
• implemented the South West Association of Directors of Adult Social Services (ADASS) framework for out-of-county residential care

In the longer-term (the next 4 to 5 years), we will:

• have developed a pipeline of accommodation schemes to meet needs, and be well on the way to delivering these
• be consistently measuring people's satisfaction and outcomes
• see strong joint working across Bath & North East Somerset (BSW) Integrated Care Board (ICB)

Our action plan

This action plan is organised around five key priorities:

1. we will change the way we commission accommodation and support
   • review GLA and use learning to re-commission new framework for accommodation and support
   • proactively manage and support the market to:
     • improve quality,
     • reduce placement breakdowns,
     • avoid spot-purchasing / off-framework commissioning
   • use data about supply and need to inform new models of care, support, and housing, and to generate service specifications
   • implement effective and consistent approach to performance management of care providers, with greater focus on outcomes
   • agree Brokerage dataset to assess provider engagement and performance
   • build key strategic partnerships with providers who perform well and demonstrate shared value base
   • work with BSW and South West (SW) England regional commissioners to grow local market providing specialist accommodation and support
   • facilitate partnerships between GLA and Homes4Wiltshire (H4W) providers
   • ensure commissioned staff are sufficiently skilled and experienced (for example, staff working with autistic people understand the different experiences of autistic people and are trained and competent in Positive Behavioural Support)
   • involve people who use services meaningfully in every aspect of the commissioning cycle
   • we will generally move away from commissioning residential care for adults of working age; we will use the SW ADASS framework when we commission out-of-county residential care
2. we will implement a recovery pathway which enables people with mental health needs to get the right support in the right place at the right time
   • analyse needs of people with mental health conditions, now and in the future
   • based on this analysis, develop five-year pipeline of new supported living projects to move away from our over-reliance on residential care - to include Care Support Plus model for people with more complex mental health needs
   • grow local market of effective supported living providers for people with mental health needs
   • work with BSW commissioners to develop short-term accommodation and/or support which effectively responds to crises, avoids the need for admission, supports people in an enabling way and supports them towards recovery
   • develop business case for Care Support Plus in Wiltshire (see Appendix 4)
   • we will ensure that pathways to recovery and independence include employment opportunities for people, and we will champion work placements, internships, and opportunities for work, as well as working with our commissioned providers to increase paid work for people with mental health needs, learning disabilities and/or autism spectrum conditions
3. we will create more housing choices for people, and this includes building new supported living in the places where they are most needed
   • review and further develop pipeline of new housing projects for people with learning disabilities and/or autism which are designed around the physical, mental, cognitive, and sensory needs of the individual
   • ensure people who use services are involved in design of new projects, and that all regulated services meet Care Quality Commission (CQC) standards for registration and are cost-effective and agreed in advance by Housing Benefit
   • ensure pipeline of people to move into each project - including care leavers with Special Educational Needs and Disabilities (SEND)
   • promote other alternatives to residential care - including Shared Lives, co-housing, use of Direct Payments, Individual Service Funds (ISF) etc
   • develop a range of tenure options in each geographical area; more respite provision; more tailored support around substance misuse.  We also need to manage expectations of families and individuals
   • explore feasibility of de-registering residential care to become supported living
   • ensure existing extra care offer meets the needs of older people with learning disabilities
4. we will review our ways of working, and where they are not clear or fit-for-purpose, we need to change them
   • start planning with people around their future transitions as early as possible (this includes understanding the profile of people currently living with parents, so that we can plan for when parents are unable to continue supporting
   • all new packages of care will be reviewed after 6 to 12 weeks, with an expectation that many packages can be reduced as people's needs change
   • develop pathways for people with learning disabilities who are ageing and / or may have dementia
   • clarify roles, responsibilities and pathways
   • agree and implement a consistent and shared dataset to capture activity and outcomes for people with MH/LD/A
   • clarify H4W allocations process, particularly around prioritisation of housing
   • explore inter-Authority arrangements with neighbouring Counties, especially Bath & North East Somerset (B&NES) and Swindon, where there are high numbers of Wiltshire people placed and vice versa (for example, high numbers of Swindon residents in Wiltshire)
5. we will provide clear information which helps people to find the accommodation and support which best meets their needs
   • manage expectations, particularly in the transition from children's to adults' services. Schools to support these discussions, setting expectations early, planning what a person's life looks like beyond their education, health and care plan (EHCP)
   • we will indemnify housing providers if a person lacks capacity to sign a tenancy; if things go wrong, we will indemnify the provider, as part of our duty of support
   • promote Your Care Your Support and H4W to publicise accommodation-based services - with clear service offer, specialisms (if any), inclusion/exclusion criteria, etc

Market disruption

To deliver these ambitions, we need a local market of providers with the right expertise and culture to provide excellent, enabling support to people; and we need suitable housing in the areas where people want or need to live. 

In reality, we know that the housing and care markets are challenged.  In some parts of Wiltshire, adults cannot live with friends or flatmates because housing providers will not accept multi-tenancies; we also have major challenges in supporting tenancies for people who may lack capacity to sign a tenancy, particularly where housing providers require Deputyships.

Likewise, the market is not always able to deliver the care and support that people need, particularly in certain areas of Wiltshire where labour supply is limited.

The Council will therefore take a more proactive role in developing housing and care solutions.  We will use data about the children, young people and adults we support to forecast and plan what housing we will need and where and will involve people in the design of future housing.  We will also explore building on the successes of our in-house Shared Lives and Intensive Enablement Service and, where there is a viable business case, we will lead the way in providing the kind of time-limited, enabling support that people need.

Adult Social Care Transformation Programme

The delivery of the strategy will be managed and monitored through Wiltshire Council's Adult Social Care Transformation programme.  An implementation group for the Independent Living Strategy will report to the Adult Social Care Transformation Operations Board.

The Independent Living Strategy project will influence and be influenced by a number of other projects within the programme, including:

• Technology Enabled Care strategy - creating a technology first culture for adult care delivery
• Practice development - ensuring all staff in Adult Social Care develop practice, knowledge and experience
• Mental Health Act reforms - the successful implementation of the new Mental Health Act Amendments
• Market Oversight - reducing the average cost of supporting working age adults and continuing to improve practice across service

We have high aspirations for people in Wiltshire. We believe everybody has the right to live an independent life, to make choices about how, where and with whom they live, and to achieve the things they want out of life. Our starting point is to celebrate people's strengths and give people the support they need to build on those strengths.

Accommodation and support should promote healthy, independent, meaningful lives. Living in the right type of housing, in the right place, with the people we choose, makes all of us feel secure and provides a sense of place and community.

The vision of this strategy is to maximise the independence, choice, and control for people with a learning disability, mental health condition and/or autism spectrum condition in Wiltshire by providing the right accommodation and support in the right place at the right time. By enabling people to take risks, we will enable individuals to live the kinds of lives they want for themselves.

Purpose and scope

The strategy addresses where we are now, highlights the gaps and obstacles that stop us achieving our vision, and provides a plan for getting there. The strategy has been led by Wiltshire Council, but it won't be possible to achieve our vision without us all working together. To create real choice and quality, we also need to develop our local markets further.

The strategy focuses on people with learning disabilities, mental health conditions and/or autism spectrum conditions¹. We follow a "whole life" approach, which means that we emphasise the person over their diagnosis and that we support people to manage the stages and transitions in their lives. We will use the information we have about today's 11-year-olds to plan the right support when they become adults. However, this strategy does not address the needs of younger children; and whilst it will highlight the needs of an ageing learning disabled population, it will not address wider needs around frailty and dementia.

Specifically, this strategy will:

• increase the choice and quality of accommodation and support for people with MH/LD/A as their lives progress
• move away from residential care as far as possible towards housing and support that promotes independence and control
• address gaps so that we enable people to access and keep their own tenancies
• understand, review, and develop pathways towards recovery and independence - especially for adults with mental health conditions
• engage with housing and social care providers (including the Council) and stimulate the market to create new accommodation and support in the right places
• inform capital spend planning and clarify revenue/rents affordability
• provide certainty and stability - enabling us to plan for next 5+ years
• promote employment opportunities for people with learning disabilities, mental health needs and/or autism spectrum conditions
• ensure that people who use services, carers and professionals can access clear, simple information to help them make informed choices - this includes having a shared language around different types of services and support
• address health and housing inequalities faced by people with mental health needs, learning disabilities and/or autism spectrum conditions
• address exceptionally high spend/unit care costs in Wiltshire
• create flexibility, so that where possible people do not have to move home when their needs change (except in exceptional circumstances)
• learn from other areas identified as best practice
• improve and clarify our processes - both within our organisations and across partnerships

During the COVID-19 pandemic, young people, adults, parents, and carers have faced significant challenges. The social care market has been under enormous pressure to meet needs, and many of the national challenges facing social care - labour shortages, a depleted workforce, funding etc - apply in Wiltshire too. However, we have also seen new solutions during the pandemic - new innovations in how people are supported (including through better use of technology), stronger relationships between the Council, NHS and independent sector, and a sharper focus on quality and outcomes.

¹ Definitions of these terms can be found at Appendix 1.

The vision and objectives of this strategy are based on what people in Wiltshire say they want from accommodation and support. In this section, we provide a summary of some of these conversations to bring out some of the key themes and messages.

In June 2021, Wiltshire Parent Carer Council (WPCC) interviewed parents, carers and young people who still lived in the family home. Whilst two thirds of parents and carers wanted their child to continue living with them, the remaining third felt they would flourish more by living more independently¹. One young person said:

I don't have enough independence living with my parents. I am nearly 19 and should be with similar aged people in supported living, but I want to live part time with my parents.

In the same survey, 100% of people said there is not enough information to help them plan for the future. One young person said:

I have no idea about what my future holds once my family are unable to take care of me. I think these conversations should start a lot earlier than they currently do.

When asked "What is the one thing you would change"? Parents, carers and young people gave a range of answers including:

• To have the autonomy to do what I like.
• To be treated with dignity and respect.
• There are not many choices.
• I would like to live with friends in my home town.
• It should not be a minimum wage job. We trust our most vulnerable to sometimes the youngest and most inexperienced, who are usually paid the least, and then wonder why it all goes wrong.

Wiltshire Centre for Independent Living (CIL)'s report "A place I call home" (2021) summarises the voices of people with mental health conditions, learning disabilities and/or autism spectrum conditions in Wiltshire.

The report's key messages were:

• accommodation options need to reflect that everybody is different, they need to be varied, adaptable and responsive to the needs of people in Wiltshire
• people want to live in a place they call home, with the people they choose in their local community
• a priority for any accommodation is that it supports positive relationships both with close networks and with people in the wider community
• the most important factors for people when considering where they live is that they feel safe, they can be independent, and they can choose where they live

A survey completed by people who use Good Lives Alliance services in May 2021 found that the majority of people are happy where they live, like the people they live with and the people who support them and feel safe and part of their local community.

¹ This was for several reasons, including the need for friends and other relationships, to gain more independence, because parents were or would soon be struggling to provide the necessary support for their child or young person.

In November 2021, the Government published its White Paper on adult social care reforms. The White Paper identifies that too many people live in unsuitable homes that do not provide a safe environment for care and support to be effective. It states that older and disabled people are more likely to be digitally excluded, and many care home staff cannot access the Internet and lack digital skills. It adds that there is insufficient innovation of new models nationally that have the potential to transform the ways care and support are provided. It makes national commitments of:

• £500m for social care workforce training and qualifications
• £300m to integrate housing into local health and social care strategies
• £150m to adopt new technologies and digitisation
• a new support service to make repairs and changes to people's homes
• £25m to unpaid carer support
• £30m innovation fund

The White Paper follows other policy documents in recent years:

• building the right home¹ highlights the need for personalised housing for adults with learning disabilities and/or autism spectrum conditions, with security of tenure/ownership and housing rights, a separation of landlord and care provision, design adjustments and flexible support which minimises restrictions for the person
• building the right support² aims to shift resources from acute or institutional settings to the community. It argues the case for re-designing pathways and provides commissioners with a National Service Model, so that people with a learning disability (LD) and/or autism spectrum condition (ASC) who have been in hospital for a long time can move into the community. This is part of the Learning Disabilities and Autism Programme (formerly known as the Transforming Care Programme), which emphasises the need for commissioners to take a positive and enabling approach to risk
• right support, right care, right culture³ emphasises the leadership and staff ethos, values, attitudes, and behaviours that are needed to ensure that people who use services lead confident, inclusive and empowered lives. This document, which supports the regulation of registered providers, places good-quality care and support within a framework of human rights and citizenship
• the NHS Long Term Plan⁴ aims to improve community-based support so that people can lead lives of their choosing in homes, further reducing reliance on specialist hospitals
• Out of sight - who cares?⁵ states that successful outcomes come from treating difference with dignity and respect, and that the built environment and the right support can promote this. The report finds that too often difference is dealt with through restraint, seclusion, and segregation - this is especially the case in hospital settings, but sometimes in the community too. The report recommends timely diagnosis, earlier intervention, better training (for example, around de-escalation, communication tools such as Picture Exchange Communication System (PECS) and Makaton), review of psychotropic medication (which should only be used as a last resort), and a culture of openness whereby providers routinely tell commissioners/regulators about incidents of restraint and seclusion
• the recovery model has been central to mental healthcare for over a decade.  It is a strengths-based approach that emphasises resilience and control over life's challenges. Research suggests that important factors on the road to recovery include good relationships, satisfying work, personal growth, and the right living environment. This strategy describes how we will embed pathways to recovery within our care and support model in Wiltshire

In December 2021, NHS England and Improvement published the independent review into the death of Clive Treacey, a man with learning disabilities who tragically died at the age of 47 in January 2017. An independent review found that a lifetime in institutional settings had seriously impaired his quality of life and safety, and that he was failed by a system that did not work together to make sure he lived independently with good quality care and treatment. The review found that these failings placed Clive at a higher risk of sudden death. There are a range of recommendations for practitioners and commissioners to ensure that this tragedy does not happen again, and to support people to live in psychologically safe spaces that they can call home, with support flexing as their needs change.

In September 2021, Norfolk Safeguarding Adults Board also published a Safeguarding Adults Review (SAR) into the avoidable deaths of three young adults: Joanna, "Jon" and Ben (all in their 30s), all of whom had learning disabilities and had been patients at Cawston Park Hospital⁶. One key recommendation in the SAR is that Clinical Commissioning Groups complete an in-depth review for all individuals (all age) with a Learning Disability and/or Autism in a mental health hospital⁷, including anyone on s.17 leave. BSW Integrated Care Board has (as of 31 January 2022) completed these reviews, and once an Executive panel has provided assurance, oversight and challenge, an Action Improvement Plan will be developed in response to lessons learned.

Local vision, challenges, and opportunities

Wiltshire Council's vision is to create strong communities where people can fulfil their potential, be actively involved, and included in their communities, make informed decisions, have control over their lives, and be valued and included within society.  In Wiltshire, we start from people's strengths, talents, and assets - this means looking beyond their diagnosis or needs, however important these may be. This vision reflects what people in Wiltshire have told us they want to live well.

In 2021, Wiltshire Council published its first market position statement (MPS) for whole life commissioning⁸. This will influence our local care and support provider market, so that it provides an excellent service to people in Wiltshire. The MPS notes several challenges that currently prevent us realising this vision of excellence, including:

• too many people move outside of Wiltshire to get the support they need. We are over-reliant on residential, and around half of placements outside of Wiltshire occur because our local market could not provide an appropriate service to that person. Around two thirds of these placements are for residential care, so we must enhance supported living in Wiltshire to meet demand
• there is not enough early intervention, prevention and enablement support provided to people with mental health conditions, learning disabilities and/or autism spectrum conditions. We must ensure that people are offered the least restrictive option to meet their needs - this means expanding our Shared Lives provision and Intensive Enablement Service and re-specifying supported living so that it is the default option for people with complex needs, giving them tenancy rights and housing security. We will also indemnify housing providers if a person lacks capacity to sign a tenancy; if things go wrong, we will indemnify the provider, as part of our duty of support
• there is not enough support for autistic people.  Our emerging joint all-age autism strategy will be published in 2022. One of its key aims is to make Wiltshire a more inclusive place for autistic people to live, learn and work. This means that universal services must be accessible for autistic children, young people and adults, from mainstream education and libraries to housing and social care
• transitions sometimes feel like falling off a cliff-edge. We need to support people earlier and ensure that children, young people and families are supported on a pathway to adulthood - our Growing up and moving on guide is the framework for this work⁹
• people and their families don't always know what is available. We will ensure that the information we produce is accessible, useful and kept up to date. We will signpost people towards the most relevant information

We need to make a fundamental shift away from residential care by commissioning the right amount of high-quality, responsive supported living and transitional step-down services. Nursing and residential care will be needed for small numbers of people with particularly complex needs, but we would expect most people to have their own tenancy (or ownership), their own front-door and sharing with others or living alone if this is appropriate.

As we commission and develop more supported living options, we will expect the providers we commission to abide by the CQC's principles, as set out in Registering the right support¹⁰. We expect providers to work with us from the start of any planned development to ensure that any new service is:

• designed to meet a clearly identified local need
• co-designed by people who use services, their family and representatives
• prioritised for people who already live nearby or whose families live nearby, so they maintain their local networks
• located in a place where people can participate in the local community
• located near to local health, social care and other services
• sufficiently small-scale to avoid being institutional or "campus-style¹¹"

The organisation which provides care and support to an individual should be separate from the organisation that provides their accommodation. Personal care and accommodation arrangements should be provided under separate legal agreements to ensure tenancy rights are protected even if care provision changes.

We will develop and expand our high-performing Shared Lives and Shared Days services, so that people with learning disabilities, autism spectrum conditions and/or mental health conditions can benefit from being matched with a Shared Lives carer.  During 2021/22 (up to end of February 2022), 43 people with learning disabilities, 8 people with mental health conditions and 2 people with autism spectrum conditions used this service. The service has continued to recruit new carers and is marketed across social media, as well as on Wiltshire websites.

The aims and actions of this strategy will be developed in the context of an emerging Integrated Care System (ICS). Bath & North East Somerset, Swindon and Wiltshire (BSW) Partnership is an ICS made up of NHS and local authority organisations working together. The Partnership brings together one ICA, three local authorities, three hospital trusts, private providers, a mental health trust, an ambulance trust and voluntary sector organisations. Within the Partnership, Wiltshire Integrated Care Alliance (ICA) has focused on supporting people to go home from hospital more easily, helping people with long term conditions get the care they need, and providing support for our ageing population and those with complex needs. Wiltshire ICA is moving away from a sole focus on service improvement and integration to improving the health and wellbeing of our population and working collaboratively with the interests of the Wiltshire population at the heart of all decisions. This Independent Living Strategy reflects these priorities.

¹ NHS England, 2016

² NHS England, 2016

³ Care Quality Commission, 2020

⁴ NHS England, 2019

⁵ Care Quality Commission, 2020

6 Safeguarding Adults Reviews (SARs): Joanna, Jon and Ben - published September 2021 (norfolksafeguardingadultsboard.info) (opens new window)

⁷ Admissions after 31/10/21 are not in scope of this reviewing activity

⁸ Whole life commissioning - market position statement (PDF, 1 MB)(opens new window)

⁹ Growing up and moving on

¹⁰ Care Quality Commission, 2017

¹¹ Campuses are defined by CQC as group homes clustered together on the same site and usually sharing staff and some facilities. Staff are available 24 hours a day.

Wiltshire is a mostly rural county in the South West of England. It borders the Council areas of Gloucestershire, Swindon, West Berkshire, Hampshire, Dorset, Somerset, B&NES and South Gloucestershire. The county is relatively affluent. However, there are substantial pockets of deprivation.

Census data

New Census data released in 2022 shows that 510,400 people live in Wiltshire. This makes Wiltshire the ninth-largest local authority in England by population size, but the eleventh lowest by population density. Wiltshire's population has increased by 8.4% since the last Census - a higher rate of increase than the overall rate of increase in England (6.6%). Wiltshire has an ageing population - whilst 22.1% of residents are aged 0 to 19, 21.8% are aged 65 or older. Overall, in England, there has been an increase of 20.1% in people aged 65 years and over between 2011 and 2021; by contract, in Wiltshire there has been an increase of 30.5% in people aged 65 and over. Wiltshire is one of only three local authorities in the South West whose 65+ population has increased by more than 30%. People are generally living longer and healthier than ever before. However, our Joint Strategic Needs Assessment¹ shows that these gains are not enjoyed equally across the population, and we have a number of long-term health challenges. In particular, we know that adults with long-term mental health problems and/or learning disabilities have much lower life expectancy.

Forecasting adults with learning disabilities

The national Projecting Adult Needs and Service Information System (PANSI²) and Projecting Older People Population Information System (POPPI³) databases forecast how many adults with learning disabilities, autism spectrum conditions and mental health conditions live in Wiltshire now, and how this will change over the next 20 years. They show that the overall numbers of working-age adults with these needs will stay much the same over this period, but the numbers of older people with LD and/or autism - whilst small in comparison with working-age adults - will increase significantly.

Our view locally is that these forecasts should be treated with caution, as they have historically not been accurate indicators of our population. (NB: most of these residents will not have Care Act-eligible needs; figures for people with personality disorder or psychosis aged 65+ are not available on POPPI).

This indicates that we need to develop a greater range of options for older disabled people, such as extra care designed around people with learning disabilities, in the coming years. Approximately 200 learning disabled adults aged 55+ in Wiltshire currently live in residential care. Where supported living is not suitable, due to age-related frailty or cognitive disorders such as dementia, extra care will be our preferred option as, unlike residential care, it provides the person with a tenancy and is more cost-effective than more restrictive alternatives such as residential care.

Forecasting demand for accommodation and support

Our market position statement provides more detail about our demographics, and in particular the prevalence of learning disabilities, autism spectrum conditions and mental health conditions. This section summarises what this means in terms of forecasting demand for accommodation and support:

• as of May 2022, there are around 4,800 households on the housing register. Of these, around 1,000 are on the open market register - this means they do not qualify to join the main Housing Register, but they are interested in housing options such as Low-Cost Home Ownership
• there are around 18,000 serving military personnel living in Wiltshire, many of whom will have partners and families
• there are around 4,400 children and young people (CYP) with an education, health and care plan (EHCP), of whom around 60% are secondary school age (year group 7 onwards). The number of CYP with EHCPs is rising. 9% of school-age children and young people are from non-White British backgrounds
• there are around 425 children looked after (CLA), of whom 20% are non-White British. There are around 20 unaccompanied asylum-seeking children and around 275 care leavers at any one time. We know that poor social, emotional and mental health are more prevalent in these groups
• there are around 55,000 adults of working age living in Wiltshire with common mental illnesses such as anxiety and depression, 17,000 with a personality disorder, 2,000 with a psychotic condition such as bipolar disorder and schizophrenia, 15,000 with post-traumatic stress disorder (particularly prevalent, given Wiltshire's military population) and 6,000 with an eating disorder⁴
• there are likely to be around 4,300 autistic adults and 2,000 autistic children and young people in Wiltshire. The rate of children and young people diagnosed with an autism spectrum condition increased by 83% between 2015 and 2020, whilst the rate of autistic adults per 1,000 population has remained static. Around one third of autistic people are likely to also have a learning disability. 40% of autistic people experience anxiety⁵
• the national PANSI System estimates that there are around 7,000 adults with an LD in Wiltshire, of whom around 1,600 have moderate to severe LD⁶
• the overall number of people with LD is unlikely to change much over the next 10 years, but the number of older people (aged 65+) with a moderate to severe LD is forecast to increase from 308 in 2020 to 428 in 2040. This is likely to mean a higher prevalence of learning disabled people with dementia and other age-related frailties in the coming years

The impact of the pandemic on mental health

We have seen the impact of the pandemic on mental health. National research in 2020 and 2021 has predicted that up to 10 million people, including 1.5 million children, are likely to need new or extra mental health support as a direct result of COVID-19⁷. Carers UK estimated in June 2020 that an additional 4.5 million people nationally had become unpaid carers since the pandemic began. By October 2020, 81% of unpaid carers said that they were providing more care since the start of the pandemic. Charities have reported significant increases in demand for advice and information⁸ and there are reports of more people experiencing mental distress presenting in emergency departments and acute trusts struggling to find appropriate care and support in the community⁹. A Young Minds survey of 2,500 CYP with mental health needs in January 2021 found 67% believed the pandemic would have a long-term negative effect on their mental health¹⁰.

Mental health patients with learning disabilities

At any one time there are 40 to 50 patients registered with a Wiltshire GP who are inpatient in a mental health hospital bed, around a fifth of whom have a learning disability and/or autism spectrum condition. Many of these people will need support and accommodation once they are discharged, which helps them live well in the community.

In November 2021, there were 1,154 adults from the Council's Learning Disabilities & Autism Service (LDAS) and Mental Health adult social care teams placed in supported living or residential care. The data below breaks this down by customer group, and shows how many of these people are placed outside of Wiltshire:

Children and young people with learning disabilities

There are currently around 2,200 young people who are secondary school age and above with an education, health and care plan (EHCP). The table below shows this broken down by educational Key Stage.

The following chart shows the primary need of this group of children and young people with an EHCP:

Whilst not all these young people will need support from adult social care when they reach adulthood, we can begin planning and designing this accommodation and support to help young adults to live independent lives.

In May 2022, a needs analysis was undertaken of all young people and adults with disabilities who have been identified by social care teams as needing or wishing to move, but for whom finding appropriate accommodation and support is challenging. A detailed breakdown of their needs can be found in Appendix 3. There are some gaps in the data, which points to the need to improve data quality to help us plan for the future. The needs analysis can be summarised as follows:

There were 162 people ready to move, of whom:

• gender: around 60% were male, 40% female
• age: most were relatively young, with more than 80% being under 40, and nearly 60% being under 25
• primary needs: The majority of people had two or more different needs; more than half had a learning disability, and over a third had a mental health condition; perhaps surprisingly, less than a quarter had an autism spectrum condition
• current location: 39% lived in the South of Wiltshire, 31% lived in the West, and 14% lived in the North. The most popular locations are Salisbury (53 people), Trowbridge (18 people) and Chippenham (11 people)
• current situation: Over a third were living with family (with a significant number in full-time education)
• capacity to share: Over half said they were able to and/or wanted to share with others (for some, it was specified that they could/would share with people of a similar age, similar ability, a specific person, or either males or females only)
• where people want to live: the most popular destinations for people were Salisbury (38 people), Trowbridge (15 people) and Chippenham (12 people). For 40 people, geographical preference was not stated

¹ Wiltshire Intelligence Network (wiltshireintelligence.org.uk) (opens new window)

² Projecting Adult Needs and Service Information (pansi.org.uk) (opens new window)

³ Projecting Older People Population Information (poppi.org.uk) (opens new window)

⁴ Projecting Adult Needs and Service Information (pansi.org.uk) (opens new window), Projecting Older People Population Information (poppi.org.uk) (opens new window)

⁵ Figures taken from Wiltshire Autism Strategy, to be published in 2022.

⁶ Locally, we believe this is an over-estimate. The PANSI gives the following background for how this figure is calculated: "These predictions are based on prevalence rates in a report by Eric Emerson and Chris Hatton of the Institute for Health Research, Lancaster University, entitled Estimating Future Need/Demand for Supports for Adults with Learning Disabilities in England, June 2004. The authors take the prevalence base rates and adjust these rates to take account of ethnicity (for example, the increased prevalence of learning disabilities in South Asian communities) and of mortality (for example, both increased survival rates of young people with severe and complex disabilities and reduced mortality among older adults with learning disabilities). Therefore, figures are based on an estimate of prevalence across the national population; locally this will produce an over-estimate in communities with a low South Asian community, and an under-estimate in communities with a high South Asian community."

⁷ Covid-19 and the nation's mental health: October 2020 (centreformentalhealth.org.uk) (opens new window)

⁸ Demand for mental health advice soars in year after first lockdown (rethink.org) (opens new window)

⁹ CQC, 'The state of health care and adult social care in England 2020/21', October 2021.

¹⁰ Young Minds, 'Coronavirus: impact on young people with mental health needs', February 2021.

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)

Appendix 1 - definitions

Mental health

This is "a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (World Health Organisation). Mental health conditions - including so-called "common mental illnesses" such as anxiety and depression, more severe affective disorders (personality disorders, for example), eating disorders, and psychoses such as bipolar disorder and schizophrenia, etc - often impact negatively on well-being, but with the right support people can live well with hope and resilience.

Autism

This is defined in Wiltshire's market position statement for whole life pathways as a spectrum condition which affects different people in different ways. Autistic people may experience difficulties with social communication and interaction, repetitive and restrictive behaviour, sensitivity to light, sound, taste or touch, highly focused interests or hobbies, and anxiety and depression. This document uses the term autism spectrum conditions (ASC) in preference to autism spectrum disorders. It also uses the term "autistic people" over "people with autism," as research by the National Autistic Society nationally and by Wiltshire Parent Carer Council locally found this was generally the preferred description.

Learning disability

The Department of Health and Social Care states that a learning disability means the person will have difficulties understanding, learning and remembering new things, and in generalising and learning new situations. Due to these difficulties with learning, the person may have difficulties with a number of social tasks for example, communication, self-care and awareness of health and safety.

Appendix 2 - glossary of abbreviations

Appendix 3 - needs assessment

A snapshot in May 2022

This is a summary of children, young people and adults who were identified as being ready to move to alternative accommodation, or for whom we should start planning now for independent accommodation in a few years time. It is a snapshot of needs and preferences in May 2022.

There are some gaps in the data, which points to the need to improve data quality to help us plan for the future.

Total

• 162 customers

Gender

• male: 99
• female: 63

Age

• less than 18 years: 11
• 18 to 25 years: 82
• 26 to 39 years: 37
• 40 to 49 years: 12
• 50 to 59 years: 12
• 60 to 69 years: 3
• older than 70 years: 1
• not stated: 3

Primary need

• 92 of 161 have a learning disability
  • of these: 48 are listed as having only an LD; 24 also have an ASC; 9 also have a PD; 5 also have an MH
• 61 of 161 have a mental health condition
  • of these, 52 are listed as having only an MH conditions; 9 also have an LD and/or ASC
• 37 of 161 have an autism spectrum conditions
  • of these, 24 also have a learning disability; 6 are listed as having only an ASC
• 18 of 161 have a physical disability or health condition
  • of these, 9 also have a learning disability
•  5 of 161 have a sensory impairment

Team

• Children and Young People's Disability Team (CYPDT): 60
• Mental health (MH): 52
• Learning difficulty assessments (LDA): 46
• not stated: 4

Current location

• Salisbury: 53
• Trowbridge: 18
• Chippenham: 11
• Devizes: 7
• Warminster: 7
• Melksham: 5
• Westbury: 5
• out of county (OOC): 25

All other locations have fewer than 3 people living there.

Current situation

• 62 are living with parents, of these, 21 are in full-time education and 11 have either recently finished or are about to finish an education placement. In 7 cases, it is stated that parents/family can no longer care for the customer (in one case, due to overcrowding); in 5 cases, the customers wants to move out of the family home to become more independent
• 31 customers with MH needs live in move-on supported housing schemes
• 18 are in residential schools, college or children's home placements. Most of these are CYP with SEND, with 2 at specialist VI provision, 1 at specialist HI provision
• 22 are in residential care, 16 of these have a primary need of MH, 5 with LD, 1 is in a respite placement
• 14 are living in their own flat/house with support - around half want to move elsewhere either to share with others or to stop living with current housemates; another half are being evicted or served notice
• 8 are in hospital, 6 as long-stay patients (3 of these are in the Daisy unit), 1 as a voluntary inpatient
• there are also individual customers in hostel, low secure, sheltered housing and foster placement

Support required

Data provided around what levels and types of support people need is very incomplete. 

Of 161 customers:

• sharing ability/preference is not stated for 41 customers
• type of property required is not stated for 85 customers
• night support needs are not stated for 104 customers
• housing registration status is not stated for 100 customers
• timescale for move-on is not stated for 79 customers

These very significant gaps in data make it difficult to say comprehensively what support is required. However:

• sharing: 70 can share, 42 cannot (or do not wish to) share, 9 may be able to share; for 41, sharing ability/preference is not stated 
• type of property/adaptations: 13 people need wheelchair accessibility inside and outside the property; 13 need adapted bathroom; 11 need adaptations to support with behaviour; 9 need significant outdoor space
• type of support: 39 people are noted as needing supported living, but it is clear that the vast majority of the 161 customers listed would need SL rather than residential care. 2 need residential care. For 6, both SL and residential have been listed. Shared Lives is needed for 1 person
• level of support required: Exact hours required are only given for 23 customers. 9 people are stated as needing 1:1 support only (X needing 2:1 at times), 9 as needing shared support only, and 27 as needing a combination of both
• night support needs: 38 people need sleep-in support, 15 need waking nights, 6 are listed as having no night-time support needs. However, for 104 people night-time support needs are not stated
• housing registration: for 100 of 161 customers, housing registration status is not stated. For 45 customers, registering them on H4W has not commenced, for 5 it is stated as "not applicable," for 3 the registration process is "in progress," and for 9 of 161 the customer is registered and (in most cases) actively bidding
• when the property/service is required: 54 people need a service/property in 2022 (some have been waiting to move since before the start of 2022), 4 in 2023, 5 in 2024, 4 in 2025, 7 in 2026, 8 in 2027 or beyond. For 79 customers, it is not stated when the service/property is required

Location required

• Salisbury: 38
• Trowbridge: 15
• Chippenham: 12
• west: 18
• south: 10
• anywhere: 9
• not stated: 40

All other locations have fewer than 5 wishing to move there.

Appendix 4 - Care Support Plus model

Excerpts from mentalhealth.org.uk Mental Health and Housing report 2016

Definition

Care Support Plus is a model of supported housing, launched in 2012, in response to the need to create supported housing which could accommodate people with a high level of mental health support needs who might otherwise be in hospital or residential care.

The scheme was developed through a tripartite agreement between the housing provider, the local NHS Foundation Trust, and the local authority to develop a new type of supported accommodation specifically geared towards people who had often been excluded from supported accommodation due to their complex mental health needs.

The approach has proven successful on several of levels, including recovery of customers and improved quality of life. There is also a clear economic case to using this model with an overall annual saving per customer estimated at around £450,000.

The scheme was able to tackle a local problem across several areas of concern: A high number of people being placed in expensive out of area care; care that was not particularly suitable for the client group; a system lacking rehabilitation work; as well as concerns over the quality of care being received.

From another angle, the Care Support Plus model also provided an appropriate level of support for people in hospital unable to find suitable supported accommodation which could meet their needs. Although the impetus to develop the scheme was created by local demand, in practice the core elements of building and service can be reproduced to see how they might apply to customer needs across the country.

Building

At present the Care Support Plus model is not widespread. However the principles behind the construction are indicative of what other schemes might look like. Evidence from interviews suggests that the building formed part of the success of the scheme, proving a core element of effective support and may well be for further housing aimed at customers with similar mental health and support needs.

The scheme is purpose built supported accommodation, but to same specifications as private sale housing by the same provider. According to a member of the team:

The organisation has the philosophy that anyone with a mental health problem should get the same quality of accommodation as anyone else.

However, there were specific technical considerations, given that the model is aimed at customers with a high level of support needs:

• the scheme provided fully self-contained flats with each customer holding their own tenancy
• the flats contained essential items which might otherwise preclude someone from moving on from hospital, such as a bed, dining table, and cookware
• regarding physical access needs, the building itself is step-free and fully accessible. This included a lift to all three floors with the first floor containing all wheelchair accessible rooms, so as not to prevent someone with mobility problems needs from accessing the scheme

The effectiveness of the accessibility measures was confirmed by the resident interviewed who felt the building met all their physical access needs.

The safety features of the building comprised an important part of the scheme. There were three elements of the building in particular which contributed: a 'front facing office, airlock doors, and sensitive use of CCTV'. In each of these areas, the safety appeared mindful of the specific concerns of people with high level mental health needs.

The position of the office functioned as a safeguarding feature as it enabled staff to be aware of who is entering and leaving the building and prevent unauthorised visitors from entering the scheme. This was bolstered by the 'airlock' system, which is a two-stage glass entry door, which helps to manage visitors' access to the scheme.

According to staff this has resulted in fewer safeguarding incidents compared to other schemes.

The levels of staffing also mean that visitors can be closely monitored and customers supported in this area; however in lower level supported housing with nine to five staffing it may not be possible to support customers in the same way.

CCTV in the scheme provided a final security feature, however it was set up to avoid being 'too obtrusive' and therefore mindful of the fact that it can make the scheme feel too 'big brother'-like. The building clearly responded to the support needs of customers by installing an appropriate level of security.

The importance of creating the right 'feel' for the building was evident across other areas. The staff member interviewed believed that the physical environment supported the mental wellbeing of residents:

I think having an environment which is non-institutionalised, homely, is quite important, it enables residents to feel part of the project.

Part of this was making sure that information was displayed but would not be too intrusive, drawing away from a supported housing stereotype.

This was reflected in the views of one of the residents, who thought that the physical environment supported their mental wellbeing, and was happy with the look of the flats on first seeing them:

I thought the flats were very nice... I still do think they are very nice.

The building also has a shared lounge and kitchen for customers to use, alongside the self-contained flats. This is a space for residents to socialise if they want to use the lounge, as well as maintaining space for privacy in their own apartments, and the resident interviewed felt that the space made it easy to interact with other residents.

However there were some drawbacks to the current building as highlighted through the interview. There was no private space outside the development such as a garden, although this was not an issue picked up by the resident interviewed.

Concerning inside space, another drawback of the building was the lack of a separate room that would staff space to meet with residents.

These characteristics demonstrate the significant role that the building has to play in the provision of excellent care in supported housing. Understanding the customer needs was evidently central to this building, although shortcomings of the building through experience demonstrate shortcomings to be learned from.

Service

The package of services, put together for the Care Support Plus model, was pioneering in the way it drew together three different stakeholders to provide high level wraparound support for a group previously excluded from supported accommodation.

The principal difference of the arrangement was that it enabled NHS staff to be embedded into the scheme itself, through sub-contracting agreements. Having clinical staff based in the scheme meant that customers can receive a higher level of support, and equally it enabled staff to work with different customers.

The two clear differences in staffing in the Care Support Plus scheme compared to more traditional models were the level of staffing, and the presence of NHS staff on site.

Concerning the level of staffing, this meant that the scheme could work with individuals who may previously have been too high risk for supported housing schemes to manage, for example those with forensic backgrounds. Provisions therefore included double staff cover twenty four hours per day. Staff were also required to have prior experience of working with people with mental health problems, and were also supported by risk management procedures embedded in the scheme.

On top of the higher level of staffing provided by the housing scheme, there was also a higher level of clinical input. This meant that more intensive work could be done with residents and issues could be addressed more quickly than if clinical staff were off site.

Among other clinical staff, the care coordinator, psychologist, and Occupational Therapist would be on site each week:

We can sit down with the Deputy Manager and the psychologist and Care Coordinator and work out a plan. In a traditional model you fire off emails and meet in three weeks' time while people are struggling. We can deal with things very quickly and very effectively here.

The high level of support also enabled staff to work intensively on the skills that customers need to develop in order to move on to more independent accommodation.

Feedback from a staff member suggested that this service provided the independence and rehabilitation work needed to empower people towards more independent living. This included intensive work around areas such as boundaries and safeguarding, to provide customers with the skills to avoid incidents such as financial exploitation when they move to less intensive support. As above, the key difference which complements the intensity of the service provided is the speed with which support plans can be put in place when issues arise.

From the customer perspective the most important element of the service from the interview was the activities:

I just think it's brilliant we do an activity every day.

This reflected the work toward skills for independent living and the personal goals that had been achieved by the customer through the scheme. The activities available in the scheme were also compared to the customer's experience of residential care, where daily activities were not available to the same level. This was also reinforced by the customer as they said the availability of daily activities was the main thing for a future development to bear in mind. This reflected that beyond the essential provision of clinical support, there are a wide range of interventions which support and enhance daily life.

Certain shortfalls were also identified in the services provided by the scheme. In particular this included the need renegotiate the exact level of clinical input at the scheme in order to provide customers with the right level of support.

This highlights the need for open dialogue between partners and the role that a joint commissioning can play in bringing about effective support for excluded groups. Overall the member of staff interviewed said that joint commissioning of the scheme addressed a problem which was both costly, and not serving a community which could benefit from a better level of care in supported accommodation.