Hambleton, Richmondshire and Whitby Clinical Commissioning Group

TRANSFORMING OUR COMMUNITIES CONSULTATION DOCUMENT (FULL VERSION) JULY 2016

@HRW_CCG

facebook.com/HRWCCG Contents

Chapter Page

Glossary of terms 3

1 Introduction and Background 5

2 Health Needs Assessment and Commissioning Vision 11

3 Evidence Base 13

4 Current Community Service Provision 16

5 Opportunities to Transform Care 20

6 Engagement and Pre-consultation 26

7 CCG Commissioning Intentions 36

8 Formal Consultation: What are we formally consulting 53 with our population on?

9 Options Appraisal 55

10 Equality Impact Assessment of options and Assurance 66

11 Next steps 70

Appendices

Appendix 1 Fit for an ageing population - A Case for Change Appendix 2 Community Transformation Programme Board Terms of Reference Appendix 3 Integrated Locality Team Model Appendix 4 Opportunities for Step up Step Down Beds Appendix 5 Communications and Engagement Strategy Appendix 6 STHFT Recruitment Literature Appendix 7 Clinical Summit Report Appendix 8 NHSPS Lambert Hospital Survey – Summary Document Appendix 9 NYCC Extra Supported Housing Strategy Appendix 10 Primary Care Estates Strategy Appendix 11 Summer 2015 engagement report Appendix 12 Dales Project Overview

Page 2 of 71 Glossary of Terms

Term Description Acute Care Medical or surgical treatment usually provided in a general hospital. Buurtzorg Model Founded in the Netherlands in 2006/07 Buurtzorg is a unique district nursing system which has garnered international acclaim for being entirely nurse-led and cost effective. It has sparked particular interest in the UK where a key challenge is meeting the needs of an ageing population increasingly susceptible to co- morbidity and complex long-term conditions. Care Pathway An agreed and explicit route an individual takes through health and/or social care services that detail the activities and professionals involved at different times and stages.

CCG Under the Health and Social Care Act (2012) from 1 April 2012 CCGs (made up of GPs from constituent practices and other primary care professionals) will take over from Primary Care Trusts the responsibility for commissioning hospital and other healthcare services for the local population. Front line clinicians are provided with the resources and support to become more involved in commissioning decisions and clinicians have greater freedoms and flexibilities to tailor services to the needs of the local community.

Clinical Literally means ‘belonging to a bed’ but is used to denote anything associated with the practical study or observation of sick people.

Clinician A qualified professional who carries out clinical work as opposed to experimental/research work. Can include doctors, nurses, therapists etc.

Commissioning A continuous cycle of activities that underpins and delivers on the overall strategic plan for healthcare provision and health improvement of the population. These activities include stakeholders agreeing and specifying services to be delivered over the long term through partnership working, as well as contract negotiation, target setting, providing incentives and monitoring.

General A doctor who has a medical practice (general practice) in which he treats all Practitioner illnesses. Usually referred to as a GP and sometimes known as Family Doctor/Practitioner.

Heartbeat Alliance A federation across HRW of GP Practices.

Integrated Care Bringing together health, social care and voluntary and private sector services to provide a ‘one-stop shop’ for health and social care. May include community wards, outpatient clinics, GP and dental practices, social services department.

Integrated Health & Bringing together commissioning and provision of services by health and local Social Services authorities to work in partnership and deliver integrated care for patients.

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Intermediate Care Short term intervention (usually up to six weeks) by a multi-disciplinary team, provided in patients’ own homes or a care environment, aimed at preventing

hospital admissions or facilitating hospital discharge.

Long term Conditions (for example, diabetes, asthma and arthritis) that cannot, at present, conditions be cured but whose progress can be managed and influenced by medication and other therapies.

Minor injuries Examples are cuts, bruises, scalds and suspected closed limb fractures. The role of a minor injury unit or service would be to provide treatment for such minor

injuries.

Models of Care Guidance on ways of treating patients that are based on clinical evidence.

NHS Foundation Public bodies providing NHS hospitals, community and mental health care and Trust ambulance services.

Non-Elective An NHS term of art for an unplanned, often urgent admission (often via A&E), Admissions which occurs when a patient is admitted at the earliest possible time; usually resulting in an inpatient stay.

Re-ablement The active process of regaining skills, confidence and independence after a traumatic or ischaemic injury.

Secondary Care Specialist health care services that treat conditions which normally cannot be dealt with by primary care practitioners (i.e. GPs, therapists, community nurses

etc) or which are as the result of an emergency. It covers medical treatment or surgery that patients receive in hospital following a referral from a GP. Secondary care is made up of NHS foundation, ambulance, children’s and mental health trusts.

Social Care Care provided in people’s own homes or in care/residential homes which does not require nursing skills, for example, washing, dressing, and housework, help

with eating.

Vanguard Sites The intention is for the vanguards to make a major contribution to addressing the NHS’s financial challenges – both through improvements in their local systems and blueprints that can be adopted across the rest of the NHS and social care.

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Chapter 1 Introduction and Background Introduction

The aim of this document is to outline proposals for the transformation of the community system in line with the Clinical Commissioning Group (CCG) vision for community services across Hambleton, Richmondshire and Whitby (HRW). It also identifies opportunities to ensure the CCG vision is achieved.

The NHS Hambleton, Richmondshire and Whitby CCG (HRW CCG) footprint is geographically large and is situated in rural North Yorkshire, covering nearly 1000 square miles including parts of the Yorkshire Dales and the A1 corridor to the east and across to the coastal town of Whitby and its surrounding villages.

The population of approximately 142,000 live mainly in small towns and villages. Northallerton is the largest centre of population with approximately 18,000 people and the largest British Army garrison in the UK is situated at Catterick in Richmondshire.

There are currently 24 GP practices (22 civilian and 2 military) in the CCG and the Hambleton and Richmondshire population is served by one district general hospital within the boundary of the CCG, the Friarage Hospital, Northallerton.

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The local population has articulated an expectation for care closer to home, to enable the CCG to ensure this is a viable option wherever possible, it is important that services are in place that can support this and that these services work together across the system to shift the focus from illness to wellness, making every contact count. The case for change outlines the community system transformation with this overarching objective in mind.

This document also demonstrates compliance with the Department of Health four test criteria for service change which include:

• Support for proposals from clinical commissioners • Strong public and patient engagement • A clear clinical evidence base • Consistency with current and prospective need for patient choice

NHS England is responsible for the review of evidence presented to them by the CCG as part of their service change assurance process to ensure that the CCG has complied with all requirements.

The CCG will also seek independent clinical advice from the clinical senate throughout the process of transformation. The clinical senate supports the health economy to improve health outcomes of the community by providing impartial, independent and evidence-based clinical advice to the CCG on major service changes and transformation.

Background

Patients have clearly articulated to the CCG that they expect care as close to home as possible. GP colleagues have long identified deficiencies in the community system and realised that if more services were available they could provide a greater level of care in a community environment. Acute colleagues have identified that significant numbers of patients are remaining in hospital for too long because the services available in the community, e.g. step down beds, services for patients with delirium, discharge to assess for continuing healthcare, access to care support at home, are either not available or not easily accessible. Colleagues working in the community identify there are opportunities for greater integration and more flexible working but the organisational systems, processes, structures and permissions are not necessarily in place. The CCG has identified a range of overarching programme objectives in the transformation of community services, these reflect the North Yorkshire Health and Wellbeing Board Strategy and include: • ‘Living well’ – Fewer hospital admissions and lower death rates from heart disease, stroke and cancer • ‘Ageing well’ – Patients should be able to make choices to self-manage their care to help them stay independent for longer and their carers are supported

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to live their own life. More health and social care staff will be working together across local GP surgeries and primary health care centres to support older people in the community. A range of options will be in place to help people keep their independence for longer, e.g. intermediate care or reablement services. New community hubs will offer advice, access and care to people receiving services and those who care for them. • ‘Dying well’ – A greater range of support options for people in their last years of life with more people and their families receiving support and dying at home or in the place they choose, supported by trained staff and carers. • Improved experience of care, based on the National Voices “I” statements. • Delivery of care in the most appropriate place – potentially up to a ward of patients at any one time are being cared for at a higher level of care than is necessary. This programme should enable this cohort of patient’s to be cared for in a more appropriate community or home location. • Financial efficiencies, such as reductions in emergency admissions, inappropriate spend on the continuing healthcare budget, increased productivity of commissioned services, fewer older people entering nursing or residential homes for long term care. • Up-to-date commissioning specifications to ensure the delivery of services are in line with need.

In 2013 HRW CCG published its Case for Change in Fit 4 the Future: Reconfiguring older peoples services in Hambleton and Richmondshire: A Discussion Document, this can be found in Appendix 1. It outlined the CCG vision for the development of community services in the coming years.

At the time of publishing its Case for Change document, the CCG realised that there was a requirement to review the use of its community hospitals in light of extensive public and stakeholder engagement and in reviewing the national evidence base on community based services. Public and stakeholder engagement undertaken during this time demonstrated general support for this case for change with a real understanding from the public for the need to change.

To enable the review of its community hospital facilities the CCG recognised that work was required to strengthen the impact of historic disinvestment of community services and needed to be addressed as a priority. As a result a number of actions have taken place since 2013: • During the period 2013-2016 the CCG has invested considerably using health and social care monies known as the Better Care Fund (BCF) in additional community services in Hambleton, Richmondshire and Whitby to the value of £1.7 million. This additional investment has been spent on community based therapists, nurses, social care, practice nursing, voluntary sector and

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specialist roles to enable the transformation of the community system to take place. In 2015-16, these services demonstrably led a reduction in non-elective admissions, particularly for over 65 year olds and increased delivery of integrated services.

• There has been a continued emphasis on discharge to the community through hospital case managers and a functioning discharge steering group that has connected acute and community colleagues, including social care throughout Hambleton and Richmondshire. Prototyping work has taken place to test trusted assessment as part of discharge arrangements into intermediate care from the Friarage Hospital.

• In 2014 the CCG launched the Dales Project, with the intention of working with a clinical community team to start to build functionally integrated health and social care teams to create a sustainable model of delivering care close to peoples own homes. The Dales Project was initiated to see whether a much more integrated approach based on the Buurtzorg model could be introduced in the most rural areas.

• In Whitby, transformation has proceeded through a procurement of urgent and community services for the local population which has led to a new provider, Humber Foundation Trust, being appointed to lead the transformation of care delivery. A more integrated model of care has been specified and a detailed service development and improvement plan has been built into the contract. In addition, night nursing and fast response capacity has been put in place through Better Care Fund investment.

• Support for a sustainable future of the Friarage Hospital in Northallerton as the expert hub for a rural community was also a key priority for the CCG at this time. Work over the last 18 months has demonstrated that there does need to be some changes at the Friarage Hospital to secure its long term sustainable future, but it has shown the necessity for the Friarage remaining as an acute centre.

Throughout the summer of 2015 the CCG attended a number of country shows and other events to test its vision and proposed models of care with the public. The support was overwhelmingly positive which was reinforced further at the CCG Clinical Summit event in the autumn of 2015 where over 200 representatives attending from a variety of partner organisations, including: South Tees Hospitals NHS Foundation Trust (STHFT), County Durham and Darlington NHS Foundation Trust (CDDFT), Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV), North Yorkshire County Council (NYCC), GP practices, local District Councils, Voluntary Sector. The event achieved organisational and professional buy-in to doing things differently and at-scale across our whole CCG area.

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The governance and assurance process for the community transformation work of the CCG has been established. The accountability for the project rests with HRW CCG. The Senior Responsible Officer for the project is the Chief Nurse, Gill Collinson. The GP Lead is Dr Mark Hodgson. It is important that this project is clinically led and a project team has been established to support the development of this transformation project. The project development will be monitored through the CCG Community Transformation Programme Board, the terms of reference of the group can be found in Appendix 2. This Board will report into the CCG Governing Body and Whole system Transformation Board.

Phase 1 of the project includes:

• An extensive public engagement exercise which informed the commissioner’s option appraisal process and commissioning intentions. • Development of options and proposals for the provision of services. • Development of an option appraisal process that engaged the constituent practices in determining which options would be part of a formal consultation exercise. • Development of a business case which would make the case for change set out the options appraised including the impact assessment concluding with recommendations on which options go forward to formal consultation.

Phase 2 would entail:

• A formal consultation process on a shortlisted range of options. • Detailed design of the pathways to enable detailed commissioning plans to be developed. • Development of a plan for implementation of the preferred option.

Phase 3 would entail:

• Implementation of the preferred option

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Summary of Activity to Date:

Date Activity

2013 Vision for Hambleton & Richmondshire laid out in the Fit 4 the Future Preparing for an Ageing Population discussion document

2014 Financial investment in services through BCF – Fast Response Team, Intermediate Care, Integrated Night Service, OPAT etc 2014 Initial stakeholder and patient engagement

2014 Development and understanding of our strengths, weaknesses and opportunities available to us, forming an intended direction of travel. 2015 Public and staff engagement – Summer Shows and Clinical Summit. Testing the direction of travel and asking what matters most 2015/16 Understanding the outcomes of the engagement and forming our over- arching strategy. Key strategic direction formed from ideas from local community, GPs, nurses and front line staff. 2016 The development and refining of ideas into proposals

2016 Pre consultation engagement to inform a formal consultation on options

Now Formal Consultation on options developed

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Chapter 2 Health Needs Assessment and Commissioning Vision

The population in the Hambleton, Richmondshire and Whitby CCG area is markedly different to England. Compared to the national population, the area is below the percentage average for those aged < 45s and over the percentage average for those aged > 50s. The State of the Region report highlights this marked increase in older population which is predicted by ONS (Office for National Statistics). A major component of this is that the baby-boomers are moving into retirement. This is not an increase in population – rather the aging of the existing one. These older people are generally healthier than previous generations.

The higher proportion of older people in the CCG leads to higher demand for services including a requirement for the CCG to ensure that it is appropriately commissioning services that are fit for an ageing population.

In terms of local drivers for change HRW CCG has considered:

• The changing health needs of the local population • Accessibility of services across a rural community • Fit for purpose facilities • Views of patients and members of the public, which are becoming clearer • Local GPs’ concerns about services and their desire for greater input

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• Value for money • Innovation in healthcare

A joint strategic needs assessment, often referred to by its abbreviation JSNA, brings together local authorities, the community and voluntary sector service users and NHS partners to research and agree a comprehensive local picture of health and wellbeing needs. It also supports and encourages organisations to work together when developing services.

North Yorkshire's Joint Strategic Needs Assessment, (JSNA) looks at what is known about the people of North Yorkshire and their current and future health and well- being needs. It does not look at the particular needs of individual people; it looks at the 'big picture' of people's needs and where needs are not being met as well as they could be.

The CCG has used the North Yorkshire JSNA to establish its commissioning priorities and reviewed the issues mentioned during the engagement events for the Hambleton and Richmondshire areas and North Yorkshire.

In summary, HRW CCG is expecting:

• The number of people in Richmondshire District aged 65 and over to increase from 9,200 to around 12,300 by 2021. • The number of people in Hambleton District aged 65 and over to increase from 19,400 to around 25,400 by 2021. • The number of people in Scarborough District aged 65 and over to increase from 25,500 to around 31,300 by 2021.

Commissioning Vision

The CCG vision is to create high quality care, closer to home for the people of Hambleton, Richmondshire and Whitby especially given the challenges of operating in a rural environment which creates inequity of access. The CCG will do this by being responsive to the health needs of the local population, and commissioning high quality services in a timely and cost effective way. The CCG mission is to be an outstanding organisation that is clinically led and professionally managed and which makes the very best use of resources in order to deliver safe and high quality services for all of the population.

HRW CCG has five strategic priorities. These are based on the health needs of the local population, feedback from GPs and other senior clinicians, partners and the public. These priorities focus on areas where the CCG believes a real difference can be made to improving the health of the population. These key priorities are supported by five enabling workstreams and focused support for vulnerable groups. All priorities are aligned to achieve the National Outcomes detailed in the NHS Operating Framework.

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The CCG ‘Fit 4 the Future’ over-arching mission is to develop a beacon of rural health and care services. The CCG serves a deeply rural community, who are passionate about local services. However, it is recognised that the traditional way of organising and delivering services is not sustainable and together the CCG wants to radically reimagine how care and support for the local population is provided. By doing this the CCG believes in taking a whole life and integrated approach, with the needs of the individual and the community at its heart. Chapter 3 Evidence Base

There is a weight of international evidence on the impact of hospitalisation on frailty. Hospitalisation can be followed by an irreversible decline in ability to carry out Activities of Daily Living (ADL) and quality of life. In one study of 1,279 patients of 75yrs+ admitted to hospital from home with acute illness1:

• 31% experienced decline in ability to perform ADLs at discharge • 16% of patients who experienced functional decline died within 3 months of discharge

Decompensation can occur as early as the second day of admission into Hospital. A functional decline can lead to2:

• Increased risk of illness and death • Diminished quality of life • Less autonomy and greater dependence • Admittance to nursing and residential homes • Increased lengths of hospitalisation • Readmission to hospital

There are a number of national factors which inform how care should be delivered in the future. These include:

1. NHS system changes – the NHS is facing large and complex changes in the way it delivers care. The length of time patients stay in hospital is decreasing but at the same time there is a growing expertise required in many specialities, meaning to deliver the best quality care some services can only be delivered in specialist hospitals where the right clinical teams, nursing teams and medical equipment is available.

Advances in clinical tests and treatments for illnesses like cardiac disease and cancer mean that more of the population are now living much longer than their parents’ and grandparents’ generations. However, this also means that a substantial number of older people are also frail, and living with chronic illnesses which need a great deal of care. Already more than 70 per cent of patients admitted to hospital as an emergency are frail, older people.

1 Sager MA, et al. Functional outcomes of acute medical illness and hospitalization in older persons. Arch Intern Med 1996;156(6):645-52 2 Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med 1993:118(3):219-23

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It is forecast that over the next 20 years, the number of people aged over 75 will increase significantly. Evidence from elsewhere in the UK shows that patients, particularly the frail elderly, are more likely to be able to remain in their own homes if they receive care there when they are ill than if they are admitted to hospital and that the cost to the NHS and social services is reduced if admissions can be avoided.

A key outcome of ‘Fit 4 the Future’ has been to invest more in community services; enabling the CCG to focus on providing much more care to people in their own homes or close by, and relying less on inpatient hospital beds.

2. High quality care for all – In recent times the NHS has had to address the outcomes of recent reviews into significant failures of the health and care system. There are a number of significant reports published, including; Transforming Care, the Government’s final report on Winterbourne View; and the public inquiry chaired by Robert Francis QC on Mid Staffordshire NHS Foundation Trust and Patients First and Foremost, the Government’s initial response.

HRW CCG is fully committed to responding positively to these important reviews, ensuring that a culture of compassionate care is fostered in which patients are genuinely and consistently at the centre of everything the service provides.

An integrated approach to commissioning services and providing care offers a way to improve the patient experience and provide safe and clinically effective care.

3. Integrated health and social care and the BCF - Recent reforms to the health and care system and the Health and Social Care Act of 2012 focus on a drive towards integration to ensure the kind of care and support that best meets patients’ needs. The Better Care Fund (BCF) was announced by the Government in the June 2013 spending round, to ensure a transformation in integrated health and social care, it is a key enabler to achieving the CCG vision of true integration.

4. Prioritisation of prevention and early intervention – This is widely recognised as being essential to improving health and well-being and in securing a sustainable health and care system for the future. A range of current national policies have given renewed emphasis on the promotion of wellbeing, the prevention of ill health and early intervention.

The Marmot Report highlighted the crucial importance of prevention and early intervention in the early years as this sets the foundation for health in later life, improves individual life chances and can help in breaking the cycle of health and social disadvantage across the generations.

5. Provision of more personalised care - The Government and the Department of Health is rolling out a personal health budgets policy nationally

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in the NHS. A personal health budget is an amount of money to support a patient with identified healthcare and well-being needs and is planned and agreed between the patient and their local NHS/social care team.

At the centre of a personal health budget is a patient care plan. This plan helps patients decide on their health and well-being goals together with the local care team who support them. For the care plan to be effective, it needs to form part of an integrated health care record that can be shared across a multi-agency care team to ensure the co-ordination of care from a cross- organisational basis.

The CCGs’ care planning approach is to enable people with long term conditions and disabilities to have greater choice, flexibility and control over the health care and support they receive.

Research undertaken by the Kings Fund on community transformation highlights the importance of place based systems of care working together to improve health and care for populations. This means organising and collaborating resources, ensuring appropriate governance and leadership is in place all of which need to be supported by a sustainable financial model of community care.

The Kings Fund3 also talk about the importance of ensuring that the NHS and other national bodies remove barriers to ensure the success of place based systems of care, ensuring a co-ordinated approach to development of local systems.

The ambition to move care closer to home has resulted in some reduction in lengths of stay in hospital settings but it is evident that further significant changes are needed in the way that care is delivered.

The Nuffield Trust has undertaken a review of the vanguard sites which were set up to inform the delivery of new models of care. The Nuffield site a number of interesting interventions that can be defined and which can be adapted and put into use quickly.

These include:

• Working to understand the needs of the residents and supporting carers and families. • Improving care planning and ensuring regular review with a particular emphasis on end of life planning and advanced directives. • A new approach to managing medications. • Training care home staff and up-skilling GPs and other staff. • Providing specialist input into homes to support the staff and providing real time advice. • Aligning homes to one practice. • Getting the ambulance service on board to reduce conveyance.

3 Ham C & Alderwick H, Place Based Systems of Care: A Way Forward for the NHS in England, The Kings Fund, November 2015

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Although these areas seem simple, there is a cultural barrier to ensure they are embedded into everyday practice and the development of productive relationships underpinned by mutual respect are important factors for consideration.

These new models of care have already started to produce some impressive results. There’s been a 15 per cent reduction in emergency admissions to hospital and seven per cent fewer calls to 999. Fewer people are dying in hospital. Levels of Urinary Tract Infections, pressure ulcers, medication errors, and serious incidents have all fallen. And the reduction in the number of medicines being taken has saved £250 per resident.

A report published by the NHS Confederation supported by the Royal College of General Practitioners (RCGPs) in 2012 “Making Integrated Out of Hospital Care a Reality” describes the foundations for integrated care with a focus on implementing out-of-hospital care, and connecting primary, community and social care. It highlights key evidence and draws on learning from partners across health and social care and sets out how a set of principles, each underpinned by a range of drivers and enablers at primary and secondary levels, can support the effective delivery of integrated out- of-hospital care.

Chapter 4 Current Community Services Provision

Community Teams

Community teams are currently based in central locations with outreach to the wider localities. A recent productivity review highlighted that on average 23% of time spent by community teams was on travelling therefore reducing time spent on direct patient care. This has prompted a review of all non-direct patient facing time to ensure rural challenges such as poor IT connectivity and long distances travelling on country roads are addressed in the development of a new model of care. A summary of current teams is detailed below: Community Nursing - available on a continuous basis to meet nursing needs. Examples of services provided will include: wound care, palliative care, bowel and continence care, catheter care, administration of medication, and management of long term conditions, although this list is not exhaustive. Community Rehabilitation - the aim of a rehabilitation service is to facilitate the process of recovery from injury, illness, or disease to regain maximum self- sufficiency and function in a normal or as near normal manner as possible.

The service provides a flexible programme of rehabilitation enabling patients to develop and regain a level of functional independence, working towards patient centred goals. It is expected that any rehabilitation in the community can take up to six weeks.

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Case Management - based on the principle that a defined cohort of patients can be identified as being at higher risk of deterioration with their pre-existing condition, placing them at greater risk of hospital admission. Case management is achieved through providing a coordinated care approach for patients with complex long-term health problems. Falls and assessment and prevention - this service offers a clear structure within which to proactively identify those at highest risk of falling, carry out multifactorial falls risk assessment of internal (health & social) and external (environmental) risk factors, introduce multifactorial intervention, ensure an individual care plan is in place and manage risk through onward referral where necessary, appropriate care management, timely review and planned and supported discharge. Fast Response - the fast response teams are multidisciplinary teams that incorporate Occupational Therapists, Physiotherapists, Nursing staff and generic support workers. The service aims to support people safely in their own homes and helps towards avoiding unnecessary admissions to acute settings.

Fast response services also provide rapid intervention and care packages to enable a patient to be managed safely within their own home or in an intermediate care setting, in the event of an identified risk, exacerbation or deterioration in a patient’s condition. This service is also picking up additional care and support for patients at end of life due to a lack of domiciliary care in the area.

START – The Short Term Assessment and Re-ablement Team is made up of social care assessors and occupational therapists to provide an initial assessment for reablement services and simple equipment to enable a person to be more independent and not reliant upon formal services. The START service is provided free of charge up to the point of review between 1 to 6 weeks. START work with the fast response team to provide an integrated night services. Intermediate Care - a generic term laid down by the Department of Health

“Integrated services (Health and Social care) to promote faster recovery from illness, prevent unnecessary acute hospital admission, support timely discharge and maximise independent living”. (NSF for Older People, DOH June 2002)

The aim of the service is to provide a re-enablement service through assessment and rehabilitation, referring to associated services in a timely and appropriate manner. The service can be time limited, approximately up to six weeks, dependant on the needs of the individual.

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Specialist Nursing - a range of specialist nursing functions operate in the community at present, these services include:

• Specialist Pulmonary Rehabilitation Service • Specialist Continence Service • Palliative care • Discharge Facilitators • Heart Failure Specialist Nurse • Specialist Respiratory Service • Tissue viability

Community Beds

There are four commissioned community hospitals across Hambleton, Richmondshire and Whitby. Patients and members of the public have consistently told the CCG through its widespread engagement that they expect care close to home and the challenges that the locality bring in terms of travel time needs to be addressed in considering a new provision of community based beds for step up and step down care. Another recurrent theme from the engagement is that patients, where possible, would prefer to be treated in their own home, the population feel hugely supported by their GP and primary care team.

Feedback from GPs in the area concludes that they rarely use the current community hospital facilities for step up care due to lack of access. The community hospitals generally have long lengths of stay at the present time.

A summary of the current bed provision is detailed below: • The Rutson ward in the Friarage Hospital, Northallerton is technically a community hospital which includes 9 community rehabilitation beds and 10 stroke beds, with an interim 6 additional beds due to the temporary closure of the Lambert Hospital in Thirsk. The Rutson doesn’t work effectively as a community hospital with difficulties in accessing the beds and long lengths of stay. The commissioning outcomes for this facility would benefit from being re- specified. • The Lambert Hospital, Thirsk is commissioned for 16 beds although due to room configurations and ongoing workforce issues a realistic bed number of between 10 and 14 have been provided recently. Eventually in September 2015 the inpatient beds had to close on a temporary basis due to staffing shortages. The inpatient unit has not reopened and its future will be determined following a consultation process. This hospital is an ageing property with many practical estates problems, including a short-term requirement for substantial repairs to heating and electrical systems. Medical accountability for patients being admitted and discharged at the Lambert Hospital has come from the Acute Physicians at the Friarage Hospital and local GPs have ably provided medical support to these patients. Local GPs have also used the Lambert to admit and provide medical support to patients

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requiring palliative and/or end of life care. • The Friary Hospital, Richmond, is a more recent PFI build that includes 18 Community rehabilitation beds, of which 12 are designated GP beds and 6 are general rehabilitation beds. Currently there are difficulties in accessing beds, particularly for discharges from Darlington Hospital.

• Whitby Community Hospital is commissioned to provide an inpatient, outpatient and community services. Activity data over the last 3 years shows long lengths of stay and levels of care are, at times higher than clinically necessary, which have been considered. The new provider, Humber NHS Foundation Trust have established a service transformation plan which identifies more appropriate community services resulting in less reliance upon inpatient stays. The facility is large and under occupied by approximately 75%. The fabric of the building is poor and requires significant work. A redevelopment plan is in place and the CCG is working with partners to create a health and social care hub on the site.

End of Life Care

There is an unmet need when it comes to end of life care within this area. Due to the extensive distances required to travel in the rural areas, private care providers struggle to provide a service and as such meeting the demand is difficult. The biggest challenge in end of life care is in relation to provision of domiciliary care as part of the national fast track policy; it is becoming increasingly difficult to procure services on an any qualified provider basis. The fast track policy is a fast assessment to get NHS funding in place as quickly as possible, but the lack of providers can lead to a delay in services being available.

End of life care is currently provided by a combination of teams. Palliative Care Team provides care Mon – Fri. The Fast Response Team holds the Palliative Care phone at weekends and also bolsters the Palliative Care Team through the week. There is a lack of domiciliary care through fast track in this area. Due to a lack of provision of dedicated end of life care the Fast Response Team has been filling the gap, a role they were not intended to deliver.

Hospice care can be provided in a Hospice or in the patient’s own home. In recent years there has been an increase in the provision of Hospice at Home. The End of Life Care profile for the CCG shows the rate of deaths in hospice settings is at 2.9% which is below the Regional (6.7%) and England (5.7%) averages. This is down to the dedication of the local GPs and community nursing teams. GPs in the area are clear that they would like to be the lead care clinician for their patients supported by community teams and the specialist palliative care team where required.

The CCG footprint is surrounded by hospices although there is no hospice located within this area. The CCG buys services from these hospices and also works closely with Marie Curie.

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Chapter 5 Opportunities to Transform Care

It is recognised that the traditional way of organising and delivering services is not sustainable and together the CCG wants to work with its providers and local population to radically reimagine how care is provided to support the community.

In 2014 the CCG worked with local stakeholders to define the vision for community services, this has informed the direction of travel and is summarised in the picture below:

Everyone Counts: Planning for Patients 2013/14 signalled that the NHS will move towards routine services being available seven days a week – a development which is essential to delivering a much more patient-focused service and one which offers the opportunity to improve clinical outcomes. Seven day service provision is about equitable access, care and treatment, regardless of the day of the week. The level of service provided should ensure that the patient has a seamless pathway of care when accessing services no matter what day of the week. The CCG has identified a number of proposed projects to enable the delivery of a transformed community system. These are detailed below:

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Title Description Key Deliverables Integrated locality teams Integrated working in communities, Greater productivity with with advanced nursing based on a new flexible approach to more direct patient care skills care delivery in line with the Care closer to home Buurtzorg model. Re-engineered health and social care services will Reduced emergency prevent admissions and act as “pull” admissions to bring patients home from hospital to a suitable care environment far more quickly preventing deterioration and achieving a better return to a higher level of functioning Community-based step- A vision for the future needs of our Care closer to home up and step-down beds community hospitals will be Reduced emergency in community hospitals developed recognising opportunities admissions and care homes to create a wider spread of step-up and step-down beds linked to More efficient model of integrated community teams, but also care recognising the rise in numbers of older people and the need for sub- acute levels of care. A financial model that facilitates the right kind of beds for the right care in the right place will underpin our approach. Developing frailty and A key enabler to all of the projects Falls prevention related pathways within this programme, the intention Reduced emergency is to create a comprehensive, admissions modern, effective pathway covering identification and support for frail Better outcomes elderly, the role of frail elderly ‘hot’ including return home clinics, delirium and falls prevention. following delirium Developing end of life It is difficult to recruit care services Reutilise existing costs services for end of life, particularly in rural incurred through CHC areas. This project will develop a new Fast Track model of care linked to emerging More people dying at integrated care models. It will also home if it is their choice consider the wider opportunities and Care closer to home investments through the Voluntary

sector, Marie Curie, Hospice Care, and specialist palliative care services commissioned with NHS providers that can be strengthened within the model.

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Integrated Locality Teams

The establishment of integrated locality teams wrapped around GP practice clusters would be a key enabler to improving and extending access to care for the locality. Developing the Primary Care Nursing workforce and Integrated Locality Teams is fundamental to delivering flexible services based on the needs of the local population.

The vision for this service is to create integrated multi professional teams with a more flexible approach to delivery of care, 24 hours per day, 7 days per week. The teams will be based and work within specific localities centred upon GP clusters and will be a natural extension of current multi-disciplinary working.

The Integrated Locality Teams will coordinate integrated care planning with a wide range of local services including community nursing, GP Practice Nursing, GPs, community therapy, fast response, social care, voluntary services, housing providers, Mental Health Teams and the NYCC Living Well Team. This will provide a vehicle to agree proactive care planning for patients at risk of hospital admission that require wider service support and to discuss frequently admitted patients identified from within the community who are at risk of repeated admissions.

The Integrated Locality Teams will deliver:

• Care closer to home – more people helped to self-manage their own care at home or through local community hubs • Earlier discharge, including facilitating discharge to assess for long term care to be in a more appropriate community location than an acute hospital • Fewer older people entering nursing or residential homes for long-term care • More people receiving support for themselves and their families at the end of life, with more people dying at home or in the place they choose • More efficient use of scarce health and social care resources, including reduced emergency admissions, caring for people at the most appropriate level of care, and efficient use of the health and social care estate • Effective utilisation of technology to underpin the model of care

• Direct Patient Care through increasing face-to face contacts and providing care within a Patients Home.

A proposed model for integrated locality teams can be found in appendix 3. Advanced Nursing Skills

Advanced and Specialist Nurses will be contributors to both the Integrated Locality Teams and the implementation of delivery of Community Beds as the educators and clinical support for the new models of care.

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As a collective group they will support the Primary Care Clusters to deliver enhanced services to support patients in care homes and Extra Care Housing to provide patient focussed care to all, including ‘housebound’ patients and patients at the end of their life.

A review of advanced and specialist nursing will be undertaken as a starting point to this important transformation work. The future vision of these roles is that advanced and specialist nurses will work creatively to deliver care as part on an Integrated Team in line with best practice drawn from similar work which is being conducted in Scotland.

Community Bed Base

The vision for the future provision of a community bed base is to utilise existing and planned extra care housing schemes as facilities for the location of step up/step down beds. The service will bring together both medical and nursing care adopting a rehabilitative and re-ablement ethos to service delivery. The service aims to meet the needs of individuals who require a higher degree of care and support than can be provided in a home setting, even with new technology and enhanced care support, and for whom care in an acute hospital bed would be the default outcome, however these individuals do not require the care of an acute physician.

To enable the delivery of equitable access to community step-up and step-up down beds across the whole geographical area, with a community facility in each if its localities, beds would be in a range of settings from community hospitals to extra supported housing schemes to care homes.

Where step-up or step-down beds are created they would need an appropriate supporting infrastructure of community-based staff who can deliver care as part of an overall integrated team approach. Patients would be under the care of a GP.

The service aims to support individuals to maximise their potential and remain as independent as possible, and reduce hospital readmissions and admissions to long term care, by providing opportunities and actively encouraging re-ablement and rehabilitation whilst undertaking health and social care assessments and providing nursing and / or medical care. Staff will work pro-actively in partnership with health and social care professionals, carers and the individual themselves, to discuss risk management and sharing, ensuring that an individual’s potential for self-care and self-management is maximised.

The bed base would be supported by the integrated locality teams providing responsive wrap around care. Staff within the service will work proactively and collaboratively across the wider health and social care community to ensure an integrated approach that maximises both acute and intermediate care bedded resources effectively and efficiently, to increase the potential for prevention of admission to acute hospital beds and facilitating timely and effective discharge, returning patients to the most appropriate setting that meets their needs.

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Bed bases will be provided based on the philosophy of ensuring all aspects of the service including the staff and the physical structure of the building provide a dementia friendly environment. The physical aspects consist of changes, where possible in the constraints of the existing building but built into in any re- development, such as opening the spaces and changing signs to be easier to understand. Dementia awareness and ensuring all staff has core skills in dementia care underpin the philosophy.

The step up/step down bed model will deliver the following objectives:

• Care closer to home – more people helped to self-manage their own care at home or through local community hubs • Earlier discharge, including facilitating discharge to assess for long term care to be in a more appropriate community location than an acute hospital • Fewer older people entering nursing or residential homes for long-term care • More people receiving support for themselves and their families at the end of life, with more people dying at home or in the place they choose • More efficient use of scarce health and social care resources, including reduced emergency admissions, caring for people at the most appropriate level of care, and efficient use of the health and social care estate • Effective utilisation of technology to underpin the model of care • Improved experience of care built around the National Voices “I” statements

Appendix 4 shows the opportunities available in the locality for a step up step down bed base Frailty Assessment and Care

The ageing population is recognised as one of the principle health issues for Hambleton, Richmondshire and Whitby.

The Frailty Pathway project has been established in partnership with Heartbeat Alliance, the GP Federation, with the purpose of reviewing the underpinning pathways and guidance for frailty, falls and delirium to ensure that they meet the needs of our population and support the work of services and the transformation programme as a whole. This work incorporates frailty, falls and delirium and all three need to be developed together to work effectively.

The aim of this project is to develop a pathway for the frail patients with non-specific symptoms that often end up in acute crises and place demand on urgent and emergency care. This will run through the different facets of the overall scheme and will have multiple benefits both to patients (in terms of outcomes and better quality of life) and to the health economy by reducing avoidable admissions and the crises that result in the need for patients to access primary care both urgently and routinely.

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It will require a genuinely integrated model of care that brings in all care sectors including the social care sector, supported housing, and the voluntary sector. It will also require a strong element of education and learning to ensure that all members of the workforce are equipped with the relevant and up to date skills and knowledge with which to maximise the benefits of a cohesive frailty pathway.

End of Life Care

There has been a historical emphasis in the CCG footprint of care at home, this is due to rurality challenges and long distances to travel in order to receive care. All of the challenges in providing care for the frail and elderly are replicated for end of life care. Care at home has been led by GPs with support from the specialist palliative care team and nurse consultant, all of which are community based. There is a desire from clinicians for care at home to be continued ensuring that there is an enabling infrastructure to support this.

The community hospitals in the CCG footprint all had a small provision for palliative care where a GP could admit patients in circumstances where they could not be managed at home.

The CCG is developing a solution for domiciliary provision of end of life care with all key stakeholders involved, ensuring that a high quality and sustainable services can be commissioned within the financial resource available. It is clear that a creative solution in working with all statutory and independent sector organisations is needed.

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Chapter 6 Engagement and Pre-consultation

The CCG as commissioners for local services are required to assess whether the four tests for service reconfiguration (set down by the Secretary for State in 2010) have been met:

• Support for proposals from clinical commissioners • Strong public and patient engagement • A clear clinical evidence base • Consistency with current and prospective need for patient choice

Through the engagement process the CCG has sought to ensure all of the four tests are met fully, this will also be assessed during the formal consultation. Purpose of Engagement

The CCG has undertaken significant public and stakeholder engagement over the last 3 years. In preparation for the formal consultation and to assist in scoping out feasible options, a series of pre-consultation listening events have taken place. The purpose of the engagement exercise was to:

• explain to interest parties – patients, the public, elected members, local authorities, partner organisations – the issues facing community services in the future, and the various options which were being developed with local teams in an effort to find a solution; • understand the views of local people about the various options; • ensure that the views of local people were taken into account in developing recommendations for the future of community services; and • assure the local community that the Friarage Hospital was the key component of the CCGs vision for the future

The process of engagement has been clinically led – with strong support from clinical colleagues. The Engagement Process

A communications and engagement strategy has been developed to outline the range of methods designed to engage with local stakeholders prior to the consultation process. It includes the six principles for engaging people and communities guidance published in June 2016. It also describes the consultation requirements. This can be found in appendix 5.

Regular liaison with the North Yorkshire County Council Scrutiny of Health Committee has taken place throughout the period of engagement and their advice sought on specific topics. The Chairman of the Committee has sat on the leading panel of the introductory public meeting; this meeting was independently chaired by a local councillor.

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The main components of the engagement process have included a mix of information-giving and opportunities for people to have a say. The CCG used social media and flyers to give information about the engagement process.

There were a number of mechanisms for people to give their views about the potential changes:

• By emailing views to a general email address • Writing a letter to the CCG via a Freepost address • Attending one of the public open forums arranged during the pre- consultation period.

Using the findings of the engagement to develop options

The CCG endeavours to ensure an open and honest dialogue with patients and members of the public. The CCG “Let’s Have a Proper Chat” engagement has enabled a genuine conversation with local communities. The table below details some of the key themes of what people have told us throughout the engagement process.

Patient and members of the CCG Response Featured within public told us Options People wanted to be cared for at This is in line with the CCG vision for Yes home when at all possible. On the care closer to home. As part of the occasions when it is not possible community transformation or practical to offer care at home, programme the CCG addresses people wish to receive treatment issues of services not being local as close to home as possible and requirements to travel long distances to receive care There are concerns that the The CCG recognises that due to the Yes transport systems in the County rurality of our localities, transport can are an issue in being able to be an issue for many people. The access some health care. It was proposed new model of community felt that in order to access health transformation reduces the care, then transport links would requirement for patents to travel and need to be improved and enables a more resilient community strengthened. workforce serving a smaller footprint People would like end of life care The CCG has commissioned a bed Yes to be provided locally so that at Sowerby House to provide people can remain close to home. palliative and end of life care. The This would give relatives and CCG has been working closely with visitors more options to be able to local stakeholders to develop a see them if based locally. Patients model for end of life care which is would also be able to receive care responsive and timely and can be from known and local health tailored to meet individual needs. By providers such as GPs integrating end of life care services

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in with the integrated community teams, patients would receive end of life care from their local clinical team and GP The community would like to see The CCG has been working closely Yes improved integration in providing with all its health and social care health and social care services partners to look at how to deliver health and social care support more effectively. The CCG co-hosted a Clinical Summit in November 15 in which key themes were discussed and action plans developed. In attendance were over 200 health and social care professionals who had the joint vision to streamline and provide more effective health and social care to our population. The establishment of integrated locality teams would provide a mechanism for health and social care colleagues to work together as one team, sharing resources and expertise. The CCG and NYCC are working jointly on a number of projects to improve the system for patients. People told us that they would like The CCG has invested in District Yes to see care delivered in their local Nursing and the Primary Care communities by district nurses and nursing workforce project which has other local health care seen GP practice nurses working in practitioners different ways. It has enabled the practice nurses to visit nursing homes and support house bound patients to manage long term conditions. These nurses also work closely with district nurses and the intention would be to incorporate the practice and district nursing expertise into the integrated locality team, these teams would serve their local GP practice population. It was important to people that the The sustainability of the Friarage Yes Friarage remains a focal point of Hospital, as the only acute hospital local healthcare and that no further within the CCG footprint, is key to services are removed. There was the success of delivering a locally concern that the consultation and accessible service to our population. its plans would see services Some of our work has highlighted removed from the Friarage some patients who would be better

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cared for closer to home than in an acute focussed environment, this is backed up by a strong evidence base for community based care and our significant investment in community services over that last few years. We intend to ensure appropriate services are available in the community but that where there is a need for an acute intervention, that the Friarage Hospital is able to meet these needs. People shared experiences of GP colleagues recognise the need to Yes when there used to be local GP develop innovative ways of services provided at satellite delivering care and working in a points within local villages. It was more integrated way with clinical suggested that that GPs could colleagues. In recent times this has work in different ways. i.e. placing seen GPs working alongside acute GP in hospitals physicians in the Friarage Hospital, GPs being commissioned to provide an extensive range of ‘out of hospital’ care such as deep vein thrombosis diagnosis and treatment, Anti-coagulation/monitoring and Insulin Initialisation. The CCG has been working with the local GP Federation, Heartbeat Alliance, to pilot several projects that supports the work of the General Practice. These pilots have enabled GPs to look at working in different ways in order to provide more services to their patients. Examples of working in different ways have been the use of clinical pharmacists in GP surgeries and a minor ailments service in pharmacies. The newly formed GP Practice clusters which will be supported by integrated locality teams is creating wider opportunities for GPs to further develop new ways of working. The introduction of step up step, down beds gives our GP colleagues more opportunity to provide a higher acuity of care in the community People felt that the service they The CCG are very proactive in Yes

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received from their GPs was very supporting the GP and work closely good. GPs were highly valued on various projects. The CCG in and their patients expressed conjunction with the GP Federation concerns over the added have engaged extensively with the pressures that GP can experience. population around their views on 7 day access to GP services. This has sat alongside the projects that the CCG and GP have been working on together. The creation of integrated locality teams would see a local team of health and social care colleagues wrapped around a cluster of GP practices. This creates huge opportunities for GPs to work in different ways, by utilising the expertise of these community teams to support patients to live independently and manage well with long term conditions It is recognised that the area has The programme of work “Fit 4 the Yes an aging population and that this Future” looks at providing and comes with various challenges. commissioning health care that is planned for the ageing population. The CCG commenced this programme in 2013 and has already implemented various projects under this banner. The inception of step up step down beds and integrated locality teams incorporating end of life care enables a fit for the future service for our ageing population It was felt that James Cook The CCG is continuously looking at N/A University Hospital is a long way to ways to ensure that treatment and travel to for some treatments and appointments can be delivered as appointments and that there is a close to home as possible. preference for treatment to delivered locally. The Lambert is valued by the The decision to close the Lambert Yes residents of Thirsk and there are inpatient unit was taken by South strong feelings that they would like Tees Hospitals NHS Foundation to see it remain open. The Trust due to staffing issues. Added building has a strong history with to these issues there are concerns Thirsk and was donated and paid about the condition of the building for by residents of Thirsk and its ability to deliver 21st century healthcare. The CCG recognise that the Lambert hospital building is highly valued by the residents of

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Thirsk and it has a long local history. The CCG is committed to providing equitable care to all of the population that it serves and will continue to work with local people to develop services. It was proposed that the Lambert Previous activity tells us that GP Yes could continue in another form in direct admissions for palliative care order to provide palliative and end into the Lambert Memorial Hospital of life care in the form of a is on average 24 people per year in hospice. terms of a bed base, this would equate to a requirement for one or two beds for palliative care to support the population of Thirsk and surrounding villages. A model based on traditional hospital palliative care provision would be unviable from both a patient safety and financial perspective as a fully functioning hospice. Residents felt that they were not Following the temporary closure of N/A to options but has being listened to in relation to what the Lambert Hospital, the CCG has enabled the was happening with the Lambert held 17 events to listen to the public establishment of a hospital. It was expressed that views and suggestions and met with robust process for there is a need to have clear the Lambert Hospital Action Group. communications and communications and engagement The CCG has a full communications engagement processes and engagement strategy in relation to the Transforming Our Communities project and consultation. (appendix 5) People wanted to know where the The CCG have been working to look Yes bed base would be provided if the at providing equity of services across Lambert was not to be re-opened. HRW. Having looked at the bed It was felt that there is now a gap usage figures from previous years, it in the provision for in-patient and can be seen that the Thirsk area palliative care in Thirsk and would need approximately 1.5 beds district. to accommodate the health needs for palliative care. Over 50% of the usage of the Lambert was by patients out of the area. As part of this process of service redesign, the CCG wishes to ensure that the whole of the population are able to access end of life care, palliative and rehabilitation care closer to home. There has been a temp provision of care whilst the Lambert has been

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closed; this is based in the Rutson, Northallerton and Sowerby House, Thirsk. The CCG preferred option would be to commission a range of step up and step down beds for rehabilitation and palliative care, details of which are explained in chapter 7. The public felt that South Tees The CCG maintains good working Yes were not interested in delivering relationships with the current the service in Thirsk and therefore provider STHFT. The CCG has could another provider be sought. closely monitored efforts by STHFT There is a suggestion of using to recruit into vacant posts at the another North Yorkshire based Lambert Hospital and has robust trust to provide the management contractual mechanisms in place to of the services. give assurances around appropriate service delivery, the CCG has no direct concerns relating to STHFT ability to provide community services. However concerns and suggestions from the public regarding the temporary closure of the Lambert Hospital has resulted in the development of option 2. In discussions around the reasons The CCG has closely monitored N/A for the temporary closure of the recruitment efforts by STHFT and we Lambert, recruitment was the are assured in their efforts to try and reason for some of the pressures secure permanent posts, appendix 6 and contributed to the closure. of this document includes a selection The public would like to see the of advertising methods used by evidence base for this decision STHFT. In addition to the usual methods of advertising which is used widely in the NHS, activities have also included:

• Running separate Lambert Hospital adverts on the STHFT website • Advertised via the Job Centres • Promoted via social media • Attended recruitment fairs at Leeds and York Universities • Leafleted Catterick Garrison to target the partners of service personnel

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• Lambert staff have also actively encouraged friends and colleagues to apply for roles There is good evidence to demonstrate that safety issues arise when there is a lack of clinical leadership and no consistent continuity of staffing, this was the situation with the Lambert Hospital. In response to the temporary The CCG will always look into any N/A closure of the Lambert, the CCG complaints in relation to any of the has commissioned a bed at services that it commissions. This is Sowerby House for end of life done through the Complaints care. There was a negative procedure. perception of Sowerby House and Sowerby House is under new the public was seeking management and there are no reassurance as to the actions of specific areas of concern, however the CCG in response to this the CCG is aware of the perception of some members of the local population. Expert advice was sought in form of consultant nurse in palliative care working with the CCG to develop the specification for the bed at Sowerby House. The services at the Lambert were The CCG recognises the high regard Yes valued. It is the services that are placed on services delivered at the important. Lambert Memorial Hospital, and shares the view that the services are the most important factor in ensuring high quality care for our population. The CCG role is to ensure equity of provision of service across the whole of the population it serves. People would like to see more of The CCG has recently invested in Yes the use of technology in being able various methods of digital to access appointments and technology innovations and is consultations. currently developing its local digital road map with partnering health and social care providers. Recent investment has seen a range of consultants at the Friarage now being able to access patient records and diagnostic results via technology from their home, thus reducing time (including travel) waiting for the consultant to return to the Hospital

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and gain access to results. Two telemedicine carts have recently been installed in the Friarage which enables consultants on call to access and diagnose patients remotely – i.e. from their own home. This is providing care locally and also more expediently for the patients with improved health outcomes. The CCG is working with the GP Federation on a project to introduce tele-consultation to care homes and this will be part of the new bed model. Some people have a negative The CCG works in partnership with N/A perception of NHS 111and it was NHS111 to continually improve all felt it was not always reliable. urgent and emergency care services delivered across HRW. The service received by the population of HRW from NHS111 is continually reviewed and performance managed to ensure its resilience and quality are sustained at the levels commissioned by the CCG and any operational issues are addressed quickly and effectively with the service. We will make the provider aware of the concerns raised. With discussions around the bed The CCG has scoped out a new Yes base within the area, the public model for step up step down beds would like to see how this would which would be supported by an work in practice. integrated locality team, medical cover would be provided by local GPs and enhanced by a telemedicine link to the Airedale Hub. More information about this is detailed in chapter 5. People are open and receptive to The CCG shares the view that it is Yes new ideas and pilots being tested important that new ways of working before services are fully put into are evidence based and tested in the place. local area. The Dales project is in the early stages of using teams in the Dales to test new concepts of integrated care and a step up step down bed has been commissioned in Bainbridge as a test bed for the CCG commissioning intentions.

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The public were interested in the STHFT made the difficult decision to N/A clinical reasons for closing the close the in-patient beds on a Lambert temporary basis due to significant and unsustainable staffing shortages. Despite best efforts they have not been able to recruit placing concerns around appropriate clinical leadership, safe staffing levels and increased staff sickness. These circumstances lead to increased risk of hand-offs between different staff/agency staff and risks around safety generally increase without consistent continuity of staffing. People wanted to know who owns The Lambert Hospital ownership Yes the Lambert building and what are passed to the NHS in 1948. It is the plans for it if it was not to re- currently managed on behalf of open. There was a strong sense secretary of state for health by NHS of identity and it being a valuable Property Services. However the community asset by some CCG has been working with GPs in members of the public. the Thirsk Locality to develop a bid to NHS England to secure feasibility funding to identify options in addressing issues with primary care estate in the area, it is envisaged that the Lambert Memorial Hospital and surrounding site would be part of this feasibility work. People wanted honesty in relation The CCG is committed to having Yes to affordability of schemes and honest and open conversations with plans. all its stakeholders. Each option within the consultation has been assessed based on the impact on clinical and quality, estates, financial and equality. People wanted to be assured that As part of the consultation process, the clinicians were on board with the CCG has assured NHSE that it the plans. conforms to the four standards required when starting the process of changing services. One of those standards is that the clinicians need to be on board with any suggested plans. In November 2015 the CCG co-hosted a Clinical Summit in which over 200 local health and social care professionals came together. (see appendix 7 for full report)

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Chapter 7 CCG Commissioning Intentions Commissioning intentions in the Hambleton Locality Background

Hambleton is a large mainly rural district, running from York in the south to Darlington in the north. Approximately 10% of the locality falls within the North Yorkshire Moors National Park. There are five market towns, Bedale, Easingwold, Northallerton, Stokesley and Thirsk, and 130 villages. Just over half of the population live outside the market towns and population density is one of the lowest in the country. (Easingwold is not in the CCG area). Friarage Hospital

Our local acute hospital is based in Hambleton. For the local population, practically and emotionally, the Friarage District General Hospital is the focal point for the delivery of care. The CCG is committed to commissioning the delivery of strong and effective urgent and emergency care services from the Friarage, designed through an integrated model; a broad range of elective and outpatient services, including bringing more specialities or services here from James Cook University Hospital, and maintaining our reconfigured services for paediatrics and maternity, based on the midwifery-led unit and short stay paediatric unit.

The Rutson Ward, is based in the Friarage Hospital, Northallerton. In October 2007 the decision was made to relocate services from the Rutson Hospital to the Friarage Hospital site following a survey revealing the poor state of repair and extensive work required to ensure the building met health and safety standards. The services were transferred in August 2008. At the time of these services being relocated, a revised specification was not developed and the services continue to work to the same specification. Rutson Ward

The Rutson ward has 9 community rehabilitation beds and 10 stroke beds. Currently it has an additional 6 beds due to the temporary closure of the Lambert Hospital, Thirsk. The activity figures tell us that the majority to patients admitted require comprehensive rehabilitation following a stroke or other neurological condition. This leaves a small number of beds available for patients requiring rehabilitation following an acute illness, fall or general/orthopaedic surgery or for palliative care.

There is a general difficulty in accessing the beds due to long lengths of stay on the Rutson Ward and local GPs tend not to admit patients into this facility. In fact, last year, 18% of patients admitted to the Lambert Hospital in Thirsk were actually from Northallerton, Brompton or Romanby because there was no local alternative.

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2014/2015 Admissions into Rutson Ward

Patients home postcode Admissions Percentage

Northallerton 87 34.8

Thirsk 27 10.8

Bedale 18 7.2

Stokesley 31 12.4

Harrogate 11 4.4

Richmondshire 62 24.8

Northallerton Surrounding Villages 6 2.4

Ryedale 5 2

Other 3 1.2

Total 250 100%

Lambert Memorial Hospital

The Lambert Hospital, Thirsk is commissioned for 16 beds although due to room configurations only 14 beds have been provided in recent times, added staffing shortages means at times there were as few as 9 beds in operation. In September 2015, the provider, South Tees Hospitals NHS Foundation Trust (STHFT) made the difficult decision to close the in-patient beds on a temporary basis due to significant and unsustainable staffing shortages. Despite best efforts the beds remain closed and STHFT has no plans to re-open them due to a failure to recruit. The CCG has closely monitored recruitment efforts by STHFT and we are assured in their efforts to try and secure permanent posts, Appendix 6 includes a selection of advertising methods used by STHFT. In addition to the usual methods of advertising which is used widely in the NHS, activities have also included:

• Running separate Lambert Hospital adverts on the STHFT website • Advertised via the Job Centres • Promoted via social media • Attended recruitment fairs at Leeds and York Universities • Leafleted Catterick Garrison to target the partners of service personnel

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• Lambert staff have also actively encouraged friends and colleagues to apply for roles

The Lambert Hospital is an ageing property with many practical estates problems, including a short-term requirement for substantial investment to enable repairs to heating and electrical systems.

Due to its age, design, layout and condition, it has become increasingly difficult to deliver 21st century care from the Lambert Memorial Hospital. It is approaching its next round of period maintenance and has been assessed as requiring extensive remedial work costing in the region of £680,000 over the next 5 years; this investment will not improve the layout of the physical environment, but rather upgrade things like the electrical infrastructure and boilers. This investment excludes ongoing and quite often unpredictable maintenance which can be costly and impact adversely on business continuity.

The CCG understands that in previous years the services delivered from the Lambert Memorial Hospital were much valued, however the building is coming to the end of its lifespan and the CCG do not see this as an appropriate location for healthcare delivery in the future. A summary of the survey can be found in Appendix 8.

Previous surveys on the Lambert Hospital have identified that in terms of quality, the premises do not afford a suitable standard of accommodation in the 21st century. The fabric, décor and environment standards are considered to be poor.

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2014/2015 Admissions into Lambert Hospital

Patients home postcode Admissions Percentage

Thirsk 78 36.11

Thirsk Surrounding Village 16 7.41

Bedale 23 10.65

Northallerton 41 18.98

Stokesley 16 7.41

Easingwold 2 0.93

Harrogate 12 5.56

Richmondshire 7 3.24

Ryedale 3 1.39

Stockton on Tees 3 1.39

Middlesbrough 2 0.93

Redcar and Cleveland 2 0.93

Darlington 1 0.46

Unknown 10 4.63

Total 216 100%

The table above shows the patient admissions into the Lambert Hospital during the period April 2015 to March 2015, split by patients home postcode, this shows that 56% of patients usual place of residence is over 9 miles away from the Hospital.

Community Beds

The strategy for the whole CCG footprint is to establish a vision for the future needs of our community hospitals following extensive public engagement, where the overwhelming message was that people want to receive care as close to home as possible within their own communities. This vision has led to the identification of opportunities to create a wider spread of step-up and step-down beds linked to integrated community teams, but also recognising the rise in numbers of older people and the need for sub-acute levels of care.

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These opportunities are being identified in partnership with North Yorkshire County Council and extra care supported housing providers. NYCC has developed a strategy for extra supported housing across North Yorkshire, this can be found in Appendix 9. The ongoing needs of an ageing population will be assessed in future commissioning intentions and may result in further additionality of step up step down beds in the future to meet these needs.

In Hambleton, it is proposed that a number of step up/step down beds will be commissioned utilising extra supported housing and care schemes throughout Hambleton. The diagram below shows the proposed location of beds in Hambleton. These beds will be supported by a robust clinical framework in the form of integrated locality teams.

Diagram: Hambleton Step up Step down bed proposal

Step up Step down beds Stokesley Friarage Hospital Northallerton

Step up Step down beds Northallerton

Step up Step down beds Step up Step down beds Thirsk Bedale

The CCG has long believed that there should be equity of access to community step- up and step-up down beds across the whole geographical area, with a range of facilities in each if its localities. There are significant opportunities to develop community beds to serve patients with a range of needs, from complex to those waiting for adaptations to their homes, from End of Life care to respite care to a facility catering for the particular needs of patients with dementia or delirium. With the transformation of community teams, the optimum place for a patient to receive care is at home, where community teams can provide wrap around care, with the

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ability to step up care when appropriate to a local facility which is easily accessible to family, friends and the local community. Community Teams

The CCG has led organisational development work to start to build functionally integrated health and social care teams. There has also been a continued emphasis on discharge to the community through a discharge steering group that has connected acute, community and social care colleagues.

In Hambleton, the integrated locality teams are being developed to wrap around clusters of GP practices as detailed in the table below. The clustering of GP practices has self-formed as a result of other transformation work, where practices have been looking at ways to meet some of the challenges they face in terms of resources by testing new ways of working in a more integrated way.

Team GP Practice Cluster Opportunities for step up step down beds Northallerton Integrated Mowbray House, The Orchards Locality Team Northallerton Rivendale Mayford House, Other residential / Northallerton nursing homes Stokesley Integrated Stokesley Health Centre Town Close Locality Team Great Ayton Other residential / nursing homes Bedale Integrated Locality Glebe House Surgery Benkhill Lodge Teams Other residential / nursing homes Thirsk Integrated Locality Lambert Medical Practice Meadowfields Team Thirsk Health Centre Sowerby Gateway Topcliffe Surgery Other residential / nursing homes

The Integrated Locality Teams will coordinate integrated care planning with a wide range of local services including community nursing, GP Practice Nursing GPs community therapy, fast response, social care, voluntary services, housing providers, Mental Health Teams and the NYCC Living Well Team. This will provide a vehicle to agree proactive care planning for patients at risk of hospital admission that require wider service support and to discuss frequently admitted patients identified from within the community who are at risk of repeated admissions. End of Life Care

Work is ongoing to address pressures in end of life care, there is a particular shortage throughout the CCG footprint, and its neighbouring CCGs for providers of domiciliary care and the current fast track process is therefore not meeting the needs of the population. A stakeholder group has been established and collectively, a new model of care has been developed linked to emerging integrated care models. It will also consider the wider opportunities and investments through the Voluntary sector,

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Hospice Care, and specialist palliative care services commissioned with NHS providers that can be strengthened within the model.

In Hambleton, this means that specialist palliative care will continue to be provided in the usual way and where care cannot be managed in a patients’ own home environment by the community specialist palliative care team, they would access specialist services in their nearest acute hospital or hospice setting.

Patients on an end of life pathway require a responsive and resilient service which is tailored to their individual needs and wishes and the new model will see practitioners and carers working as part of the integrated locality team and linking into specialist palliative care services where required to enable this level of care to be delivered. This will result in services being local, responsive and designed to meet individual needs, enabling access to a range of health, social care and voluntary sector practitioners in a timely manner. Enabling Projects

A key enabler to the transformation of community services is the establishment of a frailty pathway. This pathway has been developed with GPs, nurses, therapists and frailty specialists to enable a comprehensive, modern, effective way of supporting the patients who become frail. This includes effective identification and support for frail elderly, the role of frail elderly “hot” clinics, delirium and falls prevention. This pathway will identify individuals who are at risk of becoming frail and ensure appropriate intervention at an early stage to enable people to live well.

The CCG is working with the GP Federation to introduce telemedicine units into Nursing and residential homes in Hambleton, Richmondshire and Whitby, these will be linked to the Airedale telemedicine hub. One month into to project delivery two homes are now operational and linked to the Digital Nursing Hub. They are now able to make secure video calls to a Digital Nursing Hub that is located in an Acute Hospital setting. The Digital Nursing Hub is available 24/7 and can provide an immediate assessment of a resident’s condition prior to a local intervention being initiated, or the resident having to leave their home. Three more homes will be linked up by the end of June with a further 11 homes engaged.

Primary Care Estate

An estates assessment undertaken by NHS Property Services in December 2015 on behalf of NHS England has identified 5 high priority primary care properties requiring re-provision/redevelopment. 4 of the 5 properties are located within Hambleton and 2 of these are located in Thirsk.

GP Practices in Thirsk have come together to identify how to address the issues highlighted in the estates strategy around primary care provision and limitations of their current estate, and have also expressed a desire to identify new ways of working in an integrated way to enable an innovative solution to estates and workforce issues in the area. There is an emphasis on the need for extra supported housing in the area, together with a strong presence of social housing providers; this

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concept is something which is advocated strongly by members of the public in ensuring the locality is fit for the future.

There is a real energy within the locality for working collaboratively amongst health, social care, voluntary sector and local housing providers. Opportunities for partnership working are being explored in various forums within the locality. The CCG primary care estates strategy can be found in Appendix 10.

GP practices have submitted a joint bid to NHS England for funds to support the undertaking of a feasibility study regarding a new primary/community care development. Within this work the CCG want to work with GPs to look at options for a single site, integrated care hub model which will see all Thirsk GPs on one site working collaboratively with the integrated locality team.

The GP Practice in Bedale has submitted a bid to NHS England for funds to develop a significant extension to its existing premises; this would create real opportunities for integration with community teams by generating space for co-location as well as needed additional space for GP expansion. There are no community hospital beds in Bedale, and there is currently no extra supported housing facilities in the town. The CCG is therefore pursuing opportunities with a local residential home for the establishment of step up step down beds.

The GP Practice in Stokesley has submitted a bid to NHS England for funds for complete replacement of their existing premises; a new build would be developed to reflect the growing population. There is one extra supported housing scheme in Stokesley and the CCG is currently exploring with local GPs the need for a step up step down bed in the town, particularly in relation to the impact of the recent closure by South Tees CCG of the inpatient unit at Guisborough Hospital.

Commissioning intentions in the Richmondshire Locality Background

Richmondshire is one of the largest districts in England, covering an area of just over 500 square miles (1319 square kilometres) two thirds of which is in the Yorkshire Dales. Main centres include Richmond, Catterick Garrison, Leyburn, Hawes and Reeth. Outside of urban centres and market towns the locality is sparsely populated with 70.6% of the population living in rural areas and 15.3% of the population living in areas which are defined as super sparse (less than 50 persons/km).

A vision for this locality has been developed to establish the best model for the sustainable provision of community services. This vision addresses; the facilities available through the Friary Hospital including limitations on capacity, the extreme rurality of the area and the need for wider services across the Dales, the project to develop a healthy town in Catterick linked to the ambition for more integrated services with the military and opportunities to work with partners to utilise capacity within extra-care and supporting housing schemes in the locality.

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Friary Hospital

The Friary Hospital in Richmond is a Private Finance Initiative (PFI) building that includes 18 beds, of which 12 are designated GP beds and 6 are general community rehabilitation beds. Currently there are difficulties in accessing these beds, particularly for patients being discharged from Darlington Hospital. There is a demand for beds at the Friary due to a lack of nursing home facilities within the locality, the demographics of the population and the long distances required to travel to any alternative inpatient hospitals.

Although the Friary is the nearest hospital for most residents of Richmondshire, it is still a long distance to travel or many people on country roads, especially those living in the Upper Dales.

Catterick Garrison ‘Forces Family Health’ Project

Our vision for Catterick Garrison is to support veterans, reservists, and the dependants of serving forces personnel to be healthy and well. And when they're not, to ensure that they have ready access to high quality health services.

To support the delivery of this vision of care, we are seeking to design, develop and create a new, modern, integrated community health facility on a major strategic site. This will include holistic health and social care provision and opportunities for wider partnerships with the voluntary sector and other services.

The proposal involves a new build, single integrated care hub bringing together GMS, Defence Medical Services, community services, mental health services, social care services, and other allied services, for example those provided by the voluntary sector or other community-based locally-led schemes.

The Dales Project

The Dales project was initiated to scope out the challenges of providing community services in a hugely rural and sparse population, it has also looked at how a more integrated approach to the delivery of care can be adopted and principles based on the Buurtzorg model are being trialled.

The Dales is deemed as a sound test bed for projects as it has elements of all challenges seen in each of the three localities. A number of models have been developed in partnership with local community health and social care teams in response to the challenges and prototyping is underway these models include integrated locality teams, step up step down beds and trusted assessment as part of robust discharge arrangements.

Community Beds

The strategy for the whole CCG footprint is to establish a vision for the future needs of our community hospitals following extensive public engagement, where the

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overwhelming message was that people want to receive care as close to home as possible within their own communities. This vision has led to the identification of opportunities to create a wider spread of step-up and step-down beds linked to integrated community teams, but also recognising the rise in numbers of older people and the need for sub-acute levels of care. These opportunities are being identified in partnership with North Yorkshire County Council and extra care supported housing providers. NYCC has developed a strategy for extra supported housing across North Yorkshire, this can be found in Appendix 9.

In Richmondshire, due to the different ownership model of the Friary Hospital in Richmond, there is 8 years remaining on the lease, in the long term the CCG will be required to specify the future intentions for the Friary Hospital in line with the timescales of this lease. In the short to medium term, the additionality of step up step down beds is proposed, this will address issues of a widely disperse population resulting in long distances to the nearest community hospital. Richmondshire also has areas of poor nursing home provision leading to a reduced number of options for a community which has an increasingly ageing population.

The diagram below shows the proposed location of beds in Richmondshire. These beds will be supported by a robust clinical framework in the form of integrated locality teams.

Diagram: Richmondshire Step up Step down bed proposal

Step up Step down beds Leyburn Friary Hospital Richmond

Step up Step down beds Bainbridge

Community Teams

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The CCG has led organisational development work to start to build functionally integrated health and social care teams. There has also been a continued emphasis on discharge to the community through hospital case managers and a functioning discharge steering group that has connected acute and community colleagues, including social care.

In Richmondshire, the integrated locality teams are being developed to wrap around clusters of GP practices as detailed in the table below. The clustering of GP practices has self-formed as a result of other transformation work, where practices have been looking at ways to meet some of the challenges they face in terms of resources by testing new ways of working in a more integrated way. This model was developed and is being piloted by the team in the Dales.

Team GP Practice Cluster Opportunities for step up step down beds Catterick Integrated Locality Catterick Village Health To be determined in Team Centre light of future Colburn Medical Centre developments Harewood Medical Centre Richmond Integrated Aldbrough St John To be determined in Locality Team Quakers Lane light of future Scorton Medical Centre developments Friary Medical Centre Dales Integrated Locality Leyburn Practice Harmby Road, Leyburn Team Dales Medical Practice Sycamore Hall, Aysgarth Practice Bainbridge Reeth Practice

The Integrated Locality Teams will coordinate integrated care planning with a wide range of local services including community nursing, GP Practice Nursing GPs community therapy, fast response, social care, voluntary services, housing providers, Mental Health Teams and the NYCC Living Well Team. This will provide a vehicle to agree proactive care planning for patients at risk of hospital admission that require wider service support and to discuss ‘frequent flyers’ patients identified from within the community who are at risk of repeated admissions.

End of Life Care

Work is ongoing to address pressures in end of life care, there is a particular shortage throughout the CCG footprint, but most significantly in Richmondshire, for providers of domiciliary care and the current fast track process is therefore not meeting the needs of the population. A stakeholder group has been established and collectively, a new model of care has been developed linked to emerging integrated care models. It will also consider the wider opportunities and investments through the Voluntary sector, Marie Curie, Hospice Care, and specialist palliative care services commissioned with NHS providers that can be strengthened within the model.

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In Richmondshire, this means that specialist palliative care will continue to be provided un the usual way and where care cannot be managed in a patients’ own home environment, they will access services in their nearest acute hospital or hospice setting.

Patients on an end of life pathway require a responsive and resilient service which is tailored to their individual needs and wishes and the new model will see practitioners and carers working as part of the integrated locality team and linking into specialist palliative care services where required to enable this level of care to be delivered. This will result in services being local, responsive and designed to meet individual needs, enabling access to a range of health, social care and voluntary sector practitioners in a timely manner.

Enabling Projects

A key enabler to the transformation of community services is the establishment of a frailty pathway. This pathway has been developed with GPs, nurses, therapists and frailty specialists to enable a comprehensive, modern, effective way of supporting the patients who become frail. This includes effective identification and support for frail elderly, the role of frail elderly “hot” clinics, delirium and falls prevention. This pathway will identify individuals who are at risk of becoming frail and ensure appropriate intervention at an early stage to enable people to live well.

The CCG is working with the GP Federation to introduce telemedicine units into Nursing and residential homes in Hambleton, Richmondshire and Whitby, these will be linked to the Airedale telemedicine hub. One month into to project delivery two homes are now operational and linked to the Digital Nursing Hub. They are now able to make secure video calls to a Digital Nursing Hub that is located in an Acute Hospital setting. The Digital Nursing Hub is available 24/7 and can provide an immediate assessment of a resident’s condition prior to a local intervention being initiated, or the resident having to leave their home. Three more homes will be linked up by the end of June with a further 11 homes engaged.

Primary Care Estate

An estates assessment undertaken by NHS Property Services in December 2015 on behalf of NHS England has identified 5 high priority primary care properties requiring re-provision/redevelopment. 1 property is located in Richmondshire.

Quakers Lane Surgery, in Richmond has submitted a bid to NHS England for funds to create an extension to its current premises enabling GP expansion and generating opportunities for new ways of working.

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Commissioning intentions in the Whitby Locality

Background

Whitby a seaside town, port and civil parish in the Borough of Scarborough. Whitby and surrounding areas of Danby, Esk Valley and Fylingdales are located within the HRW CCG and had a population of 25,094 at the 2011 Census. Demographic analysis undertaken by Scarborough Council in preparing an assessment of housing need considered scenarios for its population trajectory to 2030 of +/- 4%. Whitby is a popular retirement area and 31% of the population is aged 60+ compared to 28% in North Yorkshire and 23% in England and Wales as a whole.

Conversely only 11% of the population is aged between 20 and 29 years, compared to 14% in England and Wales. This raises concerns about what can be done to retain and attract young people to the area, and how best to meet specialist needs in terms of health and social care, as well as housing which is capable of being adapted to suit changing life circumstances.

The transformation of Community and Out of Hours Services in Whitby and surrounding area has led to a procurement exercise to find a new provider, services were re-specified following significant public and stakeholder engagement prior to the procurement. Humber NHS Foundation Trust took on the 7 year contract in March 2016.

Whitby Hospital

The new community and out of hours contract places a redeveloped Whitby Hospital at the heart of the service vision. The project objectives for Whitby have been to take this vision and work with partners, the public, stakeholders and NHS Property Services to turn the vision into a reality.

The redevelopment of the hospital is central to the recommissioned urgent and community care services in the locality. Humber Foundation Trust, in partnership with the CCG and key stakeholders, have developed a service transformation plan, which, over the next 3 years will see a vast transformation of the delivery of community services. The significant engagement undertaken over the last 3 years with patients, members of the public and stakeholders has included the transformation plans for both the community services and the redevelopment of the hospital.

The Hospital is commissioned to provide an inpatient, outpatient and community services. In more recent times, due to the additional investment and service transformation work in community services, demand for inpatient beds has reduced as the CCG moves to a model of care closer to home, in line with the feedback from members of the public.

The current activity shows that the inpatient unit is operating within a bed range of 16-24, with an average of 21. This includes day case activity. Additional investment

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into community nursing, which is now provided 24 hours a day, 7 days a week has led to less emphasis on inpatient bed occupancy.

From a commissioning perspective the hospital does not provide an appropriate or value for money environment to address the health needs of the local community or for proposed new models of care needed. The hospital in terms of functionality and condition is not fit for the future in that:

• Up to 75% of the current facility is not occupied • Privacy and dignity issues continue • No suitable training rooms • No dedicated treatment rooms for integration of Out of Hours and Minor Injury services • In parts the building is beyond its life and needs replacement • The current site layout does not allow for joint working between mental health, primary care and community services

Architects were appointed in 2015 to work with the CCG and service providers on the space requirements; healthcare planners have assisted the project team with development of a schedule of accommodation, which has influenced the size of the site. A project team was also established by the CCG to develop a programme of works for the redevelopment of the Hospital.

Community Beds

The strategy for the whole CCG footprint is to establish a vision for the future needs of our community hospitals following extensive public engagement, where the overwhelming message was that people want to receive care as close to home as possible within their own communities. This vision has led to the identification of opportunities to create a wider spread of step-up and step-down beds linked to integrated community teams, but also recognising the rise in numbers of older people and the need for sub-acute levels of care. These opportunities are being identified in partnership with North Yorkshire County Council and extra care supported housing providers. NYCC has developed a strategy for extra supported housing across North Yorkshire, this can be found in Appendix 9.

In Whitby and the surrounding area, the CCG has plans in place to develop a facility within Whitby to promote health and wellbeing, through the provision of integrated care in order to develop strong and sustainable local services for many years to come. The services that will be developed on the hospital site include a health and wellbeing hub, ambulatory care, a community urgent care centre and inpatient/outpatient services. Stakeholder and public meetings have brought a range of comments to inform the planning and development of the vision and raised key priorities and views which have been taken into account by the CCG.

The redevelopment of the hospital means that a bed base will be re-provided on the site. Humber FT is working on the principles of care closer to home, with no-one from Whitby being admitted to an acute hospital if they can be cared for at least as well at home or in a community bed.

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Additional investment into the community services enables Humber FT to offer a range of ‘community beds’ which includes a patients’ own bed with wrap around 24/7 care right through to a community hospital bed.

The redevelopment will see a range of 4 bed bays and en-suite individual rooms being provided within the hospital creating a suite of 19 beds. This will be supported by an ambulatory care model of 5 additional beds providing day case activity and ‘time to think beds’ which can be used in the short term to assess a patients’ individual needs.

In line with the proposals in Hambleton and Richmondshire, opportunities are being identified in partnership with North Yorkshire County Council and extra care supported housing providers for the implementation of step up step down beds across the locality. The CCG and NYCC are actively developing plans for an extra supported housing unit to be located on the hospital site, creating a number of exciting opportunities for a health and social care hub and utilising step up step down beds in a range of ways.

Community Teams

The CCG has led organisational development work to start to build functionally integrated health and social care teams. There has also been a continued emphasis on discharge to the community through the connection of acute and community colleagues, including social care.

In Whitby and the surrounding area, as part of the new contract Humber FT will be implementing integrated locality teams in the form of a Neighbourhood Care Services (NCS). The NCS are multi professional teams of health and social care professionals and support workers, delivering care 24 hours per day, 7 days per week. The staff will work with individuals who have physical health problems and work in partnership with the local provider of Older Adults Mental Health (both functional and organic (dementia) illness). NCS ensure a patient centred, joined up approach to health and social care to avoid duplication and improve patient and carer experience.

The NCS teams will be wrapped around a cluster of GP practices. The clustering of GP practices has self-formed as a result of other transformation work, where practices have been looking at ways to meet some of the challenges they face in terms of resources by testing new ways of working in a more integrated way.

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Team GP Practice Cluster Opportunities for Step up Step down beds Whitby Town NCS Whitby Group Practice Newly developed extra Sleights and Sandsend supported housing Surgery scheme proposed for hospital site Whitby Surrounding area Danby Surgery Abbeyfield, Esk Moors NCS Staithes Surgery Lodge Castleton Egton Practice

The Neighbourhood Care Service will provide a vehicle to agree proactive care planning for patients at risk of hospital admission that require wider service support and to discuss ‘frequent flyers’ patients identified from within the community who are at risk of repeated admissions.

End of Life Care

Work is ongoing to address pressures in end of life care, there is a particular shortage throughout the CCG footprint for providers of domiciliary care and the current fast track process is therefore not meeting the needs of the population. A stakeholder group has been established and collectively, a new model of care has been developed linked to emerging integrated care models. It will also consider the wider opportunities and investments through the Voluntary sector, Marie Curie, Hospice Care, and specialist palliative care services commissioned with NHS providers that can be strengthened within the model.

In Whitby, this means that specialist palliative care will continue to be provided un the usual way and where care cannot be managed in a patients’ own home environment, they will access services in their nearest acute hospital or hospice setting, specialist palliative care will continue to be provided by St Catherine’s Hospice.

Patients on an end of life pathway require a responsive and resilient service which is tailored to their individual needs and wishes and the new model will see practitioners and carers working as part of the Neighbourhood Care Service and linking into specialist palliative care services where required to enable this level of care to be delivered. This will result in services being local, responsive and designed to meet individual needs, enabling access to a range of health, social care and voluntary sector practitioners in a timely manner.

Enabling Projects

A key enabler to the transformation of community services is the establishment of a frailty pathway. This pathway has been developed with GPs, nurses, therapists and frailty specialists to enable a comprehensive, modern, effective way of supporting the patients who become frail. This includes effective identification and support for frail elderly, the role of frail elderly “hot” clinics, delirium and falls prevention. This

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pathway will identify individuals who are at risk of becoming frail and ensure appropriate intervention at an early stage to enable people to live well.

The CCG is working with the GP Federation to introduce telemedicine units into nursing and residential homes in Hambleton, Richmondshire and Whitby, these will be linked to the Airedale telemedicine hub. One month into to project delivery two homes are now operational and linked to the Digital Nursing Hub. They are now able to make secure video calls to a Digital Nursing Hub that is located in an Acute Hospital setting. The Digital Nursing Hub is available 24/7 and can provide an immediate assessment of a resident’s condition prior to a local intervention being initiated, or the resident having to leave their home. Three more homes will be linked up by the end of June with a further 11 homes engaged.

Primary Care Estate

The following bids have been submitted to NHS England for feasibility funding to improve their estate.

Egton Surgery, Egton Whitby – to enable expansion of the existing surgery, to improve access into the building with an extension at the rear of the property and to increase accommodation to create additional capacity for GP services and for the voluntary sector.

Staithes Surgery, Staithes – to enable expansion of the existing surgery to create two additional treatment rooms to allow more clinical activity to be delivered. Whitby Group Practice, Whitby – Extension and modification of the existing surgery to create additional space for delivery of multidisciplinary services and voluntary sector activity.

Sleights and Sandsend Medical Practice - new community facility adjoining the current premises to allow services to be delivered in collaboration with other organisations, including social services, diseases specific self-help groups and other voluntary sector groups to create an innovative health and well-being hub attached to the surgery.

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Chapter 8 Formal Consultation: What are we formally consulting with our population on?

Hambleton Locality

Hambleton presents a number of challenges in ensuring the effective delivery of high quality, responsive and value for money community services. Significant investment in community services over the last 2 years has enabled us to work with clinicians, social care colleagues and wider stakeholders to shape plans to ensure resilient services are commissioned which are fit for the future.

The Lambert Memorial Hospital in Thirsk is currently closed due to the provider being unable to sustain adequate staffing levels, in addition to this issue, the physical building is in a poor state of repair and a recent independent survey concluded that without significant investment over the next 5 years, it would not be fit for purpose.

The Rutson Ward in Northallerton is situated within an acute hospital and this environment is not ideal, in addition to this, GP access to these beds has been limited due to increased pressures from acute services and post hyper-acute stroke rehabilitation.

Our proposals for the transformation of community services seek to address these issues and provide an alternative solution to the provision of high quality services. Our proposals also meet growing public expectation for care closer to home. A move away from community hospital provision to one of step up, step down care supported by integrated locality teams which are spread across our communities to ensure there is access to beds in the areas of highest demand, would denote a significant service change and therefore these proposals are included within the formal consultation process. An options appraisal has been undertaken which can be found in chapter 9.

Richmondshire Locality

Our proposals for Richmondshire see a number of exciting projects taking shape.

The development of a health and social care hub in Catterick Garrison is in the very early stages of development, timescales for this are yet to be determined and the CCG plans to undertake an engagement exercise with members of the public and local stakeholders to help shape these plans.

The establishment of integrated locality teams and the commissioning of step up step down beds via the Dales project build on the incredible community resilience which is a key strength throughout the locality and provide much needed additionality of services to tackle the challenges of widely disperse populations with scare resources. This does not represent a significant service change that would adversely affect the local population. This is therefore excluded from the formal consultation process.

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Whitby Locality

The redevelopment of Whitby Hospital has meant a regular link with local communities in the form of events, drop in sessions, surveys, meetings, focus groups, newsletters and briefings on social media and the CCG Website. The aim of this engagement was to share developments and to seek information to help to shape our plans for the transformation of services and the hospital redevelopment.

The CCG has also maintained good relationships with local councillors and provided regular briefings to the Scarborough Borough Council Health and Wellbeing Scrutiny Committee on progress with plans. This relationship has proven to be truly valuable and the CCG has, on many occasion, sought advice and support from members.

As the project to redevelop Whitby Hospital progresses, the CCG will continue to maintain the same standard of engagement with members of the public and local stakeholders at each stage of the redevelopment. This engagement will be undertaken in partnership with Humber FT as they implement the exciting plans for the transformation of community services throughout the locality.

A number of engagement events are planned in the coming months.

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Chapter 9 Options Appraisal

Option 1: Do nothing – The Lambert Memorial Hospital would remain closed and additional beds would continue to be commissioned alongside the current provision of community rehabilitation beds on the Rutson Ward in Northallerton.

Options Appraisal of Option 1

Clinical Quality Impact

This option would see the Lambert Memorial Hospital close permanently for the provision of healthcare, current configuration of the Rutson Ward in Northallerton would be retained which would continue to host additional beds to accommodate demand for those patients had would ordinarily have been treated as an inpatient at the Lambert Memorial Hospital.

Our work has highlighted issues with this configuration of beds, relating to long lengths of stay, limited access to beds and decompensation of the frail elderly, and the adoption of this option on a permanent basis would mean that these issues would not be addressed as an outcome of the consultation.

Access to community beds would continue to be in a centralised location, with limitations on availability as the long lengths of stay would remain as they are at the present time. However this option would represent additionality of beds in the Northallerton area.

The GPs in the Northallerton area rarely admit patients onto the Rutson ward and, due to its location being within an acute facility, the beds are mainly utilised for those requiring intensive stroke rehabilitation or to be used as overspill for acute wards, leaving less access for patients requiring community based rehabilitation. The activity figures from the Lambert Hospital for the period 2015/2016 show that over 50% of patients came from outside Thirsk and surrounding villages, it would be difficult for this demand to be met solely by the Rutson ward.

The CCG plans to develop a home first approach to end of life care, which would be less viable with this option. The new model, developed in partnership with local stakeholders, sees an integrated approach to the delivery of end of life care, this utilises the principles of integrated locality teams working collectively to respond to the needs of the population, an added benefit of this model would be to have a range of options for palliative care patients in accessing specialist palliative care and end of life care, particularly for those patients whose wish is not to die at home. This option

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would present limitations to patients having choice to receive care in a facility which is located within their own community, which is particularly for those at end of life.

Evidence tells us that decompensation of the frail elderly can occur as early as the second day of admission into Hospital and evidence tells us that a functional decline can lead to increased risk of illness and death, diminished quality of life and greater dependence on care and support. The CCG vision for community services is to, wherever possible, enable individuals to maintain their independence and ensure that an acute or community hospital admission is a last resort. When patients are required to be admitted to a hospital setting, it is important, particularly for the frail elderly, that the length of this admission is a short as possible to reduce the impact of hospital decompensation. Traditional models of care, as specified in the Rutson and the Lambert Hospital, are not the best way of delivering care for the frail elderly and can lead to decompensation, and in some cases to an irreversible decline in an individuals’ ability to carry out activities of daily living.

This option represents the current service model, this service model arose due to issues outside of the control of the CCG, and it does not represent a service model that we would have chosen to commission. The Lambert Hospital closed at very short notice and interim options were limited. The Rutson Ward remains as specified prior to its move in 2008 and, since its inception, the CCG has been working to build the community system with additional investment as the priority to enable the re- specification of community hospitals to take place.

This option does not meet the commissioning vision for the CCG. The CCG is committed to commissioning high quality services which are in line with the expectations and requirements of the population in Hambleton, Richmondshire and Whitby. This option does not present the advantages to the delivery of high quality community services in line with what our population has told us they expect during our engagement phase.

Estates Impact

The Lambert Memorial Hospital would close on a permanent basis and the hospital site would be deemed as void by the CCG, returning responsibility to its owner, NHS Property Services. Recent surveys of the building conclude that it requires significant remedial work and in its current condition is not fit for purpose.

The configuration of the Rutson Ward in Northallerton would remain in place and would continue to provide additional beds to accommodate demand for those patients who would ordinarily have been treated at the Lambert Memorial Hospital. In the long term, with the impact of the inpatient activity that would have previously

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gone to the Lambert Memorial Hospital, capacity of this ward would be compromised.

Equality Impact

Activity figures tell us that patients from across our CCG footprint have been admitted to the Lambert Memorial Hospital and the Rutson Ward, not just serving the people of Thirsk and Northallerton, this demonstrates a need for access to community beds which are spread across communities. This option would not provide local provision of community beds for the people of Thirsk and therefore would result in the majority of the population with poor provision of service.

This option would not address the public expectation of care closer to home, and services would become more centralised, reducing the location of community beds to just Richmond and Northallerton. This creates inequity across the localities of Hambleton and Richmondshire with many communities required to travel excessive distances to receive community inpatient care.

Due to lack of access to the beds at the Ruston presently, GPs tend not to admit patients onto this ward. This is because its location is within an acute facility and the beds are mainly utilised for those requiring intensive stroke rehabilitation or to be used as overspill for acute wards. This further reduces the equity of community bed availability within Hambleton and Richmondshire.

Financial Impact

The cost of a hospital bed day is on average 60% more expensive than that of a community based step up step down bed as represented in the table below. Recent activity into the Rutson Ward and Lambert Memorial Hospital shows a number of delayed transfers of care, longer stays in hospital and repeat admissions. The CCG aims to reduce this, primarily to improve patient experience but also to reduce unnecessary expenditure which results from these issues.

Bed day cost £ Average community hospital bed in Hambleton and Richmondshire £229 Average step up step down bed support £142 Average nursing home cost lower level support £91

This option would generate a saving of approximately £170,000 from the closure of the Lambert building, on the premise that the building was entirely empty. If elements of the building remained in use, this would generate a void charge to the CCG for the unused space.

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Option 2: Re-open the Lambert Memorial Hospital with a new North Yorkshire based service provider delivering Inpatient care, Services on the Rutson ward would remain as currently specified

This option would require the CCG to undertake a competitive tender process to procure a new service provider. There are only two other North Yorkshire based hospital trusts, these being York Hospitals NHS Foundation Trust and Harrogate District NHS Foundation Trust.

Clinical Quality Impact

In commissioning services, the CCG requires a level of assurance that these services can be appropriately clinically led and managed effectively to deliver good outcomes for patients. Likewise, in making a decision about future procurement of services, we require assurance that the specification being procured is achievable and will meet the patient outcomes specified.

The recruitment issues facing the Lambert Memorial Hospital has stemmed back since 2007, the recent closure of the Hospital was a decision made by the current provider, STHFT, following extensive measures to try and retain a safe level of service. As at June 2016 STHFT had 76 unfilled registered nursing posts, representing a vacancy rate of 5.5% which is not dissimilar to that of its neighbouring North Yorkshire based Hospital Trusts and nationally the average vacancy rate for these posts is 10%. This recruitment pressure has put additional strain on the services provided at the Friarage Hospital where staff were required to support both sites.

Sustainability of safe and resilient services has not been possible at the Lambert and due these recruitment challenges, not only in Thirsk but across rural Yorkshire as well as a nationally, in particular for elderly care, and it is likely that another provider would face the same recruitment challenges.

The usual and most effective medical model for community beds is for medical input to be delivered by local GPs. This provides much needed continuity of care for local people in the event that they are required to be admitted to a community bed, in addition to this, the GP would be familiar with the patient and their medical condition/s.

The medical model for the Lambert Memorial Hospital has, for a number of years, been configured in a different way following the local GPs decision to provide medical accountability for admitting and discharge for their palliative care patients in the Lambert. Medical accountability for all other patients came from acute

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physicians based at the Friarage Hospital with medical support ably provided by the local GPs. The procurement of a new service provider would not address this issue and medical accountability would need to be sought, potentially based from York or Harrogate, the CCG regards this as a clinically unsafe model of care.

The clinical quality impact on decompensation, particularly in the frail elderly would be the same as that of option 1. Admitting the frail elderly into a hospital setting increases the risk of significant functional deterioration known as decompensation and is not always conducive to supporting an individuals’ rehabilitation needs to maintain activities of daily living.

The continued use of community hospitals in their current form would not add value to patient experience, there are traditionally long lengths of stay and without the re- specification of this ward, we would be restricted in our ability to commission a more personalised and responsive service to be delivered in communities. To tackle these issues the services would be required to not only be radically redesigned but also to maintain strong links with other aspects of community provision, this option would see these other service areas sitting with a different provider and as a result there would be less opportunity for integration of care.

The clinical quality impact on end of life care would be the same as that of option 1. The CCG plans to develop a home first approach to end of life care would be less viable with this option, the new model developed in partnership with local stakeholders sees an integrated approach to the delivery of end of life care, this utilises the principles of integrated locality teams working collectively to respond to the needs of the population, an added benefit of this model would be to have a range options for palliative care patients in accessing specialist palliative care and end of life care, particularly for those patients whose wish is not to die at home, by utilising step up, step down beds in the community. This option would not allow the commissioning of step up step down beds therefore limiting the options available to the residents of Hambleton and Richmondshire of step up care and in many cases requiring additional travel to access this care, from a clinical quality perspective this would be detrimental, particularly for those at end of life. However for the population of Thirsk, the Lambert Hospital has provided a much appreciated and valued palliative care service and has enabled GP to provide care to their patients at end of life.

This option represents a sense of familiarity for the local population whom know the Lambert Hospital and are used to receiving care from there. The local population has demonstrated an affinity to the building and the CCG recognise that this is a valued community asset.

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Estates Impact

Due to its age, design, layout and condition, it has become increasingly difficult to deliver 21st century care from the Lambert Memorial Hospital. It is approaching its next round of period maintenance and has been assessed as requiring extensive remedial work costing in the region of £680,000 over the next 5 years; this investment will not improve the layout of the physical environment, but rather upgrade things like the electrical infrastructure and boilers. This investment excludes ongoing and quite often unpredictable maintenance which can be costly and impact adversely on business continuity.

The CCG understands that in previous years the services delivered from the Lambert Memorial Hospital were much valued, however the building is coming to the end of its lifespan and the CCG do not see this as an appropriate location for healthcare delivery in the future.

The CCG has been working with GPs in the Thirsk Locality to develop a bid to NHS England to secure feasibility funding to identify options in addressing issues with primary care estate in the area, it is envisaged that the Lambert Memorial Hospital and surrounding site would be part of this feasibility work. Exciting opportunities to work collaboratively with primary care, health, social care and social housing providers to develop a primary care/community hub are emerging, this would generate innovative ways of working and address the forthcoming likely increase in demand within the area. It would also assist with increasing outpatient services which would enable repatriation of patients from attending appointments at the Friarage Hospital or James Cook in Middlesbrough. This option would reduce the options to be considered as part of a feasibility study.

Equality Impact

The bed configuration that this option is describing would result in long distances for patients, family members and carers to travel to access them, with only the three community hospitals available for the delivery of care in the community (Friary Hospital in Richmond, the Rutson Ward in Northallerton and the Lambert Memorial Hospital in Thirsk). This option would not allow the commissioning of step up, step down beds therefore limiting the options available to the residents of Hambleton and Richmondshire of step up care and in many cases requiring additional travel to access this care, generating more inequalities in the health system.

This option could result in out of area patients being admitted into the Lambert Memorial Hospital, reducing the availability of beds for HRW residents.

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This option would have a detrimental effect on rest of population of Hambleton and Richmondshire particularly in relation to rehabilitation and end of life care and from a bed base perspective we would not be responding to the needs of the population for care closer to home.

Financial Impact

The community contract for which the services delivered traditionally from the Lambert Memorial Hospital sits, is held with South Tees Hospitals NHS Foundation Trust, and includes all of the services listed in Chapter 4 of this document. The total community services contract value for Hambleton and Richmondshire is £10.8m of which the Lambert represents 10%.

The community system in the Hambleton and Richmondshire has been delivered as one service for many years resulting in integration of teams and the excellent sharing of resources which are flexed around demand, reduced trade-off between organisations and achieving economies of scale. The impact of taking out a small element of this service specification to enable the re-procurement of the Lambert Memorial Hospital would have a detrimental impact on service delivery and the stability of the Lambert Memorial Hospital as a standalone unit.

Having a separate service provider for the Lambert Memorial Hospital would have a financial implication for the cost of pathology transport, deliveries of stock and drugs and access to diagnostic services such as x-rays and scans.

Due to the finite resource available, this option would not allow the commissioning of step up step down beds therefore limiting the options available to the residents of Hambleton and Richmondshire. The CCG would not be in a financial position to implement its proposed new model of care for step up step down beds supported by integrated teams and providing responsive, locality based end of life care.

The cost of remedial building work required at the Lambert Memorial Hospital would need to be met by the CCG, this is estimated to be in the region of £680,000 to bring electrical systems, boilers, back-up generators and emergency lighting up to standard. This does not include the extensive ongoing maintenance costs associated with an ageing building.

A procurement exercise to find a new provider for the Lambert Memorial Hospital would be an additional one off cost to the CCG, estimated at £150,000. This cost is not included within the current CCG financial plans.

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Option 3: Provide step up step down beds supported by integrated locality teams

Options Appraisal of Option 3

Clinical Quality Impact

A vision for the future needs of our community hospitals has been developed and this option would see the creation of a wider spread of step-up and step-down beds linked to integrated locality teams, but also recognising the rise in numbers of older people and the need for sub-acute levels of care.

This option would meet the needs of individuals who require a higher degree of care and support than can be provided in a home setting, even with new technology and enhanced care support, and for whom care in an acute hospital bed would be default outcome, however these individuals do not require the care of an acute physician

These beds will be supported by more robust integrated working in communities. Integrated Locality Teams based on a new flexible approach to care delivery in line with the Buurtzorg model will consist of community nursing, practice nursing, GPs, Mental Health, Social Care, Voluntary sector and personal care support. These reengineered health and social care teams will prevent admissions and act as “pull” to bring patients home from hospital to a suitable care environment far more quickly, this will prevent deterioration and achieve a better return to a higher level of functioning.

The step up, step down bed model would support individuals to maximise their potential and remain as independent as possible, and reduce hospital readmissions and admissions to long term care, by providing opportunities and actively encouraging reablement and rehabilitation whilst undertaking health and social care assessments and providing nursing and / or medical care.

This option would create a robust mechanism for the responsive and person centred delivery of palliative and end of life care, this means that specialist palliative care will continue to be provided in the usual way and where care cannot be managed in a patients’ own home environment, they will access services in their nearest acute hospital or hospice setting, Specialist palliative care will continue to be provided by South Tees Hospitals NHS Trust.

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At end of life patients require a responsive and resilient service which is tailored to their individual needs and wishes and the new model will see practitioners and carers working as part of the integrated locality team and linking into specialist palliative care services where required to enable this level of care to be delivered. This will result in services being local, responsive and designed to meet individual needs, enabling access to a range of health, social care and voluntary sector practitioners in a timely manner. Access to step up step down beds in the community, will provide a local option for patients whom wish for their care to be stepped up into a facility that is not in their own home.

Audit data supplied by STHFT through a system called MEDWORXX has summarised that with in recent times up to one full ward of patients at any one time were being cared for at a higher level of care than is necessary, this is true of many hospitals across the country and is largely a result of poor access to community services/facilities, this impacts negatively on patient outcomes.

This option requires a whole system change as referenced in NHS England’s Five Year Forward View; these system changes require true partnership working and strategic support from all health and social care providers. However this change is long overdue and nationally there is evidence of good practice where areas such as Torbay are highlighted as exemplars of integrated working. This model is proven to be successful in other parts of the country, but we are only in the early stages of piloting the concept in the Dales, it is therefore unproven for our population.

Estates Impact

The Lambert Memorial Hospital would remain closed due to the current providers’ inability to recruit to key clinical posts and the hospital site would be deemed as void by the CCG, returning responsibility to its owner, NHS Property Services.

As detailed within option 2, the CCG has been working with GPs in the Thirsk Locality to develop a bid to NHS England to secure feasibility funding to identify options in addressing issues with primary care estate in the area, it is envisaged that the Lambert Memorial Hospital and surrounding site would be part of this feasibility work. Exciting opportunities to work collaboratively with primary care, health, social care and social housing providers to develop a primary care/community hub are emerging, this would generate innovative ways of working and address the forthcoming likely increase in demand within the area.

Equality Impact

To enable the delivery of equitable access to community step-up and step-up down beds across the whole geographical area, with a community facility in each if its

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localities, beds would be in a range of settings from community hospitals to Extra Supported Housing schemes to care homes.

The CCG has long believed that there should be equity of access to community step- up and step-up down beds across the whole geographical area, with a range of facilities in each if its localities. There are significant opportunities to develop community beds to serve patients with a range of needs, from complex to those waiting for adaptations to their homes, from End of Life care to respite care to a facility catering for the particular needs of patients with dementia or delirium. With the transformation of community teams, the optimum place for a patient to receive care is at home, where community teams can provide wrap around care, with the ability to step up care when appropriate to a local facility which is easily accessible to family, friends and the local community.

Financial Impact

The CCG has been clear as part of the Fit 4 the Future programme that to make system changes to ensure a responsive, local and individualised approaches to community care, that investment in community services was necessary. This additional investment is in place and has resulted in more health and social care staff working in the community.

This option would support individuals to maximise their potential and remain as independent for as possible, as well as impacting hugely on improved quality of life this would also generate financial rewards for the health system, through reduced hospital admissions and readmissions, reduced lengths of stay where a hospital admission is necessary and reduced number excess bed days created through earlier discharge, including facilitating discharge to assess for long term care to be in a more appropriate community location than an acute hospital.

This option would generate a saving of approximately £170,000 from the closure of the Lambert building, on the premise that the building was entirely empty. If elements of the building remained in use, this would generate a void charge to the CCG for the unused space.

The cost of an acute inpatient stay is on average £390 per day, the cost of a community hospital inpatient stay is on average £229 per day and the cost of a step up step down bed stay is on average £142 per day. The NHS is facing significant financial challenges and innovative new models of care are required otherwise issues such as this will not be addressed.

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Summary

Based on the valuable information received during our engagement from members of the public, GPs, hospital consultants, voluntary sector, social care and other local stakeholders, the CCG has developed a set of criteria to assess each option against. This can be found in the table below:

Criteria Option 1 Option 2 Option 3 Care closer to home for the majority of our population

Convenience and accessibility of services, especially for older people who may find it difficult to travel Local provision of end of life care for majority of our population enabling patients to remain close to home Improved integration in the provision of health and social care

Enables GPs to better support out of hospital care

Provides support for our ageing population to maintain independence Retains the Lambert Memorial Hospital Building for service delivery Creates opportunities for the better use of technology

Tried and tested model of service delivery in our CCG area

High quality care with good clinical outcomes

Would actively reduce long lengths of stay in hospital

Equality in relation to the location of beds for the majority of the population of Hambleton and Richmondshire Maintains a sense of familiarity of services being delivered in known facilities Financial sustainability

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Chapter 10 Equality Impact Assessment of Options and Assurance

This section describes the process of an Equality Impact Assessment (EIA) for the proposed models of care under consideration, undertaken by the CCG. This identifies the impact that any potential changes might have and any adverse effects on particular groups of the local population.

This assessment is part of a statutory obligation in The Race Relations (Amendment) Act 2000, Disability Discrimination Act 2005 and the Equality Act 2006 to assess the impact of its policies, strategies and services on the population affected by them to ensure that no group suffers detriment as a result and that positive action to improve community cohesion is taken wherever possible.

This EIA, like all others, considers the possible impact of the proposed models of care on the local population according to nine protected characteristics - age, disability, race, religion and beliefs, marriage and civil partnerships, gender, sexual orientation, transgender, pregnancy and maternity. Additionally, issues of socio- economic deprivation will be considered because deprivation is a determinant of health and leads to health inequalities as well. Potential impacts on human rights have also been considered.

The EIA therefore aims to:

• assess whether the proposed models of care options are likely to have any adverse effects on any of these groups • alert commissioners and providers of the need to monitor the impact on these groups and make changes to mitigate any inequality

Risk Assessment

Risk Assessments provide an opportunity to consider the likelihood and potential impact of all the elements of a proposed service reconfiguration. The CCG has undertaken risk assessments to diagnose the associated risks and mitigations relating to the pre consultation and formal consultation process.

The CCG risk assessment process is outlined below:

The CCG has a consistent method of quantifying risk, the results of which can be processed to produce the acceptability of the risk(s) and follow a Risk Matrix methodology to designate each risk with a rating of Low, Moderate, High or Extremely High. Together the CCG/GP Council of Members will assess risks by defining the likelihood of the risk occurring or re-occurring (on a score of 1 to 5) and its consequence (also on a score of 1 to 5). These are defined as follows:

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Likelihood (2) (3) (5) Risk Matrix (1) Rare Unlik Possi (4) Likely Almost ely ble certain

(1) Negligible 1 2 3 4 5

(2) Minor Conse 2 4 6 8 10 quenc (3) Moderate e 3 6 9 12 15

(4) Major 4 8 12 16 20

(5) Extreme 5 10 15 20 25

Details of any associated risks with the community transformation programme are discussed, logged and, where possible, mitigating action is agreed at the community transformation programme board. Risks are reported through the CCG assurance process and recorded on the corporate risk register.

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Assurance for the 4 reconfiguration test expectations

The CCG are continually assessing the process against the four reconfiguration tests, a summary of the evidence to date is summarised below:

Test Expectation Summary of evidence Strong public and patient 2013 engagement - Launch of Fit 4 the Future with a number of local focus groups to scope a vision for Hambleton and Richmondshire and Whitby. - Vision documents shared with members of the public and used as a further discussion document to seek further views 2014 - Stakeholder and patient engagement to develop an understanding of strengths and weaknesses and explore opportunities, forming a direction of travel for community services - Stakeholder and public engagement informed the launch of a procurement exercise in Whitby for a new community service provider, linking in the vision for Whitby locality 2015 - Testing the direction of travel with members of the public and local stakeholders - Launch of the Dales Project to undertake detailed scoping with clinical teams with a view to piloting new models of care - Public engagement at Summer Shows, see appendix 11 for summary report - Clinical summit attended by over 200 stakeholders, see appendix 7 for outcome of this event 2016 - Pre-consultation listening events with members of the public Consistency with current The range of new models of care seek to ensure that: and prospective need for - care closer to home is achieved whilst also patient choice commissioning safe and sustainable services which are fit for the future. - Robust end of life care which is responsive and resilient to enable patient choice in their preferred place of care - The ability for patients to have a wider range of options in relation to the rehabilitation requirements, retaining the ability to remain in their own community rather than travelling long distances for care - Development of an integrated locality team to ensure that patients are better supported in the community reducing the requirement for admission into hospital

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Clear clinical evidence A range of clinical evidence has been collated and reviewed base in the development of the proposed plans, all options put forward as part of the formal consultation and new models of care will be fully evidence based. Support for proposals The pre consultation listening has been led by the CCG with from clinical active support from STHFT and primary care. The listening commissioners events have been attended by a range of clinical and non- clinical colleagues from STHFT, Heartbeat Alliance and the CCG.

The Dales Project has been responsible for the operational development of processes which would enable the implementation of the new models of care, there has been strong support from GPs, practice nursing, community nursing and therapy teams, social care, mental health and the third sector throughout this pilot development. See appendix 12 for outcomes of this work.

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Chapter 11 Next Steps

It is important that this consultation process is transparent and that the NHS is accountable for the decisions it makes.

What happens to the responses?

During the consultation, all the feedback and responses will be collated, in the same way as we have done with information received during the pre-consultation engagement events. At the end of the consultation a report will be produced identifying the themes and issues raised.

Decision making process

The outcomes report will be discussed with the CCG Council of Members (which is made up of representatives from each of our member GP Practices). The final decision will be made by the CCG Governing Body once they have had time to consider the consultation feedback and responses.

The role of the Scrutiny for Health Committee

The way we have developed our proposals and the way we will reach a decision on them, is being overseen by North Yorkshire Scrutiny for Health Committee, made up of local councillors. The Scrutiny for health committee has the power to refer both the outcome of the consultation and the decision making process to the Secretary of State for independent review.

Get Involved

The views of the public are extremely important to the CCG and we would like you to get involved by telling us what you think of the options listed within this document.

The CCG website includes a dedicated page for the consultation, an online survey is available to complete.

CCG Representatives will also be available in numerous locations during the consultation to answer questions and receive feedback; a paper version of the survey will also be available. Please see the Communications and Engagement Plan in appendix 5 for more details.

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Appendices

Appendix 1 Fit for an ageing population - A Case for Change Appendix 2 Community Transformation Programme Board Terms of Reference Appendix 3 Integrated Locality Team Model Appendix 4 Opportunities for Step up Step Down Beds Appendix 5 Communications and Engagement Strategy Appendix 6 STHFT Recruitment Literature Appendix 7 Clinical Summit Report Appendix 8 NHSPS Lambert Hospital Survey – Summary Document Appendix 9 NYCC Extra Supported Housing Strategy Appendix 10 Primary Care Estates Strategy Appendix 11 Summer 2015 engagement report Appendix 12 Dales Project Overview

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Contents

Foreword 3 Acknowledgements 4

1. Introduction 6 2. The local challenge: rising numbers of elderly people 7 3. National context and drivers for change 8 4. The Case for Change: ‘i.e. what’s not working locally’ 10 5. The overarching vision for Hambleton and Richmondshire 16 6. Implementation and way forward 20 7. Conclusion 21

Appendix 1 22

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A note on the focus for this document

The ‘Fit 4 the Future’ programme is intended to drive the reconfiguration of older people’s services across the whole of Hambleton, Richmondshire and Whitby.

“One vision, three localities, local delivery”

The over-arching vision will ensure there is consistency of access and equity of service provision across Hambleton, Richmondshire and Whitby, as a whole, while allowing flexibility to respond to local needs.

The CCG recognises that the three different localities may be at different starting points, with different local issues and service pressures, and may need to progress at different paces. The intention is to allow different localities to respond to local circumstances, while all the time making sure that they each to respond to the needs identified the first engagement phase of ‘Fit 4 the Future’. Therefore, the more detailed service redesign work for each locality will be taken forward through local projects.

The Governing Body will retain the over-sight for each project to make sure the objectives identified through ‘Fit for the Future’ are delivered in each locality. HRW CCG will also work with North Yorkshire County Council through the Integrated Care Board to ensure consistency with emerging county-wide strategies.

Vision and Case for Change for Hambleton and Richmondshire

The focus for this document is the localities of Hambleton and Richmondshire. Its purpose is to provide an over-arching document to be used as the basis to start detailed discussions in both localities. As discussions progress further, it is increasingly that locality-specific ideas and issues will be identified, which will need to be reflected in locality documents and project plans accordingly.

Companion document published for Whitby

For information, discussions about the future of services in the Whitby area are being undertaken in parallel to the work in Hambleton and Richmondshire. This work is driven by specific pressures on the local hospital and the need to make changes to community services. A specific “Vision for community health and social care services in Whitby and surrounding area” was published by the CCG as a document for discussion in October 2013. This document also consolidated issues that have been raised in the locality over the previous two years. This revised vision is now being tested out with local service users and stakeholders as part of the local project to drive service change in that locality.

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Foreword

Welcome to the Vision for ‘Fit 4 the Future’ in Hambleton and Richmondshire. This outlines – and sets the scene for open debate – the priorities for developing health and social care services in the area over the coming years.

This Vision introduces the engagement phase of our ‘Fit 4 the Future’ programme following on from its initial launch last year. We’d like to know what you think about the plans, what else should be in here and what we need to prioritise.

We have identified, thanks to their help, some of the main issues and priorities of our patients, their carers and our partners. We now move on to the next stage, which is to present our initial thoughts and open up the debate again to canvass more views and refine the Vision. We have tried to detail the issues and challenges that we face and the opportunities that we have to address them.

The only certainty is that with ever increasing frail elderly population and the health needs associated with then that services cannot remain as they are. We have a great opportunity to improve the services that we provide to our population while following our general principles of providing care closer to home wherever possible, allowing people to remain at home as long as possible and putting quality of care, patient safety and experience at the heart of what we do.

By the end of this engagement work we hope to have identified the changes that we need to make to ensure local NHS services are the best they possibly can be to meet future healthcare needs. We are looking forward to meeting as many people as possible and hearing your ideas and opinions.

Please take the time to read this Vision, and let us know you thoughts about the future of your local healthcare services.

Yours faithfully

Dr Mark Hodgson Hambleton, Richmondshire and Whitby CCG

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Acknowledgements The writing and development of this document has been carried out in partnership through a working group, SDIP 2 (Unplanned Care and Community) Group. Representatives from Hambleton, Richmondshire and Whitby Clinical Commissioning Group, South Tees Hospitals NHS Foundation Trust, North Yorkshire County Council and County Durham and Darlington NHS Foundation Trust sit on the group.

This Vision is intended as a partnership document led by Hambleton, Richmondshire and Whitby Clinical Commissioning Group in partnership with other local organisations. It may evolve and develop before a final version for members of the public is published.

This first draft document, intended for discussion with a wider stakeholder group, is brought to you by:

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1. Introduction Hambleton, Richmondshire and Whitby Clinical Commissioning Group (HRW CCG) is responsible for commissioning (buying) of the vast majority of the healthcare services received by its population. Ensuring that people receive the best possible care within the resources available is a complex task and HRW CCG is committed to undertaking this in partnership with patients, their carers, partner organisations and local stakeholders.

Once we were established, we quickly recognised that the growing numbers of elderly people in our area represented one of our biggest challenges and opportunities for improving the design and delivery of care. In this area alone, by 2021 we expect to see the number of people over the age of 65 increase by 30 per cent. Considering that people aged over 65 account for around 70 per cent of all health care spend, this will bring new and significant challenges for the local health economy.

In addition as part of commissioning community services for adults, we also need to consider the wider needs of patients, for example those with mental health problems, learning disabilities or dementia.

Earlier in 2013, we launched the ‘Fit 4 the Future’ programme to involve local people and service users in the commissioning of services and prepare the local health and social care system to meet the challenges of an aging population. The first phase was to take a blank canvas approach to understanding the views of patients and stakeholders. A series of events were held to understand the key themes and messages. These were:

 Keeping people in their own homes for as long as possible  More information for patients and their carers  Better patient transport  Facilitating social interaction  More support for carers  Utilise new technologies as part of the solution

The challenge of a rising elderly population will not just affect HRW CCG, but will impact upon North Yorkshire County Council, a wide range of statutory providers of health and social care services, including South Tees Hospitals NHS Foundation Trust, services provided by the Voluntary Sector, as well as local towns, villages and communities. The CCG intends to commission services in partnership. We will work closely with the North Yorkshire Joint Health and Wellbeing Board, which has identified “the increasing care needs of a rapidly growing population of older people” as one of its key challenges.

However, we also want to engage and consult directly with patients, service users, carers and communities as part of developing and agreeing its proposals and plans.

This document describes the key components of a successful health and social care system and explains why, at this current time, and supported by appropriate evidence, they are not yet optimally established to meet the future need. This information is intended to form the basis of an informed discussion about how services should be commissioned for the future.

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2. The local challenge: rising numbers of elderly people

Hambleton, Richmondshire and Whitby has a predominantly rural area with a local population that is increasing and ageing, with significant in-migration from other parts of the UK in the pre-retirement and the recently retired age groups.

Many older people are healthy and well and make a major contribution to the health and wellbeing agenda as direct carers, as volunteers in their local voluntary organisations and through silent, often un-noticed work both with families, their neighbours and their faith groups. However, older people also have specific needs around accessing and receiving high quality support and information; managing their own support as much as they can; maintaining a family and social life, including contributing to community life; and avoiding loneliness or isolation.

It is well-recognised that age is directly linked to the prevalence of long term conditions, such as heart disease, diabetes, chronic obstructive pulmonary disease, or dementia. As people get older, people are increasingly likely to have at least one long term condition, with many older people having to manage several such conditions. In addition, frailty is increasingly being recognised as an important health and social care issue. Particularly in those patients who are 85+, frailty makes people more vulnerable to falls, more at-risk of an admission to hospital, and less able to recover after a crisis or episode of ill-health (and then often not to the same level of function). Age therefore has a significant impact on the utilisation of health and social care services, both in acute hospital as well as the community, as well as significant impacts on housing, transport, and carers and families.

There will be much we can do to help people to self-manage and prevent deterioration of their condition through better education and awareness and putting plans in place to help them respond in a crisis. We can also provide better support for family and carers to help them understand and be part of the new approaches we are using to support people, for example using new technologies for those at-risk of falling and caring for more people at home where possible.

It is vital that we do not just treat the health needs of older people, but consider what preventative strategies we can employ to keep people healthier for longer and invest in work with the younger population, who are both able to support the older generation now and who will also become the elderly population of the future.

The Joint Strategic Needs Assessment describes how we need to avoid seeing old age as an inevitable burden on society, but recognise that some older people may be frail and in need of intense support for some period in their lives but many others are fit and well and a major asset to our communities. Nonetheless, we need to develop versatile and flexible local responses and services to reflect a person-centred, user-led approach for the population, and plan for increasing numbers of older people with more intensive needs. To do this we are likely to need to strengthen services for prevention and provision of care close to home, as an alternative to continually investing in acute services.

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3. National context and drivers for change As well as local commissioning knowledge, there are a wide range of policy, evidence and good practice drivers emerging nationally, which are influencing our local plans.

Prioritise prevention and early intervention Prevention and early intervention is widely recognised as being essential to improving health and wellbeing and in securing a sustainable health and care system for the future. A range of current national policies, including Sir Michael Marmot’s report on health inequalities (‘Fairer Society, Healthy Lives’ February 2010) have given renewed emphasis on the promotion of wellbeing, the prevention of ill health and early intervention. Evidence shows that partnership working between primary care, local authorities and the third sector to deliver effective universal and targeted preventive interventions can bring important benefits. Public health services have transferred to Local Authorities and North Yorkshire Council is leading the development of a prevention strategy, which includes access to information and advice at an early stage at its heart.

Provide more personalised care The Government and the Department of Health is rolling out a personal health budgets policy nationally in the NHS. A personal health budget is an amount of money to support a patient with identified healthcare and wellbeing needs and is planned and agreed between the patient and their local NHS/social care team. At the centre of a personal health budget is a patient care plan. This plan helps patients decide on their health and wellbeing goals together with the local care team who support them. It also sets out how their budget will be spent to enable them to reach their goals and keep healthy and safe.

Extend access to primary care and provide a named GP for elderly and vulnerable Changes to the national GP contract are currently being announced, including that older patients will be assigned a single ‘named clinician’ who is accountable for their care at all times when they are out of hospital. Other developments include a new enhanced service for patients with complex care needs who may be at risk of unplanned admission to hospital and the roll-out of the ‘Friends and Family’ test.

Ensure Integrated Care and Support From 2015/16, each CCG will need to create an Integration Transformation Fund which will comprise an almost four-fold increase in the pooled budgets with NYCC. This is intended to support investment in the integration of health and social care and the shift to community provision away from acute provision. Plans are to be jointly agreed between health and social care and ensure: • protection for social care services (not spending) • as part of agreed local plans, 7-day working in health and social care to support patients being discharged and prevent unnecessary admissions at weekends • better data sharing between health and social care, based on the NHS number • a joint approach to assessments and care planning • an accountable professional where funding is used for integrated packages of care • risk-sharing principles and contingency plans for where targets are not met (including redeployment of the funding if local agreement is not reached) • agreement on the consequential impact of changes in the acute sector

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High quality care for all In recent months the NHS has had to address the outcomes of recent reviews into significant failures of the health and care system. The CCG is fully committed to doing this and ensuring we foster a culture of compassionate care in which patients are genuinely and consistently at the centre of everything the service provides. The key reports published include:  Transforming Care, the Government’s final report on Winterbourne View; and  The public inquiry chaired by Robert Francis QC on Mid Staffordshire NHS Foundation Trust and Patients First and Foremost, the Government’s initial response.

Provide sustainable housing models to meet future needs of local communities Vulnerable and older people require homes and opportunities that meet their particular needs, foster self-determination and support a good quality of life. The needs of older and vulnerable people can be met in a variety of settings, such as shared specialist supported housing, extra care housing, care settings, as well as through general housing. We recognise that vulnerability can be a temporary or a permanent state and therefore a wide range of solutions need to be available. Locally, North Yorkshire County Council is deploying the largest procurement nationally, with 15 Extra Care facilities across North Yorkshire and development of up to 56 proposed. These facilities give people the opportunity to live independently in a home of their own, but with other services on hand if they need them.

Continue to improve financial efficiency of services Nationally, both the NHS and Local Authorities face pressure on budgets and the need to make continued efficiencies if they are to remain in financial balance. For the NHS, the emphasis is on reducing inappropriate acute care activity, while Local Authorities need to reduce the long-term size of care packages and care home placements, through more effective reablement and prevention of ill-health.

National evidence and good practice from elsewhere HRW CCG doesn’t intend to “reinvent the wheel” unnecessarily. We will develop proposals in line with the latest thinking from leading health research organisations, such as the King’s Fund. We are also adopting the recommendations from National Voices, whose work has been central to a local programme of multi-agency workshops to create functionally integrated health and social care teams in the community and support the development of our integrated overnight fast response service.

The North Yorkshire and Humber Commissioning Support Unit (NYH CSU) has researched examples of best practice across the country and beyond. A consistent theme is that patients, particularly the frail elderly, are more likely to be able to remain in their own homes if they receive care there rather than being admitted to hospital. The overall cost to the NHS and social care is also reduced if unnecessary admission can be avoided and patients receive the right level of care at the right time and in the right place.

Appendix 1 provides a more detailed summary of the King’s Fund and National Voices, and the range of ideas and initiatives that have emerged from the investigation by NYH CSU of what has been published and recommended.

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4. The Case for Change: ‘i.e. what’s not working locally’

Patients and service users, particular as they get older, will require a wide range of services, which they will access at different times and to different extents depending on circumstances. Many patients already have a very good experience of care and may feel that services are already working effectively. However when we look across the system as a whole, it becomes apparent that clear problems and service gaps emerge. This means the system isn’t able to care for patients as effectively as it could do, and certainly isn’t prepared for the rising numbers of elderly people in the area.

This next section takes a subject-by-subject view of the deficiencies of services in the local area, explaining why the issues raised are important, and highlighting where improvements need to be made in order to realise HRW CCG’s over-arching vision. It is essential that these services place the patient at the centre of care and are commissioned and delivered so as to provide an integrated and co-ordinated experience of care.

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4.1 Acute hospital provision

Good quality acute hospital care is an essential part of the system of healthcare support for older people. Patients, when they become ill, need access to effective assessment, diagnostic tests, and in some cases an acute stay while they receive medical treatment. The population of HRW CCG is fortunate in that they have access to good quality care at the Friarage Hospital in Northallerton (FHN), as well as further afield, for example, through James Cook University Hospital in Middlesbrough or Darlington Hospital.

However, an acute hospital stay, especially for a prolonged period, is not always in a patient’s best interest. Hospitals are busy, noisy places with (necessarily) less privacy and limitations on access by family and friends. Older people may find their capability and level of independence deteriorates when they are away from their own home and not able to undertake their usual routines and interests. Hospital staff work hard to minimise hospital acquired infections and outbreaks, but these do occur on occasions, particularly in busy winter periods.

We have considerable evidence that locally patients are spending longer than they need in local hospitals, either because they are admitted unnecessarily where they could be managed in their own home or community facility, or once they are admitted the systems and support services are not in place to bring them home quick enough. South Tees Hospitals NHS Foundation Trust undertook a Bed Utilisation Audit in October 2011 that showed that 36% non-elective patients in the Friarage Hospital did not require an acute bed.

The reasons why acute stays are understood to be too long include:

 Lack of capacity across health and social care fast response and intermediate care services to rehabilitate and reable patients in their homes or community hospitals.  There isn’t rapid-enough access to a comprehensive geriatric assessment to enable a patient to have their needs assessed and to return home with a package of support through A&E or the Clinical Decisions Unit at FHN.  There is a lack of access to more senior-decision making 24/7 at the ‘front door’ of the Friarage Hospital both within A&E and the Clinical Decisions Unit, which means more conservative decisions may be taken leading to admission. There is also a lack of regular ward rounds seven days a week to facilitate discharge.  The transport arrangements to bring people to hospital for assessment are not sufficiently responsive, particularly where a ‘999’ response is not required. The result is that many older people arrive for assessment from noon to mid-afternoon, which is often too late to prevent an unnecessary admission.

4.2 Community Facilities

Hambleton and Richmondshire are two of the most rural locations in the country with highly dispersed populations, particularly across the Dales. The provision of community facilities with inpatient beds enables care to be delivered closer to a patient’s own communities and is a fundamental part of our approach to meeting the needs of our local population.

Currently, there are three designated community facilities: the Friary Hospital in Richmond, the Rutson facility within the Friarage Hospital, Northallerton, and Lambert Memorial Hospital in Thirsk. They allow patients who do not need acute care, but who would be too 11

vulnerable to be cared for at home, to receive care and rehabilitation away from a busy acute hospital setting. The Rutson facility is housed within an acute ward and increasingly cares for acutely ill patients suffering from stroke repatriated from James Cook University Hospital.

The current model and practice of care through these three community facilities is not currently ideal. Patients remain in beds for longer than necessary. A bed utilisation audit in 2011showed that many patients didn’t meet the criteria for a community hospital bed (38% patients for the Friary Hospital, rising to 90% for the Lambert Hospital). Admitted patients are not necessarily local to that particular hospital, with both the Friary and the Lambert taking patients from across the CCG’s geographical area. In addition, while the facilities at the Friary Hospital are relatively modern, those at the Lambert Memorial Hospital are compromised because they are located in an old building which is expensive to maintain and limited in its suitability for provision of sub-acute care.

In common with acute hospital services, insufficient numbers of patients are supported with effective rehabilitation at home, where it would be possible and preferable, because there is insufficient capacity within intermediate care and fast response services. This means that the overall number of community hospital beds provided is possibly higher than the true need if intermediate care services were properly established.

In the area south of the River Tees further community hospitals are managed by South Tees Hospitals NHS Foundation Trust. These predominantly provide a service for patients on Teesside (Middlesbrough, Redcar, Guisborough, etc), but occasionally North Yorkshire residents may access them. It is noted that South Tees NHS Foundation Trust is looking at the future of these hospitals and there will be a public consultation later in 2014.

4.3 Intermediate care, Fast Response Services and START (Short Term Assessment and Reablement Team)

A range of services are provided through both health and social care to help prevent crises escalating to an acute hospital stay or long-stay care home placement, or to step-down patients back to their own homes or communities as quickly as possible. Generally these services last for a period of up to six weeks, are free to the service user, and are intended to stabilise, rehabilitate and re-able patients to the highest level of function possible. Services in Hambleton and Richmondshire are relatively comprehensive. South Tees Hospitals NHS Foundation Trust provides intermediate care and fast response services.

Intermediate Care is therapy-led (physiotherapy and occupational therapy) and proactively rehabilitates patients in their own homes or by in-reaching into community hospitals, including for those patients identified as at-risk of falls. Fast Response Services are provided by a multi-disciplinary team over a 24/7 basis and provide multiple intensive interventions for generally up to 3-5 days. START (Short term assessment and reablement team) services are provided by North Yorkshire County Council and focus on reabling people in activities of daily living with a view to promoting their independence and reducing their ongoing care requirements.

However, as explained in 4.1 and 4.2, there are problems with both the current service model and capacity, so acute and community hospitals are unable to return people to their own homes quickly enough and very often people are going into hospital unnecessarily. 12

During 2013/14, some limited pump-priming investment has been made in intermediate care through health and social care monies, but some fundamental issues remain:  Therapy provision is not properly available on a 7 days a week basis, which limits the capability to properly rehabilitate and care for patients in a community setting.  The START service doesn’t always have capacity to easily respond to requests for social care assessment within 72 hours from community hospitals or services.  While services work on occasions closely together, there isn’t a fully integrated response and there is much greater potential for joint working.  Patients recovering from stroke particularly suffer from a lack of sufficient specialist expertise and capacity to continue their care once the acute phase is over.

4.4 Health and social care integrated community teams

Vulnerable patients and service users will sometimes need support within the community to maintain their basic health and social function. This is provided from a range of organisations and services, including both health and social care.

District nursing services provide care for housebound patients or those whose care is most appropriately provided in a home setting, many of whom will be older people, including: wound care and dressings, catheter care, and palliative care. The service works in partnership with GP practices and social care assessment services, which identify the on- going social care support required for people in greatest need. Increasingly, services are being targeted at patients who are at-risk of deterioration and those with complex needs, for example those with multiple long term conditions.

There are significant capacity issues within these community services. During 2013/14, additional temporary capacity has been put into three community teams in Hambleton, but recurrent investment has not yet been identified. There are also, on occasions, capacity problems within the local social care Health Interface Team (HIT).

Currently, health and social care teams working in the community are not working in a sufficiently integrated way. We are in the process of undertaking a development programme to bring teams together, which is led for by the Centre for Innovation in Health Management (in the University of Leeds). This is already leading to improvements, but has clearly shown that services were not built around the patient. A number of barriers and obstacles to integrated working have been identified:

 Ineffective liaison between staff and organisations, through multi-agency meetings and other forms of communication.  Lack of co-ordinated working and duplication of assessments, due to poorly aligned teams, limited hot-desking and co-location opportunities and lack of processes to share and feedback information.  Lack of an effective IM&T infrastructure as an enabler.  Lack of an integrated team identity, with staff not fully aware of who and how they contact their colleagues and a lack of understanding of the roles of staff in different organisations.

4.5 Continuing health care (CHC)

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Some patients may need to go into long term care, supported with continuing healthcare funding, where assessed as appropriate. Assessments for long term CHC should usually take place in the home or at least a community setting, where the patient’s maximum level of function and properly thought-through long term wishes are understood. However, very often these decisions are taken while the patient is still in an acute hospital, at the point where their long term needs are less clear. This can lead to some patients choosing to leave their home earlier than is necessary if they had a better access to support and rehabilitation following an acute episode or crisis.

The variety of CHC provider options in Hambleton, Richmondshire and Whitby is also more limited, given the rural nature of the patch. This can lead to reduced choice and increased cost and delayed transfers of care.

4.6 Mental health services

As the numbers of older people in the area rise, so the links between physical and mental health of older people need to be clearer and more effective. In the future, the local health economy will need to be much better at identifying and supporting patients with dementia and managing acute mental health problems, e.g. delirium, closer to patient’s homes and communities.

Currently, there is a lack of an integrated approach between older people’s mental health services and the mainstream health and social care community teams. This can lead to a lack of early diagnosis of dementia and inadequate proactive responses that are able to keep people self-caring for as long as possible and enable them to stay in their own homes for longer. Better integration would also help to reduce the stigma of dementia and help to create dementia-friendly communities. There are also gaps in support to carers of people with mental health problems and liaison services with nursing homes and more work could be done to establish how teams work better with these individuals and services.

4.7 GP practices

GP practices across the CCG have the highest patient satisfaction rating in the country and are working effectively to provide a wide range of services in primary care. Nevertheless, practices will need to undergo some significant development in the next few years. There is a national move through the up-dated GP contract towards some level of seven day working, proactive identification of at-risk individuals through risk profiling, and identifying lead professionals for complex vulnerable patients.

The mechanisms for the integrated team to engage with GPs are opportunistic and depend more on effective personal relationships rather than good processes. There is sometimes a lack of effective involvement from GP practices with the work of the integrated teams and a lack of integrated working between practice nurses, who manage chronic disease, with the needs of housebound patients with long term conditions.

4.8 Extra Care Housing and care home sector

For some people, there may come a time when they need to live in some form of supported housing or care home, either on a short-term or a longer-term basis. NYCC has placed 14

great emphasis on reducing the numbers of people going into long-term residential care and instead is actively promoting the development of Extra Care Housing. However, there are some patients for whom a long-term care home placement will be appropriate. There are also opportunities for statutory services, through intermediate care or Fast Response, to place a patient within a care home on a short term basis closer to their homes or families as place of safety while they recover.

There are only 25 nursing and residential homes across Hambleton, Richmondshire and Whitby approved by North Yorkshire County Council. Their locations mean that some rural parts of the patch, particularly in Hambleton and Richmondshire, do not have a home particularly close to their local community, in comparison to the rest of the county. A significant number of beds (17% as of December 2013) are under suspension. This can put pressure on the ability to place people where needed on either a short-term or a long-term basis.

4.9 Voluntary sector / local communities

Services provided from the voluntary sector play a vital role in supporting people in their own communities. However, services may often be fragmented, disconnected and dependant on short-term funding. The result is that services do not always work effectively together and staff working in statutory organisations may not know what services exist and so are unable to sign-post patients to them effectively. Services are also patchy or incomplete in some areas, with unequal access depending on where a person lives to services such as: voluntary transport, support for shopping or home laundry, social opportunities, befriending, etc.

4.10 Information management and technology

While in recent years there have been great advances in the opportunities available through IM&T, some significant obstacles remain. Currently there are no consistent systems and processes for: using the NHS number as a single patient identifiable number across all health and social care organisations to help co-ordinate care, using safe and secure e-mail addresses to share information, obtaining shared consent, and limited capability to access different provider record systems in common locations, let alone a single common shared IM&T solution between health and social care.

4.11 Transport

Funded transport to access health and social care services is not an automatic right and is dependent on clinical need. Patients and service users therefore need a range of options to access available services, dependant on circumstance.

In Hambleton and Richmondshire, emergency and patient transport services are provided by Yorkshire Ambulance Service NHS Trust. There are also voluntary transport schemes operated by the voluntary sector.

While these services are available, there is more potential for patient transport services (or alternative arrangements) to be put in place to enable people to get to hospital more quickly and efficiently when they are referred urgently by a GP, rather than where the patient has

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called 999. There are also opportunities to better promote the use of voluntary transport schemes and to extend their coverage within the area.

5. The overarching vision for Hambleton and Richmondshire

Hambleton, Richmondshire and Whitby Clinical Commissioning Group’s overarching strategic vision is “To commission (buy) first class healthcare which improves the health and well-being of everyone living in Hambleton, Richmondshire and Whitby”. For older people, this means looking at a wide range of services, including those which respond to and rehabilitate patients when they are in crisis, as well as considering a range of more proactive services, both through statutory services and the voluntary sector, which can promote health and independence and hence improve well-being.

The intention is to make a real impact on population and system health outcomes, including:

 Enabling older people to enjoy the maximum possible good health for as long as possible.  Maintaining the number of emergency admissions at a constant level over the next five years, despite increases in the number of elderly people.  Reducing the overall number of average bed days (and lengths of stay) for emergency admissions in both acute and community hospitals.  Reducing the number of long term placements in residential and care homes.

The priorities set out below are drawn from the feedback from our service-users and stakeholder, the national and international evidence, and our local commissioning knowledge of how well the current health and social care system is performing.

“We want to keep older people safe and well in their own homes for as long as possible”

We believe that not only does this keep people healthier, but it is also more clinically- and cost-effective for the health and social care system overall. We don’t want patients to go into hospital unless it is absolutely necessary, except to access appropriate diagnostics and assessment, and where patients are admitted we want to return people to their own homes as quickly as possible.

In order to achieve this, we think we need:

 Access to high quality and responsive acute care services at the Friarage Hospital, Northallerton, including provision of assessment, diagnostics and inpatient treatment, supported by rapid and effective decision-making at the ‘front door’ (i.e. A&E, Clinical Decisions Unit) and effective discharge arrangements supported by hospital case managers, so that those patients requiring acute care access this quickly admitted and those who are able to return home with a package of support do so.  One hospital with community facilities in each of our three localities (Hambleton, Richmondshire and Whitby) that is able to provide diagnostics, intermediate care beds, geriatric assessment, palliative care support and other services that help meet the needs of older people.

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 Effective district nursing teams, working as part of integrated teams with social care professionals, that are able to provide care for patients in their own home, whether responding to a crisis or illness or helping patients to recover from a spell in hospital.  Comprehensive geriatric assessment for patients with complex, multiple illness or frailty, which is available seven days a week in hospital and community locations in all three of our localities.  Round-the-clock integrated nursing and social care services that are able to provide short-term packages of intensive support for patients in a crisis, so that they are able to remain in their own homes as an alternative to a hospital admission.  Sufficient rehabilitation services that can deliver care in both community settings and the patient’s own home, seven days a week, including for those with more specialist needs, for example those patients recovering from stroke.  An effective equipment service, seven days a week, that ensures fast provision for patients in need and minimises the time spent by clinical staff on arranging and fitting.  A viable and high quality care home sector with homes in locations across our three localities, which is able to provide short and long-term stays, in line with North Yorkshire County Council’s contracting arrangements, for people recovering from a crisis or illness from which they can then return home. For those patients who self- fund their care, they should have access to independent advice to maximise the use of their own funding.  Greater integration with mental health services for older people, so frail elderly patients receive holistic, co-ordinated care for both their physical and mental health needs, including supporting patients with dementia and delirium.  No increase in the numbers of acute hospital beds, despite the rise in numbers of elderly people, because the evidence suggests that patients are already spending more time in acute care than is necessary if community services were available.  Assessments for continuing care and long term placement in nursing or residential homes to be undertaken in the patient’s own home or a community setting, with appropriate reablement and therapy support, rather than in an acute hospital bed, so that their choices can be better aligned to their needs and capabilities.  Access to appropriate palliative care so that those patients who wish to do so are able to die at home if that is their choice.

“We want patients to be empowered and better able to self-care, supported by more information for patients and their carers”

We recognise that if patients and service users are to achieve their personal goals and maximise their health and independence, then we need to commission support for them from across the health and social care sector to enable them to do this. In order to achieve this, we think we need:

 Integrated and properly aligned health and social care teams within the community which are able to sign-post people effectively to all appropriate health and social care services, as well as acting as a gateway to the wide range of services provided by the voluntary sector and services such as housing.  For patients with more complex needs to receive a generic health and social care assessment from community services that is enshrined in a holistic care plan that

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describes: a patient’s actions and responsibilities, the range of services that a patient is receiving, and information on how to respond in a crisis.  Extended services within primary care from GPs and pharmacists, which are able to provide a greater range of services closer to the patient’s own homes, so patients are better able to access care closer to home and hence self-manage their condition and health more effectively.  Improved management of medicines leading to improvements in compliance and outcomes, through greater review by professionals, better patient information and aids, and systems for supporting the most vulnerable patients where they are no in receipt of a social care package of care.  Identified lead clinicians who are responsible for the care of the most complex vulnerable people.  A preventative approach based on a model of “health trainers”, specifically supporting people with long term conditions, to work on a one-to-one basis to motivate and signpost members of the public to make long-term healthy lifestyle choices.  Better access to ‘on-line’ information both for patients, to enable themselves to self- care, and also for professionals to understand what options for support are available.

“We want improved transport options for patients to enable older people to access services, so they are not disadvantaged by the rural nature of the area”

Accessing health services can be particularly difficult for older people, especially if they are unable to drive. While we intend to bring as many services as we can as close to the patient’s own home as possible, we will also need to improve transport options for patients so that patients are not failing to access care to the detriment of the health outcomes and quality of life. In order to achieve this, we think we need:

 Timely urgent transport in the event of a crisis, so that a patient requiring an urgent assessment is able to arrive sufficiently early at hospital for appropriate tests and consultation and for them to go home with a suitable package of support that day if possible and appropriate.  A responsive patient transport service that helps people access the care they need in a timely manner, which recognises people’s clinical and mobility constraints and applies the national criteria for both patients and their escorts correctly to help achieve this.  For those patients for whom patient transport services are not suitable or appropriate, further transport options to be available within the Voluntary Sector to enhance existing public and private transport options that work in an integrated way with NHS clinical and transport services.

“We want to better equip local communities with the skills and resources they need to care for their older population and facilitate greater social interaction”

It is well-known that older people can experience greater social isolation, leading to loneliness, depression and poorer health outcomes. Even where older people are usually able to manage quite effectively, they may find they are less able to manage during and after a crisis or episode of ill-health. HRW CCG wants to work with local councils, the voluntary sector, and patient and community groups to support community-based

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approaches to caring for older people that recognise the importance of local networks of support. In order to achieve this, we think we need:

 A range of services commissioned from the voluntary sector, such as befriending schemes, village agents, volunteering ‘time banks’, that make greater support accessible when needed from a person’s own community  Voluntary sector “hubs” for older people in each area that can be a focal point for patients to contact and partner organisations to refer to so that people are more easily access to the range of opportunities available  Ensure that people have easy and early access to information and advice as part of a concerted strategy to prevent ill-health and deterioration

“We want to ensure carers are better supported so that they are better able to look after they are caring for as well as maintaining their own health and wellbeing”

The CCG supports the North Yorkshire-wide Carers’ Strategy. The vision is to have carers in North Yorkshire recognised and valued as being fundamental to strong families and communities. Support will be tailored to meet individual’s needs, enabling carers to maintain a balance between their caring responsibilities and a life outside their caring role, while enabling the person they support to be a full and equal citizen.

In order to achieve this and support carers as part of the work under ‘Fit 4 the Future’, we think we need:

 Improved access to carer’s assessments working in partnership with North Yorkshire County Council (NYCC) and Carers Resource, including supporting hard to reach groups.  Greater sharing of carer information from the Carers Resource centres with GP practices (with consent), and , through GP carers champions, raise carer awareness, promote and raise awareness of the use of emergency carer cards, and consider the value of carer health checks.  Improved referral pathways to Carer’s Resource, including ensuring hospital discharge planning includes carers and working in partnership to increase employers’ awareness of carers.  More expert carers, supported by training programmes or other forms of support, in partnership with NYCC and Carer’s Resource.

“We want to utilise new information management and technological solutions to enable services and service users to manage their care in new, innovative and more effective ways”

We understand that new technologies are providing us with opportunities to work differently and more effectively. In recent years there have been real changes in how people are kept safe and well through the use of Telecare, with new ideas and solutions emerging across a wide range of issues. The CCG is keen to embrace new technologies and work with service users and services to find ways that improve people’s experience and outcomes. In order to achieve this we think we need:

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 To pioneer new technologies that bring service users and professionals together to improve access to services, such as video-links between different locations.  A common approach to sharing information across the integrated team, based on the NHS number as a common patient identifier, supported by safe and secure e-mail addresses and systems, shared consent, and facilitating access to different provider systems at common locations.  Technologies that help people to understand their condition better, keep themselves safe at home, and take more active control of monitoring their outcomes.

6. Implementation and way forward

HRW CCG intends to engage with patients, carers, stakeholders and partners in Hambleton and Richmondshire through locality-based engagement events between February and March 2014. The purpose of these events will be to:

 Make and confirm people’s understanding of the case for change  Present and confirm whether people agree the overall vision  Discuss the choices the CCG will need to make in order to implement the vision

Going forward, HRW CCG, with its partners, will need to decide:

 The extent to which a shift of resources is required between acute care into local community services  The exact set-up of community facilities in each locality, bearing in mind that there are currently two community facilities (the Rutson and Thirsk) in the Hambleton area  The potential to move to integrated provision through commissioning single providers for intermediate and community care

Once this engagement phase is over, the CCG will then draw up formal commissioning proposals to implement the vision. Depending on the outcomes of the engagement, this work may involve:

 Decommissioning some services that are not fully effective and re-commissioning other services closer to patient’s homes in the community  Testing the market to see if alternative providers are able to deliver services in new and more integrated ways  Jointly investing in services with North Yorkshire County Council from 2015 onwards through the new Integration Transformation Fund  Going out to formal consultation on any of the proposals which constitute significant change

In the meantime, HRW CCG and its partners have the opportunity in 2014/15 to utilise health and social care reserves from pooled budgets created over the previous three years. This investment will be used to address initial pressure points and priorities raised by partners, as well as test out new ways of working. Whether any of the funding is recurrently allocated will depend on whether it both makes and impact and is consistent with the longer- term proposals and plans.

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7. Conclusion

This document is intended to provide information and provoke discussion. It starts to set and the scope of both the challenge and the opportunity relating to commissioning services for Older People in the Hambleton and Richmondshire area. It also confirms the central idea that older people are more likely to remain safe and well in their own homes and communities if we can strengthen the care and support that they receive there. If we do this successfully, then admission to hospital can in some cases be avoided and the overall cost to NHS and social care services reduced.

Perhaps inevitably, the solutions largely lie in the reconfiguration and integration of community services. However, the exact scale and formal proposals for what needs to be developed will require extensive local discussion with service users, their cares, partner organisations and other stakeholders.

A detailed programme of engagement events will be undertaken in 2014 to start to turn this vision into a reality.

We thank you for reading this document and we look forward to hearing your views.

Ends

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Appendix 1 Examples and evidence of good practice

King’s Fund Their research shows there is considerable evidence both from the NHS and systems world-wide that suggests more integrated care can deliver: improved user experience, quality of life, reduced carer burden, greater efficiency and controlled / reduced costs. However, the evidence also suggests that often there is a very poor ‘fit’ between the needs of frail older people and the existing infrastructure of health care and social care, with access, continuity and co-ordination problems the most serious barriers to integrating health care. The main ingredients of successful integration include: person-centred focus on frail older people with relatively high care needs, including careful targeting ; responsibility for identified population and/or geographic area including single entry point into system; case managed, inter-professional, evidence-based team care; and a heavy emphasis on care co- ordination.

National Voices National Voices is a national coalition of health and social care charities in England that is working together to strengthen the voice of patients, service users, carers, their families and the voluntary organisations that work for them. It has provided a narrative for person- centred co-ordinated care that describes what integrated care and support looks like from an individual’s perspective. For example: “I tell my story once” and “When I move between services and settings, there is a plan in place for what happens next”. The messages are not necessarily new, but the over-arching impact by bringing them together is helping to make commissioners and service providers to think differently.

NYH CSU literature review North Yorkshire and Humber Commissioning Support Unit has analysed the literature and identified a range of published models of good practice from across the UK. These include: Models include Sheffield, Warwickshire, Poole, Torbay, St Thomas’, Cambridge/Addenbrookes, Hull, Birmingham, Pan Gwent, Poole. The messages that are emerging from these models include:

Torbay  Focus on most vulnerable patients  Integrated Commissioning function across acute / primary / community and social care  Single Management.  Introduction of locality teams including health and social care professionals being in the same location.  Single point of access, with a co-ordinator to arrange care packages and modify them in accordance with patient changing circumstances.  Shared electronic health & social care records.  Significant investment in community Health and Social Care Services.

St Thomas’, Southwark & Lambeth – Integrated Care  Taking a whole-persons approach, taking into account physical, mental & social care needs.  Joining up services across different organisations 22

 Stream-lined, integrated discharge process

Birmingham Community Healthcare NHS Trust  The multi-disciplinary team have access to a community geriatrician and mental health specialist

Pan Gwent Frailty Programme  People are now treated holistically rather than simply defined by their illness.  People stay longer in their own homes  Every patient is treated as an individual

Sheffield ‘Right First Time’ programme  Care homes aligned to one practice which accepts all patients who choose to register and one or two named GPs provide the service  Community integrated teams to be reshaped round groups of GP practices  ‘Redesigning the Front Door of the Hospital’, e.g. through a Frailty Unit, by reducing the number of elderly admissions and by completing comprehensive assessments at the point of referral and developing consistent thresholds for admission

Warwickshire ‘Cutting the cost of frailty programme’  ‘Choose to admit’ only frail older people who have evidence of underlying life threatening illness or need for surgery, early access to an old age acute care specialist  ‘Discharge to assess’ as soon as the acute episode is complete, in order to plan post-acute in the person’s own home, and to provide comprehensive assessment and reablement during post-acute care to determine and reduce long terms care needs  Reduce the number of beds in community hospitals, so more focused attention given to smaller number of patients, releasing resources to invest in home-based community services  Rapid (two-hour) response to frailty crisis with an older person and meet the needs of patients who would benefit from early supported discharge from hospital  Change model of community hospital provision to one that gave greater emphasis to step-up short stay care for patients not requiring the full diagnostic and treatment services of the acute hospital

Poole Rapid Assessment & Consultant Evaluation Programme  Rapid comprehensive assessment of older patients with complex needs. Facilitates early supported discharge and avoids unnecessary hospital stays  Admissions unit where medical patients with geriatric needs referred to hospital as emergencies are assessed and cared for by a consultant-led MDT.  All patients receive geriatric assessment (CGA) within 24 hours of admission and there is a daily MDT meeting to facilitate discharge planning.  GPs can refer patients to the daily emergency clinic held on the ward to access rapid diagnostics and CGA without admission to hospital

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If you would like this document in a different format, for example audio CD or Braille, or in another language, please call 01609 767600.

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Community Transformation Programme Board

Terms of Reference

Purpose

The Community Transformation Programme Board will be the engine room for the transformation of community service provision in Hambleton, Richmondshire and Whitby. The Board will develop the transformation programme with health and social care partners to strengthen, improve and integrate services available to better support patients in the community, particularly those with frailty and long term conditions, and assess its impact against key system-wide outcome and performance indicators including the Better Care Fund.

Functions of the Board

• Jointly agree the strategic priorities for the programme of work on an annual basis • Oversee all development workstreams recognising that the detail of individual projects may be delegated to task and finish groups that will report into the Board • Review progress against the CCG operating plan and key targets set for the community transformation programme • Provide exception reporting on key performance metrics and BCF • Strengthen links between physical and mental healthcare delivery and between care provision and ill-health prevention • Driving efficiency in the system and ensuring value for money • Deliver projects and developments in response to priorities set and delegated by the HRW Transformation Board and NYCC Delivery Board • Identify, prioritise and develop new schemes and initiatives in relation to the development of community based health and social care services using a business case approach • Ensure broader strategic community service development is built into individual Service Development Plans within individual provider contracts which are consistent with the overall strategic direction • Oversee local delivery of the Better Care Fund programme, including ensuring local and national expectations and requirements are met • Unblock issues that arise as part of the delivery of community transformation, enabling escalation where necessary

Key Principles

The development programme should ensure:

• Care at home or as close to home as possible • Equity of outcome • Equity of access

The overall goal should be to develop an effective, integrated system evidenced by:

• Safe, effective care • Positive patient experience • Predictable throughput • Predictable outcomes • Manageable cost

The principles guiding the Boards ways of working are as follows:

• Collective understanding of the purpose of the whole system approach • Performing effectively within clearly defined functions and roles • Establishing and promoting the values of the partnership • Taking informed, transparent decisions and managing risk • Developing skills, knowledge and experience in order to govern effectively • Engaging all partners equally and making accountability real

Frequency of meetings The Board will meet monthly to progress delivery of its responsibilities and will establish task and finish groups to ensure timely completion of workstreams. The frequency will be reviewed regularly and will move to 6 weekly once task and finish groups are established. A schedule of meeting dates will be agreed in advance and these meetings should be treated as a key priority. If a lead is unable to attend they are responsible for ensuring that a deputy can attend and is briefed on any appropriate items.

The Commissioning Lead will be responsible for the agenda and for ensuring the timely distribution of supporting papers and action/agreement records. In addition, HRWCCG will provide administrative support to all the meetings, agendas and associated paperwork will be distributed at least one week prior to each meeting.

Membership Senior Membership is required to enable decision making in line with the functions of the Board.

Lead Organisation GP/Governing Body Member (Chair) HRW CCG Executive Programme Sponsor HRW CCG Programme Lead HRW CCG Project Lead HRW CCG Project Support Officer (minutes) HRW CCG Director of Friarage Hospital STHFT Community Service Manager STHFT AHP Lead STHFT Nurse Consultant Palliative Care STHFT Locality Manager TEWV Stronger Communities NYCC Director Heartbeat Alliance Social Care NYCC HAS Commissioning Lead NYCC Community Services Lead CDDFT Community Services Lead Humber FT Health Improvement Manager Public Health, NYCC Health Engagement Representative Public/Patient Rep

A wider distribution list is in place to ensure key individuals are briefed on the transformation programme.

Quoracy The Board is critical to the integrated transformation of the community system. All members or their nominated deputy are required to attend scheduled meetings. Where there is less than 4 people in attendance the meeting will not be held.

Accountability The Board will be accountable for the leadership of the community transformation programme and overseeing the BCF schemes. In addition it will review scheme impact on performance and outcomes as exception. Any specific contractual issues arising will be flagged to Provider/Commissioner business meetings. The Board will provide reports as necessary to HRWCCG Transformation Board and Audit and Information Governance Committee. A range of task and finish groups will report in to the Programme Board on a regular basis and be exception reported during the meetings. Confidentiality

All members of the Board are expected to maintain confidentiality where appropriate. Review of Terms of Reference The Terms of Reference will be reviewed annually and ratified at the Community Transformation Programme Board

INTEGRATED LOCALITY TEAM CARE PATIENT/ LEADERSHIP & SERVICE USER FAMILY CULTURE MODEL ENGAGEMENT E NAMED N CARE LEAD A JOINT DECISION B MAKING AND INFORMATION CARERS SELFCARE SHARING L ACCOUNTABILIY ACTIVE CARE E PERSONAL CARE MONITORIN COORDINAT R G ION NETWORK S ALIGNED GP TECHNOLOGY INCENTIVES

RISK MULTI- COMMUNITY INFORMATION STRATIFICA SKILLED TION HOME CARE Mental Personal Health Care

Living District Well Nurses

Vol Social Sector care

Pracce Fast Nurses Response

Intermed iate Care COMMUNITY BEDS

ACUTE CARE

24/7

How are we going to get there?MDT MDT Richmond MDT Stokesley TBD Caerick Town Close TBD • Sustainable Friarage including an integrated Front of House – Integration of all Front of House services MDT MDT – Sustainable 24/7, 365 days per year urgent and emergency care service Whitby Northallerton Abbeyfield The Orchards • Locality Teams Rivendale – Provide Home First care – Continuity of care betweenMDT Bedale patients’ homes, primary care and the community – Integrated team workingBenkhill MDT Dales Lodge – Inclusion of Voluntary Sector MDT Thirsk Sycamore Hall Harmby Road Sowerby House • Step up/step down beds, including End of Life care,Sowerby G/Way in the community Meadowfields – Delivers care closer to patients’ homes – A safe bed base in local areas where need is greatest – working with our extra supported housing providers – Close working with GPs

• Fully utilising technology - telecare and teleconsultation - information sharing and systems that speak to each other

• Development of Primary Care Hubs and GP practices working together

NHS Hambleton, Richmondshire and Whitby CCG

Transforming Our Communities

Communications and engagement strategy

March 2016

Version control Date Version Change Author 01.03.16 V1 Initial draft Michelle Atkin 29.02.16 V2 Second draft Michelle Atkin 17.05.16 V3 Third draft Michelle Atkin

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Contents

Introduction and purpose of document ...... 5

Background ...... 6

Key messages ...... 8

Legislation – our statutory requirements ...... 9

Key principles ...... 111

Stakeholders ...... 122

Communication and Engagement Process ...... 144

Phase 1: Understand and connect ...... 155

Phase 2: Create ...... 166

Phase 3: Shape and consult ...... 188

Engagement process ...... 188

Pre-engagement and Options Development ...... 188

Phase 1: Listening ...... 199

Phase 2: Engagement ...... 199

Phase 3: The consultation process ...... 199

Post consultation ...... 20

Engagement and Consultation Timeline: ...... 22

Engagement, Communication and Consultation ...... 23

Communication and engagement plan ……………………………………………….24

Sharing Information ...... 24

Asking Questions ...... 31

Communications/engagement management and responsibilities ...... 333

Risk and Mitigation ...... 333

Reporting and Feedback ...... 333

Evaluation ...... 344

Appendices ...... 355

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Appendix 1: Legislation ...... 355

The Gunning Principles ...... 366

Best practice and managing risk ...... 377

Appendix 2: Stakeholder plan ...... 41

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Introduction and purpose of document

This paper sets out a communications, engagement and consultation strategy to underpin a review of the provision of community services within Hambleton and Richmondshire.

This document provides a framework for the engagement and consultation process and includes but is not limited to: • The aims and objectives of the strategy; including some high level key messages, • Current legislation on the ‘Duty to Involve ‘and the ‘Equality Act 2010’, • The key principles for communication, engagement and consultation, • Proposals for the engagement process including a clear action plan, • The work required preparing for consultation and any additional resources required to deliver the strategy and plan, • The action plan details the work required for all aspects of communication, engagement and consultation. This is essential to support good practice and to fit in with guidance such as that from the Cabinet Office and ‘Compact’,

There will be a period of 12 weeks for the consultation. Prior to this, there will be a pre-consultation listening and engagement period.

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Background

Our vision for Hambleton, Richmondshire and Whitby was first documented in discussion documents in 2013 (“Fit 4 the Future”; reconfiguring older people’s services in Hambleton and Richmondshire – vision and case for change). Since this time we have been refining our vision and case for change through extensive public and stakeholder engagement and service prototyping to influence our direction of travel. We have learnt from our engagement that our strengths as a health provider are: 1. Strong communities that support each other. 2. Good self care and resilience with good informal networks. 3. Lots of projects that work well to improve care. 4. Staff that are dedicated and committed to the area. 5. Multi professional team working. 6. Good communication with our population and a feeling of being empowered. 7. High regard for our GPs, urgent care and mental health working together. 8. Excellent care and service at The Friarage.

Some of our challenges include: 1. Perception that the Friarage will be closed. 2. Challenges around domiciliary provision within parts of the locality. 3. Difficulties with transport. 4. Rurality of the area. 5. Poor IT and communications infrastructure which doesn’t join up. 6. Workforce challenges. 7. Need for modern, evidence based services and care for the older population.

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Aims and objectives of this strategy • To underpin providing community services with the development of a strategy for communicating the compelling vision around the need for change. • To raise awareness and understanding of why it is important that HRW CCG has a plan to deliver sustainable and viable services in regard to care closer to home for the future. • To ensure that appropriate mechanisms are in place so that the public, key stakeholders and partners feel engaged and informed throughout the process. • To contribute to shaping public, and health services’ staff, expectations of community services across Hambleton, Richmondshire and Whitby. • To provide a framework by which HRW CCG and South Tees FT, who are both involved in the consultation are able to deliver consistent messages through a coordinated approach to communications and engagement activity.

• To maintain credibility by being open, honest and transparent throughout the process.

• To monitor and gauge public and stakeholder perception throughout the process and respond appropriately. • To be clear about what people can and cannot influence throughout the engagement and consultation phases. • To achieve engagement that is meaningful and proportionate, building on existing intelligence and feedback such as previous engagement/consultation activities, complaints, compliments etc. • To provide information and context about the proposals in clear and appropriate formats that is accessible and relevant to target audiences. • To give opportunities to respond through a formal consultation process. • To maintain trust between the NHS and the public that action is being taken to ensure high quality NHS services in their local area. • To demonstrate the NHS is planning for the future.

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Key messages

• The challenges we face: o Rurality - resulting in inequity of access o An increasing ageing population o Adverse effects of hospitalisation on patients of advancing years o Workforce challenges • The way in which healthcare can be delivered is changing and evolving. In the last 15 years, there have been great advances in medical knowledge and technology. This has enabled more services to be provided outside of hospitals, in GP practices and community-settings, while hospitals increasingly focus on the most seriously ill patients. • Caring for an older population is now able to change. We have evidence to show that hospital stay is not always the best place to care for people who are older. • Because of national challenges facing the NHS and local authority financial climate there is an increasing need to use resources effectively and efficiently. We must achieve the best outcomes for our patients within the available budget. • The public tell us that they want to see more services being provided at home or as close to home as possible. • We need to review the type of services that are available in community settings and those that are delivered in hospital. We also need to look at integrating some services and providing others so that more can be delivered locally, close to where people live.

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Legislation – our statutory requirements

Any reconfiguration of services requires a robust and comprehensive engagement and consultation process. NHS organisations are required to ensure that local people, stakeholder and partners are informed, involved and have an opportunity to influence any change. Please read appendix 1 for further in depth information.

This document is guided and influenced by the “Six Principals for Engaging People and Communities; definitions, evaluation and measurement”. The principals are: 1. Care and support is person-centered; Personalised, coordinated and empowering. 2. Services are created in partnership with citizens and communities. 3. Focus in on equality and narrowing inequality. 4. Carers are identified, supported and involved. 5. Voluntary community and social enterprise, and housing sectors are involved as key partners and enablers. 6. Volunteering and social action are key enablers.

At the heart of the principles is the assertion in the NHS Five Year Forward View that ‘a new relationship with patients and communities’ is key to closing the three gaps identified by the NHS Five Year Forward View: health and wellbeing, quality of care and treatment, finance and efficiency.

These principles require the NHS to ensure that there is a move away from paternalistic, fragmented health and social care services and that the focus is on supporting people better to manage their health and wellbeing. It is for NHS organisations to ensure that the focus is on ensuring people have as much choice, voice, control and support as they want in decisions that involved their health and care. Growing evidence shows that involvement is the key to improving outcomes and improving the experience of care.

Creating services in partnership with the public and communities and using a co- design approach to design services means working with all sectors of the community

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including voluntary, community and social enterprise sectors along with patient participation groups, carers and other agencies.

The document supports the need to focus on equality and ensuring that includes all the groups protected under the Equality Act 2010, as well as people who are less likely to use services and those who have the lowest health outcomes. Identifying and supporting carers and ensuring they are involved in this part of the process.

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Key Principles

This strategy is underpinned by the following guiding principles for communication, engagement and consultation to ensure consistent messages are adopted by all partners, adhering to the following principles of good practice: • Open – decision makers are accessible and ready to engage in dialogue. When information cannot be given, the reasons are explained. • Two-way – there are opportunities for open and honest feedback, and people have the right to contribute their ideas and opinions about issues and decisions. • Timely – information arrives at a time when it is needed, relevant to the people receiving it, and able to be interpreted in the correct context. • Clear – communication should be in plain English, jargon free, easy to understand and not open to interpretation. • Targeted – the right messages reach the right audiences using the most appropriate methods available and at the right time. • Credible – messages have real meaning, recipients can trust their content and expect to be advised of any change in circumstances which impact on those messages. • Planned – communications are planned rather than ad-hoc, and are regularly reviewed and contributed to by senior managers and staff, as appropriate. • Consistent – there are no contradictions in messages given to different groups or individuals. The priority to those messages may differ, but they should never conflict. • Efficient – communications and the way they are delivered are fit for purpose, cost effective, within budget and delivered on time. • Integrated – internal and external communications are consistent and mutually supportive. • Corporate – the messages communicated are consistent with the aims, values and objectives of NHS Hambleton, Richmondshire and Whitby CCG.

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Stakeholders

For the purpose of this strategy, the definition of stakeholders is anyone who will be affected (either positively or negatively) by a proposed change to health services locally, those who have an opinion on the proposed changes and those who could influence other stakeholders.

There are a wide range of stakeholders who will have varying degrees of interest in and influence on the acute care services agenda.

Broadly, those stakeholders fall into the following categories: • Internal • Partners • Patients and the public • Political audiences • Governance and regulators. • Under-represented groups

See Appendix 2 for a stakeholder map

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Stakeholder Segmentation

HENREPS Health Unions Professional bodies – e.g. Royal Colleges OSC watch Clinical Commissioning Group - GPs FT Governors NHS Trust staff – especially former Media Lambert staff Primary care/community MPs, MEPs 6. Represent 1. Staff

Patients Campaign 5. Influencers 2. Patients and Carers, families etc. groups Carers

Councillors 3. Health Patient support groups, 4. Community Partners Friends, PALS, HEN Council of Governors

Local Councils – county, Public district, parish, OSC

Community DoH, SoS,

Voluntary/charitable sector groups Monitor & SHAs

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Communication and Engagement Process

HRW CCG has been using the following approach in regard to communication and engagement. We have differentiated the approach in that we started with engagement, not consultation. We always want to involve as many people as possible in the development of any proposals should formal consultation be required.

The three phased plan to build a better future was approved by the HRW Transformation Board, which is made up of the following members: • Hambleton, Richmondshire and Whitby Clinical Commissioning Group • South Tees Hospitals NHS Foundation Trust (STHFT) • Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) • York Hospitals NHS Foundation Trust (YHFT) • County Durham and Darlington NHS Foundation Trust (CDDFT) • Harrogate & Rural District NHS Foundation Trust (HDFT) • Humber NHS Foundation Trust (HFT) • Yorkshire Ambulance Service NHS Trust • Hambleton District Council • Richmondshire District Council • Scarborough Borough Council • North Yorkshire County Council (NYCC), through the Joint Health and Wellbeing Board (JHWB) and the Scrutiny of Health Committee. • Heartbeat Alliance - GP Federation • Community and voluntary sector organisations • NHS England Area Team – North Yorkshire and Humber

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This is part of a three-step process.

Phase 1: Understand and connect

The first part of understanding and connecting was carried out in 2013 with the work: “Preparing for an Ageing population” which resulted in the publication of a vision and case for change document. (“Fit 4 the Future”; reconfiguring older people’s services in Hambleton and Richmondshire – vision and case for change). The project continued with a comprehensive engagement exercise, building on the previous work of the Fit 4 the Future programme. Engagement differs from consultation in that conversations and insights were not framed by outline plans or options. The process aimed and succeeded in creating a ‘bottom up’ picture of what staff, stakeholders and local people believe is possible.

These ideas and suggestions were tested and sense-checked by respected external experts and stakeholders representing patients, public and staff are now being shaped into options which can now be used within any formal consultation period. All the options produced are based upon this initial understanding and connecting phase that we have already carried out.

In this phase connections were made with people through the theme of “Let’s have a Proper Chat” and engaged extensively across the area.

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Phase 2: Create

This is the co-creation phase, where ideas and thinking are developed. Co-creation means bringing together different parties (e.g. clinicians, the public, the third sector and local stakeholders) to jointly develop ideas, models and recommendations. As part of this co-creation, a Clinical Summit was held in November 2015 in which over 200 clinicians and professionals spent time looking at the issues and challenges faced within our health economy and to influence the creation of options for solutions. (See Appendix three)

There have also been other co-creation events in Carperby, Aysgarth and Hawes, specifically as part of the Dales Project, which has been the prototype for the CCGs preferred option of community service design. This brought together agencies and community teams to discuss and create options.

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Phase 3: Shape and Consult

This is the phase where shaping and refining ideas and consulting professionals and the public happen. The complexity of the agenda means that elements of this has moved and developed at different paces. The CCG has worked hard to develop a clear vision of how services should be provided and is now ready to engage and formally consult in regard to the range of options, including the preferred option in Transforming our Communities. The consultation document will outline the full context and story.

Engagement Process

The engagement stage forms part of the early discussions and are about gathering detailed information to support the health economy to develop the formal public consultation proposal for service change.

This engagement will involve the collection of: • Existing staff, patient and public views based on previous feedback (including customer feedback, complaints, suggestions and previous surveys). • The in-depth gathering of views and suggestions from identified patients and carers. • The testing of those ideas to draft proposals with wider stakeholders and staff.

In addition, this engagement will lay the groundwork for discussions during the formal consultation.

Pre-engagement and Options Development

Three phases of pre-engagement are planned which will inform and underpin:

• the development of a proposed new model of community services across Hambleton and Richmondshire. • the case for change and business case relating to the proposals and

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• the development of a full public consultation on the proposals.

These phases of pre-engagement aim to achieve the following objectives:

Phase 1: Listening - to understand: • the experience of people and their families of using current community hospital provision. • the ways in which those people, and the wider general public, think services for older people, end of life and community services can be improved or changed. • the view of clinicians and other professionals in relation to current community hospital provision across Hambleton and Richmondshire.

Phase 2: Engagement – to engage: • and build on any gaps in the engagement conducted in phase 1. • and involve the public in developing the options criteria to assess potential health services scenarios to go forward for modelling and then as potential options for consultation. • current users of health services within those services that are in scope.

Phase 3: The consultation process Following the engagement process, there will be a formal consultation period of 12 weeks. The consultation will provide: • the public with the opportunity to comment on the options that are taken forward from the appraisal and scoring process. • a balance between clinical and public perspectives within the models going forward as potential options for consultation. • engagement around the equality impact assessment conducted by NHS HRW CCG. • validation of the equality impact assessment.

A consultation document which outlines the case for change and questions will be distributed widely across Hambleton Richmondshire and Whitby, available online and on request.

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• A range of mechanisms and activities to gather feedback and views including: • Opportunities for formal and informal discussion in appropriate and accessible locations. • Presentations to a wide range of groups and audiences (pro-active and on request). • Staff briefings and meetings. • Information in prime community and health settings. • Information on relevant websites. • Media relations. • Posters in a range of community venues throughout the health economy including health settings, libraries etc. • Information distributed and shared through public partners publications and information points. • Feedback forms and questionnaires. • Social media.

Post consultation

Once the outcome of the consultation process has been decided the communications and engagement team will provide feedback to all key stakeholders using agreed channels which will include email / letter, website and local media. Key activities: • Production of clear public information on the case for change. • Liaison with and presentation to North Yorkshire County Council and district councils Scrutiny of Health Committees. • Briefing key partners and stakeholders including MPs and local Healthwatch. • Local stakeholder events with invited audiences. • Focus group activity with protected groups (with voluntary sector organisations). • Online activity including dedicated website page and survey. • Discussion though Patient Reference Group/patient participation groups. • Discussion through Health Engagement Network.

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• Cascade of information via stakeholders, partners and community and voluntary organisations. • Social media presence. • GP engagement – clinical support for the changes. • Staff engagement. • Media relations.

As part of this work we will consider the best ways to engage with those who are easy to overlook and protected groups and ensure that information is delivered in the most appropriate format. This could include: • Using the campaign Your Health in order to deliver key messages about health and provide an opportunity to discuss proposed service changes. This campaign uses a variety of mediums that is accessible for all members of the community. • Having one to one discussions with agencies that support those communities that are often overlooked. E.g. Traveler communities within the area. • Ensuring a presence at specific summer shows in which local farmers and other members of the rural communities will be in attendance. • Holding open days within supported housing facilities and inviting carers and relatives of those who are currently or are intending on using those services.

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Engagement and Consultation Timeline:

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Engagement, Communication and Consultation

Events: Held across Hambleton and Richmondshire Meetings held in 2015: Date Event Location Sunday 5 July Northallerton Carnival Northallerton

Wednesday 29 July Borrowby Show Thirsk

Saturday 1 August Osmotherley Show Osmotherley Saturday 8 August Kirkby Fleetham Feast Kirkby Fleetham

Saturday 29 August Wensleydale Agricultural Leyburn Show Wednesday 2 September Muker Show Swaledale

Sunday 6 September Moorcock Show Hawes

Meetings to be held during the listening and engagement phase, March until end May 2016: Date Event Location 22/03/2016 Thirsk School Thirsk 30/03/2016 Golden Fleece Thirsk 31/03/2016 Thirsk & Sowerby Town Hall Thirsk 04/04/2016 Thirsk Market Place Thirsk 07/04/2016 Thirsk Auction Mart Thirsk 12/04/2016 Osmotherley Coffee Morning Northallerton 12/04/2016 Thirsk Auction Mart Thirsk 13/04/2016 Northallerton Market Place Northallerton 14/04/2016 Sandhutton & Breckenbrough Thirsk 20/04/2016 East Thirsk Community Hall Thirsk 09/05/2016 Golden Lion Hotel Northallerton 10/05/2016 Friarage 'Hub' Northallerton 13/05/2016 Stokesley Market Stand Stokesley 16/05/2016 Thirsk Market Stand Thirsk 17/05/2016 Bedale Market Stand Bedale 20/05/2016 Leyburn Market Stand Leyburn 24/05/2016 Hawes Market Stand Hawes

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Communications and Engagement Action Plan

Key players and spokespeople • Janet Probert – CCG Chief Officer (JP) • Dr Charles Parker – CCG Clinical Chair (CP) • Debbie Newton – CCG Chief Finance and Chief Operating Officer (DN) • Gill Collinson – Chief Nurse (GC) • Lisa Pope – Deputy Operating Officer (LP) • Abi Barron – Head of Strategy, Community Care (AB) • Georgina Sayers – CCG Communications and Engagement Manager (GS)

1. Announcing the consultation start date and dates of public meetings

Audience Mechanism Attending / action Date led by Key media Announce start date of the consultation and publicise dates of the public meetings GS/ GC 30/06/16 Offer interview with JP CCG staff and Announce start date of the consultation and publicise dates of the public meetings GS/ AB 23/06/16 GPs HEN Reprs HEN members South Tees staff Issue staff briefing to announce the consultation and publicise dates of the public meetings GS/ South Tees 27/06/16 coms MPs JP to brief prior to the announcement: JP 27/06/16 OSC Rishi Sunak MP Councillors Kevin Hollinrake MP Health Overview and Scrutiny Committee (OSC) Cllr Clark / Bryon Hunter County and Local Councillors Parish Councillors ALL Update website with latest dates and information GS 27/06/16 Social media update

2. Public consultation phase

Audience Mechanism Attending / action Date / frequency led by All stakeholders and Regular updates on consultation process and reminders of dates for the events and to GS Monthly from 4th media take part in the survey July 2016 Briefing pack – audience adapted AB

Online and digital engagement

Email Use a dedicated email address for this project which can be accessed by a range of people to enable continuous monitoring and response. AB/GC 04/07/16

Questionnaire Survey monkey questionnaire linked to website GS

Web presence Page on CCG website dedicated to consultation. GS FAQ document

Consultation to be shared on partner websites to link through to CCG GS

Social media Use CCG Facebook and Twitter profiles to signpost to information and engagement GS opportunities.

Engage with established pressure group sites on Facebook and Twitter to correct inaccuracies and signpost to official sources of information and engagement opportunities.

Off line engagement Background documents and hard copy questionnaires to be used at public events and distributed to key local venues e.g. libraries, GP practices,

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Consultation period

Internal Consultation launch announcement with links to key documents and plans GC 04/07/16

CCG Governing body Update at governing body GC/AB Staff Staff briefing pack/ monthly team meeting GC/AB GPs Locality meetings/ Chapter Three/ Newsletter CP/JP South Tees South Tees Comms/ JP to meet with Siobhan McCardle JP/GC NYCC JP to meet/ brief JP HEN reps Update at HEN rep meeting GC PALS Briefing paper for staff GS

Patient &Public Public Meetings Charities • Public briefing consultation meetings in Thirsk and Northallerton (see below for JP/GC/AB/DN General public opportunities) Specialist Groups • Distribute questionnaire to attendees GS to manage GP PPG HEN members Date Time Location

Thursday 7 11am – Thirsk Library, Meadowfields, Chapel Street, Thirsk,

July 2pm YO7 1TH

Sunday 10 12pm – Northallerton Carnival, Applegarth Car Park, DL7 8NT

July 5pm

Tuesday 12 9am – Coffee Morning, St. Peters Church, Osmotherley DL6

July 12pm 3BW

Saturday 16 11am – Sowerby Summer Fete, Sowerby House, Front Street, July 3pm Sowerby

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Thursday 21 11am – Thirsk Library, Meadowfields, Chapel Street, Thirsk,

July 2pm YO7 1TH

Saturday 23 10am - Emergency Services Show, Richmond School,

July 3pm Richmond DL10 7BQ

Monday 25 10am - Thirsk Market, Market Place July 2pm

Wednesday 10am – Borrowby Show, Hillside Rural Activities Park, Oaktree

27 July 5:30pm Bank South, Knayton, Thirsk , YO7 4AX

Wednesday 10am— Northallerton Market, High Street

3 August 2pm

Saturday 6 9am - Osmotherley Show, Home Farm, Thimbleby, DL6

August 4pm 3PY

Wednesday 8am - Danby Show, Danby, Whitby, North Yorkshire,

10 August 4:30pm YO21 2NP

Thursday 11 10am - Thirsk Health Centre, The Doctor’s Surgery,

August 12pm Chapel Street, Thirsk, YO7 1LG

Thursday 11am- Meadowfields Extra Care Housing, Chapel

18 August 2pm Street, Thirsk, North Yorkshire, YO7 1TH

Wednesday 8:30am - Egton Horse & Agricultural Show, Egton Cross,

24 August 5pm Egton, North Yorkshire YO21 1TZ

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Wednesday 10am - Muker Show, Upper Swaledale, DL11 6QG 7 September 5:30pm

More dates will be added as events are confirmed. These will be made available on the CCG website.

CCG Newsletter Posters to: GS to manage • Libraries • GP surgeries • Pharmacies • Care Homes • Village hall notice boards • Hospital sites

Special interest Write to groups that were involved in the engagement process with presentation packs groups and ask if they would like to have a follow up meeting.

Political Audiences Led by JP 04/07/16 Local Councillors Regular face-2-face or teleconference briefings with constituency MPs Ongoing monthly Local MPs

Partners GS 04/07/16

Councils CCG to attend Hambleton and Richmondshire District Councils, Scarborough Borough Council meetings separately as requested by their health scrutiny committees Local Medical Committee

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Governance & regulators

OSC Continuous engagement with OSC Chair and committee on the project and its Led by JP or progress. Attend NY OSC to brief and update members. designated other

NHSE Provide assurance through the service change assurance process

Media Consultation launch media release JP / CP available for interviews

Meet with Thirsk Weekly – Rupert Smith GC/AB/GS Meet with D&S Meet with Northern Echo Whitby Gazette

Formal invitation to identified events

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Materials required:

• Consultation document • DVD / presentation for public meetings and to distribute in the consultation pack – to bring the consultation to life • Questionnaire – online and hard copies • FAQ document – living document produced in house as required • Other evidence or case for change documents – produced in house as required • Dedicated web page to host information, FAQ, link to online survey – hosted on CCG website • Dedicated email address • Feedback form/mechanisms including social media

Sharing Information Information will be made available that is relevant and accessible to the public and patients. This will include the consultation document that will be prepared.

Information will also be made available via online, digital and social media channels to facilitate discussion and feedback amongst stakeholders who are more likely to engage via these channels.

Asking Questions A set of frequently asked questions will be developed to help facilitate opinions and feedback as part of the consultation. This will be distributed face to face in public meetings and also via online channels.

To engage and generate discussions with patients, carers and public • Invitations to participate in events. • Inviting staff to participate in events. • CCG website. • GP Patient Participation Groups. • CCG Health Engagement Network membership. • Patient groups/ support groups. • Social media forums – Facebook; Twitter. • Key community groups.

To seek comments and input from NHS and other partners • Invite to workshops and drop in sessions. • Encourage partner organisations to include information on websites and in newsletters. • NHS staff newsletters. • Meetings with leaders of councils.

Generate discussion with external stakeholders (community) • Volunteer organisations. • Display information.

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• Consultation meetings. • Working with the media to produce articles for inclusion. • Information through local libraries and GP surgeries.

With influencers through: • Regular one to one briefings with MPs. • Briefing material. • Regular media updates. • Overview and scrutiny committee meetings. • Health and Wellbeing Board. • Regular briefings with District councils.

With key bodies which represent the local community through: • Face to face meetings and group events. • Newsletter articles for magazines e.g. Health Watch. • Inviting representatives to meetings e.g. Health Watch. • Regular liaison with OSC.

Also available are / will be: • Pre-consultation business case. • Clinical Case for Change. • Model of care. • Engagement and Consultation timelines. All materials will be available in alternative formats as appropriate.

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Communications/engagement management and responsibilities

A communications and engagement working group comprising representatives from CCG and South Tees FT led by Gill Collinson and reporting to community transformation programme board will oversee the practical implementation of plans relating to this plan. The following resources will be in place to manage this communications and engagement process:

Agreed responsibilities are as follows:

Communications and engagement planning CCG/ South Tees Production of reports and consultation document CCG Implementing the consultation plan CCG Presenting to NYCC Scrutiny for Health CCG Presenting to Community Transformation Board Gill Collinson/Abigail Barron Management of Comms and all enquires Georgina Sayer Decision following consultation CCG Governing Body Dissemination of decision CCG - Comms

Risk and Mitigation

Risk and risk mitigation will be managed by the Community Transformation Programme Board and escalation to the HRW CCG weekly Senior Management Team meetings. Risk will be placed on the HRW CCG corporate risk register.

Reporting and Feedback

The communications and engagement workstream will meet on a weekly basis to review: • progress against the agreed timelines • the action log • the risk register • the effectiveness of the communications and engagement strategy • effectiveness in line with the wider programme strategy

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Evaluation

This communications and engagement strategy will be evaluated at four stages of the process: • At the end of the phase 1 listening stage • At the end of phase 2 engagement stage • In the middle of phase 3 consultation stage • At the end of phase 3 consultation stage

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Appendices

Appendix 1: Legislation The process for involving people requires a clear action plan and audit trail, including evidence of how the public have influenced decisions at every stage of the process and the mechanisms used.

Section 242 of the NHS Act 2006 sets out the statutory requirement for NHS organisations to involve and consult patients and the public in: • The planning and provision of services. • The development and consideration of proposals for changes in the way services are provided. • Decisions to be made by NHS organisations that affect the operation of services.

Section 244 of the NHS Act 2006 requires NHS organisations to consult relevant Overview and Scrutiny Committees (OSC) on any proposals for a substantial development of the health service in the area of the Local Authority, or a substantial variation in the provision of services.

Section 2a of the NHS Constitution gives the following right to patients:

“You have the right to be involved, directly or through representatives, in the planning of healthcare services, the development and consideration of proposals for changes in the way those services are provided, and in decisions to be made affecting the operation of those services.”

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In addition the Secretary of State for Health has outlined four tests for service change: Support from GP Commissioners Engagement with GPs, particularly with practices whose patients might be significantly affected by proposed service changes Clear clinical evidence base The strength of the clinical evidence to be reviewed, along with support from senior clinicians from services where changes are proposed, against clinical best practice and current and future needs of patients Strengthened patient and public Ensure that the public, patients, staff, Healthwatch and Health Overview and engagement Scrutiny Committees are engaged and consulted on the proposed changes Supporting patient choice Central principle underpinning service reconfigurations is that patients should have access to the right treatment, at the right place and the right time. There should be a strong case for the quality of proposed service and improvements in the patient experience

The Gunning Principles Before 1985 there was little consideration given to consultations until a landmark case of Regina v London Borough of Brent ex parte Gunning. This case sparked the need for change in the process of consultations when Stephen Sedley QC proposed a set of principles that were then adopted by the presiding judge. These principles, known as Gunning or Sedley, were later confirmed by the Court of Appeal in 2001 (Coughlan case) and are now applicable to all public consultations that take place in the UK.

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The principles are: • Consultation must take place when proposals are still at a formative stage Consultation should be at a stage when the results of the consultation can influence the decision-making (and Gunning 4). • Sufficient reasons must be put forward for the proposals to allow for ‘intelligent consideration’ A preferred option may be included and this must be made obvious to those being consulted. Information and reasons for the proposals must be made available to allow for consultees to understand why they are being consulted as well as all the options available and what these mean. Equality Impact Assessment to be completed and sit alongside the consultation document • Adequate time must be given for consideration and response There is no set timeframe recommended but reasonable steps must be taken to ensure that those consulted are aware of the exercise and are given sufficient time to respond. • The outcome of the consultation must be conscientiously taken into account Decision-makers must be able to show they have taken the outcome of the consultation into account – they should be able to demonstrate good reasons and evidence for their decision. This does not mean that the decision-makers have to agree with the majority response, but they should be able to set out why the majority view was not followed.

Best practice and managing risk This strategy takes account of NHS England good practice guidance - Transforming Participation in Health and Care - ‘The NHS Belongs to us all’ by:

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• Engaging communities with influence and control e.g. working with CVS and Healthwatch • Engaging the public in the planning and delivery of service change e.g. engage early and build on insights • Providing good quality information • Providing a range of opportunities for participation • Working with patients and the public from the initial planning stages

In summary, any reconfiguration of services requires a robust and comprehensive engagement and consultation process. The risk of not following these procedures could result in a Judicial Review. A number of public bodies across the UK have been taken to Judicial Review and deemed to have acted unlawfully in the Public Sector Equality Duty – usually linked to the four Gunning Principles.

As well as documented evidence of GP support, the case for change will need to: • State clearly the benefits for patients, quality and finance. • Demonstrate that the clinical case conforms to national best practice. • Be aligned to commissioners’ strategic plans. • Be aligned with the recommendations of Healthy Ambitions. • Have clear details of option appraisals. • Provide an analysis of macro impact. • Be aligned with QIPP work streams.

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The Independent Reconfiguration Panel (IRP), whose role is to advise ministers on controversial reconfigurations, recommends that those considering proposals for significant health service changes should: • Make sure the needs of patients and the quality of patient care are central to the proposal. • Consider the role of flexible working in the proposals – this may involve developing new approaches to working and redesigning roles. • Assess the effect of the proposal on other services in the area. • Give early consideration to transport and site access issues. • Allow time for public engagement and a discussion phase before the formal consultation – people want to understand the issues, so involving them early on will help when it comes to the formal stage. • Obtain independent validation of the responses to the consultation. The IRP has also identified a range of common themes: • Inadequate community and stakeholder engagement in the early stages of planning change • The clinical case has not been convincingly described or promoted • Clinical integration across sites and a broader vision of integration into the whole community has been weak • Proposals that emphasis what cannot be done and underplay the benefits of change and plans for additional services • Important content missing from the reconfiguration plans and limited methods of conveying them • Health agencies caught on the back foot about the three issues most likely to excite local opinion - money, transport and emergency care. • Inadequate attention given to responses during and after the consultation.

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Consultations should influence final proposals and it is important to be able to show that they have. Clearly, not all these recommendations will be applicable to all engagement and consultation exercises, but the basic principles of early involvement, and being able to demonstrate that responses have influenced the final outcome, are.

Commissioners and providers should also consider how their engagement and consultation activity impacts upon a wide range of service users including those protected groups identified within the Equality Act.

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Appendix 2: Stakeholder plan Stakeholder Stakeholder Stakeholder Prioritisation Category Communication Method(s) Group Internal CCG Governing body Key Player Face to face meetings

Internal Staff Key Player Face to face meetings and briefings

Internal GPs Key Player Face to face meetings and briefings

Internal Staff-side representatives Active Engagement and Consultation Face to face meetings/briefings

Internal Staff affected by changes Active Engagement and Consultation Team and individual briefings/meetings with line managers/ Q&As/ existing internal comms channels Internal FT Governors Active Engagement and Consultation Meetings / briefings

Patients & Charitable organisations and highly Active Engagement and Consultation Face to face meetings and Public interested groups briefings/engagement events and (charities) activities Patients & General public Keep Informed Engage and Consult Public meetings/ media releases/ Public website/information stands/ posters/info distributed at prime settings/consultation and engagement documents

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Stakeholder Stakeholder Stakeholder Prioritisation Category Communication Method(s) Group Patients & Affected service user groups Active Engagement and Consultation Meetings with identified service user Public groups/ engagement events/ consultation events Patients & GP Patient Participation Groups Keep Informed and engaged via Meetings/briefings Public practices Patients & Healthwatch Active Engagement and Consultation Meetings and presentations/ongoing Public briefings and updates/ consultation and engagement documents Patients & Protected groups, voluntary and Active Engagement and Consultation Meetings with identified groups/ Public community groups, third sector engagement events/ consultation events Patients & Health Engagement Network Active Engagement and Consultation Briefings Public Political Local MPs Key Player Regular briefings/letters/ meetings Audiences Political Local Councillors Active Engagement and Consultation Regular correspondence updating on Audiences progress /OSC/engagement and consultation documents Political Overview and Scrutiny Committees Key Player Meetings & presentations/ regular Audiences briefings

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Stakeholder Stakeholder Stakeholder Prioritisation Category Communication Method(s) Group Media Local and regional media Keep Informed Pro-active and re-active press releases and statements/ interviews / briefings/ paid-for advertorials and supplements Partners Councils Key player Briefings as required/ engagement and consultation documents Partners Local Medical Committee Active Engagement and Consultation Meetings & presentations/ regular briefings GPs GPs Active Engagement and Consultation Meetings & presentations at clinical council/ regular briefings Governance & NHS England Keep Informed Briefings via regional office regulators Governance & Overview and Scrutiny Committee Key Player Regular Briefings/ Consultation regulators Documents Governance & Local health and Wellbeing Board Key Player Meetings/briefings regulators

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http://southtees.nhs.uk/jobs/love-nursing/nursing-in-the-news/

25 November 2015

Summary Report

Clinical Summit Summary Report. December 2015 Foreword On 25 November 2015, NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group held its first Clinical Summit event in partnership with South Tees Hospitals NHS Foundation Trust, HeartBeat Alliance, North Yorkshire County Council and Tees, Esk and Wear Valleys NHS Foundation Trust. This unique event brought together over 200 clinical professionals including GPs, hospital consultants, nurses, therapists and social care colleagues from across Hambleton and Richmondshire to discuss, influence and help shape how health and social care can be delivered effectively and sustainably in the future. The key objectives of the event were:  to understand the challenges that face this health economy with a focus on Rural Care, Urgent Care, Technology in Health and Care of the Frail Elderly, from a range of perspectives,

 to bring clinicians and other professionals together to share views and experiences

 to identify the key opportunities for resolving the challenges and to start to create a shared vision of care delivery across Hambleton and Richmondshire. The keynote speech was given by Sir John Oldham, adjunct Professor at Imperial College London. He was a GP and has been involved for many years in large scale quality improvement programmes in different countries, as well as being Chair of an Independent Commission on Whole Person Care. In his speech, Sir Oldham discussed the challenges facing the health and care system and looked at examples from home and abroad where these challenges had been overcome. He shared where the evidence points to and his presentation slides can be viewed on the NHS Hambleton, Richmondshire and Whitby CCG website The final plenary of the day was delivered by Professor Gordon Peterkin. As Medical Director of a succession of changing NHS Grampian organisations, he has developed techniques to promote integrated working between primary and secondary care. Professor Peterkin emphasised the need for utilising advanced technology in health, drawing upon significant historic events. His presentation slides can be found on the NHS Hambleton, Richmondshire and Whitby CCG website

2 Clinical Summit Summary Report. December 2015 In order to capture the thoughts and ideas of those attending, there were four workshops and each attendee had the opportunity to attend two of the four workshops. The outputs from the workshops have been analysed and collated and this document captures the recurring themes and ideas that emerged from each of the four workshops:  Rural Care  Urgent Care  Technology in Health  Care of the Frail Elderly Whilst no new revolutionary ideas emerged, there was a real consensus of views regarding the need to join up services in a way that is meaningful for patients and breaks down barriers, often inadvertently created by processes, policies and organisations. The outputs of the event will be used by the leaders across all partner organisations, via the HRW Transformation Board to design and deliver services together with you, clinicians and patients, which are truly Fit 4 the Future. Further details, including an event video will be released on the NHS Hambleton, Richmondshire and Whitby CCG website, shortly. Sincere thanks to all who attended and we hope you enjoy the read.

Janet Probert Dr Charles Parker Chief Officer Clinical Chair NHS Hambleton, Richmondshire and NHS Hambleton, Richmondshire and Whitby Clinical Commissioning Group Whitby Clinical Commissioning Group

3 Clinical Summit Summary Report. December 2015 Current strengths:

 The people who live in rural areas were often part of a large, strong community that care for each other very effectively.  They have made informal networks of care and showed a strong resilience in regard to health services.  Close knit communities enable good networks and support. There is pride in being able to ‘look after their own’.  Good integrated care provided by professionals in pockets of the area.  Staff are dedicated and committed to the area and this enables good, strong working relationships.  The MDT working is a strength within this area and it was felt that there was good work- ing together towards joint goals.

Current challenges:

 Lots of challenges around the effective use of technology. These include:  Broadband access is not always available.  Poor mobile phone access/connectivity.  IT systems don’t always speak to each other effectively.  The complexities of technology can be time consuming!  Travel and transport.  Patients have challenges around local transport and accessing health care services.  Staff has transport challenges in the rurality of the area.  There are services within the area with workforce challenges. It is difficult to recruit to the care services. Providing care support packages is challenging within the area, particularly end of life care.

4 Clinical Summit Summary Report. December 2015

Opportunities:

 Integrate services into One Team.  Supporting individuals and communities to build on their resilience and ability to self-care.  Working together to improve access through transport and technology.  Moving hospital services into the community wherever possible.

5 Clinical Summit Summary Report. December 2015 Current strengths:

 The general health of the population is good.  Generally the population manage self-care effectively.  There is good communication and engagement with the population and the population is vocal in what they want in regard to health services.  There is also good communication between patients and clinicians.  The population is well informed of services and are empowered.  Mental health and urgent care was highly regarded and the services work effectively together. Mental health is present within A & E at the Friarage and this enables mental health teams to support the patient population.  There was high regard and respect between the GPs and clinicians working in Urgent Care. There are good working relationships between the various health economy organisations, for example, GP services have access to paramedics.  Participants thought that there is good communication and links between FHN and General Practice.  Participants felt that patients were generally well informed and highly engaged.

6 Clinical Summit Summary Report. December 2015 Current challenges:

 Funding and lack of resources were raised as concerns. The way funding is allocated prevents joined up care for patients.  Resources in relation to staffing and retention of staff. How can care roles be better supported both financially and as a career option? Some participants felt domiciliary care roles were not sufficiently valued, wages too low and this contributes to a challenge of workforce issues.  It was expressed that patient flow from hospital to home can be blocked through various challenges, including multiple assessments and hand-offs between professionals and organisations.  Communication in regard to patient care between agencies can be challenging at times.  Need for greater specialist care of elderly.  Staffing issues, numbers, skills, retention, were all seen as serious challenges.  It was felt that patients sometimes do not understand the various departments within Urgent care and this could cause confusion.

Opportunities:

 Integrate primary and secondary care urgent and emergency care services at FHN  Use technology to improve services within Urgent Care – share info between primary and secondary care more.  Education and communication campaigns to inform the public how to obtain the most benefit from Urgent Care services.

7 Clinical Summit Summary Report. December 2015 Current strengths:

 More technologically aware.  Good will of the staff.  Technology is often cheaper.  MDT working is good.  Telephone conversations are helpful.

Current challenges:

 Different electronic systems that don’t talk to each other. Cannot access records in different hospitals. Ineffective IT systems. Still faxing information. Systems are outdated.  Poor Wi-Fi access and 3G/ 4G access.  Rurality and being able to access technology.

Opportunities:

 Integrate systems across services.  Look at other areas of the NHS, social care, nationally and internationally to see what has worked elsewhere.  Look at innovation in other industries for potential solutions.

8 Clinical Summit Summary Report. December 2015 9 Clinical Summit Summary Report. December 2015 Current strengths:  There are lots of different services and projects already working well and working well together. Hot clinics; pharmacy; Multi-Disciplinary Team meetings; fast response; housing associations and key partners, along with voluntary services.  Close working relationships between General Practice and Friarage hospital consultants.  Patients appreciate seeing the same GP who understand them.  Close working relationships between agencies.  Enabling care closer to home, which is what engagement with the public shows to be important. Current challenges:  Insufficient capacity to meet growing demand for services.  Domiciliary care staff not available – workforce issue.  Lack of social care providers in some parts of the patch.  Access to specialist advice and investigations, Communications between services not always good. Opportunities:  Integrate services into One Team.  Identify at risk people early by using technology in General Practice.  Sharing information across agencies.  Maximising use of technology to support patient, carers and professionals.  Develop a holistic, non-medical model to support frail elderly – e.g. Social prescribing  Developing services with local communities.

10 Clinical Summit Summary Report. December 2015 11 Clinical Summit Summary Report. December 2015 Conclusion and next steps This milestone-event included over 200 clinical professionals across Hambleton and Richmondshire. The key theme from the summit was one of integration, joining up services on a local footprint, which make sense to local people and communities and enable care wherever possible to be delivered at home or as near to home as possible. Whilst the discussions at the Summit may not have introduced radically new ideas for many participants, the outputs of the Summit, along with the feedback received from patients and the public over the past 12 months provide a strong platform from which the CCG with the support of partner organisations will develop the Sustainability and Transformation Plan for the population of Hambleton, Richmondshire and Whitby. In the meantime the work, which many of you are involved in, will continue across the patch aimed at incrementally improving and developing care services. Updates on progress and opportunities to get involved in new workstreams as they emerge will be available on the website and via the regular forums and meetings.

12 Clinical Summit Report. December 2015 Appendix 1 Clinical Summit 2015 attendees There were over 200 attendees comprising of:

59 General practitioners 19 Hospital consultants

15 Practice nurses 17 Social care practitioners

10 District nurses 9 Practice managers

19 Staff from HRW CCG 2 Ambulance service personnel

52 from other professions which included:  Extra care housing  Social services  Tees Esk and Wear Valleys NHS Foundation Trust.

13 Clinical Summit Summary Report. December 2015

Lambert Memorial Hospital Thirsk

NHS Property Services (NHSPS) is the owner of the hospital property and the neighbouring health centre and 6 Chapel Street, Thirsk.

The hospital is leased by South Tees CCG to provide services commissioned by Hambleton, Richmondshire and Whitby CCG.

NHSPS has undertaking assessments of all properties in our portfolio to identify a lifecycle maintenance programme for each site and in order to understand investment requirements across our portfolio. At the request of the CCG we have prioritised the survey work for Lambert Memorial Hospital to support them in assessing their strategic service delivery and estates requirements for the area.

Attached below are two tables showing the investment requirements identified by the survey for the next 5 years. These tables are summaries of the more detailed technical reports provided to NHSPS by its contractor. The investment requirements have been risk assessed and priced by the specialist contractor and are yet to be agreed by NHSPS as a programme of work.

In 2015 NHSPS also undertook planning work related to the ongoing maintenance of Thirsk Health Centre. The two properties share a number of joint systems and a plant area. A substantial level of capital work is currently identified for the Health centre and this includes some work on mechanical and electrical systems. Some elements of this work would only proceed if the site was to remain a base for inpatient services.

Year Building Mechanical & Capital Total Electrical Programme 2016 0 1,000 50,000 50,000 2017 414,000 120,000 0 534,000 2018 0 0 0 0 2019 0 97,000 0 97,000 2020 0 0 0 0 Total 414,000 218,000 50,000 682,000

I hope this information is sufficiently clear and provides the details you require.

Karina Dare Senior Property Strategy Manager

Building Works

Description of remedial works Probability Potential Risk Risk Assessed 2016 2017 2018 2019 2020 of Failure consequ scores ranking Cost (£k) (£k) (£k) (£k) (£k) (£k) ences

Complete Overhaul of Roof, Structure, and Tiling Likely Minor 8 Moderate 130 130 Complete Refurbishment of Medical and office areas Likely Minor 8 Moderate 250 250 Replace WC Likely Minor 8 Moderate 7 7 Refurbish Kitchen Area Likely Minor 8 Moderate 1 1 Sash Window replacement required Likely Minor 8 Moderate 20 20 Refix Guttering Likely Minor 8 Moderate 1 1 Remove vegetation to chimney and repoint Likely Minor 8 Moderate 2 1 External Decorations Likely Minor 8 Moderate 2 2 Internal Decorations Likely Minor 8 Moderate 15 2 Replace Door Likely Minor 8 Moderate 1 1 1 414

Mechanical & Electrical Works

Potential Assessed Probability Risk scores Probability 2016 2017 2018 2019 2020 consequences Cost (£k) Asset of Failure of Failure (£k) (£k) (£k) (£k) (£k)

Access-Door-Auto-Swing Likely Minor 8 Moderate 6 6

Access-Fire-Door-Hinged Likely Major 16 Significant 20 20

Fire-Alarm & Detect-Panel Likely Minor 8 Moderate 20 20

Control-Window Automatic Control Likely Minor 8 Moderate 5 5

Medical Gas-O2-System Likely Moderate 12 Significant 17 17

Storage-Hot Water Cylinder-Unvented-Indirect HW Likely Minor 8 Moderate 2 2

Storage-CWS-Potable Water Tank Possible Minor 6 Low 1 1

Pump-Sewage Ejector-System Likely Minor 8 Moderate 9 5 4

Elec-LV-Distribution Panel Possible Minor 6 Low 12 1 11

Pipework-DHW Distribution Possible Minor 6 Low 50 50

Sanitation-Sanitary Fitting-Shower-Electric Likely Minor 8 Moderate 1 1

Sanitation-Drainage-Waste Water Possible Minor 6 Low 25 25

Security and call systems Likely Minor 8 Moderate 23 23

Terminal-Radiator & Valve-Hot Water Possible Minor 6 Low 3 3

Valve-Thermal Mixing Likely Moderate 12 Significant 1 1

Vent-Fan-Local Exhaust Ventilation (LEV) Likely Moderate 12 Significant 16 16

Lighting - various Likely Minor 8 Moderate 6 3 3

0 120 0 97 0

ACCOMMODATION WITH CARE DESIGN AND ETHOS GUIDE

February 2015

Extra care housing should provide safe and secure self- contained accommodation for vulnerable adults who require varying levels of care and support to enable them to live independently in a home environment

CONTENTS Page

Foreword 4 Introduction 8 Section 1 Complete and Thorough Design 11 1.1 Attractive, Safe and Secure Places 11 1.2 Putting the Customer First 12 1.3 Co-ordinating design and development with long term 13 management and maintenance 1.4 High Quality with Low Costs 14 1.5 Local Context 15 Section 2 Place Shaping 17 2.1 Supporting the Local Community 17 2.2 Well Connected and Convenient 17 2.3 Parking Provision 18 Section 3 Maximising the Use of Outside Space 21 3.1 Seating and Planting 21 3.2 Activities 22 Section 4 Maximising the Natural Environment 24 4.1 Biodiversity 24 Section 5 Energy and Resources Efficiency 26 5.1 Sustainability and Energy Conservation 26 5.2 Affordable Running Costs 26 5.3 Minimising Energy Consumption in Construction and Design 27 5.4 Minimising Construction Waste 27 5.5 Recycling Materials and Buildings 27 5.6 Environmental Sustainability 27 Section 6 Building Operations 29 6.1 Refuse and Recycling 29 6.2 Care Teams / Staffing 29 6.3 Information, Communication and Digital Inclusion 30 Section 7 Accommodation Requirements 32 Extra Care 32 7.1 Security 32 7.2 Tenure 32 7.3 Management Arrangements 33 7.4 Health and Safety Including Fire 33 7.5 Colour Contrast and Material Selection 34 7.6 General Signage 35 7.7 Communal Facilities 36 7.8 Restaurant / Café areas 38 7.9 Lounge Areas 39 7.10 Circulation 40

2

7.11 Stairs and Protection from Falling 42 7.12 Acoustics 42 7.13 Emergency Call, CCTV and Telecare 43 7.14 Lifts 45 7.15 Treatment Rooms and Assisted Bathing 46 7.16 Staff Laundry 47 7.17 Hair and Beauty Salon 47 7.18 Bariatric Care 47 7.19 Guest Suite 48 7.20 Meet and Greet 49 Section 8 Space Inside the Home 50 8.1 The Apartment / Living Space 50 8.2 Bedrooms 52 8.3 Bathrooms/En-suite facilities 53 8.4 Cooking and Eating 55 Section 9 Living, Playing, Working and Studying 57 Section 10 Designing for Dementia 59 Section 11 Designing for Visual Impairment 64 Section 12 Designing for Other disabilities 66 12.1 Learning Disabilities 66 12.2 Hearing Impairment 70 12.3 Mobility 70 12.4 Long Term Illnesses / Conditions 70

Section 13 Scheme Evaluation 71

Acknowledgements 72 Appendix 1 Fire Service Memorandum 73 Appendix 2 Schedule of Accommodation for Extra Care 84 Appendix 3 Design Standards and Guidance Documents 87

Further Design Guidance and Good Practice References 88

3

FORWARD

North Yorkshire County Council is engaged within an ambitious project to facilitate the delivery of accommodation with care to meet the needs of our current and future communities.

This includes working with partner Registered Providers to enable the provision of extra care housing schemes; core and cluster accommodation; specialist housing and supported accommodation to meet the needs of vulnerable people in the County, including:-

. older people . people with a learning disability . people with mental wellness requirements . long-term conditions including physical disability . complex needs . cognitive impairment . sensory impairment

We aspire to work in successful partnerships which will provide high-quality, vibrant, safe, attractive, sustainable and well-designed supported accommodation which creates an enabling environment for 1residents and ensures the delivery of customer centred seamless services to residents and people using the services from the wider community. We expect good design to add environmental, economic, social and cultural value which will help local communities to flourish. The accommodation and facilities should minimise people’s experience of their disability or frailty.

This Guide is intended for use by everyone involved in the supported housing development process to assist in achieving high-quality and sustainable ‘places for living’. It will support the achievement of high standards of design and construction and it will provide Planning Committee Members and Officers with the tools to challenge poor design. The Guide will be subject to regular review and subsequent updating. This will occur as a result of changes in legislation and standards and feedback from providers and developer partners as well as people who live in the schemes and people who come in to use the facilities and services.

The design of specialist accommodation often requires discussion and development of detailed layouts. Some issues may not present obvious or standard solutions. Therefore, this document is not intended to be prescriptive.

When designing accommodation, facilities and services, as much thought as possible must be given to ensuring the resultant provision is as non-institutional as possible. All concerned in a project must consider what they would find acceptable for themselves and the person they love most. Extra care housing should provide a true ‘home’ for people and all aspects of the development, management and services should be undertaken with the utmost respect for the people who will live in and use the scheme.

1 we are using the term ‘residents’ in its true sense; as a resident of a housing model rather than a residential institution 4

SERVICE OUTCOMES AND OBJECTIVES

Extra Care Housing Support and Care

The overall purpose of any extra care housing (ECH) scheme is to provide safe and secure self-contained accommodation for vulnerable adults who require varying levels of care and support to enable them to live independently in a home environment.

Service provision that:-

. contributes to the initial reduction of the levels of care and/or support previously received by the resident before entering the scheme . supports the ongoing care and support needs of its residents and reduces the likelihood of admission to long-term care . contributes to the prevention of hospital admission, re-admission and enables early discharge . contributes to supporting people to live independently, stay healthier and recover quicker from illness or accident . enables people to be supported to remain in their own home and supported to die in their own home if that is their wish . enables people living with dementia to live independent and active lives without the need to move to more restrictive accommodation

ETHOS OF THE EXTRA CARE HOUSING SCHEME

Residents who have been assessed by Health and Adult Services (HAS) Local Commissioners using the Fair Access to Care Services (FACS) criteria may live as assured tenants or leaseholders with security in their own self-contained apartments.

North Yorkshire County Council’s strategy aims to reshape the countywide provision of care accommodation options and services in order to offer residents increased choice and independence.

As well as the points listed under ‘service provision’ above it should:-

. promote independence, prevention and wellbeing . improve outcomes for residents and their carers . enable two-way community interaction to provide activities, lifelong learning and social interaction . give people choice and control over their care and support needs via the Personalisation Agenda . give people control over their personal finance arrangements including having access to welfare benefits with a view to maximising their income . provide housing, care and support solutions to all vulnerable adults of all ages and across all needs . be mixed tenure and tenure blind . involve and consult with people of all ages and need, who are likely to live in or use the facilities and services provided at the scheme 5

. include a specialism where identified as a need such as a Memory Clinic or Learning Disability Day Service . offer choice and control with a wide range of innovative, high-quality and flexible care options that are joined up and seamless

We expect Registered Providers and developers who want to build supported accommodation in the County to sign up to the principles held within this publication.

Please visit www.northyorks.gov.uk/extracare to find the most up to date document.

Esk Moors Lodge, Castleton

The accommodation should consist of self-contained homes with design features and support services that enable self-care and independent living. All services should be aimed at placing dignity and respect for people as the highest priority. People should be enabled to remain independent for as long as possible and care and support must be tailored to adapt as people’s needs change.

As a minimum, schemes should include:-

. own home with own front door, kitchen, bathroom, lounge and one or two bedrooms . care and support staff available 24 hours a day, seven days a week . services that embrace the Personalisation Agenda enabling residents to exercise choice and control over their services . properties to rent or buy including shared ownership . the opportunity to take advantage of social activities and lifelong learning . pet friendly housing management policies . assistive technology . inclusion with the local community

The physical design of the schemes as well as the delivery of services must create a sense of autonomy and achievement for residents. All decisions made by professionals during both the development of the schemes and the operational phase must bear in mind the best 6

outcome for residents in terms of:-

. dignity and respect . choice and control . financial control . value for money . personal autonomy . independence . physical and mental health and wellbeing

All services provided within the ECH scheme will be measured against the following 5 principles (the ‘5A’s model):-

. Affordability . Availability . Accessibility . Acceptability . Achievability

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INTRODUCTION

We acknowledge that there are costs and challenges associated with delivering good-quality and well-designed accommodation. However, the Council wants to ensure that supported accommodation developed in the County maintains longevity in terms of appearance; cyclical maintenance; running costs; responses to climate change and adaptability to meet future lifestyles and technologies throughout the life of the building and is future-proofed.

The County Council has a long-term ambition to significantly reduce the number of people being placed into residential/nursing care by providing them with a choice of lifestyle including a choice of quality, independent living accommodation. It is therefore our aspiration to enable the development of independent living, while reducing the numbers of residential/nursing care establishments being agreed through the planning route. It is also a requirement that the extra care housing provides accommodation and support for people of all ages (from 18 yrs) and all needs, up to and including palliative and end of life care if that is the individual’s wish.

Any accommodation must be designed to enable people to find privacy, comfort, support and companionship, in addition to being a resource to the local community. It must also meet the various requirements of staff working from within the building and respond to market changes relating to tenure mix. Good design is about creating attractive and successful buildings that work well within the local area. The benefits of good design include:-

. making people feel positive about their neighbourhood . creating a good quality of life . enriching the existing environment . supporting existing residential areas and creating higher capital values . attracting people . increasing marketability and prestige . lifting confidence in the surrounding area

Our aim is to enable provision of a choice of housing products for people who live in the County of North Yorkshire. Their aspirations and expectations around the type of accommodation they require must be met. Achieving this will be measured against the design quality; its connections into the surrounding environment and customer satisfaction with their homes.

We aspire to encourage within our enabling role:-

. partners to place residents’ needs and aspirations central to their design . joined-up approach to design, development, long-term management, maintenance and service charges . embracing sustainability and energy conservation within design . keeping quality high and costs low

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We maintain that healthy, safe, well-designed buildings, spaces and environments are central to the quality of life and wellbeing of our residents. By meeting current needs and aspirations we anticipate that people will be able to live independently for longer in their own home of choice, with support tailored to meet their individual need, which can be adapted as their needs change.

There is no single, specific design solution that will suit every need and every location. Design consideration must be site-specific and respond to the brief of requirements for a particular location. The scheme should combine with existing and other housing needs to provide a community facility that will enhance that community.

The County Council aspires to provide a flagship, dementia specialist scheme in each of the seven districts including a health and wellbeing suite, a memory clinic for the assessment and diagnosis of dementia and a care and telecare shop from which people can purchase care and telecare equipment utilising their personal budgets.

We have a need for accommodation with care for people from a range of ages (from 18 upwards) where people are living with a learning or physical disability. Such people may not wish to share a scheme with people who are many years older and each case and possible allocation should be judged on its suitability for all concerned. However, where sites allow, the County Council would like to see the development of ‘core and cluster’ accommodation with apartments and bungalows surrounding the extra care scheme to offer a range of options and enable younger people to live a little independently of the main scheme but close enough to access its services and facilities. We are also aware that there are many families remaining together long-term and the provision of general family housing with annexe accommodation would be beneficial as it would allow different generations to remain living together and provide low-level support to each other whilst still accessing services and facilities from the extra care scheme as required and appropriate. The Abbeyfield model of a large house providing shared living in a more intimate, family setting may be popular with some people and this should also be considered alongside an extra care scheme.

Designs for all types of accommodation should maximise the availability of natural daylight and personal, outside space. For instance, balconies with sitting space are preferable to Juliet balconies. A central corridor of single aspect apartments can present an institutional feel (although it is accepted that it is more cost-effective to build) and dual aspect design allows more windows and therefore daylight as well as flow of ventilation.

Finally, the general design standards that are applied should be aspirational and not just meet current need and usual financial modelling.

Social Enterprise

It is North Yorkshire County Council’s aim that each scheme brings as many positive opportunities as possible to the community in which it sits.

In the past some services in extra care housing schemes have relied upon commercial success as a private business or, in the case of most meals provision, guaranteed income via condition of tenancy. A limited number of local people have benefitted from these services in terms of business or employment opportunities.

In the case of meals provision as a condition of tenancy, this goes against the ethos of giving 9

choice and control to residents who then have little choice but to eat the meals offered, at the times offered. This is also an added burden to the Housing Benefit budget as a large proportion of the cost can be claimed via Housing Benefit for those with benefit eligibility.

Some partner housing providers operate a restaurant/café-style service that is based on a changing menu with meals at reasonable cost and further still, some providers operate a Social Enterprise model. This has proved to be an extremely valuable service to those who have experienced it. The benefits of a Social Enterprise include:-

For Service Users:-

. a feeling of empowerment . a real sense of inclusion in ‘normal’ activities such as training . social interaction with a range of people

According to HM Government in their Report ‘Increase the proportion of socially excluded adults in settled accommodation and employment, education or training’ October 2007,

“evidence suggests that ensuring individuals at risk of social exclusion have a stable home and the appropriate life skills to maintain it and are either in a job or involved in productive, employment-focused activity, can help reduce the likelihood of negative outcomes in the future. Without the firm foundations of a job or settled accommodation, the most disadvantaged adults risk a lifetime of social exclusion for themselves and their children and potentially place a lifetime cost on society.”

For Carers:-

. time off from caring . reassurance that their dependant is safe . a sense of pride in their dependant

For the Council:-

. meeting aspects of social responsibility . meeting statutory responsibility . a solution for some staff at risk of redundancy . people accessing the scheme are no longer in expensive day centre services which cost around £40 pp, per day . offering residents of extra care housing a true restaurant/café-style service that is available for longer each day and has more choice than traditional meals as a condition of tenancy models

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SECTION 1: COMPLETE AND THOROUGH DESIGN

Dialogue should be maintained with local planners; the wider local community and local business to support community ‘ownership’ and pride in the proposed development, even before it is built. If design or planning problems are encountered, the most constructive solution can often result from sharing them and working towards a commonly agreed solution.

Be flexible and adaptable as compromise may be required. If areas of contention are not addressed at pre-planning stage, then they may become grounds for refusal.

The spaces and environments surrounding our homes are an extension of personal space, bringing individual homes together and forming a community of residents. The aim would be to provide an identity to be proud of and that offers clear connections with the wider neighbourhood. This will be achieved by:-

. creating identity and variety – a safe environment where residents and the community have a sense of belonging and ownership . designing to encourage friendships; knowing your neighbours and enjoying the use of shared spaces . encouraging wellness activities in external and internal spaces . creating an external environment which is bio-diverse with multi-use opportunities providing materials which will endure and improve over time

Lifetime homes means designing in flexibility and adaptability needed to allow for easy incorporation of wheelchair accessibility, addition/removal of internal walls and ease of extension. This is particularly important for older households, or other households with support requirements who may be dependent upon nearby local networks for emotional and physical support. It is the County Council’s aspiration that all new build homes meet Lifetime Homes Standards.

1.1 Attractive, safe and secure places

A safe and secure design can involve:-

. easy access for people with disabilities and emergency services . clear definition of space . deterring crime - buildings facing onto streets and footpaths with windows facing onto them; car parking visible from homes

The Royal Town Planners Institute (RTPI) Good Practice Note 8: Extra Care Housing – Development Planning, Control and Management also provides planning guidance and refers to other guidance documents.

You should also refer to the National Housing Federation’s Standards & Quality in Development and HAPPI – Housing our Ageing Population Panel for Innovation Recommendations. 11

CHECKLIST – Have you:  . maintained dialogue with Local Planning Officers? . supported community ownership of the building? . provided clear connections with the surrounding neighbourhood? . implemented Lifetime Homes’ guidance? . provided an attractive, safe and secure design? . reflected the need in the locality?

1.2 Putting the customer first

We want to ensure that the development of accommodation meets the needs of people in our communities. To do this we aim to provide access to good quality, well-designed homes enabling vulnerable households to live independently with support tailored to meet the needs of the household. We want to ensure that the accommodation will also provide for the needs of their whole household; that it will be safe and warm; enabling the household to live fulfilling lives with access to social and wellness facilities whilst acknowledging cultural requirements.

Our aspiration is to enhance the quality of our residents’ lives with the homes they have available to them now and to ensure that the accommodation is future-proofed to meet the needs and expectations of residents into the future. We want to encourage a sense of pride in the home and neighbourhood in which they live. We want to ensure that people have access to shared and public spaces, local amenities and facilities which will enhance their quality of life. It is vital that the people who live in the scheme integrate into their local community and maintain relationships and usual behaviours in that community and that the community is encouraged and invited to come into the scheme to make new friendships.

Activity/Games Room

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It is essential that the physical environment is enabling in terms of the likely impairments that residents may experience in their lives due to increasing age, frailty, disability or impairment.

Good design can mean:- . enriching existing character . diversity . understandable places . achieving pride of place/creating a sense of place . easy movement – easy to access and move through with safe and welcoming routes . enduring and flexible places – built to last and energy efficient according to the intended use but with the ability to be easily used for another purpose

1.3 Co-ordinating design and development with long-term management and maintenance

Developing accommodation requires thought around the use of the internal and external spaces. Life issues for the people living in the accommodation must be considered to gain an understanding around how the buildings and communal areas will be used. This will enable the management and maintenance of those areas to be understood, particularly relating to service charges.

Sunnyfield Lodge, Ripon

It is expected that mixed tenure provision will be considered in all future housing developments as appropriate to the local housing market. Consideration must be given to the use of the accommodation, including considering the anticipated demographic profile which should provide an understanding of the appropriate level of management required and how innovative design and decoration solutions may help to reduce the impact on areas affected, eg heavy footfall and wheelchair use. 13

CHECKLIST – Have you:  . thought clearly about the use of all spaces? . considered the ‘life issues’ of the expected occupants and how they will use the spaces? . considered the impact of the design on service charges? . considered how the scheme will be managed and paid for? . designed areas appropriate to their use? . designed areas and accommodation that can respond flexibly to changed or future needs? . considered the impact of your design on BME communities?

1.4 High-quality with low costs

Quality should not always be costly and can be provided by innovative procurement/design and understanding the people who will be living in, working in and visiting the accommodation. Embracing value for money principles and being efficient in some areas may enable additional resources to be invested elsewhere.

Community Library, Town Close,Stokesley Community Library, Limestone View, Settle

Consideration must be given to any operational services being provided from the building and whether there is opportunity to utilise existing local services, rather than provide them within the scheme build. The last thing the County Council wishes to do is risk existing local businesses and therefore research should be undertaken about what services exist locally and whether they may be willing to provide to the scheme before services are replicated.

In turn, there is opportunity to consider services which can be provided in the building maximising use by local residents by supporting the principles of a community facility as appropriate. North Yorkshire County Council supports the social enterprise model.

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Village shop within Sycamore Hall, Bainbridge

CHECKLIST – Have you:  . identified services in the local area which could support the scheme? . identified services lacking in the local area which could be provided within the scheme? . considered how services provided in the scheme can support the wider local community? . considered what design features will encourage the community to easily come into the scheme?

1.5 Local context

Context emphasises the requirement for the layout and appearance of buildings to be based on an appraisal of the character of the site including buildings and land in the surrounding local area. Larger new developments such as extra care accommodation must cater for the needs of residents and visitors and must consider and raise the general aspirations and expectations of neighbouring residents and the general public (as appropriate).

With an application for accommodation involving ‘housing with care’, the Design & Access Statement should include specific reference to the issues related to the model. This is likely to be of considerable assistance to the planning officers dealing with the application.

CHECKLIST – Have you:  . carried out an appraisal of the site, taking into account the surrounding local area? . carried out a demographic analysis of the local population in terms of age profile, the existing provision for housing ‘with care’ in the area and its ‘fitness for purpose’ and a projection of future need to establish a case for new housing? . an explanation of the model of development including communal provision, 15

tenure opportunities and integration into the wider neighbourhood? . benefits that the development will bring to the area in terms of facilities, employment, release of existing housing in the community due to under occupation (as appropriate)? . reference to precedent and guidance on similar models to aid the planning process? . assessed/evaluated your parking requirements based upon residency and expected service provision within the scheme?

We would like to enable the creation of homes that people will positively choose to move into and want to stay in by:-

CHECKLIST – Does your design:  . create distinctive homes which are safe, spacious, welcoming and user friendly? . provide homes which are tenure-neutral in appearance and standards? . provide environmentally sustainable homes and future-proofing designs to bring long-term benefits to residents? . ensure that high quality standards and materials are maintained throughout the whole life of the building?

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SECTION 2: PLACE SHAPING

2.1 Supporting the local community

North Yorkshire is the country’s largest county and has some extremely rural areas. Great thought must be given to developments from an holistic view – considering what already exists in the area and what services can be met by providing the scheme. Extra care can be whatever it needs to be – subject to funding of course – and so a range of stakeholders should be invited to consider whether they can provide facilities and services from the scheme.

Wellbeing at home is vital and this can be achieved by ensuring there are effective links to local amenities, shops, public transport, opportunities for social interaction and green and attractive surroundings.

The opportunity to mix tenures, use Modern Methods of Construction and be innovative around design and architecture enables opportunity to create vibrant and exciting places to live and visit.

Feeling safe at home and in the neighbourhood is a recurring issue raised by our more vulnerable residents. Effective design can help achieve good connectivity between neighbourhoods, provide defensible private space and places that feel safe. The following should be considered:-

2.2 Well-connected and convenient

Creating and sustaining a community is about building homes in places where people want to live for the longer term, with access to social and wellness activities, shops, public transport and local amenities. People usually wish to remain in the community they are familiar with, where they have grown up, made and maintained friendships and have access to activities and socialising and this should be continued. To help deliver this we should: -

. at an early stage, establish the context of the site by analysing how well it will serve the client group for which the supported accommodation is being developed . local convenience shops should be available, ideally within a safe five minute walk of the site or provided by the scheme . there should be good and regular public transport nearby . if there is no large open space or park nearby will the scheme provide communal garden/outside space?

It must be noted that North Yorkshire is a large, predominantly rural county covering over 3100 square miles with only two major urban centres at Harrogate and Scarborough with most people living in one of the 28 market towns, small villages or hamlets.

Therefore, this guidance needs to be considered differently for schemes built in very rural areas as they may not have close access to local amenities but rather may replace the lost heart of a village bringing much-needed facilities such as a shop, hair salon, café/restaurant etc to the locality.

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CHECKLIST – Does your design:  . have entrances that are clearly visible from the street, well-lit and welcoming? . provide formed boundaries between public and private space using attractive and durable materials – are the barriers clear but unobtrusive? . avoid putting car parking under buildings at ground or semi-basement level so as not to create poor quality street frontages? . ensure that communal spaces and gardens have a clear purpose and are overlooked by homes or passers by (as appropriate)?

Areas for Consideration . if there are strong local patterns of design this may need to be reflected within new design. This may be re-interpreted in a contemporary way but is especially pertinent in the National Parks . if a ‘place’ lacks character or is poor in terms of design, the new development can become a beacon or exemplar for regeneration and future development . materials must be chosen for their longevity and not cause undue and costly maintenance problems . there must be no distinction between different forms of tenure within the layout or the architectural treatment of the buildings . new development must be integrated into and connected with the wider neighbourhood, avoiding the feeling of a separated estate or gated community and should help to breakdown barriers to adjoining neighbourhoods

Each development should sit within and contributes to, local communities, local businesses, local facilities, enhancing the sustainability of that neighbourhood and ensuring a positive future for its residents. Schemes should provide seating on routes within the local community to aid residents to have access to local shops and community facilities.

CHECKLIST – Does your design:  . provide sustainable and innovative designs which can strengthen neighbourhood identity and community ownership (this could include provision of district heating or CHP to the local community)? . encourage the dissolution of barriers to adjoining neighbourhoods? . provide homes and facilities to strengthen neighbourhood cohesion and sustainability? . maximise the use of green spaces as focal points, meeting places, activity areas for all ages? . understand the sustainability of services and buildings in the area and support them within the aims of the scheme?

2.3 Parking Provision

Car parking must be carefully considered and integrated with the landscape. All of these opportunities need to be carefully considered at design stage in terms of their function,

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durability and ongoing maintenance.

. local streets must not be dominated by cars and car parking associated with residents and people visiting or working at the housing provision . larger parking courts for apartment developments need to be carefully designed to avoid compromising the living conditions for ground floor homes. Parking courts should be designed to be safe for pedestrians, cyclists, people in wheelchairs and using mobility scooters. Low car speeds must be encouraged through design . car parking areas and public walkways to the scheme/front door should be well lit . a safe drop-off point is required and consideration must be given to accommodate rear tail wheelchair lifts on minibuses. It is good practice to arrange a ‘horse shoe’ drop-off configuration to avoid the need to reverse with the associated health & safety risks . the entrance canopy should be designed to allow residents to move directly into a sheltered area and minimise exposure to inclement weather and should be designed to ensure an ambulance can discharge or pick up under cover . parking should provide direct access to the main entrance

If developments incorporate local shops and facilities, are close to public transport and include attractive, safe pedestrian and cycling routes this will help reduce car usage without reducing car accessibility or car ownership. It will also enable a high quality of life for those least likely to own a car. Convenient cycle storage should be provided for any staff and visitors to the development (dependent upon scale of the building). Parking provision must be determined by locality and the availability of other forms of transport. Adequate spaces should be provided to prevent people parking in inappropriate places eg footpaths, grass verges, across local residents’ driveways, local residents’ off-street parking areas. Planning guidance is available in each local authority area for specific information.

Sunnyfield Lodge, Ripon

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CHECKLIST – Have you:  . integrated car parking into the landscape of the scheme? . considered planting of trees and shrubs in the parking areas? . provided lighting to the car park area to help with way-finding, safety and security? . designed the car parking and drop-off areas to be safe for pedestrians, cyclists, people in wheelchairs and people using mobility scooters? . provided canopy or shelter provision at the entrance to the building? . provided cycle storage areas? . provided adequate parking for the successful operation of the building and minimised inappropriate ‘public’ parking?

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SECTION 3: MAXIMISING THE USE OF OUTSIDE SPACE

3.1 Seating and planting

Outside space should be maximised to enable people to undertake indoor activities outside during warmer weather. This could include a patio with tables and chairs as an extension to the restaurant/café activity area and circuit area for people to move around on foot or in their wheelchair with pagodas and seating areas as stop-off points. Pergolas covered in climbing plants can provide shading for south-facing terraces or to shade seating areas. Water features can support a stimulating and tactile environment and provide effective focal points. Raised planting areas provide the opportunity for residents to contribute to planting/gardening activities. This also provides the opportunity for the accommodation to grow some of its own food including the use of fruit trees and herbs.

Sunnyfield Lodge, Ripon

Seating areas should be designed to meet the requirements of all residents of all abilities, particularly wheelchair users. It should be included in the design to provide distinct spaces to aid way-finding. Benches should be located at all main entrances for those awaiting transport. The design and location of seating must consider the requirements for a minibus and taxi drop-off undercover and to allow for the anticipated size and tracking of emergency and service vehicles, turning heads and waiting bay.

Secure wandering circuits of a suitable material should be incorporated into the scheme to provide opportunities for exercise. Seating points should be located to allow for rest points. Loose gravel surface treatment should be avoided because of disabled or elderly residents. Resin-bound gravel is more appropriate. Avoid unguarded changes in site level with only very gentle ramps acceptable. A minimum path width of 1200mm (1.2m) is adequate if wider wheelchair passing spaces are required. Dead ends should be avoided, short cuts 21

anticipated and paths providing a clear route back to their origin included. Giving consideration to the residents living at the accommodation, garden areas should be functional, useful and safe external spaces which can provide areas for relaxation, socialising, activities and private space. The benefits of green space have a direct effect on quality of life in terms of both physical and mental wellbeing. A greenhouse and potting shed should be provided. Consideration should also be given to providing allotments to promote healthy living and for the possible provision of a community cooperative for fresh fruit and vegetables. A brick barbeque should be provided to enable making best use of the garden in warmer weather.

Seating areas giving private but attractive space – The Orchards, Brompton Northallerton

3.2 Activities

Appropriate play provision, dependent upon the age groups living in the new development should be considered. This could be basketball area, kick-about area for young people, small play area for families with children or visiting young children, apartment green area for bowls/yoga/tai chi as well as an outdoor exercise park, specifically designed for adults which can encourage and support older people’s activities.

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Pottering in the greenhouse Sycamore Hall, Bainbridge

CHECKLIST – Have you:  . maximised the outside spaces and provided seamless access from indoors? . designed the scheme to maximise use of the outside as an extension to the building? . considered activities which could be undertaken outside and designed the external areas in such a way to accommodate those activities? . considered providing focal points including water features, pagodas, seating, sculptures, outside games areas? . provided a garden which meets the needs of residents including providing potting sheds, green-houses, raised bed planters, fruit trees, allotment space and herbs? . provided adequate and appropriate seating arrangements? . provided wandering circuits with adequate seating and providing shade? . maximised views and the landscape? . provided appropriate ground covering to meet the needs of those living in the scheme/building? . made the outside place an interesting, accessible and enjoyable place to use? . included a greenhouse? . included a potting shed? . included allotment space? . included an outdoor exercise park? . included a barbecue?

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SECTION 4: MAXIMISING THE NATURAL ENVIRONMENT

4.1 Biodiversity

Biodiversity should also be incorporated into the design to encourage wildlife into the garden space and maximise the potential of the plants used ie fruit trees, herbs for kitchen use and craft use, plants for sensory enhancement, areas to encourage fitness and social activities.

Rivendale, Northallerton

The extra care scheme at Rivendale, Northallerton includes:-

Green Roof to Entrance The roof to the entrance of the main building is a living green roof made up of a sedum mat. Sedum is a very hardy plant that can survive extremes of temperature and weather. The living green roof is climate-friendly and has good insulation and green properties.

Rainwater Harvesting The scheme incorporates an element of a rainwater harvesting system which ‘recycles’ rainwater for appropriate uses within the building.

Solar Panels Solar panels are in place to assist with the heating of the hot water.

Planting Scheme There are wild flowers within the planting scheme to attract insects, wildlife etc into the garden.

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General Energy-efficient bulbs have been provided within the lighting system throughout the building. PIR sensors are on lighting in corridors, communal rooms etc to ensure lights are turned off when areas are not in use.

The scheme is designed to meet modern building regulations and is aiming for a green assessment level of ‘very good’.

A Travel Plan was completed that set out how best to minimise the scheme’s carbon footprint for staff, residents and visitors.

CHECKLIST – Have you:  . considered plants to stimulate the senses including tall sweeping forms to provide movement, varied textures to create sounds and encourage sense of touch? . used vibrant colours and highly aromatic plant mixes? . minimised maintenance and provided opportunities for resident participation? . considered green spaces as a wide web of spaces and habitats? Planting plans should enhance the natural ecology of these spaces. . considered the use of green roofing in the scheme design to provide an attractive outlook for upper floor homes as well as contributing to rainwater retention, bio diversity and energy efficiency? . provided privacy and enclosure for residents, especially where their front windows may overlook public access areas/car parks? . maximised the use of rain water storage to provide easy recycled watering systems for garden/lawn areas? . considered providing, wherever possible/appropriate, Sustainable Urban Drainage Systems (SUDS)? . ensured refuse collection points are within limits set by the local authority and if vehicles are required to enter the site, ensured that adequate turning areas are provided?

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SECTION 5: ENERGY AND RESOURCES EFFICIENCY

5.1 Sustainability and energy conservation

New developments must consider their impact on the environment; how they can respond to rising energy cost, the need to reduce carbon emissions and for overall, long-term sustainability and recognise good practice in these areas.

We expect to see both sustainability and energy conservation embraced within design for new buildings, in particular, the use of natural light, recycling of rain water, high levels of heat conservation, solar panels, heat pumps, ground and air source and biomass heating along with renewable electricity supply where practicable. In turn we anticipate lower costs for residents in terms of heating charges and service charges due to efficiencies which can be accrued over a period of time due to reaching and surpassing sustainability standards. This will support affordable warmth and help people out of fuel poverty. However, residents, where they are responsible for paying the bills, must be able to choose their energy provider.

BedZed and Peabody Trust

5.2 Affordable running costs

The design, installation and management of energy efficient and affordable utilities are crucial to the continuing success of every home. Schemes should avoid North-facing apartments where possible. Each design must ensure that energy consumption and costs to residents are as low as possible. This will require design consideration from the very initial 26

stage of a project so that orientation, window design, heat loss and heat gain are considered along with the potential cost in use of appliances.

Sustainable energy supply should be incorporated with the intention of minimising or eliminating the use of fossil fuels and reducing carbon emissions.

For space and water heating this may result in the use of:-

. solar hot water . ground source heat pumps . air source heat pumps . biomass boilers . biomass district heating linked to the local community

For electricity supply this may result in the use of:-

. wind turbines (including off-site wind generators with dedicated supply) . solar photo-voltaic cells, panels or roof tiles . biomass combined heat and power

Long-term costs within management and maintenance that may be passed to residents through service or maintenance charges are considered early and kept to a minimum.

Early consideration should be given to the provision of telephone, TV, broadband and digital services to eliminate the need for residents to make their own arrangements. Communal TV aerials and/or cabling of services should be provided.

5.3 Minimising energy consumption in construction and design

It is the responsibility of all new development to minimise energy use in the construction and ongoing use of buildings and to maximise passive and active technologies to support the reduction of both Co2 emissions and fossil fuel energy use.

5.4 Minimising construction waste

Careful design and specification, including off-site manufacture, can help reduce waste during construction.

5.5 Recycling materials and buildings

Re-using buildings, parts of buildings or elements of buildings such as bricks, tiles, slates or large timbers all help achieve a more sustainable approach to design and construction. Re- cycling and re-use of materials can help to minimise the extraction of raw materials and the use of energy in the production and transportation of materials. Developments should maximise the re-use of existing buildings (where appropriate) which can support social environmental and economic objectives.

5.6 Environmental sustainability

Within our enabling role, the County Council will expect its developer partners to pursue BREEAM 2014 certification, aiming to achieve the ‘Very Good’ rating. Innovative design and construction, including the contribution of modern methods of construction, will be a vital 27

element of delivering this target.

The BREEAM Certification requires that the design of the buildings and the layout of the site be considered across the following topics: energy use, carbon emissions, water, materials, run-off, waste, pollution, health and wellbeing, management, land use and ecology. Our approach is to maximise passive solar gain, build airtight dwellings with adequate ventilation, shading and cooling and incorporate thermal mass to reduce overheating where appropriate.

All designs and technologies that affect how the home works must be designed and installed so that they can be easily managed by residents or, alternatively, do not require their attention at all. We believe that designs that meet the Certification standards will, at each level, have increasingly significant benefits for residents, through reduced running costs and improved health.

Needs and aspirations of residents will change in time and we must acknowledge that the pace in technological change is rapid. New developments should be adaptable to those changes over their lifespan.

Every building and each individual home should be designed for future-proofing, to allow for the addition of new technologies. Also as summers become warmer the need for cooling is likely to increase and efforts should be made to provide this through natural ventilation methods rather than by air conditioning.

Where appropriate, flood resistance and resilience measures must be considered within the development design, along with measures to reduce overheating and promote water efficiency.

Internal air pollution and toxicity is a particular issue in buildings made more airtight to prevent heat loss. Many materials used in construction and finishing give off VOCs (volatile organic compounds). This can be avoided by using natural breathable products and water- based finishes.

CHECKLIST – Have you:  . recognised good practice within sustainability and energy conservation? . maximised natural light, recycling of rain water, high levels of heat conservation, solar panels, heat pumps, ground and air source and biomass heating along with renewable electricity supply where practicable? . ensured that energy consumption and costs to residents are as low as possible alongside supporting affordable warmth? . minimised or eliminated the use of fossil fuels and reduced carbon emissions in design? . integrated communal TV aerials, satellite and/or cabling of services into the building? . achieved or surpassed Code for Sustainable Homes Level 4? . provided for natural ventilation methods? . arranged for the use of natural breathable products and water-based finishes within the building? . minimised construction waste? . provided for re-cycling and re-use of materials if practicable? . acknowledged future-proofing to allow for new technologies? 28

SECTION 6: BUILDING OPERATIONS

6.1 Refuse and recycling

. designs within the home and the building must be innovative and adaptable to meet the increasing demands for effective recycling and refuse collection . refuse/recycling points must be located in easily accessible locations but away from any windows of apartments or neighbouring houses . refuse and recycling requirements will be met within the internal arrangements of the building . collection facilities must not be intrusive in the landscape or within the communal areas . refuse collection and storage with recycling facilities puts greater demand on good management and maintenance. Adequate space must be provided for the increased size of containers and the amount of refuse which is now separated for recycling . exterior bin stores should be screened and painted with climbing plants

CHECKLIST – Have you:  . provided effective opportunity for recycling and refuse collection? . located refuse/recycling points in easily defined areas? . provided internal arrangements for collection of refuse? . provided refuse collection arrangements designed so as not to be intrusive in the landscape? . provided adequately-sized refuse collection areas which can be easily cleaned with easy collection? . provided collection points away from buildings and communal areas?

6.2 Care Teams/Staffing

The working environment must be pleasant and practical to enable staff to work within it effectively. The building must be easily accessible to staff who will require conveniently- located ancillary accommodation with comfortable and functional facilities including storage areas, changing area, lockers, shower, rest room with small kitchen area and adequate office space. It should be noted that the staff rest room will be for all staff to use when taking a break or storing their personal items, irrespective of their employer.

As the County Council has embraced the Personalisation Agenda where residents make choices about who provides their care and support service, block contracts to one on-site provider are no longer appropriate. It is possible that a number of providers will work in the building and therefore careful consideration must be given to access, security and joint working.

It is important that residents experience a seamless service despite the fact that numerous agencies may work in the building.

All agencies will need to undertake scheme-based training and orientation and adopt the relevant Scheme-Based Protocol.

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Working together at Town Close, Stokesley

CHECKLIST – Have you: 

. considered the staffing provision in the scheme and their accommodation requirements including a staff rest room that is available for all staff who work in the building, irrespective of their employer? . a clear understanding of the number of staff expected to work in the building and their roles to understand the impact on the building design?

6.3 Information, Communication and Digital Inclusion

In community living, it is important that everyone is kept up to date with information but also that everyone is given the same information, at the same time. Failure to do so could lead to tensions and misunderstandings.

There is a wide range of methods for keeping people informed such as:-

. scheme newsletter (electronic version as well as hard copy) . digital notice boards . notices . letters . meetings . community television . residents’ Representative . residents’ Forums

Partners are encouraged to adopt as many communication methods as possible to ensure that everyone is informed and feels included in the day to day life of the scheme.

Notices around schemes should be kept to a minimum to reduce the institutional feeling but, where used, they should be professionally presented and worded appropriately and sensitively. 30

Residents should be enabled to take part in decision-making in the scheme and a variety of forums could be set up that would allow people to have their say, such as:-

. friends of the scheme . fundraising . social activities . catering . service delivery . gardening

Any such groups should be managed in a way that enables all residents who wish to take part to do so. Assistance must be given where required and special consideration should be given to how to include people who will need more support such as those living with dementia.

The provision of wi-fi in the communal areas of the scheme will encourage digital inclusion and assist both residents and staff to gain access to a wide range of information and services that are provided via the internet, assisting with social engagement, health and wellbeing. The provision of wi-fi that is of sufficient strength to service all apartments in the scheme and any nearby accommodation with care should be provided, subject to a value for money test.

Research shows that older people engage online for two main reasons: social activity and cultural integration. Internet access is a “window on the world” with individuals being able to explore interests, engage in commerce and communication with friends and relatives, even those living abroad. The health and well-being benefits of encouraging on-line activity should not be under-estimated as engagement is stimulating and can counteract social isolation. Research has also shown that both resident and carers can benefit by using the internet to understand their condition and explore choices for healthy living.

The Institute for Employment Studies report (2011) into the Get Connected project states that “residents reported being able to look at websites to do with their interests and hobbies, use internet shopping sites and communicate with family members, often overseas. Some had already noted beneficial impact on their carer’s ability to help manage their condition”.

CHECKLIST – Have you: 

. considered how you will communicate with residents, their carers, friends and family? . Provided wi-fi of sufficient “strength” to benefit the maximum number of residents so that you can encourage and promote digital inclusion?

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SECTION 7: ACCOMMODATION REQUIREMENTS

Extra Care

7.1 Security

The main entrance to the scheme will have a two-way access door which will enable people to gain open entrance during working hours, however, have the ability to switch to a one-way opening after hours. Switching to one-way will ensure security of the building with access only by intercom system or fob.

The foyer area will include office space for the Scheme Manager and will act as a reception area. CCTV offers residents a means of monitoring the front door and will usually be a Secure by Design requirement.

Residents’ areas should usually only be accessible behind progressive privacy doors, giving their areas clear and distinct space. However, where apartments are provided specifically for people living with dementia, these will usually be within the main communal space and not behind progressive privacy doors – this is because the more barriers between a person living with dementia and communal facilities there are, the less likely people are to come out of the apartment to use the facilities. To ensure the security of specialist dementia apartments, proximity monitors should be used that unlock the apartment door as the person approaches and then lock as the door closes.

Ancillary access to the restaurant for service vehicles should be separate to the main entrance for safety and visual reasons.

CHECKLIST – Have you:  . provided adequate front door provision which gives two-way access? . provided an intercom/door panel for out-of-hours visitors to access residents? . provided adequate CCTV arrangements? . provided progressive privacy doors which give residents a clear and distinct space which is behind public areas? Or another method of security where PPD is not appropriate?

7.2 Tenure

Consideration must be given to mix and type of tenure proposed. There should be no discernable difference in finish regardless of tenure. Tenure choices should be pepper- potted throughout the scheme. Consideration should be given to offering alternative purchasing options for potential buyers such as flexible tenure, rent to buy etc.

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CHECKLIST – Have you:  . provided mixed tenure? . identified which apartments/housing units will be available for which tenure type? . ensured that the tenure types are pepper-potted throughout the building?

7.3 Management arrangements

Effective management of the scheme must be considered from the outset. Management is particularly important at higher density where there is more intensive usage and a greater proportion of shared, communal space. The cost of management, reflected in service charges, is a major issue in terms of affordability so designing to minimise the cost of management and spreading the cost over as many homes as possible is a key part of the design process.

7.4 Health and Safety including fire

Schemes should be designed to ensure the safety and wellbeing of residents, staff and visitors to the scheme. The fire strategy for the building and means of escape needs to be fully considered as part of the overall design. In particular the phased evacuation procedure and how the building’s structural fire precautions and the Fire Management Plan work together.

In North Yorkshire, a Memorandum of Agreement is in place between the County Council, District & Borough Councils, the Fire Service and Building Control. This Memorandum states the expectation that all extra care schemes are fitted with a sprinkler system. It is included in this Guide at Appendix 1. Although this is not strictly necessary under Planning Guidance for extra care housing, the client group will be the same as that in residential or nursing care and it is therefore considered to be the best provision that will contain any fire giving maximum opportunity for life-saving and to ensure minimum damage to the building.

If sprinklers are incorporated the design of the system shall be in accordance with relevant British Standards and LRC Guidelines.

Fire responses need to be carefully managed with the assistive technology put in place within the building.

Careful consideration must be given to using fittings that blend in as much as possible, for instance, fire sounders in flats should be white and not red. Where possible (and in agreement with the Fire Service), signage should be minimised and fire extinguishers removed. This is possible if a fire sprinkler system is installed. Fire safety must take priority and this will be agreed with the local Fire Safety Team.

CHECKLIST – Have you:  . considered the management arrangements for the scheme and how they will be paid, without impacting too significantly on service charges? . compiled a clear fire and evacuation strategy? . provided adequate fire management and fire escape facilities? 33

. arranged fire management alongside the assistive technology? . minimised signage and fire-fighting equipment where possible and in agreement with the Fire Safety Team? . designed for a full sprinkler system?

7.5 Colour contrast and material selection

Colour contrast between walls, floors, doors and architraves, as well as fittings and furniture assists residents with visual impairment in identifying the different surfaces and edges of their surroundings. Patterns and materials of similar colour should be limited so as not to cause confusion between, for example, the edge of a chair and the carpet.

Colour schemes from each area and at the entrance to each apartment give each group of apartments an individual look. This will assist residents in locating their home. Measures should be taken to ensure non-resident areas such as stores and staff areas have the facility to be locked off and the doors and frames are ‘visually lost’ in the wall colour to detract residents from trying to enter restricted areas and, where possible, handles from such doors should be removed so that staff have no choice but to lock the door to ensure it stays closed. Not doing so could lead to confusion and anxiety as residents attempt to action a sign on a door – for example a door with a ‘push’ sign on it – only to find it locked.

Handrails should be on both sides of corridors and stairways. A change in material, texture and colour at changes of direction will assist residents with visual impairment in identifying the route through the building. Stair nosings should be yellow.

Shiny surfaces must be avoided, especially on floors. Tiling in a satin or matt finish reduces glare that can confuse residents with visual impairments.

Interior timberwork painted with satinwood as opposed to gloss will reduce glare.

Patterned wallpapers should be carefully chosen as they can cause problems in the following ways:-

. bold patterns can be over-stimulating . small patterns such as geometric ones can produce blurred vision and eye fatigue . vertically striped wallpaper can make some people feel dizzy . curved and angled lines on walls can affect balance . still-life patterned wallpaper can be confused with reality

It may be more appropriate to paper a ‘power wall’ to set the tone for a room, especially where the room is large and then use a tonal colour on the other walls. Use of different papers around the scheme can assist with wayfinding.

CHECKLIST – Have you:  . carefully considered the materials, colours and interior design of the building? . considered the needs of potential residents of the building against the design? 34

7.6 General signage

Signage should comply with Approved Document Part M which includes guidelines such as minimum character size, sentence case, embossing, height, type face etc. The Sign Design Guide produced by The Sign Design Society and JMU, which is cross-referenced in Part M, is a useful reference. Appropriate signage delineating disabled parking bays will be designed in accordance with BS 8300:2001. Signage must include the wording in Braille. Signage should be minimised in the building as this will give an institutionalised feel to the building but where it is used, consideration should be given to the materials and colours used so that it is of a style likely to be used in a hotel or a general apartment block rather than the style that is often used in institutional care.

For residents with dementia, there is specific dementia signage available which can help to identify their apartment and rooms in their apartment. The signage provides both the word eg ‘Bathroom’ alongside a picture of a toilet. This enables people with either special or word issues to recognise the sign and help them to way-find in the building and in their own apartment. Signs should be fixed to the doors they refer to, rather than to adjacent walls and doors for particular purposes should be colour-coded too ie all public toilet doors should be painted one particular colour etc.

Such signs can be found:-

www.dementia-signage.co.uk

CHECKLIST – Have you:  . identified which signage you require? . considered the location of signage both internally and externally and worked to minimise its placement? . ensured that the signage meets the needs of people who will be using it? . provided specialist signage if required?

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7.7 Communal Facilities

Communal facilities are usually provided centrally to serve all residents and to encourage community use. Some have been developed in clusters or friendship groups with 8 or 10 apartments having an individual lounge and dining room. This must be decided at the first stage of the design process.

Restaurant area at Deansfield Court, Norton

The scheme will usually have progressive privacy doors (PPD) to protect the apartments except where specialist dementia provision is included. Public spaces such as communal lounges, restaurants and hair salons should be located centrally and away from residents’ apartments. Staff, visitors or day users of the building should not need to walk through corridors off which apartments are accessed to reach their destination. Guest rooms and assisted bathing areas should be located away from the public areas and closer to the individual dwellings. Entrances to service areas should be separated visually from the main entrance. However, there may be some circumstances where PPD is not appropriate, for instance where specialist apartments for people living with dementia are provided. Advice from dementia specialists is that the more barriers that are placed between a person with dementia and a facility, such as the restaurant, the less likely they are to access that facility. In this case, careful thought must be given to ensure the security of the apartments. In an existing specialist dementia scheme this has been addressed by providing proximity badges for each of these apartments so that as the resident approaches their door, it will unlock to enable them to open it but will automatically shut and lock behind them (whether they or entering or exiting the property).

The building must have a clear and logical layout which can be easily understood. Communal areas shared with members of the public should lead from the main entrance foyer with minimal barriers to encourage use and easy access.

Good lighting is important throughout the routes but higher light levels can be used to differentiate public from private areas. The lighting should be cheap to run so that people don’t switch it off to save money – a common problem in extra care schemes! PIRs (Passive Infrared Sensors) should be fitted in areas such as communal toilets but programmed to

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come on as soon as the door is opened and to stay on for the maximum period so people aren’t plunged into the dark if they sit still for a while.

Small seating bays can break up walking distances and provide a ‘rest stop’. However this should be discussed with Fire Officers to ensure that they are confident and in agreement with the proposal. These also enable people who may have been quite socially isolated to sit outside of their apartment but not in the busy main communal area.

Entrance at Limestone View, Settle

Communal spaces should be designed to accommodate specific activities and include adequate storage for related equipment.

Disabled access toilets must be provided in the communal spaces, preferably close to principal entrances. However, they should have their own recess so that doors don’t open directly onto corridors for privacy and dignity purposes. They should be easily identifiable with automatic lighting which dims as someone leaves the facility. Wash hand basins must be provided in each toilet facility and all toilet facilities must be linked into the telecare system. An alternative to a pull cord fitting for the alarm should be considered to prevent children from pulling the cord and activating the alarm.

The basin wall and the one behind the toilet should be fully tiled for hygiene purposes. The dispensers for soap, paper towels etc should match and be easy to fill and clean. Careful thought should be given to their placement ie don’t fit paper towels or soap dispensers above the toilet roll holder as water will drip from hands onto the toilet tissue.

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Seating area, Deansfield Court, Norton

CHECKLIST – Have you:  . agreed which communal facilities you are providing? . agreed the location of the facilities and ensured that they are in the most accessible location? . looked at the proposed facilities and their location in front of progressive privacy (where applicable) and away from staircases and lifts which lead to resident-only areas? . designed the layout of the facilities to be clear and logical with an easy flowing route? . removed all barriers to the communal facilities, encouraging access and use from residents and visitors to the scheme? . provided adequate seating areas in the main foyer? . provided enough disabled toilet provision with adequate lighting provision, washing provision and linked to assistive technology? . maximised the use of natural lighting whilst providing effective natural ventilation? . allowed for areas adequately/innovatively designed to meet the needs of the activity to be carried out in the area? . allowed for adequate storage facilities? . provided for a discrete ‘back entrance’ provision within the building on the ground floor, to provide dignity and privacy to those being taken from the building by ambulance or by undertaker?

7.8 Restaurant/café areas

Restaurant areas are located within the main foyer of the scheme to enable easy access for both residents and visitors to the scheme. The restaurant size should be adequate to cater for residents, staff and visitors and also provide an adequate kitchen area, changing area and office provision. The kitchen will require effective ventilation to maintain a comfortable 38

and safe working area for the catering staff.

It may be appropriate, especially on schemes with specialist dementia provision, for a ‘front’ and ‘back’ kitchen to be provided. This will enable residents to take part in food preparation in the ‘front’, more domestic kitchen with professional staff using the ‘back’ full catering kitchen.

The use of CCTV and telecare speech units should be considered (as appropriate) within the restaurant area, to facilitate the safety of residents and catering staff.

The restaurant must provide adequate turning points for people using wheelchairs and walking sticks/Zimmer frames around the restaurant’s furnishings.

Where space is available the restaurant should be clearly linked to an outside patio space to enable the restaurant to be extended outside in warmer weather encouraging ‘al fresco’ dining. Provision of a barbecue area can be advantageous to encourage social events. Access doors should not be identified as ‘fire exit’ doors as this may discourage people from venturing outside. It may be appropriate to have two areas; a full restaurant and a more intimate bistro or café.

The main kitchen should be lockable with access limited to authorised staff only.

CHECKLIST – Have you:  . located the restaurant in the best location for the building and its residents? . provided for adequate office space, kitchen space, storage, WC and changing facilities? . provided adequate natural ventilation with secondary ventilation during warmer months in the kitchen area? . considered how the restaurant area can be maximised by linking it to external spaces? . provided adequate turning spaces and walking areas for people with a disability? . provided locks to the kitchen, office, changing areas?

7.9 Lounge areas

Lounge areas use a large amount of space and consideration should be given to the location of the lounge to maximise use by residents. Such areas can often be found behind progressive privacy to ensure that residents have their own specific lounge area. Lounges accommodate a range of activities, each of which generates equipment and artefacts that need to be kept available for use, this may include television, CD player, games, books, Wii game. The ceiling and the light fittings should be domestic and homely.

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Popplewell Springs, Tadcaster

All items represent activities that people living in extra care accommodation can enjoy but adequate storage or display must be provided to remove clutter which is not helpful for people living with dementia. A design approach which allocates specific zones to different activities with adequate designated storage would produce more legible spaces.

Lounges should contain a focal point of a fireplace that appears as real as possible in terms of flame effect.

Another focal point on a different wall should be a wall-mounted TV that can be used for film screenings, Wii games, social events based on a TV programme such as major sporting events etc.

Lighting should be domestic and coving fitted. Tea bars will ideally be screened or slightly set apart. The lounge, once complete, should look as close to your own lounge at home as possible.

7.10 Circulation

Circulation areas should be adequately designed for people with poor mobility and wheelchair users, avoiding long, dull areas. Circulation spaces should be clear and rational to assist people suffering from cognitive impairment. It is also useful to break down the building into identifiable zones and the provision of visual clues (through pictures, statuary and graphics). Windows should reveal orientating external views and landmarks to help people to feel in contact with the natural world and part of a community in addition to providing reference views to the outside. Signage will greatly assist way finding, however a consistent approach to signage and display of notices should be adopted to prevent them from becoming overwhelming and creating an ‘institutional’ appearance. Spaces should clearly convey their purpose with routes designed to support way-finding using graduated spatial hierarchies from public to private space. 40

CHECKLIST – Have you:  . planned the location of your lounge(s) to gain maximum use for residents? . considered the potential use of the spaces and designed them with those activities in mind? . provided adequate TV sockets and electrical sockets in sensible locations? . considered the layout of the room to provide for furnishing and ensure a comfortable rather than institutional layout of furnishing? . provided adequate storage provision either integral or within a furnishing budget?

Providing a place to sit and enjoy a view at the end of corridors can avoid the sense of frustration suffered by residents with short-term memory loss who might wander to the end of corridors. Many extra care buildings have corridors leading to private apartments that are similar in appearance and the design challenge is to make them distinct from each other. Colour coding is often used to distinguish different zones, but it is not as effective as glazed openings with views to significant external features, which also convey information about seasonal variation.

CHECKLIST – Have you:  . avoided long corridors which can feel institutional and affect accessibility? . avoided using mirrors in circulation areas? . maximised the use of natural light? . created clear circulation patterns for orientation? . provided the ability to see outside at regular points to aid orientation? . provided regular seating areas, rest stops (if agreeable with Fire Officer)? . designed ends of corridors to avoid dead ends which can be frustrating for people living with dementia? . ensured that corridor widths are a minimum of 1800mm wide to allow for wheelchairs to pass? . designed corridors as a social space linking the apartments rather than just as a means to access accommodation? . used different colour pallets to identify different floors or clusters of apartments? . provided artwork and features such as statuary at key access points and changes in direction to aid orientation? . provided handrails which turn into the walls at the end of corridors? . provided level thresholds? . provided a shelf at the front door to enable the area to be personalised? . designed-in a 30% tonal contrast between the wall and the floor? . avoided bands or border strips of colour on floor surfaces so as not to suggest a barrier or step?

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. provided circulation areas internally to avoid residents having to go outside to gain access to central facilities? . provided hold-open devices on fire doors which are linked to the fire alarm system which are recessed flush to reduce snagging points? . provided for a 300mm space which is required to the leading edge of all doors to facilitate ease of use by wheelchair users, in accordance with Approved Document Part M? . ensured that cupboard doors and doors to non-resident areas are painted in with the wall colour so they are visually lost within the wall (if appropriate for the client group)? This will reduce confusion and frustration amongst people living with dementia? . considered using colour and personalisation to enable people to identify with their own front door? . avoided the use of a monotonous succession of doors along the corridor? . provided vision panels in doors on main traffic routes with a minimum visible zone between 900mm and 1500mm above floor level?

Residents must be able to move freely around the building without needing to carry key fobs or remember codes as this can create an institutional environment. People need to feel that they are entitled to use a space. This has important implications for the design of communal areas. If people do not feel a sense of ownership of a space they will tend to avoid it, or behave in a passive way within it. Design strategies can help to counteract disengagement, for example people are more likely to access facilities that are presented as part of a flowing route. Closed doors onto rooms tend to be avoided by people as do unlit rooms and managers should ensure that the first member of staff on duty each day takes responsibility for switching on lights in all rooms first thing. Open plan areas are used, partly for social reasons where people will sit to give them more of a chance to socialise, particularly if in an area where people are walking through.

7.11 Stairs and protection from falling

Stairs and ramps are to be guarded to protect people from falling by means of an 1100mm high guard at landings and a 900mm high guard on flights. Where possible the stairs should be designed to avoid a straight flight in order to avoid falls. The balustrades should be solid but glazed to mitigate the need for an open stair well and avoiding possible trapping of limbs etc. Stair nosings should be coloured in yellow.

7.12 Acoustics

Acoustics must be considered by separating noisy rooms from residents’ living, sitting and sleeping areas. If layout permits, try to ensure that the living rooms of two adjoining apartments are next to each other and bedrooms of adjoining apartments are next to each other. Hearing assistance systems should be made available in the main public area for residents with impaired hearing. The reverberation time of large spaces needs to be controlled in accordance with relevant guidance to improve intelligibility.

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7.13 Emergency call system and CCTV

Emergency Call

The type of system to be installed must be considered to reflect how the residents can maintain independence with an appropriate level of assistance without intrusion on their rights. Dispersed systems of telecare and telehealth assistive technology should be provided enabling peripheral technology to be added as a resident’s needs change. A telecare overlay allows the implementation and use of telecare sensors, combined with communications technology and tailored support, it helps to manage the risks associated with independent living including, falls, gas leaks and fire. It enables care staff to receive alarm calls from a variety of identifiable telecare sensors. Alarm calls received by the Contact Centre off site can provide details of the sensor type and location. The telecare system must provide the ability to configure telecare on a per-resident basis enabling telecare to be utilised to provide tailored care services.

It is North Yorkshire County Council’s preference that pull cords are not generally fitted in all rooms in an apartment. Each resident should be offered a pendant and/or wristband (they should be given the choice) with the main speech module located in the apartment’s hallway and a pull cord fitted in the bathroom between the shower and the toilet (which is where the majority of calls are generated from). It would be useful to have the pull cord fitting above the bed in the main bedroom so that a cord can be attached if a resident is bed-bound due to illness. The cord should be supplied to the Scheme Manager so it can be fitted as required.

Telecare – Standard Specification for Extra Care Housing Schemes

The system requirements for Telecare solutions within an extra care housing scheme should:-

. Provide a system programmer situated in the care staff facility to enable 24hrs access for programming . Provide a Palm Pilot with BlueTooth access . Be able to support the use of up to 16 handsets, where the scheme is over 40 units, fewer handsets may be required if the scheme is smaller. The basic system usually accommodates up to 6 handsets . Incorporate a Wanderguard system on all external doors as part of the overlay system. (Fire doors are usually alarmed independently of this system) . Be capable of incorporating a zoning feature, which will identify specific areas of the building, should an alarm be raised and the caller is not in their apartment . Pull cords in apartments are only required in the bathroom however a speech module will be included in the hall way. In addition a pull cord connector should be installed in the main bedroom to allow for the fitting of a pull cord if necessary. . Choice should be given to people regarding the availability and use of a pendant or Minuet Watch . Have sufficient relays to ensure there is signal coverage throughout the building and not have any ‘black spots‘ . Have a proportionate number of pager units, for staff with hearing impairments, as well as the usual handsets . Incorporate handsets that have the facility to make emergency calls . Have the ability to utilise as many ‘add on ‘sensors as possible – this will ensure that people have a wide choice of support options available to them . Be consistent with equipment widely used in the community 43

. North Yorkshire County Council supports the use of Tunstall systems as they are compatible with current technology and the standard stock of equipment held by NYCC. . If an alternative overlay system is installed NYCC will provide an equivalent monitory contribution for the purchase of telecare add-on equipment equivalent to the cost of providing Tunstall equipment, however NYCC telecare co-ordinator support may be reduced with this option . It will be expected that the provider will manage the installation and on-going management and maintenance of the add-on equipment if alternative overlay options are provided.

Apartments within an extra care housing scheme will have as standard:-

. A speech module . A pendant or wristband available for each resident . Flood Detectors (to be provided by NYCC inc battery replacements) . NYCC will be responsible for the replacements of batteries in all of its sensors

Where extra care schemes are offering specialist dementia care services the following telecare equipment should be considered:-

. Temperature Detector . Magi-plugs . Bed sensor and light . Property exit sensors . Universal sensor . Carer extend button . Just checking system . Tracking sensors worn as wristwatches or jewellery which are linked to satellite tracking systems . Digital display clocks . Digital display calendars . Telehealth equipment . The apartment door should unlock, open and close – both when entering and exiting – using a badge that the resident will wear so that there is no need for keys or fobs but so that the apartment is secure whether or not the resident is in the apartment.

Example of Tunstall Telecare installation

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CCTV

CCTV should cover the full curtilage of the building and will be recorded preferably on a 21- day arrangement within the Scheme Manager’s office. The CCTV monitor must be in an easy-to view position within the office and provide easy reach to the recording system. A second monitor should be provided to enable monitoring during out of hours by the care team, in an easily accessible location.

CHECKLIST – Have you:  . considered the design of staircases to reduce the risk of falls? . considered your acoustics and areas in which they need to be managed? . provided for hearing loop facilities? . provided a telecare overlay which links in with the care team and contact centre? (As appropriate) . provided efficient CCTV and recording facilities which adequately promote safety within the building, providing easy-access to visual monitors and the recording unit? . undertaken a safety check of the designed building to ensure that CCTV and assistive technology is in place as required?

7.14 Lifts

Lifts should be located adjacent to central facilities and have a clear ‘waiting’ space in front of them. If the lifts are intended to be used for evacuation they will require hold open devices.

Sizing of lifts must be in relation to the transportation of wheelchair users and stretchers. Mirrors should not be provided in lifts as these can cause confusion to people living with dementia. Each lift’s interior should be a different colour to assist people to recognise the one that suits them most for the location of their apartment.

Two lifts must be provided in case of breakdown with one wheelchair lift whilst the other needs to be at least a stretcher lift.

Through-and-through lifts should be avoided if possible as these can be very confusing to people living with dementia.

A pull-down seat should be included as well as emergency call buttons in the main control panel and at floor level.

Floor identification – both visual and verbal – should be clear and consistent, especially where there may be an upper and lower ground floor and there must be clear labelling.

CHECKLIST – Have you:  . agreed the number of lifts your building requires? . considered how lift breakdown will be managed and future-proofed this arrangement? 45

. ensured that one lift is large enough to transport stretchers and to meet hospital and undertaker requirements? . made sure that the lift manufacturer’s design does not include mirrored interiors or shiny floor surfaces? . ensured that the lift has a verbal system which advises the passenger of their location/doors opening/doors closing etc? . considered how easy the lift is to operate and how clear the signage/button/verbal systems are within the lift casing?

7.15 Treatment rooms and assisted bathing

Wash hand basins are to be provided in all clinical areas, OT rooms and medical rooms. In clinical and hazardous areas wash hand basins should be stainless steel with wall-mounted lever mixer taps to avoid cross-contamination. Hand rinse basins will not be fitted with a plug or chain-stay hole to avoid sitting water.

Soap dispensers and paper towel dispensers should be provided at each washing facility. Large paper sheet dispensers should be provided in treatment areas. They should be of a nice but practical design so as to avoid looking clinical.

A suitable assisted bath must be fitted which provides thermostatic and computer-controlled filling systems to prevent scalding. A separate WC and changing area must be provided to respect the privacy and dignity of the individual. The changing area should have door hooks and shelving/storage so the resident can safely store their clothing, shoes and other items whilst they are bathing.

The assisted bathroom and treatment rooms should be decorated in such a way to promote a ‘spa’ appearance rather than a clinical appearance. The use of plants and domestic furnishing can give these areas a comfortable and relaxing feel. Ideally there will be an external window in the assisted bathing room, domestic rather than clinical lighting, carpeting in dry areas, coving and skirting boards. The colour schemes should be ‘warm’ and vibrant. The lighting should have dimmer switch control.

The use of the treatment room must be carefully considered. It is likely to provide opportunities for external practitioners to visit to provide services such as:-

. chiropody/podiatry . beauty/massage . optical . flu jabs . bandages/dressings . complimentary therapies

A therapy chair must be provided which easily converts from a treatment chair into a strong and stable couch allowing transition from a seated to a lying position. Such an item would usually provide an electronic lift and power-assisted section. To enhance this area for relaxation, a dimmer light option should be available as well as shelving with candles, coat hooks and storage for clothing and shoes etc.

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CHECKLIST – Have you:  . confirmed which treatment/health areas the scheme will provide? . considered the uses of the rooms and designed them to accommodate those uses? . provided for changing, WC provision to respect the privacy of the individual? . provided for clinical waste disposal as required? . provided soap and towel dispensers as required? . provided storage areas for cleaning equipment, medical provisions, towels etc? . considered the cost of the equipment that will need to be supplied within the rooms to make them fit for purpose?

7.16 Staff laundry

A staff laundry will be required with a sluice facility so that staff can manage heavily soiled linen. It will need to be ventilated appropriately and a sink and drainer should be provided too.

7.16 Hair and beauty salon

This can often be one of the most successful services in an extra care scheme, often well used by the local community as well as residents.

It should look like a commercial salon and include a seated waiting area. The better set out and furnished the room is, the more services can be offered within it and the more successful it is likely to be.

The essential elements should include comfortable, easy to move seating at a mirrored station with put-down space for equipment and waist-level sockets; two hair wash basins one front- and one back-wash and the back-wash must be height- and angle-adjustable to make it more comfortable for people and so that people who have had a stroke in the past don’t have undue pressure put on the back of their necks.

Other equipment could be a nail bar; hairdresser’s trolley; capes etc. A hairdresser will usually provide their own small equipment.

Good ventilation and lighting should be provided and as much natural daylight as possible. A strong, vibrant colour scheme usually works better in this area.

7.17 Bariatric care

Consideration should be given to the level of care and need that the facilities and accommodation can offer and be designed to meet.

Any units designated for Bariatric Care (care of residents over 26 stone) if included will need to be located on the ground floor. These require wider door-sets to accommodate larger specialist equipment, wheelchairs, shower chairs etc.

The bedroom and bathroom should have the ability to provide a heavy duty XY ceiling track hoist fitted that will lift up to 45 stone. The bathroom, if furnished, will need to accommodate 47

larger residents.

CHECKLIST – Have you:  . considered the need to design for bariatric care in your building? . if it is to be designed in, have you provided this on the ground floor? . have you provided for reinforced ceilings and floors to take heavy-duty hoists? . have you considered the type of bathroom furnishing you will require to accommodate the resident and considered reinforced flooring on well- used areas? . have you designed wider doorways and spaces to accommodate larger wheelchairs in both the apartments and communal spaces?

7.18 Guest suite

A comfortable and welcoming suite must be made available for visiting guests. Twin beds with space for a wardrobe, bedside tables and easy chair. Rather than having a run of kitchen units in the bedroom, the ability to make drinks should be based on a motel model ie an integrated small fridge and hot drink making facilities on a tray. An aerial socket must be provided for TV provision, as well as providing a TV. The guest suite will provide a bath with separate shower, wash hand basin and toilet. It will follow similar principles to those outlined later for ‘Bathrooms’.

Guest Suite at Deansfield Court , Norton

CHECKLIST – Have you:  . provided a room of adequate size for a guest room? . considered the amenities to be provided in the room ie hospitality tray/shower/bath? . provided enough space for twin beds and furnishings?

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. provided aerial socket and sufficient twin electric sockets and are they located in the most appropriate place?

7.19 Meet and greet

Regardless of where residents choose to meet and greet their visitors, the environment should be welcoming and pleasant. The following must be considered:-

CHECKLIST – Have you provided outside of the home?  . space to park a vehicle or store a bicycle? . space to store a mobility scooter with charging point? . space to store a buggy, wheelchair, pram or pushchair? . communal decoration which is easily cleaned, easy to maintain but welcoming? . space for visitors in a wheelchair, or with a support frame to gain access to rooms and facilities?

CHECKLIST – Have you provided in the home?  . adequate room to enter into the home, put down bags and take off and hang up coats and outside shoes? . space to greet visitors? . easy access to bathroom facilities from the front entrance? . circulation spaces which are adaptable to meet the changing needs of residents?

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SECTION 8: SPACE INSIDE THE HOME

8.1 Apartment/living space

A resident must be able to express their own personality and lifestyle within their own home regardless of their diverse requirements. They must have the opportunity to choose their home and be proud of where they live, taking ownership in their home and the surrounding neighbourhood.

Every design for new supported accommodation must focus on the quality of the spaces created, establishing the sense that this is a pleasurable place to live in, which will adapt to, rather than constrain the changing needs of a household.

Rivendale, Northallerton

Residents’ needs and aspirations may vary according to tenure mix, culture and household mix, property size, location and adaptation due to disability.

The colour scheme in apartments should be fairly neutral so that a ‘green’ or ‘terracotta’ apartment is not imposed on someone who may dislike that colour scheme. The resident will make the apartment their own with their furnishings and floor coverings and, of course, they will be able to decorate if they wish to.

As a baseline we want to ensure that people receive in their home a sense of safety; good natural light; warm comfortable rooms; space to manoeuvre comfortably; adequate storage and a pleasant outlook, for instance no apartment windows should overlook a flat roof. A well-designed home should meet the physical and social needs of all residents and be receptive to the needs of specific vulnerable residents.

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Design for wheelchair users should be provided throughout the apartment and certain areas such as the kitchen can be designed to permit adaptation for people to use as their needs develop.

The apartment must be designed to take into account that people’s care needs may change, yet they must have the ability to remain in their apartment for as long as they wish, this includes the provision of palliative and end of life care which may be required and therefore it’s vital that all ceilings will support the provision of a ceiling track hoist.

Good natural lighting should be maximised in the apartment. Low light levels reduce the ability to read, lip-read and increase the risks of falls and is not suitable for people with visual impairment. Low energy lighting is usually being fitted in apartments but post-completion design reviews have often identified residents’ concerns about the poor lighting quality provided by such fittings. Also, the placement of pendant lights in the hallway needs careful consideration to ensure that the front door doesn’t knock the light once a shade is fitted. We want to create an environment where people can socialise and know their neighbours; feel proud to invite friends and family to their home; have access to social activities; transport; health and wellbeing facilities regardless of their tenure, income group or culture.

All door furniture should be chrome and of a nice, domestic design, not institutional but still to meet the needs of people who may have difficulty operating locks etc. The door handle should be reversed so that the lock sits above the handle so people can see and operate it more easily. A fish-eye spy hole should be centrally fitted so that people of all heights including those in wheelchairs can see who is at their door and there will be no need to fit a range of spy holes at different heights. A collapsible post basket should be fitted to the letterbox so people don’t have to bend down to pick up their post.

All door furniture, including the doorbell should be chrome so as to stand out against the background. A portable doorbell should be fitted so that a resident can take it with them to the communal facilities and still give access to a visitor at the main entrance.

Where a patio door is fitted, a window should also be present so that people can ventilate their lounge without having to have a door open. People often like to have vertical blinds fitted to a patio door and so the sill should be high enough to accommodate the fitting of the blind and still allow the doors to open when the blinds are open.

CHECKLIST – Have you:  . provided a property which someone can make into their own home?

. provided a home which will adapt to, rather than constrain the changing needs of the household? . considered the needs of the people who will be living in the building eg religious / cultural / disability requirements and fed this into the design? . ensured the living area provides a safe, comfortable space, maximising natural light, providing manoeuvrability, adequate storage and a pleasant outlook? . considered the needs of people using a wheelchair when designing the accommodation? designed the living space to consider the potential that care needs may change, yet the person needs to be able to maintain living in this accommodation? 51

. ensured natural lighting has been maximised considering those with visual impairment? . ensured the whole environment promotes opportunities to socialise; enable people to feel proud to live in it and to welcome their friends and families into it?

8.2 Bedrooms

A bedroom must provide for sleep and relaxation with safe movement and adequate space for storage. Where appropriate the bathroom should be linked directly to the bedroom to enable quick and easy access for those with poor mobility. Windows should be as large as possible to maximise the amount of natural daylight coming into the room. Windows must be easily accessible and easy to open giving consideration to people with mobility, disability and dexterity problems but secure to enable people to sleep with windows open if they wish. Ventilation must be achieved while maintaining home security/safety.

Main bedroom, Rivendale

CHECKLIST – Have you:  . provided adequate storage; a comfortable and relaxing space with safe movement? . have you linked the bathroom ‘en suite’? . provided easy access windows, which are safe and secure as well as providing adequate and easy ventilation? . ensured that accommodation is noise insulated to minimise noise from neighbours? . provided double glazing? . provided reinforced ceilings to enable hoist fixing if required? . considered those with dexterity problems when providing built in blinds, and made sure they are easy to reach from a wheelchair?

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8.3 Bathrooms/En-suite facilities

The preferred option is for a level access shower or, where space allows, a wet room, with toilet facilities connected directly to the bedroom and accessible from the hallway. There should be plenty of space to allow the easy manoeuvring of a wheelchair and the design should allow for later adaptation and/or the inclusion of additional supports and aids. The shower should be level-threshold and thermostatically controlled. The wash hand basin should be generously proportioned to improve accessibility and help minimise water spillage. The toilet should be positioned to allow easy lateral transfer from a wheelchair.

The wall tiles and slip resistant vinyl flooring should be a good colour contrast to the white sanitary wear. There should be a mirror with a light over a basin which has put-down space on or around it and that accommodates a wheelchair user or someone sitting at the sink rather than standing. There should be a free standing revolving shower chair provided, rather than a fixed pull down seat and there should be ample built in shelving, cupboard space, clothe hooks and towel rails provided.

Grab rails should not be fitted as standard but should be provided for each wet room and then fitted if the ingoing resident wishes them to be fitted. There are grab rails available which can be moved so that their position is right for each resident who lives in the apartment. They use a very strong suction method and this is our preferred option as it allows rails to be moved without damaging tiles.

The extractor fan should not be connected to the light switch but instead be activated by movement or humidity; this will allow the residents the option of leaving the light on through the night without being disturbed by a noisy extractor.

All piping should be boxed in.

Bathroom at Plaxton Court, Scarborough

A normal height toilet should be fitted. Some schemes have previously fitted higher models but subsequently removed them due to high numbers of complaints and Health and Safety concerns. Additional lighting should be placed over the toilet area.

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CHECKLIST – Have you designed a bathroom which will have:  . at least a level access walk-in shower with shower curtain (preferably coloured to tone in with the décor, not white which is clinical) and the facility to move the shower head lower on the wall for those using bath seats? . a domestic bath and walk-in shower provision with shower curtain? . combined shower head rails with a grab rail to avoid residents pulling the shower rails off the wall in the event of losing their balance? . easily operated shower controls? . thermostatic control button on the shower control? . normal toilet with normal toilet seat, economy flushing system and support rails as appropriate? . accessible wash hand basin, which can be reached at wheelchair height and has ‘put down space’ around it? . a mirror which can be used by either someone standing or someone in a wheelchair? . grab rails fitted to suit the needs of the current occupant and, ideally, which can be moved with ease? . taps with lever handles? . non-slip flooring? . towel rail with thermostatic control (if provided)? . thermostatically controlled heating? . ease of access on the approach to the bathroom? . outward opening doors which allow access by the care team, should a resident fall against it? . a simple lock which can be released from outside in an emergency? . an extractor fan which is switched on and off by person activated or humidity sensor? . been designed to building regulations part M and BS 8300:2001. This provides configurations for wheelchair access to toilets and to showers? . lighting which will immediately activate upon access into the bathroom and gradually reduce illumination when the resident leaves the room? . installed two light fittings to ensure one light is operating should a bulb fail? . a light directly above the toilet? . minimised splash-back from the shower area onto other bathroom fittings? . adequate drainage to make sure that water does not pool or leak into other living areas?

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8.4 Cooking and eating

Allow space for kitchen/dining table and chairs for the household and their visitors.

Hobs should be ceramic so that pans don’t ‘drop off’ a raised electric plate. Ovens should side open onto a worktop and be at high level.

Pelmet lighting should be fitted as well as directional spot lighting to the ceiling, rather than a very old-fashioned strip or fluorescent tube.

There should be a space for a washer/dryer as North Yorkshire County Council does not support communal laundry provision. Although it is acknowledge that a communal laundry can provide a space for social inclusion, many people prefer to have their own machine and experience tells us that, if a machine is in the apartment, people can often manage their laundry themselves, or their family do it whilst visiting or they can do it with a little support from care staff. Where they are expected to use a communal laundry, this is often impossible for many residents and therefore reduces their independence and increases their care plan.

Flooring must be non-slip. Tiling should be coloured (not white with a contrasting strip). Worktops should provide a contrast to the cupboards. A cooker hood should be fitted rather than a fan.

The kitchen often backs onto a shared corridor and some schemes have windows fitted. North Yorkshire County Council’s does not support the provision of these windows as they are costly to provide and we would rather the money be spent on other items that bring more value and because they can be intrusive and sometimes used for ‘soft monitoring’. If a provider is insistent on fitting them, we would hope that integral venetian blinds would be fitted so the resident can choose to close them. If provided, opposing windows on a corridor should be offset so people can’t see into the opposite apartment.

For ease of access and for carrying plates, drinks or trays from the kitchen, it is not advisable to have a door fitted on the kitchen, however, feedback from residents on existing schemes is that they prefer the kitchen area to be delineated from the lounge, ie walls at each side that hide the end of cupboards and the fridge/freezer.

A lockable cupboard for the storage of medication should be included.

CHECKLIST – Have you:  . provided adequate and comfortable space for seating and dining? . provided good working surfaces and plenty of space for preparing food? . Ensured that there are no unnecessary spaces or gaps between floor units? . maximised storage space while making sure that the wall units and base units are practical for frail and disabled people? . provided a lockable cupboard within easy reach for storage of medicines? . provided excellent ventilation in the kitchen area to eliminate cooking odours from moving into the living area of the home? . provided white goods with excellent efficiency ratings?

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. integrated the electric oven into the cupboards at a height easily accessed without having to bend down to lift food (taking into account frail/elderly/ disabled residents)? . provided snag-free cupboard handles? . provided a contrast between the workbench/the units and the flooring? . good lighting, especially if natural lighting is not available? . electric hob with controls to the front to stop people from reaching over and burning themselves? . provided a ceramic hob to prevent pans from being off balance on raised plates? . provided an isolation switch to enable the hob to be isolated if appropriate? . provided a washer dryer and/or dishwasher and provided a flood detector linked to assistive technology? . provided a window if there’s an external wall? If so, is it easy to reach and open without having to stretch across benches or reach up?

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SECTION 9: LIVING, PLAYING, WORKING AND STUDYING

A home must provide different areas to fulfil different needs of those living there – the ability to have a computer set up, a sewing machine, bookshelves etc. Some residents prefer two bedrooms although a single occupant may not use the second room as a bedroom but choose to set it up as a dining room or for crafts etc.

Floor coverings should be provided to all rooms including carpeting to lounge, hallway and bedrooms.

Residents must be able to control the temperature in each room and thermostats should be easy to read and operate.

All ceilings must have the capacity for a ceiling track hoist to be fitted if required.

None of the room doors should operate on a sliding mechanism as this is often difficult to operate for people with a disability or those who are frail.

Door handles must be easy to grasp and operate.

The front door must be linked to the fire system but should also be power assisted so it is not too heavy for a resident to open.

Underfloor heating is preferred as it negates the need for radiators which take up valuable wall space. Advice must be given to residents in case they choose to replace flooring, so as to ensure the heating system is not damaged.

Residents should be able to tune their TV to a channel that enables them to view who is at the scheme’s main entrance seeking to visit them. This is a valuable service to people with hearing difficulties and reassures them about who may be coming into the building.

Pets

The value that contact with animals and the ability to remain a pet owner is widely recognised. Good housing management policies ensure pet ownership can be maintained in extra care housing without unmanageable problems. NYCC expects that providers will operate a positive pet ownership policy that welcomes and encourages residents to maintain this important part of their lives.

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Esk Moors Lodge, Castleton

CHECKLIST – Have you:  . provided individual rooms and spaces with areas that can accommodate different furniture layouts? . provided adequate storage areas? . located service provisions eg TV aerial; satellite in a location which is logical, taking into account furniture layout? . provided key digital connections, such as telephone points, TV and broadband in accessible locations with telephone point provided in sitting room and both bedrooms?

Evidence shows that a second bedroom is a high priority for a number of residents. A third habitable room in housing for older people is now an HCA expectation.

Second bedroom provision at Meadowfields, Thirsk 58

, WORKING AND UDYING

SECTION 10: DESIGNING FOR DEMENTIA

Fundamental dementia design guidance includes the following recommendations, which have been addressed in the overall design guide (in particular within the section covering Extra Care Accommodation):-

. observing a domestic scale . creating a homely environment for residents . using familiar materials, textures and colours

It can be common for people living with dementia to also suffer serious sight loss or impairment and it is important that the interior design of extra care schemes is sensitive to the very particular problems faced by people with both conditions. The loss or serious impairment of sight can be devastating for people and, coupled with a diagnosis of dementia can have a hugely negative impact on people’s emotional wellbeing. Assisting people as much as possible by sympathetic and effective design can go a long way to enabling people to adjust better to their symptoms and thereby reduce the possibility or extent of depression.

Some people living with dementia may experience hallucinations, even those with sight loss/impairment. For this reason, it is important that consideration is given to patterns and pictures so that misleading messages do not trigger an hallucination. For example, pictures of skeletal trees or faces, some animals etc could give an impression of terror to a person with dementia who is subject to hallucinations and should be avoided. Great thought should be given to the selection of pictures and statuary to ensure they do not result in any confusing or frightening messages.

Colour change as a means of way finding is an established method within extra care housing but should be used only as a basic method; some people may be colour-blind or not respond to colour as a trigger for mapping their way around the scheme so, for instance, using the same picture outside the lift on each floor but changing the colour may not be enough for some people. Definite articles should be used instead such as placing a large pot Dalmation dog outside say the assisted bathing room, having an artificial red rose plant on the way to the dining room, placing a console table with lamp outside the lounge etc etc. People are more likely to recognise furniture and articles than colours and pictures. Digital picture frames that have pictures that can change with the seasons or other relevant pictures are useful prompts for residents.

There may be a reduced capacity for some people with dementia to be able to judge risk or foresee danger; forgetfulness is another issue which could lead to danger in some areas. It is common for people with dementia to get lost trying to find their way around a building. This reflects a person forgetting such basic information as the location of one room in relation to another. If numerous visual cues or reminders are incorporated in the design, these can help by acting as way finders and make the situation less stressful and confusing for those residents and hopefully reduce the evidence of challenging behaviours that could lead to other residents being unsettled.

Providing well-lit, inviting entrances to rooms, natural lighting, changes in floor and wall textures, colours, identifiable architectural features, recognisable and distinctive individual room designs help to compensate for residents’ sensory and memory losses. It must also 59

be considered that a number of people living with dementia may have other sensory disabilities; therefore, hearing and sight loss may be prevalent along with the cognitive impairment.

Clear glazed screens to communal areas will permit residents to understand the use of a room without resorting to signage. Staff must ensure that lights are on first thing each day to encourage people to enter rooms and spaces.

Clear and uncomplicated circulation routes are easier to interpret and reduce the possibility of residents getting lost and frustrated. Avoid dead end corridors and stairs with blind turnings.

There is a need for residents to personalise their own space. A shelf next to each front door can provide a space for a photo, picture or item which enables people to know they are home.

Artists impression one bed open plan Open Plan apartments suitable for people living with dementia specialist apartment dementia at Limestone View, Settle

CHECKLIST – Have you:  . taken into account the guidance already covered for extra care within this design guide? . considered the client group in your design removing features which could cause confusion or risk? . considered the accommodation types required ie one or two bedroom apartments and external bungalows? . considered that people may move into this accommodation with their spouse carer who may not suffer from dementia? . provided very clear routes, with no dead ends, use of windows and/or statuary for land-marking and identifiable features? . designed out borders on floors, across entrances to facilities and minimised shadow casting to avoid ‘false’ barriers being created? . designed the building and garden areas to be easily accessed and aid those who wander, while providing secured access at the garden boundary? . designed a building with gardens which ensures that an individual’s dignity and rights of privacy are maximised? 60

. provided visual clues and reminders within the overall design of the scheme? . maximised natural daylight and ensured that all areas of the building are well lit? . considered the potential that residents may have hearing and/or sight loss and factored this into the design? . provided clear glazed screens in communal areas and within apartments as appropriate to enable residents to find their way easily around the building and minimising frustration? . maximised the use of colours, contrasts and textures within the designs to stimulate and engage the residents? . provided areas specifically to stimulate and engage residents in activities including therapy areas which provide aromatherapy and massage, sensory rooms, texture walls and pictures to encourage touch and recognition? . provided reminiscence features eg pictures and boards? . considered dignity features within fixtures and fittings ie vivid colours can aid visually including toilet seats; handrails; door furniture? . provided dementia signage to support people to navigate their way around their apartment and the building? . considered the internal design and ensured that no high-gloss or mirrored surfaces are designed into the scheme? . provided a restaurant/café area which is warm, colourful and inviting, which encourages people to eat, is safe, respects people’s dignity, provides for the needs of the residents? . provided dignity crockery to ensure nutrition and hydration features are enhanced?

There is well-researched work going on in extra care schemes around reminiscence projects and music therapy but cognitive rehabilitation techniques such as memory training and cognitive stimulation therapy focus on improving cognition.

Many extra care schemes promote themselves as designed specifically for dementia clients or as being dementia friendly, often this claim can be as a result of one dementia specific design feature such as coloured corridors to aid orientation being introduced into a building designed to meet the needs of older people without cognitive impairments. Where a specially designed dementia scheme is different is that it is designed for people with dementia first and based on the philosophy that good dementia design is good design for all older people.

An example of this is the dementia design principle of ‘form following function’, we know that people living with dementia require a number of external cues in order to process usage of the environments they find themselves in; a restaurant must look and feel like a restaurant for someone living with dementia to recognise it as such. The creation of an internal street which has shops, restaurants, day centres and a pub coming directly off it provides the external cues necessary for residents to recognise very clearly its function and orientate themselves around the space. If it’s possible to copy the local architecture of the town or village in which the scheme is built and copy the design of the street and shop fronts, that will further increase the familiar external cues available.

This attention to evidence-based dementia detail should run through every design/ environmental feature within the building, individuals’ apartments should be designed so that 61

they are fitted with the very latest in terms of assistive technology designed to be integral to a person’s care plan and maintain their independence. Lighting that is activated by a person’s movement and that can direct them to the toilet at night, voice prompts that can orientate them in terms of day and time and bed sensors that can allow sleep monitoring should all be available as standard. Kitchens should have glass fronted cupboards so individuals can see the food contained within, the evidence clearly shows that this design adaption leads to increased food consumption and decreases in malnutrition rates in people living with dementia.

The environment is only one aspect in the delivery of specialist dementia care; an excellent environment must be complemented by an excellent evidence based dementia care system, the two are different sides of the same coin. The care delivered within a scheme needs to provide ‘real’ person centred care, care that utilises the environment in order to maximise the relationship between the carer and the person living with dementia. The scheme provides the perfect foundation to explore the development of new approaches to delivery of dementia care, the health and social care dementia worker, hospital in-reach services and specialist end of life care are a few of these services that could be developed from schemes and for which models exist within other European countries.

Service Delivery

People living with dementia require a high level of dedicated support and meaningful occupation. There are a number of success stories of people moving into specialist extra care housing late on in their condition where design features support them to orientate quickly and where support is tailored to meet their emotional needs as well as their physical needs.

Normal day to day activity should be encouraged and supported and therefore a domestic kitchen should front the full catering kitchen. This would enable residents to be involved in food preparation, table setting and clearing, baking etc if they wish to. Sideboards and dressers should be provided in the restaurant so people recognise where crockery, cutlery etc is kept.

Other facilities should offer similar opportunities to people such as the hair and beauty salon, the shop, community library etc. Being supported to do work in the gardens is also important as this encourages people to exercise and have time in the fresh air.

Accommodation

Where an extra care scheme includes units of accommodation for people living with dementia, they should be designed with the aim of enabling people to move in and settle even where they are well-advanced in their condition.

Current best practice recommends one bed/2 person apartments that provide as a minimum the same rooms, fixtures and fittings as a general extra care apartment. The main difference is that the specialist apartment will be open plan (except the bathroom for privacy and dignity purposes) enabling the resident to see all of their apartment.

The kitchen should be fully equipped as some people living with dementia enjoy cooking or helping to prepare meals. The kitchen should include:-

. at least two glass-fronted units; one base and one wall, with internal lighting 62

. a fridge/freezer or a glass-fronted fridge . one open shelved wall unit . under-pelmet lighting . obvious contrast between worktop/tiles/units/floor . a safety cut-off for oven and hob . all appliances to be white (rather than stainless steel for instance) as white is more easily recognised as kitchen equipment

The bathroom should have mirror fitted over the basin but this should be easily covered or removed in case a resident finds the provision of a mirror distressing.

The toilet should be situated to be seen from the bed thereby enhancing dignity and assisting continence.

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SECTION 11: DESIGNING FOR VISUAL IMPAIRMENT

Consideration must be given to lighting, colour schemes and tonal contrast, casting of shadows, audible signals and tactile information. There should be a contrast between the floor, walls and ceiling so that those with visual impairment can have an increased awareness of spatial dimensions. There should be a contrast between ironmongery, doors, door frames and walls to distinguish these clearly; Part M requirements of the Buildings’ Regulations should be considered.

Avoid shiny surfaces, especially shiny floor surfaces. Non-reflective materials, such as matt wall finish tiles and flooring especially in bathrooms and kitchens, reduce glare. Highly patterned floor and worktop surfaces should be avoided as this makes objects set against them harder to distinguish. Natural materials assist way finding, divide spaces, highlight level changes and help create a warm and less clinical environment. Callers can be recognised – via clear glazing beside the door, a door view, audible caller recognition or door entry system. Letter boxes should be centred within the door with a ‘letter cage’ on the inside.

Example of gated dog run for Guide dog

Where homes share a communal outdoor space, an enclosed and gated dog run, with water and drains, is available for guide dogs to be taken for toileting. A dog run in a private garden conforms to minimum size requirements defined by the Guide Dogs’ Association and adheres to good practice defined by them. Floor covering, such as laminate or hardwood flooring can be problematic for dogs who will slip on such flooring. If a building is to be provided for people with visual impairment, then non-slip flooring should be considered in all areas, to support guide dogs to carry out their working role.

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CHECKLIST – Have you:  . considered lighting requirements, colour schemes and tonal contrast within design, specifically for those people with partial sight? . minimised borders on floors and shadow casting? . maximised audible signs and tactile information? . provided contrasting between ironmongery and doors, door frames and walls, kitchen units and benches, walls and floors? . avoided the use of shiny/glossed surfaces? . provided natural materials to support way finding, enabling the resident to feel their way along corridors and communal spaces? . been careful in the selection and the use of patterns within design? . provided ways in which visitors to the building/individual apartments can be recognised? . provided for the current or future needs of guide dogs ie provided gated dog runs, non slip flooring, play pen area when dog is off duty?

Portland College, Mansfield which won RIBA award

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SECTION 12: DESIGNING FOR OTHER DISABILITIES

12.1 Learning Disability

Design features to assist people with visual impairment are generally useful for people with learning disabilities. See Appendix 2, design guidance for further information.

The Valuing People Now & PSA 16 Housing Delivery Plan (2010-2011) is a cross- government plan led by the Department of Health and Department for Communities and Local Government to help people with learning disabilities exercise more choice and control over where they live. The Valuing People Now Housing Delivery Plan is supported by the Socially Excluded Adults Public Service Agreement (PSA 16 target) that aims to increase the proportion of adults with moderate to severe learning difficulties in settled accommodation.

People with learning disabilities often have little choice and control in many aspects of their lives. Finding somewhere appropriate to live with the right support can be challenging. Providing the right accommodation and service to people will require dynamic leadership and a partnership approach with a shared vision and commitment to change.

At the moment, people with a learning disability live in:-

. 50-55% with their families . 30% in residential care (33,000 in England) . 15% own their own home or have a secure long-term tenancy (compared with 70% of the general population who own and nearly 30% who rent) Source: Valuing People Now DoH 2009

There are too many people with a learning disability living in residential care funding by local authorities. Residential care is often the only choice due to a lack of viable, appropriate alternative in the area and because it is a model that families and carers are familiar with. A cultural shift is required in how social care professionals encourage independence and manage risk. Living in residential care should not be the default option but remain a valid choice, although not the only choice available.

The majority of people with a learning disability live with their families. Again, this is a valid choice for some but not always. Some people live with older carers or families that struggle to cope with no clear plans for the future. Some people with a learning disability get housing and support in a crisis and end up living somewhere they would not ordinarily choose to live.

In recent years, positive developments have enabled some people with a learning disability to have their own tenancies with the support they need to live more independently. There are also positive case studies of older family carers moving into extra care housing with their son or daughter in the second bedroom and having right of succession to the tenancy.

People with a learning disability, including people with the most complex needs, can and do live in a full range of housing options with the right support.

Often, the accommodation will be provided for people with a learning disability who have moved from residential care into supported housing and are most likely experiencing 66

independent living for the first time. The aspiration is to create a responsive building both to its inhabitants and the surrounding area. A successful scheme will support the residents to develop their independent living skills with support from trained staff and therefore enjoy their new home just as you and I do.

An ideal model would provide:-

 1bed independent living flats over 2 storey accommodation  communal and ancillary space to support the day to day running of the scheme  external amenity and garden space

Standards for the design should incorporate:-

 approved Doc M (2006)  BREEAM Multi Residential ‘Very Good’  secured By Design  Housing Corporation – Design Quality Standards (2007)  Lifetime Homes Standards  Wheelchair Housing Design Guide (2006)

The principles behind the accommodation are:-

 good-quality housing is important in enhancing people’s quality of life  residents’ quality of life can be improved further by careful consideration of the residents’ and carers’ specific needs and wishes

It would be important to work with potential residents and their relatives/carers and staff from the start in terms of design, finishes and service delivery.

The interior design and finishing of the scheme would be important for its effectiveness and the finishes would include not only paint colour and carpet types but the use of pictures/text for signposting. Using the principles of ‘Total Communication’ we would require that partners work with us to inform future residents and staff and to provide progress reports that met with their communication needs. This could be using photo symbols, picture bank or other forms. We would discuss and explore the best format for communication with users and include that process in the project programme.

The stated objectives of the 1998 White Paper ‘Modernising Social Services’ were:-

‘to promote the independence of adults assessed as needing social care support arranged by the local authority, respecting their dignity and furthering their social and economic participation, to enable adults assessed as needing social care support to live as safe, full and as normal a life as possible, in their own home wherever feasible’

Key design principles included within the design

Construction Traditional, timber framed as well as modular construction would all be acceptable. However, the walls would need to stand up to the potential need for soundproofing and reinforcing.

Apartment design The front door should be slightly recessed with a milk shelf to the side and a light over the 67

door. As with any home, the door should include a doorbell, letter plate and fish-eye spy- hole fitted centrally. A letter catcher should be fitted to the inside for convenience. The door should be on a closer linked to the fire alarm system and be fitted with assisted opening.

The hallway should provide space for frame/wheelchair/scooter storage and be designed to meet accessibility standards. There would need to be included a cloakroom and additional storage for care equipment and potentially for medical supplies (this to be lockable).

The lounge/dining should apply an ordinary living approach to the living/dining room and include phone and TV points. It should include a fireplace setting even if only ornamental. A bay window would be preferred as a natural place for seating.

The kitchen must be wheelchair accessible with adjustable worktops and sink installed to ground floor apartments. A side opening oven opening onto a worktop allows for access by someone using a wheelchair but also enables easier transit of hot food from oven to worktop. A halogen hob with low profile should be provided to prevent pots and pans being upset on transfer from the hob. Ensuring the controls are legible and easy to read/use is important. They should also be at the front of the hob so people don’t stretch across a hotplate and risk burning themselves or knocking off a pan.

The kitchen will require plumbing for a washer/ tumble dryer. Continence can be an issue for this client group and so there would need to be the facility of a sluice somewhere on the scheme or in the adjoining extra care scheme.

The main bedroom should be built to 2 person standards (ie capable of taking a double bed) with the usual facilities one would expect ie TV reception point, telephone socket and sufficient power sockets. Allowance must be made in the design for placement of a hospital/orthopaedic bed if required. The main bedroom should have en-suite access to a level-access shower room. A wet room with a wash hand basin with put-down space, low- surface temperature towel rail and WC. A standard sized bath should also be fitted. There must also be a door to the hallway which can be locked if required.

There must be the inclusion of a hoist-bearing structure within the ceiling and associated electrical supply for the potential to provide a retrofitted hoist if required between the bed and the en-suite. A ‘knock through’ panel would allow access via hoist from the bed to the bathroom at little cost but also keeping the impact of the equipment to a lesser extent than otherwise.

The second bedroom could be used by carers, partners or visitors and should be suitable for a single bed. Alternatively, people in this client group often have hobbies that require storage or would benefit from being in a dedicated room and bedroom two can be used for these purposes as a dedicated room which enables people to leave their equipment or craft materials out thereby helping to encourage continuation of their hobby.

Communal and ancillary accommodation

 there should be a lobby and entrance area which includes an office and reception to provide secure and controlled access to visitors and tenants. Given the ordinary living principle of the accommodation, the design should sensitively reduce the impact of this area whilst leaving it clear in terms of way finding and accessing staff. The access to the lift would be from this lobby and a swipe card or other system access can be restricted to legitimate users

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 a 13 person lift should be included to ensure full accessibility to both floors  foyer-type lounge/residents’ meeting room including chairs, TV point and access onto the garden/patio area

Other key design points

Physical safety  internal doors – these should open outwards so they can be removed if needed. Hinges should either be ‘piano’ hinge or be able to be covered  door locks should be able to be opened by staff if someone becomes locked in from the inside  kitchen fittings should be household in design but with a view to sturdier design  Telecare fitted throughout the scheme with:- a. fire system call through that alerts staff first to avoid alarming residents. This could be configured to turn off cooker electricity and sockets in the kitchen and to unlock doors of apartments (if electronic locks fitted) b. a call alarm system for staff c. if linked to an extra care scheme, the fire system should be linked to that scheme  doors and windows will require a security alarm to prevent intruders on the ground floor  the services to the apartments must be accessible from a locked box accessible off corridor. Staff can therefore isolate the services in a flat if required

Design for living  consideration should be given to both sound proofing and heat gain (ie the lift location and plant room in relation to apartments and adequate sound/heat insulation)  passive venting is preferred where feasible as it is less noisy than mechanical venting  heating should be under floor

Externally The gardens are seen as providing an extension to the main building:-  an external environment that meets Lifetime Homes Lifetime Neighbourhoods aspirations (tactile surfaces that delineate changes in footpath or crossings, reducing the use of low-level street furniture etc)  provision of good-quality garden space including points of interest and sensory elements  including allotments, raised beds and greenhouses/growing frames to encourage participation, team work, engagement and the sense of achievement in growing produce  garden paths at min. 1200 mm width

Finishes Low toxicity paints should be used. This would also include floor finishes and therefore costs should allow for more natural floor coverings and use of low toxicity paints. Many people with a learning disability will tend to have poorer vision so due regard must be given to controls and finishes without losing a homely feel. Ironmongery and fittings need to be easy to use but remain homely rather than institutional.

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12.2 Hearing Impairment

Consideration needs to be given to the provision of hearing loops in all communal spaces as appropriate. Materials that reduce reverberation times are essential, particularly in larger spaces where acoustics can become a problem. Greater ‘visual access’ to a person’s surroundings can help compensate for impaired hearing. Finishes for large spaces with higher ceilings such as lounges and dining rooms should have a high acoustic absorbency to reduce echoes for the benefit of those with hearing impairment.

CHECKLIST – Have you:  . provided adequate hearing loops? . provided materials to reduce reverberation times? . enhanced visual access to compensate for impaired hearing? . provided high acoustic absorbency in communal areas to reduce echoing?

12.3 Mobility

People living in and visiting the scheme may use wheelchairs, walking sticks, Zimmer frames or any combination of these. Space standards should accommodate the use of all of these alongside ensuring level-access throughout with particular attention being given to door sills.

Any reception desk should have an area of dropped counter to enable people using a wheelchair to speak to the staff themselves rather than rely on someone else to do so on their behalf because they can’t see over the desk.

Long corridors should be avoided but resting places incorporated so people can pause on their journey around the scheme. These also serve as informal places for people to sit and chat. Some people may have been quite socially isolated and, whilst they won’t wish to remain in their apartment all the time, they may find visiting a busy communal lounge a step too far and appreciate being able to sit in a quite location nodding to passers-by.

12.4 Long term illnesses/conditions

Designs should accommodate the needs of residents with typical long-term conditions and health aspects associated with stroke, heart disease, cancer, diabetes and obesity.

CHECKLIST – Have you:  . considered within the design, the needs of residents with long-term conditions? . provided adequate treatment areas to provide preventative treatments in addition to providing medical/physiotherapy suites?

As guidance is developed for other vulnerable groups within our communities, the Guide will be updated to reflect those needs in relation to building accommodation to suit identified disabilities.

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SECTION 13: SCHEME EVALUATION

The County Council’s Extra Care Team will undertake a formal review and evaluation of a newly developed extra care scheme. This will take place in partnership with the Registered Provider, staff and residents of the scheme, people who use the scheme and also health care professionals who visit people who live in the scheme.

This process is not just around the evaluation of the individual scheme but it is a tool which will be used to feed into future schemes so that we are always aiming to improve and raise quality and standards.

One tool which will be used is a quiz based card game developed by the Elderly Accommodation Counsel. This provides a more relaxed and informal way of gathering residents’ views and also gives residents the opportunity to attend a social event.

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ACKNOWLEDGEMENTS

The following guidance has been considered when devising this information:-

 Achieving Building for Life, HATC, CABE and HCA  Code for Sustainable Homes, CLG (Communities and Local Government)  Design and Quality Standards – Homes & Communities Agency  Extra Care Housing: Environmental Design to support activity and meaningful engagement for people with dementia – Journal of Care Services Management Vol. 3 no. 3 pp 250-257  HAPPI  Housing Quality Indicators – Homes & Communities Agency  Places, Homes, People, Policy Guidance English Partnership’s Quality Standards, English Partnerships  Planning Policy Statement 1 & 3 CLG  Valuing People Now & PSA 16 Housing Delivery Plan (2010-2011)

Giving consideration to this guidance and to other publications from the Department of Health (DH) and Housing Learning Improvement Network, we have defined the principles, guidance and requirements that enforce a quality framework to encourage a consistent approach towards quality design within all future supported housing schemes.

Gratitude is also extended to Acanthus Architects, Charles Taylor, Dementia Voice, Langtry Langton Architects, North Yorkshire Fire and Rescue Service, SP+A Architects, Sunderland City Council, Tunstall and to the Housing LIN members who provided information and comments which have been drawn into this guide.

Appendix 1: Fire Service Memorandum Appendix 2: Schedule of Accommodation for Extra Care Appendix 3: Design Standards and Guidance Documents

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APPENDIX 1 – FIRE SERVICE MEMORANDUM

MEMORANDUM OF UNDERSTANDING

NORTH YORKSHIRE COUNTY COUNCIL

NORTH YORKSHIRE BUILDING CONTROL PARTNERSHIP

NORTH YORKSHIRE FIRE AND RESCUE AUTHORITY

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CONTENTS

1.0. Introduction.

2.0. Underlying principles.

3.0. North Yorkshire County Council role.

4.0. Building Control Authority role.

5.0. Fire and Rescue Authority role.

6.0. Consultation and joint commitment

7.0. Monitoring and evaluation

8.0. Approval and date of commencement

. Appendix A . Appendix B . Appendix C . Appendix E – a signed copy of the agreement is available

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A signed copy of this agreement is available

MEMORANDUM OF UNDERSTANDING

NORTH YORKSHIRE COUNTY COUNCIL NORTH YORKSHIRE BUILDING CONTROL PARTNERSHIP NORTH YORKSHIRE FIRE AND RESCUE AUTHORITY

1.0. Introduction

1.1. This agreement establishes the principles and describes the joint working understanding between North Yorkshire County Council (NYCC).North Yorkshire Building Control Partnership (the building control authority) and North Yorkshire Fire and Rescue Authority (the fire and rescue authority). The objective is to enable delivery of enhanced fire safety within Extra Care developments through the provision of sprinklers. It is a framework which provides the basis for consistent arrangements when new developments are proposed and also when subsequent fire safety inspections are conducted.

1.2. NYCC, the building control authority and the fire and rescue authority recognise that sprinkler provision within Extra Care Housing schemes would represent a significant step towards enhanced safety and active fire protection within the premises. Both the building control authority and the fire and rescue authority recognise that NYCC do not personally develop Extra Care Housing schemes though they do promote schemes of this type and work with partners who are responsible for their development.

1.3. There are great benefits from sprinkler provision in terms of added security against serious fire development. In turn, client benefits, measured in increased chances of survival in the event of a fire, reduced property damage and negligible service disruption following a fire incident.

1.4. The building control authority and the fire and rescue authority recognise and appreciate that sprinkler provision can provide flexibility against Building Regulation guidance (approved document B or BS 5588-1) at design stage of a building.

1.5. The fire and rescue authority recognise and acknowledge that sprinkler provision, active safety systems can provide benefits in terms of fire safety management when a premises becomes occupied.

1.6. The aim of this service level agreement is to recognise and acknowledge where flexibility can be accepted and broadly, what that translates into when sprinkler provision is provided within an Extra Care Development.

1.7. These collaborative working arrangements, which support the Government’s broader agenda for partnership working, will enable all three authorities to promote fire and certain other safety provisions within a number of premises more effectively or efficiently than would have been possible if they had acted in relative isolation. 2.0. Underlying Principles

2.1. The underlying principles of this protocol are as follows:

 To encourage appropriate standards of building, fire and other safety provisions to be provided and maintained within extra care developments.  To encourage consultation at an early stage of a design proposal.

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 To recognise and appreciate that sprinkler provision can provide flexibility against Building Regulation guidance.To recognise the needs and limitations of NYCC, the building control authority, the fire and rescue authority and to acknowledge that all three authorities will always seek to act in good faith.

3.0. North Yorkshire County Council Role

3.1. To recognise the importance that sprinkler systems, other fire protection equipment and adequate fire risk management can offer to Extra Care Developments. To endeavour to recommend the benefits of such systems, equipment and management to the individual organisations responsible for the development of such schemes on or before the planning stage.

4.0. Building Control Authority Role

4.1. They will advice on and ensure compliance with current guidance contained within the building regulations and associated documentation to ensure that the completed building satisfies the functional requirements of the building regulations.

4.2. They will liaise with the inspecting authority for developments not within the North Yorkshire Building Control Partnerships area (Harrogate and Craven) to ensure that they are fully informed of the proposed development by following the protocol of the LABC Partner Authority Scheme.

4.3. They will engage in formal consultation with the Fire and Rescue Authority in accordance with the building regulations procedural guidance.

5.0. Fire and Rescue Authority Role

5.1. They will engage in formal consultation with the building control authority in accordance with Building regulations procedural guidance.

5.1. The fire and rescue authority will undertake, in line with their risk-based policies, monitoring and inspection of Extra Care Housing premises identified which fall under the scope of the Fire Safety Order.

5.2. They will enforce fire safety standards in accordance with the Fire Safety Order, having regard to relevant documents published by the Government including, Fire Safety Risk Assessment: Sleeping Accommodation (ISBN 1851128175), Approved Document B, Relevant British Standards and in accordance with any guidance jointly agreed with the Local Environmental Services Authority.

6.0. Consultation and Joint Commitment

6.1. Formal consultation between building control and fire and rescue authorities should take place in accordance with the requirements of the Building Regulations 2000 – Procedural Guidance

6.2. Arrangements will be put in place to facilitate the following:

Strategic level consultation

 Formal meetings at strategic management level to monitor the outcomes of the protocol and should meet annually or at the request of any one authority.

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Early consultation

 When a scheme of works for an individual development is being considered NYCC or the building control authority may, if they wish, call a meeting at any time prior to formal procedural consultation. The fire and rescue authority will attend such meetings, if requested, represented by local fire safety officers.

7.0 Monitoring and evaluation

7.1 Any changes to this protocol, other than minor administrative changes, will be subject to approval at strategic level and the signatories to the protocol.

7.2 An annual report will be produced jointly by parties to the protocol.

8.0 Approval and date of commencement

8.1. Nothing in this agreement shall be considered as creating a contractual relationship, a contract of employment or a relationship of principal and agent between the parties and shall not add to in any way the existing statutory duties of the parties. No party to this agreement shall hold itself out as being authorised to enter any contract on behalf of any other party or in any way bind any other party to the performance, variation, release or discharge of any obligation otherwise than in circumstances expressly or implicitly permitted by this agreement.

8.2. The protocol will be approved and endorsed at a suitable strategic management level by NYCC, the building control authority and the fire and rescue authority.

8.3. This service level agreement will commence on the date indicated by the joint signatories.

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Appendix A

Introduction to Extra Care Housing

Extra care housing is a housing solution to a care need. There is no formal Government definition of extra care housing which may also be called very sheltered housing but, in essence, all extra care housing schemes incorporate the following:-  Private apartments for rent or sale for people aged 55 and over  Each apartment has its own front door with letterbox and doorbell and residents have security of tenure  Each extra care housing scheme will have a range of facilities on site such as shop, hair/beauty salon, café/restaurant, lounge, hobbies room, library etc  The building will be staffed 24 hrs/7 days by housing management, care and support staff  Care and support will be delivered to individual residents according to assessed needs and in line with a written and agreed care and support plan  Enable independent living

Private Apartments Each apartment will usually have two bedrooms, a fully fitted kitchen, a lounge and a bathroom with level access shower. Modern heating and insulation standards are high and residents control the temperature levels in each room in their own apartment.

Having their own front door is seen as a key benefit to people who live in extra care housing as it gives them control over who they allow into their home and when they allow them in. It also continues the normality of post, parcels, milk and newspapers being delivered directly to their home. Where people have moved from residential care into extra care housing, they find this aspect of particular benefit.

Each resident will pay rent and a service charge for their flat. Rent is set within the Government’s Rent Restructuring Guidelines and, combined with the larger part of the service charge can be covered wholly or in part by Housing Benefit – subject to each resident’s personal eligibility.

Where only one party in a married couple has a care need, both can move in and, should the spouse with the care need die, the remaining spouse will not move out unless it is their wish to do so. This enables couples to stay together rather than having to be split up as is usually the case in residential care.

Most providers of extra care housing have a pet-friendly policy as it is widely acknowledged that many older people would not consider a move into a supported environment if they could not bring their companion with them.

The whole building will be hard-wired for the application of Assistive Technology and, subject to individual assessment, residents can retain their independence for as long as possible by the use of a range of equipment such as falls monitors, flood monitors, medication reminder/dispenser, Epilepsy sensor, property exit sensor etc etc.

There is satellite TV capability in each apartment with TV aerials in the lounge and master bedroom and telephone points too.

Security of Tenure Residents will either have an assured tenancy if they rent or a lease if they have purchased their apartment. This gives them a strong element of control over their own future as they only move if it is their wish to do so.

Scheme Facilities Each scheme will have a range of additional facilities such as those listed above. This is to ensure that 78

residents, especially those with mobility problems or those with dementia can easily take part in social activities and continue to have as much choice and control as is possible.

So that the scheme doesn’t become isolated within the community, local people are actively encouraged to come in and make use of the facilities and services available and this enhances social interaction for residents as well as becoming a valuable resource in the locality.

The café/restaurant is a service that is available to people on a choice basis but people can choose to cook and eat in their own apartment if they wish. The specification for the chosen caterer ensures that seasonal, freshly-prepared nutritionally balanced meals that suit all ethnicities and all medical/health needs can be provided at a reasonable cost. Families and friends are encouraged to eat with residents.

The staff will work with residents to make available a range of social activities and lifelong learning opportunities, again available to residents and local people.

Staffing The building will be staffed 24 hrs/7 days by a partnership of housing management, care and support staff. This may be via a range of providers and, to provide a seamless service to residents and visitors, a Scheme- based Protocol will be agreed so that all parties understand the ethos of the service delivery and are each aware of their responsibilities.

Residents have the reassurance of knowing that, outside of their care plan delivery, staff can be with them immediately if they have an urgent need for assistance.

Care and Support to Enable Independent Living Each resident will have a person-centred, outcome-based assessment that will lead to the production of care and support plans. On site staff, because they are permanently based in the building get to know residents very well and can monitor their day to day wellbeing and plot their progression through their frailty or disability. A certain amount of flexibility is built into the care and support delivery so that for instance if someone is temporarily poorly, care and support can be increased and then gradually reduced again as they recover.

The ethos for extra care housing is one of independent living with an enabling focus. This means that people are encouraged and assisted to retain the skills they have for as long as possible and, for people moving in from residential care, to regain lost skills. This will be different for each person but the ‘use it or lose it’ cliché is particularly applicable to older people and it’s important to agree with each individual what they wish for themselves and to assist them to achieve their own personal goals.

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Appendix B

Specific fire safety design and management issues

1.0. Means of escape from flats-Travel distances. 1.2. Extended travel distances will be best considered, when supported by fire engineered proposals and calculations on a case by case basis. It is not within the scope of this agreement to suggest a variation. However it is most likely that sprinkler provision and supporting fire engineered calculations would provide the designer with evidence to enable the recommended travel distances to be extended if necessary.

1.3 Refuse chutes and storage

1.4. Approved document B 5.56 Rooms containing refuse chutes, or provided for the storage of refuse, should be approached either directly from the open air or by way of a protected lobby provided with not less than 0.2m2 of permanent ventilation.

1.5. The provision of sprinklers, in the event of a fire within a refuse storage area is likely to prevent a serious fire from developing. It is therefore accepted that mechanical ventilation would be an acceptable alternative to the recommended not less than 0.2m2 of permanent ventilation.

1.6. Management of waste removal should be included within the fire risk assessment to ensure that accumulations of large volumes of waste do not occur within the internal waste storage areas.

1.7. Vehicle access

1.8. The provision of sprinklers as a compensatory feature in respect of requirement Approved document B 16.3 should be acceptable if the vehicle access for a pump appliance to blocks of flats is to within 75m of all points within each dwelling. This would allow a hose reel hoses from a single pumping appliance to be extended and reach every point within each dwelling with minimal delay.

1.9. Signs and signage.

1.10. British Standard 9999 guidance provides a risk assessed methodology for signs and notices provision rather than prescriptive requirements. It is anticipated that some notices i.e. fire door keep shut, may be omitted when identified within the fire risk assessment and replaced with suitable, robust management actions.

1.11. Fire Fighting Equipment

1.12. The Regulatory Reform (Fire Safety) Order 2005, guidance document Sleeping Accommodation suggests for class A fire risk, 2 fire extinguishers per 200 m2 of floor space with a minimum of 2 fire extinguishers per floor. 1.13. The Fire and Rescue Authority recognise that sprinkler provision, active safety systems do provide benefits in terms of safety management once a premises becomes occupied. The Fire and Rescue Authority are willing to consider management proposals (at design stage) reducing the provision of fire extinguishers within common areas of extra care facilities where sprinkler protection is provided.

1.14. Ancillary accommodation facilities such as shops, hair/beauty salons, cafés/restaurants, lounges, hobbies rooms, libraries etc. Also other specific risk areas i.e. lift motor rooms, boiler rooms, electrical circuit distribution rooms, laundry rooms, should be equipped with the appropriate fire fighting equipment as per

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guidance documents.

1.15. Fire Safety management

1.16. Continued successful management of an extra care premises is an essential element of the faire safety provision. The standard of management expected to be adopted is defined as follows.

2.0. Management of Fire Safety.

2.1. British Standard 9999, Section 4 Managing Fire Safety, gives comprehensive guidance and defines 3 management levels. It is appropriate that a management level 1 is adopted within Extra care premises.

2.2. ‘A level 1 system anticipates and proactively identifies the impact of any proposed changes, including changes to the occupancy, periods of abnormal occupancy, and fire growth characteristics. The system identifies any alternative protection and management measures that will be required as a result, and ensures that they are implemented.’

For further information on management issues refer to British Standard 9999, Section 4.

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Appendix C

1.0 Regulatory Reform (Fire Safety) Order 2005

1.1. The Regulatory Reform (Fire Safety) Order 2005 (Fire Safety Order) requires responsible persons to undertake a fire risk assessment to identify the general fire precautions they need to take to ensure, as far as is reasonably practicable, the safety of relevant persons from fire.

1.2. Having identified the general fire precautions necessary, the responsible person must implement them. Where five or more persons are employed or any form of license or certification applies to the use of the premises, the significant findings of the fire risk assessment must be recorded.

1.3. The responsible person is identified as, the employer, the occupier or the owner as far as their control extends. In premises covered by this protocol which are not workplaces, the landlord or managing agent is likely to be the responsible person. Tenants must cooperate with the responsible person.

1.4. In most cases the local fire and rescue authority is charged with a duty to enforce the Fire Safety Order and have a range of enforcement options, from education and advice, through agreed action plans to formal enforcement notices and prohibition notices. Failure to comply with the Fire Safety Order may constitute a criminal offence.

1.5. In general, the Fire Safety Order applies to all areas of premises except those areas occupied as private domestic dwellings. Where there are areas used in common by the occupants of more than one such dwelling, the Fire Safety Order applies.

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Appendix E

Signatories to protocol

On behalf of the North Yorkshire Council Extra Care Housing

Name

Position

Signature

Date

On behalf of the North Yorkshire Building Control Partnership

Name

Position

Signature

Date

On behalf of the North Yorkshire Fire and Rescue Authority

Name

Position

Signature

Date

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APPENDIX 2 - SCHEDULE OF ACCOMMODATIONS

We recommend the typical 1 bed apartment to be 54m squared and the 2 bed apartment to be 68m squared. The following schedule represents a scheme of 40 apartments and gives an indication of spaces to consider with suggested floor areas. Project specific factors will dictate which spaces are appropriate and where they are located within the scheme. For example, some schemes may offer formal day care and will therefore, be able to sustain more activity spaces and there will be different requirements in schemes located in vibrant urban settings as opposed to a quiet rural area.

Accommodation

Residents’ Accommodation 1 bed 2 person apartments Approx 54m squared 2 bed 3 person apartments Approx 68m squared

Communal accommodation & facilities

Main communal lounge 1.5m squared / apartment Located near to and visible from the main entrance with a focal point such as a fireplace or similar. Dining and lounge spaces may be linked but should occupy distinctly separate spaces. Views and direct access onto a south-facing terrace and garden are a major benefit. Alcoves and niches will allow smaller groups to gather together. Domestic ceiling lighting should be fitted.

Dining area 1.2m square / apartment If possible this room should link to an external terrace to allow dining outside in good weather. This space could be designed in several ways, as a restaurant or café with table service or servery counter, or as a domestic dining room. Allow space for residents using wheelchairs and walking aids. The overall area is dependent upon the number of diners eg use as a luncheon club by outsiders.

Residents’ tea kitchen 10m squared Provide adjacent to lounge and dining space, for use by residents and for refreshments for small functions. Should be outside of the main lounge rather than along a wall within it.

Small lounges or hobby rooms (2 min) min 15m squared Can be located on upper floors and used for private parties with relatives, small gatherings, specific activities etc. Should be easily accessible and not located at the ends of corridors or isolated from the main circulation route. The number of these will depend on the size of the scheme and whether the apartments are arranged in clusters.

Communal WCs 4m squared Located near to entrance area and communal lounge / dining areas. Designed for wheelchair accessibility.

Assisted bathrooms (1 min) 12 – 15m squared Equipped with baths to allow both assisted and independent use by residents. These rooms 84

should be designed to be as domestic as possible, space should allow baths to be located in a peninsula position. WCs should be located in a separate but adjoining room.

Hairdressing and beauty therapy 6m squared Could be located near to entrance area and might have a multi purpose use.

Informal seating spaces 3m squared (min) (Throughout scheme)

Large charging store for electric buggies 25 – 30m squared and scooters

Staff and ancillary accommodation 15m squared Manager’s Office With views into the main entrance area, space for desk, computer table, chair, plus two visitors’ chairs and document storage.

Care staff office 18m squared Space for two desks, files storage and table for handover meetings. Privacy is important due to the confidential nature of the work.

Photocopy area 4m squared Easily accessible by all staff

Staff rest room with kitchenette 15-20m squared Space for table and chairs plus a couple of armchairs.

Staff locker / change room & shower/wc 12m squared All staff will need locker space and possibly an area for changing clothes. Provide at least two dedicated staff toilets and consider the need for a separate staff shower.

Guest room with en suite 20m squared To be designed for wheelchair user access, accommodating twin beds with en suite shower, bath, WC and basin.

Back office laundry 20 m squared For use by staff for heavily-soiled laundry that can’t be dealt with in a domestic machine in a resident’s apartment and for care-plan laundry. The machine must have a sluice facility. A wash basin should be provided as well as appropriate ventilation and the room should be away from any areas where staff may be eating.

Main catering kitchen and associated 60m squared storage and staff facilities

Cleaners’ storage 5m squared General storage 20m squared

Services and plant 2600 x 1800mm Minimum of 2 no. lifts to all floors Minimum 13 person (stretcher size) Lift motor room if required 4m squared Refuse Store (including lobby and cupboard 20m squared 85

for clinical waste) Recycling collection point 6m squared

Plant room and service risers The size of the plant room(s) will vary significantly from scheme to scheme depending on the method of space heating selected and the extent of individual metering decided upon. Space required for water storage (including the possibility of booster tanks and pumps if the building height dictates) will also vary. As a guide allow 20-25m squared, but ensure specialist service engineer’s advice on size and location at the earliest possible opportunity.

Electrical Intake / Meter room 10m squared

Other spaces to consider: A number of additional spaces should be considered which will of course be determined by factors specific to the site, the scale of development and local need. The need for such additional facilities may be identifiable but it may still be financially prohibitive. Where appropriate consider the following additional facilities:-

. shop (if there is no provision in local area) . library . therapy room . treatment room . IT facilities / information points / touch screens . café / bar / pub . leisure facilities . outreach staff offices.

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APPENDIX 3 – DESIGN STANDARDS & GUIDANCE DOCUMENTS

Compulsory standards: The following is not an exhaustive list of all standards and legislation to be met when designing and building extra care housing but does give the main documents that apply specifically. A definitive guide to extra care with statutory status does not exist so careful interpretation and detailed knowledge of all the related standards is essential.

. Approved Document M (2006 Edition) – The Stationery Office

The Building Act 1984 requires compliance with the building regulations. Within England and Wales this is covered by guidance found within the ‘Approved Documents’. Approved Document M gives technical guidance on providing access to and within buildings by all building users including disabled people. The latest version of this document is informed by BS 8300:2001 Design of Buildings and their approaches to meet the needs of disabled people - Code of Practice (see below).

. Disability Discrimination Act 1995 - The Stationery Office, 1995

Please note: Under ‘The Care Standards Act 2000’ the Department of Health has published ‘National Minimum Standards for Care Homes for Older People’. This document is not applicable to the built environment of extra care sheltered housing as the building would not be registered as a care home.

Housing Corporation – Design and Quality Standards, April 2007

These standards now classify housing for older people into 3 categories:-

1. Housing for older people (all special design features) = extra care 2. Housing for older people (some special design features) 3. Designated supported housing for older people

The documents to which the new Design and Quality Standards refer to are:-

Wheelchair Housing Design Guide, Stephen Thorpe National Wheelchair Housing Association Group, 2006

Design Guide for the Development of New Build Accommodation for Older People, by PRP Architects for the Abbeyfield Society, 2001 Secured by Design - http://www.securedbydesign.com

Factsheet No 6 – Housing LIN – Design Principles for Extra Care - 13.02.2008

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FURTHER DESIGN GUIDANCE & GOOD PRACTICE REFERENCES

NHF: Standards and Quality in Development – A Good Practice Guide Relevant Sections – Part C: The Internal Environment Part E: Accessibility & Technical Illustrations, with in the appendices National Housing Federation, 1998

Adapting Homes: A guide to adapting existing homes for people with sight loss, Linda Rees and Caroline Lewis, RNIB Cymru, 2003

A Design Guide for the Use of Colour and Contrast to Improve the Built Environment for Visually Impaired People, Dulux Technical Group, ICI Paints, 1997

BS 8300:2001 Design of buildings and their approaches to meet the needs of disabled people – Code of Practice, The British Standards Institution, 1999

Building Sight: the Royal Institute for the Blind – a useful handbook of building and interior design solutions for the needs of visually impaired people. Peter Barker, Jon Barrick, Rod Wilson, HMSO in association with the RNIB, 1995.

The following documents are also recommended:-

. BREEAM guidelines

. The Extra Care Housing Toolkit, October 2006: Provides a range of papers, ideas, checklists and diagrams designed to help in planning specialist housing and service provision. Replaces the document ‘Developing and Implementing Local Extra Care Housing Strategies’. www.icn.csip.org.uk

. Extra Care Housing: Development Planning, Control and Management RTPI Good Practice Note 8, 2007. www.integratedcarenetwork.gov.uk

. Housing Green Paper, Homes for the Future, July 2007. Briefly discusses ‘Housing for an Ageing Population’ in chapter 5, also refers to the ‘National Strategy for Housing and Ageing Society’ paper for more detail. www.communities.gov.uk.

. Lifetime Homes, 16 design feature ‘Standards’ that together aim to create accessible and adaptable housing gin any setting. www.lifetimehomes.org.uk

. Building for Life, CABE: 20 Questions which form a basis for writing development briefs. www.buildingforlife.org.

. National Affordable Housing Programme 2008-11 Prospectus, Housing Corporation September 2007. www.housingcorp.gov.uk.

. Planning for Retirement Housing, A Good Practice Guide by the Planning Officers

88

Society and the Retirement Housing Group, November 2003.

. The Suffolk Very Sheltered Housing Design and Management Guide, Ninth Revision, January 2007, Available on line from www.suffolkcc.gov.uk.

. Towards Lifetime Neighbourhoods: Designing Sustainable Communities for All, published in partnership with Communities and Local Government November 2007

. Legislation Maze: Inclusive Accessible Design, Guidance on accessibility design issues required during the course of a building project, using the new RIBA Plan of Work Stages.

. National Strategy for Housing in an Ageing Society, 2008. This Strategy includes announcements such as Lifetime Homes becoming a mandatory part of the Code for Sustainable Homes. www.communities.gov.uk

Various Publications on Designing for Dementia are available from:-

. Design for Dementia, Stephen Judd, Mary Marshall & Peter Phippen, London: Hawker Publications, 1998

. Dementia Services Development Centre, University of Stirling, Stirling, FK9 4LA, Scotland. www.stir.ac.uk/dsdc

. Designing for Special Needs. An architect’s guide to briefing and designing options for living for people with learning disabilities, Maurice Harker & Nigel King, the Shirley Foundation, 2002, RIBA Enterprises

. Homes for the Third Age, a design guide for extra care sheltered housing, David Robson, Anne-Maria Nicholson, Neil Barker, University of Brighton and Hanover Housing Association, E&F N Spon, 1997

. Housing Sight, a guide to building accessible homes for people with sight problems, Linda Rees and Caroline Lewis, RNIB Cymru, 2003

. Put Yourself in My Place, designing and managing care homes for people with dementia, Caroline Cantley and Robert C Wilson, The Policy Press, 2002.

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Hambleton, Richmondshire & Whitby CCG Interim Strategic Estates Plan Public Document - Dec 2015

Document Control Interim SEP agreed by: Name Title Date A Levin CCG Head of Finance DD/MM/2015

K Dare NHS PS Property Strategy Manager DD/MM/2015

Version control:

Version Issue Ref. Status / Summary of changes Amended By Date Interim document 18/01/2016 Document for Review Karina Dare, Version 1 Property Strategy Manager Interim document 23/02/2016 Incorporating initial CCG comments Karina Dare, Version 2 Property Strategy Manager Interim document 24/03/2016 Incorporating further CCG comments Karina Dare, Version 3 Property Strategy Manager

2 Notes to Strategic Estates Plan

• This document has been produced for Hambleton, Richmondshire and Whitby CCG by NHS Property Services Ltd. • The supporting information in this plan was gathered in November 2015 and will be developed an improved in further iterations of the strategy document. • This interim strategy takes account of the plans of local providers and commissioners including NHS England and other NHS and local authority stakeholders • A number of the property opportunities contained within the review are at outline proposal stage only and are subject to further public engagement • The costs and benefits set out in the document are indicative, and are subject to further planning and viability testing • The document should be read in conjunction with the CCG’s forthcoming revised Strategic Plan for 2016-21, which will be produced by April 2016 • This pubic facing version excludes some commercially sensitive matters.

3 Contents Executive Summary 1. Scope 2. CCG key drivers and challenges 3. Estate overview 4. Key themes emerging from the review 5. Property strategy forward view 6. Summary of property opportunities 7. Investment considerations 8. Financial Analysis 9. Work Plan 10. Recommendations

Back-up slides: • Annex A – Telemedicine

4 Executive Summary • A vision and plan for Hambleton and Richmondshire Hambleton, Richmondshire & Whitby CCG Estate Strategy • ensuring wider access to step-up and step-down beds closer to home (2015 -2020) • continuing to ensure local access to a fit for purpose primary care estate that is able to deliver an increasing range of out of hospital This paper provides a summary of the CCG local estate strategy services on a local basis review process and the proposals to support the NHS 5 year • working with NHS Property Services to identify more efficient estate forward view: utilisation options 1. Scope overview: 5. Property opportunities and savings: • this interim strategy takes account of the plans of local providers and • potential gross running costs savings of £359k pa in NHSPS portfolio a commissioners including NHS England and other NHS and local 9% reduction on existing cost base authority stakeholders • potential to reduce floor area in NHSPS estate by 4.5% (31% • a number of the property opportunities are at outline proposal stage reduction if the proposed Whitby Development proceeds) only and are subject to further public engagement 6. Investment requirements • the document should be read in conjunction with the CCG’s revised • significant redevelopment of the existing Whitby Hospital Strategic Plan for 2016-21 (April 2016) • potential for integrated solution in Thirsk 2. The CCG drivers and challenges: • development of urgent care facilities on The Friarage site • making our services ‘Fit 4 the Future’ across our whole system is our • development requirements for Catterick +/- military healthcare priority • consolidation of services in Leyburn • developing innovative solutions to meet the problems of rurality, an • opportunities to utilise PCTF to support transformational change in ageing population and financial pressures primary care • embracing new opportunities and ways of working, particularly 7. Other property considerations: embracing new technologies as a fundamental part of our approach to • detailed review of health centres required to support investment care planning 3. Property overview: • Common understanding of provider plans for consolidation required to • General Practice, 28 premises, 11k m2 space, reimbursed £2.2m pa support strategic decision-mak ing • NHS PS running costs c£3.9m pa, 18 Holdings, 18k m2 • Carter review opportunities within Foundation Trusts to be explored • STFT running costs c£12.5m pa, estate footprint 33k m2 8. Recommendations • TEWV running costs more than £1.5m pa, 14 holdings 6k m2 • utilisation review for community space • further develop community hub property strategy 4. Key themes emerging from the review: • business cases prepared for lease break and end opportunities • supporting a sustainable future for the Friarage Hospital as the expert • vacate / reduce leasehold estate early 2016 hub for a rural community 9. Next Steps • reviewing community facilities in each of our three localities so that a • establish local estates forum to consolidate estates plans across health wider range of community-based services are available closer to economy patients own home • develop action plans to bring forward the property opportunities • Whitby significant redevelopment of the hospital

5

1. Scope Overview

• This strategy was developed to support the commissioning strategy of HRW CCG. • This strategy includes information about the general practice estate, community estate (largely owned by NHS Property services) and buildings owned and operated by South Tees NHS Foundation Trust and Tees, Esk & Wear Valleys NHS Foundation Trust. • ‘Heartbeat Alliance’ the local GP Federation have, undertaken detailed evaluation of the general practice estate. The initial outputs from that work have informed this plan but are subject to further development and by the CCG. • This document sets out a number of opportunities for the next 3-5 years but a number of these proposals will require detailed development and dedicated project teams for successful completion.

6 2. CCG Key Drivers and Challenges

About Hambleton, Richmondshire & Whitby CCG • we are a commissioning group made up of 22 practices serving 142,000 people. • the CCG budget for the 2015/16 financial year is £176.4m. Our aims • Involve people in their care and as part of that we will encourage self-care • Buy quality services • Change services for the better and in doing so we will provide care as close to home as possible that is easily accessible • Use the money we have in the best possible way Our biggest challenge • Making our services ‘Fit 4 the Future’ across our whole system is our priority. We serve a deeply rural community who are passionate about local services. Their over-riding priority is to be able to stay in their own homes and for care to be delivered as close to home as possible. To do this we recognise that traditional ways of organising and delivering services are not sustainable and we want to engage with our local population to radically re-imagine how we provide care and support. We believe we should take a whole life and integrated approach which places the needs of the individual and the community at its heart. • We therefore need to develop innovative solutions to meet the problems of rurality, an ageing population and financial pressures. • The challenge of living within our means is going to be particularly difficult over the next few years. • We will engage with and listen to patients, staff and everyone else with an interest to understand how services could be delivered differently in the future, for the benefit of our whole community. • We will embrace new opportunities and ways of working, particularly embracing new technologies as a fundamental part of our approach to care (Use of Telemedicine Annex A).

7 2. CCG Key Drivers and Challenges Our priorities As a group of GPs, we intend to transform local health services to better meet the needs of our local population. To help us achieve this, we have been working to a five year strategic plan which sets out our priorities and guides our work. Our 7 broad strategic initiatives are:

1. Transforming the community system – to create effective, integrated community services that enable patients to be cared for as close to home as possible and ensure a resilient urgent care system.

2. Mental health and dementia care – to ensure parity of esteem, improved access to mental health services and meet the challenge of providing the best possible care for the rising numbers of patients with dementia.

3. Clinically appropriate planned care – to ensure care pathways and referrals across all specialties are as clinically efficient and effective as possible.

4. Children’s health – to ensure that urgent care services are safe and sustainable and we build improved services in the community for vulnerable children and those with complex needs.

5. Patients with long term conditions – to improve patient’s ability to self-care and achieve their own goals, supported by earlier diagnosis and better identification of patients who are at risk.

6. Prevention of ill-health – to work with the North Yorkshire Health and Wellbeing Board to take forward plans and projects to improve the health of the local population.

7. Primary care development and productivity – to work with our local GP practices and their supporting GP Federation to ensure high levels of continued patient satisfaction and facilitate the provision of more services close to home.

8 2. CCG Key Drivers and Challenges

9 2. CCG Key Drivers and Challenges

Integrated services built around the patient is a core principle for the development of all services and estate solutions.

Better Care Fund 2015/16 • HRW CCG are signatories to the Better Care Fund (BCF) for North Yorkshire Health and Well Being Board which covers six clinical commissioning groups, six acute hospital trusts and three mental health trusts. • This fund has been a key vehicle for facilitating closer integration between health and social care and includes both county-wide initiatives and local transformational schemes. • The agreed value of the budget is £46.7 million in 2015/16. • The BCF plan currently identifies eight broad categories: Social care base budget protection County wide infrastructure projects (data sharing, equipment services). County wide changes built upon • New models and transforming services • Prevention strategies and early intervention models • Community development – resilience models Covering mandated but as yet undefined costs- eg Care Bill Maximising admission reduction and timely and safe discharge from hospital • In HRW, a locality fund of £3 million has been used to drive forward a range of local initiatives, including: Overnight Fast Response Service Significantly extended intermediate care provision Frail elderly clinics Hospital case management District nursing Lifestyle referral GP hospitalists at the Friarage hospital Liaison psychiatry and IAPT

10 2. CCG Key Drivers and Challenges

Integrated services built around the patient is a core principle for the development of all services and estate solutions.

Better Care Fund 2015/16 • For 2015/16, the CCG has modelled emergency admission activity, identifying which areas are amenable to potential change through BCF initiatives and the impact this might be expected to have upon acute capacity, if these deliver as anticipated. • A reduction of approximately 8% in emergency admissions was built into provider plans for 2015/16 in order to release funding to cover the investment in community services. • Work has also focused on reducing lengths of stay through expediting discharges. Together these changes are mitigating the national rise in non-elective admissions and pressure for additional hospital beds

New Strategic Plan 2016-21 Looking ahead to 2016 and beyond, the CCG will be creating a revised strategic plan in line with requirements for NHS England. This will build on the CCG’s work over the past three years but will also lead to a description of new drivers and priorities. Within this Plan, the following issues are likely to be significant drivers and challenges or the next five years. • Transforming our community system will remain our central priority but increasingly we will be taking an integrated and whole system approach to radically re-imagining care delivery. The Dales Project will be the key vehicle for establishing the best way forward. • We will continue to maintain the Friarage Hospital at the centre of healthcare provision for the population of Hambleton and Richmondshire for both elective and non-elective services. Ensuring its prosperous future is a key issue for the local population and a key priority for the CCG and STHFT. • We have just undertaken a new 7 year contract for the provision of community and urgent care services in Whitby through Humber Foundation Trust. This provides significant opportunities to improve the services for the local population, including a significant redevelopment of Whitby Hospital.

11 2. CCG Key Drivers and Challenges

• Local Federation of general practices ‘Heartbeat Alliance’ which has been facilitated through Prime Ministers’ Challenge Fund with a view to maintaining and improving primary care access. Heartbeat Alliance has commissioned 2 reviews, which are starting to identify estates and service challenges and solutions: • A fit for purpose estates and facilities infrastructure review • Service scoping and feasibility review • The CCG has started developing wider partnerships in relation to Catterick town and the military population and increasingly recognises the need for a whole system approach to addressing the health needs of this population. • Ensuring access to step-up / step-down beds for rehabilitation / recuperation and access to palliative care beds right across our communities is a significant challenge. To meet the needs of an ageing population we will need to review the provision of community hospital beds and also look for wider opportunities in care homes or extra-care housing • A new model of urgent care services of the Friarage Hospital will be a key challenge. This will need to bring together a range of services at the front of house, including greater GP presence both in and out of hours. • Developing new care partnerships between GPs, social care, hospital consultants, community and mental health providers to extend the range of services and expertise provided in communities and community locations

12 3. Foundation Trusts • There are a number of Foundation Trusts delivering services in the HRW CCG area • South Tees NHS Foundation Trust • Tees, Esk and Wear Valleys NHS Foundation Trust • Harrogate and Districts NHS Foundation Trust • Humber NHS Foundation Trust • York Teaching Hospitals NHS Foundation Trust • County Durham and Darlington Foundation Trust • There is also a substantial military health presence in the area

South Tees NHS Foundation Trust • South Tees NHS Foundation Trust operate from substantial sites in Northallerton Thirsk and Whitby and from a multitude of community locations in general practice and NHSPS health centres. The Trusts occupation on key sites as reported on ERIC are; (2) (25) Gross internal site Site Area Annual Operating Operating cost 2 floor area (m²) (hectare) Cost £000 £ per m Friary 1,780 0.2 716 402 Lambert Memorial Hospital 1,588 0.2 142 90 The(32 Friarage holdings) 29,594 5.6 11,678 395 32,962 6 12,537

• South Tees estate strategy is currently under review and once completed will inform the next stages of the CCG estates plans

13

3. The Friarage Hospital • The Friarage Hospital is the District General Hospital serving the Friarage Hospital locality STFT has made changes at FHN including introducing a successful Clinical Decisions Unit and changes to medical cover • It serves a rural population of 122,000 people. arrangements i n A and E. Growi ng difficulty i n obtaining and • It serves an area of 1,000 square miles extending from the North retaining trainee doctors in Acute Medicine at FHN and a Yorkshire moors to the central Pennines, the borders of York district consequent reliance on locums is however driving a need for in the south and the borders of Darlington in the north. review of current staffing arrangements. HRW CCG continues to work with the Trust on this agenda.

The introduction of the clinical decisions unit (CDU) in 2013 combined with improved access to community services has

resulted in reduced use of non-elective beds during the summer months. The elective/surgical bed base will remain untouched.

Decontamination enhancements Upgrade of decontamination facilities at the Friarage Hospital

has been completed to maintain on-going compliance with regulations The scheme involved re-configuration of existing facilities and provision of new equipment. This is fundamental (25) to maintaining service delivery.

Estates maintenance

A further £1.9m will be invested at the Friarage Hospital. Adequate estates maintenance underpins the delivery of trust (32 holdings) objectives including compliance with health and safety standards. • Around 1,100 staff are employed on the Friarage site which provides approximately 160 beds. Community hospitals Beds will be reviewed in 2016/17 in line with demand patterns • The total floor area is 34,205 m2 and once an understanding of the impact of a transformed • STFT operate a full range of secondary care services from the site community system has in line with CCG commissioning • There is a Ministry of Defence Hospital Unit on site intentions. • HDFT provide podiatry & speech therapy services

14 3. Foundation Trusts

Tees, Esk and Wear Valleys NHS Foundation Trust • Tees, Esk and Wear Valleys NHS Foundation Trust deliver mental health services in the HRW CCG area from a number of general practice and community locations • They occupy 14 properties a floor area of circa 6k m2 and the occupations are 86% (by number) leasehold costing more than £1.5m pa • The Trust’s biggest occupation is on the Friarage site where they operate 21 beds and 4k m2 at an annual cost of £1.3m • TEWV have identified the requirement to address the sub-standard estate in HRW CCG area which includes sub-standard in-patient accommodation at Friarage Hospital • Their Estates & Facilities Management Framework Sept 2014 – Mar 2017 identifies the following capital aspirations which are subject to business case approval

2015/16 2016/17 2017/18

Baseline Baseline Baseline Scheme (2) Locations budget budget budget £000 £000 £000 CMHTS Reconfiguration Alexander House/Gibraltar House 218 1,182 IP Beds Reconfiguration Harrogate General Hospital/Friarage 1,000 6,500

(32 holdings)

• It is proposed to create a hub for non-inpatient facilities in Northallerton which would replace some of the existing facilities. This is expected to align with lease end and break opportunities within the NHSPS community estate

15 3. The Estate Overview NHS Property Services - Estate Map

16 3. The NHSPS Estate Overview • Below is a brief summary of the NHS Property Services community holdings * Cost of unitary charge only 18 Holdings / 18k sq m NIA Total Cost of Estate

Based on 15/16 costs: £3.9m p/a 9 Holdings 4 Holdings 2 4.5k m2 NIA 11 k m NIA

Health Centre Hospitals Top 5 buildings by cost

0 Holdings 4 Holdings Property Running cost £k p/a

2k m2 NIA

Nursing / Care Home Offices Whitby Hospital £1,954

Friary Hospital* £479* 0 Holdings 1 Holdings

0.4k m2 NIA

Land without Other / Gibraltar House £299 buildings Unk nown

Top 5 properties (by size – NIA sqm) Lambert Memorial Hospital £224

Whitby Hospital 8808 Catterick Garrison HC £135 Friary Hospital 1607 Catterick Garrison HC 909 Lambert Memorial Hospital 835 Total £3,090k (c80% of total cost) Gibraltar House 794

17 3. The Estate Overview

• 20% of the NHSPS estate is leasehold. This offers some immediate opportunities to release property running costs if local consolidation is possible • A full list of lease ends and breaks to 2020 is included in the back-up slides in Annex A • The key opportunities in the next 5 years are summarised below:

NIA X sq. m (X Holdings) Lease End + Break Profile (NIA sq m)

Leasehold 1800 Lease end Freehold 1600 8% 12% lease break Other 1400 1200 1000 800 (32 holdings) 600 400 80% 200 0 2016 2018 2021 2023 2023 2025 2085

18 3. Whitby Hospital Whitby Hospital Proposals Hambleton, Richmondshire and Whitby CCG and Scarborough and Ryedale CCG currently spend £5.3m on commissioning hospital The site is in a conservation area and is within services in Whitby and HRW CCG spends a further £1.5m on other walking distance of Whitby town centre and the community services for the area. railway and bus stations, thereby giving easy access to public services. The redevelopment of the existing Our ambition for Whitby is to increase years of healthy life and reduce site is the preferred option for the general public in the social isolation that unfortunately is experienced by so many initial feedback received, although the response rate people in later life. was low.

Key priorities The intention for this scheme is to redevelop the • Adapt to the changing health needs of the local population. Community Hospital site in Whitby to provide a • Accessible services across a rural community. health and social care hub to support the integrated • Fit for purpose facilities. delivery of care between primary care, secondary • Engage with patients and members of the public. care, community services and the third sector. The • Gather local GPs’ concerns about services and their desire for newly configured community hospital would bridge greater input. the gap between home and specialist hospital care • Value for money. • Innovation in healthcare. through the delivery of both outpatient and inpatient (25) services in Whitby. . The existing Whitby Hospital site is freehold and currently owned by NHS Property Services Ltd. It is approximately 1.72ha (4.25 acres) and is developed (32 holdings) with 10,800m² of buildings, built around 1979, with 128 car parking spaces and green space.

The annual revenue cost for the site in 2013/14 was identified as £1,954,856

19 3. Whitby Hospital

Whitby Hospital Plans

The current facility if 10,000 m2 is 75% underutilised so the CCG initiated a feasibility study to plan for a new facility which will support the clinical strategy.

As part of the development process modelling was undertaken to define the different activities which would be provided for in the new site and opportunities for shared spaces and co- locations considered. This will support the detailed design process for the new facility.

A project initiation document has been completed and outline business case is being developed.

The 4 storey block at the rear of the site would provide 3500m2 for healthcare facilities, on an average construction cost of refurbishment of £2800 per m2 (including VAT, fees and contingency) the estimated capital cost would be £9.8million. The revenue benefits are not yet fully established.

Adoption of this approach would result in a residual site area for sale of circa 0.77 ha (1.9 acres) which could reasonably be expected to realise capital funds depending on the marketing and development strategy adopted.

20 3. The Estate Overview

Estate Map – General Practices

21 3. GP Estate Overview

• There are 22 practice operating from 28 general practice properties in the HRW CCG area. The general practice estate is a significant resource totalling circa 11k sqm and 57% is owner occupied. The reimbursement cost baseline (2013) was £1.9m. Total expenditure on GP premises is £2.2m pa in 2015 • The CCG is a Level 2 joint commissioner for primary care • There has been limited investment in general practice premises in recent years. • There is significant pressure on space in some practices with a number of practices at/near the thresholds for investment highlighted by NHS England

Space as a % of Space Gap m2 List size required

Lambert Medical Centre, Thirsk 28% 588 8,268 Glebe House Surgery, Bedale 30% 556 9,591 Quakers Lane Surgery, Richmond 42% 364 6,300 Dr Casey & Partners & Dr Trzeciak & Partners, Thirsk 57% 303 7,097 (2) Dr Duggleby & Partners,(25) Stokesley 61% 361 9,336

• The Heartbeat(32 holdings)Alliance have identified a number of priority areas for investment. • Opportunities to access premises funding exist through Primary Care Infrastructure Fund and the CCG will have a key role in assessing strategic fit of schemes.

22 3. GP Estate Overview

• There were two Primary Care Infrastructure Fund (PCIF) bids in year one, but one of the bidders withdrew so we have one active bid which is being assessed against national and local criteria for funding support.

Practice Capital Cost Code Practice Type £000 Recommendation Support in principle for funding in 2015/16, B82019 TOPCLIFFE SURGERY Improvement Grant 55 subject to clarifications Support in principle, but further work required B82062 EGTON SURGERY Improvement Grant 600 and defer

• A bid was also submitted by Harewood Medical Practice for remodelling but this has not been supported yet due to recurrent revenue implications • Primary Care Infrastructure Fund will be Primary Care Transformation Fund from 2016/17 year • The general practice federation have undertaken a review of the GP properties. This is linked to the establishment(2) of the Conrane model of primary care. This study has identified some opportunities for development of hub(25) and spoke sites by locality. The CCG will take the results of this study into consideration as part of the work programme for the 2016/17 onwards. • A number of feasibility and utilisation studies have been identified to assist in bringing forward transformational schemes for Primary Care Transformation Funds. (32 holdings) • Thirsk • Catterick / Richmond • Bedale • Stokesley

23 3. GP Estate Overview

• Redevelopment is currently underway at Sandsend Surgery. This will replace the old building with a larger modern surgery on the same site, with appropriate disabled access, additional consulting rooms, and the ability to provide more services including podiatry, child health and counselling. The surgery closed in October 2015 for 6 – 8 months. • A number of other practice premises were highlighted as requiring improvement in historical survey work. These are identified below.

Gross Physical Functional Space Statutory Internal Year of Condition Suitability Utilisation Compliance Area Construction Score Score Score Score Sandsend Surgery East Row, Whitby 44 1970 DX DX O DX

The Friary Surgery, Richmond 564 1750 C DX F DX

7-8 East Side , Hutton-Rudby 167 1890 B DX O DX

The Health Centre High Street, Catterick Village 500 1976 D D O D (2) (25) The Doctors' Surgery The Health Centre , Thirsk 400 1981 D D O D

The Harewood Med Practice , Catterick Garrison 1027 1960 D D F D

Health Centre, Stokesley 563 1975 D DX O C (32 holdings)

General Ratings Space Utilisation A very satisfactory, no change needed; E Empty or grossly under used at all times B Satisfactory, minor change needed; U Under used - Generally under used. Utilisation could be significantly increased C not satisfactory, major change needed; F Fully used - A satisfactory level of utilisation; and D unacceptable in its present condition; and O Overcrowded overloaded and facilities generally overstretched X total rebuild or relocation needed

24 4. Key Themes Emerging from the Review 1. Immediate Priorities:

• Whitby Hospital development • Replacement for Brentwood Lodge • Leasehold exit opportunities • General practice infrastructure opportunities linked to community hub model 2. Healthcare Planning and Challenges:

Hambleton is a large mainly rural district, running from York in the south to Darlington in the north. Approximately 10% falls within the North York Moors National Park. There are five market towns, Bedale, Easingwold, Northallerton, Stokesley and Thirsk, and 130 villages. Just over half of the population live outside the market towns and population density is one of the lowest in the country. (Easingwold is not in the CCG area)

Richmondshire is one of the largest districts in England, covering an area of just over 500 square miles (1319 square kilometres) two thirds of which is in Yorkshire Dales main centres include Richmond, Catterick Garrison, Leyburn, Hawes and Reeth. Outside of urban centres and market towns HRW is sparsely populated with 70.6% of the population living in rural areas and 15.3% of the population living in areas which are defined as super sparse (less than 50 persons/km).

Whitby a seaside town, port and civil parish in the Borough of Scarborough. Whitby and surrounding areas of Danby, Esk Valley and Fylingdales are located within the HRW CCG and had a population of 25,094 at the 2011 Census. Demographic analysis undertaken by Scarborough Council in preparing an assessment of housing need considered scenarios for its population trajectory to 2030 of +/- 4%. Whitby is a popular retirement area and 31% of the population is aged 60+ compared to 28% in North Yorkshire and 23% in England and Wales as a whole. Conversely only 11% of the population is aged between 20 and 29 years, compared to 14% in England and Wales. This raises concerns about what can be done to retain and attract young people to the area, and how best to meet specialist needs in terms of health and social care, as well as housing which is capable of being adapted to suit changing life circumstances.

For HRW, the 2010 Index of Multiple Deprivation (IMD) identifies 2 Lower Super Output Areas (LSOAs; out of 95 total within HRW) which are amongst the 20% most deprived in England. The total population is currently 154,600 people and is set to increase to 155,000 by 2020. The population is ageing. Life expectancy at birth is 81.1 for men and 84.6 for women, both above the national average. Life expectancy varies for men and women considerably across North Yorkshire.

Key areas of concern • The number of children living in poverty for the CCG area is in the region of 4000 children which represents nearly one third of the county’s total. Specifically for the Hambleton area the rate of homelessness is significantly higher (3/1000 households) when compared to the national average (2.4/1000 households).

25 4. Key Themes Emerging from the Review

2. Healthcare Planning and Challenges (cont):

• The prevalence of Fuel Poverty is significantly higher for HRW when compared to the national average. Addressing fuel poverty issues is likely to have benefits for primary, secondary and social care pressures over the winter months. • Unintentional and deliberate injuries in children are a particular problem for HRW. • The rate for killed and seriously injured (KSI) casualties on England's roads is significantly worse than the national average • Ri chmondshire - 102 per 100,000 compared to 40 per 100,000 • Hambleton - 89.5 per 100,000

Hambleton, Richmondshire and Whitby CCG has a significantly lower mortality rate compared to the national average. Long term conditions i n HRW are varied; CVD, hypertension, stroke and COPD are all significantly higher when compared to the national average. Diabetes prevalence is lower than the national average for HRW, given the relationship with CVD this is surprising. HRW detection for diabetes is lower than the national rate at 67% compared to a national average of 88%. Improving the detection of hypertension and diabetes is likely to reduce the premature deaths in the area.

3. Service Model Developments /Changes: • Maintain district general hospital services Friarage • Maintain community hospital services Whitby • Development of community service hubs • Fit 4 Life developments • Service models that respond to rurality

4. Financial considerations: • Savings required to allow investment in new services and models • Legacy debt position from predecessor organisations • History of acute contract over-runs

5. Existing strategies and plans: Strategic Commissioning Plan 2014 – 2019, revised plan due April 2016 Carer’s Strategy for North Yorkshire CCG 2015-16 Operational Plan North Yorkshire Joint Health & Wellbeing Strategy 2013 – 2018 North Yorkshire County Council Joint Strategic Needs Assessment North Yorkshire Community Plan 2014 - 2017 Hope, Control and Choice, North Yorkshire’s Mental Health Strategy 2015 – 2020

26 4. Key Themes Emerging from the Review

6. Future Housing Growth The housing growth picture across the CCG area is complex encompassing plans for multiple local authorities, substantial areas of national park and also the housing growth associated with the return of troops from Germany to the Catterick area. Overall there is planned housing growth but as there is only small population increase expected the impact of housing growth per se has been disregarded in the preparation of this strategy.

The high and increasing proportion of older households is more significant as it indicates a future need for specialist provision as well as services and adaptations to support older people living independently in their own homes.

7. Key site requirements: A review of the current estate of the CCG matched against its over-arching strategic organisational priorities enables a clear set of priorities to emerge for this estates strategy. These priorities can then be used to drive and inform specific estates plans and projects. The priorities are as follows:

• Supporting a sustainable future for the Friarage Hospital – This recognises that this hospital will continue to be at the heart of healthcare for this community. The estates strategy therefore needs to identify long-term opportunities, in partnership with STHFT, TEWV, GPs and other providers, to establish a wide range of services at this site as the expert hub for a rural community. • Ensuring access to community facilities in each of our three localities so that a wider range of community-based services are available closer to patient’s own homes. • Whitby this will be achieved through a significant redevelopment of the hospital. • A vision and plan for the longer term needs to be created for the community hospitals in Hambleton and Richmondshire, considering the needs of the Thirsk, Catterick, Richmond and Northallerton communities. • Ensuring wider access to step-up and step-down beds closer to home, through new partnerships with social care, care homes and GP practices, so that patients right across our geography have improved access when they need it. • Continuing to ensure local access to a fit for purpose primary care estate that is able to deliver an increasing range of out of hospital services on a local basis. This will involve identifying premises that are below the acceptable standard and utilising opportunities such as the primary care infrastructure fund to develop a prioritised improvement programme. It will also involve consideration of the potential for hub and s poke models in developing approaches to care. • Working with NHS Property Services to identify more efficient estate utilisation options and ensure best value utilisation of premises that are available, including encouraging integrated ways of working where possible.

27 5. Property Strategy Forward View As-Is Position To-be Position • Integrated community solution for Whitby . Whitby community hospital is in poor • Leasehold opportunities taken and community condition no longer suitable for future holdings reduced . Vacant space cost risks as H&DFT reduce • 24/7 urgent care available at Friarage their community occupancies • Further community hub solutions identified and . Requirement for 24/7 urgent care facility plans in place . Requirement for community hubs identified • Friarage site maximised as core of service . Lease Break opportunities available Clinical Estate delivery

. The CCG occupy an small office within . TEWV and H&DFT reduce operating costs Hambleton District Council offices aligning through reduced admin estate footprint and with public sector partners changes in working practices . There are substantial administrative holdings . Administrative cost savings agreed and co- in Northallerton with potential for ordinated across health economy consolidation . STFT have reviewed office space requirements . H&DFT are reducing their admin estate in Northallerton to align to GPU space Admin Estate following a review of community service standards and maximise use of Friarage site delivery General Practice General Practice Estate . 28 premises, 11k m2 space . Enhanced utilisation through community hub models . 57% owner occupied NHS PS Running costs: . Reimbursed costs £2.2m pa . Reduced annual operating costs by £350k NHS PS Running costs: NHSPS Estate Footprint . Running costs c£3.9m pa . Replacement for Whitby Community Hospital . Estate Footprint 18 Holdings, 18k m2 . Strategy in place for Thirsk STFT . Plans in place for Bedale, Stokesley and Great Ayton . Running Costs c£12.5m pa* to respond to new service models Estate Metrics . Estate Footprint 33k m2 . Consolidation in Leyburn completed TEWV STFT, HFT, H&DFT & TEWV Running Costs . Running Costs more than £1.5m pa . Reduction in line with Carter Report . Estate footprint 14 holdings 6k m2

28 6. Property Opportunities & Savings

6.1 Consolidation and disposal opportunities:

• The local authority have disposed on their interest in the Brentwood Lodge Nursing Home site in order to facilitate an extra-care housing development in Leyburn • The NHS have a long-leasehold interest in the site due to previous NHS capital investment • The option to consolidate local health service delivery is currently being explored and one option is using the Leyburn Medical centre site which will enhance that facility as the local service hub

Estimated Estimated disposal Target Financial Year Opportunity Running Cost proceeds £k of savings savings £k pa Brentwood Lodge 19 tbc 2016/17 Totals 19 tbc

29 6. Property Opportunities & Savings

6.2 Improved utilisation and sublet savings:

Gibraltar House • H&D FT are reviewing their administrative space requirements • TEWV have consolidated to this site from Carrick House • There may be opportunities to achieve cost savings

Great Ayton • the health centre is not fully occupied but recent 6 facet survey results suggest that the general practice in the building is under space pressure – a utilisation survey is proposed to realign space to meet service and care model requirements

Estimated Void Maintenance Target Financial Opportunity Cost savings £k Savings Year pa £k

Gibraltar House tbc 0 2016/17

Great Ayton Health Centre 13 0 2016/17

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30 6. Property Opportunities & Savings

6.3 Leasehold opportunities

Carrick House • TEWV are currently in occupation of Carrick House. Carrick House to be vacated at the end of its lease January 2016 Civic Centre Stone Cross • The CCG offices are co-located with Hambleton District Council. Omega Business Park • The leases at Omega Business Park have a break in 2018

• A business case process will be initiated to review any under-utilised properties and to review all leasehold premises

31 7. Investment Considerations

• Whitby Community Hospital is no longer considered fit for purpose, an integrated community solution is proposed for the site • Community Hubs to support changes in service delivery are a core strategy • Seven day Urgent Care facilities are linked to improvements in delivery of effective care – proposals are in place to expand diagnostic capacity and co-locate A&E, GP out of hours on The Friarage hospital site • Opportunities for redevelopment of facilities in Thirsk • Two co-located properties in Thirsk, Lambert Memorial Hospital and Chapel St Day hospital • These properties are located near to local general practices • It is proposed to undertake a feasibility study of the opportunities for a new model of care and facilities to meet the requirements of Thirsk • Planned investment in Catterick Garrison sites • Opportunities for co-location in Bedale • Consolidation of healthcare services on one site in Leyburn

Top: Lambert Memorial Hospital, Thirsk Bottom: Catterick Garrison Health Centre

32 9. Work Plan

• A number of organisations have independent delivery plans and strategies • The establishment of a local estates forum will ensure co-ordination and ensure savings are to the benefit of the broader health and social care economy • The timeline below provides a brief summary of work programmes

Lease Exit Carrick Undertake feasibility & House, review utilisation studies to support PCTF bid Gibraltar House Review lease Omega evaluation Business Park

Q3 2015/16 Q4 2015/16 16/17 2017/18 2018/19

Confirm Improvements Business case requirements for to front of house development Leyburn for urgent care Whitby scheme consolidation at The Friarage

Plans for Leyburn agreed

33 10. Other Property Considerations

. A number of the facilities are currently identified as fully let but this does not ensure they are well utilised. A utilisation review would support community services procurements and Community Hubs planning. . A detailed understanding of H&DFT consolidation plans is required to ensure that the benefits are to the health economy as a whole. . The Carter review has identified potential for acute trusts to improve their estates efficiency and reduce costs through benchmarking improving practice. The largest proportion of estates holdings and costs rest with South Tees Foundation Trust and therefore the greatest potential opportunities.

34 10. Recommendations Hambleton, Richmondshire & Whitby CCG Estate Strategy (2015 -20) Recommendations for CCG approval:

1. Implementing priority 3. Dealing with void space 5. Work Plan healthcare changes . Leasehold exits could improve the . project initiation documents for . confirm infrastructure elements of administrative estate utilisation key schemes will be developed community hub strategy both . utilisation will continue to be by the CCG for NHS England's number and scale monitored and reviewed and any approval . Identify locations for step-up and significant changes will be . capital investment will need to be step-down beds proactively managed in line with this secured for investment . suggested utilisation review for strategy opportunities at Whitby and other community space to support . development of a local estates opportunities brought forward as commissioning plans including forum will assist in aligning a result of feasibility studies, Bedale, Great Ayton & Stokesley organisational plans and confirmation of community Hub . feasibility studies recommended opportunities across the health and sites and also in mental health for Catterick/Richmond and Thirsk social care sector facility development opportunities . NHS PS and the CCG will work 4. Improving estate utilisation together to drive forward the 2. Cost reduction . the plan at section 9 outlines a opportunities and optimise the opportunities number of key projects that will benefits . the review has identified savings of need to be progressed to realise the £350k pa that can be realised with savings minimal impact on clinical provision . The CCG has a dedicated project . Carter Review has identified team to progress the Whitby project opportunities for reduction in with the support of partners operating costs in secondary care.

35 Back-up Slides

36 Annex A – Telemedicine

The use of Telemedicine within Hambleton and Richmondshire

Within the Hambleton and Richmondshire areas we have an ageing population living in a rural and remote environment. The infrastructure within the Yorkshire Dales is far from robust, with intermittent public transport links to The James Cook University Hospital, Middlesbrough, and The Friarage Hospital, Northallerton. Travel time by private vehicle from areas of the Dales to either hospital is upwards of one hour, and longer by public transport. In winter access to anywhere beyond the most immediate locale becomes impossible. The vision for the Hambleton and Richmondshire areas is to have a digitally connected healthcare system using telemedicine; for the community, whether GP surgeries or nursing homes to be digitally connected to the hospitals, and vice versa, to enable the delivery of care closer to people’s homes. In order to achieve this vision four phases are proposed:

Phase 1 – Remote access to hospital systems from consultants’ homes The first phase is to provide remote access to the Friarage hospital systems for consultants whilst at home. This will speed up clinical decisions out of hours. 9 of the 14 laptops have been installed with the remainder to be installed by the end of July 2015.

Phase 2 – Telecart providing video link between the Friarage's Clinical Decisions Unit and consultants’ homes The second phase will provide a video link between CDU and the consultants’ homes, via a telecart which can be wheeled to the side of a patient’s. This will increase patient safety and allow for more timely decisions to be made by senior clinicians without them having to travel from home to the hospital. Two telecarts and necessary licenses have been ordered and are due to be installed by autumn 2015.

Phases 3 & 4 will follow, looking at connecting community hospitals and nursing homes with CDU, and linking GP practices and community locations with the Friarage.

37

Hambleton and Richmondshire Fit 4 the Future

Summer 2015 Engagement Report

Contents

1. Executive Summary

2. Key findings

3. Format of the engagement work

4. Summer events

5. Conclusions

6. Recommendations

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1. Executive summary

The strategic framework for the Fit 4 the Future project, was agreed at the Hambleton, Richmondshire and Whitby Transformation Board in January 2015 and describes the background to the programme, the key objectives and our approach to be taken in regard to engaging with our public, staff, patients, carers and community group.

The views of healthcare professionals, members of the public and other key stakeholders have been sought from the very beginning of the project, and the engagement period covered by this report is a continuation of this work.

This Engagement Report sets out the “understand and connect phase” conducted during the period of summer 2015, commencing in June 2015 and finishing September 2015. It explains the steps taken to engage the public, which mainly focused upon the summer agricultural shows that are held across the area of Hambleton, Richmondshire and Whitby. It includes the key points raised and recommendations for next steps.

We wanted to involve as many people as possible in having conversations about what is important to them in regard to health and social care and with this in mind, the approach to engagement has been designed to ensure this is possible.

This engagement campaign has been developed to ensure open conversation is encouraged, and people feel able to comment on whichever aspects of the health care is of particular interest to them.

In this phase of the project (summer 2015) we have begun with a ‘deep’ engagement exercise, building upon the initial work of Fit 4 the Future that focused on older peoples services. The engagement undertaken is different from consultation in that the conversations and insight gained were not framed by any options or outline plans. We went to speak to people with a clean slate and no agenda. This enabled us to create a ‘bottom up’ picture of what the public and stakeholders believe to be the issues, concerns and suggestions for the health and social care services within the area.

2. Key Findings

The Friarage

At all the events attended, the Friarage was always mentioned. It was felt that services were slowly being taken away from the Friarage and the =fear that the Friarage would ultimately close was expressed on numerous occasions. The Friarage is seen as the heart of the health care within this area and there was a real desire to ensure that it was kept open. When reassuring people that the Friarage was remaining open and active, the feedback received was that the perceived evidence did not support that commitment. The overall feedback in regard to the hospital was very positive with people feeling that it offered a good service locally and the staff there were appreciated. One concern expressed was around the Friarage MRI scanner appeal. It is felt that the money raised will buy a new scanner, but then the new scanner will be placed at James Cook and the Friarage will receive a second hand one. The thoughts around the Friarage was that it was only a matter of time before it is closed down.

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Transport

The issue of lack of good transport links across the area was of key concern. It was felt that as services moved out of the area that being able to get to the larger hospitals was an issue. It was felt that there are poor transport links, especially in the Dales and people did not want to travel for services that could be offered locally. This applied to patients who were accessing services and also to those who would be visiting hospital stay patients.

Some people were not always aware of the shuttle bus service and therefore did not use it. There were concerns that the timings of the shuttle bus did not always fit in with appointment times at the times at James Cook and this then meant people had to find an alternative means of transport. It was suggested that extending the hours of the shuttle bus and making it a paid service may be options.

The volunteer patient transport service was referred to and people had positive experiences about the service. This is run by volunteers and one lady had been a volunteer for several years and was able to offer insight into the personal value of the service. It seemed that the volunteer transport scheme is able to offer more than just a travel experience but also offer moral and peer support to patients who may be undergoing cancer treatment, as an example.

The Dales

The rurality of the area was mentioned on several occasions in relation to being able to access health and social care. Along with this was the acknowledgement that as people got older, access and transport would become more of a consideration and challenge.

One experience of issues within the Dales was in relation to motorbike accidents. The member of the public felt that they may need to move out of the area due to the number of accidents outside their house and the distress it caused when people called to ask where to leave flowers.

Having services nearer to home was felt to be useful, thus enabling people to remain in their homes. The rurality and reduction in workforce of the area was recognised as a barrier to health care and this caused concern.

When discussions were had in relation to a “Burtzuug model” type of approach for rural health and social care, this was received positively. It was felt that the current model of care was stretched and examples were given where people were aware that care packages had been difficult to arrange.

GP experience

Overall, the experience of patients when accessing their GPs was positive. The GP surgeries were held in high regard and in the majority of cases gave positive feedback as to being able to access appointments and services there. One patient had moved out of the area of their GP, but continued to attend the practice due to the treatment received. Patients felt that they could, on the whole, get an appointment with their GP quickly, thought at times it may mean seeing another GP in the practice.

In regard to the GP extended hours scheme, some people only became aware of it, after reading about the closure of the service and so had been unable to access the service. They felt that if they had known then they would have made use of the extended hours.

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Technology

When discussing technology in health care, people were supportive of the idea and the principle of being able to access health care nearer to their homes and not travel for appointments that could be delivered through technology, for example using Skype for consultations between GP surgeries and patients and for consultant appointments.

The concerns raised were mainly around IT infrastructure due to the lack of full broadband/ internet access in the area.

Social Care

It was felt that social care was sometimes difficult to access as there are a lack of independent domiciliary agencies and there needed to be greater joining up of services between health and social care. One lady had developed and set up her own social care organisation in order to provide local care after being unable to find adequate provision.

End of Life

There were several end of life experiences shared. It was felt that there was not enough support for those wanting to stay at home and the experience of dying within a hospital setting was not always satisfactory. The problem of Do Not Resuscitate forms not being accepted at all hospitals was also raised.

3. Format of the engagement work

We wanted to involve and speak with as many people as possible during the engagement period and to create a relaxed, informal atmosphere in order to develop conversations.

We wanted to approach this engagement period in an open manner, making sure the conversation wasn’t controlled and ensuring people felt they could input in the way they wished to and upon the subjects that mattered to them. Our aim was to start conversations or ‘chats’ with people with no specific agenda or subject matter in mind. This approach, along with the design of the ‘inside out living’ room enabled conversations to be started in a relaxed and informal way. The design was also a talking point for those attending the shows as it moved away from a more traditional NHS model of questions and answers and moved towards having discussions with our public.

With this in mind, we created an ‘inside-out living room’ and went on a roadshow to speak to people within our area. Over the summer months, some of the main activities and attractions within North Yorkshire are the agricultural shows. The size of the shows range from the Wensleydale Show which attracts about 5,000 people to the smaller village based shows, such as Kirkby Fleetham, which was aimed at the village. It was decided to target the agricultural shows that were village based or had criteria of only being able to exhibit and compete if you lived within the catchment area. This was to help ensure that the time spent would be in order to have discussion with people within the area. A lot of the larger shows attract visitors who are out of the area.

Inside – Out living room The concept behind the Inside-out living room was to create a relaxed atmosphere in which to hold conversations. The strapline: “Let’s have a proper chat” was also incorporated and

5 supported by the living room. We had discussions with Herriot Hospice and they kindly loaned us the furniture in order to create our living room and we were able to promote their services as we attended the events. This promoted cross agency working and built relationships with a third sector organisation. People were welcome to come and have a chat and a cup of tea on the settee in a more relaxed environment. The actual set was also a talking point as it moved away from a more traditional NHS model of talking to people.

Inside Out Living Room at Northallerton Carnival and Wensleydale

Promotion of events

In order for people to know that we are embarking upon an engagement roadshow, we promoted the events through a variety of forums. We issued press releases and engaged on social media. We also publicised the events, both before and after, through our monthly newsletter and local newsletters.

In order to promote the events and in order to raise the visibility of the Fit 4 the Future programme, we supported the inside out living room with a variety of branded materials. This included:  Pull up banners advertising “Let’s have a proper chat”  4.5 x 3 m gazebo branded with F4F and “’let’s have a proper chat”  Invitations with all the dates of the shows across the summer  Thank you business cards with additional dates to give to the public

Events Attended Through the months of June, July, August and September, we took the Inside – out living room to:  Northallerton Carnival – 5th July  HRW CCG AGM 7th July  South Tees AGM – 21st July  Borrowby Show – 29th July  Kirkby Fleetham Feast – 8th August  Wensleydale Show – 29th August  Osmotherly Show – 1st August  Muker Show -2nd September  Kildale Show – 5th September

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 Moorcock Show – 6th September

Other engagement included:  Stokesley traveller site  Parents for Parents support group in Catterick

A total of 151 conversations were held over the summer shows.

4. Social media

The primary social media channel for engagement with members of the public was the Fit 4 the Future Twitter account. The main aim of tweeting was to raise awareness of the public meetings and the information resource on the website, and encourage attendance at the events.

Tweets were regularly posted throughout June through to September, particularly encouraging attendance at the events.

The challenge around the social media was as it was a new account, the following was limited. In order to help to overcome this, the twitter accounts of South Tees HT and HRW CCG were also copied into all tweets.

Following established communications principles, tweets featured photos to boost profile and encourage engagement.

The CCG has a Facebook page, which covers general CCG news across all its area. Similar to the promotion on the CCG’s Twitter account, news of the events were added on a regular basis to encourage attendance at engagement events.

5. Conclusions

This period of engagement has been a series of conversations with our public and patients, within new settings, namely the agricultural shows. There were no pre-set questions or subjects to ask people, it was to be information discussions as to their experiences of health care. This was to establish and to start to create relationships with the public as part of an ongoing, longer term engagement plan. With this in mind it can be seen that, whilst there are common themes, it also affords the opportunities for different conversations to happen. The use of a branded gazebo and living room set was also positively received, and to continue to look at innovative ways to engage and converse with people, so that people feel comfortable expressing their views and sharing stories.

Members of the public were primarily concerned with the continued opening of the Friarage. They see it as the centre of healthcare and to lose this, would mean that people would have to travel for an exceptionally long time for treatment. It was seen at the hub of health care and people had a real affinity and loyalty to it.

The findings of the engagement over the summer months confirmed the themes that were expected to arise. People are passionate about local health care and also having good transport links to be able to access health care. The style of discussion allowed for other concerns and conversations to arise. The ability for people to be able to sit and ‘have a

7 proper chat’ allowed for an honest dialogue to occur and people felt they were able to share very personal stories.

In terms of the engagement process we will now look to further develop the engagement plan in order to continue with the conversations with the public. In particular the following groups:  Those living in the Dales within the villages and farms  People accessing urgent care at the Friarage  To consider the nine protected characteristics

A strong theme throughout the feedback provided is the issue of rurality. This is already a strong consideration, but rurality needs to continue to be a major ongoing consideration. The related subject of travel and transport also regularly cropped up; both in terms of local transport links and not knowing about the shuttlebus

6. Recommendations

• Consider the conclusions made in this Engagement Report, and refresh and update the engagement plan where appropriate. • Develop a communications plan to reassure the public in relation to the Friarage • Consider other innovative ways of engaging with the local population, to boost the numbers of people who are able to take part and provide their views. Consider which local organisations may be able to advise on which methods work best for them. • Share this report with members of the public and stakeholders via key communications channels. • To develop a long term plan of engagement to continue with the conversations and further develop relationships with the public.

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NHS Hambleton Richmondshire and Whitby Clinical Commissioning Group Civic Centre Stone Cross Northallerton DL6 2UU

Telephone: 01609 767600 Email: [email protected] Website: www.hambletonrichmondshireandwhitbyccg.nhs.uk Patient Relations: [email protected]

@HRW_CCG

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