Market Overview

Advocacy – A single provider is commissioned to deliver all statutory and non-statutory advocacy across Knowsley utilising a central advocacy hub model. The model facilitates Care Act 2014 guidance to allow a continuity of advocate (where someone may qualify for different advocates under different legislation). A legal duty to provide this service and considered vital in supporting choice.

Social Prescribing (previously known as Community Navigation) – Knowsley Council has commissioned a service called Knowsley Networkers. This contract is jointly funded with NHS Cheshire and Merseyside (Knowsley Place).

Evidence from a Council review of the existing service, as well as an evaluation by Liverpool John Moore’s University (LJMU) in 2019, has informed the design of a new service, which the Council commissioned in 2022 following engagement with partners and stakeholders. This new model, Knowsley Networkers, is designed to offer a more holistic approach to the health and wellbeing of residents (based on the principle that health is often determined by social, economic, and environmental factors, so people’s needs should be addressed in a holistic way).

In a significant change from the previous service, most referrals will now be made via the Healthy Knowsley Service (HKS) Single Point of Access (SPA). Residents who are assessed as appropriate to receive this type of support will be referred to the Knowsley Networkers service for support such as debt advice, befriending and support to access community groups and activities; for example, gardening, arts, group learning, cooking, and volunteering.

Technology Enabled Care (TEC) – (previously been referred to as (AT) Assistive Technology) – Technology Enabled Care helps people to live independently whilst reducing demand for more intensive and expensive forms of support. TEC is regularly used to improve people’s lives and in some cases with life-changing effect.

TEC is available to all people to meet a range of different care and support needs. Most current users of Technology Enabled Care are older people who may suffer from a physical impairment or conditions, such as dementia, which affect their ability to remain living independently at home. We aim to diversify the user group for TEC in the coming years to ensure a wider range of needs are being met.

The majority of current TEC services in the borough are provided by a single provider who is responsible for TEC assessments, installations of kit, monitoring and maintenance, and the operation of an alarm receiving centre.

Carers Support – Knowsley Carers Centre is operated by a locally commissioned charity which provides support to Knowsley carers. They provide a range of services to support and enhance the lives of unpaid carers throughout Knowsley. Knowsley Carers Centre provides, phone-in, drop-in, home visits (Kirkby, Huyton and Halewood) and facilitates core services for carers including the provision of information and advice, emotional support, and empowerment. All carers providing necessary care can access prevention and wellbeing services.

Around 16,500 people living in Knowsley said they provided some unpaid care in Knowsley at the 2021 Census. This equates to 11.4% of those over the age of five, which is higher than the England rate of 8.8%.

Alongside the prevention and wellbeing universal support offer, Knowsley was providing targeted support to 515 carers from the period of April 2021 to March 2022 who have been assessed as requiring additional support from social care to continue in their caring roles.

Domiciliary Care – Domiciliary care is provided to people who live in their own homes but who require additional support with household tasks, personal care or any other activity that helps them to maintain their independence and quality of life. Domiciliary care may be provided to people with learning disabilities, mental health problems, sensory impairment or physical disabilities and older people. Our ambitions around Technology Enabled Care and our current plans for Extra Care result in projections showing that there will be a short-term reduction in need for domiciliary care. However, underlying population trends mean that demand will start to increase again after 2024.

Knowsley Council commissions approximately 13,864 hours of domiciliary care services per week as of November 2022, including 2,345 hours per week funded by Continuing Healthcare (CHC). Packages are commissioned to meet the needs of a variety of service users.

There are currently 4 lead providers, which are allocated across nine specific geographical zones in the Borough. A pseudo-dynamic purchasing system is in place across the borough for approved providers on the Knowsley framework to deliver care on a spot-purchase basis.

Complex Community Support – There are currently 347 people in Knowsley who receive group support in traditional day care settings. The vast majority of these services are delivered by the Council with a smaller proportion delivered in the private sector. The majority of people who access day services in Knowsley are aged between 18 and 64 and have a Learning Disability or Physical Disability. There are also a small number of older people with dementia who also receive support in group settings.

Personal Assistants (PAs) – There were about 535 people who are supported by the Council to employ their own Personal Assistant (PA) in 2022; this is achieved via a Direct Payment. Direct Payments enable people to have greater control over their care and support than using a universal commissioned service or agency. We anticipate that many young people transitioning from children’s to adult services will take up this model of support. To support people to manage their Direct Payments the Council commissions an information and advice service and operates an Open List of providers who can provide support services such as Managed Accounts and Payroll.

Shared Lives Carers – The Shared Lives Carers Scheme is currently managed by Knowsley Council’s in-house provider services. The scheme currently supports 49 people, mainly with a Learning Disability.

Shared Lives is a scheme where carers provide care in their own homes for disabled adults, older people and vulnerable people who need care and support. Shared Lives Carers can offer a permanent home and meet the needs of a person as part of a long-term care arrangement and/or can also provide respite to give permanent carers a break from their caring role.

A review is currently underway with phase one already completed and phase two to be completed by the end of 2023. The aim of the review is to diversify the service to also include support for adults with lower-level mental health needs, and children who are transitioning to adults’ services, as well as to increase the number of Shared Lives Carers who are supporting people in the borough.

Supported Living – Supported Living is a combination of suitable accommodation alongside the delivery of care and support for adults with support needs. Supported Living models and services can vary widely, each person receiving a package of support based on their individual needs.

There are currently a range of Supported Living services across Knowsley, supporting around 338 people. This type of housing ranges from single properties, grouped provision and core and cluster models which have both individual properties and grouped provision on the one site. The care and support in these services is provided by a range of providers and this type of provision is usually accessed by people with Learning Disabilities or Mental Health support needs.

Extra Care – Extra Care housing is a type of housing, which provides care and support that falls somewhere between traditional sheltered housing and residential care. It combines accommodation with care services to support older people as well as adults of working age with support needs. There are many different types of Extra Care housing, from small communities of flats and bungalows to retirement villages.

There are currently 8 Extra Care schemes across Knowsley providing 566 self-contained apartments, all units are designated as social rented or shared ownership and are allocated via the dedicated Extra Care Allocations Policy. The care and support within the schemes is delivered by a range of providers who provide domiciliary care to the residents within the schemes and who also provide the onsite 24-hour support for all residents. As of November 2022, there are approximately 3351 hours of care delivered per week across all 8 schemes.

Residential and Nursing Care – Knowsley has been significantly reducing the number of residential beds it has commissioned over the last 5 years as it escalates its prevention and early intervention programme and the commitment to develop alternative, fit for purpose provision such as Extra Care and Supported Living. However, the pandemic has led to an increase in the number of people accessing long term residential care.

Occupancy levels in Knowsley for the different categories of residential and nursing care with high demand are typically between 75%-85%.

Home First – In Knowsley, the Council and NHS colleagues work in partnership to implement a “Home First” approach. This is underpinned by a variety of initiatives and commissioned services that promote people’s independence and utilise resources that prevent the requirement to enter hospital in some cases, and ensure that wherever possible an individual is able return home from hospital. People are provided with the right support to make sure that happens as soon as possible. Home First also means that where appropriate people are discharged from hospital prior to assessment by a care provider, with the understanding that care and support needs will be assessed in the person’s own home or in a Step-Down setting.

The Council currently has the following measures in place to in respect of services that support our Home First Approach and Step Up / Step Down services:

An internal rapid response service which supports rapid discharge from hospital once someone is medically fit and can support up to five days bridging the gap until long term care arrangements are in place. It can also help prevent hospital or residential care admission or carer breakdown. There is also an internal reablement service which provides short-term, intensive support to people so that they can live independently – typically helpful where somebody has had an illness or a fall, or where they are experiencing a major life change. The service supports rapid discharge from hospital and provides short term care and support for people to return to their own homes and live independently. Regulations require that Reablement Services must be provided free of charge for up to six weeks. The Urgent Crisis Response Team offers quick assessments and treatment in a person’s own home to prevent them from going into hospital due to a clinical or social care issue. This team can mobilise urgently to give a 2-hour crisis response and help people who are at risk of being admitted to hospital due to issues including falls, a need for urgent catheter care, respiratory issues, confusion, or risk of carer breakdown.

Block contract arrangements are in place for discharge to assess nursing care beds allowing people that require nursing care to be accepted into a nursing home prior to the completion of an assessment. Transitional bed arrangements are in place, both for those requiring residential care or nursing care in the short term, while their long-term care needs are planned for, and the required services are commissioned. Individuals will return to their own home where possible. Alternatively, arrangements for longer term residential or nursing care can be made during this period, if this is required to meet the person’s needs Step up / step down apartments commissioned within one of Knowsley’s Extra Care schemes. The Council also commissions Discharge to Assess beds in residential and nursing care settings. Discharge to assess beds allow people who are clinically optimised and no longer require a hospital bed to be discharged to a safe care environment, where assessment for longer-term care and support needs can take place. Commissioned intermediate care beds which provide people with therapy support in addition to standard nursing care provision with an aim to re-enable people and maximise independence, meaning they can return home with an appropriate support package, often including the support of a package of care delivered by a domiciliary care provider.

Ageing population
Many older people are accommodated in residential settings when home-based support would improve their experiences and outcomes. Some older people who have remained living in their own homes, are particularly vulnerable to isolation and loneliness which are contributors to poor mental and physical health. As a consequence of a high number of deaths in care homes, particularly between April and June 2020, combined with a much lower level of referrals to care homes, the immediate impact of the COVID-19 pandemic has been the higher level of available care home ‘beds’ (to around 500 in the City) and under-occupancy (a fall from around 94% average occupancy to 83% average occupancy). It is possible that there will be a more enduring impact on residential and nursing care. However, even before the pandemic, our ambition had been to change the balance of available care and support options for our older residents.

Adults with learning disabilities
In Liverpool, there are currently around 11,700 adults with learning disabilities. Around 1,600 of these adults have an eligible care need and are supported by Adult Social Care services. This number increases by approximately 25 individuals each year as young people move into adulthood. Around 45% of adults with learning disabilities in the city live with their parents. However, it is estimated that 70% of carers over the age of 65 will be unlikely to be able to continue
providing home-based care beyond the next five years. We currently accommodate most adults with learning disabilities within supported accommodation, in shared housing arrangements. However, this combination of accommodation and care means that there are adults who have the capacity to live independently, who are in receipt of 24-hour care. We estimate that at least half of these adults would thrive in Independent Supported Living arrangements and we want them to have choice and control over who provides their care.

Adults living with mental health conditions
Approximately 66,000 people in Liverpool have a diagnosed mental health condition. There are clear links between deprivation and poor mental health, and this is a particular challenge in Liverpool where around 4 in 10 people live in the 10% most deprived areas in the country. Whilst most people requiring support access it via Primary Care or other health services, there are others who require longer term support. Supporting people who have a mental health condition equates to just over 15% of the total Adult Social Care spend. Currently, a large proportion of this spend is on supported living arrangements, which again, don’t always ensure the best outcomes or empower people to live independently. Too often, the care provided to people is dictated by their accommodation rather than their care needs or outcomes.

Homelessness
Overall, homelessness in Liverpool has increased by 300% over the past 10 years. The visible representation of this, to most is the increased number of people begging in the city centre and although this is reflective of some of the challenges we face, there are more significant challenges that aren’t visible to the public; such as people living in temporary or unstable accommodation in the city and households with children living in bed and breakfast accommodation. These challenges were highlighted by the COVID-19 outbreak, during which Liverpool City Council provided emergency accommodation to 490 vulnerably housed people. We used a range of emergency accommodation, including leased aparthotels, spot purchased bed and breakfast and ex-student housing.
In 2019-20, LCC spent £11.4m on homeless and associated services; this included community based prevention services, a Housing Options service, around 750 units of temporary accommodation, street outreach workers, and a day and night hub. In addition to the spend on homelessness services, Public Health spend £12m per year on substance misuse services.

Unpaid Carers
Liverpool City Council and Liverpool CCG acknowledge that effective support for carers needs to go beyond the health and social care system, and beyond public services, and recognise the role that the wider social, economic and cultural environment needs to play in supporting carers.
Informal carers have also been profoundly affected by the COVID-19 pandemic, with many thousands more relatives and friends becoming the critical ‘life-support’, link to community and provider of basic care that people shielding and with care and support needs have relied on. Sometimes carers are stretched to their limits. It is essential therefore, that all sectors and communities take ownership of this issue and work collaboratively with carers and their families to achieve the aims of the strategy

Community Support for Vulnerable adults – we would like to see the market deliver more:

■ Short term enabling provision focused on outcomes such as improving ability to travel, work, and eat a healthy diet.
■ Real social networks that can sustain and support people’s independence on a lifelong basis.
■ Development of independent living and functional skills. This includes adults living in residential care: emphasis for more working age adults planning to move from residential care into supported living.
■ Working with individuals to reduce the occurrence of challenging behaviour by building behavioural skills and by changing aspects of a person’s social environment that affect challenging behaviour.
■ Sustainable employment: provision of support to access employment through evidence-based interventions such as job coaching.
We are also looking to maximise the utilisation of Assistive Technology to increase independence and avoid restrictive practice and locally delivered response services would benefit local communities.

Advocacy
Current arrangements for the provision of independent advocacy will be reviewed and redesigned with a view to have a joint Health and Care Advocacy Hub by October 2021 to accommodate the new Liberty Protection guidelines due to come into effect from April 2022. Further engagement with market and opportunity to co – design will happen over the next 12 months.

Day Opportunities
The Council seek to provide a building-based option for those people with the most complex needs and enabling others to achieve a much more enriched range of opportunities within the community, where enhanced opportunities for employment could be developed.

We need more services in the community that people can buy directly with a direct payment, personal budget or from their own means to provide flexible support for everyday living and independence. We wish to encourage the uptake of Direct Payments and Personal Health Budgets, to help encourage choice and control and diversity of offers in the market.

In general Sefton has a high proportion of Care Homes rated good or outstanding by the Care Quality Commission (CQC). This partly reflects the structure of the Care Home market in Sefton which relies on a significant number of small and medium independent providers rather than a single large national provider and research suggests that in general small to medium homes receive better ratings than larger ones. We hold an ambition to get our all our homes to good or outstanding and will work with Health colleagues and providers to develop a joined up approach to supporting Quality and delivering the best we can to our older population.
Estimates suggest that self-funders occupy around 1,000 of the Care Home beds available in Sefton; and many more are likely to manage their care needs informally through support from family, friends, and neighbours given Sefton’s high proportion of informal Unpaid Carers.
We would welcome discussions with local care home providers about opportunities to secure contracted capacity at the Council’s usual fee.
We would like more homes to have dual residential and nursing registration to avoid people having to move if their needs increase.
We would like more care at home providers to offer same day discharge from hospital and hope to work with providers to understand how best we can achieve this.
In 2020/21 we will begin to explore the opportunities presented by aligning our Care Home Commissioning with our CCG colleagues.
We want our care homes to be equipped to meet more complex needs and to think about how they may start to evolve to deliver further care in the community. We see the future of care home provision as meeting the needs of those with a higher dependency. We are looking for something different from the Care Home Market and we expect greater focus in prevention will mean a decrease I low end needs coming to residential and nursing provision.
We will support the Care Home Market through offering a program of grants for Care Home Improvements, these may be to bring in innovation and technology, improve access to outdoor space or support homes in their quality improvement journey.

Sefton supports approximately 1,920 clients in home care services (including Direct Payment – home care) on any one day and spend 11.8 Million in 19/20. We will seek to move towards a model whereby we are confident that the Home Care resource is used in the most appropriate way and alongside other sources of supporting people to remain independent. This includes the expansion ofreablement, discharge to assess model and Sigle Handed Care
In 2018/19 we spent some £12.3m on care home provision (excludes Direct Payment clients who may be purchasing home care direct) 16% of which is spend on clients under 64. We have the110th Highest Home Care Unit Costs