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Older People’s Accommodation in the Royal Borough of Kensington and Chelsea April 2008 Final Version

Executive Summary 3 1.0 Introduction 5 1.1 The Royal Borough of Kensington and Chelsea 1.2 The Sub-Group Brief 1.3 Methodology 1.4 Membership 2.0 Current provision 8 2.1 Overview 2.2 Registered Care Homes 2.2.1 Patterns of placement 2.2.2 Those funding their own residential care 2.3 Specialised provision 2.4 Extra Care Housing 2.5 Sheltered Housing 2.6 Personal care for people in the community 2.7 Support to Older People living in general housing 2.8 Benchmarking provision 3.0 Population and need / demand 25 3.1 Overview 3.2 Elders from Black and Minority Ethnic Communities 3.3 Localities 3.4 The Need for specialised accommodation and care 3.5 The views of voluntary organisations 3.6 The “discovery” interviews 3.7 Demand and aspiration 4.0 New and emerging forms 41 4.1 International experience 4.2 Good Practice examples from within the United Kingdom 4.3 Understanding Extra Care Housing and what it can offer 4.4 Extra Care as an alternative to Residential Care 4.5 Financial considerations 4.6 Intangible but real benefits for older people 4.7 Extra Care for sale 4.8 Retirement Villages 4.9 Telecare or Assistive Technology 4.10 Housing models for Dementia 4.11 Lifetime Homes

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5.0 Related issues for further consideration 50 5.1 Planning 5.2 Workforce 5.3 Housing Conditions and Housing Needs surveys 5.4 Measuring and assessing rising expectations among

Older People 6.0 Conclusions 53 7.0 Recommendations 56 Annexes 1. The context in public policy 61 2. The current and projected population of older

people in Kensington and Chelsea 67 3. Elders within the Black and Minority Ethnic

communities of Kensington and Chelsea 74 4. Variations in tenure within the Borough 78

5. Understanding Extra Care Housing 81 6. Providing appropriately for people with

dementia 87 7. List of Stakeholders interviewed by

Contact Consulting 92

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EXECUTIVE SUMMARY - THE FUTURE OF OLDER PEOPLE'S ACCOMMODATION IN THE ROYAL BOROUGH The Housing, Environmental Health and Adult Social Care Overview and Scrutiny Committee commissioned an enquiry into residential and nursing accommodation for older people. The enquiry was established to meet the following objectives: 1. To examine the full range of provision of older people’s

accommodation in the Royal Borough of Kensington & Chelsea (RBKC).

2. To assess whether the available provision meets demand (hidden and known) and what is likely to be required in the future.

3. To consider the changing nature of demand, specifically: a. For different types of provision. b. For specialist care, e.g. for people with dementia. c. By different groups, e.g. those who qualify for state support and those who don’t, BME groups.

4. To consider national trends and new developments in residential and nursing care of older people.

The main issues arising out of the enquiry were as follows:

• The population of older people will increase substantially over the next twenty years and the strongest growth will be among the over 85 year old population.

• RBKC are using the Greater London Authority (GLA) population estimates as a predictor of demand for planning services. The Sub-Group believe the GLA figures to be an under-estimate. Their report recommends that RBKC’s current population, as estimated by the Government when calculating the grant settlement, is used as the starting point for population projections in order to plan services.

• Since 2000 the Borough has seen the closure of four residential and nursing care homes for older people: Vicarage Gate, Delves House, Joan Bartlett and Edenham. Although three new homes have been established during the same period overall the Borough has lost 119 places.

• The main findings related to provision in RBKC were: o A lack of choice with few residential places available on a leasehold or shared equity basis. o The number of spaces is declining faster in RBKC than elsewhere; and provision of all types of residential and nursing care is significantly less than the national average. o There is substantial capacity in neighbouring boroughs upon which RBKC is dependent in order to meet its statutory obligations.

• There is a waiting list for sheltered accommodation despite the fact that stock is less and less suitable for older people today. Most stock was built to 1970s standards, is below mobility access standards and many units are bed sitting units, unsuitable for couples.

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• The models of Extra Care Housing employed within RKBC do not meet core national standards. They could be more effective as alternatives to residential care if they were to offer greater choice of tenure, including the sale of leasehold units, and if they were geared to meeting a greater diversity of care need.

• The Sub-Group commissioned research among older people in receipt of residential, nursing or home care support. A number of respondents felt that with more support they could have remained in their existing homes. Most older people value their independence and wish to remain in their own homes for as long as possible.

• The research made clear that the quality of life for older people rests on more than the provision of practical services. The meeting of their social and emotional needs is just as important. This is reflected in not just what they receive, but in how it is delivered to them and the sensitivity with which care is administered.

• There are a large number of older people living in the borough whose assets disqualify them from local authority support but who cannot afford private residential and nursing care places.

• RBKC have not made a commitment (beyond using best endeavours) to the Lifetime Home standard. This and other factors undermine attempts to enable older people to remain in their own homes for as long as possible: o Shortage of care staff in the borough. o Pay rates for care staff and issues around the standards of spoken English on the part of carers. o Pressures on the budget for Disabled Facilities Grants.

• In spite of these issues there has been a significant increase in the number of older people in receipt of home care. New services have been made available under the ‘Staying Put’ umbrella and RBKC is one of the few London boroughs to continue to deliver care at home to those in “moderate need”.

• The policy of the Borough has been to retain land and buildings formerly used by older people for their continued use. However enforcement of the policy has been lacking.

• There is a need for the conclusions drawn in this report concerning the future provision of all forms of accommodation for older people to be carried through into the development and enforcement of Planning Policies that defend the interests of our older residents.

A summary of the recommendations made by the Sub-Group in response to the above issues can be found on page 56.

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1.0 INTRODUCTION 1.1 The Royal Borough of Kensington and Chelsea In size of population Kensington and Chelsea is one of the smaller London Boroughs and among the Inner London boroughs larger only than the City of London. It is a borough in which averages can be deceptive. For example, the average level of deprivation is low when compared with the average for England. However, wards in the north of the Borough exhibit signs of having some of the most acute levels of deprivation in England. Although RBKC has a relatively young population it does face the challenge of responding to the needs of older people within its communities. The number of those in advanced old age has increased and will continue to increase over the coming years. That increase carries with it a growing demand for services that will support independence and dignity in old age. At the same time there is within that older population enormous diversity, with significant differences of age, financial circumstances, health, culture, religion, and informal social networks. There can therefore be no one response to their needs for accommodation and care. The strategic approach must be that whatever their circumstances older people should have access to a range of choices that reflect their circumstances and aspirations. The direction of policy and the rising expectations of older people converge in a move away from established patterns of provision toward a more diverse range of opportunities that will provide genuine choice and quality of life: Levels of owner-occupation continue to rise and increasingly older home owners are looking for options in old age that will allow them to maintain their tenure of choice. There are significant challenges to be faced in maintaining the appeal of existing sheltered housing schemes for a rising generation of older people. Their expectations in relation to space standards and amenities are higher than the generations whose requirements the design of these schemes reflects. New, housing based, models are emerging such as Extra Care housing that offer the prospect of high levels of care and support but in a non-institutional environment. The capacity of these forms to provide an adequate environment for those who would otherwise have been directed to Registered Care Homes adds a complication to consideration of the volume of Registered Care that will need to be available to meet the current and future needs of older people in Kensington and Chelsea. This report seeks to examine the implications of some of these newly emerging challenges for current and future housing, health and care commissioning policy in the Royal Borough.

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1.2 The Sub-Group Brief The Sub-Group was created with a brief that it should undertake the following: 1. To examine the full range of available provision of older persons'

accommodation in the Borough. 2. To consult with all existing providers of older persons' accommodation

in the Borough including the TMO which provides Sheltered Housing, and the Royal Hospital.

3. To assess whether the available provision meets demand, both demand that is known about and possible demand that is hidden. To what extent was there an element of choice?

4. To consider whether there is potential over capacity. 5. To consider the changing nature of demand:

- for different models of care such as sheltered, extra care, full nursing etc and the possibility of future alternative models e.g. from the USA, - persons with special needs, - persons with dementia, - changes in the private residential market.

The Sub-Group also indicated a number of topics it wished to look at within these terms of reference: (i) the USA approach to the private sector/leasing, (ii) models of good practice elsewhere in London (and possibly elsewhere

in the UK), (iii) the views of local voluntary groups, (iv) residential homes staff recruitment and retention, (v) population projections/estimates. 1.3 Methodology Having confirmed its remit and identified a number of specific questions that it wished to address the Sub-Group :

(i) received preliminary presentations from representatives of Care UK

and Draycott Nursing, (ii) appointed an external consultant, Nigel Appleton of Contact Consulting, to assist them in assembling and reviewing evidence, (iii) received a number of briefing papers that set out the context for their considerations, (iv) considered a number of matters that form the basis of their report.

The Consultant drafted materials that provided a view of the current and future population of older people within the Borough, their likely needs, the current range of services and facilities available to meet those needs before reviewing some of the new styles of service that may be appropriate in exploring a new pattern of service.

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The Consultant also interviewed some twenty stakeholders who either commission or provide a range of accommodation and care services in the Royal Borough. In addition a range of accommodation and care providers were surveyed to more clearly establish the volumes and nature of placement behaviour and representatives of voluntary organisations were consulted. The Sub-Group encouraged the Consultant to explore more fully the data on current and future population, believing this to be the cornerstone of their enquiry, and sought clarification in the data provided on the supply of accommodation and care. The Sub-Group identified and debated the issues that have enabled them to come to a view of the adequacy of current provision, the desirable direction for future development and to formulate their recommendations. The Sub-Group recognised that the operation of the Authority’s Planning powers could be influential in shaping and encouraging the future pattern of provision and sought specialist advice from the Planning Officer. 1.4 Membership The membership of the Sub-Group comprised:

Councillor Margot James (Chairman) Councillor Christopher Buckmaster Councillor Emma Dent Coad, MA Councillor Dr Iain Hanham, MA, MSc, DIC, FRCP, FRCR Councillor The Lady Hanham, CBE Stella Baillie - Head of Adult Social Care, RBKC Peter Molyneux- Chairman of Kensington and Chelsea PCT Gwyn Morris - Head of Older People Services, RBKC (has now left RBKC) Amanda Johnson - Head of Supporting People, RBKC (now on Maternity Leave) Liz Zacharias - (Acting) Head of Supporting People, RBKC Peter Ebenezer - Continuing Care Manager /Lead, Kensington and Chelsea PCT Cynthia Dize - Director, Sixty Plus Angela Hamlin – Managing Director Draycott Nursing Gareth Ebenezer - Governance Services, RBKC was the Sub-Group's Administrator

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2.0 CURRENT PROVISION 2.1 Overview There have been substantial changes in the volume and range of provision of registered care places within the Borough in the past two years. The closure of Joan Bartlett House removed thirty beds and the closure of Edenham removed a further forty five beds of which twelve were designated for people with dementia. At the same time there have been a number of gains:

• The opening of the accommodation at Highlever Road has added five new dementia places

• James Hill House has opened providing twenty-eight Extra Care places • Ellesmere House, open in Spring 2008, will, when fully occupied,

provide ten rehabilitation beds, twenty personal care beds for people with dementia and thirty Nursing Home beds.

The impact of these changes are summarised in Figure One Figure One Gains and losses in bed spaces 2005 to date Gain Loss Cumulative Gains

and losses Establishment Older

People Dementia Older

People Dementia Older

People Dementia

Joan Bartlett 30 -30 Edenham 33 12 -63 -12Highlever House

5 -7

James Hill House

28 -35

Ellesmere House

40* 20 +5 +13

*Includes rehabilitation beds Over the period there is thus an overall gain of five places for older people in general and a gain of thirteen places for people with dementia. However these additions come after a period of significant reduction in the registered care home beds provided within Kensington and Chelsea. Both Delves House and Vicarage Gate were closed in 2000/2001 which removed 132 beds. These changes have happened against a background in which the PCT and the officers within the local authority responsible for the accommodation and care of older people have been convinced that there is sufficient capacity in the registered care home sector to provide for the needs of those older people for whom the statutory authorities have responsibility in Kensington and Chelsea. Others, including a number of elected members, have been equally

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sure that the loss of places has led to under capacity and a limited number of options for those who choose and fund their own care. 2.2 Registered Care Homes There are nine Registered Care Homes within RBKC, five providing personal care and four providing nursing care. Figure Two Registered Care Homes in RBKC providing personal care

Places designated for older people

Places designated as dementia care

Number of places Of which RBKC

Alan Morkill House 26 21 47 28

Mary Smith Court 16 16 8

St Teresa’s Home 25 25 4

St Wilfred’s 44 44 4 Thamesbrook 20 20 20

152 Figure Three Registered Care Homes and Homes operated by the NHS

in RBKC providing nursing care Care provided Number of places

Avon House Nursing Care 35 Princess Louise Nursing Care 53 Thamesbrook Nursing Care 36 The Kensington Nursing Home Nursing Care 53 Total Places Nursing Care 202

To limit the computation of places available to older people in RBKC to establishments located within the Borough’s boundaries is of course artificial. There is substantial capacity in neighbouring boroughs and some will be closer to the parts of RBKC in which people live than establishments within RBKC itself. Figure Four Registered Care Homes in neighbouring boroughs

but close to the boundaries of RBKC

Places designated for dementia Places for older people

LB WANDSWORTH

Ashley House Personal Care 16

Dawes House Personal Care 29

George Potter House Nursing Care 33 36

Meadbank Nursing Care 176

WESTMINSTER

Forrester Court Nursing Care 110

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Norton House Personal Care 38

Westmead Elderly Resource Centre Personal Care 42

St Georges Nursing Care 44

HAMMERSMITH & FULHAM

Farm Lane Care Home Personal Care 24 40

Gloucester House Personal Care 15 51

St Vincent House Personal Care 48 44

The Wakefield Centre Nursing Care 102

Nazareth House Nursing Care & Personal Care 25 70

2.2.1 Patterns of placement The selection of a Registered Care Home needs to reflect proximity to the community in which people have been living or have family or social connections, and their own preferences. Some chose to be located outside RBKC because it returns them to a community in which they formerly lived, or where they have family or other connections. In some cases the motivations for the choice of location will be known only to the individual concerned and their care manager and on occasions this has led to misunderstanding. There is a widely held view, based on anecdote, that people are forced to move considerable distances outside the Royal Borough to find a place in a Registered Care Home. We have been unable to establish any evidence that this is more than an isolated problem. There would appear to be a legacy issue here. Best practice in the past was not as focused upon placing people within the Borough or very close to its boundaries. This has meant that the current population of older people supported by the Authority in Registered Care Homes is widely dispersed. RBKC currently supports 279 people in Registered Care Homes, the majority of whom are in homes outside the Borough. One hundred and thirty one of these are in registered care home places providing personal care and 148 in Registered Care homes providing nursing. A high proportion of those supported by RBKC are either experiencing high levels of physical frailty or some level of mental confusion. The Royal Borough currently makes relatively few allocations to Registered Care Homes (slightly below 50 a year). This very low level is made possible by the availability of care packages that allow people to return directly to home from hospital, rather than making a temporary move to a Nursing Home that may have in the past proved to be permanent. This we feel reflects effective collaborative working between the Authority and the PCT.

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Contact Consulting, has undertaken a survey of the Registered Care Homes within RBKC and a further ten in locations in Wandsworth, Westminster and Hammersmith and Fulham that were close to the boundary of RBKC. With one exception, where difficulty was reported in attracting residents, all reported that they were able to fill vacant places fairly readily and that the number of vacancies available in any given week was limited. However they also reported that only rarely did they turn people away on grounds of capacity. Extensive interviews with staff within the Authority, and from provider organisations indicate that they are confident there is sufficient capacity to meet need. This confirms the assessment that capacity in Registered Care homes within the Borough and in adjacent boroughs is sufficient to offer appropriate options for the placement of people within Kensington and Chelsea who need such provision. Regular reviews of older people placed outside the borough suggest that their location is not a significant problem for them. Current placement practice reflects greater attention to retaining people as close as possible to their former residence than was the case historically. Where individuals are placed outside the borough it is usually because they have specific needs (for example dementia care or functional mental illness) that cannot be appropriately met within the borough. This may be because the specific service is not available or that the locally provided service is significantly more costly. The opening of Ellesmere House has provided a greater capacity to place a larger proportion of older people needing care within the borough boundary. 2.2.2 Those funding their own residential care There is limited evidence about those older people living within Kensington and Chelsea who have chosen their own Registered Care Home and are meeting the cost from their own or other private resources. It is not possible to estimate the numbers of those who may have chosen to move out of the area to secure the accommodation and care they require. The census data seems to suggest outward migration of older people but the desire to secure a place in a Care Home may be only one of many possible explanations. Existing providers of Registered Care Homes who accommodate both self-funders and those supported by local authority funding report a good level of demand but adequate capacity. There is also some appetite among care home providers to offer new developments based on their assessment that there will be a market for attractive Registered Care Homes within the Borough. Repeated approaches have been made to private sector providers of care, seeking to establish the proportion of those whom they serve who meet the cost of care from their own resources. We have received some indications from those providing registered care homes both in the Borough and in surrounding areas. However, attempts to survey those delivering care to that larger group currently funding their care at home who may, in the course of

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time, be looking to self-fund their care in a residential setting have been less successful. The question that no-one can answer is “What demand would there be from older people within the Borough for new, high quality care provision?” Whether a proportion of those whom it is presumed move out of the Borough to secure high quality care of their choice would stay within Kensington and Chelsea can only be a matter of speculation. Such decisions are dependent on a range of factors such as the advice available to people, the circumstances in which they make their decision, the range of options they believe to be available to them and their attitudes to those options. The analysis of the likely prevalence of conditions suggesting a need for accessible accommodation and the provision of care apply to people in all parts of the Borough and in all economic circumstances. This suggests the probability of unmet need but there is no immediate way of quantifying this and responding to that potential need is a matter for commercial sector providers. If such provision is to be encouraged then there are appropriate levers through the Planning process. The evidence from a number of larger commercial providers is that those with the means to finance their own solutions to their accommodation and care needs tend increasingly to opt for a solution built around lifestyle rather than a traditional Registered Care Home. This would suggest that any deficit in current provision would be better met by the encouragement of a range of developments that reflect the Extra Care Housing or Continuing Care Retirement Community models. These would be built to specifications that meet the expectations and financial resources of the full range of social and economic circumstances to be found in the Borough. This would have the consequence of encouraging developments by “social” developers that would be accessible to those with limited means, through “middle market” offering to high end developments to cater for those with substantial resources. 2.3 Specialised provision The provision of specialised settings for the care and support of older people is further supplemented by the provision of twenty-eight Nursing Places at 3 Beatrice Place which accommodates older people with functional mental health problems. 2.4 Extra Care Housing RBKC currently has seventy-six units of accommodation in three schemes that are designated as Extra Care. Currently there is no nationally agreed definition of Extra Care and there are a range of quite different models operating under this generic label. Whilst the three schemes in Kensington and Chelsea offer significantly greater care support than sheltered housing and all operate as effective alternatives to residential care they do not embrace all of the features that are increasingly recognised as best practice.

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Extra Care Housing aspires to offer more than accommodation and the prospect of access to care services. It looks to provide a positive lifestyle in old age. It will thus generally include imaginative communal facilities: exercise suite, hairdressing facilities, possibly a shop, art and craft rooms, a restaurant, a bar, internet connection, and so on. This will be provided within a culture of activity, learning and participation by those who live in the scheme. Typically they will look to attract a population of mixed levels of dependency. Care services will be dedicated to the scheme with a commitment to support people in place as their levels of need increase. Good practice for such schemes suggests that they should be developed on a mixed tenure basis. Providing an alternative to sheltered housing at one end of the spectrum and to residential or even nursing care at the other Extra Care offers a positive and inclusive alternative option. The three Kensington and Chelsea schemes are comparatively small in scale and as such are not able to offer the range of services that larger schemes make more economically and operationally viable. They are also increasingly focussed on being an immediate alternative to residential care. The threshold for allocation or placement is that the older person should be in need of at least nineteen and a half hours of personal care per week. The impact of this is that increasingly the schemes have populations of older people with high care needs only. Figure Five Extra Care Homes in RBKC

Provider Number of places Burgess Field RBKC 28 Miranda House Octavia Hill HA 20 James Hill House Octavia Hill HA 28

76 If the “mixed population of dependency” model is adopted, as emerging best practice would suggest, then the level of substitution for Registered Care places that can be achieved will be around one third of the Extra Care places provided. Thus if a further ninety-six units of Extra Care were to be developed it they would provide thirty-two places that would substitute for Registered Care Home places. In many areas the development of Extra Care is being seen as a means of re-providing older examples of sheltered housing, providing a more positive environment for those with significant care needs than will generally be found in Registered Care homes and a cost-effective option for Social Care budgets. 2.5 Sheltered Housing Sheltered Housing has been a core strand in the provision of specialised accommodation for older people. Its role has changed over the years and the model has been adapted in the fifty or so years that Sheltered Housing for rent has been available. Much of what is available is provided for rent from the RBKC and from Registered Social Landlords. There are currently one thousand and eighty-six units of sheltered housing for rent within RBKC.

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Whilst some of the stock has characteristics that in other parts of the country, or even other parts of London, might be leading to difficulties in attracting new tenants that is not the case in RBKC. For the stock in the management of the Local Authority demand is reported to be strong with three hundred and eighty-two current applications awaiting vacancies and void levels being below recognised performance standards. Figure Six, setting out the age structure and mobility limitations of those currently applying for sheltered housing, shows that a substantial proportion of the demand is from people in early old age with no mobility problems. Other forms of small and easily managed accommodation might be more appropriate for their needs than the style of accommodation and support available in sheltered housing. Such alternatives are not widely available in Kensington and Chelsea, particularly in the social rented sector. If such provision were available a substantial proportion of the current demand attributed to sheltered housing would be dealt with in other ways. At present inappropriate allocations are made for lack of alternative which leads to less than optimum outcomes for older residents and those younger tenants mis-allocated. Figure Six Applicants for Sheltered Housing at March 2008 Age Range

Mobility Category Total

MOB 1 MOB 2 WC 1 WC 2 Not Applicable

50-60 1 1 0 0 12 1460-65 6 13 55 7465-70 7 11 45 6370-75 10 14 2 42 6875-80 6 7 24 3780-85 10 6 14 3085-90 2 2 9 1390+ 1 8 9Total 308MOB 1 Requires level access, cannot manage any stairs MOB 2 Can manage up to 6 external steps WC 1 Person fully dependent upon wheelchair, including throughout the home WC 2 Wheelchair users within the home but not required in all areas Continuing strong demand masks underlying problems arising from the age of much of the stock and limitations in its design. The overwhelming majority of the sheltered units have limited accessibility. Currently a survey is being conducted of the accessibility of housing stock, benchmarking the individual units against accessibility standards. This study has been led by the senior occupational therapist in Housing. The results of the survey should be available in April 2008 and are anticipated to present substantial challenges for current provision. Space standards and facilities also reflect the standards of the 1970s and 1980s rather than contemporary and future expectations. Almost 70% of the RKBC TMO stock is bed sitter or studio flat accommodation with no separate

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bedroom. Even the designated Extra Care scheme, Burgess Fields has predominantly studio flat accommodation Built some 22 years ago, before the concept of Extra Care was developed in most parts of the UK the scheme is of overall attractive design but presents substantial problems of accessibility within individual units. A survey of Registered Social Landlords suggests that demand for their stock is also strong with difficulties arising from the operation of Nomination Rights rather than from any lack of demand. Bedsit accommodation is also a feature of much of the Registered Social Landlord stock. A feature that has emerged over the past few years is for the bedsit accommodation to be let to comparatively younger men, of whom some have alcohol or drug dependency problems. Often the nature of the accommodation and available of low level support through the Warden Service is an appropriate response to their needs. However the introduction of these tenants with complex needs into a traditional sheltered housing environment can lead to difficulties and change not only the original intention of the provision, for frail elderly persons, but the character of the populations of some of the schemes. This has led most of the RSL providers to consider the development of strategies for future remodelling. The challenge remains of how these individuals who are approaching old age, or are in early old age, and have complex needs may best be supported and the solution may well lie in the designation of a specific scheme that will provide the support services they need, rather than mixing them with a traditional sheltered housing population. For some providers these are not priorities for development action at present in RKBC when compared with their stock in other boroughs of the UK because demand within Kensington and Chelsea continues to hold up. However most providers interviewed felt that in the longer term this would be a problem in RKBC. There is a legacy within RKBC of a significant number of people accommodated within single rooms in highly desirable large properties, often in protected tenancies, who in advanced age require alternative accommodation. These people currently represent a continuing demand for bedsit provision. It is difficult to determine how long this type of demand is likely to be sustained as expectations in the population increase. The ratio of provision of sheltered housing in RBKC (that is places per thousand of the population seventy-five years of age or over) is 118 per thousand compared with the average for England of 136.2 which would not be considered to represent serious under provision. Note: The provision of places at the Royal Chelsea Hospital have not been included in any calculations as these places are not available to the generality of older people living in the Borough. The challenge is much greater in relation to the provision of sheltered housing that may be purchased by those older owner-occupiers who wish to maintain their existing tenure. There are currently only two leasehold retirement

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housing schemes within RBKC providing a total of sixty units of accommodation. Around thirty percent of those seventy-five years of age or older living in RBKC are owner-occupiers. Whilst many older people may be making provision for themselves through the purchase of serviced accommodation that is not specifically intended for older people the indications are there is a latent demand for an increase in leasehold retirement housing. The further challenge in relation to sheltered housing is to encourage the strengthening of the current model so that it may support an ageing tenant population without the need for the majority of them to transfer to other accommodation. This may be through the provision of additional facilities, such as those for assisted bathing, through improvements to standards of accessibility both within individual flats (for example the substitution of level access showers for baths) and in the common parts of the scheme, through the development of dedicated care services and other forms of support. 2.6 Personal care for people in the community The Authority has a responsibility under legislation to provide assessment to older people whose conditions suggest that they would benefit from services to meet their personal care needs. Having established that an individual has a need that meets the criteria the Authority has established there is a responsibility to ensure that the need is met. This may be by directly delivering and/or funding a service or by providing advice and support to the individual and their carers in securing appropriate assistance for which they will themselves provide the funding. Social Care staff, and their NHS partners in joint services, carry out assessments. Care plans are developed which specify the services to be provided to meet the users and their carers needs and support them to live as independently as possible. In 2006 / 2007 3356 older people received services during the year of which 2889 received services in the community (i.e. in their own homes rather than residential or nursing care). 1631 older people received home care in the year and hundreds received day care, meals, professional support, equipment and adaptations and other services. Packages of care vary greatly according to need – from small preventive packages to intensive home care (over 10 hours and more than 6 contacts visits per week). In September 2007 329 people received intensive home care in a sample week - a substantial increase over 229 in a comparable week in 2006. In addition an unquantified but substantial number have received care from private agencies which they arrange and fund themselves. Repeated approaches to the agencies delivering services to people in these circumstances have failed to elicit data on which a reliable estimate might be based. The experience of the member of the Sub-Group who works in this field suggests that the numbers are substantial. Carers of older people are entitled to assessments in their own right and provision of carers services to help them continue to offer support. Kensington

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and Chelsea’s current provision of carers services is rated as excellent with 639 receiving a service in 2006/2007 up from 508 in 2005/2006. Support to carers is an important part of the strategic response to the ageing of the population. The vast majority of low level support that allows older people to maintain their independence is provided informally through family, friends and neighbours. Providing support and information to those providing this informal care and support is an important part of supporting people within the community and limiting their need for formal care and support services or a move into supported housing or registered care. The response to the needs of carers includes the provision of respite in various styles and for varying periods. There are often difficulties in providing these opportunities through the evening and at weekends. The capability to respond to these needs has increased but will need to continue to expand if carers are to be appropriately supported. A wide range of services are supplied by both council and external providers. Increasing use is made of “telecare” or Assistive Technology (community alarms and peripheral devices that can be added to them) to improve safety. The Community Alarm Service(CAS), managed by the TMO has a comparatively small client base of 2,500 with 1,400 units in sheltered accommodation and 1,100 dispersed alarms in general housing. The majority of these are providing a service to frail elderly persons, offering not only the security of monitoring and accessibility to contact with designated carer key holders but for an additional premium access to a floating support service provided by the TMO. At the time of the Supporting People implementation a decision was taken that the Community Alarm Service contract would include all users of the service known and in receipt of Housing Benefit. This had the effect of limiting any ability to provide the service to self funders or those referred through Adult Social Care. Following review of these arrangements three levels of service are now provided: the Community Alarm Service alarm, a Community Alarm Service monitoring service (key holders and emergency assistance) and a floating support service. Presently the monitoring and floating support services are operated on a cross tenure basis. To determine whether a person should pay for the service a financial assessment is offered. Our interviews with stakeholders suggest that whilst this is an effective service it is not as well integrated into the overall system as it could be and there is substantial scope for development expanding its potential for monitoring both the safety of individuals and the services delivered to increased numbers of older people in the community. More advanced forms of Assistive Technology utilising sensor technology to monitor falls, domestic flooding, gas leakage and door entry systems are proving to be increasingly popular. Although there are currently only 170 advanced Assistive Technology packages installed and monitored by the TMO the majority of these have been provided in the last six months following the appointment of a dedicated technology assessment officer within Adult Social Care. It is predicted that the demand for this service is likely to continue

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to expand, particularly with the predicted growth of the numbers of people Assistive Technology is currently time limited and therefore any substantial additional growth in this service is likely to present future challenges to the Authority unless it can be more closely integrated into the overall system of provision. Most older people want to remain in their own homes and Kensington and Chelsea has one of the lowest rates of permanent admissions to residential and nursing care in the country. In large part this is a consequence of the development over recent years of an effective preventative partnership between the PCT and Adult Social Care. Agreements on the use of Continuing Care Beds and the joint development of Intermediate Care and Re-ablement services such as step up/step down care, rehab services and intensive post hospital discharge care packages have substantially reduced the demand for long term residential and nursing care. There are still gaps in terms of respite care and improved community health care particularly to people in supported housing to sustain some of these joint developments, but in the view of most stakeholders the system works well compared with most neighbouring Authorities. The threshold for accessing care in RKBC is comparatively low when compared with most of the UK which greatly assists the joint preventative agenda. However some stakeholders would identify gaps in service for those in moderate need where a lack of information on access to service tends to suppress demand if not reflect hidden need, particularly for those deprived of limited means and for some who are asset rich but income poor. The number of older people supported to live independently at home (as defined by performance indicator C32) has risen from 1641 in 2002/2003 to 2017 in 2006/2007. The Royal Borough is a pilot site for Individual Budgets through which users receive a pot of money and commission their services themselves (with support if necessary). The government is committed to personalisation of care and self-directed care including Individual Budgets will be a growing element. The ability to support older people in their own homes has an obvious impact upon demand for specialised housing and for places in registered care homes. The willingness of the Authority to fund quite large care packages will allow some who wish to do so to remain in their own homes longer. In addition to the provision of care there is a need for support of a less specific kind, this may be re-assurance, information and encouragement. The Floating Support service provides a range of services:

• Assisting with the completion of forms and official letters • Checking welfare and benefit entitlement • Help in accessing GPs, health and local authority services • Giving advice on accessing counselling and care services • Accessing community and leisure facilities • Giving support and guidance through transition and difficult periods.

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The availability of these services is relatively limited at present. The three schemes currently operating have capacity to support three hundred and sixty two clients. The style of the service may deter some who can finance solutions to their practical needs but need access to support and advice. There is considerable scope for development of this service. 2.7 Support to Older People living in general housing The majority of older people living within the Borough live in general housing (that is to say not in residential or nursing care, nor in sheltered housing or one of its variants). Many of them maintain their independence relying only on their own capacity or that of informal carers, family members and so on. For those who are tenants the major elements of repair and maintenance of the property they live in will be the responsibility of their landlord. For home owners these responsibilities fall on their shoulders and some experience difficulties: both practical and financial in managing matters of repair, maintenance and adaptation that will keep their property in good condition and suitable for their needs. There are a range of services across the Borough that respond to these needs:

• The Staying Put service that provides advice and assistance in arranging repairs, maintenance and adaptation.

• A Handyperson service to provide help with small tasks that it may be difficult to arrange by other means from changing tap washers to putting up curtains.

• The Housing Advice service to provide information and advice on housing options and to help resolve housing problems.

Staying Put provides a range of services to assist older home owners in improving, repairing and adapting their homes so that they may continue to live in them independently. The service includes the provision of a Housing Advice Service. The handyman or small repairs service operated by Staying Put was a grant funded service wholly commissioned by Adult Social Care to provide small repairs to older people and people with Physical Disabilities. Staying Put also received monies for the Sanctuary Scheme and a furniture service via mental health. Supporting People provided funding under contract to contribute to the HIA's overall work but with no funding or involvement with the handyperson service as these were, until very recently ineligible for Supporting People funding. Difficulties with the delivery of the Handyperson service led Adult Social Care to consider the withdrawal of their funding. The importance that Supporting People attaches to the service in helping older people and other vulnerable adults to maintain their independence led them to negotiate with Adult Social Care a joint funding arrangement, setting new targets, introducing a new Service Level Agreement that will encourage the delivery of a more “joined up” service, and to bring all HIA services under a contracted performance managed framework.

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These services are perhaps not as well known to all older people in the Borough as they might be and the extent of service is determined more by the availability of funding than by the extent of potential need or demand. The indicators of need shown in the following section suggest that a large number of older people in Kensington and Chelsea, many of whom are living in general housing, would benefit from an extension of these services. Current good practice would also suggest that there is scope for the existing services to extend the range of what they offer with greater attention being given to preventative services: the provision of home safety checks and remedial services to respond to them for people in all tenures, advice on low maintenance solutions for homeowners are two examples. The provision of adaptations is an important element in maintaining independence for older people, regardless of tenure. The Borough has a programme for delivering adaptations but the rising numbers of people living into advanced old age will continue to exert pressure on resources. Research has demonstrated that the key element in the provision of adaptations is timeliness. If maximum benefit is to be achieved for the recipient and in relation to maintaining that person in their own home for as long as possible the adaptation needs to be delivered speedily. Expenditure on Disabled Facilities Grants for the larger adaptations has increased more than eightfold in the last 3 years from a very low base of £50,000 per annum to over £400,000, but demand will continue to increase and there is no scope for complacency. Relationships between occupational therapy services, grants officers and the Staying Put Agency appear strong and effective. Waiting lists for major adaptation are comparatively short and the turnover time for work is good when compared with most other parts of the UK. However the handy person service specialising in small jobs and maintenance support is heavily oversubscribed with long waiting times. RKBC only currently funds one half of a handy person post on the Staying Put agency establishment. 2.8 Benchmarking provision In the appendices to the report of the Royal Commission on the future of long term care there are statistics on what was then the level of provision of specialised accommodation for older people. By expressing this as a ratio to the population of people at various age thresholds we can obtain a benchmark figure for historic levels of provision, as shown in Figure Seven. In practice the key indicator will be the ratio to the population of 75 years and above as this is widely accepted as a threshold age for appropriate entry to specialised housing, residential care and nursing home care.

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Figure Seven Provision of places for older people in England

Number of units/places

Per 1,000 of the population 65 +

Per 1,000 of population 75+


Sheltered and very sheltered housing 516,524 68 136 491

Residential care places 288,750 37 76 274

Nursing home places 157,500 20 42 150

(Source: Contact Consulting, based on PSSRU for the Royal Commission on Long Term Care and ONS projections) Figure Eight Provision of places within the boundaries of RBKC

Number of units/places

Per 1,000 of the population 65 +



Sheltered and very sheltered housing (includes 1/3rd Extra Care Housing)*

1,093 56 118 436

Residential care places (includes 1/3rd Extra Care Housing)*

203 10 22 81

Nursing home places 202 10 22 81

*This assumes that Extra Care would normally be occupied in a ratio of 1/3rd having housing and social needs, 1/3rd having low care needs and 1/3rd having higher care needs The Figure demonstrates that provision within the boundaries of Kensington and Chelsea are significantly below national averages. The reasons for this are undoubtedly complex and include past difficulties in developing within the Borough given high land costs and the difficulty of securing sites, along with recent reductions in some categories of provision that are elaborated upon elsewhere in this report. These comparisons should therefore be treated with some caution and the available capacity in the neighbouring areas of surrounding boroughs borne in mind. In recent material from the Department of Health and Communities and Local Government a series of norms have been suggested as a basis for planning future levels of provision that reflect changing patterns of provision, the direction of policy and guidance, and the changing needs and aspirations of an ageing society.1 These norms are all set at 2001 population levels, projected forward this means that, as numbers in the upper age groups increases, the ratio of institutional and specialised housing provision will

1 More Choice, Greater Voice (February 2008) Department of Health and Communities and Local Government

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decline, in line with national government targets to support an increasing proportion of older people in their existing homes. These “norms” are inevitably arbitrary and may be moderated to take account of the rate of change that would be required to meet them. The pattern projected is for the medium to long-term and may need to be adjusted as newer forms are developed and mature. Applied to the population of those seventy-five years of age and above in Kensington and Chelsea it becomes clear that provision in the Borough is significantly at variance with national norms and typical profiles. Figure Nine Applying Benchmark Norms Type of provision

Benchmarking ratio per 1,000 75+

Resulting Number

Comment

Conventional sheltered to rent

50 465

Leasehold Retirement Housing

75 697 The lower than average level of owner-occupation in the Royal Borough and the high cost of development suggests the figure projected is unrealistically high

Enhanced Sheltered Housing

20 186 This would be equally divided between rented and leasehold stock and represents what improved sheltered stock might become.

Extra Care Housing

25 232 The low levels of provision of Registered Care suggest that this figure should be higher for Kensington and Chelsea. The provision should be divided between renting and leasehold ownership.

Housing based provision for dementia

10 93 This is in addition to the inclusion of “dementia sensitive” features in other categories

Registered Care offering Nursing Care

65 604 This figure, although reflecting a moderate reduction in most parts of the country far exceeds the current level of provision in the Royal Borough.

Registered Care offering Nursing

45 418 This figure, although reflecting “steady state” against the typical position across the country far exceeds provision in the Borough.

The identified issues are principally around:

• the appropriateness of some current provision, • whether any limitations in current provision should be met by the

development of conventional Registered Care Homes or by new forms, • whether capacity in the whole system needs to be expanded in

preparation for a future growth in the older population and • what encouragement should be given to the development of provision

for those who do not access the accommodation and care they need through the statutory services route?

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SUMMARY OF SECTION TWO

1. The Royal Borough has in the main coped well with the re-provisioning

of in-house residential care services and there currently appears to be a reasonable balance of demand and supply in both residential and nursing home care in relation to those placed and funded by the local authority.

2. There are some residual problems of historical placement patterns

outside the area but generally current placement undertaken by officers of the local authority reflects appropriate consideration of the needs of individuals constrained only by the need for specialist provision or cost.

3. The future intentions of potential self funders for the purchase of care

are difficult to predict as they tend not to approach the authority in its role as welfare provider.

4. The models of Extra Care Housing currently employed within RKBC

are significantly different from the emerging best practice nationally in that they generally allocated places to those who would otherwise move to Registered Care Homes. This is to the exclusion of those with housing and social needs but no immediate need for care services. The creation of a mixed community of those with various levels of care requirement is seen to be good practice in that it allows for peer support and generally for a more lively and less institutional environment. Whilst current practice in RBKC may be effective in deflecting some demand for more institutional forms of care in the current system the threshold for access is set so high that they do not realise the potential for re-ablement that some more advanced models offer with more mixed populations, mixed tenure and expanded service provision.

5. The Sheltered Housing stock in all sectors continues to show high levels of demand, but much of the provision has limited accessibility for persons with mobility problems. A significant proportion of the stock is bed-sit accommodation which is unlikely to be attractive to future generations of older people. 6. There is an effective joint working relationship between Adult Social Care and the PCT in the Borough which has contributed significantly to the success of Kensington and Chelsea in retaining older people in the community. Intermediate care and re-ablement services appear to be generally working well although there is some scope for improved protocols to assist operational effectiveness. 7. The low threshold of access to supportive care at home means that those with low support needs in the community are comparatively well provided in RKBC compared with most areas of the UK. There is less confidence amongst stakeholders that those with moderate to

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substantial care needs are as well catered for and a significant proportion expressed the view that a significant proportion that those in supported housing are served least well. Some stakeholders are of the view that there is a level of suppressed demand, if not hidden need, as a consequence of a paucity of adequate and accessible information and advocacy services. 8. The capacity for the adaptation of property to meet the needs of persons with disability has expanded over recent years but demand is likely to continue to increase. The ability to respond quickly to minor repairs and maintenance is not as well developed and there is currently some pressure in the system. This is likely to be further increased by the PCT's desire to commission services closer to home and in the home for people with long-term conditions. 9. There is also an expanding demand for Assistive Technology services

as an effective means of monitoring risk and responding to emergency. There is scope for further integration and development of the Community Alarm System.

10. Benchmarking against emerging national norms for specific service provision raise interesting questions about the current configuration of the service system in RKBC which are worthy of further consideration and debate. The capacity for further integration in the planning of future service provision particularly between housing providers and Adult Social Care requires more detailed examination.

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3.0 POPULATION AND NEED/ DEMAND 3.1 Overview

The issue of population is a far from straight forward one. The accuracy of the 2001 Census has been challenged as it is widely believed within the Borough to understate the population of the Borough. It follows that estimates based on it used to project future growth will be ill-founded. Projections of future population are also heavily influenced by assumptions about inward and outward migration. In this section we seek to explore the scenarios that are shaped by the varying estimates of current and future population.

Table 1 shows that the 2001 Census enumerated fractionally below one hundred and fifty-nine thousand people living in the Borough among whom women were in a slight majority. That imbalance was more marked in the higher age cohorts. Table 1 Census 2001 population figures

Age range Total Males Females

0 - 4 9,953 5,104 4,849

5 - 9 7,643 4,074 3,569

10 - 14 6,093 3,036 3,057

15 - 19 6,397 3,168 3,229

20 - 24 11,662 5,222 6,440

25 - 29 17,388 7,890 9,498

30 - 34 17,817 8,648 9,169

35 - 39 14,952 7,565 7,387

40 - 44 11,737 5,989 5,748

45 - 49 9,378 4,451 4,927

50 - 54 10,798 5,172 5,626

55 - 59 8,660 3,990 4,670

60 - 64 7,026 3,339 3,687

65 - 69 5,235 2,470 2,765

70 - 74 4,924 2,184 2,740

75 - 79 3,857 1,742 2,115

80 - 84 2,893 1,121 1,772

85 - 89 1,649 611 1,038 90 and over 857 183 674

Totals 158,919 75,959 82,960 (Source: 2001 ONS census)

There were 23,102 people above statutory pension age of whom 8,311 were Men over 65 years of age and 14,791 were Women over 60 years of age. The gender imbalance is accentuated by the inclusion of an additional cohort of

25

Women (those between 60 and 64 years of age) but is still marked and increases with age. The numbers of men and women in their sixties are broadly comparable but among those in their eighties there are more than three Women for every two Men. Much debate has centred around the projections prepared by the Greater London Authority. These propose two alternative projections on different data and assumptions: one low and the other high. The GLA itself is highly critical of the projections prepared by the Office of National Statistics in relation to London boroughs and set out the detailed reasons for its disquiet in evidence to the Treasury Sub-Committee on “Counting the Population”.2 Their argument rests upon the adequacy and accuracy of some of the data included in the ONS estimates; problems that the ONS itself has acknowledged.3 The GLA has therefore proposed its own estimates. Even among the experts there is no consensus about how these differences are to be reconciled. The recent funding settlement for the Borough was made on the basis of a revised estimate of population of 196,800 in 2008/2009, rising to 205,800 by 2010. This suggests that whilst not quite adopting the trajectory suggested by Office of National Statistics projections current assumptions by central government are much nearer to this than suggested by either the Higher or Lower range of GLA estimates. The GLA projections are believed to understate the current and future levels of population for the Borough and will not therefore give a reliable basis for planning for the future population of older people. On the other hand it is accepted that the Office of National Statistics projections represent an over estimate of likely future population levels and need to be moderated downwards. The total population figures used as the basis for the recent funding settlement from Central Government represent a possible basis for calculating a set of projections that are above the GLA projections but below those offered by ONS. A new set of figures have been prepared that follow the trajectory implied by the population estimates used as the basis of the funding settlement, these run at an average of fifteen percent below the ONS projections. Whilst having some limitations, in the absence of a definitive resolution to the conflicting estimates of the GLA and ONS projections, this may offer a more accurate basis for estimating future trends. The resulting adjusted numbers are set out in Table Two and details of the alternative population estimates and projections with a detailed commentary appear in Annex Two.

2 http://www.london.gov.uk/gla/publications/factsandfigures/DMAG-Briefing-24-2007.pdf November 2007 3 See DMAG Briefing 24-2007

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http://www.london.gov.uk/gla/publications/factsandfigures/DMAG-Briefing-24-2007.pdf

Table 2 Current and total projected population 50+ (000s) 2001

census* 2004* 2009 2014 2019 2024 2029

Total 50-54 10.8 9.6 9.01 11.90 14.45 11.06 17.25 55-59 8.7 10 8.07 8.84 11.39 13.68 15.04 60-64 7.0 7.6 7.90 7.48 8.16 10.45 12.49 65-69 5.2 6 5.95 7.22 6.88 7.56 9.52 70-74 4.9 4.9 4.67 5.44 6.63 6.29 6.88 75-79 3.9 3.9 3.37 4.08 4.76 5.78 5.52 80-84 2.9 3.2 2.80 3.06 3.57 4.16 5.10 85+ 2.5 2.9 3.14 3.74 4.33 5.18 6.20 All 50+ 45.9 48.1 45.13 51.76 60.18 69.19 78.03 (Source: ONS 2001 census, click licence no. C02W0003323 Adjusted) * Unadjusted On this basis we may say with some confidence, if not great precision, that the population of older people in Kensington and Chelsea is likely to increase substantially over the next twenty years and that the strongest growth will be in the oldest age groups. The more substantial increases in the numbers of people in advanced old age have a direct implication for the pressures that will be placed on existing services. This gives a sense of urgency to the business of ensuring that accommodation and care responses will be adequate to meet the needs and aspirations of this fast growing proportion of the population. Whilst there is no strong link between chronological age and infirmity in early old age from seventy-five the connection becomes more explicit. The chronic illnesses of old age that bring rising levels of difficulty with mobility and in performing the tasks of daily life make the connection firmer. Eighty-five years of age brings a further threshold in which levels of demand for services will increase. It is therefore highly significant that the projected increase in older age groups grows steeper as we progress through the age cohorts. The rate of increase in the early cohorts of old age: around doubling in numbers in twenty-five years. The rate of increase falls for those in their late seventies but increases again for those in the highest age group where numbers are projected to double. Equally significant is the increase in the projected numbers of older men from the current situation in which women outnumber men by roughly two to one in the eighty-five plus age group to near parity. These fluctuations are more pronounced among the projected female population of older people than among the male population and it would appear that the upward trend toward the end of the period under review is driven, at least in part, by improving survival rates among older men. The projected rise over an extended period in the number of older people suggests that it will be important to modernise services and facilities if the pressure on public funding is not to overwhelm the available resources.

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3.2 Elders from Black and Minority Ethnic Communities ` Table 3 sets out the numbers of older people who in the 2001 Census identified themselves with particular Black and Minority Ethnic communities. The age profile of the larger communities reflects the length of settlement in the United Kingdom. Thus there are substantial numbers of elders from the Black Caribbean community stretching right up into the 90+ cohort. Whilst those from the Indian community have a rather younger profile with smaller numbers in the highest age cohorts. The profile is younger again for the Pakistani community and younger still for the Bangladeshi community where there are no elders at all in some of the oldest cohorts. A number of the smaller communities also have small but significant numbers of elders. There is a substantial community of older people within the Irish community. Providing appropriately for elders from these communities requires a mixture of dedicated services that are specific to their community where the numbers make such services viable and sensitivity to cultural, language and religious needs in generic services where numbers are insufficient to make a dedicated service feasible. The evidence is that elders from BME communities will generally have a poorer health profile than the general population and the need for more intensive levels of service will be proportionately higher or will need to be accessed at a lower chronological age.

The Borough wide picture obscures the variations to be found within Kensington and Chelsea. If we divide the Borough into three: North, Central and South those variations become clearer. The tables for each of these sub-divisions are to be found in Annex 3. It is evident that the north of the Borough includes substantial numbers of elders from the Black Caribbean community right up into the most advanced age cohorts. This would generally be taken as an indicator that a community specific provision would be appropriate and viable. There are significant numbers in their seventies in both Indian and Black African communities. In the central band of the Borough a quite different picture emerges with substantial numbers of people from the Indian community approaching old age and in early old age but more limited numbers in all BME communities in middle to advanced old age. This would generally be taken to suggest that the priority should be in ensuring that generic provision is sensitive to a range of ethnic and cultural requirements. In the most southerly wards there very few members of BME communities in the age groups beyond seventy-five years of age and relatively small numbers even in the younger age groups.

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Table 3 Population by ethnicity and age

All

peop

le

All

Whi

te B

ritis

h

Whi

te Ir

ish

Whi

te o

ther

Mix

ed w

hite

/bla

ck

Car

ibbe

an

Mix

ed w

hite

/bla

ck

Afri

can

Mix

ed w

hite

Asi

an

Oth

er m

ixed

Indi

an

Paki

stan

i

Ban

glad

eshi

Oth

er A

sian

Bla

ck C

arib

bean

Blac

k Af

rican

Oth

er b

lack

Chi

nese

Oth

er e

thni

c gr

oup

Totals 158,909 79,597 5,219 40,156 1,259 1,061 1,864 2,278 3,275 1,180 1,140 2,153 4,083 5,995 943 2,607 6,099

50-54 10,769 6,276 442 2,363 15 36 46 92 197 110 39 148 134 207 17 128 519

55-59 8,667 5,099 462 1,881 9 27 39 58 151 48 32 78 219 149 20 102 293

60-64 7,034 4,245 413 1,265 15 30 39 34 175 36 32 87 221 160 23 67 192

65-69 5,255 3,271 426 780 6 3 9 15 134 30 17 69 217 99 15 41 123

70-74 4,913 3,401 365 620 3 9 22 9 97 12 10 39 142 55 6 21 102

75-79 3,841 2,820 260 445 0 0 28 9 58 3 6 33 100 35 3 14 27

80-84 2,919 2,214 209 299 0 4 3 9 35 12 0 12 52 25 6 27 12

85-89 1,648 1,338 96 116 3 0 3 0 6 0 3 0 65 3 0 6 9

90+ 864 697 30 107 0 3 0 0 3 0 0 6 12 3 0 0 3 (Source: ONS 2001 census, click licence no. C02W0003323)

3.3 Localities It is clear that the characteristics of the older population of the Borough vary according to the part of the Borough in which they live. Whilst it is important not to caricature areas within the Borough each of the sub-divisions: North, Central and South, do have distinct characteristics that typify the average circumstances of those living in that area. That observation should not obscure the fact that services need to take account of the needs of individuals not averages: in the most prosperous parts of the Borough there will be individuals who are marginalised and may find difficulty in accessing the services they need. North In the north of the Borough the majority tenure for all older people is social rented housing, whether from the local authority or from registered Social Landlords. Relatively small numbers of people are living in communal establishments when compared with other areas of the Borough.

Central In the central area of the Borough levels of owner occupation are higher and the number of older people living in privately rented accommodation is strikingly higher than in the north with the number of private tenants outnumbering those in social housing. Those over sixty-five years of age include a substantial number who are owner-occupiers.

South Whilst the South has a substantial number of older people who are private tenants they do not out-number those in social housing. The South also has the largest number of older people living in communal establishments. Here too levels of owner occupation are relatively high. Whilst the boundaries to the three areas are to some extent arbitrary there are clearly differences between them that need to be reflected in the styles of service offered to respond to the needs of older people within them. The tables that set out the data on which these observations are based are to be found in Annex 4. 3.4 The Need for specialised accommodation and care Turning to indicators of need within the Borough there are variations between North, Central and South. Life expectancy for women within the Borough is the highest in England and that for men the third highest but there are large differences between wards with some in the North of the Borough having a life expectancy some twelve years less than the average for the Borough as a whole. Indices of deprivation measure deprivation across a range of indicators and these are not specific to older people but within Golborne Ward one sub-area is within the 4% of most deprived areas in England and two further small areas in the North are within the 10% most deprived areas in the country.

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Four of the five wards with the highest levels of self-reported ill health are in the North of the Borough (Golborne 13%, St Charles 11%, Notting Barns 11% and Colville 10%) The highest levels of ill health among older people in the Borough are to be found among elders from the Black community where the incidence level is 34% compared with a Borough wide average for the white community of 20% and 27% for both Asian elders and those recorded as Chinese or other ethnic groups. Table Four models the likely incidence of older people in the North of the Borough experiencing difficulties with various tasks of personal care. Accurate local data concerning the potential need of older people for services is often difficult to establish. It is possible to take prevalence levels established by national surveys and apply them to local populations. The General Household Survey of 2001 asked people about their difficulty with a range of tasks in the areas of personal care, mobility and domestic tasks. From the reports of the study it is possible to establish a percentage of incidence by age cohort and then to apply that to the number of people in that age group within the local community. Table 4 Difficulties with Personal Care in the Northern Wards

65 - 69 70 – 74 75 - 79 80 - 84 85+ Age range

% No % No % No % No % No Total

Bathing, showering washing all over

3 54 5 74 6 65 11 90 21 149 431

Dressing & undressing 2 36 2 30 2 22 4 33 8 57 176

Washing face & hands 0 0 0 0 0 0 1 8 2 14 22

Feeding 0 0 0 0 0 0 0 0 3 21 21

Cutting toenails 18 323 24 357 34 367 43 351 64 453 1,851

Taking medicines 2 36 3 45 3 32 5 41 10 71 224

At least one of above 19 340 25 372 36 389 45 367 67 474 1,943

Base number 1,792 1,487 1,080 816 708 5,883 (Source: Contact Consulting based on prevalence in 2001 GHS & 2001 census)

Whilst the number likely to be experiencing difficulties with dressing and undressing are striking the larger number likely to be experiencing difficulties with bathing, showering or washing all over suggests the need for a variety of

31

responses from the provision of adaptations to provision of specifically designed accommodation Table Five shows further substantial numbers of older people who have a potential need for accessible accommodation and for care. Table 5 Difficulties with Personal Care in the Central Wards

65 - 69 70 – 74 75 - 79 80 - 84 85+ Age range

% No % No % No % No % No Total


3 64 5 105 6 99 11 121 21 204 593


Washing face & hands

0 0 0 0 0 0 1 11 2 19 30

Feeding 0 0 0 0 0 0 0 0 3 29 29




Base number 2,140 2,107 1,651 1,096 972 7,966

(Source: Contact Consulting based on prevalence in 2001 GHS & 2001 census) Whilst the population of the Southern wards is smaller the concentration of older people within that population suggests significant numbers of older people with a requirement for specialised housing and for care. Whilst only indicative these numbers contrast with the volume of service delivered through statutory agencies and suggest the high level of need being met either through informal care or through self-funded and privately contracted care. With the projected increase in the oldest cohorts of older people where incidence of these difficulties is most marked the level of latent requirement for specialised accommodation and for care and support services will continue to grow.

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Table 6 Difficulties with Personal Care in the Southern Wards 65 - 69 70 – 74 75 - 79 80 - 84 85+

Age range % No % No % No % No % No

Total


3 39 5 67 6 67 11 108 21 175 455


Washing face & hands 0 0 0 0 0 0 1 10 2 17 26

Feeding 0 0 0 0 0 0 0 0 3 25 25




Base number 1,297 1,331 1,124 980 832 5,564

(Source: Contact Consulting based on prevalence in 2001 GHS & 2001 census) Recognising the needs of those with dementia Whilst there is no firm connection between chronological age and frailty among those in early old age from seventy-five years of age the connection becomes much stronger and develops as people move into advanced old age. The effect is well illustrated by the rising incidence of mental confusion. Tables Seven to Nine set out projections of those likely to be experiencing cognitive impairment provided by the Director of Public Health for the Royal Borough: Table 7 Incidence of cognitive impairment (moderate to severe) in Kensington and Chelsea

Age range Population within catchment area Prevalence % Number within

catchment area

65 – 74 10,500 2.30% 241

75 – 84 7,100 7.20% 511

85 + 2,700 21.90% 591

Total 1344 (Source:Ely M, Melzer D, Opit L, Brayne C Estimating the numbers and characteristics of elderly people with cognitive disability in local populations)

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Table 8 Incidence of dementia in Kensington and Chelsea

Age range Population within catchment area Prevalence % Number within

catchment area

75-79 3,900 6 234

80-84 3,200 13 416

85+ 2,700 25 675

Total 9,800 1325 (Source: Forget Me Not, Audit Commission 2000 citing Ely et al and Medical Research Council)

Table 9 Care Need arising from these prevalence figures

Care Need Prevalence % Number

None 5 66

Long Interval Care 11 146

Short Interval Care 50 662

Critical interval care 34 451

Total 1325 (Source: Forget Me Not, Audit Commission 2000 citing Ely et al and Medical Research Council)

In this area more than any other the projected increase in people living into advanced old age will have an enormous impact. The needs of people with dementia and their carers are not limited to more suitable accommodation. There is a need for access the respite care, to stimulating day activities, advice and support. Whilst there are evident high levels of need for service to combat the levels of deprivation to be found in the north of the Borough the projections suggest that there will be significant numbers of older people throughout the Borough who have a need for appropriate accommodation and care, although their means of securing it may be different. The characteristics of the Borough suggest that strategic priorities may be different in each of the three sub-areas. Whilst in the north, with high levels of deprivation, high prevalence of ill health and a dependence on social housing the emphasis will be upon accommodation and care services provided by statutory organisations. In the south with high levels of owner occupation and high property values there will be a substantial proportion of older people who will wish to make their own arrangements, and have the means to do so. The picture in the central area is rather more varied and the concentration of older people living in privately rented accommodation presents a challenge. It is here that a significant proportion of older people may have some means to assist them in addressing their needs for suitable accommodation and care

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but will need access to provision that is not entirely shaped by what the market finds to be viable. Hence, different strategies for information and advocacy as well as service provision may have to be deployed in the three areas. 3.5 The views of voluntary organisations

The representatives of voluntary organisations interviewed suggest that access to information and advice is more of an issue than the physical condition of the accommodation. However housing and social care issues are among the biggest issues among enquiries and requests for information. This includes not only how to access specialised housing and information about what is available but also issues around repairs, adaptations and getting help at home. The voluntary organisations speak of the need for low-level support, the lack of opportunities for keeping involved in the community, the difficulty of maintaining social contacts and conviviality. Most of all they point to a deficit in the availability of good independent advice. Age Concern for example report that the key issues are not around the actual number of beds but the appropriateness of what is on offer, and the difficulties access and securing support in seeking to access appropriate accommodation and care. “Often people are asked to make decisions when they are at their most vulnerable. It sometimes seems unclear if the decision being made truly in their best interests or whether it is rather in the interests of those around them and the person feels they have to go along with this to avoid being a trouble to anyone.”

They cite examples that are to do with communication and the difficulties in understanding the requirements of a bureaucratic system, rather than the adequacy or capacity of what is available. Local voluntary organisations are concerned to promote the development of new forms of provision and are aware of the limitations of much of the existing stock of sheltered housing. There is also an awareness of a “void” in relation to the needs of people with the resources to finance their own care. They are more likely to go directly to commercial providers without the benefit of information, advice or support. The voluntary organisations recognise that their “welfare” image will be a deterrent to being recognised as offering information and support regardless of financial means. In pursuing matters on behalf of individual older people the voluntary organisations often find that their clients are reluctant to complain for fear of being labelled as 'difficult'. This can make it difficult for service providers to accurately gauge the appropriateness or adequacy of what they provide. Satisfaction surveys will consistently return positive results but these can, in the view of the voluntary organisations, mask concerns, anxieties and frustrations that service users are reluctant to raise with those who provide their services.

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3.6 The “discovery” interviews The independent charity Sixty Plus carried out interviews with twenty-nine respondents representing a range of housing and care circumstances. The respondents were drawn from those receiving care packages in general housing, others in sheltered housing, in Extra Care housing schemes and people living in registered care homes. Owner-occupiers are not represented through the difficulties encountered in recruiting potential interviewees from this section of the older population. The interviews were undertaken by specially trained older people and the interviews transcribed and analysed for common themes. They shed light both on people’s needs and aspirations, and on their experience of current services and accommodation. A number of themes emerge.

• An overwhelming theme through many of the interviews was a sense of confusion. Several respondents were not clear about how they had come to be placed where they now found themselves and felt that the arrangements had been managed by others: whether family members or social workers.

• There were a number of instances in which people spoke of their

experiences of seeking information, advice or support from housing or care professionals are difficult, bureaucratic and insensitive. One respondent in particular who was greatly concerned that her private landlord might learn of her application for social housing and react adversely felt that her anxieties had not met with an understanding or sympathetic response.

• One of the younger respondents (a 57 year old daughter who had

moved into a sheltered scheme to be close to the parents for whom she provided a high level of informal care) complained of the small size of her flat and its dilapidated condition.

• Others were unhappy with some aspects of the care they received,

especially when this was delivered by agency staff. They spoke of anxieties arising through staff not arriving, through frequent changes of personnel and inflexibility by staff in relation to the tasks they were able to perform. One respondent said that she thought care staff were much clearer about what they couldn’t do than about what they could do!

• For those who faced the greatest difficulties through health conditions

or general frailty there was little evidence of support being provided to maintain their engagement with the community or to offer them activity and stimulation.

• A number of respondents felt that with more adequate support they

could have remained in their existing housing or in another non-institutional setting. A number expressed preferences for housing based solutions if these were available.

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The transcripts reflect the views of a group of older people with modest expectations of service and whose experience was that often even these modest expectations were not met. Officers would point to high levels of satisfaction expressed to them from service users and seek to balance the negative elements of the discovery interviews against this response, both solicited through satisfaction surveys and unsolicited. The truth of course is that some are satisfied and some not and others, as suggested by the voluntary organisations are wary of expressing their dissatisfaction or have insufficient comparative information available to them to offer a critique of the service they have received. Sixty Plus have fed back the summary and inferences drawn from the interviews to those who conducted them and find that the interviewers felt that this accurately reflected the content of the interviews and resonated with their own experience as older people living in Kensington and Chelsea. 3.7 Demand and aspiration The key aspiration that older people have, whatever their circumstances, is the one they will have pursued throughout their lives from childhood and adolescence, through adulthood and into old age: the desire to have control over their own lives. It is the desire to remain in control that motivates people to struggle on against enormous odds when their existing housing situation becomes difficult. That desire for control covers all the most basic aspects of our lives: with whom, in anyone, we chose to share our living space, what time we get up and go to bed, what we eat and drink and when and where, how we fill our free time, with whom we will socialise, and on and on. These are the basic decisions of our lives. Traditional forms of accommodation and care for older people have tended to compromise this autonomy. That desire for some degree of control over their own lives leads to concern for the future: what will happen if the capacity to care for oneself is diminished, if savings are exhausted and income is inadequate, if other circumstances change? Whilst recognising that change for themselves and in the world around them is inevitable older people look for some degree of predictability in the matters that will affect them and their ability to live as they would wish. So will the place they move to continue to accommodate and care for them if mental, physical, financial circumstances change? What can they expect and what are their rights? The autonomy that older people aspire to includes the freedom to choose their own life style. Traditional forms of accommodation and care have implied a degree of conformity: to fit in, to live conventionally, to join in with communal activities. Older people increasingly wish to assert their distinctiveness: in the decoration and furnishing of their living space, in their choice of relationships, in the ways in which they spend their leisure time, and so on. There is too a concern about eventual access to care. That the accommodation they occupy may be suitably designed and equipped that when the need for care arises it does not necessarily precipitate a move. That

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the care they require can be provided without a complete surrender of privacy, autonomy and lifestyle. Closely linked with all these aspirations are concerns about financial autonomy. That they should maintain control of the resources they have built up through their working life and have a degree of control over how those resources are used. To maintain their status as home owners, if that is their choice, not to see their capital drained through the narrow accommodation options available to meet their care needs when they arise. For that minority of older people who enter old age as tenants and have limited other financial resources exercising the same degree of choice will be difficult. Unless providers are willing to offer genuinely mixed tenure schemes in which social renters and home owners live side by side they will contribute to rather than dilute the emergence of a two class old age.

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SUMMARY OF SECTION THREE 1. Whilst there remains a continuing debate as to the precise rate of

increase of the elderly population of RKBC it is likely that numbers requiring service will significantly increase over the next 20 years with the strongest growth in the oldest age group. This has implications for the modernisation of services if the pressure on public funding is not to overwhelm the available resources.

2. Elders from BME communities will generally have a poorer health

profile than the general population and the need for more intensive levels of service will be proportionately higher or will need to be accessed at a lower chronological age. The current pattern of BME settlement suggests the need for a differential approach to the provision of service in the northern, central wards and the south of the Borough.

3. The different housing tenure mixes in the three areas also point to

differences in the nature of demand and the need for differential service responses in the respective areas.

4. The north of the Borough has markedly higher levels of deprivation and

substantially lower life expectancy than wards in both the central and southern wards of the Borough. However the projections suggest there will be significant numbers of older people in all three areas who have a need for appropriate accommodation and care.

5. Meeting that need, however, may require a differential strategic

response. The current configuration suggests that the north of the Borough, with comparatively high levels of deprivation, ill health and dependence on social housing is likely to continue to need accommodation and care services provided by statutory organisations.The population of the southern wards are likely to have significant proportion of older people who have the means to purchase there own care and will continue to exercise a desire to make their own arrangements without reference to a welfare authority.

6. The central wards present potentially the most complex challenge for

the future where comparatively high levels of older people in privately rented accommodation may have some means to address their need for appropriate accommodation and care but will need access to provision that is not entirely shaped by what the market currently finds to be viable.

7. There is a need for improved and accessible information and advocacy

services. This is highlighted in both the input from voluntary organisations and the discovery interviews and from the evidence presented to the Working Group by providers that older people do not receive the advice they need at moments of crisis to i) ensure that they

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are aware of the options available to them and ii) that they are making an informed choice.

8. Future cohorts of older people are likely to have significantly different

aspirations in terms of the nature and quality of accommodation and care services with a greater emphasis on choice, lifestyle and financial autonomy.

9. The older people who enter old age as tenants with limited financial

resources are likely to be at a significant disadvantage, without the availability of mixed tenure schemes of accommodation and care.

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4.0 NEW AND EMERGING FORMS 4.1 International experience Across most economically developed countries the past twenty years have witnessed a high degree of convergence in thinking in relation to provision of housing and care for older people. North America, Europe, Japan, Australia and New Zealand all face the challenges of an ageing population. In North America there has been a long-established pattern of retirement communities shaped around lifestyle, with many of the paradigm examples situated in the warmer southern states and offering leisure facilities such as golf courses and sports facilities. Some models have a more institutional feel with a culture of Nursing Home, although the individual units are spacious and communal facilities finished to a good standard. Financial circumstances generally determine access to quality provision with Faith Communities playing a large part in provision for the middle and lower range of financial circumstances. In many cases provision for people with mental confusion, especially where this is linked to limited financial resources, have not been of the same standard as those in flagship schemes for active and prosperous older people. The North American models have been influential in shaping the notion of retirement communities and of lifestyle rather than dependency as key elements in provision. In the UK context Extra Care Housing, Retirement Villages and Continuing Care Retirement Communities all take a good deal of their inspiration from the North American experience, albeit moderated by other influences. In Europe the pattern has been very varied. In Scandinavia where state funding has been the norm there has been a roller-coaster of development from the provision of large institutions from the 1960s to a drive to smaller scale and community based solutions from the 1990s onward that includes in some countries a complete moratorium on the building of new Nursing Home places. Scandinavian practice in the 1990s offered examples of how the provision of accommodation and of lively social, recreational and cultural activities might be combined on a smaller scale than in North American models. In the south of Europe there has been continued reliance on family and informal care networks with institutional provision often seen as “last resort”. They have produced some excellent practice in community support. Greece, for example, has its “centres of social protection” that combine social activities with access to information and advice and primary health care, offering a best practice model of what day care can be. In the middle band of Europe the picture is much more mixed with the Netherlands providing in the 1990s some models of integration of provision for older people with neighbourhood development work to achieve inclusion. The Australian and New Zealand experience reflects a fusion between North American and European, especially British, forms. Retirement Communities are pervasive but not generally on the scale of North American developments. What we would characterise as the “campus” model been widely adopted,

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generally identified as “Continuing Care Retirement Communities” and comprising a central higher dependency unit surrounded by individual dwellings. From the 1990s there has been an increasing emphasis in Australia on outreach services that will allow people to remain in their existing housing. In shaping the development of new forms in the United Kingdom the North American experience, moderated by European scale and practice, has been most influential. It directs us toward a model that recognises the need to provide older people with a good place to live that will also be capable of supporting them should their care needs increase. In both commercial and voluntary sectors providers have embraced this model as having relevance to people in a wide range of circumstances and across tenures. 4.2 Good Practice examples from within the United Kingdom The City of Wolverhampton was the first authority to set out a comprehensive strategy to substitute Extra Care for existing residential care provision. That programme has now been completed and the evidence is that the overwhelming majority of those who would otherwise have been supported in residential care are now provided for within an Extra Care setting. The considered evaluation by commissioners is that it is right to leave some capacity in the system, provided by private sector registered care homes, to provide some flexibility and to offer a degree of choice. Throughout the country there are a number of examples of good practice in the provision of accommodation that will support a positive lifestyle in old age whilst providing the capacity to offer care. Following the example of Wolverhampton a number of other authorities (County Durham, Cheshire and East Sussex were early leaders) have undertaken a comprehensive programme of re-provision building Extra Care Housing schemes to replace existing residential care schemes. Kent County Council tendered the re-provision on eight sites as a single PFI contract building Extra Care Housing schemes of around fifty units on each site. The London Borough of Barking and Dagenham were one of the first authorities to adopt a strategic approach that linked the provision of an alternative to residential care with the replacement of redundant sheltered housing. Barking and Dagenham used their debt free status to realise a major programme of re-provision through the use of Local Authority Social Housing Grant enabling the building of seven new schemes between 1987 and 2004. The defining features of Extra Care Housing, reflecting best practice, are set out in the following section and further expanded in Annex Five.

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4.3 Understanding Extra Care Housing and what it can offer In the United Kingdom a variety of models that all claim the title “Extra Care Housing” have been at the forefront of attempts to re-shape the pattern of provision for older people. The debate around how Extra Care might be defined has been carried on between academics, commissioners and providers for most of the past decade4. Fundamentally there are two schools of thought:

• Those whose main driving criterion is the capacity of Extra Care to provide an alternative to Residential Care.

• Those whose aspiration is more toward the development of a model

that enhances the lifestyle of older people with the capacity to deliver care blended into the background.

At the extreme end of the first school of thought there are those who feel that allocation to Extra Care should only be available to those with care needs that would otherwise be sufficient to merit placement in residential Care. In describing Extra Care their emphasis is upon those facilities that will support the delivery of social care and possibly primary health care: assisted bathing facilities, treatment rooms and so on. In staffing the emphasis is upon on-site care teams as the pre-eminent requirement. Those who take the alternative stance emphasise the need to make Extra Care a good place to live, think in terms of a balanced community in terms of care needs and give prominence to facilities that support an active and positive lifestyle: an exercise suite and spa bath, a coffee bar and perhaps licensed bar, facilities for arts and crafts; all supported by appropriate staffing. Whilst they include the care facilities and staffing they are matched by these lifestyle requirements if the scheme is to be considered as truly Extra Care. In Annex Five we set out a full set of fifteen criteria that we recommend the Borough should endorse in relation to Extra Care Housing schemes that are developed and operated within Kensington and Chelsea. Whilst we would regard all fifteen of these criteria as crucial if the schemes are to meet the standards of good practice nationally, reflect existing guidance and be “future proofed” against rising standards and expectations, five represent an irreducible core definition. These five core elements may act as a checklist:

• The basis of occupation: that is to say by tenancy or ownership. • Accessibility • 24/7 care on site • Social, recreational, craft and cultural facilities and activities • The creation and maintenance of a balance in care needs among the

population of occupants. 4 See for example Appleton N:Extra Care Housing for Older people, Care Services Improvement Partnership Housing LIN

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Any scheme that does not meet these five core elements cannot properly be regarded as Extra Care Housing. The issue remains of the standards and features that should be expected in schemes that emerge from the re-modelling of existing sheltered housing. In an ideal world they would meet the full specification for Extra Care but in many cases that will not be achievable. The constraints of the site, the structural characteristics of the building, the number of units achievable, the available finance will all act as constraints. It would not be sensible to discourage investment in existing stock because it cannot be brought to a full Extra Care standard. There is some guidance available5 in carrying out an option appraisal on an existing sheltered scheme and specifying the scheme that can be achieved through modification. Those carrying out such appraisals need to be very clear about the timeframe: quick fixes that do not address fundamental issues like flat size do not last long. 4.4 Extra Care as an alternative to Residential Care The capacity of Extra Care to provide a genuine and safe alternative to residential care depends upon the adequacy of the model adopted. Clearly a scheme that does not provide 24/7 care service on site cannot be regarded as a safe or appropriate context for the care of an individual who may need that level of support or oversight. As the need for that capacity: either to routinely provide care overnight or to be capable of responding rapidly should need arise, would be a factor in many residential care placements the connection is obvious. If the balanced community of need model of Extra Care is to be adopted then approximately a third of the people accommodated would be those who otherwise might have been allocated to residential care. Substitution of Extra Care for residential care would therefore be at the rate of thirty residential care beds substituted for every ninety Extra Care places provided. Achieving this outcome depends on both the capacity to provide sufficient levels of care and accurate allocation processes to achieve and maintain an appropriate profile within the scheme. 4.5 Financial considerations There are obvious and quantifiable benefits for older people in moving into Extra Care, rather than registered care homes. If they are owner-occupiers and the scheme offers the possibility of whole or partial purchase of their dwelling it will allow them to maintain a level of equity either to provide potential funding to meet changes of circumstance or to leave to family and other legatees. By contrast a move to a Registered Care Home will generally mean that equity will gradually be eroded by inclusive charges. The structure of charges will also mean that individuals will have more disposable income

5 See for example Stilwell P (2005) Refurbishing or remodelling sheltered housing: a checklist for developing Extra Care, CSIP Housing LIN

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when compared with the “pocket money” allowed to those in Registered Care Homes. The financial benefits of the model are even more pronounced for the public purse in general and for Social Care budgets in particular. In its guidance to those seeking to develop these new forms the Department of Health spells out the fundamental principle in relation to revenue funding: “The fundamental principle applying to the revenue funding of Extra Care Housing is that it is housing and not care. The same rules generally apply to residents of Extra Care Housing as apply to people living in other forms of housing of the same tenure type.”6 4.6 Intangible but real benefits for older people For those who move to Extra care it offers an active lifestyle and the possibility of continued engagement with others within the scheme and beyond it. It is an alternative to the passive wait for declining physical and mental capacity. Extra Care offers a sense of security to those moving in that, whatever their current circumstances, their future needs will, in almost all circumstances, be met. For many couples where one is more frail than the other it offers a positive environment for the fitter of the two and a supportive environment for the partner; with the added assurance that the survivor will be able to continue where they are. 4.7 Extra Care for sale Extra Care developments, of the style described in section 4.3 above, are increasingly offered on the basis of mixed tenure. Up to half of the units in a scheme may be offered for sale on a long lease (on much the same basis as leasehold retirement housing) with some offered on the basis of shared ownership and the remainder for rent. For the provider and commissioner the benefit is that a high proportion of the development cost of the scheme is immediately returned through the proceeds of sales. For the individual it allows them to retain a proportion of the equity released from their previous home so that it may be passed to legatees or drawn upon through equity release products to finance needs that may arise in old age. From a strategic point of view it broadens the range of options available to older people, facilitates the development of a new and innovative style of provision and supports the creation of a diverse community. 4.8 Retirement Villages To achieve a scale that will make more elaborate social and recreational facilities viable some developments are now being proposed on a scale of around two hundred and fifty units on a single site. Whilst some would resist

6 Funding Extra Care Housing, CSIP Housing LIN 2005

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the scale of such developments the experience of providers is that there is a high level of demand. There are essentially two models for this style of provision: the campus model and the integrated model. The campus model is exemplified by the Joseph Rowntree Trust Hartrigg Oaks development in York or by a number of Continuing Care Community developments in the private sector. These provide units for independent living in a campus with a residential care and nursing home facility to which residents transfer when their needs cannot be met in their own home. They thus remain in the same community with continuity in both fellow residents and staff. Experience has shown that residents in the independent living units will depress their presentation of need to avoid reaching the threshold for transfer to the higher dependency unit. The integrated model, exemplified by the retirement villages operated by Extra Care Charitable Trust, provides floating social care and nursing care to residents in their flat of bungalow, where ever it is located within the scheme. 4.9 Telecare or Assistive Technology Telecare or Assistive Technology is the generic name given to a range of devices that can be added to a standard Community Alarm to provide alerts that help manage risk and support the delivery of care. The devices broadly fall into two categories: those that have to do with managing risk in the environment in which an older person lives, and those that address risks arising from the health or mobility issues that an individual may be experiencing. In the first category would be included devices that detect flooding (arising from taps being left on, for example) extreme heat detectors, gas and smoke detectors and devices that detect movement when people enter or leave a room or a building. All these can be added by way of an “overlay” to a standard community alarm telephone. The second category of devices include activity monitors that, for example, will detect if someone leave their bed in the night and does not return within a pre-determined time, will detect when people have had a fall, and more specialised equipment that will detect when people are experiencing an epileptic fit. In all cases the device will raise an alert with a central monitoring station and the staff will use the two-way speech capability of the community alarm to ask if there is a problem or to prompt remedial action. If there is no response, or if it becomes evident that there is a problem that the individual cannot resolve for themselves then the staff will contact an appropriate individual or agency to respond: whether a son or daughter, a neighbour, or a doctor or the emergency services. Whilst early applications of Assistive Technology tended to focus on those at greatest risk, for example people living alone with dementia applications are now becoming much moiré diverse. The installation of devices in the first

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category: those that protect against risk in the home environmental are being recognised as part of standard equipment for the homes of people who may be vulnerable. Devices that support the management of risk in relation to specific health and mobility issues are increasingly recognised as part of the array of responses that a modern Community Equipment Service can offer to those who need support. Any new developments of accommodation for older people should include the infrastructure to facilitate the installation of Assistive Technology in response to individually assessed need. Where major refurbishment of existing specialist accommodation is envisaged then arrangements for providing Assistive Technology should be included. 4.10 Housing models for Dementia Finding appropriate options for people with dementia is a major and increasing challenge. Among housing colleagues there are many who are reluctant to engage with the accommodation issues and this inhibits the development of innovative solutions. Extra Care has developed as a model capable of supporting communities of older people among whom a proportion are living with high levels of physical frailty. The capacity of the model to support people in such circumstances, whilst providing a quality of life that exceeds what they might have experienced in a Registered Care Home or by remaining in their existing home, is well documented. In an increasing number of instances this includes the provision of nursing care where this is needed. The providers of Extra Care have been much more cautious in responding to the needs of people whose frailty arises from some degree of mental confusion, including people with dementia.7 The majority of providers have followed the rubric established by their predecessors in relation to conventional sheltered housing: if people move in with no more than slight symptoms of dementia they will be supported in place for as long as possible. It will not be appropriate to accept people as new occupants who are already showing more advance signs of dementia. In Annex Six we have provided a fuller discussion of the issues that arise in seeking to provide an appropriate accommodation and care response to the needs of people with dementia and their carers

7 Molyneux P & Appleton N (2005) Supporting People with Dementia in Extra Care Housing: an introduction to the issues. CSIP Housing LIN

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4.11 Lifetime Homes Lifetime Home standards are now well established as a means of ensuring that new properties will provide the space and amenity standards that will allow people to remain in occupation as they become less mobile. Lifetime Home standards incorporate specifications to meet sixteen criteria. Some cover elements of the dwelling to be provided at the time of its construction: Entrances and doorways and hallways for example. Others require the provision of capacity or infrastructure that will allow elements to be added at a later date without major building works: such as the incorporation in the design of a tracking hoist route.8 The sixteen elements comprise requirements in relation to:

1. Car Parking width 2. Access from car parking 3. Approach gradients 4. Entrances 5. Communal stairs and lifts 6. Doorways and Hallways 7. Wheelchair accessibility 8. Living Room 9. Entrance level bedspace 10. Entrance level WC and shower drainage 11. Bathroom and WC walls 12. Stairlift / through floor lift 13. Tracking Hoist route 14. Bathroom layout 15. Window specification 16. Controls fixtures and fittings

Although some elements of the standards are now incorporated in Building Regulations the adoption by Local Authorities of the full range of Lifetime Home standards as a basic requirement for new dwellings will greatly enhance the capacity of the housing stock to support the continued occupation by older people and other who may have mobility problems.

8 For further information see http://www.jrf.org.uk/housingandcare/lifetimehomes

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SUMMARY OF SECTION FOUR 1. New models of care embracing retirement communities have been

predominantly influenced by the North American experience, although in the UK are usually commissioned on a smaller scale. The emphasis is on housing with care, where the owner or tenant exercises a substantial degree of autonomy over the care delivered.

2. Extra Care Housing in the UK embraces a wide variety of models.

Some local authorities in the UK have developed a strategy whereby Extra Care Housing is seen as the major substitution for residential care. An alternative approach continues to pursue substitution of residential care as a primary goal but within the context of a more balanced community of need and the promotion of a more positive and re-enabling lifestyle.

3. There are 15 criteria identified as the benchmarks for future

developments of extra care to respond to anticipated rising expectations of future generations, with five of these identified as an irreducible core definition.

4. Extra Care Housing can realise financial benefits to the individual older

person accommodated as well as to the commissioning care authority and to the overall public purse. The principal benefit however is an improved quality of life for the older person.

5. Increasingly Extra Care Housing is being made available for sale

usually though not exclusively in mixed tenure schemes. Extra Care Housing providers are more reticent in providing for older people suffering dementia, though some providers have made great strides in recent years. For those older people who enter a scheme without significant dementia it is often possible for them to supported successfully as their dementias advance. For those older people whose symptoms are already well advanced purpose designed housing and care settings, usually of no more than 8-12 units are likely to be the most successful.

6. Currently Kensington and Chelsea has only three Extra Care Housing schemes, none of which meet the 15 identified criteria for future best practice development. There is no leasehold Extra Care Housing in the Borough or mixed tenure schemes. 7. The scale of operation that would enable the provision of facilities to

promote a positive lifestyle within a mixed community of need would require a larger site than those schemes currently operating in the Borough. The capital investment required would probably mean that any such scheme would need to be of mixed tenure.

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5.0 RELATED ISSUES FOR FURTHER CONSIDERATION 5.1 Planning The operation of Planning powers by the Borough is one of the key means by which it may influence developments that will advance its strategic objectives and facilitate provision to meet future levels of need. Some confusion arises in relation to Planning law and practice because Extra Care Housing, has emerged subsequent to the current Use Class Order and does not fit easily into its established categories. The Use Class Order recognises “housing” (Class 3) and “institutional care” (Class 2). Whilst seeking to develop from a base that is clearly housing, in that people have the rights of a home owner or tenant, Extra Care is clearly very much more: offering through its design and menu of services a high potential level of support and care. If regarded as de facto Class 2 then those developing such schemes would not be required to make an affordable housing contribution under Section 106 requirements. The Sub-Group recommends that that the Royal Borough of Kensington and Chelsea recognises developments that meet the criteria for Extra Care Housing enumerated in Annex Two as qualifying to be treated for planning purposes as if they fell within Class 2. One of the routes by which the Authority may seek to encourage the development of new forms of provision is by applying a proportion of the proceeds which it is able to collect through the Section 106 contributions made by housing developers. The Sub-Group understands that the Authority does exercise the opportunities available to it to secure community benefits through the planning system using Section 106 provisions. At present the Authority does not prioritise the purposes to which these planning gains may be applied. It does seem likely that resources available through the application of Section 106 provisions may be applied to the provision of community facilities where these form part of an Extra Care development but are available to older people within the locality on the same basis as those living in the scheme. The Sub-Group may be minded to suggest that the more pro-active stance the Authority is taking through the appointment of a “Section 106” Officer might be coupled with assigning priority to the needs of older people. Whilst the resources accrued through this process will not be sufficient, of themselves to fund major developments they may provide leverage to attract funding from other sources or mitigate the development costs of schemes that incorporate the features associated with Extra Care developments. The Planning Department is conscious of the need to make provision for the development of an appropriate range of accommodation to respond to the needs of an ageing population within the Borough. Reference to the need for a range of specialised housing to meet the needs of older people is included in the Core Strategy of the Local Development Framework. The themes of that Core Strategy, currently under consultation, presents a number of themes

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that could guide the future development of the Borough. These are Keeping Life Local, Fostering Vitality, Life in the Public Realm, Renewing the Legacy, Diversity of Housing and Securing our Children’s Future. This report is primarily concerned with the creation of a diversity of housing that promotes mixed and balanced neighbourhoods. However, it will be important that such schemes are developed in such a way that contributes to the other themes and that they are set within the neighbourhoods that themselves enable older people to fulfil their aspirations to access the services they need in their local area, to be able to negotiate their way around the local area and that the external spaces created work well for them. The adoption of Lifetime Neighbourhoods principles could be a helpful way of expressing this. 5.2 Workforce In any discussion of future patterns of care for older people the capacity of the labour market to provide personal care is identified as an increasing challenge. The overall demographic trend is that as the numbers of older people in our society increase the number of those in the age ranges from which employed carers have generally been drawn is shrinking. There are particular factors influencing the characteristics of the labour market in RBKC. Whilst the proportion of the population that is of working age is relatively high the participation of women in employment (who make up the majority of those employed in care delivery) is low and other indicators suggest that there is little spare capacity in the local labour market. Whilst labour may be attracted from neighbouring boroughs the limitations to the availability of locally resident workers will be a factor affecting the viability and cost of local provision of care. At 69.8% the proportion of the total population of RBKC that is of working age is slightly higher than the average for London (67.0%) and more markedly above the average for Great Britain (62.2%). However the proportion of those economically active at 66.9% is below both the average for London (74.8%) and the Great Britain as a whole (78.6%). (NOMIS official labour market statistics, Crown Copyright) This is largely explained by the relatively low rate of participation in the labour market of women. This has direct impact upon the availability of staff for personal care provision. Women are over represented in personal service occupations, which includes the provision of personal care; making up around 80% of the workforce. RBKC has the third lowest rate of employment in the United Kingdom among women of working age at 49.5%. The average for Inner London boroughs is 56.7% and the United Kingdom average 69.6%. (GLA Data Management and Analysis Group). The most evident consequence of this situation is that many jobs in care are taken by newly arrived immigrants. Both the Discovery Interviews and the evidence given to the Sub-Group by service providers, such as Care UK, suggests facility in the use of English among those willing to work in this sector can present a problem. In the conditions of the labour market operating

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in the Borough there is no easy solution to this issue: to move directly to set a higher standard would in itself simply reduce the available pool of labour still further. The Authority might consider whether it can work with service providers to offer training in language and communication skills, alongside encouraging the development of a more skilled workforce. 5.3 Housing Conditions and Housing Needs surveys The most recent House Condition Survey undertaken by the Borough shows that whilst there are isolated examples of properties occupied by older people that fall below the Decent Homes Standard the means exist to address these difficulties as the Borough moves toward its target of eradicating sub-standard housing. Lest that judgement is thought to imply complacency we would point out that the Decent Homes Standard represents a baseline and the challenge of providing high quality housing for older people within Kensington and Chelsea remains. Ensuring accessibility through adaptations is likely to be a more prominent issue in most cases. This will make increasing demands on the budget for Disabled Facilities Grants. As noted elsewhere expenditure on these grants has increased very substantially but meeting the rising tide of demand will continue to be challenging. The Housing Needs Survey suggests that for older people the prospect of moving to other accommodation is not their option of choice. Most wish to remain in their existing accommodation for as long as possible. The survey indicated that demand for sheltered housing remains strong. The challenge remains as to whether the current sheltered housing stock will meet the raised expectations of future generations of older people in the Royal Borough 5.4 Measuring and assessing rising expectations among Older People We have identified the challenge presented by the anticipated raised expectations of future cohorts of elderly people. It is difficult to predict what exact form these might take and neither current younger age cohorts or those already in receipt of service are the best placed to act as predictors. Further thought should be given to means whereby the RKBC might engage with those in their 60s or newly retired to assist in identifying a profile of service that might be acceptable for them in 20 years time. A parallel but separate process should be considered to assess the future specific needs of the separate BME communities in the Borough. It may be necessary to consider a slighter younger age cohort for some of the BME communities as consultees. Not only do some of the BME communities tend to require access to care at an earlier age but the differential experiences of those who have lived the majority of their lives in the UK may lead to a different pattern of expectation than those who are currently identified as community elders.

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6.0 CONCLUSIONS Current and Future Population of Older People Whilst there remains a continuing debate as to the precise rate of growth of the older population of RKBC it is likely that numbers of older people requiring service will significantly increase over the next 20 years with the strongest growth in the oldest age group. This has implications for the required modernisation of services if the pressure for public funding is not to overwhelm the resources available. There is a need for a differential approach to the provision of services in the wards in the north, central and south of the Borough, particularly in services to BME communities. While there are markedly higher levels of deprivation and substantially lower levels of life expectancy in the northern wards than in the central or south there will be significant numbers of older people in all areas in need of accommodation and care. Meeting that need, however, may require a differential strategic response. The northern wards are likely to continue to need accommodation and care services commissioned predominantly by statutory organisations. The southern wards are likely to continue to have a significant proportion of older people with both the economic means and desire to purchase their own care without reference to a welfare authority. In the central wards the comparatively high levels of privately rented accommodation may mean that whilst many older people will have some means to address their accommodation and care needs many will need access to provision that is not entirely shaped by what the market currently finds to be viable. The needs of Elders from Black and Minority Ethnic Communities Older people from BME communities will generally have poorer health profiles than the overall population with the consequence that the need for more intensive levels of service will be proportionately higher or will need to be accessed at a lower chronological age. The need for improvement in information, advice and advocacy services Most stakeholders and older people as service users interviewed suggested there was a level of suppressed demand, if not hidden need, driven by a paucity of access to information on service availability, system operation and advocacy. From the discovery interviews and from the evidence presented to the Working Group by providers it was clear that older people do not receive the advice they need at moments of crisis to i) ensure that they are aware of the options available to them and ii) that they are making an informed choice.

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There is an urgent need for an improved and accessible advice and advocacy service that is sensitive to the differential needs of geographical communities, BME communities and economic status. Services for those living in general housing Whilst investment in major adaptation of the properties of persons with disability has increased exponentially in recent years, the demand on Disabled Facilities Grants is predicted to continue to grow. Whilst the very substantial increase in funding is very welcome the challenge of providing adequate resources to meet demand will continue. The ability to meet that demand is likely to impact on the PCT's ability to commission services closer to home and in the home for people with long-term conditions. The small repairs and handy person service has inappropriately long waiting lists and a comparatively small investment in staffing could substantially improve the delivery of service. The Community Alarm service has a comparatively small client base. Whilst it appears to work effectively it does not realise its full potential as it is insufficiently well integrated into the overall service system. Sheltered Housing The demand for sheltered housing in all sectors continues to be strong with a substantial waiting list for allocation. However, much of the stock is significantly below mobility access standards and there is a high proportion of bed sit accommodation particularly within the TMO stock. It is highly unlikely that current levels of demand will be sustained with the predictable rising expectations of future cohorts of older people. Extra Care Housing The models of Extra Care Housing employed within RKBC are significantly different from the emerging best practice nationally. They are effective as alternatives to residential care but do not realise the potential for re-ablement and pursuit of a positive lifestyle that more advanced balanced communities of need models offer. The three Extra Care Schemes in the Borough currently all fall short of meeting the 15 criteria identified as best practice. The scale of development that would enable the provision of facilities to promote a positive lifestyle within a mixed community of need would require a larger site than any of the schemes currently operating in the Royal Borough. The capital investment required would probably mean that any such development would need to be of mixed tenure. There appears to be agreement between most commissioners, stakeholders and older people interviewed that there is a need to develop both more Extra Care Housing and more advanced models of such provision in the Borough

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with an emphasis on mixed tenure. The south of the Borough currently has no Extra Care and it is felt by many stakeholders that a leasehold development would be an asset to the overall system of provision. The provision of Registered Care Home places In relation to those placed and funded by Adult Social Care there currently appears to be a reasonable balance of supply and demand for residential and nursing home care in Kensington and Chelsea, with no real evidence of either under or over capacity in care provided. While some people in need of residential or nursing home care continue to be placed outside the borough boundaries this appears to be as a result of them exercising choice or for the need for particularly specialist care not immediately available in the Royal Borough. Current placement practice and the opening of Ellesmere House is likely to increase the proportion of supported placements within the Borough in future. The low level of placements of Kensington and Chelsea residents in residential and nursing home care reflects the effectiveness of joint working between Adult Social Care and the PCT to retain people in their own homes. Intermediate Care, rehabilitation and re-ablement post hospital discharge appear to work effectively to deflect people from inappropriate institutional care. The future intentions of potential self funders for the purchase of care are largely unpredictable as people of substantial means are unlikely to approach or be prepared to dialogue with a welfare authority. There is a perception amongst some stakeholders interviewed that those older people with a low level of need and those at imminent risk of admission to institutional care are served well, those in moderate to substantial need, particularly those in supported housing are served less well by community services. Planning There is a need for the conclusions drawn in this report concerning the future provision of Extra Care Housing and other forms of provision for older people to be carried through into the development of policy and formation of practice in relation to the Planning functions of the Authority

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7.0 RECOMMENDATIONS 7.1 The Local Development Framework (LDF) must address the challenges specific to RBKC as set out in this document: (i) There is a declining level of accommodation of all types and particularly of those types that will best meet the changing needs and aspirations of older people in the borough. (ii) The amount of accommodation of all types per thousand compared with national averages. (iii) The inadequate choice offered to older residents in search of suitable accommodation, particularly those who do not qualify for public support but who cannot afford private alternatives. (iv) The relative lack of newer, housing based, models of accommodation. (v) That whilst many older people will want to receive home care there will always be a group of older people who will need to access some form of nursing care and that this may be in a residential setting. (vi) The projected increases in the population of older people, especially those in advanced old age. (vii) The scarcity and price of land and air space.

7.2 In response to the above challenges the LDF must prioritise land and property for the social and community use of older people specifically: (i) Retain and develop land formerly used by older people e.g. Edenham for continued use by older people in a more modern setting. (ii) Designate Extra Care developments as C2 for planning purposes. (iii) Adopt “Lifetime Home Standards” across the borough in respect of new developments/re-developments. (iv) Incorporate the needs of older residents into major new developments (e.g. Wornington Green) and the need for housing and accommodation options for older people there. 7.3 RBKC should work with the Primary Care Trust (PCT) to develop a housing and accommodation strategy for older people that accelerates improvements to the current range of options on offer, specifically: (i) More Extra Care Housing that:

• Meets national standards. • Serves a wider population of older people than currently in terms of levels of care needed. • Provides for shared equity and lease purchase in addition to rental options.

(ii) Improving the quality, accessibility and range of ownership options of in all categories of provision. (iii) To develop a greater understanding of why there are long waiting lists associated with the current stock of sheltered accommodation and to develop a new understanding of the best use of this type of housing.

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(iv) Reviewing the need for more investment in the Sheltered Housing stock in line with the overall housing and accommodation strategy. 7.4 RBKC and the PCT should incorporate the latest knowledge in the care of people with dementia into housing and home care services. There should be an increase planned in the amount of accommodation designated as suitable for people with dementia in line with the substantial increases in the population of over 85 year olds projected for the borough, 22% of whom will suffer from dementia. 7.5 RBKC and the PCT should research the needs of older residents who do not qualify for state support but are very limited in their ability to fund their own residential or home care. 7.6 RBKC should set and agree standards with providers of home care services to deliver a personalised service and leave the client feeling cared for in respect of the following: (i) The language skills necessary to respond effectively to the client and in particular the standard of spoken English among care workers. (ii) Training in the specific care needs of older people including an appreciation of the loneliness and isolation experienced by some older people. (iii) Consistency of workers to enable clients to see the same carers every day and at agreed times more frequently than they do at present. 7.7 RBKC should challenge the GLA population figures as the basis for service planning. The GLA projections should be replaced by projections based on figures accepted by the Government for the most recent grant settlement. 7.8 Many older residents are not well informed about the types of accommodation and care options available. Indeed many older residents with some financial assets have the misperception that they are not eligible for any help. RBKC and the PCT should develop an advice and information service that reaches out to all older residents, irrespective of their financial status, with information about residential, nursing, housing and care services operated by the PCT and/or the Local Authority or by other organisations for older people in the borough.

Format for the Cabinet’s Response to the Recommendations in this Report

Recommendation Cabinet response

R1 The Local Development Framework (LDF) must address the challenges specific to RBKC as set out in this document: (i) There is a declining level of accommodation of all types and particularly of those types that will best meet the changing needs and aspirations of older people in the borough. (ii) The amount of accommodation of all types per thousand compared with national averages. (iii) The inadequate choice offered to older residents in search of suitable accommodation, particularly those who do not qualify for public support but who cannot afford private alternatives. (iv) The relative lack of newer, housing based, models of accommodation. (v) That whilst many older people will want to receive home care there will always be a group of older people who will need to access some form of nursing care and that this may be in a residential setting. (vi) The projected increases in the population of older people, especially those in advanced old age. (vii) The scarcity and price of land and air space.

R2 In response to the above challenges the LDF must prioritise land and property for the social and community use of older people specifically: (i) Retain and develop land formerly used by older people e.g. Edenham for continued use by older people in a more modern setting. (ii) Designate Extra Care developments as C2 for planning purposes. (iii) Adopt “Lifetime Home Standards” across the borough in respect of new developments/re-developments.

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(iv) Incorporate the needs of older residents into major new developments (e.g. Wornington Green) and the need for housing and accommodation options for older people there.

R3 RBKC should work with the Primary Care Trust (PCT) to develop a housing and accommodation strategy for older people that accelerates improvements to the current range of options on offer, specifically: (i) More Extra Care Housing that: • Meets national standards. • Serves a wider population of older people than currently in terms

of levels of care needed. • Provides for shared equity and lease purchase in addition to rental

options. (ii) Improving the quality, accessibility and range of ownership options of in all categories of provision. (iii) To develop a greater understanding of why there are long waiting lists associated with the current stock of sheltered accommodation and to develop a new understanding of the best use of this type of housing. (iv) Reviewing the need for more investment in the Sheltered Housing stock in line with the overall housing and accommodation strategy.

R4 RBKC and the PCT should incorporate the latest knowledge in the care of people with dementia into housing and home care services. There should be an increase planned in the amount of accommodation designated as suitable for people with dementia in line with the substantial increases in the population of over 85 year olds projected for the borough, 22% of whom will suffer from dementia.

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R5 RBKC and the PCT should research the needs of older residents who do not qualify for state support but are very limited in their ability to fund their own residential or home care.

R6 RBKC should set and agree standards with providers of home care services to deliver a personalised service and leave the client feeling cared for in respect of the following: (i) The language skills necessary to respond effectively to the client and in particular the standard of spoken English among care workers. (ii) Training in the specific care needs of older people including an appreciation of the loneliness and isolation experienced by some older people. (iii) Consistency of workers to enable clients to see the same carers every day and at agreed times more frequently than they do at present.

R7 RBKC should challenge the GLA population figures as the basis for service planning. The GLA projections should be replaced by projections based on figures accepted by the Government for the most recent grant settlement.

R8 Many older residents are not well informed about the types of accommodation and care options available. Indeed many older residents with some financial assets have the misperception that they are not eligible for any help. RBKC and the PCT should develop an advice and information service that reaches out to all older residents, irrespective of their financial status, with information about residential, nursing, housing and care services operated by the PCT and/or the Local Authority or by other organisations for older people in the borough.

ANNEX 1. The context in public policy The Policy Drivers There is an increasing appreciation in public policy that housing provides the necessary underpinning for the engagement of older people in wider civil society and particularly as a route through to the kinds of choices that enhance someone's sense of well-being. Across Government, in the White Paper Strong and Prosperous Communities9, the Commissioning Framework for Health and Well-being10 and, the Hills Report, Ends and Means: The Future Role of Social Housing in England11 there is a requirement for health, housing and social care commissioners to work together to enable people to play their full role as citizens. The best support services enhance the quality of life for citizens, linked with this is the growing acceptance, underpinned by Equalities and Human Rights legislation that individual’s rights to service should not be compromised by age, physical or mental disability. Whilst there will undoubtedly be major changes in public policy in the next five years it seems highly likely that promoting independence, well-being and self-determination will remain consistent themes. Promoting Independence for Older People Partly as a result of improvements on the standard of living, partly as a result of the shift away from traditional forms of employment and partly as a result of advances in medical science we are all living longer. Arguably, we are still working through the wider implications of these changes and the changing need for housing that flows from it. What is clear is that there is a need to provide an environment in which older people can thrive and live life to the full for as long as possible – making a full contribution to society rather than being perceived as dependent on it12. Traditionally, services for older people have often been focussed on a narrow range of services that are designed to deal with dependence or deficit rather than independence and well-being. In recent years there has been a recognition, enshrined in policy, that older age is a period in which people are as likely to want to be active and treated as an integral part of the mainstream of life.

9 DCLG (2006) The Local Government White Paper : Strong and Prosperous Communities. SO : London. 10 DH (2007) Commissioning Framework for Health and Well-Being. SO : London. 11 DH (2007) Ends and Means : Future of Social Housing in England. SO : London. 12 ADSS (2004) Public Services for Tomorrows Older Citizens : Attitudes to Ageing. www.adss.org.uk/publications/other/public.pdf.

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Quality and Choice for Older Peoples’ Housing : A Strategic Framework13 set out the Government’s overall housing policy for older people. Its stated objective was to offer everyone the opportunity to have a decent, affordable and appropriate home and so promote "social cohesion, well-being and self dependence''. As people become frailer, it said, there needed to be strategies in place to address the particular housing issues that arise in relation to the location and physical characteristics of their home, coupled with the interface with care and support and the interface with support and care services. There was a recognition that effective housing, allied to the right care, support and wider services, such as good transport and community safety, can be the springboard that enables older people to remain involved and live their lives to the full. In Opportunity Age14 the Government set out an overall strategy for addressing the needs and aspirations of an ageing population. Underpinning this is a belief that older people are not just the passive recipients of care and support but living active lives that are fulfilling and engaged as full members of the wider adult population. In housing terms, the impact of larger numbers of older people on housing stock is significant. The tendency for older people to stay in the ‘family home’ has an impact on the housing market as it reduces the amount of stock available to younger couples with dependent children. As a result there may be pressure to build more ‘family’ housing whereas the real need may be for attractive options for older people to move to. This implies a need for accessible and adaptable housing that is inexpensive to run. The trouble has been that where the needs of older people have been recognised in policy it tends to be in relation to specific care or support needs. As HOPDEV15 have said, “there was not an approach that accepted – or indeed expected – that housing aspirations might be found alongside housing need”16. This, they argued, would need to be supported by the development of strategies that look at the best way of meeting the housing anaccommodation needs of the whole of the older population not just those with specific care and support needs

d

17. PSA 8 aims to improve the quality of life and the ability of people, particularly, vulnerable older people, to live in their own homes where possible by requiring authorities to increase the proportion of older people being supported to live independently in their own home by 1% for each of 2007 and 2008. The Audit Commission report Older People – Independence and Well-Being : The Challenge for Public Services (produce in partnership with Better

13 DETR (2001) Quality and Choice for Older Peoples’ Housing : A Strategic Framework. SO : London. 14 CM 6466 (2005) Opportunity Age : Meeting the Challenges of Ageing in the 21st Century. SO : London. 15 HOPDEV = The joint Department of Health and Communities and Local Government interdepartmental group: The Housing for Older People Development group. 16 Easterbrook, L (2005) Older Peoples’ Housing Strategies : Key Policy Drivers. Hopdev : London. 17 Easterbrook, L (2005) Delivering Housing for an Ageing Population : Informing Housing Strategies : and Planning Policies. Hopdev : London.

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Government for Older People) prioritises the holistic approach to services for older people provided by Extra Care Housing (ECH) schemes18. ECH has been seen as an important vehicle for meeting the changing needs and aspirations of older people. It is a method of service delivery that enables older people to live independent lives, access a broad range of services and engage with wider civil society. It also changes the expectations about the extent to which it is possible to staircase up or down as the need to access services changes in response to changing needs. As such it enables a new set of expectations between the resident, the provider and their partners19. In the next section we will look at how ECH has been seen as a way of meeting different policy objectives across health and social care agendas and the wider goal of improving health and well-being for older people. Promoting Choice and Well-being The public have indicated an increasing desire to receive care at home or closer to home in community settings. New providers and the flexibility to develop new patterns of provision (working with current and potential users) provide an opportunity to deliver quality public services. There will be a need to develop new facilities that enable the co-location of services. Good quality housing - be that Lifetime Homes, specialist provision such as ECH or well designed general needs housing - will be key to the effective implementation of preventative strategies and to allow people to design their own care pathway and exercise real choice over the type of service they want and where they want to receive it. In Choosing Health20 the focus is very much on signalling a shift away from support and care towards the prevention of illness with the ultimate aim of a more positive approach to well-being and engagement in civil society. Older people themselves have argued that independence must mean more than doing things for themselves but making choices and having control over things such as their housing, social networks and access to information. Choosing Health emphasises the importance of minimising personal and environmental risk and the importance of well-designed housing in achieving this. Traditional models of designated housing for older people may inhibit older people from accessing opportunities for exercise and calls for housing to be better designed and measures taken to make the neighbourhood environment safe, accessible and welcoming to older people have resulted in shifts in design that ECH responds to well.

18 Audit Commission (2004) Older People, Independence and Well-being : The Challenge for Pubic Services. SO : London. 19 Molyneux, P and Appleton, N (2005) Supporting People with Dementia in Extra Care. CSIP Factsheet 14. 20 DH (2004) Choosing Health : Making Healthy Choices Easier. SO : London.

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Commissioning a Patient-Led NHS21 confirmed the themes of customer focus, engagement and localisation as key drivers for the NHS in the Government’s third term. In addition, it envisages new providers entering thealth and social care market to provide more choice. Independence Well-being and Choice

he

ments and he

s

22 envisages greater choice for users and a focus on prevention and independence. There will be more use of direct paythe development of individual budgets. There is an intention to stimulate tmarket increase the number of providers from which people can choose by offering full cost recovery, encouraging market entry by smaller community based organisations and proportionate monitoring. The White Paper, Our Health, Our Care, Our Say23, envisaged i) the development of a new generation of community facilities where different service providers can work together (e.g. extra care housing schemes or community centres), ii) greater recognition of the importance of neighbourhoods as a locus for healthy lifestyles, and iii) supporting people to remain in their own homes and iv) planning for the health and social care implications of new housing developments. This presents opportunities for providers, and housing associations in particular, to develop new patterns of provision, to assist in improving access, to use their expertise to promote engagement and bring services closer to where people live. Certainly, a number of PCTs have seen the potential of ECH schemes as a centre for a range of demand management exercises and as a centre for a series of preventative interventions targeted both at residents of the scheme and older people living in the locality. Partnerships for Older People Projects (POPPs) have been designed to promote new thinking in terms of prevention – especially for those who experience the worst inequalities – and a number of these have used ECH schemes as a base for their activities. ECH is playing a significant role in enabling older people to avoid emergency hospital admittance and live independently for longer. Where a spell in hospital is unavoidable suitably designed and equipped ECH provides an appropriate enabling environment for intermediate care24. ECH can be used for supported discharge (step down) and for prevention of the need for hospital admission25. The combination of an environment designed to promote re-ablement and staffing to provide temporary therapeutic inputwhich facilitate self care and independence can be an effective intermediate resource between home and hospital26 providing, as it does, the thinking, breathing and planning space to consider options and to plan and prepare for the return home if that is what is decided – and to trial equipment.

21 DH (2005) Commissioning a Patient Led NHS. DH : London. 22 DH (2006) Independence, Well-being and Choice. SO : London. 23 DH (2006) Our Health, Our Care, Our Say. SO : London. 24 DH (2001) National Service Framework for Older People. SO : London. 25 DH (2003) Discharge from Hospital : Pathway, process and practice. SO : London. 26 Shreeves, M and Appleton, N (2005) An Introduction to Extra Care Housing and Intermediate Care. CSIP Factsheet 11.

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For people experiencing mental health problems, including dementia, there has been a similar emphasis on providing care closer to home27 and where possible early identification and intervention. Standard 7 in the NSF for Mental Health requires older people who have mental health problems to have access to a range of integrated mental health services as well as housing and housing related support services. People with dementia can be fully integrated in a ECH scheme (especially if they acquire the dementia after becoming a resident) although there is a discussion about whether they need to be housed in designated wings or floors. What is clear is that ECH with its ability to offer 24 hour cover provides the potential to meet the needs of people with dementia which less supported forms of housing cannot28. Recent policy statements have emphasised the importance of providing choice and dignity at the end of life and enabling people, where possible, to die in their own homes29. These see a danger in a over-emphasis on independence can obscure a full discussion of how to improve the quality of life of older people who are facing death30. Nonetheless, it does seem that the new and emerging models of housing with care, such as ECH, provide an ideal environment in which to provide end of life care31. The development of large scale ECH schemes has meant that a wider range of tenure options can be developed and a choice of community facilities can be offered. Such schemes also offer the opportunity to develop units to provide discrete services and facilities such as intermediate care or dementia care without disturbing the primary function of a home for life for the majority of tenants and lessees. Joint Strategic Needs Assessments will be based on a joint analysis of current and predicted health and well-being outcomes, an account of what local people want from their services and a view of the future and particularly predicting new or unmet need. As it informs the sustainable community strategy and local area agreements it will be crucial to ensure that appropriate linkages are made to older peoples’ strategies and that they have a real opportunity to engage in a dialogue about their aspirations. The Commissioning Framework for Health and Well-being recognises that there is a need to commission through a proactive approach to place shaping, show an interest in long-term health providing organisations and commission for outcomes as well as outputs. Providing the Infrastructure The overall objective of central government policy is to ensure that peoples' ability to live independently is not constrained by virtue of the construction,

27 CSIP (2005) Everybody’s Business – Integrated Mental Health Services for Older People : A Service Development Guide. CSIP : London. 28 DH (2006) Extra Care Housing Fund : Application Guidance Notes 2007-2008. SO : London. 29 DH (2006) Dignity in Care. SO : London. 30 Seymour, J (2005) End of Life Care : Promoting comfort, choice and well-being for Older People. Policy Press : Bristol. 31 Croucher, K (2006) Housing with Care for Later Life. JRF : York.

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layout and design of peoples' homes. The Housing Green Paper32 recognises that 48% of the growth in new households between now and 2024 will comprise older people and that a substantial majority of new households in many regions will be over 65. This means that new housing (and its surrounding infrastructure) needs to reflect this change. Houses need to be easily accessible and supported by the right infrastructure, so that people have access to health, housing, transport and care services. This will be supported by the requirement for Regional Spatial Strategies and Local Development Frameworks to consider demographic trends in terms of the housing requirements of older people. This will include the development of more attractive options to downsize for older people currently living in larger homes that are difficult for them to manage. There is also a recognition that older people will particularly benefit from better quality development. By promoting Lifetime Homes, by improving thermal comfort, by ensuring that new homes are carbon neutral (by 2016), and by making efforts to ensure that the architecture helps to prevent falls they believe they will improve the quality of life for all members of the community, as well as improving the environment, creating safer and stronger communities and reduce the Nation's carbon footprint. The Green Paper stresses that new settlements should be attractive places with good quality neighbourhoods and green public spaces that help create healthy communities. Key to this is the provision of a good local infrastructure – transport, schools and healthcare facilities. A new homes agency will work with local authorities to support them in their place-shaping role, including how local authority and other disused land can be used to create a better living environment for local people.

32CLG (2007) Homes for the Future : More Affordable, More Sustainable. SO : London.

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ANNEX 2. The current and projected population of older people in Kensington and Chelsea This Annex re-states and expands the information given in Section 3.1, providing fuller information about the divergent estimates made of the future population of older people in the Borough. The Sub-Group have taken the view that whilst the GLA projections understate both the current and future populations the projections provided by the Office of National Statistics probably err in the opposite direction. This leads them to an approximation of future population, shown in Table 2 in Section 3.1, the rationale for which is set out here. Table A shows that the 2001 Census enumerated fractionally below one hundred and fifty-nine thousand people living in the Borough among whom women were in a slight majority. That imbalance was more marked in the higher age cohorts. Table A Census 2001 population figures Age range Total Males Females

0 - 4 9,953 5,104 4,849

5 - 9 7,643 4,074 3,569

10 - 14 6,093 3,036 3,057

15 - 19 6,397 3,168 3,229

20 - 24 11,662 5,222 6,440

25 - 29 17,388 7,890 9,498

30 - 34 17,817 8,648 9,169

35 - 39 14,952 7,565 7,387

40 - 44 11,737 5,989 5,748

45 - 49 9,378 4,451 4,927

50 - 54 10,798 5,172 5,626

55 - 59 8,660 3,990 4,670

60 - 64 7,026 3,339 3,687

65 - 69 5,235 2,470 2,765

70 - 74 4,924 2,184 2,740

75 - 79 3,857 1,742 2,115

80 - 84 2,893 1,121 1,772

85 - 89 1,649 611 1,038

90 and over 857 183 674

Totals 158,919 75,959 82,960 (Source: 2001 ONS census)

There were 23,102 people above statutory pension age of whom 8,311 were Men over 65 years of age and 14,791 were Women over 60 years of age. The gender imbalance is accentuated by the inclusion of an additional cohort of

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Women (those between 60 and 64 years of age) but is still marked and increases with age. The numbers of men and women in their sixties are broadly comparable but among those in their eighties there are more than three Women for every two Men. Much debate has centred around the projections prepared by the Greater London Authority. These propose two alternative projections on different data and assumptions: one low and the other high. The GLA itself is highly critical of the projections prepared by the Office of National Statistics in relation to London boroughs and set out the detailed reasons for its disquiet in evidence to the Treasury Sub-Committee on “Counting the Population”.33 Their argument rests upon the adequacy and accuracy of some of the data included in the ONS estimates; problems that the ONS itself has acknowledged.34 The GLA has therefore proposed its own estimates. Even among the experts there is no consensus about how these differences are to be reconciled. The recent funding settlement for the Borough that was made on the basis of a revised estimate of population of 196,800 in 2008/2009, rising to 205,800 by 2010. This suggests that whilst not quite adopting the trajectory suggested by Office of National Statistics projections current assumptions by central government are much nearer to this than suggested by either the Higher or Lower range of GLA estimates. The first, referred to as Review of the London Plan (RLP) Low, is entirely driven by the increase in homes as seen annually since mid-2001 from data collected at borough level by the London Development Database (LDD) up to 2006 and the London Housing Capacity Study (LHCS) from 2006 to 2027. After 2027 it is assumed that the LHCS average values for 2017 to 2027 continue until 2031. The second projection, RLP High, was prepared to establish the impact on London of the Government Actuary’s Department’s (GAD) 2004-based population projection for the United Kingdom. Apart from following the trends in fertility rates and improved survival, the RLP High assumes that London’s proportion of UK international migration inflows and outflows for the calendar years 1999 to 2004 will continue. The distribution of London’s population amongst the boroughs is then determined by the distribution of the RLP Low projection. These two projections are summarised in Table B.

Table B Projections of Population for RBKC (000s)

2001 2006 2011 2016 2021 2026 RLP low 162.2 167.2 172.6 176.3 179 181.5 RLP high 162.2 169.5 176 182.1 187.3 191.7

33 http://www.london.gov.uk/gla/publications/factsandfigures/DMAG-Briefing-24-2007.pdf November 2007 34 See DMAG Briefing 24-2007

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http://www.london.gov.uk/gla/publications/factsandfigures/DMAG-Briefing-24-2007.pdf

Table C sets out the overall projections for population growth in Kensington and Chelsea for the period to 2031 as developed by the RBKC Data Management and Analysis Group. These are based on the GLA “low” projections. The higher range of increase reflected in the RLP high projections shows a difference of outcome over the period 2001 to 2026 of slightly over five percent. Carried through to the increases analysed in the following section this would have a modest impact on demand for accommodation and care. The projections shown in Table C suggest a growth in the total population of the Borough of around fifteen percent by 2031 to almost one hundred and eighty-five thousand people and a continuing gender imbalance in favour of Women. Table C Current and total projected population (000s)

2001 census 2003 2008 2013 2018 2023 2028 2031

Total 158.9 163.4 169.3 174.2 177.4 180.0 182.8 184.7

Males 76.0 79.7 81.3 83.2 84.3 85.3 86.5 87.4

Females 83.0 83.7 88.0 91.0 93.1 94.7 96.3 97.4 (Source: Kensington and Chelsea projections using GLA low projection data, supplied by John Hollis of the Data Management and Analysis Group, and manipulated into suitable age groups and years, to 2031)

By contrast Table D sets out projections from the Office of National Statistics that show a radically different outcome with population in the Borough rising steeply throughout the period to reach more than a third of a million by 2029. These projections are based upon the 2004 population estimates. Even among the experts there is no consensus about how these differences are to be reconciled. The recent funding settlement for the Borough that was made on the basis of a revised estimate of population of 196,800 in 2008/2009, rising to 205,800 by 2010. This suggests that whilst not quite adopting the trajectory suggested by Table D current assumptions by central government are much nearer to this than suggested by either the Higher or Lower range of GLA estimates.

Table D Current and total projected population (000s)

2001 census 2004 2009 2014 2019 2024 2029

Total 158.9 184.1 231.9 265.7 294.2 317.9 337.6

Males 76.0 90.1 115.2 133.2 148.4 161.1 171.5

Females 83.0 94 116.7 132.5 145.8 156.8 166.1 (Source: ONS click licence no. C02W0003323)

The adjustment of population estimates may be influenced by changes in the calculation of base numbers and also changed assumptions about the numbers of people moving in or out of the Borough.

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Relying on the GLA projections Table E provides detailed projections for the increases in people fifty years of age and over through to 2031.

Table E Current and total projected population 50+ (000s)

Age range

2001 census 2003 2008 2013 2018 2023 2028 2031

Total 50-54 10.8 9.9 9.3 10.5 11.5 11.9 12.0 12.0

55-59 8.7 9.3 9.1 8.8 9.6 10.4 10.7 10.9

60-64 7.0 7.1 7.8 7.6 7.5 8.1 8.7 8.9

65-69 5.2 5.4 5.9 6.4 6.2 6.1 6.7 7.0

70-74 4.9 4.6 4.4 4.8 5.2 5.1 5.1 5.4

75-79 3.9 3.8 3.8 3.6 3.9 4.3 4.3 4.2

80-84 2.9 3.0 2.8 2.8 2.8 3.1 3.4 3.5

85+ 2.5 2.5 2.7 2.8 3.0 3.1 3.4 3.6

All 50+ 45.9 45.5 45.8 47.4 49.7 52.1 54.3 55.5

Males 50-54 5.2 4.8 4.6 5.1 5.6 5.7 5.7 5.6

55-59 4.0 4.3 4.5 4.4 4.8 5.2 5.3 5.3

60-64 3.3 3.3 3.7 3.8 3.7 4.0 4.3 4.4

65-69 2.5 2.6 2.7 2.9 3.0 3.0 3.2 3.4

70-74 2.2 2.1 2.0 2.1 2.3 2.4 2.4 2.6

75-79 1.7 1.7 1.6 1.6 1.7 1.9 1.9 1.9

80-84 1.1 1.2 1.2 1.2 1.2 1.3 1.4 1.5

85+ 0.8 0.9 1.1 1.2 1.3 1.4 1.5 1.6

All 50+ 20.8 20.8 21.4 22.4 23.6 24.8 25.8 26.3

Females 50-54 5.6 5.0 4.8 5.3 5.9 6.2 6.4 6.4

55-59 4.7 4.9 4.6 4.4 4.8 5.2 5.5 5.6

60-64 3.7 3.8 4.1 3.9 3.7 4.1 4.4 4.5

65-69 2.8 2.8 3.2 3.4 3.2 3.1 3.4 3.6

70-74 2.7 2.6 2.4 2.7 2.9 2.7 2.7 2.8

75-79 2.1 2.1 2.1 2.0 2.3 2.4 2.3 2.3

80-84 1.8 1.8 1.6 1.6 1.6 1.8 1.9 2.0

85+ 1.7 1.6 1.6 1.6 1.7 1.7 1.9 2.0

All 50+ 25.1 24.6 24.5 25.0 26.1 27.3 28.6 29.3 (Source: Kensington and Chelsea projections using GLA low projection data, supplied by John Hollis of the Data Management and Analysis Group, and manipulated into suitable age groups and years, to 2031)

Table F further illustrates the way in which, on these assumptions, the growth in the population of older people in the Borough is broadly proportionate to the projected rate of growth for the whole population. If this accurately describes the situation then, compared with many other London boroughs and metropolitan areas throughout the country, the percentage of older people

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within the whole population remains relatively low throughout the period to 2031.

Table F Current and total projected population 50+ (%)

Age range

2001 census 2003 2008 2013 2018 2023 2028 2031

Total 50-64 26.5 26.2 26.2 26.9 28.6 30.4 31.5 31.8

65-74 10.2 10.0 10.3 11.2 11.4 11.3 11.7 12.4

75+ 9.3 9.2 9.3 9.3 9.7 10.5 11.1 11.3

Males 50-64 12.5 12.5 12.8 13.3 14.1 14.9 15.2 15.3

65-74 4.7 4.6 4.7 5.1 5.3 5.4 5.6 5.9

75+ 3.7 3.7 3.9 4.0 4.2 4.5 4.9 5.0

Females 50-64 14.0 13.8 13.4 13.6 14.4 15.5 16.3 16.5

65-74 5.5 5.4 5.6 6.1 6.1 5.9 6.1 6.4

75+ 5.6 5.5 5.4 5.3 5.5 5.9 6.2 6.3 (Source: Kensington and Chelsea projections using GLA low projection data, supplied by John Hollis of the Data Management and Analysis Group, and manipulated into suitable age groups and years, to 2031)

However, if the projections provided by the Office of National Statistics are the basis of prediction, as set out in Table G these would suggests very different picture with the numbers of those in advanced old age, that is to say seventy-five years of age and above, increasing much more substantially in absolute numbers.

Table G Current and total projected population 50+ (000s)

Age range

2001 census 2004 2009 2014 2019 2024 2029

Total 50-64 26.5 27.2 29.4 33.2 40 47.3 52.7

65-74 10.2 10.9 12.5 14.9 15.9 16.3 19.3

75+ 9.3 10 11.2 12.8 14.9 17.8 19.8

Males 50-64 12.5 12.6 13.7 16 19.8 23.9 26.9

65-74 4.7 5.1 5.7 6.6 7.1 7.3 9

75+ 3.7 4.1 4.8 5.8 6.9 8.1 9.1

Females 50-64 14.0 14.5 15.6 17.1 20.2 23.4 26

65-74 5.5 5.7 6.9 8.3 8.8 9 10.4

75+ 5.6 6 6.3 7 8 9.7 10.7 (Source: ONS 2001 census, click licence no. C02W0003323)

However Table H suggests that, because of the growth in younger cohorts the proportions of the total population in these older age groups will be less that previously predicted.

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Table H Percentage of population aged: Age range 2001 census 2004 2009 2014 2019 2024 2029

50-64 28.9 26.1 22.9 22.9 24.1 25.6 27.2

65-74 12.2 11.4 10.2 10.4 10.5 10.7 11.6

75+ 5.8 5.4 4.8 4.8 5.1 5.6 5.9 (Source: ONS 2001 census, click licence no. C02W0003323)

Based on the new projections Table I sets out in greater details the numbers of older people expected in the period to 2029. The impact of the changes is considerable. These projections show that rather than increasing by around 50% the number of people over eighty-five years of age will increase almost threefold over a similar period.

Table I Current and total projected population 50+ (000s)

2001 census 2004 2009 2014 2019 2024 2029 Total 50-54 10.8 9.6 10.6 14 17 18.9 20.3 55-59 8.7 10 9.5 10.4 13.4 16.1 17.7 60-64 7.0 7.6 9.3 8.8 9.6 12.3 14.7 65-69 5.2 6 7 8.5 8.1 8.9 11.2 70-74 4.9 4.9 5.5 6.4 7.8 7.4 8.1 75-79 3.9 3.9 4.2 4.8 5.6 6.8 6.5 80-84 2.9 3.2 3.3 3.6 4.2 4.9 6 85+ 2.5 2.9 3.7 4.4 5.1 6.1 7.3 All 50+ 45.9 48.1 53.1 60.9 70.8 81.4 91.8 Males 50-54 5.2 4.6 5.1 7.1 8.8 9.8 10.6 55-59 4.0 4.6 4.5 4.9 6.7 8.2 9.1 60-64 3.3 3.4 4.1 4 4.3 5.9 7.2 65-69 2.5 2.8 3.2 3.8 3.7 4 5.4 70-74 2.2 2.3 2.5 2.8 3.4 3.3 3.6 75-79 1.7 1.7 1.9 2.2 2.5 3 2.9 80-84 1.1 1.3 1.4 1.6 1.9 2.1 2.6 85+ 0.8 1.1 1.5 2 2.5 3 3.6 All 50+ 20.8 21.8 24.2 28.4 33.8 39.3 45 Females 50-54 5.6 4.9 5.5 6.8 8.2 9.1 9.8 55-59 4.7 5.4 4.9 5.5 6.7 7.9 8.7 60-64 3.7 4.2 5.2 4.8 5.3 6.4 7.5 65-69 2.8 3.1 3.9 4.7 4.4 4.9 5.9 70-74 2.7 2.6 3 3.6 4.4 4.1 4.5 75-79 2.1 2.2 2.2 2.6 3.1 3.8 3.6 80-84 1.8 1.9 1.9 2 2.3 2.8 3.4 85+ 1.712 1.9 2.2 2.4 2.6 3.1 3.7 All 50+ 25.1 26.2 28.8 32.4 37 42.1 47.1

(Source: ONS 2001 census, click licence no. C02W0003323)

In this situation of conflicting evidence what conclusions can be drawn? On the balance of probability it seems that the current and future population of Kensington and Chelsea is at a level higher than either of the GLA generated

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estimates but probably not at quite the level suggested by the ONS projections. The estimates used for calculating the grant formula in relation to the financial settlement for 2008 to 2010 suggest a level of overall population in the Borough about fifteen percent below the ONS estimates set out in Table G. This is worked through in projections set out in Table J:

Table J Current and total projected population 50+ (000s) 2001

census* 2004* 2009 2014 2019 2024 2029

Total 50-54 10.8 9.6 9.01 11.90 14.45 11.06 17.25 55-59 8.7 10 8.07 8.84 11.39 13.68 15.04 60-64 7.0 7.6 7.90 7.48 8.16 10.45 12.49 65-69 5.2 6 5.95 7.22 6.88 7.56 9.52 70-74 4.9 4.9 4.67 5.44 6.63 6.29 6.88 75-79 3.9 3.9 3.37 4.08 4.76 5.78 5.52 80-84 2.9 3.2 2.80 3.06 3.57 4.16 5.10 85+ 2.5 2.9 3.14 3.74 4.33 5.18 6.20 All 50+ 45.9 48.1 45.13 51.76 60.18 69.19 78.03

(Source: ONS 2001 census, click licence no. C02W0003323 Adjusted) * Unadjusted On this calculation the numbers of those in early old age are likely to increase by something around sixty percent whilst those in advanced old age (eighty-five years and above) will more than double. It is highly significant in projecting future levels of need for specialised accommodation and related services that the projected increase in older age groups grows steeper as we progress through the age cohorts. The rate of increase in the early cohorts of old age: around doubling in numbers in twenty-five years. The rate of increase falls for those in their late seventies but increases again for those in the highest age group where numbers are projected to double. Equally significant is the increase in the projected numbers of older men from the current situation in which women outnumber men by roughly two to one in the eighty-five plus age group to near parity. These fluctuations are more pronounced among the projected female population of older people than among the male population and it would appear that the upward trend toward the end of the period under review is driven, at least in part, by improving survival rates among older men.

ANNEX 3 Elders within the Black and Minority Ethnic communities of Kensington and Chelsea Table K sets out the numbers of older people who in the 2001 Census identified themselves with particular Black and Minority Ethnic communities. The age profile of the larger communities reflects the length of settlement in the United Kingdom. Thus there are substantial numbers of elders from the “Black Caribbean” community stretching right up into the 90+ cohort. Whilst those from the “Indian” community have a rather younger profile with smaller numbers in the highest age cohorts. The profile is younger again for the “Pakistani” community and younger still for the “Bangladeshi” community where there are no elders at all in some of the oldest cohorts. A number of the smaller communities also have small but significant numbers of elders. There is a substantial community of older people within the Irish community. Table K Population by ethnicity and age

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Totals 158,909 79,597 5,219 40,156 1,259 1,061 1,864 2,278 3,275 1,180 1,140 2,153 4,083 5,995 943 2,607 6,099

50-54 10,769 6,276 442 2,363 15 36 46 92 197 110 39 148 134 207 17 128 519

55-59 8,667 5,099 462 1,881 9 27 39 58 151 48 32 78 219 149 20 102 293

60-64 7,034 4,245 413 1,265 15 30 39 34 175 36 32 87 221 160 23 67 192

65-69 5,255 3,271 426 780 6 3 9 15 134 30 17 69 217 99 15 41 123

70-74 4,913 3,401 365 620 3 9 22 9 97 12 10 39 142 55 6 21 102

75-79 3,841 2,820 260 445 0 0 28 9 58 3 6 33 100 35 3 14 27

80-84 2,919 2,214 209 299 0 4 3 9 35 12 0 12 52 25 6 27 12

85-89 1,648 1,338 96 116 3 0 3 0 6 0 3 0 65 3 0 6 9


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This Borough wide picture obscures the variations to be found within Kensington and Chelsea. If we divide the Borough into three: North, Central and South those variations become clearer.

Table L Population by ethnicity and age in Kensington and Chelsea North (St Charles, Golborne, Notting Barns, Colville, Norland and Pembridge)

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Totals 51,704 25,994 2,152 8,433 849 579 539 872 742 278 599 697 3,069 3,584 676 482 2,159

50-54 3,244 1,895 187 501 6 11 15 29 55 22 22 42 93 126 14 47 179

55-59 2,580 1,429 214 388 9 18 15 21 25 6 20 19 177 100 9 21 109

60-64 2,239 1,261 205 268 9 21 15 16 40 6 17 19 178 91 14 19 60

65-69 1,791 984 222 178 6 3 0 6 43 3 11 18 186 56 6 16 53

70-74 1,472 956 180 130 3 6 6 0 23 3 4 3 105 20 3 0 30

75-79 1,092 732 109 96 0 0 6 3 21 0 6 6 78 29 3 0 3

80-84 822 580 100 59 0 4 0 3 9 3 0 3 46 9 6 0 0

85-89 484 342 36 41 0 0 0 0 0 0 0 0 59 0 0 3 3


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From Table L it is evident that the north of the Borough includes substantial numbers of elders from the Black Caribbean community right up into the most advanced age cohorts. This would generally be taken as an indicator that a community specific provision would be appropriate and viable. There are significant numbers in their seventies in both Indian and Black African communities. Table M Population by ethnicity and age in Kensington and Chelsea Central (Holland, Camden, Abingdon, Queen’s Gate, Earl’s Court, Redcliffe, Courtfield and Brompton)

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Totals 73,470 34,329 1,930 23,471 233 334 952 1,024 2,023 738 296 1,091 692 1,615 173 1,729 2,840

50-54 4,969 2,802 169 1,276 3 15 13 45 112 68 12 83 28 55 3 61 224

55-59 3,959 2,311 158 1,006 0 9 6 31 89 42 9 47 30 32 5 53 131

60-64 3,100 1,823 135 698 3 9 21 15 103 24 9 56 27 40 6 35 96

65-69 2,163 1,368 116 416 0 0 9 0 70 24 0 35 19 30 3 22 51

70-74 2,118 1,462 104 331 0 0 13 6 56 9 3 30 21 18 3 12 50

75-79 1,635 1,195 76 247 0 0 22 6 21 3 0 21 6 6 0 14 18

80-84 1,116 835 54 158 0 0 3 0 14 6 0 3 6 13 0 21 3

85-89 610 503 26 51 3 0 3 0 6 0 3 0 3 3 0 3 6


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Table M shows a quite different picture in the central band of the Borough with substantial numbers of people from the Indian community approaching old age and in early old age but more limited numbers in all BME communities in middle to advanced old age. This would generally be taken to suggest that the priority should be in ensuring that generic provision is sensitive to a range of ethnic and cultural requirements. Table N Population by ethnicity and age in Kensington and Chelsea South (Hans Town, Stanley, Cremorne and Royal Hospital)

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Totals 33,735 19,274 1,137 8,252 177 148 373 382 510 164 245 365 322 796 94 396 1,100

50-54 2,556 1,579 86 586 6 10 18 18 30 20 5 23 13 26 0 20 116

55-59 2,128 1,359 90 487 0 0 18 6 37 0 3 12 12 17 6 28 53

60-64 1,695 1,161 73 299 3 0 3 3 32 6 6 12 16 29 3 13 36

65-69 1,301 919 88 186 0 0 0 9 21 3 6 16 12 13 6 3 19

70-74 1,323 983 81 159 0 3 3 3 18 0 3 6 16 17 0 9 22

75-79 1,114 893 75 102 0 0 0 0 16 0 0 6 16 0 0 0 6

80-84 981 799 55 82 0 0 0 6 12 3 0 6 0 3 0 6 9

85-89 554 493 34 24 0 0 0 0 0 0 0 0 3 0 0 0 0


Table N completes the picture with very few members of BME communities in the age groups beyond seventy-five years of age and relatively small numbers even in the younger groups.

ANNEX 4 Variations in tenure within the Borough Whilst it is important not to caricature areas within the Borough each of the sub-divisions: North, Central and South, do have distinct characteristics that typify the average circumstances of those living in that area. That observation should not obscure the fact that services need to take account of the needs of individuals not averages: in the most prosperous parts of the Borough there will be individuals who are marginalised and may find difficulty in accessing the services they need. North In the north of the Borough the majority tenure for all older people is social rented housing, whether from the local authority or from registered Social Landlords. Relatively small numbers of people are living in communal establishments when compared with other areas of the Borough. Table O Age and Tenure North

All Males Females

50+ 50-54 55-59 60-64 65-

74 75-84 85+ 50-

54 55-59 60-64 65-

74 75-84 85+

Own outright 3,389 421 274 275 351 145 40 541 404 281 430 174 53 Own with mortgage or loan

1,526 277 184 144 103 33 6 331 207 105 88 34 14

Shared ownership 136 31 12 12 6 0 0 31 10 6 19 9 0

Rented from council 2,658 243 202 249 352 209 50 235 233 220 410 188 67

Other social rented 4,511 388 367 366 513 285 99 444 416 362 612 468 191

Private rented 1,167 134 94 94 139 73 21 108 92 68 139 143 62

Living rent free 298 25 24 27 27 18 3 28 28 18 42 38 20

Living in a communal establishment

249 0 6 3 16 26 10 9 7 8 30 59 75

Central In the central area of the Borough levels of owner occupation are higher and the number of older people living in privately rented accommodation is strikingly higher than in the north with the number of private tenants outnumbering those in social housing. Those over sixty-five years of age include a substantial number who are owner-occupiers.

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Table P Age and Tenure Central All Males Females

50+ 50-

54 55-59 60-64 65-74

75-84 85+ 50-

54 55-59 60-64 65-

74 75-84 85+

Own outright 8,343 913 699 565 935 507 109 1,022 921 807 1,086 588 191 Own with mortgage or loan

2,694 531 395 242 182 40 7 522 357 191 162 46 19


Rented from council 729 53 49 41 76 76 13 80 59 61 127 70 24


Private rented 4,328 578 426 336 409 260 65 483 380 278 405 479 229

Living rent free 829 101 91 80 77 33 3 108 89 78 77 62 30


334 39 20 14 15 29 10 25 15 9 44 40 74

South Whilst the South has a substantial number of older people who are private tenants they do not out-number those in social housing. The South also has the largest number of older people living in communal establishments. Here too levels of owner occupation are relatively high. Table Q Age and tenure South

All Males Females

50+ 50-54 55-59 60-64 65-

74 75-84 85+ 50-

54 55-59 60-64 65-

74 75-84 85+

Own outright 4,386 434 334 263 480 289 45 555 507 435 563 346 135 Own with mortgage or loan

1,274 230 175 111 77 23 6 251 171 112 78 37 3


Rented from council 1,496 98 106 75 173 177 27 139 106 118 230 194 53


Private rented 2,080 238 187 169 198 123 51 214 212 152 180 247 109

Living rent free 472 62 48 44 43 21 9 56 53 37 45 36 18


425 3 3 0 77 166 83 6 3 3 12 22 47

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Whilst the boundaries to the three areas are to some extent arbitrary there are clearly differences between them that need to be reflected in the styles of service offered to respond to the needs of older people within them.

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ANNEX 5 Understanding Extra Care Housing Understanding Extra Care Housing and what it can offer In the United Kingdom a variety of models that all claim the title “Extra Care Housing” have been at the forefront of attempts to re-shape the pattern of provision for older people. The debate around how Extra Care might be defined has been carried on between academics, commissioners and providers for most of the past decade35. Fundamentally there are two schools of thought:

• Those whose main driving criterion is the capacity of Extra Care to provide an alternative to Residential Care.

• Those whose aspiration is more toward the development of a model that enhances the lifestyle of older people with the capacity to deliver care blended into the background.

At the extreme end of the first school of thought there are those who feel that allocation to Extra Care should only be available to those with care needs that would otherwise be sufficient to merit placement in residential Care. In describing Extra Care their emphasis is upon those facilities that will support the delivery of social care and possibly primary health care: assisted bathing facilities, treatment rooms and so on. In staffing the emphasis is upon on-site care teams as the pre-eminent requirement. Those who take the alternative stance emphasise the need to make Extra Care a good place to live, think in terms of a balanced community in terms of care needs and give prominence to facilities that support an active and positive lifestyle: an exercise suite and spa bath, a coffee bar and perhaps licensed bar, facilities for arts and crafts; all supported by appropriate staffing. Whilst they include the care facilities and staffing they are matched by these lifestyle requirements if the scheme is to be considered as truly Extra Care. Whilst recent research evidence suggests that varieties of model are equally effective in different situations36 we would propose a set of criteria which will provide a benchmark for schemes under development and a standard for future schemes as they are brought forward. The criteria are appropriately aspirational. If RBKC aspires to reflect best practice, to “future-proof” what it develops and to offer the best possible accommodation and care facilities to its older people these criteria provide a basis upon which to build:

35 See for example Appleton N:Extra Care Housing for Older people, Care Services Improvement Partnership Housing LIN 36 Croucher K, Hicks L, Bevan M & Sanderson D (2007) Comparative evaluation of models of housing with care in later life, Joseph Rowntree Foundation

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1. That the accommodation offered in the scheme would be self-contained flats meeting a minimum size standard of 55m2 for one bedroomed properties and 65m2 for two bedroomed properties.37

2. That the proportion of two bedroomed properties should be the

maximum that the site and funding will allow.38

3. That all properties are occupied on the basis of a tenancy or a long lease.39

4. That all common parts of the scheme and its approaches should be

fully wheelchair accessible.40

5. That at least forty percent of the units should be to wheelchair standards and that the remainder should be visitable by people using wheelchairs.41

6. That the scheme should have the infrastructure to deploy Assistive

Technology devices within individual dwellings in appropriate cases.42

7. That at least one meal a day should be available to those who live in the scheme.43

8. That a care team should be located within the scheme, under the

direction of a member of staff onsite and able to use the team flexibly to meet changing patterns of care needs on a day to day basis.44

9. That care from the team should be available to those who live there on

a 24/7 basis.45

10. That the scheme should include assisted bathing facilities, in addition to accessible bathing facilities within each unit. 46

11. That exercise facilities should be provided within the scheme with

appropriate staff or volunteer support to ensure their safe use.47

37 See Housing Corporation Design Standards and Nicholson AM and Heather M (2004) Design Principles for Extra Care CSIP Housing LIN and Stilwell P (2005) Refurbishment or re-modelling sheltered Housing: a checklist for developing Extra Care, CSIP Housing LIN 38 Nicholson & Heather (2004)Op Cit 39 Appleton N (2003) Op Cit 40 Nicholson & Heather (2004) Op Cit 41 Nicholson & Heather (2004) Op Cit actually propose 100% wheel accessibility. Our recommendation moderates that position on the grounds of viability. 42 Assistive Technology in Extra Care, Factsheet 5, CSIP Housing LIN, Telecare Implementation Guide, CSIP Housing LIN & ICES 43 Appleton N (2003) Op Cit 44 AppletonN (2003) & King N (2004) Op Cit 45 AppletonN (2003) & King N (2004) Op Cit 46 Nicholson & Heather (2004) Op Cit 47 Appleton N & Shreeve M (2003) Now for something different – The Extra Care Charitable Trust approach to retirement living, ECT

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12. That a range of provision should be made for social, recreational, craft and cultural facilities within the scheme and staff or volunteers provided to support the use of these facilities.48

13. That the facilities and activities of the scheme should be available to the families and friends of those who live within it and also to other members of the surrounding community.49

14. That access to the scheme should be through a joint allocation process

involving housing, social care and provider organisations.50 This ensures that need is recognised before allocation and an appropriate balance maintained within then population of the scheme.

15. That the aim should be to achieve and maintain a balance within the

community of approximately one third of people whose support needs arise from housing, personal or social circumstances but who have no immediate requirement for care; one third who have minimal needs for care and one third whose needs for care are more substantial and might otherwise have led to allocation to a registered Care Home.

Extra Care as an alternative to Residential Care The capacity of Extra Care to provide a genuine and safe alternative to residential care depends upon the adequacy of the model adopted. Clearly a scheme that does not provide 24/7 care service on site cannot be regarded as a safe or appropriate context for the care of an individual who may need that level of support or oversight. As the need for that capacity: either to routinely provide care overnight or to be capable of responding rapidly should need arise, would be a factor in many residential care placements the connection is obvious. Good practice suggests that a model of Extra Care that meets all fifteen criteria set out in this paper will be capable of supporting the overwhelming majority of people who, in other circumstances, would have been allocated to residential care. Whilst the majority of schemes throughout the country that would meet at least the five fundamental criteria would provide personal care up to the levels that might be found in a residential care home some are now developing the range of care provided beyond that level. Extra Care Charitable Trust for example have adopted a five level assessment of care need, of which the fifth level is nursing care. In their schemes people will be supported within their own accommodation up to and including this level. Their model, which does meet the fifteen criteria definition, provides well established evidence of the capacity to substitute for residential care and beyond. The major reservation to be expressed is in relation to the suitability of most Extra Care schemes for people with moderate to high levels of mental

48 Appleton & Shreeve (2003) & Nicholson & Heather (2004) Op Cit 49 AppletonN (2003) & Nicholson & Heather (2004) Op Cit 50 Appleton (2003) & Lloyd P (2006)

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confusion. This issue is explored in a later section of the report but in brief we conclude that the design of most mainstream Extra Care schemes makes them unsuitable for people to be allocated to them once they have developed more advanced symptoms of mental confusion, including dementias. Much better levels of success may be achieved in supporting people who are existing residents of an Extra Care scheme if they subsequently develop such symptoms. For people with mild forms of mental confusion, who might be allocated to residential care homes in order to manage the risk to themselves arising from their condition, Extra Care can provide a very effective alternative. If the balanced community of need model of Extra Care is to be adopted then approximately a third of the people accommodated would be those who otherwise might have been allocated to residential care. Substitution of Extra Care for residential care would therefore be at the rate of thirty residential care beds substituted for every ninety Extra Care places provided. Achieving this outcome depends on both the capacity to provide sufficient levels of care and accurate allocation processes to achieve and maintain an appropriate profile within the scheme. Financial considerations There are obvious and quantifiable benefits for older people in moving into Extra Care, rather than registered care homes. If they are owner-occupiers and the scheme offers the possibility of whole or partial purchase of their dwelling it will allow them to maintain a level of equity either to provide potential funding to meet changes of circumstance or to leave to family and other legatees. By contrast a move to a Registered Care Home will generally mean that equity will gradually be eroded by inclusive charges. The structure of charges will also mean that individuals will have more disposable income when compared with the “pocket money” allowed to those in Registered Care Homes. The financial benefits of the model are even more pronounced for the public purse in general and for Social Care budgets in particular. In its guidance to those seeking to develop these new forms the Department of Health spells out the fundamental principle in relation to revenue funding: “The fundamental principle applying to the revenue funding of Extra Care Housing is that it is housing and not care. The same rules generally apply to residents of Extra Care Housing as apply to people living in other forms of housing of the same tenure type.”51 Extra Care Housing, and other enhanced variants of sheltered housing, bring together a number of different funding streams in order to provide a range of services which despite their disparate funding sources are well coordinated and cohesive at the point of delivery. The breakdown of costs and sources of

51 Funding Extra Care Housing, CSIP Housing LIN 2005

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potential support to those who cannot meet the full costs themselves is set out in Exhibit One. Exhibit One: Costs and Sources of Funding

Cost Source of funding Rent (including some services)

Housing Benefit

Council Tax Council Tax Benefit Home Care / Domestic assistance

Attendance Allowance / Disability Premiums

Support to maintain tenancy / lease

Supporting People Grant

Personal Care Care contract funded by Social Services

Heat, light and power within the dwelling

Pension or other income

(Source: DoH Housing LIN Extra Care Housing Strategy Guidance 2006) In Registered Care Homes charges relate to all elements of the service provided: accommodation, “hotel” costs such as food, support costs and care costs. In the Extra Care model these costs are disaggregated and can be dealt with separately. The accommodation is provided on the basis of a tenancy, or in some cases by sale of a lease, and where the individual cannot meet these costs support is provided by way of Housing Support in the same way as would have applied had the individual remained in general housing. (The local authority is normally able to recover the cost of providing support to housing costs through Housing Benefit from central government at 100%). Support costs are met by Supporting People funding. Individuals may contribute to the cost of their care through access to the Benefit system. Personal care is provided into Extra Care settings through domiciliary care agencies. Nursing care, when required, is accessed from Health on the same basis as applies to those living in general housing. Intangible but real benefits for older people For those who move to Extra care it offers an active lifestyle and the possibility of continued engagement with others within the scheme and beyond it. It is an alternative to the passive wait for declining physical and mental capacity. The levels of satisfaction achieved in Extra care Housing are high52 and with measurable gains in confidence and capacity for many. A study completed for Extra Care Charitable Trust by the University of Keele53 measured the

52 Croucher K, Hicks L, Bevan M & Sanderson D (2007) Comparative evaluation of models of housing with care in later life, Joseph Rowntree Foundation 53 Referenced in various publications by the authors, see, among others: Bernard M with Bartlam B, Sim J, and Biggs S Housing and Care for Older People: life in an English purpose-built retirement village', Ageing and Society, 27(4): 555-78, 2007. Bernard M with Biggs S and, Sim J (2004) New Lifestyles in Old Age: Health, Identity and Well-being in Berryhill Retirement Village, Policy Press,

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functional capacity of people, previously residents of a Registered Care Home, who moved into one of the early Extra Care schemes and a control group among older people living on the social housing estate within which the scheme was set. The study found that, although the level of functional impairment in the control group was much lower than that of the Extra Care residents subsequent decline was steadily downwards. A significant number of those who moved into the Extra Care scheme showed improved levels of functional capacity and subsequent decline was slower than that for similar individuals in the control group. The results are explained by a number of factors: an accessible and supportive environment, good nutrition, the ability to receive small care and support interventions in ways that prevented the development of more serious problems, most important of all was the impact on mental health, confidence and well-being. Extra Care offers a sense of security to those moving in that, whatever their current circumstances, their future needs will, in almost all circumstances, be met. For many couples where one is more frail than the other it offers a positive environment for the fitter of the two and a supportive environment for the partner; with the added assurance that the survivor will be able to continue where they are.

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ANNEX 6 Providing appropriately for people with dementia Reviewing the experience of the application of the Extra Care model to the needs of people with dementia and their carers54 there are five questions that seem to arise:

• Whether mainstream Extra Care schemes can cope with a broader range of people with dementia if the design of their buildings, facilities and services can be made more ‘dementia friendly’

• Is it possible for people with more florid symptoms of dementia to be

supported successfully in a mainstream/mixed population Extra Care scheme?

• Are there some people who can only be supported in a discrete

specialist Extra Care unit where all other occupants will be liaising with dementia? If so are the design requirements for such a scheme different from those for Extra Care and can a scheme with this concentration of mental confusion be regarded as being a genuine Extra Care model?

• Should such schemes be developed as an adjunct to mainstream Extra

Care schemes and how far should the boundary between the two be permeable.

• What is the appropriate role of Assistive Technology in supporting

people with dementia in Extra Care schemes? Creating a dementia friendly environment in mainstream Extra Care The principles of physical design to create an environment appropriate for people with dementia have been well set out in various publications from the Dementia Services Development Centre at Stirling University55 amongst others. Some of these can be readily incorporated into mainstream Extra Care design, such as colour coding and other visual prompts to help orientation. Other principles may be more difficult to apply: for example the avoidance of long travel distances from individual dwellings to communal facilities such as the dining room, the avoidance of long dead-end corridors and the creation of

54 Garwood S (2004) The Challenges of Providing Extra Care Housing to People with Dementia. CSIP Housing LIN & Garwood S (2006) Extra care Housing is not the answer for everyone with Dementia. CSIP Housing LIN 55 Judd S, Marshall M and Phippin P, (1998) Design for Dementia, Journal of Dementia Care. Cox S Housing and Support for people with dementia, Housing Corporation, Leichsenring K, Strumpel C and the Salmon Group, (1998) The use of small housing units for older persons suffering from dementia, The European Centre (undated) Among many others, but these are the cornerstones.

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clusters of eight to ten living units to create “knowable” communities within the scheme. In addition to general design principles mainstream Extra Care schemes can incorporate reminiscence rooms and programmes to encourage recall and strengthen recognition. ExtraCare Charitable Trust operate a number of large Extra Care schemes and within them have piloted a ‘Locksmith’ programme. The Locksmiths work with people who are developing symptoms of dementia to strengthen orientation and re-enforce memory that supports a sense of identity. They operate out of a purpose designed suite within the scheme and in addition to prompts to reminiscence they include training kitchen facilities. Supporting people with more advanced signs of dementia in Mainstream Extra Care This is generally recognised as being problematic. For the non-partnered individual arriving in an Extra Care scheme with an existing high level of disorientation and anxiety arising from their dementia initial settlement and integration will be extremely difficult. There is some evidence that intensive one-to-one working may be effective in some cases but the current consensus would appear to be that a more specialised facility may be necessary. For people living with a partner successful placement may be achievable and for those whose symptoms remain at a low level, or are not characterised by behaviours that others find disruptive or threatening, Extra Care may provide a successful environment. There is anecdotal evidence of people with quite advanced dementias being supported in communities where they had already established themselves: individuals wandering into the dwellings of other people and being treated as a guest and then gently returned to their own flat, people being willing gently to steer confused neighbours to where they need to be. However the presence of onsite 24/7 staff to provide support both to the person with dementia and to neighbours is essential. Some argue that there are a large body of people with moderate dementias who, through lack of other option, are allocated to Registered Care Homes but whose need is for light surveillance to manage risk and prompting to encourage self-reliance for personal care, rather than direct care interventions. For such individuals Extra Care not only provides a better quality environment it is also more cost effective for those commissioning their care. Providing specialist housing and care units for people with dementia For those whose dementias are more advanced with behaviours that place them or their neighbours at risk, where disruptive patterns of behaviour cannot

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be modified or there are high needs for personal care a specialist unit may be appropriate. Methodist Homes are widely recognised as the leading providers of specialised housing settings for people with dementia56. Their schemes are typically of eight to twelve units and support people with high level needs as an alternative to Registered Care Home placement. The Methodist Homes scheme at Newton-le-Willows provides a model for such small scale specialised schemes. Eight people are accommodated in good sized en-suite bed-sitting rooms with a range of communal facilities. There are high levels of support available to residents through an on-site care team. The design of the overall scheme and of individual elements within it provides a safe, small-scale environment in which orientation and navigation is easy. An alternative model has been developed by some providers with a campus approach that combines a unit supporting people with high levels of need alongside those whose needs may be more moderate and, in some cases, providing accommodation for partner-carers also. Fold Housing Trust in Northern Ireland has developed a number of schemes for people with dementia of which the best known is the Seven Oaks scheme in Derry. This accommodates just over thirty people with moderate to very severe dementias. Its basic footprint is of two connected loops, each round an internal courtyard with sitting and dining areas for each eight units. Within the campus there is also a day centre for people with dementia, the base for the community support team, the office of the local branch of the Alzheimer’s Disease Society and five bungalows in which couples that include a partner with dementia can be housed. The scheme has also pioneered the use of Assistive Technology in managing risk and supporting quality of life for people with dementia in this setting. Reviewing the specialist schemes that have been developed it seems that some of the assumptions we have made about the basic requirements for mainstream, Extra Care may not apply: the provision of a one or two bedroom flat as a basic requirement, some of the social, cultural and recreational facilities (although this may be more on the grounds of viability in the scale of the scheme rather than that they are not relevant) are two examples. Most fundamentally of all they require a concentration of people of moderate to high dependency which makes the creation of the ethos of mainstream Extra Care arising from the presence of a mixed community impossible57. It may be confusing to refer to such schemes as Extra Care, as if they were comparable with the mainstream model; this is Extra Care housing for people with dementia and quite distinct.

56 Cox S (2006) Home solutions 2: housing care and support services for people with dementia, Dementia

Services Development, Stirling 57 See the discussion in Garwood S (2006) Op Cit

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Adopting a campus approach Whilst there are strong arguments for creating small scale units that create an environment in which people with advanced dementias can be appropriately supported there may be benefits in locating these on the same site as mainstream Extra Care. Some would have reservations about such a development, seeing a sub-unit of this kind negatively and characterising it as a ghetto. The practicalities of providing for people with advanced dementias make specialist provision as an alternative to Registered Care very attractive and the sharing of some facilities with a mainstream may enrich the provision available to them. The sharing of staff cover may also be of benefit. We would therefore suggest that co-location with “semi-permeable” boundaries may be a good solution. Alternative approaches may be illustrated from the American and Australian experience. In the United States there is often a distinct difference in the quality of environment and the culture of care between assisted living facilities and neighbouring dementia care facilities. In Australia, on the other hand, dementia provision in specialist wings to assisted living schemes is of high quality. Whilst in the 1990s they were pressing ahead with such specialist annexes many Australian providers have now re-integrated provision and the flexibility of design has made that possible. Making best use of Assistive Technology A number of the most developed uses of Assistive Technology have been in relation to supporting people with dementia. There are of course some major issues around informed consent and aversion to anything that seems like “tagging”. The Fold Housing Trust experience is that sensitively applied Assistive Technology devices can help manage risk and make supervision less intrusive. For those who need to be checked at night the accepted practice had been to enter the resident’s room at hourly intervals to check that all was well. With bed-occupancy and movement detectors it is possible to monitor night-time disturbance without entering the room. Staff spend less time on these “custodial” tasks and are able to make better quality interventions with residents who do have disturbed nights. Conclusion In summary we may conclude that for people who move to mainstream Extra Care schemes without significant signs of dementia it may be possible for them to be supported successfully as their dementias advance. The capacity to support people through that process will be enhanced if basic design principles are adopted, if some specialised facilities and services are provided. For people whose symptoms are already well advanced specialised housing and care setting may be more appropriate. Purpose designed and with

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generally no more than eight to twelve units such a scheme may either be completely free-standing or co-located with a mainstream Extra Care scheme.

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ANNEX 7 List of Stakeholders interviewed by Contact Consulting Stewart Bakewell Area Manager St Mungos Hash Chamchoun Head of Supported Housing TMO Beryl Chyat Head of Placement Review RBKC ASC Mark Creelman Associate Director PCT Paul Devine Head of Supported Housing - Octavia Housing Cynthia Dize Director, Sixty Plus Babs Doran Service Manager Notting Hill Housing Trust Peter Ebenezer Continuing Care Manager /Lead, PCT Steven Forbes Commissioner Adult Social Care RKBC Julian Freeman Head of Leasehold Services TMO Abigail Garraway Supporting People Commissioning Manager Angela Hamlin Managing Director Draycott Nursing Amanda Johnson Head of Supporting People, RBKC (now on

Maternity Leave) Henry Leak Service Manager Older People RKBC Gwyn Morris Formerly Head of Older People Services, RBKC Peter Okali Age Concern Kensington and Chelsea Fran Pearson Older Peoples Partnership Manager RKBC/PCT Gillian Peckham Service Development Manager Anchor Trust Graham Raine Director- Staying Put Services Andrew Seymour Senior Social Worker Older People RKBC Amjad Taha BME Forum Michelle Thurston Supported Housing Manager Peabody Trust Sandra Watts Manager Burgess Fields Extra Care RKBC Jo Whitehouse Senior Occupational Therapist Housing RKBC

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older people’s accommodation in the royal … - older peoples...although rbkc has a relatively...

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