This was a multi agency review looking at people supported in residential care, nursing care or supported living arrangements across the borough. The review is part of a bigger Best Value review of residential and nursing care.

Twelve people were visited as part of the review. This included 9 men and 3 women. 4 were aged over 50 years, 6 were aged 30-50 years and 2 were under 30 years. There was a cross section of types and levels of disability. Ten were white, one was Asian and one was African Caribbean.The people visited represented a cross section of models of provision: 3 lived in a supported tenancy, 3 lived in a small home of 4 or less people, 3 lived in a larger residential home and 3 lived in a nursing home. A total of 8 providers were represented, of which 3 are voluntary organisations, 1 is an NHS trust and the remainder are independent providers. There is no "in-house" local authority provision in Sandwell.

People living in NHS provision (continuing care beds) were excluded as a separate Quality Network review is being completed on this service.

The Quality Team consisted of the Joint Commissioning Manager and the CLDT Team Manager, 4 members of Sandwell People First, one social worker, one independent manager from a neighbouring borough and 4 staff (across all grades) from independent and voluntary sector service providers. No one visited a person supported by his or her own organisation.

Some of the findings were very positive, with a significant number of people experiencing a good quality of life. However, 2 out of the 12 people were found to be "unsafe", resulting in one adult abuse investigation and one referral to the CLDT and contract section. If this is representative, it implies that 16% of service users may be in similar situations.

There was no particular pattern that suggests that one model of service delivery or provider achieves better outcomes than another, though generally those in supported living arrangements do seem to experience better outcomes. The key issue appears to be around staff culture and staff attitude and services which implement the key features that are often associated with supported living such as a person centred approach, choice and control, dignity and respect have achieved the best outcomes, regardless of model – so for example the only "gold star" service to fully achieve every outcome was a registered nursing home.

It should be noted, however, that this is a person centred review – a good outcome should not lead to complacency on the part of the provider, as it does not imply that everyone they support will likewise be receiving a good service!

It was observed that there is generally a lack of good person centred planning – for example, though some people’s lives are currently very good, there is no active planning for the future and no account taken of the fact that people’s lives change and move on. This is particularly so for those people who have had bad experiences in the past and there may be a fear that enabling more control could lead to failure.

It is clear that those who receive a good service are generally more able and more assertive and that those who have poorer outcomes all have more complex needs, and little or no communication. There is a real gap in communication issues (not simply speech therpay but rather the communication environment) with staff generally not being trained or skilled in communication and not using relatively simple techniques such as using pictures or photographs. In addition, there is a shortage of good quality, independent advocacy, particularly for people with communication difficulties.

With regard to choice and decision making, a key recurring issue is around lack of control over money – though some people in supported living have full control over their own money, with support, this is often lacking with people having to ask for money, not knowing how much they have, going out without money to pay for a drink etc. It was noted that the Appointeeship arrangments, set up to counter financial abuse, also added to this problem. No one is yet receiving Direct Payments in Sandwell.

Friendships and relationships tend to be a major issue for those who are less active and able – for example, some people have no friends, even amongst those they live with, whilst others commonly depend on seeing friends at structured activities – staff need to take a more active role in facilitating this. In particular, some people experience little privacy, particularly to develop or maintain more intimate relationships and there is generally a lack of access to sex education and sexual health advice.

The development and use of Circles of Support could be used more effectively to address some of these issues, and also to improve the involvement of family and relatives.

Those who are most able are generally aware of who to speak to in order to make a complaint, though they may not be aware of the formal complaints procedure. These need to be more accessible.

Relatively few people hold their own records and though there are some examples of good practice – for example people being told what is in their records - issues of respect and dignity are not always reflected with the use of negative language or confidential information being inappropriately recorded. More people could, for eaxmple, hold their own records on audio tape or video.

There are implications for the commissioning of services and there is a need to develop outcome based contracts with person centred reviews and monitoring arrangments. The newly established Providers Forum provides an opportunity to develop a consortium based training plan and to specifiy compliance as a contract requirement.

It was also observed that college courses tend to be segregated – in some cases with people being taught at home or in a seperate building. Though there are some good examples of people recieving work based training and work preperation, these often don’t lead to a paid job. Staff supporting people at home also tend not to consider this to be part of their remit, whereas they are in the best position to support people in accessing New Deal or supported employment.

It was also sad to note that some people had a poor reception and welcome from the staff and organisations they were visiting.

Finally, there was a clear message emerging from people with learning disabilities in Sandwell:

(A message for Tony Blair)