Mapping the as-is model in Conwy

This “finding out” stage is broken into four sub-stages as suggested by Checkland and Poulter (2006), namely: Analysis One- Intervention, "Rich Pictures", Analysis Two- Social and Analysis Three- Political.

Analysis One: Intervention

This analysis focuses on the intervention itself and involves identifying the practitioner, clients and owners for the purpose of the study. The researcher took the role of practitioner in this SSM project, so that someone worked full-time on achieving the goals laid out by the Steering Group. The clients are the people that caused the intervention to happen. These were the Head of Housing Strategy at CCBC and the Director of Operations at Cartrefi Conwy. They had engaged the University as they wanted to develop an Older Persons’ Housing Strategy for Conwy that was well researched and thought out, but they did not have the appropriate resources in-house. The SSM research informed this housing strategy by focusing on building a picture of the whole system of care for older people in Conwy, and how Housing could be integrated into this system

Finally, the ‘owners of the issue(s) addressed’ are the people who could be concerned with, or affected by, the system and the effort to improve it. The issue owners were invited to sit on the Steering Group so that it consisted of representatives from:

 Local housing associations with housing for older people: Cartrefi Conwy, Clwyd Alyn, North Wales Housing, Wales and West Housing and Tai Clwyd

 Charitable organisations with housing for older people: Abbeyfields

 Council departments with responsibilities in the system: Housing, Social Services, Housing Renewals, Partnerships and Provider Services

 Conwy Care and Repair Agency: offer adaptations for older home-owners and have a handyman service

110

 Conwy Voluntary Services

 Councillors from the local authority: Housing, Social Care and Health

 Older Persons’ Champion for Conwy: able to represent views of older people living in the county

 Betsi Cadwaladr University Health Board

Older people were implicitly represented by these organisations, and explicitly represented by the Older Persons' Champion for Conwy. Having a representative sample of older people included in the Steering Group was not feasible, as it would have made the group too large for in-depth discussion. Older people were engaged during the 'Finding Out' stage on an informal basis (explained below) and then were formally engaged later in the project through focus groups and RSL Board Meetings. Although Health is a major player in this system, the group struggled to find a representative who could consistently make meetings at this early stage of the research. This was because the Health Service in North Wales had gone through a recent merger (detailed in the political analysis) and so was experiencing a period of turmoil. This left the Steering Group unsure of who to invite from Health, as employees seemed unsure of whose responsibility it was to engage with groups such as this one. The lack of early involvement is reflected in the rich picture, where Health should play a large part, but the group did not understand, or feel able to describe, the complexity of the health system and how it links to the whole system of care. Rich pictures are intended to be a summary of the group's understanding of the system. Therefore, technically, this omission could not negatively impact on the value of the rich picture, as it is only supposed to summarise the group's understanding; the group cannot summarise that which it does not understand. The issue owners all have varying worldviews, which adds ‘richness’ to the inquiry (Checkland and Poulter, 2006:30).

However, in terms of the overall thesis, a lack of engagement from Health in the early stages of this research is a limitation. The overall thesis is focused on the whole system of care, i.e. how each element of the system interacts. The throughput of the Health subsystem is therefore not relevant to this work. However, the inputs and outputs of this subsystem are, i.e. how older people enter the health subsystem and what happens to them once they leave. Information about this can be obtained

111 from the other organisations on the Steering Group. However, Health's perspective on it may differ slightly, so its involvement was important. Health representatives began attending Steering Group meetings in the second year, and were able to offer this perspective.

Rich Pictures

In order to find out about the problematic situation, this objective began with field based research focusing on the case of Cartrefi Conwy, to assess its current activities. The researcher spent time immersed in the organisation to gain an appreciation for how a stock transfer housing association runs and the issues it has to deal with regularly. Cartrefi Conwy was seeking the guidance from CCBC that the Older Persons' Housing Strategy would eventually provide. This was because it had a high proportion of sheltered housing amongst its housing stock (one-third) and the executive management team wanted to discover whether this type of housing was still fit for purpose, following the development and growth of extra care housing. To this end, Cartrefi Conwy was extremely helpful in providing the researcher with access to the information required to conduct this work.

Informal interviews were then conducted with each representative on the Steering Group, as they had already been identified as the key stakeholders for this research. Some interviewees recommended that it would be beneficial to the research to interview other people from outside the group, which is an example of snowball sampling. Representatives from the following departments within CCBC, that would be impacted by the strategy, were interviewed: Housing Strategy, Provider Services, Social Services, Housing Renewals, Supporting People, Reablement, Direct Payments and Telecare. The researcher also interviewed representatives from other organisations involved in the whole system of care for older people namely: Care and Repair, Conwy Voluntary Service Council and Betsi Cadwaladr (Health). Brief notes were taken during each of the interviews, which each lasted between 30 and 90 minutes. The researcher then made field notes shortly after each interview to capture detail. The notes were then combined, typed up and sent back to the interviewee for approval to ensure that no mistakes had been made. This was considered necessary due to the complex nature of the organisational structure of

112 the local authority, its funding streams and cultural norms, such as the extensive use acronyms.

Interviews covered a variety of topics due to the range of organisations and services being questioned. The purpose of these interviews was to enable the researcher to develop a comprehensive picture of the services involved in the whole system of care and establish some of the issues facing these services. Interviewees were asked about their role in the whole system of care for older people in Conwy, and what they thought the Older Persons' Housing Strategy should include. Due to the wide range of services interviewed, the focus of each interview differed widely. However, there were some common themes that emerged across multiple services, including;

i. client dissatisfaction with the number of carers that visit them to fulfil their care plans;

ii. all care packages are outsourced to external providers by CCBC Social Services, except for reablement and care packages for dementia as these are highly specialised;

iii. importance of 'doing with' instead of 'doing for' which reflects changes in policy around effective delivery of care;

iv. concerns over lower budgets for services which meant tighter eligibility criteria and reduced services;

v. high turnover of support services offered by Health and the third sector, as not enough people take up the service so funding is lost;

vi. the role of technology in supporting older people;

vii. contemporary approaches to care such as reablement and direct payments. Checkland and Poulter (2006) recommend drawing the system in picture form, as a picture can display the system as a whole and show the multiple relationships between the entities, leading to more in-depth discussions in the later stages. The system, as established by the above research, is drawn in Figure 8 (page 113).

113 Figure 8: Rich picture of problematic situation from Steering Group’s Perspective

114 Figure 8 highlights that it is common for numerous services to be visiting the client in their home, including carers, housing renewals assessors, support workers, Rowan advisors (for direct payments) and the reablement team. A brief description of these services is given in Table 3.

The Steering Group felt it was important to use an existing service to help integrate Housing into the whole system of care as there was no budget allocated for this purpose, so this would be the most feasible option in practice. Therefore, the five services mentioned above were considered as potential integrating functions. Rowan and Housing Renewals were quickly ruled out as they provide highly specialised information on direct payments and adaptations respectively, and each only intervenes in the short term, usually only visiting the client once or twice. The other three options were examined in more detail.

Table 3: Summary of services visiting the client in their home Service Service Provider Nature of Service

Carers External care agencies commissioned by Social Services following an Unified Assessment (UA)

Provide care to the client in

accordance with their care plan, which is written based on Social Service’s assessment

Housing renewals assessors

Assessors for works paid for by the Welsh Government's Disabled Facilities Grant (DFG)

Assess client's home for adaptations, usually with help of occupational therapists who assess client needs Support

workers

Wardens working for client's Registered Social Landlord (RSL)

Provide support for client in

accordance with their annual support plan (sheltered housing only)

Rowan advisors

Charitable organisation commissioned by Social Services

Give advice on direct payments and help clients to employ someone if they opt to receive care using direct

payments Reablement

team

Joint specialist team with reablement workers from both Health and Social Services

Six weeks reablement to help improve client's health following a hospital stay, or before conducting a Unified Assessment to access care from Social Services

115 The rich picture (Figure 8, page 113) focuses around the 'client in their home' but does not delve into the different types of housing that this could apply to. As this research is focusing around integrating all types of housing into the whole system of care, it was necessary to obtain more detail about the different types of housing available for older people. As Chapter 2 suggested, some types of housing, such as extra care and care homes, were integrated into the whole system of care and others were not. To this end, the researcher met with a representative from each of the local providers of housing for older people (Cartrefi Conwy, Clwyd Alyn, North Wales Housing and Wales & West Housing) in order to review their housing stock. Abbeyfields schemes and a private residential home, Bryn Eithin in Colwyn Bay, were also visited.

These visits had numerous benefits. First of all, they gave the researcher the opportunity to view the different models of housing for older people, such as sheltered housing and extra care. Secondly, spending a considerable amount of time with the Heads of Service from each of these organisations helped the researcher to develop an appreciation for the different providers’ approaches to providing support within their housing stock. This was essential considering the time that the researcher initially spent at Cartrefi Conwy, as major differences between the ways in which the RSL's ran their support services were noted. Finally, it gave the researcher the opportunity to meet some of the wardens/managers and tenants of the different models of housing. Although these meetings were very informal, they highlighted some of the issues with the current system and started to build the picture of tenants' opinions for and against the model of housing they had chosen to live in. For example, many tenants of sheltered housing were unhappy with their care, due to the fact that they see multiple carers on a weekly basis, so there is little opportunity to develop relationships. This was not a problem for tenants of extra care, who had a dedicated team of carers onsite. Again, field notes were taken throughout and the researcher reflected on these and added to them at the end of each day. The researcher also attended five local forums for older people across Conwy to gather the views of older people on an informal basis.

The informal research involving visits to different types of housing, and talking to tenants, enabled the researcher to develop an understanding of the linkages

116 between housing and tenants. Figure 9 was developed from the findings in this section, in order to help the Steering Group better understand older people’s decisions to move between housing types and their accommodation choices.

Figure 9: Pathways through Housing 76% of older people in the UK are owner-occupiers and the majority of these people wish to stay in their own homes for as long as possible, with only 3% of all older- person households moving each year (Pannell et al, 2012). The advantages of staying put include familiarity with the home, links to the neighbourhood and a sense of continuity with the past that the home gives (Tinker, 1997). There is also an issue with tenure, as the majority of specialist housing available for older people currently is available to rent but not buy, which presents an issue for those who have previously been owner occupiers. The issue with selling units in specialist housing is that the allocations policy presents complications when the owner passes away, in terms of selling the unit on. Research shows that around three-quarters of older people who do move house, move into one of the same tenure (Pannell et al, 2012).

Own home Develop support needs Sheltered Housing Choose Housing Type Can care needs be met in Sheltered Housing? Develop care needs Downsize/ Prepare Can care needs be met in Extra Care Housing? Can care needs be met in own home?

Extra Care Housing Health Deteriorates Health Deteriorates Choose Housing Type

Residential Care End of

Life Smaller Home •Re-ablement? •Possible homecare package? •Adaptations to home? Yes •Re- ablement •Possible homecare package? •Adapt home? Yes _Yes No No No Quality Location Cost Care

117 Therefore, of the 3% of older people that are choosing to move, the majority will not be moving from owning their home to renting specialist housing from a housing association. Following on from this, it is reasonable to assume that the majority of people living in specialist housing are social housing tenants and not owner occupiers.

Figure 9 (page 116) demonstrates that the development of support or care needs are major drivers for moving into housing which is specifically designated for older people. This may be due, for example, to the development of a disability or illness, or the loss of a partner. The Communities and Local Government New Horizons (2008) research found that the most common reason for older people to consider moving is that their house cannot be adapted to meet their mobility health needs. The 'Finding Out' section of the SSM highlighted that quality, cost and location are important factors in choosing where to live and care options may also have an impact on the decision depending on the needs of the individual. Obviously, end of life can happen in any type of housing. However, it is included after residential care to highlight that it is unusual for people to move back from residential homes to another type of housing, because, for example, they have developed dependencies on onsite care, such as the provision of meals, etc. Deciding to move into a care home is commonly an emotionally difficult journey, with new residents commonly feeling sad and anxious about; "leaving a familiar environment to join a new social group, giving up many of their possessions and coming to terms with the loss of independence admission represents" (Rogers, cited in Mulley et al, 2015 :4). It is therefore not a decision that people commonly change their mind about, so once living in residential care the majority of residents stay until they pass away (Naraen, cited in Mulley et al, 2015 :420).

These findings were in support of the literature, as extra care housing and residential homes in Conwy were found to be integrated with the whole system. In terms of extra care, schemes have an allocations board which is responsible for deciding which applicants would benefit the most from moving in, and representatives from both Health and Social Services sit on this board. Social Services also provide the care within the schemes, on a means-tested basis. One extra care scheme had a joint Health and Social Care building next door, as part of the complex. In another

118 scheme, Health rented an apartment for respite care to avoid long stays in hospital. Residential homes also have their own care teams, who work closely with Social Services to ensure that care plans are carried out effectively.

In 2012, around 10% of specialist dwellings for older people also offered onsite care (Pannell et al, 2012). This leads to the conclusion that the majority of specialist housing is not integrated with the whole system of care for older people, as only housing with care is integrated. The focus therefore needs to shift to how to integrate sheltered housing and people living in their own homes into the system. The 'Finding Out' research highlighted that people living in these types of housing often do not enter into the system until they have reached a crisis point, which is not ideal as this is not a good time to try and navigate this complex system.

Social Analysis

The social analysis focuses on the social aspects of the system, such as the values, norms and both formal and informal roles of people operating within the system. "If we are to learn our way to practical action which will improve a situation under investigation, then changes involved in improvement have to not only be arguably desirable but also culturally feasible" (Checkland and Poulter, 2006:32). The social aspects of the partner organisations were noted and analysed by the researcher from the beginning of the project. Effort was made to integrate into the community by working in both the Cartrefi Conwy office and the Housing Department of CCBC, socialising with staff and talking to people from different departments.

This research spans multiple organisations, so this analysis is multidimensional. It is