Housing Related Support Specification for providing outreach to older persons living in the ...

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Service specification final August 2017: Locality lots NCC41257

Service Specification

Supported Living and Community Enablement and Support
Services for People with Mental Health Needs in Norfolk

SERVICE SPECIFICATION –

Supported Living and Community Enablement and Support Services for People

with Mental Health Needs in Norfolk

Norfolk wide – 3 areas based on Clinical Commissioning

Group boundaries / Norfolk County Council Locality areas:

Central – (North, South, Norwich), West, and East

GEOGRAPHICAL (Gt.Yarmouth District Council boundary).

AREA There is a fourth lot covering the Norwich locality for

intensive outreach and the successful bidders of the 3

geographical lots will be expected to work in partnership with

the Provider of the outreach service.

Supported Living and community Support Service for People
SERVICE TYPE
with complex mental health needs

People with mental health needs and with related support
CLIENT GROUP
needs

SUPPORT

DURATION FOR No fixed term. Dependent on eligibility and needs

INDIVIDUALS

START DATE 1 March 2018

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Service specification final August 2017: Locality lots NCC41257
Contents

Section Section Title Page
1 Introduction 3
2 Service values and principles 4
3 Service objectives 5
4 Core service requirements 5
5 18
Outcomes
6 Service levels and activity for each lot 21
7 Quality Assurance and Performance Monitoring 28
Framework

Appendices
1 Mental health support: detailed activities 35
2 Service specification for supported living 36
3 Details of supported living schemes 44
4 Annual contract review report 47
5 Breakdown of support hours 51
6 Pricing spreadsheet 52
7 Outcome Measurement: performance management framework 53

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Service specification final August 2017: Locality lots NCC41257
Introduction

1.1 Norfolk currently provides support to working age adults with mental health needs
through:
1.1.1 Supported living schemes with 24/7 support on site, funded through block contracts,
for people with eligible social care outcomes. Each scheme has been commissioned
separately.
1.1.2 Floating support in their own homes with accommodation related issues. This has also
included support for people in acute mental health hospitals to support discharge This
is delivered through one county wide block contract with health and social care
funding.
1.1.3 Outreach support to individuals with eligible social care outcomes in their own homes
provided by a range of providers on spot contracts. This service includes community
engagement.

1.2. Through re-commissioning and remodelling these services together, the aim is to
deliver an integrated service on a locality basis. This Service will:
 Support people to live independently and safely in their own homes through the
provision of support in their homes and the community.

 Enable people to recover and develop the capacity to live more independently in
their communities.

 Develop the capacity of people to maintain their recovery and their ability to live as
independently as possible.
There is a fourth lot covering the Norwich locality for intensive outreach and the
successful bidders will be expected to work in partnership with the Provider of this
service to provide an integrated service.

1.3 In particular the service will:
1.3.1 Create a pathway for people to move from residential care to supported living and
then to independence in the community, where the support at each stage is provided
by a team of staff whom the service user is familiar with.
1.3.2 An integrated staff team where support workers are recovery focussed, are operating
on the principles of psychologically informed environments and support people to
develop their ability to do things for themselves.
1.3.3 Provide flexible levels of support to minimise the risk of crisis, to be able to provide
more intensive support when needed and increase the potential for long term
recovery.
1.3.4 Where approaches have failed in the past, take a creative approach based on
services user’s strengths and wishes to develop hope and resilience.

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Service specification final August 2017: Locality lots NCC41257
1.3.5 Know what’s in the local community and be able to link people in with activities and
friendship groups which offer sustainable support and use community assets. This will
include locality based services for women in the service.

1.3.6 Utilise supported living schemes in the service as a ‘hub’ for support to service users
in the community outreach element at evenings and weekends.

1.3.7 Provide support to and engagement with people who have dual diagnosis or who are
difficult to engage to prevent them going into crisis and becoming ‘revolving door
patients’.

2 Service Values and Principles

2.1 The following values and principles will underpin all activities undertaken in the
delivery of the Service:

2.1.1 The Service shall promote and encourage choice and be based on promoting
independence through support to achieve desired outcomes
2.1.2 Service users are supported in achieving their full potential
2.1.3 Service users shall be treated with courtesy, dignity and respect and will be at
the centre of all decision-making that impacts on their lives
2.1.4 Personalisation, meeting the needs of individuals in ways that work best with
them
2.1.5 Incorporation of the Recovery Approach, summarised by the phrase ‘hope,
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agency (i.e. control) and opportunity for all’
2.1.6 Continuity of support within the service, with trusting relationships with familiar
staff, under-pinned by multi-disciplinary working
2.1.7 The Service shall seek to meet and promote the cultural and religious needs of
service users from ethnic minority backgrounds. It will be a fundamental principle of all
policies and practices that all people are equally valued regardless of their gender,
disabilities, race, ethnic origin, language, religion or sexual orientation.
2.1.8 To treat service users and carers as peer partners with expertise in support and
care. To work with them using a co-productive approach in the planning, development
and monitoring of the Services and in establishing good practice, reviewing policy and
procedures and maintaining and continuously improving delivery of the Service
2.1.9 The Service will liaise with other Providers of services to vulnerable people in
order to develop effective and efficient practices and partnerships which will optimise
the effectiveness of all services in Norfolk. This will include information sharing to
avoid service users having to repeat their stories.

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http://www.rcpsych.ac.uk/pdf/Recovery%20is%20for%20all.pdf

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Service specification final August 2017: Locality lots NCC41257
3. Service Objectives

3.1 The high level service objectives of the service are:

3.1.1 To provide a outcome based and personalised support service to people with
mental health needs
3.1.2 To support people to improve and maintain their own health and well-being,
operating on the recovery model
3.1.3 To work collaboratively with partners, and in particular services in other areas
commissioned under this specification, social services, housing and support
providers, and the Norfolk and Suffolk Foundation NHS Trust (NSFT)
3.1.4 To provide services that reflect best practice and strategic policy direction and
are responsive to emerging legislation and structures
3.1.5 To provide services that reflect local needs and also the rural nature of Norfolk
3.1.6 To provide cost effective support that achieves improved outcomes
3.1.7 To engage and use volunteers and to develop peer support to extend the range
and coverage of the service
3.1.8 To provide services in locations used by the target population and which
engage people in their communities and maximise use of community assets
3.1.9 Longer term, to enable people with services funded through a personal budget
to be supported with all their personal budget funded services, including direct
payments, and personal health budgets through an Individual Service Fund
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process operated by Provider s.

4. Core Service Requirements

Key features of service delivery

4.1 The Service will comprise a community support service that delivers support to
people aged over 18 with severe and enduring mental health needs in Norfolk in
their own homes and communities. The support is ‘attached’ to the person, not the
property and can follow the person if they move to another address (subject to
exclusions). It includes supported living schemes included in the specification.
Support is wide ranging and covers:

4.1.1 Assistance in setting up and maintaining a home / tenancy, including cleaning,
support with maintenance, repairs, payment of rent and arrears, being a good
neighbour
4.1.2 Independent Living Skills, including support with budgeting and paying bills,
support to apply for benefits, support with finding and securing alternative
accommodation and through the move
4.1.3 Well-being and general support, including emotional support and advice,
support with monitoring own health and well-being and signposting to health
services

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WHAT IS AN ISF? An ISF is an internal system of accounting within a Provider that makes the personal budget transparent to the
individual or family. This helps provide flexible support by making the organisation accountable to the person
http://www.thinklocalactpersonal.org.uk/_assets/Resources/SDS/TLAPISFsContractingFINAL.pdf.

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Service specification final August 2017: Locality lots NCC41257
4.1.4 Support in overcoming social isolation by linking people to local social, faith and
leisure activities and supporting people to develop a range of opportunities
likely to increase independence, including employment and education

4.1.5 Advice, advocacy and liaison, including support to access and secure other
services, signposting to specialist advice services and community groups,
developing self-advocacy skills
4.2 The service is not expected to provide the full range of personal care and
prompting support to service users eligible for support from social services which
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constitutes personal care as defined by CQC in the Scope of Registration under the
Health and Social Care Act 2008. However the ser vice will be required to develop
working relationships with local domiciliary care providers , in order to ensure that
individuals in supported living and the community who need personal care can receive
a more holistic and integrated service .
Eligibility Criteria

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4.3 The service is for people with severe and enduring mental illness aged 18 over and
will include adults over the age of 65 who do not have dementia or complexities
associated with ageing. The Department of Health has defined people with 'sev ere
mental illness' as individuals who:
 are diagnosed as suffering from mental illness (typically schizophrenia or a severe
affective disorder, and including dementia);
 are substantially disabled because of their illness, e.g. they are unable to care for
themselves or independently, sustain relationships or work;
 are currently displaying florid symptoms or are suffering from a chronic, enduring
condition;
 have suffered recurring crises leading to frequent admissions/interventions;
 may at times present significant risk to their own safety or that of others

4.4 The service will be expected to support people who would fit within the client group
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historically served by assertive outreach . These clients will often have a history of
severe mental illness with:
 sporadic or non-engagement with mental health services that may not meet their
needs;

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http://www.cqc.org.uk/content/what-registration#accordion-1

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Payment by results is a Department of Health initiative to change the way that health services are commissioned (paid for),
moving away from block contracts to a system where funding is linked directly to the care service users receive. A care
cluster is a grouping of service users of similar clinical needs This group corresponds to people in the Payment by Results
clusters of 5-15. www.gov.uk/government/publications/mental-health-payment-by-results-arrangements-for-2013-
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http://www.jcpmh.info/resource/guidance-for-commissioners-of-rehabilitation-services-for-people-with-
complex-mental-health-needs/
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This is likely to correspond to people in the Payment by Results clusters of 16 and 17.

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Service specification final August 2017: Locality lots NCC41257
 sporadic or non-compliance with medication resulting in their impaired mental
health;
 frequent unplanned psychiatric admissions;
 frequent involvement with the police because of mental illness;
 complex multiple problems in addition to severe mental illness, (such as alcohol/
drug misuse,
 frequent periods of homelessness
 a personality disorder
 an additional learning disability.

4.5 The service will comprise funding from two funding streams:
 Adult Social Services for supported living and community outreach
 Clinical Commissioning Groups (CCGs) for community outreach
The provider will need to operate to the different eligibility criteria and referral /access
routes for both service elements which will have their own activity levels (hours
delivered and service users).

Social care eligibility criteria

4.6 The support service will be the core commissioned element of the package to meet
service user’s social care needs. Service users in the service who are assessed as
eligible for support under the Care Act will have personal budgets to meet their
outcomes. Their personal budget will form part of the contract which will be expected
to meet the majority of their support needs. The provider will work with NCC staff to
make sure that service users are aware of this and will offer support with the Norfolk
County Council financial assessment and charging processes. Staff will be expected
to contribute to support planning and review as part of the personal budget process,
building on the Care Act assessment. The provider will be expected to meet the needs
of people referred via
a) the mental health funding panel for those whose needs are deemed to be most
appropriately met in supported living
b) the social work service/Care Arranging Service for others
The referral arrangements set out above may change during the life of this contract.

NHS funded service eligibility criteria

4.7 This service element will focus on meeting the needs of Norfolk residents on the
mental health acute wards or who are with the crisis response and home treatment
team. The Service will provide an in-reach service to the wards for this group in order
to support timely hospital discharge, with a focus on housing and related debt and
benefit issues. Generally this group will need some on-going post discharge support to
promote their recovery and this will be expected to be provided for a time limited
period and at reducing intensity following hospital discharge.

4.8 The Provider of the lot in which a mental health acute hospital is situated will be
expected to pick up all discharge referrals from those wards, including for Norfolk
residents who are placed in mental health acute wards out of their local area (but still
within Norfolk). In addition the Provider of the service in Great Yarmouth will be
expected to deal with initial referrals from Carlton Court in Lowestoft for Norfolk
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residents who are placed there. The Provider will be expected to have arrangements
for transfer of service users between the other providers commissioned to provide
comparable services in each area, so that support follows them with any change in
placement. The Provider of Lot 2 will also be expected to pick up issues around
hospital discharge for people served by the Norwich intensive support service (Lot 4),
in the first instance.

4.9 The Provider will be expected to produce a joint protocol with mental health acute
hospitals and NSFT’s crisis response and home treatment team for the element of
service delivered to people in acute settings within 3 months of the start of the service
contract. This will be reviewed annually thereafter, in both cases the protocol will be
agreed with the commissioners. At present NSFT have a bed management team to
support discharge and the Provider will be expected to work closely with them and to
operate to shared protocols. As NSFT may change the location of beds during the
lifetime of the contract, the location of service capacity provided for this service
element may need to be adjusted accordingly, in agreement with commissioners.

4.10 Criteria for prioritisation of referrals will be agreed with commissioners, including
CCGs, and NSFT teams. The following factors will be used when determining
priorities for access to the Service:
4.10.1 People who may be at risk of admitted to hospital
4.10.2 People who are being discharged from hospital
4.10.3 People in the forensic service/ low secure service where a move into the
community is planned
4.10.4 Security of current accommodation
4.10.6 People who have few other support systems in place and are socially isolated
4.10.7 People who because of the consequences of their mental ill health are at
increased risk in the community, including self neglect
4.10.8 People who are unlikely to sustain their independence and accommodation
without on-going low level support for an indefinite period in order to maintain
their recovery and mental health

Transition to new contract

4.11 The Provider will be required to support the transition of service users from the
existing services to the new contract, to ensure continuity of services. Commissioners
will finalise eligibility criteria with the Provider during the transition phase from the
current service to the new contract.

Referral Criteria and pathways
4.12 There will be a written policy on acceptance and exclusion criteria for referrals which
will be agreed with the Council, including NCC Mental Health Social Care Service, and
appropriate NSFT teams who can refer into the NHS funded service elements.

4.13 Potential grounds for non-acceptance or exclusion for the service are where:
4.13.1 People do not meet the agreed eligibility criteria
4.13.2 People have substance misuse as their primary diagnosis with no significant
mental health needs;
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Service specification final August 2017: Locality lots NCC41257
4.13.3 People have learning disabilities as their primary diagnosis, excluding people
with Asperger syndrome and high functioning autism, where the mental health
needs are paramount;
4.13.4 People have predominant forensic issues over psychiatric issues;
4.13.5 People are no longer mentally ill and/or who cope independently with little or
no support
4.13.6 People with low level mental health needs e.g. mild to moderate depression
who have been supported in primary care or the Wellbeing Service (IAPT), or
in other forms of community support
4.13.7 People who are already living in high-support residential or institutional
settings (such as residential care, forensic or inpatient accommodation) and
who are likely to stay there for the foreseeable future;
4.13.8 People who normally live in independent supported living schemes not
included in this contract or in subsequent contract variations where no move
on is planned,
4.13.9 People who live outside the defined catchment area i.e. the county of Norfolk.
4.13.10 The level of risk is deemed unacceptable as a result of the outcome of an
evidenced needs and risk assessment and in view of the Provider’s policies
and procedures
The service will be expected to work with people in residential care, supported living
and in-patient accommodation where move on is being progressed to plan and support
service users in the process.

4.14 In addition people who fit within the NSFT eligibility criteria for complexity in later life
will not be eligible for the NHS funded service. This includes people of all ages with
dementia, and people with mental health problems who also have complexities
associated with ageing. However the social care funded service may be asked to work
with younger people with dementia, including people with Korsakoff’s and people with
Huntingdon’s disease, who need support in the community.

4.15 Structured assessments should be used to assess clients referred for the service. The
mental health recovery star or other appropriate methodology for assessment, goal
setting and outcome monitoring should be central to this approach.

Service levels

4.16 More detailed descriptions of what is expected to be included in supported living
schemes is appended in Appendix 2, and in each locality based contract lot area in
Section 6, and the separate specification for the intensive outreach service in the
Norwich locality. The Provider shall deliver the service requirements as outlined in
this Service Specification using a fair and equitable approach to the allocation of
resources across each lot area. It is not envisaged that the Service will differ
significantly between localities, unless specified in Section 6. However as
commissioning plans develop during the lifetime of the contract, it is anticipated that
the Provider will actively engage with partners and seek to develop the service in line
with local needs and by agreement with Commissioners.

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Service specification final August 2017: Locality lots NCC41257
4.17 The Provider will ensure that people with mental health needs are key partners in
shaping the service and work with them, their carers and Commissioners to adapt the
service to meet changing needs in an appropriate way.

4.18 The Provider should use a range of methods for delivering the service to maximise
coverage and capacity and to meet people’s needs in a personalised way. The
Provider will ensure that contact is maintained with service users in a range of ways,
including those set out below, to ensure that ‘missed visits’ are minimised and
people’s needs are met. The service delivery model should include:

4.18.1 Opportunities for planned 1:1 face to face contact in a variety of locations,
including the service user’s home, the Provider’s premises, partner agencies’
premises, community venues, hospital
4.18.2 Opportunities for service users to attend drop in sessions to deal with
pressing issues that need an urgent response, e.g. eviction notices,
completion of claim forms within deadlines
4.18.3 Opportunities for people to ‘buddy up’ to access opportunities in the
community
4.18.4 Opportunities for group sessions in a range of locations across the locality
and county to promote opportunities for social interaction and provide general
information and support. Groups will be primarily linked to meeting the needs
of those eligible for service. Whilst only those eligible for the service may be
counted in any contract performance management reporting, including
families and friends, or members of the local community, could improve
people’s willingness to engage and the outcomes delivered, therefore groups
can be opened up to people who are not service users. Where groups are
being provided for social interaction and engagement, and networks in
community activities, the provider is expected to work to develop the
independence of the groups and to ensure that they remain open and
welcoming to new members. The provider will be expected to support groups
to access funding eg third sector grants, to develop and sustain their
activities.
4.18.5 Women only support groups /networks should be developed in each locality
and across the county. There should be a women only safe space /group offer
available in each locality for the commencement of the contract, with services
further developed through co-production.
4.18.6 Peer support groups which are led by staff or volunteers from the service and
peer led groups. In the latter, where the organisation and running of the group
is provided by service users/volunteers from the community, the groups
should be able to access support from the provider when needed.
4.18.7 Access to advice and support using a range of technologies and media, for
example social media, online/telephone support, Skype, smartphones

Service provision will mainly consist of 1:1 support, however all methods above need
to be utilised. There is an expectation that providers will become familiar with, and
utilise, community assets and capacity to promote recovery for service users.
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