Specialist Care and Support

Market Context

Residential Care services commissioned through SASIS include, but are not limited to, those that support people with specialist needs including learning disabilities and/or autism, mental ill-health and physical and sensory impairments on a long-term basis. Going forwards, the Council’s strategy is to reduce the overall number of residential placements through supporting people to be more independent within their own homes and connected to their communities where that is the right approach for them. However, we also recognise that for some adults’ residential care is, and will continue to be, the right model of care particularly where they:

• Have a level of need that means that this is most appropriate service in order to meet that need. This includes people with complex medical needs.
• Require a level of restriction that that means that this is the most appropriate service.

The intention of the Council is to work with the market to better meet our requirements for adults we support, in order to ensure that we only place people into services outside the administrative boundaries of Somerset, or a short distance from, unless this is an individual’s choice, or they require a type of support that is not available within Somerset.

Residential care is by its very nature a type of service that involves a level of restriction which will not be suitable where we are seeking to support people to increase their level of independence. It is therefore expected that some services which do not meet our direction of travel may need to consider transition to other service types, or to remodel their offer to include supporting people with more complex needs.

Market Rating

Market Quality: Good

Market Supply: Stable

Demand: Stable

Commissioner ambitions: Ensure that we only commission residential care where it is appropriate, and that we review existing placements to ensure they remain so

Market workforce: Stable

Market maturity: Mature, with multiple long-established services

Current market status

There is capacity in the local market, with Somerset being a “net importer” of specialist residential care placements as the Council’s direction of travel has been towards other models of care that promote greater independence for some time. Going forwards, new placements will predominantly be for very complex needs, and ongoing work needs to be done with the market to support it to adjust.

All placements made via SASIS are based on individual need and therefore there are no standard rates. As part of the introduction of SASIS Somerset Council is introducing Care Cubed as a benchmarking tool to ensure that all new placements are made at rates where we can evidence that we are achieving value for money.

Market Data

All data is as at [insert date] and only includes specialist care homes.

Distance from desired commissioning objectives

The current specialist care home market in Somerset is distorted by the large volume of placements made from outside of Somerset, which has resulted in some residential care homes continuing to offer models that do not fit with our direction of travel. While Somerset Council has continued to make some placements into these care homes, our overall direction of travel is expected to reduce these further.

While relatively small in terms of the number of placements required each year, the types of need that we would like to see more support for in Somerset include:

• Adults with autistic spectrum conditions who do not have a learning disability.
• Adults with a history of contact with the criminal justice system including, but not limited to, forensic behaviours and/or arson.
• Adults with a co-morbidities of mental-ill health and substance misuse including, but not limited to, those who we are seeking to put support in place to enable discharge from acute mental health wards.
• Adults with complex physical needs, including as a result of acquired brain injuries and degenerative conditions.

Market Risks

• Staffing is an ongoing risk, particularly in those areas of Somerset where national infrastructure projects are taking place, and the use of agency staff is widespread and costly to providers which compromises their viability and increases costs of new placements.
• There are also specific risks for those organisations that have a high reliance on international recruitment due the evolving approach taken by the Home Office.
• In the past some specialist care homes that have been reluctant to develop their model to meet local commissioning objectives have relied on people placed form outside of Somerset in order to remain viable. This means they will be particularly vulnerable if other local authorities change their own commissioning approaches and/or develop services that enable people to return to their own local area.

Current areas of focus for commissioners

• Ensuring that all specialist residential care providers, including those without vacances, are registered on SASIS.
• Reducing the number of placements outside of Somerset through developing capacity to support people within, or as close to, Somerset as possible who might have been placed outside of Somerset in the past. While we know that this will not always be possible where people have specific needs, we want to work with the market to develop options. As part of this work, we are keen to collaborate with regional colleagues to develop solutions within the region for those individuals who require highly specialist services for which no one system has sufficient demand to strategically commission on its own.

We have identified instances where people have been living in specialist residential care homes for many years who, as a result of age-related conditions, would be more appropriately supported within environments that have been designed to meet these needs. We will therefore be undertaking work to ensure that people who may have previously had a specialist need, which has been superseded by an age-related condition that is now their predominant need, are able to access the right service to meet their needs.

Market Context

Respite and short break services are commissioned to support people with specialist care and/or support needs and their unpaid carers. It can be provided using three broad models:

• Respite residential care in a care home. This includes both dedicated residential care homes and, where appropriate, spot placements in other care homes
• A short break in non-care environment away from their usual home and care arrangements, with care package to support them during their stay
• Respite care provided by a specialist respite residential care home provider that is provided into the adult’s home rather than them having to go to the care home itself. This is a relatively new model in Somerset that we are working to develop.

Dedicated capacity is currently commissioned within two care homes in Somerset, focused on adults with learning disabilities, that will be moved fully onto the SASIS DPS during the 2025/26 financial year. A further four placements are currently commissioned outside of SASIS for people with physical disabilities that we will be reviewing our commissioning arrments for during the 2025/26 financial year.
Market Rating

Market Quality: Good

Market Supply: Limited

Demand: Rising

Commissioner ambitions: To better balance capacity with demand

Market workforce: Stable

Market maturity: Mature, with all services long-established

Current market status

There is capacity in the local market, but it requires careful management to balance capacity and demand during peak periods, situations when someone is unable to return home. Further work is also required to develop alternative options to someone having to go to a residential care home.

Market Data

All data is as at [insert date]

Distance from desired commissioning objectives

Demand for respite residential placements and short breaks is not constant and has peaks and toughs. This has led to some people not always being able to get respite care from their preferred provider when they wish to. Under the current arrangements we have identified the following issues that we are working to address:

• Balancing capacity with demand, particularly during peak periods
• Facilitating more rapid move on to a longer-term service where it becomes clear that someone cannot return home during their respite stay.
• Lack of choice within the dedicated residential care home respite element of the market in which only two providers operate.
• People needing to book a respite stay for short periods when they would have preferred to remain within their own home, which is why we have worked with the provider of our learning disabilities respite provider to develop an alternative offer.

Market Risks

• Staffing is an ongoing risk, particularly in those areas of Somerset where national infrastructure projects are taking place.
• Supply not meeting peak demand, but it also not being viable to maintain capacity to meet this at all times.

Current areas of focus for commissioners

• Reviewing the commissioning arrangements for respite services for adults with physical disabilities
• Further developing alternative options for people to access support they want without needing to stay within a dedicated respite residential care home and expanding this offer beyond adults with a learning disability.

Managing existing capacity and ensuring move-on to longer-term arrangements when it becomes clear that someone cannot return to their home during a stay in a respite residential care home or following a short break.

Market Context

Supported living services commissioned through SASIS include, but are not limited to, those that support people with specialist needs including learning disabilities and/or autism, mental ill-health and physical and sensory impairments on a long-term basis. The service provides adults with the opportunity to hold a tenancy in their own home and focuses on maximising each individual’s independence and skills.

A fundamental element of supported living is that housing and care are separate, and therefore a care and support provider can be change without someone needing to move home. All supported living services commissioned in Somerset is contractually required to follow this model.

Supported living is a 24/7 service and the construct of each person’s care and support will consist of:

• Shared hours (sometimes referred to as ‘core’ or ‘background’). This is the minimum staffing support provided to continuously meet the needs of the individual(s) accommodated within the supported living. This is care and

support provision in situ, which is to actively support people who may not have

any designated 1:1 support, which in practice is usually to be adjusted on an individual basis to reflect 1:1 hours and other services that each person may use.

• Shared nighttime support. Depending on the level of need within a supported living service this is usually a sleep-in or waking night shared between the people living within the service.
• Individual 1:1 support. Each person must have choice and control over who provides this. We expect this 1:1 support to be targeted, outcome focused and individualised as identified within each individual’s support plan. This support is commissioned to achieve a specific outcome or goal that cannot be achieved through shared support and will be stated within the individual’s Care and Support Plan. Care providers should not seek minimum levels of 1:1 hours or any other arbitrary figure as it must be based on the care and support plan and evidence as to why targeted support is required.

Supported living services can be either consist of single occupancy accommodation units clustered together (normally no more than 10) or where tenants live in a shared houses where they have a tenancy that encompass their bedroom and shared communal areas (e.g. living room, kitchen, utility room). In recent years Somerset Council has been moving away from shared living environments for any new services it is involved in developing, and we expect this to continue. For all new services we commission, including any to replace existing services, we will not agree to fund void costs for vacant rooms or the associated staffing costs.

The majority of the supported living services commissioned within Somerset are for adults with learning disabilities. Our experience is that where a service involves a communal living environment it is not appropriate for people with different types of need (e.g. mental-ill health and learning disabilities) to be supported within it. However, where a service consists of single occupancy accommodation units there can be greater flexibility depending on the needs of both the individual and those already living within the service.

The intention of the Council is to work with the market to better meet our requirements for the adults we support within supported living settings, and ensure that supported living services are providing appropriate levels of support that are person centred and promote independence, skill development and, where it is right for the person, move-on to other types of housing.

Market Rating

Market Quality: Moderate

Market Supply: Good

Demand: Rising

Commissioner ambitions: To develop the supported living model to support people with complex needs in a person-centred way and promote independence

Market workforce: Stable

Market maturity: Maturing

Current market status

There is capacity in the market, however, not all vacancies will be suitable for adults seeking accommodation and matching and compatibility will always be a big driver for demand management. Some vacancies may also be present in services where the accommodation that was developed many years ago and requires reprovision to remain fit for purpose in the longer-term.

There are shortages of some categories of support, especially for people with unpredictable behaviours, and for those who require their own individual living space or a second bedroom for a dedicate sleep-in. There are several providers who are currently looking to expand and develop new services, and property developers are showing interest in setting up schemes within Somerset however these new developments need to be aligned to our requirements including rents that are affordable within housing benefit rates.

Market Data

All data is as at [insert date]

Key drivers of demand are through transitions of young people into adulthood, and working age adults with learning disabilities whose informal carers are no longer able to support them (for example, due to their own care needs).

Distance from desired commissioning objectives

The supported living market in Somerset has a mixture of providers operating within it, with degrees of variance from the objectives commissioners wish to achieve. Areas where change is required include:

• Supported living services that were formerly residential care homes that have not evolved sufficiently following deregistration
• The skill base of staff delivering supported living services
• The quality of service delivered by some providers
• Ensuing built environments that are fit for purpose in the long term

Market Risks

• Staffing is an ongoing risk, particularly in those areas of Somerset where national infrastructure projects are taking place, and the use of agency staff is widespread and costly to providers which compromises their viability and increases costs of new placements.
• New providers seeking to enter the market who do not understand the supported living model, do not always have the experience needed to support they type of need that they are seeking or who seek to apply arbitrary levels of support that would result in services that are restrictive rather than enabling.
• The long-term viability of services that have shared living environments. Due to the size of these services small numbers of people leaving them poses risk that services may become unstable if vacancies are not filled.
• There are specific risks for those organisations that have a high reliance on international recruitment due the evolving approach taken by the Home Office.
• The fitness for purpose of some built environments in the longer term

Current areas of focus for commissioners

• Ensuring that all supported living providers, including those without vacancies, are registered on SASIS.
• Working with the providers to ensure that supported living services meet our expectations with regard to service quality
• Responding to approaches regarding new developments and steering them so that they are based on demand, are an appropriate model and sustainable
• Ensuring that models of support are person centred and enabling, that outcomes are being identified and that providers are delivering them.

Working with providers to develop and implement appropriate plans, where built environments are unlikely to be sustainable in the longer term

Market Context

Domiciliary care (sometimes also referred to as home care) is a range of services that are put in place to support an adult to remain in their home. The professional, known as a carer, will provide support and complete tasks that aid an adult to remain independent and safe. The type of tasks can vary from personal care, administering medications, or supporting the adult with activities. Their primary role is to maintain the adult’s quality of life and support them to meet their outcomes. The domiciliary care that is commissioned via SASIS is commissioned on a bespoke basis to support adults with care and support needs that go beyond those that can be supported by [insert DPS name], including, but not limited to, adults with learning disabilities and/or autism, mental ill-health and physical and sensory impairments Domiciliary care commissioned via SASIS can be provided on a short-term or long-term basis with the rates paid bespoke to the needs of the individual being supported.

Market Rating

Market Quality: Good

Market Supply: Moderate

Demand: Rising

Commissioner ambitions: To improve consistency of support across Somerset

Market workforce: Moderate

Market maturity: Maturing

Current market status

The availability of the support we wish to commission is not consistent, with some areas of the County, for example areas of the East and South where there are opportunities for providers who are able to offer skilled, person-centred, support to develop capacity.

Market Data

All data is as at [insert date]

Distance from desired commissioning objectives

While quality in this area of the market is generally good commissioners wish to see a great focus on skill development and delivering individual outcomes in a person-centred way. Some providers in the local market have developed their offer from established services focused on the delivery of personal care and need to innovate and develop their workforces further to deliver the type of support that we would expect to see when delivering support adults with specialist needs.

Market Risks

• Staffing is an ongoing risk, particularly in those areas of Somerset where national infrastructure projects are taking place, and the use of agency staff is widespread and costly to providers which compromises their viability and increases costs of new placements.
• There are specific risks for those organisations that have a high reliance on international recruitment due the evolving approach taken by the Home Office.
• Providers seeking to apply minimum package sizes or seeking rates that are not reflective of an individual’s needs

Current areas of focus for commissioners

• Increasing the capacity of skilled support in those areas of Somerset that we have identified as requiring further development.
• Working with providers across the market to ensure that their staff are appropriately skilled to deliver the model of support that we require going forwards.
• Further developing a support model for people, primarily with mental-ill health and mild learning disabilities who, while needing relatively low levels of care and support, require this support to be delivered by a skilled provider alongside a housing offer to support recovery and build and maintain their independence.

Market Context

This service is designed to support adults with learning disabilities, mental ill-health, physical or sensory impairments, and older people through a broad range of support activities that fall outside of the scope of Care Quality Commission regulation, with the aim of delivering some or all of the following types of outcome:

• Social inclusion: Including making friendships that are based on mutual interests and not based on a shared diagnosis (such as a learning disability), and are real and not reliant on both people attending a paid service. While supporting people to maintain friendships may include facilitation through a paid service, this should be based on what people wish to do with their friends.
• Cultural and creative opportunities: Including supporting people to access creative spaces that are not based on a diagnosis.
• Supporting Health and wellbeing: Including exercise, sport, diet/nutrition and access to appropriate therapies.
• Building independence: Including supporting Individuals to progress towards paid employment, skill development and/or maintenance, volunteering, positive risk-taking, learning and education, leisure activities and trying new things. Individuals should be supported to maximise independence within their home lives where appropriate; this may mean supporting to achieve outcomes focussed, time sensitive pieces of work for example, cooking a meal for mum and dad.
• Day time respite care and/or support for unpaid Carers

Market Rating

Market Quality: Moderate

Market Supply: Moderate

Demand: Stable

Commissioner ambitions: To increase the number of providers operating in Somerset who are registered on SASIS

Market workforce: Moderate

Market maturity: Evolving

Current market status

The market has evolved significantly over recent years, and we expect this to continue for at least the medium-term. As part of this evolution have seen some providers exit the market for the provision of buildings-based servicers to focus on a community outreach offer, and be replaced by new or smaller providers with a focus on specific types of needs. At the same time there is a growing cohort of people, particularly with mental ill-health, who do not require personal care but do require relatively small amounts to targets support to support their recovery.

There is capacity in the market, however some providers have chosen to not register for SASIS and instead focus on offering support to people who self-direct their care and support. This presents challenges when we are trying to source day time support for people at pace and we are therefore going to be working with all providers of day time support and community outreach during the first quarter of 2025/25 to actively encourage them to registered on SASIS.

Market Data

All data is as at [insert date]

Distance from desired commissioning objectives

In recent years we have seen a move away people needing to go to a buildings-based service in order to receive support during the day, and we welcome the divert of offer that this has created in the market for people who did not which to go to specific place or mix with a specific group of people. However, this fragmentation of the market and the focus of some providers entirely on people who self-direct their own care and support presents challenges when people wish the Council to commission a package on their behalf and we are therefore working with the market to address this.

In terms of further development, we would like to work with the market to develop the community outreach offer to increase the option available to people who do not have personal care needs, but may have a mild learning disability or have experienced mental ill-health, who require support to build and maintain independence.

Market Risks

• Staffing is an ongoing risk, particularly in those areas of Somerset where national infrastructure projects are taking place

Current areas of focus for commissioners

• Ensuring that all providers of day time support and community outreach, including those without current capacity, are registered on SASIS.
• Responding to approaches regarding new offers and steering them so that they are based on demand, are an appropriate model and sustainable
• Further developing a support model for people, primarily with adults with mental-ill health or mild learning disabilities who, while not needing any personal care require relatively low levels of support to build and maintain their independence.