Interview with Ms Sue Stower, Kent County Council’s Head of Service for the Maidstone and Malling Locality.

The Chairman welcomed the Head of Services for the Maidstone and Malling Locality, Ms Sue Stower, and the Senior Practitioner, Mr Peter Buckley, from Kent County Council’s Adult Social Services to the meeting and asked them to provide an introduction to the role of Occupational Therapy with regard to Disabled Facilities Grants (DFGs).

Kent Adult Social Services had been restructured from 1 October 2009 to encompass the Self Directed Support, part of the Government’s Personalisation Agenda, which gave people more choice and control over their lives and the support they received.  The Kent Contact and Assessment Service now received all Kent Adult Social Service’s referrals, giving advice and guidance and undertaking as much fast track work as possible that did not require assessments.  This included arranging delivery of minor equipment and adaptations to people who were clear about what their needs were.  In addition a six week period of enablement could be arranged to help someone regain their skills and confidence in activities of daily living.  This helped them to live as independently as possible in their home without the intervention of long term care packages or major equipment.  The enablers were able to put in minor equipment if necessary. 

The Assessment and Enablement Teams consisted of Care Managers, Occupational Therapists, the Hospital Teams and Kent Home Care Teams.  Occupational Therapists within this team were known as ‘Case Managers (OT)’.  This team was responsible for assessing clients needs, including for equipment and adaptations.  Once the needs had been established and an indicative budget set, the case was passed to the Coordination Team who helped the service user create their own support plans.  OT cases did however remain in the Assessment and Enablement Team because it was not considered good practice to hand over a case to a new person halfway through the DFG process given its complexities.

Occupational Therapists (OTs) completed three year Occupational Therapy degrees (or equivalent) and were required to be state registered to practice.  OTs carried out home visits and used both their medical knowledge and clinical reasoning to assess the customer’s physical capabilities to carry out certain actions in the home, such as a person’s ability to get in and out of a chair, on and off the lavatory and up and down stairs.  In response to a question, Ms Stower advised that the client’s needs would not be exceeded as the assessments were formalised and OTs were trained to supply only what was absolutely necessary.  She noted that some adaptations could be counter productive if not required, such as a stair lift, as the stairs were good exercise.  The OT made recommendations in consultation with the client, and elected for the most modest solution, such as the utilisation of a shower stool to aid showering or a stair lift rather than an extension.  The OT also considers the prognosis of the client and major adaptations may be suggested if appropriate.  An OT’s recommendation for a major adaptation was discussed in supervision to ensure the recommendation was justifiable.  Adaptations enabled by DFGs needed to be reasonable, practical, necessary and appropriate.  Members noted that the OT Service provided: assessments for DFGs to help with the cost of major adaptations; assessments for equipment and minor adaptations funded by KCC; provision of short periods of rehabilitation; and information and advice about sources of help for disabled people and their carers.  Seventy per cent of the OTs work was made up of DFG assessments.

Mr Buckley outlined the process undertaken by OTs in assessing a client for a DFG:

·  The OT team received a referral from the customer, a family member, a carer, a health professional or a specialist;

·  The Senior Practitioner reviewed and prioritised each case.  Cases where people were most at risk, such as having problems with mobility on stairs or transfers from toilets or beds were prioritised due to the risk of falls, which could lead to fractures.  The remaining cases were ranked in date order;

·  The OT assessed a case to determine the client’s needs and whether a DFG was required.  Trained assessors worked closely with OTs to assess clients needing minor adaptations.  A number of these trained assessors were previously employed by Maidstone Housing Trust when they carried out their own adaptations;

·  If the assessment showed that the most modest solution available was a requirement suitable for DFG funding, a request for a preliminary test of resources was made to Maidstone Borough Council’s (MBC) Grant Officer to determine whether a grant would be payable and/or how much the resident needed to contribute;

·  Once the client’s contribution had been assessed, the OT worked with the client to identify a key worker to draw up the specifications for the adaptations.  OTs continued to provide advice to the client, including considering the most appropriate plans to meet their needs, even if they did not qualify for a grant; 

·  The OT prepared the recommendations to ensure that the needs of the client were incorporated into the adaptation;

·  The client was able to elect to use the local home improvement agency, In-Touch, to undertake project management of the adaptation process, including drawing the plan, at a percentage fee;

·  The OT, once satisfied that the plans met the customer’s needs, sent a letter of support for the adaptation to the Grants Officer and confirmed that it had met the client’s needs;

·  The case was then closed and responsibility transferred to the key worker or Home Improvement Agency to progress.  The case could be re-opened if the suitability of the adaptation was questioned, or if the customer’s needs developed and required further adaptations.

Ms Stower advised Members that there were currently four OTs working in Maidstone and two Rehabilitation Coordinators.  The average time to install an adaptation varied depending on what was needed, for instance extensions took longer than readily available equipment.  The oldest case requiring assessment dated from August 2009 and officers were exploring methods to address increased work volumes as they arose.  Agency OTs were employed on an ad-hoc basis as required.  A Member queried why there had been an increase in the number of DFGs paid and was informed that there had been a 71 percent increase in the number of referrals for DFG assessments since 2001, with 1500 referrals in the last year.  Ms Stower felt that the increase may be attributable to increased life expectancy, resulting in people living longer with serious disabilities, and because more seriously disabled children were living beyond 2 years with complex needs. 

The majority of DFGs funded stair lifts and/or level floor showers.  Ms Stower noted that it was MBC’s role to say yes or no to their recommendations for a DFG.  In response to a question, Members were advised that short life expectancy was a factor in determining the suitability of a client for an adaptation, as the assessment was based on both the diagnosis and prognosis.  This was understandably a difficult decision, but consideration of the upheaval caused by an adaptation was considered in relation to the client’s life expectancy, in addition to cost effectiveness.  KCC had a capital budget which could fund emergency major equipment and they also used recycled equipment from their stores.  They did not advise clients to apply for a DFG if their life expectancy was under a year, as the DFG process took time. 

34% of KCC’s equipment was recycled in 2008, however Ms Stower was unaware of any DFG funded adaptations that had become surplus to a client’s requirements.  The client’s prognosis was considered as part of the OT assessment and therefore it was unlikely that equipment would become redundant unless the client had undergone an operation such as a hip replacement and improved or the customer had passed away.  The feasibility of removing an adaptation, such as a through floor lift, would be considered and discussed with MBC’s Grants Officer.  Members noted that DFG funded adaptations were owned by the customer and they or their family were ultimately responsible for disposal of that adaptation.  Members were advised that KCC equipment remained under the ownership of KCC and was therefore maintained by KCC, whereas adaptations enabled by DFGs were owned and maintained by the customer.

Ms Stower informed Members that it was important to note that DFGs were paid for from the public purse and the most attractive aids were therefore not necessarily installed.  She noted that owner-occupiers may sometimes be willing to make an additional contribution to ensure the equipment of their choice was installed.  Customers were also able to request that the money for the minimum requirement, such as a lift, be used towards a more elaborate adaptation, such as an extension.  The approval for this was determined by MBC.

In response to a question Ms Stower noted that care was usually more expensive than aids and adaptations as a carer required a year-on-year wage, whereas aids and adaptations required one off funding.  She also highlighted that the majority of customers wanted to be as independent as possible.  However, the OT did not insist a customer exerted all their energy to be independent and assessed customers on a case by case basis. 

A Councillor asked whether the witnesses felt that enough was being done to ensure that the aging population was being planned for in respect of disabled housing.  Ms Stower informed Members that properties met Lifetime Homes Standard, but felt that more could be done.  She was unsure how rigorously developments were checked to ensure that they met the standard.  She also advised Members that her wish list would include: wheel chair accessible homes in terms of turning spaces, particularly in bathrooms; ramping; gradient steps; room for ground floor bedroom conversations (by having dining rooms); and wide, straight staircases suitable for stair lifts.

Ms Stower advised Members that 39% of their referrals were from MHT tenants, 47% were owner/occupier and 14% were from privately rented or other housing associations tenants, however not all referrals were necessarily regarding DFG adaptations.  In response to a question Ms Stower informed Members that there was increasing tension across the country regarding the fact that Registered Social Landlords (RSL) were receiving increasingly large shares of DFGs, and that this was ultimately improving the RSL’s housing stock.  Questions were therefore being asked as to whether the RSL had a level of responsibility to fund these adaptations themselves.  Mr Buckley advised Members that they were working closely with MHT to seek opportunities to reserve vacant adapted properties for customers with needs.  MHT recorded which properties were adapted and identified customers with the OT who would benefit from a vacated adapted property.  A Member queried whether information was available on the percentage of the population likely to need adaptations and considered whether housing should therefore be built to accommodate at least that percentage.  Ms Stower agreed to investigate the percentage for Members.

A Member queried why Registered Social Landlords such as MHT were required to use their own technicians for the installation of minor adaptations whereas KCC provided the service free of charge to other customers.  Members were informed that KCC did not have the capacity to take on MHTs minor adaptations, but that MHT residents were not charged for the MHT service.  She also noted that the Housing Association had a responsibility to act on the recommendations for minor adaptations put forward by OTs.

A Member queried whether the witnesses felt there were any weaknesses with the DFG assessments and was advised that the financial assessments carried out by MBC did not incorporate outgoings, such as mortgage payments, but noted that the assessment was prescribed by Government.  In cases of hardship, KCC was able to offer a 0% interest loan over a five year period to residents which assisted residents in funding their contribution to the adaptations.  Ms Stower noted that legislation had changed to ensure that means tests were not applied to households where a child required the adaptation.

Mr Buckley advised Members that OTs ensured that their recommendations for DFGs were necessary and appropriate, whereas MBC’s grant officer ensured they were reasonable and practicable.  A Member queried whether it would be more efficient for DFGs to be orchestrated by KCC rather than MBC; Ms Stower felt that this was possible, as Medway processed its own claims, but noted they would also require resources to do this and that it could potentially mean OTs had more sway over DFG allocations.

The Chairman thanked Ms Stower and Mr Buckley for assisting the Committee in its review and for an informative presentation.

Resolved:  That

a)  Ms Stower inform Members of the projected percentage of population likely to require adaptations; and

b)  The information received be noted as part of the Committee’s ongoing review of Disabled Facilities Grants.