The proposed new model for Community Led Care and Carers services

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Current provision

The current community led care support services are provided by over 23 organisations, under 26 different contracts, and are made up of the following.

  • Community well-being services, focusing on prevention and access to good quality information and support to enable individuals to maintain independence and good health, and to promote wellbeing.
  • Early intervention and prevention services, which aim to identify people who are currently well but at risk of developing long-term conditions, who will benefit from support that might prevent or delay this. These services also provide support for people with existing long-term conditions who might benefit from early identification and treatment to stop or delay progression to frailty or disability.
  • Rehabilitation and reablement services that focus on minimising disability or deterioration of health conditions or complex social care needs.

The current carers support services are provided separately by eleven organisations under four contracts, and are made up of the following.

  • Carers support service, which provides comprehensive information, support and advice to carers aged 18 and over.
  • Carer breaks service that delivers breaks and support services, including things like wellbeing breaks, 1-1 support, and activities and trips for adult carers. It also covers young carer respite support. Cheshire West and Chester Council, in partnership with Cheshire Clinical Commissioning Group, grant fund organisations to deliver these services.
  • Young carers service, which provides support for young carers between the ages of six and 18. It covers things like information and advice, emotional support and focused activities, as well as training.

Proposed model

Our vision for a new service

We believe that buying in these support services from so many providers in the way that we do currently causes confusion for residents. This is also not the most cost-effective way to ensure that residents are receiving the best services possible. We believe that the services on offer, and the ways to access them, would be much easier to understand if they were under one Community Led Care and Carers service.

The new Community Led Care and Carers service would:

  • make sure that there is a wide variety of community providers to offer support to residents by being part of the service,
  • make sure that we are working as closely as we can with our community, health and hospital partners to make it as easy as possible for residents to access the right support,
  • ensure that the Council and its partners can make the service flexible, with the ability to adapt the support available to the needs of residents,
  • allow us to support and invest in valuable community support networks, including the volunteer base, to help them to grow,
  • ensure that support services that residents pay contributions to are affordable and accessible and fees are set fairly to the level of support received.

This new approach would include the following.

  • The development of a community grants scheme with a focus on prevention, that will deliver services such as wellbeing activities, befriending services, and carer breaks. This will be responsive to changes in demand, allowing new services to be developed and funding to be re-directed to respond to emerging needs.
  • An increased focus on targeted support services delivered in the community to support those with long-term conditions.
  • The development of home support services to compliment discharges from hospital and support people to live longer and independently in their own home.
  • The development of a single all age carers service, merging services for adult carers and young carers into a more connected and efficient service.
  • To ensure that services remain affordable and accessible, the Council would like to understand what types of services residents would be willing to contribute to, what would be a reasonable amount to pay towards these services, and which services should remain free of charge.

The Council is proposing that the new service will have four key elements.

Community Led Support

Community-based services help to promote and maintain health and wellbeing, with a focus on prevention. Some of the community-based services we are proposing to offer include carer breaks, activity-based support, befriending services, practical support with things like shopping and cleaning, and support to access mainstream services.

We are proposing to move community led support services together under one funding stream, which will allow community organisations to bid for community grants. By delivering these services through a community grants scheme rather than securing a support service that runs for a number of years and cannot be adapted during that time through a contract, it allows more flexibility in the way the services are delivered so that we can be more responsive to evolving needs. We also think this approach will make the service more efficient due to a reduction in administrative tasks associated with grants compared to managing individual contracts.

Targeted Community Support

Services focusing on intervention and prevention by providing targeted community support and treatment that might prevent or delay the onset of long-term conditions for those at risk of developing them. This includes services for individuals with dementia, learning disabilities, physical disabilities, autism, sensory impairments, and mental health needs.

Services we are proposing to offer include personalised care planning, advice and support for people to manage conditions themselves at home, medicine management, and prevention services to stop or delay progression to frailty or disability.

Intensive Community Support

Intensive community support focusing on services for people with complex needs or frailty who require a long-term arrangement of personalised and coordinated care.

Services we are proposing to offer include support after leaving hospital, reablement, services to support independent living, and home support which we are proposing to provide using a well managed Good Neighbour Model. The model responds to the needs of local people by providing help with activities such as befriending, home visiting, companionship, someone to go to social events and other practical support. It is about local people helping their neighbours to enjoy a better quality of life. It will also support the discharge process by having services in place for those needing low level, non-care related support on return from a stay in hospital, but who could not manage independently. Other support includes bereavement support.

Carers in the Community

Carer support focusing on the needs and wellbeing of the carer and what they need to maintain their role. This ranges from information and advice to assessments, carer breaks, specialist support and access to the Care Well fund, which provides criteria based financial support to carers to help maintain their caring role.

Following previous consultations and discussions with carers (more information is available here), we are proposing to have one comprehensive carers service for carers of all ages that operates using a central contact centre to coordinate more localised community services for carers.

In addition to this, we are proposing to introduce criteria-based levels of support, where some support will require the completion of a carers assessment to help accurately assess levels of need and provide the correct level of support. There will be three levels:

  • Universal support (No Carers Assessment required) – This is accessible to all carers and does not require a full carers assessment to be completed. However, the service will still need to ask questions to be able to advise if a carers assessment would be beneficial. Services included within universal support are things like information and advice services, access to peer support groups, signposting to other agencies and access to the emergency card scheme.
  • Targeted Support (Carers assessment required) – This is aimed at carers requiring low level support to help them maintain their caring role. This would include training, complementary therapies, and carer workshops.
  • Intensive support (Carers assessment required) – This is aimed at carers requiring medium level support to help them to maintain their caring role. This would include access to support such as, the Take a Break service (respite support), Care Well fund (Financial support) and 1-1 support.
  • The three levels are in addition to the statutory support offer, which is there to help carers whose level of need exceeds the services available thorough community services. In these cases, a formal assessment must be carried out to look at the level of support for both the cared for individual and the carer.


Cost of the service

The Council’s budget remains incredibly tight and a funding gap of around £60 million must be bridged over the next three years, however the Council is committed to funding £1.6 million for Community Support Services and Carers services.

The Council believes that services can be maximised by aligning the two commissions. This will be achieved through the review of management costs and single pathways of support. The move to a new, Community Led Care and Carers Service will enable the current levels of service delivery and support to continue but still deliver some financial savings at the same time.

Alternative options

The proposal detailed in this consultation is one option. Another option would be for the Council to continue to commission services separately under two independent contracts. However, this may mean that efficiencies would not be achieved. It may also mean that we lose the opportunity to coordinate and modernise the service into one that is more holistic, and flexible. Additionally, it would not afford the chance to build increased connectivity between the local authority and charitable/voluntary organisations.

Current provision

The current community led care support services are provided by over 23 organisations, under 26 different contracts, and are made up of the following.

  • Community well-being services, focusing on prevention and access to good quality information and support to enable individuals to maintain independence and good health, and to promote wellbeing.
  • Early intervention and prevention services, which aim to identify people who are currently well but at risk of developing long-term conditions, who will benefit from support that might prevent or delay this. These services also provide support for people with existing long-term conditions who might benefit from early identification and treatment to stop or delay progression to frailty or disability.
  • Rehabilitation and reablement services that focus on minimising disability or deterioration of health conditions or complex social care needs.

The current carers support services are provided separately by eleven organisations under four contracts, and are made up of the following.

  • Carers support service, which provides comprehensive information, support and advice to carers aged 18 and over.
  • Carer breaks service that delivers breaks and support services, including things like wellbeing breaks, 1-1 support, and activities and trips for adult carers. It also covers young carer respite support. Cheshire West and Chester Council, in partnership with Cheshire Clinical Commissioning Group, grant fund organisations to deliver these services.
  • Young carers service, which provides support for young carers between the ages of six and 18. It covers things like information and advice, emotional support and focused activities, as well as training.

Proposed model

Our vision for a new service

We believe that buying in these support services from so many providers in the way that we do currently causes confusion for residents. This is also not the most cost-effective way to ensure that residents are receiving the best services possible. We believe that the services on offer, and the ways to access them, would be much easier to understand if they were under one Community Led Care and Carers service.

The new Community Led Care and Carers service would:

  • make sure that there is a wide variety of community providers to offer support to residents by being part of the service,
  • make sure that we are working as closely as we can with our community, health and hospital partners to make it as easy as possible for residents to access the right support,
  • ensure that the Council and its partners can make the service flexible, with the ability to adapt the support available to the needs of residents,
  • allow us to support and invest in valuable community support networks, including the volunteer base, to help them to grow,
  • ensure that support services that residents pay contributions to are affordable and accessible and fees are set fairly to the level of support received.

This new approach would include the following.

  • The development of a community grants scheme with a focus on prevention, that will deliver services such as wellbeing activities, befriending services, and carer breaks. This will be responsive to changes in demand, allowing new services to be developed and funding to be re-directed to respond to emerging needs.
  • An increased focus on targeted support services delivered in the community to support those with long-term conditions.
  • The development of home support services to compliment discharges from hospital and support people to live longer and independently in their own home.
  • The development of a single all age carers service, merging services for adult carers and young carers into a more connected and efficient service.
  • To ensure that services remain affordable and accessible, the Council would like to understand what types of services residents would be willing to contribute to, what would be a reasonable amount to pay towards these services, and which services should remain free of charge.

The Council is proposing that the new service will have four key elements.

Community Led Support

Community-based services help to promote and maintain health and wellbeing, with a focus on prevention. Some of the community-based services we are proposing to offer include carer breaks, activity-based support, befriending services, practical support with things like shopping and cleaning, and support to access mainstream services.

We are proposing to move community led support services together under one funding stream, which will allow community organisations to bid for community grants. By delivering these services through a community grants scheme rather than securing a support service that runs for a number of years and cannot be adapted during that time through a contract, it allows more flexibility in the way the services are delivered so that we can be more responsive to evolving needs. We also think this approach will make the service more efficient due to a reduction in administrative tasks associated with grants compared to managing individual contracts.

Targeted Community Support

Services focusing on intervention and prevention by providing targeted community support and treatment that might prevent or delay the onset of long-term conditions for those at risk of developing them. This includes services for individuals with dementia, learning disabilities, physical disabilities, autism, sensory impairments, and mental health needs.

Services we are proposing to offer include personalised care planning, advice and support for people to manage conditions themselves at home, medicine management, and prevention services to stop or delay progression to frailty or disability.

Intensive Community Support

Intensive community support focusing on services for people with complex needs or frailty who require a long-term arrangement of personalised and coordinated care.

Services we are proposing to offer include support after leaving hospital, reablement, services to support independent living, and home support which we are proposing to provide using a well managed Good Neighbour Model. The model responds to the needs of local people by providing help with activities such as befriending, home visiting, companionship, someone to go to social events and other practical support. It is about local people helping their neighbours to enjoy a better quality of life. It will also support the discharge process by having services in place for those needing low level, non-care related support on return from a stay in hospital, but who could not manage independently. Other support includes bereavement support.

Carers in the Community

Carer support focusing on the needs and wellbeing of the carer and what they need to maintain their role. This ranges from information and advice to assessments, carer breaks, specialist support and access to the Care Well fund, which provides criteria based financial support to carers to help maintain their caring role.

Following previous consultations and discussions with carers (more information is available here), we are proposing to have one comprehensive carers service for carers of all ages that operates using a central contact centre to coordinate more localised community services for carers.

In addition to this, we are proposing to introduce criteria-based levels of support, where some support will require the completion of a carers assessment to help accurately assess levels of need and provide the correct level of support. There will be three levels:

  • Universal support (No Carers Assessment required) – This is accessible to all carers and does not require a full carers assessment to be completed. However, the service will still need to ask questions to be able to advise if a carers assessment would be beneficial. Services included within universal support are things like information and advice services, access to peer support groups, signposting to other agencies and access to the emergency card scheme.
  • Targeted Support (Carers assessment required) – This is aimed at carers requiring low level support to help them maintain their caring role. This would include training, complementary therapies, and carer workshops.
  • Intensive support (Carers assessment required) – This is aimed at carers requiring medium level support to help them to maintain their caring role. This would include access to support such as, the Take a Break service (respite support), Care Well fund (Financial support) and 1-1 support.
  • The three levels are in addition to the statutory support offer, which is there to help carers whose level of need exceeds the services available thorough community services. In these cases, a formal assessment must be carried out to look at the level of support for both the cared for individual and the carer.


Cost of the service

The Council’s budget remains incredibly tight and a funding gap of around £60 million must be bridged over the next three years, however the Council is committed to funding £1.6 million for Community Support Services and Carers services.

The Council believes that services can be maximised by aligning the two commissions. This will be achieved through the review of management costs and single pathways of support. The move to a new, Community Led Care and Carers Service will enable the current levels of service delivery and support to continue but still deliver some financial savings at the same time.

Alternative options

The proposal detailed in this consultation is one option. Another option would be for the Council to continue to commission services separately under two independent contracts. However, this may mean that efficiencies would not be achieved. It may also mean that we lose the opportunity to coordinate and modernise the service into one that is more holistic, and flexible. Additionally, it would not afford the chance to build increased connectivity between the local authority and charitable/voluntary organisations.