14 - 2025-09-17 IJB - Home Support
North Lanarkshire Council · 17 September 2025
Back to Health and Social Care Integration Joint Board — 17 September 2025 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 14 SUBJECT: HOME SUPPORT TO: INTEGRATION JOINT BOARD Lead Officer for Report: Diane Fraser, Chief Officer (Adult Social Work Services) Author(s) of Report Margaret Flavell DATE: 17 September 2025 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 2. ROUTE TO THE BOARD This paper has been: Prepared By: M Flavell ☒ Reviewed By: ☐ Endorsed By: D Fraser ☒ NLC - Adult Care and Social Work Committee
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2 3. RECOMMENDATIONS It is recommended that the Integration Joint Board acknowledge the developments within Home Support Service and the progress being made to implement the approved operating model. 4. VARIATIONS TO DIRECTIONS? 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 The Health and Social Care Partnership remain committed to providing services at the right time and place, leveraging a personalised, choice-driven model that enhances wellbeing and independence. 5.2 The plan for the new operating model to deliver Home Support was agreed by the IJB in March 2018. The model was based on the outputs of the Cross−Party Working Group, the advice from support officers and wider officer research, the proposed model focuses on five major elements: Integrated Model (Discharge to Assess in Localities) Same Day Response/Reablement/First Support (Intensive and time limited) Specialist Teams (e.g. supporting people with frequently changing needs and end of life / Palliative Care) Ongoing Paid Support (allocation of an individual budget to deliver individual outcomes as part of SDS) Quality Assurance (improving standards of care) 5.3 There has been considerable work undertaken to implement a functional model —through assessment and planning and delivering long-term support via Living Well at Home which is outlined in the Home Support Service report that was presented to IJB Performance and Audit Committee 21st August 2024.This is now in the final stages of implementation. 5.4 It is widely recognised that robust assessment at home which includes direct support can determine more accurately what supports an individual may require longer term. The home support workforce is key to maximising an individual’s independence through practical tasks as well as following a rehabilitation programme to work on specific tasks and confidence. Generally, home support staff will work closely with other members of the multi- disciplinary team such as Occupational Therapists, Physiotherapists and Social Workers and families. The Home Assessment, Reablement, Integrated Rehabilitation and Intensive Yes ☐ No ☒ N/A ☐
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3 Teams can support individuals to ensure a thorough assessment is complete to inform any decisions regarding longer term support. This should assist in managing demand and directing resources to those most in need. 5.5 North Lanarkshire continue to have a positive balance of care, a term which is used to refer to the balance of support and care available within the community - based settings compared with support within residential settings. This is supported by the continued investment in community – based supports and a long-standing commitment to self-directed support. This is underpinned by community support which is codesigned with individuals and their carers/ families. This approach has resulted in a high proportion of individuals remaining at home. The model will support more people being assessed at home and supported to be as independent as possible. This will ensure that people who need short term reablement to reach their full potential receive this. 5.6 This approach is necessary to address the demographic changes and increasing pressure on financial resources including the impact of changes in the cost of living, which means that “more of the same” is not the right response. The 2022 census demonstrates the potential demographic change which supports the case for change. Between 2011 and 2022 the 25 to 44 age group saw a percentage decrease (- 7.3%), in contrast the 75 and over age group saw a percentage increase (+21%) Although the population is projected to decrease from 2028 to 2043 by 1.2% there is a forecast increase of 71.4% in the age group 75 years and over across the same timescale 20% of North Lanarkshire data zones are within the 20% most deprived in Scotland Individuals who reported themselves ‘in fairly good health’ as opposed to ‘good health’ has grown by 15% (+7036). Individuals who reported themselves as having ‘long term health conditions’ has grown by 30.6% (+43,943). Individuals self-reporting mental health issues has grown by 158.6% (+24,903) Individuals self-reporting as providing informal / unpaid care has grown by 31.6% (+10,877). 5.7 The delivery model required for assessment and planning and Living Well has had to align with the new operating model for the Health and Social Care Partnership which is outlined in the report Back to Basics to Getting it Right for Everyone presented to Adult Care and Social Work Committee in May 2025. There has been considerable work to embed the values and principles of Getting it Right for Everyone and an enabling approach into the home support workforce. 5.8 This report will outline the progress that has been made over the past 12 months in four key areas; embedding an enabling approach, realigning and preparing
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4 the workforce to focus on home first and ongoing paid support, implement a dynamic scheduling tool and continue with the transition of analogue to digital to ensure continuity through community alarms whilst maintaining quality service. Overall, the report confirms our capacity to deliver a flexible and efficient operating model for North Lanarkshire. Embedding an enabling approach 5.9 The enabling approach that has been adopted in each locality promotes the following principles: Do no harm Home First Empower People Focus on prevention Whole system approach No waits 5.10 The learning through the Back-to-Basics programme has influenced the home support redesign and staff have been involved in the range of work that has supported new practice and processes to ensure that we can provide a quick and effective response whilst retaining a focus on one of our key principles helping people to help themselves. The delivery model relies on organising the home support workforce to be able to support assessment and planning to identify what long term support is required as well as provide ongoing paid support. The Living Well Service will provide ongoing support. This model promotes the key tasks of assess, plan, intervene and review. 5.11 We have introduced this approach in all six localities however we started the learning process in Wishaw with a focus on all referrals being directed through Home Assessment Team and Reablement. The performance in this area improved and was evidenced through improved waiting times, as outlined below, and importantly feedback from individuals and their families was positive. They reported feeling more included, information and processes were clear, they felt respected and empowered. Professionals also reported feeling optimistic, safe, motivated, and inspired. March 2025 March 2024
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5 5.12 Home support staff have played an important role to proactively supporting a home first ethos. They have supported this by committing to adopting an outcome focused approach to their intervention. There will be ongoing training to refresh the assessment and planning activity undertaken. Through the assessment phase people will receive a period of reablement/ rehabilitation to support their recovery. It is important that longer term support is not decided in environments such as hospital unless in exceptional circumstances. To support this, we have worked closely with NHS Lanarkshire colleagues to develop a process to request for assistance. Through an enabling approach staff will work on the principles of early intervention and prevention and ensure that people are provided with information, advice, and signposting relevant to their ongoing assessment. Planned interventions will include carers support, use of technology enabled care, as well as being able to use their own resources. Our staff undertaking assessments and providing support and care which promotes self-management and slow stream rehabilitation. 5.13 The ethos of Home First is currently being promoted and whilst this approach is not exclusive to HAT the performance of the team, provides an indicator of the outcomes for people. Key indicators show consistent improvements in response times and service user satisfaction. Staff feedback highlights growing confidence in applying the enabling approach and working across disciplines. These successes have contributed to timely hospital discharges, supported community resilience, and informed best practice. 5.14 The existing Home Assessment Team has supported around 3700 people since its inception, with the ongoing strong focus on rehabilitation and assessment the service continues to deliver strong results as evidenced below. 5.15 Service Users with no ongoing Home Support Needs following HAT Assessment 0 5 10 15 Jan 2024 Jan 2025 Wishaw HAT Completions July 24 v 25 Ongoing Service Req. No further service req. Readmission to hospital SU refused futher service Death
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6 5.16 The table above identifies that: 45% of individuals required immediate support from hospital but with support did not require longer term intervention. 37% of individuals required ongoing service, a high proportion of these individuals were assessed as benefiting from a community alarm hence this being recorded as ongoing service, however, crucially this does not involve ongoing paid supports at home. 14% of individuals readmitted into hospital. 5.17 Readmission rates appear to be high and relate to premature discharge, general decline in health and new acute episode. This also needs to be considered against the age profile of the service users that are being supported. However, with the focus of early intervention and discharge 86% of those being supported via HAT are not being readmitted. 5.18 The model will support hospital discharge flow, allow early planning, and facilitate a smoother transition from acute care settings to community-based support. Coordination will involve locality-based decision-making, informed by real-time scheduling data. Over the past 6 months there has been an improvement in the number of delays and have consistently remained below target as demonstrated below. However, by improving flow with the new delivery model, Home Support staff will work within a multi-disciplinary way to
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7 respond to surges within the system. This will be dependent on a whole system response to improving the persons journey in hospital. 5.19 This new way of working reflects the strategic ambition set out in previous committee reports under the Back-to-Basics programme which has evolved into the Getting It Right for Everyone programme. A particular focus will be placed on improving evening and out-of-hours support, recognising historic service gaps identified through consultation and service performance reviews. The aim is to ensure a balanced and resilient service which can respond to both planned and unplanned care needs at all times of day. 5.20 The Living Well at Home service continues to be locality-based, allowing responsive, integrated care aligned to the needs of communities. A new service descriptor for this service has been devised setting out what the service will provide moving forward. 5.21 The aim of the Living Well at Home service is to promote independent living, choice and control, social inclusion, and wellbeing for the adults that it supports. Living Well at Home will do this by providing personalised assistance to meet individual’s identified outcomes.
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8 5.22 The primary focus will be to support individuals where there is significant complexity of need. This may be complex physical and/or complex social need including where there may be public protection issues. Acknowledging that levels of complexity can be difficult to quantify, decision making around this will be determined in line with the outcome of a person’s assessment and a multi- disciplinary team approach to support. Workforce 5.23 The workforce is key to implementing the new delivery model for assessment and planning and Living Well. Staff have participated in a range of engagement sessions and are supportive of change that will lead to an improved quality of service for people who receive support as well as benefit the workforce. There are 1235 Home Support Workers employed in the Service across Reablement, Home Assessment Team, Intensive, Community Alarm and Living Well Service. The worker profile is made up of 94% female and 6% male with over 60% of our workforce over age 50. The management and support roles were previously reviewed. These roles support with scheduling visits, carrying out reviews, supervision, and training. There is no other employment change proposed at the moment other than the Senior Home Support Managers and Service Delivery Manager with the other aligned staff. However, future practice with consideration of demand and capacity could indicate potential further movement required. 5.24 Significant progress has been made in aligning the operational level of the workforce structure to support the assessment and care delivery. Frontline and supervisory roles, including Home Support Workers, Schedulers, and Team Leaders, have now been aligned to the appropriate service and this will be seamless in supporting the models of delivery. 5.25 To fully implement the model and to maximise flow it will be necessary to align key management posts. The proposed management and supervisory structure include Service Delivery Managers and Senior Home Support Manager roles within both Assessment and Planning and Living Well at Home need to be finalised. There will be an HR process to follow, working with the services HR Business Partner. 5.26 The recruitment and retention of Home Support Workers remain a priority for the service. Between Jan 2024 and May 2025, a total of 55.62 fte (75 head count) new recruits have started since January 2024 however this has been offset against the leavers of 81.82fte (117 headcount) employees within the same period. These figures are reflective of the aging workforce with the service seeing an increase, in retirement and termination through capability. 5.27 To improve this position there have been changes to recruitment practices to attract new people into social care with the format of the interviews taking a value-based approach. This has allowed a wider pool of staff to be recruited
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9 successfully allowing investment in those individuals looking for a career change. The latest recruitment campaign seen an increase in the number of successful applicants. 5.28 Participation within the Council’s summer programme has also seen several young people come forward with an interest in working in care. This has given us the opportunity to work with these young people to help them achieve their goals through modern apprenticeships in care as well as securing sessional post for those young people still in full time education. 5.29 The model of delivery will provide clearer roles and improved career paths. This will provide staff opportunities to develop skills and confidence in specific elements. With the intention of increasing the retention of staff. For example, staff will have the opportunity to work closely with Allied Health Professionals, Social Workers and nursing staff providing intervention based on rehabilitation. In addition, to focusing on recruitment and retention there has been considerable work undertaken to provide training to ensuring that we have a competent, confident workforce as we move into a new delivery model. With support from Learning and Development there has been a targeted approach to ensure staff have appropriate training. Dynamic Scheduling System 5.30 The service has undergone two significant system changes in the past 6 months which have included the introduction of the dynamic scheduling tool and Mosaic the client information system for Social Work. The dynamic scheduling tool will offer a wider range of benefits to service users and staff by improving consistency, reducing missed visits, and incorporating travel time accurately. For the first time, the service will be able to monitor care delivery in real-time as well as improve quality of service which in turn improves the experience for people who receive support. It also can produce accurate reports which will help to inform future demand upon the service. 5.31 A revised project timeline was devised for the roll out to Home Support Teams and at present Bellshill, Wishaw, Airdrie and Motherwell Home Support Teams are using the new system. There has been significant work undertaken to maintain service delivery whilst implementing a new system. It has been challenging for staff who have gone above and beyond and shown incredible dedication. The project team have worked closely with the provider to deliver this with minimal disruption. The programme for the project is outlined below with a completion date of 31st September 2025. Systems will require to be updated until the interface between Mosaic and the scheduling tool. The service is also preparing for the implementation of the Council’s new telephony system.
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10 Home Support Team Back Office Go Live Date Full Go Live Date Bellshill 17/03/2025 24/03/2024 Wishaw 26/05/2025 02/06/2025 Motherwell 23/06/2025 30/06/2025 Airdrie 14/07/2025 21/07/2025 5.32 Service users and their families are registering for the new Client Portal, which will allow service users and/or their family members to view scheduled care visits, including the times and names of Home Support Workers who will be delivered the care and support. The website is being updated to provide users and carers with information on how to register. 5.33 Staff have embraced the new system and are using basic functions to facilitate the implementation across the Home Support Service within a tight timescale. The go live is not the end of the journey; it is only the beginning in terms of introducing the full capabilities of the system and reviewing the information now available on supports being delivered to ensure the right support is being provided to service users at the right time. Community Alarms Update 5.34 The Community Alarm Service currently provides support to 7,859 people in North Lanarkshire with the confidence that they can call for help at any time of the day or night, every day of the year and is an essential service when people experience difficulties such as a fall or sudden illness. Of these individuals, 6,306 people are using dispersed analogue and or digital community alarms and 1,553 people are within sheltered accommodation. The Community Alarm staffing structure is being reviewed to support the outlined changes in the wider service. Improving Quality 5.35 The work that has been undertaken to embed Getting it Right for Everyone has led to improvements in the quality of service being provided. This has been achieved working closely with the Care Inspectorate to address areas identified for improvement through inspection. Staff absence, workforce availability, and recruitment of skilled professionals have previously impacted service consistency, but recent trends indicate a positive shift in performance across all locality teams.
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11 5.36 Significant improvement planning has been developed across localities and is actively monitored by the Senior Manager Adult Social Work, in conjunction with Care Inspectorate input and support. 5.37 The Service has been advised that only registered services who are rated 3/ adequate or below will receive a full inspection in the inspection year which commenced April 25. Services sitting on 4/ good or above will be chosen on a random basis to ensure quality grades are maintained. The Airdrie Home Support Team were the first team to receive their full inspection (July 2025) which resulted in an improved grade for the staff team and identified the need for improvement in key performance areas of the job role undertaken by Home Support Team Leaders. 5.38 Monthly improvement plans, and performance data are collated and reviewed for each Home Support Team by the Service Managers and Senior Manager. This supports the registered managers to focus on providing the best quality service. This ensure that any outstanding statutory work required for inspection and provides senior managers with a clear position on the strengths and areas of development within each of the teams. Quality Assurance colleagues have been working with the service to undertake self-evaluation to highlight areas that need immediate improvements to satisfy the regulator and improve outcomes for people. 5.39 Whilst the Service has continued to work in partnership with both the Care Inspectorate and Quality Assurance Team to deliver improvements within the service it should be noted that significant work remains to restore the previously high-level grades. Next Steps 5.40 To operationalise the new operating model there is a need to finalise the management structure. Benchmarking and learning visits to other areas have
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12 taken place and the workforce are kept informed throughout the process through regular consultation and updates. 5.41 Working towards full implementation of the new operating model for assessment and planning with Home Support staff already aligned will support the transition to the new way of working. There will be a communication plan and training programme in place over the next 6 -12 months. The progress will be reviewed and evaluated in conjunction with the wider programme of work, Getting it Right for Everyone. 5.42 The dynamic scheduling tool implementation will be complete by September 2025 and will be evaluated. Once this is complete it will be possible to use the data to make further improvements. 6. CONCLUSIONS 6.1 The report demonstrates significant progress in transforming the Home Support Service in North Lanarkshire, aligning with the strategic objectives of delivering high-quality, person-centred care. 6.2 The clear functional separation of Assessment and Planning from Living Well at Home marks a pivotal development phase, allowing targeted service delivery and efficiencies. 6.3 Multi-disciplinary Home First Assessment Teams (HATs) have had a measurable positive impact, with the alignment of reablement and intensive support this impact will continue at pace. 6.4 Implementation of the dynamic scheduling system (Access CM) has improved data accuracy, scheduling, and real-time monitoring, though challenges remain regarding system performance and workforce resource demands. 6.5 Note the updated position within the Community Alarm Service as it transitions from analogue to digital and progress made to date. 6.6 Locality-specific improvement plans, and quality assurance processes have contributed to more consistent service quality, with several localities achieving 'Good' inspection ratings. 6.7 The transition plan for full rollout by the end of 2025 is well-structured and supported by training, communication, and workforce engagement. 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health and Wellbeing Outcomes
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13 People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) The following measures of success have been identified: Improved wellbeing of supported peoples’ outcomes. Service Quality Improvements - Inspection ratings increased across all localities. Technological Integration of the Access CM dynamic scheduling system. The technological integration of the digital ARC within the Community Alarms Service. The Home First Assessment Model to be implemented across all six localities by 31stOctober 2025. Improved discharge response from Lanarkshire and Glasgow Hospitals. Living Well at Home will prioritise ongoing longer-term support. Workforce Stability and Engagement. Ensure a sustainable financial model. 7.3 FINANCIAL This paper has been reviewed by Finance: 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner Key risks is the delivery of the project; ongoing service risks relate to training and Medium Diane Fraser Yes ☒ No ☐ N/A ☐
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14 workforce availability to the transferring of information to the DRS. Risks are recorded on the Corporate risk register and project risk register 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes Engagement and participation plan ☒ Provide stakeholders with information on how to get involved Family feedback encouraged in every review ☒ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs ☒ Measure how well we involve community stakeholders in the planning, design and delivery of our services Through oversight group in structure ☒ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery ☒ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings Locality Action Plans ☒ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff Communicaton Plan being updated ☒ Support engagement planning and participation in localities, taking account of other engagement activity and local plans across the Community Planning Partnership 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY
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15 EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: EQIA added to website: 8. BACKGROUND PAPERS 9. APPENDICES Please include a glossary of terms if not already included. N/A Diane Fraser, Chief Officer (Adult Social Work Services) CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Margaret Flavell Yes ☐ No ☒ N/A ☐ Yes / Date added ☐ No ☒ N/A ☐
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16 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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