Exploring the Difference Made by Support at Home

Exploring thE diffErEncE madE by Support at homE Sarah Joy, Susana Corral and Femi Nzegwu

Exploring the difference made by Support at home 1 Exploring thE diffErEncE madE by Support at homE Sarah Joy, Susana Corral and Femi Nzegwu

2 Exploring the difference made by Support at home

Exploring the difference made by Support at home 3 acknowledgements Special thanks to: > All the service users, staff, volunteers and referrers who participated in the interviews and discussions, who gave up their time to share their views and experiences > The service teams in our five research sites for their collaboration and participation in the research study > Our London service team, in particular Debby Mulling and Lucie Maresova, the staff at King’s College Hospital for supporting the research set-up phase and piloting of our questionnaires, and for their invaluable feedback and support > Our project interns that supported many aspects of the research during their individual three-month internships with us, from policy and literature reviewing to data collection and inputting: Catriona Burniston, Hannah Florish, Eriq Lindqvist, Domitilla Masi, Nicola Mason, Reya Shah and Gayathri Sundar > Our fieldwork team of interviewers who travelled around the areas interviewing service users in their homes: Christine Bradley, Sharon Goodridge, Clíona Hallissey, Kimberley Rennick, Antonia Shahab and Kate Steele > Jennifer Tuft for her organisational skills and support at critical points throughout the research, and Fernanda Velasco for her dedicated co-ordination in compiling the data for the analysis of Hospital Episode Statistics > Our research and policy colleagues for providing opportunities for discussion to shape the project along the way, and our Health and Social Care colleagues for their support and advice

4 Exploring the difference made by Support at home Copyright © 2013 Any part of this publication may be cited, translated into other languages or adapted to meet local needs without prior permission of the British Red Cross, provided that the source is clearly stated. This publication does not necessarily represent the decisions or stated policy of the British Red Cross. ISBN 978-0-900228-16-2

Exploring the difference made by Support at home 5 Executive summary 7 1 policy context 11 2 research aims 15 3 Evaluation methodology 19 3.1 Design 19 3.2 Sample 19 4 Evaluation findings: the difference made by Support at home 23 4.1 Who do we support? 23 contents 4.2 What are their needs (before receiving Support at home)? 25 4.3 What difference do we make? 30 4.4 What service challenges do we face? 33 5 implications 35 5.1 Conclusions 35 5.2 Recommendations 36 appendices a references 43 b descriptions of services selected for the evaluation 45 c demographic profile of service users interviewed in the study 47 d pre- and post-service questionnaires 48 E interview template – red cross staff & volunteers 57 f interview template – referrers 59

6 Exploring the difference made by Support at home list of tables and figures table 1 Number of service user interviews by site location 20 table 2 Dimensions measur ed in the survey 25 figure 1 Diagnostic histories of British Red Cross service users – co-morbidities 24 observed in the two years prior to referral to Support at home figure 2 Physical & practical capabilities – percentage reporting a poor score by site 26 figure 3 Psychological capabilities – percentage reporting a poor score by site 27 figure 4 Social contact – percentage reporting ‘no’ contact at all or ‘a little’ contact 28 with family, friends or neighbours figure 5 Emotional support and leisure activities – percentage reporting a poor 29 score by site figure 6 The difference made by Support at home: Average service user scores 30 (from 1 to 5) reported before and after the service

Exploring the difference made by Support at home 7 Executive Summary “She took the time background to sit and talk to me Support at home provides time-limited care and support to people at a time of crisis who are and it made me feel finding it difficult to cope at home. In 2012, the research, evaluation and impact team undertook like I was a human an evaluation of the British Red Cross Support at home services. The main aim was to gain a being again.” better understanding of the difference made by red cross service user the service for our service users, and to grow our evidence base. Overall the research was designed to provide the organisation with a comprehensive overview of the impacts of Support at Home, from which it can make strategic for the next strategy and beyond.

8 Exploring the difference made by Support at home findings conclusion Overall the research highlighted that the common What difference do we make? area of major impact of Support at home is the enhancement of service users’ quality of life. The Our findings showed that four service user support provided is characterised by a strong outcomes were significantly improved or increased sense of trust by service users in the Red Cross following receipt of Support at home: brand (and, therefore, in its staff and volunteers), 1. Improved wellbeing: We support people to feel alongside a compassionate, caring, non- in good spirits; we provide reassurance and judgemental, time-flexible and person-enabling alleviate worries. approach. Service users in the study attest to the impact of this approach on their own wellbeing. 2. Increased ability to manage daily activities: These are the Red Cross’ strengths and should be We support people to rebuild/regain their central in any national shaping and marketing of confidence and to get back on their feet again the Support at home service. after a stay in hospital. 3. Increase in leisure activities: We support people recommendations to build their social confidence, as well as the The findings from this research have led us to physical confidence to go out and they have develop seven recommendations to make to more things they enjoy doing with their time. the organisation, drawn from the impacts and challenges found in the study. 4. Improved coping skills: We support people to keep on top of things and make decisions on a 1. Champion our strengths: The Red Cross range of issues they are dealing with and help would benefit from carefully marketing its to reduce the struggles people face. offer by selling its strongest points – e.g. improving the wellbeing and quality of life Other positive changes were also reported related of the people it supports. to the wider benefits of the service beyond the service user outcomes alone: 2. Respond to the changing profile of our service 1. Enabling safe discharge: We provide users: The Red Cross would benefit from reassurance (to both service users and making a strategic decision about how we best referrers) that they will be checked up on, and support our service users, given the observed that there will be someone to turn to when shift in the profile of our service users (now they get home from hospital. including people with more complex needs). 2. Supporting carers: We alleviate some of the 3. Develop active partnerships to extend our stress, providing reassurance and giving reach and maximise impact: The Red Cross valuable information on local sources of would benefit from expanding and intensifying support. our partnerships in order to reach greater numbers of people in need. 3. Enabling patient advocacy – developing advocates for our service users: We support 4. Clarify the Red Cross’ position for people in service users to get help and ensure their needs need who fall outside of our commissioned are met. contracts: The Red Cross would benefit from devoting resources to understanding the experiences of frontline staff and acknowledge the reality of delivering Support at home as a contracted service in a humanitarian organisation. 5. Collect consistent and routine local and national data to inform service learning and development: The Red Cross would benefit from a better understanding of the profile of its service users, to develop more comprehensive knowledge of our service

Exploring the difference made by Support at home 9 users’ contexts and needs. 6. Develop signposting to ensure long-term impact: The Red Cross should ensure people are transitioned from our care appropriately through good signposting. 7. Grow our skills in order to advocate on behalf of our service users: The research suggests that we embed and enhance this vital component of our work by encouraging the development of advocacy skills through clear organisational guidance and training for staff and volunteers.

10 Exploring the difference made by Support at home

Exploring the difference made by Support at home 11 1 Policy context he UK’s population is ageing and people are living longer. The number of people aged 65+ years old is expected to rise Tby nearly 50% in the next 20 years, 1 reaching over 16 million. This is a human success story and should be celebrated. Older people are assets to society and the economy, with much to contribute. But equally, as a consequence of this ageing population, more people have long-term health conditions putting more pressure on our health and social care services. Within the context of increasingly limited public funds and rising health/social care needs in the population, these services are already struggling to cope. In 2007, the Department of Health published Putting People First, a shared vision and commitment to the transformation of adult social care aiming to ensure that people who need care and support have choice, flexibility and control to live their lives the way they wish. The report set out plans to reform public services with a focus on personalisation, enabling people to plan their care tailored to their own needs for independence, wellbeing and dignity. 1 National population projections, 2010-based, Office for National Statistics, 2011

12 Exploring the difference made by Support at home Still recognising the role of personalisation, the Acute Trusts and Community Care. Ellins et publication of the draft Care Bill in February al. (2012) explored older people’s experiences 2013 put forward new duties for local authorities of care transitions and highlighted that how to promote wellbeing, prevention services, people are treated, interactions and interpersonal information and advice, a stronger framework for relationships have the biggest impact on patient eligibility and assessment, new rights for carers experiences. Lack of communication, clarity and and an approach that recognises and builds on involvement in their discharge arrangements was the strengths of people and communities. Yet the often cited as the most frustrating thing. They reality is that, at the same time, local councils are found that people with moderate levels of need, 2 facing cuts to their social care budgets , leading hence those who are not usually eligible for a many of them to raise their eligibility thresholds care package, can end up feeling isolated and for the receipt of social care and support, and unsupported. making it increasingly difficult for people to access these services.3 commissioning priorities The NHS is entering into a period of major Alongside structural reform, the NHS structural reform in the way its services are commissioning process is changing. In England, provided and funded. There is a focus on reducing NHS decision-making has shifted from Primary hospital stays by shifting care and treatment Care Trusts to GP consortia, and in Scotland new from acute hospital-based care to the community commissioning models are being explored which delivered by community-based, multi-agency could change the way services are delivered. teams. The discharge process inevitably works to Reducing unnecessary emergency hospital extremely tight timescales and is often described admissions is a clear priority for everyone. This as fraught with communication issues between the outcome carries the largest financial incentive for the newly formed Clinical Commissioning Groups 4 2 Following funding cuts of 28% in the Spending Review, Local Authorities in their Quality Premium targets. have reduced their budgets by £2.68 billion over the past 3 years, reported in the ADASS Budget Survey, May 2013 3 The number of people receiving publicly funded social care has fallen 4 Of the Quality Premium targets, avoiding unnecessary emergency by 17% since 2006/7, while the population aged 85 years and over has admissions is the largest portion worth 25%. There are 4 national targets risen by more than 20% over the same period, reported in The King’s applicable to all CCGs and 3 local ones allowing them to respond to the Fund Briefing (2013), The Care Bill: Second Reading in the House needs of their local population. See Quality Premium: 2013/14 guidance of Lords. for CCGs, NHS England, March 2013.

Exploring the difference made by Support at home 13 In 2011, three pieces of research (two in England In 2007, the National Strategic Partnerships and one covering Scotland) were carried out Forum highlighted that the voluntary sector’s role on behalf of the British Red Cross to capture in health and social care is distinct from other commissioners’ experiences, views and current providers in the commercial or statutory sector. commissioning practices for services offering The “added value” that voluntary organisations low-level support at home.5 In line with the can offer is suggested to include community policy priorities set out above, three specific engagement, access to “hard-to-reach” groups, commissioner objectives were evident across innovation, cost-efficiency, strong user and the board: carer involvement, volunteers and absence of > Developing prevention strategies and stigma and threat. However, a review carried avoidance of unnecessary admissions into out by Dickinson et al. (2013) for the National hospital. Initiatives supporting this are a major Institute for Health Research (NIHR) School priority. For example, exploring better options for Social Care Research suggests caution in for falls response and prevention. attributing these common values across all voluntary sector organisations delivering social > Expanding the provision of time-limited re- care. They highlighted that the nature of the ablement services. This is viewed as critical relationship between state commissioners and to help people “get back on their feet again”, voluntary organisations is critical in achieving either when they have been discharged from the greatest impacts. While there is evidence of hospital or when there is a risk of them strong partnerships between trusts and voluntary needing to be admitted to hospital. However, sector providers in achieving high-quality, patient- a pressure on resources was also acknowledged centred care, there remain some barriers to as a barrier to expanding this provision. effective partnership working, including a lack of mutual understanding and clarity of roles > Ensuring flexible, personalised care. The and responsibilities. personalisation agenda is a big influence on commissioners and is driving a shift in the In addition, the current economic context emphasis of care from fixed, condition-centred of restricted financial resources presents a care to flexible, person-centred care. challenging environment for volunteering. Naylor et al. (2013) highlight the importance of Further priority areas mentioned by having a strategic approach, a clear vision and a commissioners included: minimising delayed focus on volunteering as a means of improving discharges; dementia care provision; relief support quality rather than cutting costs. These factors for carers; re-ablement services for people with are described as key enablers for seizing the chronic conditions; and emphasising choice and opportunities that exist in health and social care control in social care support, including more now and in the future. people using personalised budgets. the role of the voluntary sector in delivering social care Voluntary sector organisations have been involved in the delivery of social care for a very long time. In a recent King’s Fund report, Naylor et al. (2013) highlighted that around 3 million people volunteer in health and social care, making an important contribution to people’s experience of care. 5 A survey was carried out with 169 Local Authority and NHS commissioners in England and 3 in-depth interviews with GP Consortia commissioners (in Care in the Home Commissioners, IFF Research, 2011); 14 in-depth interviews with LA and NHS commissioners were also carried out in England (in the Study of Care in the Home Commissioning, IFF Research 2011); In Scotland 8 interviews were carried out with Red Cross staff and 11 interviews with LA and NHS commissioners (in Care in the Home Commissioning Environment Scotland, Emma Naismith 2011). All studies included commissioners who do currently commission Red Cross services and those who don’t.

14 Exploring the difference made by Support at home

Exploring the difference made by Support at home 15 2 Research aims 6 he Support at home programme at the British Red Cross offers short-term, practical and emotional support to help Tpeople build their confidence and regain their independence. Support at home services are varied in focus and approach across the organisation, allowing local teams to respond to local needs and to reflect commissioner priorities. For example, some services focus on supporting people after a stay in hospital, and others work specifically alongside A&E teams to prevent people being admitted into hospital from A&E. Many of our services provide support for people at home, to prevent them from having to rely on higher-intensity and costly social care. In 2012, the research, evaluation and impact (RE&I) team undertook an evaluation of the Support at home service. There were three main aims of the study: > To understand better the difference made by Support at home for our service users 6 The service has recently undergone a name change to Support at Home, it used to be called Care in the Home (CITH).

16 Exploring the difference made by Support at home > To gain increased knowledge of the health and wellbeing outcomes derived by service users and the factors influencing these individual outcomes > To grow our evidence base and feed directly into the strategic development of the service Alongside this study, two additional projects were carried out. The first, conducted in partnership 7 with the LSE , looked at the economic impact of our services. The second, in partnership with the Nuffield Trust, aimed to better understand how selected services affect hospital utilisation patterns. These reports are available separately from www.pssru.ac.uk/acrchive/pdf/dp2869.pdf and www.nuffield.org.uk 7 The findings of these 2 additional analyses are summarised in sections 4 and 5 and individual reports have been produced by Nuffield and LSE providing further detail on these analyses.

Exploring the difference made by Support at home 17

18 Exploring the difference made by Support at home

Exploring the difference made by Support at home 19 3 Evaluation methodology 3.1 design assess change, and also included a section on the service users’ experiences of the service (see 8 A mixed-methods approach was taken, Appendix D for a copy of the questionnaires). incorporating quantitative and qualitative data collected from service users, Red Cross staff and Semi-structured telephone interviews were volunteers, and referrers to the Support at home conducted with Red Cross staff, volunteers and service. Face-to-face interviews were conducted referrers to gather their views on and perceptions with service users in their own homes, before and of the service (see Appendices E and F for a copy after receiving the service. In the interviews we of the interview schedules used). asked them how confident they were that they could do certain things, such as carrying out daily Data analysis incorporated summary descriptives, activities (looking after themselves, doing tasks cross-tabulations and significance tests to look for around the home, or getting out and about), and differences before and after the intervention, as managing their finances. We also asked service well as thematic analysis of the qualitative data users about their coping skills (whether they were gathered across all the interviews. able to take their mind off their worries, make their own decisions, keep on top of things and 3.2 Sample cope with life at home). Emotional wellbeing, perceived social connectedness, and satisfaction 3.2.1 Site selection with life were also key measures of interest. The questionnaire was designed following a A case study approach was adopted, due to review of validated scales that measure older distinct local contexts, varied needs for service people’s health and wellbeing, alongside a wider provision and the different local commissioning consultation exercise, both internal and external. priorities, which lead to a varied service offer The questions were then cognitively tested and across the country. piloted. The post-service questionnaire had the 8 All research fieldwork documentation is available from the research team same questions as the pre-service interview, to at the British Red Cross, i.e. information sheets, advance letters, consent forms, interviewer instructions etc.

20 Exploring the difference made by Support at home > Yorkshire: Care in the Home service in East Red Cross services in five locations across the Yorkshire UK were selected to take part in the study. This selection was based on a number of essential > Wales: Swansea Floating Tenancy Support variables of interest, including geography – to Service ensure coverage in the four countries of the UK; continuation of contract funding past March > Northern Ireland: Care in the Home service in 2012; size of service; and type/aims of service – the Southern H&SC Trust to try to reflect the range of different Support at home services on offer.9 The five locations selected > Scotland: Neighbourhood Links & Red Cross as our case study sites to be explored Buddies in the Scottish Borders. in the evaluation were: > London: Next Steps service at King’s College See Appendix B for further details of these Hospital individual services. 3.2.2 Participant sample After the service users’ initial service assessment, the service teams sought consent for the research to be conducted. Service users were fully briefed on the purpose of the study in order for them to decide whether they would like to participate. We interviewed 90 people before their service had begun. The needs and demographic profile of our evaluation participants are described in section 4. Sixty one interviews were achieved with these service users after their receiving the service (following attrition). In an attempt to boost the number of interviews, some one-off retrospective interviews were conducted in evaluation locations where the ‘before’ cohort numbers were originally low. Table 1 illustrates the interviews conducted 10 in this study. Table 1: In addition, 58 semi-structured telephone interviews were conducted with stakeholders across the five locations, including Red Cross staff (22), Red Cross volunteers (24) and referrers (12). TABLE 1 NuMBER OF SERVICE uSER INTERVIEWS BY SITE LOCATION11 London Yorkshire Wales N. Ireland Scotland Total Pre 32 32 14 9 3 90 Post 20 25 9 5 2 61 Retrospective – – 21 5 9 35 10 The length of the fieldwork period differed across the sites according to capacity and other factors, hence, more interviews were achieved in some locations than others. In general, the pre-service interviews were 9 The sites were chosen for their differences and so will reflect many but conducted by the service team and the post and retrospective interviews not all of our services across the country. Services providing personal were conducted by the research team. However, in London, the pre- care were excluded and no A&E based services are represented in the interviews were also conducted by the research team. 5 sites in this study.

Exploring the difference made by Support at home 21

22 Exploring the difference made by Support at home

Exploring the difference made by Support at home 23 4 Evaluation findings: The difference made by Support at home 4.1 Who do we support? 11 4.1.1 Demographics Overall, the service user profile across four of the five sites evaluated does not differ significantly in terms of age and gender. Just over half (57%) are between the ages of 65 and 80, with the average age being 76 years. Thirty-five per cent are 80+ and 9% under 65. There are many more women (75%) than men (25%). However, in Wales, the service has a much younger population – 67% are under the age of 65 years, with a mean age of 62 years. As in the other sites, the majority (67%) of 12 service users are women. The ethnic profile differs markedly across sites. Only in London and Wales are ethnic minority populations seen among service users. This is most prevalent in London at 42% and largely made up of people of African Caribbean background, due to the characteristics of the local population in the surrounding London boroughs. 11 The demographic questions were asked in the POST interview hence, the data in this section is largely based on the 61 service users interviewed both at the beginning and end of their service intervention, unless stated otherwise. 12 It is worth noting that many commissioned contracts do specify age related criteria for the services to target.

24 Exploring the difference made by Support at home Regarding housing, London and Wales service Appendix C provides more data on the users in the study also differed by tenure to those demographic profile of the service users we in Yorkshire, Scotland and Northern Ireland. The interviewed. This overall profile broadly aligns majority in London (79%) and Wales (89%) rent with the findings from a 2010 internal review from a social landlord (local authority or housing of service user feedback forms. In this review of association tenants). By contrast, service users in over 5,000 service users, the majority were over the other three sites predominantly owned their 75 years (67%), women (61%) and classified own homes (over 80% were owner occupiers). themselves as white (93%). The majority of our sample of service users live 4.2.2 Health alone – almost seven in 10 in four sites, and a higher nine in 10, in Wales. This is significantly Not unexpectedly, many individuals (74%) higher than the general population estimate – the reported having significant health issues that affect proportion living alone is 37% for people aged their day-to-day lives. People most commonly 65 and over, and 49% for people aged 75 and expressed a difficulty with mobility (60%). Fifty- over (Age UK, 2013). five per cent considered themselves as having a disability. Some of the main health conditions FIGuRE 1 DIAGNOSTIC HISTORIES OF BRITISH RED CROSS SERVICE uSERS – CO-MORBIDITIES OBSERVED IN THE TWO YEARS PRIOR TO REFERRAL TO SuPPORT AT HOME Hypertension 66% Injury 52% Falls 37% Mental Health disorders 33% Peripheral vascular disease 25% Ischaemic heart disease 25% Atrial Fibrillation 25% Cardiovascular disease 23% Diabetes 23% Anaemia 21% Congestive heart failure 19% Respiratory Infection 19% Cancer 18% Chronic Obstructive Pulmonary Disease 17% Angina 13% Asthma 12% Renal Fail 10% Alcohol misuse 8% Heart valve disorders 8% Latrogenic problems 8% Connective tissue disease/Rheumatoid Arthiritis 6% MildLiver 3% Cancer Benign 3% Congenitive heart disease 1% Drug misuse 0% 0% 10% 20% 30% 40% 50% 60% 70% Source: NHS HES data – (n=1573) Note: Dementia and Alzheimer’s are coded in the Mental Health category.

Exploring the difference made by Support at home 25 that participants talked about in the interviews Clearly, Support at home sees a population that included arthritis, poor memory, poor vision, is older, largely female, often living on their own, lupus, diabetes, high blood pressure, mental and with significant chronic health conditions. health (depression, schizophrenia and addiction), In some areas, our service users also appear to be stroke, cancer, fractures and hip replacements. quite homogenous, with limited diversity within the group. Further insights into the types of medical/health conditions experienced by service users were 4.2 What are their needs (before highlighted in the NHS data collated by the Nuffield Trust for a separate analysis of hospital receiving Support at home)? utilisation patterns. Figure 1 shows the diagnostic histories of 1,573 service users upon discharge We asked participants about their state of health from hospital (records taken from Support at and state of mind prior to receiving support 14 home schemes in seven hospitals across London). from the Red Cross. People were asked to score The most common health conditions largely align themselves on a number of questions using a with five-point scale. Our focus when reporting these those directly reported by respondents themselves findings is to explore the needs of our services in our study. users, those who felt less than able to cope with their lives, on the range of dimensions we A heavily medically-reliant population with measured. Participant scores of one and two were complex health care and social needs, 99% of taken as a self-rating of having “poor” ability to respondents had accessed their GP, nurse or carry out the task in question. hospital in the three months before referral to the service, 21% had accessed a social service Table 2 shows some of the key measures we will carer, and 27% had other help/support services report on in the sections to follow, with the items such as cleaning, gardening, shopping or a (or individual questions) that make up each of 13 meals-on-wheels service. the dimensions explored. See the questionnaire in Appendix D for the specific question wording. TABLE 2 DIMENSIONS MEASuRED IN THE SuRVEY Section dimensions items Physical & Practical Daily activities Ability to look after yourself capabilities (4.2.1) Ability to do daily tasks around the home Ability to get out and about Manage finances Ability to manage your finances (e.g. organise payments and bills) Control Control over daily life Psychological Coping skills Ability to take your mind off your worries capabilities/ State of Ability to make your own decisions mind (4.2.2) Ability to keep on top of things Ability to cope with life at home Wellbeing Feeling good about yourself Feeling in good spirits Safe at home Feeling safe and secure in your home Satisfaction with life Satisfaction with life as a whole Social support, Social contact Contact with family, friends and neighbours emotional support & Someone to talk to Can find someone who will really listen to me if leisure (4.2.3) I need to talk Leisure activities Have activities that I enjoy doing with my time 13 Based on all 90 PRE-service interviews 14 Based on all 90 PRE-service interviews

26 Exploring the difference made by Support at home FIGuRE 2 PHYSICAL & PRACTICAL CAPABILITIES – PERCENTAGE REPORTING A POOR SCORE BY SITE 79 84 Daily activities 81 71 70 18 Managing 14 finances 3 69 all sites 8 london yorkshire 17 Wales 15 northern ireland Control 7 & Scotland 33 27 0 10 20 30 40 50 60 70 80 90 100 15 There were differences across sites, seemingly around the home” (59%), then “looking after related to the type of service delivered. For themselves” (26%). example, where the service focused on a particular aspect of support – e.g. daily living activities – While 18% of the overall population rated there was a tendency for those service users to themselves as poor in managing their finances, report poor capacity in these aspects prior to the the variation across service sites is noteworthy. service. This is a good indicator that the service is It is understandable that a significantly higher need-responsive. proportion (69%) in the Wales tenancy support project (with a strong financial support In this section we examine the service users’ component) would rate their capacity as poor in reported physical and psychological states, and this area (Figure 2). the associated needs of service users prior to receiving Support at home. Seventeen per cent of all respondents said they had no control at all over their daily lives, again 4.2.1 Physical and practical capabilities highest in Wales at one in three (Figure 2). Physical health was mentioned as one of the main We looked at how able people felt they were to factors restricting people’s ability to feel in control carry out their daily activities and manage their of their daily lives. finances, and the amount of control people felt they currently had over their life. Overall, significant numbers of service users before receiving the service reported that: Overall, 79% of all participants rated themselves > Going out is stressful and causes anxiety. Fear as poor in carrying out daily living activities in at of falling and stumbling – outside as well least one of the three activities measured (Figure as inside the home – is very real (e.g. going 2). Within this dimension, people most commonly upstairs is not possible for some people). rated themselves as poor at “getting out and Having someone there is very important to about” (64%), followed by “doing daily tasks enable them to try and slowly regain their confidence. 15 Due to the low numbers of interviews achieved in Scotland and Northern Ireland we have not been able to include them when reporting variation > Transport issues are common in both urban figures across sites. However, we have combined them together to and rural settings. This relates to adjusting to include in the graphs.

Exploring the difference made by Support at home 27 FIGuRE 3 PSYCHOLOGICAL CAPABILITIES – PERCENTAGE REPORTING A POOR SCORE BY SITE 49 Coping skills 64 20 85 56 37 39 Wellbeing 18 67 56 17 20 all sites Safe 6 london 39 18 yorkshire 32 Wales 41 northern ireland Satisfaction 7 & Scotland 62 27 0 10 20 30 40 50 60 70 80 90 100 not being able to drive anymore, as well as not rated their capacities as ‘poor’ in at least one of being able go out alone. Having to completely the questions under each of these dimensions. rely on other people and trying to find other ways of getting to places (taxis, public Across all sites, nearly half of our participants transport routes etc.) are issues confronting (49%) rated themselves as ‘poor’ for at least one this population group. item under coping skills. However, the variation across sites is important to note – higher in > Doing heavy, physical things is difficult or London (64%) and Wales (85%) (Figure 3). not possible for some people – e.g. carrying shopping bags, vacuuming, lifting, and having Thirty-two per cent reported their satisfaction the strength to do certain things around the with life as ‘poor’ across all sites, ranging from home. 7% in Yorkshire to 62% in Wales (Figure 3). > Capability varies on a day-by-day basis – Many respondents expressed worry and anxiety people have good days and bad days, with in their feedback. Reasons why people did not needs changing accordingly. feel good, or found it difficult to take their mind off their worries, varied according to individual > “Not being able to do what one used to be circumstances. Four factors emerged as feeding able to do” and “everything taking more time into this anxiety: than usual” – e.g. washing, dressing, tidying > Feeling limited and frustrated: Being unable – are adjustments people deal with regularly. to look after your home was a source of These constitute a source of frustration and frustration, coupled with a lack of confidence upset for many. and self-esteem and/or a fear of falling for some, particularly when no one is around 4.2.2 Psychological capabilities to help. We looked at coping skills, wellbeing, feeling safe > Feeling lonely and alone: Some people reflected and secure in one’s home, and overall satisfaction on having too much time to sit and think, with life to assess the state of mind of our reporting it is difficult being on your own a participants. Figure 3 shows the proportions who lot, and that they do not have much to look forward to.

28 Exploring the difference made by Support at home FIGuRE 4 SOCIAL CONTACT – PERCENTAGE REPORTING ‘NO’ CONTACT AT ALL OR ‘A LITTLE’ CONTACT WITH FAMILY, FRIENDS OR NEIGHBOuRS Family 13 43 no contact a little contact Friends 21 44 ALL SITES Neighbours 22 46 0 10 20 30 40 50 60 70 80 90 100 > Feeling like a burden on other people: Some interviewed stated that they would like more people recognised that the only reason they contact with other people than they currently were able to cope was that they had help from have. others. This help was hugely influential, but also left some people feeling like a burden, > Four out of 10 service users have only a little particularly on family members. contact or no contact at all with family, friends or neighbours. Out of this group, nearly two- > Financial worries about not having enough thirds (62%) said they wanted more contact money to pay bills: This was the cause of a lot with people. of stress and worry for some people. People reflected on the stark reality of not having The consequences of not being able to cope at as many people around you as you get older as home loom large. People really feared losing their family and friends pass away. Some recognise that independence. They saw it as possibly resulting in they spend a lot of time on their own. Some admit having to go back into hospital or having to move that they feel quite lonely, that they like having into a nursing home. company, but do not have as much contact with other people as they would like to. 4.2.3 Having a social support network We also asked about people’s access to a listening and emotional support ear – someone who will really listen to them if We asked participants how much contact they they need to talk. have with family, friends and neighbours. Thirteen per cent had no contact at all with family (highest > One in four did not have access to someone in London at 19%), 21% had no contact with to talk to. Here, as with the other variables friends (again highest in London at 29%), and examined, responses differed across sites 22% had no contact with neighbours (highest in (Figure 5). 16 Wales at 33%)(Figure 4). Finally, we asked people whether they have things We explored people’s social contact in more detail: they enjoy doing with their time. > Forty-three per cent of all the service users we > A significant number of people (46%) reported that they did not have any activities that 16 5% had no contact with family or friends and 3% had no contact they enjoyed doing with their time. This with any of the all three groups – that is, neither family nor friends nor ranged from 19% in Yorkshire to 75% in neighbours.

Exploring the difference made by Support at home 29 FIGuRE 5 EMOTIONAL SuPPORT AND LEISuRE ACTIVITIES – PERCENTAGE REPORTING A POOR SCORE BY SITE 26 41 Someone to 7 talk to 39 70 46 62 all sites Leisure 19 london activities 75 yorkshire 50 Wales northern ireland & Scotland 0 20 40 60 80 100 Wales (Figure 5). Over half of them (61%) There were mixed views about council services, indicated that they would like to take part in primarily around insufficient time being allocated more leisure activities – ranging from 33% to support them (service users) in the ways they in Yorkshire, to 44% in Wales, to 75% in want. There were also mixed feelings about London. calling upon family for help, linked to not wanting to be a burden on other people with busy 4.2.4 Access to help at home lives. Some people reported experiencing difficulty finding someone to give that bit of extra paid help Having help at home was essential for many and with the housework. the only way they were able to cope with life at home. As noted previously, 79% of the sample 4.2.5 Summarising the needs of service population reported needing help with daily users prior to Support at home activities (Section 4.2.1). For this group of people, individual circumstances varied and help came The findings show that a significant proportion of from different sources: Support at home service users (89%) have a need > 20% had access to a formal carer of some sort, in at least one of the areas explored in the study.17 for example, a social services carer coming There is some variation by site, ranging from 81% in to support them a few times every day, or in Yorkshire to 100% in Wales and London. social services support of another kind (e.g. intermediate care). Need appears to vary by the type of service provided. In London’s hospital-based “Next > 32% accessed another sort of formal help, for Steps” service the main areas of need identified example, a cleaner, gardener, shopper, meals on are help with daily activities (84%), need for wheels service etc. improving capacity to cope (64%) and need for leisure activities (62%). For the service users of 18 > 69% got informal support from family, friends Wales’ “Tenancy Support” programme , high and neighbours. levels of need revolved around the capacity to cope (85%), the need for leisure activities (75%), > However, 14% of those that reported needing help had no access to people or places providing help around the home. 17 We define the population in need as those who rated their physical, psychological or social capacities and resources as poor, a self-rating of 1 or 2 on a scale from 1 to 5. 18 Many service users in this service have housing difficulties and some have associated alcohol or drug misuse issues where the Red Cross is one of the last lines of support.

30 Exploring the difference made by Support at home FIGuRE 6 THE DIFFERENCE MADE BY SuPPORT AT HOME: AVERAGE SERVICE uSER SCORES (FROM 1 TO 5) REPORTED BEFORE AND AFTER THE SERVICE 5 4 * indicates a 3 statistically significant change between the pre and 2 post scores at 95% confidence 23 level. 1 pre cith 0 post cith Daily Manage Coping Someone Leisure Wellbeing* Safe at Satisfaction activities* finances skills* to talk to activities* home with life and help with daily activities (71%). East 4.3 What difference do we make? Yorkshire’s service19, on the other hand, identified the most prominent need for 81% of their service Overall, the greatest impacts of Support at home users as the ability to carry out daily activities. are seen in seven key areas. The first four areas of impact are service user outcomes (observed as Significant proportions of the population seen statistically significant from the interviews with 20 by our service have complex health care needs service users pre- and post-intervention). Other alongside social and emotional needs. These needs positive changes were also observed and reported are not always picked up by other people or around the wider benefits of the service beyond organisations, formal or informal, of any kind. the service user outcomes alone. These form the final three areas of impact. Many service users worry about the present and their capacity to cope in their day-to-day lives. 4.3.1 Service user outcomes They have limited social support and life is often felt to be a struggle. They also have worries about Figure 6 shows the degree of change (before and the future, and do not always see an easy way after Red Cross support) in the self-reported forward. capabilities of our service users on the different 21 dimensions measured. * For those who define their capacity as ‘poor’ in any of the key areas explored in this study, there As indicated in figure 6, Support at home is little doubt as to the need for extra support. contributes to the following service user outcomes: This support needs to aim at alleviating some of their struggles and making life that bit more comfortable, indeed bearable, at a time of crisis. 20 There was no control group for this study due to ethical and logistical constraints. Hence, while attribution is always a challenge in studies of this kind we are confident, in analysing the qualitative data alongside the quantitative outcomes, that Support at home makes a strong contribution to the differences observed. 21 Further analysis into those who reported “poor capacity” shows statistically significant improvements in their capacity after the service in 19 Many service users in this service need support to change their anti- all the dimensions measured except managing finance. This reinforces embolism stockings following being discharged from hospital after an the importance of correctly targeting those most in need – for whom the operation. impact of the service is greatest.

Exploring the difference made by Support at home 31 1. improved wellbeing > Clearly, an improvement in service users’ overall quality of life, especially through the “I’m old, I’m not in good health and I live on provision of a listening ear, and a sensitive my own, so for them to take an interest that’s and encouraging voice is a significantly an awful lot and I’m very grateful.” (Red valued aspect of Support at home from all Cross service user) perspectives. In addition, the practical support and advice provided make a real difference > Data from this study shows wellbeing as a to the lives of those most in need. The impact significant area of impact of the service. Service may not necessarily occur for a prolonged users’ narratives confirm this. Repeatedly period, but for the period in which the service across the five sites, when asked for their is provided to service users, at a low point in thoughts on the “best aspects of Support at their lives, the service appears to make a real home” service users spoke about the company difference to how people experience the quality – having someone to talk to and seeing of their lives. a friendly face to have a chat with; and reassurance – knowing someone is thinking 2. increased ability to manage their daily about them, helping to alleviate their worries, activities their sense of isolation and knowing there is someone to turn to when needed. “The aftercare coming out of hospital, it’s been a God send because I wouldn’t have improved > We asked respondents in this study to reflect really.... I was down, I couldn’t; I didn’t have on what helped them to feel good about the confidence at all to go out, no.” (Red Cross themselves and their lives. Four factors were service user) most prominent: > Having people around and support (feeling > Another key area of impact supported by well looked after) the data is service users’ “ability to carry out daily activities”. Specifically, this relates > Looking forward to getting better/being to supporting people to regain/rebuild their mobile again confidence in their own abilities to manage their lives, by helping them do much-needed > Having a positive outlook and feeling able practical tasks. For example, enabling them to to take an interest in things get out and about to shop, or to shop on their behalf, or generally to get back on their feet > Taking care of their appearance following a hospital discharge. Of of the three components measured (whether people felt > These factors capture the greatest strengths of able to look after themselves, to do daily tasks the service. Support at home is grounded in around the home, and to get out and about), a philosophy and practice that supports the people experienced the biggest increase in their wellbeing of people made vulnerable by ill- ability to get out and about. health, age and poverty. The service works by helping to make their lives easier to manage. > Staff perspectives on this key area of Support It supports people to rebuild their levels of at home’s impact were similar to service self-worth and confidence in themselves, by users’. Amongst the main areas mentioned appreciating and being there for them. This by staff were building confidence to support ultimately enables people to rediscover some people “to get back on their feet again”, enjoyment in their lives once again. helping them to regain their independence and, consequently, increased health and wellbeing > Many of the strengths of the service are noted because of being at home instead of in the in the way service users describe how staff/ hospital environment. volunteers do things. Some of the words capturing the Red Cross’s approach include: > In all sites, people’s capacity to manage Responsive (to individual’s needs); Committed; their daily activities increased following the Trustworthy (linked to people’s trust in the intervention, although the change was highly Red Cross generally); Non-judgemental; Time- significant in all but Wales. flexible (due to it being volunteer delivered); Supportive; Understanding and Interested; and Kind and Caring.

32 Exploring the difference made by Support at home 3. increase in leisure activities 1. Enabling safe discharge “Red Cross introduced me to the group, “It’s a nice way of getting rid of people’s which has raised my confidence level a hell anxiety and if there’s any problems upon of a lot.” (Red Cross service user) discharge, sometimes the hospital can sort of make ... assessment, but then when they get > People were more likely to have things they home it’s a different story. So, the Red Cross enjoyed doing with their time at the end of can also sort of highlight any risks as well the service. People spoke about the service there.” (Referrer) introducing them to places they could go, building their social confidence as well as > The NHS stipulates, as a fundamental giving them physical confidence to get out requirement of the discharge process and and about again. good practice, that hospitals identify at discharge, what patients need to enable a 4. improved coping skills smooth transition from the hospital level of care to another. Part of this information is “Honestly, I just like to appreciate everything obtained through discussion with patients or they have done for me.... I don’t know how their families about what is needed to support to thank him; he’s a gentleman. He gave me a the patient, including who will prepare meals, lot of support…. They listen and, as well, they provide transportation and undertake chores; feel how you feel and they understand your what activities they need help with; as well situation….” (Red Cross service user) as information on medication and diet. This discharge process does not often take place > An improvement in coping skills was found as effectively and efficiently as it should to be significant in one site only – our Wales (Glasby, 2003). service, which provides a longer-term source of support for individuals in crisis. Service users > Staff and referrers in this study talked about spoke about the service playing a big part in how the service supports and impacts the their lives by reducing the struggles they were health and social care sector by enabling safer facing, being there to listen to them, discussing discharge. They reported how it does this in a issues and offering support in finding solutions number of ways: to a wide range of problems, from debt, > Addressing potential unmet need – referrers to housing applications, to accessing local mentioned how volunteers, through their services and other practical and health related home visits, are well placed to flag up risks needs. in the home environment that may impact the person’s immediate and long-term The data reveals that Support at home does health and wellbeing. impact health and wellbeing outcomes for its service users to varying degrees. Although there > Providing referrers with reassurance and is evidence of some consistency across the peace of mind that their patients are being services, some outcomes are clearly influenced checked up on after discharge. 22 by the components of the programme on offer. > Allowing social services and hospital staff 4.3.2 Wider benefits of Support at home to focus on more complex cases – that is, supporting people with a higher level Wider benefits of the service were also observed of need. in the study, particularly in the interviews with staff, volunteers and referrers. These are: > Relieving some of the pressure on hospital staff by doing some of the smaller tasks associated with discharge (e.g. getting keys cut, chasing up family members). 22 Differences were observed between the five services, with the most significant outcomes (by site) reflecting the key components of the service on offer. In Wales – coping skills significantly improved following support. London’s hospital based “Next Steps” service saw a significant increase in ability to carry out daily activities, improved psychological wellbeing and a greater engagement with leisure activities, while for Yorkshire’s service which commonly supports people to change their anti-embolic stockings, daily activities emerged as the key significant outcome for participants.

Exploring the difference made by Support at home 33 2. Supporting carers > The clear need for staff and volunteers to ensure service users have information about “It provides enormous relief and support to and access to the services they need has been families and carers of the individuals that we the catalyst for the development of this role are actually supporting because [they may not] locally. Advocating on behalf of individual have the knowledge of the local community service users varies in its depth across Support nor the knowledge of the welfare system in at home services and, critical as it is in order to know what can be done in order to strengthening health and wellbeing outcomes help them out.” (Red Cross staff member) for service users, currently it is not supported by any organisational training/development. > One of the consistent research findings about the failure of many hospital discharge 4.4 What service challenges do processes is the lack of attention paid to the needs of carers. Not only is inadequate we face? information available to carers, they are often not provided with sufficient discharge notice The research also found a number of challenges for their family member (Glasby, 2003). to our services working to deliver a quality service, and responding to people’s needs and the > Amongst the vast majority of staff and changing external environment. Challenges were volunteers consulted for this study, there was highlighted in the following areas: a consensus that Support at home has, as one of its by-products, strong support for > Supporting more people with long-term health the service users’ carers or families. This is conditions achieved in a number of ways: > Enabling families to have a few hours > Transitioning people off our service a week to themselves when the staff appropriately through effective signposting member or volunteer is present in the home – thereby alleviating some of their stress. > Recruiting volunteers and running a volunteer- delivered service > Helping carers to identify longer-term local services, options for respite care > Targeting our resources most efficiently to (e.g. day centres) and local carers’ achieve greatest impact support organisations – providing both the information/advice and support to > Service visibility and outreach work access these. > Pressures to meet internal and external targets > Providing reassurance to families who and grow services in an uncertain external do not reside close to their relative that environment an eye is being kept on them. > Collecting systematic data and information on 3. Enabling patient advocacy – developing our service users’ contexts and needs advocates for our service users The learning from these challenges are reflected “Everything from helping me move in to and incorporated into the Implications and helping me get a GP, change my address with Recommendations in section 7 of this report. everybody that I have to, [negotiating with] all the agencies....” (Red Cross service user) > Another clear outcome of Support at home is the development of a group of skilled negotiators, knowledgeable about where and how to access a range of local services on behalf of their service users. The development of this skill has been occurring over the life of the service. This has significant implications for supporting service users to get the best services for their particular needs in the longer term.

34 Exploring the difference made by Support at home

Exploring the difference made by Support at home 35 5 Implications 5.1 conclusions The research study highlighted that the major area of impact of the British Red Cross support at home service is the enhancement of service users’ quality of life. The impact of the service is greatest for those who report need – that is, a lack of capacity in the areas supported by the service – highlighting that we should clearly target our resources to people and places where need is indicated. The support provided is characterised by a strong sense of trust by service users in the Red Cross name (and, therefore, in its staff and volunteers), alongside a compassionate, caring, non- judgemental, time-flexible and “person-enabling” approach. Service users in the study attest to the impact of this approach on their own wellbeing. These are the Red Cross’ strengths and should be central in any national shaping and marketing of the service.

36 Exploring the difference made by Support at home 5.2 recommendations of life is given a prominent place on the agenda within the wider health and social care sector. The findings from this research have led us For example, as the clinical commissioning to develop a number of recommendations to groups start to choose the local indicators make to the organisation, drawn from the that will be matched to their Quality Premium impacts and challenges found in the study. The Targets, the Red Cross is well positioned to recommendations are a result of both the research try to influence them to consider quality of life findings and subsequent discussions with staff related indicators. focused on drawing out the implications for the organisation.23 2. respond to the changing profile of our service users The following seven recommendations emerge The findings suggest that, as social services tighten from this study: their eligibility criteria, Support at home staff and volunteers are seeing greater numbers of people 1. champion our strengths with complex needs – especially mental health The findings from this study confirm that our needs. The Red Cross would benefit from making greatest impact is observed in improved wellbeing a strategic decision about how we best support and related quality of life, which directly supports our service users and, indeed, whether this the NHS outcome “Enhancing quality of life observed shift is acceptable and desirable to us. for people with long term conditions” (Dept of Health, 2012). Furthermore, these positive If it is Red Cross policy to respond increasingly changes are more marked for those who rate to this new group of service users with increased their capacity in these areas as ‘poor’ before needs, then there are key activities that could they receive the intervention. In other words, occur to support this proactively. These include 24 the greatest change can be seen in those with the sharing learning from existing services , greatest need. providing necessary training for staff and volunteers, and ensuring referral criteria reflect Our evidence also suggests the service supports this shift towards those with increased needs. both safe hospital discharge and carers, where present. These are the strongest qualities of If it is not desirable that this group form part of Support at home, and they need championing Support at home’s core support group, then the over areas where the evidence is weaker. Red Cross will actively have to turn down these higher-level referrals, possibly with humanitarian Implications for the organisation to consider: and contractual implications. > Use the evidence available to promote what we’re good at. Look at what the data is telling Implications for the organisation to consider: us (from this study and other sources) about > Acknowledge the implications of supporting the outcomes we achieve. In addition, we people with more complex needs and the should continue to gather further evidence, internal and external consequences of this. where needed, to support our work. Support Internally, the Red Cross would benefit at home is not a “one size fits all”. There is a from exploring its role in this new “care variety of services that sit under the umbrella framework”, where limited resources are of Support at home, with different strengths increasingly deployed to address greater and selling points. Consistent evidence numbers of individuals with more complex gathered on these and other services will needs. By doing so, it would be necessary to highlight the specific strengths of each. reflect upon the implications to existing service delivery models – most notably whether this > Ensure quality of life is high on everyone’s reduces the time afforded to service users with agenda. The importance of the quality of life lower-level needs. There are also resource of our population needs to come to the fore implications for taking on this additional level of our discourse on Support at home. The of need – in terms of staff/volunteer training, research suggests that the Red Cross is very time and patient outcomes. Externally, our well placed to advocate and ensure that quality commissioners should be kept fully aware of the implications of this changing landscape, as well as any potential risks and other general 24 Some services have specific experience in supporting people with more 23 Discussions of the findings were held across the country with staff from complex needs and are well placed to share their learning, e.g. the the services that participated in the research. Tenancy Support Programme in Wales.

Exploring the difference made by Support at home 37 impacts on the desired outcomes for older > Collate evidence on the needs of our service people in the population. users. The Red Cross would benefit from accurately and routinely collected information > Consider the creation of a different service on the needs of service users, in order to delivery model. Time spent working with develop a service that is responsive to these people with more complex needs often changing needs. This will also enable us to demands more staff input. This can be a play a critical role with our commissioners, challenge to the way some of our services informing them on the changing needs currently operate and the Red Cross principle landscape as well as provide essential of being a volunteer-run organisation. This evidence for our work. (See direct link with indicates a need to consider creating a recommendation 5) different, higher-spec service for this group of people with more complex needs, with a > Provide training for staff and volunteers to clear focus and approach distinguished from meet the rising needs of our service users. Staff our “traditional” role supporting people with and volunteers would benefit from consistently lower-level needs. acquiring the correct type of training to meet the needs of service users with more complex > Clarify our current role and aims for people needs. From the research, the observed skills with increased needs and longer-term issues. that would be particularly useful include: There is an immediate need to acknowledge psychosocial skills to learn how best to work explicitly the changing needs of our service with our service users who have mental health users with front-line staff and volunteers, and issues and sometimes people with suicidal to clarify what this means for them and their thoughts; specific health knowledge to support roles. They need to understand what we are service users to manage the common health seeking to achieve for people with increased conditions we see25; and advocacy skills to needs and/or longer-term health issues, and ensure service users get the support they need. what elements of these needs can realistically (See direct link with recommendation 7) be met. 25 See section 4.2.2 of this report for a discussion of Red Cross service user’s health conditions highlighted in this study.

38 Exploring the difference made by Support at home enable a growth in the Red Cross’s reach, and also identify critical gaps in the current support available to meet the often longer- term, unmet needs of our service users. (See direct link with recommendation 6). It also contributes to strengthening local, “under the radar” and other potentially innovative grass roots community groups, as well as the community’s resilience. Community links are vital in times of crisis. The research highlighted that the Red Cross is well placed to contribute to the building of these links and bringing people together.28 > Make our services more visible. Life on hospital wards can be dynamic and busy. Without making the services offered more visible to all referrers (including agency staff who may not be familiar with the ward or the Red Cross offer) the degree to which we are automatically called upon, as an immediate choice for referrers looking for this type of support, becomes limited. Similarly, in non- hospital-based schemes, Red Cross offices are often out of town and out of sight. Staff and 3. develop active partnerships to extend our volunteers acknowledged that more linking in reach and maximise impact with hospital and community health and social The Red Cross aspires to reach greater numbers care settings is necessary to provide that vital of people in need across a wide spectrum safety net and ensure we reach more people of communities. The most effective ways of in need. A strategic and deliberate choice of doing this are by expanding and intensifying where staff are located was also considered our partnerships with those organisations that critical to visibility and outreach. already work with, and are well connected to, 26 these communities, and increasing awareness 4. clarify the red cross’ position for people of our services amongst those who would refer in need who fall outside of our commissioned to us. This also enables us to play to our own contracts strengths and consider how to fill gaps where The Red Cross delivers Support at home as need is highlighted, as well as looking outside a contracted service within a humanitarian for innovations and new ideas to offer a support organisation. Ensuring clarity on whether we can 27 role to smaller organisations where appropriate provide support to people in need who fall outside (Jarvis and Marvel, 2013). Such a strategy of of the existing commissioned criteria or catchment actively partnering in this way will also allow us area (contract obligations and restrictions) would to explore solutions for the challenges raised in be of benefit to the Red Cross. recommendation six around signposting – that there are fewer places/community resources to Implications for the organisation to consider: signpost people on to. > Capture and understand the experiences of frontline staff. The research highlighted that Implications for the organisation to consider: frontline staff are left dealing with the question > Intensify the degree to which the Red Cross of how our contract-driven model fits with the promotes and supports the capacity of Red Cross vision that “everyone gets the help local organisations and community groups. they need in a crisis”. The study suggests that Partnering with groups delivering similar or further exploration of the scale of this issue, specialist support in their communities could and consideration of the options for our ways of working, is desirable. 26 The evaluation of the TESCO funded Care in the home projects indicated a growing understanding of partnership working and its strategic importance in the development of the service. 28 For example, one Red Cross service in the study identified a need and 27 Some of our services have specific experience in partnership supported a group of service users to set up an exercise class in the development and are well placed to share learning, e.g. the local village hall – contributing to potential health outcomes and the Neighbourhood Links service in Scotland. building of social networks.

Exploring the difference made by Support at home 39 > Provide guidance on our position to frontline This would enable the evidence we need for staff and volunteers. A clear communication recommendation 2. to staff on the way forward is needed. > Prioritise the importance of data collection for 5. collect consistent, routine local and our service delivery and credibility. A positive national data to inform service learning and cultural shift is recommended in the way the development organisation collects and uses data. We need The Red Cross would benefit from a better to ensure staff and volunteers see the tangible understanding of the profile of its service users, uses of the data they collect and input into to track trends and develop a more comprehensive the system. Real examples of this should be knowledge of our service users’ needs. incorporated into training and be an on-going part of the information fed back by managers Large organisations do face challenges in at a local level to frontline staff and volunteers. collecting data, but it is integral that the data collected is of a high quality and as complete as 6. develop signposting to ensure possible, and that systems in place are robust long-term impact enough to ensure record keeping is thorough. The Red Cross would benefit from ensuring that our staff and volunteers know how to signpost Implications for the organisation to consider: well, with the aim of transitioning people from > Ensure essential information is captured in our services gently. This may require follow-up existing data collection systems to enable where appropriate. services to learn and develop. We need to ensure that data collection systems and The nature of our service users and the services we governance are designed to collect key offer (short-term interventions for a largely older national and local data. This includes basic population with considerable health problems) demographic data, as well as information on often means that being able to signpost people the needs and contexts of our service users onto more long-term support is a challenging, but e.g. does the person live alone? Are they essential part of our work. 29 are in receipt of social services support?). 29 Key service user data this study suggests we should be collecting Implications for the organisation to consider: include: Health conditions; Social isolation (living alone, contact with > Make signposting a priority and acknowledge family, friends and neighbours); Access/ use of services (health services, the time needed to do it well. Good social services, private services, other voluntary services); Family carer signposting and making professional referrals support.

40 Exploring the difference made by Support at home to other, sometimes stretched, services is The Red Cross is in a unique position of being very labour intensive. It requires a significant able to support people to access other services time investment with outcomes that may as a respected and impartial organisation. This not immediately materialise. The very short is a core part of our work and requires a certain nature of some of our services can restrict the understanding and skills set which people can be follow-up necessary for good signposting. developed to achieve. Although we may describe However, good signposting provides continuity this as advocating for our service users it should of support (where needed) to the service user not be confused with independent advocates, and can mitigate the impact of our service professionally trained roles focussing on ending. We need to ensure that we build into supporting people to have a stronger voice. our service delivery models the capacity and time necessary for good signposting to take The research found many good examples of place. For example, the need for signposting where Support at home staff and volunteers were onto a longer-term service should be assessed advocating on behalf of service users in varied and identified at the start of the service, giving situations, and to varying degrees. This ranged staff/volunteers the maximum possible lead from cancelling a mis-sold life insurance policy, to time to put the service in place. supporting a service user refused food by a food bank, to chasing up and ensuring service users get > Support the development and sustainability the appropriate support or assessments they need of local community resources. The study from mental health or other social service teams. highlighted the added complication that there Exercising these advocacy skills can often occur are sometimes no other organisations where as our service is coming to an end, and as such people can be signposted on to. The Red Cross contributes to ensuring a continuity of support is well placed to support the capacity of locally for the service user. based community organisations to provide additional community support to those people Implications for the organisation to consider: who have lower levels of social need. This > Provide training for staff and volunteers to would also feed into enabling recommendation use advocacy skills when appropriate. The 3 – extending our reach through partnership research suggests we enhance and embed this working. vital component of our work and encourage the development of advocacy skills through > Provide training for staff and volunteers on clear organisational guidance and training signposting. Guidelines are needed for new for staff and volunteers. In order to ensure a and existing staff and volunteers. The study consistent approach across the organisation highlighted that the quality and depth of training sessions should cover when and signposting across the UK varies from simply how it is appropriate to advocate, as well as handing someone a leaflet, to accompanying for how long. Information could be shared them to the new organisation and fully on, for example, what rights people have supporting the transition. Examples of very regarding access to community care services, good signposting practice can be found in the the assessment processes and common Red Cross’s services – including identifying issues people encounter. In addition, an service users’ needs and potential need for understanding of the difference between the signposting upfront – but the research also work we do and the work of professional found that this does not occur consistently independent advocates would serve to ensure across the service. that it is clear when we should act and when we should refer onto specialist services. 7. grow our skills in order to advocate on behalf of our service users “When they say we’re from the British Red Cross, I’m a supporter on behalf of so and so... I feel the other side, they [start] listening.” (British Red Cross service user) Enabling service users get what they need, through the resource of time, attention and persistence is a core part of the service. The research highlighted the value that our service users place on this.

Exploring the difference made by Support at home 41

42 Exploring the difference made by Support at home

Exploring the difference made by Support at home 43 appendix a References Addicott, R. (2013) Working together to deliver the Mandate: Strengthening partnerships between Naylor, C., Mundle, C., Weaks, L., Buck, D. the NHS and the voluntary sector. [Online]. (2013) Volunteering in health and care: Securing The King’s Fund. Available from: http://www. a sustainable future. [Online]. The King’s Fund. kingsfund.org.uk/publications/working-together- Available from: http://www.kingsfund.org. deliver-mandate [Accessed: 6 December 2013]. uk/publications/volunteering-health-and-care [Accessed: 6 December 2013]. Age UK. (2013) Later Life in the United Kingdom. [Online]. Age UK. Available from: NHS England. (2013) Quality Premium: 2013/14 http://www.ageuk.org.uk/Documents/EN-GB/ guidance for CCGs. [Online]. NHS England. Factsheets/Later_Life_UK_factsheet.pdf?dtrk=true Available from: http://www.england.nhs.uk/ [Accessed: 6 December 2013]. wp-content/uploads/2013/05/qual-premium.pdf [Accessed: 6 December 2013]. Department of Health. (2012) The NHS Outcomes Framework 2013/14. [Online]. NHS, LGA & ADASS (2007). Putting People Department of Health. Available from https:// First, A shared vision and commitment to www.gov.uk/government/publications/nhs- the transformation of Adult Social Care. outcomes-framework-2013-to-2014 [Accessed: [Online]. HM Government. Available from: 6 December 2013]. http://webarchive.nationalarchives.gov. uk/20130107105354/http:/www.dh.gov.uk/ Dickinson, H., Allen, K., Alcock, P., Macmillan, en/Publicationsandstatistics/Publications/ R., & Glasby, J. (2013) The role of the Third PublicationsPolicyAndGuidance/DH_081118 Sector in Delivering Social Care. [Online]. NIHR [Accessed: 6 December 2013]. School for Social Care Research. Available from: http://www.lse.ac.uk/LSEHealthAndSocialCare/ Rodríguez-Artalejo F., Guallar-Castillón P., pdf/SSCR-Scoping-Review_2_web.pdf [Accessed: Herrera M C., Otero C M., Chiva M O., Ochoa 6 December 2013]. C C., Banegas J R., Pascual C R. (2006) Social Network as a Predictor of Hospital Readmission Ellins, J., Glasby, J., Tanner, D., McIver, S., and Mortality Among Older Patients With Heart Davidson, D., Littlechild, R., Snelling, I., Miller, Failure. Journal of Cardiac Failure. 12 (8). R., Hall, K., Spence, K. and the Care Transitions p.621-627. Project co-researchers. (2012) Understanding and improving the care transitions of older people: a The College of Social Work. (2013) How Budget user and carer-centred approach. [Online]. NIHR Cuts are Affecting Eligibility Thresholds for Service Delivery and Organisation programme. Care.[Online]. TCSW and Age UK. Available Available from http://www.birmingham.ac.uk/ from: http://www.tcsw.org.uk/uploadedFiles/ Documents/news/SDOTransitions-Report.pdf TheCollege/_CollegeLibrary/Policy/ [Accessed: 6 December 2013]. EligibilitySurveyPolicyReport.pdf [Accessed: 6 December 2013]. Glasby, J. (2003) Hospital Discharge: Integrating health & social care, Radcliffe Publishing Ltd. The King’s Fund. (2013) Briefing: The Care Bill: Second Reading in the House of Lords. [Online]. Jarvis, O., & Marvel, R. (2013) When Bees meet The King’s Fund. Available from: http://www. Trees. How large social sector organisations can kingsfund.org.uk/publications/briefings-and- help to scale social innovation. [Online]. The responses/briefing-care-bill-second-reading-house- Clore Social Leadership Programme. Available lords [Accessed: 6 December 2013]. from: http://www.cloresocialleadership.org.uk/ userfiles/Owen_and_Ruth_Report_FINAL.pdf [Accessed: 6 December 2013].

44 Exploring the difference made by Support at home The National Strategic Partnerships Forum. (2007) Making Partnerships work: Examples of good practice.[Online]. Available from: http:// www.bipsolutions.com/docstore/pdf/16271.pdf [Accessed: 6 December 2013].

Exploring the difference made by Support at home 45 appendix b Descriptions of services selected for the evaluation next Steps service in london hospital (aged 18-65). It is a time-limited, 30 currently largely staff delivered 12-week service The service is based in King’s College Hospital offering advice and practical support on a range and supports the hospital discharge teams. It of issues including: provides up to four volunteer home visits over > Money advice, e.g. benefit checks, debt advice, a four-week period, as well as telephone calls reducing household bills to check the person is coping at home after discharge. > Help with moving home, e.g. assessments, sourcing appropriate housing, practical needs The service provides support to meet the needs e.g. furniture needs, accessing local services, of the individual. For example, accompany them education to and from GP appointments, prescription collection, collecting or assisting with shopping, > Practical help and advocacy, e.g. paperwork help to access social services and/or other and form filling, arranging meals on wheels or community support, and friendly chats and shopping services, liaising with social services, company. housing or health professionals on person’s behalf The service aims to provide time-limited care and support in the home for people after an accident > Emotional support, e.g. talking through or illness, giving people the confidence to continue problems, identifying information needs, with their daily lives. accessing befriending services care in the home service > Signposting to local groups and specialist support (e.g. mental health, substance mis-use in East yorkshire support groups) and accompanying people to these groups The service is provided for up to six weeks and delivered by a mix of trained staff and volunteers. The service aims to ensure vulnerable people The service can offer social visits and support are supported through crises and are made to for rebuilding confidence, help with essential feel safer, more secure and more able to live light household chores, shopping, prescription independently within their community; and collection, and information about other support to enable vulnerable tenants to manage their services in the local area. Trained staff and tenancies successfully, and have appropriate volunteers also provide help with changing anti- support to maintain and develop their embolic stockings, a specialist component of this independence. service, following discharge from hospital after an operation. care in the home service in the The service aims to enable individuals to be Southern h&Sc trust, northern promptly discharged from hospital or prevent ireland admission/ readmission for others by facilitating 31 independence and ongoing self-care. The service consists of an eight-week programme for clients whose needs have been assessed by floating tenancy Support Southern Health and Social Care Trust staff and referred to the Red Cross. Each service user is Service in Swansea matched with a volunteer and receives an average of one visit per week, which will vary in duration The service supports older people (aged 55+), 30 However, the nature of some of the work involved and the outcomes the refugees and patients being discharged from service is measuring itself against are, in reality, much longer term. This can result in the service supporting people for up to a year and longer. 31 Note the service length has recently been increased to 12 weeks in line with service user & volunteer feedback.

46 Exploring the difference made by Support at home depending on the activity undertaken. The service provides home support, transportation, access to wheelchairs, accompanied shopping, therapeutic care massage, and accompanying clients to local clubs/groups in order to promote the physical, mental, social and emotional health and wellbeing of older people. The service aims to improve the quality of life for vulnerable clients by providing a range of services and activities to support independent living at home. neighbourhood links and red cross buddies in the Scottish borders The service provides support to people with low-level social needs by assisting them to re- engage with their community, and providing information to enable them to manage their day- to-day activities better. It consists of two distinct elements: > Neighbourhood Links. An extensive information, advice and signposting programme in the local communities of the Scottish Borders. This is delivered by Red Cross staff. > Red Cross Buddies. A 12-week service offering social support in the form of weekly visits from a volunteer. Not everyone requires a buddy, but for those that do a support plan is drawn up to cover the individual’s specific wishes and needs from these visits. The service aims to support people with low- level needs to live at home, and to promote and develop the capacity of locally based voluntary and community organisations to provide additional community support to those people who have lower levels of social need.

Exploring the difference made by Support at home 47 appendix c Demographic profile of service users interviewed in the study The demographic questions were asked in the post interview. Therefore, these are based on our 61 service users interviewed both before and after the service. The symbol ‘–’ denotes no service users reported in this demographic. Please note some of the sample sizes are very small, in particular in Scotland and NI, hence percentages are not recorded for these sites. ALL LONDON WALES YORKSHIRE NI SCOT count % count % count % count % count count Male 16 26.2 4 20 3 33.3 6 24 2 1 gender Female 45 73.8 16 80 6 66.7 19 76 3 1 total 61 100 20 100 9 100 25 100 5 2 White 49 81.7 9 47.4 8 88.9 25 100 5 2 Mixed 2 3.3 2 10.5 – – – – – – Ethnicity Asian – – – – – – – – – – Black 9 15 8 42.1 1 11.1 – – – – Chinese – – – – – – – – – – total 60 100 19 100 9 100 25 100 5 2 Min-Max 32-93 n/a 52-93 n/a 32-82 n/a 56-86 n/a 72-81 74-84 age Mean 73.8 n/a 74.5 n/a 61.6 n/a 77.2 n/a 76.0 79.0 Std.Dev. 11.2 n/a 11.3 n/a 15.4 n/a 7.1 n/a 4.7 7.1 total 55 n/a 16 n/a 9 n/a 24 n/a 4 2 under 65 10 18.2 3 18.8 6 66.7 1 4.2 – – age 65-80 28 50.9 8 50 2 22.2 14 58.3 3 1 bands Over 80 17 30.9 5 31.3 1 11.1 9 37.5 1 1 total 55 100 16 100 9 100 24 100 4 2 live Yes 54 68.4 18 69.2 10 90.9 18 60 7 1 1 No 25 31.6 8 30.8 1 9.1 12 40 2 2 alone total 79 100 26 100 11 100 30 100 9 3 Owner 31 52.5 4 22.2 – – 22 88 4 1 tenure Renting 26 44.1 14 77.8 8 100 3 12 1 – total 57 100 18 100 8 100 25 100 5 1 Social 26 100 14 100 8 100 3 100 1 – rent Private – – – – – – – – – – total 26 100 14 100 8 100 3 100 1 – health Yes 42 73.7 17 89.5 6 75 15 62.5 3 1 condition No 15 26.3 2 10.5 2 25 9 37.5 2 – total 57 100 19 100 8 100 24 100 5 1 Mobility 29 60.4 11 55 6 85.7 8 50 2 2 Sight 10 21.3 4 21.1 1 14.3 4 25 – 1 Hearing 6 12.5 3 15 1 14.3 2 12.5 – – Speech 4 8.3 – – 2 28.6 1 6.3 – 1 Read/Write 4 8.3 – – 2 28.6 2 12.5 – – Other 19 39.6 9 45 2 28.6 7 43.8 1 – total 48 100 20 100 7 100 16 100 3 2 Yes 26 55.3 8 72.7 4 44.4 11 47.8 3 – consider No 21 44.7 3 27.3 5 55.6 12 52.2 – 1 disabled total 47 100 11 100 9 100 23 100 3 1 1 This question was asked in the PRE interview. Therefore, based on the service users interviewed before the service started

48 Exploring the difference made by Support at home appendix d Pre- and post-service questionnaires Date & time of interview BRC number Postcode Name of interviewer prE- service Questionnaire Remember to gain consent! Please reassure the service user that it is their views and experiences that are important to us. There are no right or wrong answers! i would like you to think about your daily life, carrying out your day to day activities. I’m going to ask you some general questions, could you indicate for me using the scoring system on this card how confident you currently are that you can do certain things (SHOW CARD 1). One means you feel you cannot do it at all, 5 means you feel certain that you can do it. And the middle of the scale is 3. Thinking about your daily activities, cannot certain Depends/ how able are you to do the do at all can do DK/NA/ following: Refuse 1 2 3 4 5 Write in 1. To look after yourself, for 1 2 3 4 5 example, to wash, get dressed... Comments 2. To do daily tasks around the home, for example tidying, 1 2 3 4 5 cleaning… Comments 3. To get out & about, for example, 1 2 3 4 5 go shopping, do your errands… Comments 4. Do you have someone to help Yes / Sometimes / No / DK you do any of these things? If so, Who? Circle all that apply 1. Family 2. Friends 3. Neighbours 4. Homecare 5. Other Please specify: 5. Can I just check who you live with? If already mentioned, write in… 6. Are you currently taking any Yes / No / DK (if No → Q8) medication? and how able are you to... cannot certain Depends/ do at all can do DK/NA/ Refuse 7. To take your medication when 1 2 3 4 5 you need to

Exploring the difference made by Support at home 49 Comments 8. To manage your finances well, for 1 2 3 4 5 example organising bills & payments Comments 9. To take your mind off your worries 1 2 3 4 5 Comments 10. To make your own decisions 1 2 3 4 5 Comments how able are you to... cannot certain do at all can do 11. To keep on top of things 1 2 3 4 5 Comments 12. To cope with life at home 1 2 3 4 5 Comments 13. Do you know how to get equipment to support you around Yes / No / Depends the house if you needed it, for example an alarm, a shower seat…? Comments 14. I’d now like to ask you about any health related services you’ve Further details had recently. In the last 3 months, have you…read out.. (please circle /write in) 14a. Seen your GP? Yes / No / DK If YES: At home / At surgery / Both 14b. Seen a nurse? Yes / No / DK If YES: At home / At surgery / Both 14c. Had any hospital appointments Yes / No / DK in the daytime? 14d. Had to stay in hospital Yes / No / DK overnight? 14e. Had any health appts Yes / No / DK If YES: Where? elsewhere (e.g. physio)? 14f. Had a carer support you at Yes / No / DK home? 14g. Had a meals service at home? Yes / No / DK 14h. Had any other services or Yes / No / DK support? Comments

50 Exploring the difference made by Support at home please use this scoring card to answer the following questions... ShoWcard 2… none a little a lot Depends/ at all DK/NA/ Refuse 15. How much do you know about what help is available to you from 1 2 3 local organisations in your area? Would you say you know...read out Comments none a little a lot Depends/ Further details, at all DK/NA/ e.g. who? Refuse 16. How much contact do you have with other people, firstly, with: 16a. Family… read out… 1 2 3 16b. Friends…read out… 1 2 3 16c. Neighbours…read out… 1 2 3 16d. Anyone else? e.g. local people 1 2 3 or groups in your area 17. Can I just check would you like Yes / No / DK more contact with others? Comments none a little a lot Depends/ at all DK/NA/ Refuse 18. How much control do you have 1 2 3 over your daily life at the moment Comments Now, I’m going to read you a few statements, could you indicate for me using the scoring system on this card how much you agree or disagree with each one (SHOW CARD 3). One means you strongly disagree, 5 means you strongly agree. And the middle of the scale is 3. Strongly Strongly Depends/ disagree agree DK/NA/ Refuse 1 2 3 4 5 Write in 19. It’s easy for me to find someone who will really listen to me if I need 1 2 3 4 5 to talk Comments 20. I have activities that I enjoy doing 1 2 3 4 5 with my time Comments

Exploring the difference made by Support at home 51 21. Can I check would you like to Yes / No / DK take part in more activities? Comments and i have a few statements about how you feel…. 22. I feel safe & secure in my home 1 2 3 4 5 Comments 23. I feel in good spirits 1 2 3 4 5 Comments 24. I feel good about myself 1 2 3 4 5 Comments 25. Finally, I’d like to ask a question about how satisfied you feel. (SHOWCARD 4). thinking about your own life & personal circumstances, how satisfied are you currently with life as a whole? completely completely Depends/ DK/ dissatisfied satisfied NA/ Refuse 1 2 3 4 5 Comments 26. is there anything else you’d like to tell me about how you’re coping with life in general? chEcK Is it ok for me to pass on some of the things you’ve mentioned to the Red Cross service team to inform any support they might be able to Yes / No offer you? END OF PRE-SERVICE INTERVIEW

52 Exploring the difference made by Support at home The POST service interview asked all of the questions in the PRE interview above (except 14, 17, 21 and 26) plus an additional section (below) asking for views and experiences of the service and some demographic data. poSt- service Questionnaire (Section 2) Now I’d like to ask you about the support that the Red Cross provided over the past few weeks, for your experiences and views of this support. Your answers will help us improve our service. 23. First of all, can you tell me a bit about the support you got from the Red Cross. What did they help you with over the last few weeks? intErViEWEr: We need as much detail as possible at this question. probES: How many visits did you get? Who visited you and what did they do? What happened on visit 1, visit 2, visit 3… etc.? Did you get any telephone calls? Did you get any practical support? anything else? 24. Can I just check, were you visited by the same Same / Different / DK / only had 1 visit person each time or did you see different people? Details 25. Do you know if they were staff or a volunteer? Staff / Volunteer / Both / DK 26. What was the best thing about the Red Cross support for you? What was most helpful? 27. Was there anything you didn’t find helpful? 28. Was there anything you needed that the Red Cross didn’t provide? 29. And how did you find the way you were treated by Red Cross staff and volunteers? PROBES: Were they helpful or unhelpful? Were they easy to talk to or not always? 30. Was the Red Cross service explained clearly to you? Were you clear what support they could Yes / No / DK offer you? Comments 31. I’d like you to think about whether the Red Cross helped you to get support from any other services – either by referring you to other places or by telling you about them? First of all, did they help you get support from: 31a. any health services Yes / No / DK / Not needed

Exploring the difference made by Support at home 53 31b. any local organisations or groups Yes / No / DK / Not needed 31c. any other services providing practical support Yes / No / DK / Not needed at home If YES: Where/ which service(s)? How did that happen? If NO: Would you have liked this? Yes / No / Not needed / DK Comments I’d like to ask you how satisfied you were with certain things about the service. Please be honest in your responses as we’d like to understand how we can improve things. Your answers are confidential. using the same scale as before... SHOWCARD 4... First of all how satisfied were you with... completely completely depends/ dissatisfied neutral dissatisfied dK/ na/ refuse 32. The time of day you were visited 1 2 3 4 5 Comments 33. The number of visits you had each week 1 2 3 4 5 Comments Thinking about the overall length of the service from the first visit to the last. How satisfied were you with 34. How long the service lasted for 1 2 3 4 5 Comments 35. Can I just check, has the service ended? Yes / No / DK Comments If YES: How were you informed? If NO/ DK: Are you aware when the service will be ending? 36. Did you have any choice over the type of support you got from the Red Cross? Would you None at all / A little / A lot / Other say...READ OUT..

54 Exploring the difference made by Support at home I’d now like you to think a little bit more about how you were treated and supported by Red Cross staff and volunteers. Did you feel that they... SHOWCARD 5… not a little a lot Depends/ DK/NA/ Refuse at all 37. Were friendly & compassionate 1 2 3 Comments 38. Treated you with dignity & 1 2 3 respect Comments 39. Listened to your needs 1 2 3 Comments 40. Supported you in the way you 1 2 3 wanted Comments 41. understood your situation 1 2 3 Comments 42. Helped you to cope better 1 2 3 Comments 43. Helped you to increase your 1 2 3 independence Comments 44. Check - have you ever had this service from the Red Cross Yes / No / DK before? 45. Finally, would you recommend the service to a friend? Yes / No / DK Why? I just have a few final demographic questions to ask you. This is so that we can build a better picture and profile of the people we support 46. Do you mind me asking how old you are? (write in) 47. Gender (interviewer to simply make a note)  Male  Female

Exploring the difference made by Support at home 55 48. How would you describe your ethnicity?  White:  White British  White Irish  Other White  Mixed:  White and Black Caribbean  White and Black African  White and Asian  Other Mixed  Asian or Asian British:  Indian  Pakistani  Bangladeshi  Other Asian  Black or Black British:  Black Caribbean  Black African  Other Black  Chinese  Other group (specify):  Prefer not to say 49. Do you own your own home or are you  Own renting?  Rent  Other (specify): If RENT: Are you renting from the council, a  Council / Local Authority housing association or a private landlord?  Housing Association  Private landlord  Other (specify): 50. Do you have any long term health conditions  Yes  No  DK that affect your day to day life? If YES: How does this affect you?  Mobility  Sight  Hearing  Speech  Reading/ writing  Other (specify): 51. And can I just check, do you consider yourself  Yes  No  DK as having a disability? 52. We may like to contact you again. Would you be happy for us to contact you again in the future  Yes  No  DK for a short conversation to see how you are? QualitatiVE promptS if person unable to complete questionnaire 1. How able are you to carry out daily activities (e.g’s Q1-3)? 2. Do you get any support from other people or services (see list at Q.14)? 3. How much contact do you have with other people? And who do you live with? 4. How do you currently feel – e.g. in control of daily life? Safe at home? Satisfied with life? 5. Can you tell me about the support you got from the Red Cross? What did they help you with? 6. Did the Red Cross help you to get support from any other services (such as any health services or local organisations)? 7. How did you feel you were treated and supported by Red Cross staff and volunteers? PROBES: Were they friendly and compassionate? Did they understand your needs? Did you feel they helped you cope better? Helped you to increase your independence? 8. How satisfied were you with the service, in terms of the number of visits you got, the time of day they came? Were you clear when the service was coming to an end? 9. Would you recommend the service to a friend?

56 Exploring the difference made by Support at home intErViEWEr Questions (to be completed after the interview) a. how long did the questionnaire take to complete? b. how long did you spend with the service user? c. Was anyone else present during the No / Yes Who? _____________________ interview? d. We’d like to get the perspectives of family members to ask for their views on how/ whether BRC service & support addresses needs. No / Yes Who? _____________________ did the service user talk about any family members that may be appropriate to interview? E. how easy or difficult was it to complete this questionnaire? (please circle) Very Fairly OK – Fairly Very Other difficult difficult neither easy easy easy (explain below) nor difficult please explain: e.g. how much guidance/interpretation did you need to give? f. Were there any particularly difficult questions or contradictory responses? Please note the question number & Yes / No / DK issue below g. Summary of ongoing support needs that the service user reported during the interview h. is there anything we need to follow up for this service user? if so, please state who needs to do this follow up activity and alert/log appropriately i. any other comments or observations?

Exploring the difference made by Support at home 57 appendix E Interview template – Red Cross staff & volunteers you & your role about it then please reassure them that’s fine & go to Q21. 1. When did you start working/ volunteering 16. Are there any specific criteria for referrals, in your current role for the Red Cross? for example, regarding the needs or current 2. What attracted you to the role? situation of potential service users? What 3. What was your background? are these? 4. Could you briefly summarise what you do 17. Do many people get turned down, because – what does your role involve? they don’t fit our criteria? Why would that be? 5. Thinking back to when you started this role, 18. And do many people refuse the service did you get any specific training to prepare themselves or decide they don’t need it? you for the job? Why would that be? 6. And what, if any, ongoing training and 19. Does the service have any targets to meet support do you get in your role? regarding the number of service users? What PROBE TO CHECK: Any training sessions, effect, if any, does this have on the service? workshops, briefings or information sessions, 20. Do you think the commissioning environment debriefing, one to ones/ supervisions, peer influences the work we do? For example our support etc. service priorities, developments or otherwise? How is that? the service 21. In your view, do you feel we are reaching people in the greatest need (who fit our 7. What would you say the aim of the service is? criteria), and who have nowhere else to turn? How would you describe that? Why is that? 8. Imagine I am completely new to the service – could you tell me about the key things you Value & impact provide? 9. Thinking about your past week, have you had 22. Thinking about the impact the service has on any direct contact with service users – either people’s lives. What difference do you think home visits or telephone calls? it makes to service users? Can you give me an If yes – could you tell me a little more detail example? Please probe fully… To what extent about those? do you feel the service users value the service? 10. Check if not already mentioned – Do you 23. What do you think people would do provide befriending? otherwise, if the service didn’t exist? If yes, could you tell me how this is done? 24. Do you think the service prevents people from i.e. Who provides this? How often? For how being admitted or readmitted into hospital? long? What does it involve? What makes you say that? Can you give me 11. Check if not already mentioned – Do you an example? provide signposting? 25. Can you describe any specific things in If yes, could you tell me how you do this? place that enable the service to prevent i.e. Who provides this? What does it involve? readmissions? How are staff & volunteers 12. In your view, what’s the best thing about equipped to do this through the information the service? or support they offer? 13. Is there anything you might like to change 26. Check if not already mentioned – Does the about the service? service support people who have just been discharged from hospital? your service users If yes, go to 27 If no, go to 28 14. Who is the service targeted at? 27. Do you think the service enables patients to be 15. Can you tell me a little bit about how referrals discharged quicker who might have otherwise are assessed and accepted as service users? had to stay in hospital longer? What makes INTERVIEWER: If the volunteer is not you say that? involved in this / doesn’t know anything

58 Exploring the difference made by Support at home finally… 28. Do you think our service impacts other people? For example the NHS hospital or social services staff or the families & carers of our service users? Anyone else? And how is that? 29. So summing up, what would you say are the main successes of the service? 30. And what would you say are the main challenges of the service? 31. (Volunteers only) Finally, what does volunteering for the service mean or bring to you? 32. Is there anything else you would like to add? Any further comments?

Exploring the difference made by Support at home 59 appendix f Interview template – Referrers you & your role out? Please probe fully… What are it’s main strengths? Anything else? 1. Which organisation or department do you 14. Is there anything you would like to change work in? What is your role? about the service? Anything that doesn’t work 2. Could you briefly summarise what you do as well as it should? Anything that could be – what does your job involve? improved? 3. How did you learn about the Red Cross 15. Do you think the service prevents people from service? When was that? being admitted or readmitted into hospital? 4. And can I check, do you personally refer What makes you say that? Can you give me people to the Red Cross? How often? an example? 16. Check if not already mentioned – Do you work in hospital discharge? the red cross service & your If yes, go to 17 referrals If no, go to 18 17. Do you think the service enables patients to be 5. How would you describe the Red Cross discharged quicker who might have otherwise service, it’s aims and what it provides? had to stay in hospital longer? What makes Anything else? CHECK: if they feel clear what you say that? the BRC service offer is. 18. Do you have any ideas for the future 6. Can you tell me how you would assess development of the service? How we can build someone and decide to refer them to the Red on our strengths? Are there any specific gaps Cross. What characteristics or criteria would that the service could fill? you use? For example, regarding their needs 19. Is there anything else you would like to add? or current situation? Anything else? CHECK: Any further comments? if they are aware of any specific criteria that the Red Cross Service has and what they are. 7. What would you do otherwise, if the Red Cross service didn’t exist? Are there any other services to refer to? Or any other options? 8. I’d like you to think about the last person you referred to the Red Cross. Could you tell me a little bit about them, why you referred them and what you wanted the service to provide? 9. Are there people you would like to refer but don’t fit our service or our criteria for referrals? If yes, who are they/ why is that? 10. And can I just check, how do you refer people to the service? Does the referral process work ok for you? Are there any ways it could be improved? Value & impact 11. Thinking about the impact the service has on people’s lives. What difference do you think the Red Cross service makes to people? 12. How does the Red Cross service impact your work? What difference does it make for you to be able to refer people to the Red Cross? 13. In your view, what’s the best thing about the service? Is there anything unique about the Red Cross service that makes it stand

Photo credits are listed from left to right, in clockwise order © BRC Front Cover: Jonathan Banks, Patrick Harrison, Page 10: Jonathan Banks, Page 12: Patrick Harrison, Clara Dow Page 15: Patrick Harrison, Page 17: Matthew Percival, Page 18: Patrick Harrison, Page 21: Patrick Harrison, Page 22: Layton Thompson, Page 33: Anthony upton, Page 34: Bob Johns, Page 38: Patrick Harrison, Page 39: Patrick Harrison, Page 41: Jonathan Banks, Page 42: Patrick Harrison

Exploring the difference made by Support at home 61

British Red Cross uK Office 44 Moorfields London EC2Y 9AL The British Red Cross Society, incorporated by Royal Charter 1908, is a charity registered in England and Wales (220949) and Scotland redcross.org.uk (SC037738)