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					Delivery Partnership                                                             Care, Health and Independence
Co-ordinator                                                                             Jayne Brown
Date completed                                                                               Nov-08
Version                                                                                         3

No.        Outcome                             Activity                                                                        Location               Resources              Timescale       Lead               Activity/Outcome measure                          LAA or NIS             Progress
Outcome    As identified on outcome charts     Actions to deliver outcome                                                      Countywide, specific   Cost of the activity   When will the   Named person       What will success look like? If the outcome is    Link to designated/    What is the current status or
number                                                                                                                         district(s),           and where the          action be       within an          delivered what will be different?                 statutory/ local LAA   the activity? - in progress,
                                                                                                                               communities, wards,    funding is coming      completed by?   organisation                                                         targets and NIS        completed. Delayed etc
                                                                                                                               clusters etc           from
                                               Provide information through 'Suffolk Information on Prescription about                                                                                           Increase in the number of people accessing
                                               managing long and short term conditions like dementia and diabetes.                                                           Currently a 3                      Suffolk Infolink. Information on falls prevention,
           People are supported to adopt       Includes signposting to information on falls prevention, caring and mental                             £120k per annum,       year project                       caring and mental health needs are regularly
HEW1       healthy lifestyles                  health needs.                                                                   Countywide             from ACS               2008- 2011      Sue Nicholson      updated.                                           NI124                 Currently in 1st year
           People are supported to adopt       Continue to raise awareness of free vaccination/ immunisation programmes                                                                                         Greater take up in free vaccination/ immunisation
HEW1       healthy lifestyles                  offered by Suffolk health services                                              Countywide             NHS budget                                                programmes                                         LT2d
           The emotional wellbeing of all
           people is supported and their                                                                                                                                                                        Manage the Supporting People budget to best
           mental health needs addressed at    Deliver a flexible supported housing service to mental health service users in                                                                                   reflect the needs of the recipient. Move-on       NI124, NI141,NI142,
HEW3       the earliest opportunity            Suffolk who need it, including people who are homeless                         Countywide              ACS budget                             Clare Smith        strategy                                          NI149

           The emotional wellbeing of all      Work with voluntary and community organisations that enhance the quality of
           people is supported and their       life for those with mental health problems through community involvement
           mental health needs addressed at    schemes (e.g. Ipswich's Town and Bridge Ward's Community Garden                                                                                                  There is greater participation in community
HEW3       the earliest opportunity            scheme and the Bury Volunteer Centre's work placement scheme)                                                                                                    projects for people with mental health problems   NI127, NI138, NI150
                                                                                                                                                                             initially for 12
                                                                                                                                                                             months, with an
           The emotional wellbeing of all      Roll out the Suffolk Dementia Pilot via the Waveney Enhanced Domiciliary                                                      opportunity to
           people is supported and their       care project, which will provide an integrated home support service for                                £140,000 from          extend for
           mental health needs addressed at    people with dementia, to lengthen the time someone can manage in their                                 locality purchasing    another 12       John Lambert/     Update on the formal Dementia Strategy to be     NI124, NI125, NI132,    Due to become operational in
HEW3       the earliest opportunity            own home before admission into residential or nursing care.                     Waveney                budget                 months           Cathy Craig       heard by the CHI delivery partnership in January NI133, NI136, NI149     January
           The emotional wellbeing of all
           people is supported and their                                                                                                                                                                        Befriending service is up and running and
           mental health needs addressed at    Sponsor a telephone (or face to face) befriending service for the over 65s to                                                                                    success of project is monitored to get individual
HEW3       the earliest opportunity            tackle isolation and loneliness.                                                Countywide                                                    Age Concern        feedback                                          NI136, NI138
                                                                                                                               Year 1 rolling out in                                                            Recruitment of 60 trained low to high intensity
                                                                                                                               selected East and                                                                practitioners in year one, another 60 in year
           The emotional wellbeing of all                                                                                      West Suffolk                                                                     two. Establishment of two major call centres                             Currently in 1st year.
           people is supported and their    Direct mental health patients to the Improved Access to Psychological              communtities. Year                                                               (in Ipswich and BSE) to have practitioners on                            Project also makes monthly
           mental health needs addressed at Therapies programme via their GPs, or the Suffolk mental health                    2 rolls out to the                                                               duty to provide access to psychological                                  reports to SHA, and
HEW3       the earliest opportunity         partnership community mental health teams.                                         rest of Suffolk       NHS budget                              Graham Shelton     therapies.                                        NI149, NI150, LT5      quarterly reports to DoH

           People have the same                Identifying more people with LD – sharing the records GPs hold & those                                                                                           Increase the number of people with learning                              Work taking place to share
           opportunity to achieve their full   held by social care at SCC and also more training and financial                                                                                                  disabilities who are provided with health                                records, once DoH issues
           health and emotional wellbeing      incentives through DES (Directed Enhanced Scheme) for GPs that                                                                                                   screening - specifically percentage of adults                            guidance on Annual health
           regardless of where they live in    identify people with LD. The DoH will also be issuing guidance soon on                                                                                           aged 18 or over identified on the practice LD                            Check work can be targeted
           Suffolk or their personal           the annual health check, after which more work can be done to target                                                                          Mashbileg          registers who have had an annual health                                  to ensure it reaches people
HEW4       circumstances                       people with LD to ensure they receive health screening                 Countywide                      NHS budget                             Maidrag            check                                             LT2c                   with LD

           People have the same                                                                                                                                                                                                                                                          Work currently taking place
           opportunity to achieve their full   Increase the number of people from Gypsy and Traveller communities                                                                                                                                                                        to idenitfy a baseline, as
           health and emotional wellbeing      who access health services. A health needs assessment of Gypsy and                                                                                                                                                                        one of the main challenges
           regardless of where they live in    Traveller communities takes place, which will provide the basis of a                                                                                                                                                                      with the G&T community is
           Suffolk or their personal           G&T strategy which will lead in to targeted action towards increasing                                                                         Janine Potter/     Reduce health inequalities for people in the                             ensuring that agencies
HEW4       circumstances                       the health of the G&T community.                                                Countywide             NHS budget                             Jennifer Yip       Gypsy and Traveller community                     LT2d                   know how to reach them.
                                                                                                                                                                                                                Personal health care plans are used to support
           Reduce the number of people                                                                                                                                                                          people with coming out of hospital, and
           suffering from preventable          Develop and commission timely supported discharge plans for when people                                                                       Anna McCreadie/    effectiveness is monitored by various patient
HEW5       conditions                          come out of hospital                                                            Countywide             NHS budget/ ACS                        Julie Collier      surveys                                           NI124, NI131
           Reduce the number of people
           suffering from preventable          Make sure that the risk of falling is minimised for people who are most at risk,                                                              Anita Walkenshaw, Provide a Suffolk-wide falls prevention strategy   NI124, NI125, NI136,
HEW5       conditions                          by providing equipment, information and support                                  Countywide            ACS budget                             Ann Hunt          with partners.                                     NI141
                                               A joint strategy between ACS and NHS to improve rehabilitation/
                                               intermediate care is devised and implemented. Audit have recently                                                                                             Provide intermediate care in a person's own
                                               conducted a review of rehab and int care service, which will need into a                                                                                      home, or as close to it as possible, for a
           More services are provided in the joint strategy. 'Joint Intermediate Care Group meetings are held monthly                                                                                        period of up to six weeks after an initial
           home, closer to friends, family     to inform the joint strategy, and include staff from the PCT and from                                                                         Anna McCreadie/ assessment and for a longer period if
QL2        and familiar surroundings           SCC                                                                              Countywide            NHS budget/ ACS                        Julie Collier   required.                                            NI124, NI125
           More services are provided in the   Support and promote volunteer-led befriending services for elderly people to                                                                                  Befriending service is up and running and
           home, closer to friends, family and prevent social exclusion and inform these citizens about local services and                                                                                   success of project is monitored to get individual
QL2        familiar surroundings               opportunities for socialising                                                    Countywide                                                   Age Concern     feedback                                             NI136, NI138
      More services are provided in the      Provide a phone-line through Customer First where citizens can get advice
      home, closer to friends, family and    for themselves or a relative or friend with an out-of-hours number for
QL2   familiar surroundings                  emergencies                                                                   Countywide    ACS budget                 David Evans        ISN'T THIS DONE ALREADY? CHECK                      NI132, NI135

                                                                                                                                                                                       Provide A Move-On service, delivered via a
                                                                                                                                                                                       range of activities, including planned
                                             Provide effective move-on services to allow service users to make the                                                                     programme of support, Quality Assessment
      A decent, safe and affordable          most of their time in supported housing and move into permanent                                                        Vince Gates/       Framework, and Resettlement service. This is
QL3   home is available for all              accommodation and/ or employment.                                             Countywide    ACS budget                 Clare Smith        also Supporting People's KPI2 target         NI141, NI142, NI145
      Provide more opportunities for
      people to be involved in decision-
      making and develop more ways for       Monitor care standards and provide real-time information to commissioners,                                                                Provide real-time information to users and          NI127, NI128, NI132,    In process of developing
PC2   giving people a voice.                 users, users' families and relatives, and other stakeholders                  Countywide    ACS budget   ongoing       Sandra Clennell    commissioners                                       NI133                   database
                                                                                                                                                                                                                                                                   already done, but phase
      People are able to take personal       Use Info Link to hold information relevant to people who hold an individual                                                                                                                                           three of infolink dveleopment
      control and responsibility for their   budget for care services, including high quality accredited information on the                                                            Use of Infolink increases. Use of personalised                              will make it an even more
CC1   well-being                             local care market.                                                             Countywide   ACS budget   ongoing       Jill Terrell       budgets increases                                   NI136                   personalised space.
      People are able to take personal       Train and Support frontline care and support staff to enable them to help
      control and responsibility for their   service users make best use of their direct payment or individual budget to                                                              Increased take up of 'ACS personal budgets'          NI124, NI127, NI132,
CC1   well-being                             access services within their community, appropriate to their needs.            Countywide   ACS budget                 John Rowe         training courses.                                    NI133
      People are able to take personal                                                                                                                                                Take up of training and support for advocates in
      control and responsibility for their   Develop county-wide advocacy standards and code of practice for advocates                                                                appropriate budget management and                    NI124, NI127, NI136,
CC1   well-being                             , backed up by training courses for advocates                             Countywide        ACS budget                 Liz Whitby        communications skills is increased.                  NI139
                                                                                                                                                                                      Increased take up of advocacy services related to
                                                                                                                                                                                      health and wellbeing by those in need of it.
                                                                                                                                                                                      Increase in number of disabled and/or vulnerable                             Work has taken place since
                                                                                                                                                                                      people accessing services within their local                                 the implementation of the
      People are able to take personal                                                                                                                              Dominic Naysmith- community. Supporting people to make decisions                               Mental Health Act from April
      control and responsibility for their   Work with VCS to provide advocacy through the Independent Mental                                                       Miller/ Pauline   on medical treatment, care reveiws and the           NI124, NI127, NI136,    2007. The final part of the Act
CC1   well-being                             Capacity Advocacy (IMCA) scheme, to help vulnerable people.                   Countywide    ACS budget   ongoing       Martin            protection on vulnerable adults                      NI139                   will be in place from April 09
                                             Provide clear information on what personalised budgets can and cannot be
      People are able to take personal       spent on and ensure brokerage services within the local care market are
      control and responsibility for their   appropriately monitored and specified to ensure they do not discriminate in                                                               Greater take-up of direct payments, operation of    NI124, NI127, NI132,
CC1   well-being                             favour or against certain providers.                                          Countywide    ACS budget                 John Lewis         an independent support brokerage service.           NI133

                                                                                                                                                                                       Greater take-up of direct payments, greater
      Options are available so that people                                                                                                                                             awareness amongst staff of self-directed support,
      can choose the way in which their Ensure that services are in place to support the development of self-directed                                                                  and person-centred planning. Available
      health, support, care and wellbeing support including staff training, appropriate written information, brokerage                                                                 information is on website and in leaflets. Self-help NI124, NI127, NI132,
CC2   needs and preferences are met        services and a self-help toolkit                                            Countywide        ACS budget                 John Lewis         toolkit linked to Suffolk County Council website     NI133, NI135

      Options are available so that people                                                                                                                                             Increase in the number of recipients of telephone
      can choose the way in which their Support people living independently at home by working with the voluntary                                                                      befriending services that give positive feedback.
      health, support, care and wellbeing sector to provide befriending, referral, transport and community services in                                                                 Increase in the number of people volunteering to
CC2   needs and preferences are met        particular to older people and those living alone                               Countywide                               Age Concern        be telephone befrienders.                           NI136, NI138
                                                                                                                                                                                       Increase in the number of people provided with
                                                                                                                                                                                       supported accommodation or floating support
                                                                                                                                                                                       helped to live independently in accommodation of
                                                                                                                                                                                       their choice. Increase in number of users of care
      Options are available so that people                                                                                                                                             services enabled to live in their own homes.
      can choose the way in which their Ensure successful transition of residential or floating support services to the                                                                Increase in number of people with complex care      NI124, NI127, NI128,
      health, support, care and wellbeing private sector and ensure customers' existing needs are maintained                                                                           need able to access services within the             NI130, NI136, NI141,
CC2   needs and preferences are met        wherever possible                                                               Countywide    ACS budget                 Ian Patterson      community.                                          NI142
                                                                                                                                                                                                                                                                   Information is availble, but
                                                                                                                                                                                                                                                                   not currently shared with
      Options are available so that people                                                                                                                                                                                                                         customers and carers yet.
      can choose the way in which their Use the care Quality Monitoring team to develop knowledge of the local care                                   Ongoing - OLM                    Increase in the number of people aged over 65                               Will impove when OLM self-
      health, support, care and wellbeing market, particularly in rural areas. Impart this knowledge to users, carers,                                project begun                    who are helped to live in their own homes and       NI124, NI127, NI132,    directed support project is
CC2   needs and preferences are met        and potential providers                                                     Countywide        ACS budget   1/12/08       Sandra Clennell    access services within their community.             NI133, NI135            underway (begins 01/12/08)

      Options are available so that people                                                                                                                                             Number of people provided with supported
      can choose the way in which their                                                                                                                                                accommodation or floating support helped to live
      health, support, care and wellbeing Conduct a review of floating support services for people with supported                                                                      independently in accommodation of their choice
CC2   needs and preferences are met        housing needs in Suffolk                                                        Countywide    ACS budget                 Clare Smith        is increased.                                    NI141, NI142, NI145

      Options are available so that people                                                                                                                                             Number of people provided with supported
      can choose the way in which their                                                                                                                                                accommodation or floating support helped to live
      health, support, care and wellbeing Work with the voluntary sector to ensure elderly people with housing and                                                                     independently in accommodation of their choice
CC2   needs and preferences are met        domestic needs get help and support from a wide range of service providers Countywide         ACS budget                 Clare Smith        is increased.                                    NI141, NI142, NI145
                                                                                                                                                                                                                                                                    Information is availble, but
                                                                                                                                                                                                                                                                    not currently shared with
      Options are available so that people   Use Suffolk County Council's Care Monitoring team to gather and share                                                                                                                                                  customers and carers yet.
      can choose the way in which their      information on different parts of the local care market enable service users                              Ongoing - OLM                     Greater take-up of personalised budgets.                                   Will impove when OLM self-
      health, support, care and wellbeing    with an individual budget or direct payment to choose a service provider                                  project begun                     Customers and carers are encouraged to share        NI124, NI127, NI132,   directed support project is
CC2   needs and preferences are met          suitable for them.                                                              Countywide   ACS budget   1/12/08       Sandra Clennell     their expereinces with other users.                 NI133                  underway (begins 01/12/08)

      Options are available so that people
      can choose the way in which their Ensure people with personal budgets have easy access to diverse                                                                                  There is provision of advice and support services
      health, support, care and wellbeing information ranging from management and payroll advice, CRB checking and                                                                       through Suffolk Independent living, and local care NI124, NI127, NI132,
CC2   needs and preferences are met        information on local care market                                        Countywide             ACS budget                 John Lewis          market information is availible on Suffolk InfoLink NI133
      Options are available so that people   Suffolk Partnerships for Older people - work with Age Concern Suffolk to
      can choose the way in which their      build a database of local businesses in rural areas that can deliver relevant
      health, support, care and wellbeing    private services to the elderly to enable them to control their wellbeing. We                                                               Increased awareness of local businesses and
CC2   needs and preferences are met          will expand this database to meet local demand.                                 Countywide                              Age Concern         care market for users in rural areas                NI138, NI139


                                                                                                                                                                     Craig Moran/
      Family Carers are fully involved in                                                                                                                            Carers team/ links Family Carers given training to reinforce links
      the planning and choice of care and Offer training and support to enable family carers to have the knowledge to                                                with Family Carers with partnerhsip boards. Also links with Multi-
CC3   support services from the outset    help plan future service developments                                              Countywide   ACS budget   ongoing       Partnership Board. agency carer's startegy                              NI135
                                          Work with the voluntary sector to involve and include family carers in
      Family Carers are fully involved in planning and commissioning services, and getting feedback on service                                                                           A multi-agency carers' strategy to support family
      the planning and choice of care and provision, such as the steering group with the VCS, staturoty providers and                                                Craig Moran/        carers in Suffolk is currently being devised, and
CC3   support services from the outset    family carers, for the emergancy planning scheme.                                  Countywide   ACS budget   ongoing       carers team         will cover the period Jan 2009 - Dec 2013.          NI135

      Family Carers are fully involved in                                                                                                                                              A multi-agency carers' strategy to support family
      the planning and choice of care and                                                                                                                            Family Carers     carers in Suffolk is currently being devised, and
CC3   support services from the outset    Support the development and adoption of the Suffolk Family Carers Charter Countywide            ACS budget   ongoing       Partnerhsip Board will cover the period Jan 2009 - Dec 2013.            NI135
                                          Suffolk County Council Adult and Community Services Quality Care
      Family Carers are fully involved in Monitoring team will seek and publish feedback from family carers on                                                                           A multi-agency carers' strategy to support family
      the planning and choice of care and services they use or purchase, and report this feedback to the Suffolk County                                              Craig Moran/        carers in Suffolk is currently being devised, and
CC3   support services from the outset    Council procurement team.                                                     Countywide        ACS budget   ongoing       carers team         will cover the period Jan 2009 - Dec 2013.          NI135

      Family Carers are fully involved in Ensure suitably regulated advocacy and brokerage services are available for                                                Carers Team/ Self
      the planning and choice of care and consultation by family carers responsible for a direct payment or individual                                               directed support  Ensure that Advocacy is in place for Family
CC3   support services from the outset    budget owned by a service user.                                              Countywide         ACS budget   ongoing       team              Carers                                                NI135

      Family Carers are fully involved in Ensure financial, management and human resources/payroll advice is                                                                             Direct payments continue to work for the
      the planning and choice of care and available for family carers using an individual budget or direct payment on                                                                    interestes of Family Carers, including changes to
CC3   support services from the outset    behalf of a service user.                                                          Countywide   ACS budget   ongoing       Craig Moran         payments to a 3rd party                           NI135

      Family Carers are fully involved in Arrange and/or pay for cover care when a family carer attends a skills                                                                         A multi-agency carers' strategy to support family
      the planning and choice of care and workshop or consultation event if the service user cannot attend the event                                                                     carers in Suffolk is currently being devised, and
CC3   support services from the outset    themselves.                                                                        Countywide   ACS budget   ongoing       Fiona Knott         will cover the period Jan 2009 - Dec 2013.          NI135

      Family Carers are fully involved in                                                                                                                            Carers Team/       A multi-agency carers' strategy to support family                           Currently wiating for bids to
      the planning and choice of care and Introduce a carers I.D. card scheme to enable family carers to be recognised                                               Public involvement carers in Suffolk is currently being devised, and                           roll out scheme. A national
CC3   support services from the outset    by GPs for their own health and wellbeing needs assessments.                 Countywide         ACS budget   ongoing       team               will cover the period Jan 2009 - Dec 2013.           NI135                  startgey is expected in 2009
                                                                                                                                                                                                                                                                    Partially completed through
      Family Carers are fully involved in                                                                                                                                             A multi-agency carers' strategy to support family                             short break work. PPI
      the planning and choice of care and Complete local profiling to map there whereabouts of carers and their                                                                       carers in Suffolk is currently being devised, and                             function will help to complete
CC3   support services from the outset    specific individual needs.                                                         Countywide   ACS budget   ongoing       Carers Team/ PPI will cover the period Jan 2009 - Dec 2013.             NI135                  this work
                                                                                                                                                                                                                                                                    Working with Customer first
                                                                                                                                                                     Carers Team/                                                                                   to improve their skills in
      Family Carers are fully involved in                                                                                                                            Customer First/     A multi-agency carers' strategy to support family                          indentifying carers. Suffolk
      the planning and choice of care and Engage specialist frontline social services staff and General Practitioners in                                             Suffolk Family      carers in Suffolk is currently being devised, and                          Family Carers lobbying GPs
CC3   support services from the outset    the identification process for hidden carers.                                      Countywide   ACS budget   ongoing       Carers              will cover the period Jan 2009 - Dec 2013.          NI135                  to raise awareness

      Family Carers are fully involved in Engage local private, voluntary and public sector employers in the                                                         Carers Team/       A multi-agency carers' strategy to support family                           Work on employment and
      the planning and choice of care and recognition process for hidden carers and the process of supporting them in                                                Partnerhsip Board/ carers in Suffolk is currently being devised, and                           volunteering stratgey
CC3   support services from the outset    their workplace.                                                                   Countywide   ACS budget   ongoing       Sarah Sharlott     will cover the period Jan 2009 - Dec 2013.           NI135                  underway

                                             Increase the number of carers receiving needs assessment or review
                                             and a specific carer's service, or advice and information. Making sure
                                             that the recording of carer assessments is accurate, through ensuring
                                             that reviews are conducted in a timely fashion, providing a wide range
                                             of opportunities and services for carers through the carers strategy,
      Family Carers are fully involved       drawing up a carers pathway to create a visual representation of the                                                                        A multi-agency carers' strategy to support
      in the planning and choice of          assessment process including where services and opportunities                                                                               family carers in Suffolk is currently being                                A draft action plan for work
      care and support services from         available for carers can be discussed. This will all be included in an                                                                      devised, and will cover the period Jan 2009 -                              towards this target has
CC3   the outset                             action plan for ACS Management Team.                                            Countywide   ACS budget   ongoing       Craig Moran         Dec 2013.                                           NI135                  been completed
      Family Carers are fully involved in    Use a variety of means, such as literature, conferences, the internet, and                                                            A multi-agency carers' strategy to support family
      the planning and choice of care and    consultation events, to raise the profile of carers and pay tribute to their                                                          carers in Suffolk is currently being devised, and
CC3   support services from the outset       achievement and contribution to our economy and society.                       Countywide   ACS budget   ongoing   Carers Team        will cover the period Jan 2009 - Dec 2013.            NI135                   Part of information startegy
      People have the opportunity to
      influence decisions that affect them
      in respect of their health and         Use a wide variety of media to collect feedback from service users, front-line                                                        Increased user involvement in shaping and             NI127, NI128, NI136,
CC4   wellbeing                              care staff, service users, carers, and others.                                 Countywide   ACS budget             Liz Whitby         delivering services                                   NI138, NI139
      People have the opportunity to
      influence decisions that affect them   Ensure all user comments on services are recorded and that users are
      in respect of their health and         updated swiftly about action taken to improve services that came from user                                                            Increased user involvement in shaping and             NI127, NI128, NI136,
CC4   wellbeing                              feedback.                                                                      Countywide   ACS budget             Liz Whitby         delivering services                                   NI138, NI139
      People have the opportunity to
      influence decisions that affect them   Involve stakeholders in the commissioning of health and wellbeing services
      in respect of their health and         in Suffolk – e.g. invite service users to sit in on care staff recruitment                                                            Increased user involvement in commissioning           NI127, NI128, NI136,
CC4   wellbeing                              exercises.                                                                     Countywide   ACS budget             Stella Burgess     services                                              NI138, NI139
      People have the opportunity to
      influence decisions that affect them
      in respect of their health and                                                                                                                                               LINKs are fully established and able to               NI127, NI128, NI136,
CC4   wellbeing                              Support the Suffolk LINKs                                                      Countywide   ACS budget             Liz Whitby         communicate user feedback to service providers.       NI138, NI139
      People have the opportunity to                                                                                                                                               More customers exercising choice - evidence
      influence decisions that affect them                                                                                                                                         from customer records show a more person-
      in respect of their health and                                                                                                                                               centred approach and greater uptake of direct         NI124, NI127, NI132,
CC4   wellbeing                              Train and support frontline social care staff work in a person-centred way     Countywide   ACS budget             John Lewis         payments. Greater uptake of self-help tools           NI133, NI135
      People have the opportunity to
      influence decisions that affect them                                                                                                                      Carers Team/ Self A multi-agency carers' strategy to support family
      in respect of their health and         Ensure the carers or families of a service user are included in the users’                                         directed support  carers in Suffolk is currently being devised, and
CC4   wellbeing                              person-centred plan.                                                           Countywide   ACS budget   ongoing   team              will cover the period Jan 2009 - Dec 2013.             NI135

                                        Pilot the Supporting People service which provides advisors to draft home                                                                  Commission a study of how to record incidents
                                        support plans with elderly people wishing to live at home. These will include                                                              where people get assistive technology installed.
                                        assistance with applications for home improvements (e.g. access to assistive                                                               Increase in the number of people receiving needs
      More people receive treatment and technology, insulation, and home improvement grants). Advice on the                                                                        assessments for ATT. Increase in the numbers of
      services closer to home when they location of required private services in rural areas will also be given (e.g.                                                              people supported by assistive technology in their     NI127, NI128, NI139,
CC5   need them                         local handyman schemes, community wardens, drivers, removals firms).          Countywide         ACS budget             Clare Smith        own homes.                                            NI141
                                                                                                                                                                                   Increased number of people supported by ATT
                                                                                                                                                                                   on hospital discharge. Increased number of
                                                                                                                                                                                   dementia sufferers assisted by ATT to live in their
      More people receive treatment and Use Assistive Technology to support people in their own homes when they                                                                    own homes. Increased number of people able to
      services closer to home when they have short or long term health problems, to help them to stay independent,                                                                 purchase ATT through individual budgets or            NI127, NI128, NI139,
CC5   need them                         reduce the likelihood of falling, and to prevent crime.                             Countywide   ACS budget             Louise Perkins     direct payments.                                      NI141

                                        LT conditions boards to oversee the development of a joint strategy for                                                                    Support the development of L-T pathways for
                                        long-term conditions. Includes the development of L-T condition                                                                            people living with long-term conditions, and
      More people receive treatment     'pathways' to map which services are provided and by whom. The                                                                             the development of community-based health
      and services closer to home       setting up of joint teams for LT conditions in PBC surgeries is                                                         LT conditions      and social care teams to support people with
CC5   when they need them               underway, with a successful pilot based in Southwold.                      Countywide            ACS budget             board              L-T conditions in their own homes            NI124
      More people receive treatment and Provide rehabilitation and treatment services for people coming out of
      services closer to home when they hospital by a multi-agency team including district Nurses, therapists, and                                                                 Increase in the number of people aged over 65
CC5   need them                         generic heath and social care staff.                                       Countywide            ACS budget             Anna McCreadie     helped to live in their own home.                     NI125

                                                                                                                                                                                   Recruitment of 60 trained low to high intensity
                                                                                                                                                                                   practitioners in year one, another 60 in year two.
      People have access to specialist       Commission a new primary health service for mental health which includes                                                              Establishment of two major call centres (in
      care and hospital services when        access to all evidence-based first line interventions within our local                                                                Ipswich and BSE) to have practitioners on duty to
CC6   they need them                         communities and improve access to psychological therapies.                     Countywide   NHS budget             Graham Shelton     provide access to psychological therapies.            LT5
                                                                                                                                                                                   Increase in the number of gypsy/travellers
                                                                                                                                                                                   registering with a General Practitioner. Increase
                                                                                                                                                                                   in the number of travellers gaining access to
      People know their rights and           Develop accessible and easily understood health-related messages in areas                                                             mainstream learning opportunities. Increase in
      associated responsibilities and are    travellers are known to visit and identify actual number of travellers                                                                the number of travellers gaining access to
DH1   supported to exercise them             registered with a general practitioner                                    Countywide        NHS budget             Janine Potter      mainstream employment.                                LT2C
                                                                                                                                                                                   Number of people with learning disabilities living
                                                                                                                                                                                   in supported accommodation or at home able to
      People know their rights and                                                                                                                                                 access employment and training. Increase in the
      associated responsibilities and are    Recruit and train “total communication co-ordinators” across all relevant                                                             umber of people with learning disabilities
DH1   supported to exercise them             service providers for people with learning disabilities in Suffolk.            Countywide   ACS budget             Howard Pugh        accessing floating support.                           NI, 127, NI136, NI139
                                                                                                                                                                                   Increased take up of advocacy services related to
                                             Support and be part of the Suffolk Advocacy Forum. Agree the Suffolk                                                                  health and wellbeing by those in need of it.
      People know their rights and           Advocacy Forum Standards, Code of Best Practice for Advocates and                                                                     Increase in number of disabled and/or vulnerable
      associated responsibilities and are    guidelines for supervision of independent advocates within the voluntary                                                              people accessing services within their local
DH1   supported to exercise them             sector across Suffolk.                                                         Countywide   ACS budget             Liz Whitby         community                                             NI141, NI142
                                                                                                                                                                          Increase in the number of gypsies and travellers
      People have equality of access to   Provide appropriate means to GPs to enable them to visit sites registered for                                                   able to access mainstream services (e.g. register
DH3   services                            gypsies and travellers.                                                       Countywide          NHS budget   Janine Potter    with a GP).                                       LT2C
                                                                                                                                                                          Increase in the number of homeless people in
                                                                                                                                                                          supported accommodation accessing floating
                                                                                                                                                                          support. Increase in the number of homeless
      People have equality of access to   Ensure homeless people staying in supported accommodation gain access                                                           people accessing mainstream health services
DH3   services                            to a nurse or GP through the receipt of appropriate floating support.        Countywide           ACS budget                    such as GP.                                       NI141
      People are able to access and       Make sure that information and practical assistance is available about the
      maintain employment suitable for    help that the voluntary and community sector can provide to help people with                                                    Increase in the number of people suffering from
EW1   them                                disabilities, or who have had injuries get into employment.                  Countywide           ACS budget   Sarah Sharlott   disability gaining employment.                    NI124, NI146, NI150
                                                                                                                                                                          Increase the percentage of people aged over 60
                                                                                                                                                                          claiming Attendance Allowance. Increase the
                                                                                                                                                                          percentage of people aged over 60 claiming
                                          Offer training courses for all front line staff in the public, voluntary and private                                            Pension Credit. Increase the percentage of
      The number of people living in      sectors so that they can maximise the benefit entitlement of those they work                                                    people aged over 60 claiming Council Tax
EW2   financial poverty is reduced        with.                                                                                Countywide   ACS budget   Clare Tolliday   benefit.                                          NI142,
                                                                                                                                                                          Commission a study of how to record incidents
                                                                                                                                                                          where people get assistive technology installed.
      We will deliver services in                                                                                                                                         Increase in the number of people receiving needs
      environments that promote                                                                                                                                           assessments for ATT. Increase in the numbers of
      wellbeing, respect, privacy and     Promote the use of telecare and other assistive technology to enable those in                                                   people supported by assistive technology in their
DR2   dignity                             need to live independently in their own homes.                                Countywide          ACS budget   Louise Perkins   own homes.                                        NI139, NI141

                                          Increased proportion of people with learning disabilities in supported
                                          community based accommodation. The 'Moving-on' project looks at
                                          people in residential care who could go on to settled accommodation,
                                          and making this happen. 'Moving on' will create capacity through a)
                                          Care service procurement arrangements with care service providers b)
                                          Housing enablers in district housing authorities, led by Supporting
      We will deliver services in         People c) ACS officers reviewing the people who are placed with more                                                            Help people with a learning disability move
      environments that promote           expensive care packages. There is also work going on with Mencap and                                                            from current campus accommodation to
      wellbeing, respect, privacy and     United Response to de-register their services, so that they can be                                                              supported community based accommodation
DR2   dignity                             counted as tenants in settled accommodation.                           Countywide                 ACS budget   Howard Pugh      by December 2010.                           NI145
      We will deliver services in
      environments that promote
      wellbeing, respect, privacy and     When service users are nearing the end of their life, make sure care plans                                                      More people are able to have the choice of dying NI127, NI128, NI129,
DR2   dignity                             are reviewed and shared with carers whenever this is needed.                      Countywide                                    in their own home                                NI135
      We will deliver services in
      environments that promote
      wellbeing, respect, privacy and     Ensure that the services are available to allow people the choice of dying in                                                   More people are able to have the choice of dying NI127, NI128, NI129,
DR2   dignity                             their own home including palliative care                                          Countywide                                    in their own home                                NI135

				
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