• Project name: Anglesey Social Housing Home Dialysis Pathway
• Lead organisation: Isle of Anglesey County Council
• Partner organisation: Betsi Cadwaladr University Health Board

Statement of support

Patients living in social housing are being offered a pathway to home dialysis, thanks to a partnership between Betsi Cadwaladr University Health Board home dialysis services and Anglesey Council.

By allowing patients to undergo treatment in their own homes, the new social housing home dialysis pathway aims to make the experience less daunting and more convenient. It will also provide financial savings by being more cost effective.

Currently, patients whose homes are unsuitable for home dialysis must attend Ysbyty Gwynedd for treatment up to three times a week – for up to four hours per session.

The new pathway will seek to provide patients in social housing with a property that is suitable for treatment at home.

If able to perform home dialysis the patients can have their dialysis treatment daily or overnight which improves quality of life, whilst reducing costs to the NHS. Whilst home dialysis is not a new offer, the fact this pathway supports patients and staff through developing a specific home dialysis housing application and then a pathway of support with our housing OT, barriers are reduced and the pathway for a housing application to become active on our housing register is clear from the outset. We're discussing this pathway on a Pan-Wales basis and are already seeing some positive outcomes for local renal failure patients.

The rate of home dialysis therapy for patients living the least deprived areas in Wales is 26.5 per cent, whilst the rate in the most deprived areas is 14.6 per cent.

The council and health board are eager to increase the number of patients who receive dialysis at home. Using home dialysis machines means patients are not required to attend to the renal ward as their health needs can be met from the comfort of their own home.

The cost of in-ward dialysis is in the region £3,000 per month. The cost of using home dialysis is in the region of £1,200 per month. Costs are met by the health board.

The choice of which option, either home or in-ward dialysis, remains with the patient and the medical multi-disciplinary team.

The National Kidney Federation concludes that home dialysis is exactly the kind of cost-effective innovation that will represent a major step forward for both patients and the NHS itself.

Outcomes and achievements

• We were shortlisted for a national award - St David's Award - https://www.anglesey.gov.wales/en/newsroom/news/anglesey-home-dialysis-scheme-nominated-for-national-award
• We have patients that have started going through this pathway and achieving positive outcomes from home instead of ward. This has now occurred within three counties in North Wales.

• Project name: Dechrau Services
• Lead organisation: Caredig Ltd
• Partner organisations: Local area co-ordinators, fire service, PCSO’s, GP’s, local councillors, The Wallich and Platfform

Statement of support

The overall aim of our Dechrau service was to connect people to their community and peer support services to enhance their mental wellbeing and build on their own strengths and capabilities.

Loneliness and isolation, which was exacerbated during the pandemic, has led to physical and mental health problems. We know that mental ill health is a common factor in many of our cases. Our wellbeing coordinator helps our tenants to access community activities which significantly improves wellbeing, confidence and combats loneliness and isolation.

We have increased the number of partnerships formed and have particularly noticed the improvement in activities aimed at men’s health and wellbeing.

Many of our tenants are finacially exlcuded and it has been a huge help to assist people to access activities which are either free or charge a small fee which we can pay.

We publicise the project internally to staff who can then inform tenants. We do this in team meetings, via our intranet and it is built into paperwork. We also use our website, newsletters and tenant events.

People can self-refer into the project but we also get referrals from other organisations such as:

• Fire service
• PCSOs
• GPs
• Local councillors and local authority staff such as area co-ordinators
• Charities such as the Wallich and Platfform.

The project has been running for three years and is now entering its fourth. Number shave increased year on year.

• 2021/22 – 322 interactions/interventions, 156 beneficiaries
• 2022/23 – 339 interactions/interventions, 163 beneficiaries
• 2023/24 – 491 interactions/interventions, 209 beneficiaries.

Police have reported that there is less demand on their resources and time from tenants who were contacting them regularly. Less anti-social behaviour has been reported.

We have been able to co-produce some services with partners such as local area co-ordinators.

Dechrau has released capacity in our over 50’s support team.

Forging new relationships and collaboration with partners. A multi agency approach works very well and gives people multi-layered support and advice e.g. We have forged a new partnership with a counselling service to get immediate help for people in imminent crisis.

We have recruited volunteers for charities. As well as assisting the tenants to build confidence, get out and socialise, build skills, etc. we have been able to provide volunteers for local charities and organistaions. Some of the tenants have become committed volunteers, using their lived experience to help others.

Tenancy sustainability – 100 per cent of our supported tenants have manitained their tenancy, preventing them from entering the homeless support services. Eviction costs have been avoided – average cost to landlord is £6,000. Rough sleepers - average annual local authority expenditure per individual is £7,900.

Also noted is that around a third of the people we support have had drug and alcohol issues. We have supported half of those to quit. Alcohol misuse - estimated annual cost to the NHS of alcohol dependency, per year per dependent drinker is £1,800. Drugs misuse - average annual savings resulting from reductions in drug-related offending and health and social care costs as a result of delivery of a structured, effective treatment £3,614.

Average cost of service provision for adults suffering from depression and/or anxiety disorders, per person per year (fiscal and economic costs), based on 2020 figures was £830.

Outcomes and achievements

Showing one of the outcomes is a case studies and quote:

CJ had become depressed and isolated. The only people bothering with him were drug addicts whom he was trying to get away from. By giving him the opportunity to access a climbing wall group, he has reignited his love of climbing which is massively improving his mental and physical health and keeping him away from bad influences.

“Shelene is amazing and I don’t know where I would be without her – she is making such a difference.”

“I’ve benefitted because you help me lots. You have helped me get to GROW and Jac Lewis which I am enjoying. You’ve supported me at home and to apply for my PIP. You’ve helped me with form filling and debts. You supported me and visited me when I was in hospital. If I didn’t have your support, I wouldn’t go to things and I would go downhill and it would affect my mental health”

• Project name: Getfit.Wales
• Lead organisation: Newydd Housing Association
• Partner organisation: University of Wales Trinity Saint David

Statement of support

GetFit.Wales is an innovative digital platform dedicated to enhancing the health and wellbeing of people across Wales. This initiative, led by Newydd Housing Association in partnership with the University of Wales Trinity St David, motivates individuals to become more active and improve their overall health through engaging and innovative approaches.

Collaborative partnerships:

GetFit.Wales exemplifies excellence in health and wellbeing through its strong partnerships. Collaborations with Cwm Taf Morgannwg University Health Board and the Welsh Institute of Digital Information have enabled the project to create a comprehensive, multi-faceted approach to improving health outcomes. These partnerships ensure that the project is grounded in evidence-based practices and can effectively reach diverse communities across South Wales.

Innovative technology:

At the heart of GetFit.Wales is its use of gamification and technology to promote physical activity. The platform seamlessly integrates with popular fitness trackers and smartphones, making it accessible to a wide range of participants. With 568 registered users, the project has demonstrated its appeal and effectiveness in engaging individuals in their health journey.

The platform's virtual quests, ranging from "Walk the length of Pen-y-Fan" to "Keep up with a police officer," provide varied difficulty levels to suit all abilities. This innovative approach not only makes exercise fun but also provides a sense of achievement and community support. The gamification element, where participants earn points and "claim land" on an adventure board, has proven to be a powerful motivator for sustained engagement.

Impactful outcomes:

GetFit.Wales has achieved remarkable outcomes for its participants. The community has collectively walked over 229,850,784 steps, equivalent to circling the Earth 4.102 times. This incredible achievement highlights the project's success in increasing physical activity levels among participants.

Participants have reported significant health improvements, including weight loss, increased mobility, and enhanced mental health. Testimonials demonstrate the project's life-changing impact:

"I have lost three stone since starting the project. I haven't taken the Fitbit off, I love it. I love seeing how many steps I have done."

"Life got in the way of my health before the pandemic, and I found myself in a place I physically and mentally didn't want to be. The project is helping me push myself to get back to where I want to be, and I feel a lot better for it."

Inclusivity and accessibility:

GetFit.Wales excels in promoting inclusivity. The project offers a range of easy, medium, and hard quests, ensuring that participants of all fitness levels and abilities can engage meaningfully. For those without access to technology, the project provides step trackers on loan, breaking down barriers to participation.

The project has also shown remarkable success in supporting individuals with physical disabilities and mental health challenges. As one participant shared:

"Getfit.Wales has been a game changer for me. It has motivated me to be more active and improved my mental health. I never thought I would enjoy exercise, but the virtual quests and step challenges have made it so much fun!"

Community impact:

GetFit.Wales goes beyond individual health improvements by fostering community connections and supporting local economies. The rewards system, which offers vouchers for local businesses, puts money back into the community while incentivising healthy behaviours. This innovative approach creates a sustainable model that benefits both individuals and the wider community.

Measurable social value:

The project's commitment to excellence is further evidenced by its rigorous approach to measuring social value. Using the HACT Social Value Insight tool, GetFit.Wales has calculated that for every £1 invested, the project creates £8.33 of social value. This impressive return on investment demonstrates the project's efficiency and effectiveness in improving health and wellbeing outcomes.

Outcomes and achievements

User engagement: 568 registered users on the platform.

• Physical activity: Participants collectively walked over 229,850,784 steps, equivalent to circling the Earth 4.102 times.
• Weight management: Numerous participants reported significant weight loss, with some losing up to three to four stone.
• Mental health improvement: Testimonials indicate enhanced mental wellbeing, reduced anxiety, and increased confidence among participants.
• Local economic support: 902 rewards redeemed at local businesses, putting money back into the community.
• Inclusivity: Successful engagement of individuals with diverse abilities and health conditions.
• Behavioural change: Participants report sustained lifestyle changes, including daily walking routines and improved eating habits.
• Social value: For every £1 invested, the project creates £8.33 of social value, as measured by the HACT Social Value Insight tool.
• Research impact: Ongoing research by the University of Wales Trinity St David on the project's impact on long-term health conditions.
• Health system integration: Established referral routes with Cardiff and Vale and Cwm Taf Morgannwg Health Boards.
• Technology adoption:Increased use of fitness trackers and health apps among participants.

• Project name: Severn View Park Care Home
• Lead organisation: Lovell
• Partner organisations: Monmouthshire County Council, Gwent Regional Partnership Board, Welsh government

Statement of support

Severn View Park is Monmouthshire County Council’s stake-of-the-art, brand-new care home which opened in March 2024 and is innovating how care is delivered to people with dementia, allowing them to live a life that matters to them. The care home brings a bespoke environmental design based upon innovating best practice standards for people with dementia and a relationship-centred care model.

The care home was constructed by Lovell and funded through a partnership between Monmouthshire County Council and the Gwent Regional Partnership Board via the Welsh government’s Integrated Care Fund and Housing with Care Fund.

Community integration and accessibility

A key aspect of Severn View Park’s design is its seamless integration with the surrounding community within the new Crick Road, Elderwood Parc housing development.

The care home promotes strong community ties through social interactions by having a new village hall, which is a building located in the central area of the care home. The community can use the space free of charge with the condition that they involve the residents with their activity in the hall. This interaction not only benefits the residents by allowing them to maintain a sense of personal identity and inclusion but also fosters understanding and support within the broader community.

Residents can enjoy unrestricted access to various outdoor spaces, safely enhancing their mobility, wellbeing and engagement with nature. The facility features a private garden for each household, an allotment space for community collaboration and a large courtyard garden around the village hall. These spaces are designed to be safe and inviting, encouraging residents to move freely and maintain physical activity.

Innovative approaches and design

The design of Severn View Park is groundbreaking, emphasising familiarity and homeliness. Unlike traditional care homes, Severn View Park features front doors that open directly into living spaces and the kitchen, fostering an immediate sense of being at home for residents. This innovative approach minimises disorientation and enhances comfort for those living with dementia.

The care home is divided into four households, each accommodating eight residents, focusing strategically on reducing scale to create a more intimate and supportive environment. This layout ensures that the care home operates as a series of small, connected communities, enhancing the sense of belonging and personal identity among residents. Three households cater to long-term dementia care, while one household is dedicated to short-term care, providing flexibility in the care provision.

Innovative staffing and care model

Severn View Park’s staffing model is uniquely innovative. The approach integrates residents into all aspects of daily living, promoting independence and involvement. Staff are trained to support residents in household tasks and communal activities, fostering a sense of purpose and belonging. The relationship-centred care model emphasises building strong, meaningful connections between staff and residents.

This model shifts the focus from routine-based care to personalised, relationship-driven support, ensuring that each resident’s emotional and social needs are met. Staff members maintain each resident’s personality by matching support and care to their individual preferences and life history, involving loved ones in the care process to create a role and purpose for them.

Conclusion

Severn View Park Care Home exemplifies excellence in health and wellbeing through its innovative design, community integration, and relationship-centred care model. This initiative not only sets a new standard in dementia care but also fosters a thriving, inclusive community where residents and staff experience enhanced quality of life.

Outcomes and achievements

Positive outcomes for residents and staff

Since opening, Severn View Park has demonstrated significant positive outcomes in the health and wellbeing of its residents and staff. Residents exhibit increased engagement, reduced anxiety, and improved overall wellbeing due to the familiar and supportive environment. The integration into daily living activities has empowered residents, providing a sense of autonomy and satisfaction.

For staff, the innovative care model has led to greater job satisfaction and a more profound connection with the residents. The emphasis on relationships and personalised care has created a positive, supportive workplace where staff feel valued and motivated.

“Severn View Park allows Monmouthshire County Council to provide the best possible care for people with dementia. The innovative design and staffing structure aim to ensure inclusion for the residents in all aspects of daily life. Thank you to all our partners to supporting us in developing this new care home. We are committed to providing the best possible care to the most vulnerable residents and the opening of this new care home will allow people in Monmouthshire to receive the best care.”

Ian Chandler, cabinet member for social care, safeguarding and accessible health – Monmouthshire County Council.

• Project name: NCH and Dragons in the Community
• Lead organisation: Newport City Homes

Statement of support

NCH and The Dragons in the Community (DragonsIC) have combined to support NCH customers through the Dragons’ diverse and fully inclusive ‘Family of provisions’ (20 different initiatives). The service provisions include community health and wellbeing outreach, sporting memories, autism support, mental health support, visually impaired support, military and veterans support, disability support, and additional learning needs support to over 10,000 residents and the wider community of Newport.

Working collaboratively, NCH and DragonsIC identified an opportunity to introduce the DragonsIC family of provisions to NCH customers and wider communities to promote health and wellbeing activity, remove barriers, and discourage isolation.

DragonsIC has invigorated the NCH 55+ schemes with the introduction of activity sessions such as kurling, to promote health and wellbeing. Five schemes across the city now have their kurling kits purchased as a result of the success in sessions held by DragonsIC to enable activities to continue.

There are key challenges NCH customers within schemes have faced; social isolation, mobility issues, lack of health and welling activity are prime examples. We know from our older customers that 65 per cent of our 65+ customers live alone in their homes, and this increases to 77 per cent of our customers aged over 85 with a third (34 per cent) of our 55+ customers indicating experiencing poor physical and mental wellbeing.

These challenges were embraced by DragonsIC and so it endeavored to overcome these through its activity.

Alongside the activity at NCH 55+ schemes, NCH and The DragonsIC have broadened the partnership approach to include the following:

Warm Wales and NCH – Energy smart people and communities – The launch of this project, has been supported and endorsed by Dragons RFC, with a player (George Nott) assisting with the publication of the launch (November 2023) – in addition to this, Dragons RFC has put forward staff members and shared with all local rugby clubs to create ‘energy champions’ in the community. Matchday programmes moving forward will contain the information required (including a QR code) to enable a person who may be struggling with energy costs to seek assistance through the project.

University of South Wales (USW) – Community ambassadors via course – Links have been created with USW around the youth qualification and the need to spend time doing practical work associated with youth work. This link will enable youth workers of the future to learn from a sporting franchise but also develop the skills to potentially look at future employment with Dragons RFC or the sporting arena.

Newport Transport – Removing the transport barrier to matchday experiences and session. Two matchday experiences have been facilitated to date and a partnership has now been created between Dragons RFC and Newport Transport. This has created stronger links that enables travel to and from different communities to access the full range of provisions run by DragonIC.

The collaboration has brought people together to improve health and wellbeing by providing opportunities to venture outside their community, stimulating memories amongst the scheme residents from their younger years.

One resident stated: “We had become mainly confined to our room/bubble/facility for so long that we lacked the drive to keep active and socialise, not anymore. Having the Dragons visit us regularly gives us the enthusiasm and passion back to keep our bodies and brain activity through interactive and fun activities from quizzes to informal chats and indoor kurling.’

The partnership has put smiles on faces, supported health and wellbeing, mental stimulation, and mobility to improve independent living skills. The regular contact has also allowed for improved relationships within schemes and the legacy of the kurling clubs that have been set up by residents keep the momentum beyond visits.

Outcomes and achievements

Since the start of this partnership, NCH and the Dragons have engaged and directly supported over 1,000 residents living in over 55 schemes in Newport over some of their provisions.

Over the last year, the DragonsIC have visited 50+ times, with an additional 50+ sessions planned for 2025. The average attendance is approximately 15 customers – totaling over 500 positive engagements with NCH customers over the last year. Alongside the 55+ scheme sessions, the Dragons have provided customers with three matchday experiences to reward their full engagement. Over 150 customers have taken the opportunity to attend games at Rodney parade and soaked up the amazing atmosphere. This is something NCH’s customers would not have been able to do if it weren’t for the support of DragonsIC. The matchday tickets, transport and merchandise were provided free of charge.

The partnership has strengthened participation, created a sense of belonging through team activity and changed the way NCH views health and wellbeing. As a result, NCH has invested in two health and wellbeing coaches to develop and design bespoke health and wellbeing packages across Newport. The partnership has created a system change within NCH to allow them to centralise more health and wellbeing activity.