This document outlines a winter warmth assessment and energy efficiency measures service for vulnerable residents in the London Borough of Richmond upon Thames. The goals are to reduce winter deaths and illness through improving home energy efficiency. The service has two components: 1) Referral management by voluntary organizations, and 2) Home visits by trained advisors to assess needs, provide advice, and refer residents to services or install energy saving measures. The home visits will screen 198 residents and aim to complete 198 energy efficiency installations. Residents over 65, with disabilities or long-term conditions are eligible if referred. The service runs from October 2016 to March 2017 with home visits scheduled promptly in coordination with referrals.

1. Service Specification
Winter Warmth Assessment (in the Home)
and Energy Efficiency Measures Service
September 2016/17
Project Lead- Dr. Pradnya Gaikwad

2. 1. GENERAL OVERVIEW
1.1 Morbidity and mortality increases in the winter months, this has an avoidable and
detrimental impact on residents’ quality of life and demand for both health and social
care services. Older residents are more vulnerable to the impact of cold weather.
There are evidence based measures which can be implemented to prevent morbidity
and mortality from seasonal variation, and enable residents to stay warm and well in
the winter.
1.2 The aim of this service is to improve health and well-being and reduce preventable
excess winter death rates. This should in turn result in reduced undue pressure on
health and social care services. The service will achieve its aims by increasing the
level of energy efficiencies in the homes of vulnerable residents in the London
Borough of Richmond upon Thames (LBRuT) and enable access to appropriate
health and social care support for those who are at risk of fuel poverty or fuel debt
and the ill health associated with cold homes.
1.3 The core components to an effective service are an evidence-led approach to:
 The identification and referral of vulnerable adults (NICE Guidance)
 Winter Warmth Assessment conducted in the residents’ home (comprising
guidance).
 The onward referral and support to access further appropriate energy, health
and social care support.
1.4 A comprehensive evaluation of the winter warmth programme (2015/16) highlighted:
 The delivery of the service with the partnership with the London Borough of
Richmond Voluntary Sector improved the identification and referral of
vulnerable adults.
 The identification of vulnerable adults requires relationships and the opportunity
to embed access points into referral into pathways.
 Winter Warmth home assessments conducted in residents’ homes delivered by
a specialist them that were trained was well received by residents, resulting in a
significant increase in the uptake of energy grants from those who would not
have otherwise had access.
 There is an identifiable need to improve the access to the service and onward
referrals for health and social care issues.
1.5 The findings of the evaluation have informed the development of the specification for
the delivery of a winter warmth service in 2016/17.
1.6 There will be two distinct components to the provision of Winter Warm service model
in 2016/17 as set out below:
1.7 Component 1 of the Winter Warm service - Referral Service
1.7.1 This component of the service is for the management of inward and outbound
referrals. This provision has been integrated into the scope of services provided as
part of the Community Independent Living Service (CILS) Contracts held by Age UK
Richmond, Integrated Neurological Services (INS) and Richmond AID (RAID). The
Service Providers responsible for the delivery of this component of the service are
referred to as the Referral Service Provider within this Service Specification.

3. 1.7.2 NICE Guidance provides 7 recommendations on identifying people at risk including
identifying people at risk of ill health from living in a cold home by making every
contact count by assessing people who use primary and secondary care and health
and social care services. Utilising the relationships and understanding of the health
and social care system, the Referral Service Provider will also manage referrals for
support back into health and social care offers.
1.8 Component 2 of the Winter Warm service - Evidence-based Winter Warmth
Assessment (in the home) and Energy Efficiency Measures
1.8.1 This component of the service is in relation to assessments in the home that will be
carried out by trained advisors who complete a comprehensive and holistic checklist
with residents which inform discussions and advice in respect of health, Social Care
and Energy Efficiency. During a home visit, if the client is identified with energy
efficiency measures (such as draught proofing or emergency radiators); the Provider
will be responsible for onward referral and inform the outcome of the visit to Referral
Service. If the client is identified for and health and social care needs, the Provider
can either;
 refer client directly to the Health and social care services available in Richmond
and inform Referral Service about referrals made to Health and Social care
services OR
 In cases where the home visit staff is unsure about clients need or need
multiple services, the provider is expected to inform Referral Service about the
client’s referrals to them, enabling Referral Service Provider to further follow up
the clients.
1.9 Energy Efficiency Measure Service- This component of the service is in relation to
implement Energy Efficiency measure service such as draught proofing or
emergency radiators in the home once the client is referred by Home visit
Assessment staff. The Energy Efficiency Home measures should be implemented in
the property by trained staff and inform the outcome of the visit to Winter Warm
Assessment (in the Home) provider.
1.10 This Service Specification relates to the Component 2 of the Winter Warm Service.
The Service pathway that is applicable to the provision of this service is set out in
Appendix 1.
2. BACKGROUND
2.1 In the UK mortality and morbidity greatly increases in the winter months with an
impact on demand of both health and social care services. The JSNA in 2012
identified that there were over 50 excess seasonal deaths a year in the over 65s.
2.2 Older groups are more vulnerable to seasonal effects as they are more likely to be
living with a long term condition, spend more time indoors, lower body fat mass for
insulation and more likely to be living in fuel poverty.

4. 2.3 While much of the excess seems to be related to the cold,1
a drop in temperature
alone cannot explain all excess winter mortality.2
Evidence shows that there is an
increased risk of excess winter death where:
 Individuals have an underlying health condition such as heart disease or a
respiratory disease. In Richmond, levels of excess winter deaths are higher in
individuals with circulatory problems compared to London and England
averages.
 Individuals experience a respiratory infection e.g. flu. In cold weather people
spend more time in doors and in close proximity to each other which can aid
the spread of infections. Exposure to the cold indoors or outdoors also
suppresses the immune system, diminishing the lungs’ capacity to fight off
infection which can then lead to respiratory problems.
 Inappropriate or malfunctioning appliances are used to heat homes and
ventilation is reduced, as windows are closed to conserve heat, as this can
increase exposure to carbon monoxide.
 Individuals experience a lack of affordable warmth - fuel poverty. In Richmond,
7326 or 9% of households are fuel poor.3
 An individual is malnourished as a result of having to choose between heating
or eating.
 An individual lives in a poor quality home. Homes that lack insulation can be
difficult to heat and so remain cold through the winter months. In addition, a
house that is damp promotes the growth of mould which in turn increases the
risk of respiratory infections, particularly asthma. It is estimated that 2759
homes in the Borough suffer from excess cold.4
 Behaviours increase exposure to cold temperatures e.g. wearing inadequate
clothing, heating one room or keeping bedroom windows open.3
Whether an
individual is able to or chooses to adopt behaviour is shaped by their attitudinal
factors, for example, thrift, pride, stoicism.4
2.4 Winter Warm service builds on the potential mitigating actions’ that can be taken to
prevent and reduce hazards in the home and promote healthy behaviours to keep
residents warm and well in winter5.
3. REQUIREMENTS OF THE SERVICE
3.1 The main requirements of the service as detailed within the Service Specification are:
 198 home visits to vulnerable households by trained advisors to complete a
holistic checklist with residents and offer health, social care and energy advice.
 To respond in a timely manner (i.e. within 2 days) to the referrals made by
Referral Service Provider (See Appendix 1 for Service Pathway).
1 Pattenden S, Nikiforov B, Armstrong B. Mortality and temperature in Sofia and London. J Epidemiol Community
Health 2003;57: 628–33
2 McKee C. Deaths in winter:can Britain learn from Europe? Eur J Epidemiol 1989; 5: 178–82.
3 Eurowinter Group. Cold exposure and winter mortality from ischaemic heart disease, cerebrovascular disease,
respiratory disease, and all causes in warm and cold regions of Europe. Lancet 1997;349: 1341–6
4 Tod A et al. (2012) Understanding factors influencingvulnerable older people keepingwarm andwell inwinter:a
qualitative studyusing social marketingtechniques. BMJ Open Access.
5 BRE A Quantitative HealthImpact Assessment:The cost of private sector housing andprospective housing
interventions inthe LondonBorough ofRichmonduponThames

5.  As required undertake the installation of energy saving devices such as draught
proofing or emergency radiators. It is anticipated that during the time of
contract, 198 Energy Efficiency measures and up to 5 Emergency radiators
should be implemented (where required).
 Impart appropriate referral service information available in the London borough
Richmond upon Thames to promote the services during the home visit.
 Maintain links and referral network with the Referral Service Provider to ensure
a full understanding of relevant stakeholders (such as GPs, CPs, community
groups and community organisations, health and social care partners and front-
line professionals) to support referral of vulnerable patients for an energy
efficiency home visit and other services according to the needs of an individual.
 Undertake screening and make key referrals to the relevant services available
in Richmond including but not limited to Falls Service, Fire Service, Lifestyle
Prevention service etc.
 Complete applications for Cold-buster grants for eligible residents and sign-
post to relevant services or for other services such as benefit maximisation.
 Collect the Referrals data made to Home Visit Assessment from Referral
Service Provider to deliver home visits.
 Collect the data of the onward referrals made for a client to Energy Efficiency
measures (such as draught proofing and emergency radiators) to provide
energy efficiency services.
 Collect the data of the onwards referrals made to the client to the relevant
services available in Richmond borough and the outcomes of the referrals.
 Collect the data of the referral made to the Referral Service Provider for the
client in need of multiple health and social care services.
 Collect the data of complete eligible home visits carried out by Home
Assessment staff.
 Collect the data of complete Energy Efficiency measures implemented by
energy efficiency staff.
 Monitor referrals to record outcomes and evaluate each visit.
 Report monthly the completed home visit assessment data and the outcome of
referrals made to the health and social care services and energy efficiency
measure services to Public Health lead/Commissioner.
 Payment to the Provider will be made only for the successful completion of
Winter Warm home Assessment and the successful implementation of energy
efficiency measures (such as Draught proofing and Emergency Radiators).

6. 4. OBJECTIVES OF THE SERVICE
4.1 The overall objectives of the service are:
 To reduce ill health and excess winter mortality associated with cold homes in
LBRuT through improving the energy efficiency of home of people at risk of
experiencing fuel poverty.
 To improve health and wellbeing of vulnerable residents though raising
awareness and providing relevant prevention information, signposting, and
referrals to promote good health.
 To alleviate fuel poverty in income poor households by offering tailored energy
efficiency advice and completing grant applications as well as referrals for
energy efficiency measures.
 To improve equity of access by working co-jointly with the Referral Service
Provider to enable single point of access for inward and outbound referrals to
health and social care partners (Please see Appendix 4)
5. AIM
5.1 The overall aim of the Winter Warm Home assessment carried out as part of this
service will be to identify and put measures in place to reduce exposure to the
underlying factors which increase an individual’s risk of exposure to cold homes. The
Health Inequalities National Support Team, Department of Health (2010), reviewed
evidence base, NICE guidance and good practice and developed a support tool for
the commissioning of services for the prevention of seasonal excess deaths. This
included 9 core components which will form the content of the Winter Warmth home
assessment:
 Assessment of affordable warmth interventions including energy efficiency,
household income and fuel cost.
 Regular review of benefits entitlement and uptake,
 Provision of annual medication review (every 6 months if taking 4 or more
medications,
 Annual flu and pneumococcal vaccination,
 Provision of annual MUR and follow up support for adherence to therapy,
 Implementation of personal brief health interventions plan which includes
advice and support to stop smoking, sensible drinking, healthy eating and
adequate hydration and daily active living,
 Assessment and support to help falls,
 Assessment of appropriate assistive technologies e.g. pendants to call for help,
 Help to develop a personal crisis contingency plan (I.e. including buddy
scheme and points of contact with family).
5.2 The Provider will be required to complete 198 home visits to undertake a home
assessment to vulnerable residents with the aim of increasing warmth and comfort in
their homes. As a result of the service there should be a reduction in the levels of ill
health associated with cold homes as well as fewer winter excess deaths. It is
anticipated that during the term of the contract, approximately 198 energy efficiency
measures and up to 5 emergency radiators are successfully implemented (where
required).

7. 5.3 Once the Referral Service Provider refers clients to the Winter Warm Home
Assessment and Energy Measures service, the Provider is required to Identify and
target individuals and families who are living in cold homes and meeting the following
criteria for the service i.e. residents who:
 Are over 65
 Have a disability
 Have a long term health condition.
5.4 Deliver the home assessment visit once the information of the client is provided by
the Referral Service Provider and deliver the Energy Efficiency measures aspect of
the service once the information of the client is provided by the Home Assessment
staff to efficiency measures staff.
5.5 The provider will be required to obtain details of the client for the home visit from the
Referral Service Provider prior to conducting the home visit. The Provider must verify
client’s eligibility and undertake an eligibility test prior to visiting the client at home.
5.6 During the home visit if the client is identified with Energy Efficiency measures (such
as draught proofing or emergency radiators), the home visit staff must refer the client
to the Energy Efficiency measures provider available in the LBRuT.
5.7 During the home visit, if the client is identified with other health and social care needs
such as referrals to finance (cold buster grants), Falls prevention service, Safety
services and Lifestyle services, the home visit staff employed by the Provider can
refer client to the applicable health and social care services available in Richmond. If
the client is identified with multiple health and social care needs, and the staff are
unsure as to which service the client should be referred to, the client is to be referred
back to Referral Service Provider and inform Referral Service Provider about the
referrals made to them who will further follow up the client and signpost client to the
relevant available services according to their needs.
5.8 The provider is required to obtain knowledge on the health and social care services
available to residents within the borough (including i.e. flu vaccinations) and advice
on how to overcome any challenges to uptake these services.
5.9 Disseminate correct information of Winter Warm services and other health and social
care referrals available in the London Borough Richmond upon Thames.
6. HOURS OF OPERATION AND TIMELINE
6.1 The Service as defined within this Specification is to be delivered from 01 October
2016 to 31 March 2017.
6.2 The Provider is required to ensure that the service will be accessible via website,
telephone, email or fax and will be available during normal working hours Monday-
Friday from 09:00 to 17:00.

8. 7. IDENTIFICATION OF ELIGIBLE RESIDENTS
7.1 The Service is available to residents of the borough who meet the following eligibility
criteria:
 Residents over 65
 People with Long term conditions
 People with a disability.
 Residents from Black and Ethnic Minority groups.
7.2 The client will be referred to Winter Warm Home Assessment and Energy Efficiency
Measures service once the Referral Service Provider confirms the clients’ eligibility.
The Referral Service Provider will obtain the clients’ consent for sharing the clients’
details.
7.3 Once the referral is received from Referral Service, the Provider must contact the
client within 48 hours to verify client’s eligibility and book an appointment with the
client to undertake a home assessment visit.
7.4 The Provider is expected to offer a date and time that is suitable to the client before
booking the home visit to carry out the home assessment or to provide energy
efficiency measures.
7.5 Prior to visiting the property, the home visit staff (i.e. Home visit assessment staff or
Energy efficiency measure staff) should confirm the clients’ name, address, date and
time of visit.
7.6 If there are any amendments to the time and date of a home visit, i.e. Home visit
assessment staff or Energy efficiency measures, staff are expected to give an option
to the client to re-arrange the home visit.
7.7 Home visit staff should record all the details of contacts and any amendments which
are made for the home visit assessment and report to the Referral Service.
7.8 Energy Efficiency measures staff employed by the Provider must record all the
details of contacts and any amendments which are made for the Energy Efficiency
measures and report to these back to the office.
8. SPECIFIC REQUIREMENTS OF THE SERVICE
8.1 The Provider is required to review all referrals to ensure that the individual is referred
and/or signposted on to the appropriate service where this is required. Although
Winter Warm service is not an emergency service, where it is felt that an individual
who may be at risk or in danger staff should contact emergency services (999) or
refer the individual to the Access team on 020 8891 7971 or email
adultsocialservice@richmond.gov.uk
8.2 The Provider must act in accordance with the Councils’ Interagency Guidelines for
Protecting Adults which are available on request or can be found on the Councils’
website https://www.richmond.gov.uk/safeguarding_adults

9. 8.3 Consent must be obtained by the service when making onward referrals to other
services as required. The checklist (Please see Appendix 2) ensures that Individuals
are made aware that by consenting to the service, the Provider may share relevant
information about them to other services to ensure they receive the necessary
support required. Information will also be shared with the Public Health team and
commissioners to allow for service evaluation and improvement.
8.4 The Provider must record demographic information for all home and telephone
assessments. The Provider should also record time of call or home visit. All referral
information, which will include details such as postcode, age, gender, disability and
ethnicity, must be held on a secure database and in accordance to Data Protection
Act 1998. The Provider must maintain strict confidentiality about the clients’ details.
8.5 The Provider will be responsible for the referral system and database and must
ensure they have the IT infrastructure to accommodate a secure method of receiving
referrals and storing information.
8.6 The Provider will conduct a holistic assessment which will cover as a minimum, but
not limited to, issues relating to their health, social wellbeing, housing, financial and
energy efficiency needs as set out in Appendix 2.
8.7 The Provider will inform the client about how they will be supported and provide
information on services that they will be referred to.
8.8 The Provider will be expected to ensure referrals are sent directly to a wide range of
services or organisations available in the London Borough of Richmond upon
Thames. The contact information of current services available in the Richmond
borough will be shared with the Provider by the Commissioner prior to the
commencement of the service.
8.9 The Provider will ensure that applications are completed when necessary to ensure
that clients can access appropriate services or grants.
8.10 The Provider will be expected to measure and monitor all referrals it receives from
Referral Service Provider
8.11 The Provider will be expected to measure and monitor all referrals made to Energy
Efficiency Measure service.
9. ONWARD REFERRALS
9.1 This will involve a single home assessment visit where the property will be assessed
for its energy efficiency. If the individual is identified:
 With energy efficiency measures (such as Draught proofing or emergency
radiators), the Provider is expected to arrange for Energy Efficiency staff to carry
out a visit.
 With other health and social care needs, the client is referred to available health
and social care services in Richmond and informs Referral Service Provider
about the outcome of home visit assessment.
 If the individual is eligible for grant schemes, Lifestyle services, the Provider is
expected to refer the client to the relevant services and record the details of the
client.

10.  If the Provider is unsure about the referral for the clients’ needs, the Provider is
expected to refer client back to the Referral Service Provider and inform them
about the referral to enable the Referral Service to further follow up the client.
9.2 The Provider will follow up every 10th case referral for monitoring outcomes.
9.3 The Provider is required to use a standardised format for the delivery of the home
visits. This will involve individual’s following the prescribed checklist for assessment
and the Service Manager is required to manage the following with home visiting staff:
 Provide home visits between the hours 9am -5pm Monday – Friday
 Ensure that all home assessment visitors have identification in a form acceptable
to the Council which they will carry whenever providing the service and show the
clients on demand, identification must include a photograph of the home
assessment visitor, the name of the Provider, and a telephone number which can
be used to verify this information
 Provide security back up for all home assessment visitors
 Make visit on arranged date – within 2 weeks of first contact
 Allow clients to re-arrange appointments
 Get consent (signature) from client for information to be used for evaluation and
referrals
 Ensure all data is secure and not shared with any other organisation without the
clients consent
 Ensure data is shared with secure system approved by the commissioner
 Store all identifiable data securely.
 Use thermometer internally and externally for temperature recording
 Explain referral procedure to the client and obtain a signature agreeing to specific
referrals.
 Leave winter warm brochure with client
 Leave a feedback form with the client
 Work in partnership with Referral Service Provider to plan scheduling of visits.
 Ensure that the staff who are delivering the service have completed the training
offered (by the commissioner i.e. online MECC) and meet the required
qualifications and experience in the specification to carry out the home
assessment visits.
 Ensure that staff have an understanding of the health and social care offers and
are confident and competent to raise the important of addressing health and
social care issues with clients.
9.4 During and after the home visit the Provider is required to:
 Complete the assessment and referral forms with residents as well as any grant
application forms and refer the client to the relevant services or Referral Service
Provider to further navigate to the relevant service according to client’s needs.
 Deliver messages and encourage behaviour changes.
 Make referrals to the relevant department if the client is identified with energy
efficiency services or grant schemes and complete application forms with clients.

11.  Make referrals and signpost residents with multiple health and social care needs
to the Referral Service Provider for further advice and health and social care
offers.
 Show dignity, respect and courtesy – All those involved in the provision of service
are guests in the client’s home and should act accordingly and with respect. This
includes respecting the clients house rules.
 Have empathy for clients who have health and social care needs (e.g. it is
important that staff have an understanding of sensory loss and are sensitive to
the effects of this issue).
 Ensure that the staff visiting clients in their homes dress in a professional and
appropriate manner.
 In the event that staffs are responsible for any damage/loss caused to the clients’
home, the Provider will be responsible for reimbursing the client.
10. ENERGY EFFICIENCY MEASURES SERVICE DELIVERYMECHANISM
10.1 On the identification of Energy Efficiency Measures are required for a client following
on from a Home Visit Assessment, Energy Efficiency Measures Service staff must
contact the client within 5 days in order to make an appointment with the client to fit
the agreed energy efficiency measures available.
10.2 Energy Efficiency Measures staff must obtain clients consent for a home visit and
confirm the date and time of home visits with the client.
10.3 Energy Efficiency Measures staff should provide briefings to the client on the role of
all energy efficiency measures required for the individual property.
10.4 Staff will carry out five energy saving initiatives as part of the service and other
measures for referred households as set out in 7.25 above.
10.5 The Energy Efficiency Measure Service staff should confirm the date, time and
clients home address before visiting the property.
10.6 Staff should offer the Resident the opportunity to book an alternative date for the
home visit.
10.7 Each Energy Efficiency Measures visit will be limited to two hours per household. In
the time, staff should identify the items in need of installation, complete other DIY
tasks that help the resident to live in a more sustainable way reduce energy being
wasted and minimise their impact on the environment.
10.8 The Provider will ensure that Energy Efficiency Measure Service staff have all the
required materials to complete energy efficiency measures.
10.9 Each Energy Efficiency Measure visit will result in the installation of:
a. Five of the measures listed below using the materials provided
 Front door draught proofing
o with adhesive draught proof strip
o draught proofing door brush
o letterbox draught brush

12.  Back door draught proofing
o with adhesive draught proof strip
o draught proofing door brush
 Reflective Radiator Panels (x2)
 CFL Energy Efficient Light Bulbs (x4)
 Hot Water Insulation Jackets
 Pipe insulation
 Door frame draught proofing (1 door to main living room)
 Additional Draught proofing Door Brush (1 door to main living room)
 Additional Adhesive Draught Proof Strip (1 roll to main living room)
 Additional Radiator Panels (up to 2)
And as appropriate also undertake/install/provide
b. Carbon monoxide alarms
c. Smoke Alarms
d. Radiator Bleeding
e. Emergency heating.
11. SUPPORT AND MANAGEMENT OF THE SERVICE
11.1 The Provider is required to:
 Develop dedicated referral mechanism to enable the Referral Service Provider to
make referrals to the home assessments visit service.
 Liaise and define referral mechanisms and reporting with the Referral Service
Provider. This could be achieved by providing a dedicated email address,
telephone line and booking service to the Referral Service Provider to enable
referrals to book a home visit from Monday to Friday 9am – 5 pm.
 Identify a manager, home assessment visitors and energy efficiency measures
staff for visits that are appropriately qualified and meet the requirements for the
service.
 The manager/s and front line staff employed by the Provider must have
experience of managing people/teams. They must have a minimum of one year
of experience in completing assessment form for health, well-being and social
care or referral forms.
 The frontline staff must have experience encouraging client for behaviour change
and making referrals to partner organisation.
12. HOME ASSESSMENT VISITOR QUALIFICATIONS AND EXPERIENCE
12.1 All the home visiting staff employed by the Provider must have completed mandatory
training which includes the Local Authorities, Making Every Case Count (MECC)
training and safeguarding training.
12.2 All home assessment visiting staff employed by the Provider must have valid
Disclosure and Barring Service (DBS) documentation.

13. 12.3 All the home visiting staff employed by the Provider must have a minimum of one
year of experience in delivering domestic energy saving advice.
12.4 The Service Manager employed by the Provider must hold the following qualifications
and experience
 Proven experience and demonstrate capability to deliver the home assessment
visit
 Experience of delivering a home visiting assessment service.
12.5 The following qualifications would be beneficial
 City and Guilds Level 3 6281
 Level; 3 Domestic Energy Assessor
 Benefits advisor training and experience
 Over three of experience of home visiting
 Motivational interviewing (or similar behaviour change interventions).
13. ENERGY EFFICIENCY MEASURE STAFF
13.1 All the Energy Efficiency measure staff are to be fully trained in providing energy
efficiency measures in the home.
13.2 Key qualities required of Energy Efficiency measures staff are:
 Proven track record of providing an Energy Efficiency Measure Service.
 Make homes run more efficiently by reducing energy bills, creating a warm home
and contributing to a greener environment.
 Knowledge of the Disabled individual needs.
 Experience of producing information in various accessible formats in plain
language.
 Innovative approach to developing the range and type of services.
13.3 All the new staff recruited must have induction followed by shadowing to understand
the nature of the service. This includes communicating courteously with clients by
telephone, email, letter and face-to-face, assessing needs of an individual and
referring to the relevant services available in the Richmond Borough, providing help
and advice to the client about the services available in the Richmond, maintaining
details and confidentiality of clients in relevant database, understanding
organisations policies and protocols, maintaining risk register.
13.4 Arrange home visits and complete the checklist with clients as set in Appendix 2.
13.5 Make referrals, completing application forms and other documentation as appropriate
and share with Referral Service Provider (if needed).
13.6 Record all visits and referrals made to Referral Service Provider /Energy Efficiency
measures aspect of the service. The Provider is expected to deal with any client/staff
issues in a professional manner (See Appendix 4).

14. 14. TRAINING
14.1 All home assessment visitors and managers must have completed a comprehensive
training programme for completing an assessment. The Provider is required to
ensure a percentage of home visits carried out by home assessments visitors are
undertaken in the presence of an expert and evaluated.
15. COMPLAINTS AND SERIOUS INCIDENTS
15.1 The management of complaints is a shared duty between the Provider and the
Authority. The Provider shall notify the Authority of any complaint received,
acknowledge the complaint within two working days and respond within a timescale
negotiated with the complainant. A copy of the response will be provided to the
Authority. The complainant must be given the option of making their complaint to
either the Provider or/and the Authority.
15.2 The Provider shall keep a log of complaints, the time taken to respond and the
outcome of the complaint and provide this as a quarterly return to the Authority.
15.3 The Service Provider shall issue the Service User with a fully documented and
accessible complaints procedure prior to the commencement of the Service. If the
Service User has difficulty understanding the procedure his/her next of kin or
representative or the relevant member of staff should be involved.
15.4 The complaints procedure should be available in an appropriate format and where
appropriate in Braille, large print, on tape or an easy read version or translated as
appropriate. Where the Service User’s language is not a main community language,
the Authority will cover the cost of translation.
15.5 The Service Provider has a responsibility to adhere to the principles of the Health
and Adult Social Care complaints procedure to aid resolution for the Service User.
15.6 Specifically this means:
 Providing direct assistance to the Service User to access the complaints
procedure, including obtaining an advocate where necessary;
 Providing an ‘interim’ response, in writing, outlining how the matters might be
resolved;
 Providing details to the Service User of how they and/or their advocate may
respond to the ‘interim’ response by contacting the authority’s Corporate
Complaints Team;
 To forward to the Council’s Corporate Complaints Team the details of the
complainants response to the Provider’s ‘interim’ response;
 All staff employed by the Service Provider must make themselves available for
interview by an investigating officer or Local Government Ombudsman;
 All records must be made available to an investigating officer;
 The Service Provider must comply with the outcomes/recommendations arising
from an investigation.
 The Service Provider must have in place a system that demonstrates how they
will monitor the quality of the implementation of agreed outcomes/
recommendations of an investigation and how they will comply with them.

15.  Service Users have a right to make a complaint directly to the Council’s
Authorised Officer, independent of the Service Provider and this will be made
clear to the Service User. The Council’s Authorised Officer has the right to
investigate a complaint at any stage.
15.7 Complaints received by the Provider must be notified to the Authority’s Senior Public
Health Lead for sexual health immediately. The notification details must include all of
the following:
 Complainant address and contact details (and how known to customer).
 Service User’s address and contact details (ethnicity, gender, age, disability).
 Date complaint received/how complaint received.
 Involved workers.
 Date of response/delays in responding.
15.8 If the Service User is dissatisfied with the Provider’s response, or wishes to make a
complaint directly to the Authority, the Provider must advise the Service User of their
right to refer the matter to the Authority’s Corporate Complaints Team, and contact
details must be provided.
15.9 The Provider shall inform the Service User of their right to complain directly to the
Local Government Ombudsman.
15.10 Any complaint must be listened to in a sympathetic manner, taken seriously, and the
complainant assured that it will be dealt with.
16. CONTRACT MONITORING ARRANGEMENTS
16.1 In 2016/17 the Provider is expected to undertake home assessment visits and
complete the assessment at the clients’ home, once the client is referred by Referral
Service Provider.
Table 1 Home Assessment Visits Key Performance Indicators
Key Performance
Indicators
Target Reporting/ Frequency
Number of Home
Assessment completed
successfully
198 (term of contract)* Monthly
Referrals for Energy
Efficiency measure service
198 (term of contract)* Monthly
Referrals to emergency
radiators
5 referrals (term of
contract)*
Monthly (if referred)
Number of individuals
referred for health and
social care needs (i.e. Flu
vaccinations, falls
>50% of eligible
assessments
Monthly

16. Key Performance
Indicators
Target Reporting/ Frequency
assessment Lifestyle etc.)
Referrals for Annual
medication review (every 6
months if taking 4 or more
medications)
100% Review (where
applicable)
Monthly
Referrals to Cold-busters
grants, benefit
maximisation and follow
up for uptake
100% Referrals to the
appropriate services
Monthly
Referrals to Health and
social care services
100% Referrals to the
appropriate services
Monthly
Percentage of Individuals
that have been referred to
Home Visit Assessment or
appropriate services and
dealt with within 48 hours
(Number of individuals
who have been contacted
within 48 hours divided by
the total number of
referrals to the service)
>85% Monthly
Percentage of Individuals
that have been referred to
Home Visit Assessment or
appropriate services and
have been contacted by
the service within 2 weeks
(Number of individuals
who have been contacted
within 2 weeks from the
time of their home or
telephone assessment
divided by the total
number of referrals to the
service)
>50% 3 months
NB: * The clients will be followed for monitoring and service review even after the
term of contract
Table 2 Energy Efficiency Measures Key Performance Indicators
Key Performance Indicators Target Reporting/Frequency

17. Key Performance Indicators Target Reporting/Frequency
Number of Energy Efficiency Measure
implemented successfully
198 (term of contract)* Monthly
Emergency radiators implemented
successfully
5 referrals (term of
contract)*
Monthly (if referred)
Percentage of Individuals that have
been referred for energy efficiency
measures and dealt with within 5 days
(Number of individuals who have been
contacted within 5 days divided by the
total number of referrals to energy
efficiency measures)
>85% Monthly
NB: * The clients will be followed for monitoring and service review even after the
term of contract
16.2. The provider is expected to carry out, everymonth-
 33 eligible Winter Warm Home Assessment.
 Implement 33 efficiency measure service (where required) and 5 emergency
radiators (till the term of contract).
16.3. The Provider should not exceed the set targets mentioned above (i.e. in point 16.2).
17. MONITORING AND EVALUATION
17.1 The Provider shall meet with the contract manager every month to review
performance in relation to the contract. The home assessment visitor may be
accompanied occasionally to enable the provider to carry out quality checks. The
Provider (Service Manager) shall specifically provide the following monitoring
information (in a secure format) about residents who received a visit.
 Name, address and contact details
 Equality monitoring data
 Date call or referral received
 Date of home visit
 Health condition
 Home owner /tenant
 Time spent on home visit.
 Has client had a visit from this service in previous years.
Table 3- Performance Indicators
Information about residents who received Home visit Assessment

18. Performance Measures
Reporting
Frequency
Number of referrals received from Referral Service Provider Monthly
Number of eligible referrals received from Referral Service Provider Monthly
Number of visits undertaken for eligible residents made from Referral
Service Provider
Monthly
Breakdown of each visit in accordance with checklist Monthly
Number of referrals made for Energy Efficiency Measures and the
outcome
Monthly
Number of direct referrals made for Health and social care support
specifically and the outcome.
Number of referrals made for Health and social care via Referral Service
Provider for support and the outcome
Monthly
Number of referrals made for Health and social care via Referral Service
Provider for support and the outcome
Monthly
Number of referrals made to Referral Service Provider where the Home
Visit Assessment staff unsure about the referral pathway or clients needs
Monthly
Breakdown of referrals and outcomes Monthly
Percentage of individuals that have been referred on to home visits or
dealt within 48 hours
Percentage of individuals that have been referred on to home visits or
dealt within 2 weeks
Percentage of individual that have been referred to the service and
contacted up by the service after 3 months.
Monthly
Any issues arising from visits, outcome of issues, Complaints received,
Compliments received
Monthly
Outcomes of referral monitoring (i.e. referrals from Referral Service
Provider, onward referrals to relevant services and Energy efficiency
measure service)
Monthly
17.2 The provider is expected to provide the details of demographic data and quality
assurance data every month to the contract manager (See Appendix 4).
17.3 The Provider shall provide administration and management of the visits and provide
home assessment visitors with promotional resources.

19. 18. REPORTING ARRANGEMENTS
18.1 A monthly review will be held between the Provider and the Commissioner to review
their performance.
18.2 The Council will also monitor the contract on a day to day basis and through
complaints, customer satisfaction reviews, spot checks, site visits and any other
appropriate method.
18.3 The Provider will provide monthly statistics of energy efficiency measures. The
statistics will need to show details of residents and the works completed at each
property required and the format to be used to be agreed at initial review meetings.
18.4 A proportion of individuals participating in the programme will be followed up to check
that the planned service has been accessed/delivered, to revisit any behaviour
change goals that were set, check progress and to assess the impact of the changes
18.5 The Provider shall meet with the contract manager at the end of the contract period
and provide with the feedback and recommendation of the services which will further
aid decision-making to commission winter warm services.
19. PAYMENT MECHANISM
19.1 Payment will be made to the Provider by the Council only;
 for the successful and complete Home Visit Assessment.
 for the successful energy efficiency measures implemented in the property.
19.2 The Provider shall submit a monthly Invoice to the Public Health Lead. Invoices shall
show:
 Number of successful and complete Home Visit Assessment undertaken.
 Number of successful energy efficiency measures implemented in properties with
a spreadsheet identifying measures installed per property. The invoice should
identify hours spent installing measures as well as the cost of materials

20. 9.
10.
11.
Members of the
public
GP Practice Staff
Social Services
Staff (i.e. Social
workers/OTs)
Community Healthcare
Staff (i.e. District
nurses, health visitors)
Housing and Other
Council Staff
Community and
Voluntary Sector
Winter Warm Assessment (in the home) Provider
CILS PROVIDER
(AGE UK, Richmond AID and Integrated Neurological Services- delivered as a part of CILS contract)
Referral Service
Clients are referred to Winter Warm Home visit once they have been identified as meeting the eligibility criteria
If the client is identified with Energy
Efficiency measure services, the client
is referred to Energy Efficiency
Measure Service Provider/Staff
If client identified with health and social care needs, the client is
referred to the available Health and social care services in the
Richmond. If the staff is unsure about the referral, refer client to the
Referral Service Provider and inform Referral Service Provider to
further follow up the client
Home Visit undertaken
successfully and inform the
outcome of the Home visit to
Referral Service
Energy Efficiency Measure
Service (i.e. Draught Proofing or
Emergency Radiators)
Inform Home Visit Assessment
(in the home) Service Provider
outcome of the Energy Efficiency
Measure Service Referrals.
Schedule 1- Service Pathway

21. APPENDIX 2: Winter Warmth Assessment 2016/2017
Name: Temperature of main
living room
Address: External Temperature
Name of Home Assessment Visitor:
INTRODUCTION
Introduce yourself explain about consent and
confidentiality of visit.
Ask the client:
Can you tell me why you requested the visit
is there anything particular you would like
to discuss?
Can you tell me a little bit about yourself?
You need to steer the conversation to gather
information on the following: prepare the
visitors for lots of questions as you are there to
help them. Also be aware of their need.
Clients comments:
Lives alone:
Yes No
Retired:
Yes No
Communication needs:
Yes No
If yes, what
Physical health needs (do they have a long
term health condition?): Yes No
If yes, what

22. Ask the client:
Please tell me which of these best describes how you’ve been feeling over the last
two weeks.
I have felt calm and relaxed Not at all Rarely Sometimes Often Always
I’ve felt cheerful and in good
spirits
Not at all Rarely Sometimes Often Always
Would you like information
on social events or ways to
get involved in events
locally
Yes No
ENERGY EFFICIENCY
Ask the client:
Can you tell me a bit about how you heat
your home. You will need to visit each
room
You need to steer the conversation to gather
information on the following:
Client Comments:
What do you use to heat your home? (central
heating, free standing convection heater etc.)
If its central heating, is the system over 15
years old? Yes No
How do you control the heating?
(timer, TRVs, Cylinder thermostat, room
thermostat)
Which rooms are heated?
When do you heat these rooms?
Is the main roof space insulated?
If so how thick?

23. Does loft need to be cleared to facilitate loft
insulation?
If the walls are cavity walls are they insulated?
Yes No
Are basic energy saving measures – Hot water
insulation jackets, front door draft proofing,
back door draft proofing, door frame draft
proofing, draft proofing of windows, radiator
panels, draft proofing door brush, energy
efficient light bulbs – already being used?
Yes No
Summarise and reflect back what the person has told you about heating their home.
Say that: From our discussion there are a few things that we can explore which will
help to improve your energyefficiency, this includes: [List the areas identified from
the discussion where changes could be made to address energy efficiency]. Which
of these would you like to explore further?
Provide information on and discuss the options for action on each of the areas that the
client wants to explore.
Then agree with the client the next steps and actions for the options that they want to
progress. Record the agreed actions below.
Agreed actions:
Support the client to submit an application
to Cold busters grants Yes No
Date application submitted:
Make the referral for the client to Energy
Efficiency measure service (offer for up to
five of the nine) available energyefficiency
measures
Yes No
If yes, list the desired measures:

24. Make the referral for the client to a comfort
pack
Yes No
Make the referral for the client to the energy
efficiency measures or other relevant
services such as Fitting key safes and grab
rails, locks, spy holes and door chains
Yes No
If yes, list what for:
Client has agreed to take action directly to
improve the energyefficiency of their home.
Yes No
If yes, state what they have agreed to
do:
Other Please describe what the action is.
Ask the client: Is there anything else that you think you might do?
HEALTH
Ask the client: Can you tell me about what you
already do to prevent yourself from becoming
unwell over the winter months.
You need to steer the conversation to gather
information on the following:
Any contingency plans for emergency situations
or to watch for danger signals where friends or
family are unavailable
Client Comments:

25. Have you had your flu jab?
Yes No
Have you had your pneumococcal jab?
Yes No
When did you last have a medicine review?
Date:
How do you make sure that you don’t run out of
prescription and medicines for colds over the
winter?
Do you have a hot meal every day?
How do you make sure that your diet is healthy?
What exercise do you do regularly?
Do you get out and about socially ?
Ask the client: Can you describe what you do to
stay warm.
You need to steer the conversation to gather
information on the following:
Client comment
Limit time outdoors during cold snaps
Yes No
Heat sitting room to 21 degrees and bedroom to
18 degrees.
Yes No
Wear multiple layers of clothing.
Yes No

26. Can you tell me about any concerns or worries
you have about getting around in your home.
You need to steer the conversation to gather
information on the following:
Client comment
Do you have any difficulties using steps, stairs,
bathroom facilities Yes No
Have you had any falls or stumbles
Yes No
Ask the client: Can you tell me about any
concerns or worries that you have about the
safety and security of your home.
You need to steer the conversation to gather
information on the following:
Client comment
Smoke alarm
Yes No
Carbon monoxide detector
Yes No
Summarise and reflect back what the person has told you about their health.
Say that: From our discussion there are a few things that we can explore which will
help to keep you healthy well, this includes: [List the areas identified from the
discussion where changes could be made that will help them to stay healthy]. Which of
these would you like to explore further?
Provide information on and discuss the options for action on each of the areas that the
client wants to explore.
Then agree with the client the next steps and actions for the options that they want to
progress. Record the agreed actions below.
Agreed actions:
Client to go to their GP or local pharmacy for a
flu jab Yes No

27. Client to go to their GP for a pneumococcal jab
Yes No
Client to go to their GP for a medicines review
Yes No
Make the referral for the client to
Lifestyle services Richmond for advice and
support on lifestyle e.g. healthy eating,
exercise, alcohol etc.
Or refer to CILS to improve social connectivity
Yes No
Yes No
Make the referral to Careline for access to
assistive technology e.g. fall alarms Yes No
Make the referral to social services
Yes No
Support the client to sign up for AirTEXT cold
weather alerts Yes No
Client agreed to take action to keep
prescription medicines in stock. Yes No
Client agreed to take action to limit time
outdoors during cold snaps. Yes No
Describe what they will do:
Make the referral to Hounslow and
Richmond Community Health Care Trust
falls service
Yes No
Make the Referral to EnergyEfficiency
measures service such as smoke alarm/
carbon monoxide alarm Yes No
Which alarm?

28. Ask the client: Is there anything else that you think you might do?
FINANCE
Ask the client: Would you like to discuss any
concerns that you might have about your finance?
Client comments
Do you need any support with Debt issues?
Yes No
Are you interested in information about community
transport?
Yes No
Summarise and reflect back what the person has told you about their health.
Say that: From our discussion there are a few things that we can explore which will
help with your finances, this includes: [List the areas identified from the discussion
where changes could be made]. Which of these would you like to explore further?
Provide information on and discuss the options for action on each of the areas that the
client wants to explore.
Then agree with the client the next steps and actions for the options that they want to
progress. Record the agreed actions below.
Agreed actions:
Make the referral for the client to Citizens Advice
Bureau
Yes No
Make the referral for the client to Debt Advice
Foundation
Yes No
Make the referral for the client to CCCS Debt Remedy Yes No

29. Make the referral for the client to Blue Badge Scheme Yes No
Make the referral for the client to Taxi Card Scheme Yes No
Is there anything else that you would like to discuss?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Client Consent: I understand this form is designed to help me access information/
services/ benefits that I may be entitled to.
Referrals
I therefore agree to Referrals being made on my behalf as specified in this Checklist. I
understand that my personal details will only be passed to a 3rd
party for the purpose of
referral or to enable evaluation of this service.
Consent for referrals
If you would like a referral to be made on your behalf for a benefit check, auxiliary service or
grant we require your signature to acknowledge your consent.
I agree to a referral from the home visitor for the following services/support
Client Signature:……………………………………..………………..
Home Visitors Signature………………………………..……………
Date: …………………………………………………………………….
Home Visitors Name………………………………………………….

30. APPENDIX 3
Monitoring and Evaluation
The performance measures that the service will be required to submit are set out below for
the full term of the contract.
Performance Measures Reporting
Frequency
Demographic Data
Number of individuals supported by postcode Monthly
Number of individuals supported by ethnicity Monthly
Number of individuals supported by age (information to be provided
in agreed age bands)
Monthly
Number of individuals supported by gender Monthly
Number of individuals supported with a disability (to be self- reported
disability)
Monthly
Number of individuals supported with a health condition (to be self -
reported health condition)
Monthly
Number of individuals supported by tenure Monthly
Quality Assurance Data
Number and percentage of individuals who would recommend the
service as reported through the client satisfaction questionnaire
Monthly
Number of complaints received Monthly
Number of compliments received Monthly
Number and percentage of individuals who received a completed
service at follow up
3 month
Number and percentage of individuals who did not the meet the
referral criteria for the home visit service.
Monthly
Number and percentage of individuals who were already known to
the services they were referred to (calculated as number of
individuals who were already known to the services they were
referred to divided by the total number of referrals received to the
assessment and referral service)
Monthly

31. APPENDIX 4 - LIST OF POTENTIAL ONWARD REFERRALS
Names of the Services available in LBRuT
Hounslow and Richmond Community Health care
Trust Falls Services
Richmond OT team
RRRT Team
Respiratory team briefing
Access team briefing
Lifestyle services- NHS Health checks, Walking Away
from Diabetes, Exercise Referrals
Kick-It Stop Smoking Services
Safety services
Richmond Housing Department Services
Housing Improvement Agency
Careline Services
Age UK for smoke alarm/carbon monoxide alarm
Citizens Advice Bureau
Debt Advice Foundation
CCCS Debt Remedy
Blue Badge Scheme
Taxi card
Neighbourhood scheme
Note - This is not an exhaustive list but a source.