Health and Social Care Committee
HSC(4)-13-12 paper 1a
Inquiry into residential care for older people– Evidence from Cymorth Cymru
Cymorth Cymru Evidence to: Health and Social Care Committee
Inquiry into residential care for older people
12/12/2011
Background
Cymorth Cymru is the representative body for providers of housing-related support, homelessness and supported living services in Wales. We have over 120 organisational members who all work to assist people who are vulnerable, isolated or experiencing housing crisis, including:
· people who are homeless, or at risk of homelessness
· families fleeing domestic abuse
· people dealing with mental or physical health problems, or learning disabilities
· people with alcohol or drug problems
· refugees and people seeking asylum
· care leavers and other vulnerable young people, and
· older people in need of support
This list isn't exhaustive, and individuals may often face a range of challenges that make it difficult for them to find or maintain a stable home and build the sort of lives we all aspire to.
Cymorth Cymru's members help people address these issues, supporting them in finding both emergency accommodation and long-term, secure homes, where they may fulfil their potential and build happy and fulfilling lives.
We have three overarching objectives:
· To improve the links between policy and practice by ensuring that those working in frontline service delivery understand and are influenced by the wider policy context, and those working in policy development understand and are influenced by the experiences and knowledge of those working on the ground.
· To ensure that the sector maximises its contribution to the lives of citizens and the communities in which they live by helping to build and develop the sector’s capacity and professionalism.
· To increase public understanding and support for the sector and the work it does in helping people build the lives they aspire to within the community.
Acronyms used in this response:
HWC – Housing with care
BASW – British Association of Social Workers
RSL – Registered Social Landlord
CSSIW – Care and Social Services Inspectorate Wales
LD – learning disabilities
LGB&T – Lesbian, Gay, Bisexual & Transgender
Overview of evidence
It is understandable that reviews or inquiries into residential care tend to focus on issues relevant to mainstream care provision. Cymorth Cymru is particularly grateful to the Committee for not limiting its remit in this way and for giving us the opportunity to highlight issues regarding the care needs of more marginalised older people and also to draw attention to alternative models of housing with care (HWC) provision that exist which can help meet the future care needs of older people in Wales.
In drafting this response we are grateful to our members working within housing associations, third sector organisations and local authorities for their input.
We have also liaised with partner organisations and would like to take this opportunity to endorse the evidence provided by Community Housing Cymru.
Our evidence is presented in the following format:
· General comments
· Responses to the Inquiry’s specific points
· Summary of our key points
General comments
Cymorth Cymru’s vision is that all people in Wales are able to build and maintain happy, successful lives that maximise their independence within welcoming and supportive communities. With an ageing population, many of our members who work with older people are seeing and anticipating further increases in demand for services. Some members are specialists working in housing, support and care for older people, and others specialise in particular services that we are seeing increasing numbers of older people accessing such as those responding to homelessness, drug and alcohol issues, domestic abuse, learning disabilities/autistic spectrum disorders, mental ill-health and services working with people with a history of offending/prison leavers.
As well as outlining the issues faced by older people in relation to residential care, our evidence will pay particular attention to the experiences of marginalised older people and the future provision of residential care to meet the changing needs of older people in Wales.
Our main points are:
· We need to see a move away from care provision that is driven by profit in favour of ethically run, mutual based models. Although we recognise the advantages of some private sector providers, third sector organisations have proved to be a new and emerging model of care provision and can aid in meeting the future needs of the ageing population and, as such, should be further developed.
· More choice and control is needed so that individuals can access the right type of housing with care that best meets their needs. Provision such as Extra Care schemes and care at home needs to be a real option for individuals. Better use should be made of assistive technology to help people meet their health and care needs without having to move or lose their home.
· A characteristic of more marginalised older people is that they have difficulties in engaging with statutory services. This is often due to both a lack of appropriate services and a lack of willingness of health and social care professionals to work with people with complex needs. Service provision needs to take account of the needs of more marginalise older people and services need to be tailored appropriately.
Responses to the Inquiry’s specific terms of reference
Terms of reference 1 - The process by which older people enter residential care and the availability and accessibility of alternative community-based services, including reablement services and domiciliary care.
Feedback from our members indicates that there is great disparity around the range of provision offered to an individual. Access to different types of provision is largely determined by the local knowledge of the social worker or person advising as to the range of services that are offered. As a result, the offer of provision within a locality can differ vastly.
As a direct result of the lack of knowledge of different types of provision available, many individuals have found themselves entering residential care settings when more independent forms of housing with care would have been more suited to their needs and helped them to maximise their independence for longer. We are aware of a number of instances where individuals have been inappropriately placed in a residential care setting due to their social worker not being aware of other more suitable options. In the current economic climate, this issue is even more pertinent now as we do not know how many other people are living in inappropriate situations which are both expensive for the public purse and limit the individual’s independence unnecessarily.
Evidence shows that supporting a person to remain independent has an important role to play in the health and wellbeing of an individual – this reduces the burden and cost to other areas of spending such as the Welsh NHS. There needs to be further work into determining how many people in Wales have been inappropriately placed and we suggest that the Welsh Government (WG) commission research into the range of options that individuals are made aware of in order to fully maximise the return on public spend.
We would also endorse the recent study carried out by the Care Council for Wales around person centred planning which resulted in guidance to the sector. This guidance points to the positive outcomes of taking a structured person centred approach in terms of choice and wider information to inform better care and support. The guidance is available at: http://www.ccwales.org.uk/development-and-innovation/adult-workforce/older-people-workforce.
Terms of reference 2 – The capacity of the residential care sector to meet the demand for services from older people in terms of staffing resources, including the skills mix of staff and their access to training, and the number of places and facilities, and resource level.
In light of the recent Winterbourne View case, there are serious concerns around staffing skills and levels within residential care. The use of poorly paid and under-qualified care staff is an ongoing cause for concern as highlighted by a recent BASW survey in which 81% of social workers stated having come across abuse within adult residential care homes across the UK.[1]
Poor levels of pay for frontline workers in older persons services, in comparison to equivalent positions in adult services, does not allow care services to attract and retain ambitious staff. As a result, the skill mix of staff tends to focus on delivering a task focussed rather than an outcome focussed service. This results in staff doing things for, rather than with, the client.
One of the barriers often faced by organisations in relation to staff training can be ensuring that there is a comprehensive training plan in place for all of their staff when places on approved training courses are limited. In some instances, local authorities insist on providing their own training courses of which usually only 2 places are allowed on a quarterly basis. This can make it difficult for provider organisation to meet their statutory requirements as they are unable to gain access to enough local authority provided training courses and therefore struggle to adequately train the whole of their workforce.
Terms of reference 3 – The quality of residential care services and the experiences of service users and their families; the effectiveness of services at meeting the diversity of need amongst older people; and the management of care home closures.
Residential care services vary widely across Wales in the level of the quality of the service that they provide. We support the intention of the Care and Social Services Inspectorate Wales (CSSIW) to place more focus on the experiences of service users and their families. Other initiatives such as CareChecker in Wales ( www.carechecker.co.uk) are playing a crucial role in raising the standards of care provision through training volunteers – made by of people receiving care, their relatives, visiting professionals, or local community members – to make judgements about the quality of the service being provided. Central to their approach is judging how committed a service is to person centred working.
Care home closures cause much distress, especially for vulnerable people and we strongly feel that a more robust oversight of finances would prevent closures from happening as a surprise and would therefore limit the distress caused.
For more marginalised older people who often experience greater discrimination and isolation and that sometimes don’t enjoy the support or understanding of the general public (such as people with offending behaviour and/or drug/alcohol issues, those requiring gender specific care, LGB&T people, or ethnic minority groups), mainstream residential care services are often unsuitable for a variety of reasons. For older people with alcohol dependency issues, residential care is can be an unattractive option due to the financial implications accompanying it – for example, some individuals may not want to give up drinking but would not be able to afford to continue if they moved to a residential care setting. The mix of residents in mainstream residential care often acts as a further barrier as many individuals fear that their lifestyle may be acceptable to other residents.
It is often the case that the needs of more marginalised older people – such as those with substance misuse issues – are often not recognised and, as such, there needs to be greater awareness within the care sector of such issues as Korsakoff's syndrome – a brain disorder usually associated with heavy alcohol consumption over a long period which is not always manifest due to the confabulations (inventing stories to fill the gaps in memory) that it causes – in order to better tailor service provision.
As more and more people with learning disabilities (LD) are living longer, they are increasingly suffering from age related conditions such as Dementia. A recent report[2] in England has highlighted the need for a “significant improvement” in the training of nursing staff in relation to issues around caring for those with Dementia, adding that nursing staff need more support, training and recognition for the difficult job they do. In addition to this, mainstream residential care is often unsuitable given that staff are rarely skilled in relation to LD issues. There can also be an age imbalance it is the case that, with some forms of LD, individuals may suffer from Dementia at a relatively young age and would therefore be wholly unsuited to a mainstream residential care setting.
In order to meet this diversity of need both now and in the future, there needs to be improvement in the quality and spread of specialist care services in Wales that are underpinned by an understanding of the specific needs of socially excluded older people. We would also like to see national strategy and policy development better recognise and meet the needs of socially excluded, marginalised and vulnerable older people.
Terms of reference 4 - The effectiveness of the regulation and inspection arrangements for residential care, including the scope for increased scrutiny of service providers’ financial viability.
We are keen to support the move to a more outcomes driven approach to regulation and inspection arrangements for residential care as such an approach can make services more client focused and needs led by identifying what works well, and what could be improved.
It is felt that there is not enough scrutiny on the quality of the service provided, such as care planning and whether clients are treated with respect and dignity. There is no method that accurately captures the viewpoints that families and clients hold towards the service. We would like to stress the importance of actually speaking with service users in relation to inspection as opposed to simply focusing on what may be contained within paperwork. In this way, inspections can gain a fuller picture of the service provided and better identify any need for improvement.
In addition, the quality of inspection reporting can be poor and not be of a high enough standard. The same inspector may visit a service on several occasions and build up personal relationships with staff, which can impact on the outcome of the inspection report and produce inconsistencies. A consideration towards alternative methods of inspection and regulation, such as mystery shopping, could help alleviative inconsistencies in reporting and result in reviews that reflect experiences more accurately.
In light of the Southern Cross case, serious concerns around the financial viability of other residential care homes that are driven primarily by profit still remain. Given that inspections do not consider whether services are applying their resources flexibly, there is currently no way of knowing whether service providers are experiencing financial difficultly.
We would urge the WG to consider much more robust regulation in terms of the financial information that organisations are required to provide on an annual basis. Third sector organisations are required to conform to ‘open book accounting’ as in the sense that registration with the Charity Commission[3] makes their accounts open to public scrutiny and it is essential for any organisation that works with vulnerable people to be accountable in the same way.
Terms of reference 5 – New and emerging models of care provision
In order to fully meet the care and support needs of older people in Wales, we strongly believe that a range of service provision is needed as opposed to a ‘one size fits all’ type of approach. Where as good residential care services are suited to some individuals, more independent models of care are needed to satisfy others. Having your own home gives you a level of independence that it is impossible to achieve in other, more institutional settings.
Extra Care
For this reason, many people are choosing Extra Care as their preferred option of dealing with their increasing care needs as it allows individuals to have their own tenancy or ‘own front door’, allowing them the control to dictate who does or does not enter their home at any given time. Also, for older people in receipt of benefits, it gives them a higher income which in itself increases independence.
Extra Care are one type of housing with care provision that offer a model of housing, support and care provision that promotes independence and provides older people with a home for the rest of their lives. The ethos behind Extra Care is that it enables people to live fuller, healthier lives with the emphasis on improving quality of life rather than only providing a safe, caring environment as offered by traditional models of residential care. Extra Care housing is popular with people whose disabilities, frailty or health needs make ordinary housing unsuitable but who do not need or want to move to long term care (residential or nursing homes). Although older people make up the majority of users of extra care, people with disabilities that are not age related are increasingly making use of this type of housing. Extra care provision comes in a huge variety of forms and may be described in different ways, for example 'very sheltered housing', 'housing with care', 'retirement communities' or 'villages'.
Whilst a concerted effort is made to make Extra Care a home for life, there are many cases where individuals are forced to move into more dependant forms of provision when their care needs increase to a level where funding is no longer available to meet their needs within an Extra Care setting. For instance, if the needs of an individual increase considerably on an intermittent basis then such occurrences can be dealt with but where this is ongoing it creates difficulties. Therefore, limitations are sometimes caused by the pre-conceived level of need that comes with the block contact of funding. It appears that that model itself is able to meet increasing and decreasing support, care and health needs but current funding arrangements may be limiting this flexibility.
We suggest that further work needs to be done to consider how financial arrangements could be configured to allow greater flexibility in terms of what is offered to residents to ensure the changing range of needs are met over their lifetime.
Increasingly Extra Care housing is recognised as an essential component of joint commissioning by health and social care with Extra care now being used for reablement as well as longer term housing. Extra Care schemes and also Registered Social Landlord (RSL) nursing homes located near district general hospital may offer an effective option for high quality care to enable earlier hospital discharges of frail older people. The partnership arrangement to support this form of early discharge will depend on the scheme involved but despite the growing need to ease demand for Secondary Care services, most arrangements of this type tend to be informal arrangements on a small scale. Many RSLs are keen to explore the possibility of annualised block bookings for planning and cost reasons but some Health Boards are wary of committing to such arrangements in order to retain maximum financial flexibility.
There is generally a lot of support for this approach as it allows individuals to regain the confidence to live independently. We suggest that the WG supports this approach by rolling out the current good practice in this area across Wales.
Care at home
An increasing number of people are choosing to remain in their own home and wish to receive care and support within this setting. Therefore, many providers of sheltered accommodation who provide housing-related support to their tenants would also like to offer care services to support their tenants in general needs housing to remain in their own home for as long as possible. Bringing additional (continuing) healthcare into these schemes may help prevent admissions to hospital and provide a community base for other services.
A key element of being able to remain and receive care at home is the availability of adaptations. Adaptations enable people to stay in their own homes and in their own communities with their existing support networks and also support peoples’ rights to make a real choice about where they live and can avoid the trauma and cost of more institutional provision types. They also produce a range of lasting positive effects such as improved dignity, privacy, independence, health (physical and mental) and social inclusion.
As such, it is estimated that for every £1 spent on adapting a person’s home, £7.50 is saved from health and social services budgets. The value of investment in services that enable people to live at home longer has been recognised by the WG, most recently in the form of a £4.77 million package awarded directly to Care & Repair agencies in Wales for 2011-12. However, as Care & Repair services are focused on private housing, we support CHC’s call for its expansion to all tenure.
As with housing adaptations, the demand for telecare and telehealth provision is increasing as both technologies offer the potential to reduce visits by patients to health care providers (and vice versa), facilitate more localised health care and services, providing more timely diagnosis and intervention, and even reductions in costs.
Telecare uses a combination of alarms, sensors and other equipment to help people live more independently by monitoring for changes and warning the people themselves or raising an alert at a control centre. (Examples of telecare devices include personal alarms, fall detectors, temperature extremes sensors, carbon monoxide detectors, flood detectors and gas detectors). Telehealth covers the remote monitoring of physiological data e.g. temperature and blood pressure that can be used by health professionals for diagnosis or disease management. (Examples of telehealth devices include blood pressure monitors, pulse oximeters, spirometers, weighing scales and blood glucometers). Telehealth also covers the use of information and communication technology for remote consultation between health professionals or between a health professional and a patient e.g. providing health advice by telephone, videoconferencing to discuss a diagnosis or capturing and sending images for diagnosis).
We envisage technology such as the above being used more and more to help people meet their health and care needs without having to move or lose their home. Despite the benefits brought by assistive technologies, some schemes in Wales are currently at risk as they are not statutory funded. Should these schemes be removed, we anticipate an immediate cost implication for the NHS – for example, owing to an increase in severity of need following a fall at home.
It would seem that there are real savings to be made from further investment in this area as both a preventative measure and in responding to immediate need. Given the current strains on public spending, we suggest that more attention is given to assistive technology as a compelling method of delivering care at home.
Term of reference 6 - The balance of public and independent sector provision, and alternative funding, management, and ownership models, such as those offered by the cooperative, mutual sector and third sector, and Registered Social Landlords.
Increasing numbers of residential care homes for adults are being privatised despite the growing opinion that care homes should not be run for private profit. In contest of this, many RSLs in Wales are making the strategic shift to include ‘care’ as part of their core offer alongside the spectrum of accommodation that they provide. RSL run nursing care homes aim to deliver mid-market price care services whilst maintaining quality standards. Such nursing homes can also become a hub for a range of other services such as day care or hosting other out of hours teams.
Support for ethically run, not for profit care provision is gathering pace in Wales as they purport to be a better use of public (and services users’) money given that all income is spent on care and support and any surplus is reinvested in the organisation. They are also service driven by values and principles and crucially not by profit – therefore delivering higher standards of care and dignity to those using their services. The third sector is also able to work together more effectively and flexibly to deliver joined up services, provide extensive infrastructure and provide quality services across the continuum of care. Organisations’ services are normally rooted in the communities which they serve, providing local holistic and outcome focussed services for people.
As such, the opportunity for Third Sector run nursing care across Wales seems significant; yet the move into a highly regulated service area can be daunting. For those already committed to nursing care, and for those considering the move, clarity about the potential demand would be welcomed.
Cooperative Models of Care
Cymorth Cymru recently hosted a master class with Mutual Advantage who have carried out a number of projects looking at how cooperative models of care can be used to provide better services and more control to older people and people with disabilities. There is much to learn from such initiatives and we would suggest that the principles and approach could be adapted to the Welsh context:
http://www.mutual-advantage.co.uk/CMS/uploads/CoopsUK_Care_Report.pdf
However, to achieve this in Wales the citizen directed support agenda needs to be taken forward. We would like to see the WG take advantage of this opportunity to effectively combine cooperative models of care and personalisation in order to transform care provision in Wales.
Summary of key points
In summary, reviews or inquiries into care provision understandably tend to focus on the needs of the general population and we welcome the invitation to contribute to the Inquiry so that we can highlight the specific issues that our most vulnerable citizens experience in accessing residential care.
In relation to residential care for general needs older people, we feel that improvements can be made through:
· Better awareness of the range of care provision available to individuals by social workers/person advising;
· Further work into determining how many people in Wales have been inappropriately placed in residential care;
· More robust regulation in terms of the financial information that organisations are required to provide;
· The development of alternative models of care such as Extra Care and increased availability of receiving care at home;
· The expansion of Care & Repair services to all tenures;
· More investment in assistive technologies
· The development of ethically run, not for profit and cooperative care provision.
Although it is important to challenge the prevalence of negative images of ageing, it’s equally important to recognise that for some marginalised older people, ageing can be far from a positive experience. In order to better meet the care needs of more socially excluded older people in Wales, we would like to see:
· Increased availability and better quality staff training (especially in relation to understanding the more complex needs of marginalised individuals) and;
· Increased range of service provision to cater for the needs of more marginalised older people.
Taking a broad approach to this issue and exploiting all possible vehicles for meeting the growing need for a range of care provision is, we believe, the best way forward in the current climate and as part of that we would suggest further exploration of what cooperative models of housing with support/care could deliver. We would like to assist the WG in taking this forward and would be more than happy to arrange visits to new models of Third Sector care provision in Wales.
Once again, thank you for the opportunity to give evidence. In the current economic climate organisations working with people facing a range of challenges and conditions are worried that without a lead from the Welsh Government, those with the most acute care needs will be forgotten and face lives spent in institutions or on the streets when they could and should be able to achieve rewarding, independent lives within the community.
Nicola Evans
Policy & Information Officer
Cymorth Cymru
Norbury House
Norbury Road
Fairwater
Cardiff, CF5 3AS