This briefing has been produced by the Research Service for use by the Health and Social Care Committee. For further information, contact Stephen Boyce in the Research Service Telephone ext. 8095 Email: Stephen.boyce@wales.gov.uk

1.         Introduction

The Committee agreed to undertake an inquiry into residential care in Wales at its meeting on 13 July 2011, and that Members would consider a scoping paper at its meeting on 22 September 2011.  This paper sets out the possible scope of such an inquiry.

Background

For some time social care services have been the subject of scrutiny, particularly around the issue of funding services for an ageing population.  In addition, recent events at Southern Cross have focused attention on the stability and sustainability of the residential care sector.

Earlier this year the Welsh Government published a policy paper[1] setting out its plans for social care for the next ten years, which include the publication of a Social Care Bill in the Fourth Assembly.  

The Deputy Minister for Children and Social Services is setting up a Task and Finish Group to examine issues around the care and accommodation needs of older people.  Its membership is to be announced in autumn 2011.

The Committee may wish to agree to undertake an Inquiry into the capacity and sustainability of the residential care sector in terms of meeting the current and future needs of older people in Wales, and alternative models for providing such care. This would consider the needs of older people only, but could be extended to include younger adults.

The Inquiry could address the following aspects of residential care.

2.         Pathways into residential care

For some time the emphasis in social care policy has been away from institutional care and towards provision that helps to maintain independence and autonomy.  This focus continues to inform current policy: the Welsh Government’s social services policy paper[2] envisages a ‘transformation’ of services for older people driven by wider provision of re-ablement schemes and innovative community-based support services. 

The high costs of residential care, together with the negative outcomes associated with institutionalisation have led to increasing numbers of people with high levels of need receiving care services at home.  New approaches to care, such as the Gwent Frailty Programme, and developments in technology, such as Telecare, have expanded the possibilities for non-institutional care.  Nevertheless the pace of change from institutional to community-based forms of care has been slow[3] and the balance between the commissioning of residential and non-residential care is variable across local authorities[4].  

The assessment process undertaken by local authorities (soon to be the subject of a Welsh Government review) and, particularly for private fee payers, the information and advice service users and their families receive, impact on decisions about the type of care they receive. 

The Committee may wish to consider the process by which people enter residential care and the availability and accessibility of alternative services

 

3.         Resources and commissioning

Most care homes for older people in Wales (87 per cent) are operated by the private and voluntary sectors[5], although local authorities are the largest purchasers of residential care services.  The planning and commissioning activities of local authorities therefore strongly influences the shape of local care markets.  The Welsh Government is planning to introduce a national outline contract for residential care. 

Disputes[6] over fees for residential care between providers and local authorities in Wales have highlighted the difficulties facing commissioners and providers in times of public spending constraint[7].  A memorandum of understanding promoting cooperative working between social care providers and the Welsh Local Government Association has recently been under pressure following court action against local authorities by care providers in some parts of Wales, and there is evidence[8] of an increasing number of care providers going into administration. 

Lower average occupancy levels in care homes in Wales have contributed to the financial pressures on care providers[9], although the long term prospects for demand appear to be more positive, and there is significant demand from private fee payers who purchase 40% of residential care.

Local authorities have a role in providing advice and information to self-funding care home residents, some of whom may later become eligible for public funding as their financial resources diminish.

There has been a considerable amount of consultation and discussion around the issue of paying for social care both in Wales and at the UK level in recent years.  Most recently, the publication of the Dilnot report[10] on funding social care in England has contributed to the debate on future arrangements on both sides of the border.

The Committee may wish to consider the process of commissioning places in residential care by local authorities and the ability of the sector to meet demand in the context of constraints on resources.  The Committee may wish to consider the support provided by local authorities to privately funded residents.

 

4.         Capacity of the residential care sector

The development of more community-based health and care services in recent years means that people entering residential care tend to have higher levels of need than was the case in the past.  Research evidence[11] suggests that investment in improved staff training is required to meet this need, and that better staff training leads to improved quality of life for residents.  

The Care and Social Services Inspectorate Wales[12] has identified incidences of the admission of people with dementia to care homes lacking capacity and staff competence to meet their needs.  A summary[13] of Directors of Social Services Annual Reports identified a need to develop more services for people with dementia, and its Preliminary Analysis of Dementia in Wales report stated that:

A significant finding of the preliminary analysis is that there are wide variations in what is available across Wales and that this variability doesn’t seem to be related to need. Crucial gaps have also been identified. This means that the needs of people with dementia and their families and carers are not being adequately or equitably met by social care and social services (p.3)[14].

The Committee may wish to consider the capacity of the residential care sector to meet the demand for services for people with increasingly high needs, including those with dementia, in terms of number of places and facilities and staff knowledge and skills.

 

5.         Quality of services in residential care home 

The experiences and views of care home residents and their families provide a measure of the quality of service provision in the sector.  Research studies[15] have identified a range of factors that influence residents’ satisfaction with care including staffing levels, staff turnover, family involvement, meal-time experience, personal control, recreational activities and residential environment.  The research also indicates that family and peer support enhances quality of life, as do choice and the empowerment of residents.  Regulation and inspection arrangements, resources and staff training also determine service quality. 

The effectiveness of services in meeting the needs of specific groups of older people, such as Welsh speakers and those from BME groups also fundamentally affects the experiences of those users of residential care.

Given the current volatility of the residential care market, continuity of services may be threatened when providers transfer or close care homes, causing distress to service users and their families.  The Older People’s Commissioner for Wales has expressed concerns[16] about the impact of care home closures on older people.  The Commissioner is currently considering utilising her powers in relation to the adequacy of advocacy provision for older people in residential care.      

Recent reports have highlighted a need for improved healthcare for older people in residential care homes[17], including those needing palliative care or mental health care[18]. 

The Welsh Government is reforming the arrangements for promoting service improvement in social care to meet objectives in a new National Outcomes Framework.  Progress will be measured through a “revised set of high level indicators”[19].  

The Committee may wish to consider the quality of residential care services and the experiences of service users and their families, including the effectiveness of services at meeting the diversity of need amongst older people. The Committee may also wish to consider the arrangements for ensuring continuity of care for older people when care homes close.

 

6.         Regulation and inspection

The regulation and inspection regime for care homes is intended to ensure consistent standards of provision across the large and diverse residential care sector. The current arrangements have been in place since the implementation of the Care Standards Act 2000, since when changing demands and new models of care have emerged.  

Recently, the financial difficulties experienced by Southern Cross Healthcare have focused attention both on this large provider of care homes (thirty four of which are in Wales) and on the residential care sector generally.  It has been suggested that an economic regulator is needed to monitor the finances of larger private care providers[20]. 

In a Cabinet Written Statement[21] on 25 July 2011 the Deputy Minister for Children and Social Services Gwenda Thomas AM stated, in reference to the problems experienced by Southern Cross:

I have been asked whether I am considering measures needed to prevent similar situations from arising again.  Options for financial regulation or other measures will be considered as part of the development of the forthcoming Social Services Bill.

The Welsh Government has outlined plans to reform arrangements for regulation and inspection in social services.  Its policy paper on social services signals a shift in emphasis from inspection of individual care settings to a focus on the registration requirements of organisations providing services; a ‘licence to operate‘.  It states:

The time is now right to shift the balance of regulation and inspection from the point of service delivery to the organisation which provides the service and to specific professional roles in the work force.  This will enable us to reduce the burden and the quantity of regulation.

The Welsh Government has also decided not to pursue plans to register social care staff beyond social workers and care managers.

 

The Committee may wish to consider the effectiveness of the regulation and inspection arrangements for residential care, including scope for increased scrutiny of service providers’ financial viability.

 

7.         Coordination and integration of residential care and other health and social care services.

Residential care is one element of the range of interdependent health and social care services; therefore it does not operate in isolation from them.  Services such as re-ablement that aim to maintain the independence of older people interact closely with, and impact on demand for, residential care services.  Effective coordination between services affects both the experiences of service users and the efficiency at which interdependent services operate.  For example, poor social care provision can increase the rate of delayed transfers of care from acute healthcare settings. 

Better integration of services, especially health and social care, has long been a policy objective of the Welsh Government; its recent social care policy paper reinforces that aim[22].

The Committee may wish to consider arrangements for the co-ordination and/or integration of residential care with other health and social care services.

 

8.         Future provision

A continuing emphasis on developing service models that promote independence, further changes to the demographic profile of the older population in Wales, and higher expectations of service quality are likely to require new approaches to the provision of care for people with the highest levels of need. 

Models of care that are sufficiently flexible to meet the changing needs of older people without necessitating disruptive changes to accommodation may be needed in future.  Extracare housing, for example, offers care with housing, allowing residents to retain their independence, as do retirement villages on a larger scale.

The Committee may wish to examine the role of new and emerging models of care provision, such as Extracare, care villages and others that promote independence and offer flexible care.

There has been a significant shift in residential care away from local authority to private sector provision since the 1980s so that 84 per cent of care homes are now in private ownership. 

However, given the recent financial problems experienced by Southern Cross Healthcare, alternative models of funding and ownership may be explored.  Not for profit organisations such as Registered Social Landlords, for example, may help to diversify the care economy by expanding their involvement in provision.  In some countries, such as Canada, the cooperative sector is a major player in housing and care provision.

The Welsh Government states in its social services policy paper[23] that “social care is ripe for the development of social enterprises”.  The previous Welsh Government (2007-11) made a commitment to developing ‘not for profit’ nursing homes[24]. 

The Committee may wish to consider the opportunities available for developing alternative funding and ownership models such as those offered by the cooperative and mutual sector.