Health and Social Care Committee

Inquiry into residential care for older people


RC41 – Age Cymru

Age Cymru logo (CMYK Coated)

Consultation Response


Health and Social Care Committee Inquiry into residential care for older people in Wales


December 2011




Age Cymru is the leading national charity working to improve the lives of all older people in Wales. We believe older people should be able to lead healthy and fulfilled lives, have adequate income, access to high quality services and the opportunity to shape their own future. We seek to provide a strong voice for all older people in Wales and to raise awareness of the issues of importance to them.


We are pleased to respond to the Health and Social Care Committee’s Inquiry into residential care for older people in Wales. This response was developed in consultation with My Home Life Cymru, an initiative aimed at improving the quality of life of those who are living, dying, visiting and working in care homes for older people. My Home Life Cymru aims to celebrate existing best practice in care homes and promote care homes as a positive option for older people. The programme is currently working intensely with 38 homes in Wales and is in contact with 225 care homes.


We consulted Age Cymru local partners, and our networks of older people to inform our response. We also reference research by Age Cymru Gwynedd a Mon carried out in January 2011 with care providers to monitor their progress with implementing the Dignity and Respect in Care Programme for Wales within Gwynedd. We also consulted with the Alzheimer’s Society, and Age Cymru’s Older LGBT network report into the specific needs of older lesbian, gay, bisexual and transgender people.


We are a member of Welsh Reablement Alliance, and have also contributed to their response. The Welsh Reablement Alliance is an umbrella organisation for professional associations, voluntary sector partners and care providers who provide reablement services in Wales.




The residential care system in Wales must improve to meet the current needs of residents as well as the future population, with increased training and support, and an appropriate regulatory system. Age Cymru’s recommendations to the Committee include:


·         The Welsh Government should work with local authorities to ensure increased and consistent levels of funding for high quality independent information, advice and advocacy services for older people across Wales to help them through the process of entering the care system.


·         The Welsh Government should bring forward adult safeguarding legislation which places the individual at risk of harm truly at the centre of any assessment, decision or action taken. This should include legislative duties on agencies to: investigate concerns of abuse; cooperate in investigations; to report concerns of potential abuse, and provide independent advocacy support where required.[1]


·         The Welsh Government should work with local government and health bodies to increase availability of alternative care options in the community including extra-care housing, reablement services, and respite care services to give unpaid carers a break and enable them to continuing caring.


·         The Welsh Government must improve education and training for health and care professionals on understanding, recognising and managing of dementia-related conditions. Residential care homes should conduct regular reviews of the environment to identify improvements to stimulate residents with dementia and take their needs into account.


·         We believe staff training needs to improve, and are calling for mandatory dementia awareness, equality and human rights, and basic values training for all residential care staff.


·         All care providers must ensure that the rights enjoyed by opposite-sex couples are also provided to same-sex couples


·         The Welsh Government should consider establishing stronger guidance or frameworks to local authorities on appropriate fee levels to ensure that care services are sustainable and there is greater uniformity of fees across Wales.


·         Regulations must be strengthened to ensure that inspected care homes can prove that they are financially stable and operate viable business models to reduce consequent threats to the security and wellbeing of residents.


Age Cymru’s response


1.    The process for entering a residential home


A frequently identified issue is the lack of information, advice and advocacy that is available to people and their families during this process of choosing and entering residential care. The process is often not clearly explained and in many cases there is a lack of support and assistance in making decisions about care options or choosing the right residential or nursing home.


We have heard cases of hospitals advising a patient’s family that they need to go into a residential home but providing no help or information on how to choose the right home. My Home Life Cymru are often told by families that they have simply ‘Googled’ care homes in the area and admit that they do not know what to look for when researching or  visiting residential or nursing homes. Many people have no previous knowledge or experience of care services and feel that they are unable to make fully informed decisions. We believe that standardised information should be available to help with choosing a care home and Age Cymru plans to shortly produce a Welsh version of an Age UK care home checklist to assist individuals and families with this.


Case from Age Cymru’s information and advice line:


A caller’s mother was in hospital and was judged to be unable to return to her home. The caller rang for advice as she was concerned about finding a care home, and did not feel she had enough information or support for doing so. Our advisor asked her whether an assessment of her mother’s needs had been carried out. The caller said yes but she felt that it may not have been carried out adequately or in sufficient depth, and that eligibility to NHS Continuing Health Care may not have been looked at properly.


The care system must be straightforward and clear, and people need accessible information which empowers them to make informed decisions. Currently many older people and their families find the care system complicated and daunting, and do not know where they can access information. The most common type of enquiry to Age Cymru’s information services relates to social care. Independent advice and advocacy services are essential in enabling people to make choices on the care and support services that are right for them at any given time. However current provision of information and advice services is patchy across Wales, largely as a result of unequal funding and support in different areas. We believe that everyone should be able to access information, advice and advocacy services in order to ensure that they are receiving all the support to which they are entitled. This should be available regardless of assets, income or method of funding for care.


Further support should be provided to older people and their families both when making the initial choice about care options, and during the transition period of a person moving into a residential home. The Welsh Government should work with local authorities to ensure increased and consistent levels of funding for high quality independent information, advice and advocacy services for older people across Wales.


The stress at this time can also be compounded by negative perceptions of residential care, which is often seen as the end of the road rather than simply another place to live and a potentially positive experience. My Home Life Cymru has noted that micro-commissioners (social workers, care managers, hospital discharge staff) frequently have negative attitudes towards care homes and present it as a negative choice: “I’m afraid that they will have to go into a care home, I’m very sorry…” This is inappropriate as care professionals should be neutral in their recommendations and residential care can be a positive solution that is most appropriate for many people.







There is no consistent method across local authorities (LA) in Wales for allocation of fees for residential care. Authorities are under an obligation to provide a choice of potential homes but in our experience this is often not done satisfactorily in practice, with cost forming the primary consideration. If the funding for the care is provided by the LA, frequent practice is to get quotes from three care homes and then recommend the cheapest one to the family. We are also regularly told that authorities do not always listen to the person or their family’s wishes.


Additionally, older people and their families are often unaware of third party top-ups and it can be a shock when they are told if you want that home you will have to pay ‘X’ amount yourself. We are concerned that some local authorities expect third party top-ups from families as a matter of course, when Welsh Government guidance is clear that this should be regarded as purely optional for families who wish their relatives to live in a home above the local authority rate.  Unfortunately the reality for many seems to be that, even where a person is eligible for local authority funding, the standard fees that some local authorities pay leave very few realistic options for residential homes.  This can be a particular problem in rural areas. It is unacceptable for families to be emotionally pressurised to provide additional top-ups because a local authority does not pay a realistic level of fees for residential care.


The court case involving Pembrokeshire County Council and four private care homes (Forest Care Home Ltd and Others v Pembrokeshire County Council, 2010) ruled that it was illegal for the council to impose a freeze on funding for care home services in reaction to funding cuts from national government, and forced them to pay higher fees. We support this judgment; however it is indicative of the funding problems facing social care and the financial pressures that both local government and many care providers are under. Given current public finances and no guarantee that any increases will match the rate of inflation, the situation may get significantly worse in future.  We believe that reform of the care system should be a pressing priority for the Welsh Government with a view of improving quality and sustainability of the system.




Under the current funding arrangements a significant number of people are required to self-fund their care. Many of these self-funders do not go through social services when arranging care provision, and often do not have access to information or advice services. My Home Life Cymru have found that the residential home’s first question is often "who is paying for the care?", and many homes will increase fees for self-funders. Age Cymru believes that it is extremely unfair that two people receiving exactly the same care in a residential home could be charged very different fees, with those in private arrangements effectively subsiding state provision.


Furthermore older people who self-fund their own care in private residential homes are among the most vulnerable as they are not currently covered by the Human Rights Act.  Age Cymru believes that this loophole must be closed by the UK Government to ensure that all older people have the same protection from mistreatment.


Social services departments should provide and publicise information about the residential care system and homes in the area, to both local authority funded and self-funding older people entering care.


Ø  Availability and accessibility of alternative services


It is important that older people have access to a range of good-quality housing options which meet their needs as they age.  Specialist housing, including sheltered accommodation and extra care housing, can offer basic support for many people allowing them to live independently for longer within a safe and secure environment.  Recent controversy over removal of onsite wardens and the reconfiguration of support services has highlighted pressures on traditional sheltered housing and the next few years will be important in determining their future role.  Specialist housing can provide community living and associated benefits to quality of life.  The presence of a warden can be a key factor in reducing demand on emergency services and hospitals.


We hear many positive accounts of extra care housing, though we know that its availability as an option varies across Wales. We believe that Wales needs to develop more extra care housing provision as a priority in order to meet increased demand for it in the future; this requires national direction and leadership from the Welsh Government.


“Extra care facilities are the way of the future. Willowbank in Newport is excellent”


- Quote from an older person at a recent consultation event



Age Cymru Swansea Bay note that there are good alternatives like sheltered housing or extra care housing but a lack of awareness and availability in the area can mean that professionals often suggest residential care rather than looking at other options. They also point out that there can be perceived risks about alternative options and that residential care is often seen by families and professional as the safest option. Older people should be enabled to make more informed decisions themselves through the use of independent advocates, and if possible to visit residential care settings, and the alternatives, and be able to speak with current residents and service users before making decisions about appropriate living environments and care provision.


Reablement services


We support the Welsh Reablement Alliance’s points about the need to improve the availability of reablement support. The case for properly-funded and effective reablement is a compelling one. However current provision of services is patchy across Wales.


There are several projects around Wales which provide a range of different services. Sound evaluations should start to identify learning for use around Wales. The Welsh Government has provided £9m of Invest to Save funding for the Gwent Frailty Project over a three-year period. The project’s sustainability is based on its ability to shift resources from acute or institutional care to community based and preventative services that promote independence.


Savings should come from:

·         reduced admissions to hospital;

·         reduced average lengths of stay as a result of operating the ‘pull system’;

·         reduced delayed transfers of care through facilitated supported discharge;

·         reduced longer-term care packages through the enabling approach;

·         reduced admission to care homes.


Please see the Welsh Reablement Alliance response for further details.


2.     The capacity of sector to meet the demand for services




Dementia is the strongest determinant of entry into residential care in people aged over 65 years. As social care policy continues to focus on helping those with lower level needs to remain in their own homes, it is likely that the proportion of people with dementia in care homes will continue to rise and that they will have more severe symptoms[2].


Treatment services must provide a holistic approach and address all the needs of individual patients within the same setting. Currently specialist mental health beds are often not equipped to support those with frailty and physical needs, whereas intermediate care services are reluctant to admit people with dementia. As a result, discharge from hospital becomes extremely difficult, even when it is clear that hospitals cannot provide the most appropriate support for the patient. Many older people with dementia have little access to consultant geriatricians and other specialists. Often, and particularly when older people are resident in care homes, their dementia will be diagnosed and managed by a GP.


Care home managers have identified lack of support from specialist services as a challenge in provision of good dementia care[3].


It is vital that understanding of dementia is spread to GPs and their staff, social workers and other professionals throughout the health and social care sector. There is also currently a lack of understanding around the issue of mental capacity and therefore training on dementia should include awareness of how to implement the Mental Capacity Act.


Age Cymru believe the Welsh Government must improve education and training for health and care professionals on understanding, recognising and managing dementia-related conditions. Residential care homes need consistent dementia awareness and planning, including regular reviews of the environment to identify improvements to stimulate residents with dementia and take their needs into account.



Good practice identified by Age Cymru Gwynedd a Mon:
 One home in particular, had a recently-opened eight bed specialist unit, with the responsible architect ensuring that the design included the latest expert guidance on accommodation for residents with dementia.
 This included:
 • bedrooms being colour coordinated, with the entrance door, furnishings and fittings all in the same colour, to help the occupier identify his/her bedroom and thereby provide re-assurance
 • ‘memory cabinets’ containing residents’ photographs and memorabilia were fixed on the wall next to each bedroom door
 • staff being based directly adjacent to the residents’ lounge/living area, interacting with them throughout the day and having meals with them
 • wide corridors, with no doors directly in front of the resident as he/she walks along and with glass partitions so that staff are able to see the residents at all times
 Another home which caters for residents with dementia had implemented a number of safety initiatives, including alarm mats placed next to the beds of those who tend to wander at night, as well as fitting alarms on their bedroom doors.


Levels of staff training and identified training needs are crucial issues in residential care. We believe that mandatory dementia awareness, equality and human rights, and basic values training should be provided to all residential care staff. This should include dignity and respect principles, attitudes and values, empathy, equality and human rights, and challenge negative stereotypes. Values training is prioritised in other sectors such as learning disabilities but is not currently identified as a priority for working with older people with dementia and other care needs. We believe this would be of great benefit both to staff and the quality of life of residents.


We are concerned that in reality some staff are trained using E-learning tools and that this is indicative of the fact that this type of training is not treated as a priority within the care home. We have heard that staff can go from an E-learning course onto the NVQ 2 course without receiving practical/physical training, and indeed may never receive such training.


We agree with the Alzheimer’s Society that training programs should target front-line workers, shift leaders and home managers. Given the range and seriousness of the symptoms of dementia, it is clear that caring for residents with dementia is a highly skilled task. Yet this work is accorded a low status in our society, which is compounded by low wages, as well as a lack of a structured career path and training opportunities.


In the majority of residential homes visited by My Home Life Cymru, the issue of low staff wages is raised by residents and families, they hear, “these people are not paid enough”, “the work they do should be better not valued”.


Low wages for care assistants often results in a high turnover of staff and a lack of consistency in care. Care home managers say they would like to give higher wages but cannot afford to do so under current resources. As referred to earlier, in practice care homes are using self-funders to subsidise their costs because of the pressures on rates paid by local authorities. Local authority rates can vary hugely, often even with neighbouring authorities. We believe that the Welsh Government should investigate whether it can intervene to provide guidance or frameworks to local authorities on appropriate fee levels to ensure that care services are sustainable and there is greater uniformity of fees across Wales.


3.    Quality of residential care services and the experiences of service users and their families


It is difficult to generalise about quality of care services in Wales due to the huge variations which exist. Quality of services can range from abuse and neglect, in the worst cases, to fantastic homes where residents have an excellent quality of life.



“Care homes need to be standardised as some are very good but others are quite diabolical”


- An older person at a recent consultation event



Unfortunately abuse does occur in some residential care settings, and 36% of all alleged victims of abuse were living in care homes at the point of referral in 2009-10[4]. Age Cymru’s new campaign, Rule Out Abuse, calls on the Welsh Government to commit to 3 principles which must underpin all work to protect adults at risk of abuse:

·         Prioritise safety

·         Protect from harm and respect choices

·         Promote the right to dignity and respect


These principles mean creating a system which values people’s choices and wishes, dignity, respect, and protection from harm. Over the last five years Age Cymru’s Elder Abuse project has worked in partnership with professionals, older people and decision makers to identify examples of best practice and develop these principles.  At present, there is no single legislative framework for safeguarding adults in Wales which sets out clear responsibilities on and powers for key agencies. We are calling for strengthened legislation as part of a robust toolkit that needs to be engaged to protect adults from abuse, including renewed guidance, training, increased public awareness and access to advocacy services. The development of any new legislative framework must ensure that the individual at risk of harm is truly at the centre of any assessment, decision or action taken. The Rule Out Abuse Charter makes a number of recommendations for Welsh Government including to introduce duties; to investigate concerns of abuse; on agencies to cooperate in investigations; a duty on staff and professionals to report concerns of potential abuse, and a duty to provide independent advocacy support where required[5].

Case from Age Cymru’s information line:


A caller’s mother has been in a nursing home for four years following a severe stroke, and has also recently been diagnosed with dementia. The caller was unhappy with several aspects of her mother’s care. Her mother had been left in a conservatory in the home with no buzzer to contact staff, she had not been showered or had her hair washed for three weeks and the dentist has become concerned that her teeth are dirty and not being cleaned. This has resulted in a few of her teeth decaying so badly that they are being taken out. The care home manager said she can do her teeth herself, so it is up to her if she is not doing it. The manager also said the resident refuses to accept help, which is why she had not been washed, and that if they forced her to do these things it would be abuse. The caller felt that this was as an excuse and said staff had not attempted to build up a rapport with her mother and if they did she could probably be persuaded to accept the help. The caller was concerned not just about her mother but also that the care home had applied for extra EMI beds and she felt that if the home couldn’t cope with the early stages of her mother’s dementia, they wouldn’t be able to look after residents with more severe needs.



We, like the RCN, are concerned about the lack of access to healthcare and reassessments for residents. While GPs may be retained by a home there is no duty on the GP to reassess the residents’ needs, and this must be addressed. Additionally, if a patient is released from hospital with a specific condition, their care plan may relate entirely to that condition and neglect other issues. We know that the quality and consistency of care plans vary significantly both across homes and regions of Wales.


Often the cost or location of a home has no correlation with the quality of care. My Home Life Cymru staff have spoken to many care home residents over the course of the project, and are consistently told that the majority of good experiences in residential care homes centre on the staff. A well trained, motivated, empathetic workforce will provide the best quality care and build positive relationships with residents.


Quotes from care home residents to My Home Life Cymru:


“Every home does the same basic stuff but some are awful and some are great. It’s the people that make the difference”


“It ain’t what you do; it’s the way that you do it!”


“It’s nothing to do with gold taps, it’s the people”



font-family:"Arial","sans-serif"'>Age Cymru Gwynedd a Mon’s research[6] found generally a high level of satisfaction with the care services provided by each of the seven residential homes it investigated. The report acknowledged however that this was a very small sample and that some care home residents may have been reluctant to mention instances of when they may not have been treated with dignity, for fear of ‘getting into trouble’ with the care home manager.


Activities and social interaction


Through the work of My Home Life Cymru we have identified that providing meaningful activities and regular social interaction is an area in need of improvement for residential care homes. The level of staff interaction with residents is an important part of quality of care and residents need to be both stimulated and re-assured, through interaction with staff at regular intervals.


In research conducted by the Alzheimer’s Society[7], 54% of people said that their relative in a residential care home did not have enough to do during the day. Many were concerned that staff spent time with the more able residents to the detriment of those with more severe cognitive impairment.


Access to outside space and gardens was a particular concern for carers of people with severe dementia. Carers frequently reported that gardens were completely off limits to their relative/friend because no staff were available to accompany them. It is important that responsibility for providing stimulation and activities is recognised to extend beyond the activity provider to all care home staff.


Age Cymru Swansea Bay have found that the reduction in group based activities in some local homes because of the lack of activity coordinators has resulted in residents becoming passive and has seen a reduction in their participation in meaningful activity and social interaction. This in turn has a great impact on their emotional and physical well-being.


Four of the care homes included in Age Cymru Gwynedd a Mon’s research[8] had a designated activities coordinator, which was shown to result in a more extensive programme of activities compared to those that did not have a designated member of staff.


The research also found that in some homes, residents assisted in the dining room by helping to lay tables, folding napkins, doing some washing up, helping out in the garden or greenhouse, but examples of this were few and far between. Operational and Health and Safety considerations were cited as one of the reasons for this, which is a concern given the benefits of providing residents with opportunities to contribute and have some control over their lives in the care home where possible.


It was also apparent that many residents would appreciate having more interaction with persons from outside the ‘enclosed’ care home environment, particularly with someone who came from the same area as them, knew the same people, etc., so that they could keep up to date with local events or reminisce about the past. They also found that some care homes have their own minibuses but others have to share, with one home only having the use of one every four weeks, which was not ideal and restricted the number of opportunities to take out the residents.


Good practice identified by My Home Life Cymru:


Penylan Residential Hotel in Cardiff.


One resident is an avid gardener and staff started noticing that she was showing interest in the garden a few years ago. Following conversations she took on the role of looking after plant pots in the garden. Now, she is single-handedly maintaining both gardens for the home, growing seeds, turning the soil, weeding, buying ornaments and much more. The home is supporting her in however way she wants it, like her request in digging up deep seated roots from the front garden, giving her a small green house as a present on her most recent birthday. This allowed her to plan and decide what plants to purchase for ‘her garden’.


As part of the home’s role in maintaining identity of our residents, they allow residents to take calculated risks. One of resident has limited mobility but has always enjoyed going out with her male friend three times a week every Tuesday, Thursday and Saturday.  During these days out, the resident and her friend go to the local gym and partake in gentle arm exercises. They have lunch, stay for a few hours in the resident’s house (she still owns her own home) and if there are items she wants to buy, they go to the supermarket to buy them. 


A local junior school also visit the home every Christmas to sing carols and join residents for a meal.



The benefit of volunteers


The work of My Home Life Cymru also demonstrates a clear benefit of good voluntary activity within care homes. We believe that the sector needs to work more with the volunteer community and better utilise opportunities such as befriending schemes. My Home Life Cymru have provided grants to local Age Cymru partners to stimulate volunteer schemes with care homes, for example, Age Cymru Swansea Bay have established a project with Mumbles nursing home.


In Age Cymru Gwynedd a Mon’s research, all care home managers reported that they would welcome a formal system whereby volunteers could come into the home, at regular intervals, to talk to residents and possibly, take them on outings[9].





Layout of residential homes


The layout of care homes can have a bearing on the quality of life of residents. Age Cymru Gwynedd a Mon reported that at some homes, residents were seated in the more ‘traditional’ care home lounge, with a number of chairs arranged in a semi-circle, all facing a large TV, which was on, but with very few really watching it or being able to hear it. Some residents appeared bored, whilst others were sleeping and it did not appear to be a very satisfying way of spending the day.


Staff supervision and interaction with residents was considered to be easier to achieve in some care homes due to the physical layout of the building. There appeared to be more interaction between staff and residents in care homes where staff areas were adjacent to the residents’ communal lounge, as opposed to those where the staff were more remotely based.

The research noted that smaller lounges encouraged more interaction with residents.


“In a much larger day room where there was very little interplay between the residents …What other stimulation was provided is not known but when she was visited in the large day room, it was a case of a large number of older people sitting around the room ignoring the television and either asleep or gazing into space.”


- Extract from Pensioners Forum Wales response



Ø  Effectiveness at meeting diversity of need


Age Cymru believe that significant work is required in residential care to meet the needs of the Lesbian, Gay, Bisexual and Transgender (LGBT) population in care. We facilitate an Older LGBT Network for Wales and supported the Network to produce a report on challenges facing older LGBT people.  Recognition of LGBT older people in care homes is a major issue and may be due in part to the fact that people will have often hidden their sexuality in the past. However, societal changes mean that the LGBT population coming through into residential care in the future may be a lot more open about their sexuality, which may pose a challenge for many homes.


Care providers and institutions are seen by many LGBT people as assuming heterosexuality at the least and even exhibiting homophobic views in some instances. Whilst the majority of older LGBT people do not want their sexual orientation to define them, their needs must be accepted and catered for and their privacy respected in a safe environment. People also want their needs and definitions of ‘family’ and ‘next of kin’ understood and respected. Whereas a married couple may be offered a shared room or flat in a care facility, an LGBT couple appear to rarely be offered the same treatment. This can also result in their next-of kin being disregarded by care professionals.


Older LGBT people can be discouraged from complaining about poor treatment in case they are ‘outed’ to others, or face homophobia from appointed carers. There is not a clear-cut policy when it comes to LGBT couples in rented or shared accommodation as to whether one is allowed to continue tenancy if the other has to move into a care facility. It is then uncertain whether the partner’s needs are taken into account, especially if they are not in a registered Civil Partnership[10].  


Sensitive allocation policies should be established to ensure that people are safe and secure in their home and not placed in a threatening environment. All care providers need to ensure that the rights enjoyed by opposite-sex couples are also provided to same-sex couples.

We believe mandatory equalities training is required for all staff in addition to a zero tolerance policy on prejudiced or discriminatory attitudes or behavior.


Ø  Management of care home closures


Age Cymru frequently receives requests for information and support from families of residents who are concerned about the impact of care home closures. Unfortunately there is not always good communication and consultation with residents and the community before decisions are made. We accept that some closures will be necessary or justified by service reconfiguration, however it is paramount that communication, engagement and consultation is made a priority in all cases and steps are taken to minimise disruption to residents.


Age Cymru Swansea Bay report that third sector organisations such as themselves are not normally consulted on closures, but are left to pick up the impact and support older people and their families, this should be addressed to ensure there is adequate consultation and joint working and with relevant third sector organisations on possible care home closures.


4.     The effectiveness of regulation and inspection arrangements


The need to improve regulation is an issue which is frequently raised with Age Cymru. We believe there are significant variations in how regional officers and inspectors work. Inspectors come from varied areas of expertise (social work, nursing, children or adults services, etc), and can often be inspecting services they have limited experience of. Prospect union has CSSIW members and have told us that there has been a move away from specialists to more generic inspectors in recent years and there is a shortage of expertise. Inspectors need better training to reduce the inconsistencies that currently exist.


Age Cymru Swansea Bay has also noted their belief that the quality of inspections need to be standardised, and more direct feedback from residents, family and professionals should be taken into account in making recommendations.


The Care Quality Commission in England have an ‘Acting Together’ project  in which people who have experience of using care services (‘Experts by experience’) take part in inspections services. Experts by experience spend time with inspectors to observe the care environment and identify good and bad care. Their findings are used to support the inspector’s judgment on the service and can also be included in the inspection report. We believe it could be a positive move to establish a similar procedure in Wales. Age UK have been involved in this work and Age Cymru would be pleased to work with the CSSIW on this.


Day centres and day services at care homes (such as respite care) remain unregulated. This does not seem logical and we are concerned that it may be resulting in some services being of poor quality. Older people accessing any care services should receive the same safeguards and monitoring on standards of services.


Additionally there is currently unnecessary duplication in some areas by CSSIW, Health Inspectorate Wales (HIW) and local authority inspection teams (who perform contract monitoring) which is putting pressure on care homes. For example, they all inspect CRB checks separately, even if another body has just completed this task. Better joint working could resolve this issue and enable all parties involved to work more efficiently.


We are concerned that some inspection reports are could be significantly improved and currently contain insufficiently robust requirements on homes to improve or rectify issues of concern. Below is an extract from inspection report in which inspectors identify numerous problems and unsatisfactory practices which are not sufficiently addressed by the new requirements and recommendations made. For instance, the inspector observed that some residents were brought down for breakfast and then left for four hours without being given food or drink but did not set any robust new requirements that would address this issue.









CSSIW Inspection report:
 Care homes for older people
 Planning for individual needs and preferences
 Inspector’s findings:
 Care planning documentation for service users seen on floors 1 and 2 did not detail how their continence needs should be managed. It would be expected that individual toileting regimes would be in place for specific service users in an aim to maintain and promote independence for as long as possible. For some service users it would be how incontinence would be managed i.e. types of pad etc. This was identified as a concern during the last inspection.
 • One care plan did not reflect that a service user required one to one nursing.
 • Risk assessments were in place for oral mouth care, however no care plan was in place for one service user who had a sore mouth and was taking only sips of fluid and another service user who was nil by mouth. 
 • Care plans for the prevention of pressure sores did not include the type of mattress and setting required for an individual and frequency of turning required.
 • The nurses daily records were kept in a separate file from the service users care planning documentation. This was poor practice and did not enhance the care planning documentation being used as a ‘live’ document which informed staff and improved care for the service user. It also demonstrated why the daily evaluations statements completed by the registered nurses did not always reflect the care plans.
 • It was noted that service users’ care planning documentation was stored on the nurse’s station in unlocked cupboards which did not comply with The Data Protection Act 1998.
 New requirements from this inspection:
 The registered person must ensure that an audit of service user plans is undertaken to ensure that they set out in detail, the actions needed to be taken by staff, to meet the health, personal, and social care needs of service users
 Good practice recommendations:
 Quality of life
 Inspector`s findings:
 The inspectors looked at the daily living routines such as timing of meals, supervision of service users, activities and how choice was promoted for service users. In terms of breakfast service, there was no evidence that service user’s needs or choices were considered. This was evidenced by:
 • 8 service users were seen at 06:40 hours in the main lounge area on floor 2; a carer indicated to the inspector that they had been in the lounge for at least 30 minutes. It was 10:10 hours before the last 2 service users of the 8 were assisted to eat breakfast, a wait of approximately four hours. There was also no evidence that one of these service users had been offered a drink during this time.
 • Some service users were slumped in their chairs and eating from a small table would not have been easy in that position. Service users also required prompting and orientation, as some were seen to be falling asleep during their meal, but this was not undertaken. One service user was seen sitting at the table for an hour with his cooked breakfast in front of him, but no staff assisted him. Another service user was served her breakfast in the hall area, she was noted to be asleep, however, the meal was still in front of her.
 New requirements from this inspection:
 The registered persons must ensure that service users’ nutritional needs are being met.
 Good practice recommendations:
 More use of the outside spaces should be facilitated for service users.

My Home Life Cymru has identified a need for mechanisms to provide better support to small homes in the independent sector as, unlike larger providers who have their own legal, finance and human resource teams; everything can rely upon the home manager. My Home Life Cymru is working to share good practice with networks of home, it is vital that information and good practice examples are shared across the sector to ease the pressure on managers.


Ø  The scope for increased scrutiny of financial viability of business models


It is a weakness of our current care system that the financial problems of a private company can cast a shadow of doubt over the long-term care and housing needs of vulnerable people. Regulations must be strengthened to ensure that inspected care homes can prove that they are financially viable and reduce consequent threats to the safety and wellbeing of residents.

Increased scrutiny over the financial viability of providers should be required, in addition to what they invest in the development and quality of the service that they provide, to ensure they are sustainable. 


One option is that if services are to be delivered by private companies, as a condition of operating in the market, they should have to enter into an insurance arrangement whereby the costs of failure can be absorbed, as proposed by Mark Drakeford AM.


We believe open book accounting is needed to safeguard older people and demonstrate financial security. Companies that are not able to show that they have a sustainable business model should not be allowed to run care homes. We know that another large provider (HCI) has taken over the majority of Southern Cross homes in Wales, and carried over many of the same staff, so it is vital that safeguards are increased to ensure the same crisis does not happen again.


In England, in the wake of the Southern Cross crisis, tighter regulations are being brought in by the Department of Health to prevent a repeat of the scandal. Companies wanting to take over the running of care homes could see their accounts probed by town hall accountants to ensure they have a robust business plan, and those continually in the red will be banned from taking over. Under the plans, experienced troubleshooters could be sent in to manage failing homes. We believe that the Welsh Government should also produce amended regulations to ensure that care providers operating in Wales are likely to provide sustainable care.


Community Health Councils


In the care home sector, the regulator has obligations to the provider, to the staff, to funders and to residents. We agree with Mark Drakeford AM that these interests are too often competing, and the voice of the user needs to be strengthened. The focus of Community Health Councils (CHCs) remains upon the experience of users but their remit has remained firmly confined to the National Health Service.  A positive move would be to extend the remit and responsibilities of CHCs in Wales to the social care setting. This would need to be done with legislation to give the same set of statutory rights which allow CHCs rights of access to NHS premises and services in both primary and secondary care.




5.    Models of care provision


Extra care schemes, sheltered housing, and retirement villages can all be excellent alternatives to residential care for some people. As discussed earlier, we believe extra care housing has a lot of potential and should be further developed.


The Eden Alternative[11] is a very positive model of care provision. The Eden Alternative is an international not-for-profit organisation dedicated to transforming care environments into habitats for human beings that promote quality of life for all involved. The Eden Alternative's principle-based philosophy empowers care homes to transform institutional approaches to care into the creation of a community where life is worth living, and could be replicated.


Paying for care


Reforming the care and support system is one of the most pressing political challenges today. In addition to ensuring that people receive quality services which protect their dignity, the current funding arrangements (and resulting resource shortages) require urgent attention.


It is widely acknowledged that the existing arrangements for providing care in Wales are struggling under increasing pressure and a lack of resources. The current system is felt to be too complex, inequitable and penalises savers and people with even modest assets. Quality of services, eligibility criteria and level of personal contributions vary significantly across Wales.


There are a number of convergent trends which clearly point to a significant level of unmet need within the current system.  These include the ageing population and the fact that local authorities have been tightening eligibility criteria over time.  In most local authorities people with low, moderate (and often substantial needs) do not receive any public support.


The issue of how we fund care services has seen a great deal of public and political debate in recent years, and reform must remain a priority for the Welsh and UK government. Any major reform of how care is paid for will need to be led by the UK Government as key areas such as taxation, National Insurance and welfare benefits are not devolved to Wales. The UK Government set up the Commission on Funding of Care and Support (the Dilnot Commission), which has reported with recommendations for reform. A White Paper on care is due to be published by the UK Government in early 2012, though it now appears extremely unlikely that it will address the issues of care funding,  and uncertainty still surrounds the issue of how any new system will be paid for. We are extremely concerned about the likelihood of delays as urgent care reform is needed now.


We welcomed the previous Welsh Government’s Social Care Charges (Wales) Measure 2010 as a way of eliminating some of the widespread inconsistency in local authority charging practices for non-residential care.   It is now vital that the Welsh Government continues to make improvements to our failing system for funding residential care, though we recognise that, given the levels of financial commitment involved, Wales remains to a degree dependent upon changes implemented at a UK level.


The Dilnot Commission recommendations


We believe that the Dilnot Commission recommendations set out a clear blueprint for long term sustainable reform of social care.  Though the Commission specifically looked at care in England, the situation in Wales is so similar that we believe the recommendations can read across to care funding here.


We and Age UK have repeated throughout this process that governments in Wales and England cannot afford not to reform care and that by investing in better essential services the Governments will save more in health, housing and welfare interventions. Setting a clear cap on contributions towards the cost of care would lift the fear and uncertainty for many, and help to protect people who have to meet extremely high charges in the current system. Whilst the recommended £35,000 cap is not insubstantial, the reality is that many people pay more than this currently for their care, and those that don’t are fearful they might have to.  The cap would provide increased certainty and encourage people to plan ahead. 


The Commission estimated that around a quarter of current 65 year olds in England can expect to reach the cap. It is very likely that it will only apply to people who spend a significant period of time in residential care, and is even less likely to apply to people receiving home care in Wales due to the Welsh Government’s Fairer Charging Measure which sets a maximum cap for home care charges of £50 a week.


Age Cymru also welcomed the proposal to greatly increase the means-test threshold to £100,000 beyond the current £22,500, which is felt by many to be far too low.  This is good news for many people, easing the concern about leaving assets as inheritance and the frustration of using assets for care fees.  In reality this threshold will only affect those people who need residential care, as it is a small proportion of older people who have more than £100k in savings and non-housing assets (which are all that are taken into account in home care charges). We also agree that there should be a taper so that the effect of a ‘cliff edge’ threshold is not so severe.


An information and advice strategy is urgently needed, and we agree with the Commission that it is critical that the public has access to better, easy-to-understand and reliable information and advice about services and funding resources.


We urge the Welsh Government to put pressure on the UK Government to bring forward proposals in 2012 and, following this, to implement significant changes to the paying for care system in Wales. We maintain that in the long term, as it becomes affordable, we believe the Welsh Government should abolish charging for any care provided through a community care assessment.




We hope these comments are useful to the Committee. We would be more than happy to provide further information as required, and would be pleased to give oral evidence.

[1] Further information on the Rule Out Abuse campaign can be accessed here:

[2] Home from home: A report highlighting opportunities for improving standards of dementia care in care homes, Alzheimer’s Society, 2007

[3] Ibid

[4] Protection of Vulnerable Adults Monitoring Report 2009-2010, CSSIW, 2011

[5] Further information on the Rule Out Abuse campaign can be accessed here:

[6] Dignity in Care Survey, Report to Gwynedd Council by Age Concern Gwynedd a Mon, Age Concern Gwynedd a Mon, 2011

[7] Home from home: A report highlighting opportunities for improving standards of dementia care in care homes, Alzheimer’s Society, 2007

[8] Dignity in Care Survey, Report to Gwynedd Council by Age Concern Gwynedd a Mon, Age Concern Gwynedd a Mon, 2011


[9] Dignity in Care Survey, Report to Gwynedd Council by Age Concern Gwynedd a Mon, Age Concern Gwynedd a Mon, 2011


[10] A report of the Older LGBT Network into the specific needs of older lesbian, gay, bisexual and transgender people, Older Lesbian, Gay, Bisexual, Transgender Network, Age Concern Cymru and Help the Aged in Wales, 2009.