Health and Social Care Committee

Inquiry into residential care for older people


RC52 – Care and Social Services Inspectorate for Wales



The National Assembly for Wales’ Health and Social Care Committee inquiry into residential care for older people December 2011


Submission by the Chief Inspector Care and Social Services Inspectorate for Wales




1.            The role of the Care and Social Services Inspectorate for Wales (CSSIW) is to encourage the improvement of social care, early years and social services by regulating, inspecting and reviewing services. We provide professional advice on care and social services issues to Welsh Ministers and policy makers. Our aim is to raise standards, improve quality, promote best practice and tell people about social care.


2.            Our work covers the whole of Wales. We review services at both a national and local level so we can tell the public whether services are up to standard; suggest ways of improving services, and help safeguard the interests of service users and their carers. We inspect and review the performance of local authorities on specific topics. We regulate and inspect services for everyone from the very young to older people. Our work can affect the lives of the majority of people living in Wales at some time in their lives.


3.            The population aged 65+ stood at 539,000 in 2008. This grew by 3.5% to 558,000 in 2010. Projections suggest that the number of people aged 65 and over will have grown by a further 10,000 in 2011. In 2009-10, we regulated more than 6,000 settings. Regulation includes registering services that wish to provide care and social services, inspecting the services, dealing with complaints about services, ensuring that they comply with the regulations and standards and taking enforcement action if services do not comply with the law. The settings (or services) we regulate include care homes for adults – including care homes with nursing facilities; domiciliary care agencies and adult placement schemes. At 30th September 2011, CSSIW had registered 23,318 residential care places for older adults, which were provided in 702 residential settings across Wales.


4.            In the last four years the number of adult residential care settings has decreased, but the total number of places has remained fairly stable. Across all adult care homes, there is a shift from personal care homes to care homes with nursing. The number of care home places without nursing have decreased by approximately 480 places, whilst settings with nursing care have increased by nearly 400 places. Domiciliary care services have also increased.




Process by which older people enter residential care and the availability and accessibility of alternative community based services, including re-ablement and domiciliary care


Process by which older people enter residential care:


5.            One main process is whereby service users are subject to an assessment of need and care plans are put in place by placing the responsible social services department.  Another method is where the service user and their family decide that residential care is the best option for them, and opt fund their care this way.  The proportion of self funding arrangements varies across Wales and across local authority areas. In all cases the residential care home is also required to carry out an assessment of need and confirm their ability to meet the identified needs of the person.


Availability & accessibility of community based services:


6.            The availability of community based services and domiciliary care provision is increasing, but can be inconsistent across local authority areas. Local authorities are responding to the need to modernise and change levels of community provision but the pace of this change is variable.  There are recognised challenges in the most rural areas to meet increasing and diverse needs in smaller communities where both transport and recruitment of workforce can pose difficulties.


7.            Re-ablement services are developing and are believed to be contributing to the improving trend of older people remaining in their own homes; however there is a lack of firm statistical evidence to confirm this.  


8.            The model of short term ‘step-up/step-down’ care within residential care homes is developing in some areas and is reported to be a successful re-ablement model with a large proportion of people returning to independent community living.


9.            A table providing information about the number of registered services across Wales by region from March 2008 – March 2011 is provided at Annexe 1. The number of registered services across Wales  provides evidence that the number of residential / personal care homes for older persons has been in gradual decline since 2008 and that the number of domiciliary care agencies has been steadily increasing.  








The quality of residential care and experiences of service users and their families – effectiveness at meeting diversity of need and the management of care home closures.


Voice of the Service Users


10.         CSSIW regularly engages with service users and carers to ascertain their views about the quality of the services that they receive.  This is usually done during the process of inspection, but service users and carers can also raise concerns with us directly.  Service users highlighted that they need appropriate support to have their voices heard. Whether they were actually heard, they felt depended on who was listening: some staff being better than others. They also reiterated that poor or no feedback have left individuals unsure about what will change after the event. Concerns were raised at wide-spread use of e-participation which would exclude a large number of service users. The carers group felt that managers were often defensive about any criticism of services, which deters complaints from service users and  carers as they don’t wish it to lead to confrontation as they ‘already have enough on their plate’


11.         CSSIW is undertaking a review of the way we handle concerns, safeguarding information and whistle blowing for services that we regulate and inspect. In January 2012, we will consult on proposals for a new guidance within CSSIW, that simplifies processes, creating a seamless front door approach for our customers and stakeholders; improves the timeliness of the service we deliver and practice that stays within the scope of our powers as regulators.



The quality of residential care services and the experiences of service users and their families


12.         From inspections and reviews of adult residential homes and local authority social services for older people, CSSIW have found that generally, the quality of commissioning adult social care is mixed, with some inappropriate admissions, particularly for people with dementia. There are a small proportion of regulated services that need to significantly improve and CSSIW is closely monitoring progress in achieving this


13.         In 2010, CSSIW conducted a series of engagement events, and published a report on the views of service users. Generally individual services are felt to be positive but there are certain issues that were common to all groups. The service users said that they want to be treated with respect and for staff to be accountable. They felt that sometimes staff forget that they are there to help service users.  Standards of personal hygiene, the cleanliness of the buildings and food hygiene were of particular concern in some areas, and it is clear that this has a big impact on the quality of life of the residents. There was concern about people with dementia being left alone, with employed carers frequently putting people to bed early as ‘an easy way to deal with them’ Some carers felt that in some instances,  is provided to suit the carer’s rather than the patient’s needs. Several carers raised issues with regards the physical needs of those they cared for in terms of having enough qualified people to handle those who physical difficulties at one time and also training in manual handling for carers not being suitable for a context in which they are the only person to hand.


14.         From April 2010 until March 2011 CSSIW undertook a thematic inspection of infection control standards in all care homes for adults across Wales and the report of our findings will be published shortly.  This followed a scoping study conducted in 2009. For the purposes of the scoping study, a 10% sample of care homes for older adults only, was selected, as this represented the largest category of care homes in Wales.  The majority of those visited were generally satisfactory.  A smaller number were found to be either excellent or poor.  Within the findings however the indications were that should an outbreak of infection occur,  the majority of homes would lack the capacity to prevent the spread of infection as this could be compromised due to the degree of poor facilities, equipment or practice. Inspectors made over 750 recommendations concerning the premises in which care was delivered and focussed on the provision of appropriate laundry and sluice facilities in properly sited areas; the management of clinical waste the maintenance and cleanliness of equipment used in the care setting and general upkeep and hygiene in the setting Carer’s also reported that the administering of medication could also be a cause for concern.   Many of the findings from this work indicate that there needs to be improvement in the quality of the environment that many service users live in.


Safeguarding and protection of vulnerable adults.


15.         CSSIW publishes a yearly monitoring report about safeguarding vulnerable adults. The most common victims of alleged abuse in Wales during 2009 -10 were older women. 36% of all the alleged victims of abuse were living in care homes at the point of referral. The proportion of the population living in care homes that were identified as alleged victims has increased over the last two years.


16.         Physical abuse is the most commonly referred concern, followed by neglect. Staff who care for older people made up the largest category of person alleged to be responsible for the abuse (42%) followed by relatives (27%).  These findings indicate the importance of minimising risk of harm, and ensuring the safety of residents of older peoples care homes.




Management of care home closures.


17.         The inspectorate can report that the closure of care homes has been generally well managed.  Some local authorities have decommissioned their own care home provision in favour of providing more modern, community based provision. Overall these changes have been well communicated and managed in local areas, although not always without meeting some resistance to the proposed changes.


18.         The escalating concerns protocol has provided a good framework for a multi agency approach to services that require improvement.  In some cases it has proved to be effective in stimulating and sustaining improvement.  In others it has provided a framework to manage a process of decommissioning and / or closure.


The capacity of the sector to meet demand in terms of staffing resources, including skill mix and access to training – the number of places and facilities and resource levels


Quality of staffing


19.         Inspection findings by CSSIW generally indicate that staff are trained and qualified in accordance with registration requirements.  The availability of suitable staff can be variable, and at times turnover can be high. 


20.         Training of staff for specialist situations is less good. Training and education in infection control, especially amongst managers was poor. The scoping study found that a number  of managers had never attended an update or training session in infection control, or had not attended any formal training or update in infection control within the last two years.  Evidence also suggests that staff and managers in care homes do not always keep up to date with the relevant research or Welsh Government initiatives.There is an identified lack of accredited training for care staff working with people with dementia needs as well as a lack of accredited management of medication training.


21.         There is now a requirement within the Care Home regulations (from October 2011)  that in order to be in charge of a care home managers must have obtained a specified level 5 qualification in management and be registered with the Care Council for Wales.   This is causing some tension in the sector.   The driver for this requirement has been a commitment by the Welsh Government to improve the quality of management and care delivery in care homes, recognising the pivotal role and responsibilities of the manager to achieve standards of excellence.


22.         CSSIW and the Care Council for Wales have also been developing a programme of collaborative working to be implemented in the next few years in response to Sustainable Social Services.  This programme will include pooling our knowledge and information about the social care workforce and should enable a better understanding of the staffing resources available in residential care for older adults.


Places and facilities and resource levels


23.         The number of registered care services and places available continues to change and evolve.   The population of people using residential care services has changed dramatically over the last 15 – 20 years with services now caring for older and more frail persons, often with complex needs.  Whilst the number of residential care homes has been reducing, many of those left in the market have changed or adjusted their service to meet these needs.  There has been a significant move from some providers towards adapting / changing service provision to care for the ‘elderly, mentally infirm ‘ (EMI) and to meet a growing need for dementia care services.   There are also moves in some areas to explore greater use of community health service support going in to care homes to avoid moving individuals to alternative care settings as their health needs increase towards the end of life.




24.         Through national reviews and inspections, and in providing policy advice to Ministers, CSSIW has collected evidence that a key factor affecting the provision of residential care for older adults is cost and sustainability.


25.         In 2009 the Care and Social Services Inspectorate Wales (CSSIW) undertook a review of the application of third party payments in Wales. Some independent care homes charge fees which are higher than the maximum amount that the local authority has set. This maximum amount is often referred to as 'the usual costs'. If Social Services contributes towards the care home fees, and the service user chooses to move into a home which charges a higher fee than the ‘usual costs’ then the difference between the two amounts is paid by a third party, usually a relative. The CSSIW review found that around 40 per cent of homes in our survey charged third party payments.  The view of service providers was that the fees paid by local authorities to care homes for older people did not cover the full costs to the care home of providing care, plus a reasonable profit margin. Provider groups representing the sector in Wales confirmed that the majority of their members stated that they charged third party payments due to the pressure on finances and the need to ensure that they remained financially viable as required by Regulation 27 of The Care Homes (Wales) Regulations 2002. Another reason given was that the payment reflected the difference between the local authority rate and the providers published rate and that the payment was charged to provide equity between local authority and privately funded service users; In some areas the local authority paid above the average fee rate yet providers still charged third party payments. The review also noted that there were regional variations in the number of homes in an area charging third party payments.


26.         The review engaged a number of service users, and CSSIW concluded that it is difficult to underestimate the impact of the practice of third party payments on both service users and carers. It potentially restricts choice when choosing long term care options and may restrict access to care based on affordability. It causes continuing confusion for both service users and carers at a time of stress.


27.         In January 2011, three care home companies were successful in obtaining a judicial review of the amount of fees payable to them by Pembrokeshire County Council. The providers challenged the decision of the council in relation to the fee rate for the year 2010-2011 as the fee set was insufficient to maintain their businesses.


28.         The Judge granted the challenge and set the local authority decision aside. The local authority decision was unlawful for a number of reasons one of which was the failure to appropriate local data in relation to the average number of care hours spent on each resident and  take into account local variations in staffing levels; it based its calculations on data from homes with 20 or more registered places and failed to take into account data from smaller care homes, which represent a significant proportion of the care homes in Pembrokeshire. This judgement, combined with the evidence of regional variability in charges and third party payments demonstrates that care services for the elderly cannot be sustainable in the long term unless there is a more collaborative approach to purchasing and commissioning. 


29.         CSSIW was involved, with others in helping to plan for continuity of care following the problems faced by Southern Cross care homes. Southern Cross had 34 of these homes in Wales caring for 1550 residents (about 6% of the Wales total) with 83% of these placed and supported by councils.  The problem faced by these homes had its roots in the pre 2007 financial market and a business model of purchase, sale and lease back of the care home properties that has become unstable because of rising rents, restricted fee levels from councils and a lower level of placements of older people. Local authorities have the statutory responsibility for protecting the interests of residents and for making contingency arrangements should they be necessary.  However, CSSIW found that at the time contingency planning by local authorities was not always sufficient to cope with the crisis. It is the view of CSSIW that robust and collaborative contingency planning for all residents placed by local authorities in the independent sector should be an essential part of commissioning.





Effectiveness of Regulation and Inspection arrangements, including scope for increased scrutiny of financial viability


30.         CSSIW is modernising its structures and its approach to regulation, inspection and enforcement and this includes a strong commitment to a more ‘people focused’ inspection. Inspectors have already adopted an approach that spends more time talking with service users and their families and observing care and interactions in practice.  The style of reporting is also being changed to ensure that the service user experience is more clearly reflected in public reports. New approaches to inspection are being developed for introduction in spring 2012 which will represent a leaner, smarter way of working and a move to outcome based rather than standards based inspection. Future inspections will have four themes, for all specific service areas. The themes will be mapped against the relevant current regulations and any applicable national minimum standards in order to demonstrate that inspecting against those themes is checking those statutory standards. The themes are:


·         Quality of life

·         Quality of staffing

·         Quality of leadership and management

·         Quality of environment


31.         The inspectorate is currently developing a quality measure for care homes that will assist in providing a national evidence based overview of care services across Wales.


32.         During 2011 the inspectorate has developed and piloted a risk assessment tool and is developing a quality and judgement framework for regulated services. This will provide an inspection report with clear judgements in each theme to inform everyone as to the quality and safety of the services provided under these themes.  A review of the categories of registration that have historically been in use has also been undertaken, with the assistance of Bangor University. This work will continue to be taken forward in conjunction with providers and the commissioners of services


33.         CSSIW aim to establish greater connectivity between ourselves and the community in which the regulated operate.  In 2012 CSSIW will recruit, train, support and manage lay assessors to undertake inspections, which will be incorporated in the inspection reports. Working with people who use services, providers of good quality services and commissioners of services, we also intend to establish quality panels with then as members to quality assure our reports.


34.         The CSSIW modernisation programme is overseen by a Stakeholder Board, which has a wide range of members external to the Welsh Government and includes Older People’s Commissioner, Care Forum Wales, Care Councils Wales, Association of Directors of Social Services Cymru, and the Children’s Commissioner.


35.         CSSIW has been in discussion with the Head of Finance in the operations division in the Welsh Government to explore how we can develop specialist expertise within the organisation to assist in the scrutiny of financial viability.  This is an area of growing concern and focus of attention for commissioners and regulators across the UK following the recent collapse of Southern Cross.


New and emerging models of care provision


36.         There are emerging models of community care provision integrating health and social care.  The Gwent Frailty Project which commenced operation and is continuing to develop is an example of this.   


37.         Community service models are beginning to provide services such as rapid response teams, intermediate care, step-up / step down care and domiciliary services that focus on re-ablement.


38.         Extra care housing schemes are also being commissioned in some areas, linked to the remodelling of services and closure of some residential homes.   Again this provision is very variable, with some local authority areas already well serviced by such provision.


39.         A small number of adult placement schemes are now also providing a service for older persons.


Balance of public and independent sector provision


40.         The balance of residential care provision has continued to shift away from public provision to the private and independent sector.










Annexe 1


Number of registered services across Wales by region from March 2008 – March 2011




Adult Residential

Total Older
(Adult Residential)

Domiciliary Care



Care Homes Older Adult

Nursing - Older Adult












North Wales




































Mid & South Wales




































South East Wales




































South West Wales