Response from the Older People’s Commissioner for Wales

to the

National Assembly for Wales, Health and Social Care Committee

on the actions taken to implement recommendations made in the Committee’s  report on residential care for older people and

 ‘A Place to Call Home?’

 

December 2015

 

 

 

For more information regarding this response please contact:

Older People’s Commissioner for Wales,

Cambrian Buildings,

Mount Stuart Square,

Cardiff, CF10 5FL

08442 640670

About the Commissioner

 

The Older People’s Commissioner for Wales is an independent voice and champion for older people across Wales, standing up and speaking out on their behalf. She works to ensure that those who are vulnerable and at risk are kept safe and ensures that all older people have a voice that is heard, that they have choice and control, that they don’t feel isolated or discriminated against and that they receive the support and services they need. The Commissioner's work is driven by what older people say matters most to them and their voices are at the heart of all that she does. The Commissioner works to make Wales a good place to grow older - not just for some but for everyone.

 

The Older People’s Commissioner:

	·        Promotes awareness of the rights and interests of older people in Wales.
	·        Challenges discrimination against older people in Wales.
	·        Encourages best practice in the treatment of older people in Wales.
	·        Reviews the law affecting the interests of older people in Wales.

 

 

 

 

 

 

 

 

 

 

 

 

Residential Care in Wales: where we are now

 

Welsh Government policy and recent legislation, such as the Social Services and Wellbeing (Wales) Act 2014, has increasingly focused on supporting older people to remain living independently in their own homes for as long as possible.  This is to be welcomed as the focus on reablement, prevention and wellbeing outcomes has the potential to be truly life changing for the individuals concerned.  However, it is also essential not to lose focus on ensuring that the 23,000 older people living in the 674 care homes across Wales have the best possible quality of life.

 

That is why I conducted my Care Home Review[1], which built upon the National Assembly for Wales’s, Health and Social Care Committee’s Inquiry into Residential Care for Older People in Wales. 

 

As you will be aware, there are many similarities in what we found: a lack of sensitivity to the needs of people living with dementia and their carers, a failure to recognise the importance of meaningful activities and purpose in older people’s lived experience, low levels of access to independent advocacy for potential and current residents of care homes, an inequality of access to NHS healthcare, wide variations in commissioning practices across Wales and a failure to recognise the care home sector as one of national strategic importance.  These themes have also been recognised more recently in the Flynn Review, John Kennedy’s Care Home Inquiry, the Commission On Residential Care, and ongoing work conducted by the Joseph Rowntree Foundation to enable older people to live better lives in long term care.

 

A fundamental shift in thinking and action is now taking place, which increasingly recognises the quality of life of older people living in care homes..  However, the level of cultural change required will not happen until it is recognised that the interactions and relationships between older people and the care home workforce are not only defined by care home managers and providers, but also by commissioners, inspectors and regulators, who are contribute and influence the culture of care through their actions and who will have duties to reinforce the new standards for care homes under the Regulation and Inspection of Social Care (Wales) Act 2016. A whole system approach aligned around quality of life is required in which all elements of the system understand their impact upon outcomes and have in place effective mechanisms and approaches to deliver the outcomes that older people have a right to.

 

It is for these reasons that I welcome the strong cross-sector endorsement of my Review and Requirements for Action, as well as the establishment of the Welsh Government’s Care Home Steering Group to provide leadership and ensure action is taken to address the issues identified by my Review and the reviews/research highlighted above.

 

Implementing the Quality of Life Model  

 

As outlined in my Framework for Action 2013-17, which sets out my priorities as Commissioner, I have a wide interest in the quality of health and social care and the impact that this has on the quality of life of older people.

 

Through extensive engagement with older people while developing the Framework, I developed my Quality of Life Model, which makes clear that older people have a good quality of life when they:

 

·        Feel safe and listened to, valued and respected

·        Can get the help they need

·        Can do the things that matter to them

·        Live in a place that suits them and their needs

 

When all of these things are achieved, older people feel that they have a voice, as well as choice and control over their lives, and that their lives have value, meaning and purpose.

 

Having the best possible quality of life is hugely important to everyone and it is essential that this is formally recognised and sits at the heart of the residential and nursing care sector in Wales.

 

I have therefore structured this response around my Quality of Life Model, indicating the extent to which I consider each outcome has the potential to, or will, impact upon the Quality of Life of care home residents, both now and in the future.  

 

 

What do we know about older people living in care homes?

 

As people are living longer, the average age of admission to a care home has risen  and the care home workforce are supporting increasingly emotionally and physically frail individuals who are often living with multiple coexisting health conditions. It is important to note that more than 70 per cent of all care home residents aged over 65 have a form of dementia, 1 in 3 people over the age of 85 are living with sight loss and 71.1 per cent of those over the age of 70 are living with hearing loss. People with advanced dementia will also often have sensory loss as a result of age-related eye conditions and/or damage to the brain caused by the disease.  By 2030, the proportion of the UK aged over 85 is expected to double and, as a result, there will be a significant increase in the number of people living with dementia and sensory loss in care homes in Wales.

 

Evidence from my Care Home Review and other research/reports, as well as the work of the regulator and inspector, is clear that the care home system is not yet equipped to meet the increasingly complex needs of older people. This is brought sharply into focus by the inappropriate use of antipsychotics within residential and nursing care homes to control the behavioural and psychological symptoms of people living with dementia, the impact of which is made clear by the quote below

 

Evidence that the care home system in Wales is not yet equipped to meet the increasingly complex needs of older people is most sharply brought into focus through:

 

‘When she was at the Home she was sedated all day and every day. It was explained that since there were not enough staff it made handling and managing her easier. We didn’t want this. It appeared that they were treating her as though she was without significance, without a history…’[2]

 

Whilst this quote, which was included in my Care Home Review report, is from a family member talking about events that happened some time ago, the issues are still as relevant today.  This is one of many reasons that embedding quality of life and a rights-based approach to care delivery is so vital.

 

The impact of failing to deliver Wales’s intent to put quality of life at the heart of our care home system remains significant for too many older people. The test of the very significant actions now underway must therefore be the impact upon the quality of life of older people living in care homes in Wales.

 

A rights based approach

One of the opportunities I do not believe we have yet sufficiently understood or begun to use as a mechanism is the use of a rights based approach in residential care (see section under Outcome 3: I can do the things that matter to me). In 2014, the Welsh Government launched ‘A Declaration of Rights for Older People’, and while this has no legal status, it is evidence that the creation of a Wales where older people can enjoy their rights, and live free of abuse, neglect, ageism and discrimination, continues to be of significant importance. Additionally, the Senedd is the first legislature in the UK to place the UN Principles for Older People on the face of legislation, a beginning for Wales to build upon, but not sufficient..  On Human Rights Day this year, I therefore called for a single piece of legislation to be created that would bring together a number of internationally recognised instruments designed to protect older people’s rights and address any gaps that are identified. This legislation would create specific duties for public bodies and ensure that they adopt a rights based approach to service delivery.

To take this work forward, I have brought together a group of experts from across the public, legal and third sectors, as well as older people, to support my work to determine what could be included within the proposed legislation and how it would work in practice. The findings of the expert group will be presented to the new Welsh Government in 2016.

 

Embedding rights-based duties and empowering older people to claim their rights is a powerful tool to drive out unacceptable care and embed good practice so it becomes standard practice.

 

 

Outcome 1: I feel safe, listen to, valued and respected

 

There has rightly been much focus on adult safeguarding within the care home sector and this is something to be welcomed.  Whilst this is a positive step forward, older people tell me that action is still not always taken quickly enough to remedy poor care, that poor care is tolerated that and no-one seems to be held to account when things go wrong.  I am therefore particularly encouraged by three areas of work, which aim to protect older people from abuse and neglect more effectively:

 

Fitness to own a service

A key aim of the Regulation & Inspection of Social Care Bill is to ensure a more robust approach to accountability for poor care.  In addition to those working within a service, accountability must also extend to owners of care homes.  The inclusion of a ‘fit and proper person’[3] test on the face of the Bill is intended to ensure that those who provide services that have closed because of significant poor care are prevented from providing services in the future.  Whilst proposed amendments to ensure that the ‘fit and proper person’ test would be applied to anyone who has authority to give orders within services were not included within this Bill, I have been assured that this test will also apply to the owners of services, in addition to the Registered Individual. 

 

Registration of the social care workforce

Requirement for Action 5.7 in my Care Home Review called for the registration of residential care workers to bring parity to the way in which we safeguard vulnerable people.  Workforce registration, through its link to mandatory training, is vital to ensure that people working within the sector have the right skills and know what is expected of them, and that those providing poor care are excluded from working within the system.  I therefore welcomed the Minister’s statement to extend workforce registration for adult care workers from 2020 onwards and I look forward to receiving information on the detail of plans to upskill and drive up standards within the unregulated workforce in the short term to provide me with further assurance (see workforce training).

 

New safeguarding legislation

The placing of adult safeguarding on a statutory footing in the Social Service and Wellbeing (Wales) Act 2014 was a significant and important step forward, notwithstanding the concerns I have expressed about the definition of safeguarding within the act.

However, in order for its potential to be realised, it is crucial that the underpinning regulations and associated action fully understand the nature of abuse faced by older people living in care homes, in particular fully understanding the scale and impact of emotional neglect, with this recognised as a form of abuse. It is also crucial, as highlighted by the Flynn Review and within my own casework as Commissioner, to recognise that behind many safeguarding and serious case review issues is an individual living with dementia, an individual often unable to make their voices heard, This highlights the key role of independent advocacy and the importance of rights based duties, both of which will strengthen safeguarding in Wales.

As with any policy or legislation, the ultimate measure of its success will be the extent to which it keeps people safe and protects them from abuse and neglect.  I will therefore continue to pay close attention to the impact of these areas of work, in particular the publication of the Statutory Guidance under Part 7 of the Social Services and Wellbeing (Wales) Act 2014, and will work to ensure that the revised Escalating Concerns Guidance is embedded within secondary legislation under the Regulation and Inspection of Social Care Bill.

 

Access to independent advocacy

The Social Services & Wellbeing (Wales) Act 2014 gives an explicit commitment to enable people to make their own decisions and control their own lives, and to provide help to ensure people’s voices are strong, clear, listened to and acted upon. This is reflected in the National Outcomes Framework that is now being implemented. As part of the Welsh Government’s response to this aim, the Act brings in a statutory entitlement to independent advocacy. Notwithstanding my strong welcome for the National Outcomes Framework, I have significant concerns that the Code of Practice on Advocacy[4] places significant hurdles in the way of some individuals – for whom advocacy is essential if they are to be safeguarded and have choice and control over their lives – to access independent advocacy and achieve the outcomes they have a right to. I am particularly concerned that older people should have a right to be offered independent advocacy when a care home is closing, when a person is moving from hospital into a care home, and when a person is at risk of abuse and neglect. 

 

Alongside the issue of ‘the offer’ to older people, I also have concerns regarding the availability of independent advocacy. Responses to my Review from Local Authorities and providers highlighted that there is currently a lack of consistency in the availability of independent advocacy.  Whilst I was pleased that Local Authorities showed a commitment to delivering my Requirement for Action, a number of Local Authorities and providers highlighted their inability to access independent advocacy as a significant barrier. 

 

Whilst responses to my Review showed that independent advocacy seems to be offered in relation to safeguarding, it is not always offered in relation to care home closure and transition from hospital. Additionally, responses indicated that there is a lack of understanding in relation to the benefits of independent advocacy amongst some providers: a number of Care Home Managers stated that they are best placed to provide independent advocacy on behalf of their residents. 

 

Reviewing access to and use of independent advocacy will remain a key area of interest in my work. 

 

 

 

Outcome 2: I can get the help I need when I need it in the way that I want it

 

The primary focus of my Care Home Review was on quality of life, including how the standard of care and access to services impacts upon this.  During my Review, older people told me that staff often lacked the skills needed to meet their needs and that the importance of how things are done was overlooked all too often. Too many older people living in care homes are unable to access basic services and support.   

 

Mandatory staff training

Whilst workforce registration makes provision for mandatory training, which will be extended to the currently unregistered workforce from 2020 onwards, it is important to also address the variable levels of training that exist for the current unregulated workforce.  Present basic mandatory training for care staff, which consists only of manual handling, fire safety and health and safety training, does not sufficiently prepare individuals to understand the needs of older people and provide the appropriate support. Furthermore, as highlighted by my Care Home Review, a significant number of care staff (estimated to be 40% of the workforce[5]) are delivering care without even this most basic of training. 

 

In response to this, a number of my Requirements for Action in my Care Home Review related to staff training.  The Welsh Government’s updated response to my Care Home Review stated that, rather than developing interim new training provision, they intend to map the training that already exists and also consider existing research. The intent is to address variations in the quality of and access to training by setting out a framework using evidence based approaches and enables signposting to appropriate training provision.  I welcome this as it will help to ensure that providers know where to source good training that will be aligned to a new Framework being developed by the Care Council for Wales. 

 

Additionally, the Welsh Government stated that they will work with the Care Council and Care Forum Wales to determine whether there could be agreed outcomes for training the workforce that would standardise qualifications in relation to dementia training, in response to Requirement for Action 3.1. 

 

However, achieving the outcome of all care home staff understanding the physical and emotional needs of older people living with dementia will only be met through ensuring that Requirement for Action 3.2, which called for mandatory dementia training for all care home staff on induction and for care home managers to receive additional training, is fully implemented.  I was therefore reassured to note that many providers were proactively responding to the areas specifically in relation to dementia training and dementia champions, as set out in Requirements for Action 3.2. and 5.5 respectively. 

 

Dementia and frailty

Currently, the social care workforce is ill-equipped to understand the impact of dementia felt by people living with the condition and their families.  As a consequence, older people do not receive the care and support that they need to sustain their physical, emotional and mental wellbeing.   This is not to negate the steps that public bodies, the third sector and independent providers have taken in response to my Requirements for Action to ensure that the vital role of the care home workforce is recognised and valued, that all staff working in care homes understand the physical and emotional needs of older people living with dementia and that assumptions about capacity are no longer made.

 

Requirement for Action 3.1 called for a national training programme to enable staff to better understand the needs of people living with dementia.  I therefore welcome the positive examples of this work, which include the development of a ‘Learning and Development Framework’ by the Care Council for Wales to support the workforce to support people living with dementia, as well as a DVD and learning resources that clearly demonstrate the importance of the Welsh language to individuals living with dementia and the impact of positive and negative experiences of care.  Additionally, I welcome the development of a similar framework for use within healthcare settings and I have received assurances that this work is being taken forward collaboratively with the outcome of a single framework.

 

 Physical Health

 

My Review found that many older people are not having their basic physical health needs met. I identified significant issues in relation to oral health, sensory loss, and preventative care, for example in relation to falls. All of these impact significantly upon the quality of life of older people living in care homes.

 

1 in 3 older people, for example, are affected by malnutrition upon entry into residential care and if their diets are not properly managed, the clinical consequences can include impaired immune response, reduced muscle strength, impaired wound healing, impaired psycho-social functioning and impaired recovery from surgery. Recent publications[6]^,[7],[8] have also shown that care home residents are five times more likely to be dehydrated than individuals living in the community with this risk increasing for individuals living with dementia.

 

I welcome the Welsh Government’s intention to ensure a sustained focus and improvement in relation to the physical health and mental well-being of older people living in care homes, and I look forward to receiving updates about progress being made in the following areas: the national plan for primary care, the review of enhanced GP services and the new holistic admissions assessment of residents’ mental and physical health that will be provided within 28 days of admission into a care home. 

 

Additionally, I also welcome the Ministerial commitment to include standards of care for integrated and co-ordinated physical care, including sensory deficits, oral health, dietary wellbeing, physical exercise, mental health, social interaction and preventative care, within the new regulations that will underpin the Regulation and Inspection of Social Care Bill.

 

 

 

Another concern highlighted by both my Review Care Home Review and the Flynn Review was the inappropriate use of antipsychotics to control the behavioural and psychological symptoms of people living with dementia, a direct breach of NICE Guidance.  I therefore welcome the fact that all health boards have agreed to publish information on the use of antipsychotics in care homes in Wales in response to my Requirements for Action 3.5. This will provide a previously unavailable data source that will make clear the extent of antipsychotic use within care homes, essential to support the delivery of change to improve the lives of older people.

 

Access to healthcare

My Care Home Review stated that in terms of access to the most basic of health care, such as GPs, dental care, dieticians, access to sensory loss screening and reablement services to sustain and improve an individual’s physical, emotional and mental wellbeing, a move to a care home should be treated as nothing more than a change of address. However, a fundamental inequality in access to healthcare exists for a significant number of care home residents, which has a profound impact upon their quality of life.

 

I included a number of Requirements for Action in relation to this and I particularly welcome the Welsh Government’s commitment to develop a ‘National Statement of Entitlement' to be included in care homes in response to Requirement for Action 4.1. This will give providers, family members and older people a clear means to challenge inequalities in service delivery, as well as confirmation that the National Health Service is still required to meet their needs irrespective of the place they call home.  The ‘National Statement of Entitlement' will be included as part of the Welcome Pack provided to new residents by each care home (Requirement for Action 1.2 sets out the need for all care homes to provide a Welcome Pack to residents).   

 

I am pleased that Health Boards, in their responses to my Care Home Review, provided real assurances that Requirement for Action 3.4, which called for in-reach multidisciplinary specialist mental health and wellbeing support to be made available for all older people in care homes, will be met.  The examples below clearly demonstrate the seriousness with which all Health Boards took this Requirement for Action:

·        Cwm Taf University Health Board have committed to publishing an annual report from the recently established Mental Health Support Team (which has been designed to support and build the knowledge and skills of care home staff). This report will include information on the service’s progress, future development needs, and case studies, as well as information about the quality of these services for individuals living with dementia in care homes.

·        Abertawe Bro Morgannwg University Health Board has committed  to work with GPs to review the numbers of patients prescribed antipsychotic drugs.

·        Aneurin Bevan University Health Board has a dedicated care home pharmacist and has committed to review its in-reach mental health services and take action to enhance services if that is deemed necessary.

 

 

Outcome 3: I can do the things that matter to me

 

A simple concept needs to be reclaimed across residential care: it is not just about being safe or having physical needs met, essential as these are, it is also about having the best quality of life, in whatever way that is defined by an individual older person.  Being able to do the things that matter to them, being treated in a way that encompasses compassion, friendship and kindness needs to sit at the heart of and as rights within our new emerging system.

 

A rights based approach

I have repeatedly stated throughout pre-legislative scrutiny that the Regulation and Inspection of Social Services Bill must be about people and it is therefore important that information is available on how the rights of older people are upheld.    Public bodies, and individuals acting on their behalf, are key to ensuring that people’s rights are made real.  I welcome the fact that CSSIW are developing a human rights based framework to sit alongside their inspection framework, which will embed a human rights based approach within their work, setting a bench mark for unacceptable care.   Additionally, I welcome the duty to on CSSIW report against the UN Principles for Older Persons under Section 42 of the Regulation and Inspection of Social Care Bill.   

 

New regulatory standards

The importance of responding to emotional frailty, supporting individual identity and ensuring that high-quality, dignified and respectful care and support is consistently delivered in care homes must sit at the heart of the new regulatory standards for independent providers if we are to make a difference to the lives of older people living in residential care.

 

I have maintained that the definition of care contained within the Regulation and Inspection of Social Care Bill is old-fashioned and focuses on a task-based approach. However, I have been assured that the Definition of Care under Section 3 of the Bill serves to provide a parameter to ensure that services do not unintentionally fall within the regulatory regime, rather than refer to the standard of care.  Instead, the regulations under Section 27 of the Bill will set out the quality of life and standard of care, as well as prescribing service specifications. 

 

It is vital that the Regulations on Regulated Services embed quality of life as the standard that services are required to meet in addition to quality of care.  The regulations must set out clear quality standards that CSSIW can inspect against, to ensure that care homes are places of belonging and significance, and that the risks of institutionalisation, often characterised by an inappropriate use of antipsychotics and a failure to recognise the emotional neglect of older people, are eradicated.  These regulations are central to this Bill and I have expressed concern that they are yet unseen.  I look forward to working with the Welsh Government to inform the development of these regulations. 

 

 

 

 

 

 

Outcome 4: I live in a place that suits me and my life

 

One size does not fit all, even across good care homes. A home that might suit one individual’s life might not suit another.

It is very difficult for older people to judge the quality of care and support received or planned because of a lack of meaningful, accessible and understandable information and they place their trust in the system that wherever they choose, they will be safe and well cared for. It can often feel like navigating through a maze of different reports that can be opaque and inconsistent, which makes it difficult for individuals to make decisions that are appropriate for them and to raise concerns and complaints.

 

Ensuring a robust inspection process 

I recognise from my conversations with older people and the case support that I provide, that many negative experiences with health services are fundamentally down to a need for a more integrated health and social care system.  Requirement for Action 6.4 called for an integrated system of health and social care inspection to provide effective scrutiny in respect of the quality of life and healthcare of older people in residential and nursing homes.   I will therefore continue to follow the progress of the NHS Quality Green Paper as it develops to ensure that the inspection process, irrespective of the structures of regulatory bodies, ensures that all aspects of care homes are fit for purpose.     

 

I welcome the fact that CSSIW are developing a human rights based framework to sit alongside their inspection framework, which will embed a human rights based approach within their work and set a bench mark for unacceptable care.    Requirement for Action 1.5 of my Care Home Review called for an explicit list of ‘never events’ to be developed to clearly outline the practice that must stop immediately. I am therefore pleased that CSSIW will be taking this forward by ensuing that human rights will be a fundamental element of their future inspection regime and that where unacceptable care is identified, “enforcement action will be triggered”[9].

 

Requirement for Action 6.3 of my Care Home Review called for lay assessors to be used on an ongoing basis, as a formal and significant part of the inspection process.  Whilst Section 41 of the Regulation and Inspection of Social Care Bill includes a general duty to engage the public in the inspection process, this does not sufficiently meet my expectation of a real and meaningful citizen role in the inspection process.  Whilst I welcome the establishment of CSSIW’s National and Regional Advisory Boards to provide scrutiny at a strategic level, this is in no way equitable to the information that could be captured from lay assessors about the real and lived experiences of care home residents in Wales.

 

Requirement for Action 6.9 listed a number of areas that I wanted to see reported on in the Chief Inspector’s Annual Report.  I welcome the fact that the CSSIW Annual Report must report against the well-being of people who use regulated services, as well as the duty to report against the UN Principles for Older Persons.  Whilst Section 42 of the Regulation and Inspection of Social Care Bill makes provision for other information to be included within the report, as there are no regulations under this Section, I cannot be assured that my Requirement for Action will be implemented in full at this point.  However, I am pleased that the regulations under Section 56 of the Bill, which will prescribe the content of the Local Authority Annual Reports, will now be subject to the affirmative procedure.   Requirement for Action 6.7 of my Care Home Review sets out the information that I want to see reported on by Local Authorities and I look forward to working with the Welsh Government to take this matter forward.  

 

Providers have been clear with me that too often they are unable to access the support they need to move them away from a position of unacceptable risk or care. Many commissioners invest significant resources in propping up ‘failing’ homes. It is therefore essential that practical support is in place that can be drawn upon to quickly turn around failing homes at an early stage.   Requirement for Action 5.6 of my Care Home Review called for a National Improvement Service to provide expert support and guidance to providers and commissioners to drive up the standards of care homes in Wales, work that the Welsh Government has already initiated through the establishment of its Care Home Steering Group.  I therefore welcome the Welsh Government’s commitment to working with key stakeholders and myself to further explore a national approach in response to this Requirement.

In addition to a robust inspection process that embeds quality of life at its heart, it is important for care homes to communicate effectively about the service that they provide in addition to their inspection reports.  I am therefore pleased that the regulations that will prescribe the content of the provider Annual Returns under Section 10 of the Regulation and Inspection of Social Care Bill will now be subject to the affirmative procedure.  Requirement for Action 6.10 of my Care Home Review sets out the information that I want to see reported on by providers to ensure that these reports provide older people with the information that they need.  I look forward to working with the Welsh Government to ensure that my Requirement for Action is reflected and to ensure that the regulator provides a view on the accuracy of the annual return. Without this, it will not be possible to challenge the new indictable offence of false descriptions or false statements.   I am pleased that a technical group looking at this issue will be established early in the New Year and that I will be invited to be involved in this work.

 

Commissioning to deliver quality of life

I have repeatedly made the point about the crucial nature of commissioning. The quality of life and care of older people living in care homes in Wales should therefore be at the heart of the commissioning process and at the front of all commissioning decisions. Cost, particularly where price raises questions about the providers’ ability to meet the individuals care and support needs, should never be the primary driver in the selection of an individual’s new home.  I do not yet believe that the changes required to commissioning are reflect sufficiently within or throughout the breadth of system change taking place.

Requirement for Action 6.1 of my Care Home Review called for a single outcomes framework to be used in the commissioning, regulation and inspection of services and I therefore welcome the requirement in the Regulation & Inspection of Social Care Bill for Local Authorities to report against the extent to which they have acted to deliver the wellbeing outcomes set out by the Social Services & Wellbeing (Wales) Act 2014.  However, these are high level and do not provide the consistent framework that is required.  This is a particular concern given that in parts of Wales quality of life is beginning to be embedded within commissioning.

For example, as a result of their quality of life commissioning framework, Flintshire County Council has developed an Action Plan, “A Place to call Home – A programme for Change”, that sought to stimulate social interaction and communication in care homes, that promoted meaningful interactions between carers and residents that was based around the shared experiences that make people laugh and learn together.    This initiative, which has a particular focus on understanding the needs of people living with dementia, will help to enable paid carers to see beyond the resident as someone to be cared for, seeing them instead as individuals with feelings, interests and an identity.,. 

 

I expect Welsh Government to extrapolate learning from the commissioning framework that sits behind this to inform the new regulatory standards under Section 27 of the Regulation & Inspection of Social Care Bill to ensure that there is one defining standard of quality in Wales, in line with my Requirement for Action 6.1.

 

The introduction of a National Living Wage will place further financial challenges upon commissioners.  Requirement for Action 5.8 of my Care Home Review called for a cost-benefit analysis of the terms and conditions of care staff in care homes.  I therefore welcome the fact that the Welsh Government is currently developing an assessment of the impact that the National Living Wage will have on the sector, due to be published in 2016.  My expectation is that this will provide evidence for the development of policy proposals to improve the recruitment and retention of the care home workforce, in line with the work that the Welsh Government has already commissioned to understand and improve the recruitment and retention of staff within the domiciliary care sector.

 

Effective workforce planning is also essential to delivering high quality care that gives older people living in care homes the best quality of life.  The ability to recruit and retain specialist staff, especially Registered Mental Health Nurses and Care Home Managers, is a significant barrier within the sector.  Requirement for Action 7.2 of my Care Home Review called for NHS workforce planning projections to include the need for nurses within care homes.  Whilst I welcome the Welsh Government’s commitment to use the Integrated Medium Term Plans as a means of planning for the future staffing needs of the NHS in Wales, as well as for the Independent Sector from October 2015, a focus on the whole sector will be needed to ensure that an integrated approach to the planning, recruitment and retention of staff in care homes is embedded across all Health Boards in the face of NHS staffing shortages.  It is for this reason that I welcome the establishment of the Care Home Steering Group’s Workforce Workstream, which will aim to deliver its work programme by November 2016.Without the correct workforce – the right number of staff, with the right skills, in the right places – care home provision will continue to be unstable and unable to meet the needs of older people, both now and in the future. I will continue to support this work but will also closely monitor its efficacy (see also market provider base below).

 

The importance of the market/provider base

My Care Home Review highlighted that the lack of a strategic overview to ensure appropriate care home places has a negative impact on the care received by older people living in residential care.  At best, the lack of capacity within the sector restricts the choices available to people, resulting in people having to move away from their family or live in a care setting that is not entirely appropriate for their needs.  At worst, the lack of care home provision results in instances where care homes that are delivering poor care remain in operation as there is simply nowhere else for the residents to live. 

 

Provisions made within the Regulation and Inspection of Social Care Bill, together with the Market Analysis Workstream led by the Welsh Government, provide some assurance that the need to ensure an appropriate provider base will be addressed.  It is essential that these two areas of work reflect the detail in Requirement for Action 7.1 of my Care Home Review and that there is an action plan to ensure demand is met, both now and in the future.  The Requirement sets out the information that needs to be included in any future plans to ensure the supply of high quality care homes.  I therefore welcomed the inclusion of the requirement for Welsh Ministers to consult before drafting regulations under Section 63 of the Regulation and Inspection of Social Care Bill and I looking forward to working with officials on this matter.  In addition to this, however, and for change to be delivered, Welsh Ministers must also make a statement on when and how they will meet any recommendations contained within the National Market Stability Report. 

 

Conclusion

 

It is clear that there are significant changes underway and action being taken within Wales that are aimed at creating a focused and more joined up care home system. Much of the detail that will make real for older people the opportunities afforded by these new approaches and structural devices has yet to be developed. It is important that these continue to be scrutinised so that their potential is delivered.  

 

It will take time, perhaps even a decade, for the work that is underway to deliver the change required and have the impact I expect upon the lives of older people living in care homes in Wales. In the interim, we must not lose focus on the people who today live in our care homes and experience an unacceptable quality of life. I am encouraged by the growing good practice I have seen and early work in anticipation of the new legislative and system frameworks, but I am concerned that we are not yet doing enough to roll out and support commissioners and service providers to make this good practice standard practice.

 

It is, ultimately, all about impact. It is about ensuring older people are safe, listened to, feel valued and respected, can do the things that matter to them, live in a place that suits them and their needs and can get the help they need, when they need it in a way that they want it.

 

That is why will undertake a follow-up Review in 18 months’ time to look at the progress that has been made in specific areas.  This will include looking for evidence of the impact upon older people’s lives of the action taken as a result of my Review and Requirements for Action.

 

Ends

 

 

 

 

 

Annex A – Commissioner’s Statement on Care Home Review (Published 11 August 2015)

 

In November 2014, I published ‘A Place to Call Home?’ the findings of my year-long Review into the quality of life and care of older people living in care homes in Wales.

 

Whilst I found examples of great care and support being provided across Wales, and older people living in homes that truly lived up to the meaning of the word home, I also found that for too many older people their quality of life was unacceptable.

 

Alongside the publication of my Review report, I therefore wrote to all Local Authorities, Health Boards, CSSIW, Welsh Government, Care Council for Wales and care home providers outlining the action I expect to see taken to ensure that the best care and support I found becomes the standard for Wales. All of these bodies responded to me, detailing the action they would take to deliver the outcomes my Review focused on.

 

Through this statement I am today publishing my analysis, based on the evidence provided to me, and my assessment on whether the bodies who are subject to my Review will deliver the action allocated to them.

 

I am currently analysing the responses received from care home providers and I will make a statement in November that provides an overview of these responses, one year on from the publication of my Review Report.

 

Across Wales there was recognition that my Review report painted an accurate picture of life in care homes in Wales today. Despite my report making for hard reading, it was welcomed by all of the bodies subject to it and they gave a commitment to ensure that the outcomes and the changes that I called for were delivered.

 

Responses

 

Each body subject to my Review responded to specific Requirements for Action. In analysing their responses, my team looked for evidence that the outcomes included in those Requirements for Action would be delivered.

 

Local Authorities

 

Local Authorities submitted clear information that has provided me with sufficient assurance that they are committed to meeting my Requirements for Action and delivering the intended outcomes by the deadlines stated. The majority of the responses to each Requirement for Action have been rated as acceptable, with no responses being rated as unacceptable. It is also positive to note that a number of Local Authorities submitted joint responses outlining how they will work in partnership with other Local Authorities and Health Boards to deliver the intended outcomes.

 

Responses to a number of my Requirements for Action (RfA) were particularly positive:

 

RfA 1.6 - Independent Advocacy – older people living in care homes that are closing as well as older people who are at risk of or are experiencing abuse will have access to independent or non-instructed advocacy.

 

RfA 3.3 - Befriending - older people will be supported to retain their existing friendships and have meaningful social and/or cultural contact, both within and outside the care home.

 

RfA 6.7 - Annual Quality Statements – older people will have access to relevant and meaningful information about the quality of life and care provided by or within individual care homes, essential to create a more open and transparent system.

 

In a small number of cases, responses have been rated as partial, specifically in relation to dementia training (RfA 3.2) and using feedback from older people to drive continuous improvement (RfA 6.2). Feedback has therefore been provided that offers further guidance on how the Local Authorities can deliver the intended outcomes.

 

Health Boards

 

Health Boards have shown a genuine commitment to improving the provision of services, creating plans for change that provide me with sufficient assurance that they will meet my Requirements for Action and deliver the intended outcomes.

 

The majority of responses to each Requirement for Action have been rated as acceptable, with no responses being rated as unacceptable. It is also positive to note that a number of Health Boards submitted joint responses outlining how they will work in partnership with the Local Authorities in their area to deliver the intended outcomes.

 

Responses to a number of my Requirements for Action were particularly positive:

 

RfA 1.3 - Specialist Care Home Continence Support – older people will be better supported to maintain their continence and independent use of the toilet and have their privacy, dignity and respect accorded to them at all times.

 

RfA 3.5 - Information on the Use of Anti-psychotics – information will be published annually about the use of anti-psychotics in care homes, which can be used to ensure that people are not being prescribed anti-psychotic drugs inappropriately.

 

RfA 4.3 - Understanding Health Needs - care staff will understand the health needs of older people and when and how to access primary care and specialist services.

 

In a number of cases, responses have been rated as partial, specifically in relation to medication reviews (RfA 4.4), using feedback from older people to drive continuous improvement (RfA 6.2) and developing a nursing career pathway within care homes (RfA 7.3). Feedback has therefore been provided that offers further guidance on how the Health Boards can deliver the intended outcomes.

 

Care Council for Wales

 

Care Council for Wales has provided me with partial assurance that they will meet my Requirements for Action and deliver the intended outcomes by the deadlines stated as their responses were rated as either acceptable or partial. No response was rated as unacceptable.

 

Of the four Requirements for Action that the Care Council was subject to, two were rated as acceptable:

 

RfA 5.4 - mandatory induction and on-going training programme for care staff – improved induction and training will ensure that older people receive compassionate and dignified care that responds to them as an individual.

 

RfA 6.11 - national, competency based training programme for commissioners – older people will be placed in care homes that can meet their needs by commissioners who understand the complexities of delivering care and are able to challenge providers about unacceptable care of older people.

 

Two of the responses were rated as partial, specifically in relation to developing and implementing a programme to recruit and train future care home managers (RfA 5.1) and developing and implementing a standard set of mandatory skills and values based competencies for the recruitment of care staff (RfA 5.3). Feedback has therefore been provided that offers further guidance on how the Care Council can deliver the intended outcomes.

 

CSSIW

 

The response from CSSIW provided me with only limited assurance that they will meet my Requirements for Action and deliver the intended outcomes as their responses were rated as either partial or unacceptable.

 

Of the four Requirements for Action that CSSIW was subject to, three were rated as partial (RfA 1.5 - development of an explicit list of never events, RfA 6.2 - using feedback from older people to drive continuous improvement and RfA 6.9 – information about quality of life in the annual report) and one was rated as unacceptable (RfA 6.3 - using lay assessors as part of the inspection process.

 

Feedback has therefore been provided that offers further guidance on how CSSIW can deliver the intended outcomes.

 

Welsh Government

 

The majority of responses by the Welsh Government to each of my Requirements for Action failed to provide adequate detail to assure me that the intended outcomes will be delivered.

 

The Welsh Government did demonstrate a commitment to developing a national approach to care planning (RfA 1.1), improving continence support in care homes (RfA 1.3), developing good practice guidance related to mealtimes and the dining experience (RfA 1.4) and developing new safeguarding arrangements that explicitly recognise emotional neglect as a form of abuse (RfA 3.6). However, it is extremely disappointing that of the 21 Requirements for Action that the Welsh Government was subject to, only these four responses were rated acceptable, with six rated partial and 11 rated as unacceptable.

 

Feedback has therefore been provided that offers further guidance on how the Welsh Government can deliver the intended outcomes.

 

Conclusion

 

The majority of the statutory bodies subject to my Review have provided me with the level of assurance I need that change will be delivered to meet the intended outcomes, clearly outlining the action they will take to improve the quality of life of older people living in care homes in Wales.

 

However, CSSIW and the Welsh Government have not provided me with the overall level of assurance I need and older people have a right to expect.

Annex B – Commissioner’s ‘One Year On’ Statement on Care Home Review (Published 10 November 2015)

 

When I published my Care Home Review in November 2014, I set out six Requirements for Action for Care Home Providers to improve the quality of life and care of older people living in care homes in Wales.

 

In analysing responses from Providers, I was looking for evidence that would provide me with assurance that the change that older people living in care homes want and need to see will be delivered.

 

Overall I have been pleased with the level of engagement from many providers, who have clearly taken time and put thought into their responses to me.

 

Many care home providers have assured me that they will take the action needed to improve the quality of life and care of older people living in care homes.

 

Responses to a number of my Requirements for Action (RfA) from these providers were particularly positive:

 

RfA 1.2 – Welcome Pack – all older people receive a standard ‘Welcome Pack’ upon arrival in a care home that states how the care home manager and owner will ensure that their needs are met, their rights are upheld and they have the best possible quality of life.

 

RfA 3.2 – Dementia Training – all care home employees undertake basic dementia training as part of their induction and all care staff and care home managers undertake further dementia training on an on-going basis as part of their skills and competency development.

 

RfA 3.3 - Befriending – older people will be supported to retain their existing friendships and have meaningful social and/or cultural contact, both within and outside the care home.

 

RfA 5.5 – Dementia Champions – all care homes must have at least one member of staff who is a dementia champion.

 

These providers have a shown a real commitment to delivering the change needed, not only providing detailed information through their responses, but also by attending the good practice seminars I have held in partnership with other key organisations working within the care home sector.

 

However, I am disappointed that a number of Providers did not fully engage with the Review process: some providers did not respond, while others did not provide further information when requested. I therefore cannot be assured that these providers will deliver the change that older people living in care homes want and need to see. It is important to note that this is not a reflection on the standards of care provided. My Review did not look at the standards of care provided against the National Minimum Standards as this is the role of the regulator and inspector of social care in Wales (CSSIW).

 

Despite the good practice I saw, my analysis shows that there are clearly areas where further work and support is needed if the outcomes of my Review are to be delivered. This does not take away from the commitment amongst many Providers to continually improve, but demonstrates the scale of the challenge ahead.

 

To support Care Home Providers to deliver the change required, I have delivered good practice and learning seminars throughout Wales, in partnership with key organisations such as My Home Life Cymru and Care Council for Wales.

 

The seminars, which included presentations from experts working in the care home sector and a number of workshop sessions, allowed Providers to learn more about key themes including dementia, listening to residents and staffing.

 

The seminars were attended by hundreds of Care Home Providers who are clearly committed to making a difference to older people’s lives. This commitment was demonstrated by the pledges made during the seminars, which included promises such as:

 

"To recognise, publicise and encourage the ‘little things’ that matter in Care Home settings for staff, residents & families i.e. simple/kind gestures, acts of kindness."

 

"To develop life, love and laughter becoming the care in creating our organisation and staff to care about people each and every day."

 

"To provide the framework and support to allow our residents to lead a full and rewarding life that they are in control of."

 

"To make at least 5 people smile each day."

 

I will continue to work with a wide range of organisations, such as the RCN, Royal Pharmaceutical Society and Care Forum Wales, as well as with care home providers directly, to continue to grow our thinking, knowledge and good practice. In addition, I will continue to share the learning from my Review and associated work with statutory organisations and professional bodies to support them in playing their role in delivering the outcomes I expect to see. 

 

Public Bodies Delivering Improvements for Older People

 

My statement today is also an opportunity for me to reflect upon the improvements delivered by public bodies across Wales since the publication of my Care Home Review Report one year ago today.

 

I am pleased to note that Local Authorities and Health Boards have already provided me with examples of good practice that will underpin their delivery of my Requirements for Action.

 

For example, Blaenau Gwent County Borough Council has developed a questionnaire that will be distributed to care home employees in the Local Authority to assess current and future dementia training needs so that training can be organised to improve staff skills and competencies to ensure that the needs of residents living with dementia are fully understood and the care provided meets their needs.

 

Aneurin Bevan Health Board is looking to develop an innovative volunteer befriending scheme, working with the Soldiers, Sailors, Airmen and Families Association (SSAFA) and the Police Coordinator for Police Cadet Volunteering to provide befrienders to older veterans and retired police officers living in care homes. Whilst still in its early stages, this initiative has real potential not only to tackle loneliness and isolation – which is a significant issue within many care homes – but also to create stronger links between different generations.

 

Hywel Dda University Health Board has recently commenced the delivery of comprehensive Oral Health Training to staff working within care home settings, with Oral Health Champions being identified in all care homes who will have extra training and resources so they can train new members of staff. Each home will be provided with a Resource Box that includes oral hygiene resources along with documentation to meet national requirements and the Health Board will undertake 2 annual Quality Assurance Visits, reporting outcomes to Dental Quality and Safety Group. There will also be the facility for a visit from the Dental Clinical Team to provide treatment where possible and sign post to other Dental Services, with Clinical Sessions being allocated to Dentists and DCPs within the Community Dental Service.

 

Welsh Government Response

 

I am unable to provide a further update in respect of my assurance around the Requirements for Action allocated to the Welsh Government as they have not provided further information in respect of the action they have underway or planned to deliver the change required.

 

I have written to the Minister expressing my disappointment and indicating my continued willingness to provide both advice and support, where appropriate, in the taking forward of the required action.

 

Going Forward

 

In August, I made clear my intention to undertake a follow-up review in 18 months’ time to ensure that the action promised by public bodies and Care Home Providers is underway – essential to deliver the outcomes for older people that were set out in my Review report.

 

The follow-up review will be structured around the quality of life model included in my Framework for Action 2013-17 and will be looking for evidence that the action underway across Wales is ensuring that older people living in care homes:

 

·        Can do the things that matter to them

·        Feel safe and listened to, valued and respected

·        Live in a place that suits them and their lives

·        Can get the help that they need

 

As part of this Review, I will also be looking for evidence that a national plan is in place to ensure the future supply of high quality care homes and that Wales has the right care home staff, with the right skills, to deliver the best care possible to older people.

 

In the interim, alongside my work to share knowledge and good practice, I will be meeting with the statutory bodies subject to my Review so they can provide me with updates on the action they are taking to deliver the outcomes set out in my Review.

 

As Commissioner, I have been clear that my Review is fundamentally about the lives that people lead in the place that they should be able to call home. Whilst accountability to improve practice and support people’s right to a good quality of life sits with the bodies subject to my Review, I will continue to support them to improve our care home system, growing their knowledge and understanding, and highlighting good practice that can be rolled out more widely to ensure that older people living in care homes in Wales can have the best possible quality of life.

 

In my Review I made very clear the impact upon older people and the price paid by them if the required action is not implemented and the intended outcomes are not delivered. I am not prepared to see that price continue to be paid, nor should any of us in public service or our wider society.

 

I will stay focussed, for as long as required, on the delivery of this action and outcomes. Over the coming year, I will work in partnership with a range of professional bodies, key stakeholders and older people to continue to grow knowledge and share good practice across those areas where further improvements need to be made.

 

I will also undertake a further review in 18 months, which will be focussed on the outcomes I made explicit in my Review report. I will outline the scope and remit of my follow-up review in November, but it will again have the voices of older people at its heart. Through this follow-up scrutiny, I will be looking for evidence that the commitments given to me, reflected in this statement, have been translated into tangible and impactful improvements in the quality of people’s lives.

 

My Review was about people and the lives they lead, the value we place on those lives and the value we place as a nation on older people. My Review makes very clear the impact of failing to deliver systemic change and the price which is paid when failures occur. Those public bodies subject to my Review are accountable for the change that is required and through my on-going work I will hold them accountable to older people.

 

 

 

 

 

 

 

 

 

 

 

 

 

Annex C – Supplementary information to Commissioner’s Care Home Review provided by CSSIW (Received 27 November 2015)  

 

Further to our meeting on Wednesday, 25 November, I am writing to provide you with an update on the actions being taken by CSSIW following our first response dated 2 February. It also responds to your letter dated 9 November 2015 where you requested an update on our work of embedding Human Rights within the new inspection framework. You advised us that the information will assist you with providing evidence to the National Assembly for Wales Health and Social Care Committee.

 

As we discussed on the 17 September, we are keen to work positively with you and to support the action you are taking to drive improvement in the care home sector. However, as a regulator, we also have to operate in the context of a legal framework. As we explained, in addition to responding to your review, we must also take account of the expectations of the Regulation & Inspection of Social Care Bill (Wales) and the recommendations of the “In Search of Accountability”, the report published following the review conducted by Margaret Flynn.

 

Having said this, when we met on 17 September we updated you on the positive developments outlined in our response to your review, in particular:

 

·        Progress with the Quality Judgement Framework

 

The initial pilot study of 14 inspections has been completed and evaluated, and your representative was present at the stakeholder group discussion for this project. A number of the themes in your review have been replicated within the inspection framework. The outcome of our pilot study was extremely positive. The framework clearly helps providers to understand how their services need to improve and, importantly, fosters aspiration and motivation to improve. We will be introducing the new inspection framework in 2016.

 

·        Embedding Human rights and setting a bench mark for unacceptable care

 

We have developed a Human Rights based framework to sit alongside our inspection framework. This has been co-produced and shared with a number of stakeholders including our National Advisory Board. It is still subject to revision on the basis of recent feedback. The framework promotes good care but also highlights unacceptable care akin to the “never events” you describe in your required actions. A positive aspect of this approach is that where unacceptable care is identified enforcement action will be triggered. Therefore, Human Rights will be mainstreamed within the new framework. We will publish the framework in the provider and inspector’s handbooks which we will implement in 2016.

CSSIW has also become a member of the recently established advisory group for the Equality and Human Rights Commissioner which is developing practical guidance for private social care providers. Our framework has been shared with them.

 

·        Use of Lay assessors

 

We explained when we met on 17 September that whilst we are keen to engage people in our work, we do not believe lay assessors are the best approach to strengthening regulatory practice and engaging citizens in our work. We have had experience of using lay assessors in the past and found them to be problematic. We note your recommendation and would welcome any evidence based evaluation you can provide to justify the requirement you have made. We are in discussion with the Community Health Council to explore what contribution their volunteers may be able to make to the inspection and evaluation of care homes.

In relation to broader citizen engagement, our National Advisory Board, 50% of whom are citizens, has remained active with members being directly involved in a number of the project groups within CSSIW, and contributing directly to the development of the Bill, and giving evidence to the Health and Social Service Committee. Recruitment to our three Regional Advisory Panels has been completed and we held an induction event in November. The regional panels go live in January 2016 and will bring the voice of the citizens even more centrally into the work of CSSIW. We have recruited 14 citizens, six registered care managers and four commissioners of services to the three panels. Members of the panels will work with regional inspection teams to check the quality of CSSIW’s work and will support the greater involvement of citizens in CSSIW’s work across Wales. The panels will discuss challenges facing care, social services being delivered across their region and how those challenges can be met.

 

·        Quality Forum

 

The Quality Forum has been developed by CSSIW and is a collaboration of leaders in the social care community, including health and social care commissioners, domiciliary care and care home providers. Together with CSSIW, HIW and CCW as regulators of care, we have developed a unified framework of practical support to drive improvement for quality integrated care around the person.

 

The forum aims to bring a common understanding of what constitutes quality and the expectation of each partner through an active deal to ensure consistent interpretation of “quality” in their respective roles and as a forum. The central aim of the forum is to identify, analyse the evidence base and endorse best practice which can be tested to see what impact and influence it has made on the quality of delivery in health and social care services. This collaborative work can both endorse and promote key products, thereby improving quality of care and well-being.

 

Domiciliary care and care homes are priority areas. The forum has identified a list of “wicked issues” for action starting with falls prevention in care homes and in the community. Using best practice endorsement, collaborative promotion, wide dissemination and publication of key products, the forum aims to see a standardised approach for falls prevention and responses to falls; likewise for hydration, nutrition, ulcers/pressure sores and safe medication. The collective action and application of a standard for each of these matters will mean that commissioners contract to these standards, providers deliver these standards and regulators include these standards in their inspections and reports.

 

·        Chief Inspector’s Report

 

The development of a revised on-line version of self-assessment has progressed and we hope to introduce this in 2016. This will, for the first time, give CSSIW a sound evidence base to use in the Chief Inspector’s report which will enable us to report on a number of the aspects of care you reference in your required actions. Importantly, it will, in time, reduce duplication in data collection with other agencies (health and social care commissioners and the Care Council for Wales). We have now successfully completed a small trial of a shortened “on-line” version of the new self-assessment with providers. The significance of moving to on-line completion is that it will enable us to collate information to create a database for a proper evidence based analysis.

 

I hope this response assures you that CSSIW is continuing to make positive progress in driving improvement in the care home sector.

Annex D – Final response / supplementary information to Commissioner’s Care Home Review provided by Welsh Government (Received 08 December 2015)

 

A review into the quality of life and care of older people living in care homes in Wales: Update on progress

 

Introduction

 

The Welsh Government is committed to improving the outcomes, wellbeing and quality of life for older people in care homes. Our legislative framework has a clear focus on improving the quality of life of all people living in Wales, this includes the framework for the transformation of social service provision in Wales through the Social Services and Well-being (Wales) Act 2014, the Well-being of Future Generations (Wales) Act 2015 and the Regulation and Inspection of Social Care (Wales) Act 2015. 

 

The Care Home Steering Group has been established to provide leadership and ensure action is taken to address issues in relation to the care home sector, including the specific recommendations from the Commissioner’s review. This group has multi-agency representation and involves all stakeholders who have a key role to play in relation to the care home sector.

 

There are a number of workstreams which support the work of the steering group. These include:

 

·        Vision and New Models – Led by Welsh Government (WG) this workstream has focused on creating a vision for care homes in Wales.

 

·        Market Analysis – Led by the National Commissioning Board (NCB), this workstream is designing a methodology to undertake a detailed market analysis of the sector which can be regularly updated and that can report at local authority, regional/local health board and at an all-Wales level.

 

·        Integrated Planning and Commissioning – Led by the NCB, this workstream encompasses the planning and commissioning of long term placements in nursing homes and residential care homes, transition or interim placements to facilitate hospital discharge and choice of accommodation. This will include work on model contracts, guidance and standards.

 

·        Workforce – Led by WG this workstream is focusing on actions in relation to recruitment, retention, training and development. It will also be used to inform workforce planning.

 

·        Good Practice and Quality – Led by WG this workstream is focusing on identifying and sharing of good practice. It will also look at how we can raise awareness and improve information to the public.

 

·        Fee Setting – will look to establish an agreed approach in relation to costs of care/fees (to be formally established in December).

 

There is also a regular meeting of lead policy officials within Welsh Government, who have responsibility for specific policy areas identified within the Commissioner’s review. Formal quarterly updates will be provided to the Care Home Steering Group. Officials are also considering establishing a quality assurance group and are exploring the best way to involve older people, residents and their families in the work of the good practice workstream.

 

The following section provides a detailed update on progress in relation to specific recommendations within the Commissioner’s review.

 

Action 1.2 [Welcome Pack]

 

·        The Social Services and Well-being (Wales) Act includes a statutory requirement for the provision of information, advice and assistance – and for this to be in a form that is accessible for the individual. There is currently a requirement for information to be made available to all individuals moving into residential care in Wales, this is for all people and would therefore include self-funders. This requirement will be strengthened on a legal basis through the Regulation and Inspection of Social Care (Wales) Act. It is also the intention for an information pack to be produced and issued as part of the development of the regulations and codes of practice that will underpin this Act. This will be taken forward in the timescales set out for the respective legislation.

 

·        Work to address recommendations within the Commissioner’s review will be undertaken through the good practice workstream of the Care Home Steering Group. This will include working with people and their families, to test and ensure the welcome information pack meets their needs. This will be taken forward in the short term by the good practice work stream (anticipated date for delivery May 2016) and will be used to inform the development of work being taken forward under the Regulation and Inspection of Social Care (Wales) Act.

 

·        We will work with key stakeholders such as Care Forum Wales and the Care Council for Wales to develop a framework setting out the core content that should be included in the information provided to all new residents in care homes and their families. This will be considered alongside the requirement in the Regulation and Inspection of Social Care (Wales) Act in terms of what should be in statutory regulations and codes of practice and what should be good practice guidance.

 

·        It is our intention through this work to ensure people will be aware of the care and support they will receive whilst at the care home and what they should do and who they can talk to if they have any concerns.

 

Action 2.1 [National Plan for physical health and mental wellbeing promotion and improvement in care homes]

 

·        The Social Services and Well-being (Wales) Act focuses on the care and support needs of people with the aim of improving wellbeing, with a clear emphasis on prevention and early intervention. There is a requirement for local authorities and local health boards to undertake a joint assessment of the needs of their population and to ensure care and support is in place to meet these needs. The National Outcomes Framework will be used to measure progress in relation to the Act and this is in relation to all people who need care and support, including people in care homes.

 

·        The Regulation and Inspection of Social Care (Wales) Act will establish the framework within which care homes must operate. This will include standards of care for integrated and co-ordinated physical care including sensory deficits, oral health, dietary wellbeing, physical exercise, mental health and social interaction and preventative care. We will be working with Public Health Wales on this.

 

·        There is a range of work being taken forward through the national plan for primary care. This includes identifying and meeting the needs of all people, including those who live in care homes to sustain and improve their health and wellbeing. Delivery against the national plan will be monitored and made publicly available so people can see the progress being made.  The timescale for this work is still being developed.  We will ensure that the updates are available to the internal policy leads team responsible for taking the recommendations of the Commissioners report forward, and the Care Home Steering Group for consideration; we would encourage the Commissioner to publish this information on her own website.

 

·        The intention is to ensure there is a sustained focus and improvement in relation to the physical health and mental well-being of older people in care homes.

 

 

Action 2.3 [National Falls Prevention Programme]

 

·        The care home good practice workstream will undertake a mapping of existing work and good practice and ensure that this is shared and implemented. The aim is to ensure that good practice becomes standardised practice. The work stream will link to the Expert Advice Group on falls, as part of the Ageing Well in Wales Programme. This work will be taken forward by the good practice workstream (anticipated date for delivery May 2016).

 

·        The Welsh Government is working with partners to develop an approach to falls prevention interventions in a number of settings, including care homes. This includes osteoporosis risk assessments as part of the GP enhanced services for care homes specification (it is envisaged falls management will be considered as part of this process), and initiatives through the 1,000 lives programme. This indicates the significant role for public health and primary care in relation to falls prevention. 

 

·        The focus will be to reduce immobility and loss of muscle strength/balance to minimise the risk of a fall. As well as assessment of an individual's cognitive ability, physical ability, level of independence, and falls history, the care plan for an individual in a care home must include a robust assessment of the environment. Individual and organisational plans must also be tailored to the needs of specific individuals and promote increased strength and balance activities as part of daily living.

 

Action 2.4 [National best practice guidance about the care home environment]

 

·        As stated in response to action 1.2, work will be undertaken in relation to good practice guidance. This will be undertaken to ensure it is appropriate for the needs of all people, including those with dementia and sensory loss. Good practice guidance will be developed and issued to ensure good practice becomes standardised practice.

 

·        In relation to the care home environment (including aids to daily living), further work will be undertaken by the good practice work stream to identify existing good practice (anticipated date for delivery May 2016). This can then be incorporated in to the work being taken forward on model contracts, guidance and standards as part of the work on commissioning by the National Commissioning Board. This will consider how to ensure the requirements in relation to sensory impairment and dementia are best incorporated in the commissioning framework and to ensure providers meet the requirements specified. This work on model contracts, guidance and standards will be taken forward in the next 6-12 months (anticipated date for delivery October 2016).

 

·        There is a requirement in the Regulation and Inspection of Social Care (Wales) Act to produce standards for care homes. The work of the good practice work stream and the National Commissioning Board will help inform this work. Once these standards have been developed, we will examine the most effective means of implementation which will include the provision of equipment, staff development requirements, and support from professionals with appropriate expertise. In relation to the design of the physical environment, we will draw on the knowledge and expertise of organisations, such as the RNIB and Action on Hearing Loss, at the planning stage, to maximise the opportunities to improve the quality of life for people with dementia or sensory loss.

 

Action 3.1 [National, standardised values and evidence based dementia training programme]

·          The workforce workstream will be considering issues in relation to the workforce, including training and development across the NHS and other sectors.

 

·          Rather than developing new training provision, Welsh Government will map what already exists and also consider existing research. The intent behind this work is to address variations in quality of and access to training by setting out a framework using evidence based approaches and enables signposting to the appropriate training provision. 

 

·          The Care Council for Wales has undertaken an in-depth survey to find out more about the characteristics, motivation and views of a workforce that makes up the largest proportion of care workers in Wales. They have also commissioned a learning framework and resource for social care workers working with those affected by dementia.  Welsh Government will work with the Care Council and Care Forum Wales to determine whether there could be agreed outcomes for training the workforce that would standardise qualifications from the most suited perspective, i.e. what competencies people leave the course with rather than how they get to those competencies.

 

·          The Minister has announced that the Government intends to register all domiciliary and adult residential care workers by 2020 and 2022 respectively. This registration will be supported by a significant development programme for those workers prior to those dates.

 

Action 4.1 [National Statement of Entitlement]

 

·          We will develop a ‘National Statement of Entitlement'. Importantly this will include what care is available to a resident.  They will be entitled to the same care as anyone who is a patient in a GP practice, including access to public health screening services; the care available to a resident through the enhanced service for care homes; and the access to the range of wider primary care and community services (such as dental services, eye testing services, social services).  The care available to people living in care homes will be communicated clearly and included as an information insert in the welcome information pack.

 

·          The review of the GMS enhanced service with GPC Wales and NHS Wales will include our response to the detailed recommendations of the Commissioner’s review. It is anticipated the revised enhanced service provision for care homes will be applied from April 2016. The outcomes of the enhanced service will be reviewed and reported on annually.  We will also consider how the Quality Operating Framework could be used for this purpose. 

 

·          The GMS service will, it is proposed, offer new holistic admissions assessment of residents’ mental and physical health to be provided within 28 days of admission.  The health board, through primary care clusters and primary care teams, will ensure the needs of people in residential care are provided for. For example, dental services, eye testing services, community nursing, outreach services and specialist nursing (for example, tissue viability nursing). The health board and the GP contractor will also consider how they can support staff training and improve the skill mix in care homes.

 

·          As part of this holistic admissions assessment, it is envisaged that falls management, the provision of palliative care, mental health support, together with speech and language therapy and physiotherapy will be considered. The enhanced service review also includes proposals for a comprehensive annual review, together with at least one medication review.  Regular communication between the GP practice and the care home will be integral to the quality and continuity of care. 

 

·          End of life care will be a feature of the review.  It is intended GPs will have a register of patients who are considered to be in their final 12 months of life. This will enable a plan to be prepared to set out the care, treatment and support to enable the individual to end their life in their preferred place.  Care homes will have access to specialist palliative care teams.

 

Action 4.5  [CHC spot checks on compliance with National Statement of Entitlement]

·          The Regulation and Inspection of Social Care (Wales) Act was amended during stage 2 to ensure that the Care and Social Services Inspectorate Wales must set out how they will engage the public in inspections in their work. This amendment was brought forward to respond directly to stakeholder comments including the Older People’s Commissioner and also a recommendation from the Health and Social Care Committee. An additional amendment was made to add Community Health Councils to the list of relevant authorities who must co-operate with each other in the exercise of their functions.

 

·          The Minister for Health and Social Services published a Green Paper on 6 July for consultation until 20 November 2015.  We have received over 100 responses and officials are reviewing these. A consultation response will be published to address the responses received. One of the issues under discussion is the future role of Community Health Councils and whether the existing model is fit for purpose within a more integrated system.  The Green Paper provides an opportunity to address the perceived deficits in the current system, and to achieve a better, more joined up approach.  This provides a further opportunity to debate the role of CHCs in relation to the quality of care provision.

 

·          Welsh Government is in discussion with Community Health Councils to explore what contribution their volunteers could make to bring a lay perspective to the inspection of care homes.

 

Action 5.2 [national standard acuity tool]

·          The Commissioner’s review makes reference to the level of staff needed to provide good quality and safe care. This is a complex issue as it is not just about the level of support needed by the individual but is also dependent on the skills and values of care staff.  There are clear lessons to be learned from the “Delivering Safe Care, Compassionate Care” report.  

 

·          The workforce work stream is considering issues in relation to staffing. This will be used to inform the work of the National Commissioning Board and ensure the commissioning standards/guidance developed encompass the need to have the right level and quality of staff to deliver high quality care and support.

 

·          Cwm Taf University Health Board is working on a national dependency workload tool for the care home sector which is being supported by the University of South Wales on behalf of Welsh Government. This work is particularly focussed on how the acuity tool that is in current use will apply to the care sector.

 

·          Having the appropriate level and quality of staff is essential to safeguarding and ensuring the rights of older people are met. There are new care and support standards within the Regulation and Inspection of Social Care (Wales) Act. These will make explicit reference to the appropriate levels of staffing to provide the physical and emotional needs of older people.  The work undertaken by the workforce work stream, the National Commissioning Board and Cwm Taf UHB will all be used to inform the standards within this Act.

 

Action 5.6 [A National Improvement Service]

·          With regard to the Commissioner’s recommendation to ensure there is a national approach to improving care homes where there are significant issues or risks, initial discussions have been held. Welsh Government is committed to working with the Commissioner and other key stakeholders to consider the best way to take this recommendation forward. This work will take place during the next 3 – 6 months (anticipated delivery date May 2016). The good practice workstream will also consider whether there are specific areas of improvement that need to be addressed.

 

Action 5.7 [Workforce Registration]

·          The Regulation and Inspection of Social Care (Wales) Act provides for the further development of regulation of the workforce.  In November 2015 a timetable was set out for the development and registration of domiciliary and adult residential workers by 2020 and 2022 respectively. This registration will help ensure that staff have the right skills and experience to provide good quality care and support and that older people will be safeguarded from harm or neglect.

 

Action 5.8 [cost-benefit analysis is undertaken into the terms and conditions of care staff]

·          The Commissioner’s review highlights evidence that indicates the terms and conditions of staff in the care sector have an impact on the quality of care and support they provide and the outcome of this. 

 

·          The Welsh Government has already begun work that will enable us to better understand the issues around the terms and conditions of the workforce. There will be a Written Statement in January 2016, published alongside the consultation document.  The research will be published in February 2016 and will provide evidence for the development of policy proposals to improve the recruitment and retention of home care workers. 

 

·          Following the UK government’s announcement of the “national living wage” policy, Welsh Government is also developing an assessment of the impact that the policy will have on the sector in Wales, this will be made available during 2016.

 

·          The workforce workstream of the care home steering group is focusing on action to improve recruitment retention, training and qualifications for registered managers, nurses and direct care staff. A guide to good/exemplar terms and conditions for staff will be developed within 6-12 months (anticipated delivery date November 2016). The output of this work will be used to inform the work being taken forward by the National Commissioning Board and ensure the commissioning guidance reflects the need for good staffing and employment practice.

 

·          These measures will bring greater understanding of the effect of terms and conditions in the sector and ensure workforce planning and commissioning guidance reflect the need for the appropriate level and skills of staff to deliver good quality care.

 

Action 6.1 [A single outcomes framework]

·          A well-being statement and National Outcomes Framework have been developed under the Social Services and Well-being (Wales) Act. This provides a framework with a clear focus on outcomes and improving wellbeing of all people.

 

·          We need to ensure that there is a consistent approach across the entire social care sector, and consider how we could use best standardised annual reporting arrangements for service providers. These annual reports are likely to include an element of reporting against the quality standards and outcomes for service users.

 

·          Given the aims of introducing standardised annual reporting include increasing transparency and accessibility of this information to citizens, it is expected that this would also lead to a wider public awareness of the quality of services that should be expected.  This expectation will be reinforced by the National Statement of Entitlement (Action 4.1)

 

·          Technical groups looking at these issues will be established early in the New Year. The Older People’s Commissioner will be invited to be involved in this work and invitations will be extended to other stakeholders with an interest.

 

·          Recommendation 28 of the Health and Social Care Committee Stage 1 report refers to placing a duty on the Care and Social Services Inspectorate Wales to review local authority and health board commissioning of social care services against quality of life outcomes. As a result of this recommendation, an amendment was brought forward at stage 2 linking commissioning of social services functions to the inspection process, however we are unable to extend this amendment to include local health boards (LHBs) as CSSIW’s powers under this Act do not extend to LHBs. 

 

Action 6.4 and 6.5 [An integrated system of health and social care inspection] [Annual integrated reports]

·          The inspectorate landscape is complex. This was acknowledged in the review of Healthcare Inspectorate Wales (HIW) that was commissioned and published in January 2015 and reinforced the issues raised in the Commissioners’ review.

 

·          An integrated system of health and social care inspection is being considered as part of the consultation on the Green Paper which closed on 20 November 2015.  Officials are considering the responses received.  The legislative time table meant it would not have been possible to include such a proposal within the Regulation and Inspection of Social Care (Wales) Act without compromising the time that needs to be spent consulting on this proposal as part of the Green Paper.

 

·          This could be taken forward in a future Health Quality Bill which could set out a clear rationale for the way forward.  This is however a long term strategy.  In the short term CSSIW and HIW will continue to share intelligence and take action together where there are serious concerns in relation to nursing home care which is commissioned by NHS Wales

 

·          The National Commissioning Board will develop guidance to ensure a consistent approach to integrated commissioning by health and social care. This will be used to inform any work taken forward under the Regulation and Inspection of Social Care (Wales) Act and any future Health Quality Bill.

 

Action 6.6 [An annual report on the quality of clinical care of older people in nursing homes]

·          There is a requirement in the Regulation and Inspection of Social Care (Wales) Act for an annual report to be prepared and annual reports from all providers. The format of the report is to be laid out in regulations.

 

·          The Fundamentals of Care Standards were developed and published in 2003 and the Fundamentals of Care Audit has been completed in Wales each year since 2009. For the first time in 2014 an audit was piloted in community settings whereas previously the audit was conducted in hospital. The intention was that the community settings would include residents in care homes and the intention is to build on this in the future as the new monitoring framework is developed.

 

·          The NHS standards for health care were reviewed in 2014/15 and the new Health and Care Standards were launched on 1 April 2015. These new standards incorporate the 2003 Fundamentals of Care standards. A new monitoring regime for the revised Health and Care Standards is being devised that will form part of the performance monitoring of NHS Wales alongside the NHS Wales Outcomes Framework.

 

·          As 2015 is an interim year in the move towards the new monitoring framework, the Fundamentals of Care audit tool has been used this year to gather patients’ views on their experience of receiving care, and this element of the national audit will be reported to Welsh Government. The data will be collected during October and November as in previous years and reported in 2016.

 

·          In the future, the outcome of specific care metrics, such as falls, pressure ulcer prevention, etc. will be reported through the NHS Outcome Framework and new Health and Care Standards monitoring arrangements. These data will be gathered at frequent and regular intervals through the year so will give trend data through the year rather than one point in time. This would replace the staff self-reported data in the annual Fundamentals of Care audit.

 

Action 7.1 [A national plan to ensure the future supply of high quality care homes]

·          There is a requirement in the Regulation and Inspection of Social Care (Wales) Act for local authorities to prepare an annual market stability report which will look at the future supply and demand. There will also be a national approach and report on the market prepared by regulators.

 

·          The National Commissioning Board is currently undertaking a market analysis exercise with regard to residential and nursing home provision across Wales. The market analysis will provide a detailed picture of current provision as well as identifying any significant gaps. This work will be taken forward in the next 3-6 months (anticipated delivery date May 2016). This will enable local authorities and local health boards to work alongside national and local providers to determine the type of provision needed in the medium term and to identify areas where alternative models of service delivery may be appropriate.

 

·          Welsh Government is committed to working with the Commissioner and other key stakeholders to consider the best way to take this recommendation forward. This work will take place during the next 6 – 12 months (anticipated delivery date November 2016).

 

Action 7.2 [NHS Workforce planning projections]

 

·          This requirement for action will be built into work already in hand through the Integrated Medium Term Planning (IMTP) process. These plans were most recently commissioned in October 2015, prior to which the education section was updated to make clear the requirement for health boards/trusts to liaise with independent, private sector and local authority organisations when compiling education commissioning numbers. 

 

·          As part of this process the Workforce and Education Development Service (WEDS) have regular discussions with all health boards and trusts to consider the basis for numbers provided and they also consider national programmes which may have an impact on the overall numbers.

 

·          All health boards and trusts will be required to provide a refresh of their plans for 2016/17 and the Welsh Government will take this opportunity to further update guidance in relation to workforce planning for the residential and nursing care sector. 

 

·          The workforce workstream will also be considering issues in relation to workforce planning, recruitment, training and development. This work will be undertaken during the next 6-12 months (anticipated delivery date November 2016).

 

 

 

 

 

 

Annex E – Copy of letter from Commissioner to Health and Social Care Committee following updates from CSSIW and the Welsh Government

 

 

David Rees AM

Health & Social Care Committee

National Assembly for Wales

Tŷ Hywel

Cardiff Bay, CF99 1NA

 

23 December 2015

 

Dear David

 

Evidence submission

 

Further to my submitted written evidence, please find attached copies of letters that I have sent to the Chief Inspector of CSSIW and the Health Minister. I thought it would be helpful for you to be sighted on these in advance of my attendance at Committee.

 

You will note from these letters that I now have sufficient assurance that both these bodies are committed to meeting the majority of my Requirements for Action and delivering the intended outcomes.

 

The Committee’s Inquiry into Residential Care of Older People and my Review ‘A Place to Call Home?’ have been important contributors to ensure that the quality of life of older people in care homes has become a priority in Wales. I have already announced my intention to undertake a follow up Review, which will focus very strongly on outcomes. I would be happy to discuss this, as well as the action that I will be taking in the interim, when I attend the Committee session.

 

I look forward to attending the Committee meeting in January.

 

Yours sincerely

 

 

Sarah Rochira

Older People’s Commissioner for Wales

 

Annex F – Copy of letter from Commissioner to Chief Inspector following analysis supplementary information provided by CSSIW

 

 

 

Imelda Richardson

Chief Inspector

CSSIW

Cathays Park

Cardiff, CF10 3NQ

 

23 December 2015

 

Dear Imelda

 

Thank you for your letter dated 27 November following our constructive meeting on 25 November in which you provided information on a range of actions that you are taking to embed quality of life and rights within your work.

 

The information you submitted has provided me with sufficient assurance that you are committed to meeting my Requirements for Action and delivering the intended outcomes.

 

I particularly welcome the work you have underway in respect of a human rights framework and your intent to mainstream this in 2016 within the new Quality Judgement Framework and Provider and Inspector’s handbooks.

 

I also welcome the development and work of the Quality Forum, in particular the framework of practical, evidence based support to drive improvement through a more standardised and consistent approach (thorough commissioning, provision and inspection) in key areas such as falls prevention, hydration, nutrition and safe medication.

 

Whilst we hold different views in respect of lay assessors, I welcome your commitment to broader citizen engagement and that you are in discussion with the Community Health Council to explore what contribution their volunteers may be able to make with the inspection and evaluation of care homes.

 

I thank you for your ongoing commitment to improving the quality of life for older people in care homes, as well as ensuring positive outcomes for older people are achieved

 

Yours sincerely

 

 

Sarah Rochira

Older People’s Commissioner for Wales

 

Annex G – Copy of letter from Commissioner to Minister for Health and Social Services following analysis of final response / supplementary information provided by Welsh Government

 

 

Mark Drakeford AM

Minister for Health and Social Services

Welsh Government

Tŷ Hywel

Cardiff Bay, CF99 1NA

 

23 December 2015

 

Dear Minister

 

I write following a number of constructive meetings with your officials and the receipt of your letter dated 2 December, and the subsequent information provided by your office in relation to the actions arising from my Care Home Review, ‘A Place to Call Home?’, which were relevant to the Welsh Government.

 

The information submitted has provided me with sufficient assurance that you are committed to meeting the majority of my Requirements for Action and delivering the intended outcomes.

 

There are a small number of Requirements for Action (5.2, 6.2, 6.4, 6.5, 7.1, 7.2), out of the 20 applicable to the Welsh Government, that I cannot yet form a view on as these are still to be progressed through regulations or other legislation. I will continue to work with the Care Home Steering Group as well as directly with your officials as the regulations and other relevant legislation are developed.

 

I do, however, still have concerns in respect of one Requirement for Action, that being ‘reporting on fundamentals of care in nursing homes’, and I have already agreed to discuss this further with your officials.

 

As you are aware, I will be undertaking a follow up Review in 2017, the details of which I will publish in the new year. In the interim, in order to maximise the impact of some of the early work underway, your officials and I have agreed a series of scheduled meetings alongside quarterly updates from the Care Home Steering Group.

 

I thank you for your ongoing commitment to improving the quality of life for older people in care homes, as well as ensuring positive outcomes for older people are achieved.

 

Yours sincerely

 

 

Sarah Rochira

Older People’s Commissioner for Wales