Health and Social Care Committee
HSC(4)-11-12 paper 3
Inquiry into residential care for older people – Ceredigion County Council
1 The process by which older people enter residential care and the availability and accessibility of alternative community–based services including reablement services and domicilary care
Process by which older people enter Residential Care
The decision to move into residential care is not taken lightly by service users, their families, informal carers or Adult Services staff. It is a life changing experience and has been compared to bereavement by some: leaving behind your home, memories and independent living.
Every effort is made by Adult Services staff to provide services to enable service users to continue to live safely and as independently as possible in their own homes. When a referral is received whether it is a self referral, referral by family or friends or from a professional, a comprehensive assessment is made of needs. This assessment is informed by the service user, their family and friends (with their consent) and other professionals involved in their care (District Nurse, Psychiatric Nurse, GP, Hospital Staff, Occupational Therapist, and Physiotherapist, as appropriate). In discussion with the service user, family and friends a care plan is drawn up to meet the eligible needs identified and promote independence. This care plan is reviewed regularly and amended to meet changing needs.
This care plan can range from referrals to community services e.g. Age UK cleaning service, support by the Reablement Team for up to 6 weeks to regain previous independence, long term domiciliary care, or placement in a residential or nursing care home. Our priority aim is to provide the service in the service user’s home for as long as possible with the appropriate management of risk and placement in a residential care home is only considered when this is no longer achievable.
It should be noted that those with the ability to fund their placement can enter private residential homes without recourse to Social Services.
Other than Joint Care or Emergency admissions, the Registered Manager or Assistant Manager will meet with service users who have been referred to their Residential Home and carry out an assessment to ascertain if the Home can meet the needs of that service user.
Reablement Servicesare available by referral from a health or social care professional. It is a free service for up to 6 weeks and provides occupational therapy, physiotherapy and specialist support. It can arrange minor adaptations and equipment. This service is a targeted intervention aimed at regaining independence.
Meals at homecan be provided free for up to 6 weeks post hospital discharge if they will not be required in the long term, subject to assessment and meeting eligibility criteria. They can also be provided on a long term basis, at a charge of £3.50 per day, subject to assessment and meeting the eligibility criteria. A regenerated meal option is also available.
Day Careis provided at various venues with some specialising in day care for people with dementia. This service is designed to address social isolation for those that attend and respite for their carers.
Respite carein a residential home can be arranged to support informal carers. This has the additional benefit to service users of the opportunity to have a break and socialisewith their peers. This service is charged, subject to a financial assessment.
Short term careThe Reablement Service’s role includes reducing dependency on residential care. Anyone admitted to a short-term placement in residential care can be referred to the Reablement Service. Physiotherapists can work on improving transfers and mobility and Occupational Therapists can undertake home visits, provide advice about equipment and adaptations that may enable a return home and undertake a functional assessment to inform assessment of social care needs. Anyone admitted to a Joint Care Bed (joint health and social care funded beds in Local Authority residential homes) is thereby referred to Reablement to facilitate their return home. Where this is not possible within the maximum 28 day admission, the person is transferred to a short-term bed where the service will continue to work with them if it appears realistic they may be able to return home with this intervention. Anyone in long-term residential care can also be referred to the service if they wish to return home again.
Domiciliary Careis provided for those requiring assistance with personal care and activities of daily living, to enable them to continue living in the community, in accordance with their own lifestyle, with independence, dignity and respect; Subject to assessment and meeting the eligibility criteria. This is subject to the fairer charging policy (maximum £50 per week).
Emergency Admissions
Home of Choice – The Hywel Dda Health Trust use the Home of Choice policy in instances where the patient’s preferred place of care is not available. The patient is transferred to a Home of Choice bed temporarily until their preferred place of care becomes available. The policy is being reviewed at present, therefore cannot be included in this report.
Delayed Transfers of Care (DTOC) – A weekly meeting of Health and Social Care professionals is held to validate delayed discharges from hospitals in the catchment area. The group identifies any patients who may potentially have problems with discharge from hospital. All agencies work together to ensure that patients are discharged as soon as they are fit to a safe environment.
Bad weather contingency – During spells of bad weather ‘place of safety’ admissions are arranged for service users. This can be due to a failure in the electricity, heating or water supply, or if service users live in a remote area where care visits cannot be guaranteed.
Joint Care Beds – A health or social care professional can arrange for a service user to have a temporary care bed for a few days (up to a maximum of four weeks) to avoid being admitted to hospital or to avoid staying in hospital when reablement can be beneficial to recovery. The scheme ensures that service users receive the care and support that they need to help improve their ability to do things, so that they can return to their own homes as soon as possible.
5th December - The number of empty beds in our own Homes is 23. The number of empty beds in Ceredigion for residential and nursing care homes is 42, plus a further 20 will be available this week when the commissioning department receives the appropriate registration certificate for Hafan Y Waun.
Supporting Peopleservice is provided following assessment and referral for tenancy support. This can involve applying for sheltered accommodation or extra care housing, debt management, budgeting etc.
Sheltered accommodation- There are a number of sheltered accommodation facilities available across Ceredigion
Extra Care Housing- Not everyone wishes to move from their home the additional services and security of sheltered accommodation and in the Cardigan scheme the in-house domiciliary care service provide an alternative to residential care for some.
Welfare Benefits Advisor - Ceredigion Social Services currently has a Welfare Benefits Advisor for those with a diagnosis of cancer or terminal illness and is in the process of appointing a Specialist Social Worker. These posts are funded by MacMillan.
There are various services in the community provided by charities:
Age UK: Cleaning, Befriending, Welfare Benefit Checks, Advocacy
Crossroads: Respite for carers by sitting service, Saturday Club, Dementia Day Centre
Beacon of Hope: Various services for those, or their carers, with terminal or life limiting illnesses
Several community transport schemes e.g. Country Cars, Cars 4 Carers, Volunteer drivers from Ceredigion Volunteer Bureau.
Ceredigion Volunteer Bureau is an invaluable source of information for Adult Care staff when creating innovative care plans to suit individual needs.
Adult Care Staff are also aware of general services provided by commercial providers in the home:
Home delivery of shopping, prescriptions, meals
Home visits by hairdressers, chiropodists, dentists, opticians, solicitors etc.
Taxis with wheelchair access.
The services available within the community both from Social Services, Private Providers and Charities that Adult Services staff will continue to provide innovative person centred support that will support people to continue to live safely and as independently as possible in their own homes for as long as possible. When this is no longer possible they will continue to support the service user in making their decision to move to residential/nursing care and ensure the move is managed as sensitively as possible.
2 The capacity of residential care sector to meet the demand for services from older people in terms of staffing resources, including the skill mix of staff and their access to training, and the number of places and facilities, and resource levels.
Capacity to meet the demand for services
Staffing resources
The Authority employs 281 staff at 7 Residential Homes within the county.
There are no minimum staffing levels suggested by CSSIW but the department has set agreed safe levels as standard and the staffing levels are raised if there are high dependency; or end of life issues at a Home.
Sickness levels are above average for the authority in Social Services. The percentage of absenteeism for salaried staff within the Department is 4.98% whilst the percentage absenteeism for weekly paid staff is 10.3 %. The Department is implementing the sickness policy and undertaking absence review interviews in conjunction with Corporate Personnel for members of staff who are on long term sick and those who have reached trigger points. This is an ongoing process for the Department.
All staff absences are covered by other members of staff taking on extra shifts, relief care assistants covering or at times staff from other residential homes assist. When a resident requires extra care due to medical issues, GPs, District Nurses, the ART team, Beacon of Hope and Macmillan Nurses will assist the staff.
Skill mix
The majority of staff are qualified at NVQ level 2, 3 or 4 appropriate to their job role. Over 90% of staff in residential homes are qualified. 68% of residential homes staff speak Welsh
Access to training
On-site training is the preferred way of delivery of to enable staff to meet the regulations and registration requirements, in house training has been supplemented through Health Professionals coming in to the Homes and also Managers undertaking training through DVD training packs, thereby,
Managers can monitor and meet the 90 hours required for Care Council registration.
Change of use at Awel Deg Residential Home
Cabinet has agreed that Awel Deg Residential Home which is a general residential home with a dementia unit can go ahead with plans to become a Care Home specialising in dementia care.
3 The quality of residential care sevices and the experiences of service users and their families; the effectiveness of services at meeting the diversity of need amongst older people; and the management of care home closures
Under the regulations each Home has four Responsible Individual visits per year, this highlights any issues at the Homes. All Homes have gained certification under the ISO 9001:2008 Standards and have proved continuous improvement.
Residents meetings take place regularly and minutes are taken and action points are fed back.
Monthly care plan reviews with Residents enables them to voice any choices or concerns they may have
Questionnaires are given out to residents, next of kin and staff; there is a very high satisfaction score. CSSIW Inspectors also carry out questionnaire surveys with residents, next of kin and staff they also include other agencies such as GPs, District Nurses.
The Authority has a robust complaints procedure in place and all residents have leaflets and are assisted should they wish to make a complaint. All compliments are forwarded to higher management.
Since 1st January 2011 our Homes have received 4 complaints and 153 compliments.
Diversity
Comprehensive person centred service user plans are completed and all relevant information is available to staff.
The residential care Statement of Purpose includes a detailed philosophy of care – (attached)
Escalation of concerns
Escalating concerns arise when there are accumulating issues relating to the operation of, or quality of care provided in a registered care home. Meetings held under the escalating concerns protocol focus on the care provider and are separate to adult protection meetings.
In circumstances where a failure in the provision of care causes or may cause significant harm, this is adult abuse. Where abuse is suspected the policy and procedures to protect vulnerable adults must take precedence. In many situations it may be in the interest of service users to use the escalating concerns procedure alongside the adult protection procedures.
4 New and emerging models of care provision
Cylch Caron Project, Tregaron
Proposed project for a new development, bringing health and social care partners together to provide ‘extra care’ housing. Bryntirion, Tregaron Hospital, Tregaron Surgery to amalgamate to provide hospital, nursing, residential care, day centre as well as ‘extra care’. Other services are expected to be involved, for example, assistive technology, reablement, domiciliary care etc. The Cylch Caron area will cover an area within, approx. 7 – 10 miles radius of Tregaron.
The project is at the ‘Outline Business Case’ stage with the Welsh Assembly Government
OP Modernisation – See attached document
5 Effectiveness of the regulation and inspection arrangements for residential care, including the scope for increased scrutiny of care home closures
The Department is currently reviewing the inspection arrangements for all contracted services including residential care and is developing a monitoring framework that will provide a range of information that relates to the quality, value, viability and effectiveness of services in delivering outcomes for service users. Aspects of this framework include:
· Regular monitoring meetings with providers,
· Tracking and risk assessment of POVA referrals, complaints and concerns
· Annual reporting and onsite inspection/ reality checks on a thematic basis covering key areas identified
· Scrutiny of annual accounts
· Scrutiny of CSSIW and other reports to highlight issues and avoid duplication
In addition the department has introduced a care provider forum to share good practice, discuss issues and joint working.
6 The balance of public and independent sector provision, and alternative funding, management, and ownership models, such as those offered by the cooperative, mutual sector and third sector and Registered Social Landlords.
The department has an understanding of the balance between private and public sector provision and is working with private sector providers to deliver quality services and sustainability through the Monitoring framework, Care provider forum and the fee setting exercise.
Currently in Ceredigion within the Private Sector there are 110 private residential beds (including up to 12 EMI Residential beds. Cartref Henllan) and 62 private EMI residential beds.
The Local Authority homes provide 184 residential care beds and 8 EMI residential beds.
As a rural dispersed area the county does not have experience of a greater range of ownership models but would be keen to consider alternative options. In the last year the council has worked in partnership with an RSL to deliver the counties first extracare model of housing in Cardigan which has 48 units. The authority is keen to explore future developments along this theme and is currently working on an extracare proposal in Tregaron that will include health resources. This model will provide community hospital beds, residential care places, extracare housing units and a community health centre and is seen as an innovative approach to providing services to a rural community.
With regard to financial viability the department is working closely with the care provider forum to understand and fairly agree older persons residential care costs in response to the Welsh Assembly Government Statutory Guidance on commissioning: Social Services Fulfilled Lives, Supportive Communities Commissioning Framework Guidance and Good Practice.
This document requires that
Parry Davies
Director of Social Services
Ceredigion County Council
13th December 2011
Enclosures
The documents listed below can be accessed on the Committee’s website through the link below – RC 19 Ceredigion County Council.
http://www.senedd.assemblywales.org/mgIssueHistoryHome.aspx?IId=2222
A - OP Integration Document
B - Eligibility/Commissioning Panels
C - Ceredigion Assistive Technology at Home leaflet and charges
D - Training Diary November 2011 – August 2011
E - Social Services Direct Services Training Strategy
F - Contract for Independent sector- Domiciliary Care/Residential/Nursing Homes
G - JCB Statement of Purpose
H - Extra Care document
I - Statement of Purpose for Residential Homes.
J - Meals at Home leaflet
K – Statement of Purpose for Ceredigion Reablement Service
L – Delayed Transfers of Care Working Group Terms of Reference