Health and Social Care Committee

HSC(4)-23-12 paper 5

Inquiry into Residential Care for Older People – Note of Reference Group meeting 24 May 2012

Background

1. The Health and Social Care Committee established a reference group for its inquiry into residential care for older people in spring 2012. The group comprises those who have recently – or who are currently – supporting friends and family in residential care settings, or who are facing the prospect of doing so in the future.

2. The role of the external reference group is to provide a view to the Committee on the key issues raised during the course of the inquiry. This includes their views on the extent to which they feel that the information being provided in evidence reflects their own personal experiences and the extent to which they agree with the current policy direction for residential care for older people.

3. The reference group will meet on a monthly basis during the course of the oral evidence gathering, considering evidence already received and proposing lines of inquiry for future evidence sessions. All notes of reference group meetings will be agreed by the group prior to publication.

Summary

4. The group met on 24 May 2012 to discuss the key themes emerging from the Health and Social Care Committee’s evidence sessions on 26 April and 2 May 2012, both of which considered the role of third sector providers and alternative models of provision. 

5. The group also considered matters relating to the regulation and inspection of care, and potential questions which could be asked at the evidence session with CSSIW, HIW and CCfW on 30 May.

Key themes

6. The reference group agreed that the key themes emerging from the formal evidence sessions listed in paragraph 4 are as follows:

- The focus of service provision should be person-centred care. People need to be seen holistically, and there must be support for the whole person with all their existing and potential conditions being identified and treated.

- Reablement, and other such services should be available for everybody, at all points of the residential care journey. A key part of recovery is allowing and encouraging people to be as independent as possible. Work should be undertaken to raise the awareness of all available services.

- There is a need for better partnership working and sharing of good practice and expertise. There should be an increase in flexible working and fewer silos within health and social care sectors. There should be better communication between organisations, especially with respect to record keeping, to ensure continuity of treatment for the patient.

- There needs to be sufficient funding for services, and a minimum payment level for care services, whether delivered at home or in residential care.  Commissioning for cost rather than quality is potentially damaging to the services people receive.

- There needs to be better, more accessible information about the types of care available. This will help to provide answers to questions such as what good quality care looks like. There should be clear definitions of what reablement is, which will help to provide consistency and guidance about what constitutes reablement to those delivering it.

- Training on issues such as dementiaand Parkinsons needs to be wider than just awareness-raising; it should also be about how to deal with these conditions and should aim to up-skill staff across the board in hospital wards, GP Surgeries and care homes.

- A greater value needs to be placed on staff working within the care sector. A care worker both in care homes and domiciliary care has a number of responsibilities, as well as often being constrained by financial pressures and pressures on their time, which should receive more recognition.

7. In exploring the key themes and the evidence heard, the group made the following points:

- Discussions about people’s future careneeds should take place at an appropriate time, with all the relevant people. Typically this should be as early as possible – but this will vary depending on the situation and people involved. There is a need for support and advocacy to make sure this is effective.

- The assessment process for those receiving care, or identified as potentially needing care, must be ongoing, and should not be a one-off occurrence. People can potentially appear lucid during the course of a one-off assessment, but a more comprehensive understanding of the individual’s wellbeing can be established if continuous assessments are undertaken. Furthermore, people’s needs can increase or decrease depending on their conditions and the treatment they receive, which should be monitored through the assessment process.

- The group felt that there needed to be more information available about reablement. They discussed what reablement involved and the difficulty in defining it. This was an area they felt needed clarification, along with the need for some baseline data about reablement services, in order to move forward in this area. The group felt that, at present, the provision of services like reablement were not properly formalised and were delivered in an ad hoc fashion. They felt that there should be a greater amount of awareness about these services and a standard provision for everybody.

- The group discussed how isolation was an issue for those in rural and urban settings. They felt that the involvement of third sector through projects like befriending was very valuable. They also felt there were a number of challenges delivering home care in rural locations as often there was little or no provision for travelling times or cost within contracts. This can result in the contracts being unviable or unattractive to suppliers.

- The risk averse nature of health professionals needs to be addressed. The group felt that there need to be a change in attitude and less focus on the ‘what ifs’. They felt this would help with making people more independent, and could help reduce costs in the long term.

- The group felt that direct payments for older people are paid at a level which is too low to enable people to purchase regulated services,  which currently makes them unviable. It appears that the system does not want to support older people in their homes.

- The group felt that better regulation of the Home Care system would be a positive thing.

- The time allocated, and support for home care visits is often inadequate for the tasks they are required to undertake. This is especially the case where the patient may be suffering from dementia and it may take time to access the home and win the trust of the client. The insurance and liability payments required for homecare staff to administer medicine is inhibitive to most providers being able to offer this service.

- Good design, which takes account of elements such as sensory loss and dementia, is essential in developing new care settings. The development of new housing should also account for the changing needs of the population, and they should be future proofed for the elderly. The group felt that without sufficient grants to adapt people’s homes, some of the choice of staying home is taken away.

- The group discussed that it was often difficult to hold conversations with family members about their care needs, especially when they did not want to acknowledge their condition. Many of the issues about lack of information, and the difficulties around having conversation with older family members, were considered by the group to be generational, and the group felt that they and future generations would be more prepared for the choices and discussions they would need to have.

- The group felt that dementia and the need for care should not be seen as a one way street of decline and that it was essential for people to have choice and independence. This is vital to give people a purpose for life.

- There was a previous assumption amongst group members that all nursing staff in residential care settings were trained in dealing with dementia. They noted that the need to check what training staff had received when choosing a home had not occurred to them.

- The language used around treating dementia patients is often unhelpful - for example, the group felt that a description of an individual suffering from dementia as being “stubborn” may in fact be a case of the individual having difficulty communicating.

Questions for future sessions

8. The group discussed areas of concern for the inquiry regarding inspection and regulation. They also suggested that the following questions and observations should be put to CSSIW/HIW and CCfW:

- The inspection process must include spending sufficient time with residents and their families.

· What is being done to ensure that more focus is placed on residents’ experiences of the care home?

- In the group’s experience there seems to be very little enforcement of, or repercussions from, bad inspection reports. There needs to be clear follow up on actions for enforcement – similar things seem to come up year after year.

· What is being done to strengthen enforcement of the inspection regime findings?

· Is there any follow up around ensuring that care home managers and staff do not seek employment in other care homes following dismissal?

- There are a number of professionals working in homes with residents such as social workers and complex care assessors (if patient is funded by the health service).

· Do CSSIW work with these people in advance of an inspection to establish any areas of concern? Is there any on-going liaison with them about the key concerns emerging from homes?

- The reference group felt that care homes were aware of when inspections were likely to occur as they tend to follow the same pattern across regions. They felt there needed to be more spot checks and lay inspectors.

· What is being done to bring lay inspectors back into the system? [It is the group’s view that there needs to be a greater involvement of people and procedures including lay inspectors.]

· HIW are doing unannounced inspections in hospitals around dignity – are these being rolled out to care homes as well?

- There should be regulation for other staff below managers- the cost of registration should not be put forward as a restriction.

- The group raised concerns about why there has been an increase in self-assessment of homes – as family members they felt a great deal of concern about this.

- The group used the written inspection reports as a source of information for making a decision about where to send family members – they think they could be improved, and could contain more accessible and informative information, which gives a clearer illustration of the reality of a resident’s life in a particular residential setting. Furthermore, the group thought

· more consideration of the potential audience for reports was needed, and the reports should explain matters in laymen terms;

· the inspectorate should give consideration to the inclusion of things like interesting facts and figures about the homes;

· reports should be widely available, not just on the internet;

· reports are currently too heavily weighted with procedure and paper work and that more work should go into hearing the voices of people involved with the care home through direct contact; questionnaires are not enough;

· resident meetings should be considered as useful sources of information for inspectors.

- The group questioned what CSSIW did to ensure data protection is being implemented in homes. Examples from the reference group included family pictures being used as advertising for homes, which there has not been any consent for. It is important that the residents’ privacy is maintained.

- Given the prevalence of certain conditions such as sensory loss /dementia / mental illness, the group wanted to know what level of training do inspectors have around these areas to identify if they are being addressed sufficiently within the homes.

- The group was interested to know if there is any monitoring of the numbers/types of falls occurring in residential settings and, if so, the extent to which this is followed up.

- The group wanted to know how staff morale is captured in inspection reports. This includes the extent to which:

· adjustments are made for questioning those whose 1st language isn’t English or Welsh; and

· consideration is given to things like the living accommodation supplied for staff, which the group believed could be of a very low standard and thus impact on the ability of care workers to do their jobs.

- The group believed that there must be monitoring for staff training and that an increase in compulsory elements of training is needed e.g. mandatory training on dementia.

9. The group agreed to consider potential questions for the Committee’s session with private providers, which is scheduled for 14 June 2012.

10. The group agreed to consider matters relating to funding and a job description for a care worker at the next meeting.