Short Debate: Caring for care homes: How we could do more to care for care homes in Wales

Janet:

Diolch, Deputy Presiding Officer. The purpose of this debate is to trigger a conversation about how we can do more to care for our care homes in Wales. And I'd like to invite Jayne Bryant AM and Angela Burns AM to speak for a minute or so.

Over 15,000 people aged 65 or over live in a care home. According to the state of the nation report launched yesterday, the average age at which an older person moves to a care home is nearly 83 years, and people tend to live in the home, on average, for around two years and four months. As you'll be aware, there are three broad categories of care homes in Wales: residential, nursing, and EMI—elderly mentally infirm. Now, unfortunately, when searching for a home of any type, sadly, too many negatives present. Now, Welsh Conservatives believe that safeguarding our residents is key and essential, and I know that none of us would stand by until this is actually implemented. I've raised concerns about care standards in Wales, but we must also—tonight's debate is about celebrating the good care and the need that we have to support our care homes.

Anyway, rather than focus on non-compliance, I would like to use this opportunity to highlight some of the excellent work that is being undertaken. The need for this is apparent when considering that the number of care homes fell by 30 in less than three years, after the publication of 'The Care Home Market in Wales: Mapping the Sector' in 2015. As we know from Care Forum Wales, this forms part of a downward decline, as it has been estimated that 16 per cent of remaining homes will close in five years' time. So, supporting the care sector needs to rank high on the agenda.

Having visited a number of care homes in Aberconwy, and across Wales, I have seen at first-hand some amazing services provided. It was magical for me dancing with an elderly resident to 'Singing in the Rain', and having an umbrella full of decorations on the ceiling within the main living room. And that was in an EMI home. I was also pleased to join with two ladies, just relaxing and chatting out in the sun, at a nursing home in Ynys Môn. And I can never forget singing, with a resident in another home, a duet—a very heartfelt duet that the lady had remembered from her childhood days, and I sang with her.

Now, when visiting these homes, I have seen the passion that staff have for looking after their patients and residents, and have been pleased to listen how they—the people working in the sector—think we could do more to care for care homes. This brings me to the first way through which we could champion care home: communication. Dementia is a condition that affects linguistic ability, so not providing care through the medium of Welsh can lead to frustration and the loss of dignity and respect.

I have met Welsh-language staff in care homes, but the Welsh Language Commissioner and Alzheimer’s Society Cymru have highlighted that care is not often available in Welsh unless someone requests it. This cannot be right, so I would like to see you, as Deputy Minister, putting more plans into implementation to support homes to develop a capacity to make an active offer of care in Welsh—through the medium of Welsh.  

Additionally, there is a serious need to look at improving care home communication with health boards and local authorities. For example, we should look at the digitalisation of patient records. It is true that you have the Welsh Community Care Information System, and I accept that implementing the new ICT system across local authorities and health boards could help accessibility to information, but what about care homes?

It was explained to me by one manager that they would benefit greatly from being able to access information on the health board’s system about their clients—the very same clients that they are caring for on a daily basis—wanting to meet all their needs, including their health needs. The Welsh Government does not have oversight of the content of health boards’ internet platforms, but it does have the ability to set a clearer level of expectation.

This could actually result in care homes more easily accessing information that could improve care. Another way through which connectivity between health and social care could be strengthened is by acting on calls by Age Cymru for a duty to co-operate. I agree with the organisation, and believe that a duty could go a long way in boosting quality of care for people being transferred from care home to hospital setting and vice versa. I was actually quite shocked to realise that a patient can leave a care home needing to go to hospital, but actually return needing significantly more care.

The need for a stronger dialogue is apparent when considering incidents such as care home staff not being told what rehabilitation their residents have had in hospital, patients being discharged to care homes with no information at all, and care home staff not being asked for important information, such as how an individual signals their need for the toilet and whether they like drinking form a particular cup, contributing to the situation in which some patients return to homes from hospital unrecognisable from when they went in. I've heard of a simple thing like false teeth going missing in hospital. So, patients return to a care home, without their false teeth—something so simple and such a basic requirement, but so important has been highlighted by Angela Burns here earlier on dental healthcare.

Care home staff have a wealth of information that could transform the care of some patients in hospital. However, as Age Cymru have stated that 'existing professional boundaries militate against the engagement of care home staff, and even against informing them at a very basic level of how their resident is while the resident is in hospital.'

There's a cut-off—once the resident goes to hospital, there is very little dialogue continued then with the care home. The onus is on the care home to contact the hospital. That can't be right. This has to change and steps taken to ensure that the Welsh NHS recognises the value of the contribution care home staff can make, and how much they care about their own residents.

Such a wall has been a point of concern with regards to staff training too, which brings me to another way through, which we could do more of to support care homes. Wales needs around 20,000 more people to work in care by 2030. Now, I recognise that you've recognised this, and it is only fair that I acknowledge the work that is being undertaken to attract

being undertaken to attract, retain, and recruit staff in Wales as part of the We Care Wales campaign. However, more could be achieved by looking at the training which is provided to nursing staff. Organisations have spoken to me of the need to ensure that nurse training includes experiences in both the NHS and social care sector. Too long, there's been this division between the two, it needs brining together.

For example, we should encourage nursing placements in care homes as this could help address the lack of cross-pollination between nursing and care skills. People assume that a nurse can only train in a hospital. Its not correct. They could learn a lot of skills actually training in care homes. Also, you cannot deny that there is much that can be learnt at care homes, as many are a hive of activity. In fact, they have the potential to be even more important community hubs.

I have already had it confirmed to me in writing that health boards are allowed to organise walk-in clinics in a non-NHS setting, and know that some homes are keen to open these up to the local community where they can, such as by holding intravenous therapy clinics, blood testing clinics. This idea is worthy of consideration.

Such co-operation could represent value for money, especially for the service user, where they would otherwise have to travel considerably further than a home to see a nurse. Care homes professionals are well trained, and where there is a will, it should be the Welsh Government’s mission to ensure that there is a way for homes to host these clinics and undertake tasks its staff are more than capable of doing.

For example, it is ridiculous that some care home staff have had to wait hours for a GP to attend to take blood pressure and temperature readings, and it is disheartening that some homes face a long wait when someone falls. We should all be supporting staff to take readings, and looking at up-scaling proven models, such as the Welsh Ambulance Service's I-Stumble toolkit for care homes. Common sense dictates that an increase in clinical interventions available in homes would reduce the need to send patients to hospital in the first place, or the need to call an ambulance or a GP, so the Welsh Government should get on with it.  

This brings me to my final suggestion as to how we could do more for care homes. I know of a home with a resident funded by a local authority, who as a result of a deterioration in health will have responsibility for fees transferred to Betsi Cadwaladr University Health Board. Shockingly, despite providing more intensive care, the home will be paid less. In fact, the health board pays less than local authorities pay in north Wales, setting one care home on course to be £155,000 worse off this year in their budget, because of the difference between local authority and CHC fees.

Clearly, you must look at ensuring that care homes are paid the actual cost of the care, and certainly at least match the CHC fee to that paid by local authorities. Undoubtedly, this should be regarded as a short-term solution, as I believe that a full review of how care homes are funded is required, and it is required now. 

Nonetheless, such a move towards sustainable and fair funding would be a boost to private sector homes that feel as if they are being repeatedly punished. It is time, Deputy Minister, that we start to show our  care for our care homes and that we take some actions, such as some of those that I have outlined today, to show our seriousness, the Welsh Government's intent, about helping to secure a positive future for the homes of over 15,000 people in Wales. Thank you.

 

Response from Julie Morgan AM, Deputy Minister for Health and Social Services:

Thank you very much, Deputy Presiding Officer, and thank you Janet Finch-Saunders for bringing this debate to the Chamber tonight. I think it’s a great opportunity to recognise the importance of care homes and the social care sector as a whole, and I’m really pleased that Janet has been able to highlight some of the really good work that is done in the care sector, because I think it is behoven on us to boost that sector as much as we can. So, I’m very pleased to be able to respond to this debate tonight, because it’s absolutely clear that the care homes make a vital contribution to the lives of people who need care and support in Wales. It also allows me to share with you some of the areas that this Government and our partners are focusing on to ensure the social care sector is supported effectively and is in the best possible position to care for itself.536

Obviously, the sector does not and cannot operate and thrive in isolation. We must each play our part at national, local and indeed at service-provider level, and we’ve got a clear role as Welsh Government to work with the sector and to understand the issue it faces, and in ensuring the quality of the services it provides. Our partners, in particular local authorities and local health boards, as commissioners of care home services, each have important responsibilities at a local level. The sector itself also has a vital role to play. Welsh Government is actively supporting care homes in a number of areas, including funding and workforce, as well as measures to support both the quality and sustainability of services.537

The financial challenges faced by the sector are well known and well documented, and we fully recognise this, and are working to achieve a more sustainable model 

 

Angela Burns AM: 

Just a point of clarification, because that's really positive. Does that include all care workers, including the ones in domiciliary settings as well as care homes? I just wanted to clarify.

 

Continued response from the Deputy Minister:

At the moment, we've extended the register on a voluntary basis to domiciliary care workers ahead of their mandatory registration. So, yes, it's going to include both—domiciliary and care workers in homes. So, as I say, this should be very positive in terms of giving them more status and recognising that they are a profession. Because what more important job could anybody be doing, really?

Where we've seen that the sector is facing difficulties, we have taken direct action to help alleviate them. One such example is the national living wage. We've invested £19 million of recurrent funding to local authorities in order that they can help service providers to manage the impact of implementing the national living wage. The Business Wales social care pilot project is another example of our commitment to support the sustainability of the care home sector. It provides a free specially designed business support package, which includes advice on a range of issues such as tendering, human resources and finance. It's a practical solution that recognises that care homes are businesses and offers the help they may need to become more resilient and grow sustainably. I'd like to thank those provides who have participated and provided very valuable feedback. And although, originally, it focused on the Valleys taskforce area, the offer is being made available across the south-east Wales business region, with a view to evaluating how to extend the offer to remaining regions in Wales. I'd encourage others to take advantage of this opportunity, recognising that care homes are businesses.

In terms of supporting the improvement of services quality, we're funding the care home improvement Cymru programme over a three-year period. It's aimed at building supportive care home environments that move away from the top-down compliance approach and start with what matters to people living in, visiting, working in or managing a care home service. I was very struck by what Janet Finch-Saunders said about the lively nature of the care home, and how much actually goes on in a care home. This programme engages with all parts of the organisation, including front-line staff, residents and families, to understand each other's contribution to achieving outcomes for people.

I also think that that very important point was made by Janet Finch-Saunders about the link between the hospital and the home, because I think it is those transition periods when things happen, like false teeth get lost, and all these really important things that are so important to people's lives. That transition is vital, so I'm very pleased you made those points so strongly. Certainly, that is something that I think we have to emphasise in the support that we are giving to care homes.

So, as I say, this care home improvement Cymru programme does engage at all levels. We also intend to support care home providers by developing an online facility as part of the Dewis website, which will allow them to display real-time vacancies. We see the real benefits here in terms of time saved and engaging with commissioners and in opportunities to market their services. But this is in its early stages, and we'll be working with providers and others in its development.

I'm acutely aware that adding the prospect of the EU exit into the mix does create further uncertainty for providers. I was actually at a forum today where we were discussing the impacts of the EU exit on care home providers and maintaining the quality and sustainability of care homes and other social care provision is a top priority throughout this unsettling process. So we are taking a range of measures in co-ordination with wider contingency planning arrangements, to support providers and to mitigate the impact of a 'no deal' EU exit. Two examples that are particularly relevant to care homes are food and medical supplies.

In terms of food, we've established arrangements to allow providers to report any local food supply disruption to local authorities quickly and easily. They in turn can escalate the matter to local resilience fora if necessary. Welsh Government is also fully engaged in UK Government planning for the import and distribution of critical goods, including medical supplies and clinical consumables. We've procured additional storage capacity, including providing a 12 to 15-week supply of these products, which will help increase resilience in both the Welsh NHS and the social care services, because these are issues that are being brought to us by the social care providers, and we think it's very important to try to address those as much as we can.

Turning now to our partners and their contribution, our regulators, Care Inspectorate Wales and Social Care Wales, have both undertaken significant work to implement the regulatory framework established by the Regulation and Inspection of Social Care (Wales) Act 2016. As part of the transition to the new system of regulation, the inspectorate has reregistered 1,550 services since last April, and this is a considerable achievement and is in addition to its day-to-day responsibilities and inspection activity. I'm extremely pleased with the very positive feedback that the inspectorate has received about this process, and the level of support it provided from providers themselves.

This legislation represents an exciting opportunity for us all. It recognises the role of service providers and responsible individuals as professionals with responsibility and accountability for the care and support services they provide. It deliberately doesn't seek to manage services at arm's length, but enables providers to focus on what matters to individuals, their well-being and personal outcomes. Both Care Inspectorate Wales and Social Care Wales will support improvement through their regulatory roles.

I mentioned the importance of workforce earlier, and that has been mentioned by Janet Finch-Saunders and by Angela—the importance of workforce. I think there is a consensus that we need a better understanding of the social care workforce, including in care home services. Social Care Wales and Health Education and Improvement Wales are developing a joint health and social care workforce strategy to identify current and future capacity and capability requirements and how these can be met. This will help ensure we have the right number of people in place able to deliver flexible and agile health and social care that meets the needs of the people of Wales. I know that Angela raised the importance of having a professional way of moving up in the service, and that's one of the things that we are looking at, because there is a differentiation between jobs that are done in the social care service and that are done in the health service, and other places as well. So, I think this is one of the areas that we are going to look at. 

The health service, of course, has been mentioned. Local authorities and health boards also have a key role here, both in terms of their statutory responsibilities and as commissioners of care home services. I know that Janet raised that issue at the end of her contribution, and I'd be grateful if you could write to me about what happened with that individual person and how that differentiation arose. Local authorities and health boards must work with providers to ensure that there is the right care and support available to meet people's needs within the care home they have contracted to provide effective care. I also expect them to play their part in supporting care home sustainability by paying fees due to the providers quickly and efficiently in order to help avoid unnecessary cash-flow pressures, which does happen.

Last year, we issued the 'Let's agree to agree' toolkit to assist commissioners of and providers of residential care for older people in agreeing appropriate fees for placements. This was developed in collaboration with providers and commissioners. Initial feedback from local authorities is that the toolkit is being considered as part of their fee models for care homes, with some adopting it in full or in part. A more detailed review of the toolkit will be undertaken by the national commissioning board next year, and I want to encourage all local authorities to make use of this resource. Then finally, the sector itself, including those who own services and the people who work in those services, is integral to both the quality and future sustainability of care home services. I really want to recognise here at the end of my contribution the significant contribution they've made to adapt to the new regulatory framework and to making their own contribution towards meeting cost pressures and through investment in the workforce. 553

I hope I've been able to show that the Welsh Government is working on a number of fronts in terms of recognising the importance of the homecare services and that we have got plans about trying to further and support the workforce in what is now a very difficult and unsettled time. But I do think that we do want to end on the optimistic note that Janet started with about the great service that is provided in so many homes and the really good practice that there is. I was particularly appreciative of the comments as well made by Jayne Bryant and her reference to the work with people with dementia, and particularly her mention of the Forget-me-not choir, because I've had personal experience of the Forget-me-not choir in my constituency of Cardiff North. I do believe, as Jayne had said, it is one of the most moving experiences you'll have to listen to the Forget-me-not choir. I know that they do operate in a number of homes. 

I also take into account the proposal that clinics should be able to take place in local authority homes, because I think there does need to be a degree of flexibility. And as it was said, there's absolutely no reason why that shouldn't happen. In fact, it does happen in some voluntary settings in Cardiff now. I know that the health authority does provide clinics in voluntary sector settings. I think the more that that can be done—because the nearer it provides them to homes, and to people's own homes, it makes them more likely to take advantage. So, I will finish now. We must continue to work together to ensure that this very important sector thrives and goes from strength to strength in providing the best possible care and support for people in Wales. Thank you very much.