National
Assembly for Wales / Cynulliad Cenedlaethol
Cymru
Health
and Social Care Committee/
Y Pwyllgor Iechyd a Gofal Cymdeithasol
Regulation and Inspection of Social Care (Wales) Bill/ Bil Rheoleiddio ac Arolygu Gofal Cymdeithasol (Cymru)
Evidence from RNIB Cymru – RISC 28 / Tystiolaeth gan RNIB Cymru – RISC 28
23 April 2015
RNIB Cymru is Wales’ largest sight loss charity. We provide support, advice and information to people living with sight loss across Wales, as well as campaigning for improvements to services and raising awareness of the issues facing blind and partially sighted people.
· There are currently 106,000 people in Wales living with sight loss (1).
· It is estimated that the number of people living with sight loss in Wales will double by 2050 (2).
· The prevalence of sight loss increases with age: one in five people aged 75 and over are living with sight loss; one in two people aged 90 and over are living with sight loss (3).
· Older people with sight loss, particularly those over the age of 75, are often living with up to three or more long term health conditions, making it even more of a challenge to maintain independence, social networks and wellbeing. Many need care and support (4).
· Sight loss impacts on every aspect of a person’s life: their physical and mental health, their ability to live independently, their ability to find or keep a job, their family and social life. As a result, people with sight loss form a significant group of users accessing social care services in Wales.
There is a higher prevalence of sight loss among people with certain other conditions. In particular:
· Up to 70 per cent of people who survive a stroke have difficulty seeing or processing visual information (5);
· It is estimated the number of people over 75 years with dementia and sight loss, is 2.5 per cent. This figure is likely to be an under-estimate because studies have not accounted for individuals who are considered to be ‘untestable’. The degree to which a person with dementia is able to cope will be influenced by their sight loss (6). As the population ages, the number of people with both dementia and sight loss will increase;
· People with learning disabilities are ten times more likely to have serious sight problems than other people. People with severe or profound learning disabilities are most likely to have sight problems. Six in ten people with learning disabilities need glasses and often need support to get used to them (7). Sight loss is often overlooked in people with learning disabilities, because the individual may not know they have a sight problem or be unable to communicate the problem, and problems caused by their sight loss might be attributed to other causes.
This means that people with sight loss are accessing a broad range of social care services with a range of intensity of use. Blind and partially sighted people who receive community or residential care because of their sight loss and/or additional disabilities will be more vulnerable to abuse or exploitation, because of their visual impairment – for example, they may not be able to see what is occurring around them, or physically identify social care staff who are abusing them. It is vital that the proposed Regulation and Inspection Bill provides a framework capable of safeguarding people with sight loss and ensuring high quality care and support that can meet their needs.
It is only a small proportion of social care services which require enforcement action via regulation. However, we would stress that recent reviews have highlighted a failure to provide high quality social care services for people with sight loss.
It is clear from the evidence that there is a lack of understanding of the needs of people with sight loss, despite the significant numbers of older people accessing care who will have sight loss. For example, the Equality and Human Rights Commission’s (EHRC) review of home care services in England (8) found evidence that people with sight loss were involved in some of the most disturbing examples of poor treatment:
“I recently had to stop a carer throwing a blanket over a service users head, she seemed to think it was amusing to humiliate [the] service user who was visually impaired but the most concerning thing was that she did not understand what she was doing wrong” (Homecare worker – private sector)
The EHRC inquiry report noted that people with sight loss found it difficult to complain and indeed, were viewed by carers as less likely to complain than those with sight. Despite this, the inquiry also heard complaints about carers who were clearly unaware of the needs of people with sight loss and noted that of the 50 service specifications submitted, only 17 mentioned sensory impairment or people with sight loss, indicating a lack of awareness of sensory loss both at the point where social care is being provided, and when it is commissioned.
While the EHRC inquiry looked at home care services in England, its findings have been reiterated elsewhere, such as the Older People’s Commissioner for Wales’s recent review (9) of quality of life and care of older people in care homes in Wales, which found:
· Homes were poorly lit, with no consideration of the importance of lighting, particularly for residents with deteriorating eyesight and sight loss, impeding residents’ ability to easily and safely move around the home environment with support.
· Older people were not routinely screened for sensory loss upon entry into care homes, and there is a lack of ongoing/regular screening for sensory loss for older people in care homes. This is despite NICE guidance stating that organisations providing care should ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan (10).
· Care home managers who stated that sensory loss did not affect any of their residents, when, given the prevalence of sensory loss among older people, this is almost certainly not the case, and means that a large number of older people could be missing out on essential assistance and support.
As noted by NICE (11), mild but progressive sight and hearing losses are a common feature of ageing and may go unnoticed for some time, but can have a serious effect on a person’s communication, confidence and independence. Recognition and recording of the sensory needs of older people in care homes is essential to improve their quality of life and avoid isolation, which can have a detrimental effect on wellbeing. We would expect any system of inspection to ensure that care homes are meeting the recommendations made by NICE, that:
· organisations providing care ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan;
· social care staff are alert to and recognise specific needs arising from sensory impairment in older people in care homes and record them in their care plan;
· local authorities commission services from providers that can produce evidence of protocols for training staff to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.
RNIB Cymru is seriously concerned that residential care homes are failing to take into account the needs of people with sight loss. If due regard is not taken of residents’ sight loss, residential care homes will be in breach of the Equality Act by:
· not removing or minimising disadvantages experienced by people due to their protected characteristics;
· not taking steps to meet the needs of people from protected groups where these are different from the needs of other people.
1. Do you think the Bill as drafted will deliver the stated aims (to secure well-being for citizens and to improve the quality of care and support in Wales) and objectives set out in Section 3 (paragraph 3.15) of the Explanatory Memorandum? Is there a need for legislation to achieve these aims?
RNIB Cymru agrees that there is a need for new legislation on the regulation and inspection of social care to achieve the aims and objectives set out in Section 3 of the Explanatory Memorandum. However we believe that there are potential barriers to implementing the Bill, as set out in our answer to question 2.
2. What are the potential barriers to implementing the provisions of the Bill (if any) and does the Bill adequately take account of them?
RNIB Cymru believes that the main barriers to successful implementation of the Bill are:
· Staff training: changes to the social care sector will not happen without a properly trained and engaged workforce. In particular, the skills of inspectors and the regulatory workforce will be crucial to the implementation of the new system of outcome based measurement and a quality framework. There will only be public confidence in the judgments of the inspectorate and regulator if judgements by inspectors are consistent and accurate. It is vital that this is given consideration when determining what will constitute a person to be “appropriately qualified” (part 4 of the Bill) and in planning transition to the new inspection and regulation regime.
· Insufficient investment in the social care sector: the social care system is chronically under-funded and needs significant additional investment to ensure it is a viable system capable of providing high quality person-centred services that can meet the needs of people with sight loss. An ageing population means that the number of people in Wales who need support from social care will increase. Without investment in social care, it seems unlikely that already stretched services will be able to meet the needs of the population, regardless of the system of regulation and inspection. We look forward to commenting on Welsh Government proposals on the funding of social care as part of the forthcoming consultations on regulations under the Social Services and Well-being (Wales) Act.
· A lack of support for the social care workforce: as highlighted by the Older People’s Commissioner (2014), care staff work in highly challenging circumstances, yet they currently receive low pay, often have poor terms and conditions, lack training and work in a sector that is rarely seen as having a valuable status. There is little support available to care staff to ensure that they have the right skills and knowledge to provide high quality care, and limited opportunities for continued professional development or career progression. In addition, CSSIW’s annual report for 2013-14 highlights the overriding imperative for local authorities to make significant savings in 2014-15, 2015-16 and beyond, as a risk to workforce stability. The cultural change needed is not addressed by the Bill, but is a major threat to achieving its objective of supporting the best development of the workforce possible. Once established, it must be a priority for Social Care Wales.
· A lack of reference to human rights: a fundamental function of Regulation and Inspection is the reduction in both risk to, and breaches of, human rights. Thus RNIB Cymru would like to see an explicit requirement on the face of bill for due regard to be given to the United Nations Convention on the Rights of the Child, the United Nations Convention on the Rights of Disabled People or the United Nations Principles for Older Persons. We see the lack of reference to human rights as a potential barrier to the implementation of the Bill.
We would also stress that there must be effective transition arrangements to ensure that users of social care services are safeguarded while the move to a new regulatory and inspection system is implemented.
3. Do you think there are any issues relating to equality in protection for different groups of service users with the current provisions in the Bill?
RNIB Cymru would stress that social care services should be required to include in their annual report how they are meeting their requirements under the Equality Act. For example, the Older People’s Commissioner’s recent review of care homes (2014) highlighted that many care homes, both internally and externally, do not enable the independent mobility of people with sensory loss. The review identified a lack of hand rails and clearly marked ramps, which impeded residents’ ability to easily and safely move around the home environment without support; notice boards which provided essential information for residents, such as information about activities, advocacy services and other local information, were often hard to reach or difficult to see.
CSSIW’s annual report for 2013-14 also highlights that the Quality of the Environment is commonly cited in notices of non-compliance for adult residential homes, with a lack of ongoing investment, maintenance and repair highlighted in a number of care and nursing homes for older people. This can pose a particular risk for older people with sight loss, who have 90 per cent higher odds of multiple falls than a person with normal sight (12).
It is simply not acceptable that people with sensory loss have little choice but to accept that they must be accommodated in physical environments that are not safe or appropriate for their needs, can limit their mobility and independence. RNIB Cymru is seriously concerned by the lack of regard for making reasonable adjustments to meet the needs of residents’ with sight loss. In some cases, we believe residential care homes will be in breach of the Equality Act. Inspection of care homes must include consideration of the safety and accessibility of the environment and identify actions to secure improvements.
4. Do you think there are any major omissions from the Bill or are there any elements you believe should be strengthened?
RNIB Cymru believes that there is opportunity to better integrate processes for the whole social care sector. Currently the Bill misses the opportunity to strengthen and streamline current processes to create improvement and more effective regulation of integrated services.
6. What are your views on the provisions in Part 1 of the Bill for the regulation of social care services? For example moving to a service based model of regulation, engaging with the public, and powers to introduce inspection quality ratings and to charge fees.
RNIB Cymru is supportive of the provisions set out in Part 1 of the Bill, including the move to service based regulatory provision.
We welcome the move towards greater engagement with the public. To ensure that blind and partially sighted people can engage fully it is vital that all information, such as the proposed annual reports, is available in a range of accessible formats. We would like to see a commitment to ensuring provision for all types of communication and information needs within the new regulatory regime, and that these needs can be met within the same timeframe as standard information would be provided.
RNIB Cymru strongly supports powers to introduce inspection quality ratings. We believe that this will enable service users to make comparisons between services, and hence more informed choices about the services they need to access. However we would like to see commitments to ensure that information on the quality of services is made as accessible and transparent as possible. We would also like further information as to how such a ratings system will work, including how it will incorporate specific consideration of sensory loss. For example, when a person with sight loss and/or their family or carers are making a choice of care home, it will be important for them to know how accessible the physical environment of a care home will be for an individual with sight loss.
7. What are your views on the provisions in Part 1 of the Bill for the regulation of local authority social services? For example, the consideration of outcomes for service users in reviews of social services performance, increased public involvement, and a new duty to report on local markets for social care services.
RNIB Cymru broadly supports the provisions in Part 1 of the Bill on the regulation of local authority social services. We believe that routine reviews of local authority performance will be instrumental in raising standards of social care commissioning.
It is vital that outcomes for service users are considered in reviews of social services performance, but for this to be meaningful it must be based on the outcomes that matter to individual service users. We would like further clarity about how outcomes will be assessed and measured in practice before we can comment further.
We welcome the new duty to report on local markets. We believe that this will offer the opportunity to ensure that local markets are capable of meeting the social care needs of the population they serve, and in planning services to meet future demand. We note that CSSIW’s Annual Report for 2013-14 (13) identifies that based on the current provision, there won’t be enough nursing or residential beds by 2025. The Bill must ensure that when such information is available, it is acted on, to prevent a future crisis in social care provision.
8. What are your views on the provisions in Part 1 of the Bill for the development of market oversight of the social care sector? For example, assessment of the financial and corporate sustainability of service providers and provision of a national market stability report.
RNIB Cymru is supportive of provisions in part 1 of the Bill to develop market oversight of the social care sector. We would hope that this will support greater stability in the sector and avoid unexpected and unplanned service closures. Even where service closures are unavoidable, we would hope that such information would help to anticipate and mitigate the impact on those people who are using the services. In particular, moving to a new care home can be a source of huge anxiety. For someone with sight loss there is the additional challenge of orientating yourself in an entirely new and unfamiliar environment; this difficulty would be further compounded for someone who has dementia as well as sight loss. People need to have confidence that when they make a choice about their social care, that there will be stability and continuity in the services they are accessing, and that they will not suddenly be left without support.
The Older People’s Commissioner’s review of residential care (2014) has identified that there is a lack of clear national understanding of what the future need for residential and nursing care will be, nor an understanding of how acuity levels within care homes are likely to further change as a result of wider changes in the model of health and social care within Wales, and the potential for further development of other models that combine housing and care, such as extra care, has not been explored. This means that there is a lack of effective forward planning, and action to ensure, the future supply of appropriate, high quality care home places in Wales with the appropriate numbers of specialist staff required. RNIB Cymru would hope that the development of market oversight would assist in forward planning of services and workforce planning.
However, as we have already stressed, RNIB Cymru believes the social care sector is underfunded. Market oversight and annual reporting alone will not solve this problem. There needs to be significant additional investment to ensure a viable social care system capable of meeting the needs of citizens in Wales.
9. What are your views on the provisions in Part 3 of the Bill to rename and reconstitute the Care Council for Wales as Social Care Wales and extend its remit?
RNIB Cymru believes that Social Care Wales has the potential to be an effective means of driving up standards in social care and ensuring the social care workforce has necessary skills and understanding to deliver excellent care. We would urge that this includes consideration of how best to equip the social care workforce with an awareness of sensory loss. However we also have some concerns that there may be conflicts of interest for Social Care Wales – for example, the functions of regulation and of promoting improvement must be separated.
10. What are your views on the provisions in Parts 4 - 8 of the Bill for workforce regulation? For example, the proposals not to extend registration to new categories of staff, the removal of voluntary registration, and the introduction of prohibition orders.
RNIB Cymru believes the scope of current workforce regulation does require changes to reflect available care and support services that people with sight loss may access. Currently there are various services, such as sheltered accommodation, day centres and day support services, which are not covered by regulation. These gaps in the regulatory system must be addressed in order to minimise risk and ensure high quality care and support that promotes the wellbeing of blind and partially sighted service users.
11. What are your views on the provisions in Part 9 of the Bill for co-operation and joint working by regulatory bodies?
RNIB Cymru notes that the provisions for cooperation and joint working make no reference to health or UK regulators of members of the social care workforce. Where services are being provided by integrated teams, as is increasingly the case, there may be good reason for these bodies to be cooperating and working together in order to protect the wellbeing of service users. We would welcome further discussion of this point.
For further information, please contact Tess Saunders, Policy and Campaigns Officer.
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1. Estimate based on Access Economics 2009, Future Sight Loss UK 1: The economic impact of partial sight and blindness in the UK adult population, RNIB, and Office of National Statistics (2014), Subnational Population Projections, Office of National Statistics.
2. Access Economics 2009, Future Sight Loss UK 1: The economic impact of partial sight and blindness in the UK Adult Population.
3. Access Economics, 2009, Future Sight Loss UK 1: The economic impact of partial sight and blindness in the UK Adult Population
4. Tate R, Smeeth L, Evans, J, Fletcher A, Owen C, Rudnicka A, 2005. The Prevalence of Visual Impairment in the UK: a review of the literature. RNIB.
5. MacDiarmid S, Rowe F, 2007. Interdisciplinary aspects of vision and communication deficits following stroke. British and Irish Orthoptic Journal vol 4, pp21-26.
6. Roy Jones and Dr Richard Trigg, 2007, Dementia and serious sight loss, Thomas Pocklington Trust. Occasional paper number 11, February 2007
7. Emerson and Robertson, 2011. The estimated prevalence of visual impairment among people with learning disabilities in the UK. Improving Health and Lives: Learning Disabilities Observatory report for RNIB and Seeability.
8. EHRC, 2011. Close to home: an inquiry into older people and human rights in home care. EHRC.
9. Older People’s Commissioner for Wales, 2014, A place to call home? A review into the quality of life and care of older people living in care homes in Wales.
10. NICE, 2013. Quality Standard SQ50, Mental wellbeing of older people in care homes. Quality Standard 4. Recognition of sensory impairment.
11. NICE, 2013. Quality Standard SQ50, Mental wellbeing of older people in care homes. Quality Standard 4. Recognition of sensory impairment.
12. Scuffham PA, Legood, R, Wilson, ECF, T2002. The incidence and cost of injurious falls associated with visual impairment in the UK. Visual Impairment Research 4, 1-14.
13. CSSIW, 2014, Annual Report 2013-14. Available online at: http://cssiw.org.uk/our-reports/annual-reports/2013-2014/?lang=en