Health and Social Care Committee
Inquiry into residential care for older people
RC45 – Community Housing Cymru and Care & Repair Cymru
A Response by Community Housing Cymru (CHC) and Care & Repair Cymru (CRC) to the Inquiry into Residential Care for Older People
1.0 About CHC
Community Housing Cymru (CHC) is the representative body for housing associations and community mutuals in Wales, which are all not-for profit organisations. Our members provide over 130,000 homes and related housing services across Wales. In 2010/11, our members directly employed 6,500 people and spent over £800m in the Welsh economy. Our members work closely with local government, third sector organisations and the Welsh Government to provide a range of services in communities across Wales.
Our objectives are to:
· Be the leading voice of the social housing sector.
· Promote the social housing sector in Wales.
· Promote the relief of financial hardship through the sector's provision of low cost social housing.
· Provide services, education, training, information, advice and support to members.
· Encourage and facilitate the provision, construction, improvement and management of low cost social housing by housing associations in Wales.
Our vision is to be:
· A dynamic, action-based advocate for the not-for-profit housing sector.
· A ‘member centred’ support provider, adding value to our members’ activities by delivering the services and advice that they need in order to provide social housing, regeneration and care services.
· A knowledge-based social enterprise.
1.1 Last year CHC formed a group structure with Care & Repair Cymru and the new Centre for Regeneration Excellence Wales in order to jointly champion not-for-profit housing, care and regeneration.
2.0 About CRC
Care & Repair Cymru is the “Older People’s Housing Champion”. We are a national charitable body and actively work to ensure that all older people have homes that are safe, secure and appropriate to their needs, helping them to remain living independently in their own homes.
We provide services to the network of 22 Care & Repair Agencies across Wales. Our services to Agencies include policy information and briefing, training and networking events, co-ordination of the national database (CARIS), agency support, national PR and communications, funding allocation and performance evaluation.
Through our work, and close relationship with the 22 Agencies, we listen to the needs and desires of older people and on the national stage articulate this information to policy makers at the Welsh Government. This advocacy work helps inform thinking on older people Housing Policy and wider Health and Social Care policy which is intrinsically linked to appropriate, good quality housing.
Our Vision is:
All older people in Wales shall have warm, safe, secure homes that meet their individual needs.
Our Mission is:
Care & Repair Cymru exists to ensure that all older people have access to housing services that enable them to live in housing that meets their individual needs
3.0 Our Joint Response
3.1 Community Housing Cymru and Care & Repair Cymru commissioned a study to identify opportunities for the community housing sector to support health outcomes, particularly in meeting the needs of our ‘ageing society’. The findings of this study will be useful to inform this inquiry. Through a series of interviews and focus groups, involving professionals from both health and housing, we developed an understanding of the barriers to closer health and housing collaboration and five key practical opportunities that may be realised. The key opportunities relevant to this inquiry are:
3.2 Early discharge support in Extra Care schemes and nursing homes
Extra Care schemes and Registered Social Landlord (RSL) nursing homes located near district general hospitals may offer an effective option for high quality care to enable earlier hospital discharges of frail older people.
RSLs in at least three areas are in active talks to create or consolidate such services. Others have shown interest but conversations have not yet been held. To date, most such bookings have tended to be ad hoc and involve a handful of beds. Many RSLS are keen to explore the possibility of annualised block bookings for planning and cost reasons. However, some Health Boards are wary of block booking, wanting to retain maximum financial flexibility.
The partnership arrangement to support this form of early discharge will depend on the scheme involved. Nursing homes have existing trained healthcare capacity, and arrangements with local GPs, and there is scope to up skill staff in Extra Care schemes to some degree.
3.3 Expansion of not for profit nursing care
Three RSLs have made the strategic shift to make ‘care’ part of their core offer alongside housing. All three offer nursing care, aiming for a mid-market price – aiming cheaper than publicly provided services but maintaining quality standards. Such nursing homes can form the hub for a range of other services. For example, day care is offered from several homes (if the residents are content). They can also host other teams such as out of hours teams.
The opportunity for RSLs to offer nursing care across Wales seems significant, yet the move into a highly regulated service area can be daunting and many RSLs may decide to remain focused on their core housing mission. For those already committed to nursing care, and for those considering the move, clarity about the potential demand would be welcomed.
3.4 Increasing the level of care available in sheltered housing and Extra Care schemes
A number of RSLs interviewed as part of this research, particularly those who do not offer
Extra Care, stated that their organisations would like to offer a wider range of care within a sheltered housing setting. They would like to be able to support residents to stay in the sheltered housing homes for as long as possible, as they become increasingly frail. Enabling sheltered housing schemes to cope with greater levels of frailty could meet people’s preference for staying at home, for couples to stay together, and reduce the risk of institutionalisation in a nursing home.
Interviewees anticipate that residents of Extra Care schemes will become increasingly frail too, and reluctant to move from what are now their homes. Bringing additional (continuing) healthcare into these schemes may help prevent admissions to hospital and provide a community case for other services.
3.5 Ongoing support to enable older people to live more independently and healthier at home
Adaptations don’t only ensure that older people can remain living independently in their own home for longer, they also alleviate pressure and financial strain on NHS and social services budgets. It is estimated that for every £1 spent on adapting a person’s home, £7.50 is saved from health and social services budgets.
The value of investment in services that enable people to live at home for longer has been recognised by the Welsh Government, most recently in the form of a £4.77m package awarded directly to Care & Repair agencies in Wales for 2011-12.
The trusted access that Care & Repair agencies have into older people’s homes can be used as a channel for other forms of support too. For example,e in Monmouthshire, the Healthy Homes project has seen the initial assessment expanded to a more holistic case assessment, supporting older people to access additional care support, benefits etc. This has been highlighted as good practice within the Gwent Frailty project but, as a classic ‘cinderella service’, it is now at risk of losing funding. The Hospital to Home projects in Conwy and Caerphilly offer similar support, but target people before they leave hospital.
The key opportunities to support older people to live healthier at home via Care & Repair breaks down into three parts:
1. Increasing the current rapid response adaptation programme (RRAP) to meet demand;
2. Expanding RRAP to all tenure, from its focus on private housing;
3. Expanding the programme to have a wider preventative purpose, building on models such as the Monmouthshire Healthy Homes and hospital to home type schemes.
All these opportunities should save / delay NHS spend on frail older people and, more importantly, improve people’s lives. A recognised challenge is that such preventative work requires investment alongside ongoing increasing demand for acute care.
4.0 Other opportunities:
4.1 Expanding and protecting telecare provision
Several RSL interviewees highlighted their interest in increasing the provision of telecare to residents across their stock. Telecare varies from scheme to scheme, but generally involves a community alarm service and regular contact by telephone. Further technology may be included such as detectors which monitor motion, falls or fire and gas risks. When activated, these technologies then trigger action by a response centre.
Some current telecare schemes are at risk because they are not statutory and are voluntarily funded by local authorities. One RSL highlighted that their scheme supports hundreds of vulnerable people in the city, both their own residents and people in private housing. As a recent stock transfer organisation, they were pleased to inherit operational responsibility for the scheme but cannot afford to finance the scheme.
Some RSL interviewees point out that should telecare be removed, there is likely to be an immediate cost implication for the NHS – for example, owing to an increase in severity of need following a fall at home.
5.0 Specific Comments
Our comments below mainly relate to our ambition to keep older people out of an institutional care setting wherever possible, whilst acknowledging that for some older people remaining at home may not be the most appropriate or desirable option. Comments follow the headings provided for this initial response.
· Process by which older people enter residential care and the availability and accessibility of alternative community-based services, including re-ablement services and domiciliary care.
Whilst acknowledging that for some older people remaining at home may not be the most appropriate or desirable option, evidence suggests that most people as they age would prefer to remain living in their own home[i][1]. Care & Repair Cymru have long been concerned about older people being placed in residential care, when it is both unnecessary and undesirable for the older person. Care & Repair work and provide services across all 22 local authority areas in Wales to maximise the independence of older people to enable to them remain living at home. This is achieved by providing tailored advice, brokering local solutions and providing and accessing grants and charitable funding that improve the home environment to meet individual needs and improve safety.
Care & Repair agencies have also supported many thousands of older people in Wales to return safely home from hospital after illness or injury (including falls and strokes) through the Rapid Response Adaptations Programme (RRAP). The programme facilitates an immediate response to specific needs by providing minor works and adaptations such as ramps and handrails, shower seats, door entry and repairs to paths and steps to enable people to return to their own homes following hospital discharge. Such adaptations can also prevent the need for admission to hospital or residential care. The programme is a fast-response initiative, with an average time of 8 days achieved in 2010/11. Older people in hospital can feel extremely vulnerable and fear returning home without support. This may lead to consideration of a residential placement. With the advice and practical support of Care & Repair, however, many people have felt confident enough to return home. During 2010/11 alone, 13,605 jobs were completed for older people through the Rapid Response Adaptations Programme, with some 9,500 preventing hospital or residential care admission and 4,200 being supported to return home from hospital.
Remaining at home is not only desirable but often cheaper than moving to a supported living environment. Care & Repair can evidence outcomes for older people that save both the older person being somewhere they don’t want and need to be, and subsequently contribute a cost saving benefit to Health and Social Care. Services delivered by Care & Repair across Wales are estimated to save the NHS and social services £7.50 for every £1 spent by keeping older people out of hospital and residential care, and by helping them to return home from hospital quicker. A recent study by the Wales Audit Office of adaptation services in a Welsh Local Authority also concluded that providing a housing adaptation through a DFG delayed entry into residential care by an average of 4 years, with significant cost savings given that the average DFG cost is £7000, and an approximate 4 year cost of residential care is in the region of £110,000.
Care & Repair Cymru would welcome improved provision of community-based resources, which are tailored to the needs of older people, and advocate for greater resources to help older people remain living independently in their own homes.
New models of integrated community care would require a more ‘joined up’ approach, including adequate targeted local investment to ensure that home safety, wellbeing and independence are maximised through a proactive approach from statutory and third sector preventative services. Care & Repair Cymru would advocate that this integrated community service perspective should be clearly reflected in commissioning arrangements.
· New and emerging models of care provision.
We support increased diversity and mutual ownership of services such as domiciliary care that would help support the objective of older people remaining living in their own homes and communities.
· 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.
Stronger mutual, co-operative, third sector and RSL involvement in residential care and domiciliary care would be desirable. Care & Repair Cymru are happy to be involved in partnership arrangements that facilitate more efficient access and exit into and out of residential care, with a strong desire to help older people move to the accommodation and setting they prefer as quickly as possible.
6.0 Conclusion
We appreciate the need for a rational approach to preventing ill health in older people and supporting their independence. This can mean providing a range of holistic services to keep people active and involved in their communities, rather than having acute treatment or residential care.
Registered Social Landlords have shown themselves to be a new and emerging model of care provision who can aid in meeting the future needs of the ageing population.
CHC are CRC would welcome involvement in future discussion in this area.
CHC & CRC
December 2011