Health and Social Care Committee

Consultation on terms of reference for inquiry into residential care for older people

RC27 ToR – College of Occupational Therapists

College of Occupational Therapists response to invitation to comment on the Terms of Reference of the Health and Social Care Inquiry into Residential Care.

General comments:

Thank you for the opportunity to comment on these terms of reference. Overall, the College finds the terms of reference broad and inclusive, showing good opportunity to really consider the issues impacting on residential care provision. This is a complex and intricate area and draws in a number of other considerations and types of service and the committee may need to exercise great care in keeping this inquiry manageable. Each of the individual statements could stand for an individual inquiry on their own.

Specific comment of the terms of reference

‘Examine the provision of residential care in Wales and the ways in which it can meet the current and future needs of older people, including:’

This is vitally important and a good scope. The committee is aware that the needs of older people change over time and will also be very different for individuals. It will be important to ensure that while keeping this manageable there is acknowledgement that solutions to older people’s care needs will be as varied as the people themselves. People with dementia or other cognitive needs will require very different solutions to those with physical needs: many people as they age, experience both. Will the inquiry include nursing needs or the complexity of continuing care or only focus on residential care?

‘The process by which older people enter residential care and the availability and accessibility of alternative services’

This might include many issues. The committee may wish to consider whether it includes all of them as presented by witnesses or focuses on particular situations. For example, for some this is at a time of crisis following hospital admission and may include issues of good service and care planning, effective integration between services, finance, availability and choice as well as issues such as separation from life partners. For others it is a planned step in a long process and the committee may be in discussion about choice and control, extra care and other housing alternatives, continuing care, reablement alternatives and nursing homes. There are many alternatives to residential care and again the inquiry may need to include, rurality, family and social networks, finance, as well as the variability of statutory services. Service ethos is also vital and an enabling service, based on an intention to ensure people achieve their best rather than seeking a risk averse of easy solution will also influence routes.

Occupational therapists are leading reablement services and these can truly slow down entry to residential services. This could be a major area of the inquiry, one we would not want overlooked as it is so central to many decisions about moving home for care need reasons. The importance of wide ranging primary care services is also vital.

‘The capacity of the residential care sector to meet the demand for services from older people in terms of staffing resources and the number of places and facilities.’

We would anticipate this would need to include availability and funding routes, long term sustainability and how flexible accommodation can support keeping families together. Many people with more complex needs are being sustained at home and thus those entering residential or nursing care really do have significant needs. This places high demands on care homes which need to be profitable to remain in business. You may need to consider business models as well. A major area for the inquiry might be around size, quality of facilities and maintaining skills and capacity for residents. This will be considered further below.

‘The quality of residential care services 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. ‘

The inquiry may need to include issues of staff mix and availability of activity and how homes continue to enable independence is vital to ensuring a good quality of life. There are issues around how homes participate in their communities or if they sit as separate entities with residents never going out. The enabling ethos is also important- how do homes ensure that people retain their skills and roles, control and decision making? For example can people make their own drinks and snacks? Is there a means of allowing people to control the menu, activity or excursion choices? 

Staff recruitment, training and development also influence quality. Also the environment in terms of having good design that enable interaction, such as loops on TVs, seating that people can get in and out of, and fire doors which pin people to certain rooms unless they have a carer to open doors for them. The committee may wish to decide the level of consideration to be included.

In relation to closures, this is complex and emotive for people. This is someone’s home but where services need closing or changing how can that best be managed. That issue could take significant investigating to be meaningful.

It will be important to not focus on older physically frail people, but ensure that those who have lifelong needs, such as those with learning disabilities, lifelong mental ill-health or physical disabilities are considered as they age as well as those with age related needs, such as Dementia.

‘The effectiveness of the regulation and inspection arrangements for residential care, including the scope for increased scrutiny of service providers’ financial viability.’

Again, this could be a large area; the committee may need to consider all the Care and Social Services Inspectorate Wales processes. It might be useful to consider the similarity or otherwise of the regulations across different types of care home, and link between different regulators, burden of regulation versus proportionality to protect people. Where people have communication, cognitive or other difficulties which inhibit their ability to voice concerns how are people protected? Presumably this will include a significant discussion about the balance between ensuring a proprietor is financially and professionally a ‘fit’ person, alongside the burden and complexity which might keep really good providers out of the market.

‘New and emerging models of care provision’

This offers an opportunity to explore potential new options which may be more suited to a 21^st century care system. This is a really useful area to explore and should includewhat care should look like as an alternative to residential care. Reablement and a focus on maintaining people in their own communities is vital so the inquiry might want to really investigate where and how people can be kept independent as long as possible. This may lead the committee to considering housing design, adaptations, extra care, the role of other housing providers and the integrated working of hospital admission and discharge with community care and reablement services. Benefits are key but not devolved, yet finance, poverty, home maintenance and community support, access to care services and the impact of differing charging regimes for different components adds another layer that might be included.

‘The balance of public and independent sector provision, and alternative funding and ownership models, such as those offered by the cooperative and mutual sector’

This could lead to major investigation in terms of the model for care services in Wales. Issues such as affordability, profitability, sustainability and complex charging schemes will need to be considered. We would also suggest that you could consider how people prepare for their long term home and care needs. This might include financial means but could also include other options. Issues of rurality and attractiveness of the sector for employees also arise.

Currently the sectorisation of provision impacts on provision, yet as people live longer with more complex needs and the acceptance that they may move in and out of continuing care for example, may mean future models have to build in more flexibility to allow long term support. So the committee may wish to consider the relevance of separation in definitions of nursing and residential home, homes for those with different types of needs or whether more flexible provision would allow people whose needs are complex or change to remain in their home rather than having to more to another home. Would the committee report seek to define what integrated services look like at a local level, for example?

Conclusion.

We welcome the decision of the committee to investigate this important topic. The terms of reference appear excellent, but we are concerned that they could lead to a very wide ranging inquiry which could impact on the quality of scrutiny. It would be a shame if the inquiry spread too widely to allow depth of study. We have tried to identify for you many of the areas we think you are including in with these terms of reference in the hope it helps the committee identify whether they draw out what the committee wishes them to. We hope this approach is useful

The committee may wish to direct the inquiry to include or exclude certain areas, or allow sufficient time to really investigate such an important tropic and do it justice in making recommendations.

The College looks forward to participating in the inquiry in due course. Please do not hesitate to ask if you require anything further.

Ruth Crowder                                                                

Policy Officer Wales/ Swyddog Polisi Cymru

College of Occupational Therapists/ Coleg Therapyddion Galwedigaethol