Y Pwyllgor Cyfrifon Cyhoeddus a Gweinyddiaeth Gyhoeddus

Public Accounts and Public Administration Committee

27/04/2022

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Cefin Campbell MS
Mark Isherwood MS Cadeirydd y Pwyllgor
Committee Chair
Mike Hedges MS
Natasha Asghar MS
Rhianon Passmore MS

Y rhai eraill a oedd yn bresennol

Others in Attendance

Adrian Crompton Archwilydd Cyffredinol Cymru, Archwilio Cymru
Auditor General for Wales, Audit Wales
Andrew Doughton Archwilio Cymru
Audit Wales
Dave Thomas Archwilio Cymru
Audit Wales
Helen Twidle Swyddog Polisi ac Ymgyrchoedd Iechyd a Gofal Cymdeithasol, Age Cymru
Health and Social Care Policy and Campaigns Officer, Age Cymru
Mary Wimbury Prif Weithredwr, Fforwm Gofal Cymru
Chief Executive, Care Forum Wales
Matthew Mortlock Archwilio Cymru
Audit Wales

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Fay Bowen Clerc
Clerk
Owain Davies Ail Glerc
Second Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Cyfarfu’r pwyllgor yn y Senedd a thrwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:17. 

The committee met in the Senedd and by video-conference.

The meeting began at 09:17. 

1. Cyflwyniad, ymddiheuriadau a dirprwyon
1. Introductions, apologies and substitutions

Bore da. Croeso. Good morning and welcome to Members and other attendees at the meeting. No apologies have been received. Do Members have any declarations of registrable interests? Mike Hedges. 

I'm not sure if it's registrable, but I'd like to declare I chair the cross-party group on age and ageing. 

Thank you. Perhaps I should declare, because there are some cross-cutting issues, I chair cross-party groups on hospices and palliative care, funerals and bereavement, and disability and some others, which may relate, which are all declared on my own register of interests.

For participants who are physically present here at the meeting today, please note that headsets are available in the room for translation and sound amplification, with translation on channel 1 and the amplification on channel 0. Members, please ensure that any electronic devices are on silent, and that's reminded me to do the same. Note that in the event of an emergency an alarm will sound and ushers will direct everyone to the nearest safe exit and assembly point.

2. Papurau i'w nodi
2. Papers to note

We have a number of papers to note. The first paper is the Welsh Health Specialised Services Committee letter from the Welsh Government. The Welsh Government has provided an update on progress being made in relation to recommendation 5 of the Auditor General for Wales’s report in May 2021 into Welsh Health Specialised Services Committee governance arrangements. The recommendation related specifically to the recruitment of independent members to WHSSC. The letter states a number of arrangements have been agreed to ensure the requirement of the recommendations have been met. But, Adrian, would you like to comment?

In as far as this piece of correspondence is concerned, we're comfortable that this addresses the recommendation that we'd made, but, Dave, I believe there were some other recommendations that are still outstanding. 

There were two to the Welsh Government that were outstanding. I think you're probably due further updates in relation to the NHS executive, which are central to the completion of those recommendations. So, the committee may want to request a further update from Judith Paget at some point in the future on those.

09:20

So, Members, other than seeking that, are you content to note the letter? Thank you. 

Our second item of correspondence is the WeCare recruitment campaign letter from the Welsh Government. In response to the committee's request, the Welsh Government has provided further information on the WeCare recruitment campaign. This letter sets out a number of initiatives to build awareness of job opportunities in social care and the value of such a career, with the objective of increasing visits to the WeCare.Wales jobs portal. The letter highlights that, between December 2021 and January 2022, there has been an increase of 176.5 per cent in people visiting the jobs portal compared to the same period 12 months previously, which is seen as an indicator of success. Again, could I ask, Adrian, do you have any comments as auditor general?

No comments. Nothing from us.

And are Members otherwise, then, content to accept or note the letter? Thank you.

Our next item of correspondence, or paper to note, is on the implementation of the Well-being of Future Generations (Wales) Act 2015—a response from the Minister for Social Justice to the Chair of the Equality and Social Justice Committee, in a letter dated 7 March this year. The Chair of the Equality and Social Justice Committee wrote to the Minister for Social Justice regarding the current review of public bodies subject to the Well-being of Future Generations (Wales) Act 2015. Her letter also referred to the commissioner's concern about comments made by the former Permanent Secretary when giving evidence to the Public Accounts Committee, our predecessor committee in the fifth Senedd. When asked whether she had had to challenge a Minister regarding an inconsistency between the policy or approach that a Minister wanted to take and the Act, the Permanent Secretary replied that she could not think of any examples. The letter asked the Minister if she could confirm whether she agreed with this assessment and if she could outline what systems the Welsh Government has in place to ensure that its business and conduct are compliant with the Act. The Minister has responded to the letter, and we've received a copy of that response, included in the papers circulated to each of you.

So, could I invite you, Members, please, to discuss this response and consider whether you would like to write to the Chair of the Equality and Social Justice Committee with any comments or concerns to assist their work? It's worth noting that the committee has the opportunity to take up the issue relating to the systems the Welsh Government has in place to ensure that its business and conduct are compliant with the Act as part of its forthcoming evidence session with the Permanent Secretary on 12 May. So, do Members have any issues they'd like to raise or items to discuss arising from that letter? No. So, we can pursue that otherwise on 12 May, as you've indicated. I think the main point, if I remember from the letter correctly, was the Minister emphasising that the Minister is not bound to deliver; they just have a duty of care to consider the requirements of the legislation. Adrian.

Could I just make one small point, Mark? It's not on the core question you've just raised, but, just to make Members aware, I'm pleased to see the signal from the Government about extending the coverage of the Act. That, in turn, may have implications for us at Audit Wales if we have to undertake work under the Act in those bodies, especially if we're not currently undertaking any performance work in those bodies. So, I hope that the Government will engage with us as an interested party in that discussion, and we'll keep a close eye on it and keep you informed accordingly.

Thank you. Well our next item to note is on the annual scrutiny of the future generations commissioner—an update letter, again from the Chair of the Equality and Social Justice Committee. The Equality and Social Justice Committee held its annual scrutiny session with the future generations commissioner on 7 February. They agreed to publish a short report highlighting some of the key themes identified during their scrutiny. A copy of this report has been included in the papers circulated to you. The letter specifically draws our attention to that committee's first recommendation, which reads:

'We recommend that the Public Accounts and Public Administration Committee carry out a review of the resourcing arrangements of Wales' Commissioners. This review could include consideration of whether any economies of scale can be achieved by the sharing of some backroom functions and staff.'

The letter acknowledges that each commissioner has different roles and responsibilities and that resourcing needs vary accordingly, but notes that clarification on the justification behind different resource allocations is lacking and warrants further scrutiny.

The Equality and Social Justice Committee has agreed that a review of the situation would be timely and that, with our expanded public administration remit, we may be best placed to carry out this work. So, Members, again, I invite you to discuss the letter received and consider whether you wish to conduct a review, as they propose, of resourcing arrangements of Wales's commissioners. If you are in agreement, the clerking team will draft a scoping letter for such a review for our consideration. I see three happy here. Is Rhianon happy? Great. Thank you very much indeed.

The next item is the inquiry into the Welsh Government public bodies unit, and the response from the Welsh Government to the letter that I sent on 7 March 2022. I wrote requesting an update on a number of issues discussed during our evidence session on the work of the Welsh Government public bodies unit, which we held on 26 January. The Welsh Government has provided us with a comprehensive and detailed response, and there are a number of possible queries arising from that. There's a discrepancy between the diagrams in annex 1 and annex 2 as to where Transport for Wales is positioned. The letter states there are 52 public bodies in Wales that could be subject to a tailored review. However, there are only 33 bodies listed in the two annexes, including some companies. So, it may be worth the committee seeking clarification from the Welsh Government on the scope of the coverage of the tailored reviews and the figure included in the letter, and also request detail of the remit of the public bodies unit.

Our letter to the Welsh Government noted the commitment given to us to provide recent figures on the Welsh Government's progress on delivering the five diversity and inclusion goals for public appointments included in the 'Reflecting Wales in Running Wales' report. This arose from our concerns that while the Welsh Government has published 'Action Plan: Year 1: 2020-2021', which set out a broader range of actions linked to the five goals in the strategy, progress against that plan has not been reported. Neither has the strategy been updated. The response to our letter does provide some specific updates on figures quoted previously, but does not expand more broadly on progress against actions. The response also raises questions around the Welsh Government's performance in terms of the diversity and inclusion in public appointments. The figures provided in the response would suggest a decline in performance. There's therefore scope for the committee to undertake further work on the area of public appointments as part of its public administration remit.

So, again, can I invite Members, if they wish, to comment on the response received and indicate whether they would like to undertake further work on the area of public appointments as proposed? Mike.

09:25

You'll remember, Mark, like, I think, most of the other people in this room, Rhodri Morgan's bonfire of the quangos. It didn't work. I think that there are an awful lot of bodies there that I find great difficulty in understanding why they have to be arm's-length bodies. Careers Wales is a classic example of why it has to be at arm's length, and I think we need to look at investigating the appointments procedure and who's on it. I think we need to speak to Welsh Government or Welsh Government officials about why so many of these bodies are arm's length. Some of them make a lot of sense, and they have to be, such as the boundary commission—that has to be arm's length—but others, why they're arm's length, I find very difficult to understand. And I think that we may wish to, when we get the Permanent Secretary in, actually tease out of the Permanent Secretary why so many organisations need to be at arm's length when, effectively, all they are are arms of Government, they're wholly funded by Government and only carry out Government policy.

09:30

I agree with Mike on this. I think it would be very beneficial for us to bring that up in a future session.

Okay. I think Careers Wales, if I remember correctly—I remember working with them in the old days—were a social enterprise, or regional social enterprises previously. I'm not commenting on the rights and wrongs, because that's not my role today, but I suspect that that might be why they have the current structure they have. But, as you say, we need the evidence and we need the facts.

And some of us remember when they were part of local authorities, and the careers service was part of a local authority. What we've seen, and it's something I find disappointing, is the movement of organisations from being under control of local government into something like a halfway house to eventually ending up as a quango. Then again, I'm a fan of local government and it's not necessarily the view of everyone in Government.

Well, I'm a fan of local government and social enterprises, so it's where we draw the line, I think. I won't go in to the bonfire of the quangos, because that was rehearsed, as you will recall, many times in the Chamber, particularly in the context of the Welsh Development Agency at the time.

Sorry, Chair, Rhianon's indicating. Rhianon's indicating to say—

Thank you, Chair. Not much more to add to what to Mike has said. I think it does no harm to review where we're at with this. We all remember the bonfire of the quangos and the Great British potato, et cetera, et cetera. But I think this is something that needs to be done, in a sense, regularly, to assess where we are. I think we'll find an outcome of many different reasons for why they are like they are, but I think it's important that we know, and then we have oversight, and I think we would be minded to do so. I think it's a good usage of looking at our public funding and where it's going to as well.

Thank you very much indeed. So, I think there's a clear direction, Fay, to take forward, with your able assistant. Thank you very much indeed.

That moves us, then, to the end of the items to note and to the main items on today's agenda, looking at our work on care home commissioning for older people, and our first evidence session regarding this.

3. Comisiynu Cartrefi Gofal i Bobl Hŷn: Sesiwn Dystiolaeth 1
3. Care Home Commissioning for Older People: Evidence Session 1

So, I welcome Mary Wimbury from Care Forum Wales to the meeting. For the Record, could I ask you, please, to state your name and role?

Mary Wimbury, chief executive, Care Forum Wales.

Thank you very much, Mary. Of course, I've known you for a long time. As you'll expect, we have a number of questions. I'd like to ask both Members and yourself to be succinct to enable us to cover the wide range of issues the topic has generated. And I'll start the questions according to convention, which is for the Chair to ask the first. So, could I ask you, in your view, and the view of Care Forum Wales, what are the main issues that make the system for care home commissioning across Wales complex and difficult to navigate?

In terms of complexity, I think the Auditor General for Wales's report set it out in terms of the complex number of bodies that are involved, where some care is commissioned through local authorities, some through health boards, and some through people commissioning their own care, and care itself is complex. I think people, without much knowledge of the system, tend to think, 'Oh a care home is a care home is a care home', but, actually, of course, there are different specialisms: some care homes provide nursing, others don't; some provide care for people with dementia, others don't. And I think when you're, as families often are, thrust into the system in a crisis, it can be quite difficult to navigate and understand. And I think it is understanding those complexities about what care homes can offer, what different care homes can offer in terms of types of care, but also in terms of funding and interaction with the public bodies who might be involved in commissioning that care.

Thank you. It might be early in the questioning, but can you think of any potential quick wins to simplify the system and process that could be easily and quickly done or stopped?

09:35

I think we spend a lot of time—. People are complex, people's needs are complex and they're usually on a continuum and we spend a lot of time deciding where people fit on relatively arbitrary lines about, perhaps, whether things are health care or whether they're social care. If we could reduce some of that complexity by providing the care that people need in real time and cutting out some of that bureaucracy, that will actually save some funding as well as potentially meaning that there are additional payments for care that might not have been paid for originally. Care homes can be really flexible, but we need to actually invest and trust in the people working in care homes, upskill them to enable them to be able to care for wider ranges of people, rather than just assuming it's, 'What's the cheapest care we can get?', effectively. So, I think it is finding ways of cutting through those bureaucratic barriers that are relatively hard lined between health and social care and recognising that there's a continuum. I think it's also investing and working with care providers and having trust between the systems and between commissioners and providers to enable them to provide the best care possible for that person. That brings us into interaction with regulators as well. So, it's not straightforward, but I think that that's the direction we need to move in.

Thank you. I know that Members will want to develop that in further questioning later. But given that the initial Audit Wales report was focused on north Wales, can you tell us whether Care Forum Wales has now agreed a revised pre-placement agreement with commissioners in north Wales, why some providers have not previously been signing the agreements, and clarify, if you would, the extent to which similar issues are reflected in other parts of Wales?

So, the latest position is that we have sent in our latest comments on the draft of the pre-placement agreement, and we're waiting to hear back from the local authorities and the health board on that. I think we are fairly close to having something that meets needs, but there are a few remaining niggles to be ironed out. I think the pre-placement agreement has been a saga that has gone on for far too long, and it does reflect the situation in other areas of Wales as well. We're currently in negotiations in Hywel Dda, with the health board and local authorities there, on a contract. Swansea bay have just issued a pre-placement agreement with no consultation whatsoever with providers. And I think the way the sector works is you've got a range of providers, so people are going to have different concerns about that, but Care Forum Wales is representing the majority of those and what we've tried to do is work in partnership with health boards and local authorities to get contractual arrangements agreed.

But what we are also seeing is a move from individual local authorities having their own to regional contracts, which I think is a good thing. I mean, I think actually the direction of the White Paper is that we should move to more of a national framework, and I think that's the right way to go, because most of the differences don't reflect local needs or different political directions of local authorities, or whatever; most of the differences are just because they've been drawn up separately, effectively. And actually, what we could move towards is what they have in Scotland, which is a national care home contract. But, I think, inevitably, when you're amalgamating different contracts, you're going to get some terms and conditions that are slightly more favourable in some and slightly more favourable in others, and there's always going to be a bit of discussion that you have to have around that. But it's not been straightforward, let's just say that.

Thank you. Are you confident that providers will now sign up to the proposed new shiny model, or are there still concerns that some may be unhappy to do so, as we go forward?

I think until we've got the final version it's difficult to say. I think we've got a much improved version of what we had, and that ought to mean that providers are more likely to sign up. But, obviously, for each provider, they do have to take—. You know, we can give broad legal advice that we've received as an association, but if there are specific circumstances with that care home, and specific issues, they've got to take their own advice and satisfy themselves that the contract is appropriate for them.

09:40

Thank you. Can I bring Natasha in? I think you have a question on this.

Thank you so, so much. I'd just like to ask you, you mentioned about various areas, and you mentioned about how needs will be different, depending on where the desire is to have them, but to what extent do you find that similar issues are reflected, that we have in various parts of Wales, across the board? Because you mentioned the example of Scotland as well, how it would be nice to replicate what they have. So, from your experience, what would you make of that?

In terms of commissioning, I think broadly we see similar issues across Wales. I think what we do see is, as ever, you've got a variety in terms of 22 local authorities and seven health boards. I think it's fair to say that some have much better, more collaborative commissioning relationships with their local providers, and some have much more adversarial relationships, which I don't think actually leads to good commissioning and good care. But a lot of that, the issues might be the same, but it's about how you resolve them effectively and the relationships you have locally that enable you to do that.

Okay. My final question for this particular segment: you mentioned funding in one of your previous answers to our Chair, if we could give you a magic bag of money—I know you mentioned that training would be essential for many of the professionals who work in the field, et cetera—what would that funding be going towards, in your opinion, professionally?

I think the top priority in terms of funding is improving the terms and conditions for care workers. We're obviously in a position where we've just had the real living wage pledge from Welsh Government, but prior to that, most local authorities were commissioning at the legal minimum wage, or if not the legal minimum wage, a rate just very small amounts above, effectively, and that's what they were using to calculate their fees. Actually, we're moving towards registration of all front-line care workers. It's a responsible job, it requires a significant amount of training. We actually need to put money into investing in those people, both in terms of providing that training, but also in terms of the rewards they get for doing the work that they need to do. That will be the top priority.

In addition to that, though, we do have relatively old care home stock in Wales. Before the implementation of the Registration and Inspection of Social Care (Wales) Act 2016, Care Inspectorate Wales undertook a survey and, for example, in north Wales, in over 50 per cent of care homes, the original building was over 50 years old. In terms of if you were to offer a bottomless pit of money, there is investment in bringing buildings, either new buildings in or buildings up to scratch, to meet modern environmental standards, the expectation for en suites et cetera. But also, just the facility, improving infrastructure, improving lifts, improving things like energy consumption within care homes as well, because the insulation—. There's an environmental issue there, but there's also a cost issue as we see energy costs increasing. That's providing another pressure on the sector, but the top priority is investing in the workforce.

Thank you. Can I now bring in Rhianon Passmore, please, who will pick up the next line of questioning?

Thank you very much, Chair, and welcome to Mary. It's good to see you here. We've mentioned where you feel the overall priorities are within the sector, and I don't disagree with that, but would you also comment in terms of the broad provision of the variety of care home provision across Wales? Do we have enough? Is there enough qualitative provision, and where do you feel the future lies in that?

So, in terms of provision, certainly there's unmet demand out there, and there are also some empty beds in the sector. I think what we're seeing is a greater need for dementia care in particular, in both residential and in particular in the nursing sectors. Now, some of that is about provision, but some of it is about the ability to recruit nurses, and in particular registered mental health nurses as well, to the sector. Now, some of that again comes down to funding and whether we can match NHS pay rates, terms and conditions and make it a sufficiently attractive place for people to work, but some of it is also just about the availability. We've seen relatively few new builds of care homes in Wales in recent years, and, in particular, where they are coming in, it's where there is a significant private market, where fees are going to be higher fees than local authority rates, because it just isn't feasible to build to modern standards on the rates that are offered by local authorities and health boards across Wales. There are geographic issues—rural homes tend to be smaller because you've got a smaller catchment area, but, actually, you're providing care close to home for people to enable them to remain part of their communities, to enable friends and family to visit more easily, and we do need to get that balance right. We need care where it's needed and we need the right type of care as well.

In terms of upskilling, there are levels of dementia where people need immense specialist training, but, actually, in most care homes for older people there is some degree of dementia in the residents and the levels of training that are available to meet that are not so great. We do need to invest in the workforce to enable us to recruit and retain. 

09:45

Thank you—multifaceted. In regard, then, to public sector funding arrangements and potential then for division amongst our public sector partners around payment, who pays, how can that potentially be simplified? You mentioned earlier on simplifying bureaucracy, but could you briefly outline a better way? 

There are two aspects, in a sense. One is the actual setting of the fees and who's paying for those, and then there's the aspect about what falls within the health domain and what falls within the social care domain. So, in terms of setting fees, the White Paper envisages a national fee structure, which I think, again, is something they have in Scotland, and we just don't have the capacity amongst commissioning staff in each individual local authority and health board to understand, I think, the complexities of care provision, what's needed, how you cost it. Having 22 plus seven separate negotiations inevitably creates difficulties, just because of that lack of understanding. It creates anomalies, where we see vast differences between the lowest and the highest paying local authorities for the same care. Now, a small amount of that might be land cost differences for care homes, but roughly two thirds of care homes' expenditure goes on staffing. Actually, we should be providing the same levels of care, we should be paying roughly the same across Wales for that, and we shouldn't be seeing the disparities that we are. So, I think the move towards a national structure for fee setting will significantly help there and also reduce the amount of time that different people are having to spend exercising setting fees but not doing it as well as we could if we had one national structure.

In terms of the division between health and care, there's a lot of time spent deciding which side of the line people fall, and then, actually, people's needs change as well. They're not on one side of the line and then they continue to be that side of the line, effectively. We need to develop a more holistic approach, and that's again something that the expert panel that I'm sitting on for Welsh Government as part of the co-operation agreement is looking at, and how we ensure that the care provided is right, but also are there ways of separating that out from accommodation costs, for example, thinking about how we manage divisions there, and what the contributions are that people might be assessed as needing to pay or how we, indeed, could move towards a free care service.

Thank you. Where there is disagreement around—. Where public sector partners do not agree on commissioning placements, what's the impact on service users, families and providers? 

09:50

It can be really difficult, and we often see—. We do see people remaining in hospital while there is haggling going on about who should be paying: is it the family, is it the health board, is it the local authority—where does that sit? And that can have a real impact, including people acquiring hospital-acquired infections. Care homes are then left with they've got someone who wants the bed but the funding hasn't been agreed, so they've then got an empty bed that they're not getting any income for that period. We have seen some discharge-to-assess schemes that have worked quite effectively in terms of discharging someone and ironing out the finer details afterwards, but that does require greater input from the care home as well in terms of the amount of time to input into assessment processes about people's needs, but I think also you do get a better picture when someone is assessed in a care home where they're planning to live than you do when they're in hospital where, inevitably, they're disrupted by their surroundings. So, we need to recognise that actually that probably is a better way of doing it, but it does impose extra time commitments and extra staff commitments on the care home as well.

Thank you. And my final question then, Chair, if I may: so, in regard to the pooled funding arrangements for care homes, do you feel pooled funding arrangements have been developed as expected? If not, why not? And do you feel, as you've inferred, a unified health and social care service may help the challenges in this regard? 

I don't think—. I think, firstly, it's not been clear what pooled funds were meant to achieve. And I think, because of that, they haven't been developed in a way that has achieved. I think the difficulty is that the way the pooled funds were probably envisaged was that you had to pool across local authorities. Local authorities have understandably been quite concerned about cross-subsidy of people living in other areas, whether that's within or without their powers, et cetera. But, actually, the difficulty is—. That's not where the difficulty is, in a sense. The difficulty is that boundary between local authority and health. And while I can, again, understand why health boards wouldn't want to have—well, in north Wales—six pooled funds, one with each local authority, actually, I think if we were to go down that route, that's where the difficulty is, and that perhaps might lead to greater advances because it is that if you've got a pooled fund, we can then use that to fund those discharge-to-assess arrangements that I was talking about previously, but also look at where people sit in that continuum. Again, you might say, 'Well, over the last year, roughly 40 per cent of the time this person had wholly health needs, but, actually, for 60 per cent, some of their needs were health and some of them were social care', and there are things you can do in that space between health and social care. But I think, by trying to mix it up with a number of local authorities as well, it just made it too complex for that engagement to happen in any real way.

Okay. And finally, if I can just ask you this: how fit for purpose is our current system, if you were starting from scratch today?

I wouldn't start from here, I think it's fair to say. I think we've inherited a mix of provision, going back to the National Assistance Act 1948 and it's just been built on in a relatively higgledy-piggledy way. I think, for a country the size of Wales, moving towards the national framework, national fee setting, national contract, with then local input into placements, actually engagement with providers, looking at market shaping on a local and regional basis, is what would make far more sense. 

Thank you very much indeed. Before I pass on to our next questioner, you're probably aware that the auditor general recently produced a report on direct payments, which looked at issues around pooled funding. I don't know if you've had a chance to see that paper, but is there any element of the discussion around whether or not direct payments should be available for pooling with health and social care that would impact on the answers that you've just given us more broadly?

09:55

At the moment, you can't use direct payments to pay for care home provision, so it is more in the area of domiciliary care where I'd see changes around those pooling arrangements making a difference. I think we also need to be mindful—. I think direct payments can offer people a real opportunity to shape their own care, but, equally, sometimes what we see is what feels like an undercutting of domiciliary care agencies, in terms of the rates that people are paid and the rates that they're then able to pay through direct payments. But I do think it's more in the area of domiciliary care.

Thank you. Though would I be correct that some of the membership of Care Forum Wales would also be domiciliary care providers? 

Yes. Yes, and, in terms of direct payments, what we'd like to see is a level playing field, effectively. Some of our domiciliary care providers are sometimes approached by people receiving direct payments who might mostly employ personal assistants, but need domiciliary care provision as back up, either to cover holidays or to cover particular times or activities that the personal assistants can't cover and, quite often, they're being asked to provide those at lower rates than the local authority are paying them. We sometimes come across cases of personal assistants who, in terms of employment, paying for holidays et cetera—. There just isn't the infrastructure there that ensures they have proper terms and conditions. And also we see agencies placing personal assistants that feel very close to being domiciliary care agencies, but don't have all the requirements of registration. So, I do think there are a number of issues around that that need thinking through and managing, going forwards.

Thank you, and just—. My closing comment on this. Some years ago I proposed a community care direct payment Wales Bill, and elements of that were taking into the Social Services and Well-being (Wales) Act 2014, including the call on each local authority to establish a co-operative care agency. Have you had any engagement or experience of co-operative care agencies established since?

There have been some relatively small, locally based pilots. There was also some work done, which you may well be aware of, in north Wales, looking at a co-operative employment agency. I think one of the difficulties we got into in the discussions around that did all come back to terms and conditions of the workforce and, actually, how we have a level playing field between different types of provision, but also reward people as appropriate, as they should be rewarded. And that's moving into the real living wage but also going above and beyond that to recognise people's skills and experience. And at the moment, we're still in a position where I think local authorities and Welsh Government are, effectively, batting that challenge between them.

Okay, thank you. Well, if we could move on, I invite Natasha to open the next session of questions.

Thank you, Chair. So, Mary, I'll be asking you a couple of questions and I'll be passing over to my colleague, Mike, to ask you the remainder. I'm going to ask you about regional partnership boards and I'm slightly going off key by asking you this, but I'd like to know what are three benefits of these regional partnership boards, and what are, perhaps, three hurdles that you encounter by having these regional partnerships. It could be enlightening us today in this meeting today.

Okay. I think the biggest benefit is getting everyone around the table, from both the statutory sector, local authorities and health boards, but also other partners as well. So, each regional partnership board has a provider representative on, but also carers reps, citizen reps, housing reps, so it's bringing everyone in that social care, health and social care, space together around a table and leading to, I think, both collaboration but also understanding the different perspectives that are within the system. And I think that's been the biggest benefit, effectively, and I think it's taken quite a bit of time—different amounts of time for different places—for those regional partnership boards to gel and bring together those perspectives. But it really is ensuring that everyone has a level of engagement. Sorry, that's kind of one big benefit, but I do think that's been the most important thing—engaging the statutory sector, bringing health and local government together, but also bringing partners into that space as well.

In terms of challenges, that creates its own challenges, because some of the people around the table have statutory responsibilities, have funding pots that they manage, and others don't, but actually, in terms of delivering for citizens, we do need that engagement from right around that regional partnership board table. But actually, again, one of the challenges is that the accountability sits primarily with the statutory bodies, and within the statutory bodies, rather than the people sitting around the table necessarily having that delegated authority to make agreements on a regional partnership board basis. So, that can become quite clunky. It can also mean there are separate discussions between the statutory agencies, which then sometimes means they feel, 'Oh, well we've already discussed this', whereas for other partners around the table, actually it can feel as though things have been discussed and decided in other spaces outside the regional partnership board. But I think all of that is a reflection of the complexity of health and social care and the number of stakeholders you've got, and it's a matter of trying to find ways of working through it.

10:00

Fantastic, thank you so much. And what sort of strategies are you working on at the moment with the other groups and organisations to ensure that we create and shape a great care home system for the future?

There's a number of pieces of work going on. Obviously, we're working in the technical groups around the White Paper, and looking at developing that national framework, national contracts, a national office to ensure we do have less of a postcode lottery, effectively, and greater provision across Wales, wherever you live. There's also work through the fair work forum, which has spent a lot of time working on the real living wage implementation, but is now moving on to look at other areas of fair work and, in particular, issues around pay and progression for care workers, and how we recruit and retain those. And then, we've also obviously been involved in fee negotiations for this year, including implementing that real living wage commitment. But I think the priority really is that national infrastructure and improving terms and conditions for the workforce, enabling us to retain current members of the workforce and recruit the additional members that we're going to need going forward to deliver the system that's needed.

Okay. And my final question is that we all know that health conditions change on a regular basis—for example, there are various ones, Alzheimer's, dementia, et cetera—and health conditions are going to be varying over the years and perhaps the next decade, century, et cetera, et cetera, however long we're going to be here. But my question now is going to be what provisions are being put in place to deal with those evolving health conditions that people are encountering, particularly within the care home sector.

I think it's challenging. I think one of the challenges where we still don't know how it's going to play out is long COVID, for example, and we don't know what that's going to mean. In terms of the care home sector, it's very much about as much training as possible, ensuring that you can meet people's needs, but one of the challenges for care homes is, as people's needs change, getting them reassessed. It might be that people need to move from a residential home to a nursing home, or from a general care home to a dementia care home, and sometimes the delays in staff available to do those assessments can create challenges. That can create challenges for that individual who needs that assessment and needs that greater level of care, but also for other residents of the care home as well, in terms of what they need and the disruption that can sometimes be caused in those situations. Sometimes it's just a case of, 'Actually, this person needs some one-to-one care, or they need greater inputs during the day, and we're going to need to take extra staff on to do that, but we can only do that if we're funded to do that, effectively.' But there are significant delays in assessments at the moment.

Thank you, Mary. I'll pass you over to my colleague Mike Hedges.

Thank you, Natasha. How does Care Forum Wales work with the regional partnership boards to help develop market capacity and the problems on borders? I mean, Ystalyfera and Ystradgynlais—you cross a little bridge and you've moved counties. And I would argue that Ystradgynlais has far more in common with what's going on in Neath Port Talbot than it does with what's going on in Welshpool. But you've also got the English border, haven't you? Wrexham and Cheshire are effectively one conurbation with a boundary going through the middle of them. So, how does that work?

10:05

We provide a representative on each regional partnership board, and obviously we're always looking at agendas coming up, what the opportunities are and what the engagement we could have is. I have to say that, in general, what we see in terms of market shaping I think too often focuses on sticks rather than carrots. So, we've got a couple of counties in north Wales, for example, who have just reduced fees for basic residential care because they think they don't need as much of that. Well, actually, in a way, that feels not like market shaping; that feels like saying, 'We want some of you to go out of business. We're not deciding which ones, but we're just going to reduce fees until some of you do.' Actually, I think a far better way would be, 'We need more residential dementia care. Who would be interested in stepping up into that space and how can we help you?', both in terms of the training of staff but in terms of transition as well, because obviously as you transition from one cohort of residents to another there are potential issues there about how you cohort people and how you manage that process. So, I think there does need to be a much greater degree of engagement. 

I think wherever we draw the borders there are always going to be border issues. And even if we had the national framework for Wales, as you rightly point out, we're still going to have issues across the Welsh-English border, and we have people who live in Wales and have GPs in England, and vice versa, effectively. But, really, it's got to be also about putting the citizen at the centre of this, and it's about what works for people within the systems that we've got, effectively. Again, I do think moving towards a national framework will help. It would certainly help in Ystradgynlais, even if it doesn't help on the Wrexham-Chester border in the same way.

I don't disagree with that. I have a fear of large national bodies. You talked about the problem of a postcode lottery. We don't have a postcode lottery with the ambulance service—everybody gets a bad service. And I do have concerns that, if you have one big body, everybody can end up having a very bad service. Do you share that concern?

I think it's about getting the balance right. What I see in the care system at the moment is that a lot of things are done individually by each local authority, and actually for no particular reason other than it's just like, 'Can someone in each local authority work on this?' Actually, if we give people a national framework but flexibility within that to meet local and regional needs, then I think we get a better system. With the hardship fund, the element supporting the care sector during the pandemic, in the first quarter of it, what we saw was that it was up to each local authority to decide how to spend it. Actually, some took relatively quick, relatively efficient decisions, and others developed quite complex processes that then also, if you were working across local authority boundaries, meant different things to do in one local authority than in another, and that created additional bureaucracy at a time exactly when people didn't need it. What we then had was that we moved forward, after the first quarter, into a national system, which worked very well, but had sufficient flexibility around it for local authorities, to enable them to do that. And I think a national system with that local flexibility is what we need. If you're happy with the national system, you've got something you can just take off the shelf and just deliver that. If there are things you need to change, you've got the flexibility to enable you to do that. But, otherwise, we spend a lot of time working out 22 different systems. 

I won't pursue that. I was very happy with the old system, where local authorities provided virtually all services. But, the question I want to ask is: what is Care Forum Wales's position on the policy question of whether regional partnership boards should be put on a statutory footing, or not? 

Sorry, I didn't quite catch that. 

That's partly because my voice started to go as well, so that was mainly my fault rather than yours. Do you support regional partnership boards being put on a statutory footing?

10:10

We would certainly support a greater statutory role for regional partnership boards, and the importance of bringing all partners around the table effectively. How that's done I think is open to discussion, but we've certainly found that we do achieve economies of scale by doing things on a regional basis, and it's exactly what I was talking about earlier—do it once rather than, in north Wales, six times; in Gwent, five times; in Powys, only once still. We can achieve economies of scale by doing that, and I think having a stronger role for regional partnership boards as a statutory body would enable that to happen more easily, and we would certainly want to play our part in that as provider reps, and would see that as something that could provide improvements in the system. 

Thank you. If I could ask one supplementary on that before I move on to the next section, how would your proposed national model and national funding model, including, presumably, national minimum pay rates and so on, be reflected in processes and funding processes, where currently, as you know, parts of north Wales have the highest proportion of oldest people in Wales, virtually the highest in the UK, and yet the current local government funding formula, according to those local authorities, doesn't adequately reflect that? So, would we be looking at a different type of funding stream to be delivered in accordance with new national agreements outside the normal local government funding formula, or an adjustment to the local government funding formula? 

So, from a Care Forum Wales perspective, we've just seen significant money going to local authorities to enable the real living wage to be paid to care workers, for example. We would have preferred if that had been done through a specific grant process—if that money had been ring-fenced and it had been very clear how that went through. That wasn't what the local authorities corporately wanted; they wanted it in the revenue support grant settlements. But what we've seen is, actually—. We're not seeing that money get through into social care. We've seen too many local authority fee settlements that are lower than the general rate of increase those local authorities have got this year through the RSG. So, we would certainly prefer to see that national framework agreed, and designated money going through the system to care providers, but I wouldn't want that to be a blockage to having a national system. So, I'd rather have a national system where we still had to work through the RSG than not have a national system at all. 

Okay, thank you. Moving on and, again, still looking at funding but at variations in expenditure, as you know, Care Forum Wales has for some time been highlighting the impact of the variation in expenditure on residential care and continuing healthcare weekly costs in policy application across Wales. Can I ask you, back in 2020, why you published the cheapskate awards, and what you were seeking to achieve from that and whether it worked? 

So, we're about to publish again—we're just waiting for the last one to come in, which is today, I believe—a league table of the different care home fees set by each local authority for care homes for older people, because I think it's important, as that's public money, that that information is transparent and that people in areas know what the payments are that are going to pay for the older people in that area who are living in care homes. We did, actually, see one in particular, I recall, significant rise, following one local authority that was very near the bottom of that table, and it did, I think, in part help to push them to recognise that they did need to look at what they were paying and review that. We're certainly seeing significant disparities. In particular, we're seeing much better engagement in, I would say, south-east Wales with providers in terms of looking at actual costs. In other parts of Wales—north Wales, and in Swansea bay in particular—we've seen some significant increases in Swansea bay, but because they were starting from such a low base, there are still, actually, going to be lower fees than there are in other parts of Wales. And in north Wales, there was a great deal of detailed work going on that the individual local authorities then decided mostly not to take into account, when care providers have put an enormous amount of effort into sharing details about their actual costs.

10:15

Thank you. I think Rhianon Passmore would like to come in.

Very briefly, Chair, if I may, on that particular point, because this is at the crux of a lot of the issue, although not the main issue by any means. In regard to this, though, being, in a sense, a buyers market, it could always go up, couldn't it? And I understand the purpose of the league table, but would you not agree that there is a massive capacity issue, though, in regard to where some local authorities can go? Therefore, you could technically put as much into that as you possibly have in the whole RSG, but if there's not the capacity there, it is a buyers market. I don't know what comment you have on that.

The way the market works—the way it feels to a lot of providers—is that you've got one purchaser, you've got the local authority, and they can effectively set and drive down a fee. And from a provider's perspective, you can provide the care you can provide for that fee. Obviously, it's got to be care that CIW will accept when they register you, when they inspect you, but actually, in terms of variations, a lot of providers feel that we've got a monopsony situation where they've got effectively one purchaser.

I think we need to be much more honest in the conversations we have about what we are buying. Understandably, there's a push up on quality, but a lot of that quality is about staff ratios, it's about the qualifications and experience of those staff, and we do need to pay for that. There is a care home in Cardiff—entirely private payers—that has its own cinema, its own chauffeur-driven car, all that kind of thing. No-one's expecting local authorities to commission at that rate and that sort of capacity, but some people who can afford to are paying for that themselves.

But what we do need to agree is, I think, that honest conversation about what is being bought, what the level of quality expected is, what the level of staff ratios are, and what that means for an individual person in terms of how long you might have to wait if you need assistance to go to the toilet, for example. We need to have those honest conversations about what level of care we do want to buy, and recognise that there is going to be a limit on that. But we need to provide the best care we can and get that balance right.

I would totally agree with that. I think my point, really, is around how that balance is then reflected, because you know as well as I do, Mary, that you can pay the adequate amount of money, a good amount of money, but that doesn't necessarily get reflected in terms of the workforce terms and conditions or even the quality of care for residents in some cases. Thank you, Chair.

I suppose what I'd say on that, in a sense, is if you're paying for a low quality of care, everyone's going to provide a low quality of care. If you're paying for a high quality of care, it's going to be really clear where that money is getting through to the workforce but, actually, more importantly to the citizen receiving care, because of the quality of their environment and the quality of the workforce that is caring for them. There is user choice in this system as well. So, actually, by paying that, you do get the money through, and it will be the care homes that are making sure that that money gets to the citizen that thrive and have people living in all their beds.

Okay, thank you. If I can further develop this theme, what, in Care Forum Wales's opinion, are the reasons for variation in unit costs, for example weekly placement cost, across Wales and the extent of possible cross-subsidisation where providers operate in more than one area? Clearly, that could be a privately owned chain, it could be a social enterprise or housing association, or it could even be a local authority-owned provider.

In my experience, the variations largely depend on how much priority and how much funding that particular local authority is prepared to put into care. It's very frustrating. We have mechanisms in each local authority for setting care fees, and in some we have toolkits, where there are staff hours, there are staff rates of pay, there's a certain amount for groceries et cetera. And I've been involved in negotiations around those fees, where we've said, 'Well, we don't think this line reflects the true costs.' And the local authority representatives just say, 'Well, that's fine, but if we up that line we're taking the money out of somewhere else because that's the budget we've got to pay for care.' So, that feels a very unrealistic exercise, but some authorities I think have recognised they do need to invest more in care home provision if they want that quality of provision and they want to ensure access for their citizens who need it. And it does, unfortunately, feel as though it is just about prioritisation at the moment. I know local authorities have lots of demands on their budgets, but it does feel about prioritisation. Sorry, I can't quite remember if I've answered the question now. 

10:20

The degree to which there's an issue with cross-subsidisation, where a provider might straddle more than one area. 

Yes, and we're certainly—. I think there is potentially an issue of cross-subsidisation across areas, but I think the bigger issue in that is around private fees, third party top-ups. And I think, increasingly, we are certainly hearing from members who avoided for as long as possible charging more than local authority rates, but more and more are feeling that the only way they can provide the quality of care they are happy providing is to charge those higher fee rates. And I think, in some areas—we haven't done the detailed analysis on this yet—it is becoming increasingly difficult to find care at the local authority rate, which, of course, then creates other knock-on difficulties and effects potentially for that local authority. But we are increasingly seeing providers feel they have to set their own rates. 

Thank you. How well do bodies work together locally or regionally, including with providers, in determining, for example, charges or fees for placements and the merits or otherwise of greater national co-ordination?

So, Welsh Government commissioned 'Let's agree to agree' on care home fee setting in 2018, which envisaged a great deal of joint working between local authorities and providers to properly understand costs and to implement fees. I think in some areas we have seen that work. Torfaen, for example, has just undertaken a significant exercise with providers in terms of a detailed analysis of costs, and what was appropriate to pay for care in their area. In other areas we are still seeing either, 'Here's the fee; maybe if you push back really hard we'll have some discussions about it, but take it or leave it', effectively, or, in some ways worse, we're seeing engagement with providers providing detailed information about costings, which is then ignored by the local authorities when they come to make their fee-setting decisions. So, I'd say it's a really patchy picture, and I don't think it's really based on reasonable local differentiation. And that's one of the reasons why we would support a national system for doing this and a national framework. And some of that is about, I think, the capacity within local authorities to do that work as well. 

Okay, thank you. And, presumably, some of that is reflected in your earlier comments regarding the regional bodies as well, where, as you say, whilst people are talking the language of co-operation, at the same time they're each protecting their own budgets. Thank you. 

In north Wales, why do some care home providers, or why have some care home providers been renegotiating placement rates outside of the local authority agreed toolkit rates?

So, the north Wales toolkit was agreed in—I think it was 2013. That was initially by the three north-east Wales local authorities, and then the other three came into the fold, effectively, with the transition arrangements around their existing fees. At that point, when it was first established, there was an agreement that, if providers had increased costs over and above that, the local authority wanted that provision, then there could be a level of individual negotiation. And that was because of things like—you know, you might want to keep a rural care home that serves a very specific community, but because of the size of that home, and because of the size of the community, there isn't capacity to expand but you haven't got economies of scale, so you've got greater costs there. We also see some care homes just have a cohort of residents, perhaps because they've got a specialism, that are much higher need than others, and so their costs are higher in terms of staffing input. So, again, people have very different needs, even within a specific category, and if you have a large cohort of higher need residents, your costs are going to be higher. So, there's always been that capacity to do an open-book accounting exercise with the local authority and negotiate a higher fee, provided there's a requirement from the local authority—it wants that care home, it wants those placements and it's prepared to do that.

I think what we've also sometimes seen, and I've had conversations with members, who've said, and I've said, 'Well, you could go down this route if you think you can't provide the service'—. Some of it might be about things like layout of buildings as well, in terms of how you manage staffing. You could go into an individual negotiation. And I think people have been quite nervous about doing that, thinking that they wouldn't necessarily get placements if they negotiated a higher fee. But, actually, what we're seeing increasingly is that the inflationary mechanisms used in the north Wales toolkit, and bits being sliced off in other places, have meant that providers just feel they can't provide care on the fees that the local authorities are offering, and so have gone into those individual negotiations. And I think the bottom line is it's due to the inadequacy of the fee that's paid and the negotiating process that's achieved that.

There was detailed work done with a small group of providers on this year's fees. One local authority has said they will look at honouring the staffing hours in that, but they want to do some more work, so they'll make a decision in June. All the others decided not to take on board that detailed work and just inflate the toolkit as it was. But what the work that was done exposed, in particular, was that staffing ratios in care homes were significantly higher than the care that local authorities were paying for. And because of that, providers feel that, in order to maintain the staffing ratios, they need a higher fee to enable them to do that.

10:25

Okay, thank you. Why has Care Forum Wales recently resigned from the north Wales care fees group?

Exactly that reason. We put a lot of effort, with a small number of members, into doing that detailed fees work. The sector has been under enormous pressure for the last two years, more so than ever. The capacity for people to do that—they were prepared to do it because we were assured at the start of the process that the work would be taken into account in terms of setting this year's fees; that just didn't happen. We've been told by the local authorities that's because of the settlement that they've got, but, actually, we've seen fee rates come in with lower percentage increases than the RSG settlement. So, we felt there was no way that we could persuade our members to engage in another process like that without—. This year, we supposedly had a guarantee that it would be taken into account—it wasn't. So, we really didn't feel that we could continue in that process unless there was significant reform and commitments about how it would be taken forward. Interestingly, we've had responses from, I'm not sure if it's all or five of the local authorities to our letter and our resignation, supporting the establishment of a national framework for fees setting.

Okay, thank you. My final question in this section. The findings from north Wales suggest that not all providers provide the required financial information on their costs. What would encourage them to do so?

10:30

I was surprised by that comment in the report and I'm not sure where it came from. I mean, certainly, I don't think there's been a refusal by providers to provide costs. The work that was done this year, for example, decided specifically to focus on going through a small number of providers' accounts in detail. That was done at a regional level. Then, some local authorities said, 'Oh well, there are are only a small number of providers included in this. We'd need information from a wider number of providers', but providers hadn't been asked for that information initially. 

There's an amount of work involved in providers providing that information—not everyone does their accounts in the same way; not everyone puts everything in the same categories. Some people have a mix of staff who do staffing and activities; some people separate those out. So, there is quite a lot of work involved, both on providers' part and on commissioners' part, in terms of looking at those toolkits. But the general feedback that we have from our members is that they understand that they're receiving public money and that needs to be justifiable and they need to be able to share their costs to justify that. And the only way across Wales where we've got higher fees agreed by local authorities recently is by providers sharing costs.

So, I was slightly confused by that reference, if I'm honest. I don't think there's been a refusal; I think there might have been a 'not necessarily asking everybody'. There are a lot of requests for information from care providers and it's, 'If I put some effort into putting together this information in the format that's required, is that going to be used and is there going to be something productive out of it or is this a box-ticking exercise, effectively?' So, I think if we're going to get that information from providers, we have to reassure them that it will be taken into account in a meaningful way.

Thank you. Does Audit Wales wish to comment? No. Thank you. I'll now bring in Mike Hedges.

Can I just pick up on some of the things you've just said? You talk about local authorities not spending at capacity in terms of their rate support grant, but the rate support grant is not the whole income had by local authorities. You're right to say 'almost all', but I think all local authorities actually have a capacity to spend less than their rate support grant because they get fees, charges and council tax that will not have increased by the same amount as the rate support grant. So, are you willing to accept that it has to be on the total income of a local authority rather than just on the rate support grant?

Of course local authorities have to spend based on their total income, but equally, the revenue support grant does have percentage increases for different categories and there was a specific amount that was higher than their general increase that went into social services. So, actually, it would seem that in cases where that happened, the prioritisation those local authorities are putting on social care and social services is not the same that Welsh Government has put on it when allocating the RSG.

I don't expect you to be able to answer this question now, but could you write to us and tell us, through you, Chair, of any local authority spending less than the standard spending assessment allocation on care?

I can certainly—. Yes. I'd certainly be happy to follow that up in writing. I suppose the other thing I'd say is that, obviously, the social services budget as a whole is wider than just care homes for older people, but we know there was a specific requirement to invest in care homes for older people and in the care sector in commissioning specifically for the real living wage pledge this year.

But if you go into a standard spending assessment, it goes down in detail on large numbers of different areas, so perhaps I'd just ask you if you could provide that.

The question I want to ask is on performance information. I'm a great believer in performance information. Far too often in Wales, instead of collecting data we get an expert group to look at something without any data behind it. What I'd like to know is: what role do providers play in ensuring appropriate information to commissioners to help demonstrate policy aims, well-being goals and service user outcomes?

Again, I think there are various people who providers report to on this. Providers now, going forwards, under the Registration and Inspection of Social Care (Wales) Act, are required to do an annual report to CIW, and then there are also requests from both health board and local authority commissioners. One of the things that we've sought to do is streamline these requests, effectively, so that we don't have different people—. You know, a care home may cater for residents from a couple of local authorities, particularly if it's in a border situation. Streamline those requests so that, actually, we're not asked to provide slightly different information in slightly different ways to a number of people. I think the annual report will provide some of that information that goes to CIW. That should have come in already, but because of the pandemic and the other pressures on the whole system it has been delayed. But then there is significant monitoring information required, both around the care home as a whole and around individual placements within that care home. I'm not sure if you want me to be more specific.

10:35

No. Just really leading on from what you've just said there, what role should Care Forum Wales play in co-ordinating the information from providers?

So far, what we've sought to do is co-ordinate the systems in terms of how that information is asked for and how that information is then passed on to both CIW and to local commissioning bodies. Then they've used that information for their commissioning purposes, effectively. It's not something that we've so far been asked to aggregate in any way.

Thank you. If I could now bring in, please, Rhianon Passmore.

Thank you, Chair. What is your assessment of the overall sustainability and quality of care within the care homes market?

I think sustainability is challenging because of the fee issues that we have discussed already. I think the other issue that's contributing to a lack of sustainability is just the pressure that providers have been under over the last two years in particular. We know, across Wales—actually, the last data we had was about 2017—that half of care homes in Wales are single, where providers are running one care home, effectively. Those people have been working 24/7 to keep residents safe during the pandemic, and I think the pressures cannot be underestimated. I was talking to one of our members who actually sold his care home business last week. He said he actually took less than it was valued at, because he just felt he didn't have the capacity to do it any more and he wanted to leave the sector. So, I think there are real issues in terms of financial sustainability, but also the capacity of people; that's both people owning, running, managing care homes, and the staff capacity that they're working with at the moment. It feels like the rest of society has gone back to normal, but actually because care staff are still COVID testing twice a week, because of the high community prevalence rates, again a lot of our members say that every day is just a juggle with the rotas and hoping someone else hasn't tested positive or someone's come through with a negative test. There were systemic issues around staffing, around sustainability, around finances going into the pandemic. I think it has just exacerbated that and I do have real concerns about provision going forwards.

In terms of quality, I think there's a baseline of quality that everyone is expected to provide, and we would certainly expect our members to provide, to meet CIW registration regulatory requirements. I think there are some care homes that are able to go way over and above that. Some of that is about personality, some of it is about management, and some of it is about money as well, and just what you can afford in terms of both staffing inputs and other inputs in terms of provision. I talked about the quality of buildings earlier. I think the fact that staffing is quite fragile and we're struggling to both retain and recruit staff makes it harder to provide the quality of care that you'd like. And in particular, again, I think due to just sort of pressure issues, we've seen a lot of experienced members of staff leave the sector recently, and that has an obvious knock-on effect, because even if you can replace them, you're replacing them with people with less experience. I think all the steps that have been made in terms of terms and conditions are really important, but it's a start; we need to go further.

10:40

Thank you for those comments. In regard to the need for addressing the systemic issues around sustainability, around workforce pressures, and then COVID, how do you think in regard to the response from providers that they are going to anticipate meeting the rising costs that we're all facing across society? What do you think their anticipated response is, and basically, is there a need now for real transformational change to meet these pressures?

I think there is a need for real transformational change. Some of that is within the care home provision, and some of that is outside that in terms of what we do in terms of things like prevention and fewer people or a smaller proportion of the cohort of that age group needing care homes. On the pressures, we've obviously talked quite a bit about pressures on wages, but that is two thirds, as I said, 60 to 70 per cent, of care home costs. But actually, there are other costs; we all know that fuel costs are rising, food costs are rising, insurance costs have gone up significantly for the sector in the anticipation of claims around COVID. We've seen people with 200 to 300 per cent increases in insurance premiums and we're seeing insurance providers not taking on new business as well. I think all providers are looking at their books, effectively, and trying to work out how they can manage efficiently on the fees they are getting. And as I said, we're seeing increasing numbers setting higher fees than local authority rates because they feel that's the only way that they can stay in business.

Thank you. I'm not going to ask you whether there is a place for profit. You've mentioned thematically 22 and seven different funding arrangements throughout the commentary this morning, and it's been very interesting. Regarding your comments around capacity within local government, around market stability reporting, is there potential here of changing the shape of care home capacity and services, or is it not a panacea, and there is that need for a more holistic change?

I think there's some capacity. I think part of the problem is, as I said, in some areas, there's quite a good relationship between commissioners and providers, and they are able to work together. But if we're changing provision significantly, if you're looking at people expanding, investing, I think too often, we know that there are some areas where it's much more of an adversarial relationship, but equally, I think even in those areas where there is a good relationship, providers are aware that quite often that's based on individual relationships with individual people within a local authority, and that can feel quite fragile if you're talking about making a significant future investment.

You could have discussions with someone within a local authority and health board about future needs and 'This is what I'm going to do', but then it takes quite a significant amount of time to realise that investment. That person might have moved on, things might have changed. So, it is about reassuring providers that if they do want to engage for the long term in certain types of provision, that that is still going to be wanted, and it is about how we build those trusting relationships, effectively, to enable that to work.

Even in a basic residential home, if you wanted to change to provide dementia specialist care because you know there's a need, actually, that's quite a transition. Have you got a building in which you can cohort people who are the basic residential people who are still living there, and the new dementia people that you're taking in; can you manage that? What does that mean for your cash flow in the medium term? You really need to be able to have a trusting engagement with commissioners to work these things through.

Thank you for that. In regard to the expert panel that you are sitting on, I do hope that there is note being taken of the intermediate rehabilitative care for dementia sufferers in Sweden—and Scandinavia, as an aside—because it is absolutely fantastic. What impact, finally, has the sustainability toolkit, 'Let's agree to agree', which you've mentioned, had on the market, fair pay for the workforce, and what outcomes for residents, at its very heart, which is what we're really, really, focusing on as well?

10:45

If I'm honest, I don't think 'Let's agree to agree' has had the impact that anyone hoped it would. I think, in some areas—. To be honest, the pandemic hasn't helped in terms of that, because in terms of—. Setting up new processes, more collaborative processes, when everyone's under great strain just dealing with the here and now, hasn't helped. But we've seen some—. I think we've seen a few local authorities that have gone into proper processes and proper engagement around the principles of 'Let's agree to agree' with providers. We've seen some more who have paid a level of lip service to it, but it hasn't necessarily had that kind of meaningful result. And we've seen some that haven't really done anything with it. And, in particular, I would say penetration in health boards and that engagement in health boards is worse, in general, than with local authorities. Again, to sound like a broken record, I think that's why we do need that national structure.

Thank you very much. Cefin, I'm conscious you're short on time, but we'll now land everything back on you.

Diolch yn fawr iawn. Bore da, Mary. I'm going to be asking my questions in Welsh, so you'll need to put your simultaneous translation button on.

Mae'r cwestiynau sydd gyda fi am y gweithlu, ac rŷch chi wedi sôn tipyn am ddatblygu'r gweithlu yn barod. Ond y cwestiwn cyntaf yw: pa mor dda mae partneriaid a darparwyr yn gweithio gyda'i gilydd i ddatblygu'r gweithlu, a bod hynny wedyn yn ymateb i anghenion heddiw a'r dyfodol, mewn gwirionedd, mewn byd sydd yn gystadleuol iawn rhwng y sector gofal a'r sector iechyd?

The questions I have are about the workforce, and you've mentioned workforce development already. But the first question is: how well are the partners and providers collaborating to develop the workforce, and that that, then, responds to the needs of today and the future, in truth, in a world that's very competitive between the care sector and the health sector?

Yes, and I think what we see is that we see people leaving the care sector for two reasons. We see a set of people who say, 'This is a really pressurised job, and actually I can earn as much in retail, in hospitality, with much less pressure, and so that's what I'm going to do, even if it's just for a break and then I'm going to come back to the sector.' What we also see is people leaving and moving into not dissimilar roles within health, because they really enjoy the work, but they can be better rewarded for that. 

Again, the sector was under pressure going into the pandemic. The pressure of the last two years and the pressure now, just in terms of staffing—. And it is around things like, previously, if you had a cold, you'd just go into work. Obviously, for the last two years, everyone's fear has been, 'That's COVID. You can't look after vulnerable people.' And so, even with the testing regime, you've been waiting for tests to come back et cetera, and it's all just added to pressure on the individual workforce.

The pandemic has made training more difficult as well. Everyone's had to adapt in terms of things like not having people in the same room, providing online training; some of the training for care work you can't provide online. So, I think, while there is a will and a commitment, and we all want to see greater professionalisation of the workforce—we're moving towards the registration of care home workers now in October; obviously, it was originally due to be this April, but, because of the pandemic pressures, that's been put back—I think it's still difficult. It's still a struggle. And it's a struggle both in terms of retaining, motivating and registering the workforce, but also in terms of what we can do in terms of terms and conditions over and above the real living wage, in particular given the other inflationary pressures on the sector. So, I think everyone's trying to move in that direction, but we're trying to move—. It feels like we've got one arm tied behind us as we're making that progress.

Diolch yn fawr iawn. Rŷch chi wedi sôn am siẁd mae'r sector yn cefnogi'r gweithlu a bod hynny wedi bod yn anodd iawn yn ystod y pandemig. Felly, siẁd mae comisiynwyr o'r sector cyhoeddus a darparwyr yn gweithio gyda'i gilydd i gefnogi datblygiad proffesiynol gofalwyr yn y sector?

Thank you very much. You've mentioned how the sector is supporting the workforce and that that's been very difficult during the pandemic. So, how are the commissioners from the public sector and providers working together to support the professional development of carers in the sector?

10:50

We have training provided through the social care workforce development programme through commissioners, but, obviously, some providers run their own training programmes as well, and prefer to work in that way and ensure that things fit in with their own organisational policies et cetera. I think, again, we've seen some commissioners work really proactively with providers around training. We've seen some health boards set up, for nursing homes, specific training and support programmes, but, again, it's patchy. And I think a lot of it depends on individual relationships, but also individual capacity within commissioners as well.

Diolch yn fawr. Rŷch chi wedi sôn yn barod am y pwysau sydd ar recriwtio gofalwyr, ac rŷch chi'n colli llawer, wrth gwrs, oherwydd y pwysau gwaith. Siẁd ymateb sydd wedi bod i ymgyrch ddiweddar Llywodraeth Cymru o dan Gofalwn Cymru/We Care Wales? Ydych chi wedi dechrau gweld bod yr ymateb i'r ymgyrch honno yn dwyn ffrwyth?

Thank you very much. You've already mentioned the pressure on recruitment of carers, and you're losing many because of work pressures, of course. What kind of response has there been to the recent campaign by the Welsh Government, namely the We Care Wales campaign? Have you seen that the response to that campaign is bearing fruit?

At the moment, it's quite difficult to tell, to be honest. We are seeing new people coming in to the sector. There's some evaluation work being done, interviewing new recruits to the sector coming through, which will, I think, gather a picture of what motivated them. But it's interesting; I've actually just spent the last two days with care provider associations from across the rest of the UK and Ireland, and one of the representatives there had been at a European care workforce conference, and interestingly was saying—. There were reports I think from 22 countries, but what everyone was saying, and this is what we hear from providers as well, is the thing that works best in terms of recruitment is word of mouth: it's existing care workers selling the job to people they know and telling them about why they would do it, why they should do it, why they would enjoy it and why they'd engage. So, at the moment, I know the workforce have seen the We Care Wales ads and liked them, but I don't have a picture about how many new people they've brought through as yet, but hopefully we'll get that out of the evaluation that's coming.

A'r cwestiwn olaf ar yr adran yma yw: beth yw'ch barn chi am rôl gwirfoddolwyr i weithio mewn cartrefi gofal, ac oes yna unrhyw bryderon gyda chi ynglŷn â hyn?

And finally, what is your opinion of the role of volunteers working in care homes, and do you have any concerns about that?

I think it depends very much on the role of volunteers, and, obviously, again, we've been through two years, effectively, where we've really tried to minimise footfall within care homes—or for the best part of those two years, anyway—and so additional people volunteering in a way that they used to hasn't obviously been part of that, and there will be concerns about infection prevention and control. But I think there's got to be a clear boundary between—. You know, in terms of providing personal care, for example, that's a skilled, trained workforce who you need to do that. In terms of volunteers providing extra enrichment within care homes, it's something that can add real benefits, and whether that's someone coming in once a week and doing a particular activity with residents within that, small groups of residents within that care home, there can be real benefits to that. Sometimes, it's a relative who's happy to undertake some enrichment with other people who don't have anyone to visit them. So, I think there's potential, and it can be really positive, and lots of care homes have and have had those really positive relationships. But we also need to be clear where the boundaries are and that we can't rely on that as well.

There has been a pilot that some of our members have been involved in with Age Cymru. That was around bringing volunteers to manage the visiting process, because, obviously, we're still not back at the days where care homes had an open door and you could come in and out and visit your friend or relative whenever you wanted. People are still having to test for COVID before going into care homes, and there's a degree of bureaucracy and management around that and ensuring people understand what the latest rules are in terms of what they can and can't do from an infection control perspective. So, we had a series of volunteers in I think it was about 14 care homes undertaking that role. That's been really positive, and there's a toolkit to enable other people to do that or for that to be used for other roles going forwards. So, there is a role, but we can't rely on volunteers, and we shouldn't, actually, rely on volunteers to provide a full professional care service to people. 

10:55

Diolch yn fawr iawn. Jest i ddod â'r sesiwn yma i ben, mewn gwirionedd, gaf i ofyn dau gwestiwn i gloi? Y cyntaf yw: ydych chi'n hyderus bod Llywodraeth Cymru yn symud i'r cyfeiriad cywir ac yn ddigon cyflym o ran diwygio comisiynu gofal cartref i bobl hŷn?

Thank you very much. Just to bring this session to a close, in truth, could I ask you two questions to close? The first is: are you confident that the Welsh Government is moving in the right direction and quickly enough in terms of its policy reform on commissioning of care homes for older people?

So, I think the White Paper, the national frameworks that we've talked about, that national structurefee-setting national office, is very much the right direction to go in, and I think that will yield savings and additional capacity at a local level, actually, to do more of the proactive stuff that we've talked about. I'll be honest and say I would like to see it happen faster. I've been told that it's proably two years away. I'd like to see that happen for the next financial year, because the problems in the sector really need that national solution.

Finally from me, Chair, if I can, would you like to comment on anything else, maybe an aspect that we haven't delved into as a committee, or do you want to share any good practice with us that you would want the opportunity to do?

Thank you. In terms of what we haven't delved into, I think Rhianon mentioned, 'I'm not going to ask you about profit', but I suppose there is an element of understanding, and I think, sometimes, when commissioners—. Again, we have this issue when commissioners are setting fees. We have a responsible individual who might own a care home, actually, they're not taking a salary for that, but they'll take an element of profit, effectively, and, again, it's the different ways that different care homes are structured. Also, if we want investment in care homes, and we want people to invest money in the care home infrastructure, there's going to have to be some level of return on that. That's whether—. We have members in the private sector and the third sector, and, actually, they all see the same pressures in terms of costings around staffing, in terms of having reserves, if you need them because something goes wrong with the roof, for example. It's all those issues, and I think sometimes that all gets wrapped up in profit and isn't seen as what it could be. So, again, I think it's—. We've talked about the whole commissioning, fee-setting model, and I think having that expertise and understanding of the sector in order to be able to do that properly is really important, and I don't think we're ever going to have that 22 times over.

In terms of good practice, I do think we have seen, as I said, some real engagement, but what I'd say is that it's too dependent on individuals doing that real engagement from the commissioning side, and we need a structure and a culture that expects and enables that, and that needs to happen right across Wales. Again, I'd hope the national structure can free people up to do that more, but I think, ultimately, care providers are caring for some of our most vulnerable citizens. Commissioners shouldn't actually be commissioning them if they don't feel they can have a trusting relationship with them that is working on mutual respect, because why would you put someone you didn't have that mutual respect and trusting relationship with in charge of caring for vulnerable citizens? So, I think there are some issues there that we need to work through, and it's cultural and it's about that working together effectively and spreading the culture of doing that.

Thank you very much indeed. That does, as Cefin indicated, bring us to the end of our question session with you, so, Mary, thanks very much for being with us and for answering our questions. A transcript of today's meeting will be published in draft form and sent to you for you to check for accuracy before it's published in its final version. Otherwise, thanks again, go off and have a coffee, tea, water or whatever it is you need to recharge your batteries, and, again, thanks very much for being with us.

11:00

Diolch yn fawr. Thank you.

Right, committee, can we have a short shutdown? Yes, please.

Gohiriwyd y cyfarfod rhwng 11:00 ac 11:17.

The meeting adjourned between 11:00 and 11:17.

11:15
4. Comisiynu Cartrefi Gofal i Bobl Hŷn: Sesiwn Dystiolaeth 2
4. Care Home Commissioning for Older People: Evidence Session 2

Welcome back. I'm pleased to welcome—croeso—Helen Twidle from Age Cymru. Apologies for delaying you, but thank you for being here. Just for the Record, could you please state your name and role? 

Yes. I'm Helen Twidle. I work for Age Cymru as their health and social care policy and campaigns officer.

Thank you very much indeed. We have a number of questions for you, as you might expect, and I remind Members and I'd be grateful if you also could be succinct to enable us to cover the wide range of issues that this topic has generated. I'll begin the questions myself as Chair, and then colleagues will pick up the line of questioning from there on. So, I'd like to begin by exploring issues around making the system less complex and easier to navigate from the perspective of a service user. So, what do you believe are the main issues that make the system for care home commissioning across Wales complex and difficult to navigate?

That's a complex thing to answer in and of itself, as you'd expect. From an older people's perspective, older people have told us repeatedly that they just don't understand why there are differences between what health will pay and what social services will pay, and as far as they're concerned they just want the right care, in the right place, at the right time, regardless of who's going to pay for it. The funding legacies that have happened over time with changes don't seem to have kept pace or adapted to the changing needs of older people. So, whilst there is a lot of information out there and there's been research done around the levels of funding, what's been demonstrated through the reports produced in August 2020 around rebalancing health and social care is that whilst funding for social care has remained fairly stable, the amount of funding dedicated to older people has actually gone down in real terms. I can send over the information later if you wish, because I can't remember the references off the top of my head. But all the differences and the ways in which different placements are funded just seem to serve to slow down the process, which can reduce people getting the right help at the right place at the right time, as I've already said, which is what we would aim for for any person that requires that sort of service. With the differences between what health will fund and what social care will fund, and all the time that is spent between those bodies deciding who will pay for what, that money could be much better spent on front-line services if the complexity could be reduced.

I'd love to have a perfect answer for you for how to do it, but, from outside, obviously, that's quite difficult. But it does seem that pooled funding, if it's actually pooled funding as opposed to the tweaks and adaptions and the small moves that have been made so far—. Really, we're not seeing the changes through the social services and well-being Act that we would expect to have seen by now. And whilst we appreciate the last two years have been so incredibly difficult, these last two years have really shown the fragility of the system and that this does need to change.

11:20

Thank you very much indeed. In your view, how does the experience of accessing care impact on service users and their families? I'll give you a couple of examples: perhaps issues arising from out-of-area placements and issues arising where the resident's first language is Welsh.

There are a range of difficulties around that. Firstly, often when a placement's made, it's usually as an emergency. Not usually as an emergency; a lot of a time it's an emergency, because people often reach crisis point before they'll go for help, and particularity through the last two years we've seen that people haven't been coming forward for the support that they need. And so, by the time they do need it, it's more of a crisis, and it does take a lot to arrange those sorts of things.

There's been a change over the years in what the needs of older people are, in terms of residential care. So, we're seeing a large increase in demand for dementia-related support, but not as large a shift in care homes to be able to meet that sort of level of demand, and that can really push people out of county so that they get the help that they need in the right place. Particularly for people with dementia—as it is with everybody else, but particularly for dementia—it is vital that placements are made close to home so that families can visit and maintain their well-being. But we've seen through the pandemic terrible things that have happened when people haven't been able to visit, and people that are living with dementia have gone downhill much, much faster than they should have done in other circumstances.

In terms of Welsh language provision, again there can be various issues around that. Whilst Welsh language provision should be there, and therefore providers should be making every effort to provide that service through the medium of Welsh where people need it, and there's no doubt that they do, the availability of Welsh language provision is patchy, from what we've heard back. We've heard people talking to us that have come to our advice line asking for support where they haven't been able to get support through the medium of Welsh. Their loved one then has not been happy in the placement that they've had, and they've ended up pulling them out when they actually do need residential care. But because they can't get the right care in the right place, then they've not been able to provide that. I don't think I've answered that question very well. Could you say the rest of it again, sorry?

I think that was essentially it. Out-of-area placements was the other particular issue I mentioned, which tied in with your first comment. But I suspect a lot of those will relate to people with particular support needs, such as dementia.

Particularly when people have got what's called 'more complex needs', and I don't know whether it is actually complex needs or lots of things happening at the same time, and somebody may not recognise themselves as having complex needs. They may have a physical need, they may have a need around dementia, and they may have other things as well. Particularly the more specialist placements tend to be fewer and further afield, and whilst everybody needs to be close to home, it's worse for people with more complex needs who do need more support from the people that love them, that want to visit them. We've had calls from carers who haven't been able to visit loved ones who are in distress because of the lack of visiting, and, yes, we do need much more localised provision. How it's provided is very, very difficult of course, but it does need to be local to home in order for people to have better outcomes, where that's their wish.

11:25

Thank you. I note the comments that Age Cymru's made in the past about engagement amongst your members with regional partnership boards, for example, but what engagement has Age Cymru had with public bodies and providers to develop solutions to the problems identified to you by service users?

Now, I'm not sure that I can answer that fully, because I haven't worked for Age Cymru for all that long, so I'm not sure historically what's happened. I work for Age Cymru as the national organisation, and of course we have local partners, local Age Cymru partners, who would be more involved at local level, at regional level, with those sort of decisions. What we're hearing back from some of the regional organisations is that the level of involvement of older people representation isn't as good as they would like it to be, and through the development of regional partnership boards we'd like to see more meaningful engagement of more older people, and their representatives being involved in those developments, particularly when we're looking at market stability and what people are going to need for the future. Having those conversations with people themselves about what they want would be really beneficial.

Thank you very much indeed. Before we move on, then—I suspect my colleagues will cover a lot of this in their own questioning— and sorry to put you on the spot at this stage, but can you suggest any potential quick wins that could be introduced to simplify the system and that could be easily done or easily avoided or stopped?

That's a million-dollar question, isn't it? I wish I did have the answer to that, and I don't think there is a simple solution. In particular with some work we've been doing recently, looking at the delays in care generally, not specifically around care homes, what we've been finding is that there have been increased delays, obviously through the coronavirus pandemic, and that—. How shall I say it? Oh, I'm so sorry, my brain's gone blank. The thought's gone in one ear and out the other.

I can come back to this later, when I've looked at my notes. What was the question again?

It was whether you could think of any quick wins, quick things that could be done, to either improve things or prevent things or stop things that are currently preventing an improvement.

I'm not sure that what we've been looking at is actually a quick win, but what we've been finding is that there's been a lack of communication between health and social care through the pandemic, and that is not in any way to say anything negative about them, but the circumstances have been incredibly difficult, where it's been difficult for everyone, to make all the decisions at the right time in the right place, and, in particular, communication with the people requiring the service themselves has not been brilliant. If people know what's happening whilst they're waiting for care to be arranged for them, then they're much better able to deal with it, whereas if there's not that much communication coming forward, then it leaves people in a worse situation and potentially they may make the wrong decisions, like going to the wrong place, the wrong care setting, or where they're not sure what's happening with residential placements but the family may try and make other arrangements themselves, and in particular where people need a lot of care and families are trying to provide it but they've not had access to information around safe handling and nutrition and all those sorts of things that would help maintain people whilst they're waiting for the right decisions to be made—. Other than that, I don't think there are many quick wins. I think there are some changes that need to happen longer term, but it's a difficult situation. It's always a difficult situation, isn't it? The changes that need to happen will be longer term, so in the meantime what's important is that everything's communicated, and I think particularly better understanding for the public about what is arranged and how it's arranged would benefit people in terms of when they're looking forward and what they're going to need in the future. And reducing that complexity that we were discussing earlier would certainly help with that. 

11:30

Okay, thank you. If I can bring Rhianon Passmore in, who has got some questions for you. Over to Rhianon. 

Thank you, Chair. I've got later questions down for myself, 10 and 12. 

Right, okay. Hang on, two seconds. Could you go to the next question, Chair, because I—

Diolch yn fawr iawn. Thank you, Helen. My first question, and the context of these questions, is about the overall stability and quality of care in older people care homes across Wales. So, the first one is: what is Age Cymru's overall assessment of the state of the care homes market for older people in Wales and its overall sustainability and the quality of care?

Right. In terms of stability and quality, there are some differences. I should just state that, obviously, from Age Cymru's perspective, when we hear from older people we tend to hear more about issues than about where things are going right, and what we hear just depends on people coming forward to us a lot of the time, apart from through national engagement work. The issues that we're hearing from older people are issues around top-ups for funding for those sorts of things. Not much is coming through in terms of the quality of the care itself, except where it's not available through the Welsh language. In particular, the difficulties are around not being able to get care locally, where people have to be placed further apart. 

As we know, care home provision in Wales is pretty much a monopsony. There are an awful lot of very small providers and only a few larger ones. And from a commissioner's perspective, that's difficult for them to manage. But because we've got an awful lot of smaller care providers, they may be very good at providing really good-quality care, but whether they're able to negotiate with the commissioners around the true costs that they're facing and the changes in costs that have particularly happened through the pandemic is a different matter. In our discussions with care home networks, they've said that they feel like they need some more support around that in order to be able to negotiate these appropriately. And if you don't have the right level of these, then you can't provide the right quality of care. So, the changes with the real living wage have seen an increase in the commissioning arrangements. The—the term has gone out of my head, and it's such a simple one—placement fees, how much each placement is made for, have gone up more this year because of the real living wage, but care homes don't see that as enough. And if they are struggling to recruit staff, then quality does go down. 

The activities and other wider stuff that's available through care homes can sometimes be lacking. So, whilst the real living wage is covering the care staff, it doesn't cover activity co-ordinators, who are completely integral to providing good-quality care. So, activity co-ordinators will be ensuring that people have got things to do during the day, that some of that is around physical activities, which is maintaining their physical health and their mental well-being, which is integral to their care. Cleaners are talking to residents every day, they're making sure that their needs are met in terms of how the cleaning is done in their individual rooms. Cooks are providing good-quality care in making sure that they have their nutritional needs met. And they can be very, very complex in care homes, and they're dealing with a wide range of things. So, the inequalities and who is paid what in a care home and how those areas haven't been completely considered with the move to the real living wage—which is great, we appreciate the additional funding that's going into it, but there is more to do there to ensure that the quality of care continues, because there are differences in terms of what's available in which homes. So, there are some activities available in some, fewer activities available in others because they can't afford a full-time activity co-ordinator, or two full-time activity co-ordinators. So, the quality can really go down when the costs aren't fully covered through the way that care home placements are commissioned at the moment. 

11:35

Okay. Diolch. Moving on, what expectation do you have as an organisation of the work undertaken by local authorities at the moment around the market stability reports, and how these reports could inform future direction for the sector? 

It'll be interesting to see what's in all the market stability reports. I've only seen one so far from the west Wales care partnership, which seems to largely cover everything that it should have done, and, to be honest, that's the only one that I've read. I'm not sure if there are any more out there, because I've had very little time to prepare for today, unfortunately. From what I read within that one, there was nothing new that I wouldn't have expected from any other region in Wales, and that is not in any way a criticism of that; it did seem to look in detail at the issue with wage levels and the market and what's available, how much is in private ownership, and all those sorts of things—that's all there. The reports themselves don't really identify solutions in terms of how to change things for the future, and I think that's where the real work will be needed, because there needs to be more done looking forward to the future, because the changes that seem to be happening—. And we have seen some improvements through the Social Services and Well-being (Wales) Act 2014, we have seen some improvements through the regional partnerships, but there's still an awful lot more to do. 

Diolch. Given the increasing costs on care homes, what do you think Age Cymru—? What do you think the Welsh Government and commissioners should do to respond to manage the impacts of this on service users? 

Oh, I wish I was a more intelligent person who could answer all these questions perfectly. The population of Wales is ageing, as it is across the rest of the UK, and while people are ageing, they are living longer with more life-limiting conditions and more complexities, so the latter part of life is spent in ill health. So, considering that that move is happening, we would expect to see that the level of funding, or changes in funding, and changes in how things are commissioned should be changing at a fast pace to address that. This isn't anything new; we've known about the ageing population for a very long time. It was there pre pandemic, and the pandemic has just shown the fragility of the system with care homes closing under the pressures that they've had in the last couple of years with everything that they've faced. 

In particular, you'll all know that recruitment is a huge problem to them in social care, particularly for care workers. The move to a real living wage is welcomed, but it's not going to change things that much when considering that they can get jobs that are easier to do for the same amount of money or more than working in care homes. I've gone off thread again, I'm so sorry.

I've always got more to say but it doesn't always come out of my head all at the same time. 

No, we asked you to be succinct at the beginning, so that's very helpful. Cefin.

My final question is two-pronged. So, the first is: how well do partners work together to develop a sustainable workforce and provide professional development for that workforce? And secondly, what is your opinion of using volunteers in care homes? What are the advantages and potential challenges around using volunteers? So, it's development of the workforce, No. 1, use of volunteers, No. 2.

In terms of developing the workforce, the changes that have come through with registration, what we've heard back from care home providers is that the process can be onerous to get workers registered, but they can address that in some ways. Their concern is around how people can be a very, very good carer, but not digitally literate, and going through that process can be more difficult. So, I think they need more support to get through that process. It's important that the workforce that is employed has access to full training that covers all older people's needs, covers all those sorts of things. With the turnover in staff, it's quite difficult to get a dedicated workforce that has that level of—not responsibility, the word's gone again—experience, levels of experience. You need stability in your workforce and you need people to stay in that role in order to be able to do it well. People change over time and the presentation of a person in a care home can go down. So, having the same carers that understand what the person looks like is really important in terms of maintaining them.

In terms of volunteers, there is a role for volunteers in care homes. We piloted a project that was trying to support care home visiting by providing volunteers during the crisis to free up care home staff so that they could do what they needed to do and then volunteers could support visitors to come in. So, there are roles in that sort of way. In terms of providing care, that actually needs to be done by paid people, because a volunteer can't do everything that's needed to be done and get all those levels of training and all those sorts of things that can be particularly impractical. 

I'll mention our cARTrefu project, because we've been working in care homes for several years on an arts project to maintain well-being and improve people's well-being, which has been particularly beneficial to people with dementia who've regained some of the skills that they thought they had lost. We've had feedback from carers in care homes that have said that, through the arts project, they've realised how capable the residents were. It has changed their view on them. Those sorts of projects really do improve quality of life. I'm talking about Age Cymru's project because it's the largest one across Europe and it's been independently evaluated and seen to be a really good one, but there are other volunteers that could go in and do similar things. The role of volunteers should be on the—I don't really want to call it the softer side, because that makes it sound less important, but it's around the wider well-being and all those sorts of things that we're more able to help with rather than the day-to-day care responsibilities. Does that make sense?

11:40

Thank you very much indeed. Rhianon, are you ready to come back in?

Thank you for that last answer, that was interesting. In regard, then, to potential division or division throughout the public sector partners working within the care sector, how do you feel that the public sector funding's current approach could be made easier to reduce any tensions among our public sector partners in terms of those who are paying? Have you got any thoughts around that question?

My thoughts around that are kind of related to it but not directly around the division. Currently, the way that funding's allocated year on year is they go through an annual process of uplifts and consultation with providers of services about what their increased costs are in order to arrive at a figure. Feedback that we've had from across Wales is that the 'Let's agree to agree' toolkit isn't being used consistently, and that is an issue for them. So, the public sector may be using other methods but they may not be the best methods, so some consistency about how those decisions are made across Wales would help things a lot. 

In terms of division between public sector partners, as I said earlier, it would be better to have the money on the front line, where it could—but it needs sorting out initially in order to actually get to that stage anyway. That's just the additional part. There's an awful lot of time spent in commissioning meetings between health and social care where they're deciding who pays for what for each individual placement. As I said earlier, older people just don't understand where those divisions are because, as far as they're concerned, if they need residential care—it's a health need not a social need—they see it is as an artificial division in many ways.

The categories of care have gone between the 'Am I residential?' and stuff in theory, but in practice that's still how things are worked around in terms of sorting out how much each placement will cost. If that could be streamlined, if the funding could be pooled, then that would reduce it. How that pooled funding could work would require more looking at, and I know a lot of work has gone into that. Take an example from many, many, many years ago. When Supporting People funding came in, all the funding from different pots was put into one, and then it was allocated out. That seems to be a sensible thing to do—why can't they not just put all the funding in one and then argue about how it's allocated afterwards? Because you've got to have a starting point, and you've got to try something.

But, it's an awful lot of management time, a lot of high-level people's time spent in meetings, which shouldn't really be needed for each individual person. It's not every single person that goes through that, but it's an awful lot of time, and an awful lot of money, which would be much better spent on the front line if guidance could be agreed. And also, there are the differences with regional commissioning and local commissioning, and local decision making, about how things work—those areas still need to be overcome in order to get a good solution. 

11:45

You see a lot of scope, then, in terms of simplification, and you've mentioned the vehicle of the Supporting People package previously, retrospectively. So, you see there's a lot of scope there in terms of simplification so that the service user has that better outcome. 

In terms of outcome, what is the impact you feel—you've already touched upon this—on residents, service users and their families when public sector partners just don't agree on commissioning placements? You've mentioned the time spent between health boards et cetera, and local authorities. Have you got any comments around that, Helen?

I don't have any hard facts around that, but at Age Cymru, we've been recently working on a campaign around delays in care, and we've put in a freedom of information request for every local authority on delays in access to assessment, and delays in actually providing the care. I've not been able to get full data across Wales because the systems just simply aren't there for a local authority to pull off all the information that I wanted, which I think is an issue in itself, in terms of how their care management systems work and what they're able to pull off, which also goes into the performance management questions around this session—if you can't pull off information regularly, how can you plan and how can you take things forward?

But through the freedom of information requests that I've had back from that, and discussions with local authorities, there are some very long delays in getting a full assessment of someone's need between all partners and all those sides, from health and social care and what's needed. And that leaves people in a situation in the meantime where families are pulling together trying to provide care in the community, and their own health and their well-being is going down. We've heard examples where people couldn't get the care that they wanted, not specifically for residential, but they've ended up ill and in hospital themselves from injuries through providing personal care. So, whilst carers are happy to provide care where they can, they need support to do so, and they need help in the meantime while these longer term decisions are being made. 

From those freedom of information of requests, we had some quite worrying data that some people were waiting over a year for a full assessment to be made of their needs. We know that there have been delays through the pandemic, and we know that some people's needs are very, very complex, but if their needs are complex, then they need the assessments done sooner rather than later in order for things not to go downhill. 

Thank you. My question further to that is: out of all of the complications and difficulties and tensions that you have outlined to us this morning, do you feel that a unified health and social care service under one roof might help to address these challenges, or at least some of them?

It seems like a sensible solution. There are so, so many details to sort out within that, but a move to a unified system, similar to the NHS but different, where it's free at the point of need, and then things are sorted later, would be good. At the same time, sorting out who pays for what also needs to be clearly communicated in terms of what people's responsibilities will be around what they will be expected to pay. For example, our fact sheet on paying for care runs to 71 pages in order to explain all the details of different circumstances, and it's unfair to expect anybody to understand that level of detail. I used to work in a commissioning team myself, and I struggle to explain it, so how an end user is supposed to understand what's happening and where is a major issue.

11:50

Thank you, Chair. Welcome, Helen. I'm going to be asking you a series of questions about regional commissioning, and it will be followed by my colleague Mike, who'll be taking the reins from me. But before I go into that side of things, can you just tell me—in fact, all of us—a little bit more about the Tell Me More project, which was funded by the Welsh Government, and some of the learnings that you've taken from that, please?

Thank you very much for that. I should have brought that up earlier, when I was talking about other things. I'll send the link round to you later. The Tell Me More project has been running in care homes to allow people resident in care homes to explain what their experiences have been like through the pandemic. There's a video available now, and it's really, really impactful, understanding what people have been through. Because of the restrictions, people in care homes have been so cut off from the rest of the world, and there has been very, very little opportunity to understand what they've been going through because of restrictions and people not being able to go in. The Tell Me More project has produced videos, which are like talking heads—it's not people's faces, it's their own voices, explaining the different things that they've gone through. Some of the stuff in there is really heartbreaking to hear, in terms of watching people with dementia going downhill, how people have been affected by not being able to see people—all those sorts of things. It's been a great project, it's allowed care home voices to be heard quite clearly in terms of what's been going on, and really highlighted how older people's human rights have been sidelined under the pandemic because of the situation they've been in with the lack of visiting, and how it's—. Sorry, I get quite upset, because I've watched that video a few times, and it gets me every time just how badly some people have been affected. But, on the upside, there's people's resilience through the pandemic, and how they say, 'Oh, we've coped, we've coped with other things, we've coped really well, because we've been together and we've all been in the situation'. And so, some people really feel that they've pulled together a lot through it. Is that what you wanted, Natasha?

Yes. It's great feedback—to hear from yourselves. We do get briefings, and we've read the report—I'm sure many of my colleagues are aware of it as well, as much as I am. And it's nice to hear from you as to how much of an impact it's actually had.

I genuinely can't do justice to how impactful it is—people really need to listen to it, you need to hear people's voices. I've not explained it half as well as you would just get by watching the video. But I'll send that link to everybody afterwards.

Thank you, Helen. Following up from that, obviously, you've gained a lot of insight from the Tell Me More project, clearly, from what you've just told us. But I want to know, in relation to regional partnerships now, particularly the boards, they are developing regional strategies, which are ultimately there to help partners shape the care home market. Based on what you've learned from this particular project, and other work that you've perhaps carried out, how much of an influence and what contribution has Age Cymru made specifically to these regional partnership boards?

I would actually have to ask our local partners what contributions they've made. Nationally, we don't get involved with the regional stuff. We've got our local brand partners, so Age Cymru Dyfed would be able to answer that better than myself. I can find that information out later, but generally speaking, the feedback we get is that, where planning is done, sometimes involvement of our partners can be a little bit tokenistic or not enough involvement, not enough notice in advance. You'll have heard this from other sectors before, but charities don't have huge amounts of staff or ability to be involved in everything immediately, all the time. And that's the same across Wales for other areas. But more involvement earlier would be preferable to what's happened previously. So, some strengthening around that with the regional partnership boards would be really welcome.

As I'm sure you're aware, the elderly tend to go through an exponential level of health conditions, which can evolve at such a rapid rate—it's beyond anyone's comprehension at times. But particularly when it comes to building new care home infrastructure, what do you think some of the challenges are going to be, bearing in mind that the ageing population is going to go through a multitude of health conditions that will perhaps evolve over the next 10, 20, 50 years or so?

11:55

I wish I had a crystal ball, Natasha. We know in many ways what's going to happen in terms of increases in dementia because people are living longer and will be living with more conditions as they get older. And it's not necessarily a fact of life that that all has to happen—if we can age healthily, then those needs may reduce over the next 50 years or so. 

In terms of the provision we've got across Wales, some of my knowledge comes from when I used to work in the commissioning department in social care. A lot of care homes, as I've said previously, are very small and some of them are very, very old and not easily adapted to new uses. So, there may not be sufficient room to allow nursing care as well as purely residential care; older properties have struggled to provide safe visiting because of the lack of space and the lack of ability and those sorts of things.

Going forward for the future, we would like to see that all categories of care can be provided in all local areas so that people aren't travelling, as was discussed earlier. But any new builds really need to have involvement of older people about what their needs are going forward. So, you'd want more space for activities, you'd want more space for visiting, you'd want sufficient room sizes—en suites and all the rest of it. It's really important that any new developments involve older people and older people's groups in those to discuss their needs. In terms of design and things, there are things around dementia where you'd expect or where you'd want certain—. You wouldn't want too much—. I'm trying to explain this clearly and all the words have gone.

It's been a busy week and I've been a little bit pushed trying to get ready for this, so I'm a little bit frazzled. Particularly for people with dementia, you'd want the layout to reflect their needs, so you would want different areas to be decorated differently—things like that—so that you can differentiate where you are and people are less confused. There are things like that. But in terms of the wider provision, I think it's going to need a move towards more complex needs cases. I don't like using words like 'complex needs'—are they complex or are they just multiple needs? Let's call them 'multiple needs'. Ensuring that all those different things are met is what's really important and that older people are involved in those decisions about how they're made. 

Thank you so much, Helen. I'm going to pass you over to my able colleague Mike, who'll be asking you the rest of the questions.

Hello, Helen. I'm coming on from where Natasha stopped. We know—in fact, you mentioned it earlier—about the increasing complexity of conditions, and we've got comorbidities. Is enough being done to anticipate and plan for dealing with this in the short and medium terms?

I think all of this is known now, but how quickly it's translating into changes in practice isn't something that we're seeing. There are moves in different parts of Wales to address those sorts of needs. We know that people tend to not want to go into residential care until it's the last resort. And we've got concerns that people maybe have been put off from going into residential care when that's what they really need because of the difficulties they've seen through the pandemic, and then the infection rates. Residential care is seen in a lesser light now and it really shouldn't be, because that can be a perfect place for someone to be who's been socially isolated and is not able to look after themselves and all those sorts of things. 

There are some moves in different parts of Wales to make those changes. I was talking to a local authority last year that not only have increased their volume of residential care for people with dementia, but have also made moves to reduce the need to go into residential care in the first place, by providing earlier interventions so that people don't need to go that far. So, there's a whole range of things, Mike, that need to be done, not just along the lines of the provision itself, but making sure that everything's being done to provide care in the right place, at the right time, before they even need to go to residential and possibly put that off.

I think some areas have better relationships with the providers of those services and care homes than others, and that needs to be worked on in some areas. We've heard that in the annual rounds of fee negotiations a lot of the small providers have been put off by it; they feel that they've not been heard over the years and they just don't see the point in engaging anymore because nothing's changed in terms of those sorts of things. And, also, the regional differences in what's available needs to be looked at as well, I think. So, we know what some are; we know what they're likely to be in terms of complexity of need, but it is a very, very difficult thing to do, and I appreciate that for commissioners, to actually shift things along as quickly as they would like, because there's very, very little residential care that is now run by public services, and my perception is that the ones that are run by public services tend to be sort of respite care and some longer term residential.

But the move to it being more private, which has happened since the 1980s—. So, in the 1980s, I think there was a huge proportion that was local authority-run and now we're down to a very, very small proportion that's run by local authorities. I think that has been a particular issue during the pandemic because the local authority-run ones have been what local authorities have been able to fall back on, in the absence of other things during the pandemic, when they've not been able to make placements. So, there's an imbalance in the market. I'm not saying that everything should be public service-run; I am not qualified to make that decision at all, but it particularly seems that, through the pandemic, where local authorities are in charge of things, they've been able to adapt quicker and make those changes.

Those changes can happen when they've also got the relationship with an outside provider as well. If that relationship's there, and that relationship of trust exists, there shouldn't be a problem shifting things along. So, I'm not saying it should all be public sector-run; I'm saying that there are differences there that need to be looked at in terms of longer term planning because the position is changing. But it's not changing quickly enough and with the delays that we're seeing now, and which are going to happen for the foreseeable future because of the effects of the pandemic, this is a really good time to look at it and change things because those relationships have improved through the pandemic—providers of services and local authorities have been working so closely together to try and overcome issues—so this is the time to do it, if there's any time at all. Does that answer your question properly, Mike?

12:00

It certainly does, Helen, and I think that we've seen, haven't we, in rough numbers, that it's gone from about 95 per cent local authority, 5 per cent private sector, to about 5 per cent local authority and 95 per cent private sector. I have views on it that no-one else wants to hear in here, so if I can move on to your view on regional partnership boards. Have you any thoughts on them? Do you think they're working? Do you think they can be improved?

I think there are always opportunities for improvement. I think regional partnership boards have been there for a while, and, don't take this the wrong way, but, as with anything, the moves are slow to make changes. So, when regional partnership boards first came up, there were issues around both the regional, who does what, and how do our local statutes around funding, and what those were, fall into this. So, there are all those sorts of things that still come to the regional partnerships for decision. The 'Rebalancing care and support' agenda, and the move to strengthen regional partnerships, should help shift things along further, but, again, it requires time and effort of those partners, and they need dedicated time in order to make the changes that are needed and to bring things together. And that level of trust needs to be there from all partners, that they're all in it together, and that if they pool funding, it will be spent in the right ways. How that goes forward is not clear to me. It might just be me that hasn't seen the full picture, but there have been some moves that look promising, but change is slow, and how that can be shifted to meet current population needs is something I wish I had the answer to, but I'm afraid I don't.

12:05

Thank you. Perhaps a comment: I think the 95 per cent private sector includes the large number run by charities and housing associations as well. I think we made some references earlier, so there's the ongoing debate we might have about this. But if I can bring in Rhianon Passmore to talk about variations in expenditure.

With regard, then, to those variations in terms of weekly placement costs, what does Age Cymru see as perhaps the reasoning for those differences in unit costs, particularly around weekly placement costs? And do you feel that there is any justification for such variation, Helen?

There are some vast differences across Wales. I've not seen the full 2022 fee levels yet, and that in itself is an issue—that it's last-minute when these decisions are finally made. I appreciate that each local authority will be going through a process in determining what those levels are, and how much they go up, but that seems to be—. It should possibly happen earlier, because going into April, those things still are not known.

We had a caller to information and advice from one of our local partners that had received a letter from a care home in March, saying that their prices were going up. The local authority prices weren't going up by that same amount and the top-up that they would have to pay would be much larger than it was previously. We know that we're in a cost-of-living crisis. This is more of an issue this year, now, than it probably ever has been before, but the way in which fees are arranged, and the differences between when a local authority will increase its fees and when a provider themselves will, there's a disconnect there; they're doing it at different times of the year.

It seems the providers are getting there before local authorities, sending out what the new things are, and then we have an awful lot of families that are in complete crisis, not knowing if they're going to be able to meet that additional cost, wondering if they're going to have to move their loved one out of that care home into another one that is cheaper and will the quality of care be there. And that happens year on year. That happens year on year regardless, but this year is particularly bad. Coupled with that, it's not only families that are paying those top-ups, it can be carers that are paying them. So, somebody that's been providing informal care can sometimes pay these top-ups because they want their best friend to go to the right care home, and that seems kind of morally wrong that somebody with no formal relationship would be paying for that top-up.

The regional differences themselves, I've been trying to get to the bottom of this, and I've wondered about it for many, many years, but there doesn't seem to be rhyme or reason for it. So, if you compare the differences between the unit cost price in north Wales and south Wales, there's a big difference there, but if you compare those with the how much per older person is paid by each local authority—that was included in the 2020 report about rebalancing care and support—the local authorities that are paying more money per care home placement are not the same ones that are paying a lot for older people's services generally. That might be a false comparison, because those services could be community services, that they're paying for more services in the community, so there could be a difference there, but there are vast differences.

So, when I've been speaking to partners across Wales, wage levels don't seem to have really come into it with the differences, and it is wages that are a huge part of the costs, obviously. Any care service relies on good-quality staff, so you'd expect the funding to be towards the front-line sort of thing. Local authorities, or coastal ones, struggle to recruit because they haven't got the hinterland. If you've got sea beside you, you can't recruit dolphins or fish to the care sector, so they have more difficulties recruiting in that sort of sense. So, you'd expect that maybe their costs would be higher in terms of those, but that doesn't seem to really reflect it, either.

So, what do you think it is, from your sort of perspective? You've highlighted to us this disconnect, and it does seem very unfair to the service user, family and friends that this top-up continues to grow. I mean, what do you think it reflects, from your experience?

12:10

It could be down to local decision making and how much the cabinet is prepared to top up and how much based on other budget pressures, but it's difficult to know. What we've had from discussions with some commissioners and some care home providers—not specifically older people, because they don't tend to be involved in those sorts of high-level things, obviously—is that commissioners are willing to pay more, but they just don't have the opportunity to pay more because they can't get that level of funding agreed. So, it could be down to local decision making, but that's just my perception, and it's not something that I know as fact.

That's interesting, nonetheless. I'm going to ask in terms, then, of the disparity between charges for care in the community that service users pay compared to the contributions for a care home placement. I mean, what's your perspective in terms of the differing cost brackets within that? Do you feel that's fair or does it reflect the costs involved? Have you got a comment, Helen, to make?

It's another difficult area, Rhianon. Care in the community obviously has capped costs per week, and it's different for residential care, as you well know. We have concerns that people may be put off going to residential care because of the selling up of assets and then trying to provide more community care, or struggling and not managing, so that that person then doesn't go to residential care at the right time. So, more parity between how those are funded would probably be beneficial. 

There are people who are able to pay, there are some much richer older people, but there are increasing numbers of poorer older people, which we all know about through the cost-of-living crisis, and the pension triple lock having recently been—what's the word? It's not been stopped, it's been halted, hasn't it, despite the fact that the cost of living has gone up much more. So, there are those sorts of issues as well to look at, obviously.

But in terms of the difference between the two, again, it's something people don't understand. Why would one be capped and one not be? Why do they work in different ways? So, bringing those more in line with each other may assist. We're just concerned that knowing that someone may have to sell their home or have deferred payments with interest rates—and the interest rates, actually, have gone up there as well—may be putting off people from going to the right care that they need to maintain their quality of life. So, if that could be addressed, that would be great.

Okay. So, to summarise, if I can understand that: you would think they would be better aligned in terms of that variation and, obviously, without putting off earlier intervention in terms of care in the community.

And my final question, then, really, is more, again, a personal view, or perhaps Age Cymru has a view, in terms of the overall fairness of the funding model in Wales in terms of what's been mooted now for England. Have you got any consideration of the England versus Wales landscape?

The moves in England to increase the levels with the caps are an improvement. The move—. Are you talking about the social care levy as well, or are we just talking about the—?

I mean the overall funding model in terms of care, and we've obviously spent some time talking about the Welsh landscape and architecture. So, it's just really a comment from Age Cymru in that regard.

Yes. We believe that care should be available free at the point of need and that those who can pay, and are reasonably able to pay, can contribute to that. Where we have more concerns is whether financial assessments and people's understanding of the process is actually followed in all cases, and that it's completely clear to people how this works. So, like I said, it's a very complex system. Reducing that complexity would help. People that are able to pay, that have that level of funding, can do so and they can choose to take their care where they wish. It's also worth mentioning that those with more finances can sort their own placement out completely independently of social care, but through the social services and well-being Act that doesn't give them the same level of protection in terms of quality and monitoring. So, the local authority has got no—if they've not made the placement they can't check on the quality of care for that person, and that is of concern to us.

We have concerns in terms of how people that are privately funding may be shoring up the care market, with local authorities not being able to meet the full amount through their funding rounds and all the rest of it, and that shouldn't be the case. But it does appear that where local authorities can't make their fees as high as providers would want them to be, the private funders are then topping them up, and that's an inequality that shouldn't be there. Does that answer what you asked, Rhianon? I think I've lost myself again.

[Inaudible.]

12:15

Are you content, Rhianon? Yes, thank you. I think that last question—. I think, if I remember correctly, in England, they're introducing an £86,000 per person cap, which is a variation on the system or different to the system in Wales. We're running short of time, and we've got a lot of questions. I'll invite Mike to ask a final question, but if you wouldn't mind, we'll write to you with the few remaining questions afterwards, and perhaps in that we could also expand on that final point. Am I right, that it was £86,000? I think it was in the briefing paper—[Interruption.]—yes, by comparison with the figures currently applicable in Wales. Thank you. So, Mike. 

I think everything, really, if we're taking about them—. We talk about money, we talk about everything else, but really it's the citizen, it's the person in the care home who is the most important part of the system. Are you seeing, during all these changes and approaches, any more focus on the outcome for the service user?

Not really. A lot of performance monitoring is around outputs not outcomes. We'd like to see more involvement of older people in making those decisions about what that outcome monitoring should look like, Mike, and that would be around having their rights of power, having opportunities for social engagement, all those sorts of things, which we've not been seeing in the pandemic because of the restrictions that have been in place. So, in terms of quality and monitoring, more could be done to look at what people expect and what matters most to people is having those 'What matters most to people' conversations that is a part of that outcome monitoring—[Inaudible.]—will end up in residential care anyway, but having more of a focus on whether people's rights are being met in full. Because this is someone's home. It's a care home and it's their home. And their rights are very difficult to be delivered fully and they have been difficult to be delivered fully through the pandemic, but there needs to be more of an emphasis around those and making sure that they're all met. So, when we talked before about the cARTrefu project, bringing arts into care homes, which gives them more opportunities, more interaction—. It doesn't have to be that sort of thing, but more of those sorts of things, which are maintaining people's well-being and quality of life, should be looked at, and how much of that sort of availability is available through residential care should be included as part of the outcomes monitoring. 

I've been very impressed by Musical Memories, which has been used both in homes but also in community centres, which really does have a tremendous effect and beneficial effect on elderly people. Although, I was very disappointed to discover that ABBA was in a Musical Memories set, as others in the room might be. But my last point is: are we convinced that everybody is being sent to the most suitable accommodation as opposed to the most easily available?

12:20

Again, that's a difficult one to look at. I think there is a lot of compromise, a degree of compromise in, 'Do I want my loved one in a care home that's close to me, or do I want them in the perfect place to meet their needs for the rest of the time when I can't visit them?' So, when you're looking at whether they're getting exactly the right care, in the right place, at the right time, that can be down to those negotiations with families and carers about which way that goes. Also, in terms of placements that are made as part of hospital discharge, I'm not sure whether all the information is there with which to make the right decision at the right time, because sometimes those placements can be made very quickly to get someone out of a hospital. And that's not to say anything against health; they're working on the information they have available at the time, and it's been very, very difficult during the last couple of years, but unless everybody who is involved with the care of that person is fully involved in that decision and has had opportunities to do so, there are times when the right care isn't provided in the right place, at the right time, and that can lead to placement breakdown.

We've heard of cases where families have taken their family member out of a care home because they just didn't feel like it was doing what it was supposed to do, and then you go back through the same cycle again with them, trying to find the right placement, while families are trying to maintain them in the community whilst another placement is found. So, I think the intention is there every time to find the right place, at the right time, but in practice, because of the gaps for dementia care and for higher levels of need in particular local areas, I don't think everybody is put where they need to be, but it certainly can be improved over time.

Well, thank you very much indeed. So, the clock has more than overtaken us. If you don't mind, we will write to you with the three final points that we haven't had time to cover yet.

Thank you very much indeed. So, thanks to Helen Twidle—I apologise for the mispronunciation at the beginning. 

Don't worry about it. I've had it all my life and it doesn't bother me at all.

My briefing paper had you down with a double 'd' in the middle, so that's my only excuse, but now I know that that's incorrect.

That's a good excuse. [Laughter.]

So, thank you very much. A transcript of today's meeting will be published in draft form and that will be copied to you and you'll have an opportunity to check it for accuracy before publication of the final version. So, thank you again for being with us. I hope you can relax a little bit now before you have to continue with, I'm sure, the rest of your working day.

Right. Back to the care campaign. Thank you for your time and thank you for this opportunity.

5. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o’r cyfarfod
5. Motion under Standing Order 17.42 to resolve to exclude the public from the meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o eitem 6 a 7 y cyfarfod yn unol â Rheol Sefydlog 17.42(ix).

Motion:

that the committee resolves to exclude the public from items 6 and 7 of the meeting in accordance with Standing Order 17.42(ix).

Cynigiwyd y cynnig.

Motion moved.

I propose, in accordance with Standing Order 17.42(ix), that the committee resolves to meet in private for items 6 and 7 of today's meeting. Are all Members content? I assume that Rhianon is—yes. Thank you. In that case, the clerk will move to private session.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 12:23.

Motion agreed.

The public part of the meeting ended at 12:23.