Jan 31, 2011 - review and update its guidance 'Escalating Concerns with, and closures of, care homes providing services
Report to the First Minister concerning the Welsh Government Guidance ‘Escalating Concerns with, and closures of, care homes providing services for adults’ Purpose This report is issued to the First Minister under Regulation 16 of the Commissioner for Older People in Wales Regulations 2007 in relation to the Commissioner’s general function of promoting awareness of the interests of older people in Wales and the need to safeguard those interests1. On the evidence I have available to me, I am asking the Welsh Government to: review and update its guidance ‘Escalating Concerns with, and closures of, care homes providing services for adults’; address the limitations in this guidance that have been brought to my attention; include good practice that has been identified in Wales and elsewhere in the UK; increase access to independent advocacy services for older people; and ensure that the legal duty to provide Independent Mental Capacity Advocates in certain circumstances is fulfilled.
1
Commissioner for Older People (Wales) Act 2006, s.2(1)(a)
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Background Older people in Wales and their families have brought to my attention their concerns about the interests of older people who are living in care homes that are closing or are under threat of closure. In 2009, I supported a funding bid by the Centre of Innovative Ageing at Swansea University for research into care home closure, its prevalence and the impact on older people. There had been a paucity of research in this area and the opportunity to have a Welsh focus on such an important area of interest could not be missed. The final report has recently been made available, and has been shared with the Assembly’s Health and Social Care Committee. My staff have also provided support to older people and their families in a number of situations where care homes were under threat of closure. In all such cases I have raised with the Local Authorities concerned whether as commissioners or providers of services - and, where relevant, with the independent providers the importance of protecting the rights and welfare of older people during what can be a period of uncertainty, distress and upheaval.
Evidence The Welsh Government guidance ‘Escalating concerns with, and closure of, care homes providing services for older adults’ requires Local Authorities and Local Health Boards to ensure that appropriate local arrangements are put in place to deal with issues as they arise. The guidance correctly places emphasis on proactive measures to address and prevent escalating concerns, as well as reactive measures to deal with any requirements to close a home as a consequence of any concerns. The guidance does not, however, adequately cover all types of care home closure and fails to provide Local Authorities with sufficient direction as to how to close a home that they operate as a consequence of a change in policy. The primary purpose of the current guidance is to address concerns about the provision of care within homes. The use of this guidance can Page 2 of 10
therefore cause unnecessary worry amongst relatives and older people where the decision to close a home is based on a change in policy. The current guidance is also more suited to the closure of homes that are operated by the independent sector, where the role of the Local Authority is to intervene and oversee the closure process. The current guidance does not make allowance for those circumstances where the Local Authority itself is the provider of services and is planning to close a home as a matter of policy. This raises questions as to how useful the guidance can be in such circumstances. The current guidance contains some references to home closure good practice but it should be enhanced to recognise more recent experiences from Wales and from elsewhere in the UK. The absence of guidance that addresses closure of homes by Local Authorities as a consequence of a policy decision means that relatives and older people do not know what they should expect to experience in such circumstances. They can feel isolated and uninformed, with no-one to turn to. Whatever the reason for closure, the end result is the compulsory relocation of an older person from what they regarded as their own home. Older people have shared with me the worry and distress caused by not knowing what the future holds in such circumstances. The process of closing a home where there are no concerns can cause great uncertainty and complexity. The timescales involved can often be long and drawn out, heightening anxiety levels. There is also evidence to indicate that homes are ‘run down’ during these times: new admissions halted, staff redeployed and sections of the building decommissioned. Older people and their families want a clear explanation for the reasons that a home may be closed. They also want to know what the options are and ask that decisions be taken promptly to avoid unnecessary distress. They want reassurance that they will remain safe and well cared for in their current home during the process and that the transition to a new home will take into account their emotional as well as physical needs, e.g. transferring couples and, where possible, friends so they can remain together. Older people as individuals also need ready access to independent advocates who can help them voice their questions and concerns. The Page 3 of 10
decision as to whether an older person needs an advocate should not be determined by the Local Authority, the social worker or even relatives, as these parties may not have objectives views. Advocacy should be a core resource available to all care homes and is particularly important as part of any home closure process.
Actions taken In January 2011 I wrote to Head of Adult Social Services Policy Division bringing to his attention the following key concerns: A lack of clarity in the current guidance about how it would apply where the threat of closure is a result of a strategic or policy decision rather than due to concerns about the quality of care, safety concerns or financial viability. Consultation processes that are not engaging with older people, take place at the wrong time in the process and run for an indeterminable period of time. Limited use of independent advocacy services being considered for older people in care homes threatened by closure, especially Independent Mental Capacity advocates for those older people who may lack capacity. I received a response in April 2011 which is attached as Appendix A. Since then I have looked further into the use of the Welsh Government Guidance by Local Authorities in Wales. This included informal discussions with a number of Directors of Social Services in Wales. They shared their recent experiences and felt that the current guidance needed to be updated to reflect current trends for home closure processes. They were also looking for improved sharing of good practice at an ‘All Wales’ level. My staff have also been working closely with Professor Vanessa Burholt, of Swansea University, as part of the Centre For Innovative Ageing research project ‘The Closures of Care Homes for Older People in Wales: Prevalence, Process and Impact’. As part of that research, I have shared relevant information relating to the concerns of older people in Wales that I have investigated in the past two years. This report makes explicit reference to the need to review and update Welsh Government guidance relating to the closure of care homes in Page 4 of 10
Wales.Their findings go as far as making suggested changes to the existing guidance, which would address the limitations identified.
Recommendations I acknowledge that the current guidance contains useful information on care home closure, encourages multi-agency working and sets out clear actions when concerns are raised about the quality of care within a home. However, on the evidence I have available to me, I am asking the Welsh Government to: review and update its guidance ‘Escalating Concerns with, and closures of, care homes providing services for adults’; address the limitations in this guidance that have been brought to my attention; include good practice that has been identified in Wales and elsewhere in the UK; increase access to independent advocacy services for older people; and ensure that the legal duty to provide Independent Mental Capacity Advocates in certain circumstances is fulfilled. I anticipate a prompt response to this report, as Local Authorities are currently making difficult decisions concerning care homes, with limited guidance to support them. Older people in Wales are currently in needless distress where a closure process is not providing them with the best information, support and advice.
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Appendix A
Cambrian Buildings Mount Stuart Square Cardiff CF10 5FL Mr Steve Milsom Head of Adult Social Services Policy Division Welsh Assembly Government By email
31 January 2011 Dear Steve, Re. Statutory Guidance: Escalating Concerns With, and Closures of, Care Homes Providing Services for Adults In recent months, I have been contacted by older people who live in care homes facing potential voluntary closure because the care home is said to be no longer financially viable. These older people and their representatives have shared with me concerns about the uncertainty of the situation in which they find themselves. They have told me about the worry, and sometimes distress, they are caused by not knowing what their future holds. Page 6 of 10
Members of my staff have been looking carefully at this matter in order to promote awareness of the interests of these older people and encourage best practice when dealing with matters that affect their home life. We have also spoken with some Directors of Social Services, particularly about their use of the 2009 ‘Escalating Concerns’ Statutory Guidance. This has led us to think that there is a gap in the guidance in relation to care homes where there are no concerns about quality of care, no concerns about safety and where there has been no final decision about closure. For example, there are an increasing number of local authority areas where the possibility of care home closure is announced and thereafter follows a long period of consultation and, sometimes, delay. In such scenarios, we have found that older people may be told that although no decision has been made to close the care home they must still visit other care homes with a local authority social worker so they can decide where they would like to go when the care home closes. If they express that they would rather wait until a final decision to close is made, they are told that if they wait until then they will ‘miss out on a good place’. We are deeply concerned about what seems to be an insufficient use of Independent Mental Capacity Advocates in these situations. Local authorities and NHS bodies have a duty to instruct IMCAs where accommodation arrangements are being made on behalf of an older person lacking capacity without friends or family. Neither are we convinced that older people have access to independent advocacy services at an early enough stage to allow them to voice their opinions about the potential closure, for example, from the point when potential closure is first announced and then followed by a period of consultation. Local authorities do not seem to be sufficiently clear about the role of the statutory guidance and have expressed to us a need for further clarity. The Older People’s Commission is supporting research by Swansea University into the prevalence, process and impact of care home closure in Wales. We are holding a set of seminars to look at the emerging findings from this research and other research evidence on extra-care facilities. However, we do not want to wait until the final outcome of Page 7 of 10
these initiatives before raising our concerns about the statutory guidance with the Welsh Assembly Government. I would welcome a meeting to discuss these concerns more fully. I see this as an opportunity to make the statutory guidance even more widely applicable, which will in turn promote and safeguard the interests of older people in Wales. Yours sincerely,
Ruth Marks Older People’s Commissioner for Wales
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