Agenda item

The committee had requested a report on domiciliary care following their scrutiny meeting in September. The committee recognised that "Turning the World Upside Down" is the Council’s approach to developing sustainable domiciliary care provision, however, having understood from previous discussions that the market is somewhat fragile, they agreed that an overview of the state of play in the social care sector at a future scrutiny meeting would be helpful. The committee agreed to focus on the challenges within the sector and understanding how the council would respond to those challenges.  Two care providers had been invited to attend the meeting.

Members heard that domiciliary care provision is a recognised challenge across UK, but that specific challenges for Monmouthshire were:

• the rurality of the county
• The demographics in central and south of the county, together with an ageing population
• An increase in care needs

The committee heard that this posed challenges as to how the workforce can meet the demand.  Adult Services have been working on a model (Turning the World Upside Down), which will be implemented in April 2020.  The report provided a contextual analysis of the challenges posed, supported by data on which highlighted issues with sourcing longer term care provision.  Officers explained that traditional models of care have been based on the provision of care in a transactional way and that whilst has met personal needs, it doesn’t contribute to the longer term health and well-being needs of an individual or their families and carers.  The new model intends to build meaningful relationships and provide a model of support that delivers better outcomes for people.  The committee heard that the patch based approach should enable twelve patches to provide support for individuals and their carers through a mix of in house care and independent provision and that the success of the patch based approach will be evaluated. The benefits of the approach are to develop the relationships between all stakeholders working within the patch and to ensure care plans are focused on what matters to the individual and the way in which they choose to live their life.  It is hoped that the approach will greatly improve experiences for service users, will support their carers and will provide fulfilling roles for staff.

Challenge:

• Members asked for an explanation of the meaning of ‘outstanding hours’.

Officers explained that at the moment, there are people who need some level of support and that at the moment, we are unable to meet that need in its entirety and that whilst people are not without any support, the support being provided may not be the ideal support package.

• Questions were asked around the preparedness for winter weather and winter pressures in terms of increased demand on services.

 
Officers confirmed that the council is suitably prepared for inclement weather and that the right vehicles are in place. They explained that they work with other service areas, for example, district nurses to ensure that people on the council’s priority list are assisted. 

• Members asked for a detailed explanation of the patch based system. 
  They were reassured that the approach had been based upon an analysis of population, demographics and rurality and that locating a central hub with patches based around the hub should enable the delivery of integrated services, so that service provision is not ‘done to the community’ but ‘with the community’. The approach will be person-centred and will enable a far greater degree of coordination. Developing the work to the current point has taken time and has been done so carefully. Officers explained that they do not want a system whereby a person requesting care is provided with care from wherever it’s available, moreover they are seeking high quality localised care delivery. The approach should be more sustainable and should enable local relationships to be built, that will enhance the support for both for staff and service users. The approach is very different to how care is being provided in other counties and that recognising each council will have its own set if unique challenges, this approach will provide a bespoke way of working for Monmouthshire. 

• Members asked the care providers to offer their thoughts on the cost model.  They responded to say that the cost model has not yet been shared with them, however they advocated the approach that Monmouthshire was taking.   Officers explained that this is very much regarded to be a partnership approach to delivering care and that recruiting the right individuals will be crucial.  Members heard that recruiting the right people to work in the field can be a major challenge because whilst there are national recruitment initiatives, there is a need to provide local incentives via the Intermediate Care Fund to encourage people to come to Monmouthshire to work ~ for example, a £2000 towards an accommodation bond.  Officers are aware that people are training in this field, but are not entering the care sector due to low pay and few incentives, so targeted initiatives are encouraging people to join the sector through care apprenticeships and ‘back to work’ schemes.  Staff are being trained on ‘values based recruitment’ to ensure people who are recruited have the important values that match the role. 

• The chair asked the providers to offer their view on what it is like to be an independent provider working with the council and how the council could support them in responding to the key challenges faced in delivering social care. 
  The providers responded to say that the key issue is recruitment.  She explained that the new carer registration process that will require carers to be registered by 202 will ensure carers are qualified, but may also pose difficulties for recruitment, given that the role is still only paid the living wage, which means the sector is paying people very little to undertake a professional role. Some carers who are experienced are therefore undertaking the qualifications in order to become registered at their own expense and that maintaining the registration and the changing qualifications can act as a deterrent, given that other non-professional roles in retail are paid similarly.   The pay of the role was deemed to be a nationwide issue, with little understanding of the importance and professional nature of the role.  She suggested that as there is no current plan nationally to increase the pay for the role, whatever that could be done to incentivise locally through ‘patch base working’ could only benefit staff in terms of flexibility and a local area within which to work. Members also heard that staff are only paid for the time spent with the individual rather than an entire shift and that this would be assisted through the new approach.  In Usk, the council has been trialling purchasing blocks of care that has led to staff based in the Usk patch being paid for their shift, which is a significant incentive for staff. This has also helped to ensure a continuity of service.

• Members queried whether the patch based system was operating in other areas. 
  Officers explained that the approach has been piloted and will be implemented across the county in April 2020. The care provider explained that this is not currently happening in Abergavenny and that those working in Usk earn more as a result. She suggested that if the approach could be rolled out across the county, this would help the recruitment situation significantly. Officers explained that they needed to incentivise Usk as they had struggled to recruit, but that it was really interesting to hear that this approach had already delivered enhanced working conditions for staff during its pilot phase.

• Members asked about why there is such difficulty in recruiting to the sector and whether the issues were solely related to pay. 

Officers advised that whilst pay is a key issue, the major challenge is also recruiting the right people and making the role attractive.   The incentives that could attract people could also be the ability to make meaningful connections with people and to coordinate your day, so the plan is to grow staff as a resource within the patches.   In terms of accommodation and transport, conversations are being held with our housing department and Monmouthshire Housing Association.  A project is being tested in the south of the county in a crisis area where 39 people who are needing care, has enabled a ‘live in’ model to be tested for home care using 2 properties in Chepstow.  This has created a care supply close to the properties and the carer is paid a weekly wage to devise a plan to meet people’s needs until April when ‘turning the world upside down’ will be implemented. Other models are also being trialled in Chepstow.  

• Questions were asked around whether there are difficulties recruiting male carers.
  The care provider suggested that whilst the field is female dominated, they have attracted male carers via the ‘Carer Pathway’ and that recruitment has not been an issue.

• The chair asked the care providers for their final thoughts on pressures and challenges.
  The providers advised that Monmouthshire is leading the way in terms developing different care models and that they are pleased to have the opportunity to be involved.
• Members highlighted the need to evaluate the performance of the model once it is implemented, particularly in terms of outcomes for people and questioned how we would be able to assess whether the model was delivering these. They questioned whether there was consideration of any academic evaluation or whether the council intended to do this in house. They asked how regulators such as Care Inspectorate Wales would assess the model.

Officers responded saying that there wasn’t a framework for evaluation at the moment but that they had held discussions with CIW on this could be evaluated and that they were fully aware of the plans.  They explained that it would be challenging as the model is very different and that given that the new model will be based on relationships as opposed to task, this will pose difficulties in terms of measuring its success, given that task is easier to measure.  Developing quality assurance methods focussing on outcomes will be important, as will gathering information through different measuring techniques, considering the wider consequences, such as fewer people going to hospital or visiting GP’s that may arise out of the changes. In terms of research, a partner has not been sought to evaluate this, but discussion with colleagues implementing different procuring models suggests that there would need to be thought given to the point at which research would be useful. The favoured approach would be to talk to service users to see if their experience matches our expected outcomes. They explained that some of the complaints in the past such as a lack of continuity in the carer or carers not turning up are no longer common complaints, which demonstrates how the model is changing experiences. Welsh Government have developed a digital tool named “measuring the mountain” that can help analyse the difference made. 

• Members asked for officer’s thoughts on whether the council should increase its domiciliary care service or enter into partnership with others to provide care.

Officers advised that they had considered opportunities to set up a co-operative and staff felt that the model currently being piloted is working really well and that if something is working well, why would you change it. Also the early exploration of this had concluded that whilst Monmouthshire was fertile ground for a co-operative scheme, it does not have the economies of scale and that there wasn’t the appetite in the market.  Officers explained that they had the advantage of flexibility at the moment given that there are large and small providers, specialist providers, therefore offering a good balance.

Outcome and Chair’s Conclusion:

The chair concluded that the care provider’s contribution at the meeting had been really helpful and that the committee felt reassured that Monmouthshire is considered to be leading the way in terms of delivering this model.  The relationship with providers was clearly regarded to be positive.  Acknowledging that there are complicating factors, such as qualifications, the new registration process and the low rates of pay, the chair stated that it was pleasing to see that the council is placing a high value on the role and is considering ways in which to incentivise.  The committee agreed they were content with the Usk pilot which appears to be working well and asked that the care providers be sighted on the payment model as soon as practicable. The committee is interested in how the model will be evaluated, given the change from measuring ‘task and time’ to measuring ‘relationship based outcomes’. The chair concluded that the ‘placed based approach’ will be an important step forwards in ensuring service users see a familiar face and develop relationships through continuity in service provision. The committee requests a progress update in 6 months’ time.