Agenda item

Domiciliary Care

To discuss the current challenges faced within the care sector and the Monmouthshire context.


Eve Parkinson delivered the presentation and answered the members’ questions with Tyrone Stokes.


Are there differences between care packages and domiciliary care? Are we working in hand with health authorities or separately?

Predominantly, packages of care and domiciliary care are the same thing. We would assess someone; the majority sits with the local authority unless it’s continuing health care. Following assessment, the package of care is provided either by our in-house domiciliary care services or commissioned providers. In-house tends to be a lot of enablement, reablement and the more complex cases.

Are we partly responsible for bed blocking if we don’t have the staff numbers to do the assessments more quickly?

Our staff go into the hospitals to do the assessments. But it’s following the assessment, whereby it’s decided that that person needs a package of care, we hit a stumbling block where we can’t provide what the assessment has determined. The whole system is very complex. It’s not as simple as someone being admitted to hospital but then we can’t get them out because we haven’t got a package of care. From Welsh Government’s perspective sometimes people shouldn’t have been admitted into hospital – there is a level of risk adversity around admissions – and the evidence is very stark that as soon as someone with several conditions, or who is older, is admitted they deteriorate very quickly. There are people who go into hospital needing nothing, and by the time they are ready for discharge they need a lot of support.

So, at a critical care hospital i.e. The Grange, the assessment will be done when they transfer from there to another hospital, e.g. Nevill Hall?

No, we assess in The Grange as well.

Presumably occupational therapists in hospital do an assessment? Is the Social Services assessment part of that? How does it work in terms of discharge from wards?

It varies across the county: there is a slightly different model at Nevill Hall in that Health Board OTs transfer into our team – so we ‘in reach’ into Nevill Hall, and work with our own people. So, for the most part, our own social workers, OTs and nurses in-reach into the hospital. In the Royal Gwent the model is different. We have a Rehabilitation Support Worker and a Discharge Liaison nurse from our Chepstow team who go into the Gwent to identify people who are from Monmouthshire and bring them out. In our Chepstow and Monnow Vale community hospitals our integrated team works completely.

In the table on p7, there are 104 people with no care at home who are waiting for it. How are they supported in the interim?

It is often family and carers who support them. It is a case of any extra support, respite or day service provision but it is very challenging. If the situation deteriorates, we try to do our best to pull something together, but we don’t have the staff. We have daily conversations with the hospital to ascertain what risk people are put in when discharged.

Regarding domiciliary care at home, in Wales there is a cap limit on what a family has to contribute.  There might be financial implications for going into a care home as, presumably, the caps then don’t apply? How would that work out financially for people who are struggling?

The financial assessment is laid down as an act of law in the Social Services and Wellbeing Act 2014. Someone identified as having a care need undergoes a financial assessment. For non-residential services (which covers domiciliary care), there is a maximum charge that we can levy of £100 per week. That will be maintained by Welsh Government in the next financial year, so the most someone will have to pay is £100. There is no cap with residential. So, someone might have an identified need, where they need to go into a care home, but if the financial assessment determines that they can afford to pay for that care themselves, they won’t be entitled to any local authority funding support. This is sometimes an area of conflict i.e. when someone is fit to be discharged from hospital the financial assessment says they need to go into a care home, but they can afford to pay for themselves. Services from health are free but as soon as social care intervention is needed then they are chargeable under the Act.

Even in care homes there’s an element of support that should be contributed to by the health board.

Yes. With care homes there are two avenues: residential care or nursing care, which is what you’re referring to. Continuing health care is 100% health funded. If someone needs to go into a care home but with a small element of nursing provision, that is called ‘free nursing care’. The health authority will pay for the nursing care element, and there’s a supplement that the health board pays, but the accommodation cost is payable by the local authority, which is where the financial assessment comes in.

As the process is so complicated, does it cost more money? Could it be made simpler?

Yes, it is complicated, and has always been though it has become more so since the Act came in in 2014. We have differing rates for the cap compared to England, which means English residents accessing Monmouthshire care homes, which creates extra complexity.

But this can take time, especially if there are appeals against the financial assessment, coming back to bed blocking. Are we saying that the process is not as straightforward as it should be?

We have to ensure that we are compliant with the law, part of which is performing a means-tested assessment to determine if people can afford to pay for their own care. We try to turn that around as quickly as possible, but we need to make sure that it is robust, equal and fair. Good engagement with the family is very important, including sometimes being frank. There is the right to reject the financial assessment but that means that if the person goes into residential care, they forego any financial support from the local authority. Those who are in hospital waiting for residential or nursing care homes are usually those who don’t have the capacity to make that decision themselves, which adds another layer of complexity. Reaching the decision in that person’s best interest involves the family, and when there is no lasting power of attorney it ends up in courts – we can’t facilitate the discharge until the court has made a decision.

Do we get many appeals?

We get a lot, even more so recently. Law firms and financial advisers are increasingly involved. Pre-2014, there were perhaps 1-2 appeals per month, now it is 3-4 per day. This is time-consuming and expensive, but people have the right to challenge.

Is it not time to look at how complex things are, and go back to a simpler system, particularly in providing things ourselves rather than buying services from private companies?

Although we outsource some of our care, it is a way for us to carry out our duties. A carer who goes in does so on behalf of MCC. We have been employing more in-house carers over the last few years, so much so that in the Month 9 forecast, it is one of the reasons we continue to overspend in Adult Social Care. Pension contributions are a factor here: in the private sector the employer contribution is 3% but in MCC it is more like 23-4%, so immediately there is a greater overhead from employing our own carers. Also, if the external sector is struggling to recruit and retain carers then we will too. It comes back to social care not being seen as an attractive industry for people to enter – jobs in supermarkets and bars often pay more, for example. Furthermore, a carer has to be registered i.e. qualified, whereas those better paid jobs don’t require a qualification.

Do we know that the private companies we use are financially sound, or are any at risk of going under?

At this time we aren’t aware of any companies that are on the brink. However, they are under extreme financial pressures currently masked by the Covid Hardship Fund – once that ceases in 29 days’ time we will get a clearer picture of the challenges. We are in constant dialogue with the providers to understand any difficulties that they have. We have sometimes had significant handbacks from companies that aren’t on the brink but have decided that working in Monmouthshire is no longer viable for them; they have therefore given us notice on some packages of care, some of which are significant, creating a lot of stress to address them. It is often not cost-effective for companies to bring their carers into Monmouthshire from, say, Blaenau Gwent, rather than have them stay in that county to work.

Is it really the case that someone can leave hospital without having had an assessment?

We have eyes on all of our hospital patients: we know who is admitted and when, with lists sent to us daily. We are very active in the conversations about the risks when discharging, what support they have at home, etc. We actively work to ensure that we can put in the best resources possible.

Can training for family members who provide care be provided? Stepdown facilities have been provided for patients leaving the Royal Gwent. What about those in Monmouthshire?

We work closely with family members, particularly around manual handling and equipment. There is currently a scheme called Step Closer To Home in which the health board funds people going into a residential setting as a stepdown from hospital. So, the hospital will discharge the person into a home, not necessarily in Monmouthshire. The health board provides the funding for 6 weeks, after which time if we still haven’t found a package of care, we try to assess the person to understand their long-term needs, whether they need to stay in the residential setting or look at other options. It is a very complex situation. Funding for Step Closer To Home finishes at the end of March; we will have to consider then what the other options will be. We have many discussions with colleagues about how to stop someone going into hospital in the first place: if we were to have a more proactive and robust offer in the community then we could prevent a lot of this.

Chair’s summary:

Thank you to officers for this report and their continuing efforts in a very difficult area. The committee has great concerns about recruitment and the ability to attract staff to social care. Members have strongly expressed their dissatisfaction with the system’s complexity but are very grateful to officers for their hard work and dedication in working within it.

Peter Davies, Deputy Chief Executive and Chief Officer for Resources, drew attention to the affordability challenge. Putting Adult Social Care on a sustainable footing features in the draft budget proposals. MCC carries a significant budgetary risk because of the system’s fragility. It is right that those providing care are paid at a suitable rate; there are clear efforts from Welsh Government to do this, and to try to attract and retain the right supply of quality labour. There is targeted work to be done/continue in our commissioning arm. We have tried to get the Society of Welsh Treasurers, local government finance and WLGA more closely aligned with the work of the Association of Directors of Social Services, with the aim of working collectively to shape what a sustainable system for Adult Social Care would look like. We want to bring a very informed business case forward to Welsh Government, to engage in a meaningful conversation about moving ASC to a sustainable future.


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