Dear Mrs Sutherland Regulation 28 Report to Prevent Future Deaths – Mrs Eirlys Wynne Roberts Thank you for your letter enclosing the Regulation 28 report following your investigation into the death of Eirlys Wynne Roberts who sadly passed away on 17 July 2021. I am responding on behalf of Eluned Morgan, Minister for Health and Social Services. Welsh Government recognises that people who need care and support, including those who need to move into residential, nursing or EMI care facilities, are generally best cared for within their local communities, and that we should be striving to ensure that there is sufficient provision to meet local demand. However, a range of different circumstances can mean that unfortunately this is not always possible and alternative arrangements must be made. It is deeply sad and regrettable that Mrs Roberts had her fall and subsequent admission to hospital before she could move into the specialist nursing EMI home that had been secured for her in Gwynedd. Having explored Mrs Roberts’ journey it would seem that on this occasion Covid-19 may have had a detrimental impact on securing her a nursing EMI home. At the time of her fall Mrs Roberts was in a specialist EMI home on Anglesey (just 7 or 8 miles way from her home in Bangor) but was awaiting a place in a nursing EMI home having been assessed as also requiring nursing care. Unfortunately a combination of staffing shortages in two local care homes with suitable provision (in part due to Covid 19) and a Covid-19 outbreak in another care home meant that there were delays in her accessing the specialist nursing EMI provision she needed. When arranging care home placements a range of factors are considered by health and social care commissioners, including the ability of that home to meet the specific care and support needs of an individual and its closeness to their own community and support network, even if that may be just across the border into another County. With the Regional Partnership Boards established under Part 9 of the Social Services and Wellbeing (Wales) Act 2014 (‘the Act’), Local Authorities within a regional (Local Health Board) footprint have developed much stronger working relationships and now actively collaborate to meet the care and support needs of individual across the whole region. This can mean that Local Authorities boundaries become more permeable and less of a barrier to meeting people’s needs. Ynys Mon and Gwynedd have a strong track record in working as a sub-regional collaborative.

More broadly Welsh Government clearly recognises the challenges across the health and social care system in ensuring peoples increasingly complex care and support needs can be met within the community, as close to home as possible.

The changing and growing care and support needs of our population alongside the impacts of Covid-19and the challenges of recruiting and retaining a skilled social care workforce has created unprecedented challenges in our health and social care system. As a Government we are working hard, alongside delivery partners to strengthen our system so it can support people better.

Financial support During the Covid pandemic the Welsh Government has made significant resources available to local authorities and health boards, to ensure that social care providers can meet the additional costs arising because of the pandemic. The recently published Welsh Government budget for 2022-25 provides an additional £180m to local authorities directly to strengthen the social care sector, with further reform and capital funding also being allocated.

Integrated planning and commissioning Welsh Government has put in place mechanisms to enable Local Authorities and the NHS to better meet changing population needs. They have clear responsibilities to plan and commission care and support services that meet the needs of their local populations, including the commissioning of residential and nursing care for those who need it. Under the Act, local authorities and health boards are required to work together, through the Regional Partnership Boards, to produce five yearly Population Needs Assessments and Market Stability Reports. These must be based upon assessments of local population needs, the range and level of services required to meet those needs, sufficiency of provision, and the stability and sustainability of the market for regulated services such as domiciliary and residential care. Together these feed into the strategic joint Area Plans, which in turn underpin the commissioning decisions of local authority and NHS partners.

The next round of Population Needs Assessments and Market Stability Reports are due to be published in April and June this year. In preparing their assessments, the Regional Partnership Boards must engage with a wide range of stakeholders, including citizens, carers, third sector and community groups, and care providers, so that the provision of care and support can be appropriately tailored to local need.

The Part 9 guidance of the Act also states that local health boards and local authorities must jointly commission care homes through regional pooled funds. It states that in relation to care homes they should agree an appropriate integrated regional market position statement and a regional commissioning strategy. These should specify the outcomes required of care homes, including the range of services required, and consensus on the methods of commissioning. In addition, the guidance states that local authorities and health boards should:  agree a common contract and specification;  agree common contract monitoring criteria and processes that include service user feedback;  develop an integrated approach to agreeing fees with providers.  develop an integrated approach to quality assurance; and  adopt a transparent use of resources. Budgets must be aligned with overall expenditure identified, together with the financial commitments of both agencies to the commissioning of care homes.

In September 2020, the Auditor General wrote to the Welsh Government and copied the letter to all local authority and health board chief executives in Wales, raising concerns about regional

pooled funds in relation to care homes for older people. These concerns emerged from audit work at two of the local authorities in North Wales earlier that year.

The Audit Wales report on care home commissioning for older people published in December 2021 concluded that there were some significant concerns around the practical application of pooled budgets for care-home provision in North Wales, and potentially more widely in Wales.

In January 2021 Welsh Government issued the Rebalancing Care and Support White Paper, proposing legislative and other changes we believe are essential to securing the vision set out in the Act.

These included the development of a strategic National Framework for care and support, which will set standards for commissioning practice, reduce complexity, and focus on quality and outcomes. The implementation of this Framework will be overseen by a National Office within Welsh Government. In addition, we are committed to strengthening regional partnership arrangements to support stronger partnership working and deliver for local populations, with a focus on governance and scrutiny, planning and performance, engagement and voice, integrated service delivery, and rebalancing the social care market.

This programme of work will also enable Welsh Government to respond to Audit Wales concerns by strengthening integrated commissioning practice and specifically the use of pooled funds.

Looking to the future, we are also setting up an Expert Group to support our ambition to create a National Care Service for Wales, free at the point of need and continuing as a public service, as set out in the Co-operation Agreement.

Workforce Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.

In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.

The Minister for Health and Social Services will write to the Chairs of the seven Regional Partnership Boards in Wales, the Chief Executives of the Health Boards and Directors of Social Services to ask them to review their current provision for older peoples residential care, including EMI beds and to ensure that their imminent Population Needs Assessments and Market Stability Reports robustly explore the sufficiency of provision. Any action to improve the commissioning and sufficiency of such provision should then be set out in their forthcoming Area Plans.

We hope you find this information helpful.

Dear Ms Sutherland, Re: Regulation 28 - Prevention of future deaths I write to you in response to the Regulation 28 I received from you on 2 February 2022. Firstly, I wish to extend my sincerest condolences to the family of the late Eirlys Wynne Roberts during a very difficult time for them. The Regulation 28 notice makes a link between the availability of care placements and the individual’s incident and the risk of death. However, the exact nature of this link is not explained in the notice. As the Council was not party to the Inquest, nor did the Council receive a request to provide evidence, I must frame my response within the context of this information. In light of this, I have attempted to highlight the situation in regard to care provision in Gwynedd, and also the arrangements in place for safeguarding individuals who are in a transitional period in terms of their needs or who are waiting for an alternative placement. You have specifically requested that I explain to you the steps we have taken to ensure sufficient availability of care placements in Gwynedd, as well as the steps that are underway for the future. Therefore, within this response, I will endeavour to note appropriate details on the above, in accordance with your request to me. Seeking to ensure the best care for the people of Gwynedd is a priority for me as a Statutory Director, and for the Council as a whole. We seek to ensure that we have the appropriate number of care placements for our residents on an ongoing basis, so that our residents can avoid any degree of delay when moving from one care and health setting to the next. It is important to note that when an individual has to wait for a new care placement, we take our safeguarding duty seriously, and endeavour to put additional health and care arrangements in their place to care for the individual in their current placement.

Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol Gwasanaethau Cymdeithasol Corporate Director and Statutory Director of Social Services

Council Offices Caernarfon Gwynedd LL55 1SH 01766 771000

As you will perhaps be aware, the care market is mixed in its nature, i.e. the provisions can be ones that are provided internally by the Council, or they can be provisions that we commission from the independent sector or third sector. Subject to the nature of the individual's needs, some are jointly commissioned with the Health Board. Therefore, our role as a Council, jointly with the Health Board as appropriate, is to seek to ensure that these provisions are sufficient to meet the care and health needs of our residents.

Unfortunately, there is a current shortage in the number of care and health placements which means that a delay is experienced when transferring and giving individuals access to these placements. Recently, part of this shortage derives from fewer beds due to Covid-19 restrictions, staff shortages and also provisions being closed. I wish to ensure you that the Council, along with its key partners, are working hard and continuously to try and manage and improve the situation in order to avoid excessive delays for individuals as they move from one placement to another.

As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.

Some of the challenges faced by our nursing home providers are problems with the recruitment and retention of nurses and care staff, as well as financial sustainability, which adds to the challenge of providing care. The North Wales Region is responding to the challenges posed by the lack of care and nursing workforce through the Regional Workforce Board, and National efforts are also being made via the HEIW/SCW Workforce Strategy. You may be aware that Welsh Government has recently agreed to fund the Real Living Wage for our care workforce, and this will assist us to support the recruitment challenges; although, it is likely that we would wish to see this commitment taken further in terms of the future salary levels in order to genuinely be able to compete with employers outside the care field.

In terms of the financial challenge faced by care providers, the Council is attempting to ensure that the fee that we pay our providers for a placement is fair, although of course any fee would need to be affordable to us as a Council. For nursing placements, it is also important that the fee paid by the Health Board for the nursing element of the care is sufficient to meet

Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol Gwasanaethau Cymdeithasol Corporate Director and Statutory Director of Social Services

Council Offices Caernarfon Gwynedd LL55 1SH 01766 771000

the needs and for providers to be sustainable. The Councils' settlement needs to be at a sufficient level annually, so that we are then genuinely able to invest in the local care market.

In addition, we are facing a challenge with the availability of residential EMI placements. In terms of general residential placements, the availability of placements against the demand is much better. In order to respond to the lack of residential EMI placements, the Council, for a number of years, has converted general residential beds into residential EMI beds within the internal homes. This work has involved a substantial investment in the buildings and in additional staff. Over the past 5 years, Gwynedd Council has almost doubled the number of Residential EMI beds in our homes.

Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Blodau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd. In the future, our hope as a local authority will be to develop a residential EMI provision at Plas Gwilym Home (as a part of Canolfan Lleu), Plas Pengwaith Home and within the development of the Penyberth site, Penrhos. We are also working in partnership with the Health Board and partners in the social housing field to develop the market further. An example of this is the plans being developed on the Penyberth site at Penrhos, Llŷn and for Canolfan Lleu, Penygroes.

It is important to note that we are working in partnership with other counties in North Wales, and more specifically, with those counties that are on our border here in Gwynedd (e.g. Anglesey), in order to plan and commission these care provisions. Often, individuals and their families who live in Gwynedd, but who are on the boundary with another county, prefer to have a placement located closer to their home rather than one situated in Gwynedd, but further away. Therefore, it is important to note that we work across boundaries when considering care placements. Consequently, providing a care placement for an individual in a nearby county is not a problem in itself, but I appreciate that the placement preferred by the individual and the family continues to be the ideal outcome.

A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high

Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol Gwasanaethau Cymdeithasol Corporate Director and Statutory Director of Social Services

Council Offices Caernarfon Gwynedd LL55 1SH 01766 771000

level assessment, more localised detailed work will be done and this will provide key information in order to reflect on whether we have the correct number of placements for the future.

We are also considering the care market and its ability to respond to the demand for care services today and in the future, and we intend to present the report on the 'Stability of the Care Market in North Wales' to the Government during the summer 2022. The conclusions within this report will show the steps that need to be addressed in order to ensure a suitable provision to meet the demand.

I wish to draw your attention to two recent Audit Reports by the Audit Office in this field, which have set out a number of challenges and obstructions generally faced by councils and health boards as they seek to commission care home placements. One report is for the attention of the North Wales Care and Health Partnership Board, Commissioning Older People’s Care Home Placements, and the other is a report aimed specifically at Welsh Government: Care Home Commissioning for Older People. It is fair to say that our national system does not make the process easy or completely effective.

Of course, as you are aware, a part of the context for the period in question is the fact that Covid-19 related regulations were operational. This has meant that a large number of care homes, at some point in time, were closed to admissions in order to control the spread of the virus. Unfortunately, for many individuals, although a bed was available within a home, and that it had been agreed for the individual to be admitted, Covid-19 regulations meant that they had to wait until the home was completely free of the virus. This has had an impact in this case. Therefore, in reality, and very unfortunately, the Covid-19 related regulations, as well as problems with staff capacity, have had quite a substantial impact on the number of placements that are available at any given time.

The situation of waiting for a bed in an alternative placement is quite common for a number of individuals across the country. Of course, we have given careful consideration to the notice, however as I have previously noted, the link between the circumstances of the incident and the availability of an EMI placement is not entirely clear. However, wherever a higher level of care is needed when attempting to find or secure an appropriate placements, more advanced care arrangements are put in place in order to safeguard the individual until a solution is reached. This is based on appropriate risk assessments and care plans.

As a Council we are wholly committed to doing everything within our ability to provide and commission high standard care placements, that can meet the needs of our population. We will continue with this work and play our part in attempting to influence and improve national policies in the field.

Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol Gwasanaethau Cymdeithasol Corporate Director and Statutory Director of Social Services

Council Offices Caernarfon Gwynedd LL55 1SH 01766 771000

If you require any further information or explanation regarding the response, please do not hesitate to contact me.