National Assembly for Wales / Cynulliad Cenedlaethol Cymru

Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol

Safe Nurse Staffing Levels (Wales) Bill / Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from Hywel Dda University Health Board - SNSL AI 13 / Tystiolaeth gan Bwrdd Iechyd Prifysgol Hywel Dda - SNSL AI 13


Contractual arrangements


Adults who require joint funding by the both the LA and the NHS, in the Care Home setting  i.e. NHS Funded Nursing Care, the Local Authority is often the lead commissioner and Hywel Dda University Health Board (in common  with the process developed across Wales), utilises LA procurement/contracting services to enter into joint funding arrangements. As such there is a joint contract signed by both organisations for all the Nursing Homes within the Health Board community.  These contracts include standard terms and conditions, but also a service specification for the provision of services for adults in care homes which are based on the National Minimum Standards for Care Homes for Older People.


For patients who are fully funded by the NHS, ‘spot purchasing’ and individual contracts are utilised. These are used in conjunction with the standard contracts as above.


Prior to admission to a Care facility however, the provider will be expected to assess the individual and confirm that their needs can be fully met within that facility. This assessment will form the basis of the Care Plan that the provider is expected to put in place and which will be scrutinised as part of the ongoing monitoring and review of the individual concerned.


In relation to looked after children, each Local Authority has a Complex Needs/Out of Area placement panel who consider applications for children and younger people whose needs cannot be met in county. Currently the Local Authority is often the lead commissioner and Hywel Dda makes use of their procurement/contracting services to enter into joint funding arrangements. 


Information within contracts


Hywel Dda University Health Board (HDUHB) has a number of processes in place to ensure the appropriate selection of Providers.  All placements are supported by a contract devised and signed by both HDUHB and the 3 Local Authorities within the region.


This contract covers a number of key elements as listed below:


o   Commencement and duration

o   Complete Agreement

o   The Service

o   Care Management

o   Nursing Care Assessment

o   Standards of Service

o   Liaison and Access Arrangements

o   Information and Communication

o   Trial Period

o   Review of this contract and individual placement agreements

o   Absence from Residence

o   Emergencies

o   Inability to meet terms of contract

o   Termination

o   Termination of Individual Placement Agreement

o   Monitoring and Evaluation

o   Protection of Vulnerable Adults and Children

o   Complaints

o   Confidentiality and Data Protection

o   Freedom of Information and openness

o   Legislative Requirements

o   Equal Opportunities

o   Welsh Language Act 1993

o   Health and Safety

o   Staffing

o   Criminal Records Bureau/Protection of Vulnerable Adults

o   Care Standards Authorities

o   Insurance and Indemnity

o   Assignment and Sub Contracting

o   Agency

o   Resolving complaints and Disputes

o   Default

o   Declaration of Interest

o   Waiver

o   Severance


The Service Specification sets out the Providers duty of care to provide appropriate services at an acceptable standard of quality to individuals, irrespective of the care setting and within the regulations of the CSSIW.  Work is currently being undertaken to develop a further service specification based on the 12 aspects of care outlined within the Welsh Governments Fundamentals of Care – Quality of Care for Adults 2004.


Additionally, the current service specification sets out the providers obligations for safeguarding, admission and discharge, access, medication management, accidents, health and safety, records management, staffing and training.


Contact is made with the Provider if issues are identified following any complaint or incident. This would include requests for written evidence that regulatory breaches have been actioned. 


Inspection Reports are reviewed.  Generally these are accessed via the Regulator sites on the internet and also up to date reports are routinely forwarded to the Funded Nursing Care Department.  These reviews aim to:


·         Confirm the care category registration e.g. care home with nursing, residential care, domiciliary care etc.

·         Determine whether there are any regulatory breaches or any other areas of concern

·         Identify any concerns that might impact on the individual to be placed e.g. concerns around staff training, any clinical, care planning, risk assessment concerns etc.

·         Written evidence required to support that actions have been taken/risks mitigated.


Significantly, from a Mental Health and Learning Disability perspective most out of county placements are delivered within locked rehabilitation units or seldom, low security hospitals.  Locked rehabilitation hospitals are currently spot purchased however the low secure facilities are commissioned within the National Secure Service Framework which was introduced on February 1st 2012.  Phase 2 of the project will next include all non-NHS rehabilitation units.


The National Secure Services Framework provides a collaborative procurement programme to acquire Secure Services for NHS Wales.  The project was in part financed by the Welsh Government Invest to Save funding.


The objectives are to:


It was identified that there were enormous variations partially explained by clinical factors but other factors were evident:


The Framework has enabled the following –


In respect of residential, nursing homes and domiciliary care agencies, the contract leads tend to sit with the Local Authorities.  Contract monitoring and provider performance meetings are held monthly, attended by health professionals/commissioners.


The Regional Commissioning process consists of a consortium of preferred providers offering residential care.  These outcomes are scrutinised at the monthly multi-agency Commissioning panels taking into account of any concerns raised at the performance meetings.


Monitoring arrangements


For patients with physical needs


HDUHB has a number of processes in place to ensure the maintenance of adequate standards of care and clinical/contractual monitoring.


In line with the Statutory guidance set out in WHC (2004)024, individuals in receipt of NHS Funded Nursing care, are assessed within a time period of no more than 3 months following admission by a Nurse Assessor employed by the NHS and following that, are then assessed or reviewed on an annual basis or more frequently should the needs of the individual change. 


For patients in receipt of NHS Funded Continuing Care, the individual patient reviews and assessments are undertaken with a frequency that reflects the arrangements for NHS Funded Nursing Care albeit at times the assessments will be more frequent in response to the fluctuation in care needs that may occur in patients whose needs may be both complex and unstable. The assessments are recorded on comprehensive documentation and held within the patient’s record. Details of all individuals funded by the Health Board are recorded on a confidential password protected database which not only assists the Health board in the patient management and review but also performance management arrangements with the respective Care facility. Patients and their relatives are fully engaged with the assessment process and in line with good practice; patients are expected to confirm their participation in the process on the relevant documentation.


A Nurse Assessor is allocated to every Nursing Home across Hywel Dda, which enables a constructive relationship to be developed between the Care Home Registered manager and the Health Board, providing the basis for development and support. However, the Nurse Assessor not only has the role of reviewing patients within the homes, but is also responsible for monitoring and reporting any issues identified in relation to general care within that specific Home.  As patients, relatives and staff become used to the Nurse Assessor being present in their Home on a regular basis, this has led to a greater openness and confidence in sharing any concerns and issues that they may have.

For patients who are subject to sectioning under the Mental Health Act, there are regular CPA reviews, which are undertaken in addition to assessments undertaken by Nurse Assessors.


For individuals with Mental Health or Learning disabilities in non NHS settings


The monitoring and review of the individual and placements will be undertaken via a number of methods including the following:-


A The nurse assessor will link with care co-ordinator and clinical team to make the necessary review arrangements


·         Care Programme Approach (CPA) meetings are attended by care co-ordinators, other members of the clinical team and where necessary nurse   assessors or commissioning representatives.


·         Routine checks of CSSIW or HIW inspection reports are undertaken by the commissioning team.


·         Multi disciplinary team recommendations in respect of specific placements are considered, pre visits are undertaken and discussion with families.


·         Local Authority contract / provider meetings are held with health representation.


·         Close working relationships exist with the regional low secure service team and regular meetings are held to review caseloads, database and consider any information available.


·         The Learning Disability “Placement, Planning and Provision” team, have a specialist remit for the development of future provision and identification of individuals future needs.  They visit providers and develop considerable intelligence in relation to these services.


HDUHBs expectations with regard to use of physical restraint entail the following:-


·         A Multidisciplinary agreement to the Care Plan and Risk Assessments.

·         Full review of needs to rule out other reasons of behaviours that challenge.

·         Regular training by BILD accredited Positive Behaviour management.

·         Monitoring and Evaluation of Positive Behaviour Plan.

·         Safeguarding training/procedures for all staff.

·         Whistle blowing policy/procedures.

·         Communication between Health Boards, Local Authority, Quality Care Commission, Health Inspectorate Wales and respective Safeguarding to   highlight outstanding conditions, embargos, highlight patterns of concern, how recorded, how reported, how communicated, 2:1/1;1 monitoring.


Joint Monitoring


Robust joint monitoring arrangements are in place with all three Local authorities within the Hywel Dda community. 


In Carmarthenshire a Provider Performance Monitoring Group has been established within the Carmarthenshire division of Hywel Dda, in which any issues identified in care homes, however small, are discussed and consequently monitored. Should the need arise within a nursing home a joint team including the nurse assessors from the Health Board and Social Care staff will work with the Care Home in a remedial and supportive manner to assist the organisation to address the areas of concern and meet the standards of service expected in line with WAG-issued guidance, ‘Escalating concerns with, and Closure of Care Homes providing Services for Adults’ (2009). Support will include more frequent visits by the Health Board and Local Authority, holding the Provider to account through the development of an Action plan by the Provider to address the issues of concern, and where appropriate a review of individual clients, with the aim of preventing the escalation of the issues of concern and achieving a return to the appropriate standard of service quality.


Within Ceredigion and Pembrokeshire whilst the meeting arrangements differ, there is a sound working relationship between the organisations and any issues, are shared immediately and joint monitoring arrangements are put in action.


In all three Counties of the Health Board, however where concerns are of a serious nature, a performance monitoring meeting will be organised by the Local Authority as the statutory lead for the Protection of Vulnerable Adults  and a decision taken where necessary to implement a more formal process in line with the ‘escalating concerns’ etc guidance, which may result in the temporary embargo on any new admissions to the Care facility until  the issues of concern have been addressed, and commissioners are satisfied that the quality and standard of care provided is satisfactory.  In these situations all individuals funded by the NHS are assessed immediately to ensure that they have not been adversely affected by the cause for concern. Within the review process the care of individuals will be paramount and whilst the majority of situations would be normally managed through the remedial arrangements set out above however where appropriate a decision would be taken to move individuals to an alternative Care setting.


Children’s Complex Needs Panel receives regular updates regarding children’s placements and feedback from the Social Worker/Independent Reviewing Officer (for LAC) or the Education Co-ordinators for those who are not LAC but are in a specialist school/college.  Where issues are raised the action required is agreed by the Panel.


Liaison with Inspectors


All HDHB professionals engaged in the monitoring of clinical placements and / or contracts with non NHS providers are aware of the need to alert the CSSIW of care concerns.  Liaison is proactive and borne out of the need to ensure the protection of vulnerable adults is safeguarded in registered provider premises or through domiciliary care agencies supporting NHS funded care packages in the community.


The issue of liaison with CSSIW would benefit from further debate.  There is indeed a lack of clarity between the roles of the Regulatory Bodies and the roles of statutory organisations that place individuals in registered care settings with care being delivered by non NHS professionals. Previous discussions with the Health and Safety Executive (HSE), CSSIW and legal services have provided some clarity on the statutory duty of Health Boards. 


Care and Social Services Inspectorate Wales (CSSIW) undertake regular inspections of all homes within the Hywel Dda community and these reports are shared with the Health Board. Prior to the commissioning of new placements the Inspection reports will be scrutinised by the Health Board and made available to the patient/ family to inform their decision regarding future accommodation. All homes that are used by the Health Board are expected to meet the required National Minimum Standards and will be expected to have a satisfactory report. Should issues have been identified whilst patients are residing within the homes, processes and procedures will be put in place in accordance with the WAG guidance ‘Escalating Concerns With, and Closures of, Care Homes Providing Services for Adults (2009).


Representatives of the Health Board meet with CSSIW on a regular basis at which time all Care Homes within the geographical area are discussed, CSSIW works with both Health and Social care commissioning organisations with the aim of ensuring together that arrangements are in place to ensure that all individuals funded by the Health Board in non NHS settings are receiving safe and effective care.




With regard to staffing levels within the Nursing Homes this is regulated through CSSIW.  Staffing levels currently are based on the dependency of the individuals being cared for in any particular setting.  If it is highlighted to the Nurse Assessor by the Nursing Home staff that there are inadequate staffing levels to meet the needs of individuals within the home the Nurse Assessors would report this to CSSIW and the LA".