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STATES OF JERSEY
Health, Social Security & Housing Panel Long Term Care of the Elderly
WEDNESDAY, 30th JULY 2008
Panel:
Deputy A. Breckon of St. Saviour (Chairman) Deputy J.A. Martin of St. Helier
Deputy R.G. Le Hérissier of St. Saviour
Mr. J. Forder (Adviser)
Witnesses:
Ms. E. Crabb (Chairperson, Jersey Care Federation) Ms. G. Le Leivre (Secretary, Jersey Care Federation)
Deputy R.G. Le Hérissier of St. Saviour :
Okay, well we can all sit down and, as you know, the proceedings are recorded because it is essentially an evidence session so we are taking your evidence. But anyway thank you very much for coming and for waiting. I think you are aware, because some of you have been here before, you are aware of the Scrutiny caution and basically you are under privilege - not underprivileged - so you are protected as long as obviously you do not stray into the areas of malice and knowingly slandering people. So, I would like to welcome you. We will introduce ourselves and then if you could introduce yourselves, but if you could tell us the role in the areas of association we would like to know that. So, we will very quickly introduce ourselves. Roy Hérissier.
Deputy A. Breckon of St. Saviour (Chairman): Alan Breckon.
Mr. J. Forder (Adviser): Julien Forder.
Deputy R.G. Le Hérissier:
Julien is the adviser to the group from the University of Kent.
Mr. C. Ahier : Charlie Ahier .
Mr. M. Orbell: Malcolm Orbell.
Deputy R.G. Le Hérissier: Good; and yourselves?
Ms. E. Crabb (Chairperson, Jersey Care Federation):
My name is Eileen Crabb and I am chairperson of the Jersey Care Federation and I am also the Manager of Pinewood Residential Home. I have worked in the independent sector since 1973 since I have come to Jersey.
Deputy R.G. Le Hérissier: Okay, thank you.
Ms. G. Le Leivre (Secretary, Jersey Care Federation):
I am Gloria Le Leivre and I am the Secretary for the Jersey Care Federation. My background was about 35 years in the public sector within the hospitals Health and Social Services and I have recently been doing some short-term contracts within the independent sector.
Deputy R.G. Le Hérissier:
Well, okay, you have obviously both got an interesting background and we will be very interested to hear, as well as your immediate concerns, maybe we can draw out some of your experiences on an historical basis. So, just to basically redo this with most people, but in order that Julien may be put in the picture and in order that we may get all the evidence down, what we ask you to describe is the role of your organisation; how many members; how you relate to Government and then - and this is the biggie - tell us what your current assessment is of the situation, strengths and weaknesses of the situation that we are in, and we will rely on you. I am sure you are both democrats, so you will allow each other to speak. We will just put the questions out and just rely on you to pitch in.
Ms. E. Crabb:
Okay. The Care Federation we meet once a month. We have got 25 members currently and we represent quite a broad sector of the community really. I know you have met with some of our members already. So, we have the Parish of St. Brelade ; the Parish of St. Helier - 3 homes there; Family Nursing Services is also a member. Then we have got the Trust homes which is Glenville; we have got both the Methodist homes - Stuart Court and Maison La Corderie; the private homes with the big providers with Four Seasons have got 3 establishments, and I am sure you know who they are - Barchester, Lakeside, ourselves at Pinewood we are now under a U.K. (United Kingdom) company as well.
Deputy R.G. Le Hérissier:
What is the name of your company, Eileen?
Ms. E. Crabb: Maria Mallaband.
Deputy R.G. Le Hérissier:
It is a sort of a medium sized operator, is it?
Ms. E. Crabb:
Yes, 36 homes all together, but they do specialise in learning difficulties; autism is one of their forte, really, as well as nursing and residential.
Deputy R.G. Le Hérissier:
Throughout the U.K. they have got homes all over the
Ms. E. Crabb:
Throughout the U.K. and one in the north of Ireland as well. We are very pleased with our takeover, I must say. So, that gives you just a broad idea of how many of us there are. Initially we started out really, it was just us exchanging knowledge and supporting one another because we felt there was a lack of that, and especially for the heads of home to have other heads of homes supporting was quite important because it is only in the last few years, as you will realise, that we have got input from U.K. providers. So, we were supporting each other. Obviously, it helps with training and learning as well and over the last few years we obviously have opened up dialogue with Health and Social Services, and that has opened up a few links, and then we have been seconded on to various committees like the long-term care, endemic flu, you name it, that we are representing the Care Federation. As regards, obviously, currently what is happening within the Island, that is very much on our mind and it is very, very important to all of us, especially as opposed to the private sector that business has now got to remain viable. So, there are lots of issues there that obviously we probably want to discuss through this afternoon.
Ms. G. Le Leivre:
I am sure to do with finance that you will have heard a lot already. I think it is quite good to focus on the different needs of the older generation because people tend to put them just either nursing or residential. But within those categories you have got the brain injury - older ones - you have got alcohol related; the Korsakovs, and I know from quite a few years I was involved in some of the meetings to try and find appropriate placement for them. Particularly to try as far as possible to maintain them in their own homes, but all these do present a lot of challenges; that is true to say. The young brain injured that we have got now - the individuals, the youngsters from road accidents or whatever - trauma acquired injury, well, they are getting older and again it is not just to put them into an institution. It is to try to maintain them at home, even just within their own environment, and it is very specialised the care they need. So, again if you were going to provide care in the home you are going to need the people to do it. You are going to need the training and you are going to need the funding. Now, I know everybody is aware of that already, but that has a major cost; basically any forms of dementia. A lot of it is to do with choices. Well, it is all to do with choices really because it would appear that if the Island is not careful, in my opinion it would appear that people's choices are going to be really restricted because the money is not going to be all there. That is the impression that people have got; their perception. So, it is going to be restricted choices for where they want to be.
Even now the Island is only just starting to realise that. I would hate us to go down the road of the U.K. where because one of the spouses has not quite reached the stage of the other spouse that they would be separated. So, we have got to think of couples as well.
Deputy R.G. Le Hérissier:
That is an issue that has arisen, Gloria, thanks for raising it. Eileen mentioned that we were going to come back to finance, and she is quite right. There are various issues. There is the one you raised, Gloria, whether the Government can sustain the kind of funding that is going to be required as the numbers escalate upwards. There is the personal issue which we have heard a lot about in this evidence, of course, of the taking of people's homes and this looms large in people's thinking and it almost traumatises them and their family, and I wonder if you would like to comment on that. As you know there is this alternative which we were quite impressed with, but we are going to get a pro and con argument, particularly this afternoon from the Minister of Social Security of an insurance scheme. So, I wonder if you would like to comment on that whole issue.
Ms. E. Crabb:
Okay, well, I think it is very important that we do look at the funding and we all realise that living in a residential home or having care in a nursing home is very, very expensive and from the time we opened to now our staffing levels have doubled. So, the costs are phenomenal really and all our homes provide a different facility, so hence obviously the fee structures are obviously quite varied. But we do hear time and time again people are coming in to the home saying: "Well, will I have to sell my home?" and of course it is their families' inheritance. They worked all their life and of course they want to leave this to their children. So, they feel cheated, to be quite honest, and that is a major issue, but how are we going to address that? We do need to look at some form of insurance.
Deputy R.G. Le Hérissier:
Do you find that people are - although I suppose they cannot officially admit it - is there shifting of assets going on as a result of this sort of fear?
Ms. E. Crabb:
Well, we would not be aware of that, but obviously they will discuss with us that they would have to sell their home and it has happened on a number of occasions.
Ms. G. Le Leivre:
It is tempting for them to do that really. I know for years that the public sector have worked hard to try to get people back into their own homes, but sometimes if there is a push on the beds there has to be sort of a time limit and a lot of the element of fear. When an older person has a stroke they lose confidence; they lose everything basically and from my experience getting back the confidence takes longer. So, it has all got to be individually assessed and financed and wherever the individual goes the money should follow them. It should not be a stop and a start. You have got to have a seamless system, I feel, from start to finish. Getting back to people's homes, what has been missing - and a lot of attention has gone on residential and nursing care - but what has been missing is helping people with even, like, little jobs in their homes. A lot of them, because the family unit is not there like it used to be - I can remember grandmother living next door and all that - but now a lot of people are isolated and they lose the ability to manage their own little home, if you like, and things become too much for them. That can lead to depression. So, very often these people, because their mental state goes down, they lose their physical ability and that has an impact and costly as well. The insurance, well, I recognise as an individual that it has to be paid for and I could not comment really on if that is one option to look at, there are other options to look at. But I think the last option should be that they live in poverty or they go into care - inappropriate care - due to funding and their homes get sold.
Deputy R.G. Le Hérissier:
Have you, Gloria and Eileen, picked up - I suppose it would have to be anecdotally - have you picked up where the people are going because we certainly picked up a lot of people telling us that residential care is overused on the Island or wrongly used? Have you picked up inappropriate care to a fairly major extent?
Ms. G. Le Leivre:
What do you mean, that they could stay in their own homes?
Deputy R.G. Le Hérissier:
With the right support they could stay; what is your view on that?
Ms. E. Crabb:
Yes, that has happened, I think, in the past, but again I think, as Gloria was saying earlier, it is isolation, is it not, and loneliness sometimes would stare them in the direction of residential care because their families are on the mainland and you can be quiet isolated, and they go into a residential home for the company and for the support. Packages of care are a brilliant idea, but it is a 24/7. There would be some gaps there and sometimes in that gap perhaps they have had a fall and again they will lose their confidence. Again, packages of care in the private sector are quite expensive as well, so you have got to weigh up the cost of residential care versus packages of care in the private sector. The other thing that we have come across fairly recently is when you have got somebody in a residential home and their funds diminish and, of course, then they are going on to income support, and the top end of income support is £720 per week and to include there are dietary supplements, continence products, membership to Family Nursing Services. Let us say that person was already paying £800-£850 so you have then got, do the company pick up the shortfall or do you ask that person to move to a less expensive establishment?
Deputy R.G. Le Hérissier: So, what does happen?
Ms. E. Crabb:
I would not like to comment really, but I think that is going to be a problem in the future.
Deputy J.A. Martin of St. Helier :
So, that is their standard now, is it, for residential care they have set as £720?
Ms. E. Crabb:
Well, this is what is being offered at the top end.
Deputy R.G. Le Hérissier:
Has it been accepted, Eileen? You said this is what is being offered. Has it been accepted?
Ms. E. Crabb:
Well, in some places, yes, it has been accepted and again you have got to take into account if you have had a good relationship with somebody. It is very, very upsetting and heartbreaking to say: "I am sorry, you have got now to move somewhere else."
Ms. G. Le Leivre:
I do not think we should forget that the larger homes can take the shortfall on quite a few. It is the smaller homes that cannot. Eventually, well, I will not say standards would drop, but eventually they could be squeezed out. So, I am not putting a plug in for smaller homes, but it is realistic, is it not, that there are economies of scale with a larger home.
Ms. E. Crabb:
We do need the smaller homes as well. You do need that variety as well.
Deputy R.G. Le Hérissier:
We have had that issue, it is a favourite old chestnut of mine and I will just flog it a bit further, so to speak, and then we will move to Eileen. It came up in the regulatory discussion because obviously there was a feeling, which is not all home support I should add, that smaller homes suffer from tighter regulation because they cannot spread their costs as much, but that is the argument that we were using, Gloria. But then again you could argue a lot of the smaller homes in Jersey, it is a bit like people in the hotel industry, because they have owned the property from the year dot they are not amortising the property. They are not having to put a lot of money into keeping a mortgage up or heavy borrowings. So, that in a way is a subsidy to the residents, I suppose. So, are you really sure of that view, Gloria, that the smaller homes will keep suffering financially?
Ms. G. Le Leivre:
Well, as sure as anything because it is obvious, is it not, if you have got economies of scale it is the same with shops. The supermarkets, they can afford to have lost leaders with their products. The smaller ones have not got that and I am not sitting here pleading for the smaller homes, by the way. I am just trying to look at it with a lateral view.
Ms. E. Crabb:
In the meantime, obviously, they have got to comply with registration and legislation, staffing levels, but you are doing that with them with less income and you have still got to make sure that your staff are well taken care of and they get their pay increase. So, it is the company that will suffer and eventually it will be cut back somewhere.
Ms. G. Le Leivre:
We have answered the questionnaire from the Public Health about regulations and the update and we are all for them, by the way. It has to be.
Deputy R.G. Le Hérissier: Yes, absolutely.
Ms. G. Le Leivre:
We are very pleased about the screening and the regulation and the update for agencies because that is something at the moment - I am not criticising agencies - I am just saying the lack of assured quality - quality assurance - among the agencies has caused a lack of confidence in the service within individual homes. They are very good, but I think now bringing them up to the standard that people can invest in that service I think is very good because that is where it is going to lie. Because Family Nursing are excellent; Family Nursing and Home Care are excellent, but they cannot meet everybody's needs all the time, so there has got to be other options. A lot of it comes from the family which is costly in time, assuming the family is there, of course.
Deputy R.G. Le Hérissier:
Yes, well, we have heard about it, but I think Julien wanted to follow on.
Mr. J. Forder:
Just a point of clarification really because when you are talking about the £720 that is for Social Security paying for residential care?
Ms. E. Crabb:
Yes, residential care and that works out at £4.27 per hour fully inclusive.
Deputy J.A. Martin: That is higher residential?
Ms. E. Crabb:
That is higher residential.
Ms. G. Le Leivre: Higher needs.
Deputy A. Breckon:
Are there a range of fees leading up to that?
Ms. E. Crabb:
Yes, there are, but that is the one that I am familiar with obviously.
Deputy J.A. Martin:
So, someone with income support, even if they were entitled to a small pension like a States pension that would be taken off and the maximum is £720?
Ms. E. Crabb: Yes.
Deputy J.A. Martin:
So, my question is then that you are saying that it might be £850 or something, the bed prices?
Ms. E. Crabb: Yes.
Deputy J.A. Martin:
All right, you could move a couple of people, but are there enough beds out there at £720 for the low end of the income support; the lower earner, but are high needs?
Ms. E. Crabb:
I do not think there would be at that price, no.
Deputy J.A. Martin:
So, this research would have been done by Social Security, I presume? Well, it should have been done because we need to know where these people are going to go because I do not think there would be enough beds at that price.
Ms. E. Crabb:
Obviously the resident - our client - would then get a personal allowance of £29 per week.
Mr. J. Forder:
Can I ask about on the nursing home side rather than the residential care, you have States funded nursing home places contracted into the private sector there somewhere, I understand?
Ms. G. Le Leivre: Yes.
Mr. J. Forder:
They work on a different fee basis, I also understand?
Ms. G. Le Leivre:
But it is different fees between the different homes.
Ms. E. Crabb: Different providers.
Mr. J. Forder:
Right. Okay, but do you also get people that fully privately pay in nursing homes?
Ms. E. Crabb:
Yes, and residential homes they pay privately, obviously, as well.
Mr. J. Forder:
Right. Okay, so people with nursing care needs do not all go through the States route then? There are people who pay?
Ms. E. Crabb: Yes.
Mr. J. Forder:
How is it that some people are in the States system then and some people are in the private payer?
Ms. E. Crabb:
It is finance again.
Mr. J. Forder:
It is just a work issue?
Ms. E. Crabb:
Yes, if you do not have any money then the States will fund you and if you can afford to then you have got to pay yourself.
Deputy A. Breckon:
Is there any co-funding that you know of where somebody with a high dependency need, but with their own funds, could get their contribution and a contribution from Health for their extra health need and dependency or does that not happen?
Ms. E. Crabb:
That does not happen.
Deputy A. Breckon:
So, you have not got a co-funding thing?
Ms. G. Le Leivre:
The thing that I found quite hard to understand is since income support has come in - and obviously if I am wrong here somebody correct me - there cannot be any top up. Say, for an example, my older parent was going to go into care, I could not top up for them to go somewhere else which seems a bit odd.
Deputy R.G. Le Hérissier:
Yes. No, that is a good point, Gloria. No, there is not that provision?
Ms. E. Crabb: There is not, no.
Ms. G. Le Leivre:
Because that goes into their income, does it not?
Deputy J.A. Martin:
Yes, right. To clarify what Julien said, we had Health in yesterday and they had bought in to the private sector nursing beds. But Mia said that income support are dealing with contracts even with the nursing beds, so if the person has got no money, they would pick up at the hospital, or whoever they pick up, it will be people with money or not with money. If they need a nursing bed they can pay, they go. I do not know if they pay them the price that the home wants to charge. If they cannot pay, I think that they are also negotiating with income support on a very tight contract and we do not know yet what that scale is for nursing beds, but I think me and Julien need to clarify this. But that was my understanding of it, even in the nursing beds that if you have got no income or you are low income, those beds are now being negotiated. Who needs to go in and by the panel - this new placement tool - and then who pays either, because Social Security is in the best place to know. Obviously you are either in income support or you are getting a very good pension from them and/or other pensions which they would know about and tax. So, they have always been in the best place to know one's income, if you like.
Mr. J. Forder:
I know that if it is States supporting nursing then they are charging an accommodation cost of £420 per week which is means tested.
Deputy R.G. Le Hérissier: Which they means test.
Mr. J. Forder:
So, people who can afford it pay it or people that cannot afford all of that pay some of it?
Ms. G. Le Leivre: Yes, so pensions.
Mr. J. Forder:
But what I was not clear about is that there seems to be some people that are fully private payers who take up nursing.
Ms. G. Le Leivre: Yes, there are.
Mr. J. Forder:
I just wondered why they were not in the States system because when they are in the States system they would only have to pay £420, according to my understanding of it?
Deputy R.G. Le Hérissier:
Well, the States system they have to be in a States run system like St. Saviour 's.
Mr. J. Forder:
Or they can be contracted out into --
Deputy R.G. Le Hérissier: No, I do not think they do.
Ms. G. Le Leivre:
Yes, they are contracted out.
Deputy R.G. Le Hérissier:
We do means test people there as well, okay? Sorry, Julien. It gets more complicated by the minute.
Ms. G. Le Leivre:
It does, yes. It is quite convoluted, yes.
Deputy R.G. Le Hérissier:
Back to the role of the Care Federation; you are one of these interesting groups which is composed of people who are in competition with each other, but yet have certain interests where you want to present a united front to the Government. So, do you feel that there is enough - and this goes back to one of Judy's questions - is there enough differentiation in the fees charged or do you all happen to charge fairly much the same fees? If somebody was put - to use a not totally nice phrase - was shopping around for a place, is there real fees competition out there?
Ms. E. Crabb:
I think, as I have said earlier, because we provide different facilities it may be different to hotel facilities and obviously staffing levels and things like that, everything is taken into account. Of course if you are buying a new car you will go to 3 or 4 garages, and this is a big investment if you are paying fees out of your own pocket as well, and people will visit the homes and they will compare. It may be different things that entice them to use X; it may be a bit more expensive; maybe it could be location and maybe perhaps they could meet the needs of that person better than somewhere else. But, yes, people will shop around. I do not think there is a huge difference in the top end of the market, but we have got a variety of fee structures. Some homes it may be the facility; it could be the room would maybe have a patio or balcony or different things like that. So, yes, people do shop around.
Deputy R.G. Le Hérissier:
Okay. We did mention, and you said it from your own personal Pinewood experience, it has been very good having outside ownership, but have you found that the really large operators have changed the competition on the Island?
Ms. G. Le Leivre: Yes.
Ms. E. Crabb: Yes.
Deputy R.G. Le Hérissier: How have they done that, Gloria?
Ms. G. Le Leivre:
Well, now going back a few years ago there was a surplus of beds and then some closed and some needed to close. But now of course the market has all opened up, and that is good because once again it brings it back to choices. However, to have choices you have got to have the funding. You have got to be able to pay for it. It is no good having all singing and all dancing places if the people cannot afford it. But marketplaces change anyway, do they not, no matter what the industry or the services; they change. Coming back to the point you made, if I may about competition, yes, we are in competition, but we all share the same constitution that we want the high standard within the community. We want to train our staff and we want the facilities and the money to be able to do it. That is a bit of an anxiety at the moment, is it not, with New Directions? We want to be sure that the training and the money is there because you can have a lovely building, but if you have not got the staff who are competent and well qualified then you are not providing the service are you really?
Ms. E. Crabb:
Because there is lack of funding in the private sector we call ourselves the independent sector; that is what we have been titled as now.
Ms. G. Le Leivre:
Yes, we do not like private.
Ms. E. Crabb:
We are in negotiations with Highlands College and Health and Social Services to set up a partnership, like a cadet/apprenticeship scheme, because we hear such a lot about the ageing population, but are we going to have suitably qualified staff out there to look after them, and that is a huge concern within the sector.
Ms. G. Le Leivre:
We are looking for mature students as well because there are a lot of skills among the older generation as well, and that is something which I would just like to touch on. I think the older generation could be brought more into providing services, and I know it is happening, but I think we maybe need to build on it a bit more on the Island because there is a wealth out there.
Deputy R.G. Le Hérissier:
That is a very interesting remark that Eileen has made about staffing and you, Gloria. This is a continuing issue, recruitment of staff; is that correct?
Ms. E. Crabb:
Yes. We have got a very mobile workforce, have we not, in Jersey and a lot of money is invested in training and then people move on. Okay, if they move within the Island that is great because it will benefit another establishment, but when they move off Island then the cost of recruiting and training staff is quite a big issue for us really.
Ms. G. Le Leivre:
We do sometimes share staff. We will refer staff on if somebody has got a need for something; say for a chef and if you have got a relief chef. So, we work well together because even this morning there was one home that contacted me to see if a member of our staff would be available. So, while we are effectively in competition we --
Ms. E. Crabb:
We have got a very good working relationship really. That did not happen in the past, you know, and none of us came to Jersey, my goodness me. Everybody just, you know, looked after themselves and even if a manager went to another home to assess a prospective client that would not go down very well at all but now, you know, we all realise that you have got to have a good working relationship and sometimes if you have got a resident in a residential home they need nursing care, of course they have got to be assessed and perhaps moved on. So, you know, we are all looking for the benefit of the resident, really, that is our patient. That is the most important thing.
Ms. G. Le Leivre:
Could we make a comment about the placement tool that you mentioned, care placement tool? It still - obviously, it has got to be -- it started in January, if my memory serves me right. It is just about to be reviewed. We have heard of a couple of instances where someone has been assessed as their needs not being as great as somebody going into assess and, to give an example, I will go into a general ward and I am told: "Oh, they are just high residential care" when, in actual fact, once they are out of the hospital where they are in a ward and they have only got to say: "Nurse", you know, call a nurse and that, and they are not being stretched to be as independent as we would encourage them, you find their needs are greater.
Deputy R.G. Le Hérissier: Yes. That is interesting.
Ms. G. Le Leivre:
So if they have been assessed as just being, say, high residential and they actually fall into the lower nursing because there is like the phasing in and out
then that can have a -- it can be a battle to get the money for them.
Deputy R.G. Le Hérissier: Yes, very good point.
Deputy J.A. Martin:
Who appeals then? How long would that take? They are assessed, the placement, and they go into the high residential but really they need low nursing care and that is sort of spotted by -- probably within, I do not know, a few days by the home or the ...
Ms. G. Le Leivre:
Then you have to go back and appeal. I personally, have not had to do it so I could not comment on the time.
Ms. E. Crabb:
That did happen to me but, again, you have got to have your own home and what your dependency levels are, and every home has their own policy for an admission assessment as well but the 2 just did not seem to tally. Obviously, then, we would go back to the social worker and they would review it and then that person would either go on to nursing care or perhaps another establishment would be quite happy to take them.
Ms. G. Le Leivre:
But we think the care placement tool, the principle, is good.
Deputy J.A. Martin: Yes.
Deputy R.G. Le Hérissier:
We have had a lot of comments about family nursing, particularly yesterday when there were witnesses and other people knew their work. We have had a lot of comments about family nursing and about providing care in the community and we have also heard at the other end, in looking at dementia services, you know, about the role of Social Services and we have had more mixed reviews there although we have had very good reviews of people like Dr. Wilson 's unit, labouring under great resource shortage, and the work of the community's psychiatric nurses, but it has been a bit harder to fix on the role of Social Services. So what is your view of the role of family nursing, how could that be improved to make your job somewhat easier, if that is the right phrase? What about Social Services? Do they get involved in supporting your clients?
Ms. E. Crabb:
Do you mean as in social workers?
Deputy R.G. Le Hérissier:
Yes, social workers, yes.
Ms. E. Crabb:
Any of the social workers we have had, I myself have been very impressed with them. Again, Family Nursing Services, you know, they are very stretched as well.
Deputy R.G. Le Hérissier: Yes.
Ms. E. Crabb:
In residential care they come in for dressings, insulin and things like that and I must say I have always found them very supportive. Perhaps, I mean, when you have got homes like continuing care, you have got the nursing and you have the residential. Obviously there would have to be a change in the legislation for this. If you have nurses upstairs should they be allowed to come downstairs and do a dressing and give insulin, then that would save Family Nursing Services. A lot of quality --
Deputy R.G. Le Hérissier:
They have to come into the residential home?
Ms. E. Crabb:
Yes. Even though, as I say, you may have nursing on the premises and you know -- and I think that is something that could be looked at in the future and, again, perhaps Family Nursing Services could direct their time to somebody that is in residential care that is high dependency and they would not have to be moved on to nursing care. They could stay there.
Ms. G. Le Leivre:
I was just going to say I would like to see -- sorry.
Deputy R.G. Le Hérissier: No, no, carry on.
Ms. G. Le Leivre:
I would just like to see a situation where eventually, with the training for staff and the competency has increased, that Family Nursing might not need to go into residential homes. They could concentrate on people in their own homes, which they do very well.
Deputy R.G. Le Hérissier: Yes.
Ms. G. Le Leivre:
But the ones, and particularly at home, they need the same service 7 days a week, so that things do not go down at weekends because care is a 24/7 day.
Deputy R.G. Le Hérissier: Yes, good point.
Deputy J.A. Martin:
I was just going to say is this since ... I do not remember how long, but dual registration has not been that long has it; 5 years?
Ms. G. Le Leivre: Quite a few years.
Ms. E. Crabb:
Quite a few years, yes.
Deputy J.A. Martin:
This has been -- ever since, you still have nurses on the top and they have never changed it?
Ms. E. Crabb:
There would have to be a change in there with the legislation.
Ms. G. Le Leivre:
Oh, yes, there would be and I think the changes, I think the proposals are very good. I mean, we work a lot closely with Public Health and with Christine Blackwood and we get great support, do we not, now?
Ms. E. Crabb:
Yes. The independent sector, as you know, are the only section of the community that are inspected.
Deputy R.G. Le Hérissier:
Yes. That point has come up clearly today.
Ms. G. Le Leivre:
I am glad you made it.
Ms. E. Crabb:
We are very confident the standards in the community are quite high. I mean, they are there on an advisory capacity as well which is very useful and, again, for training, they do put on courses as well, so that is all very, very beneficial too, the standards of care.
Ms. G. Le Leivre:
We would like to see independent inspection, though, as opposed to Public Health, which is part of Health and Social Services inspecting us.
Deputy R.G. Le Hérissier: Yes.
Ms. G. Le Leivre:
Particularly within their own areas.
Mr. J. Forder:
Independent organisation, do you mean?
Ms. G. Le Leivre:
Independent organisation, yes.
Deputy J.A. Martin: Do they register as well?
Ms. G. Le Leivre: Yes.
Deputy J.A. Martin:
There has always been a public registration and inspection and there is always -- it has always been going to change and it has never got there yet.
Ms. G. Le Leivre:
An inspection is needed, is it not?
Deputy J.A. Martin: Yes.
Ms. E. Crabb:
Those of us that are are under U.K. companies, we have area mangers that come over and inspect us as well. So that happens, you know, to us once a month.
Deputy R.G. Le Hérissier:
What is their view, Eileen, of the Jersey standard versus the standard they work with in the U.K?
Ms. E. Crabb:
Yes, well, it is very, very different because I mean, they are under C-Sky and, of course, they have got to comply with that. I have been over to see some of their homes and I feel, for meeting, the dependency levels in residential care, I found, were much higher than what they were here in Jersey in residential care, but you know the more input we have from outsiders in that field is beneficial to Jersey, really.
Deputy R.G. Le Hérissier:
Do you feel, back to Family Nursing or, indeed, the whole issue of community care and this growing sector which we were told about this morning - which Gloria has alluded to - the agencies, the private agencies who were operating more and more in the field, do you feel if Family Nursing was not so stretched that more people could stay in the community? We get told tales of twilight service has to start at 6.00 p.m. and we have heard, obviously, comments about people being put to bed before they can see Coronation Street and so forth or their favourite football match. Also, it is not only sheer numbers that might be pressing on them but it is the complexity of the cases they are dealing with.
Ms. E. Crabb: Yes.
Deputy R.G. Le Hérissier:
Obviously, there are real issues with challenging behaviour in homes and whether they wish to sort of get drawn into some of these situations. Do you feel, if we were to develop things, we could deal with more of that and keep it in the community?
Ms. G. Le Leivre:
I think so because I think there is always the risk element of anybody staying in their own home, and the point you made about twilight starting at 6, I mean, they can only cut their cloth accordingly and that is where individual's choices are eroded if they have to go into bed. It might seem like a small thing but if somebody told me I had to get into bed at a certain time I would not be very happy.
Deputy R.G. Le Hérissier: Yes.
Ms. G. Le Leivre:
They are very good, excellent, but we do need a more comprehensive and cohesive service within the community and challenging behaviour is quite -- it is going to be an issue even more. Remember I said Korsakovs and brain injury and all that.
Deputy R.G. Le Hérissier:
What is Korsakov?
Ms. G. Le Leivre:
That is the alcohol-related injured patients. I know years ago they were looking at where they were going to be placed. There are some could stay at home but then, as it progresses, they need to be in somewhere but you have to be very careful, again, when you come back to accommodation. You are going to mix brain injured, challenging-behaviour individuals with that with somebody who is just getting older and maybe is just frail and maybe got all their mental faculties. It must be very distressing. Well, it is.
Deputy R.G. Le Hérissier:
I think you have given us such a comprehensive overview.
Ms. G. Le Leivre:
We have rambled on, sorry.
Deputy R.G. Le Hérissier:
You have struck us dumb temporarily.
Ms. G. Le Leivre:
Or bored you to tears, one or the other.
Deputy R.G. Le Hérissier:
Well, it is the post-lunch section. We have given you the most difficult one but --
Ms. G. Le Leivre: Did we wake you up?
Deputy R.G. Le Hérissier:
No. We hear a lot of how, sadly, how bad it becomes as one gets older and you hear a lot about the medical management of the issue. I mean, we have heard that time after time but we have had the odd little insight into the social management of the issue, you know, if you provide the right social environment or if you handle the thing in a social sort of context things need not be as grim, perhaps, as we are hearing. So that means bringing in the community, for example, into homes and all that. What results have you had from trying that, for example?
Ms. G. Le Leivre:
Well, that became evident years ago, did it not, that social isolation does help prolong a good quality of life and even in nursing homes we still encourage the individuals to go out to their day centres to maintain community links.
Deputy R.G. Le Hérissier: Yes.
Ms. G. Le Leivre:
Equally, and sometimes you will find that the people in nursing homes have a better social life than somebody who is stuck at home because they are on their own, because they cannot afford to go out or they have lost all their peers, maybe somebody of 80-odd, you know, all their peers, their family, have died off. So, the social element is excellent and there are a lot of organisations in Jersey that help to keep all that going. I think that needs to be built on much more though.
Deputy R.G. Le Hérissier:
Right. Have you found, Gloria, we have had the odd complaint, and I like your idea of taking people into the community as well as bringing the community into the home, but have you found cut backs in services like mini bus services, have affected - - like Public Health have cut back, I understand, quite dramatically on their mini bus service.
Ms. G. Le Leivre: Yes, they have.
Deputy R.G. Le Hérissier:
They are making it more and more strictly ambulance, so to speak.
Ms. G. Le Leivre:
Yes, and that has cut out -- I remember years ago that we used to let the Association of Retired People use an office and for that they provided some community service and driving, volunteer driving. You would remember that, would you not?
Deputy J.A. Martin:
I do remember that and it was not that many years ago.
Ms. G. Le Leivre: It was not, no.
Deputy J.A. Martin:
Yes, and there was a big to-do when it did finish.
Ms. G. Le Leivre: Yes, and it did finish.
Deputy J.A. Martin: Yes, it did finish.
Ms. G. Le Leivre:
Through lack of volunteers and various things and, just for an example, some of the homes have got their own mini buses and one that I am working at has its own mini bus, but, of course, if you have not got a driver or the bus is off the road or something it is very expensive. A disabled taxi is, well, I cannot remember the exact amount but ...
Ms. E. Crabb: £14.
Ms. G. Le Leivre: £14.
Deputy R.G. Le Hérissier: Minimum call out, is it?
Ms. G. Le Leivre:
So, who funds that for this person? The individual I am thinking of is funded by the Health and Social Services so just gets his £29. So, £29 and £14 to pay for a taxi to go to a social function, you know, just a day centre or something or a social club; it is very expensive. I feel we have lost a lot with the income support when the Parishes -- I know there was good things and bad things, by the way. I am aware of that. It was the welfare state and there was charity, viewed as charity, but we have lost that now because we -- I remember going to, when I was within the public sector, the Constables and they would help us out and we could get things and it always seemed that they could be creative and help you. I am sure you have had examples like that.
Ms. E. Crabb:
Well, this is it and, again, that link with the Parish, you know, the Constable knew the family and they knew the needs and things so I think, you know, we will lose that eventually, that community spirit as well.
Deputy J.A. Martin:
It is a shame though, because we have asked at St. Helier and there are still big pots of trusts that people have left for the community and just because they are not capable it should not be lost, really. I would not be -- I am not saying I am an advocate but definitely do not be afraid to ask, especially in St. Helier, because there is. I mean, you know, the things like -- Simon now has the elderly dinners in the Town Hall because he has more and that fund is running low but because he is doing it this way now, instead of lasting 3 years it will last for anther 10 years and things like that, but there are add-ons, you know, to get people there and things like that. He is doing lots of dances and things like that and I think if someone approached him, if it was only needing to get there, Simon would -- well, the Constable at the time that I am talking about; so do not think because the payment now - official payment fund - all the Constables have told me there is still trusts, that they should be approached to do it for the community in their Parish.
Ms. G. Le Leivre:
But it is important though - and that is good - but it is important that the older people, any individuals but obviously we are focused on older people today, that they keep their dignity, that you do not have to make a bid for charity, that they have an affordable standard of living.
Deputy R.G. Le Hérissier:
You mentioned day centres and I was very interested to hear. Most people would see day centres as a step ... one of the steps on the road to going into a residential place whereas you mentioned, Gloria, people are coming out of places like yours and visiting day centres.
Ms. G. Le Leivre: Yes.
Deputy R.G. Le Hérissier:
We have heard - well, I heard, sorry - one or 2 cases where it appears the numbers going to day centres were falling off for reasons that are not entirely clear.
Ms. G. Le Leivre: Yes, they are.
Deputy R.G. Le Hérissier:
Now, if you are saying, and that is excellent that they are an integral part or should be --
Ms. G. Le Leivre:
I think it is transport.
Deputy R.G. Le Hérissier: Is it transport?
Ms. G. Le Leivre: Well, I am assuming.
Deputy R.G. Le Hérissier: Yes.
Ms. E. Crabb:
Transport and dependency levels I think was the --
Ms. G. Le Leivre: Are higher.
Ms. E. Crabb:
-- case with the Willows, was it not?
Deputy R.G. Le Hérissier:
The Willows was the issue, was it?
Ms. E. Crabb:
Yes, that is right because also the volunteers there now are of a certain age and you know they cannot cope with too many strenuous tasks. Sorry, I did have to say the age group there. Also transport was an issue.
Ms. G. Le Leivre:
Yes. Transport is a big issue, and I am not saying that I know the answers but definitely that is a stumbling block.
Deputy J.A. Martin:
Because people from the Willows used to go into the -- the one at Gorey, is that the Hollies.
Ms. G. Le Leivre: Yes, yes.
Deputy R.G. Le Hérissier: Yes.
Deputy J.A. Martin:
Then vice versa on another day and then Sunday lunch used to be a big thing absolutely --
Ms. G. Le Leivre: Absolutely.
Deputy R.G. Le Hérissier: They all meet together.
Deputy J.A. Martin:
Not a lot of money and, you know, had a nice drink and everything. I was invited out there and it was a very nice lunch.
Ms. E. Crabb: Yes.
Ms. G. Le Leivre:
Do you remember luncheon clubs were started as well for the older people? We did them at the Limes and at -- well, we did them at the Limes anyway, a luncheon club and then the Hollies used to do it. But, again, it is accessing all of this is it not?
Deputy J.A. Martin: Yes, yes.
Deputy R.G. Le Hérissier:
That is a very good point you have raised about access.
Ms. G. Le Leivre: Yes.
Deputy R.G. Le Hérissier:
I think Julien wants to join in.
Ms. G. Le Leivre:
Sorry.
Mr. J. Forder:
It really is a question about referral routes and the way that people get referred into the system because it is also quite pluralistic, shall we say. There are a number of ways that people can get referred. They can get themselves referred to you via a G.P. (General Practitioner) or by the hospital. I have probably missed some referral routes. I am trying to get a sense of whether you feel that this is lacks some co-ordination or not or whether there would be something to be gained from having a more -- a way you could co-ordinate the way that people access services, not just care home services, but for the range of different services.
Ms. G. Le Leivre:
I think there is a danger in that as well.
Ms. E. Crabb:
The social workers really would know now, if somebody is in hospital and perhaps they say this person needs special care, residential care, and the social worker on duty that day then would obviously make the inquiries, check on the availability and so that would be looking at addressing in residential. Obviously, the G.P. I think still has got quite influential ... you know, they may use one home more than another, so to speak. Then the families as well may have experience with one home and they would probably like to use that again. Location is the other thing that, obviously, would be important for visiting.
Ms. G. Le Leivre:
You have raised a good point, because referrals do come from the wards as well but a lot of the staff who are making the referrals do not know much about the homes that they are referring people to, and for obvious reasons. They may not have been over here long or maybe they have not had the opportunity to visit so they get -- and this is where there is a little bit of a lack of equity at the moment I feel within the sector, where they hear of a name of a nursing home, especially the private ones: "Oh you know, we know about them, this is a good home for you" sort of thing.
Deputy R.G. Le Hérissier: Yes, yes.
Ms. G. Le Leivre:
And that is unfair because that is not proper competition, but the Jersey Care Federation are aware of that and I think it is okay for me to say that in looking at -- one of our members is going to produce a one-page information sheet on all of the Care Federation homes and take it in and put it into the hospital. I know Social Services were going to do that but it has never come to being yet so we thought we would take the initiative
Ms. E. Crabb:
It is going to be the same format for every home.
Ms. G. Le Leivre: Yes.
Ms. E. Crabb:
So, that there is no pressure.
Ms. G. Le Leivre: Level playing field.
Deputy R.G. Le Hérissier: Yes, excellent.
Ms. E. Crabb:
So it is going to be the same so there will be one on every ward and then they will have that information on hand.
Ms. G. Le Leivre:
Getting back to your question, I think it is better to have various routes for access to a service because it becomes almost like they are channelled in and I think that has become long-winded and bureaucratic, quite honestly.
Deputy R.G. Le Hérissier: Right. So --
Ms. G. Le Leivre: In my opinion.
Mr. J. Forder:
As an example, if someone was in ... someone goes to hospital, maybe after a stroke or a fall or something, and is seen by the consultant and after the acute bit of their care is done then the consultant feels that they should be referred to long term care of some type, maybe a care home, so the consultant is doing an assessment of their needs. Then what would be the process? Would the consultant either make inquiries or probably, obviously, give it to someone more junior, but would someone working for them then make inquiries as to where that person could be placed?
Ms. G. Le Leivre:
It depends if it is funded or private. If they are private, the social worker or somebody just gives them a list of homes or just a couple of names of homes. That is --
Mr. J. Forder:
They do not give him any more help than that?
Ms. G. Le Leivre:
Oh, they might do but we --
Ms. E. Crabb:
Then the home, if they contacted the home, then the manager or whoever would go in and assess that person, but obviously if they were to be funded by Health and Social Services there would be a social worker involved, placement tool and then --
Ms. G. Le Leivre:
Possibly a contract bed if they had an empty one. Not a lot of choice, I would say.
Mr. J. Forder:
For the States-funded people that is when the placement tool kicks in. That is when it works. After that they are then assessed using the placement tool, established into however many categories there are in the placement tool. We have not seen it yet, have we?
Deputy R.G. Le Hérissier: No.
Mr. J. Forder:
Then they are directed to a home with spare places, yes?
Ms. E. Crabb: Yes.
Deputy R.G. Le Hérissier:
We have covered an awful lot of issues, which is excellent, and we certainly appreciate that. Are there any further questions from the panel?
Deputy A. Breckon:
Just in general terms, what is your relationship really with other professionals in the States? You mentioned something about having too much bureaucracy but is the system working for the benefit of the clients or are there things we could do better, do you think?
Ms. G. Le Leivre: You mean throughout?
Deputy A. Breckon:
Yes, yourself and the income support thing. Are we ...
Ms. G. Le Leivre:
I think income support has raised a lot of issues and challenges and I think that has to be --
Deputy A. Breckon:
Is the challenge over how much you get paid for that, is it?
Ms. G. Le Leivre:
That as well, and I think it is a very hard thing for the elderly, particularly those who have not got an advocate for them, and I do not mean a legal advocate. I mean somebody who will act, an agent, who will act for them. If they are within Social Services, that is fine, but I think it is still in the teething stages, is it not? It is very difficult, I think, for them.
Deputy R.G. Le Hérissier:
I hesitate to do this because we have an expert here, but what about the actual payments and how the components are brought together, Gloria? Have you seen any teething problems in that regard?
Ms. G. Le Leivre:
Yes. There seems to be a backlog. I know of one case where - and I never got to find out exactly why - but I received a letter, an account, for a patient who was the old H.I.E. (Health Insurance Exception) and it was a bill for about nearly £400, and I got in touch with the family and got in touch with Social Security and had the son, the next of kin, got on to the policy principal at Social Security and it was sorted but I wondered why - and I have heard of other cases like that - that was happening.
Deputy R.G. Le Hérissier: Had to go so high.
Ms. G. Le Leivre:
Yes. Was there somewhere that they missed in the loop, somewhere?
Deputy R.G. Le Hérissier: Yes, good point.
Ms. G. Le Leivre:
But I have not heard anything else so I am assuming it was sorted.
Deputy A. Breckon:
How would that work if somebody was on -- say you needed a G.P., and then you had somebody who was funded by Social Security and they are trying to set up their own medical account - Judy is the expert on this - but how does that work then with the funding. Would the doctor bill the person or are they doing it direct or how is it working, do you know?
Ms. G. Le Leivre:
Do you mean if they have income support?
Deputy A. Breckon:
Yes. How does the G.P. funding work?
Ms. G. Le Leivre:
Well, we had a lot of anxieties, did we not, Eileen, about the amount of visits that patients could have because I can say now - I am not breaking any confidentiality - that one of our ladies has had about 7 visits in the last 10 days, and necessary visits.
Deputy J.A. Martin:
They are like a call out to a home visit, which is between £80 and £100, yes.
Ms. G. Le Leivre: Yes, so --
Deputy J.A. Martin: She is on income support?
Ms. G. Le Leivre:
Yes, you have only got to top that up. This is just to give you an example, now. I know, living within the community, there are anxieties now; if I am going to need the doctor how many am I going to have? I know that there is a pot that they can get top ups and all the rest of it but I think it is because there is always that fear that I might sort of outlive my amount that I am allowed.
Deputy J.A. Martin:
Again, the pot is not good because again it is the generation who will not ask and it is, again, like: "May I please have?" or fill in that form, put another --
Ms. G. Le Leivre: That is right.
Deputy J.A. Martin:
Questions in, and we may help you but then it can also say: "We gave you X to save and you have not been saving it." There are really lots of teething problems.
Ms. G. Le Leivre: Well, that is right.
Deputy J.A. Martin:
Just one thing that was brought up at the meeting, but people who are coming into care, and we heard a lot last night, is because, I mean, obviously they are elderly, the package has broken down. It is also because the people who are keeping them in at home, not Family Nursing, they are informal carers, family friend, or mainly family, are not getting any respite or not much help and they were admitted on the top table, they were very bad at it, and I know it got cut back years ago. That was for children and people kicked up a fuss then but it never really got results at that end, so I can imagine with the elderly end, the less, well you know, if you do not like it sort of thing, but that is the ... they said they have been very, very bad at respite.
Ms. G. Le Leivre: Well, yes.
Ms. E. Crabb:
There are nursing beds available and, obviously, these were people who would have gone into McKinstry or Leoville.
Deputy J.A. Martin:
This is it. They were saying coming out into your own home respite, you know, for the carer to go out for the evening. It might not necessarily be a week, but it could be. We do not do any of that.
Ms. E. Crabb:
No, no, and there are just 2 beds in the residential side, so that is something which should be opened up I think, really.
Ms. G. Le Leivre:
I do remember a few years ago the Carers' Association had some money for that; just for someone to come in for maybe the carer to go to the hairdresser, to the cinema or something, and I do not know why but I do remember them saying people were not taking it up readily and it could be, in my opinion, that maybe the person who was being cared for was not comfortable to have somebody they did not know coming in and staying with them and all that.
Deputy R.G. Le Hérissier: Yes.
Ms. G. Le Leivre:
But it is something I think that should be raised again and I think that should be looked at.
Deputy J.A. Martin:
I can understand that if it is a regular person.
Ms. G. Le Leivre: Yes.
Deputy J.A. Martin:
If it was fortnightly. They do not have to be left on their own at first, come round, you know, get to know each other.
Ms. G. Le Leivre:
It is giving them a break from their carer, quite honestly.
Deputy J.A. Martin:
As well, yes. It is something that is very needed in the caring of 24/7.
Deputy R.G. Le Hérissier:
Okay. Are there any further comments, Gloria? Eileen, you would like to make any?
Ms. E. Crabb:
I think just one thing left, you know, in the past when in the private sector, residents were getting their Transport Mobility Allowance and, okay, that was put in to the bank, was it not? Also they had an Attendance Allowance and that was means tested but I think the ceiling was £53,000 or something, and that was income not assets. That money went in the bank and that helped subsidise their fees. So it was indirectly maybe a third party top-up, so to speak. But, of course, that is not going to be the case any longer. So it will be interesting to see, you know, a few months or a year down the road how that is going to affect people with their private fees as well.
Deputy R.G. Le Hérissier: Any other point, Gloria?
Ms. G. Le Leivre: No.
Deputy A. Breckon:
Just thinking though, something you have mentioned there. We have got Social Security in next, are there any questions that you think we should ask them? I know you have not got long or you might like to make a list but, I mean, that is one thing because if you do put pressure on then it is an extra burden on somebody, is it not, which is on the care and attentions and whatever else.
Deputy J.A. Martin:
I cannot moan that they have extended the transitional period to 28 January, but I can moan that they have, let us say, not releasing the bad news that people are going to lose a lot of money in January before the elections. I am having Paul this afternoon because I have told him I want to -- he was going to write to people in July and tell them what they were losing, in actual money, and now they have moved the date and he will not write to them before October. It is still worrying for people, they are going to lose a lot of money. Especially with the people you were talking about who are on the high ceiling, they are going to be cut off completely. Completely.
Ms. E. Crabb:
That is going to hurt.
Deputy J.A. Martin:
It has not been explained well and they have just moved the date, not the bad news.
Ms. E. Crabb:
That will definitely, you know ...
Deputy J.A. Martin: It will impact.
Ms. E. Crabb: Absolutely.
Deputy R.G. Le Hérissier:
I would like to thank you, there is a whole can of worms just be opened so I will quickly close it until the Social Security Minister comes, but I would like to thank you very much and it has been really interesting learning about -- well, both your association.
Ms. G. Le Leivre:
Are you sure we have not put you to sleep?
Deputy R.G. Le Hérissier:
Not at all - and what is happening in your own homes, so thank you both very much indeed.