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STATES OF JERSEY
Health, Social Security and Housing Panel
Long Term Care of the Elderly
WEDNESDAY, 30th July 2008
Panel:
Deputy A. Breckon of St. Saviour (Chairman) Deputy R.G. Le Hérissier of St. Saviour
Mr. J. Forder
Witness:
Ms. S. Walker (Home Manager, La Haule Residential Home)
Deputy R.G. Le Hérissier of St. Saviour :
The session is recorded because it is basically -- the whole idea of Scrutiny is we publish all the evidence, and you are some of the evidence, and then from that we then draw up the report. There should be a link between the evidence and the report. It should not be what we sort of conjure up in a pub at night. It should have a connection between the 2. So welcome here. We will make the introductions and if you could just tell us briefly what your role is and what your background is, because I understand you have had quite an interesting and fairly lengthy background in this field. I am Roy Le Hérissier, I am one of the politicians.
Deputy A. Breckon of St. Saviour (Chairman): Deputy Alan Breckon.
Mr. J. Forder (Adviser): Julien Forder.
Deputy R.G. Le Hérissier:
Julien is the adviser, he has come from the University of Kent to advise.
Mr. C. Ahier : Charlie Ahier .
Mr. M. Orbell: Malcolm Orbell.
Deputy R.G. Le Hérissier:
We have 2 other members who cannot be with us today, there would usually be 4 here. If you would like to introduce yourself.
Ms. S. Walker (Home Manager, La Haule Residential Home):
My name is Sharon Walker . I am currently a home manager from the La Haule Residential Home which is part of the Four Seasons Healthcare Group. I recently came to the Island as home manager at the commencement of June. Having had a period of time at Four Seasons, 3 and a half years as a development manager developing training materials and delivering them and doing other kind of resources, if you like.
Deputy R.G. Le Hérissier:
This was for Four Seasons, U.K. (United Kingdom)?
Ms. S. Walker :
This was still with Four Seasons. I am a R.G.N. (Registered General Nurse) by profession. I hold level 4 training and development, level 5 in management. So I felt qualified to undertake the task in hand, if you like. Albeit a challenge, but, you know, it is a challenge and ...
Deputy A. Breckon:
Can I ask you; what was the attraction in Jersey? Was it the job, the challenge, the sea air?
Which part of the country did you work in?
Ms. S. Walker :
I worked all over the country. My previous role was all over so, I think it appealed at my stage in my career, if you like, something completely different. While I had managed a home before for another company, home management per se was not appealing, it was the whole package, if you like. It is very, very different managing a home here as opposed to the U.K.
Deputy R.G. Le Hérissier: Tell us some of the differences?
Ms. S. Walker :
The Commission of Social Care Inspection for one, the regulations are different. What they look for is different. The sanctions that can be applied are different. It is managed more very much, I would not say a tighter hold ... I felt Jersey has a more humane approach, to some degree, while still achieving the end result. I do not know what sort of differences, do you -- the way they inspect, they do a self-inspection process over there, where they would obviously put forward where they think their home is at, at that period of time. The inspection would be based on those set of standards. They measure the quality of the home against the K.L.O.RA. Guidelines which are the Key Lines of Regulatory Assessment. I feel that those K.L.O.R.A. Guidelines are an extremely valuable tool, even to manage here as a basis, because they provide a good quality-based framework. Here, I think, we would exceed perhaps expectations.
Deputy R.G. Le Hérissier:
Good. Focusing on La Haule itself, Sharon, and dementia care as its focus, that is correct?
Ms. S. Walker : Yes.
Deputy R.G. Le Hérissier:
We have had a presentation or we have had a witness this morning, the president of Jersey's Alzheimer's Society, so we have obviously had some interesting insight. The general view, I think, I could summarise his evidence, is that it is essentially an unrecognised problem, there is an awful lot of work to be done and we have to work out the services that we need and the kind of support, and that Government really has to wake up to the extent of the problem. In terms of your home, do you feel that we have a lot of work to do in developing dementia services on the Island?
Ms. S. Walker : Yes.
Deputy R.G. Le Hérissier:
What are the areas that have struck you as needing a lot more work?
Ms. S. Walker :
I feel that we are approached more as a home that takes people with dementia, rather than a home that provides or is a centre of excellence, if you like, for dementia. I feel the standards need to be looked at. That reflects on me as well. I am kind of forgetting this is getting recorded. I think there is a training issue for providers as well that we provide people who have the knowledge and expertise to meet clients who have mental health needs. Not just Alzheimer's but other mental health illnesses, that mean that they are not able to cope in their own home or environment.
Deputy R.G. Le Hérissier:
Where do the referrals come from to your home?
Ms. S. Walker :
Referrals, sometimes they could be private, directly private, or they come mainly from, is it St. Saviour 's Hospital?
Deputy R.G. Le Hérissier:
They would come from what, the manager, at St. Saviour 's?
Ms. S. Walker : Yes.
Deputy A. Breckon:
Do generally your clients come, Sharon, with a care plan? So has somebody done an assessment or are you more involved in that when they come to you?
Ms. S. Walker :
I am involved -- if somebody approaches me for, do I have or am I able to take a resident, I would not be able to take that resident until I have undertaken my own assessment. However, Social Services do their own review and care plan because I think it is very fee related as well, because they will just measure the resident's needs, but sometimes that is ever changing. That is changing all the time. An assessment in a different environment, that person presents differently.
Deputy A. Breckon:
In your experience do your residents come to you with family or extended family or are many alone?
Ms. S. Walker :
It varies. It varies. Some have supportive families, some are estranged from their families. Some have nobody. Nobody at all.
Deputy A. Breckon:
Is there anything in the community which support you? Does anybody come in, like the local school or the W.I. (Women's Institute) or anybody connected to that?
Ms. S. Walker :
Voluntary, no. We have our own activities organised, if you like, within the home who come link into -- I am not sufficiently familiar with Jersey to know what we can access and what we cannot. So it is probably unfair of me to respond.
Deputy A. Breckon:
With the level of services and support you are providing how would you compare it with places like Four Seasons in the U.K.? Are there regional variations of what they do and where does your place in Jersey fit with that now?
Ms. S. Walker :
The difference I see at the moment is -- I think Jersey is different altogether. The standard of living in Jersey is different and therefore the standard of homes are different. They complement that. Care homes from my experience in the United Kingdom varies from somewhere in the north east to somewhere in the south west, for instance, the London area.
Deputy A. Breckon:
That is because of the client catchment, is it?
Ms. S. Walker :
I think absolutely. Because depending on the background of that person depends on what they want, what their expectations are as well.
Mr. J. Forder:
Are the fee rates a bit higher here than they are in the U.K?
Ms. S. Walker :
Yes. The rates are higher, but the costs are higher here as well. We pay people a lot more here than they are paid on the mainland.
Deputy A. Breckon: Is staffing an issue?
Ms. S. Walker :
Yes, I think staffing is probably an issue anywhere in the care environment. It is not finding the staff, it is finding the right staff, the qualified staff.
Deputy R.G. Le Hérissier:
Does that mean, Sharon, that you have to do a lot of training or you have to basically import staff? How do you handle that situation?
Ms. S. Walker :
I am able to take 15 non-Jersey nationals at the moment. That takes a little bit of juggling. Because I have recently appointed a deputy that I could not recruit on Jersey, I had to recruit on the mainland.
Deputy R.G. Le Hérissier:
You provide accommodation, do you, for staff who come here?
Ms. S. Walker :
Yes. We assist with accommodation. Myself, they have assisted with mine because I am obviously a non-Jersey national as well. I am part of that 15.
Deputy R.G. Le Hérissier:
In terms of dementia, Alan raised the issue of, are there links with a school and so forth? What kind of support do your clients get from agencies like social services?
Ms. S. Walker :
Social services follow up their residents. They follow them up, and that is variable depending on how ... that condition of the resident really is how frequent they would come in and assess that person to see if their needs have changed.
Mr. J. Forder:
In terms of the way that the funding works for people. You obviously have people that are entirely self-payers. You have people that would apply to social security for additional funding. Do you also have - and you might put me right on this - is there a dementia care kind of supplement that -- do you have a number of beds that are registered as dementia beds as well, or are they ...?
Ms. S. Walker :
They are all registered for elderly mental health needs. So they are all registered for that. I do not have any just, you know --
Mr. J. Forder:
Just regular residential?
Ms. S. Walker : Yes.
Mr. J. Forder:
Is there any kind of supplement that the Health Department pays you for dementia care?
Ms. S. Walker : No.
Mr. J. Forder:
Not even for the States supported?
Ms. S. Walker :
No, the only thing I think, as far as I am aware, I might be wrong on this, is those that apply for family nursing, that rate is included, I think, in that and I think that is £50 or £60.
Mr. J. Forder:
I am just really trying to get to the issue of, if someone is a self-payer, for example, and they had fairly advanced dementia but they had some savings and some income of their own, then they would be entirely paying the fees from their own pocket?
Ms. S. Walker : Yes.
Mr. J. Forder:
Just to clarify, really. Thanks.
Deputy R.G. Le Hérissier:
Back to the issue of support, Sharon, how many of your residents would be getting active and positive support from their families, what percentage?
Ms. S. Walker :
Probably 25 per cent maximum.
Deputy A. Breckon:
How many residents do you have, Sharon?
Ms. S. Walker :
At the moment I have 46.
Deputy A. Breckon: Is that a full house?
Ms. S. Walker :
No. At 54 I am full. I am registered for 61 but that registration incorporated shared rooms which we are doing away with.
Deputy R.G. Le Hérissier:
Back to the issue of support. An issue we have come across is married couples. Have you got that potential to take married couples?
Ms. S. Walker :
I have 2 married couples at the moment. I had 3 but unfortunately we lost one, yes, we have the facilities to accept married couples.
Deputy A. Breckon:
That could be one partner with dementia and one without? Can you cater for that?
Ms. S. Walker :
Yes. We have situations whereby the frailty of that other person means that they would benefit.
Deputy R.G. Le Hérissier:
You mentioned your U.K. experience. Does Four Seasons in the U.K. , so to speak, mix in dementia with other residents or does it specialise? Or does it have a policy that dementia sufferers will be essentially in a separate home?
Ms. S. Walker :
Not necessarily in a separate home. Maybe in a separate unit. Many of the homes within Four Seasons have perhaps 3, might have 3 units, one might be nursing, one might be E.M.I. (Elderly Mentally Ill) nursing and then you might have the E.M.I. residential.
Deputy R.G. Le Hérissier: E.M.I, could you ...?
Ms. S. Walker : Elderly Mentally Ill.
Deputy A. Breckon:
Then you would have share facilities, kitchen and things like that within that?
Ms. S. Walker :
The main kitchen but then they would probably have a mobile trolley that would go to the units. Many of them have satellite kitchens and things like that attached.
Deputy R.G. Le Hérissier:
You mentioned earlier, Sharon, that a lot of your referrals come from St. Saviour 's Hospital. Why would people be transferring from what is a public dementia unit, in a sense, to your unit? Is it family preference? Is it ability to be a self-payer?
Ms. S. Walker :
Not necessarily because I have State funded as well as private in the home. It would really depend that they would be perhaps needing to vacate that hospital bed, if you like. The relatives may well be given a list of, these are the homes that can offer the services for your family and then it might be availability who has a bed available.
Mr. J. Forder:
They are given in, St. Saviour 's in the assessment unit, presumably?
Mr. J. Forder:
Dr. Wilson would do an assessment of their needs and then they would get referred.
Deputy R.G. Le Hérissier:
One of the big issues which almost sometimes cuts across decisions is, of course, taking the person's property and this seems to cause a lot of distress to people. We have picked this up. Is this an issue with some of the families you deal with?
Ms. S. Walker : Yes.
Deputy R.G. Le Hérissier:
They are afraid almost of releasing their loved one to you because they can see ...?
Ms. S. Walker :
Yes. That is a message I do get from residents' meetings and things like that. Many issues that are raised or complaints, even, are because of the fact that the whole cost of care is ... I suppose it is looking at, where does that cost go? How can you justify that cost?
Deputy A. Breckon:
How does that attitude, Sharon, of selling the family home compare with the U.K.? What is the situation in the U.K? Do the local authorities do the same thing?
Ms. S. Walker :
Exactly the same. Exactly the same and it causes equally as much distress.
Deputy A. Breckon:
On the co-funding issue, would the local health authority contribute towards a person's care if it was at a level above residential? If they have a nursing or a
specialism like dementia, would the local authority contribute to that from the health point of view, or not?
Ms. S. Walker :
Not if they are not private. If they are private then ...
Deputy A. Breckon: They pay the lot?
Ms. S. Walker :
They would pay towards it.
Deputy A. Breckon:
Supposing you have a referral from the U.K, and it was similar to St. Saviour 's or it could be a county hospital where a patient would say: "Well, it is not a health issue, it is actually dementia and a level of care and supervision for a specialist", would they then contribute to that person's upkeep or would they just say the family need to sort it and refer it to Four Seasons?
Ms. S. Walker :
I think the family would. They have things like continuing care beds in the U.K. A continuing care bed is where somebody perhaps no longer needs hospital but they would then -- the hospital would buy a continuing care bed in a care home.
Deputy A. Breckon:
The local authority would contribute towards that?
Ms. S. Walker : Yes.
Deputy A. Breckon:
They would then allocate a patient to you and say, that person needs that level of service?
Mr. J. Forder:
In the U.K. a way -- if you are in a nursing home there is a nursing care contribution. So for the nursing element of your care the - even private individuals - you get funded for that part, right? Because nursing is part of the N.H.S. (National Health Service) which is free. So you pay for your personal care and you pay for your accommodation but there is a nursing care contribution on top.
Deputy A. Breckon:
Would that include dementia?
Mr. J. Forder:
It depends whether there is an assessed nursing need.
Ms. S. Walker :
If it is a dementia nursing, we have 2; we have residential E.M.I., elderly mentally ill, or nursing elderly mentally ill.
Deputy R.G. Le Hérissier:
In your experience, where they have drawn the line, supposing somebody had dementia that was, say, brought on by a series of strokes, then would that be assessed as clinically that the local authority would contribute because it was health related that triggered that? Or are they being a bit stingy and: "No, we are away from that When are we here?"
Ms. S. Walker :
It is very difficult because nursing is based on nursing interventions. What do they class a nursing intervention? If it is an injection once a week, then that would be residential because a district nurse could then go in and undertake that task. So if that person's ability means - if it is somebody who needs to be fed by a gastrostomy tube then that may well be nursing. However, on the mainland I have seen them in residential homes. There is a variable.
Mr. J. Forder:
Do you employ registered nurses?
Ms. S. Walker :
At La Haule, I do not. At La Haule I do not because I am purely residential at the moment.
Mr. J. Forder:
That is the distinction that is made in the U.K., that basically if you are employing someone who is a registered nurse then it is homeward nursing. If you do not have an employed registered nurse then it is residential.
Ms. S. Walker :
That was the difference here though, because they asked for an R.G.N. at least as a minimum for manager's role, whereas on the U.K. a level 4 would be sufficient to manage a care home. So they would not be a trained nurse.
Deputy R.G. Le Hérissier: Any further questions?
Deputy A. Breckon:
In your experience, where are we with dementia, are we recognising it enough? Are we doing enough? Are we supporting people at the right places? Or when you are getting people, could we have interventions before ... I mean you are free to say what you like. Have a go if you want. Are we behind the times? Are we ahead of the times? Where are we in Jersey?
Ms. S. Walker :
I do not know. It is very early for me to say because I do not feel I am equipped or qualified yet to say anything or form an opinion yet because I am still finding out. But I think Jersey is very caring, I get that impression, but I think maybe we lack specialist sort of approach because dementia is a very specialist area. We have this
umbrella of dementia but there is all different types of dementia and it presents in many different ways.
Deputy A. Breckon:
Just on something not related to that. One of the things that we did do a few weeks ago, I went to Guernsey and they have a system there where people pay through the social security system and are entitled to a level of benefit if their needs are such and the assessment is such. With your experience of the tug of war over properties and things like that, would you think that would make your job a bit easier generally?
Ms. S. Walker :
Absolutely, absolutely. I used to live abroad and that is what we used to do, is have medical insurance. I think, yes.
Deputy A. Breckon:
Even people in retirement in Guernsey pay and we were wondering how generally if you take care of that, people in retirement would accept it as well. It is a sort of insurance policy against their home.
Ms. S. Walker :
I think so. I think the biggest personal trauma to the family is losing the home, to the resident is losing the home. They are left with a little cardboard box with a few belongings.
Deputy A. Breckon:
Is that tension if you have a couple where one needs a level of care from you and the other one is still in the home and then the asset, if you like, is dwindling because of the care of one? Is that the reality of the situation?
Ms. S. Walker : Yes, it is a reality.
Deputy A. Breckon:
That is putting stress on the other partner who has not got a plan?
Yes.
Mr. J. Forder:
A little bit about -- there have been sort of new developments in dementia care, and I wondered if you want to comment on some of the techniques, procedures, skill sets that you use for caring for people with dementia?
Ms. S. Walker :
At Four Seasons really very much a person centred approach model, following Tom Kitwood's model. That is why I mentioned earlier about the training because again recruitment comes into this, recruiting people who have sufficient basic knowledge, if you like, to move on to more specialist. Some of the homes on the mainland, I know, are becoming specialist dementia units whereby they look at becoming a centre of excellence for dementia. They are looking at dementia care mapping, looking at people's wellbeing. It is very important that the resident is in wellbeing. At La Haule we take them at different levels of dementia, so we have them with their needs -- mental health needs are quite high. It is important at that level that they are in wellbeing.
Mr. J. Forder:
Can you just elaborate slightly on that wellbeing approach? What is it about - are you trying to stimulate routines or ...?
Ms. S. Walker :
It is not a routine, it is a person centred care approach. We are looking at the person not at their illness. That person, how they were before they became ill. That is not always easy to do but it is something; it is a process of observation, it is a process of discussion with people who knew that person before they came in, so we look at individualised care, plans, that meet that person's specific needs. So we do not have routine, habitual care. When I first went into nursing that is how it was. It was very much everybody got turned every 2 hours, everybody got a wash; no more. It is what that person wants. If they want their breakfast at 10.00 a.m. they do not have their
breakfast at 10.00 a.m. Getting to know that person is so important because historically it may be that we are seeing behaviours and there are reasons for those behaviours. They may have a fear of a shower because of something that happened to them in a past life.
Deputy R.G. Le Hérissier:
Good point. What is the Tom Kitwood model, briefly, Sharon?
Ms. S. Walker :
The person centred approach. It is looking at -- trying to remember it. It is like the flower and it is about everybody's needs, it is what we need. Everybody needs love, everybody needs to be understood, everybody needs to be taken care of, to be listened to. It is a holistic approach.
Deputy A. Breckon:
You would know things like if somebody would rather be called James or Jim or Mr. Jones. We had somebody come and see us a couple of weeks ago, they said that they knew Mr. Jones used to like the football, so when the European games were on we made sure the telly was on. So it was just like -- that is the sort of thing you are talking about?
Ms. S. Walker :
That is the kind of thing. That is the kind of thing. It is a very specialist approach, really. It is like a day surgery, where you say somebody goes in, has an operation, go home, because then you are dealing with a condition rather than a person.
Mr. J. Forder:
Is it staff intensive?
Ms. S. Walker : Yes.
Mr. J. Forder:
What are your staff ratios, roughly?
Ms. S. Walker :
At the moment I have 4.7 to one.
Deputy R.G. Le Hérissier: Any final points?
Ms. S. Walker :
It is more intensive than the U.K. Very much more.
Deputy R.G. Le Hérissier:
Is it? Good. Is there anything, Sharon, that you thought you were going to tell us when you came in, but for some reason --
Ms. S. Walker :
I did not really know what I was going to talk about. It is a new experience.
Deputy R.G. Le Hérissier:
Is there any other issue you want to talk about or you want to raise?
Ms. S. Walker : No.
Deputy A. Breckon:
We hope it was not too painful.
Ms. S. Walker : No, it ...
Deputy A. Breckon:
Nobody is on trial for anything, we just need to get evidence and experience of people like yourself of what is happening out there in the community. That is what it is about.
Ms. S. Walker :
I think that is nice. That opportunity never arises anywhere where I have been before.
Deputy R.G. Le Hérissier:
Good.
Not good, but it is good that we have been able to bring you in.
Deputy A. Breckon:
The thing is we need to speak with the people who are involved like yourself. We hope we have not put you on edge too much.
Ms. S. Walker :
Sorry, I have not been able to give you the ...
Deputy A. Breckon:
No, it has been very useful.
Mr. J. Forder:
The comparative was -- I found ...
Deputy R.G. Le Hérissier:
Thank you very, very much indeed for coming.
Ms. S. Walker : Thank you.
Deputy R.G. Le Hérissier:
We wish you well in your career in Jersey. We hope it works out.