Parish of St Helier and Maison St Brelade

STATES OF JERSEY

Health, Social Security and Housing Scrutiny Panel

Long-Term Care of the Elderly

TUESDAY, 7th OCTOBER 2008

Panel:

Deputy R.G. Le Hérissier of St. Saviour (Chairman) Deputy S. Power of St. Brelade

Mr. M. Orbell (Scrutiny Officer)

Witnesses:

Mr. A. Pemberton (Finance Director)

Ms. J. Garrod (Community Visitor and Homes Liaison Officer for Parish of St. Helier ) Ms. P. Thebault (Manager, Maison St. Brelade Care Home)

Deputy R.G. Le Hérissier of St. Saviour (Chairman):

I would like to welcome you to this session. It will be recorded, and I should also add, in terms of the evidence, while we will not make you swear, there is an understanding that everything you say will indeed be the truth and that you will not be motivated by malice or other negative factors. So just a warning it is being recorded and, unless something untoward was to happen, it will be put on the website, but if you were to say: "Oh, I never intended to say that", then we could, for example, review it. So I would like to thank you very much for coming. In terms of membership, it is a bigger committee, but because of other people's obligations at this time, it is myself, Roy Le Hérissier, and

Deputy S. Power of St. Brelade :

Deputy R.G. Le Hérissier:

Malcolm Orbell, the Scrutiny Officer, and Charlie Ahier , the other officer, who is managing today the transcription service, so thank you. So if you could say your names, please, for the tape.

Mr. A. Pemberton (Finance Director, St. Helier ):

I am Andy Pemberton, Finance Director of the Parish of St. Helier .

Deputy R.G. Le Hérissier: Okay.

Ms. J. Garrod (Community Visitor for Parish of St. Helier and Homes Liaison Officer for Parish of St. Helier ):

I am Julie Garrod, Community Visitor for the Parish of St. Helier and also Homes Liaison Officer for the Parish of St. Helier .

Deputy R.G. Le Hérissier:

Okay, thank you very much. Well, if I can thank you for having met Malcolm earlier and Julie for having written in. We have taken note of this, so this is excellent. Thank you very much for sending us that. We hope to finish at 2.00-ish so we will see how we get on. Our questions are going to be fairly broad because we are quite interested in your

views on policy. Although we have had evidence to that effect, we are not per se looking at whether Mr. and Mrs. Jones were rightly or wrongly treated in a home, although obviously if there were evidence that there is some sort of trend, we would obviously be interested, but at this stage of proceedings our berth was basically to do with the advent of the New Directions Health Report which of course has never quite appeared in public and it is the brave new way forward for all health services in Jersey and it covers things like  the  new role  of G.Ps. (general  practitioners),  the new  role  of day  surgery, the reduction in the residential side of the hospital service and long-term care. Unfortunately New Directions never appeared on time so we decided we would focus on long-term care. So I am assuming, unless you want to correct me, that you only will address sort of financial issues, both within the parish and the way forward for us in terms of how to finance

Mr. A. Pemberton:

Yes. Maison St. Brelade , they do not mind me talking about finance because we work together.

Deputy R.G. Le Hérissier:

Okay, and you, Julie, you will talk about issues that are internal to a home: how it should be organised, visitors, community care and the sorts of issues that matter in the organisation of homes and so forth.

Ms. J. Garrod:

Deputy R.G. Le Hérissier:

We have no problem with whoever starts, so who would like to start and just give us their general view?

Mr. A. Pemberton: I will start off.

Deputy R.G. Le Hérissier: Okay.

Mr. A. Pemberton:

I think the difficulty we are going to have is where you pitch it and whether it is going to be strategic or detailed because we could talk for hours on this.

Deputy R.G. Le Hérissier: Absolutely.

Mr. A. Pemberton:

Can I say that we all work very closely. These ladies are all experts. I am not an expert. They all run their own homes. It is like they own their own home. They are personally responsible. They deal with the finance, budgets, the care, the residents, the parish, the

Island and Income Support. They really do know what it is about, and Julie in particular is the expert in Jersey in placing residents in homes and what the funding issues are, including whether they are self-supporting or whether it is welfare or Income Support or part and part and levels of care. So Julie really is the expert when it comes to understanding the issues. Strategically I am very interested for Jersey as well as for the parish. I work very closely with the Constable whose heart is very much in the parish homes. The parish is doing an excellent job. All 4 homes, including Maison St. Brelade , in my opinion, are 4 of the best in the Island. We have had quite a few Senators up to have a look, including Senators Syvret and Shenton; Jim Perchard has been up a couple of times. Our homes are fully registered, unlike the States homes, and we conform in all aspects. You can see our reports. All the staff are fully trained; they are fully staffed. We pay the highest rates in the Island in the Parish of St. Helier , which is a problem for funding now. We are on a high grade, union grade. We pay States pensions. They are 15 per cent. So we have a problem at our 3 homes. There is no secret but I have given all our accounts to Income Support, to Richard Lang, the Finance Director. They know exactly what our costs are. We break even, as do Maison St. Brelade . We do not make a profit. We never have done. We set our fees at 98 per cent occupancy. Now, that is extremely high, so that means on average, say, one and a half beds only can be empty. If we have more than that empty, we are guaranteed to make a loss because that is how we set the fees. So say we have £5 million income, to generate £5 million income, we need 98 per cent occupancy. At the moment we are not achieving that and I think it is partially as a result of Income Support taking over from welfare. Clearly, with welfare before, we had it on our own doorstep and we made this very loud and clear, did we not, Julie, when

the change happened. We have facilitated, we have oiled the wheels for the hospital. Julie, in particular, in welfare, could be phoned up on a Friday night - Julie can tell you, clearly, if I am wrong on this - and we will place somebody the next day. We are an emergency set-up. That has its own problems with regard to infection control

Deputy R.G. Le Hérissier:

Just a bit slower, Andy, sorry, for the transcription.

Mr. A. Pemberton:

Yes, okay. I do talk too quickly.

Deputy R.G. Le Hérissier: Okay.

Mr. A. Pemberton:

So what we are doing is we have oiled the wheels. That has helped the Island. We do not just take local parishioners, although we used to favour some time ago and certainly St. Brelade did more, but now it is an Island service we provide. If we are full, we are freeing up beds in the hospital, and if we have high occupancy and everybody has high occupancy, it saves the Island money. To prove that, if we go down to 96 per cent or 97 per cent occupancy, which is what we are at the moment, I will have to charge an extra, say, 10 per cent or 5 per cent - I have not worked out the figures - next year because we base our fees on the level of occupancy. So what is important is the bureaucracy and the means must be efficient, and we have the people to do that here.

Deputy S. Power:

Can I just come in on that, Andy? You started the section by saying that you felt that the transition from parish welfare to Income Support is causing a loss of take up and it is making it more difficult for you to achieve the 98 per cent occupancy.

Mr. A. Pemberton:  Yes.

Deputy S. Power:

Have you identified what the reason for that is? Is it a lack of flexibility, slowness in response time? Can you identify what you think and what Ms. Thebault's view is? What do you think, Ms. Garrod, is the problem in the transition?

Mr. A. Pemberton:  

Yes, these ladies know more than I.

Ms. J. Garrod:

I think certainly there is an element of bed blocking at the hospital. Getting residents out of hospital, into their homes is one problem. Getting the funding in place is a second problem. Thirdly, I think it is also that there is now a lack of choice. Whereas the

residents previously were offered a choice of where they want to go, now they are being told: "Your level of care deems that your package is worth £560 a week, or your level of care is worth £726 a week" which are the 2 bands currently that Income Support are using to place residents in care. So they are being told: "You can go there at that rate." Whereas previously, I mean, I have never ever said to any St. Helier residents: "You have to stay in a St. Helier home." If their family members lived at Gorey, I would try and place them at Gorey. If their family lived at St. Brelade , I would try and place them at St. Brelade , but I would place them where it was more appropriate for them to be so they have a better quality of life, essentially. I do not think that is happening now. We have had vacancies in St. Helier House and Maison de Ville, which I think work along with the trends. You know, we have trends where everyone wants to go to residential care and then obviously, sadly, you lose some residents and there are not many people coming into care so that it does work to a certain extent like that, but we have never had a waiting list at St. Ewolds, which is probably the most glamorous of our homes in one way, simply because the rooms are en suite, the corridors are wider, it is more geared up for more disabled. There is always a call for rooms at St. Ewolds but we have certainly recently had 4 vacancies. We have filled them now. However, we have nobody on the waiting list which is something that has not happened before.

Deputy R.G. Le Hérissier:

Sorry to interrupt, Julie, but where are these people going if they are not going to your place? Where do you think they are going?

Ms. J. Garrod:

I do not know where they are going. I do not know. I am not going to say that there are underhand tactics going on because I do not know that there is. Certainly family members have come to me and said: "My mum wants to come to St. Ewolds and she has been told she is not allowed to have that much money for her funding." So we have to say: "Well, I am really sorry but our hands are tied." If Income Support will not fund them there, they will have to go somewhere else. More recently, a lady who has been a volunteer at St. Ewolds for 20 years needed to have residential care and she had always said, you know: "When the time comes, can I come here?" and we would always say: "Yes, of course you can come here. You are part of the furniture." She knows the residents, she knows the staff, and in fact she has had to be placed elsewhere. Now, as it has worked out, she is very content where she is and she is very settled now, but those sorts of things I think, really, the element of choice is being taken away from people.

Deputy S. Power:

So you would say then that the transition from parish welfare to Income Support has built in a degree of inflexibility which was not there before.

Ms. J. Garrod:

Yes. Very little else has changed. I mean, in this transition period. I think we were all expecting great things when the takeover period happened. Apart from the fact that the fee banding has been set at 2 levels at the moment and that people are being place according to their fee bands, in essence everything else is being done the same way. I am

still taking pensions on authority to the parish as I used to. I am still babysitting the rest of the residential care service for Income Support until they are ready to take it over. When people move from residential care to nursing care, I am still funding the residential component in the parish. The difference is the job has gone from me saying: "Yes, yes, you can go there now and I will sort the funding out after" to somebody at Income Support. There is a slight difference in attitude at Income Support in that I think they are very clearly a benefit payment system, and they have always said that is what they were going to be. They are not a welfare system. They are simply a benefit payment system, and their idea is that they want to empower pensioners moving into care to maintain looking after their pensions and their benefits. I think my argument is a lot of people going into residential care, I think perhaps the majority of people going into residential care, want to absent themselves from that. They want to abdicate any responsibility. They have had enough of looking after pensions and benefits and bank accounts.

Deputy S. Power:

They want someone else to do it.

Ms. J. Garrod:

They want someone else to do it. That was the role that Social Security said initially they would take over from the parish and now they are saying that they cannot do it because legally, I think, they cannot be the payer of the benefit and act as the agent to receive that benefit back.

So we have situations now in residential care homes where little old ladies or retired gentlemen are still form filling and doing stuff like that? Does that happen?

Ms. J. Garrod: Yes, essentially.

Deputy S. Power: That is happening?

Ms. J. Garrod:

Yes. I mean, in our homes, I go out and I do it for them.

Deputy S. Power: You do it for them.

Ms. J. Garrod:

I have been kept on at the parish and that is the role I fulfil. I act almost as advocate for those who have no family. Although I think we like to think that everyone has some member of the family, particularly in a place like Jersey, I think you would be surprised at how few people in care do have family members (1) who visit or (2) are able or bothered to be able to form fill for them.

Yes, we had a hearing last week where 2 separate sets of individuals were here, and one particular person explained that they have a relative in a nursing home and that there were other patients in the nursing home that never had a visitor. They just sat there all day in their room. This particular person was explaining that they look after the small things like where are the sweaters, ensuring the false teeth are in the right place and they are wrapped so they do not get cold. This particular person does not seem to have anyone there and it surprised me that there were people, to that extent, who do not have any visitors.

Ms. J. Garrod:

Yes, it is pretty common.

Mr. A. Pemberton:

I want the ladies to talk, but a couple of things that Julie said are really important. Firstly, what we are talking about, this business of whether patients should be controlling their own affairs, I think they are trying it more in the U.K. (United Kingdom). Clearly there is a benefit if somebody is compos mentis, they are independent, they have to go into a home, it is good for them, it is good for their families, it is good for society if people are responsible for their own funding, but specifically in the parishes, certainly ours - I am not sure about Maison St. Brelade - we are about 70 per cent plus of welfare/Income Support people. There is a tendency for those people to be less obviously if you are a self funder you have obviously your own house normally, you are

rich, you are probably quite successful and you have a family that are supportive. So I think there is a real problem for you guys. The aim is right to keep people independent and not have to stay nannying, which is what we do, but in reality, particularly with welfare-type people, you do have to support. An invaluable job is done by Julie and also she said she acts as an advocate. We do not charge advocates' fees. If the Island gets everybody to have a curator or an advocate, their £20,000 savings will go down to £5,000 in a couple of years, and of course then the State will have to pay for them because their money goes much quicker. That is true, is it not, Julie?

Ms. J. Garrod: Yes.

Mr. A. Pemberton:

That is the first difficulty. With regard to running pensions, we gave some notes. The parish is doing a huge role at the moment on behalf of Income Support. We are not being paid for it. That is another issue I got around with Income Support. But if we were to stop doing that - if we just said we are not doing it because we are not getting paid - then Income Support and the Island would have a problem because Julie and my team are performing an Island-wide function. The next point I wanted to make just to reiterate what Julie was saying was St. Ewolds. You have another problem here. Let us take another private home that I am aware of, Pinewood. Pinewood is a lovely home. It is about in the range of £700 to £1,000 a week for fees, I think, depending on who it is. It

has the same registration requirements as our 3 homes at the back here which only charge £560 so they are I do not know, is it called low dependency or normal dependency?

Ms. J. Garrod: Basic residential care.

Mr. A. Pemberton:

Basic dependency so it is not providing nursing care or much high dependency but they want to charge £700, £800 or £900. We only charge £560. St. Ewolds is in the middle. We want to charge £760 because we have high levels of nursing care or high levels of care there - more staff - and it has en suite and it is an expensive building and it has wide corridors and it looks after high dependency people. How does Income Support justify paying us £760 here and £560 there and £800 to Pinewood when the registration requirement is the same?

Deputy R.G. Le Hérissier:

How do they, Andy, have you asked them?

Mr. A. Pemberton:

That is why I think we have 4 vacancies at St. Ewolds because they feel they can only justify high dependency people going for a higher cost. Julie will now tell you what some of the disadvantages of that are in terms of balance.

Ms. J. Garrod:

In reality St. Ewolds is a home that can accommodate 66 residents. It is a lovely home. As Andy says we have great facilities. We can take people with a high level of dependency and we can take people moving from there into nursing care so people who choose to die at home have the option to stay at St. Ewolds. As they do have other homes I have to say, but we can accommodate nursing care from residential at St. Ewolds. But we do have a high level of staff within that environment. Income Support are now saying they will fund at £726 only so only people with a high level of residential care can go to St. Ewolds. It is all very well having half and half at the moment. You have half high level residential and half at the lower dependence who were there prior to 28th January. But if we were to take only residents in who needed a high level of residential care, the dynamic in the home would change completely. At the moment we have a mixture of younger, healthier, fitter, more able residents and we have those who are less able but between them all it is a nice mix and the dynamic in the home is such that there is a nice environment for everybody. Everyone can benefit. If we were to change that and have only people who need high level residential care the place would change completely. I do not think it is a healthy environment to only put people together who need a high level of residential care. I think it is much healthier surely to have a mixture of people and a balance.

Deputy S. Power: And a balance.

Just as an answer to that, Julie, have you put it to Social Security there could be a 2 tier fee structure to deal with the situations you outline?

Ms. J. Garrod:

We have offered. I have to say our fees are set at St. Ewolds at £760 which is a breakeven figure for us to break even with our figures over the year. But, yes, because we did not want to have empty beds, we would rather have people in at £560 than have an empty bed and to maintain the nice environment that we have currently. We have gone back to Income Support and we have said that we would negotiate. I do think and they have intimated to me that they are not just sticking to the £560 and the £726 rates. They are adjusting figures accordingly and there are people that they know who want basic residential care but they are not advertising the fact. They are not letting you know about it. So we are not already playing on a level playing field for a start because we are simply being told £560 and £726, those are your 2 rates. I do know there are people being placed in between.

Deputy S. Power:

Can I just ask a question on your relationship as the professional in St. Helier and your relationship as the accounting functions of St. Helier and St. Brelade , do you have one point of contact with regard to this benefit system in Social Security? Is there one person that you can pick up the phone to and say

Ms. P. Thebault (Manager, Maison St. Brelade Care Home): I do.

Deputy S. Power:

You do? So you have one person who is it your understanding that that person does have a good understanding of what is going on out there in the parish homes and the other homes?

Ms. P. Thebault:

Well, my understanding is

Deputy R.G. Le Hérissier:

Sorry, my fault, do you want to come to the table?

Deputy S. Power: I think they should.

Deputy R.G. Le Hérissier:

Yes, I think we better get all 3 to the table who I so cruelly stopped earlier. If you could mention your name when you first start. Do you 2 ladies wish to be witnesses?

Female Speaker:

She is doing a good job on her own.

Deputy R.G. Le Hérissier: So if you say who you are.

Ms. P. Thebault:

I am Pearl Thebault and I manage Maison St. Brelade Residential Home. With regard to your question, Sean, my understanding is I have got an administrator, Mrs. Churchill, and she does have a personal point of contact with Social Security and it is Rosie Golding. So when a social worker will recommend that somebody comes to the home, they deal with that and we use email quite a bit directly to Rosie. That is our point of contact basically.

Deputy S. Power:

Would the experience at St. Helier be the same? Is it the same point of contact or is it a different point of contact?

Ms. J. Garrod:

Rosie has historically, since 28th January, been our contact although she has now handed over to Annette Jouault and Annette Jouault is now taking on a lot of residential care responsibility. She has been visiting a couple of the people in the homes more recently. The problem I think they have had is that they have not wanted to come out and visit people. I think Income Support think that they are based at Social Security and there is not a necessity to visit people in the community but there obviously is when there is somebody elderly in care who you cannot get down to fill a form in for you.

Deputy S. Power:

I suppose if somebody is not mobile I have one experience of a lady who because of diabetes had a leg amputated and she found it extremely difficult to get into La Motte Street. In that particular situation I had them go visit her and sort out her income support. Pearl, in your experience have you had Social Security or those ladies you refer to come out to you?

Ms. P. Thebault:

Yes, they have come out and done a financial assessment on the person that needs it. Then going back to that point about families, you have some people who live in and they have family to support and that can help them to sort out the finances. But as Julie said I have quite a few and it is either appoint a curator or we do act as their advocate and sort out their finances. That is I think a big question there. There is a gap there that they have not filled in.

Deputy S. Power:

So there is a void in the system?

Ms. P. Thebault: Yes.

Ms. J. Garrod:

Yes, there is a definite gap. Following on from the set banding that is going on currently, it is a bit difficult because we are in transition at the moment. Income Support have said that they will maintain the status quo within residential care with the transfer from welfare to Income Support. They are currently. But over and above the fee rates of £560 and £726, they are also paying currently all dental bills for me, all optical bills for me, all chiropody bills for me, all family nursing care bills for me, all incontinence pads bills, all dietary supplements, all G.P. visits which are obviously now H.M.A. (Household Medical Account) payments. So they are picking up all the extras. Now what they are saying is that this fee - this £560 and this £726 - should be an all encompassing fee for the person in residential care. They do not see they should pay any extras at all. They are currently but I am waiting for the time they say to me: "Okay, now it stops. The transition is over."

Deputy S. Power:

As I understand it if you are running a series of beds in Maison St. Brelade at £560 a week or St. Helier House at £560 a week, so I understand this, they are saying to you that that is including everything; incontinence pads and all the consumables.

Mr. A. Pemberton:

In future that will be the case.

Ms. P. Thebault:

Can I just say something? I just wanted to know because we have never had any service level agreement or a contract. We have never been given anything. I certainly have never received a letter from Social Security saying that this is what they will pay for a bed. There has been no evidence. I have not found like what you are saying there is no transparency. I understood that on the fee banding it would be Island-wide and we would all  know what would be happening.  Maybe that is something that they are working on.

Ms. J. Garrod:

Yes, I think that that is it at the moment. It is all so up in the air and nothing has been decided. I think it is almost like let us make it up as we go along to a certain extent which is I know maybe not very complimentary but I do feel that I have to say it. My big concern is that these residents who essentially their pensions pay for their care. All their pensions and all their benefits pay for their care. Those that were lucky enough to be receiving a D.T.A. (Disability Transport Allowance) prior to going into care prior to 28th January have retained it as a legacy. No, it has not gone up. It is the same amount of money they are receiving now but that is only being paid to them while they are in transition. That benefit, Social Security have said, will stop.

Deputy S. Power: Will drop away.

Ms. J. Garrod:

It will gradually reduce and it will stop. Then they will be left with a £29 a week personal allowance which is all they get currently in the form of payment to them. £29 a week is not a lot of money. I think they are not realising that people who move into residential care have a quality of life that they would like to maintain. What they are doing is they are going to make it very difficult for people going into care to have any sort of quality of life. There is no way that a home can organise transport for 66 residents within its budget within a fee banding fee of £726; let alone dental, eye care, chiropody, family nursing and all the other extras that people they say that is the high level residential care. All these people will need these services and these extra facilities but they are not going to pay any more money for them.

Ms. P. Thebault:

It does affect the person because I have one resident who only has that. There is no other income support available to that person and that is £28 - £29 a week. She is a smoker. Straightaway the choice is taken away from her. She has to reduce which I know is a health thing but it is a choice she is 70-odd. Likes a pizza once a week, cannot afford it.

Deputy R.G. Le Hérissier:

As you say in your letter, Julie, of course the D.T.A. attracted a lot of criticism.

Ms. J. Garrod:

It was a bad thing.

Deputy R.G. Le Hérissier:

Yes, and of course the losers there were the people who did not qualify on the transport perspective. They did not get what people increasingly saw as almost an entitlement to a pension. There was a group who were not receiving it because they were allegedly fit and they could move around. For the others it gradually became sort of transformed, did it not, into a greater degree of discretionary money?

Ms. J. Garrod:

Yes. In fairness there are people who received transport allowance that should not have received it. Where there have been cases where it has been blatantly abused before, I have asked Social Security to suspend it. It is not needed, it is being abused by the family, let us just stop the benefit now. But there are a lot of people who rely on it. If I can say to a resident going into care as I used to do: "When you go into care, yes, I will take your Jersey pension, your English pension, your Treasury of the States pension, whatever pension benefit you are getting. Your D.T.A. is a disregarded benefit. You will keep that." It is worth £38 to £66 a week so that on top of your £29 a week money gives you a nice little amount of money to be able to go out on a bus ride and have a cup of tea. If there is a night out at the opera house they can pay for a ticket to the opera house. They can get their hair done once a fortnight. They can pay to get their feet done. They can pay their income tax bill when their income tax bill comes in because a lot of them still pay income tax. But without that benefit they are down to the basic £29 a week. Their quality of life is going to, I think, deteriorate. They are all worried about it. They are all concerned about it.

Deputy R.G. Le Hérissier:

Just to put the discussion back on track and Sean can jump in later if I have it wrong. We are partly trying to get a picture of how we should structure long-term care in the future so I am going to turn your minds to that. I am going to ask Andy what his views are about how the States as a whole should finance some of the particular issues surrounding St. Helier . Then we will come back to you, Julie, and try and pretend that transition is not happening which I know is very, very difficult. We want to hear from you and indeed, Pearl, and indeed other people if they wish. Try and tell us how you would like to see the system structured in the future. Andy, could you tell us what your views are about how the States there are all sorts of issues running around like particularly do we  move to the Guernsey  scheme, for example. Do we move to  a  scheme unlike Guernsey that involves insurance for community care as well as residential care? If we do move to such a scheme, where will we get the money from?

Mr. A. Pemberton:

Firstly, I am afraid I am going to let you down on this because I have strong views about a lot of things, but I do not have this. I have not done enough research. I did read a report on it but I do not know much about it. I think just before I try and give you a couple of things I would like to just show the depth and difficulties facing the States; the depth of the problem facing the States because clearly this is a never ending pit looking

after old people. It is an ageing population. We have talked about £726 and £560 being too little. Let us add another £100 on to that for all the extras; between £50 and £100 I guess on average. On top of that if we take St. Ewolds as an example; not because I am just trying to protect the home, but as an example. At the moment I need £760 to break even. You are paying me £726 so I am losing £34 a week per resident. If I go down to £560, which we are happy to do in consent terms to keep it full with lower dependency people, that is another £200 I am losing. If you then take the £50 or so away for the extra pads and for everything else, suddenly we are in the deficit of on average say £100 per resident. So the only way I can solve that because we only break even - do not make a profit - next year I have to put up my rates by £50. So next year to accommodate 20 people at £560 and to accommodate taking away the extras, you might be looking at £850 to £900 and that is just to break even. That is my problem but it is also your problem because you have to keep homes open on the Island. You want good homes to stay open and bad homes to close. You want new homes to open with good facilities so you have to provide adequate funding. It is extremely difficult and I do not have the answers. What I do know, surprisingly - and people will always say this - what was before was okay, right? In the past - and Julie knows the figures because we were the only people who knew the fees for all the homes in the Island - it went from about £250 a week, Abbyfield(?), was it £250? About 2 or 3 years. The figures I have got in my mind are 2 years on, say £250 to £300 up to about £1,100 for the same registration requirement; the most expensive. So the States have inherited say 20 homes or whatever it is with a range of say £300 to £900 to be reasonable and all on the same registration requirement. The risk is if you have a narrow band of £560, you will end up paying £560 to the cheap

homes - the charitable homes who do not need it - and you will be forcing the good, expensive homes like Pinewood not better but the private market ones, maybe the latest renovated ones obviously will go out of business. You will have a serious problem with strategically of how you keep places open, what you want to keep open.

Deputy R.G. Le Hérissier:

That assumes, Andy, they rely on a high proportion of public sector residents to keep them going.

Mr. A. Pemberton:

That is a problem from the parish because we are 80 per cent, though I am not sure what Maison St. Brelade you are 50, are you not? So we are the worst situation for that.

Deputy R.G. Le Hérissier:

One of the issues that we have heard about but not in detail is that the payment of the mortgage remains a great constraint. What proportion of your fees comes from having to keep paying mortgages?

Mr. A. Pemberton:

You did give me a figure for that. As a historical you thought a certain percentage were self-funded probably with a property originally, did you not?

Ms. J. Garrod:

Are you talking about those that have properties going to into care?

Deputy R.G. Le Hérissier:

No, you the parish to build these home because the private sector when it refurbishes it has to take out an

Mr. A. Pemberton:

How much does it cost me to build a new home?

Deputy R.G. Le Hérissier: What proportion of your fees

Deputy S. Power:

Do you still have loans outstanding and what proportion

Mr. A. Pemberton:

We have a strange way of financing. Maison St. Brelade is even more strange.

Ms. P. Thebault:

We have got a very good way of thinking.

Mr. A. Pemberton:

Yes, yours is because you cannot recover the cost much and the private sector of course they are trying to make a reasonable return but even there it is distorted. If you take somewhere as an example a private Home, I have reason to believe that say it cost to build £2 million, £3 million, £4 million and let us say it was worth current market value of say £6 million to £8 million. So of course you will say as there is an inbuilt re- evaluation each year. I think you are a property man, are you not, so where do you get full recovery? As an accountant, what are you looking for your return on your investment? The same when you own your own house. But then if you have invested £3 million and you have a bank loan to pay but then you might re-gear up and you could have £4 million borrowing against the £6 million now. So how you finance it is very arbitrary. What we do in the parish, we recover about £350,000 a year for the 3 homes so the average is about £100,000 per home which is like a sinking fund, like depreciation. We have no other rent charge or depreciation. But, however, if a new home is going to cost you £10 million - we have been quoted about £10 million for a new home for about 60 beds which is not more than a couple of million out so call it £10 million. So £10 million, if you finance that at 6 per cent that is £600,000 a year just on interest and no capital. For example, I am sure you know Maison St. Brelade are going to be investing I am going to guess £3 or £4 million which they need to.

Male Speaker:

A bit more I think.

Ms. P. Thebault:

It will be £4 million or £5 million. It will be.

Mr. A. Pemberton:

It is a lovely home, wonderfully respected and one of the best homes in the Island, has a very strong St. Brelade bias and warmth about it, but it is not just catering for St. Brelade people. It needs to go en suite. It needs to invest £4 million. It is in the right place catering in the right way with the highest standards. If I was advising them I say, close; that you cannot justify it. How can you possibly justify £5 million at 6 per cent, £300,000 a year? Then at the moment the figures I have seen, I do not see them recovering any of that. Maybe I should not quote things but their accounts are public knowledge so I am not being indiscreet.

Deputy S. Power:

You are coming at it from an accounting point of view as distinct from a parish or a social function point of view or a social welfare point of view?

Mr. A. Pemberton: Yes, you are right.

Deputy S. Power:

But the parish tends to absorb the capital cost.

Mr. A. Pemberton:

That is coming out of the rates and I am sure, yes, there are substantial donations but effectively your 20,000 parishioners are subsidising - about 20,000 or 10,000 in St. Brelade - the rest of the Island because

Ms. P. Thebault:

Nothing has been agreed yet. We have not sorted out our financials.

Mr. A. Pemberton:

But do not forget we dearly want St. Brelade to expand. It is a fabulous home. But you cannot justify it as an accountant. Now our homes, we need to replace Maison de Ville. A lovely home. They have been trying to close it for years. It is a good home, lovely environment, very warm, very small rooms. But it cares for some more high level of people with dementia and alcohol problems. It fits the niche and it is local and it is an excellent home, is it not? Everybody says that, a lovely home. We need to close it because the rooms are too small. In 2 or 3 years I think we will have to close it so we should replace it. Fifty people will need to go to a new home, £8 million to £10 million. Where am I going to find the extra £600,000 a year from? I cannot get it from these fees. I need to charge another £300 per resident. So if you want us to continue running good homes; highly registered, highly trained staff, warm with a great team of people, who is going to pay? The parish?

Deputy R.G. Le Hérissier:

What intrigues us, Andy, I do not know if it is because of other financing and I know Julie want to put certainly placement back into the hands of Health and Social Services, I think.

Ms. J. Garrod:

It was just a bit of a throwaway thought, to be honest, at the end simply because Income Support is saying that they cannot pay a benefit and act as the agent for it. Well, Health do it already for nursing care and fund nursing care. I am just wondering if they could act as an agent for pensions and benefits. So that might be one way forward for Health to take on the budgeting and sorting out residential and nursing care. Also because there is such a link between people moving from residential care on to nursing care, surely you get continuity there of funding instead of the situation at the moment where we move from one pot of money and one lot of funding organised by one person into a second pot of money organised by another authority. I just think sometimes it might be easier if it was all under one umbrella.

Deputy R.G. Le Hérissier:

I know it is not strictly your business but you probably know the answer. When we were involved in Overdale and we saw the closure and a lot of people were moved to another St. Brelade home. Where is that money coming from? Are they being banded in the same way you are being banded?

Ms. J. Garrod:

No, what they have done is they have negotiated

Deputy R.G. Le Hérissier: A block deal.

Ms. J. Garrod:

contract beds with certain homes. They are being paid for those contract beds whether they have a resident in them or not.

Deputy R.G. Le Hérissier:

You have not been offered that option, have you, even if you would wish it?

Ms. J. Garrod:

There was a tendering process and at the time you could tender if you wanted to tender for nursing care beds but our registration at St. Ewolds where we have 5 nursing care beds is different. We have a variation on our registration which means we cannot take people in to a nursing care bed but we can transfer from residential within the home to a nursing care bed. It is to enable us to look after our residents currently in place not to bring them in. We did talk to Mark Littler at Health at one point about going over to nursing care at St. Ewolds because it was an option and the building lends itself to nursing care but then we would have no say on who we admitted into nursing care at all. They made it quite clear whoever they wanted to put with us, they would place them so we would not be looking after our own residents. That was really what our interest was,

let us maintain the residency of those that we have at St. Ewolds as they get more poorly and less able and they move to nursing care, let us keep them. We do not want somebody else to have them

Mr. A. Pemberton:

Can I just briefly come in because it is really important? We have 5 nursing care beds at St. Ewolds at the moment which we get no extra money for; no income support. Due to a legacy agreement we get a small amount from Health; very small. But in future we want to go from 5 to 10 beds which we are allowed to do as a variation. This is fantastic for the Island. As Julie said St. Ewolds is perfect to be a nursing home or to have some nursing beds and some not. We want to do it. We do not even have to increase our staff terrifically. But we will get no funding whatsoever for it so we will not do it so you are going to have a blockage on nursing beds in the Island. But commonsense-wise we can supply extra beds quite cheaply. There is marginal cost of going from residential to nursing and keeping terminally ill people who want to die in a place they are happy in. It makes  common sense  for  the  Island but at the  moment  nobody wants  to solve the problem of paying for it.

Deputy S. Power:

Can I just come in here and ask you a specific question then? In terms of the transition in cost - the marginal cost you referred to - from residential to full nursing, what roughly do you think that would be?

Mr. A. Pemberton:

I am sorry, I do not have the figures. We were very fortunate first time round because we have highly paid staff - senior carers - who we replaced with nursing care. So the first time it went to 5 beds it cost us a marginal cost of about £20,000. We think depending on what is required, I think we talked about one extra when I was talking to the manager. I think it might only be one extra - call it £40,000 a year - because we have a little bit of surplus. Because we only have 5 beds, we have to have 3 nurses but we could probably only have 4 nurses for 10 beds so economically it would be better to expand. But the extra £40,000 will not be paid. Although we are saving money for the Island, nobody wants to pay it so we will not do it.

Deputy S. Power:

So just getting up to £40,000 a year is £800 a week?

Mr. A. Pemberton: Yes.

Deputy S. Power:

So it is about you are saying

Mr. A. Pemberton:

An extra £200 less than that.

On top of the £560 you are looking at pushing it up to about £800 each.

Ms. J. Garrod:

No, currently those in high residential care at St. Ewolds who move into nursing care, they are being funded at £760.

Deputy S. Power: Sorry, £760.

Mr. A. Pemberton: £726.

Ms. J. Garrod:

Well, £726 because Income Support will go to our new rate - our new increase - so £726 is what is being paid for them. On top of that we receive £9 a day which is the nursing care top up rate from Health

Mr. A. Pemberton: Which is a one-off.

Ms. J. Garrod:

which is what we negotiated so we could keep these 5 people in care. So for £9 a day we keep these people at the home whereas if they were in nursing care they would being paid an awful lot more for them. But it was an anomaly. We even did approach Mark Littler recently to say we would like to go to 10 because we have people sitting at St. Ewolds who really need nursing care now.

Deputy S. Power: They want to stay there.

Ms. J. Garrod:

They want to stay and the people we have in nursing care with the best will in the world they are staying where they are. They are not getting any worse. They are not getting better. But we need more nursing care beds. Will you fund another 5 beds which we can do on our variation license? He said: "No, we cannot fund any more." So what will happen is that we will get to a point where these people will have to go to nursing care. They will have to be taken out of St. Ewolds and put in nursing care somewhere else.

Deputy S. Power:

Did he give a reason for not doing this? Is it purely financial?

Ms. J. Garrod:

I do not know why.

Mark Littler is

Mr. A. Pemberton:

Basically said they do not want to do it and here is a one-off and they do not want to set precedent I should think. There was too much arbitrary funding in the past. Can I just give you an answer, I think I know the figure you are asking for and it is very, very rough. I have just done it in my head really. But I think we need about 4 nurses for 10 beds. I am not sure that is not quite marginal cost but let us start on that. Say it is £40,000 for nurses. Probably more than that for us. That is £160,000 divide that by 10 beds that is £16,000 per bed which is about £300 a week extra.

Deputy S. Power:

Extra on the top of the £700.

Mr. A. Pemberton:

Yes, so that would push it up to over £1,000. Then a true cost for nursing beds you would have to take off what it would cost you to have ordinary carers. So for 10 beds, how many carers is that, 1 or 2 over 24 hours? That is 3, is it not? Is it not one per 10? So it means you have to have 3 or 4 because it is 24 hours so call that 4. Really it is a difference in rates so you can divide it as two-thirds of that so it might be £150 true marginal cost. There will be a lot more laundry as well and things. I am going to be

really naughty and have a guess, more like for us maybe only as little as £150 per week as a guess. Does that help at all?

Deputy S. Power:

It does, yes, because when we did the Overdale Review we were given what the contracted beds are in the other homes. It is useful for you to do that and to indicate that because it shows us roughly what you can do it for as distinct from what our people are doing it for.

Mr. A. Pemberton:

I am guessing these figures but I am usually reasonably accurate. Say we need £760 at the moment to break even, my guess is the true cost should be about £900 for a nursing bed in our home.

Deputy S. Power:

Okay, that is fine. Sorry, Roy, we went off in another direction.

Deputy R.G. Le Hérissier:

No, it is okay. What I am wrestling with, Andy and Julie, is the fact that obviously you in St. Helier developed your homes for different reasons than all Island provision although you have ended up having to provide some of it. You now find yourself in a scheme which is essentially about placing people on the basis of certain criteria which are not necessarily based on parish residents as being an important criteria or an overriding

criteria. We are stuck, Andy and Julie, for good or for bad, with an all Island system now obviously. You have outlined some of the problems as we move towards that. How could that system be reorganised so that there would be good incentives for you to keep your beds full.

Mr. A. Pemberton:

I think Julie can answer that. I think it is flexibility. I think it is probably in extras and probably you start charging £560 for the first person who comes in and then someone will get £650 if they are in a wheelchair. So I think it probably needs flexibility but how Income Support do that fairly between different homes and monitor it, I do not know. Maybe it will take a lot of people.

Ms. J. Garrod:

I think banding, I think 2 bands is unrealistic. That is the first thing I say. You are either basic residential care or your high level residential care. That is not good enough. There are so many people that fall in between and you are not being paid for it. The trouble with banding as well and putting people into a band is that all it takes is for an old lady to get pneumonia and she is off her legs.

Deputy R.G. Le Hérissier: She jumps up to a higher band.

Ms. J. Garrod:

Yes, she is in another band. But are we to get them reassessed when that happens? When they become terminally ill and you try and keep them in your home, obviously their level of care gets higher and higher. Do you then get reassessed? Conversely, some people with bad chests get better in the summer. Are they going to be reassessed and have a lower band in the summer? There is always going to be it is a bit of an interpretation thing, is it not, really and realistically how soon changes can be made within your banding. That makes it almost impossible to work your budgets out for your future funding and whatever, I have to say. But I think whatever banding system we have, if that is the way we are going, I do think any extras, any supplements should be paid over and above the basic residential fee, the middle of the road, the high residential fee, whatever it is going to be. You cannot expect homes to pay all the extra fees because what will happen is that people will not get them. With the best will in the world, we would like to think that we are all going to treat people wonderfully and we are going to say: "You need new dentures, or they do not fit you, we will get you some new ones." You have to be able to know that the residents will get the best level of care and supplements and pads

Deputy S. Power: The consumables.

Ms. J. Garrod:

Everything they need. It is not the responsibility, I do not think, of the home to have to provide all those extras.

Deputy S. Power:

Following on from your comments on the banding, are you saying that we have 2 bands that obviously you are struggling with because there are many patients that do not fit within those 2 bands? Somebody breaks a wrist or somebody gets pneumonia or somebody has a digestive problem and they go way up the scale again. What are you suggesting? Would you be prepared or can you make a recommendation as to is it a third band or a fourth band or 2 more bands plus the consumables? What do you think would work?

Ms. J. Garrod:

It is not really for me to say. I have not put a huge amount of thought into it. Just from the simple point of view that there needs be more than 2 bands because nobody is either basic residential care or high residential care. Jules, for example, had a gentleman come back from hospital this week who is now much less able than he was. It is the worry also that if you say to someone come and reassess this gentleman, they will turn around and say: "He is not high residential care any more. He is nursing care." But Jules is quite happy to maintain him. He is quite happy being back at Maison de Ville with his oxygen condenser or whatever else he needs in place. So, it is very difficult. When something is taken out of your hands like that and into another authority or another body or somebody else who is going to be assessing these things, very difficult. I would say probably 4 bands just off the top of my head. That you do need 2 middle of the road bands. The other thing about the banding system currently is it is done on a multidisciplinary tool that people are using and it is tick boxes and it is tick boxes in colours. You get 4 or 5 in the green and you are one; 4 in the blue and you are another. It is open to interpretation.

Deputy R.G. Le Hérissier:

Say you receive a resident who has been banded on a certain thing then you say: "Well, they got it wrong." Have you got any comeback?

Ms. J. Garrod:

I have not as yet. I have 2 that I am going to use as a tool that Jules and I did. She worked through a placement tool last week. I am going to go back to Rosie. I am going to say to her: "These 2 people I think now need to be reassessed." I think part of this we need to accept some responsibility for in the past in that we set our home rates at a certain level. We said the rate for St. Helier House is £560. We did not work on that individual which is what they are doing now. They are saying this individual needs this level of care and they can have this amount of money. I do think it is probably the way we need to move forward if we are going to hopefully save a bit of money. It is going to work in our favour in some homes and not in others. I am sure there are some at St. Ewolds that went there for the better facilities or because they had infections and needed their own bathrooms, for example, that perhaps do not need that level of care any more. So there is going to be I think a lot of jostling of rates and things within the homes.

Deputy R.G. Le Hérissier:

We have heard this complaint even under the old system, Julie, particularly from the smaller homes that they were not being given people so to speak by the parish welfare system and this was really bankrupting them because they obviously rely on a proportion of public sector residents. If there are only these bands, what incentive is there then for a home to increase its facilities if it is only getting this amount of money and it is only budgeted? Yet within the system there are some anomalies. We know, for example, and I am sure you do, that the biggest private sector provider on the Island does not offer pensions to its staff. Yet you carry the cost of offering pensions.

Mr. A. Pemberton: Yes.

Ms. J. Garrod: Yes.

Deputy R.G. Le Hérissier: Which is interesting.

Mr. A. Pemberton:

The logic on that is then in the private sector you would say: "Let the parish homes close. They will be taken over by the private sector who will not pay pensions." You save 15 per cent off the Island taxpayers. A very difficult problem.

Yes, and you could come up with a costing mechanism or a payment mechanism that reflects that but what it would eventually do is drive people like you out of business I would have thought, will it not?

Deputy S. Power:

The other argument, if I may come in on that, Andy, is that the Island would be taking quite risk in allowing a lot of the private homes to take over and allowing homes such as yours to be put out of business because then the Island itself, whether it is the Health Department or whether it is the parishes, do lose that leverage over the private sector.

Mr. A. Pemberton: Absolutely.

Deputy S. Power:

If it all went private I think the Island would be in a much worse position.

Mr. A. Pemberton:

You are quite right. It is not just us because you have loads of charitable homes. As Julie knows the Methodist homes, for example, are very cheap, very good services. There is going to be problems trying to balance the private and the charitable and the parish sector and keep the homes you want and keep it balanced effectively. Can I just say one thing, because we are going to run out of time? You asked about insurance.

Deputy S. Power:

Yes, we were going to come back to that, yes.

Mr. A. Pemberton:

Julie said to me the other day, because she has dealt with a lot of people who have had homes to sell, I am going to quote here - and tell me if I am wrong - it is remarkable how few rational people who sell homes get truly bitter about it. There is something to be said that people who have a home and eventually sell it to go into a parish home or any home do accept it as some fairness, some equity in it. So that is one point of view. Other people clearly get fed up with it. With regard to insurance there is an argument again that Julie says - I am quoting you here and I agree with it - that again it is just the middle class if you like who are going to pay. It is all the ones who are working, they have 3 kids or 2 kids, got a mortgage, got a house and as usual it is them who end up stumping up all the cost of it. Poor people who will not be employed or below the threshold, they will not be contributing. Very rich people at the moment would be paying for all their own care. They would not have insurance. In a way the risk of insurance is that it is the working 20 per cent or whatever who are paying for everything again.

Deputy S. Power: The narrow window.

Mr. A. Pemberton:

The taxing of the steady conventional worker.

Deputy R.G. Le Hérissier:

But you could operate it like I mean education is paid for through tax and even if you want your children educated privately you pay your tax and you pay the school fees, do you not?

Mr. A. Pemberton:

Yes, I think a 2 tier thing has a lot to be said for it but I have not looked into it.

Deputy R.G. Le Hérissier:

Obviously there is a lot of enthusiasm as I said about some variation of the Guernsey model, partly to provide the security that during you whole life you are putting some money in and you do not have the shock of giving up so-called family inheritance. As you know it has become highly symbolic that we do not want to lose the house because it represents all we have worked for all our life and so forth and so on. But we are prepared to pay the equivalent amount of money, so to speak, through regular payments all our life to insurance. That seems to be how it comes across.

Mr. A. Pemberton:

How do you feel about that, Julie?

Deputy S. Power:

Have any of you got experience of the Foresters Scheme which is

Male Speaker:

I thought you meant the Foresters at Beaumont.

Deputy S. Power:

The Foresters Insurance in Guernsey.

Deputy R.G. Le Hérissier: Yes, we get that one.

Ms. J. Garrod:

This is the 1.4 per cent of your income. Yes, I just think of it as a tax if I am honest. Again there will be those that are earning who will be paying it and those that have not earned. You are paying it on your pension as well.

Deputy R.G. Le Hérissier: You do. You are quite right.

Ms. J. Garrod:

So you pay tax throughout your working life. You pay tax on your pension. Then you pay this additional tax to the residential care that you may not ever have to access. I have never ever personally, in the years I have worked in welfare, ever asked anybody, made anybody, compelled anybody to sell a property to fund their care. We have on occasion taken a lien on the property so we might in the future have asked the family at the time of the person's death: "Do you want to sell the property and pay us back? Does the family want to raise the funds and pay us back? Do you want to raise a mortgage and pay us back?" We have not even always done that. Sometimes all we have asked for is the rental income from that property during that person's lifetime if it was the main place of domicile. So there are other ways of doing it. I can see both sides of the story. I do not personally having a problem with selling my property to fund my future residential care if I need it. If my children want to inherit my property then they can fund my residential care. That is not a problem I have with that. Some people do have a problem with it. I have probably more of a problem with the fact that as a taxpayer you are asking me to pay £40,000 a year for someone who has an asset of £750,000. I am not saying it is a fair system but it is just a different interpretation. I have seen different ways of it working. I do not think there is any problem with getting a rental income from a property, for example. If you work out the rateable assessment on a particular property it gives you a relative idea of how much rental income you get from that property and maybe just ask for the rental income; whether the family want to rent the property out while that person is in care and pay it as a contribution towards their fees or whether they want to raise the money themselves and keep the property empty. I think that is an alternative solution that might work.

Deputy S. Power:

One of the models I looked at very recently because my mother-in-law has just gone into care in Northern Ireland. In Northern Ireland, Health and Social Services are one unit. What they have done there is the department is essentially saying: "If Mrs. Jones is unwell what we will do is take Mrs. Jones into one of the care homes." But what they do is they manage Mrs. Jones' house. They do the renting and rent the house on behalf of the income that is needed. Then when Mrs. Jones passes on they approach the family and say: "We have taken this rental income but we now will allow you to raise 25 per cent mortgage or 33 per cent to pay us off." But it is a different way of approaching it. It does away with the

Mr. A. Pemberton:

Can I just stop you because that is a 2 stage process You are getting the rent while the lady is alive and when the lady dies you are getting a top-up, the full cost, out of the proceeds of the house ?

Deputy S. Power:

Yes.

Mr. A. Pemberton: That is quite clever.

Deputy S. Power:

That is relatively innovative but it has just come in in the last year up there.

Ms. J. Garrod:

I have taken rental income before.

Deputy S. Power:

Yes, but you do not rent the unit yourself.

Ms. J. Garrod:

No, we get the family to organise the rent. I have used the assessment made by the rates office, for example, as to the value that perhaps the property could get. I negotiated because in fact a grandmother who wanted her grandson to live in the house and he was in a position where he was out of work at the time as well so it was a case of either welfare paid for the son who was out of work to go in to accommodation somewhere so we were going to be helping him with the rent and his wife and children - the children's allowance - and the grandmother in care. So we said: "Okay, you go in there." If you have work only then will we negotiate an arrangement of what we took in funds. But that was the beauty of the welfare system I would say. It was discretionary. It was flexible. You could make these different judgments. It may not always be fair to everybody. I just mention the point you made before about St. Helier , the parish not funding people in smaller homes.

Deputy R.G. Le Hérissier:

What we picked up, Julie, that some of the smaller homes were struggling because they were not getting placements.

Ms. J. Garrod:

Placements come from social workers though.

Deputy R.G. Le Hérissier:

Yes, from social workers. Yes, sorry, yes.

Ms. J. Garrod:

Not from the parish. I have never not agreed funding anywhere I do not think, I have to say.

Deputy R.G. Le Hérissier:

But obviously Andy outlined at the very beginning a situation where you are struggling if you are not up to 98 per cent. But obviously the smaller the home, you have only got to miss 1 or 2 clients and of course you are in big, big trouble as a private operator.

Deputy S. Power:

Can I just pick up on 2 points we have left hanging in mid air because I know we are getting on past the hour now? It affects Maison St. Brelade and Maison de Ville and both relates to room sizes and is obviously incorporated into the capital cost of borrowing to upgrade your facilities to a size that is acceptable. It is one of the things I have had incomplete discussions on this but do you think there should be a model whereby Treasury - central States of Jersey funds - should be available to parish homes like

Maison St. Brelade or Maison de Ville so that you can borrow directly from Treasury at perhaps a preferential rate?

Ms. P. Thebault:

In effect this happened before. Historically, that is how Maison St. Brelade was built. They got their arrangement in the last bill, 25 year loan, no interest. It was funded through Treasury. That really would be very beneficial.

Mr. A. Pemberton:

Briefly there are lots of variations on that. I believe ours was at I think 2.5 per cent or 3 per cent I think. It was lower. In fact in reality, talking as an accountant, I deposit our money at favourable rates. We have surplus sums in the parish because of the operational cost. We receive half percent over base on our deposits and can borrow at a similar rate. In reality for the Island my cost of borrowing is the same as my cost of lending. Obviously the benefit of what you are doing is sharing the cost of keeping these good homes more fairly through the Island through taxes but it is not necessarily cheaper for the Island as a whole. I know I am sounding contradictory. I do not want to pay for it now. I think your solution works that way but I can get very cheap borrowing.

Deputy S. Power:

But even if it was just 1 per cent over 25 years

Mr. A. Pemberton:

Deputy S. Power:

just something that encourages the parish to keep doing what they are doing because obviously you cannot pay 2 per cent over L.I.B.O.R. (London Interbank Offered Rate) or whatever it is, because that simply is not going to happen.

Mr. A. Pemberton:

I think that is a good idea.

Deputy S. Power:

I think it is something  that we may want to incorporate into what we do with our summary and recommendations but we are a way away from there yet. My second question is when you first came in, Julie, you referred to a problem being caused by bed blocking in the transition from welfare to income support. I am not quite sure what you meant. Can you explain bed blocking and how it works and what you meant by that?

Ms. J. Garrod:

Essentially when people are in hospital, and it is more so from residential to nursing care but it is happening I think to a certain extent in residential care. People are in hospital and they are being told: "You are not fit enough to go back home again now. You need to consider residential care." They have to then wait for a Tuesday for a social worker to be appointed. So if they are sitting there on a Wednesday and they are told you cannot go

back, they have to wait until the following Tuesday for a social worker to be appointed. Then we go through this whole rigmarole of a multidisciplinary team being put together to decide where that person can then be placed. Then the head of the home is invited to go and assess that person to see whether they are suitable. Then an application is made to Income Support for funding. Then a form is sent out from Income Support to the next of kin - if there is one - to fill out a form. If there is not, we have to wait for someone to come out from Income Support to go and assess that person and complete the 24 page financial assessment form. So everything then takes time. Then they get moved. Then there is the scenario whereby, okay, this person is in care, who is going to clear the flat now? That was a job that we used to do. I used to get funding for doing it. I now have not got a budget to do that sort of thing any more. I am still doing it to a certain extent because social workers are saying: "I am not doing it. I do not clear flats." There are other elements obviously then that creep in; things that are not being covered by income support that I am having to pick up.

Deputy S. Power:

Who does the house clearance now? Who does the flat clearance now? Is it

Ms. J. Garrod: Me.

Ms. P. Thebault:

I have done it on occasion for a resident who had nobody. The social worker who was appointed was off sick. Nobody was going to do it. All her things were being thrown out. I went physically myself and packed up.

Deputy S. Power:

So you literally turned up with your car or whatever, a van, or something.

Ms. P. Thebault:

I used my maintenance person and we went and did it because she had nobody else. There was nobody.

Mr. A. Pemberton:

St. Saviour pays people to do it now.

Deputy S. Power:

So the bed blocking that is a decision is made that somebody needs to go into care who has come into the hospital sick from a private house or private flat. A decision is made for them to go into residential care. That person is then blocking the bed and they could be sitting there for weeks while the process is done.

Ms. P. Thebault:

It could be weeks. It is an assessment, is it not, but the process of the assessment is time- consuming so you have got a time factor. Obviously with the close down of beds at the moment, the closing of wards there is a pressure. By the time all the assessments have been completed you may be 4 days later. That 4 days that person could have been out of hospital basically. But they do not have social security I find as well. There is a gap with regards funding like Julie has picked up. People are really not well enough to go home to their own place. They need somewhere to go to be looked after say for another week or 2. There is not the funding set aside for that. What they are saying in residential care, they are using the word. There is a play on words. Whereas before you would have a respite. Respite means that the carer who is looking after the person who is ill gets respite but there is nothing there really for the person to step up at the moment to recover. I think there is a gap there.

Ms. J. Garrod:

Definitely. We used to have convalescence. If an elderly lady went into hospital and she had broken her arm, they fixed her arm, they put her in plaster but she could not go home because she was elderly and living on her own. She could not cope. She could not brush her hair, could not get dressed, could not go home. What they would do, they would send her to Overdale for convalescence until she was fit to go home. As we all know there is no convalescence at Overdale; has not been for a long time. What happened is the parish

we used to pick up what we used to call respite discharges. The typical thing, the old lady who needs a bit more care, those who perhaps have been frail and not well at home, they do not need hospitalisation any more but they are still not fit enough really to be able to go and make themselves a cup of tea or something to eat. They need more than perhaps family nursing can offer. Again we would move them to one of the homes as a temporary measure - as a stopgap if you like - before they are ready to be discharged home with all the services in place. That is respite care. Income Support do not do respite care.

Deputy R.G. Le Hérissier: Who pays you then?

Ms. J. Garrod:

We have been paying it, the Parish of St. Helier , for St. Helier residents. Some of it I have been claiming back from Income Support. We did come to an agreement with Rosie that I have a number of gentlemen who live on their own in St. Helier . If we just get them in for a couple of weeks every 4 months or so and then I get them in, I can go into their flats, clean their flats up. Basically make things better for them at home again. Change the furniture. Change the carpet. Whatever I need to do. Then we can put them back into their home. They are not ready for residential care. They do not want to be in residential care. But by just offering that couple of weeks respite every now and then we keep them living at home in a better condition for longer without the necessity for care. We have a bit of a tentative arrangement at the moment but again it is all to do with transition. Rosie has been accommodating and letting me having these people in care but it is not something that will be covered by Income Support. It is a very temporary measure. So that something that does need to be done.

Deputy R.G. Le Hérissier:

One other major area you just mentioned family nursing, Julie. We picked up in some of the evidence, and we picked up from Guernsey as well, that in some respects numbers in residential care are going down. It is argued, particularly in the privately funded section of residential care in Jersey, we have as a proportion - say compared to Britain - we have a lot of people in residential care who maybe for various reasons they have an awful lot of money and they can afford it as some kind of special hotel experience. But we need to put more resources into community care and we need to make family nursing able to deal with more complex situations, to have more staff in the evenings so not everybody are put to bed or people are put to bed from 6.00pm onwards and all this sort of stuff. Do you feel that there is a whole lot of expansion of community care that we could push for?

Ms. J. Garrod:

I do. It is very difficult really. I used to do some district nursing so I have seen the other sign of the coin. There are a lot of elderly people living at home. I do think though there is a difference of opinion in that some people will say, for example, that a lot of people living at St. Helier House do not need to be in residential care because to all intents and purposes they look and fit and well. They can get up and they can dress themselves and they can look after themselves. But a lot of them that have gone into care have been living in fear in the community because they live alone, they are in tall, high-rise blocks, they have noisy neighbours, they cannot cope, they get agitated, the agitation means they do not sleep and they spiral then into a depressive illness. There are a lot of people that have gone into care that as a result of being in care feel that they are safe, they are being looked after, it is a nice environment. They have people around. They have friends. They have carers. They can live independently within the homes. I think that might even be cheaper or could be cheaper than putting family nursing services in twice a day, twilight services because family nursing is expensive and  care in the community is expensive.

Mr. A. Pemberton:

What you are talking about is sheltered housing should it really be that intermediate stage, where you want guardians on site to cope with some of those people.

Ms. J. Garrod:

Yes, but in sheltered housing they are on their own at night and a lot of them do dislike the fact that they are in an environment where they are being careful. I think there is a place. I am not saying every home should be like this but I do think there is a place for a low level of residential care in some particular places; just those that need a little bit more than sheltered. As I say I think to a certain extent it could be cheaper than family nursing in some ways. But there is no doubt that a lot of people want to stay at home as long as possible but they do need more input.

Ms. P. Thebault:

I think there is a certain feedback from family nursing who come in and visit the home. There are cases out there when you get people who are not coming into residential care because they cannot afford it. They are asking family nursing to increase their level of

service but they cannot meet their needs because it is equipment and it is bodies. Their environment might not be suitable at home to supply all these things, with the best will in the world. The system at the moment is not good. There are not enough resources as you say in the community but there is also the need for various other reasons other than physical health or mental health needs. There is loneliness. I find that all the time as well in my home. It is a mixed bag. Maybe people would stay at home but with the way family nursing is here on this Island at the moment, I just cannot see that happening. I think the whole family nursing would need to be looked at. I personally think it should be Health and Social Services.

Ms. J. Garrod: Yes, I agree.

Ms. P. Thebault:

I think it should be under one umbrella. There should not be a charity run organisation supplying that. That is my own personal opinion.

Ms. J. Garrod:

It is not a free service. People seem to think it is a free service.

Mr. A. Pemberton: No, it is not.

Ms. J. Garrod:

I had a phone call from a lady yesterday who asked me to go and see her as a matter of urgency living in quite appalling conditions I have to say really, obviously not coping at home. Does not want to be in residential care and neither should she be really I have to say. I got family nursing to go and see her. They were offering her level 1 care and wanted £13.50 an hour for it. She cannot afford that out of her income support benefit.

Mr. A. Pemberton:

That is a lot cheaper than putting someone in a home.

Ms. J. Garrod:

That is just one hour's cleaning. She does not need any more than that. She does not need residential care but just from the point of view of family nursing not being a cheap option at all really, I think, for some people.

Mr. A. Pemberton:

From an accountant's point of view I think if they were getting something like 10 hours so £135 a week instead of £560 a week. It might seem expensive but it is a lot cheaper for the States to pay £135 for 10 hours than it is to put somebody in a nursing home or residential home.

Deputy R.G. Le Hérissier:

Good point. One home we went in to - back to what Julie said - we saw there were apartments in the home as well as really the conventional rooms so that people had a bridging kind of where there were couples I suppose. They were able to bridge into the home if they ultimately needed to end up there. Do you think there is any merit in that? You can take part in all the social facilities in the home. You could even I suppose take your meals in the home. Then ultimately you have that little apartment to which you can go back. Do you think we could pursue that line?

Ms. J. Garrod:

Yes, I think it is something that is worth pursuing. It is something that Bonaire did previously before Bonaire changed to Highlands. They had little cottages at the back that were serviced by the home. I worked there a long time ago. A lot of them used to have access, used to come in for their lunch or for the activities that were on offer if they wanted to. There was a driver that would take them down to town every day, someone to do the laundry, someone to do the gardening. But I have to say that was quite expensive. It was an expensive way of doing it. But, yes, it was a lovely option and worked very well.

Deputy S. Power:

I think the ones you are referring to were very expensive.

Mr. A. Pemberton:

Yes, in the U.K. there is the concept of villages where you get blocks of 15 low dependency going right the way round to the highest all surrounding a common block.

Ms. P. Thebault:

Yes, but would you want to live in it? I would hate it. Too many models like that. In my personal opinion, I would not want to - and I am moving up the age scale - when I come to 70s or 80s live in a purpose built village. I would hate it. Personally I work with elderly people. I love my job but being surrounded all the time with people is not a normal existence, I think. It should be interspersed. You want to see children. You want to look at life. You do not want to be grouped. I really personally speaking do not wish that.

Mr. A. Pemberton:

That is against residential homes in total then, is it not?

Ms. P. Thebault:

No, it is against the concept of the round-tree village. That is what I am against; not residential. But like L'Hermitage, for example, I think I would hate to see that concept expand further in Jersey in an Island as small as this.

Deputy S. Power:

Yes, one of our colleagues uses the phrase "geriatric ghetto" very often.

Ms. J. Garrod:

I think it is a very good description.

Ms. P. Thebault:

But you want to see a child on a bicycle cycling past, do you not?

Ms. J Garrod:

I do think also the other thing that is going to have an indication on residential homes is going to be this new registration of homes law. It is going to be, I do not know, draft 2 years or however long off it is then suddenly backdated so the minute it is backdated Maison de Ville, for example, will fail because it has not got the room to

Ms. P. Thebault:

It is not fit for purpose.

Ms. J. Garrod: That is right.

Ms. P. Thebault:

But to be fair, I agree with the law coming in, I think is very necessary because the building is not fit for purpose. Maison St. Brelade is not fit for purpose.

Ms. J. Garrod:

Yes, but there are still homes that have multi-occupancy in one room, for example. Perhaps that is the only way they can make ends meet. Are they going to be automatically lost to your store of residential care beds?

Deputy S. Power:

We are well aware of nursing homes that are held in high regard on the Island but that because of the nature of the building and the room sizes and getting people up and down in lifts and that kind of thing, under new registration it means that they are not going to survive because they will not be able to adapt them.

Mr. A. Pemberton: Yes, very difficult.

Deputy S. Power: Which is a loss.

Deputy R.G. Le Hérissier:

Okay, we have covered an awful lot of ground. We have tried to pick your brains to solve the problems.

Deputy S. Power:

You were right when you came in and said we would need 5 or 6 or 7 hours.

Yes, very interesting. Sean and Malcolm, have you got any questions you wish to ask?

Mr. M. Orbell:

I could think of a few but I would not ask them now.

Deputy R.G. Le Hérissier: Do not be shy.

Deputy S. Power:

I think the important thing out of today is that if you feel there is anything that we have not even remotely covered that we should have, please feel free to write in A.S.A.P. (as soon as possible). Poor Malcolm here is still trying to put the first draft together very, very soon.

Ms. J. Garrod:

The only thing I just would mention now is H.M.A. which obviously as you know is the old H.I.E. (Health Insurance Exemption). As it stands it is okay. At the moment our residents are having their doctors' bills paid. But what they are not paying for at Income Support are repeat prescriptions, blood tests, consultant letters so this is a referral, epidurals and things like that that arise as a result of consultation. The argument is that Income Support is saying to the G.P.s you have £80 per consultation for these people. That should encompass everything within it. The G.P.s are saying it does except for all

these little extras. They are still trying to pass the extras on to my residents but I am refusing to pay them at the moment so I am just sending them back to the surgeries.

Deputy S. Power:

Will you make a note of that, Malcolm?

Ms. J. Garrod:

It is just going round in circles, I am afraid. I just think

Deputy S. Power:

I think it is like what you said possibly an hour ago that there are areas that are in so grey an area at the moment, particularly the transitional arrangements. What would it include? What will it not include? When is it going to end? We need to have it defined to make it as workable as possible because it is not at the moment. Being in a transitional phase is not good. It needs to be

Ms. P. Thebault: Clarified.

Ms. J. Garrod:

As a final thing, I am sorry about this because I could go on for ever. The other thing I wanted to say is that currently Income Support are funding residential care fees. Income Support is a non contributory benefit which means that anybody can come to the Island,

live here for 4 and a half years, not contribute and move into residential care and be funded. We have no reciprocal agreements with the U.K. or France, Portugal, Madeira, anywhere else that might want to bring their family members over and be accommodated here. I will tell you now I am getting phone calls weekly from people living in Jersey that have been here a long time saying: "My mother is in Scotland still. I would love to bring her over but what is going to happen?" I say: "If you bring her over and she lives here 4 and a half years with you, she will be fine at the moment because Income Support are agreeing to fund people who

Deputy S. Power:

We had this subject come up once this morning.

Deputy R.G. Le Hérissier:

Yes. Financially, it is potentially

Deputy S. Power: It is an open pit.

Ms. J. Garrod:

It is, like an open door policy for everybody else to come in and abuse it. I think it should be a contributory benefit I have to say but that is just personal opinion.

Deputy S. Power:

So if you come here and you are ill you should be able to pay your way.

Ms. J. Garrod: Yes.

Mr. A. Pemberton:

I have one thing too. I am just wondering whether you 2 ladies want to say anything because you have been very quiet. You have loads of ideas. I know you have. Are you okay?

Deputy R.G. Le Hérissier:

As Sean just said, Andy, if people have got anything that they want to say or they want to write something or they go away and say: "Heavens, I forgot that." Just give a phone call to Malcolm or if you prefer to communicate in writing, write or whatever.

Mr. A. Pemberton:

That is good. If I could just finish on one point I made.

Deputy R.G. Le Hérissier:

Yes, I was going to take a final word out of everybody, so to speak.

Mr. A. Pemberton:

I think you mentioned education earlier. I think you mentioned we have a system in Jersey where 30 per cent of people pay for their secondary education. Why when you have some of the best education free, why do they do it? It works. I do not know why. I think this is the strange thing about the system before was that it was weird. It was a mixture of a lot of choice, open market competition, people making profit and a subsidised charitable sector with loads and loads of choice and quite a lot of flexibility. Amazingly it was getting expensive. It was going up 10 per cent a year but it did seem to work. I just wonder whether other examples in the world will not fit here. That maybe

Jersey can have expensive private homes next to a different mix sector. Charitable homes, Methodist homes, do not get any recovery on their capital investment. It is not a solution but it is a thought. Maybe we should not be going for the rigid income support solution where everybody is getting the same fair amount. Maybe it just will not work.

Deputy R.G. Le Hérissier:

Julie, do you have any final thoughts?

Ms. J. Garrod:

Too many to even think about. The one thing I did want to say really was that because my residents are living on £29 a week a lot of them currently because they do not receive legacy D.T.A., historically when the benefits went up - pensions went up on 1st October - there was always an increase in their personal allowance. It has not happened this October. She has mentioned it will possibly happen in January but I have to be honest when the benefits went up on 1st May by 3 per cent in line with G.S.T. (Goods and

Services Tax), the benefit did not go up then. I had to beg and borrow for it to go up finally in August and backdated to 1st May. I just feel like my pensioners who have contributed 43 years, the majority of them, and not accessed the system are the ones being treated not very well.

Deputy R.G. Le Hérissier:

Pearl, have you any final thoughts you want to

Ms. P. Thebault: No.

Deputy R.G. Le Hérissier:

Nothing from our friends at the moment, okay? Look, it has been a very enlightening session. Malcolm did tell us that you had a lot of interesting things to say. I think you certainly did. We very much admire your passion and your interest for the work that you do. Thank you very, very much indeed. As I said if you have anything else, any brainwaves, if you know how to finance this system, we would like to hear from you.

Mr. A. Pemberton:

Come and visit us. These are 4 of the best homes in the Island, believe me. Excellently run, highly trained, all the staff have got N.V.Q. (National Vocational Qualifications), highly trained to the highest level. It is a very good place to start in Jersey.

We might well do that.