Long-Term Care Scheme - Cheshire Homes - Transcript - 24 July 2017

STATES OF JERSEY

Health and Social Services Scrutiny

MONDAY, 24th JULY 2017

Panel:

Deputy G.P. Southern of St. Helier (Vice-Chairman) Deputy J.A. Hilton of St. Helier

Deputy T.A. McDonald of St. Saviour

Senator S.C. Ferguson

Witnesses:

General Manager, Jersey Cheshire Home Honorary Chairman, Jersey Cheshire Home

[11:32]

Deputy G.P. Southern of St. Helier (Vice-Chairman):

... first time this morning and just to draw your attention to the terms under which you are giving evidence today and the usual apologies from my chairman, who is dealing with family matters in the U.K. (United Kingdom), and as usual we will just introduce ourselves for the record. I am Geoff Southern , the Vice-Chair of this Health and Social Security Scrutiny Panel, which I can never say.

Senator S.C. Ferguson:

Senator Sarah Ferguson, member of the panel.

Deputy T.A. McDonald of St. Saviour : Terry McDonald, member of the panel.

Deputy J.A. Hilton of St. Helier : Deputy Jacqui Hilton, panel member.

General Manager, Jersey Cheshire Home:

David Lord, General Manager Jersey Cheshire Home.

Honorary Chair, Jersey Cheshire Home:

Jim Hopley, chairman, Honorary Chairman of Cheshire Homes but I carry other responsibilities as well.

Deputy G.P. Southern : Okay, thank you.

Deputy J.A. Hilton:

We wanted to welcome you and are really looking forward to having a conversation about long- term care. I wanted to kick off by asking about funding. I note in your letter to us of 12th April you inform us that your income is insufficient to cover expenses to the tune of £400,000 per annum.

General Manager, Jersey Cheshire Home: Correct.

Deputy J.A. Hilton:

I was just wondering if you could just fill us in on some detail about that.

General Manager, Jersey Cheshire Home:

It is very  straightforward. We accepted the payments from Social Security for care for the residents from the level they were able to give us and we wish to give better service than would necessarily ... the very basic service that would be supplied by the amount of money available from Social Security.

Deputy J.A. Hilton: Okay, so Social ...

General Manager, Jersey Cheshire Home:

This is not something new, the £400,000, as a result of L.T.C. (Long-Term Care). The Cheshire Home has run at a financial deficit for many, many years which is why we do the fundraising we do to enable us to give the service and the additional benefits to our residents that they need.

Deputy J.A. Hilton:

That they would not otherwise get under the system ...

General Manager, Jersey Cheshire Home:

They would not otherwise get, physiotherapy, aquatherapy, outings, transport; all included in the package because I want to include everything as a sort of package and it seems to work.

Deputy J.A. Hilton:

So you raise up additional funding.

Honorary Chair, Jersey Cheshire Home:

Yes. I think what you have got to take on board is that our mission is a lot more extensive than just looking after permanent residents. We have got 23 to 25, depending on how full we are, permanent residents at the moment. That will increase when we complete a build that we are just about to engage in but we also look after as many as 400 other Islanders who need protective work done to keep them out of care, as mobile as possible, as good a quality of life as they can possibly enjoy and that is the whole point of us having a hydrotherapy and a physiotherapy set up which provides all sorts of service to all sorts of Islanders; Stroke Association,  Parkinson's, whatever else it might be. So our operational deficit annually is running roughly at £400,000 a year and we have got to cover that from 2 means; one, as David's explained, is fundraising, and donations and sponsorship. We have got significant reserves which are there primarily to cover the infrastructure. The building, as time goes on, it will deteriorate. We do draw down an investment income from that which helps us to cover part of the gap but our operational deficit is £400,000. We get no contribution from the States towards that beyond the fees that we recover from our residents under long-term care.

Deputy J.A. Hilton:

Okay. Can you just give us an overall view, your overall view, of the Long-Term Care Scheme as it exists? How do you feel ...

General Manager, Jersey Cheshire Home:

The concept is brilliant and, as I think I said in my letter, there are operational hiccups with it. One of the issues that is very important to us is that when a resident comes to us they are normally at their lowest ebb. They have just come out of hospital or they are about to lose their home. They have lost a partner. Whatever it is, they need to come into the care with us and they are at a very low ebb and they get greeted by this ... I think it is a 72-page document which is in an unintelligible language and then they have to go through assessment periods and I think that that is the weakness of the system. I do not know how you solve it. I am sure other people have highlighted this to you. But it is noticeable that you see ... and it is not just the individual who suffers from this, it is the whole family and relatives and some of them are in a pretty frightened state. If that could

be improved, the assessment system could be improved, the document made more empathetic, perhaps would be the word I would use, I think a lot of the challenges from L.T.C. would disappear.

Deputy J.A. Hilton:

Where you have a client who maybe has been in hospital, received catastrophic injuries and are looking to be cared for at Cheshire Homes so that they come to you ... presumably they would not come with an assessment, would they, because ...

General Manager, Jersey Cheshire Home:

The traditional process is that somebody comes to us either on the recommendation from their G.P. (general practitioner) or because they know about us through the day care that we have given over the years and they were residents without a bed in many cases and then eventually need the long-term care or the permanent care at home because they cannot live at home any longer. Do not forget we are dealing with physically disabled individuals who may have a brain injury which can impinge on their mental capacity as well. So we have assessed them as and when it comes up. We assess. We have our own criteria and we do not just automatically accept whoever is sent our way. We will choose who comes into the home; that they have the right need; that they are of the right age. I know we have got an upper limit, in theory, of 65 years and over the age of 18, so we cover a gap that is not covered elsewhere. But we also, very carefully, assess that the individual will benefit from the services we offer. That they are not just going to lie in bed from the moment they arrive until the moment they leave us in a coffin, to put it simply, that they will have a life and the quality of life will be worth having and that they will also contribute to the life in the home. So it is not just a case of coming in and being cared for but in that care they will give something back to the others around them. Yes, the assessments come from the medical professionals. Yes, the assessments come from the Social Services team but at the end of the day we make the choice as to who will become the resident.

Deputy J.A. Hilton:

Yes. As far as the assessment process is concerned do you find it works sufficiently?

General Manager, Jersey Cheshire Home: The Social Services assessment process?

Deputy J.A. Hilton: Yes.

No.

Deputy J.A. Hilton: No, okay.

General Manager, Jersey Cheshire Home:

Often the individuals come to us with very ineffective assessments; the assessments are not complete and clear and concise. On top of that we are supposed to have a reassessment once we have seen a resident in the home for 6 months, a year. The idea was that we would have reassessments done to make sure that the level of care and package was being covered correctly. That does not happen or if it does it happens in a very strange way where the social worker tends to come in, speak to the resident concerned and then leave forgetting a fairly important part of the equation which is the people giving the care because very often somebody will say: "I do not need any care." There they are in a care home being paid for on long-term care because that is their wish. That is their desire. "I do not need any care." But actually they have to be got up in the morning and they have to have their face washed and other things. They have to be fed. They have to have their beds made. They need a lot of care but they do not see that. They do not say that and so the Social Services social workers fill in a form saying: "Do not need any care" so suddenly you see a woof, reassessed downwards.

Deputy J.A. Hilton: And that happens?

General Manager, Jersey Cheshire Home:

Oh, yes, reassessed downwards and we go: "Hang on, why? Nothing has happened in their condition" and they say: "Oh, well, they told us they did not need any care."

Honorary Chair, Jersey Cheshire Home: Yes. I think what this is indicative of ...

General Manager, Jersey Cheshire Home: It was quite a detailed ...

Honorary Chair, Jersey Cheshire Home:

I think the indicative problem with this is the criteria is quite fixed and narrow and if you look at the various grades it specifies what is required and people's conditions are not stable. Quite often people can come in with a level of condition, quite a lot of input, and as David has explained, that is what we do. We put significant additional inputs in to try to improve people's quality of life while we can. Quite often you see people come in, their condition has improved short term, they will then go into a slow term of decline perhaps and the difference between us and most residential and nursing establishments is that our average resident spends a minimum of probably 12 years with us as opposed to the 10 or 11 months ...

General Manager, Jersey Cheshire Home: It is their home.

Honorary Chair, Jersey Cheshire Home:

It is their home for life. So, you know, we are obliged to give them the best quality of life that we possibly can and that is not recognised at this moment in time by Social Services when they do the assessments. They should be regularly discussing with us what the inputs are that we have been able to put there to improve people's conditions temporarily but what the long-term consequences are going to be.

Deputy J.A. Hilton:

What happens when you get an assessment back, the person has been reassessed, and the social worker has deemed that their need is less? Is there some form of an appeal that you can do and how do you ...

General Manager, Jersey Cheshire Home:

We are about to challenge it so I am not quite sure how we are going to deal with it. There does not appear to be a formal or organised arrangement and the one I am talking about ... the person I am talking about particularly wishes to move into the community and we are not going to stand in his way and stop him but we do not want any dreams that: "Oh, this is going to be a doddle" and the care package that is put together will be sufficient and then suddenly he goes into the community, he has given up his bed at the home, which we may well have somebody else into, and they suddenly find that the care package needed in the community is so great that it is not viable but you will not get that from the assessment they have got at the moment because they have not asked us what his care needs are.

Deputy G.P. Southern :

When you talk about "not viable" are you talking about in terms of delivering the support in the home or costing it and paying for it?

General Manager, Jersey Cheshire Home:

I think the 2 go together. The sort of care that the individuals we are talking about need is not just right, at 8.00 in the morning for 15 minutes we will get them dressed and get them up and oh,

another 15 minutes to have breakfast, another 15 minutes to ... they need ... the care is all day and all encompassing. To be able to come and knock on the office door and: "Can you help with me with my ... go down to the bank and get some money, and oh, could you just run me up to the shops?" If somebody is in their own flat, even though they have an electric wheelchair and have all the mod cons, some of these disabilities are so great and the mental challenges that these individuals have, that although they have capacity in their own right, the care they are going to need is going to need so much one-to-one attention that if we let all 25 of our residents, potentially, out into the community; (a) the accommodation does not exist, and (b) there will be insufficient staff on the Island.

Senator S.C. Ferguson:

Yes. Are you finding that the assessments are very variable and we are not getting continuity with the social workers coming in to do them?

General Manager, Jersey Cheshire Home:

Indeed. This is something that we do have a challenge with. The assessments come from different social workers dealing with different residents and they are not ... although there is a tick box system for it, different people have different perceptions of what is the question and the answer they are getting and how they attribute it.

Senator S.C. Ferguson: Are you getting the same ...

General Manager, Jersey Cheshire Home:

We do not get into the discussion with them. My care team do not get into the discussion when the assessments are done.

Deputy G.P. Southern :

With the clients or with the social worker?

General Manager, Jersey Cheshire Home: Sorry?

Deputy G.P. Southern :

Do not get into conversations ...

General Manager, Jersey Cheshire Home:

Well, we do not have a conversation with the social workers after they have spoken to the client.

Honorary Chair, Jersey Cheshire Home:

I think the problem is it is not a list that really ... if you are going to do a meaningful assessment you need to take into account the individual.

[11:45]

You also need to take into account the support that individual has got from family or friends and the input that they might want to put into the equation but certainly, in your case, quite often we end up with somebody who has been released from hospital, placed with us and the assessment is going to follow on. They do the assessment without really taking cognisance of what our professional staff, who really understand the detail, the nitty gritty of this, might want to add to the comments because, as David has already indicated, you can say to somebody in a wheelchair: "What are your needs?" and they will tell you what their aspiration is, what the reality on the ground is and they are 2 completely different things at times.

Senator S.C. Ferguson:

If you have a different social worker doing each assessment then you have no continuity.

General Manager, Jersey Cheshire Home:

Can I refer to something which I did not send you in advance? But we had a meeting with Social Services and the hospital team on 2 July 2015 and all this came up in that conversation, including the idea of having a single social worker responsible for the Cheshire Home so as we would build a relationship up with that social worker and they would know the sort of things that our residents needed and so on. It seemed a logical and sensible idea and it was agreed with but it has not happened.

Deputy G.P. Southern :

It has not happened. That reminds me ... yes, I have had that reaction from the Social Security Department, certainly not the social workers in the past when I suggested that somebody gets allocated to this particular group. It has never happened yet but I am ...

General Manager, Jersey Cheshire Home:

One of the tricks I have learnt in dealing with the departments is that you have somebody who you get to know and you get a relationship with and you work on them and, as you saw from an email I sent to the chairman, a copy of, they sent it to 2 people, one in Social Security and one in the Hospital Service, and amazingly the challenge that I had set out in our email was resolved within the week.

Honorary Chair, Jersey Cheshire Home:

Yes. I think there is a legacy problem in some ways. When this whole scheme was introduced the theoretical system was under the control of Social Security from a payments perspective. They got their act together, they had a criteria, whether it was right or whether it was wrong, there was a definite criteria there but it was all predicated on social workers, basically, doing an accurate and consistent assessment. They were not trained to do it. They virtually imploded. The backlog built up and up. They had to cut some corners to get people through the assessment procedure, which they have done to a degree because the waiting list has now come down significantly, but there is not a final sort of arbiter there. The consistency of those assessments is only dependent upon the strength of the individual doing them. It is fine when you come to low-level assessments but you have got to understand, you know, we are the pinnacle of care. We are dealing with the most complex physically disabilities in the Island in many ways and, as David has already indicated, quite often there is mental health issues hanging on the back of that and you cannot do those assessments on the fly and not a tick box. They are much more complex than that and one of your big complaints in all of this is, there is no recognition of the extra miles that we go to in terms of dealing with these very, very complex individuals and their complex cases. We reformed this when this kicked off 3 years ago; that our residents would be thoroughly reassessed on an annual basis. We have had some reassessment done but it has been pretty marginal.

General Manager, Jersey Cheshire Home: It is not done on a regular basis.

Honorary Chair, Jersey Cheshire Home: And it is not consistent, is it?

General Manager, Jersey Cheshire Home: No, it is not consistent.

Deputy G.P. Southern :

We have heard from the Social Services Department that they believe that they have achieved a level of consistency. Do you notice any difference between ... I am picking up a sense of almost distrust in the system in ...

General Manager, Jersey Cheshire Home:

That would not be an unfair pick up. I am always slightly nervous when we know a social worker is coming in to do an assessment and we await, almost with trepidation, the results of that assessment. It can have a major impact on the individual's care or could have. It does not. We

do not change our level of care depending on what the assessment says. We just go ploughing on and I end up with the job of trying to force somebody to fund it correctly. That is where the big challenge comes from. The other challenge we have with them is that there is supposed to be a process by which we can go back and say: "We need additional funds to pay for additional care" and there is a process to do that. We have never succeeded yet in getting that through the social workers. We have had it when people have come from the hospital and they have one-to-one care in the hospital and that is carried forward when they come to the Cheshire Home but if we apply for somebody to get one-to-one care through the Social Services Department, which is the way the process was supposed to go through, it has yet to happen.

Senator S.C. Ferguson:

So how do you cope in situations like that?

General Manager, Jersey Cheshire Home: We carry on and we just add to our deficit.

Deputy J.A. Hilton:

Are you aware of the new policies, policy 1 and 2, that fall outside of the bands 1, 2, 3 and 4 in the Long-Term Care ...

Honorary Chair, Jersey Cheshire Home:

We are aware that there is a mechanism for making a case for people's condition to exceed level 4.

Deputy J.A. Hilton:

That is right. There is a panel set up called ...

Honorary Chair, Jersey Cheshire Home:

There is a panel set up. We have never been able, yet, to take a case through to the panel, despite some efforts to do so, because the criteria; you have got to go through a social worker recommendation before you are put in front of the panel.

General Manager, Jersey Cheshire Home: We cannot recommend or go to the panel ...

Deputy J.A. Hilton:

It has to be a social worker?

... it has to go through a social worker.

Deputy J.A. Hilton:

So have you put forward clients to a social worker to say that...

General Manager, Jersey Cheshire Home: We have.

Deputy J.A. Hilton:

... to go to the High Cost Care Panel.

General Manager, Jersey Cheshire Home: Yes.

Deputy J.A. Hilton:

But the social worker said: "No, this person does not meet the criteria."

General Manager, Jersey Cheshire Home: Does not meet the criteria.

Senator S.C. Ferguson: I think that is very strange.

Honorary Chair, Jersey Cheshire Home:

You start with ... I mean all our residents, apart from the one legacy case I think now, are level 3 or level 4, at the top end, okay. Quite often you will have resident who is admitted at level 3 or level 4 and over time, and we are now talking 3 years, their condition would have deteriorated and in that time, you know, as I said, we have worked quite vociferously on quite a lot of individuals to improve their condition but that is only achieved by bigger inputs. You do not achieve that if you just provide the minimum level of care that the criteria stipulates. So you are left in this dilemma that your inputs are going up constantly but your income is tied to an historical assessment which is not being thoroughly reviewed.

Deputy J.A. Hilton:

Is there any form of an appeal that you can take to get a case to the High Cost Care Panel?

We have not found one yet. We also have not batted and fought it hard because, to be quite honest, the care of the residents is rather more important to us and we find ways of funding it which I suppose is a slightly weak way of dealing with it but if you are constantly battling it rather destroys the point of being there in the first place.

Honorary Chair, Jersey Cheshire Home:

As I said, our ethos is to provide the best level of possible care to some of the most disadvantaged people in the Island.

General Manager, Jersey Cheshire Home:

Can I fill something in on that? One of the challenges that we have is that when we have looked after a resident for a number of years their condition may improve and so tick box says: "Condition has improved, value of care goes down." But to achieve that improvement needs a vast amount of input and time and still carries on requiring that input and time. It is giving the quality of life to the individual but the system does not easily recognise that there still needs to be an input of care to maintain it and very quickly they will drop back.

Deputy J.A. Hilton:

What do you think needs to change then?

General Manager, Jersey Cheshire Home:

Recognition of the sort of work that individual care homes probably do and I am not just referring to the Cheshire Home. There are not specialist homes on the Island that do specialist work and there does not appear to be a clear recognition that individual homes make those differences?

Deputy G.P. Southern :

Is it a question, which we heard from earlier this morning, about the complexity of the need of this care recognised.

General Manager, Jersey Cheshire Home: Yes, that is a fair comment.

Honorary Chair, Jersey Cheshire Home:

Yes. I mean I come at this from a bit more of a holistic situation, as you know, because the Cheshire Home is only one of my responsibilities and I am afraid right across the system at the moment in time is one size fits all and it cannot possibly be like that. I think the big gap in the total situation at the moment in time is the fact that it does not look at the specifics and the detail of a requirement; it tries to put everything into set boxes and that is not achievable.

Deputy T.A. McDonald:

Human beings are not like that plus, of course, without your input the ageing of that individual patient could well be accelerated as it would normally without any input from yourselves.

Honorary Chair, Jersey Cheshire Home:

As David said, you know, this is a home for life for our people and quite often they are there for decades. They are not there for a very short of time.

Deputy T.A. McDonald:

It is not months, it is years, yes.

Honorary Chair, Jersey Cheshire Home:

Part of the responsibility, as David has also said, is to ensure that the individuals we accept into the facility fit in to the ethos because you can get a very disruptive situation if you take in the wrong type of client that does not mix with the rest of them.

Deputy T.A. McDonald:

And upset the entire apple cart as we know, yes.

Deputy G.P. Southern :

Your analysis of the situation is that with our system which essentially is designed for the elderly population and you deal with 18 plus, 18 to 65, I mean ...

General Manager, Jersey Cheshire Home:

We admit people theoretically up to 65. They can be with us into their 80s and 90s.

Deputy G.P. Southern :

Yes. I am sure you do not throw them out.

General Manager, Jersey Cheshire Home:

I am a bit hard headed. I am not that hard headed.

Deputy G.P. Southern :

Admission is 18 to 65 and therefore dealing with ...

Honorary Chair, Jersey Cheshire Home:

I suppose ... yes, the fundamental at the moment is we are where we are in this in this system. I mean if you look at the system in a holistic point of view it is a Rolls Royce system compared to other jurisdictions. You know, it is so far in advance of what Guernsey offers. It is so far in advance of what the U.K. offers, et cetera but it is predicated for the mainstream. It is not designed for the exceptions, if you take my meaning, or the unusual sets of circumstances. Whether it is sustainable is a different matter. I mean we know at the moment that, you know, it is being funded by a 1 per cent tax contribution and I think the predication is that will rise over 30 years to 3 per cent, or whatever it might happen to be. Whether it is funded in the long-term is a completely different issue but it is what it is at the moment in time. I think what also has got to be taken into account, if David would let me speak for a couple of minutes on it, is that it fits into a much broader situation. We are in the middle of a major health service review, P.82, and everything that it said about ... we know about the demographic time bomb and so forth and so forth. Everybody is going to get older, they are going to live longer, going to have more conditions so you cannot exclude L.T.C. from the rest of what is going on in the health economy. You know, we fought under the Disability Partnership, Cheshire Home being one of the major planks of that, for disability research and for a strategy. We have also been party to the Carers Strategy because we understand the need for carers to be part of the equation here. So we are in the situation now where you have got a Disability Strategy, you have got a Carer Strategy, you have got what you introduced into the House last week about the responsibilities for ethical care but the 2 missing elements at the moment is statutory backup so that the Disability Strategy is ensconced in law, so there is a discrimination policy on enablement and disability. There also ought to be a care law so that the rights of carers are protected because at the moment, you know, big gaps beyond the provision of care services is respite ... and I am sure you are going to ask questions about respite. That is a nightmare at this moment in time. None of this is holistic. None of it is joined up. I mean people are attempting to do it but we need a total strategy to deal with everything and there is going to be exceptions within this and the Cheshire Home is a classic example of an exceptional set of circumstances.

Deputy J.A. Hilton:

Can you talk about respite in relation to the Long-Term Care Scheme, how it works, how it ...

General Manager, Jersey Cheshire Home: It does not.

Deputy J.A. Hilton:

It does not. Can you explain a little bit more why ...

Yes. I mean our concept of respite is relatively short stay individuals coming in either as a taste or as a recovery of convalescence. It is fine. We have spare beds. We are very happy to put them in the marketplace for that. It tends to be somebody coming out of hospital needing a convalescent period before they go into a permanent care home or go on to their own home or become a permanent resident at the Cheshire Home and we are looking at physically disabled individuals always. The mechanism is simple from the hospital's point of view. They contact us: "Have we got a bed?" "Yes, we have. We will help." The next thing is: "Who is paying for it?" "Well, we do not know." So I say: "Well, until I know who is paying for it it is rather difficult to offer you the bed because there is a fee attached." The latest example we had was that a social worker said: "Oh well, the Long-Term Care is going to pay for it." Well, we know that Long-Term Care takes about 3 months to process and get into situation and you ...

Deputy G.P. Southern : Still?

General Manager, Jersey Cheshire Home:

Oh, yes. From the time when somebody gets round to filling the forms in and understands what they have put in it takes about 3 months and that is not unreasonable, Geoffrey. It does take time to go through that and I can live with that but when somebody is only there with me for a month on respite care they are long gone by the time L.T.C. might have been awarded or not.

[12:00]

Deputy J.A. Hilton:

Have you been left in a situation where you have taken people in for respite and you have not had costs met by the Health Department?

General Manager, Jersey Cheshire Home:

Initially yes and then I got stroppy about it and got paid for it.

Deputy G.P. Southern : By whom?

General Manager, Jersey Cheshire Home:

By Health and Social Services and by L.T.C. on one of them. So consistency does not exist.

Deputy J.A. Hilton: Okay. So does that ...

General Manager, Jersey Cheshire Home:

I also had from the social worker: "Well, we cannot ... we need respite but we do not have a budget for it." So they commissioned the accommodation and then they turn around and say: "By the way we have not got a budget for it." So I am thinking: "You are commissioning something you cannot commission because you have not got any money." The logic is not there.

Deputy J.A. Hilton:

So basically they know they need the respite bed, they need the hospital bed so they have to move the individual quickly so they are worrying about the funding afterwards basically.

General Manager, Jersey Cheshire Home: Yes.

Deputy J.A. Hilton:

Because there is no mechanism in place.

General Manager, Jersey Cheshire Home:

It took a year to get one of them paid for from last year. In fact 2 of them.

Honorary Chair, Jersey Cheshire Home:

I think what this is indicative of is the whole question of respite is in the air. It is not consistent, is it? Up until 80 people's needs are fairly well met. You do not fall off a cliff and the dimension of respite is viewed as, you know, one night stays and very short term and whatever. There is an absolute need in some instances for an adjustment period for people, particularly if they come out of hospital after a traumatic brain injury or they have got something that is physically suddenly deteriorated, et cetera and there is no real provision at the moment in time across the Island to deal with these cases and the mechanism is not there to back it up.

Deputy J.A. Hilton:

So how many respite beds do you have available?

General Manager, Jersey Cheshire Home: We do not have any.

Deputy J.A. Hilton:

You do not have any currently?

We do not have any respite beds. We use spare capacity.

Deputy J.A. Hilton: Okay.

General Manager, Jersey Cheshire Home:

If somebody moves out, dies, and that room is not immediately occupied by a fulltime resident we will take respite.

Deputy J.A. Hilton:

So does the Cheshire Homes deliver domiciliary care?

General Manager, Jersey Cheshire Home: No.

Deputy J.A. Hilton:

So all your care is delivered into your physical building.

General Manager, Jersey Cheshire Home: Yes.

Deputy J.A. Hilton:

How many clients have got coming in for ... do you have clients coming in every week or every 2 weeks for overnights?

General Manager, Jersey Cheshire Home: No.

Deputy J.A. Hilton:

So it is simply individuals ...

General Manager, Jersey Cheshire Home: As need.

Honorary Chair, Jersey Cheshire Home:

We did try that. We tried that in conjunction with the commissioners and the Health Service on the basis they had a raft of younger, fairly physically challenged and disabled people where they had

no provision or no place to put them. It did not work for us because it was quite disruptive in some ways. It was not controlled as well as it could be and it certainly did not work for the individuals concerned so we withdrew from that short term ...

General Manager, Jersey Cheshire Home:

It did not work for the other residents in the home.

Deputy J.A. Hilton: No, okay.

Deputy G.P. Southern :

Can we just stay on the theme of respite which ... we seem to have studied respite care at least twice but it seems like forever but building respite into a care system is an essential precursor, is it not? The last thing you need is for your carer, whether it is professional or otherwise, to be breaking down so that the care is not delivered. So to build respite into it you said: "What can you cope with as a family unit?"

Honorary Chair, Jersey Cheshire Home:

I think respite, in some ways, is a misrepresentation. It is a mixture of respite and convalescence because at the moment in time what you create, if you are not careful, is a situation where there is no alternatives to placing people in residential and nursing care because there is no intermediate level of provision of services in the Island. Now, whether we would provide that or somebody would it would be a different issue; that is not our speciality. We are looking after people permanently rather than short term. We use capacity if we have got it because it benefits the individual.

Deputy J.A. Hilton:

So presumably there must be instances where you are contacted by the hospital but you have not got spare capacity.

General Manager, Jersey Cheshire Home: Absolutely right.

Deputy J.A. Hilton:

So those individuals ... and obviously Cheshire Homes are well set up to cater for the needs, and cater for them extremely well, of these individuals so they must then go off to a residential home ...

They may well end up in a care home or a residential home, nursing home which may not be appropriate for them.

Deputy G.P. Southern :

Or at home with a package.

General Manager, Jersey Cheshire Home:

Or at home with a package before they are ready to go home.

Deputy G.P. Southern :

That might take some while to set up a package.

General Manager, Jersey Cheshire Home: To set up, yes.

Honorary Chair, Jersey Cheshire Home:

Or else they are bed-locked in one of the hospital wards.

Deputy J.A. Hilton:

Are you aware of any instances of that happening in the last year or 2?

General Manager, Jersey Cheshire Home:

We certainly ... we have had a couple of ... well, one individual came in last year for convalescence from a hospital stay and he came to us ... we knew him from day care and he came to us for, we called it respite, short term, whatever we call it, and he then ended up saying: "I am not going home. I am going to stay here with you." So that sort of morphed from respite into a permanent residency and that is ... I mean that is not allowed for in the rulebook. You know, that is dealing with human beings. The rulebook cannot cope with that.

Honorary Chair, Jersey Cheshire Home:

I mean the other missing element of all of this is the preventative element because, as I said, as well as looking after all permanent residents and a little bit of respite we do now have something like 400 people who use our hydrotherapy and physiotherapy to contain their conditions. Quite often they are in a slow deteriorating situation and by the actions we take we keep them out of hospital, we keep them at home for longer and whatever and the contribution we get towards that work is zilch.

Deputy J.A. Hilton:

So with the 400 clients that you are dealing with who make use of your hydrotherapy pool, so they do not have to pay a donation?

General Manager, Jersey Cheshire Home: Some of them pay a small amount.

Deputy J.A. Hilton: Just a small amount?

General Manager, Jersey Cheshire Home: Yes.

Deputy J.A. Hilton: So there is no other ...

General Manager, Jersey Cheshire Home:

They could have a month's use of the pool for £40.

Deputy J.A. Hilton:

That is a very generous facility then.

General Manager, Jersey Cheshire Home: It is a very cheap charge.

Honorary Chair, Jersey Cheshire Home:

We do not charge a commercial charge. We probably operate it at a loss, a net loss, if you take the ...

General Manager, Jersey Cheshire Home:

That probably creates £100,000 worth of our £400,000 loss.

Deputy G.P. Southern :

I am being stupid here so forgive me if I am. It often happens. So things like physiotherapy or use of pool does not form part of long-term care packages?

General Manager, Jersey Cheshire Home: No.

Deputy G.P. Southern : It does not?

General Manager, Jersey Cheshire Home: No.

Deputy G.P. Southern : Because it is outside ...

General Manager, Jersey Cheshire Home:

I see, for outside users, no. Individuals pay their own fees. If they have a care package which they have negotiated with the Social Security Department and included in their package is funding to do physiotherapy or hydrotherapy; that is fine. They can do that but an awful lot of the individuals are not on long-term care who come in to do it but are still living at home, perfectly well, but have a debilitating disease which is beginning to kick in and they want to keep mobile. They want to keep active and so they come to us to do that. Again, it presumably helps the hospital not have them occupying beds and so on or using their services. As far as the residents in the home are concerned long-term care does not recognise the specialist services that we might be offering within the home. It is a lump of money which the Cheshire Home receives from the clients for the care they get. Included in the care is physiotherapy, is hydrotherapy as and when they need it or not, depending on their needs and their desires. Some residents never want to go near the pool. Others want to go in the pool every day of the week. Some want to go in the gym, others do not. Some want to do both, sometimes 3 times a day, and then they get fed up with it and so 2 weeks later they change. We cope with that change in a nutshell.

Deputy T.A. McDonald:

Dealing with people and that is the reality.

General Manager, Jersey Cheshire Home: Not little boxes.

Deputy T.A. McDonald: That is right.

Deputy G.P. Southern :

You say you are catering in a sense for a specialist market. What is the sort of level of training which you are engaged in?

The level of training?

Deputy G.P. Southern :

Yes. How much are you reliant on putting trained people in the right place at the right time?

General Manager, Jersey Cheshire Home:

We are required by regulation to have nurses on duty. We have deskilled on nurses over the years because they are not using all their skills, nursing skills, all the time so we are making an effort to make sure that we do not let people into hospital until they really need to go in so that the nursing staff can do what they what need to. It is a long way round of saying we have to have nurses onsite. We do not always use them. They are distributing medicines and filling in forms. You do not need a fully qualified, highly skilled, very expensive nurse to do a lot of those jobs. When you do suddenly need them is when somebody becomes ill and it is great that we have got them onsite to look after them but for instance we are dual registered with nursing care and residential care. A silly anomaly is that if any of our residential care people become ill our nurses onsite are not allowed to administer the nursing care; Family Nursing have to come in and do it. Once they have been in to do it and said: "Oh, you have the competency to cope", you can take over but initially Family and Nursing have to come in and do the job that our staff can do perfectly well.

Deputy J.A. Hilton:

Why has that not changed? It just sounds ridiculous.

Honorary Chair, Jersey Cheshire Home: Well, I think it might be in the process.

General Manager, Jersey Cheshire Home:

It is going to change but it is something that has been going on for years.

Deputy J.A. Hilton:

The regulation panel is going to change, right, okay.

Honorary Chair, Jersey Cheshire Home:

But I mean at the moment we ... in some ways ... I mean we fully understand the need for regulation. We also fully understand the need for the staff delivering care, whether they are nursing staff and whether they are home care staff, they need to be fully trained and they need to be kept fully trained and they need to be of a quality that delivers the appropriate level of service

but you have got a crazy situation now where the regulations work against us. We are over- nursed, if you want to call it that, simply because we have got so many nursing beds. All residents occasionally fall ill and we have had an instance of that in the last 24 hours but quite often their conditions are relatively stable but it still means we have got to carry excessive nursing staff at certain times and that obviously has got a financial ramification. You know, we cover that by just swallowing the extra cost but still providing the level of care assistance that is required to give these people quality of life. The crazy situation, as David explained in all of this, is that it is one size fits all yet again. Nobody takes cognisance of the fact that although we are quite capable of delivering services way beyond what the regulations allow us to we cannot do it. I mean some of the things where residents do fall ill the only recourse we have got is to send them down to the hospital. We normally deliver them ourselves.

General Manager, Jersey Cheshire Home:

Well, we tend to. We try and avoid ambulances unless it is an emergency.

Honorary Chair, Jersey Cheshire Home:

But a lot of these conditions we could more than adequately cope with in-house if we were permitted under the regulations to do it because you are not making use of the skills that are out there.

General Manager, Jersey Cheshire Home:

I think one of the big differences with our residence to a nursing home and a care home that one perceives, is that our residents are not ill, they are disabled, and there is an enormous difference between being disabled and sick. They are not hospital cases. They are not nursing cases in that sense. They need nursing care because of their disability but they are not sick individuals and therefore they become ill the same way as we do. They get colds but sometimes their condition becomes more desperate because of their disability but then they recover and become  that individual again.

Honorary Chair, Jersey Cheshire Home:

I think the other big problem that lies underneath this that, no doubt you are aware of but it probably needs saying, is that there is a huge skills gap in the Island at the moment in time. The hospital and Social Services are struggling to recruit and retain staff. There is huge gaps in terms of their numbers at the time in moment and that knocks down into the voluntary sector which we are a part of and also into the private sector. It is very difficult to recruit good quality nursing staff and retain them. We are competing against the Rolls Royce package in the health service at the moment in time. People come to us quite often for other reasons than the money. They come because they like the ethos and what we are about and what we are trying to do. Although the

situation with care assistants at the moment in time is probably a little easier, as the regulations come forward, and they do need to come forward because the quality of care that people get needs to be appropriate and effective. That is going to become more of a difficulty as well and as you have got an ageing population, more people going into the system; I have got long-term fears, how we are going to cope with all of that unless we become a little bit more flexible and a little bit more sensible about the resources that are out there to provide some of these services.

Deputy T.A. McDonald:

I mean you have described the administration of the scheme as challenging and I am sure that is how you see it and especially from a financial perspective that also appears to be very piecemeal because sadly all of these things have got to be paid for and you need to know that you are being paid regularly and so on. Would you like to sort of expand on ...

Honorary Chair, Jersey Cheshire Home:

Well, David obviously is responsible for the Foundation Committee, an honorary committee, for the situation and always on the agenda, each and every one of our 6 weekly or so meetings is: "What is the level of outstanding debt, David? What are the causes of those debts and are they likely to be paid?" We will never throw anybody out. That is the last thing we would do but, you know, we have run up individuals with debts getting close to £100,000 at times while we are trying to sort out how people's finances are going to come through to us in the fullness of time. Quite often it is because, you know, somebody says something and we take it at face value, then the ground shifts. There is an investigation. All these things take in an interminable amount of time. We have written off limited amounts of debt in the past.

[12:15]

I have no doubt we are going to have to do it in the future but this is all symptomatic about the elongated situation that we are involved in and the fact that quite often there is toing and froing. I will not lay it on Social Security because at the end of the day they can only react to what is being asked of them by Social Services but I think at the moment in time until there is a completely consistent mechanism within Social Services for this to go through the system and timescales linked to that to give the recipients of people some surety on the payment side it is going to be an ongoing problem. I think it is diminished because they have put effort into reducing assessment times and so forth but it is still there.

General Manager, Jersey Cheshire Home:

The other challenges that sometimes the families are not quite a straight as they might be when they are filling in the forms which can delay payment and sometimes I suspect it is deliberate and other times I think it is just confusion but that can add quite a lot of time for payments to come through.

Deputy T.A. McDonald:

I am sure. It says 28-day cycles and 13-month years and so you do not really fit in with business ...

General Manager, Jersey Cheshire Home:

I mean I do not know of any other organisation in the world that works on 28-days as a rigid thing. You would normally work to a monthly cycle but our Social Security Department works on 28 days. We are learning to cope with it and it is taking a long time.

Honorary Chair, Jersey Cheshire Home: You are also confused with the payments.

General Manager, Jersey Cheshire Home:

Oh, the payments are hysterical. The payment system is hysterical. We get emailed advices. We get postal advices. We get remittance advices with the name, a date and the amount but no identification as to what it is for. Some of it will be for care. Some of it will be for personal allowances. Some of it will be for payments over and above, maybe dentistry or something else. But, no, all you have got is the name and the dates and the amount. So my bookkeeping team are going: "What is this for?" and so it is backwards and forwards and this way and that. If it could be just a very simple little thing on a remittance advice that said: "For care, so many days from so and so. Personal allowance, so much." It would make life so much easier. It is only a small thing but it is those sort of small things that can make life so much easier.

Deputy T.A. McDonald:

Yes, absolutely. Challenging was the word you used. I can see now ...

General Manager, Jersey Cheshire Home:

I did. Well, it is very frustrating because I cannot answer it. My team come and say: "David, what is this for?" "I have no idea." It is lovely, there is a great big wad of money come in, £40,000 or £50,000, a lot of money, but we have got to allocate it correctly and if we do not get it right the regulator comes in and says: "Why have you not put that in the right place?" when we are looking at the pocket money accounts.

Deputy T.A. McDonald:

Exactly, and you have done this before of course.

General Manager, Jersey Cheshire Home: I am sorry.

Deputy T.A. McDonald: Yes, I can see that.

Deputy G.P. Southern :

You made an appeal for flexibility in the system otherwise you said: "I do not know how we are going to cope with the ageing population."

Honorary Chair, Jersey Cheshire Home:

Yes. Well, we have to start somewhere and I think, as I said just now, I think what is on offer with the long-term care is pretty good in the total sense but it needs now to be taken one stage further and it needs to be considered in the light of all the other initiatives that are going on because if we do not step back and look at it in those terms the problems are not going to go away, they are going to accentuate and sooner or later you could be changing long-term care for the wrong reasons. In some senses you have got to fill in these gaps around the edge. Now, that is going to be costly and that might mean a reconsideration of how it is financed, whether it comes out of individual income tax because basically that is what they have done with long-term care; whether it comes out of the central pot is another issue but the Island does need to make its mind up on how they are going to cope with this.

General Manager, Jersey Cheshire Home:

It is a better system than the old welfare system which then sort of morphed into all sorts of different things and I was involved in the home in those days as well and that was a real nightmare so this is a better system. It just needs tweaking, and some fairly big tweaks, as far as operating the home is concerned for the residents.

Deputy G.P. Southern :

Our previous witness was talking about providing a fairly specialist service for a group of people and whereas you could have people looking after them in their home, on an ancillary care basis, catering for their special needs was not part of the package. Are you making a similar claim because what you do nobody else out there can do?

Honorary Chair, Jersey Cheshire Home:

We are fully aware of Les Amis's dynamic in this as well. They are again an organisation that is providing a different sort of care from the standard residential or nursing care facility, short-term, mainly with elderly people, et cetera. They have got this whole raft of fairly challenging clients that do not quite fit into the boxes, if you know what I mean.

Deputy G.P. Southern :

As you say, your clients are lifetime clients.

Honorary Chair, Jersey Cheshire Home:

So, you know, we are at 2 extremes. I mean quite a lot of their people are quite young people and certainly anecdotally the complaints I get with my disability hat on always comes back to the same thing. You get to 18 and it is fine and suddenly beyond that the provision of services you get and the support you get is very patchy and there is not a recognition that again the inputs that Les Amis need to put in to organisations or in to people to keep them in the home rather than in an institution is quite significant and I am not sure it has always recognised.

Deputy J.A. Hilton:

So overall would you say that the system, I think you have said, that the system is better now than it was pre-2014, the system that you can now (12:21:19 overspeaking)

General Manager, Jersey Cheshire Home:

I think it is a more logical ... yes, and that is true.

Deputy J.A. Hilton:

So is the assessment process one of the issues that you would raise?

General Manager, Jersey Cheshire Home:

The assessment process is an issue. If we could go to the simple idea that we had, of having a designated carer or a social worker for the home, the contact, there would be consistency, there would be an understanding, I think things would move very rapidly and very smoothly, and that was agreed 2 years ago, 3 years ago, but it just has not happened and that is a frustration.

Deputy J.A. Hilton:

So you do not have any particular concerns about the waiting list, so you are content with ...

General Manager, Jersey Cheshire Home: We tend never to have an empty bed.

Deputy J.A. Hilton:

Right. So the waiting list as far the assessments go, you know ...

General Manager, Jersey Cheshire Home: Oh.

Deputy G.P. Southern : Is long.

General Manager, Jersey Cheshire Home:

It is long and it is there and we have learnt to live with it.

Senator S.C. Ferguson:

What percentage of your residents are in fact awaiting an assessment?

General Manager, Jersey Cheshire Home: I cannot answer that because I do not know.

Honorary Chair, Jersey Cheshire Home:

It is very small because they are there for a long time.

General Manager, Jersey Cheshire Home:

They have all been assessed but it is the reassessments that we are looking for and waiting for.

Deputy G.P. Southern :

Yes. In theory, their annual reassessment.

General Manager, Jersey Cheshire Home:

Yes. The annual reassessment do not seem to be ...

Deputy G.P. Southern :

You are saying when it is done it should be done in conversation with the carers, us, as well as with the clients.

General Manager, Jersey Cheshire Home: Absolutely right.

Honorary Chair, Jersey Cheshire Home: And the families.

And the families. The family is very much part of the care and the Cheshire Home resident's families take part. They do not have to if they do not want to.

Deputy T.A. McDonald: In case the discussions ...

Honorary Chair, Jersey Cheshire Home:

Yes, because people do believe at times that these individuals have got full capacity but quite often they really have not.

General Manager, Jersey Cheshire Home:  Legally they may have capacity but in reality they ...

Senator S.C. Ferguson:

No. They will answer the question the way they think you want the answer to come.

General Manager, Jersey Cheshire Home: As I have done this morning.

Deputy T.A. McDonald:

That is the benefit of being slightly older than a lot of other people on the panel I think.

Deputy G.P. Southern :

Despite the record they are just (12:23:31 inaudible). Any other ...

Deputy J.A. Hilton:

No. I was just going to ask, is there anything else that we have not discussed that you would like to relay to us before we wrap the meeting up?

General Manager, Jersey Cheshire Home:

The only thing I think I was going to mention is the regulations coming in and the requirements will have a knock-on effect inevitably on the staffing and that inevitably has an effect on our funding requirements. So it is a bit of a vicious circle and I think we need to be very careful that we do not over-regulate and over-require but at the same time maintain safety standards and a safe environment for the residents. It is getting the happy balance. I do not know if I have an answer for it but I think it is something that should always be borne in mind when creating regulation and

passing laws that the knock-on effect is you are going to have to find money to pay for it somewhere down the line.

Deputy G.P. Southern :

If you say that that is the question of safety levels in ...

General Manager, Jersey Cheshire Home:

I think, and certainly in a place like the Cheshire Home, we tend to stick to the rules and then if the rule says: "You now need to do X" we will do X but X will have a cost and every time that cost comes on it is going to be passed on to somebody. We do not have a ... and the point is that the government tends to pay the bills for our residents, all right the money goes to the individual, which is fine, the contract is not with the States but it comes back.

Deputy T.A. McDonald:

As you pointed out in your letter 85 per cent of a home's expenses are going to salaries.

General Manager, Jersey Cheshire Home: Absolutely.

Honorary Chair, Jersey Cheshire Home:

That is because we meet the regulations and go beyond in terms of the provision of care levels. We are not profit based and we are about providing the best level of ...

General Manager, Jersey Cheshire Home:

It is a bit of a shock to the system to budget for a £400,000 loss.

Deputy G.P. Southern : Yes, indeed.

Senator S.C. Ferguson: Contrary to your opinions ...

Honorary Chair, Jersey Cheshire Home:

But that is based on an annual turnover, if you want to call it that, a shade over £2 million so you can see what the gap is. I mean if I can add one thing to what David said, I mean I think he is right to identify concerns over the impending regulations coming but what I would like to do, if it is acceptable to the panel, and I did talk to your chairman in passing the other day, is I will make an individual written submission to you with my more holistic opinion on this from the voluntary sector

in totality because I have got a lot of anecdotal information from a whole range of people that backs this up and I did not want to conflict with the discussion relative to the Cheshire Home today.

Deputy J.A. Hilton: Yes, that would be good.

Senator S.C. Ferguson:

Or you could come and spend another happy hour with us.

Honorary Chair, Jersey Cheshire Home:

You can summon me, by all means. I am more than pleased to attend these hearings. Well, I am not sure you are absolutely aware but strike the record on this one, but your chairman is coming with us so he will be making the trek. I hope he will continue with ...

Senator S.C. Ferguson:

That is why he has been practising walking.

Honorary Chair, Jersey Cheshire Home: Absolutely.

Deputy G.P. Southern :

That you, gentlemen, very much indeed.

General Manager, Jersey Cheshire Home: Have you one of those, Sarah?

Senator S.C. Ferguson:

No, I have not. Thank you very much.

General Manager, Jersey Cheshire Home:

I just brought the one in. I am sure you can share it.

Deputy J.A. Hilton: It is fine to share.

Senator S.C. Ferguson:

Well, I hope shortly to be able to return the compliment with ours because like you we have an expanding client base and good companions. I mean we are all getting ...

Deputy G.P. Southern :

With this new setup I do not how we let everybody out.

[12:28]