Cofnod y Trafodion
The Record of Proceedings

Y Pwyllgor Iechyd a Gofal Cymdeithasol

The Health and Social Care Committee

20/01/2016

Agenda – Cymraeg
Agenda - English

Trawsgrifiadau’r Pwyllgor
Committee Transcripts

Cynnwys
Contents

4....... Cyflwyniadau, Ymddiheuriadau a Dirprwyon
Introductions, Apologies and Substitutions

5....... Sesiwn Graffu gyda Chomisiynydd Pobl Hŷn Cymru: Dilyniant i Ymchwiliad y Pwyllgor i Ofal Preswyl i Bobl Hŷn ac Adolygiad y Comisiynydd o Gartrefi Gofal
Scrutiny Session with the Older People's Commissioner for Wales: Follow-up on the Committee's Residential Care for Older People Inquiry and the Commissioner's Review of Care Homes

34..... Cynnig o dan Reol Sefydlog 17.42(vi) i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod
Motion under Standing Order 17.42(vi) to Resolve to Exclude the Public from the Remainder of the Meeting

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included.

Aelodau’r pwyllgor yn bresennol Committee members in attendance
Alun Davies	Llafur Labour
John Griffiths	Llafur Labour
Altaf Hussain	Ceidwadwyr Cymreig Welsh Conservatives
Elin Jones	Plaid Cymru The Party of Wales
Darren Millar	Ceidwadwyr Cymreig Welsh Conservatives
Lynne Neagle	Llafur Labour
Gwyn R. Price	Llafur Labour
David Rees	Llafur (Cadeirydd y Pwyllgor) Labour (Committee Chair)
Lindsay Whittle	Plaid Cymru The Party of Wales
Kirsty Williams	Democratiaid Rhyddfrydol Cymru Welsh Liberal Democrats
Eraill yn bresennol Others in attendance
Sarah Rochira	Comisiynydd Pobl Hŷn Cymru Commissioner for Older People in Wales
Swyddogion Cynulliad Cenedlaethol Cymru yn bresennol National Assembly for Wales officials in attendance
Amy Clifton	Gwasanaeth Ymchwil Research Service
Sian Giddins	Dirprwy Glerc Deputy Clerk
Llinos Madeley	Clerc Clerk
Dechreuodd rhan gyhoeddus y cyfarfod am 09:46. The public part of the meeting began at 09:46.
Cyflwyniadau, Ymddiheuriadau a Dirprwyon Introductions, Apologies and Substitutions
[1] David Rees: Bore da. Hoffwn groesawu Aelodau’r pwyllgor a’r cyhoedd i gyfarfod y Pwyllgor Iechyd a Gofal Cymdeithasol y bore yma. Bydd y cyfarfod yn cael ei gynnal yn y Gymraeg a’r Saesneg. Mae clustffonau ar gael i glywed cyfieithu ar y pryd o’r Gymraeg i’r Saesneg ar sianel 1, neu i addasu’r sain ar sianel 2. Hoffwn atgoffa pawb i ddiffodd eu ffonau symudol ac offer electronig arall a all amharu ar y darllediad. Nid ydym yn disgwyl clywed y larwm tân y bore yma. Os clywch y larwm tân, dilynwch y staff diogelwch. Nid wyf wedi derbyn ymddiheuriadau y bore yma.	David Rees: Good morning. I would like to welcome Members of the committee and the public to the meeting of the Health and Social Care Committee this morning. The meeting will be held bilingually, in Welsh and English. Headphones are available for simultaneous translation from Welsh to English on channel 1, or for amplification on channel 2. I’d like to remind everybody to turn off their mobile phones and any other electronic equipment that may interfere with the broadcasting equipment. We don’t expect to hear the fire alarm this morning. If you do hear the alarm, please follow the security staff. I haven’t received any apologies this morning.
09:47
Sesiwn Graffu gyda Chomisiynydd Pobl Hŷn Cymru: Dilyniant i Ymchwiliad y Pwyllgor i Ofal Preswyl i Bobl Hŷn ac Adolygiad y Comisiynydd o Gartrefi Gofal Scrutiny Session with the Older People's Commissioner for Wales: Follow-up on the Committee's Residential Care for Older People Inquiry and the Commissioner's Review of Care Homes
[2] David Rees: Hoffwn groesawu Sarah Rochira, Comisiynydd Pobl Hŷn Cymru, i’r cyfarfod y bore yma. Hefyd, hoffwn ddiolch iddi am ddarparu papurau o flaen llaw a fydd yn helpu i lywio ein cwestiynau y bore yma. Fe awn yn syth i gwestiynau i’r comisiynydd, os yw pawb yn cytuno. Gwyn Price, a hoffech chi fynd yn gyntaf?	David Rees: I’d like to welcome Sarah Rochira, the Commissioner for Older People in Wales, to the meeting this morning. I would also like to thank her for providing papers in advance of the session to assist with our questioning. We will go straight to questions to the commissioner, if everybody is agreed. Gwyn Price, would you like to go first?
[3] Gwyn R. Price: Thank you, Chair. Good morning.
[4] Ms Rochira: Good morning.
[5] Gwyn R. Price: Your first review report painted a sombre picture of the quality of life in Welsh care homes. Over a year on, how would you describe the situation now?
[6] Ms Rochira: I think I need to answer that in a number of ways, really. In terms of what it is like to live in care homes today for older people, it is very difficult for me to answer that question. There are 650-plus homes. They still range from those that are very good to those that I consider to be unacceptable. Part of the reason that it’s difficult to answer that question is that we don’t yet have in place the mechanisms to answer it in the right way. That’s why some of the changes that have come in, ranging from the Social Services and Well-being (Wales) Act 2014 and the Regulation and Inspection of Social Care (Wales) Bill, matter—those changes in the standards that should sit at the heart of residential care. So, I guess that, in a sense, I can’t answer that across the breadth of it. What I can provide you with is some detail in terms of what I have seen and what I have seen happening since the review has taken place. When I commented on the responses that I had, I talked about the assurance levels that I had—that the action was in hand to deliver the change that was required. So, since my review, I have now received assurance from all the statutory bodies that they will take forward sufficient action to deliver the outcomes that I was looking for. There were really challenging discussions that sat behind many of those requirements for actions. I challenged people; they challenged me back. My expectations were set high. That was right and proper—they were difficult issues. But for me to be able to say that I’ve received those assurances is a very significant step forward for me.
[7] I’ve also seen a huge amount of activity already taking place, not just that which sits within the R&I Bill and other pieces of legislation and technical devices, but out on the ground as well. In my one-year-on statement, I spoke about some of the good practice I was already seeing growing across Wales. I visited much of that for myself, to see it taking place. So, where are we now? I think we now, absolutely, as a sector, take seriously the scale and the depth and the breadth of the change that takes place. I think we now absolutely understand, as a sector—I think it’s a phrase you used, Alun—that our care sector is a sector of strategic national importance. I think we’re beginning to understand what that means in practice. I see a huge amount of evidence of action under way. I started to count the various things. I think I got to about 50 things and I stopped counting. There’s a huge amount of activity taking place at a strategic level and at a local level as well. I’m sure we’ll go on to talk about some of those things in detail. What we don’t yet have is the evidence of the impact behind those—partly because it’s too early to see some of that, but also because we don’t have those new standards in practice and we don’t have the mechanisms to gaze properly onto those and to report upon those.
[8] That’s why some of the changes that have been made—for example, in the regulation and inspection Bill, to await the chief inspector of social services’ report—are important, because that should give us not just the new framework, but also the new narrative and the new commentary behind that. So, in a sense, we still can’t answer that question, based on those developing new standards—‘What is it like across the breadth?’ But, I see evidence across Wales of real change taking place and some pace behind that change as well. But, of course, my message has always been very clear: intent is important, action is important, but, increasingly, what we’ve got to focus on is the impact and the delivery behind all those changes that are taking place across Wales.
[9] I have expectations, still, of statutory bodies. That’s why I’ve made it clear that I’ll undertake a follow-up review to look for the impact of that. But I’ve also got my own programme of work that continues over the next 18 months, to try and drive and build on some of that good practice that we’ve got within Wales.
[10] Gwyn R. Price: So, there are improving signs, but you want to watch this space to see that it’s rolled out right across Wales.
[11] Ms Rochira: I think we all have to watch this space. I’m very keen to have a conversation about how we continue to align our work in terms of our scrutiny. Are we taking it seriously? Yes, I am assured, across Wales, and as sectors and different bodies within that. Is there evidence of activity? Yes. In a sense, only time will tell what the impact of that will be. It’s the cumulative impact that makes it very difficult to assess individual changes in their own right. We also need to be really careful we don’t rely on it all being tomorrow—two, three, four or five years’ time. Much of my work and much of what I see is about change starting to take place now. I’m very happy to share some of those examples later on.
[12] Gwyn R. Price: Thank you.
[13] David Rees: Lynne, do you want to follow on?
[14] Lynne Neagle: Thanks, Chair. One of the reasons, Sarah, that the committee asked to have this session with you is because you had said that you were disappointed with the Welsh Government’s response to your review and there’d been a lot of media coverage of that as well. I know that you now feel assured that the response from Welsh Government is better. But, I think it would help the committee to understand exactly what your concerns were to make the statement about being disappointed and precisely how the Welsh Government have addressed those concerns.
[15] Ms Rochira: Okay. I guess it goes back to my point about expectations. They were set high—rightly so—on behalf of older people. Some very challenging conversations, discussions—many conversations and discussions over the last year. I guess there were a number of areas that I wasn’t happy with. One was that, in some areas, the level of detail was just too little. It was too light. I needed and expected more to give me the assurance I was looking for. In some areas, I wasn’t confident that the nuanced understanding of what we needed was there. So, to just take a simple example, the difference between nutritional standards and the meal-time experience—the move from a task-based approach to one that reflected the wider needs and wants of older people. In some areas, I wasn’t confident, when I made that further-on statement, that the structure was there. All the amount of change that is going on needs structure and needs that strong leadership behind it. I was looking for a much stronger focus and a joined-up approach across policy areas, again, going back to that cumulative impact of things that were taking place. So, those were the sorts of issues that underpinned that. The responses just weren’t strong enough. To be fair, the first responses from local authorities and health boards weren’t strong enough either. We had very long, detailed conversations with them about how that needed to strengthen.
[16] On the basis of those conversations, Welsh Government has come back and provided me with more information, more evidence. We’ve built our learning together. I’ll just give you a couple of examples of some of the things that have changed. In relation to registration, for example, we had a very clear statement from the Minister that registration will come in; that was crucially important for me, as part of that. When I couple that with the work that I see that’s going on from the care council in terms of the new dementia training standards, that starts to become a much more assuring response and more powerful. So, it was the level of detail that I was looking for, the structure that was behind it and, overall, just that assurance level that I was looking for. So, I think it was right and proper we had many challenging conversations—two-way challenge—behind that, but, overall, I am assured now. And I have seen a significant shift in that.
[17] Lynne Neagle: You’ve prefaced both of your answers with the statement that your expectations were very high. Is there any sense that you’ve had to downgrade your expectations in reaching an agreement with the Welsh Government on this?
[18] Ms Rochira: I don’t feel I have. I suspect some people might say—. I know when I wrote the review and when I provided feedback, initially, to everybody who’d responded, not everybody agreed with my conclusions on that, but that’s because these are complex issues. I was very clear in terms of the outcomes that I was looking for. I think some people might’ve felt the challenge was too much and that my expectations were too high. It might’ve been meant as a criticism, but I took it as a compliment. I don’t feel I have, at all. And, if I was in that position, I would say that if I didn’t start to see the shape to it, the leadership to it, and start to see, potentially, the impact of technical devices that we’re starting to bring in, I would not be saying that now.
[19] Lynne Neagle: Okay. Can we just focus on some specifics, then? One of the areas that you said was lacking in the Welsh Government’s response was the structure and leadership. Can you tell us how that has changed, then, that has satisfied you?
[20] Ms Rochira: I think it’s really based on the conversations and discussions and the further information provided to me in relation to the care home steering group that we have—the way that that’s taking forward its work, the focus of its work, me seeing its work programme beginning to develop behind that, the structure, the best practice strands, who’s been involved, who’s been included within that. Also, the repeated statements from the Minister and then the correspondence between us in terms of the focus and the importance of the review and using it as the blueprint—and then, just down to the tiniest of detail, seeing particular pieces of work fed into work strands, so I can see who’s taking what forward and when.
[21] One of the things that I’ve agreed with Welsh Government—and this has strengthened my assurance—is a series of regular meetings, following on from the work of the steering group; a range of meetings with policy leads who are taking forward individual pieces of work, so that I can stay involved in the detail, where relevant, as well. You know my approach will be that I want to see the evidence. It’s not just enough to be told; I want to continue with those meetings with people. So, we have a kind of a structured way forward, as well. So, in the next 18 months, I’m not just going to go away and wait. I have my own programme of work working with support in Welsh Government and others across the sector, as well.
[22] Lynne Neagle: Okay, thank you. One of the areas that you have got outstanding concerns on is the reporting on the fundamentals of care in nursing homes. Can you tell us a bit more about that and how you think that’s going to be addressed?
[23] Ms Rochira: Yes. This was, I suppose, the biggest area—the one area where my assurance levels really weren’t where I wanted them to be. In a sense, it falls out of the bigger debate that will now take place in the quality Bill around integration. But, it goes back to something very simple. Nursing homes, five or 10 years ago, we would’ve called hospitals. Fundamentals of care—the standards that apply to clinical care—would’ve applied then. I know those are being upgraded, but the principle is still the same—the guidance on what good clinical care looks like. That is still systematically missing from the nursing home sector, because, in a sense, it falls out of that longer term issue. I don’t think we can wait for it to fall through from the debate that will come out on the back of the quality Bill.
[24] We have the Care and Social Services Inspectorate Wales that has eyes on the sector, but those fundamentals of care don’t sit at the heart of their work, and it doesn’t sit within Healthcare Inspectorate Wales. So, what we see now are health boards going in and picking up—rightly so—but that’s not a systematic, standardised approach across Wales. So, I’m going to have more conversations with Welsh Government. We can’t wait for that to play out through those longer discussions. What are the core clinical standards that should be being complied with in care homes and are they being complied with?
[25] Lynne Neagle: Okay, thank you.
[26] David Rees: Could I clarify a couple of points? Obviously, you’ve identified that your high expectations are there and I don’t think there’s anything wrong with having high expectations—it’s what we would expect of you, to be honest—but you’ve been given assurances, because you believe the structures are in place now. That’s clearly assurances because of proposals. When do you expect to see the evidence that those are actually being effective?
10:00
[27] Ms Rochira: I think there are two timescales to this. So, some of the issues—those changes that are taking place—will take some time to play through the system, but we can’t park everything until that happens, and that’s why my ongoing programme of work is important. So, those touch points where I want to see evidence that things are being delivered and being changed now—. In a sense, it kind of depends on what the issue is. If I just give you an example of the sorts of things that I want to track through. So, the work around the mealtime experience, for example. I want to see, in the next year, us rolling out pilot work across Wales, and that we start to standardise that. It’s something that we can bring in and should bring in earlier behind that. Some of the work that the care council is doing across Wales in terms of the dementia standardised training programme, for example—I want to see that coming in at a much earlier stage. So, those are the kinds of areas that I’m going to track in the interim to make sure that we are delivering more quickly. One of the things that I think will be particularly important—and this is some further work that I need to do—is just to try and bring some overall structure to all of the changes that are taking place. It’s something that I’m trying to do at the moment; it’s to timeline out those that are later and those that are earlier within that. I’m very happy to share that with you.
[28] David Rees: Thank you. You mentioned dementia training. I know that Lynne’s got a question on dementia as well. Do you want to raise it now, Lynne?
[29] Lynne Neagle: Yes. Obviously, there was a very strong message in the report about the need to improve things generally in relation to dementia in residential care. How do you feel things are looking now? How satisfied are you that the sector is better placed to cope with dementia?
[30] Ms Rochira: I think we are a sector that is increasingly realising that good dementia care sits at the heart of getting good residential care right. If we get it right people for with dementia, we get it right for everybody across Wales. I saw in the responses from providers both a real appetite and also real examples of people who were starting to engage with a wide range of other organisations, training opportunities and much more to upskill and upknowledge themselves. That appetite, actually—it was really important to see that from providers, but also some of the early work that the care council are doing, for example. So, the work that they’re doing, linked in with Swansea University, to develop a values-based approach to training for dementia, the way that’s linking in and across to healthcare providers as well to give us an integrated and a joined-up approach. That looks really impactful, actually, and that’s being brought forward at an earlier rather than a later stage. So, I think all of those are actually quite important, but also the work that’s coming out through the care homes steering group in terms of taking some of the best practice that we have now, mapping that and looking to roll it out across Wales.
[31] So, I think actually we’re moving at some pace on that, and that actually is quite reassuring. If I go back to the end point—and in my office I sound like a broken record on this—it’s about consistency, removing those variations, and it’s about the outcomes. That’s where we have to keep going back, checking in, but also looking right down at those fundamental outcomes, so that people are being cared for by people who are appropriately trained to care for them. But it’s also about the cumulative impact of all of these changes, and I think that’s what makes it very complex to track. But it’s also why going back to the outcomes is so important. Because if we want to make sure that people with dementia are cared for in the right way, all that stuff is just device. It’s just the stuff we have to do to get to that end point. But I do see real change. I think we have—and it’s a combination of our joint work, because there’s been your review as well, and the work of many others. I think we’ve fundamentally started to re-frame what ‘good’ looks like, and we’ve started to fundamentally understand that good dementia care sits at the heart of it.
[32] We are still in the doing process, and we’re still in the early stages of the doing process. We need to not over-egg that, but that’s a really important start.
[33] Lynne Neagle: Okay, thank you. One of the signs that dementia care isn’t as good as it should be is often the inappropriate use of antipsychotics in care homes. You’ve asked for health boards to publish data on this and they’ve agreed to that. When do you expect that to be available?
[34] Ms Rochira: Well, last year I spoke with health boards and I said that I wanted to see them using their annual quality statements to start reporting on and talking about the care they commission from care homes. We’ve started to see that developing, and I’m really pleased to see that. It’s still early days in relation to those annual quality statements, but they’re not missing from them now. I’m just about to write out to all health boards with feedback on the last round in relation to those. So, I want to see the next round of AQSs used to report more against those.
[35] I’m still thinking to some extent about what that reporting should look like, and I’m working with people like the Royal Pharmaceutical Society and the Royal College of Psychiatrists in terms of getting that right. I’m reluctant to issue a template, if you like, that everybody fills in, because that’s not what it’s about. It’s about boards understanding for themselves their duties in terms of complying with NICE guidance and the Welsh guidance as well. But I do want to try and structure a device that gives us some consistency and some standardisation. So, the short answer is that, in the next round of AQSs, I want to see them build on their reporting around care homes and I want to see them talking about antipsychotics. Then, after that, I want to see us having a more standardised approach across Wales.
[36] I have not told health boards or any public statutory bodies what issues I will focus on in my follow-up review, but I’ve said to all of them that the smart ones will know through the work that I’m doing with them now those areas that I want to see us being really strong on. We should just be complying with that NICE guidance.
[37] Lynne Neagle: Thanks.
[38] David Rees: Okay. Lindsay.
[39] Lindsay Whittle: Thank you, Chair. Good morning.
[40] Ms Rochira: Bore da.
[41] Lindsay Whittle: Bore da. It’s almost a follow-up from the last points you made in response to Lynne Neagle, really. You mentioned the poor quality of care in some homes and, on the opposite side, you mentioned outstanding issues of care in other homes. I was interested to learn that you’re going to roll out this good practice. I am concerned about abuse in care homes and your work in future with health boards, local authorities and the police to ensure that we try and stamp this sort of behaviour out. That’s a tough ask. How do you intend to do that?
[42] Ms Rochira: Okay, I guess there are a couple of answers to that. One is that I was very clear when I published my review that it wasn’t a safeguarding review because I had put some parameters around that. But you’re absolutely right, and I’ve just recently on the news spoken about a lady who suffered horrendous neglect in a care home. It’s the issue that’s at the front of people’s minds: will I be safe in the home that I’m in? So, I guess, in terms of my own work, it’s continuing to support individuals and using their experiences to drive the change and it’s continuing to work with people like the Care and Social Services Inspectorate Wales in terms of their focus but also commissioners as well and the commissioning board, particularly in terms of how we work. So, that’s about growing our knowledge, our thinking and our practice.
[43] But it’s also about supporting again some of those technical devices. So, one of the pieces of work, for example, and one of the requirements for action that fell to CSSIW, was in terms of what I call ‘never events’. They call them ‘unacceptable care’; I don’t really mind what they’re called. They’re developing what I think is actually some really, really good work about examples of unacceptable care, and they’re linking that back to a rights-based approach. We’ve been in quite a lot of discussions with them. We sit on the group that’s been developing them. I think that’s actually quite a powerful tool because it reminds all of us, including commissioners, about that which is completely unacceptable.
[44] I’ve brought a copy with me because, actually, I do think it’s really good. It just gives an example. So, it is completely unacceptable that people’s calls for help are being ignored in care homes. It’s something so small and simple but actually so crucial. It goes up to things such as that it is unacceptable if people do not have opportunities to follow their faith within care homes. There’s a whole list of things, and I think that, potentially, is a really powerful tool that can be used and rolled out across Wales.
[45] There is a range of other things taking place that I see should be able to sharpen our focus within that. One of the really important ones—and we spoke a lot about this, I think, in evidence before—was about the market and about our need to invest in a long-term, sustainable market. That’s why what I think I called ‘the national plan’ mattered within Wales. One of the big issues why poor care can exist is because there aren’t alternatives available locally. The more we get on top of the market at a strategic level, long term, the more we crowd out that poor care. We should be investing in long-term, sustainable, quality-based relationships through our commissioning with providers who know they’re in it for the long game and can invest. But, in the shorter term, some of the work from CSSIW, I think, is really, really promising. That’s actually quite high praise from me. But there is also my own work in terms of taking experiences and using those to channel and drive change.
[46] Another area where I’ve been working with Welsh Government—and I hope, or I expect them to come out to consultation shortly on—is guidance to care home providers and commissioners when care homes are closing as well. So, I think, long term and shorter term, within that, it is the big issue in the front of people’s minds, and actually, regardless of how good care is or is not, people are frightened, and they’re frightened because of what they read and what they hear.
[47] Lindsay Whittle: I have other questions, but I know you have other Members—
[48] David Rees: Yes, I know that other people want to come in. So, Darren first and then Kirsty.
[49] Darren Millar: I just wanted to follow up, commissioner, on your comments about the need for the rights-based approach. I know that, just before Christmas, I think it was, you made reference to the need for a piece of legislation in order to bring together some of the commitments that have been made here in Wales and elsewhere on the rights of older people. Do you want to just expand on what that legislation might need to look like if it’s going to provide some undergirding, if you like, for some of the themes in your report on residential care to help to transform it?
[50] Ms Rochira: Yes, I would like to. Thank you for that question. You’re right, I put out a statement before Christmas that called on the next Government in Wales to use its legislative powers to embed rights for older people in law. I’d just like to say I’m really grateful for the cross-party support that you’ve all shown for that piece of work.
[51] I guess it starts from something really quite simple, and there was a quote—. As you know, through the care home review, people who lived in care homes and their families responded, and some of those quotes stay with you. One of them was from a resident, and the gentleman said, ‘You’re powerless.’ Actually, that’s a reality for so many older people, not because they’re older people, but because, often, of the circumstances they find themselves in, particularly when in the care of the state. You are powerless, and we don’t know what ‘powerless’ feels like. I felt it once in my life and I never, ever want to feel that again.
[52] So, for me, the rights-based approach pushes and gives power back to individuals. Now, it’s a little bit too early to talk about exactly what it will look like, because I’m just starting that piece of work. I have a group of experts working with me, and they range from, as you would expect, older people, to a practising barrister, to academic experts in terms of the law. My plan is to have early discussions with the new Government to make the case for it and to have something developed and shaped by the summer of next year.
[53] What I do know, within that, are a number of things. One is that we need to make rights real for older people. It draws, if you like, on the Human Rights Act 1998, but is wider than that. We need to make rights that are in people’s own homes, in care homes, in hospital beds and in the places where they live in a way that we’ve not done before. The Human Rights Act and other conventions are too high to draw up upon.
[54] I know I want to focus on the issue of rights holders, as older people, but also duty bearers—the duty that the state has to uphold rights for people as well. But I also want it to be an empowering tool. You know, I’m a rights-based commissioner—the UN principles sit at the heart of my work. I’ve always said that it is good for individuals, but it is good for the state as well. A rights-based approach is an empowering approach. It enables us to get it right; it stops us getting things wrong. I think it can be, sometimes, frightening for people to, kind of, march down the rights-based approach, but I think we’ve started that in Wales with the declaration of rights of older people—only a declaration of intent, but an important signal of intent. Just to give you an example, I was in Powys and I went on to a ward, and they said, ‘Oh, we want to show you the declaration of rights and how we use it.’ I cannot tell you how delighted I was. They were using it as a practical, day-to-day tool for people in those hospitals.
[55] So, I want to make it real, I want to bring it back to duty bearers and rights holders for people. It’s about the transfer of power for me, down to individuals. It’s also, I think—I’m not an expert, and I don’t profess to be one, on devolution, but it also, for me, sits at the heart of Welsh devolution. So, we’ve taken those first steps, as I said, in terms of the declaration of rights of older people, and we have UN principles on the face of the social services and wellbeing Act. I’m really delighted we have UN principles now, built into the chief inspector of social services’ reporting. We’re starting to get comfortable with that. Now is the time for us in Wales to use our devolved powers to embed a rights-based approach. It’s a powerful tool that we can use. I think it reads directly back to the heart of the Government of Wales Act. If devolution transfers power to us, now is the time for us to transfer power to individuals: good for them, good for the state and good for public services. A bold move, a brave move—devolution should be bold, devolution should be brave. I guess my challenge to people who say, ‘Well, maybe we don’t need to do this’ is, ‘Come and see some of the things that I see. Come and feel what it feels like to be powerless. If not Wales, who? If not now, in the hardest of times, when rights have been created, when?’
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[56] Darren Millar: I fully support your calls, but one thing that is very important is that those rights will never be—those rights must be upheld, and there must be someone to champion and safeguard those rights. Your office can only do so much, and one of the things that you refer to in your report—and you referred to, actually, during the passage of the Social Services and Well-being (Wales) Act 2014, and on many other occasions in the Assembly—is the need for access to independent advocacy to help people realise those rights. Are you satisfied with the progress—you don’t seem to be—that has been made in enabling people to access high-quality advocacy around Wales? I know it seems to me to be a very inconsistent picture where I go. What are you doing to make sure that local authorities and others are helping to ensure that people always have access to advocacy if they feel that their rights are not being upheld in the way that you and I both want to see them?
[57] Ms Rochira: Ok. There are two issues there. The smaller one is in relation to helping people to uphold their rights. The reality is that, in law, older people have fewer rights than other groups do. I want parity, I want equality for older people. That’s all I want. No more, but certainly no less. The technical devices I have to challenge are actually relatively weak, so I don’t have those rights to draw on. That would significantly strengthen my position as commissioner.
[58] But then, to go on to your substantive point around advocacy, you know, rights and advocacy sit together—power and voice. They’re intrinsically linked. You’re right, I’ve spoken many times about the vital importance of independent advocacy. It’s not the only type of advocacy, as I always remind colleagues in the public sector when they challenge me on that, but it has a vital role to play, and I think it is intrinsically linked back to the point you made, Lindsay, about our safeguarding agenda in Wales. The better we invest in it, the better our independent advocacy is, the less we will get it wrong, and the more quickly we will be able to put things right. So, again, it’s good for the individual, good for the public purse, and good for the public sector reputation.
[59] Where are we now in relation to it? Well, we have the social services and wellbeing Act, which brings in some duties around advocacy. I am not yet convinced that those are strong enough. Now, I guess it’s that I’m not sure, because in no small part we won’t know again until it plays through the codes of practice, although—I think it’s Part 9 and Part 10—advocacy’s woven through it. So, you have to try and form an overview of that. It feels to me that potentially there are too many barriers within that, and I don’t actually know how many people at the end of it will end up with independent advocacy.
[60] Now, Welsh Government and I have different views on that. They may well be right, and if they’re right in 18 months’ time, two years’ time, I’m quite happy to say I was wrong about that. So, I’m not yet sure. But that is also coupled with the provider base that we have in Wales. We are fortunate, in a way, that we have some fantastic independent advocates across Wales, in no small part funded through what was the Big Lottery Fund, and we were very fortunate to be able to secure an extension to some of that funding. That funding is now disappearing, and despite the fact that some commissioners understand the importance of independent advocacy, we have an incredibly fragile independent advocacy base within Wales. It’s also quite variable in terms of what services are available to people locally. If we need to see our residential care sector as a sector of strategic national importance, we also need to see our independent advocacy base in that way as well.
[61] I think one of the interesting things for me, as I go around and about, is who understands and gets why independent advocacy is so important, and who doesn’t, because, actually, we should never really need, in a sense, to have built in a duty. We should be investing in, developing and growing our independent advocacy base in Wales because it is inherently a good thing to do for individuals and for others. I have been growing my work around this. It is too early for me, and impossible for me at the moment, to give detailed commentary on what any future work might be, because I’m yet to find out if I will be a commissioner for any longer, but I know that advocacy, in its breadth, will be part of that. When I say ‘in its breadth’, it’s important to remember that breadth of advocacy. We tend to think of generic, independent advocacy, and in no small part it’s quite a bit of what I do through my casework, and the role of independent domestic violence advocates, for example, and the role of independent mental capacity advocates. Someone—it may well be me, if I have an extension—needs to look at the breadth across Wales. We need a root-and-branch review of how good that advocacy base is in Wales, and I see it disappearing across Wales.
[62] David Rees: Before we got on to advocacy—I know Lindsay’s got a question on advocacy—I just want to come back to Kirsty to get back to the original point. So, Kirsty, do you want to raise your question?
[63] Kirsty Williams: Thank you, Chair. I want to go back to what you said about the importance of a strategic approach to driving up standards and improvements to commissioning, because you have constantly stressed throughout your work that, if we don’t get commissioning right, it’s very, very difficult indeed then to have consistently good care across the piece. Now, you have said that you don’t believe that the changes required to commissioning are good enough to date, and you intend to go back and look at issues around commissioning in your follow-up work. I’m just wondering what evidence do you see of improvements in local authorities’ commissioning arrangements that gives you any confidence that they are approaching their commissioning in the strategic approach that you’ve just described, of having long-term relationships with providers that allow providers to plan for their business, recruit sufficient staff, train that staff, pay those staff enough so that those staff remain within that home, or are you still seeing commissioners and local authorities act almost in panic mode, ‘Oh, we have an individual; we have to find this place for this individual, and we’ll choose that place’, so it’s ad hoc rather than that strategic nature of building those relationships that will lead to better quality provision across the piece?
[64] Ms Rochira: Okay, thank you. There’s quite a lot wrapped up in that. I think, when I gave evidence on the R&I Bill—I don’t think I coined this phrase, but it was a good phrase—I said we wanted to see more grit in the commissioning bit, and I think we have seen more grit built into that, and I think that’s welcome. So, there’s the function that CSSIW will have now to report on the function of local authorities, the stuff around the annual reports and the role that minimum standards can have in terms of picking up on the commissioning issues. So, those are welcome.
[65] I guess I would just have liked to have seen more grit again within that, because I have this kind of order of accountability. So, providers first, absolutely, because that’s the business you go into. And then people traditionally then go to the regulatory inspector, and they have a crucial role to play. Actually, for me, second is commissioning, because it is the state placing people. They might not use that phrase, but it is what it feels like when you’re in crisis and you’ve got a choice of two places to go, or when your home is closing and you’ve been given a choice of somewhere else that’s 30 miles away. It is the state placing people. Commissioning needs to be as good as it can be.
[66] I think we are—again, as, in a sense, with the other areas—really starting to shift. So, the engagement I’ve had with the commissioning board and the work that they’re doing around good practice I think is really positive work. The work that CSSIW is doing through their—I think it’s called the quality forum, in terms of looking at some of the good practice and rolling that out across Wales in terms of consistent commissioning I think is important. And I’ve seen some really good examples growing in terms of the  commissioning models that people are using as well, and a growing understanding from commissioners that you can’t simply say, ‘There are no alternatives, so we’re just going to have to prop this home up’.
[67] So, the direction of travel, yes, but, for me, I think what I really want to see is us just—well, I suppose, a couple of things. I want to see actual duties on commissioners to get it right, rather than complying with the good practice. I still want to see that one consistent approach across Wales, the one model that has quality of life at its heart. I want to see commissioners in a place where they feel confident and are able to invest in those long-term relationships. But, actually, until we look at the issue of the market in its widest sense, it’s really difficult for them to do that; you just can’t do it 22 plus eight times over. That’s where the leadership and the strategic work around that market plan matters so very much.
[68] So, I think I see signs that we are shifting at a local level, but some of the functional barriers are still huge for commissioners out there. So, I think the direction of travel, yes, but you almost can’t put too much grit into the commissioning process. I know that some of my ongoing workshops with the sector will focus with the commissioning board and with people like the Association of Directors of Social Services Cymru and others on the commissioning function and the commissioning process. It is hugely variable across Wales, but I don’t think the solution lies in the 22 addressing it; it lies at that leadership, strategic level. I think it’s one of the most difficult things for us to grasp in Wales: just the sheer lack in some places of providers and alternatives that people have, which means that it’s still that issues arise and people are then in that reactive position.
[69] David Rees: Okay. We’ll go back to the question on advocacy. Lindsay, do you want to take that one?
[70] Lindsay Whittle: Yes. Advocacy is very important. It was the first amendment, I think, to come from this side and, to be fair to the Minister, it was the first amendment that he accepted without virtually any dissent. I was concerned when I read about your concerns about the code of practice on advocacy and I’m just wondering—you were partly on the way to answering Darren Millar’s question, but what further actions do you intend to recommend to Welsh Government to ensure that we’ve actually got it right on advocacy, please?
[71] Ms Rochira: I think there’s two sides to that, isn’t there? There’s the extent to which we recognise—the point that I made a moment ago—the vital importance of our provider base across Wales. Again, it’s back to that response that we enter into long-term strategic relationships with them so that they have the sustainability that they need to grow their work. I think, in a sense, it now pushes out from Welsh Government down to local authorities and health boards.
[72] In terms of my work with them, it’s going to be continuing to focus on the impact that independent advocacy can have, showing them why, actually, it’s sensible to invest in it and why it’s sensible to use it, not in terms of the definitions within the Act, but, actually, in terms of the real-life experiences that people find themselves in. So, if Welsh Government was trying to create a framework and a kind of a duty around that, it now falls down to others to pick up on that and to implement that at a local level. I guess the evidence will be when providers of independent advocacy tell me that they feel in a strong and stable position and when individuals are actually able to access and to use that independent advocacy on a basis that adds real value to the issues that they’re facing.
[73] Lindsay Whittle: And advocacy that people trust—without that, it’s no good at all, is it?
[74] Ms Rochira: Yes, absolutely. I don’t think, until I became commissioner, that I really appreciated what it is like when you lose your voice, and then, when somebody comes along and sits alongside you and gives you your voice back, the difference that that makes. I think we understand it at a strategic level and, if you go back to the national outcomes framework that underpins social services, it has something in there—I think the words are something along the lines of, ‘I have an effective voice or someone to speak for me’. The intent is there and now it’s pushing it down to delivery and delivery on the ground that reaches into those places of vulnerability that people find themselves in. Because we know that even when, as an individual, you try and raise your voice, how hard it can be—it can be nigh on impossible. You only have to think about some of the horrendous examples of neglect and abuse that we’ve heard about whilst in state care. Do you know what? There were family members, individuals, raising their voices all the time—they didn’t have enough power.
[75] What’s so interesting about my work, when I support individuals, is that they have been trying very hard to make their voices heard and then I come along and sit alongside them and all I do is transfer a bit of power to them. That’s what independent advocacy does. There are many other forms of advocacy that are really important, but I keep bringing it back to this point, which underpins so much of my work, about power—the transfer of power from state or service to individuals. It’s such a defining change, but it’s all about the delivery of it. That’s why I said earlier that I’d be highly surprised—if my post is extended—if I don’t focus on advocacy in quite some depth.
[76] Lindsay Whittle: I hope you do. Could I just ask another question, Chair, about the integration of health and social services? Your report calls for greater integration. It’s my party’s view that they should be integrated fully in adult services. Are you able to express a view on that? What was your thinking, perhaps?
[77] Ms Rochira: I try and stay on the right line of that which is a view and that which is political.
[78] Lindsay Whittle: Yes, I just wanted to tease something out of you, perhaps.
[79] Ms Rochira: Yes, but it’s a fine line, perhaps. I take it back to what older people say. Older people say—there are five big critiques of public service—‘Why don’t people talk to each other?’ They find themselves in the cracks between services all of the time. They really are talking about the integration agenda. It’s been interesting to see the use of the intermediate care fund moneys across Wales. Those have proven to be a very powerful tool around the integration agenda. Lots of examples of good practice I see have gone to those smallest of places—the cracks that are actually chasms for people to jump over.
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[80] I’ve kind of always withheld a view in terms of whether that means we should have one system or whether we should have two that are more appropriate at working together. But actually delivering on the integration agenda is key to delivering on better public services for older people and delivering on those better outcomes for older people. I think it’s a huge challenge. I was disappointed not to see it picked up in the R&I Bill, but, to some extent, I understand why it’s going over to the quality Bill. We need a really proper, robust debate, once and for all, about how we tackle that integration agenda. The intermediate care fund moneys have been used as stop gaps, if you like, but there are bigger debates to be had around this. But that critique from older people, ‘Why don’t people talk to each other?’, is damningly accurate of what it feels like for many of them on a daily basis.
[81] Did I answer that without falling into the—?
[82] Lindsay Whittle: You did very well, yes indeed. Can I say, as part of a legacy report, I think that would be an essential piece of work for any future committee, speaking as a regional Member who covers two health authorities and eight local authorities? It’s a huge problem for the future with all the budgetary problems that we face. Thank you very much.
[83] Mr Rochira: Sorry, might I just come back on that? One of the—. We need to look at this in different ways. There’s the structural side of things: you know, 22 and eight and different organisations and how they try and bolt themselves together within that. But then there’s also the outcomes that we have. I speak a huge amount about outcomes. Increasingly, as we’re doing loads and loads and loads of things, that’s where I’m focusing my work. We’ve got a number of growingly, actually, quite good documents. There’s the national outcomes framework, which I’ve spoken about many times. We’re developing outcomes for health bodies. We’re developing outcomes for public health. The more we align those and the more we all have eyes on the same thing, the easier I think it makes it for systems and bodies and organisations to work together. Actually, I hold the view that we should have one set of outcomes that underpins and runs across health and social care. That would make it a lot easier I think, then, to consider—. It’s the form and function behind it, and we need to start, absolutely, with those very simple outcomes. Older people are really good at outcomes, just like they’re good at performance indicators; they just never pick the ones that the system picks.
[84] Lindsay Whittle: Thank you very much, Chair.
[85] David Rees: Darren, did you have any further questions on advocacy?
[86] Darren Millar: I just really wanted to emphasise that, obviously, people can’t have their rights upheld if they don’t know what their rights are—by an advocate or anybody else. So, yes, whilst we’ve got a statement of rights—a declaration of rights was made—do you think that sufficient progress is being made in educating people and raising awareness of those rights amongst older people around Wales at the moment? If you don’t, what would you suggest might need to be done?
[87] Mr Rochira: One of the things that I think was so good about the declaration of rights for older people—and it’s partly because it was older people who wrote it—was that the words in there were meaningful to older people. They could understand them and they resonated with their own lives. So, whatever we do in terms of rights, that’s, in a sense, one of the principles behind it: to draw them down from these big principles and make them real and tangible for people, because then you can start to understand what they mean. But you are absolutely right, the few rights—and they are few rights—that older people have, they’re up here, they’re impossible to reach. That’s why we need them in domestic legislation; we’re bringing them nearer to people. People don’t know about them. I think there is a huge programme, not just around duty holders, but rights bearers, to help them understand what that means in a practical sense for them, how you can use those to ensure that you do get that which you need and want, but how you can also use it to challenge as well. I don’t profess that bringing in legislation is the end point, it’s the beginning of a journey, but it’s the beginning of a different approach and everybody has a role to play within that. Clearly, a key part of my role would be to ensure that older people do understand what those rights would mean in practice, just like I’ve published toolkits for older people on other issues, trying to upskill them through—. There is a phrase, isn’t there, ‘knowledge is power’. That’s part of my role, to transfer that knowledge out to older people.
[88] Darren Millar: Okay, thanks.
[89] David Rees: John, do you want to come in on this?
[90] John Griffiths: If it’s the appropriate stage, Chair. I just wondered, in what you’ve described, Sarah, whether people are really aware of how these homes should be operated, particularly in terms of activities and stimulation. I know it is a big concern that older people can degenerate—I suppose that’s one word—quite quickly if they don’t have that stimulation in homes. So, it is about the activities that are conducted that do stimulate older people physically, mentally and socially. But I think it’s also sometimes about the mix of older people. Older people sometimes complain to me that they have been in homes where there aren’t other residents that are similar to them, in terms of their own mental faculties and physical abilities, and that they felt very isolated. They didn’t have anybody to talk to, in terms of other residents, and to interact with—you know, other residents that were on the same level as them, as it were. Is that something that you think older people are sufficiently aware of—you know, that it’s not just about the basics of care in these homes, but that it’s about these wider matters as well?
[91] Ms Rochira: You are absolutely right. Even within really good homes, not every home is the right home for you. It depends on what matters to you, where you are in your life and what you want to be doing. There are some really good publications out there. There’s a really good one that the Alzheimer’s Society has. There’s a really good one from My Home Life Cymru and Age Cymru in terms of what to look for. I think people are quite capable, in the ideal world, of thinking about those things and looking to find the right match. But there are two problems within that. One is that, often, you have very little time because, often, it is when a crisis has occurred. The other is that, often, you have very little choice as well.
[92] If you link it back to advocacy, and you go back to the statements of intent that were behind the Social Services and Well-being (Wales) Act 2014, the first or the second one was about voice and control. That’s why I’m not sure that the advocacy part yet responds to that driving intent. I would like to have seen ‘voice choice and control’, because without choice it is very difficult to do exactly what you’ve described. There are some mitigating actions behind that. It’s why things like the statements of entitlement matter. It’s why the welcome packs matter to people. It’s why I focus so strongly on the transition into a care home, because the likelihood is that, once you go into one care home, you probably won’t move to another care home even if that proves not to be the right home for you.
[93] Again, it goes back to why independent advocacy matters. It goes back to why information and knowledge matter for people. I think people are quite capable of making the right decisions, but you need time. Sometimes, you need someone to help you do that, and you need choice behind that as well. You particularly need choice if we haven’t yet delivered on a sector that, at its heart, consistently has quality of life. It’s a really difficult decision at the moment for many older people to make. I have people contact me and say, ‘I have got 48 hours to find a home. What should I do?’ That’s not where we need to be. People can do it. The information is there. You need time, you need, sometimes, some support, and you need choice behind that as well.
[94] David Rees: Kirsty.
[95] Kirsty Williams: Can I ask you, then: if choice is important, how do you deliver choice in a rural community? I can see that you could have choice in a centre of population. You can have a variety of homes in Newport and a variety of homes sustained in Cardiff or Swansea. But how do you deliver choice in a sparsely populated area, where there simply aren’t going to be the numbers to sustain a variety of settings—in somewhere like Brecon, let alone somewhere like Rhayader? How do you give choice to people in a rural setting? Many of our communities across Wales are small and rural in nature.
[96] Ms Rochira: I think it’s a really challenging one. It’s really hard to address that. I think there are kind of two levels that I would look at it. There’s the overall choice you might have between different homes. You’re right: in some areas, that’s easier than in others, although, actually, the reality is that, within most parts of Wales, the choice is actually relatively limited because of the wider sector issues. Then, there is, I think, the choice for you as an individual in terms of being able to do that which matters to you. That, in a sense, was the whole focus of my review. It was about making it personalised to you. So, you might have a very rural area and there is only one home. First of all, let’s make sure that it’s a good home, and that it ticks all the right boxes so you don’t need to worry about going there.
[97] One of the things that makes it a good home is the extent to which you can continue doing the things that matter to you. So, you might have a group of people, for example, who are still very active, like to go out and about, do all those things, go out into the community, and they should be able to do that. You might have another group who aren’t still able to do that, but the community can come in to them. It’s that individualised—I don’t want to say ‘person-centred’ because we use jargon too much—but it’s that individualised nature of care so, you have choice in your day-to-day—. You have choice about when you get up, choice about when you go to bed, choice about what you eat, choice about who you see. We can operate it very strongly at that level, and I think that was the big message behind it. If we struggle with choice—and I think, even if we address those big market issues, it’s still going to be a struggle.
[98] We can also look at choice from the individual’s perspective—still being able to do the things that matter. What matters to Mrs Jones might not matter to Mr Evans. Actually, probably it lies in those smallest of things, the things that are often so small that a system that likes to have big structure behind it struggles to focus on. It’s one of the reasons why, actually, really listening to people who live in care homes matters so much because I think that, if you listen hard enough, they will tell you, actually, whether they’ve got choice in those things. I guess that’s probably what I would want: choice about when I get up, when I go to bed, where I go, who I see, what I do, and maybe who I sit next to.
[99] David Rees: Can I ask a question there? Obviously, you’ve indicated the importance of the independent advocates for older people, but you also, earlier on, indicated that, in fact, most independent advocacy services are funded by schemes such as the Big Lottery. Are you having discussions as to how that funding will be continued beyond the dates on which the Big Lottery funding stops? Clearly, you’ve stressed very strongly this morning the important role they will play, but if we haven’t got that base, there’s going to be a problem.
[100] Ms Rochira: Actually, the reality is that the Big Lottery funding stream ran out a while ago. I think it was about 18 months or so ago, but there was continuation funding because of the conversation brokered through my office, and that was really on the premise that the social services and wellbeing Act brought those duties in in relation to advocacy, the irony being that we spend three to five years building up our advocacy base and there was a gap in between for the duty and the understanding to kick in. Big Lottery were very receptive to that, and I know they put significant funding into that. Now it is time for local authorities and health boards to step up. They are the ones that have to understand that, if they do not recognise that advocacy base as being so crucial and do not develop their own longer term sustainable relationships with it, we risk losing more of our independent advocacy across Wales. That will be bad for individuals, bad for our policy imperatives in Wales and bad for the public purse, ultimately, as well.
[101] David Rees: Have you had any discussions with the health boards and local authorities, because, clearly, they’re facing difficult circumstances with their budget proposals?
[102] Ms Rochira: Not at a strategic level at the moment, but, as I indicated earlier, advocacy in its breadth is likely to be a strong focus, and you know my approach is to work with people as well as to scrutinise. If I have the opportunity to do further work, I suspect it will cover the balance of the two across Wales. I think one of the things that we need to do, actually quite urgently, is a further piece of mapping across Wales. Where is our independent provider base at the moment?
[103] David Rees: Okay, thank you. Altaf.
[104] Altaf Hussain: Commissioner, thank you very much for your evidence and for the excellent work that you and your team have been doing on behalf of the older people in Wales. I am concerned about the care in nursing homes. I’ve not seen any change, and the elderly population is being inappropriately put on antipsychotics. I would like to focus on the use of lay inspectors in the inspection of care homes. I agree with you that lay inspectors should be integral to the inspection regime and I brought forward amendments to the regulation and inspection Bill to that end. I note that CSSIW have mentioned that they found lay inspectors problematic. Have they indicated to you how they are problematic? Despite the Minister’s opposition, do you still believe that lay inspectors have a key role to play in the inspection regime?
[105] Finally, commissioner, if we can’t use lay inspectors, how can we best ensure we incorporate the mum test in our regulation and inspection regime?
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[106] Ms Rochira: Okay. Thank you. I guess the use of lay assessors is one of those areas where I have a different view to the regulator and inspector and to the Welsh Government. I still hold the view that there is a real role for lay assessors, but I think it’s important to see it in its context, about what it’s about. What it is about is understanding what it is like to live day in, day out in a care home.
[107] Some of the other things that are going on are important. The work that CSSIW is doing through its modernisation programme and its structure to weave that in is really actually quite important; the work that I’ve seen health boards, for example, doing in going into care homes, and there are a couple of really good schemes across Wales that have been developed, from the quality circle up in north Wales to the work that they’re doing in Aneurin Bevan, for example. Those are really important as well. I think they’re examples of really good practice. Because, fundamentally, underpinning it sits that simple thing: what is it like to live in a care home? That’s actually what commissioners, I think, need to have much stronger eyes on. I’ve always said to commissioners, ‘You should be able to tell me what it is like in any of your commissioned homes on a pretty real-time basis. You shouldn’t need to refer back to a report from the regulator and inspector. You should know because you should be in and out of them all the time’. I think commissioners across Wales are starting to really understand that, if they don’t know what it’s like, they place themselves and, actually, residents at risk as well because you only find out when a crisis occurs or something has happened.
[108] I would like to have seen lay assessors. I still would. We have a different view on that. You don’t win all of them, and there are many changes that we’ve both spoken about that are reflected in legislation. We have different views on that. There are other changes taking place, but I still think they have an important role to play. But I am reassured, because I know that CSSIW, for example, are talking to the community health council about how they might join up their work more closely. I know that the community health council has a huge appetite for this. I hope it is one that we will see evolve because, at the heart of it is all those devices, so, the commissioners, the regulator and inspector, and residents and family members as well, know just what it is like on that day-to-day basis. So, I would like to have seen it. There are other things happening and I hope maybe we grow something over time.
[109] Altaf Hussain: Thank you.
[110] David Rees: Commissioner, you highlighted in your earlier item the concerns over training, and you talked about dementia training in particular, although you’ve also indicated your acknowledgement of the Welsh Government’s plans about mapping training. In a sense, does that actually satisfy you that the training aspects will be addressed, because I’ve also heard of circumstances where two hours of training to a member is sufficient to give them some sort of consideration to undertake certain duties? Are you satisfied that the mapping exercise will be sufficient, or do you still want to see more being done to ensure appropriate levels and qualifications, in one sense, are put into place for staff training, and in all areas, not just dementia?
[111] Ms Rochira: I think it’s a good thing to do the mapping. It’s an easy thing and an early thing that we can do, and I think it will add value across the sector. One of the reasons why I wanted to see registration come in was particularly because of the link across to mandatory training that comes with that, so that we remove those variations. I saw those variations through the evidence that came back to me—some people who were buying into and capable of developing really quite impactful training programmes, to others who said, ‘We use an online system’, which I thought probably didn’t really quite get at the heart of what we were looking for. So, there are still those variations.
[112] Registration gives us a link to that mandatory training. The work that the Care Council for Wales are doing in terms of their new dementia training framework, I think, is really interesting and could be really impactful, because that gives us another thing to roll out, and actually should enable us, when we get to the registration stage, to say, ‘We’ve got the training package already’, and to make it mandatory behind that.
[113] So, those are important and valuable things. I would like to see them. It goes back to the point about the grit in the commissioning. I would like to see commissioners being, on a standard basis across Wales, very clear in terms of what they are prepared to commission, and to build into commissioning the training aspects of that. I think they could take an early stage of that new dementia training framework and build that in. So, regardless of where the duty sits or where we are with the registration, actually, if that’s what commissioners are saying that they want and require in return for payment, that gives us a way to embed it within the system. Again, it’s another example; there’s actually a lot of stuff starting to happen. What we need to do is bring that together into a consistent approach and embed it across all of the sectors. I think we could do that without waiting for the registration to come in, but again, commissioning is at the heart of that. It’s still hugely variable. We are, I think, growing the good practice, and some of the stuff going on in Bangor and some of the stuff going on in Swansea is really impactful stuff and I’m starting to see that translate out into the work that others are doing.
[114] So, it’s all promising, but actually, when will we know it’s right? We’ll know it’s right when staff tell us they feel trained. We’ll know it’s right when residents and family members tell us that they feel people are being cared for by people with the right skills, and when commissioners are always commissioning care that has, at its heart, the training and skills of individuals within that. There are some other things that I’m still having conversations with Welsh Government about—so, around the national improvement service, for example, some of the stuff that we can do now, while we wait for those duties to kick in. So, a journey of travel, yes; a huge amount of promising work, yes; starting to see it trickle down, yes. But, that’s still not the same as it fundamentally being the same across Wales.
[115] David Rees: Thank you. Darren, have you got a question?
[116] Darren Millar: Yes. Can I just ask about the appointments process for the older people’s commissioner? I appreciate that you won’t want to go into too much detail on the current situation, but one thing that has been a concern of many Members in the Assembly, on all sides of the Assembly, is the different approaches to the appointments of commissioners in the Assembly and the different lengths of term that commissioners are appointed for in the Assembly. You’ve obviously started some excellent work here, which you want to see through to completion, and your predecessor, no doubt, felt the same. The current term for the older people’s commissioner is four years with the possibility of reappointment, yet we have other commissioners who are appointed for seven-year terms. Some commissioners are appointed by Welsh Government Ministers, others are appointed by the National Assembly. Do you have a personal view just on the appointment arrangements and what might need to be done to improve things and bring some consistency about?
[117] Ms Rochira: I guess I have a view that is based on a business view and a view based on parity, as well. Much of what I talk about—and I do sound like a broken record on this—I want parity and equity with other groups. I only have four years; other commissioners have longer than that. So, it just seems to me that there’s an issue of parity there. I don’t know why it should be different.
[118] But then, from a business perspective, four years is just too short. You know, many of the issues I deal with are 30 years in the making; you can’t unpack them in four years, but you can make a good start. There are some things you can do, don’t get me wrong, in four years—there are. But, many of the issues are longer than that. There are pieces of work I have now that I would like to see through and I would like to finish within that, but I know that it will take longer than the four-year period to do that. So, four years just doesn’t seem practical from a business sense, if you want commissioners to really operate in the way that they were intended to and created to operate, and it creates uncertainty, as well. You know, I’m waiting, at the moment, to see the response from a consultation that the First Minister has undertaken. I would hope to know by the end of this month what his intention is, because I need to get on with my own business planning. I have a strong sense of what I want to focus on, but I need to know whether I’m going to have that extension to be able to do that. If we can consolidate it, so that we have a term of office that is long enough to be able to do that, it just makes it, practically, a lot easier to be able to do that.
[119] So, at the moment, I guess I’m in kind of a halfway house. I have a clear sense in my mind about what I want to finish, what new pieces of work I want and think we need to grow, now, across Wales, but I just think standardisation across it—it’s an opportune time to do it.
[120] Darren Millar: In terms of length of term, what do you see as being appropriate, personally? Again, just your personal view.
[121] Ms Rochira: I think there’s no right or wrong. For me, six years feels about right within that.
[122] Darren Millar: Okay, thank you.
[123] David Rees: Do any other Members have questions? Well, I’ve got one final question. We’ve also seen the question of respite care, and, as a consequence of some of the actions of local authorities, they also may be reducing the number of respite care beds under their own control and looking to actually put more into the care sector. Do you think the care sector is in the position to actually increase its respite provision, and what’s the impact that it would have on the sector?
[124] Ms Rochira: I think the residential care sector has huge potential beyond traditional residential care. So, you’ve touched on respite care. There are all sorts of different phrases—reablement, step up, step down—that we could use. I think we need to explore all of those, and then we start to really make it work for many of the challenges that we face in our breadth.
[125] I think the danger is that we place too many demands on it. We’re struggling to get the sector right in its breadth, just in relation to residential care. We need to be careful in terms of the pressures that we push down to it. And we also need to make sure that, just as we’ve spoken about in dementia care, that if we are going to identify these new roles for the sector, that people do have the training and the skills needed. I’ve spoken about access to basic primary care in residential care. If we’re going to start to see residential care as a sector that we can adopt in terms of respite care, for example, we need to make sure that not just the basic healthcare needs are met, but also that some of the specialist health care needs are met. It requires—and I think this is one of the big messages—a degree of really good strategic planning. What are we going to need where, what skills do people need to have and do we have the skills now. We have EMI beds across Wales—and I’m sorry to use that phrase, because I actually don’t like that phrase—but we have EMI beds across Wales that are not open because we don’t have staff to put in them. We need to be really careful that what feels like a good plan, because the system has problems—that there’s robust evidence so that we can actually deliver it on the ground. And I think that’s one of the challenges; the pace of demand upon all parts of the system is causing the system to develop a whole range of plans very quickly. How robust is the evidence behind it?
[126] In a sense, that’s the position I’m in now in relation to my work around residential care. I was looking to see how robust the evidence was, and that’s why those assurances were important. But, actually, now, we’re right in that middle position—a huge amount of things going on. It’s the cumulative impact of them. They have all got to crystallise down to very clear outcomes in the future. And I would be really keen, in the next Government—. I hope you feel—because it feels to me that we’ve worked well together—that there’s the opportunity to have those debates about what we respectively focus on, how we can support each other in our scrutiny work and how we together can drill down on those outcomes.
[127] So, I’m not going to take my eyes off this. I think I got to about 50 issues that we were involved with in some shape or form in terms of follow-up work or growing the practice around that. I’ve got my own workshops which have already begun—we’ve done 10 already—with a wide range of bodies, growing that knowledge and that practice across Wales. But, it all, for me, comes back to—because it’s now actually quite difficult to track all these various pieces—consolidating them and bringing them together, and looking at what those outcomes would be. And as I grow my work, I’m very happy to share that with you, because it is just really hard now to look across the breadth of it all, and that’s why I think bringing it back matters enormously. So, I hope there’s an opportunity in the next Government for us to continue those conversations and look how we can play our respective roles, but align those roles as well.
[128] David Rees: I don’t think there are other questions. Do you have any further comments you wish to add?
[129] Ms Rochira: No, just thank you very much for inviting me back.
[130] David Rees: Thank you very much for attending this morning and for your time. You’ll receive a copy of the evidence through the transcript. If there are any factual inaccuracies, please let the clerks know as soon as possible so we can get them corrected. Once again, thank you very much.
[131] Ms Rochira: Thank you. Diolch yn fawr.
10:58
Cynnig o dan Reol Sefydlog 17.42(vi) i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod Motion under Standing Order 17.42(vi) to Resolve to Exclude the Public from the Remainder of the Meeting
Cynnig:	Motion:
bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(vi).	that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(vi).
Cynigiwyd y cynnig. Motion moved.
[132] David Rees: The next item on the agenda is the consideration to move into private session under Standing Order 17.42(vi). Are Members happy and content to move into private session? We are, so therefore we go into private session. Thank you very much.
Derbyniwyd y cynnig. Motion agreed.
Daeth rhan gyhoeddus y cyfarfod i ben am 10:59. The public part of the meeting ended at 10:59.