Public Accounts Committee

National Assembly for Wales

Cardiff Bay

Cardiff

CF99 1NA

Committee Inquiry : Auditor General for Wales Report on Housing Adaptations, February 2018

Short Paper submitted by Care & Repair Cymru: May 2018

Thank you for the invitation to the PAC meeting scheduled for 18^th June, to give evidence in relation to the Auditor General findings on delivery of housing adaptations across Wales. You also requested that we submit a short paper giving our response to the findings, please find this below.

Introduction to Care & Repair

1. Care & Repair Cymru is a registered charity. We aim to ensure that all older people in Wales can live independently in warm, safe and accessible homes, with dignity, for as long as they want. We are specialists in developing and delivering housing solutions for older people that make this possible.

2. Our network of 13 local Care & Repair Agencies deliver trusted, practical, frontline services in the hearts of communities across the whole of Wales. Multi-disciplinary teams of caseworkers, tradespeople and qualified surveyors provide advice and support on housing adaptations, home repairs, improvements and energy efficiency. We help people access grants, charitable funds and unclaimed welfare benefit entitlements. All of this helps them undertake essential works to their homes, increases their disposable income, and helps improve their well-being and quality of life. The combination of person-centred casework and technical housing expertise makes our service unique.

3. Care & Repair Cymru, as the national body, advocates on behalf of older people living in poor, unsafe, inaccessible housing, as well as representing Care & Repair Agencies. We ensure consistency across Wales, monitoring and evaluating outcomes, and raise awareness of our services and of older people’s needs. We develop and pilot innovative approaches and delivery models, helping to lever additional resources into frontline work. We reach across housing, health and social care to support integrated policy thinking and make the case for the effectiveness of strategic public/third sector partnerships and greater investment in services to support older people in housing need.

4. Last year, Care & Repair Agencies delivered £13 million’s worth of physical alterations and adaptations to improve the health, safety and warmth of 28,500 homes. We provided and installed some 17,000 small adaptations through our

Rapid Response Adaptations programme. Our Agencies helped older people claim more than £5m of unclaimed welfare benefits. Our work gives us a unique insight into the needs and lives of Wales’s older people. We welcome the opportunity to contribute to this PAC inquiry.

The nature of demand

5. Care & Repair Cymru would draw the Committee’s attention to the fact that 81% of older people live in mainstream, owner-occupied properties and 3% of older people in residential care homes[i]. These statistics reflect our experience that the overwhelming majority of older people not only desire but are able to manage in their own homes with appropriate levels of support from their families, local communities and local services. That is not to say that residential care is not a vital and essential resource for those who need it but, if the social care needs of all our older people are to be met, non-residential care requires the highest strategic attention – so too, crucially, the quality of the home into which it is delivered.

Minimising demand - the role of housing

6. Housing has a direct influence over people’s health and wellbeing, and the quality of older people’s homes has a direct relationship to the need for social care. Our work, with over 30,000 older people across Wales every year, gives us a first-hand experience of the fundamental importance of the ‘right home’ in maintaining older people’s independence, facilitating social lives, physical activity levels and mental wellbeing, and minimising social care needs and costs.

7. Older people spend proportionately more time at home and are especially vulnerable to the many, life-limiting health risks presented by Wales’ comparatively old housing stock:

· an estimated one in four older people’s households are in fuel poverty, paying more for their energy costs, heating poorly insulated homes with inefficient heating systems[ii] - poorly heated homes are directly implicated in respiratory and circulatory conditions and excess winter deaths[iii];

· 29% of older people live in a house with a Category 1 hazard which presents significant risk to the health of the occupant - 13% of older people’s homes present a risk of falling and 11% present a risk of excess cold[iv].

8. Home-based adaptations and ‘re-abling’ housing solutions promote health, prevent hospital admission, facilitate hospital discharge and avoid residential care. For comparatively small sums, they also minimise the costs of social care, maximise the contribution of unpaid care and enable older people’s highly prized independence:

· the cost of falls to the NHS is estimated at £67m a year[v] and the cost of a hip fracture, in terms NHS care alone, is nearly £29,000 in addition to ongoing social care - the installation of hand and grab rails to reduce the risk of falling can be less than £300;

· the installation of a disabled toilet and wet-room at a cost of £10,000 is equivalent to 14 hours care per week to supervise washing[vi];

· a £6,500 Disabled Facilities Grant allows an older person to continue living at home for four more years, saving over £100,000 in residential fees;

· for every £1 spent on Care & Repair’s delivery of the Rapid Response Adaptations Programme, £7.50 is saved from health and social care budgets[vii].

Demographic change

9. Wales has the largest and fastest growing proportion of older people in the UK - the demographic profile is changing with important local variation in detail:

· by 2039, one in four of the population will be over 65 - a 44% increase in the age group;

· by 2030, the percentage of the population aged over 75 will increase from 9% to around 13%[viii];

· as older people live longer, more are likely to experience age-related neurological and sensory conditions. By 2025, there could be 50,000 older people aged 65 or over living with dementia;

· the older population will be proportionately larger in rural areas where 54% are currently aged over 45 years compared to 48% in small towns and 42% in large towns[ix];

· there are clear differences between Wales’ most and least deprived areas in terms of life expectancy (8 years) and ‘healthy’ life expectancies (18 years).

Care & Repair Cymru’s key comments on the findings and recommendations of the Auditor General Report on Housing Adaptations.

10.Care & Repair Cymru welcomes the Auditor General’s report. The system for housing adaptations has long been considered to be complex and in need of improvement. Since 2005, successive reviews have led to incremental improvements, but this report makes clear that further work is needed to:

· improve information and access to services

· reduce waiting times

· introduce common service standards for different types/ size of adaptations

· bring greater equality, especially in relation to services received by people living in different tenures of housing

· improve how organisations report on quality, waiting times and outcomes for all types of adaptations

· share and replicate good practice

11.Care & Repair Cymru is pleased to be part of the “Enhanced Adaptations Steering Group” convened by Welsh Government, which has been meeting for a few years to examine and improve all aspects of housing adaptations as described above. We are particularly pleased that the Group comprises a range of stakeholders, with representation from Care & Repair Cymru, Welsh Government, Royal College of Occupational Therapists, Older People’s Commissioner, Housing Associations, Community Housing Cymru, Welsh Local Government Association and Local Authorities.

12.The Steering Group has identified similar areas of improvement to those set out by the Auditor General, and has made positive steps in many of the areas identified above and in the Auditor General’s report. Of significant relevance is the introduction of the “Enable” idea - a common way of defining and reporting on service standards, as well as introducing a new funding stream (Enable), which is delivered in collaboration between local authorities, Care & Repair, and housing associations. The key aim of Enable is to work in partnership locally to identify priorities, and deliver adaptations more flexibly.

13.There is much work to do but we are confident that the Steering Group provides a great opportunity to continue to take forward improvements in a progressive and collaborative way.

Findings of the WAO Report : Care & Repair Cymru’s Response

14.Roughly 70 organisations deliver adaptations in Wales, every year collectively spending approximately £60 million and assisting over 32,000 people. The funding arrangements for adaptations is complex and has helped to create an inefficient delivery system. One of the consequences of this complexity is that people with similar needs often receive very different standards of service simply because of where they live and which public body provides the adaptation.

We agree that funding arrangements are complex due to a mix of funding sources the main ones being Disabled Facilities Grants (DFGs), Care & Repair’s Rapid Response Adaptations Programme (RRAP), Housing Revenue Accounts of Local Authorities, Welsh Government Physical Adaptations Grants, Housing Association own resources, Social Services local funding and regional Integrated Care Funds. We also agree that, in some areas, this has led to different standards of service, something it is important to rectify.

However, we also think that care needs to be exercised when exploring wholesale changes in funding options. Some of the differences in funding are linked to primary legislation. DFGs are mandatory grants available in all tenures but, in practice, social housing providers fund works for their own tenants, while DFGs are funded from local authority un-hypothecated general funding. This system ensures that large adaptation works for social housing tenants are funded by their landlords, which we would argue should continue be the case. In some parts of Wales, the current system has been shown to work, especially where a more flexible approach is taking to funding - particularly for small adaptations, rather than using the DFG process which is better suited to larger, more complex adaptations. Similarly, RRAP has been demonstrated to integrate working between Care & Repair, Health and Social Care, and preventing hospital admissions and delayed transfers of care.

So we while we agree that it is appropriate to examine the current funding regime, we are mindful that this should not overlook things that work well, existing good local practices and systems on which we could build. It could be argued that, if common service standards are agreed for different types and values of adaptations, then the funding complexities could be addressed by monitoring performance and holding all organisations to delivery against common standards.

15.The majority of public bodies with responsibility for adaptations – local authorities, housing associations and Care & Repair Agencies (‘delivery organisations’) – have seen demand for adaptations increase in recent years and expect this trend to continue. Census data highlights that a higher proportion of the Welsh population consider themselves to be in poor health than is the case in England. Welsh Government projections anticipate that the number of people in Wales who will experience mobility problems and difficulties undertaking daily domestic tasks will increase significantly in the next 20 years.

Care & Repair Cymru agrees that significant growth in demand is inevitable due to the ageing population and larger numbers of people living longer, in their own homes but with age-related deteriorations in health and ability.

This underlines why it is so important to make lasting improvements to the system now. Care & Repair Cymru would also argue strongly that the ageing population and significant growth in demand means that funding of housing adaptations, and services such as Care & Repair should be protected, and indeed increased. While system improvements are without doubt needed, so too are adequate resources to deal with increasing demand. Such investment would be prudent and save public money in Health and Social Care, given the widely acknowledged preventative impact of adaptations and Care & Repair.

16.The speed and efficiency of the provision of adaptations can make the difference between disabled or older people staying in the comfort and security of their own homes or moving into specialist or residential care. However, assessment processes are neither streamlined nor efficient and often contribute to delays. The lack of co-ordination between delivery organisations, interruptions due to problems arising from the unavailability of staff or funding, and poor standards of communication characterise the experience of a small number of service users.

Care & Repair Cymru believes that there is a wide variation in systems and processes used by all organisations who provide adaptations. While some will have conducted end-to-end process reviews (Systems Thinking) and improved service delivery considerably, this is not the case across all organisations. The key here is to assess and seek replication of good practice in relation to the most streamlined and integrated systems.

17.Most public bodies recognise how adaptations can reduce the risk of falls and other accidents in the home and prevent hospital admissions and speed up discharge. However, health professionals often find the different local-authority and housing-association systems for administering, approving and delivering adaptations difficult to navigate. Complex delivery arrangements reduce the opportunities for health bodies to make better use of adaptations.

This is an increasingly important topic for public services in Wales. The need for stronger integrated working between Health, Social Care, Housing and the Third Sector is growing in importance, and we must get substantially better at this if we are to deliver successfully on prudent healthcare, early intervention and prevention, Sustainable Social Services and speeding up safe transfers of care from hospital wards. Care & Repair Cymru has been working to ensure that Care & Repair services across Wales are widely understood by Health Services, and have recently presented at plenaries and good practice workshops of the Wales Audit

Office on quicker safe hospital discharges. At these events, we showcased the strong, integrated relationship between Bridgend Care & Repair and Abertawe Bro Morgannwg University Health Board, where Care & Repair staff are based in hospital wards and A&E, working side-by-side with health professionals on earlier planning so that adaptations and other works in patients’ homes are undertaken without delay, enabling them to be discharged quickly to a safe, adapted home environment. This service includes access to both RRAP and the Integrated Care Fund (ICF).

Across Wales, we are trying to make the case to Regional Partnership Boards about the value of involving Care & Repair as a third sector partner in ICF but our experience is mixed at best in relation to whether our voice on these Boards is being heard. Care & Repair Cymru believes that, not only our voice, but the voice of third sector is weak on the RPBs and in relation to ICF schemes. Our Bridgend example shows the extent to which statutory services could benefit from closer, more genuine partnership working with the third sector and improve services for older people more widely.

18.Given the wide number of routes available to access adaptations, delivery organisations need to ensure they have robust systems to deal effectively and quickly with applications. However, many authorities and housing associations do not have application processes that consistently and effectively meet the needs of people. Accessible information in a range of appropriate formats, such as large fonts for visually impaired users or audio versions for people with hearing difficulties, is often unavailable.

Our response to 16 above applies and is one of the areas recognised by the Enhanced Adaptations Steering Group (paragraph 11above). The Group has produced common Wales-wide publicity leaflets, with reciprocal website links, on the services available and service expectations. We believe that this work can be built on, and additional emphasis should be given to accessible formats of this information.

19.Delivery organisations must balance carrying out building works quickly to meet the needs and wishes of the disabled or older person, and ensuring value for money in terms of cost and quality. Most local authorities, housing associations and Care & Repair agencies have established appropriate processes to oversee and manage performance of those carrying out building work, most usually through regular meetings and dialogue in respect of individual grants. However, few delivery organisations are working strategically with contractors to streamline and improve performance, and current arrangements for contracting builders have some shortcomings. In addition, delivery organisations do not always have effective arrangements to monitor, review and evaluate the performance of builders and contractors in delivering individual grants.

The majority of Care & Repair Agencies have a locally adopted set of criteria and practices for managing lists of approved contractors, and how they work with them. Care & Repair Cymru has recently secured trust funding to develop a standardised

“Care & Repair Contractors Charter”. This will define a clear set of quality criteria, along with robust vetting procedures, for those contractors who wish to be accepted onto our “Charter”. Once in place, the Charter will be actively managed so that only those contractors who continue to meet the Charter’s standards will remain on the list. Compliance checks will include customer feedback, technical officer oversight and other mechanisms, in addition to basic statutory requirements. The scheme will be publicised widely, with general advice and information provided for older people about how to recruit reliable contractors, and avoid being scammed or exploited by ‘cowboys’. Our ambitions for the “Charter” address every aspect of the WAO’s concerns in this regard and has the potential to provide a model of quality assured practice in this area.

20.Whilst public bodies are clear on the role of their housing-adaptation services in changing the home environment to enable or restore independent living, there are opportunities to better address needs and avoid and reduce demand and costs in health and social care services. Few delivery organisations have comprehensive and integrated Housing Renewal Polices that link decisions on investment with better use of existing adapted housing. Policies are often property focussed rather client focussed, and rarely make the strategic link to other organisations and the wider needs of disabled and older people.

Care & Repair Cymru cannot comment specifically on Local Authority Housing Renewal Policies, other than to endorse the importance of these being client focussed, and consistent with the ambitions of early intervention, prevention, prudent healthcare and Sustainable Social Services. It would also seem appropriate for Renewal Policies (including housing adaptations) to reference and integrate with Regional Partnership Boards, and strategic objectives of the Integrated Care Fund. This would be a good way of strengthening the housing voice and influencing in the integration agenda in order to reduce hospital admissions, prevent the falls and ill health associated with poor housing, and speed up transfers of care to a safe, appropriate home environment.

21.Delivery organisations do not always take a ‘whole resources view of their adaptations work and consider the availability and use of all monies from all delivery organisations within an area. Only seven local authorities pool funds with Care & Repair and no pooling of funding takes place between local authorities and housing associations. A small number of local authorities have developed integrated approaches to housing adaptations drawing together grants, building surveyors and Occupational Therapists into single teams. However, too many organisations work in isolation focussing on their individual responsibilities, rather than working collaboratively to better address people’s housing and health needs.

All Care & Repair Agencies have a good, longstanding relationships with their Local Authorities - in particular, Housing Renewal and Adaptation Teams, and Occupational Therapists – and have been working in an integrated way with them for 25 years, on many different aspects of housing adaptations, including RRAP and DFGs.

The relationship focuses in particular on effective and appropriate RRAP referrals, trusted assessor status (enabling us to help quickly with less complex need), advocacy for older people through the complex DFG process and good targeting of need by integrated working. Some Care & Repair Agencies are an integral part of local authority Housing Renewal Policies.

The relationship with local authorities is crucial to our work for older people, and will continue to be a focus for Care & Repair in the future.

Our relationship with Health professionals is growing in importance, and many Agencies are building their connections with GPs, hospitals and community-based health staff (paragraph 17). Building our relationships more widely with Health and Regional Partnership Boards will be an important part of Care & Repair’s strategic development and we are determined that, as a third sector charitable organisation bringing our own unique service and abilities to the table, we are a strong part of the public service integration agenda for older people.

22.Nevertheless, approximately three-quarters of people we surveyed who recently received housing adaptations have a positive experience with their housing adaptations. Just over 90% are satisfied with the time taken to deliver their adaptations, and the majority felt the work to their home allowed them to undertake everyday tasks, improving both their confidence and independence. Generally, owner-occupiers are more satisfied than those who rent from housing associations, but most disabled and older people we surveyed had little influence or choice in the adaptations made to their home.

Care & Repair is very proud of our track record in terms of the extent to which we deliver, the quality, the positive feedback and the impact of our work. Every year, we install over 17,000 RRAP adaptations for older homeowners. In 2016/17:

· the average waiting time was 8 days

· the average age of the client was 78

· 77% of RRAP adaptations prevented hospital admissions

· 23% helped people return home from hospital.

· 92% said that the RRAP adaptation had improved their quality of life

· 9% went on to receive the full Care & Repair home improvement casework and technical service.

23.Accountability and transparency in delivery of adaptations have long been poor. Despite the different sources of funding for housing adaptations, only performance in respect of local-authority Disabled Facilities Grants is publicly reported. However, by only reporting performance on Disabled Facilities Grants, the Welsh Government is currently only publishing data that covers 55% of all expenditure on adaptations and 14% of those disabled and older people who receive adaptations. The Welsh Government collates some performance data from housing associations and Care & Repair Agencies but does not make this information available to the public.

Weaknesses in current oversight arrangements mean that effective scrutiny to understand the efficiency and impact of the ‘whole’ adaptation system is not possible. This makes it difficult to judge how well organisations are performing and the positive impact of adaptations on disabled and older people’s lives.

Care & Repair Cymru agrees with this statement. We would welcome more comprehensive reporting on adaptations across all funding sources and tenures, thereby enabling a better understanding of how the whole system works (for small, medium and large adaptations), how all organisations compare in terms of their performance and, from the clients’ perspective, any discrepancies between landlords and tenures.

24.The Welsh Government is seeking to address some of these gaps by introducing new systems to monitor and report performance in delivering housing adaptations (the ‘Enable’ review). Whilst this addresses some of the long-standing weaknesses in current arrangements, gaps remain. Monitoring continues to focus too much on the mechanics of delivering adaptations and not enough on impact, wellbeing and the wider benefits of each public body’s investment. Despite highlighting equality as a key policy objective, we found that few delivery organisations collect and evaluate a sufficient range of data to demonstrate and ensure fair access to services.

As referenced in paras. 10-13 above, Care & Repair Cymru is a member of the Steering Group and the “Enable” review. The Group has recognised from the outset that performance reporting needs to be more comprehensive on all housing tenures, types and size of adaptation, and has been working on this for the past 2 years. An important focus of this process has been to improve reporting on quality, customer satisfaction, and outcomes. Equality monitoring is a part of this, and the Group will be taking this aspect forward as part of a much more comprehensive performance reporting framework.