The Future of Residential Care for Older People in Scotland - Full Report

Part 2: Home and Environment

A personalised approach to care needs to be delivered in a setting and surroundings that themselves support this agenda. Furthermore, the people delivering the care need to be committed to the principles of personalised, quality care. Two of our sub-groups, 'Place Making' and 'Workforce' have given consideration to these elements and developed recommendations for creating the right environments for care to be delivered in, and a valued and professionally skilled workforce to deliver high quality care.

While Place Making does offer the potential for an element of blue-sky thinking to take place in terms of the design of care settings we would like to see in the future, it is important to remember that we aren't necessarily starting with a blank sheet of paper. There is a vast estate of care homes and housing with care sites across Scotland, some which may no longer be fit for purpose, but the majority of which are providing a safe and secure environment for people whose needs would not be as well served in their own home on the one hand, or a hospital ward on the other.

The social care sector is a growing employer in Scotland, yet struggles to attract the right people in sufficient numbers to give us confidence in the sustainability of the workforce. A major challenge exists in building a valued workforce, something that requires a refresh of the image of the workforce as a whole. This can be done by taking steps to attract the right people into care as a vocation, but also by investing the time and money required to improve the culture within the workforce, and in turn, attitudes towards it.

Place Making

Overarching Principles

1. The Scottish Government and COSLA's vision for older people is to support them to remain in their own homes or other homely settings. We need to take steps now to develop a range of 'other homely settings' that will meet the needs and aspirations of a larger population of older people for the next 20 years. At the same time, there is a need to promote supported shared-living as a positive choice and not simply a second best necessity.
2. Future care provision should be planned, located and designed to maximise community and family/carer involvement, and service integration. This may include the potential for co-production and co-location. Just as with schools, care settings should be an active part of communities, and be seen as community assets, rather than as ghettos for the elderly.
3. Care Homes and Housing with Care should be seen as part of a continuum of provision for older people and be subject to the same planning processes. To make this a reality, we need to create a more integrated planning framework that encompasses the range of care and accommodation and applies a consistent set of principles to new development.
4. Scotland's older population is as diverse as its younger population, and so the planning of care provision has to reflect cultural, racial, and lifestyle diversity. Older people are not a homogeneous group. Individuals and groups may therefore want different things and have different priorities. Place Making has to be part of our wider commitment to personalisation and the move away from a one-size-fits-all approach.

Fitness for Purpose

If in talking about creating new care environments that look different from the care homes and housing with care that we use today, then forward planning is essential. There is a lengthy lead in time for designing and delivering new builds, not least due to the investment required in those new buildings and adaptations required to existing sites. We also have to then live with the buildings we commission for a realistic period of time, meaning it is important to get it right in the first place. In order to assess current capacity and plan future provision we need to be clear about what we want accommodation-based options to deliver, and the range of needs they have to meet. This is in addition to meeting basic quality and registration requirements. In order to future-proof buildings, we need to anticipate now the likely future demands on provision. For example, all care facilities ought to be dementia-friendly, and there is good evidence of what this needs to look like. The Dementia Studies Development Centre at Stirling University has a toolkit for building and service design and also provides a consultancy service.^[15] In addition, the Dementia Design Working Group has been established to facilitate new thinking and practice in the provision of residential dementia care. Their 'Design for the Mind: Discussion Document' has been developed to assist wider stakeholder engagement

Similarly, if we want future provision to put more emphasis on personal space, then we need to look now at how that can be achieved, and what the impact is likely to be on capacity and cost.

This also needs to be reflected in the regulatory framework(s). The registration requirements for new or adapted provision need to reflect strategic direction. If we look to create more of a continuum of provision encompassing both Housing with Care and Care Homes then there will be a need to have a corresponding integration of the regulatory frameworks of the Housing Regulator and the Care Inspectorate.

It also requires us to adopt a fresh approach to commissioning: commissioning fit for purpose places, not placements. Providers can only invest in the development of new styles of Place Making if the commissioning process offers sufficient guarantee of a return on investment. Our current approach to commissioning placements is focussed primarily on numbers and tends to produce more of the same standard product. The financial institutions are perhaps understandably more risk-averse than in previous years and will only lend for new development if there is security of demand. This has had a knock-on effect of new developments being taken forward either by public bodies, or aimed at the self-funder market which gives developers a greater guarantee of a return. The purchased care sector is being seen as more unpredictable at the present point in time, although still an area for potential investment if the commissioning is managed in such a way to instil confidence that the demand for this part of the market exists. There is general consensus that the standard procurement model used by councils (rather than a Place Making commissioning approach) is by no means perfect. A solution could be identified with the integration of health and social care, which requires joint commissioning strategies to be created within partnerships. This is a new framework which offers the ideal opportunity for a new focus on Place Making within the commissioning approach.

National and local auditing of the care estate

An obvious starting point on the path to creating desirable care settings for the future is to understand what we are currently working with. There is a need to determine to what extent the current range of provision meets the capacity and fitness for purpose requirements, and the extent to which the existing place-making footprint is adaptable to meet future need. Of the 910 Care Homes for older people, and the housing with care provision, we should ask some key challenging questions:

• How much of it is what is wanted or needed going forward?
• How much accommodation will need replacing in the foreseeable future?
• What is the gap between what we have at present and our place making vision for the future?
• What do we need to do to bridge that gap, through adapting what we have or through new development?
• How much commissioning and investment will it take?

To answer these key questions there needs to be an accommodation audit of existing provision. In keeping with Strategic Joint Commissioning it is argued that this could be the responsibility of Local Partnerships to carry out, in order to reflect local needs and priorities. However, given the scale of the challenge in relation to care for older people, there also needs to be a degree of national support. There may need to be links between the maintenance and development of the care estate and future funding, access to capital etc. Doing so will give us confidence that we have the means and support at our disposal to help us achieve our vision for the future of care in Scotland.

There are parallels in the work undertaken by NHS National Services Scotland on the Health Estate. As the 2013 Report states:

'This is the third year that the State of NHS Scotland Assets and Facilities Report has been published. The report is now widely recognised as a key reference document which is used to inform decisions on the continuing investment in assets and facilities services to deliver the Scottish Government's "2020 Vision" for sustainable high quality in health. Getting the right assets and facilities services in place will be central to achieving the "2020 Vision" and will require major change to the type and distribution of assets and facilities services and the way in which we prioritise investment in the future.' This is primarily for public estate facilities.

While there are obvious difficulties in replicating such an exercise across the care home estate (not least the fact that all independent providers would have to 'sign up' to taking part for the long-term) there may be some benefit for Local Partnerships in looking at how the NHS exercise was conducted and how it has helped shape priorities and decision making.

Similarly the Care Inspectorate is able to identify the extent to which care home accommodation meets current standards through analysis of inspection findings in relation to overall quality of environment. As of 31^st October 2013, 5.9% homes for older people were at grade 2 (weak) for environment, and only 0.7% were at grade 1 (unsatisfactory). 93.6% of homes were therefore deemed to be adequate (3) or above in terms of quality of environment. Moreover, although only 2.6% achieved grade 6 (excellent), 29.6% were graded 5 (very good). In other words, the vast majority of the sector as a whole appears to be meeting the basic quality standards. However, this does not in itself address issues of the suitability of accommodation or flexibility in relation to future place making.

Accommodation and Care

Further work is required on determining the desired mix of accommodation across the housing with care and care home continuum. This needs to look at ranges of need and cost comparisons.

At present, Housing with Care and Care Home provision are often discussed as if being at opposite ends of the spectrum of care and accommodation, with nothing much in the middle. There can be an oversimplified view that Housing with Care is seen as being part of community, and Care Homes as being more institutional. In fact both are equally valuable in meeting different ranges of need and circumstance.

Housing with Care is ideal for people with lower levels of dependency, who retain the ability to manage their own affairs, who continue to be engaged with social networks, and who require something less than a fulltime package of care and support. Housing with Care offers tenancy rights, and in relation to accommodation places greater emphasis on personal space than on group living. In cost terms, Housing with Care will tend to cost more to the public purse in overall terms, but as a proportion of this will be through Housing Benefit and Pension, the net cost to Council social work budgets may be less.

Care Homes are correctly suited to people with higher levels of dependency who require a complete package of 24 hour care. Given their complexity of need, a residency agreement rather than tenancy is deemed more appropriate. The emphasis of the accommodation is on group living, shared space and care delivery rather than personal space and independence, although homes will strive to provide the best of both worlds. In cost terms, the overall cost to the public purse is lower, but other than the DWP element, the cost is largely borne by social work for publicly-funded residents.

Nor should these be seen as the only options. Care Villages such as Auchlochan and Inchmarlo, have sought to provide a range of retirement, supported living and care options within a campus environment, in a way that blurs the distinction between 'own home' and 'care home'. There has also been the development of Intermediate Care provision with an explicit focus on short-term care, re-ablement and rehabilitation.

Place Making within local partnerships should facilitate the availability and accessibility of all the accommodation and care options, to maximise choice and the tailoring of care packages to an individual's needs and circumstances. This can best be done through an integrated approach to care planning that sees all accommodation and care as part of a single system.

Location and Distribution

Care and Accommodation provision is not evenly distributed across Scotland at present. There are areas of under provision as well as areas with excess capacity, and although this is something that can perhaps be more clearly seen in an urban vs. rural context, it is also true even within the one local authority area.

If we take Glasgow as an example, much of the development of care home provision has been in the east of the city where land and build costs have been lower, and there are parts of the south and west of the city that are under-resourced. In a similar way with Housing with Care, there are parts of the country with no provision of this sort at all.

The balance of provision may also look different in rural areas, where the delivery of home care support has to take on board the challenge of distance. This has tended to create a corresponding reliance on residential, but often non-nursing, care. Achieving the optimum balance and location of provision requires a joined up approach to planning and commissioning to ensure targeted development in line with strategic needs. Such targeted development may also require a differential model of procurement that recognises the cost and volume issues in certain areas.

Where services, such as step-up and step-down provision, are designed to support health care delivery, future co-location may worth exploring. For example, the possibility of such provision being part of hospital development to support admission and discharge strategies. Delayed discharge occurs in the health system when a patient is well enough to leave hospital, yet due to the lack of availability of suitable support, they are unable to return home, or to a residential setting. 126,000 bed days were occupied by delayed discharge patients in NHS Scotland during the quarter July to September 2013. The most recent figures published by ISD showed that over 50% of patients subject to a delayed discharge from hospital found themselves in that position as they had to await a place in a care home.^[16] The cost to the NHS is considerable, and clearly there is work to be done between hospitals, care homes and social work departments to address the issue. In tackling delayed discharge, it would be an advantage to site an intermediate care facility in the grounds of a hospital than 'boarding beds' in the hospital itself.

Equally, there may be opportunities for community co-production and shared ownership of care provision. The idea of small groups of service users "going it alone" by pooling their SDS Direct Payments to set up their own care and accommodation service is perhaps a little unrealistic given that many people in this group are either incapacitated or not able to fully comprehend the complexities within commissioning processes and contracts. However, the idea of care homes being seen as community assets and managed by community groups in the same way as sports and leisure facilities is not beyond the bounds of possibility. Similarly, as with the care village model, there may be ways of enhancing the opportunity for residents to have a stake in the ownership and management of the place they live in.

Generic v Specialist Provision

Much existing provision has been developed on the basis of a one-size fits all approach. The design of future premises may need to reflect more clearly the range of needs and care pathways, and in so doing will have to be an integral part of the personalisation agenda. Smaller units within core and cluster arrangements may provide a way of balancing the provision of targeted accommodation with shared services and some economy of scale.

This is a complex issue. Correctly there are concerns about the compatibility of different types of care within the one setting:

• how to balance the needs of people requiring respite or rehabilitation, with those requiring longer-term or end of life care;
• how to provide a dedicated environment for people with advanced levels of dementia, without creating a sense of segregation or stigma;
• how to develop the idea of a 'care hub', combining residential care, day care, and other community based outreach services, without losing the integrity of the care being provided.

There may also be parts of the country where smaller numbers require care homes or other care facilities to multi-task, because it would not be viable to have separate free-standing provision. From a service user perspective, the goal is also for care settings to offer a 'home for life' and to avoid or minimise the need for a move as needs change. There is a desire to see services developing specialist knowledge, skills and provision, without this becoming unduly limiting in terms of flexibility.

We have examples of the good use of separate units within larger care complexes, BUPA at Rodgerpark, for instance, with the development of Palliative and End of Life Care, or HC1 at Highfield for Intermediate Care. There are also care homes that offer a range of day care, respite, and home support. The key to this being done well is allowing facilities to diversify in response to local need, providing each service component is properly planned and resourced. The Care Inspectorate are in agreement that this may need to be matched by a flexible approach to Registration which allows services to innovate and develop new models of care within the framework of their existing registration. It also needs to be supported by good assessment and care planning, so that the focus is on individual needs and outcomes, rather than categories of care.

Personalising Accommodation and Care

As discussed above, Housing with Care has tended to place greater emphasis on personal rather than shared space, individual rights, control and ownership of the accommodation base, and the promotion of independence. There is no reason why these aspects should not apply to all accommodation-based care, even where 24 hour nursing care is required. It is primarily a matter of culture and cost. The care sector has been on a journey from institutionalisation to personalisation and the vast majority of services have made huge strides in terms of culture and care planning. Place Making also needs to reflect this journey in terms of enhancing identity and ownership. The My Home Life initiative^[17] which we are rolling out across Scotland under the auspices of the Change Fund, is a very good vehicle for promoting this shift.

In order to improve public image and confidence in care accommodation, there also needs to be a clear commitment establishing care settings which are imaginative, high-quality, aesthetically pleasing and integrated into the heart of communities. If the goal is to encourage the involvement of families, friends and the wider community in the care experience, the location and style of accommodation is going to make this easier or harder.

Moreover, whilst accepting that in everyday life, the level of accommodation people can access is according to means, there might perhaps be some concern about the development of a 2-tier care sector, where developers target self-funders and provide a higher standard of care environment than is available for publicly-funded care.

Investment and Disinvestment

Investment is going to be required to maintain and improve existing care accommodation, and to develop future capacity. The more significant the shift that is wanted in the style of care provision, away from the existing service footprint, the greater the required level of investment and timescale for development is going to be. Similarly, there will be a need for planned and supported dis-investment where there is excess capacity or provision which is no longer fit for purpose and not adaptable to meet future patterns of need. This needs to be done through a coordinated planning and commissioning process and not be left to market forces. Providers will need to be helped, if need be, to exit the market in a positive way, without the risk of service disruption. Sudden action to decommission sites would likely create instability rather than a strategic shaping of the market. Certain high level decisions may also need to be made about the future ownership of care premises, and there may be desirability in exploring models of public/private partnership in the development of new provision.

This may simultaneously benefit Local Authorities (as commissioners and providers) and the independent sector. Councils seeking to develop new capacity to replace existing in-house provision may find that doing so in partnership with an independent sector (and voluntary sector) provider is a more cost effective option whilst retaining a degree of control, than either keeping the development entirely in-house or completely outsourcing. Similarly, independent sector providers may in some areas find it more viable to pursue development in partnership with the local council, through the leasing of premises or the making available of sites. We have already seen examples of the latter in Edinburgh, where land and building costs would make it impossible for the independent sector to develop new provision aimed primarily at publicly purchased care. A partnership approach to development can produce benefits to all parties in such conditions.

As discussed above, an audit of the care estate, once we have determined the blueprint for future provision, may also highlight the need for Government to be involved in making the required level of investment possible.

Vision

Place Making is about creating a range of high quality aesthetically pleasing shared-living care and accommodation options for older people that offer the maximum opportunity for the retention of both personal identity and community involvement.

Recommendations

We recommend that in relation to Place Making:

• Each Local Partnership publishes its forward looking Place Making agenda, together with a 5 year plan of its commissioning and purchasing intentions in relation to accommodation and care provision for older people, and that this should form the basis of engagement with providers as to what it would take to deliver.
  
  An audit of the care estate be carried out, primarily locally, but in a way that allows for a national overview, to determine the quality, capacity and fitness for purpose of care home and housing with care provision, and that this be used to inform planning, commissioning and investment decisions. Care Home and Housing with Care provision is dealt with as part of a single system of care planning and funding, so that individuals have choice and access to the option best suited to their needs and circumstances.
• Local partnerships be encouraged to explore options for the co-location and co-production of care and accommodation for older people
• Place Making and the development of Accommodation and Care, reflect a fundamental commitment to Personalisation.
• Local partnerships adopt a strategic approach to investment and dis-investment, in developing future accommodation and care provision, and that this is supported by Government where necessary and appropriate.
• An engagement structure should be created for all care homes, based on the school parent council model to facilitate and strengthen ties with the community and to provide a layer of reporting and accountability.

Conclusion

What we think of as a 'care home', and what such provision looks like, should correctly evolve and change over time. There needs to be more of a continuum of accommodation and care options. At the same time, the need for settings that provide integrated packages of accommodation and care, including nursing and 24/7 provision, either on a short or medium term basis for people with a range of particular care needs, seems likely to remain. Doing this on a group living basis can provide both a degree of efficiency and an in-built sense of community. Having the right range of accommodation options to meet current and future need in relation to the care of older people is therefore crucial. From a Place Making point of view, it is clear that the desired direction of travel is the creation of homely settings, which are fit for purpose, which protect the rights of service users and allow them to have a greater stake in their accommodation, and which promote an optimum level of independence and community connectedness.

Workforce

The anticipated changes in Scotland's demographics, and the attached increase in complex conditions will of course have implications for the care sector's workforce in terms of the skills, values and behaviours required to undertake the role and for employers and commissioning authorities in terms of funding. The ability of the sector to meet an increased and broad range of needs will only be as good as our ability to equip it with the necessary skills and attract the right people into care as a desirable vocation.

The following section seeks to develop discussion as part of a National debate on how we as a society in Scotland value the care of older people and prepare and reward a highly skilled and motivated workforce to deliver care that is person centred and of a high quality.

The Residential Care Workforce

Over the next twenty years, there will be a considerably greater increase in the over 60 population in comparison to the 16-59 age group (see Figure 1 under 'Current Landscape').

Clearly, this means there will be greater competition across all areas of the economy for labour resource. The care sector, which already struggles to recruit in areas of high employment, will face a tougher challenge in making itself an attractive option against other sectors that currently pay better and have a better image, all at a time when there will be more of a need for a strong workforce. It will potentially place a significant strain across the whole system and on the people who depend on care services for their own wellbeing, or that of a loved one.

As Figure 1 below demonstrates, it is also expected that the working age population will have more people in their late 40's - 60's than was the case in the early 1980s.

Figure 1 Population pyramids for 1981 and 2035.

Source : http://www.scotphn.net/pdf/PDF_171212_LH_MASTER_-_ScotPHN_OPHSCNA_epid_report3.pdf

This can be attributed to falling birth rates in recent years, but aside from the actual demographics, there is the added context of people having to wait until they are 67 and eventually 68 before qualifying for their state pension. The current care workforce is ageing, with the average age in the sector currently being around 46 years - a key consideration when we consider the physical demands of caring as a career. In addition there is a significant gender imbalance, with 85% of the care home workforce being female. There needs to be consideration of how to support an ageing workforce to ensure we maximise their knowledge, experience and caring values while accommodating and adapting to a potential reduced physical capacity.

Table 1 below sets out the number of people working in the care sector in Scotland, by sector and by care type. 68% of the sector work in the independent and third sectors and just over 28% of those that work in care in Scotland are employed in a care home setting.

Table 1 - Scottish Social Services Workforce

Service Type	Headcount	% of Scottish Social Services Sector
Care Homes for adults	54,060	28.3%
Care at home/housing support	61,350	32.13%
Total	115,410	60.4%
54,360 (47.1%) of this workforce is employed in the independent sector
Total Scottish social services workforce comprises: 41% independent sector 32% public sector 27% third sector

Source: Scottish Social Services Council, Scottish Social Services Sector - Report on 2012 Workforce data

Registration, Qualifications and learning of workforce

The Register for social service workers is function based, rather than qualification based, meaning that to register with the Scottish Social Services Council (SSSC) a worker must be performing a relevant role in a service registered by the Care Inspectorate rather than holding a specific qualification, before they become eligible to register.

Under the Statutory Regulations passed by the Scottish Government in 2009, service providers will be committing an offence if they employ or continue to employ, a worker in a service who is not registered with the Scottish Social Services Council (SSSC) or another relevant regulatory body e.g. the General Teaching Council, Nursing and Midwifery Council.

The qualifications for registration are based on the National Occupational Standards (NOS), which form the basis of the suite of qualifications, Scottish Vocational Qualifications (SVQs) in Health and Social Care (HSC). Nationally, the SVQs are linked to the Scottish Credit and Qualifications Framework (SCQF), which means that all awards in Scotland (secondary education, FE, HE, vocational) articulate with each other.

The SVQ qualifications are work based - they are assessed in the workplace and delivered flexibly, enabling candidates to work while learning and being assessed on their knowledge and competence in practice, measured against the NOS. This sometimes requires time away from the workplace which may have to be backfilled.

In addition to possessing the core qualifications to practice there are a wide range of training and development requirements needed in the setting. Depending on the role, this may include skills and knowledge related to administration of medications, falls prevention, nutrition, anticipatory care planning, first aid, tissue viability, rehabilitation, moving & handling, health & safety and so on. Increasingly in the future, skills will be required in relation to self-directed support, adult protection, providing more personalised services and skills with regard to inter-agency working.

Learning and development for staff, in the context of the changing and more complex needs of people who use services, will require a higher range of skills and greater accountabilities from the workforce. These activities usually need to be purchased and may also require time away from the workplace, both increasing costs in the sector.

Future Skills - Residential Care Workforce

It is clear that a skilled and trained workforce in the future will have to have the capability and training to enable the sector to address the significant challenges and changes in the population of older people who live in care homes and their changing patterns of need. These include:

• Increasing frailties and long term conditions;
• Dementia care (use of Promoting Excellence) and Elderly Mentally Infirm (EMI);
• Intermediate care models which demand new and developing skills and techniques;
• Maximising the use of technology to underpin care and support and ensuring technological links to other care sectors i.e. health services; The pace at which telehealth and telecare is developing and playing an increasing role in maximising independence makes the provision of robust training in this area essential;
• Reablement models and promoting self-management;
• Palliative and end of life care; and
• Skill mix & staffing numbers - developing workforce planning tools to support appropriate levels of skill to meet patterns of need - across the totality of the care home workforce.

It can be seen that increasingly there is a need to provide and secure highly specialist care and support for those with the most complex needs and behaviours.

It is important that good links are established across community care and all health services (primary, community and acute settings, including mental health) to maximise the available support and expertise to care home residents and to the people who care for them in the home. While we do not advocate older people's entire health and care needs being met within the care home setting or by care staff, we recommend that the Joint Strategic Plans that will be developed under Integrated working and the Public Bodies Bill are used as a vehicle for partnerships to specify how the full spectrum of primary, community, acute and social care provision will be configured in order to support older people including those who are resident in care homes, to remain cared for in a homely setting for as long as possible.

In order to support the sustainability of appropriate skills in the care home sector it is important that a number of factors are addressed:

• It is critical that Nurses, GPs, Social Workers and Allied Health Professionals (AHPs) in training can experience high quality learning placements in the care home sector - both in order to promote some AHPs and others choosing to work in the sector in the future and to ensure those health professionals who go on to work in the NHS have an awareness and appreciation of the needs of colleagues working in the residential care sector. This would also ready the wider workforce for the potential use of care homes as step-up/step-down and rehabilitation facilities.

There are significant issues in terms of developing this workforce for both individual workers and employers. These include:

• Costs in the context of downward financial pressures;
• Staff recruitment and turnover;
• Staff motivation in the context of this predominately being a low-wage workforce and in the context of the levels of staff 'burn out' - a recognised syndrome which can occur in people working in stressful working environments with high job demands and low resources;
• Pressure on training and development budgets;
• Availability of assessors and trainers; and
• Staff time, expenses and backfill to undertake learning and the impact training and development has on rotas and the cost to provider.
• As part of their training, GPs don't currently spend any time within care homes, meaning they are often entering these environments for the first time as a qualified GP 'blind' to the ways in which care homes operate and the level of dependency of the residents.
• There is a disparity between the public and independent sectors in relation to the level of centralisation and training available.

Wages, Terms and Conditions

There is no parity for the independent and third sectors in terms of pay or other terms and conditions with NHS or local authority equivalent jobs. Successive downward financial pressure on settlements and efficiency targets mean reduced budgets to the public sector and a consequent impact on the independent and third sectors. While the National Care Home Contract has seen the application of uplifts on the weekly rate for care home placements it continues to be the case that this remains a low wage industry and it is also recognised that uplifts are not necessarily passed across to workers as wage increases, given the other demands on the sector including maintaining environmental standards, training requirements and meeting costs of recruitment.

Current financial challenges and savings targets in local authorities mean that even less resource is going to be available in future, and any recommendations in terms of the workforce need to be seen in the context of there being little new money to support its development.

Reports and submissions for this section suggest that providers are addressing financial challenges in a number of ways. Supervisory and managerial tiers within care homes in some areas have been stripped out to sustain services at the frontline and development and training budgets are reported as being under pressure. In turn these approaches potentially reduce opportunities for career progression in the sector, making entry into the workforce a potentially unattractive career prospect. This also impacts on staff support and morale as supervision of staff, if available, is often reported as being used as a management and performance tool rather than as personal and professional development tool. All of this compounds the challenges we face in securing a sustainable and skilled workforce in this sector in coming years. New means of rewarding provision and the workforce need to be explored to address this, notwithstanding the current financial pressures.

Living Wage Debate

Some of this is played out in the current debate on the Living Wage and the national Minimum Wage. Anti-poverty groups across the UK have campaigned for an end to 'in work' poverty through introduction of an agreed Living Wage. The agreed Living Wage in the UK is currently £7.65 and the National Minimum Wage is £6.31 for adults and £5.03 for those aged 18 to 21 years.

A number of employers have committed to paying a Living Wage, including in November 2012, the Scottish Government for those staff whose pay it is responsible for. A proposal for a private Member's Bill which would have created a requirement for private sector employees working on public sector contracts to be paid the Living Wage had been consulted on in 2012, but this was withdrawn at the consultation stage.

Most local authorities in Scotland have also either introduced the Living Wage for their staff or are committed to its introduction; including for care home and care at home staff where the authority employs them.

In comparison, current trends suggest that wages in the independent and third sectors are not keeping pace with the national Living Wage, with a high proportion of workers in the care sector being paid close to, or at, the National Minimum Wage. This creates a risk of the development of a two tier workforce in the care sector and also creates a challenge in terms of staff recruitment and turnover in areas where the independent, third sector and public sector staff are employed. In practice this means that workers may enter the sector through the lower paid independent and third sector route, receive induction, training and qualifications and then move into higher paid public body employment. This creates turnover and cost challenges for the independent and third sectors who find themselves in a perpetual cycle of recruitment and managing vacancies. It should be acknowledged that while independent and third sector providers must, as a minimum, pay staff the National Minimum Wage, there are no mechanisms that can compel them to pay more than this.

There is a clear need, set against the challenging context we face, to ensure the social care sector is a career pathway of choice so that it can attract people with the skills, values and behaviours desired to look after and support some of our most vulnerable citizens. Current projections suggest a need to significantly increase and retain the number of people entering the sector to meet increasing and evolving need. At the same time, the demography of a decreasing working age population with greater competition for workers across the lower paid end of the employment market is recognised as a significant challenge in relation to the availability and sustainability of the workforce.

Re-shaping residential care for older people is not just about keeping down costs of providing care but has to be about fundamental improvements in the quality of care which is provided (against the context of increasing complexity and workforce challenges). One of the most effective means of delivering consistent standards of care is to ensure that staff are well trained, respected and rewarded and this must mean that remuneration reflects the value placed on these important roles. Care should be an aspirational role which attracts people wanting to deliver high quality support, with adequate and equitable levels of pay rewarding the role. In particular regard to training, workforce development plans should be developed not in silo, but across sectors and professions to ensure that opportunities for development are clear and the risks of duplication are minimised. This is also likely to help develop a level of 'cross fertilisation' of staff between sectors and organisations.

Levelling up the terms and conditions in the care sector toward the Living Wage (or beyond) would need to be seen in the context of a range of measures designed to increase the challenges in the workforce and consideration would need to be given as to how funding increases, if made available for this, would impact positively on workforce outcomes and outcomes for people that live in care homes. It would be expected that care home contractual processes would be the vehicle for setting out the consequential quality improvements from any funding increase.

However challenging it is in the context of public sector finance in Scotland, the issue of salaries, terms & conditions of employment and parity across the whole social services workforce, needs to be part of the much wider debate on how we care for and support older citizens.

Specialisation and Flexibility

Both independent and third sectors can demonstrate areas of specialisation in the workforce - particularly in relation to the third sector's focus on Learning Disability, Mental Health, Alcohol and Drugs, Physical Disability and Sensory Impairment. In workforce terms this can however mean that workers train in a single area of specialism and stay there for the rest of their career. However, the core competencies of their qualifications should be transferable throughout social services settings if they choose to move.

It is also increasingly the case that due to the complexity of need and frailty seen in older people in care home settings that we need to consider older people's care itself as a specialism with an appropriately trained and supported workforce to meet the multiple complexities of this population. If there is a difference in the level of training available to staff within the independent sector and those in the public sector, this will be a barrier to the long-term flexibility and resilience of the care sector as a whole.

We would strongly encourage more thinking on the transferability of the workforce across the public, third and independent sectors, to ensure maximum flexibility, skills sharing and person centred focus of care. This is particularly pertinent in giving wider consideration of seamless pathways of care and the 'whole system' approach necessary now and in the future to address the challenges of demographic change and financial pressure and we would encourage Joint Strategic Planning development work to consider workforce planning and shaping across the whole spectrum of staff working in care. In this way, we might envisage care staff operating across a care home for step-down care and then, to ensure continuity, supporting an older person's transition back to home. Similarly, at times of significant pressure, registered nurses might be deployed by NHS Boards into care homes to support more complex care or relieve significant system pressures. This will require innovative approaches to staffing services across the full pathway of care.

Palliative and end of life care

The provision of good palliative and end of life care is part of the core work of residential care. Many older people living in care homes, both nursing and residential homes, have a range of chronic and potentially life threatening health problems. These can include diseases such as cancer, heart disease and dementia. These conditions tend to worsen over time and can leave residents in a fragile state of health, facing painful and difficult symptoms in their final years. Furthermore, 21% of the population over the age of 65 die in care homes. Given this, care homes are an increasingly important setting for palliative and end of life care and support.

In order to be able to provide high quality palliative and end of life care, care homes need to develop good internal resources and have well trained and well supported staff. Residential homes which have no registered nursing staff on site also need good links and support to local healthcare systems including primary and community services, as well as to specialist care resources. Also, there is real potential here to utilise telehealthcare technology to develop such links.

Key challenges in improving palliative and end of life care in residential and care home settings mostly relate to workforce issues. These are:

• Developing and embedding a culture which supports staff to provide good palliative and end of life care;
• Sustained and consistent leadership and management with the necessary focus on quality care in this area;
• Retaining staff which will help to sustain and embed the appropriate culture;
• Obtaining and affording high quality courses - which in itself raises challenge of cost and cost of backfilling participating staff;
• Developing and sustaining good consistent links to local NHS and General Practice Services and creating clear community care hubs which support people living in care homes. The locality focus to be developed under Integration as set out in the Public Bodies Bill provides a clear opportunity to configure services around communities, which, of course, include care homes.

Behaviours, Values and Culture

It is very important that we don't focus on keeping costs down ignoring the significant need to promote, foster and develop the right behaviours, values and cultures in the residential care workforce, to enable it to provide the best, person-centred, safe and effective care. The NHS for instance, has training for staff on the Patient Safety Programme, yet there is no equivalent provision within the social care sector and it may be considered that the programme should be rolled out to all within this sector. In order to ensure the delivery of genuinely person centred care we also have to ensure that the staff working in these environments also feel, and are, valued. There is real potential in considering the role of care homes and the care home sector in the Person Centred Care Collaborative work and we would encourage local collaboratives to actively engage with the sector and develop with them the capability to become involved.

From submissions to the working group we heard that the essence of good care across the complex care and support provided in residential care ensures that there is not a focus only on 'task' but on 'being with' residents, focussing on personal outcomes, relationships and being person centred.

Kindness, compassion and whole person care were key themes emerging from contributions to this section.

Current pressures on finances and availability of workforce can mean it is challenging to positively recruit for these traits or to focus on them as part of the on-going training, development and quality improvement in residential homes. However, they will have an increasing focus as we move to personalise services and where people that use services have more choice and control in the use of their own budgets.

Care Homes as Community Resources and the role of Volunteers

While not strictly within the remit of this section we recognise that there is a significant amount of volunteering taking place already in the care home context. This includes volunteering for befriending, leisure and recreational activities and community focussed activities, in addition to assisting in the governance of facilities as outlined earlier.

We suggest that consideration is given, perhaps within the developing Joint Strategic Planning processes, to developing roles for volunteers in supporting people that live in care homes and that Third Sector Interfaces, working with the public and independent sectors are charged with developing this agenda.

Sustainability and availability of the Workforce

This is a key challenge both at the present time and projected into the future. Demographic change in Scotland suggests that, as well as there being an increasing proportion of people over 85 with complex care and support needs, this is compounded by there being a decreasing working age population available to fill care and support roles.

In some areas of Scotland, particularly areas of high employment such as in Aberdeen and in cities with a large choice of low paid jobs, these problems are even further amplified as competition with retail and seasonal hospitality industries is intense. Over and above this, recruitment problems in the workforce are also being felt in the public sector and this creates further challenge across the whole system, as all sectors are effectively recruiting from the same shrinking pool.

Challenges for Reshaping Residential Care

As indicated earlier, further challenges exist in the context of the changing policy context that the Reshaping Residential Care Task Force is working within - specifically with regard to Reshaping Care for Older People, Adult Health and Social Care Integration and Self Directed Support. All these policy areas demand service change and they drive organisational development across all sectors. This will require investment and a re-prioritising of resources in order to ensure real change. Without such investment we will not be able to see the necessary shift in the balance of care delivered or sustained and will not be able to realise the outcomes from integrated and seamless models of care and the efficiencies that can be derived in working in that way.

Recommendations

The Workforce sub group makes the following recommendations:

• That as a matter of some urgency, financial modelling of a national commitment to the Living Wage in the care sector is undertaken, to support a national debate on appropriate payment and reward in caring as a career; this should include modelling against other comparable health and local authority sector roles.
• That all Joint Strategic Commissioning Plans include, as part of their needs analysis, a scoping of the workforce issues in the care home sector in their partnership. This scoping should include an analysis of skills and training requirements and gaps, issues of recruitment challenge and gaps and opportunities for role and career development.
• That consideration and testing of a national workforce planning tool for the care home sector is undertaken.
• That training and development opportunities through the use of technology, innovation and new (and more cost-effective) ways of learning are scoped in order to support excellence in practice and employers in releasing staff time to train. Training and development should be extended to include service improvement and safety programme tools and initiatives.
• That given the increasing levels of dementia seen in residential care home settings, we ensure that the good practice set out in Promoting Excellence is enshrined in a formal qualification and that work is undertaken with the sector to support the roll out of appropriate levels of training in palliative care needs in each facility.
• That research is undertaken on the level of burn-out experienced by staff in care home settings, and that models of supervision and support are developed to address this.
• That Third Sector Interfaces, as part of the Joint Strategic Planning process, create a vision for developed volunteering roles in support of people that live in care homes.
• That, as part of their training, GPs should undertake a placement within a care home in order gain an understanding of the ways in which care homes operate and the level of dependency of the residents.