Summary of the impact

Research on residential care- and extracare-supported housing conducted by Swansea's Centre for Innovative Ageing (CIA) has impacted on the development and reconfiguration of supported housing services in Wales. Our research on care home closures has directly led to Welsh Government (WG) consultation on guidance regarding `escalating concerns' for care home closures, and the Independent Advisory Group on Local Authority Closure of Care Homes has recommended that our amendments to escalating concerns should be adopted in relation to care home closures due to strategic/policy reasons. Work is now underway by the WG to publish revised guidance in relation to care home closures based on our research. Three local authorities (Swansea, Vale of Glamorgan and Wrexham) have used our research on the challenges associated with extracare provision to inform the development of future services.

Underpinning research

A programme of research on the acceptability and suitability of supported living environments for older people was initiated at Bangor University in 2000-2002, under the leadership of Prof Vanessa Burholt: Burholt moved to Swansea in 2007 as Professor of Social Gerontology and with Prof Phillips continued to lead a stream of work on environment and ageing. In 2007 the Welsh Assembly pledged £41 million for the provision of extracare housing. The Guidelines for Developing Extra Care Housing in Wales (WAG, 2006) stated that extracare schemes should "take into consideration the likely impairments that residents will experience with increasing age and frailty" (p.11). However, the burgeoning provision of extracare in Wales was not evaluated as it was implemented, and it was not clear whether it accommodated the changing needs of both fit and frail older people. Between July 2008 and June 2010 Profs Burholt and Phillips were funded by the Wales Office of R&D for Health and Social Care for a project entitled Extracare: meeting the needs of fit or frail older people? [R6] This research sought to establish whether extracare could accommodate the changing needs of both fit and frail older people (particularly those with cognitive impairments), and whether complex integrated health and social care could be delivered in extracare. Furthermore, the research examined the quality of life and experience of fit and frail older people in extracare schemes compared to residential and home care, and its cost effectiveness compared to residential and home care.

Swansea were the first to report that in Wales:

• extracare sheltered housing provides for proportionally fewer frail older people than the other care environments (residential care and home care) [R3].
• older people with cognitive impairment were systematically excluded from extracare environments through assessment and admissions processes that deem these settings as inappropriate for those `who may pose a risk to themselves or others' [R3].
• extracare sheltered housing provided the conditions for increased social interaction and that this was particularly effective for older widows. However, the increase in interactions did not necessarily lead to high quality and emotionally satisfying social relationships and had no impact on the levels of loneliness experienced by residents [R1-3].

The research led to eight recommendations for changes in WG guidelines regarding the development of Extracare provision and local RSL and private landlord practices regarding the provision of Extracare [R1-3,6]. These recommendations were supported by the National Partnership Forum for Older people in Wales which has advised the Minister with responsibility for Older People to adopt them.

The research on extracare sheltered housing (2008-2010) found that several local authorities were closing local residential care homes and remodelling the facilities to provide extracare sheltered housing [R3]. The introduction of WG guidelines on care-home closure in May 2009, provided Burholt and Phillips with a timely opportunity to examine the way that care homes are closed, and explore the process from the view of various stakeholders. In May 2010-Nov 2011, in collaboration with the Older People's Commissioner in Wales, Profs Burholt and Phillips obtained funding from the National Institute of Social Care and Health Research to examine The closure of care homes for older people in Wales: Prevalence, process and impact [R5]. In 2011, this research identified substantial gaps in local authority protocols and practices with regard to the processes adopted during care-home closure. Subsequently the researchers drafted new guidance for the Welsh Government to replace the guidelines entitled "Escalating concerns with, and closures of, care homes providing services for older adults" [R4].

References to the research

R5 Burholt, V., Phillips, J., Stone, S., The closure of care homes for older people in Wales: Prevalence, process and impact. Peer-reviewed NISCHR Grant £164,164 (May 2010 - Nov 2011)

R6 Burholt, V., Phillips, J., Phillips, C., Hillcoat-Nalletamby, S., Evans, S., O'Mahoney, S., Extracare: meeting the needs of fit or frail older people? Peer-reviewed Wales Office of R&D for Health and Social Care Grant, RFSC07-3-012 (£231,560) (July 2008 - June 2010)

Details of the impact

In 2011, 21,484 people in Wales lived in sheltered housing, residential care and nursing homes (as defined in the Census). Thus, the research of the CIA has potential to impacted on around 2.8% of the older population (60 years and over) in Wales who reside in supported living environments. The research has been wide reaching and has had significant impacts on the organisational activity of extracare sheltered housing providers, local authorities, and policy-making (through the adoption of the amended `escalating concern' guidelines that were produced as a result of the closure of residential care project) in Wales.

In November 2010, Prof V Burholt and Dr P Nash gave a briefing on the Extracare project to WG members at the Senedd. This influenced the thinking of at least two Assembly Members in 2010 (Dr Brian Gibbons AM, Andrew Davies AM) who remained engaged in an email dialogue after the briefing to acquire further information on the project. The opening speech by the former First Minister (Rhodri Morgan) on 9 Feb 2012 (Public Services 2025) acknowledged the strength of the research-policy links that have been developed through this (and other) research "Our strong relationship with the Centre for Innovation in Ageing at Swansea University, backed by a 3 year research agreement, underpins what is widely recognised as a world-leading approach to policy and delivery for older people."

The Older People and Ageing Research and Development Network Cymru (a WG-funded thematic network hosted by the Centre for Innovative Ageing), with the Office of the Older People's Commissioner in Wales organised regional seminars for practitioners and policy makers with an interest in supported living environments. The seminars presented findings from the closure of residential care facilities in Wales project and an overview of recommendations of changes to extracare based on the research. The seminars were delivered in both north (1 March 2011) and south Wales (29 March 2011), and were attended by practitioners, Care and Social Services Inspectorate Wales (CSSIW) and policy makers from Welsh Government. In 2010 and 2011, Prof Burholt and Dr Nash presented the recommendations from the Extracare project in meetings with the South East Wales Improvement Collaborative (SEWIC).

Dissemination of the research findings has directly:

Impacted on the reconfiguration of services in Wales.

• Swansea Social Services have developed a strategy for extracare for older people in the authority based on the evidence provided (contact details supplied). Specifically, in the early formulation of this strategy, the work of the CIA has been used by the Social Services Department to challenge the assumptions that they had about the ability of extracare to meet the functional and social needs of frail elders. The Local Authority Commissioning Plan states that in 2012/13 the authority will use this information to develop a position statement around extracare or housing with support including proposal for options.
• Vale of Glamorgan Council in partnership with Hafod Housing Association is currently building its first extracare housing scheme (contact details supplied).

Led to organisations changing the allocation of social care `hours' to Extracare schemes to ensure a balanced mix of older people with different levels of care needs/frailty.

• In Wrexham, the Head of Adult Social Care and the Commissioning Manager for older people have testified that the research led to consideration of the importance of, and need to create meaningful communities within extracare (contact details supplied). To achieve this, a small team of Care Managers have been housed within the extracare facility and work with individuals to explore opportunities for social interaction including enabling people to engage with their former local communities and social networks.
• The South East Wales Improvement Collaborative (SEWIC) have used the evidence to rank extracare housing as the third option within a program of work to begin to address the challenges facing the social care and health economy of south east Wales [C3].

Influenced public policy debate in Wales and WG policy [C5].

• Recommendations from our Closure of Care Homes project have been included in a report issued to the First Minister under Regulation 16 of the Commissioner for Older People in Wales Regulations 2007 in relation to the Commissioner's general function of promoting awareness of the interests of older people in Wales and the need to safeguard those interests [C6].
• The Social Care Committee of WG used the CIA evidence (also reported in C7) to feed into the Social Care Review on Residential Care [C1,C2,C4].
• Key recommendations arising from the WG Social Care Review on Residential Care are built on the CIA evidence, and endorse our suggestions that significantly improve older people's lives: 1 (access to effective advocacy); 2 (advice and information to support long-term care decisions); 8 (raising skills and awareness of staff about dementia); 9 (financial scrutiny of care homes) and 11 (strengthening escalating concerns guidance) [C4].
• As a result of our research, WG policy has changed: recommendations 1, 2 and 11 in the WG Social Care Review on Residential Care have been accepted by the Minister, while 8 and 9 have been accepted in principle [C8].
• The former Deputy Director of Social Services Policy and Strategies in the Welsh Government has noted that our research "led the Deputy Minister to ask the Commissioner for Older People to review our Guidance on Escalating Concerns and Closures of Care Homes in respect of local authority commissioning practice" [C9]. Subsequently, an Independent Advisory Group on Local Authority Closure of Care Homes was convened to advise the Deputy Minister for Social Services on how the Escalating Concerns Guidance should be updated. The Chair has noted that the advisory group have recommended that many of our amendments to escalating concerns should be adopted in relation to care home closing due to strategic/policy reasons [C10]. Subsequently, work is underway by the Welsh Government to publish revised guidance in relation to care-home closures based on our research.

Sources to corroborate the impact

C1 HSC(4)-06-12 paper 1 Inquiry into residential care for older people - Evidence from the Older People's Commissioner for Wales,
http://www.senedd.assemblywales.org/documents/s5598/Paper%201.pdf

C2 HSC , 2012, Minutes 3 Feb 2012 (pp. 5, 7, 8)
http://www.senedd.assemblywales.org/documents/s6098/23%20February%202012.pdf

C3 McNeil, E., 2011, Extracare scoping review. SEWIC
http://www.ssiacymru.org.uk/resource/a_l_Research_findings_v8.doc

C4 National Assembly for Wales, Health and Social Care Committee (NAW HSCC) 2012. Residential care for older people in Wales. National Assembly for Wales, Cardiff Bay. (written evidence pp. 24-5, 30, 77, 95-6; oral evidence from OPC on CIA research pp. 93, 107, RC 72)
http://www.assemblywales.org/bus-home/bus-business-fourth-assembly-laid-docs.htm?act=dis&id=241567&ds=1/2013

C5 Older People's Commissioner for Wales, 2011, The Commissioner's Report 2010/11: Helping make Wales a great place to grow older. Older People's Commissioner for Wales, Cardiff.
http://www.olderpeoplewales.com/en/Publications/pub-story/11-09-30/Commissioner_s_Report_2010-11_published.aspx

C6 Older People's Commissioner for Wales (OPC), 2011, Report to the First Minister concerning the Welsh Government Guidance `Escalating Concerns with, and closures of, care homes providing services for adults'. Older People's Commissioner for Wales, Cardiff.

C7 Older People's Commissioner for Wales, 2012, Voice, Choice and Control: Recommendations relating to the provision of independent advocacy in Wales. Older People's Commissioner for Wales, Cardiff.

C8 Welsh Government (WG), 2013, Written Response by the Welsh Government to the Report of the Health and Social Care Committee entitled - Residential Care for Older People in Wales. WG, Cardiff.

C9 Welsh Government. A testimonial has been sent to the CIA for further details contact the former Deputy Director, Social Services Policy and Strategies, Adult Social Services Policy, Welsh Government

C10 Independent Advisory Group on Local Authority Closure of Care Homes. A testimonial has been sent to the CIA for further details contact the Chair, Director of Protection, Scrutiny and Human Rights, Older People's Commissioner for Wales.