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Report to: Cabinet Member Adult Social Care Date: 11th July 2016Date of Decision: TBC

Subject: Care Home Fees 2016/17

Report of: Head of Commissioning Support & Business Intelligence Wards Affected: All

Is this a Key Decision? No Is it included in the Forward Plan? N/A

Exempt/Confidential No

Purpose/Summary The purpose of this report is to enable the Cabinet Member Adult Social Care to determine the fees payable to Care Homes, in respect of residents placed in those homes by the Council, during the period 2016/17.

Recommendation(s)

The Cabinet Member is recommended to note the contents of the report and having given full consideration to all of the information provided, including the responses to consultation and the equality analysis to approve the following:

(1) Implement the following fees from 1st April 2016;

Service Type 2016/17 Fee% Increase

from 2015/16 Fee

Residential £418.52 4.63Residential EMI £473.97 4.63Nursing £552.67 5.07Nursing EMI £597.85 5.07

(2) Implement the same percentage uplifts by service type to those fees in 2016/17 for the following;

a. Existing placements (approximately 4%) which are currently paid at specific, Learning Disability, Physical Disability or Mental Health rates.

b. Any fees within residential placements outside of the above ranges

(3) The commissioning (in partnership with Sefton CCGs) of an external body to conduct a detailed analysis of costs within the local care market.

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How does the decision contribute to the Council’s Corporate Objectives?

Corporate Objective Positive Impact

Neutral Impact

Negative Impact

1 Creating a Learning Community √2 Jobs and Prosperity √3 Environmental Sustainability √4 Health and Well-Being √5 Children and Young People √6 Creating Safe Communities √7 Creating Inclusive Communities √8 Improving the Quality of Council Services

and Strengthening Local Democracy√

Reasons for the Recommendation:

To enable the Council to set the fees payable to Care Homes in 2016/17, in respect of residents placed in those homes by the Council, in accordance with the requirements of legislation and statutory guidance.

What will it cost and how will it be financed?

The Head of Corporate Resources (FD4228/16) and the Head of Regulatory & Compliance (LD3511) have been consulted and their comments have been incorporated into this report.

(A) Revenue Costs:

There are additional revenue costs of £1,870,500 associated with the recommendation relating to the proposed uplift for 2016/17. In accordance with the Cabinet Decision on 7th April 2016 the costs associated with the proposed uplift can be met from within existing provisions allocated to support uplifts for 2016/17.

The cost of commissioning an external body to conduct a detailed analysis of costs within the local care market will be jointly funded by Sefton Council and Sefton CCGs and will be met from within existing Adult Social Care resources.

(B) Capital Costs:

There are no additional capital costs associated with the implementation of the recommendation to this report.

Implications:The following implications of this proposal have been considered and where there are specific implications, these are set out below:

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Legal National Assistance Act 1948National Assistance Act 1948 (Choice of Accommodation) Directions 1992LAC (2004) 20Care Act 2014Care and Support Statutory GuidanceThe Care and Support and After-Care (Choice of Accommodation Regulations) 2014

Human Resources None

Equality See Section 3

1. No Equality Implication

2. Equality Implications identified and mitigated

3. Equality Implication identified and risk remains

Impact on Service Delivery:

None, subject to risk assessment.

What consultations have taken place on the proposals and when?

The consultation process commenced on 25th April 2016, with a letter to all care home providers and ran through to 23rd May 2016 (4 weeks). The consultation period was shorter than previous consultation periods regarding fees, as Providers had indicated that a decision was required as soon as possible.

Are there any other options available for consideration?

If having taken into account all of the information available to him, the Cabinet Member considered that the recommendation would not result in the Council’s proposed rates being sufficient to meet the assessed care needs of Service Users and to take into account the implementation of the National Minimum Wage / National Living Wage, he could decide to set them at a higher level.

If the Cabinet Member wished to set the rate higher than the delegated authority from Cabinet, namely, within the context and constraints of available resources, as set out in the Medium Term Financial Plan and as agreed with the Council’s Section 151 Officer then the matter would need to be referred back to Cabinet for Decision as it will have implications for the Medium Term Financial Plan process going forward.

Each 1% increase in care home fees equates to an approximate additional gross cost to the Council of £390,000.

Similarly, if having taken into account all of the information available to him, the Cabinet Member considered that the recommendation would result in the Council’s fees for care

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being over and above that which would be sufficient to meet the assessed care needs of the supported residents, he could decide to set them at a lower level.

Implementation Date for the Decision

Following the call-in period for this Decision

Contact Officer: Peter MooreTel: 0151 934 3730Email: peter.moore@sefton.gov.uk

Background Papers:

None

Background

1. The Council is obliged, each year, to set and publish the fees it expects to pay when placing people in residential or nursing care settings (Care Homes). In setting these fees the process the Council follows and the matters it seeks to take into account reflect relevant legal requirements, statutory and other guidance and case law/legal precedents. In setting the fees for 2016/17 the Council has also needed to reflect the significant legislative change with the implementation of the new National Minimum Wage / National Living Wage.

2. People who are assessed as needing residential or nursing care are able to choose which care home they wish to reside in. The impact of that choice on the Local Authority is limited by the expectation that it shall not cost the LA more than it would usually expect to pay to meet those assessed care needs, previously referred to as the “usual cost” of care but now described as not more than “the amount specified in the adult’s personal budget for accommodation of that type”. Personal budget is further defined as “the cost to the local authority of meeting the person’s needs which the authority chooses or is required to meet”. The principle remains that the Local Authority must set these fees/personal budgets so as to be “sufficient to meet the assessed care needs of the supported resident”

3. In setting its “usual cost” statutory guidance, within Local Authority Circular LAC (2004)20, required the Council to have “due regard” to:

• The “actual costs” of providing that care;• Other Local Factors; and• The Best Value requirements set out in Local Government Act 1999.

4. The refreshed version of the Care Act 2014 statutory guidance published in March 2016 states that;

• “When commissioning services, local authorities should assure themselves and have evidence that contract terms, conditions and fee levels for care and support

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services are appropriate to provide the delivery of the agreed care packages with agreed quality of care. This should support and promote the wellbeing of people who receive care and support, and allow for the service provider ability to meet statutory obligations to pay at least the national minimum wage and provide effective training and development of staff. It should also allow retention of staff commensurate with delivering services to the agreed quality, and encourage innovation and improvement. Local authorities should have regard to guidance on minimum fee levels necessary to provide this assurance, taking account of the local economic environment. This assurance should understand that reasonable fee levels allow for a reasonable rate of return by independent providers that is sufficient to allow the overall pool of efficient providers to remain sustainable in the long term”

• “Local authorities must not undertake any actions which may threaten the sustainability of the market as a whole, that is, the pool of providers able to deliver services of an appropriate quality, for example, by setting fee levels below an amount which is not sustainable for providers in the long-term”

5. Departure from statutory guidance is permissible, but there needs to be compelling and cogent reasons for doing so and the greater the departure from guidance the more compelling and cogent those reasons would need to be.

6. As well as formal statutory guidance, the Department of Health in October 2001 issued an agreement between the statutory and independent social care, health care and housing sectors entitled “Building Capacity and Partnership in Care” (the Agreement) in which the Secretary of State for Health set out his expectations of commissioners and providers and also how the Government would assist in “building a new, more positive partnership between the statutory and independent social and health care and housing sectors”. Amongst other things the Agreement suggests that:

• Fee setting must take into account the legitimate current and future costs faced by providers as well as the factors that affect those costs, and the potential for improved performance and more cost effective ways of working.

• Contract prices should not be set mechanically but should have regard to providers’ costs and efficiencies, and planned outcomes for people using services, including patients

• Commissioners should ensure that they have in place fee negotiation arrangements that recognise providers’ costs and what factors affect them (as well as any scope for improved performance) and ensure that appropriate fees are paid.

• Providers should ensure that they (among other things) are able to provide a full breakdown of the costs of services provided and undertake prompt and timely communication with commissioners.

• Commissioners and providers should ensure (among other things) that they recognise the financial and other constraints faced by partners.

Whilst the Agreement was not formal statutory guidance the Council still needed to have regard to it and the current statutory guidance still refers to, stating that “local authorities should pursue the principle that market shaping and commissioning should be shared endeavours” with commissioners working with a range of stakeholders to find shared and agreed solutions, “in line with the Building Capacity and Partnership in Care Agreement”.

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7. Sefton Council’s current fees, set by the Cabinet Member Adult Social Care on 19th November 2015, are as follows:

Category 2015/16 FeeResidential Home – Older People £400.00

Residential Home – Older People EMI £453.00

Nursing Home – Older People £526.00

Nursing Home – Older People EMI £569.00

8. On 7th April 2016, Cabinet authorised officers to consult with care home providers on proposals for setting the Adult Social Care fees and delegated authority to the Cabinet Member – Adult Social Care to set the Council’s Adult Social Care fees for 2016/17 within the context and constraints of available resources, as set out in the Medium Term Financial Plan following conclusion of the consultation process.

Sefton Care Home Market

9. There are currently 113 registered care homes in Sefton, of which 14 provide specialist services, for example small registered homes for people with complex Learning Disabilities. Of the remaining 99 homes, 74 provide services predominantly for Older People and 25 cater for Older People with Dementia.

10. Within the 113 care homes, there are currently 3,407 bed spaces. At the time of the last weekly “Vacancy Survey” there were 97 vacancies (3%) and so the market was operating at 97% capacity.

11. A snapshot in February 2016 showed that 1304 (38%) of the occupied beds were Sefton Council placements. Typically, over recent years, at any one time Sefton placements have accounted for in the region of 50% of the occupied bed spaces.

12. Of the 113 homes, there are currently 15 where fees are calculated based on individual assessments of Service User’s needs due to the complexity of the care package requirements and diversity of need being catered for and as a result “3rd Party Top-Ups” are not applicable. Of the remaining 98 care homes, 77 (79% of applicable homes) charge residents a 3rd Party Top-Up over and above the fee paid by Sefton Council, whilst 21 homes charge no Top-up (i.e. take Sefton placements without any additional charges to the resident). The percentage of homes levying a 3rd Party Top-Up has increased from 76% in November 2015, when fees were last set.

13. As at 24th May 2016, 73 homes had been inspected under the new CQC inspection methodology. Of these 4 were rated as being Inadequate, 29 were rated as Requires Improvement and 40 were rated as Good.

14. Since setting fees in November 2015, 3 homes have closed (2 due to quality issues) and 1 home has opened.

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Consultation Process

15. The consultation process commenced on 25th April 2016, with an emailed letter to all care home providers and ran through to 23rd May 2016 (4 weeks). The consultation period was shorter than previous consultation periods regarding fees, as Providers had indicated that a decision was required as soon as possible.

16. The Consultation letter explained that in setting its Usual Cost for the 2016/17 period the Council was seeking to recognise and take into account the legitimate current and future costs faced by Providers and the factors that affect them. One key area identified was the increase in the National Minimum Wage/National Living Wage rate and Providers were advised that this was explicitly recognised and reflected within the proposed new rates.

17. The changes to National Minimum Wage/National Living Wage rate over the last 3 years are as follows. Please note that the separate “25 and over” rate was introduced in April 2016:

Year 25 and over 21 to 24 18 to 20 Under 18 Apprentice2014 N/A £6.50 £5.13 £3.79 £2.732015 N/A £6.70 £5.30 £3.87 £3.302016 £7.20 £6.70 £5.30 £3.87 £3.30

18. The letter explained that, consistent with the approach taken in previous years, rather than trying to take account of actual care costs by precise quantification, Sefton proposed to exercise its judgment and experience in the light of the market's functioning in practice and what it knows of fees paid and costs incurred elsewhere, as well as having due regard to any evidence provided relating to actual costs.

19. The letter also set out the proposal on which the Council was consulting, namely, the implementation of the following fees;

Service Type 2016/17 Fee % Increase 2015/16 FeeResidential £418.52 4.63 £400.00Residential EMI £473.97 4.63 £453.00Nursing £552.67 5.07 £526.00Nursing EMI £597.85 5.07 £569.00

The letter further explained the same percentage uplifts by service type would be applied to those fees for the following;

Existing placements (approximately 4%) which are currently paid at specific, Learning Disability, Physical Disability or Mental Health rates.

Any fees within residential placements outside of the above ranges

20. Whilst all comments and feedback were welcomed, the consultation letter advised Providers that the Council wished to particularly receive and consider feedback in relation to the following areas:

(a) Whether the level of proposed fees set out in the tables above will cover the cost of meeting assessed care needs within an efficient residential/nursing home for the period from 1st April 2016 to 31st March 2017.

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(b) If you do not agree with the above rates, in particular if you consider that they will not cover the cost of meeting assessed care needs within an efficient residential/nursing home, please provide budgeted costings, together with evidence of actual expenditure and a breakdown of your weekly bed price, in support of your comments.

Consultation Responses and Analysis

21. More than 100 consultation letters were emailed out and a total of 14 responses were received. These responses consisted of 13 responses from Providers who operate 15 care homes in the borough and also in other Local Authority areas. The remaining response was submitted by Sefton Care Association which is an organisation that represents care home providers in the borough. The detail of each response is provided in Annex 1 (suitably redacted to protect business confidentiality).

22. Four of the 13 responses from individual Providers also stated that the proposals outlined in the Sefton Care Association response were recommended and supported by them.

Sufficiency of the Proposed Fees

23. In relation to the first question referred to in paragraph 19 above “whether the level of proposed fees set out in the table above will cover the cost of meeting assessed care needs within an efficient residential/nursing home for the period from 1st April 2016 to 31st March 2017” 13 respondents stated that the proposal was insufficient. Three respondents stated that whilst they viewed that the proposed fees were not sufficient they were prepared to accept them and one respondent stated as part of their response that they were appreciative of the proposed increase.

24. Five respondents suggested alternative percentage uplifts. One respondent who operates a general Residential home stated that the increase should be 11.5%; one respondent who operates an EMI Nursing home stated the increase should be 20%; one respondent who operates an EMI Residential home stated the increase should be 18.65%; one respondent who operates a Nursing home stated the increase should be 54.64% and one respondent who operated a care home where costs are based on individual assessments, stated the increases should be between 15% and 33%.

25. The Sefton Care Association response also stated that Provider’s may seek to sell their homes as they become unviable, thus reducing market capacity and that there are currently 15 homes up for sale.

Evidence of Actual Expenditure

26. In relation to the second question referred to in paragraph 19 above “If you do not agree with the above rates, in particular if you consider that they will not cover the cost of meeting assessed care needs within an efficient residential/nursing home, please provide budgeted costings, together with evidence of actual expenditure and a breakdown of your weekly bed price, in support of your comments” no respondents submitted the full information requested. One respondent submitted a breakdown of their weekly bed price and one respondent submitted calculations detailing how their increased costs for 2016/17 were then attributed to the weekly cost per resident.

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27. Two respondents stated that they would not provide actual and budgeted costs as they stated that such information is not used by Sefton Council to determine fees.

Main Themes

28. The main themes within the consultation feedback, presented in full in Annex 1 to this report, relate to the following areas;

Impact of the National Minimum Wage/National Living Wage – Respondents stated that the proposed fees are not sufficient to take into account the impact of recent changes. These changes have resulted in higher wage bills and such increases will continue to occur given the announcement that the rate will increase to £9.20 by 2020. Respondents also highlighted that they did not feel that staff under the age of 25 should be paid at a lower rate as they would be doing the same job.

Dependency levels – levels have increased, resulting in extra staff being required, especially in the Residential Care Home sector when compared to dependency levels up to 15 years ago. Fee levels for Mental Health should be the same as those for EMI.

Staffing issues – including a shortage of Nursing staff which in turn leads Providers to use agency staff at higher cost, high staff turnover, costs associated with recruitment, increases to annual leave allowances and Pension changes, including auto-enrolment. In addition to this respondents have highlighted that it could be the case that in Sefton some homes de-register as a Nursing home

Banking Regulation changes – resulting in homes with a commercial mortgage being required to maintain minimum levels of ‘cash generation’ and ‘net profitability’ that are not provided for in the proposed fees

Care Quality Commission (CQC) Requirements – respondents have highlighted that it is felt that CQC are making demands on operators to deliver a level of service that Sefton is unwilling to pay for. Coupled with this, respondents have highlighted that it is their view that the CQC inspection process is “much tougher and more rigorous”. In addition, registration fees have also increased.

Increased Administration/Operating Costs – with respect to inflation, increased costs for services/supplies, meeting revised contractual/service specification requirements, additional administrative costs associated with Deprivation of Liberty Safeguards (DoLS), Clinical Commissioning Group (CCG) involvement and Social Work reviews.

Additional Matters

29. During the consultation some respondents also stated that the Council should reconsider paying the Gross fee and that the Council should collect Service User ‘personal contributions’ as per arrangements in a neighbouring Local Authority. Respondents stated that it was not the Provider’s responsibility to collect such contributions and that doing so hampered cash flow within smaller organisations. In addition, it was also stated that the Council should “stop taking the FNC payment off Sefton Nursing homes” and that this should be paid direct to the home in addition to the Council’s full nursing fee, again as per arrangements in a neighbouring Local Authority. There is an administrative burden and potential bad debt liability associated with paying Gross cost. We will continue to monitor the impact of the Care Act, but are not proposing any change at this point in time.

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30. Respondents also stated that consultation periods should commence prior to April each year so that increases are processed when the new financial year starts. One respondent also stated that fees should be proposed at least two years in advance and that consultation on fees should be prepared and given out to Provider’s at least one year in advance of the proposed date. One respondent stated that backdating of fees causes additional administrative work.

31. Respondents have also stated that fee levels should be determined based on a precise quantification conducted using an independent costing methodology such as that produced by Laing & Buisson.

32. Respondents also stated that ‘Private’ clients were ‘subsidising’ Local Authority clients and that if occupancy levels within homes remained high then Sefton Council may struggle to place as homes may ‘hold out’ for clients that can meet the real cost of service provision.

Impact Assessment Overview

33. The Council’s duty under Section 149 of the Equalities Act 2010 is to have “due regard” to the matters set out in relation to equalities when considering and making decisions on the provision of services. Due regard to the need to eliminate discrimination, advance equality, and foster good relations must form part of an integral part of the decision making process. The Cabinet Member must consider the effect that implementing a particular policy/decision will have in relation to equality before making a decision.

34. There is no prescribed manner in which the equality duty must be exercised. However, the Council must have an adequate evidence base for its decision making. This can be achieved by means including engagement with the public and interest groups, and by gathering details and statistics on who uses the services and how.

35. Where it is apparent from the analysis of the information that the policy/decision would have an adverse effect on equality then adjustments should be made to avoid that effect (mitigating actions). The steps proposed to be taken are set out below.

36. The Cabinet Member should be aware that the duty is not to achieve the objectives or take the steps set out in Section 149. Rather, the duty on public authorities is to bring these important objectives relating to discrimination into consideration when carrying out its public functions. “Due regard” means the regard that is appropriate in all the particular circumstances in which the authority is carrying out its functions. There must be a proper regard for the goals set out in Section 149. At the same time, Members must also pay regard to any countervailing factors, which it is proper and reasonable for them to consider. Budgetary pressures, economics and practical factors will often be important, the weight of these countervailing factors in the decision making process is a matter for Members in the first Instance.

37. The proposals for Care Home Fees for 2016/17 have been subject to consultation and engagement with stakeholders as part of the process of assessing the potential equality impact of the proposals.

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38. The options proposed do not involve any change to the criteria for residential or nursing care, as assessed via the Council’s eligibility criteria nor do they involve any changes to the capacity of services.

39. Each supported resident in residential and nursing care homes will continue to have an individual care plan which is reviewed each year in accordance with the Care Act 2014. In assessing the care needs of residents Sefton Council is required to have regard to its public sector equality duty.

40. The Council will take into account the possibility that some residential and nursing care home providers may face difficulties in adapting their services if the recommendations were implemented and as a consequence could then become unviable which would lead them to withdraw from the market. This could therefore reduce the availability of services that meet specific client needs. If this were to occur then the following protected characteristics may be affected; Age, as the majority of current service users are aged over 65; Gender, as the majority of current service users are female; and Disability, as by definition all those people assessed as eligible for residential and nursing care have a disability.

41. Since setting fees in November 2015 three homes have closed and one home has opened. This has resulted in a marginal decrease in bed spaces within the Market as other homes have increased their capacity. Officers consider that the Sefton care home market remains viable. Overall the capacity and utilisation of care home places in Sefton has remained fairly stable with in the region of 93-97% of bed capacity being utilised and currently stands at 97% occupancy.

42. The Care and Support Statutory Guidance states that “in some cases, a person may actively choose a setting that is more expensive than the amount identified for the provision of the accommodation in the personal budget” and that “in such circumstances the local authority must arrange for them to be placed there, provided a third party, or in certain circumstances the person in need of care and support, is willing and able to meet the additional cost”.

43. In November 2015, 76 care homes (76% of applicable homes) charged residents a “top-up” over and above the fee paid by Sefton Council, whilst 24 care homes (24% of applicable homes) charged no “Top-Up”. This currently stands at 77 care homes (79% of applicable homes) charging a “top-up” and 21(21% of applicable homes) not charging a “top-up” (note that the number of applicable homes has changed slightly).

44. In recent years the percentage of applicable homes charging 3rd Party Top-Ups has increased. A reduction in the level of choice of homes that a person can access without the need for a supplementary third-party ‘top-up’ being applied (i.e. if care homes choose not to continue to accept placements at the proposed rates) may result in people with protected characteristics detailed above being affected.

45. In addition, if the recommendations were to be implemented then this could result in fee structures for clients changing. For example providers may seek to obtain the difference between the existing fee amount and the fee they wish to charge from clients via increasing their contribution. This could place some clients at an economic disadvantage.

46. In order to minimise the risk of this happening the Council will continue to consult with care home providers and other stakeholders, to develop an improving

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understanding of the cost of care and assist in a continued viable care home market. It is proposed that in order to improve understanding of the local cost of care, in partnership with Sefton CCGs, an independent body is commissioned to undertake a detailed analysis of costs within the local care market. This exercise will be conducted with input from Provider’s in order to gain further understanding of both current and future costs, demands and factors affecting the Sefton care home market.

47. The Council considers that it will continue to meet the Public Sector Equalities Duty and will take the following actions:

Consultation will continue with residential and nursing care home providers regarding the cost of care, including the proposed action detailed in paragraph 45.

Ongoing assessment of the overall impact of the decision will be used to conduct further Equality Impact Assessments.

Consultation will also include obtaining provider views on the economic impact of the implementation of the decision and this information will in turn be used to ascertain any possible economic impacts on clients or regulatory impacts on individual care homes.

Regular liaison with the Care Quality Commission will also continue and as part of this any issues identified with respect to the financial viability of individual care homes will be monitored. The impacts of any potential financial difficulties identified would be assessed, especially with respect to the impact on the wider Sefton care home market, meeting demand for services and capacity in the market. To this end the capacity of current services will be monitored regularly to assess capacity levels for all categories of care homes.

The Care Act 2014 gives new responsibilities to CQC for assessing the financial sustainability of certain care providers, it also gives them new powers to request information from those providers and to request a provider who they judge to be in financial difficulty to develop a sustainability plan and arrange an independent business review, to help the care provider remain financially sustainable. The Council will work with CQC if and when they share concerns about care providers operating in Sefton.

With respect to any potential impacts of the decision on the quality of service provided in care homes, regular monitoring will continue to take place. This will include monitoring of factors such as the standard of the physical environment, the quality and retention of staff, staff training and overall management of services. Monitoring of Safeguarding referrals and regulatory notifications will also continue.

We will continue to improve analysis of data for placements with respect to fee levels charged by homes for Sefton and non-Sefton funded clients and the levying of ‘Top-up’ payments.

National and local factors concerning the cost of care and the demand for services will also be monitored, such as changes to the demographic profile of the borough and the demand for more specialist services.

Risk management work will be conducted which will include periodic analysis of the capacity within the market and the ability of the market to ‘absorb’ any individual home closures. This analysis will also be informed by performance information on numbers of placements and ability to meet demand and individual needs.

We will continue to prepare for and monitor the impact of changes introduced by the Care Act 2014.

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We will continue to explore ways in which we can better support the care home business sector.

The Council will work with NHS colleagues to develop a whole system and joined-up Market Management approach.

Consultation will also continue to take place as and when required with client and advocacy groups regarding the decision and its potential impact.

48. The Cabinet Member is requested to note and take account of the above Equality Analysis information, the Equality Analysis Report included as Annex 2 to this report, the consultation feedback and the mitigating actions in taking his decision on the recommendations made.

Risk Management Overview

49. During consultation care home Providers have raised a number of concerns in relation to potential negative impacts of the current and proposed Sefton Council fee rates. In particular all of those who responded stated the view that the proposed fees are insufficient to meet the actual cost of meeting care needs in their care home.

50. The evidence provided in response to the consultation exercise is helpful in understanding the Sefton marketplace and the views of the providers who responded, it has been taken into account in the preparation of this report, formulation of the recommendations to the Cabinet Member and will continue to be taken into account in future considerations about the care home market and fee levels.

51. Concern has been expressed, by some care home providers, that homes are now reliant upon high occupancy rates to remain viable and that any significant increase in vacancies significantly impacts upon that viability. Whilst the Sefton market generally operates at approximately 93-97% capacity (i.e. 7%-% vacancies) and is currently operating at 97% capacity the vacancy rate within individual homes may be higher or lower than that general level. This is a matter the Council needs to be cognisant of when monitoring vacancy rates.

52. As reported above, some responding providers referred to the proposal impacting

upon viability of the business. In setting its Usual Cost, the Council needs to ensure that it is “sufficient to meet the assessed care needs of the supported resident”. As identified in previous years, it may be that fees could be sufficient for that purpose but provide an insufficient level of return for some business owners, shareholders, or business models. The range of percentage uplift suggested by responding providers and the range of costs provided in previous consultation exercises indicates the differing business models, costs and required returns within the market.

53. The Care Act 2014 places new duties on local authorities to facilitate and shape their market for adult care and support as a whole, so that it meets the needs of all people in their area who need care and support, whether arranged or funded by the state, by the individuals themselves, or in other ways”. The Statutory Guidance states that “the ambition is for local authorities to influence and drive the pace of change for their whole market, leading to a sustainable and diverse range of care and support providers, continuously improving quality and choice, and delivering better, innovative and cost-effective outcomes that promote the wellbeing of people who need care and support”.

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54. The guidance states that “local authorities must work to develop markets for care and support that – whilst recognising that individual providers may exit the market from time to time – ensure the overall provision of services remains healthy in terms of sufficiency of adequate provision of high quality care and support needed to meet expected needs”. The guidance however also states that “recognising that changes to adult care and support are taking place at a time of the need to deliver services from constrained resources. Local authorities should have regard to best practice on efficiency and value for money”.

55. The Council will seek to deliver against this market shaping duty, however, within the context of the legal duties placed on the Council for meeting eligible assessed care needs and the current public sector funding environment, providers within the market place should not expect the Council or the state to fully fund all business models regardless of cost. Some Provider’s may need to either adjust their business model/offer and/or become increasingly reliant on other sources of funding within the market place (e.g. self-funders).

. The Cabinet Member is asked to note the risks associated with the recommended

fees and the mitigating actions that will be implemented if approved as part of the decision making process.

Conclusion

56. Providers who responded to the consultation all stated the view that the proposed fees are insufficient to meet the actual cost of meeting care needs. The limited evidence provided helps understanding of the Sefton marketplace and the views of the responding providers, it has been taken into account in the preparation of this report, formulation of the recommendations to the Cabinet Member and will continue to be taken into account in future considerations about the care home market and fee levels.

57. Amongst the other matters the Council is required to take account of are “other local factors”, which again is not defined. The Council has endeavoured to appropriately take into account other local factors, including an understanding of Sefton’s demographics, and an understanding of the capacity, quality, safety and indicators of viability of the local care homes market.

58. The Best Value requirements set out in Local Government Act 1999, require the Council to secure continuous improvement in the way its functions are exercised, having regard to a combination of economy, efficiency and effectiveness. This duty requires that the authority takes these factors into account when commissioning/procuring services and when assessing the appropriateness of the costs of different potential suppliers.

59. With the current 0.3% CPI rate and a general inflation level of 0.5%, there is a strong case that the Council’s proposed uplifts should be sufficient to meet assessed care needs of supported residents, including the additional cost associated with the implementation of the National Minimum Wage / National Living Wage.

60. Whilst the financial implications of any alternative decision and affordability in the context of the budgetary constraints faced by the Council, are legitimate factors to be taken into account in setting the Council’s “usual cost”/care home fees they must

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not be the sole or driving reason and would not justify the Council knowingly setting its fees below the level necessary to meet assessed care needs of its supported residents.

61. It is now for the Cabinet Member to approach this matter with an open mind, take account of all the information available, attach whatever weight he feels appropriate to the information and to arrive at his own view on which to base his decision. If having taken into account all of the information available to him, the Cabinet Member considered that the recommendation would not result in the Council’s “usual cost”/fees for care being sufficient to meet the assessed care needs of the supported residents, he could decide to set them at a higher level.

62. If the Cabinet Member determined that the fees should be set at a level beyond the authority delegated by Cabinet, namely “within the context and constraints of available resources, as set out in the Medium Term Financial Plan and as agreed with the Council’s Section 151 Officer”, the matter would need to be referred back to Cabinet for Decision.

The Proposal for Consideration

63. The Cabinet Member is recommended to note the contents of the report and having given full consideration to all of the information provided, including the responses to consultation and the equality analysis, to approve:

(1) The proposed increases in care home fees for 2016/17

(2) The commissioning (in partnership with Sefton CCGs) of an external body to conduct a detailed analysis of costs within the local care market..

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Annex 1 – Feedback from Providers

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Via email to: neil.watson@sefton.gov.uk

Consultation on Care Home Fees: Proposed fees and failure to meet costs relating to 24-hour nurse-led residential care

Orrell Grange Nursing Home,43 Cinder Lane,

Bootle, Liverpool L20 6DP

Orrell Grange Nursing Home is registered to provide nursing and residential care for up to 36 people. Profit and loss figures for the year 2014/15 (attached) show a net loss for the year of -£92,149.74 (with an average monthly loss equating to -£7,679.14) while profit and loss figures for 2015/16 (attached) show a net profit of just £4,946.02.

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Up until March 2016, and prior to the introduction of the “Living Wage”, payroll costs for Orrell Grange equated to 78.66% of total income (or £701,570.16 payroll expenditure from £891,948.46 total income). This results in a net annual profit of just £4,946.02 (or 0.55% net profit).

A 5.07% fee uplift would increase annual income – in a best case scenario – to £937,170.25 (a maximum annual increase in income of £45,221.79) – on the assumption that;-

i) Occupancy remains at 100% throughout the year and

ii) All 36 residents are nursing.

Currently (as at 20th May 2016), 29 people at Orrell Grange are funded by Sefton MBC (representing 85% of the resident population), four people are funded by Liverpool City Council (representing 12% of the resident population) and one person is funded by Knowsley PCT (representing 3% of the resident population).

On an assumption that the current funding streams for people using the service remain stable, 23.52% of the resident population at Orrell Grange are residential clients and, although average occupancy levels for 2015 equates to 89.99% and 91.5% for current year-to-date (attached), customer expectations and market forces will eliminate the desire to occupy a shared room – which will reduce the maximum occupancy expectation at Orrell Grange to 88%. Based on this figure, the fee uplift would generate a projected annual income of £824,709.82 – representing an annual reduction of £67,238.64 – giving Orrell Grange Nursing Home a projected annual loss for 2016/17 of -£62,292.92 – without factoring-in the payroll increase associated with the implementation of the “Living Wage”. Once factored-in, the additional financial burden of the “Living Wage” (which also impacted on staff employed at rates above the (former) National Minimum Wage) adds, in a best-case scenario - a projected annual payroll increase of £21,660.93 – creating an annual payroll cost for the Home of £913,609.39 (or 96.9% of gross income) if each person’s weekly fees rise by just 5.07%.

Laing Buisson cites normal staffing costs to equate to approximately 60% of gross income within the care sector. To provide staffing levels in accordance with the assessed needs of people using the service at Orrell Grange within the recommended percentage cost level cited by Laing Buisson, Sefton Council will need to increase weekly nursing fees to £813.40 per person (i.e. £813.40 x 36 (residents) x 52 weeks = annual gross income from fees of £1,522,684.80. Staffing costs equate to £913,609.39 = 60% of gross income (£913,609.39/£1,522,684.80) – or a 54.64% increase on 2015/16 fees.

The continued poor financial performance of Orrell Grange Nursing Home arises from poor fee levels from commissioning authorities and the Company’s commitment to ensuring sufficient staff are provided in response to the assessed needs of people using the service at Orrell Grange.

The sustainability of Orrell Grange arises from, and is underpinned solely by, the financial performances of 1st Care’s other services.

Nick RichardsOperations Director, 1st Care Ltd.

20th May 2016

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Simon Prance Peter MooreProprietor Commissioning OfficerCollege Green E.M.I. Rest Home 8th Floor, Merton House14 College Road Stanley Road, BootleCrosby Liverpool L20 3AA L23 ORW

Tel: 0151 928 2760 Tel: 0151 934 3744 E-mail: collegegreen1@btconnect.com E-mail: peter.moore@sefton.gov.uk

Date: 20th May 2016 Ref: ISP/130516

Dear Mr Moore,

Re: Consultation on Residential and Nursing Home Fees and concerning letter Ref: PJM/DCFC/160407 from Peter Moore, Head of Commissioning

Please find below feedback concerning the above.

I understand that Sefton have, once again, had to save enormous amounts of money but it is a fact that

for seven years we have been suffering diminishing returns because of spiralling costs and no increase

in fees from April 2009 until April 2014, an increase of £11.00 per week per resident for 2014-2015,

and an increase of £8.00 for 2015-2016. This equates to an average increase of £2.71 per week from

2009-2016. Quite frankly I am amazed that the Local Authority thinks that this increase covered the

cost of meeting care needs over this period.

Specific Consultation Feedback

Question1. Whether the level of proposed fees set out in the tables above will cover the cost of meeting

assessed care needs within an efficient residential/nursing home for the period from 1st April 2016 to

31st March 2017.

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Question 2. If you do not agree with the above rates, in particular if you consider that they will not

cover the cost of meeting assessed care needs within an efficient residential/nursing home, please

provide budgeted costing, together with evidence of actual expenditure and a breakdown of your

weekly bed price, in support of your comments.

College Green is an efficient care home (EMI) yet I think the proposed fee for EMI Residential is

inadequate and will not cover the cost of meeting assessed care needs for the following reasons:-

The fee rates increased £8.00 per week for 2015 / 2016, during this time:

our total costs for services and supplies increased by 8.75%

our payroll costs increased by 3.1%

our payroll accounted for 58.82% of our turnover

We will therefore have increased operational costs for 2016 / 2017 based on these figures and the

impact that the minimum wage will have on our suppliers costs which we have not included in the

following costings.

The assessment of cost changes for April 2016 to April 2017 for College Green Rest Home is as

follows:

Impact of the Minimum Wage Increase on Total Staffing Costs of 7.5% adding an additional

cost of £18,353.66

Impact of the increase in Services and Supplies costs of 8.75%, at last years percentage rate

but not including the impact of the minimum wage which is likely to increase this cost,

adding an additional cost of £35,828.81

Impact of the increase in Registration fee 8% adding an additional cost of £230.24

Based on the above figures this would equate to a total cost increase of £54,412.71. An increase in fees

paid by the Local Authority of £20.97 per week per resident would equate to an increase, assuming full

occupancy based on 21 residents, of £22,899.24. This would leave a shortfall of £31,513.47 which

again will lead to diminishing returns. This of course makes no allowance for occupancy levels below

100%. At 90% occupancy the shortfall would be £33,694.35

Breakdown of weekly bed price

College Green has tried desperately hard for the benefit of Service Users and their relatives to try and

keeps its costs down and work as near as is possible to the Local Authority Fee Rate. We have found

this not to be possible for the level of service we provide and we therefore charge a third party

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contribution to Local Authority funded clients, although we have not yet determined what the

contribution will be, and this will be dependent on the Local Authoritys confirmed fee rate.

Total Increased Cost 2016/17 £ 54,412.71 Increased Costs per Client per Week: £ 49.83 Increased Council Funding per Client per Week: £ 20.97Funding Shortfall per Client per Week: -£ 28.86

Funding Shortfall AFTER Council Fee Increases - 2016/17 for College Green Rest Home based on 100% Occupancy

Per Client per Week: -£ 28.86 for the HOME for this Year: - £31,513.47

The assessment of cost changes for April 2016 to April 2017 for College Green Rest Home is as follows:

Increased Costs per Client per Week: £ 49.83Third Party Contribution per week: £ 23.00

Based on the above costing’s for the period 2016/2017, this would indicate that the Local Authority’s

increase in funding for EMI Residential Care should be £72.83 per Service User per week which would

also include the third party contribution that residents’ relatives are paying at present.

It would therefore appear that the level of proposed fees set out in the tables in your letter will not cover

the cost of meeting assessed care needs at College Green Rest Home for the period from 1st April 2016

to 31st March 2017 and that in order to cover the increased costs, for the assessed needs of the Service

Users at College Green, the Council would have to increase its payment to £525.83 per week per

person. As you are probably aware this is below the figure set out by health consultants LaingBuisson

in their report as to the true cost of care in Sefton of 2011, published on 5th February 2012 which was

provided to the Local Authority as part of a feasability study in 2012. These figures stated that the true

cost of care for a resident with dementia in 2011, at break even was £528.00 per week and allowing for

a 13% return would be £588.00 per week. Just to stand still, cover costs and making no allowance for

any return the minimum fee rate should be £528.00, the report stated.

It is in my opinion, and I hope the Authorities’, essential for Sefton to set a fair price for care and to

work closely with providers to put adequate funding in place to avoid what some would say is a

possible catastrophe in the provision of care, providers want to show their commitment to improve the

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quality of their care homes as well as securing robust contracts that include better terms and conditions,

secure a fair and affordable price, and offer stability and confidence so we can invest for the future.

I hope the above is of some use, please contact me should you require any further information.

Yours sincerely

Simon Prance R.M.N., R.N.M.S., I.S.M.

Proprietor College Green Rest Home

CraignairEMI CARE HOME

SPECIALISED CARE FOR THE CONFUSED ELDERLY

3 BLUNDELLSANDS ROAD WESTBLUNDELLSANDS

LIVERPOOLL23 6TF

craignair12@btconnect.com

TEL No: 0151 931 3504FAX No. 0151 932 0505

Mr P MooreHead of Commissioning Support &Business Intelligence 8th Floor, Merton HouseStanley Road, BootleLiverpoolL20 3JA

20th May 2016

Dear Peter

Consultation on Residential and Nursing Home Fees

With reference to formal consultation on proposed residential and nursing home fees 2016/2017.

As requested please find below my feedback and I would like it to be taken into account in your decision making process and shown to the cabinet members.

History

2010 /2011 /2012 / 2013 - no increase was given despite inflation and increase of payroll.

2014 / 2015- An increase of £11.00 per week was given - 2.5 % despite overwhelming evidence being provided via the Laing & Buisson Report and substantial comprehensive documentation

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provided by Sefton Care Association proving that the rates offered would not cover the costs of meeting assessed care needs within an efficient Care Home.

2015 /2016 –An inflationary increase of 1.5 % was offered despite costs running higher than this figure due to the increases in the minimum wage, Auto Enrolment and generally people living longer with more complex care needs.

Eventually these increases did get taken into consideration and a 1.8% increase was given which was drawn out over the year and was not implemented until December 2015. It is regrettable Sefton did not implement the increase in payments within the recognised time frame as this put unnecessary pressure on Care Home Providers.

The consultation process needs to be completed prior to April so that the increases are processed when the new budget year starts.

Current 2016 / 2017

The proposed 4.63 % increase for Residential EMI will not cover the cost of meeting assessed care needs within Care Homes for the period 1st April 2016 to 31st March 2017 because it is not proportionate to the constant rises in demands that year upon year have been made on the service.

The Council have not taken into consideration;-

Increase to the minimum living wage - 7.5% 60% of Care Home expenditure is the payroll

Auto enrolment contribution to pensions for the employer and consequent percentage increases (2017 2% and 2018 3%)

Inflationary increases to the general running of the Care Home Hefty increase in CQC registration fee which is far above the rate of inflation Extra specifications within Sefton Council contract Extra Administration e.g. DoLS, New Legislation/Social Worker reviews, CCG involvement

and Auto Enrolment Extra staff due to higher level of care required for more complex care needs Extra staff required when higher level Service User transfer is delayed due to waiting on

Social Worker assessments

Local Authority funding alone does not cover all these costs – the only reason why Care Homes in Sefton remain viable is due to third party contributions and privately funded clients. If third party contributions were not charged then Homes would close.

The local authority does not have an accurate picture as all too often the third party payment is missed off the Payment Advice Document.

There is a legal obligation to pay for care at the required rate but this is ignored.

To compound things, no consideration is being given to the Care Home Providers who are obliged to meet the statutory cost of the unfunded new living wage and the 1% pension contribution while Sefton decide the increase for this year.

In Conclusion

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It is clear that the amount proposed is inadequate and could have detrimental consequences to the Care Industry in Sefton if this matter is not addressed

I urge you to review Sefton’s proposal taking into account the additional increases that I have identified and acknowledge that more support by way of appropriate funding needs to be given to help as the sustainability of the Adult Social Care sector in Sefton is threatened.

Unless Sefton addresses the chronic underfunding, many services within the area will be at significant risk with worrying consequences for the NHS, Older Disabled and Vulnerable Adults. This would then also sadly impact on their families and carers.

Yours sincerely

Steve NealeSteve NealeRegistered Provider

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MINEARCH LIMITEDHeadquartersThe Shieling

Garstangs Farm, Ulnes Walton Lane 286 Southport Road

Near Leyland PR26 8LU LYDIATE L31 4EQ

Tel. : 01772 451270 Tel.-Fax: 0151 531 9791

5 STAR RESIDENTIAL CARE FOR OLDER PEOPLE(Company No. 1963030)

9th May 2016

Dear Mr Moore

Ref: Consultation Fees, ref PJM/DCFC/160407

Thank you for your letter dated the 25 April 2016, received on 4 May 2016. I confirm that the residential fees for 2016/2017 are totally inadequate and were also inadequate for 2015/2016. I give below a detailed background and historical perspective. I feel very strongly that it it is far too little, the rate 4.63 is frankly derisory, as, indeed, have your rises/no rises been over the past ten years. I’d like to make it clear, that I am pro the increases in minimum wages , the women and men with whom I work are some of the finest human beings I know, they work incredibly hard in an exceptionally stressful and increasingly complex environment. I am utterly pro the rights of workers to earn a living wage, it’s shocking that they

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don’t, especially as I am all too aware that the low rates of inflation that are banded about, don’t seem to reflect the ever increasing costs of every aspect of living. I’ve suspected for a long time that the ‘basket’ which is used to represent inflation, started off at Waitrose and now the ‘basket’ is being purchased at Iceland Foods, there can’t possibly be another explanation.

I am a Care Home proprietor, and yes I’m fully aware that some of my peers could only be described politely as ‘Oxygen Thieves’, due to the level of care they are prepared to supply, and the conditions that people are expected to work under and live in, though that is by no means all of us. There’s a large and mostly quiet group of us who feel passionately about social welfare, social care, about the rights to dignity and respect for the elderly and vulnerable and indeed the moral obligation we have to provide a decent standard of care, and living to the vulnerable in our community. I believe in providing a level of care that I would be happy to receive, and to do the best we possibly can. Those who don’t provide an adequate level should be removed from the industry, or forced to conform, but there should be an understanding that none of us are perfect, and occasionally mistakes can be made. Please look at our inspection reports over the past ten years, we work immensely hard to fulfil the legal guidelines laid down by the Care Quality Commission, and we are motivated by recognition for our work, as opposed to profit and loss. Our annual profit stands under 1% of our annual turnover as an average over the past four years, our turnover is less than half of one percent of our investment on the last five years, so remuneration isn’t great at present, to say the least at approx 0.4% per annum, and this was before the increase in wages in April.

I’ve worked as a Carer, a Manager, a stand in Chef, I’ve covered House keeping when we’ve been short, I’ve even done the accounts and now I’m Managing Director and truth be told the general Odd Job Woman too. Over the years it equates to approximately 20 years in the same home over a 26 year period, with a couple of years out, (I have worked outside this industry, in leisure and retail at various levels but it is Care that I love) so I know every aspect of the residential care business and it is no industry for slouches. Over that time ‘residential’ care has changed dramatically, it has got harder and more and more demanding almost year on year, and no I’m not exaggerating, and unfortunately for us neither the government or our councils have enough knowledge to recognise this.

I want you to get some real idea as to the level of changes we’ve had to make that you have chosen to ignore in order for your books to balance, whilst we desperately tread water; today a ‘Residential Care’ resident/service user has a far higher dependency than a ‘Residential Care’ resident 15 years ago, 10 years ago or even 5 years ago, and expected standards of care and the complexity of care provided have increased phenomenally; rightly so in my opinion, as our knowledge, expectations and legislation have all increased for the better, whilst our nations elderly have increased in numbers they have decreased in their standard of health. Most residents we looked after 20 years ago would still be in their own homes today, and I’m not complaining, I believe that this is a good thing, it’s something I would undoubtedly want for myself and my parents too.

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I’ll give you an exact example as to what the changes have meant to our business, one I believe it to be a responsible care businesses; to run the shift to a respectable standard needs five care staff in the afternoon on the floor for 29 residents every day, we can tread water at four, but standards can’t be kept ‘high’ and, or, in my opinion ‘acceptable’ at four long term. We have tried it, but there is a level of catch up needed on the following shift, staff are flustered and stressed, sickness levels increase (and the prospect of three is untenable), you may ask why? Well paperwork can’t be consistently fulfilled to the standard expected by our council or the Care Quality Commission (CQC), only hands on care can be provided to an acceptable, but unsustainable level, once you throw activities, paperwork and anything out of the ordinary into the mix. Fifteen years ago the figure was 2 staff in the afternoon from 2.00 until 5.00 and a third carer joined the shift at 5.00 pm to help with the bed time care routine and evening dishes, 12 years ago this increased to 3 all afternoon (on the floor, all of these figures exclude management, cleaners, chefs, volunteers, kitchen assistants, etc). Today our office hours for the care home have also increased by 35 hours a week in the past 8 years, 50 in the last 15 (I’m not referring to our accounting office hours which have also nominally increased, partially due to Sefton ouncil being unable to fulfil it’s obligation to provide placement statements, and bizarre accounting techniques, yes I’d be happy to show the evidence of this too, and yes I digress, apologies) this increase is purely there to process data requested by the Care Quality Commission and manage each individual residents planned care and indeed to meet their emotional and increasingly complex health care needs of these older people, who though are living longer thanks to health care and medicines, are often living longer in a massively deteriorated state. Our ‘on the floor’ care hours have had to increase by 34 hours per day, every single day in order to fulfil the changes in care over the past 15 years, that’s 238 additional care hours a week, plus an additional 22.5 hours cleaning to keep standards acceptable due to the side affects of the increasingly complex health needs of the residents, so to give you a brief idea of what this has meant in terms of costs to the business at today’s minimum wage rates, not the April rate, our wage bill has increased in well excess of £100,000 pounds prior to the new increase, and financing this has meant we’ve already stream lined and nit picked at our once profitable business to the nth degree, come April, and the increases of the minimum wage in October, the nest Pensions and the new living wage we have got to find another £41,000 per year. That’s a £147,500 additional on wages on a company that has never in its wildest dreams made a profit even resembling that.

No, I don’t believe that I am making things inefficient, (in fact ideally we’d love another morning member of staff and if the council ever brings itself to pay the actual cost of care it will be my first investment in the re-numeration.) In fact I am behaving responsibly and meeting the needs of our residents, needs I could not meet at council rates per head, and no, staff are not being lazy and ineffectual, yes, we have invested heavily in their training to ensure they know exactly what they are doing and what's expected of them and yes, if I could save on these increased expenses and still sleep at night I would as I’d love to have a nice new car rather than our 9 year old ford and I’d also love to have a nice foreign holiday each year,

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but I can’t and I don’t, because I have responsibilities to those other than my self. We have lost six new recruits in the last 12 months specifically for our standards, standards they deemed to be ‘too high’ compared to the previous homes they’d worked in, so I think that gives a fair reflection as to what we expect of our team, though also to be fair, those standards are no higher than that which the law demand of us. The fact is simple, decent care costs decent money, there is no computer package that can stand in to replace those care hours; complex needs need more care, more care means more man hours. As you can see this in itself has financial constraints on a business like ours. Take into account all the years that the council have not increased their fees with inflation, indeed several years they reduced their contributions, let alone the ever rising costs of care establishments, the higher demands made on care which require many more hours, the cost of covering the ever increasing pile of legislation that we need to complete in order to prove that we are indeed caring enough to do our job as requested by the legislation of the Care Quality Commission (and quite rightly so!), these additional pressures don’t even begin to reflect in the mere price rises of ‘inflation’, care has become untenable for care homes that do not pander to the rich and exclusive, the basic cost of care is not £418.52, just how on earth have you got to this figure?.

In addition to these additional hours in recent years we’ve seen holidays increase from 4 weeks a year minimum, to 5.6 weeks a year minimum to find out of nowhere, and when you take into account this isn’t office work of the civil servants, we have to cover our bank holidays to keep standards constant, which means paying minimum time and a half sometimes double; simply cutting back man power is not a responsible solution. There’s also the minimum wage increases that have gone up over and above inflation, but now with the living wage what are we to do? Now as I stated I whole heartedly believe there is not a member of staff that doesn’t deserve a living wage, but here lies my problem, the fees the council work out as the cost of care are worked out on care through the eyes of standards 15-20 years ago, and the unfortunate truth is this is by and large a female industry and as such wages have been budgeted as being paid in ‘pin money’, inequality, call it what you will but, there is a genuine situation of discrimination here, and I do recognise that by being in the position I’m in I have effectively perpetuated it, and indeed when one considers my level of responsibility, accountability, and the hours I put in to support the ever increasing complexity on the demands of the home, I too am also a victim of inequality, and no, I can’t see many men accepting what I get paid for my position, and if you deem me a female chauvinist, so be it, it doesn’t stop it being true, the reality is you haven’t paid for the actual cost of care for an eternity.

The cold hard truth is that this is an industry that would never have survived if you had paid for the real cost of care at living wage rate. I don’t know if your council rates are worked out by having absolutely no comprehension of what our job entails, or whether they are worked out by the realisation that Central Government is allowing Local Government such ridiculously low budgets to fulfil the needs of those that you call ‘service users’ and that you are in affect only paying us the residue you have left over after you have paid all of your other council workers, hence us usually never knowing how much you won’t be increasing our fees for at

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least six months in an average year. If we made a fair profit then there is no doubt that these women and men should be paid more, in fact I would even go so far as to say I would be more than happy for the government to set a maximum profit on any health care providers, I would also be insistent that homes invest in their upkeep, training and level of care to resident ratios, so that the right kind of investors are attracted to the industry, rather than the greedy, or the uncaring corporates, but lets be honest here too about your stance, the council is being greedy and uncaring, and if I was to provide £418.52 worth of care to those individuals who your representatives claim to be ‘residential’ I’d have my own circle in hell waiting for me.

When our manager goes out to assess potential residents today in 2016, residents that have been assessed as ‘residential’ by your social workers, the reality is, in the last couple of months, she has had to turn down over three quarters of them, and all because we don’t have the man power to take on their incredibly complex needs; if we had more man hours, or sensibly increased rates, we could meet their care needs no problem, but not at the rates paid by our council, we just can’t afford the extra staff. Almost all residents who are classified as ‘residential’ today will have some form of dementia and/or a serious physical disability, and because they are elderly their disabilities don’t seem to count financially in the applied cost of care, and that is a cruel reality of the demographic time bomb, and you personally are exacerbating it by not doing the right thing by your community. It’s how well these issues are managed that defines their classification in the majority of cases in my opinion. We are recognised as a ‘residential’ care home yet our manning is undoubtedly the equivalent of most EMI homes in the area, If you are going to insist on not recognising the deterioration in mental and physical health of resident’s you classify as ‘residential’ and their needs we will be forced to change our service type to Residential EMI, which would just about cover the current costs per head on each resident when top up is added, at least 12 of your residents would arguably be classified as EMI, and your bill with us will go up considerably (have you not noticed how many ‘residential’ homes have changed their classification to EMI, research it, you’ll find they didn’t loose that many residents to residential homes in the change over.) To manage dementia well takes a very complex and well thought our care regime, and the majority of these residents get classified on what the council believe they can get away with paying, not what it costs the companies to care for them, some classifications must be deemed preposterous in the eyes of the social workers assessing them, and we know all too well where these orders from those assessments come from. The council, your council, and indeed many councils, need a major reality check as to what it costs to dress, feed, heat, toilet, entertain, fulfil all emotional and health care needs of today’s residential clients. So you may ask why we have not just coined in and changed to EMI? Well the reason is simple, I’m passionate about health care and the rights of the elderly, and those residents we have with dementia, and pretty advanced dementia, are happier and have a more fulfilling life in our home because we work so incredibly hard to keep them fulfilled, and they are calm and content because every member of staff is trained to an incredibly high level for a residential home or indeed an EMI residential home, and because we are not EMI we don’t at present take the more

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disruptive residents, as they can be a disrupting influence and therefore deteriorate the standard of living for the majority of the population in the home, we still care about doing the right and proper thing you see, it still matters.

Let me make it clear, I don’t blame the social workers, they have to do what is demanded of them. I’m not sure I totally blame the council, they have impossible budgets too. I don’t even know how dire things are in terms of the government purse, but I do know there are areas where money is frittered away, both in central government and local government, and I do know their are social workers that still don’t do their paper work and so leave us without funds for residents for months on end. The care industry is run on a fine balancing act, and the rope has become increasingly frayed and it has snapped in April 2016. The rotten reality today, which is why I’m having to write this is, there is no more left in the pot of my part of the sector for the decently run small to medium run residential homes (upto about 35 people), our responsibility as a company is to both our Residents who rely on us for their every need, and our staff who rely on us for a roof over their head. If we cut back on staffing, we cut back on the standards of care to be provided to the most vulnerable people in our community, are unable to provide an adequate level of care in my opinion and increase our staff sickness, stress, and decrease their job satisfaction levels to boot, and do not fulfil the list of conditions laid down by CQC. I reiterate the vast majority of resident’s who are ‘residential’ today were the residents who were nursing/ EMI a dozen years ago, residential residents of yesterday are usually still in their own home, (sometimes at the detriment to their well being, but that’s a whole different argument.) For the council and the government to deny this, is to stick their heads in the sand; ask anyone who is honest with 20 years of management experience in residential care, they’ll point it out to you, I don’t know how the other sectors of the industry are coping, but I do know that for every responsible residential home like ours there’s at least another one cutting corners to have to pay hefty bank charges, fulfil the demands of shareholders who want some kind of sensible return for their investment, (which you’d also have to say fair enough, but by doing this there are many providing substandard care in order to survive, and running their staff into an early grave too.) and that’s probably only just making an ‘acceptable’ profit by today’s standards.

It is all good and well the government dictating that the living wage has come in April 2016, and morally, it is reprehensible that we do not pay a living wage in this nation, especially when I see how many people in Sefton Council are being paid in excess of £50,000 per annum,and as for what the politicians are getting, together with their annual pay increases, and their ability to miraculously time keep and serve their constituents to the best of their ability on a part time basis by holding down not one, but two jobs, well lets be honest here, it gets us ordinary folk’s blood boiling because we know that the same rules don’t apply to the rest of us, and for good reason to!

My problem is this; the rate that the council dictate to me that they will pay us per resident, the rate they state it costs of us to look after a resident to the

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standard laid down by law, is not a rate that covers those costs, even before the living wage comes in to play, we loose a considerable sum every single week on council residents and that loss is increasing year on year. The cost of care at a rate to ‘break even’ on council residents will be £470.00 per week, this allows for no profit, and will include us having to cut back in a couple of areas, no profit at all, we’ll be serving the council for free, and families will still have to top up. Yes, that’s no profit at £470 per week plus top up to create a standard of living for the vulnerable which after 25 years in the care field is acceptable, not perfect or idealistic in my opinion, but acceptable and realistic in these austere times.

The cold hard truth is we need your council clients because we need referrals in order to stay full, we need the social workers on our side so to speak, and believe me if we’re not full our doors close, we run at 100% , rooms only vacant for turnaround purposes where rooms are cleared and whilst care plans and assessments are put in place for the new residents, and again there are times due to lack of resources at your end that can cost us several weeks fees. We need support from social services to introduce us to residents and to break even. In the last 3 years we’ve spent £300,000 on our capital expenditure in the home, and there’s still more to do, in order for it to compete successfully in our current market to a standard of care that that I consider ‘respectable home comforts’ I know it’s above what many homes provide, but I wouldn’t let my dog stay in some of the homes I’ve seen over the years. We have needed to expand in order to provide the additional staffing we desperately need to keep standards satisfactory and to move it from being a 28 bed home to a 29 bed home (actually giving us 4 additional bed rooms though, as the old registration was from the days of room sharing), yet today when I’ve sat down and looked at our accounts and I still can’t make ends meet because of these increases in pay. I cannot provide an adequate standard of care on what the council pays us, every single council resident costs us a considerable amount of money every week, as has been the case for many years now. Private residents are effectively having to subsidise the council, and we have forgone all reasonable profitability on our once very viable business, our return is substandard, less than inflation on our turnover and had we a huge mortgage of say 80% our doors would have closed many years ago. This is because of the year on year cost of actually providing care for the vulnerable, and the year on year loss of funding we have received from the council. I have to somehow find an additional 7.5% in my annual turnover in order to recoup the financial costs of wages and inflation on our turnover, 6.5% increase in turnover is needed to pay for the last October and April wage and pension changes, and only if we are permanently full! As for the possibility of our under 25’s being paid a lower rate for exactly the same job, I’ve thought long and hard about it and can only conclude this is not a possibility, it is morally outrageous, and has undone all the good work of the age equality acts, I’m waiting for it to be taken to the European courts of Human Rights, it is wrong, wrong, wrong! Yes, so that’s an additional £41,000 on top of the £106.5000+ pounds spent on maintaining care at a respectable level to cover those additional costs on wages over my 2015-2016 tax year, on a company that’s been averaging £6,000 per annum profit over the previous 5 years by increasing private fees slightly

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above inflation. This is a care company that is very successful in terms of our popularity, we are always full, we get good reports, we are not bleeding it dry financially, we change and check our suppliers annually, I could only dream of the councils senior figures income of £50,000+ per annum (and I bet I work just as hard!). For my families investment of £1.25million, 30 odd years of hard work, investment of all of our family inheritance, pensions, share sales, spare cash and sales of properties bought and sold at the right time to buy other family members out, plus an additional £250,000 loan we still have against the company. How do you justify yourself in light of this evidence?

I can’t lie and say there aren’t a couple of places we could save a few pennies on, there is our staffs Christmas night out at £40.00 per head, which had been our companies traditional way of recognizing our teams massive contribution on an annual basis, there was the up until now week and a half's bonus to every member of staff, which is now out of the window , (which has kept our meagre profits down further, but we choose to pay it in recognition of our teams hard work and under pay,) there’s £200 pound we pay to Operation Orphan Child annually, because there but for the grace of god goes I, there’s the prawns we buy in for some of some of our residents at their request for salads and prawn cocktails, and there’s the nice variety of fig roles, chocolate digestives and custard creams which are the residents special requests via their monthly meeting, which we could replace for rich tea which are substantially cheaper, (though knowing from experience how tightly many homes run it is one of our ‘unique selling points’ that keep us full!), I suppose we could also stop providing one of our local Schools and one of our local churches with Father Christmas goody bags which they make money on at their local fairs, which they desperately need because funding has been cut and the church is facing hard times too, but they do carol sing for us, and the church supports the spiritual life of our residents. There is also the donations of wine for the over worked district nurses and doctors, who need a little thank you for all their hard work, as they sure as hell don’t get it from their employers. There’s also chocolate boxes for the kids and women at the women’s refuge, especially as they can now so look forward to a so called ‘living wage’!?! The truth is if we have to stop those little things in order to break even, to reduce our losses, I know its time to pack up my bags, sell on, and get a better paid job with a lot less hassle, (possibly working for local/central government) and a darn site less responsibility, or at least with the option of living in denial as it appears our Government’s representatives have been doing on a long term and compulsory basis.

I believe that these items of good will create a good reputation for the business, indeed create our popularity and that in turn benefits the company, and as stated, we are full, so we are successful in theory, and if our local council had the resources to pay the actual cost of care, calculating their payments on wages that are to be paid not the pin money from the age of inequality, and paid the hours of labour that are needed to look after the most vulnerable as assessed by their social workers, not the fairy tail hours that their fees must be based on, and/or indeed priced into their figures the cost of running, maintaining and meeting legal standards laid down by the government, feeding, heating, safeguarding etc... then we’d also be financially secure.

So, putting thoughts into your head, I suppose you’ll tell me that I

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need to increase my fee’s to our private residents, well the increase I need in order to break even is a 7.5% increase in turnover, but I’m full, no room for expansion, or improving my business that way, I’ve had to do all those things in order not to go under when finding the additional £106,500 increase on wages per annum for the additional hours. Well That’s what I’ve increased it by but it probably should have been increased by 11.5% to cover my costs, and that isn’t right or fair, not when government is extorting freebies, and that is what you are doing, you do actually realise that that is what you are doing don’t you? These private residents have been subsidising government short falls for years, why should they subsidise this increase on their own, due to an ill-conceived and badly thought out gesture of goodwill from the Government, as they strive to put all that’s wrong in the world right, (or win a few supporters, more likely!) without really thinking it through, other than using their ‘think tanks’ who appear to be run by gormless academics with an ability to manipulate statistics to incomprehension, and have completely zero active experience of care.

These private residents don’t receive any difference in care, and we’d be expecting them to pay a minimum excess, on our smallest rooms of £115 more than council residents every single week for exactly the same care in order to function at our current rate, presuming the council continue their diabolical funding trend. Many of these residents who we care for soon use up their life savings paying for care, and in order to make the ends meet, low and behold unless we take to turfing them out on the streets, which is an ‘over my dead body’ scenario, then we are back to square one, loosing something in the region of £50 pounds a week on every single man and woman we take from the council.

Don’t get me wrong, there are those in the care community who can run their establishments with less hours and therefore lower costs, they are very often the ones who have a spectacular turnover in their management, and staff (though I have to say new job centre rulings to massage unemployment figures are causing us no end of trouble, people turn up and leave before completing their first shift! ) as many as four managers in 18 months I believe is a local record! They have ‘waiting for god’ lounges as described by a variety of your government paid employees and indeed some of these establishments don’t even serve biscuits with their tea (which although may sound like the healthy sugar free alternative, and in our ‘cuddly’ generation you’d be right, but for many of our clients tasty snacks are a great and often only way to keep the pounds on those with no appetites who are prone to loosing interest in eating healthy foods).

I ask that you take time to research our home within the community, with the dementia specialists, with the district nurses as to whether

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we provide adequate care, and whether all care home are run responsibly, investigate us and see if they believe we run things anything short of efficiently, we’re not perfect, but we strive to continue to improve, and every hurdle you’ve put out for us in the past, we’ve done our darnedest to clear it, but this one is just too high.

So my gripe is, when you work out these amounts that you dictate we should be able to provide adequate care for, just how many hours are you suggesting we provide for each resident we care for on average a week? How much are you allowing for costs of living. How much are you are paying us to maintain and support our business with management, accounting etc.? Justify your figures, explain how exactly you and your representatives have chosen these amounts. Your asking me for figures, and I’ve included a break down on the enclosed sheet, so as it’s you dictating these figures, which is what I’d call an back to front way of doing business, you owe us a break down. (Our inspections I note from Care Quality Commission have inflated at a phenomenal rate above inflation in the past five years, presumably to account for it’s improved service, it is really quite amazing what the Government run organizations get away with compared to the private run ones isn’t it?). The official line at present from the Council, Care Quality, social workers, etc.. is that the amount of care needed, ‘depends on the level of care needed for your clients’, honestly, this is what they will tell you, please try it; I’ve asked numerous times over the past 10 years, well ‘yes,’ we say ‘our residents have all been recognised as being ‘residential’ by your representatives, so how many hours on average, taking into account your residential clients needs as assessed by your representatives are the council expecting us to budget each resident?’ ‘Well it depends’ your representatives say ‘on the condition of your clients!’, ‘Yes,’ we say ‘there are perhaps 10 different categories you could classify them as in terms of care, ours are ‘residential’ you assessed them as that, so how many hours on average?’ and so it goes on like that, to infinity and beyond! I hope you’re getting some idea of the predicament we’re in, what they actually mean is, “I can’t tell you,” which translates to “I know it’s less than is acceptable in line with the standards you are expected to provide” or simply, “I’ve never actually been a care worker/my experience of care doesn’t cover the basics, and this is your problem not mine!”.

I’m going to remind you of a period in care about 12 years ago when there were a lot of council run homes sold off exceptionally quickly because they were too expensive to run, you really need reminding of this time. Yes, they were too expensive 12 years ago, you’ve no idea how bitterly ironic that sounds today. If my memory serves me well, those same care homes got a slightly higher care rate from their council per resident than us mere private home, because the council had to pay its staff a much fairer rate that reflected council rates ideal of equality. That told me long ago, it’s government policy to pay its own, a much ‘fairer rate’ than the private sector, and that was when things were relatively peachy. That also told me that even back then, you knew there was a short fall, and that short fall is now coming in at an unachievable level.

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I’m old enough and wise enough to not have sent a letter like this in previous years, because although you underpay us, without us being allowed a say, I’m wise enough to know you don’t bite the hand that feeds, but as of April, you no longer feed us, if fact you haven’t been doing for well over five years now, so instead you degrade and insult us.

What I want from you Mr Moore is honesty, that is the truth, in black and white, is that something that people in your positions are allowed to give? Sorry to be so sceptical, but I’m long enough in the tooth to recognise jargon, political answering techniques, and how gentlemen in your positions have an unimaginably extensive way to not answer any questions asked, yet at the same time making a continual stream of noises that are instilled with divine sincerity. Those same words however, if listened to carefully, twist information and generally equate to the stuff of nonsense. I’m sorry if that sounds harsh and it is a little rude, but most of the population know this to be the case of the men in power and worked it out long ago, which is why we are a nation so apathetic to the political system, the parties and their rhetoric, and why the majority of us have a healthy level of sceptical contempt towards most government organisations and officials.

Why you couldn’t have told me on the 9th March which was when I needed to know for this year? It was an unreasonable request taking into account the current years obvious financial issues, so it’s come too late for me, my fees have gone up pro rata on costs at 7.5%, so your fees have gone down by almost 3% in terms of our personal inflation, thanks to the government and that’s not acceptable!

With all the pressure government and press information on the subject this might have been a good year to have been on the ball, rather than the usual late dated fee increase fiascos, or notification of no increases, or indeed fee decreases that we’ve had over several years with regards to your contributions, but no this is after all a council that can’t even provide regular, or upto date statement places, so what was I to expect? It leaves us up the creak without a paddle with regards to fee increases though, so it means that I’m having to increase by the 7.5% of my turnover, and stop bonuses for staff.

What I want you to tell me is, are you suggesting that you believe that the standard of care that our particular care home provides in terms of it’s man hours is technically extravagant? Is it not in line with Local Governments Budgets and policies? I want you to explain to me exactly what are local government Budgets and fees based on? We already know it’s not based on evidence, after all you chose to ignore the findings on the costs of care studies you recieved. Feel free to study The Shieling, if I’ve not given you enough information and you consider you want more just ASK, don’t use it as an excuse. If not, why aren’t you paying for the cost of care, please explain in full, and if not, how can you justify your actions when you describe yourself as being head of ‘Business Intelligence’?

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If that is the case, then you have a moral responsibility to alter the legal expectations placed on care homes, and you need to take this up with central government. If you feel the need to prove me wrong, make a liar of me, feel free to come into our home and work for a month, do what we do for a living, we’ll pay you, we’ll pay for your induction, we’ll expect you to pull your weight, we’ll expect you to help us to educate and train you, we’ll teach you about the real issues in care, we’ll show you how rewarding and complex the most basic level of care can be, we’ll highlight to you the low morale of the NHS representative and Social Service Representatives that come into our home, a morale noticeable at every level so you can understand the stress governmental practices are creating though out the industry, and we’ll try to make you understand the true dignity in both life and death and how the system is letting us human beings down on so many levels, it will, or at least it should, make you weep with shame and humility.

That is of course if you successfully survive that month, because I’m afraid a lot of our new starters aren’t up to the job. After that month you can tell us where it is we are going wrong and what we need to do in order for it to be achievable for providers to meet costs, and I’ll apologise publicly for being a first class nasty bitch, tell the staff they are moaning about being over worked and that we don’t need so many of them, I’ll tell our manager with her 30 years of experience that she doesn’t know what she’s talking about either, and I’ll stand down from my position and sell the business to a competent company who can sleep at night providing the level of care you dictate should be possible on the rates provided.

If it’s a case that you just can’t afford to pay for care, that previous greedy government's local and central and money men have left the cupboards so bare that no preparation has been made for the ageing demographics of the UK population, then you need to look at real austerity measures, (for yourselves included may I add,) with pay cuts in line with the austerity, of other businesses whom you take and take and take from, to show that you to can do the right thing, if you want to only increase our fees by 4.63% then you take a drop in wages of about 3%, in fact lets look at our losses offset against your employees, after all if we are in for austerity, actually very real austerity, caused by yourselves surely you should be too? And consider it for the sins of your fathers so to speak, oh yes and you need to change the guidelines that you have set and quite frankly pontificated over together with central government and care standards and you need to make them achievable and reflect the standard of care that you pay for, and for that there will need to be honesty, hence my question, are you capable of that? If standards are to drop again, I’ll happily sell to someone who can sleep at night providing work house conditions, but honesty is a necessity.

ALTERNATIVES

A)my best case scenario; put into writing that you are going to increase our fees to a very minimum of £470 per person per head and I will be able to break even on your ‘clients’, take a loss on this at my own decision and invest in an additional member of staff for the morning shift and work towards making my company viable again, and from then forward you vow to increase that rate pro rata in line with an increase

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in the living wage as a proportion of turnover in care, which is labour intensive compared to other industries, so this would take into account the hours you allow for care, and any profits will come via our private residents (nothing new there!). B)Another solution is that you recognise when individuals with dementia and increased needs are better off in a residential environment as the Care Standards do, and you pay us the proper and correct rate of £473.97 for those residents who are obviously Elderly Mentally Infirm (EMI), and recognise that a home like ours is the best place for their welfare and undoubtedly their standard of living, understand that they cost exactly the same to care for as other EMI residents, or other residents who used to be recognised as ‘higher residential care ‘ (something else that the council chose to fall by the way and save money on). Recognise that they are better off with a home like ours, speak to the dementia specialists who we work with, contact the home, research our work, come up with a new category if you must, but please do something that entails paying a fair rate for services provided, that doesn’t leave us in the region of £45,000+ pounds out of pocket to the council each year , because that’s utterly immoral!

Obviously the other alternative is that you continue to ignore the situation as you have done for the past ten years, ignore requests for responses, demand ever increasing standards of care, do not recompense care homes that provide the high standard of care laid down by your laws, but I warn you it will come back to haunt you though. What you are doing is morally the equivalent of me bringing in a builder to my home and asking for a three bed room extension all with en-suites and additional living space and then when it’s done ignore his quotation of his costs, tell the builders that I want this at a cost of £10,000, end of story, whether he likes it or not and what's all the better for me, he has no legal redress other than to go out of business, no skin off my nose after all.

Government has done it to our industry for far too long and I believe in most circles they would describe it in terms of extortion, and it appears only the government may behave like this ‘legally’, it’s certainly frowned upon when private industry uses similar techniques.

Well we have been wrung dry, not a jot more to give to you. I don’t honestly know how you can look in the mirror knowing the wages and rises you have received in recent years, when you pump the rhetoric of improving health standards down our throats whilst cutting budgets and how we are the ones failing the ill and the elderly, I can only think your advisers have been blinkering you all, and telling you what they think you want to hear. This isn’t just the health care field that’s suffering, this isn’t austerity measures, this is daylight robbery, denial, false accounting, and blatant lies to name but a few. It costs money to run a business well, it costs money to house people to a decent standard, it costs a lot of man hours to provide an adequate standard of hands on care for today’s elderly, it costs a lot of money to complete all the documentation in man hours to ensure that no areas of an individuals needs are being overlooked, it costs a lot of money to provide all the checks and balances the government have put in place to make sure we’re responsible care owners, it costs a lot of money to have a well qualified and adequately trained workforce throughout, and a lot of money to provide a fair

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standard of living to our staff, and all these things are proper and right and morally responsible, but they do cost money, and one has to cut ones coat according to ones cloth, otherwise one ends up in a whole lot of misery. You’ve squeezed my industry dry, any responsible care home owner with a smallish home literally has nothing left to give you, I mean literally nothing if they accept council residents.

I’m sure, there are those that run 100 bed establishments quite well that can probably cope with these increased overheads, but they can hardly be called ‘homes’ and the residents can’t possibly build long and lasting relationships with their carers in line with the ‘person centred care’ demanded by the Care Quality Commission, and you need reminding not that long ago there was systematic closing of these larger ‘institutions’ under the Care in the Community Legislation, pushed forward again by cares governing body and for good reason too! Indeed there are also those homes that have left me in tears, unable to drive away from, because they really are nothing short of the modern day work house, a stain on the life of a so called civilised society, and I suspect they’ll be lucky if they’re providing care at £418.52 a week. There are of course still some profitable homes run on the lines of exclusive hotels, who can charge exorbitant fees for individuals like yourselves, were money is no object, (unless the pension investment brokers have their way with you!!) unless of course you live longer than expected and the money runs out, and they don’t need or accept council fees, so you’re stuck back with the rest of us as some of our once wealthy residents have found out to their and our disgust, having being ‘turfed out’ of ‘exclusive’ homes for living longer than expected! And last but not least, the nicest scenario, there are some homes that are lucky enough to be subsidised by charities, like the Royal Legion’s home, but most of us won’t qualify for their help, and I’ll refuse to pay my tax if you decide to start up some charitable organisation for council executives and retired MP’s. I can’t run our business like those businesses, it just isn’t an option to me, bar the charity home I’d rather be out of business. I believe in equality, and I believe that care at the end of life should not be run on lines of utter austerity, if that is the way care is going you need to be honest and tell me now so I can bow out whilst I can still just about make ends meet. Honest open communication is what you owe me and my conscientious peers, and responsible members of our industry (The one’s who run their homes mercilessly you can do as you wish).

I am preparing myself to be fully lambasted, fand my business practices torn to pieces for having the audacity for raising these issues semi-publicly, but I do so in the hope that some more people will see sense and address the situation for the care home sector, well the part that cares. These issues need raising, sensibly, publicly, realistically and by people who can be heard. This is literally peoples lives the council are playing with. Things should never have been allowed to go this far. These circumstances have been weaved from inequality, ignorance and a denial for many years, I hope that my complaint has not come too late.

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I hope this letter means something to you and Sefton Council and that you stop and think and analyse what is really happening in the care home residential sector and indeed in health care in general. In this life we must cut our coat according to our cloth, we’re all taught this concept, even in schools now, it needs using, anything else is a disaster waiting to happen. So I leave this letter now with a quote from Dostoyevsky, a man I believe has more insight and common sense than any man in Whitehall or in Authority at Local Government today.

‘ Above all don’t lie to yourself. The man who lies to himself and listens to his own lie comes to a point that he cannot distinguish the truth within him, or around him, and so looses all respect for himself and others. And having no respect he ceases to love.’

............. because you’d have to be a soulless and heartless individual to provide £418.00 of care to the people assessed as needing ‘residential’ care today by Sefton Council, and let’s face it, you’re not the only council dramatically underfunding the cost of care.

Yours sincerely

J L PoreeJeni Poree

Managing Director Minearch Limited.

PS If you need more information and/or figures, feel free to ask for it on 01772 451270, don’t use it as an excuse not to respond, I consider the council and the government owes me a response after all I’ve been doing for them both, with no thanks, in recent years.

CC:The Rt Hon Jeremy Hunt MPBill Esterson MPCllr June BurnsCllr Pat o’Harlon Cllr John SayersBBCThe Guardian Newspaper

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Tudor Bank Ltd11 Tillotson Road Harrow WealdMiddlesex HA3 6PJTel: 0208 421 5017Fax: 0208 421 5072

23rd May 2016

Peter Moore Head of Commissioning Support & Business Intelligence, 8Th Floor, Stanley Road.Bootle .L20 3JA.

Dear Mr Moore,

Re: Tudor Care Ltd to “Consultation on Care Home Fees 2016-17” Letter Dated 25Th April 2016

We welcome the opportunity to give our views on the above letter regarding care home fees.

There has been a crisis in care funding since 2010-11 which has seen in excess of a 20% shortfall in real-terms funding. There is a funding crisis which is impacting on market resilience to the extent that we are at a ‘tipping point’ in the balance between sufficiency in fees and the consistent delivery of safe, good quality, care. The latest challenge arises from the impact of the Living Wage which is a major issue for commissioners and for providers dependent in part or whole on local authority funding.

The proposed fee increase is woefully inadequate for the following reasons:

Living wage increase of 10.76% since last April, plus 25% add on costs including NI, Pension, annual leave, training time. Our Wages ratio to fees have gone up from 56% to 64% and increasing with unpredictable wages cost .The councils proposed increase of 5.07 % on Nursing fees are totally inadequate and will not cover the shortfall.

Additionally, we have to pay differentials to all current staff to retain them; therefore the wage bill affects the whole payroll equally.

Acute shortage of Nurses in the UK, including in the NHS is forcing excessive agency usage, and like the NHS we are not immune to these shortage. Rates of pay for nurses have gone up 20% in twelve months and despite paying these rates, the agency staff have to be called in at up to £40.00 per HOUR. It is not unknown for the home to pay between £350 to £500 for 1 night cover.

Shortage of Nurses and Care staff, we have to pay recruitment fees to employ Nurses of up to 20% of annual salary plus vat.

Increased staff turnover leads to increased training and retention costs.

The dependency of residents has increased substantially, residents previously classed as residential have now have a requirement of nursing level input, and previously classed nursing level residents now require CHC level input. This results in higher staffing costs.

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We will not provide our actual costs and budgeted costs, as we you mention in your letter that “…….take into account the actual costs by precise quantification.” We believe that independent costing methodology, especially LaingBuission is most transparent and fair model, fully subject to critical appraisal.

Recommendations:

1. To make up for the shortfall in fees over the period since 2010-11 would require an increase of something in the region (and probably well in excess) of 20%.

2. RNCC and DWP ‘surplus’ should be pass ported to the provider fees’ pot and not retained by the local authority.

3. Our view is that the 2% Council Tax precept as possible should be used to help support and shape the adult care market.

4. The Better Care Fund has to be part of the solution to the viability of the quality independent care sector in Sefton moving forward.

5. We note that Sefton proposes to exercise its judgement and experience in the light of the markets functioning in practice and what it knows of fees paid and costs incurred elsewhere. We therefore request that you look at the fee increases proposed by Lancashire council for 2016/17, we particularly point to the BASE fee of nursing £587.00 Nursing EMI £673.00

6. Fee increases for enduring mental health should be the same as EMI nursing; we recommend that this vulnerable group no be overlooked.

7. The council should pay gross fees and collect client contribution directly, as it must not be the provider’s responsibility to collect client contribution, and hampers cash flow vital for small organisations as ours.

Finally Sefton Care association will be sending you a detailed response; we wish to formally support their representation.

Yours Sincerely,

Raju Kanabar / Himat GamiDirectorsTudor Bank Ltd

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I am writing in response to the letter received at my office on the 26th April 2016 from Peter Moore, Head of Commissioning Support & Business Intelligence, Sefton Council.

Whilst Autism Together welcomes the offer of 4.63% it falls considerably short of what is required to meet a full cost recovery on the packages you commission from us. As detailed in previous correspondence our residential fees have not been increased for a significant period of time and therefore all of the support provided by us for Sefton Council has been cross subsidised by other packages and our own funds. Due to the whole scale nature of the financial demands placed on Autism Together by the introduction of the Living Wage, Apprenticeship Levy, Auto Enrolment and Living Wage for Sleep-in duties, we are no longer able to provide services at any level that is less than it costs to provide these services. Autism Together is a highly specialist provider of services for individuals with a complex presentation of the Autism Condition. Many of the individuals supported by us are unable to be supported elsewhere and they achieve positive outcomes as result of them being supported by our organisation.

However, even though we provide exceptional levels of service provision our cost model is for full cost recovery only, ensuring that we offer best value for the commissioning authorities, as such Autism Together is a not for profit organisation and these fee’s merely cover the direct cost of care and our Head Office Costs which run at less than 10% of our revenue.

For the individuals funded by Sefton Council, the fee level for 2016/17 needs to be as follows:

Sefton M.Daniels 1218.00 Per Week

M. Ashcroft 1183.00 Per Week

P.Greany 1182.00 Per Week

D.Adamson 4373.00 Per Week

For reasons already stated in this email we will be unable to accept any fee’s that are less than this amount. I am sure that you are aware that under the Care Act 2014 there are a number of requirements for you as a funding authority to ensure that the commissioning of services ensures that organisations are compliant with Minimum Wage Legislation and are sustainable. Please also note that any changes to these individuals care plans would need to be evidenced through a full re-assessment process with Independent Advocacy, which demonstrates that there has been a change in need. Please be aware that whilst we recognise that this years uplift is a significant one, future uplifts will be proportionate to the living wage requirements.

If Sefton Council are unable to meet the full cost of these packages then Autism Together will be forced to terminate our support contract for this individual, who has been resident with our organisation for over 25 years. I recognise that the consultation period runs until the 23rd May 2016 however, I would appreciate your urgent response to this email by the 6th May 2016.

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Annex 2 – Equality Analysis Report

1. Introduction

The Equality Act 2010 is a statutory act, therefore all the service providers and in particular public sector bodies have mandatory duties placed upon them to comply with the act and to purposely demonstrate this compliance. For the purposes of this report the engaged sections of the act are:

1. Protected characteristics (section 4,6,9 of the Act) 2. Provision of a service ( section 29 of the Act) 3. Direct discrimination ( section 13 of the Act)4. Indirect discrimination ( section 19 of the act) 5. Duty to make adjustment ( section 20 of the Act)6. Public Sector Equality Duty ( section 149 of the Act)

This report looks at the detail of the proposal and assesses them in relation to Public Sector Equality Duty in order for Council to consider the equality aspects of the proposed decision when making their final decision.

2. Summary of Policy / Function

The proposal relates to the fees payable to Care Homes, in respect of residents placed in those homes by the Council, during the 2016/17 financial year.

The specific details of the proposal are a 4.63% increase in Residential care home fees and a 5.07% increase in Nursing care home fees.

Residential care homes provide services for the following client groups: Older People Older People (Elderly Mentally Infirm) Mental Health Alcohol / Drugs Learning Disabilities Physical Disabilities (over 65) Physical Disabilities (under 65) Young Mental Health (under 65)

Nursing care homes provide services for the following client groups: Older People Older People (Elderly Mentally Infirm) Mental Health Alcohol / Drugs Learning Disabilities Physical Disabilities (over 65) Physical Disabilities (under 65) Young Mental Health (under 65) Terminal Illness (not including older people)

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Nursing Homes either cater for specific client groups (listed above) or are able to cater for more than one type of client group.

There are currently 113 registered care homes in Sefton, of which 14 provide specialist services, for example small registered homes for people with complex Learning Disabilities. Of the remaining 99 homes, 74 provide services predominantly for Older People and 25 cater for Older People with Dementia.

Within the 115 care homes, there are currently 3,407 bed spaces. At the time of the last weekly “Vacancy Survey” there were 97 vacancies (3%) and so the market was operating at 97% capacity.

A snapshot in February 2016 showed that 1304 (38%) of the occupied beds were Sefton Council placements. Typically, over recent years, at any one time Sefton placements have accounted for in the region of 50% of the occupied bed spaces.

Of the 113 homes, there are currently 15 where fees are calculated based on individual assessments of Service User’s needs due to the complexity of the care package requirements and diversity of need being catered for and as a result “3rd Party Top-Ups” are not applicable. Of the remaining 98 care homes, 77 (79% of applicable homes) charge residents a 3rd Party Top-Up over and above the fee paid by Sefton Council, whilst 21 homes charge no Top-up (i.e. take Sefton placements without any additional charges to the resident). The percentage of homes levying a 3rd Party Top-Up has increased from 76% in November 2015, when fees were last set.

3. Service User Demographics

Gender

Long-Term Nursing Long-Term Residential Total

Number % Number % Number %Female 325 20.34% 698 43.68% 1023 64.02%Male 214 13.39% 360 22.53% 574 35.92%Unknown 0.00% 1 0.06% 1 0.06%Grand Total 539 33.73% 1059 66.27% 1598 100.00%

Age Group

Long-Term Nursing

Long-Term Residential Total

Number % Number % Number %18-34 0 0.00% 16 1.00% 16 1.00%35-44 11 0.69% 29 1.81% 40 2.50%

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45-54 24 1.50% 46 2.88% 70 4.38%55-64 49 3.07% 80 5.01% 129 8.07%65-74 88 5.51% 114 7.13% 202 12.64%75-84 173 10.83% 283 17.71% 456 28.54%85+ 194 12.14% 491 30.73% 685 42.87%

Grand Total 539 33.73% 1059 66.27% 1598 100.00%

Ethnicity

Long-Term Nursing

Long-Term Residential

Total

Number % Number % Number %Any other ethnic group 1 0.06% 1 0.06% 2 0.13%

Asian/Asian British - Chinese 1 0.06% 2 0.13% 3 0.19%

Asian/Asian British - Indian 1 0.06% 1 0.06% 2 0.13%Black/Black British - Any other Black background 1 0.06% 1 0.06% 2 0.13%

Black/Black British - Caribbean 0.00% 2 0.13% 2 0.13%

Information not yet obtained 14 0.88% 18 1.13% 32 2.00%

Mixed - Any other mixed background 0.00% 1 0.06% 1 0.06%

Mixed - White and Asian 0.00% 1 0.06% 1 0.06%Not Stated 1 0.06% 0.00% 1 0.06%Refused 0.00% 1 0.06% 1 0.06%White - Any other White background 4 0.25% 7 0.44% 11 0.69%

White - British/English/Welsh/Scottish/Northern Irish

512 32.04% 1008 63.08% 1520 95.12%

White - Irish 1 0.06% 15 0.94% 16 1.00%Not Recorded 3 0.19% 0.00% 3 0.19%Asian/Asian British - Any other Asian background 0.00% 1 0.06% 1 0.06%

Grand Total 539 33.73% 1059 66.27% 1598 100.00%

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Primary Support Reason

Long-Term Nursing

Long-Term Residential

Total

Number % Number % Number %Learning Disability Support 19 1.19% 104 6.51% 123 7.70%

Mental Health Support 117 7.32% 133 8.32% 250 15.64%

Physical Support - Access and Mobility Only

38 2.38% 79 4.94% 117 7.32%

Physical Support - Personal Care Support

290 18.15% 554 34.67% 844 52.82%

Sensory Support - Support for Dual Impairment

1 0.06% 1 0.06% 2 0.13%

Sensory Support - Support for Hearing Impairment

0.00% 1 0.06% 1 0.06%

Sensory Support - Support for Visual Impairment

2 0.13% 7 0.44% 9 0.56%

Social Support - Substance Misuse Support

0.00% 5 0.31% 5 0.31%

Social Support - Support for Social Isolation / Other

0.00% 8 0.50% 8 0.50%

Support with Memory and Cognition

72 4.51% 167 10.45% 239 14.96%

Grand Total 539 33.73% 1059 66.27% 1598 100.00%

4. What is Changing

The proposals relate to the fees paid to Providers for Residential and Nursing care home placements. The specific proposals are that for the 2016/17 period it will introduce the following fees;

Service Type 2016/17 Fee % Increase 2015/16 FeeResidential £418.52 4.63 £400.00Residential EMI £473.97 4.63 £453.00Nursing £552.67 5.07 £526.00Nursing EMI £597.85 5.07 £569.00

It is also proposed that the same percentage uplifts by service type would be applied to those fees in 2016/17 for the following;

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Existing placements (approximately 4%) which are currently paid at specific, Learning Disability, Physical Disability or Mental Health rates.

Any fees within residential placements outside of the above ranges

The new fees would have effect from 1st April 2016.

5. Effects of change – potential detriments

If the recommendations were to be implemented then this could result in fee structures for clients changing. For example providers may seek to obtain the difference between the existing fee amount and the fee they wish to charge from clients via increasing their contribution. This could place some clients at an economic disadvantage.

Consultation feedback from Provider’s has also stated that as the fees proposed are insufficient then this could have an adverse impact on the quality of service provided to Service Users.

In addition, there is the possibility that some Provider’s may face difficulties adapting their services and could then become unviable which would lead to them withdrawing from the market. This could therefore reduce the availability of services that meet specific Service User needs. If this were to occur then the following protected characteristics may be affected; Age, as the majority of current service users are aged over 65; Gender, as the majority of current service users are female; and Disability, as by definition all those people assessed as eligible for residential and nursing care have a disability.

6. Consultation

The consultation period commenced on 25th April 2016, up to 23rd May 2016. As part of the outlined proposal the Council stated that it wished to particularly receive and consider feedback in relation to the following:

1. Whether the level of proposed fees set out in the tables above will cover the cost of meeting assessed care needs within an efficient residential/nursing home for the period from 1st April 2016 to 31st March 2017.

2. If you do not agree with the above rates, in particular if you consider that they will not cover the cost of meeting assessed care needs within an efficient residential/nursing home, please provide budgeted costings, together with evidence of actual expenditure and a breakdown of your weekly bed price, in support of your comments.

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7. PSED Compliance

PSED Criteria Explanation Is the criteria met?

Objective 1 – eliminate discrimination.

Residential & Nursing care home placements will continue to be provided on the basis of assessed need.

Performance monitoring of contracts regularly takes place and Social Workers and families/advocates give feedback as to the treatment of Service Users. In addition the Council monitors data on placements made to ensure that there is fair access to all that meet the eligibility criteria.

Yes

Objective 2 – Advance equality of Opportunity

a) remove or minimise disadvantages suffered by persons who share a relevant protected characteristic that are connected to that characteristic;

(b) take steps to meet the needs of persons who share a relevant protected characteristic that are different from the needs of persons who do not share it;

(c) encourage persons who share a relevant protected characteristic to participate in public life

Placements are based on a person’s individual need (2a & b) and offers opportunities for people to live as independently a life as possible including in the wider community.

Under current eligibility assessments, Service User’s religious and cultural needs are taken into account and where specific needs are identified these are met – for example by Service User’s being placed in care homes that deliver cultural specific services thus enabling them to participate in public life (2b & c).

Yes

Object 3 - foster good relationsBetween persons who share a relevant protected characteristic and persons who do not share.

(a) tackle prejudice, and (b) promote understanding

Residential & Nursing care facilitates people with disabilities to live within the community thus making sure that disability is accepted and understood by the wider community.

All Provider’s must evidence of how they will treat Service Users with respect and dignity, and create an environment free from discrimination, bullying and harassment for Service Users and staff.

Yes

PSED sub section 2 – A 1) The Council will continue to work Yes

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person who is not a public authority but who exercises public functions must, in the exercise of those functions, have due regard the three objectives

with Provider’s to ensure that they provide appropriate services to disabled people on a contract and service specification basis and monitoring of service delivery. A new contract has been implemented which contains specific requirements relating to equalities.

2) The Council as commissioning agent will remind service Provider’s, when undergoing changes to their services to treat their staff in accordance with Equality and Employment law.

PSED sub section 4– The steps involved in meeting the needs of disabled persons that are different from the needs of persons who are not disabled include, in particular, steps to take account of disabled persons’ disabilities.

Service Users are and will continue to be assessed in a qualitative manner in accordance with national guidance and Care Act 2014.

Under Section 47 of the National Health Service and Community Care Act 1990, individual services provided will be privy to regular review to assess if those services are meeting assessed needs.

YES

PSED sub section 6 – Compliance with the duties in this section may involve treating some persons more favourably than others; but that is not to be taken as permitting conduct that would otherwise be prohibited by or under this Act.

Residential & Nursing care is a program specifically designed, costed and targeted for disabled people.

Yes

8. Conclusion & Action Plan

The tasks below are to mitigate any potential detriments that could arise and it is recommended that they are followed in order to minimise any discriminatory forces that could accrue in carrying out the proposal;

Consultation will continue with residential and nursing care home providers regarding the cost of care, including the proposal that in partnership with Health an independent body is commissioned to conduct a cost of care market analysis in order to provide a more precise quantification of the cost of care. This exercise will also be conducted with input from Provider’s in order to gain further understanding of both current and future costs, demands and factors affecting the Sefton care home market.

Consultation will also include obtaining provider views on the economic impact of the implementation of the decision and this information will in turn be used to ascertain any possible economic impacts on clients or regulatory impacts on individual care homes.

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Regular liaison with the Care Quality Commission will also continue and as part of this any issues identified with respect to the financial viability of individual care homes will be monitored. The impacts of any potential financial difficulties identified would be assessed, especially with respect to the impact on the wider Sefton care home market, meeting demand for services and capacity in the market. To this end the capacity of current services will be monitored regularly to assess capacity levels for all categories of care homes.

The Care Act 2014 gives new responsibilities to CQC for assessing the financial sustainability of certain care providers, it also gives them new powers to request information from those providers and to request a provider who they judge to be in financial difficulty to develop a sustainability plan and arrange an independent business review, to help the care provider remain financially sustainable. The Council will work with CQC if and when they share concerns about care providers operating in Sefton.

With respect to any potential impacts of the decision on the quality of service provided in care homes, regular monitoring will continue to take place. This will include monitoring of factors such as the standard of the physical environment, the quality and retention of staff, staff training and overall management of services. Monitoring of Safeguarding referrals and regulatory notifications will also continue.

We will continue to improve analysis of data for placements with respect to fee levels charged by homes for Sefton and non-Sefton funded clients and the levying of ‘Top-up’ payments.

National and local factors concerning the cost of care and the demand for services will also be monitored, such as changes to the demographic profile of the borough and the demand for more specialist services.

Risk management work will be conducted which will include periodic analysis of the capacity within the market and the ability of the market to ‘absorb’ any individual home closures. This analysis will also be informed by performance information on numbers of placements and ability to meet demand and individual needs.

We will continue to prepare for and monitor the impact of changes introduced by the Care Act 2014.

We will continue to explore ways in which we can better support the care home business sector.

The Council will work with NHS colleagues to develop a whole system and joined-up Market Management approach.

Consultation will also continue to take place as and when required with client and advocacy groups regarding the decision and its potential impact.