Agenda item

Cllr. Dilwyn Morgan to present the report.

To accept the report and ask for a progress report in 18 months.

The report was presented by the Cabinet Member for Adults and Well-being, Councillor Dilwyn Morgan, the Head of Adults Department, and the Head of Adults Health and Well-being, Mari Wynne Jones.

It was reported that the project encompassed the important work of the multi-agency network in supporting residents to return home from hospital. The current arrangements of the Community Resources Teams in supporting adults after they are discharged from hospital were outlined. It was explained that the Teams supported adults with physical needs, ill-health, age-related conditions and dementia. Details were shared of the care pathways available to patients in the context of the principles of the Social Services and Well-being Act. It was emphasised that individuals' personal resources and strengths were at the centre of care and support needs assessments and plans, to ensure that individuals received bespoke care. 

It was confirmed that the principles were based on the Social Services and Well-being (Wales) Act 2014. It was noted that the legal framework was used to identify a person's personal outcomes and to assess their care and support needs. The importance of encouraging people to return home from hospital for their own good was emphasised, noting that it was a matter of concern that "an extra 10 days in hospital equated to 10 years of muscle ageing in people over the age of 80". It was emphasised that the project aimed to ensure the best possible care by supporting people to stay at home in their communities, to promote individual independence and alleviate the pressures on social care and community services that were already hard pressed.

It was elaborated that the project was being implemented in response to a report published by Senedd Cymru, investigating the role of local authorities in supporting people to leave hospital in a timely manner. It was explained that there was a lot of work undertaken between the Council and the Health Board to try and improve the journey for individuals upon leaving hospital. It was noted that the Association of Social Directors had produced a paper framing the national context in Wales and the importance of collaboration between the different agencies. It was highlighted that NHS Wales used specific codes to determine the pathway of individuals who are discharged from hospital, based on the principles of Discharge to Recover then Assess (D2RA). Details were given of the four streams.

The Project Manager detailed that this was a Pilot Scheme that would run for a period and the developments would hopefully be rolled out across the county. An overview was given of the project's objectives in the context of the Llechen Lân (A Clean Slate) report and the Ffordd Gwynedd way of working. It was explained that there would be a greater demand for care and support with an increasing older population. It was confirmed that the work resulting from the project would ensure that there was an appropriate resource to address the increasing long-term challenges.

During the discussion, the report was welcomed, and thanks was given for the work to support the residents of Gwynedd. However, disappointment was expressed that the project was limited to patients returning from Ysbyty Gwynedd. Members expressed their frustration that the project did not include patients from Gwynedd returning from other hospitals across England and Wales. It was emphasised that Gwynedd was a large county, and that residents were often referred to Maelor Hospital in Wrexham and Bronglais Hospital, Aberystwyth. It was noted that these residents often came from Meirionnydd, and therefore that the project was not inclusive of all residents in the county. It was acknowledged that there were limitations to the report, and it was noted that there would be a commitment to develop and roll out the work across the county.

Details were given of the work of the Care Academy since its launch in November 2024. It was noted that the Academy trained young people and this was a scheme that contributed vastly to encouraging people to get jobs in Care in Gwynedd. It was explained that the local authority did not employ physiotherapists, and it was confirmed that the Cabinet Member for Adults Health and Well-being would mention this during regional discussions with the Health Board.

It was confirmed that the Council had received a Care Pathways Transformation Grant in 2025, worth £1,149,449. It was explained that the purpose of the grant was to support activity towards carrying out timely assessments and providing care packages to ensure people could be discharged from hospital. It was noted that the fund would be used to strengthen community care services to support people to stay healthy in their homes. It was confirmed that the grant would strengthen the capacity for assessment and review and would sustain and extend the domiciliary care provision, particularly in some challenging areas of Gwynedd. It was noted that the Grant would also enable workforce developments to adopt the Moving with Dignity approach. It was noted that this approach ensured that care was delivered in a manner that prioritised an individual's dignity, independence and safety whilst making the best use of the available resources. It was expressed that the department welcomed the additional funding but that the Local Government budget was still low and the department was still operating under pressure. It was confirmed that the project ensured timely assessments and person-centred care.

During the discussion, several Members noted that the process of receiving care and medication was often not timely enough for residents across the county. A discussion was had around residents' frustration in trying to get a GP appointment. It was noted that this often resulted in patients deteriorating rapidly and having to go to hospital because of a lack of action at the start. It was also noted that the lack of physiotherapists in Gwynedd, particularly in the Pen Llŷn area, seriously added to the pressure of enabling patients to return home from hospital. It was emphasised that residents were suffering due to the lack of care available in more rural areas within the county, which was distressing for patients and their families having to travel to receive care and support. It was stressed that there were not enough nursing beds available locally for people in their communities and that the lack of palliative care across the county was startling.  

The content of the report was praised and it was asked if it would be possible to have more specific examples of patient histories in future. It was emphasised that the patient was the most important person in this discussion and the important work going on within the project for the people of Gwynedd was praised. The hope that patients and the people of Gwynedd would benefit significantly from the project was echoed, and that the work would be developed and rolled out across the county.

DECISION

To accept the report and ask for a progress report in 18 months.