PFD report

Eirlys Wynne Roberts · Prevention of Future Deaths report

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Issued 31 Jan 2022•North West Wales

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
5

Named on the report

Responses found
2

Of 5 recipients

Stated actions
18

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs
    Part of recurring concern: Insufficient social and community care provision to meet care and discharge needs
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.17

  1. Action

    Complete the statutory population needs assessment to inform future placement requirements.

    Stated by Gwynedd CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
  2. Action

    Work with the Health Board, social housing partners and neighbouring counties to plan, commission and develop care provision across boundaries.

    Stated by Gwynedd CouncilStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2022.
  3. Action

    Develop a new EMI unit at Hafod Mawddach Home.

    Stated by Gwynedd CouncilStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Legislative restrictions prevent the Council from providing nursing care directly, making response to a nursing-home closure challenging.

    Stated by Gwynedd CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of timely availability of care placements matching elderly people's changing cognitive and physical needs

Wider context from the report

“There was evidence heard during the Inquest that when a residential home was required given the deceased’s needs that the homes in Gwynedd were all full and that consideration would need to be given to placements outside of the area. Eventually a placement was identified. When further deterioration was noted whereby the deceased required a higher level of care by way of an EMI residential placement one was not immediately available. The deceased therefore remained at the residential home. When her needs further increased whereby an EMI nursing placement was required, again there was no availability. I am concerned by the lack of available placements for the elderly as and when their cognitive and physical needs change thereby putting them at risk. The evidence was that there is a shortage of placements and it is concerning that specific needs of the elderly cannot always be met either at all or in a timely manner. ”

Is this part of a recurring concern?

Yes — Insufficient social and community care provision to meet care and discharge needs.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete the statutory population needs assessment to inform future placement requirements.

Verbatim wording from the response

“A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Work with the Health Board, social housing partners and neighbouring counties to plan, commission and develop care provision across boundaries.

Verbatim wording from the response

“In the future, our hope as a local authority will be to develop a residential EMI provision at Plas Gwilym Home (as a part of Canolfan Lleu), Plas Pengwaith Home and within the development of the Penyborth site, Penrhos. We are also working in partnership with the Health Board and partners in the social housing field to develop the market further. An example of this is the plans being developed on the Penyborth site at Penrhos, Llŷn and for Canolfan Lleu, Penygroes.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a new EMI unit at Hafod Mawddach Home.

Verbatim wording from the response

“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop an additional EMI unit at Plas Hedd Home.

Verbatim wording from the response

“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Extend EMI provision within Council homes.

Verbatim wording from the response

“Currently, there are 70 residential EMI beds in the Council's homes across the County: Plas Maesincla Home (23), Bryn Bोडau Home Unit (17), Llys Cadfan Home Unit (15), Plas Hafan Home Unit (8), Plas Hedd Home Unit (7). In a period of cuts across the Council, I hope that you will agree that this shows the Council's continuous commitment to prioritise this field. Further work is in progress to extend the EMI provision within the internal homes. Further work is being done to develop a new unit in the Hafod Mawddach Home in the hope that the unit will open later in the year. In addition, there is an intention to develop an additional unit at Plas Hedd Home. Whilst this is a substantial increase, more needs to be done to change the balance in terms of general residential beds and the residential EMI provision in Gwynedd.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Present the North Wales care market stability report to the Government during summer 2022.

Verbatim wording from the response

“We are also considering the care market and its ability to respond to the demand for care services today and in the future, and we intend to present the report on the 'Stability of the Care Market in North Wales' to the Government during the summer 2022. The conclusions within this report will show the steps that need to be addressed in order to ensure a suitable provision to meet the demand.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 4 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consider providing nursing care internally at a Gwynedd site to increase nursing provision and stabilise the care market.

Verbatim wording from the response

“As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 2 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake more localised detailed work to assess whether future placement numbers are sufficient.

Verbatim wording from the response

“A key part of the forward planning that is done in an attempt to secure the appropriate number of care placements is the population needs assessment. This assessment is a statutory requirement and it is carried out every five years. The latest assessment was approved by Gwynedd Council at the Full Council on 3 March this year. Underneath this high”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Convert general residential beds into residential EMI beds in Council homes, supported by building investment and additional staffing.

Verbatim wording from the response

“In addition, we are facing a challenge with the availability of residential EMI placements. In terms of general residential placements, the availability of placements against the demand is much better. In order to respond to the lack of residential EMI placements, the Council, for a number of years, has converted general residential beds into residential EMI beds within the internal homes. This work has involved a substantial investment in the buildings and in additional staff. Over the past 5 years, Gwynedd Council has almost doubled the number of Residential EMI beds in our homes.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Run the WeCare.Wales national recruitment campaign to support social care workforce recruitment.

Verbatim wording from the response

“Workforce Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Strengthen regional partnership arrangements covering governance, scrutiny, planning, performance, engagement, integrated delivery and social care market rebalancing.

Verbatim wording from the response

“These included the development of a strategic National Framework for care and support, which will set standards for commissioning practice, reduce complexity, and focus on quality and outcomes. The implementation of this Framework will be overseen by a National Office within Welsh Government. In addition, we are committed to strengthening regional partnership arrangements to support stronger partnership working and deliver for local populations, with a focus on governance and scrutiny, planning and performance, engagement and voice, integrated service delivery, and rebalancing the social care market.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Announce introduction of the Real Living Wage for social care workers.

Verbatim wording from the response

“In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Develop a national care and support framework setting commissioning standards, with implementation overseen by a National Office.

Verbatim wording from the response

“In January 2021 Welsh Government issued the Rebalancing Care and Support White Paper, proposing legislative and other changes we believe are essential to securing the vision set out in the Act.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Write to regional partnership, health board and social services leaders asking them to review older people’s residential care provision and assess sufficiency in forthcoming reports.

Verbatim wording from the response

“The Minister for Health and Social Services will write to the Chairs of the seven Regional Partnership Boards in Wales, the Chief Executives of the Health Boards and Directors of Social Services to ask them to review their current provision for older peoples residential care, including EMI beds and to ensure that their imminent Population Needs Assessments and Market Stability Reports robustly explore the sufficiency of provision. Any action to improve the commissioning and sufficiency of such provision should then be set out in their forthcoming Area Plans.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Increase funding for targeted recruitment initiatives and support people considering social care employment.

Verbatim wording from the response

“Workforce Building a sustainable social care workforce remains a key priority for us, and we have been working with the regulator and the social care sector to meet this challenge. As well as the WeCare.Wales national recruitment campaign, which has been running from August 2021, we have increased funding to ensure targeted recruitment initiatives and additional supports to people who are considering entry into social care employment.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide additional funding to strengthen the social care sector and support pandemic-related costs.

Verbatim wording from the response

“Financial support During the Covid pandemic the Welsh Government has made significant resources available to local authorities and health boards, to ensure that social care providers can meet the additional costs arising because of the pandemic. The recently published Welsh Government budget for 2022-25 provides an additional £180m to local authorities directly to strengthen the social care sector, with further reform and capital funding also being allocated.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 2 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Continue working with the Social Care Fair Work Forum to consider further measures to attract people into social care.

Verbatim wording from the response

“In addition, our announcement of the introduction of the Real Living Wage provides a starting point for improved terms and conditions for social care workers, and we continue to work with the Social Care Fair Work Forum to consider what more can be done to attract people into the social care sector.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Legislative restrictions prevent the Council from providing nursing care directly, making response to a nursing-home closure challenging.

Verbatim wording from the response

“As I have already mentioned, we are facing a specific challenge regarding the lack of nursing placements, and particularly nursing homes that are able to provide EMI care. Regrettably, one of our nursing homes has closed recently, and this has added obvious pressure on the entire system. As is the case in every other county in Wales, the Council is not permitted to provide nursing care by itself due to legislative restrictions, and therefore, attempting to respond to the sudden closure of a nursing home is incredibly challenging. Consequently, we as a Council and in partnership with the Health Board, are currently considering the option of stepping in to provide nursing care as an internal provider at a specific site in Gwynedd. We are considering taking this innovative step so that we can stabilise the market somewhat, as well as increase the nursing provision in Gwynedd.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 2 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The link between the incident and availability of an EMI placement is not entirely clear.

Verbatim wording from the response

“The situation of waiting for a bed in an alternative placement is quite common for a number of individuals across the country. Of course, we have given careful consideration to the notice, however as I have previously noted, the link between the circumstances of the incident and the availability of an EMI placement is not entirely clear. However, wherever a higher level of care is needed when attempting to find or secure an appropriate placement, more advanced care arrangements are put in place in order to safeguard the individual until a solution is reached. This is based on appropriate risk assessments and care plans.”

Source location

2022-0034-Response-from-Gwynedd-Council_Published
Page 4 · response
Published 4 February 2022

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Local authorities and health boards are responsible for planning and commissioning sufficient residential and nursing care provision.

Verbatim wording from the response

“Integrated planning and commissioning Welsh Government has put in place mechanisms to enable Local Authorities and the NHS to better meet changing population needs. They have clear responsibilities to plan and commission care and support services that meet the needs of their local populations, including the commissioning of residential and nursing care for those who need it. Under the Act, local authorities and health boards are required to work together, through the Regional Partnership Boards, to produce five yearly Population Needs Assessments and Market Stability Reports. These must be based upon assessments of local population needs, the range and level of services required to meet those needs, sufficiency of provision, and the stability and sustainability of the market for regulated services such as domiciliary and residential care.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 2 · response
Published 4 February 2022

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Set up an Expert Group to support development of a National Care Service for Wales.

    Stated by Welsh GovernmentStated in progressThe respondent said that this action was in progress when they made their response on 4 February 2022.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Set up an Expert Group to support development of a National Care Service for Wales.

Verbatim wording from the response

“Looking to the future, we are also setting up an Expert Group to support our ambition to create a National Care Service for Wales, free at the point of need and continuing as a public service, as set out in the Co-operation Agreement.”

Source location

2022-0034-Response-from-Welsh-Government_Published
Page 3 · response
Published 4 February 2022

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026