Eirlys Roberts

Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol  
Gwasanaethau Cymdeithasol 
Corporate Director and Statutory Director of Social Services 

Gof ynnwch am/Ask for: 



23  March 2022 

Dear Ms Sutherland, 

Re: Regulation 28  - Prevention of future deaths 

I write to you in response to the Regulation 28 I received from you on 2 February 2022.  Firstly, 
I  wish  to  extend my  sincerest condolences  to  the  family  of  the  late  Eirlys  Wynne  Roberts 
during a very difficult time for them.   

The Regulation  28  notice makes a  link  between the availability  of care placements and  the 
individual’s  incident  and  the  risk  of  death.  However,  the  exact  nature  of  this  link  is  not 
explained  in  the  notice.  As  the  Council  was  not  party  to  the Inquest, nor  did  the  Council 
receive a  request to provide evidence, I must frame my response  within the context of this 
information.  In  light  of  this,  I  have  attempted to  highlight  the  situation  in  regard  to  care 
provision in  Gwynedd, and also  the arrangements in place  for safeguarding individuals  who 
are  in  a  transitional  period  in  terms  of  their  needs or  who  are  waiting  for  an  alternative 
placement. 

You  have  specifically  requested that  I  explain  to  you  the  steps  we  have  taken  to  ensure 
sufficient availability  of care placements in Gwynedd, as well as the steps that are underway 
for the future. Therefore, within this  response, I will endeavour to note appropriate details 
on the above, in accordance with your request to me. 

Seeking to ensure the best care for the people of Gwynedd is a priority  for me as a Statutory 
Director,  and  for the Council  as  a whole. We  seek to  ensure that  we have the appropriate 
number of care placements for our residents on an ongoing  basis, so that  our residents can 
avoid  any degree of delay  when moving  from one care  and health  setting to the next. It  is 
important to note that when an individual has to wait for a new care placement, we take our 
safeguarding duty seriously, and endeavour to put additional  health and care arrangements 
in their place to care for the individual in their current placement. 

Council Offices 
Caernarf on 
Gwynedd  LL55 1SH 
01766 771000 
www.gwynedd.gov.uk 

 
 
 
 Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol  
Gwasanaethau Cymdeithasol 
Corporate Director and Statutory Director of Social Services 

As you will perhaps be aware, the care market is mixed in its nature, i.e. the provisions can be 
ones that are provided internally by the Council, or they can be provisions that we commission 
from the independent sector or third sector. Subject to the nature of the individual's  needs, 
some are jointly commissioned with the Health Board. Therefore, our role as a Council, jointly 
with the Health Board as appropriate, is to seek to ensure that these provisions are sufficient 
to meet the care and health needs of our residents.    

Unfortunately, there is a current shortage in the number of care and health placements which 
means that  a delay  is experienced when transferring  and  giving  individuals  access  to these 
placements.  Recently,  part  of  this  shortage  derives  from  fewer  beds  due  to  Covid-19 
restrictions,  staff shortages and  also  provisions being  closed. I wish  to ensure you that  the 
Council,  along  with  its  key partners,  are working  hard and  continuously  to try  and  manage 
and improve the situation in order to avoid excessive delays for individuals as they move from 
one placement to another.  

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.   

Some  of  the  challenges  faced  by  our  nursing  home  providers  are  problems  with  the 
recruitment and retention of nurses and care  staff, as well  as financial  sustainability,  which 
adds  to  the  challenge  of  providing  care.  The  North  Wales  Region  is  responding  to  the 
challenges posed by the lack  of care and nursing workforce through the Regional Workforce 
Board, and National efforts are also being made via the HEIW/SCW  Workforce Strategy. You 
may be aware that Welsh Government has recently agreed to fund the Real Living  Wage for 
our care workforce, and this will  assist us to support the recruitment challenges; although, it 
is likely that we would wish to see this commitment taken further in terms of the future salary 
levels in order to genuinely be able to compete with employers outside the care field. 

In terms of the financial challenge faced by care providers, the Council is attempting to ensure 
that  the fee that  we pay  our  providers for  a  placement is  fair,  although  of course  any  fee 
would need to be affordable to us as a  Council. For  nursing placements, it  is also  important 
that the fee paid by the Health Board for the nursing element of the care is sufficient to meet 

Council Offices 
Caernarf on 
Gwynedd  LL55 1SH 
01766 771000 
www.gwynedd.gov.uk 

 
 
 
 
 
 
 
 
 
 Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol  
Gwasanaethau Cymdeithasol 
Corporate Director and Statutory Director of Social Services 

the  needs and  for  providers  to  be  sustainable.  The  Councils'  settlement needs to  be  at  a 
sufficient level annually, so that we are then genuinely able to invest in the local care market. 

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.  

Currently, there are  70  residential  EMI beds in  the Council's  homes across the County: Plas 
Maesincla  Home (23), Bryn  Blodau 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. 
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  Penyberth 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 Penyberth site at Penrhos, Llŷn and  for 
Canolfan Lleu, Penygroes.  

It is important to note that we are working in partnership with other counties in North Wales, 
and  more  specifically,  with  those  counties  that  are  on  our  border  here  in  Gwynedd (e.g. 
Anglesey), in order to plan and commission these care provisions.  Often, individuals and their 
families  who live in  Gwynedd, but who are on the boundary with another county, prefer to 
have a  placement located  closer  to  their  home  rather  than  one situated  in  Gwynedd, but 
further  away.  Therefore,  it  is  important  to  note  that  we  work  across  boundaries  when 
considering care placements. Consequently, providing a care placement for an individual in a 
nearby county is not a problem in itself, but I appreciate that the placement preferred by the 
individual  and the family continues to be the ideal outcome. 

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  w as 
approved by Gwynedd Council at the Full Council  on 3 March this year. Underneath this high 

Council Offices 
Caernarf on 
Gwynedd  LL55 1SH 
01766 771000 
www.gwynedd.gov.uk 

 
 
 
 
 
 
 
 
 
 Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol  
Gwasanaethau Cymdeithasol 
Corporate Director and Statutory Director of Social Services 

level  assessment,  more  localised  detailed  work  will  be  done  and  this  will  provide  key 
information in order to reflect on whether we have the correct number of placements for the 
future.   

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. 

I wish  to  draw your  attention to  two recent Audit  Reports by the Audit  Office in  this  field, 
which have set out a number of challenges and obstructions generally faced by councils  and 
health  boards  as  they  seek to  commission  care  home  placements.  One  report  is  for  the 
attention  of  the  North  Wales  Care  and  Health  Partnership  Board,  Commissioning  Older 
People’s  Care  Home  Placements,  and  the  other  is  a  report  aimed  specifically  at  Welsh 
Government: Care Home Commissioning  for Older People. It is  fair  to say that  our national 
system does not make the process easy or completely effective.  

Of course, as you are aware, a part  of the context for the period in  question is the fact that 
Covid-19  related regulations  were operational.  This  has meant that  a large  number of  care 
homes, at some point in time, were closed to admissions in order to control the spread of the 
virus.  Unfortunately, for many individuals,  although a bed was available  within a home, and 
that  it  had been agreed for the individual  to be admitted, Covid-19  regulations  meant that 
they had to wait  until the home was completely free of the virus. This has had an impact in 
this  case. Therefore, in reality,  and very unfortunately, the Covid-19  related  regulations, as 
well as  problems with  staff capacity,  have had quite a substantial  impact  on the number of 
placements that are available at any given time. 

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 placements, 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.   

As a Council  we are wholly committed to doing  everything within our ability  to provide and 
commission  high standard care placements, that can meet the needs of our population.  We 
will continue with this work and play our part in attempting to influence and improve national 
policies in the field.  

Council Offices 
Caernarf on 
Gwynedd  LL55 1SH 
01766 771000 
www.gwynedd.gov.uk 

 
 
 
 
 
 
 
 
 
 
 
 Cyfarwyddwr Corfforaethol a Chyfarwyddwr Statudol  
Gwasanaethau Cymdeithasol 
Corporate Director and Statutory Director of Social Services 

If you require any further information or explanation regarding  the response, please do not 
hesitate to contact me. 

Yours sincerely, 

Corporate Director  and Statutory  Director of Social Services 
Gwynedd Council   

Copy: 

Councillor 
Council 

 – Chief Executive, Gwynedd Council 

 – Head of Adults, Health and Well-being Department, Gwynedd Council 

  –  Cabinet  Member  (Adults,  Health  and  Well-being),  Gwynedd 

 – Chief Social  Care Officer for Wales, Welsh Government 

Council Offices 
Caernarf on 
Gwynedd  LL55 1SH 
01766 771000 
www.gwynedd.gov.uk

Dirprwy Brif Swyddog Meddygol 
Deputy Chief Medical Officer 

Yr Adran Iechyd a Gwasanaethau Cymdeithasol 
Department for Health and Social Services 

Katie Sutherland 
Acting Senior Coroner 
North West Wales 

Dear Mrs Sutherland 

18 March 2022 

Regulation 28 Report to Prevent Future Deaths – Mrs Eirlys Wynne Roberts 

Thank you for your letter enclosing the Regulation 28 report following your investigation into the 
death  of  Eirlys Wynne  Roberts who  sadly  passed away  on  17  July  2021.  I  am  responding  on 
behalf of Eluned Morgan, Minister for Health and Social Services. 

Welsh Government recognises that people who need care and support, including those who 
need to move into residential, nursing or EMI care facilities, are generally best cared for within 
their local communities, and that we should be striving to ensure that there is sufficient 
provision to meet local demand.  However, a range of different circumstances can mean that 
unfortunately this is not always possible and alternative arrangements must be made. 

It is deeply sad and regrettable that Mrs Roberts had her fall and subsequent admission to 
hospital before she could move into the specialist nursing EMI home that had been secured for 
her in Gwynedd.  Having explored Mrs Roberts’ journey it would seem that on this occasion 
Covid-19 may have had a detrimental impact on securing her a nursing EMI home.  At the time 
of her fall Mrs Roberts was in a specialist EMI home on Anglesey (just 7 or 8 miles way from 
her home in Bangor) but was awaiting a place in a nursing EMI home having been assessed as 
also requiring nursing care.  Unfortunately a combination of staffing shortages in two local care 
homes with suitable provision (in part due to Covid 19) and a Covid-19 outbreak in another care 
home meant that there were delays in her accessing the specialist nursing EMI provision she 
needed.  

When arranging care home placements a range of factors are considered by health and social 
care commissioners, including the ability of that home to meet the specific care and support 
needs of an individual and its closeness to their own community and support network, even if 
that may be just across the border into another County. 

With the Regional Partnership Boards established under Part 9 of the Social Services and 
Wellbeing (Wales) Act 2014 (‘the Act’), Local Authorities within a regional (Local Health Board) 
footprint have developed much stronger working relationships and now actively collaborate to 
meet the care and support needs of individual across the whole region.  This can mean that 
Local Authorities boundaries become more permeable and less of a barrier to meeting people’s 
needs.  Ynys Mon and Gwynedd have a strong track record in working as a sub-regional 
collaborative. 

Parc Cathays, Caerdydd CF10 3NQ Cathays Park, Cardiff CF10 3NQ 

 
  
 More broadly Welsh Government clearly recognises the challenges across the health and social 
care system in ensuring peoples increasingly complex care and support needs can be met 
within the community, as close to home as possible.   

The changing and growing care and support needs of our population alongside the impacts of 
Covid-19and the challenges of recruiting and retaining a skilled social care workforce has 
created unprecedented challenges in our health and social care system. As a Government we 
are working hard, alongside delivery partners to strengthen our system so it can support people 
better. 

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. 

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. 
Together these feed into the strategic joint Area Plans, which in turn underpin the 
commissioning decisions of local authority and NHS partners.  

The next round of Population Needs Assessments and Market Stability Reports are due to be 
published in April and June this year. In preparing their assessments, the Regional Partnership 
Boards must engage with a wide range of stakeholders, including citizens, carers, third sector 
and community groups, and care providers, so that the provision of care and support can be 
appropriately tailored to local need.   

The Part 9 guidance of the Act also states that local health boards and local authorities must 
jointly commission care homes through regional pooled funds.  It states that in relation to care 
homes they should agree an appropriate integrated regional market position statement and a 
regional commissioning strategy. These should specify the outcomes required of care homes, 
including the range of services required, and consensus on the methods of commissioning. In 
addition, the guidance states that local authorities and health boards should:  

  agree a common contract and specification;  
  agree common contract monitoring criteria and processes that include service 

user feedback; 

  develop an integrated approach to agreeing fees with providers.  
  develop an integrated approach to quality assurance; and 
  adopt a transparent use of resources. Budgets must be aligned with overall 

expenditure identified, together with the financial commitments of both agencies 
to the commissioning of care homes. 

In September 2020, the Auditor General wrote to the Welsh Government and copied the letter 
to all local authority and health board chief executives in Wales, raising concerns about regional 

 
 
 
 
 
 
 
 pooled funds in relation to care homes for older people. These concerns emerged from audit 
work at two of the local authorities in North Wales earlier that year.    

The Audit Wales report on care home commissioning for older people published in December 
2021 concluded that there were some significant concerns around the practical application of 
pooled budgets for care-home provision in North Wales, and potentially more widely in Wales. 

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.  

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.  

This programme of work will also enable Welsh Government to respond to Audit Wales 
concerns by strengthening integrated commissioning practice and specifically the use of pooled 
funds. 

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.  

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.  

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.   

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. 

We hope you find this information helpful.  

Yours sincerely 

 
 
 
 
 
 
 
          
 
 
 
 Deputy Chief Medical Officer        
Copied to: 

Eluned Morgan MS, Minister for Health and Social Services 
Julie Morgan MS, Deputy Minister for Social Services     

, Chief Social Care Officer for Wales