A week or so ago, Johann Hari, a journalist and columnist for the Independent, wrote an article about his grandmother and the poor to verging on abusive care pathway that she experienced through devastatingly shoddy system that was and is not fit for purpose.
Today he writes again for the Independent proposing a series of changes across the sector which would improve the quality of service delivery.
I have a massive amount of respect for Hari and he writes very eloquently and passionately. I desperately hope more people listen to him than have listened to us, within and engaged with the sector who have been shouting, Cassandra-like, for so long.
His proposals are quite straightforward.
– Support elderly people to stay in their own homes wherever possible
This concurs with the evidence produced yesterday by the Alzheimer’s Society in a report published yesterday ‘Support.Stay.Save’ which concludes that while care in the home (rather than premature residential home placement) is a favoured outcome – the quality and training of staff is a serious issue – however if this were challenged, promoted and improved, there would be an eventual saving in the costs of placement in residential care.
There is a whole range of services that make this possible – from Meals on Wheels to home helps who are there to help an old man to shower in the morning and get into bed at night. We should be stepping them up, to keep anybody who possibly can free and independent. Instead, we are ruthlessly stripping them away.
and it is this that breaks my heart. We are tightening criteria, raising the bar to access support and increasing the cost of these services to those who may be responsible for their own costs. Hot meals on wheels delivery is not a default position anymore – they’ve been replaced by a fortnightly delivery of frozen food. This is a saving on paper to the local government but in the longer term denying this additional personal contact of a regular face delivering hot meals, is a much larger cost.
Councils have tendered out for the services at the lowest baseline cost. Care staff are provided on minimum wage, with little, if any, training and barely any dignity in their employment conditions so no wonder that corners are and have been cut. We need to provide the best possible rather than the cheapest possible.
They are better off with their families – so offer the care home funds to them first
Again, a seemingly obvious point. Hari states that residential care can cost upwards of £450 pw. Why isn’t that same amount of money offered in the home? It makes perfect sense. It makes perfect logical sense. Of course, some people will always need the 24 hour care. To be honest, we tend to fund increasingly higher packages of care in the home and it isn’t unknown for similar levels to be provided. I have one service user who has a package of virtually double that in her home (as a personal budget) but am frequently told that that is an unusual case and it’s only possible because a family member takes on a significant amount of care.
Local authorities do need to get over their aversion to funding overnight care in the home though. That would immediately make this more possible. Personal budgets theoretically should allow this point to be immediately actionable. In practice, it is not easy to squeeze the funds out of the interminable RAS (Resource Allocation Systems).
Make being a care worker a desirable profession
Today, our elderly are looked after by people who are paid the same amount as street-sweepers, and have the same level of training..
This breaks my heart. I spent 7 years working as a care assistant in a residential home. I applaud this point. There were times when I met with friends from university and I was almost sneered at because of my job. Actually, scratch that ‘almost’.
‘When are you going to get a ‘proper’ job?’ I was asked. Eventually the pressure of that pushed me into social work. I am glad I did it but it is hard to understand where the sneering came from. Sure, money is an aspect of it but it’s wider than that. Sometimes the management seems to join in with this scornful and hierarchical approach to care workers – it’s important to remember that if a manager is not going to treat staff well and with respect you can be sure that residents will not be treated well either.
Increasing not only pay but conditions of service – decent holiday pay, sick pay and training – would make a difference. I’d like to see more of a line of career progression as well.
Retrospectively, I look back with a massive amount of fondness to those days. I was lucky to work in good homes where I was instilled with a good work ethic and values that supported resident’s rights. I know how easy it is as a worker to ‘go native’ within an organisation and agency if the work ethic and values are not good. It leads to spirals of dispirited behaviour.
I wish every social worker had had the experiences I had in hands-on care work. It was invaluable and it shapes a lot of my actions and values today. I doubt many do or will in the future. That’s more the shame.
Now, I am so proud that I was a care assistant in a residential care home. I wish I had been at the time.
Make every home publish its staff-to-residents ratio
Theoretically this should be possible. It should be easy to access. It makes a big difference. When relatives go to visit care homes I advise them to ask about this and perhaps ask the member of staff showing them round how long they’ve been there and what the staff turnover is.
Clarity would be a fantastic and simple indication of whether a care home runs on bare minimum or below minimum staffing ratios. Unfortunately the CQC doesn’t really help much here.
Every parent knows how many pupils there are per teacher in their child’s school. Nobody knows how many carers there are per resident in their granny’s home. I asked at every home I considered: nobody would tell me. But this can make the difference between a good home and a terrible one.
I’m surprised that no home could tell him when directly asked. Maybe because sickness is not taken into account – some homes seem to constantly run below the CQC required level due to ‘unexpected sickness’. The CQC could monitor this with spot inspections. It doesn’t. Or only when things are literally falling apart. It makes me angry.
Impose minimum nutritional standards for the food
This makes sense again and a menu list can’t always indicate what the quality will be like. However, unlike Hari, I have seen homes that have delivered well on this front. I am sure I’ve been to many many more over the years though.
The ‘Scores on the Doors’ system of food hygiene ratings has been extended to residential and nursing homes so perhaps that is a start.
Well, the best start is for the person responsible to think ‘would I want to eat this every day’. No-one should be serving food they would not want to eat themselves.
Change the attitude
This is a broad brush that Hari paints. The example he gives is a regimented imposition of bed times and morning times. There is something of the way that care homes are organised that sometimes some of the personal touches and individuality can be lost. This does differ in different care homes and there are as many attitudes as there are people. The key though is to emphasise individuality in choices and not to impose on others.
For me, it’s a matter both of training and staffing levels. Treat every resident as you would want a close family member of yours to be treated. It’s a very simple tenet and an easy one to remember. The difficulty is that not enough people will practice that way and so staff as well as residents are in danger of becoming institutionalised.
Stop the mass prescription of anti-psychotics to rebelling residents
This is self-explanatory really and to be fair (as Hari notes) it is one point that progress is definitely being made on. It is far less common now than it has been in the past. Quite rightly. Anti-psychotics can be dangerous for people with dementia.
Restore proper inspections of care homes
For me, this is a massive key to the whole process. The CQC needs to take responsibility for the decline in the standards and to restore spot unannounced inspections, day and night, weekend and weekday to EVERY SINGLE residential and nursing home in the country.
It is wholly unacceptable that there is a reliance on cheaper ‘paper’ inspections or ‘desk-based’ inspections and it is wholly attributable to staff being laid off by the CQC.
I have my sources (actually a couple of very good friends of mine whom I worked alongside in those days when we were all care assistants in the same residential home!) who work within the CQC and they have been given much larger caseloads and have less time to do more inspections.
Inspections need to put the providers on the spot and really and truly inspect. They need to check that what homes write about staffing ratios is really what is happening on the ground. We rely on them. They do not deliver.
As Hari says
In 2005, there were 50,000 physical inspections of care homes. This year, there will be a quarter of that number. David Cameron has called for “light touch regulation” of this sector, so homes are increasingly being asked to engage in “self-assessment”. That means they will be asked to fill in a few forms.
This, more than anything, makes me furiously angry. Light touch regulation DOES NOT WORK. It leads to increased abuse. I can give so many personal examples that I have witnessed. I will try to keep shouting until the system changes.
I wrote about this last November and have no doubt I’ll be writing about it again. And again. And I’ll mention again because I think there’s a relevance that the Chief Executive of CQC is Cynthia Bower who was Chief Executive of NHS West Midlands when Stafford Hospital was delivering contemptible and appalling care. Hardly a CV that instills much confidence.
Make sure care homes that are shut down stay shut down
This raises the issue that care homes can fail and then just re-register and open under a new name which should be wholly unacceptable.
Again, I wrote about this last November when Private Eye and Compassion in Care were trying to gain more information about care homes that were closed down.
Impose serious criminal consequences for elder abuse
There is a new law of wilful abuse of those who lack mental capacity which was introduced in the Mental Capacity Act 2005 but I agree with Hari in that the legislative framework for adult safeguarding needs to be as strong as it is for safeguarding children. Our hands are tied and the punishments do not fit the crimes.
It’s an excellent piece by Hari and I wholeheartedly applaud it. I hope more people will listen but we have to keep shouting as loudly as we can to improve the quality and attention of care for those who lack capacity and for all people who rely on others for support.
We all need to shout. Not just those of us who are directly affected or who have parents or grandparents who might be affected (as we all may be eventually) but anyone who cares about living in a civilised society as well.
Perhaps its endemic of a society that wants to push the uncomfortable realities of ageing ‘under the proverbial carpet’ that has led to institutional abuse but our humanity is lost if we don’t stand up against it.
This is not a party political issue as significant damage was done under the last government but this government can’t get away with it either.
And thanks to Hari for raising these issues among a wider readership. I wish so deeply within my heart that this piece shocked me. Unfortunately, after many years working in the care sector, I’m sad to say it doesn’t.
- Johann Hari: My grandmother deserved a better ending than this (independent.co.uk)
- The plan to solve our care home crisis (independent.co.uk)
- Letters: Caring for the elderly (independent.co.uk)