Johann Hari’s manifesto for change in care homes


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.

Hari says’

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 Hot meals on wheels delivery is not a default position anymore – they’ve been replaced by a fortnightly delivery of frozen food.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

Hari says

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.

Hari says

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.

As Hari says in his piece, this was brought up by File on Four and Compassion in Care a couple of months ago.

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.

15 thoughts on “Johann Hari’s manifesto for change in care homes

  1. Pingback: Johann Hari’s manifesto for change in care homes - Fighting Monsters - Member blogs - Social Work Blog - Carespace from Community Care

  2. What an excellent analysis of all that is wrong in the way we care for vulnerable elderly people.
    It makes so much more sense to support people to live independently in their own homes for as long as possible, yet somehow the people who could make it happen seem blind to the benefits, even though these do include saving money in the longer term.
    As you say, our attitude as a society to the importance of the care profession is amply demonstrated by the low esteem in which care workers are held, and the pittance they are generally paid.

  3. This gets me extremely angry.

    Things like of course we will always need 24 hour care

    Bollocks. I have opened and managed extra care schemes for people with alzheimers.

    The problem is institutionalisation. Does no one read Goffman anymore?

    Did no one see Mariella Frostrup The Young Ones?

    Meals on wheels is a lassic example – replacing one form of institution with another bureaucratic system.

    What should be happening is that older people are assisted to continue gardening and growing their own vegetables, cooking and cleaning, serving meals, interacting.

    Europe has ideas called cohousing. Why not au pairs for older people?

    Adopt a granny.

    Japanese elders retire to the Philippines because there are unemployed qualified nurses who can live with them as carers and family members – a win win – employment and caring.

    The first thing to do is to ban placements in care and nursing homes unles it is for temporary rehab purposes.

    The next is to attack this attitude – really a class one – that older people should have a weird lifestyle akin to upstairs downstairs but actually with no influence.

    Doing to philosophy instead of doing with.

    But the facs upper criteria only fetish destroys any hope of creating solutions for everyone that are flexible.

    Do social workers not realise how trapped they are in bureaucracy that they are no longer able to understand what needs mean because they define out most of the needs first?

    Why should a birthday destroy well founded solutions and require them to be rebuilt unnecessarily? Please reread Seebohm.

    • Urgh, just typed a really long reply and lost it. Problem with trying to reply on my phone. It’s a fair point and I accept I may be institutionalised. I maintain that in some circumstances there is a need for 24 hour care. That doesn’t have to be delivered in a residential or nursing setting but it can’t always be delivered at home.

      Extra-care housing would be a solution but it is a fantasy solution at present as the service doesn’t exist in a form that is able to manage people with very high needs where I work. I hope that commissioners look at different ways of providing services.

  4. Dear Johann,
    Thanks for your articles. My mother died three years ago at the age of 99. She was independent till 6 months before her death but had a fall, broke her femur, had the op within 12 hours. Two days later she got C. Difficle and because of Easter it could not be analysed so she did not get the antibiotic for a week. By the time CD was cured she could not move her legs at all, no rehab seemed possible and from then on she became totally helpless – slings etc.

    I moved her from the country to a home near myself in London. I think it was a very good home but it is so difficult to really know. You can’t look at your mother’s bum to see if she has sores – but they quickly got her a proper bed. The thing that made me happiest was that ANY OF US COULD GO IN AT ANY TIME TO SEE HER( at night you had to ring first but that was for security to warn the staff who you were. Because of this my daughter and I sudenly said ‘Lets go and see her’ at 10.00 at night and were there when she died. My mother was completely lucid but it was really hard to ask if she was being kindly treated – she wasn’t a complainer, she was a stoic, and she could have been afraid to complain for fear of what might happen.

    Because she couldn’t move without the sling I watched her being forced into incontinence. ‘Just do it in your pad’ This comes after a series of abortive trips to the loo. There were some lovely staff but many spoke very rudimentary Enlish. The Management were kindness itself. But there were others and there was the traditional the circle round the TV and the stimulation was minimal. I often went in to feed her because I never felt there were quite enough staff to be sure she got enough lunch. She never said she wanted to die. How do I really know what it was like for her? I think about it often.

    She was a middle- class independent woman and communal living was not her choice, though everyone had a single room to sleep in and she was paying for herself. I think for some of the local authority residents it was like a luxury hotel – clean, warm and meals provided. I am really glad if it was good for them.

    Definitely inspections and emergency closures are vital. Horrible though it is for old people to be shipped off suddenly in ambulances, they may well be relieved to escape. Where can they go?

    Visiting at any time should be added to your list of measures.

  5. Anne, thanks. Firstly, I’m not Johann. I also have to object to your distinction between ‘middle class independent woman’ somehow deserving better quality than ‘some of the local authority residents’. That’s actually insulting a lot of people and I’m sure you don’t mean it that way.
    Everyone deserves good care. I agree about spot checks but people who pay more don’t deserve better, per se. We need to deliver better services all round.

    Thanks.

  6. “Extra-care housing would be a solution but it is a fantasy solution at present as the service doesn’t exist in a form that is able to manage people with very high needs where I work. I hope that commissioners look at different ways of providing services”.

    I don’t know where you are but I have reviewed councils sheltered housing stock and made recommendations. The secret is to make the larger sheltered schemes in an area the local service hubs, from where district nurses, health visitors, care services etc etc work and get to know in detail everyone with any vulnerabilities in their locality. They normally have land to build the required infrastructure.

    There are many examples of this, they just need generalising. Every allocation decision to a care home actually stops moving to these models.

    • I’m talking about where I am, I don’t know what the provision is like elsewhere but we were told when the extra-care schemes opened that they were supposed to be an alternative to residential care – so we referred people who would otherwise need residential care. In practice the providers can deliver for ‘straightforward’ care but quickly reject referrals that they deem to be ‘difficult’.
      I work in a specialist mental health team. I work in a central London borough. There certainly isn’t land to be built on.
      I would love your planned ideas to work but while we have providers promising commissioners they can provide an equivalent service and in practice picking and choosing the referrals they accept, it won’t be a wholesale alternative.
      I hope it is in the future.

  7. In my experience we are developing two worlds – services in cities and shires. You seem to be describing 2.1 services when I am talking 2.999999 and 3.4 services!!

    One Housing Association I knew – a national one – moved people from a sheltered flat to a residential care unit in the same complex without realising there might be a teeny problem with that!

    The shires are commonly developing the services I describe, – Popps – cities are having huge problems – staff turnover, use of temps.

    The problem you describe highlights an issue about how the care teams are managed and structured and how housing understands their role.

    And there is plenty of land in inner cities – it is often a matter of putting car parking underground and going up.

    A significant point is that London Borough Adult Social Services, Mental Health teams etc are too small administratively. I would give strategic responsibility for all adult and child services to GLA with very close ties to NHS, so that everyone has person centred life time plans.

    Under explored area are cooperatives and leasehold extra care. There are many unexplored assumptions that I understand to be classic symptoms of institutionalisation of the alleged professionals.

  8. And I repeat my earlier point – if we agree residential care is not an option except in extremis, emergency or temporarily as part of an agreed process, we can begin to seriously address building the alternatives.

    We will continue to “feed the beast” of the total institutions otherwise.

    The Equality Act is very clear about indirect discrimination with multiple equality issues. We have here older people, disability and women in a perfect storm.

    Cut through the Gordian Knot – stop using residential care.

    I was at a huge conference of health and social service professionals. The speaker a very senior civil servant from DoH asked those who wanted to go into a care home to raise their hands. Response nil. We started with the bins, there are very strong arguments to close prisons, why have small – some are not – total institutions fallen off the radar?

    • Clive – I would truly love that.
      I am at the lowest point in the ‘chain of command’ though – I have no seniority at all in the ‘system’ and certainly no-one in management or commissioning would ever listen to me although I would love change.
      It’s one reason I write this blog – because people might read who may have some more ‘power’ to make the changes I want to see than I have.

      I’d love to go or even speak at a conference of health and social care professionals – it’s never ever going to happen.
      Front-line practitioners don’t get to do that kind of thing.

  9. There’s a great bit in ‘Selfish Pig’s Guide to Caring’ where a girl who has just given up her job to care for her mum, meets one of her colleagues in the supermarket.
    ‘So how are you enjoying your life as a lady of leisure?’ the colleague quips. She walked away and had no idea that she was within a whisker of being knocked to the ground and run over with her trolley..
    Caring is weird in that it is publicly admired and privately despised as a job. I lost count of the number of people who said to me, ‘So are you not working then?’ I used to reply, ‘I am working, I’m just not getting paid for it.’ It’s the same with being a mother; it’s looked down on as well. The difference is though that we have had campaigns to change attitudes and get things like maternity and paternity leave and nursery places for children. It hasn’t really happened for caring yet. As ‘Selfish Pig’ puts it, wouldn’t it be nice if when someone asked what you did and you said, ‘A carer,’ they would say, ‘That’s great!’
    Anyway, good post cb.

  10. Your feed discusses what is happening in Kent, that sounds like it is going to the extra care model I have described, but they have been reported to the Audit Commission.

    This shows a lack of understanding of what non institutionalised person centred models are, and not enough time and care being spent to explain them.

    No one is too low in a hierarchy – the whole point of being person centred is that people nearest to the client are actually in a very powerful position to argue against tina.

    It is the whole issue of prevention or reaction. The evidence is there that prevention always wins but reactive institutionalised systems actually defend the status quo and actively ignore the evidence. It does require triple bottom lining – taking into account the financial, ecological and social implications of actions together.

    I would like a kafka scale, like the Beaufort or Richter Scale, of Social and Health Services – are they really committed to person centred transformation or is it lip service or have they never heard of it?

    Technically I am a service user and that is one term I would abolish.

    What is that line from the Prisoner?

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