Personal Budgets, Personalisation, Thoughts and Hopes

Yesterday Think Local Act Personal (TLAP) published the results of a National Personal Budget Survey.

The headline ‘results’ are of course overwhelmingly positive. Personal Budgets work. Direct Payments Are Good. Everyone is happy.
Questionnaire

jrambow@flickr

Is any of this a surprise though? We know that people who can and are able to manage (or have family members to help them to manage) personal budgets delivered through direct payments (where money is paid directly to users) prefer them to less flexible local authority provided care packages – particularly when the scope of local authority care packages is limited to agencies with block contract arrangements.

In Control – which publishes the survey – highlights the following ‘implications’ from the findings. The bold is a direct quote and the italics are mine.

Other implications that can be drawn from the survey results include:

  • Personal budgets work better for older people than you might expect and direct payments work just as well for older people as everyone else.

Who said we were not expecting personal budgets to work for older people? Does this make an ageist assumption and lump together all ‘older people’. Of COURSE they work as well for people who are 65 as they do for people who are 64 but what about people without capacity or who don’t have family or friends involved? What about a more subtle distinction between 65 year olds and 85 year olds rather than a blanket ‘old people’ response.

  • The processes used for delivering personal budgets are more difficult than they need to be and that impacts badly on carers and on personal budget recipients.

Did this seriously need a survey over three months to discover? You could have asked me three years ago and I wouldn’t have charged consultancy fees.

  • More work needs to be done to make direct payments more accessible generally but especially to older people.

This could have been written 6 years ago. We KNEW this from the roll-out of direct payments initially so why was NO WORK WHATSOEVER done around trying to work with more difficult to reach groups when personal budgets were being ‘piloted’. I really can say ‘I told you so’ as I begged our Personal Budgets roll-out team to allow us to pilot or be involved in the initial processes and they said our user group was ‘too complicated’. Heh.

  • There is a need to simplify and clarify the rules and regulations surrounding personal budgets.

So those are the ‘implications’ and forgive me my cynicism. I love the idea of personalisation. I want it to work. I want to work in more creative ways or outsource my work if necessary to other third sector organisations but this is not ‘different’. This is not ‘new’. I fail to see the value of reports and surveys that tell us exactly what we already know again, and again and again instead of actively trying to work with people who actually understand and know what is happening ‘at the sharp end’ to try and work out ways to improve outcomes for those who are not receiving direct payments currently.

So back to the report – which used a Personal Budget Outcomes Evaluation Tool (POET)

in total, 1,114 personal budget holders  completed the POET survey, including 832 returns from the 10 local authority demonstrator sites and returns from at least 76 other local authorities. 417 of these personal budget holders also wrote in a comment about their experience of personal budgets.
In total, 950 carers completed the POET survey,including 782 returns from carers in the 10 local authority demonstrator sites and returns from at least 66 other local authorities. 434 of these carers also wrote in a comment about the impact of personal budgets on their own lives

And

Almost half of people responding to the survey were aged 65 years or more (43%); the social care needs of working age adults (aged 16-64 years) were largely split between learning disabilities (17%), mental health needs (8%) and physical disabilities (25%).

I don’t want to play too many games with statistics but it would be interesting to know what proportion of people who meet the FACS criteria in total are over 65 and whether 43% is a proportionate figure in relation to total recipients of social care services. I think as well, to class ‘older adults’ as ‘over 65s’ is a little disingenuous although I know it is done because that is the basis on which statistics are given but it shows some of the ways that systems restrict and inhibit knowledge. It would be far more interesting to know the differences of take up of personal budgets between 65 year olds as opposed to 85 year olds for example.

And to some of the headline figures, that can catch the press attention – most people who receive personal budgets find there is a ‘positive effect’.

Looking through some of the figures, it seems that older people were much more likely to be receiving council managed budgets – you know, that ‘easy’ way of just switching around a bit of paperwork and making it look like there is now more ‘choice’ when in fact, the services and delivery is almost exactly as it was before the ‘change’.

As for the outcomes the report says

In terms of social care need groups, older adults tend to report less positive outcomes than other social care need groups in six out
of the 14 outcome domains

I find the report to be honest, a bit of a whitewash in itself. It is only accentuating the positives and like all discourse related to personalisation and personal budgets, seems to be going over all the same ground again and again.

People like choice, people like flexibility. Yes, and rabbits like to eat carrots. It doesn’t need a survey to tell me that. What action and money and research needs to be concentrated on is the HOW.

HOW is there going to be an improvement in service delivery to those who are marginalised in this process.

HOW are we going to wriggle out of the sham that is council-managed budgets while allowing those who need to have others to manage their budget and support their care to have the same access to quality care and personal assistants that those who are able to choose and decide have.

I’m rapidly coming round to the view that personal budget support planning needs to be moved out of the hands of local authorities who currently have no interest in the process except for meeting the government targets. Where is the innovation within local government for change? Sure there are people, and I hope to be able to count myself among them, who want to do a better job and provide a better service but the constraints of the type of job I am doing means that I can’t devote the time necessary to truly inclusive and supportive care planning so Mr G whose support plan I am writing up (he doesn’t want to be involved in the process as he ‘doesn’t like forms’ and can generally only tolerate conversations with people for between 5-10 mins maximum and that’s only if he’s known you for at least a year) does get a rushed service because I have to carry out Best Interests Assessments, do Mental Health Act Assessments,  complete reviews and CPAs, liaise with other professionals, arrange discharges from hospital for other people. Yes, it’s a little bit of wallowing in self-pity and I wholly accept that. We are all busy but local authorities have no idea if they want a quality support plan without changing the ways of working in any other respect. Where is the time to devote to Mr G’s creative support plan? Oh, well, we’ll just do a regular care plan and a managed budget. Should it be that way? How has the march towards personalisation helped people like Mr G? Mr G wouldn’t complete a survey about a personal budget even if he did get a letter. Letters worry him and he doesn’t have a phone. I don’t want the Mr G’s that I work with to be forgotten in the rush towards direct payments.

When I first attended training we were told that any additional time we might be spending in our day to day work on these awful process-driven systems would be made up by the amount of time we would save by people completing their own support plans and assessments without any assistance. That may work for some people and I hope it does but for most of the people in the team in which I work it is unfeasible due to the amount of people I work with who have high support needs and who don’t have the capacity to make decisions about their own care needs.

The survey angered me, in a way that is probably irrational. Partly because it seemed to have taught us nothing at all. And partly because again, I see no new thoughts and ideas about developing systems that will be truly inclusive.

HOW can social care improve for everyone. That’s everyone. Even those who don’t want direct payments. Even those who don’t have advocates. Even those who are self-funding their own care packages as the criteria for receiving government support rise higher.

Those are the questions I want Think Local Act Personal to answer.

I have my own ideas. I think there will be a movement to roles for professional ‘support plan advisors’ who aren’t necessarily based in the local authority – perhaps individual social work consultancies but there has to be a separation between planning and delivery and the cost of these services shouldn’t need to be met out of the personal budget itself.

First and above all, there has to be a consistency and a transparency in the way resources are allocated and if necessary a weighting towards people who need assistance to access the same kinds of services who have been excluded from the process and the benefits in the past.

A survey of the skills-base of professionals who do implement support plans needs to be undertaken to establish what is needed and what is important to have.

Maybe it is a professional type qualification or maybe not. There is not much discussion about what the role of the social worker should be in the process. Should we be the ones support planning? I think there’s a argument that a social worker is well-placed to look at building plans together in conjunction with a user and family member if necessary and setting up things like trust funds or managed local authority budgets but only if the social worker is removed from the local authority talons.  Maybe some kind of team of people with different kinds of experience and expertise working together with some background and training in non-directive advocacy for people who do lack the capacity to organise their own support plans. Perhaps the social worker or support worker in these new roles could have longer term relationships with the users and carers and wouldn’t feel so pressured by management if freed from the local authority reins.

But who is going to suggest and discuss the new ideas? Where do they go? Who will collate them?

While I see lots of discussions around me about personalisation, I see little that says anything other than it HAS to work because it is best for ‘people’.

I genuinely believe that is has potential to deliver a much better system but and this is a big but, there has to be more creativity and different kind of research that looks at new models and methods of delivery and consults people – yes, like me – who while being critical really really do want things to work better.

My criticism isn’t because I want to bury my head in the sand and ‘retain the reins of control’. I really don’t. I want to relinquish control but I want more than anything an equitable system that doesn’t fob off ‘more difficult’ service users with a second class service.

Mrs J and the Mystery Bristol Care Home (update – it’s Amerind Grove Nursing Home)

There is a story on the Community Care website this morning about an ombudsman’s report relating a woman, Mrs J, who was placed in a care home in Bristol.

Bristol waterfront at night

lovestruck@flickr
This was a  care home which was not only rated ‘poor’ or had no stars under the old rating system that doesn’t exist anymore but from the time she was placed in 2005 until Feb 2009 when she finally did move (only to die later that year) , the responsible council – Bristol City Council – did not monitor or review her placement adequately.

Her son, Mr P, asked for his mother to be moved however as the cost of the identified ‘replacement’ care home was higher than the cost that the local authority would pay, he had to make ‘top up’ payments.

The Care Home which strangely is not named in the report – and I find that rather suspicious to be honest, had had a number of safeguarding alerts over the period of Mrs J’s placement there. It had received a zero star rating and there had been a couple of ‘freezes on admissions’ – probably relating to the safeguarding alerts.

The council investigated and placed the responsibility entirely on the care home however the ombudsman found that the  council had failed Mrs J as it was the commissioner of the service

As the press release on the site of the Local Government Ombudsman says

The Ombudsman considers that there was maladministration in the Council’s reviewing and safeguarding strategy and is concerned about the poor communication between the Council and the family. The Ombudsman also finds that the Council had not properly considered the circumstances around Mrs J’s move to an alternative placement, which had led to Mr J contributing to the cost.

For the pain and suffering caused by the lack of appropriate safeguarding and review procedures, Bristol City Council were ordered to pay compensation to Mrs J of £6000 and to Mr J of £500 as well as pay back the contributions Mr J made towards his mother’s care between February 2009 and October 2009 when she died.

That’s the background and now my thoughts about this – deep breath.

It’s horrific. Firstly not everyone has family that are as determined as Mr J to pursue and stand up for residents in care homes. If Mrs J had not had a son, this poor practice and abusive situation may have continued with perhaps, some perfunctory safeguarding alerts but with little action in relation to the management of the care home taking place. The care home working in conjunction with the CSCI (predecessor to the CQC as inspection service) where people living in homes that are rated as poor (of course, they are not rated at all now – easy get out of this situation?) continue to do so without batting an eyelid as long as the fees are low enough to be met by the local authority.

Another thing – what about everyone else living in the same care home? Seriously. Were they moved as well?

Why is the name of the care home not given? Surely this information should be transparent. A government (and this not not just the present one but the previous one too – I am making no party political point here) which is bound to link choice to care decisions is finding it quite handy to mask the names of inadequate and frankly, dangerous, care homes.

I did a search of care homes in Bristol which had poor ratings at the time that the rating system was abolished in 2010 and there were none listed. Perhaps they had managed to haul one more star. These are the homes I found that had one star. It may well be none of these homes but it makes pretty depressing reading looking through inspection reports from ‘adequate’ care homes.

This raises a number of issues – mostly why on earth can’t family members and social workers making placements in residential homes know which home it was that failed so appallingly? Isn’t that how ‘markets’ work? Or is it through hiding behind reports which obfuscate and confuse and seem to dance around the real issues of care – in the long periods between when they appear.

Finally, a thought or two about the way the council were criticised and censured. £6500 will not deter a council from acting in the same way again. The cost of fully staffing/training a competent review team may be much much higher than that. Quality Assurance Teams in the councils are one of those ‘non-jobs’ or ‘back-office’ jobs that Pickles seems to like to mock but in the face of a national regulatory system that is little more than a joke, they could and would provide a great service to citizens who need placement – particularly those without strong advocates and family members to stand up for them.

We need these stories to have more publicity though because there needs to be a greater understanding of the challenges faced and the poor quality that has almost become tacitly acceptable in the ‘free market’ of care.

The imposition of the market economy into the care sector hasn’t allowed the cream to rise to the top for those who are wholly reliant on support for placement from local authorities. It has allowed care homes which charge low fees to thrive despite poor care provision because it suits both parties to allow them to continue and to allow their names to be protected.

This makes me angry. I did not come into social work to deliver what I consider to be poor care or poor care services. I want everyone to be able to access good quality care and support regardless of their income, savings, property values or their family or friends’ willingness and ability to advocate on their behalf.

In a world of rose-tinted spectacles through which the Care Minister seems to envisage that people like Mrs P will have more ‘choice and control’, we have to make sure that basic minimum standards of care are respected for everyone who is reliant on them.

And we aren’t.

UPDATE – BBC have published the name of the care home  – it is Amerind Grove Nursing Home owned and run by BUPA.   Mrs J is Mrs Iris Shipway.  This is the report from 2008 which gave Amerind Grove a 0 star rating.  It is a 171 bedded home. Stop and think about that for a while. 171 people in a care home. That’s big business. That’s not a ‘home’ – that’s warehousing. Would we place younger adults in 171-bedded units. Let alone poor 171 bedded units. And what about the other 170 people living there when Mrs Shipway’s treatment was so poor. Can we see how the large companies have local authority commissioners ‘over a barrel’? They would not be able to find alternative placements for that amount of people.

The answer is less institutionalisation – more creative thinking about alternatives to residential and nursing cares – the answer is not 171 bedded homes.

Rant over.

Human Rights, Home Care, Personal Budgets and Cost Saving

I read on the BBC website among others that there is a report suggesting that care provided in the home by local authorities to older adults may be overlooking human rights issues.

Old man exmouth market

Daniel2005@flickr

An inquiry into this  was initiated by the Equality and Human Rights Commission in November 2010 and will report in December 2011 but some interim findings have already been published.

I think the context in which the inquiry is taking place is crucial in times that Cameron trying to pretend that he invented the personalisation agenda and rebrand it as a version of ‘Big Society’.

The scope then of the Inquiry as to determine where the responsibility of the ‘public authority’ under the Human Rights Act actually lies and I’m going to quote directly from the EHRC (Equality and Human Rights Commission) as I think this is a crucially important point in the progress of personal budgets and home care provision (n.b. the underlining is my own).

The nature of social care is changing rapidly with a greater emphasis on personalised services and choice.  The majority of social care services are already delivered by private sector agencies, either via contract with local authorities or directly with individuals through a mix of public and private funding.

This complex web of transactions is combined with a narrow judicial interpretation of the meaning of ‘public authority’ under the Human Rights Act. This combination has created a confused picture concerning the duties and obligations of the various groups involved in respecting, protecting and promoting human rights.

Further, an increasing number of care transactions are likely to take place at the margins of, or even outside of, regulated care. There is the possibility that these transactions are beyond the present human rights obligations of the State.

We are also seeing the emergence of new on-line care marketing and brokerage services aimed at people purchasing social care with either ‘individual budgets’ or private funds. These marketing and brokering services are currently completely outside of the regulatory system with no means of monitoring the quality of the advice and services they offer. The Government wants to accelerate the pace of reform even further. While personalised care and support has many potential benefits, this is uncharted territory. There are concerns that human rights protection (and other issues) could fall between the gaps.

I’m going to come back, I’m afraid, to my perennial bugbear of people who lack capacity to make choices regarding care provisions and care delivery and wonder again how this group of people without family members, friends or advocates will be able to secure their own well-being in a world where responsibility of the state and the public authority is being discharged to private individuals. Will it become the responsibility of an advocacy service to determine that the support package and the provider of the support package are of a good quality? Or the carer/family member? Hardly the same as a protection under the Human Rights Act.

Food for thought and while I am extremely happy with the forward march of personal budgets and direct payments to those who are able and happy to manage their own budgets, the way that local authority managed budgets provide ‘more of the same’ regarding cheaply bought, block contracted social care remains floating fairly close to the edge regarding what is acceptable and what isn’t.

My fear is that the roll-out of personal budgets has not led to choice for all. It is a false choice and a false impression of the so-called ‘success’ of the roll-out. It has led to great benefits and more choice for some, yes, but I worry that this is actually at the expense of those without the louder voices to shout who have, again, been pushed to the bottom of the pile when quality services are being distributed.

So back to the reports findings so far.

Back to the BBC report

The Commission describes cases of people being left in bed for 17 hours, or more, between care visits and a failure to wash people regularly.

It received reports of people being left in filthy nightwear and bedding after a homecare visit, or without a wash or hair wash for several weeks.

Visits are sometimes so brief, the report says, that people have to choose between having a cooked meal or a wash.

The short visits also mean that staff have to rush tasks like washing and dressing, which frustrates elderly people and care staff

That doesn’t even bat an eyelid with me. This is what I have dealt with for the years I have been working in adult social care. Complaints and apologies about the time we can allocate for specific tasks due to budgets. Apologies on behalf of private agencies who have block contracts that cannot assure any kind of continuity of care.  That’s not even mentioning the  missed visits, the non-payment to staff of travel costs so they are cutting short visits in order to make it to the next ones. This is the reality of social care for older adults in the UK. Not the ‘season tickets to football matches’, not the ‘let me choose nice Mrs Walters’ daughter who I know from church to be my home carer’ kind of idyll that we are presented in the personalisation literature.

The reality for the people I work with and for is increasingly rushed visits and yes, choosing between a cooked meal (but only if it is a microwave meal because there is never ever time to cook a meal more complicated than tinned soup or beans on toast from ‘scratch’) and a shower.

The way to solve this problem and promote dignity is to increase and not reduce budgets for social care in the home. But budgets are being cut and cut hard.

Local authorities use block contacts with private care agencies to save money. The private care agencies generally pay staff at minimum wage. There are some fantastic carers and some fantastic agencies but they are penalised if they don’t offer their services at the very very lowest cost.

As for personal budgets? It is a wonderful reality for some but for most of the people I work with and for, it is a pipe-dream for people with a different kind of disability and with different kinds of support needs from the ones which are mostly promoted in our training programmes and in our policy documents.

If the government truly and genuinely means what it says about increasing and drawing out the personalisation agenda and increasing personal budgets delivered by direct payments there have to be ways clear and research undertaken to help us to create protective and interactive systems for people who are not at the forefront of the march because they don’t realise how much they are being penalised for not having a family member who is able to help with choosing and designing a care package and because they are not able to do this for themselves.

There has to be money spent on developing ways to allow those who at the moment are most at risk of vulnerability to be protected and cared for.

There are so many problems with a society that treats older adults or, in fact, anyone in the way that older people who are in need of care are treated currently. No-one wants to address it because no-one wants to pay. And it will cost.

No-one wants to lose their homes. No-one wants to lose their savings. No-one wants to pay higher taxes. No-one wants to lose weekly bin collections. No-one wants to pay insurance premiums.

The people who hold the reins of power will never be subjected to the humiliations which become a part of daily life for older adults who have need of support that is provided because they’ll be able to buy in their own ‘help’ privately.

Older people in need of assistance are less noisy than younger adults and less emotive than children in poverty and need. Ultimately we shouldn’t ration compassion and there’s no need for a choice to need to be made between one group or another

In the roll out of direct payments and then personalisation and personal budgets, it is the more able younger adults who have led the march and those who have been setting the policy and agenda seem to have completely forgotten the group of older people who don’t have involved family members and who  might not have the capacity to take decisions about care needs for themselves in the rush towards pushing the responsibility for support planning and choice of care routines. They  have forgotten amid the wonderful stories of attending football matches instead of day centres that some peoples’ reality is more about choosing a microwave meal or a shower.

Until those issues are addressed and the protection of the most potentially vulnerable groups of people is managed, the new system will not be equitable and it will not be fair. But perhaps that suits this government that wants shift responsibility from the state to the individual – which is fine to an extent but there are some people who really need that protection.

I look forward to the final report of the EHRC in December.

Safeguarding Adults Awareness Week

I learnt from my Twitter stream (thanks to Lindsay_Pike) that as well as being Carers’ Week, this week is also ‘Safeguarding Adults Awareness Week’.  I had never come across this as a ‘week’ before so used my carefully honed research skills to type ‘Safeguarding Adults Awareness Week’ into Google to see what it might be about.

There seem to be some local events arranged in Windsor, Kent and a nice sand sculpture in Cornwall as well as other places, it had certainly completely passed me by.

While the very scientific poll undertaken in Rotherham on the site of the councillor who was promoting it says that

76 % of the people surveyed were aware of safeguarding. A similar survey two weeks ago showed 54% recognition. The campaign of posters on the back of buses had been particularly successful.

I wonder if this ‘week’ though is truly ‘national’ and how important awareness is to identification and work to fight against abuse of adults who might be at risk of abuse.

There is a vast chasm between awareness of abuse towards adults and children – for me the division is arbitrary at best. Abuse of a person with knowledge/power/influence towards someone who lacks the ability – cognitive/physical or emotional to guard against it should be tackled regardless of the age of the so-called ‘victim’.

Why should society deal differently with the perpetrator according to the age of the person who is abused if the power differential is equivalent?

This is why I find the divisions and differences between the way that safeguarding is managed in childrens and adults services so different.

There are a lot of assumptions made though in the world of safeguarding. One is that anyone ‘old’ or anyone ‘disabled’ is automatically a s0-called ‘vulnerable’ adult. That isn’t necessarily the case.

But when someone who is at risk of being abused is – the responses from all parties can be patchy.

Perhaps that is why there is a differential in the way that safeguarding is investigated – the determination of being at risk is more straightforward with children because there are clear age boundaries to guide when an action is abuse and when it isn’t.

With adults, it is a value judgement about capacity and power relationships and that loaded word that I can’t quite find a perfect replacement for – vulnerability.

What makes one adult more vulnerable to abuse than another and is there a continuum of vulnerability that can cloud the way investigations are dealt with? In some situations it is brutally clear – Winterbourne View, for example, but when an historically abusive relationship between a husband who is physically violent towards his wife progresses as she develops dementia – at what point does it become an issue for social services to step in?

Between two ‘capacitious’ adults where there are no children involved, this would not be a situation for social services. With a progressive dementia or other vulnerability, it does.

For me, this is a very live issue as I work with a few people who have historically been in abusive relationships and when we intervene and when we are able to intervene becomes a very key judgement in a safeguarding investigation.

The key issues of human autonomy and human rights come into play in so many of the judgements we make regarding decisions of when and how to investigate safeguarding issues and what is and is not a safeguarding issue.

For me, I find I relate much more to the philosophical tenets of rights, responsibilities and ethics as I try and fit together the marginal decisions and the importance that an assessment of capacity can have on the life of another. The ability to reflect on the day to day decisions that might otherwise be taken speedily become more evident and more clear.

I can’t escape of the heavy moral responsibility that I feel in my day to day work. Every decision I make about prioritising, about capacity and in much clearer terms about hospital admissions weigh increasingly with the thought of implication, choice, rights and outcomes.

A thoughtless and unexamined practitioner is a dangerous practitioner.

Sometimes we can choose to overcomplicate and overanalyse but without consideration we can forget the power that we have.

So this week of Safeguarding has more or less passed me by but it is something that I’ll ponder on for much more than a week. I hope that next years’ week, if it exists, has some more thought and coherence behind it (and that it doesn’t coincide with Carers’ Week!).

Distractions and Uncertainty

Of Local Distractions

I met one of the hospital social workers earlier this week. We don’t actually catch up with each other very often but when we do we always make a point of hanging around in whatever corridor we bump into each other in and chat.

This time, we again commented on the ebb and flow of work which seems to be balancing on an almost perpetual ebb without much flow at the moment.

We are all on edge at the moment. Another reconfiguration is in the pipeline and so many rumours are abounding that it is making it very difficult to actually get very much done.  Announcements and decisions are in the offing and have been put back again and again so all we know is that ‘this is a big one’ and that some jobs are going.

Good place to leave it with us, management team!

Seriously I do wonder if any of the so-called management executives who are paid most highly with their years of skills of organising complex projects ever remember those very first baby steps in communication skills and ponder on the way that rumours spread when a team of people are bereft of actual facts.

So my kind of friend, the hospital social worker, filled me with a swathe of new rumours that I hadn’t heard before about how our jobs were going to be directly affected by these changes and in turn, I shared with him the hotch-potch rumours that I’d heard from another AMHP at a training session a couple of weeks ago who, although she is prone to hyperbole, still seemed to deliver a fairly gloomy outcome of what might happen to all our jobs.

We smile. We chuckle. We remind ourselves how complicit we are in spreading the uncertainty through these rumours. Then I return to the office and immediately tell everyone what I’ve just heard from my new source about the talk that is going around at the hospital. He, in turn, no doubt returns to his hospital team with the latest gossip in the ‘community teams’.

And in the meantime, of course, work goes on. The increasingly distressed calls. The organisation and co-ordination of assessments and the desperate attempts to make some kind of priority from the pieces of information that have been fed through to us.

This is life at the bottom of an organisation when the top is reorganising. This is the pit of the rumour mill where scraps of invented truths and fears are ground together and occasionally spit out nonsense but this is what we are talking about in the large open plan offices. This is what is happening while the government is talking about pumping more money into the NHS. This is what is happening when officials are prevaricating and making the policies that end up on intranet sites that we don’t have time to access and read.

And it made me think of Southern Cross – I’ve been thinking about Southern Cross a lot lately.

Of National Job Losses

The announcement of 3000 job cuts yesterday although, I suppose, unsurprising coming from a company that is in such severe financial straits. Considering that they have sold off their property assets, staff costs are likely to be one of their highest expenditures. I wonder how the staff employed today feel. I wonder how the residents who  might have built up relationships with staff members feel and I wonder how people who are about to make placements in care homes feel.

Am I less likely to place someone in a Southern Cross Care Home today? Yes.

The Independent states that

The jobs to be axed are expected to include over 300 nurses,1,275 care staff, almost 700 catering posts, 440 domestic jobs and 238 maintenance posts

They don’t sound very ‘back office’ to me. Although Southern Cross maintains that this will not affect quality of care provision, it rather makes you wonder what the staff were doing in that case.

Ideally, it would be useful to check the data from CQC inspection reports to see what the inspectors said about staffing. The difficulty is that publicly available inspection reports that are recent enough to give up to date evidence.

I decided to look at a few random Southern Cross inspection reports from the London area.  Professor Google spat out some results and this is by no means scientific as I didn’t have the time for a more extensive ‘study’.

Romford Grange? Good report in 2008. That seems in order. Of course 2008 is three years ago now. A long time between actual inspections but we know they are not actually going to do inspections so frequently now. Still, three years seems to be pushing it. Lots can change overnight, let alone in three years.

Tower Bridge Care Centre? Well, that had an inspection in 2010. Oh good, I think. But wait, that was only because there were concerns regarding medication management that had been raised specifically.

Another random check on Camberwell Green Care Home  – oh, an inspection in 2010, surely that’s a good sign? Silly me, the recent inspections seem only to be where there are problems identified. Here’s what the report says

The service has been performing poorly for some time and matters have not been addressed by Southern Cross.They have started to do that recently but that has lead to lots of staffing changes and a turbulent time including managers leaving quickly. The ship has been steadied by a management team who have been sent in to the home. This inspection has identified some of their successes but more work is needed and a key need is for a stable, consistent management team to be in place. Until such time we can only view the home as adequate

Care planning is not personalised and is not considering all areas of individuals need, therefore the care arrangements are not always well informed.
The complaint’s procedure needs to be improved, it has to be open and transparent with complainants feeling that they are listened to and that issues are acted upon. Communication too is not as good as it should be, all issues whether they are minor concerns or not must be addressed.
Despite staff receiving up to date training on Safeguarding Vulnerable people,
procedures are still not fully robust at the service.

Burgess Park? Oh, it had 4 inspections in 2010. That’s what I call exceptionally good monitoring. Ah, one look at the most recent report and you’ll see that it is because there are problems that there has been so many inspections.

For example, their April 2010 inspection report states that

Our observations of a lunchtime on the second day of the inspection showed us that the systems for shift planning need to be improved. We saw that one member of staff was the only person in the dining room where there were fifteen service users. They needed various degrees of assistance and we observed that the lack of staff caused difficulties for them An example was a service user who had to wait an unreasonably long time to be assisted to go to the WC; another service user fell asleep while waiting to be assisted to eat her meal.

and while the July report says that these issues have been ‘addressed’ and more staff were recruited, it does make you wonder where the cuts are going to come from.

Lauriston House? Home to 100 older and disabled  adults – last inspected in 2007.  In fact, a random glance at the ‘most recent available assessments to view’ tells a sorry tale.

Previous reports

  • Inspection report 2007/10/26
  • Inspection report 2006/09/06
  • Inspection report 2005/11/15
  • Inspection report 2005/08/05
  • Inspection report 2004/12/14
  • Inspection report 2004/06/29

Oh, it got a good report. In 2007. But for 100 people, that’s a pretty poor show. In fact, if anything is to tell the tale of the toothlessness of the CQC and the way that CSCI was heading prior to it’s inception – it’s that list of dates. Look on it, ministers and make a decision if that is the level of scrutiny and regulation you want to maintain?

Back to the job losses though. So what will that mean for today’s residents and staff? Uncertainty. Rumours. Whispering.

Whatever we say when we look back at what we can achieve and improve today for our own old age and for that of our children – we definitely can’t say we are living in uninteresting times.

CQC and Southern Cross – a retrospective

I’ve bemoaned both the changes in the CQC and the financial troubles of Southern Cross over the last few years since I started writing this blog.

For today, a bit of a ‘lazy post’ – I thought I’d collate all the posts that I’d made on those two subjects. It provides a little bit of context and stops me repeating myself.

Southern Cross

Trouble at Southern Cross (2/7/2008)

Active Care – Another Tale of Southern Cross? (16/8/2008  – READ THE COMMENTS!

Alton Centre, Active Care and Southern Cross – An Update (5/9/2008)

Southern Cross and Hillingdon (19/12//2008)

Frozen Reading (12/2/2009)

8 deaths – 10 days (26/2/2009) – oh the irony when I comment that Southern Cross own a lot of real estate.

The concerns and worries about the financial management of Southern Cross go back a long way. This is not ‘new’ news. The ‘new’ news is that the company is now close to the brink of collapse. There is almost an inevitability in this as those who sought to make a quick buck in the care sector realise that sometimes the figures don’t add up. Property doesn’t always pay. But making money on the back of what was a public monopoly (provision of care services) can lead to some rich pickings until some of that money needs to be spent. Corners are cut. Staff costs are cut. Older people are warehoused in increasingly larger residential and nursing homes while the roll-out of the so-called personalisation agenda rings very very hollow at the moment for those who are the most dependent and those who need long term care. Where this the personalisation within residential and nursing care services? Where are the small group homes with support for older adults with dementia? They don’t exist because they wouldn’t make a profit.

That is what those involved with personalisation need to address. Not how people who have capacity and ability to manage personal budgets or have families to help them will manage but how will personal budgets (health and social care) and personalisation help and create better systems for older adults in dementia nursing care. Give me an answer to these questions and I’ll have more faith.

CQC – Care Quality Commission

From the first day the CQC came into ‘being’

DoLs, IMHAs and the CQC (1/4/2009)  – these were all introduced on the same day. Do look at the quote from Barbara Young, the first Chair of the CQC. VERY telling.

Britain’s Homecare Scandal (10/4/2009) – another Panorama investigation.

Inspections (3/12/2009)

Can Gerry Robinson Fix Dementia Care Homes? (8/12/2009) – another TV programme.

Linford Park Nursing Home (3/8/2010)

Closing Care Homes (30/9/2010)

Lessons from the Care Sector (26/10/2010)

Trouble at the CQC (3/11/2010)

Johann Hari’s Manifesto for Change in Care Homes (26/1/2011) – one of which was ‘proper inspections’.

Scrutiny, CQC and ADASS (15/2/2011)

Excellence Ratings for Care Homes (1/3/2011)

Inspections and the CQC (11/3/2011)

Whistleblowing (7/4/2011)

Which Care? What Care? (19/4/2011)

Care Home Crises (16/5/2011)

So is this surprising? I wish it were.  I want to emphasise though that it is the management of the CQC that I feel is badly serving those who need support and care rather than the individual inspectors who I know have as many criticisms of the system as the rest of us do. How did this, or the last government allow regulation so toothless just as they are ratcheting up the OFSTED inspections? Does it say anything about how we, as a society, want to value or hide away adults with disabilities?  I suspect it does.

What makes a good care worker?

I haven’t been able to shake off the Panorama programme about the abusive care environment at Winterbourne View.  We spent quite a lot of time talking about it at work yesterday as well, at meetings and in the office.

It has pushed my mind back to the time, before I qualified when I worked for about 7 years (5 years full time and 2 years part time while I was studying) as a care/support worker before I qualified as a social worker.

I was fortunate to work in well run small group homes for adults with learning disabilities and had generally very good managers who encouraged person centred planning and the environment would not have tolerated any kind of mistreatment of the residents whom we were charged to look after.

It made me think about the qualities that would make a good care worker. I’m not saying I was particularly fantastic at my job. I enjoyed it and I enjoyed the interactions with the residents – but not being abusive doesn’t make you necessarily ‘good’ at your job.

The most important thing, I think, is not dependent on personal qualities so much as the ethos and environment that you work in. A team of colleagues who show respect to the residents in their own home and who are respected by their managers and each other will not tolerate one ‘rogue’ care worker stepping over the line.

In an environment like the one portrayed at Winterbourne View, there was no regulation or censure by other staff members or managers. The staff who were abusive were openly abusive and so there was a culture that had permeated the home of mistreatment and abuse. I do wonder how much the culture has been instilled in an organisation by management – not that that excuses any individuals from the personal responsibility they hold – but cultures and systems sometimes allow abuse to be perpetuated in an almost ‘Lord of the Flies’ type way when the management take their collective eyes of the ball. It is for that reason that the management of Castlebeck have to take responsibility.

There is also the issue of training of course, but the deeply developed culture of an organisation is more than a matter of training. It helps, don’t get me wrong. Everyone should know the basics and more about an ethos and environment and what best practice demands but training costs and if you are paying staff a minimum wage without allowing them to develop professionally, you won’t have the same levels of satisfaction and retention. Retention is very important in social care settings. I was lucky to have worked in the same two homes for those 7 years. I built up relationships such that I still pop in for ‘parties’ when I get my invites to the annual ‘anniversary’ celebrations (the anniversary of the home opening!).

So taking the environmental and structural issues into account, a good care worker needs patience. This is not necessarily inherent as a quality and I believe it can be learnt. I believe that self-awareness helps as well. Patience was not high on the lists of qualities displayed in Panorama but you need to be able to show judgement and sensitivity in knowing when to talk and when to walk.

Empathy is vital. Being able to see the people you work with and think about how they feel – about how their families feels and most importantly, treating everyone as you or (insert close family member whether child or parent) to be treated. That’s a very simple catch-all and it is hard to teach to someone but it’s a very basic precept. When you see someone with a disability or someone who is particularly old or young as a ‘victim’ or an ‘other’ type of person, it almost gives you free rein to treat them differently. That is a dangerous position to be in.

An understanding of the power dynamics is also vital. Some people seek out vulnerable people to work with in order to feel more powerful. Power silences people and it instils fear. It is important that the peer group are able to identify this and scotch this. This happens across the social work and social care sector. It will never disappear but having an awareness of it can help.

I often tell families of people who are going to look at residential homes to ask the staff about retention levels in the home – how long have they been there? Are they happy? (they may lie, of course!),  how many permanent staff and how many agency staff there are? Try and talk to staff who are carers and not managers.

There is no doubt that there is a lack of societal respect and appreciation for support workers and care workers in general. We allow our most vulnerable to be cared for by those who receive minimum wages and have poor working conditions.  That won’t change overnight but going back to the CQC and inspection regimes in general, it would be useful to have a deeper understanding of organisational cultures so they can be monitored but perhaps that is too big a job to undertake.

As for me, the years I spent carrying out hands-on care in a residential setting have been crucial to my development as a social worker. In some ways, that’s why I think it’s sad that some of the social care experience needed to go into social work has been reduced as I know I wouldn’t have as much to draw on when I go to review residential homes had I not had that experience.

Sometimes I miss the care work.  It was an honour and privilege to have such an important and significant daily role in the lives of others and in some ways, I was working in a much more person-centred way back then than I am now, through the reams of (virtual) paperwork.