Rankings and Musings

Quick post today as I have a few things on the go.

So, Wikio sent me their top 20 UK Health Blogs and again, I’ve made the list. Thanks to everyone for your support and do check out the other sites there – there are some real gems and it’s a pleasure to be among such fine company.


1 PsyBlog – Psychology Blog
2 Sarah Boseley’s global health blog
3 A boy with Asperger’s
4 Dr Grumble
5 Maternity Matters
6 Bad Medicine
7 Where Are My Knees?
8 Confessions of a Serial Insomniac
9 Fighting Monsters
10 Purple Noise
11 frontierpsychiatrist.co.uk
12 National Death Service
13 The Voyage
14 Aspergers, family life and me
15 Bah! to cancer
16 PlanetOutreach-ASD
17 the DeafBlog
18 Carers blog
19 Lake Cocytus
20 DPAC

Ranking made by Wikio

I also was interested in this post from Community Care about crafting in care homes.  I wish there were more personalised activities (or any activities beyond the ‘singalong’ and ‘bingo’ ). It does raise important issues about the sense of self and differing interests and pursuits that one has when one might need residential care and why we make assumptions that what is enjoyable for one person would be enjoyable for the next, just because they are the same age.

With the move towards self-directed support in care provided at home, I wonder when residential services will also pick up.

On a related issue, I caught this link yesterday on Twitter about a care home which has installed touch-screen computers. For me, it’s an obvious step to take but its’ a shame it had to be provided by a grant and not by the provider service themselves – seeing how much they charge for placements!

I wonder how much these private companies are subsidised by these types of grants…

Still, it is good to see some different ideas about ‘activities’ in care homes and a challenge to the assumption that older people just want to sit around and sing ‘Knees Up Mother Brown’.

Which Care? What Care?

Lakeview Care Home. One of two modern care hom...

Image via Wikipedia

Another day, another story of sub-standard care in residential homes in the UK. Today, the Guardian publish a story which relates to a Which? investigation

It explains some of the way the survey was conducted

In the most extreme case, a member of staff was witnessed dragging a resident towards the toilet by one arm, while another was repeatedly pushed back down into their chair by the head and shoulders when trying to stand up. Which? reported this to the health and social care regulator, the Care Quality Commission (CQC), which suspended admissions to the home immediately.

Anyone spot the problem with this? Yes, that’s right, the CQC waits for incidents like this to be reported to them and then subsequently take action. The CQC or any regulation or inspection authority should be the ones uncovering poor practice rather than being solely reacting to complaints that are made to them.

The Guardian goes on to say

The care homes were selected at random by Which? – one had previously been rated as poor by the CQC, two were deemed satisfactory, and one had been rated good – and the actors’ resulting diaries were analysed by a panel including an expert in inspection, an expert in activity and daily living, and a dietician.

Again shows a problem that has occurred since the scrapping of the ‘star’ system. Homes are still advertising the ‘stars’ and claiming to be ‘good’ or ‘excellent’ when it is outdated system demonstrating outdated inspection reports but still it is the first thing that people looking for residential care for family members.

It is very telling that a Consumer Organisation found the evidence rather than the official regulatory body.

But back to these homes and we’ll see the real fallacy in the ‘ratings’ and the inspections because despite the so-called ‘good’ inspections,

n three homes, residents sometimes had to wait 16 or 17 hours between dinner and breakfast without food, and in one home lunch was served just 1.5 hours after breakfast at 10am. For dinner one researcher was served a small sandwich and a chocolate-covered ice cream, despite them previously stating they didn’t eat chocolate.

There was a worrying lack of activity in all four homes. In one, residents constantly said they were bored, and in another not one of the advertised daily activities (including exercise, a quiz and a singing session) took place.

Does any of that sound ‘adequate’? Let alone ‘good’?

How is this allowed? Because the reduction of age and disability to irrelevance and unimportance in our society. Because care homes illicit a sense of guilt that we barely want to look behind what actually happens behind those closed doors.

This Which? investigation took four homes at random.

The CQC chair, Jo Williams is quoted as responding

The evidence Which? shared with us describes care that falls below what people using social care services have a right to expect – in one case so seriously that we acted immediately to ensure admissions to the home were suspended, and are now considering the best action for residents currently living there.

So this random sample of four included one home where the treatment and findings were so bad that it warranted an immediate suspension of admissions.

She goes on

“CQC listens to the views and experience of people who use services and look at what data tells us in order to identify possible risks, then reviews and inspects services. Seeing for ourselves what is going on in care homes is a key part of our regulatory regime – and almost all of our visits are unannounced. Where necessary, we require improvements against clear timescales or take enforcement action, following up to ensure these improvements have been delivered.”

Almost all of their visits are unannounced and they are ‘regular’ but tellingly, they are NOT frequent. Why is she not proud of the frequency?  The views and experiences of people who use services are important but how often will people feel safe in complaining.

Lest we forget, the Chief Executive of the CQC is a Cynthia Bower, who was Chief Executive of the  West Midlands Strategic Health Authority which was responsible for overseeing the Mid-Staffordshire NHS Foundation Trust where over 400 patients were found to have died due to neglect and poor care. How was she seen as able to take up the role of Chief Executive of the CQC? Not exactly a glowing track record on the regulation front.

Yesterday, Bower was facing the inquiry into the appalling levels of care in Stafford Hospital.

The Independent explains that

She told the inquiry, chaired by Robert Francis QC, that it had been “distressing to learn of the failings of care at Mid-Staffordshire Hospital and I offer my utmost and unreserved sympathy to patients and their carers and families. “I am deeply sorry for what happened and for the fact we had oversight of the NHS in the region at that time and we didn’t pick up failings in care.”

In addition to complaints, there were other alarm signals, such as reports of poor care from the Health Care Commission, the CQC’s predecessor, and of serious untoward incidents. But she said these were not enough to reveal what was going on.

“I wasn’t conscious at the time there was intelligence that we could have put together that would have said there were major failings of care,” she told the inquiry.

“I accept there were some issues we lost track of that would have generated more concern, but I don’t accept there were serious failings to put the pieces together.”

Ms Bower said the SHA did not have the capacity to have a detailed oversight of all of the region’s health services. She said the last NHS reorganisation in 2006 had caused a big upheaval and staff cuts of 60 per cent.

The first thing that springs to mind is ‘didn’t she learn anything about her role in the Stafford tragedy about the importance of GOOD regulation in the care system?’ The second thing is amazement that she should have been appointed to the CQC position anyway after such a horrific track record.

The government’s solution to this? To increase self-regulation and to out-source the so-called ‘excellence’ ratings for those care home providers that can pay.

The answer? Well, it would be more expensive but it would be more spot checking of the things that actually matter to the quality of life of users and residents in these services. How about a radical proposal that every care home is subject to the ‘excellence’ ratings whether they pay or not?

In some ways, nothing saddens my heart more than pounding on and on about poor quality care homes and poor quality inspection regimes – especially as I know that there are many very good care providers out there but unfortunately with a system of inspection which is so broken, those that are good are not recognised and those that are not good are not castigated and closed as quickly as they should be.

How have we ended up with a system that offers so little protection to some of those in our society who are in the most need of advocacy and support? By not caring enough about these stories.

Perhaps  more advocacy is a solution but it costs. Everything that is a potential solution costs. And that’s the problem.

But this is not something that can be swept under the carpet. These stories will return and I hope they do return to haunt those who are responsible for the destruction of the regulation system.

Because until they develop a conscience and a backbone, they will not go away. It’s just a matter of how many stories can remain hidden. And for how long.

Excellence Ratings for Care Homes

Yesterday, the government announced the unveiling of a new ‘gold standard’ or excellence rating for care homes. This is supposed to address some of the poor care that is delivered through local authority funded care.

I have my doubts. Not that I’m one to be necessarily cynical. But this time I am.

There are a number of reasons for my cynicism.

I believe the problem of poor care standards in residential and nursing care could be much more easily resolved than by a further level of ‘tick boxes’. All it needs, in  my massively oversimplified world, is more spot checks and random inspections – weekend and week day – day and night.

If a care home is doing its job and providing good care with adequate staffing, there should be no problem in well-informed inspectors and lay visitors popping in at any point and being able to speak to any resident or family member.

But this is too simple for the government.

The gold standard of excellence that they are introducing will be funded by the care homes and thus by possibly increased fees as these costs will filter down of course.

They will provide a new set of ‘tick boxes’ for homes to complete.

The Independent explains what the new system will involve

What will be rated?

* What may be included in the new excellence ratings

* Ratio of staff to residents

* Turnover of staff

* Activity programmes for residents and evidence that they are taking place

* All staff to be registered with the new Health and Care Workers Professions Council

* Minimum qualifications for staff

* Spot inspections and independent feedback from residents and their families.

Firstly, it’s important to note that these are issues that ‘may’ be included. Secondly, I thought that some of these issues were already a part of the inspection programme.  And if they aren’t they should be checked for ALL care homes – not just the ones that pay more to be part of the excellence scheme.

Basically, this ‘new’ system is a way of the government trying to add another layer of cost to what the CQC (Care Quality Commission – who are SUPPOSED to be regulating care homes)  should always have been doing.

The CQC claim that the new system will be owned by the CQC but administered ‘under licence’. Why under licence? Because it allows private companies to get their teeth in and allows more money to flow in. The CQC has proved that it is spineless, toothless and unfit for purpose.

The press release goes on to say

Chief executive Cynthia Bower said: “CQC’s role is to identify and react to signs that people may be at risk of receiving poor care. This means we can say we don’t see signs of risk at a provider, but this is not the same as saying a provider is offering ‘excellent’ care.

I say she’s plain wrong. The CQC does not identify poor care. They may react but they don’t identify. It is like pulling teeth from a dog to actually report poor care to them and the thought that they might actually, you know, physically walk into a care home and check the standards is living in a fantasy land where a community and country actually pay attention to the quality of care in residential homes. It should be a role of the CQC to define and award ‘excellence’ in care as a part of the current registration regime but under this new system, this role will be tendered out, at a price, of course – because, after all, what isn’t for sale in this country now – to private providers to ‘check’ and do the job the CQC should always have been doing –  but only for those who pay for it.

I don’t understand why the ‘star’ system was abolished (as it was last year) only to introduce another system at a higher cost. Why not judge ALL homes on this excellence standard rather than attach a higher cost to those homes that wish to ‘register’.

It all seems like a complete smokescreen to hide the toothlessness of the CQC (Care Quality Commission) and a way to garner more money from the independent and private care providers to pay for an inspection system that is not fit for purpose anymore.

Does no-one else see this? I’m amazed the government have the gall to get away with announcing this as if it is something new.

If they or anyone REALLY wanted to improve the quality of ALL people in residential care, they would fatten the CQC up with more inspectors and give the inspectors more leeway to inspect.

One of the worries of mine was also mentioned in the Independent namely that

At Christmas, the Care Quality Commission (CQC) carried out spot inspections of 234 health and social-care institutions, including nursing homes, which revealed significant lapses in standards in more than a third of cases. Ten reviews resulted in the highest form of censure, which could to lead to the commission withdrawing licences to operate.

After one review, a nursing home in Luton – run by Southern Cross, Britain’s largest care-home provider – was closed immediately because conditions were so bad. The commission found that 26 other institutions were not meeting required standards in all areas and ordered improvements.

So surely more and better spot checks are the way to unearth poor practice rather than another hoop to jump through at cost.

Why don’t the CQC just adjust some of their own criteria to include those elements raised in this so-called ‘excellence’ standard? Why does it need to be a separate and discreet system? Possibly because this way the government can raise money from it and farm out the inspections to private companies rather than relying on the toothless and frankly incompetent CQC to do.

Yes, I’m angry. I am angry because a real attempt should and could have been made to improve the quality of all residential care services nationally and it was fudged and obsfuscated. We are to be fooled by this ‘gold standard’ which is another way of saying ‘if you want our money for placements, you must pay’.

I see this system as being biased towards the large care providers. The Southern Cross/Care UK/Bupa providers at the expense of some of the small operations.

Some of the best service delivery I’ve seen has been in smaller one-man operations. I remember the care home I visited where the owner’s mother was a resident, her husband was the handyman and it felt like an extended family where the owner lived next door and spent most of the day sitting in the lounge chatting to the residents.

Would she be able to pay for an ‘excellence’ rating? Who knows – but the excellence and level of care was unmistakeable.

Should we be jumping in the air and celebrating a new excellence system? Maybe that’s what the government smokescreen wants us to do.

For me, the death of an effective regulatory system makes me sick to my stomach and makes me despair for the future care for older people in this country.

Bullying

Bullying on IRFE in March 5, 2007, the first c...

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Bullying – it’s a very loaded word. As adults we’ve been through the school experiences where, if we didn’t experience it and weren’t perpetrators, we’d probably know people who were in one or the other camp.

School is just a community where identity takes hold and is shaped and as such, with children growing and developing there personalities and thrown together merely on the basis of age and location or wealth(in the case of private schools) there is no reason to believe that everyone will get on and live happily together.

Fortunately, there are some wonderful resources and help available for children who might experience bullying. Often parents will be very supportive.

Let’s turn that perception on its head though because this week, I have been discussing and processing the implications of bullying in a residential care home for adults with dementia.

This is not bullying by managers of staff or bullying of residents by staff.

This is bullying of residents by other residents.

In some ways, I’m surprised that there isn’t more debate and discussion about this. After all, in some cases, people who require residential care and who have dementia may not have many decisions about where they live. Adults are proverbially thrown together merely on the basis of age (and diagnosis), location and wealth (in the case private homes).

Why is it more surprising that the tribal nature of the human condition becomes any less apparent than it would with children?

We are still working with and alongside people who are vulnerable but are there any resources available for adults who are bullied in these circumstances or the families of adults who are bullied in these circumstances.

As mentioned above, I am involved in various safeguarding processes for an adult in a residential home who is being unfairly targeted by another resident.

Without too many details, the decisions that are taking place around the people involved  relate almost entirely to series of best interest meetings and discussions.

Should we move the target who is not even necessarily aware of what is going on around them but who is settled and has already moved a couple of times?   Or should we move the perpetrator who is adamant that they do not want to leave?

At what stage does this ribbing and teasing or just two people who don’t get on, become an imbalance in power that is usually present in ‘bullying’.

While we have come to a solid and I think, acceptable decision that is protective for both parties (and as the care coordinator for the ‘target’, she has been my primary responsibility), this case has led me to reflect on and consider other cases that I’ve been involved with where abuse has taken place between older adults in residential care settings and day centres.

I’m very surprised there isn’t more research and information about it and some of the staff in these settings seem to be constantly amazed that all people regardless of background, culture and history don’t just ‘all get on’ in the lounge to sing ‘Knees Up Mother Brown’.

Are we denying the humanity of older people by trying to pretend that they are somehow less human because they are not succumbing to some of that most human activity in ‘community environments’ of picking off the weakest or the most ‘different’.

I think by not actively and forcefully discussing issues of bullying and having plans around them, we are doing a disservice to all older adults for whom we, as a society, have a duty to care.

One day, newspapers, communities and the public will be as interested and as horrified by the stories of bullying in older people’s communities as they are in schools.

It shouldn’t really surprise us when you think about it. As I’ve said many times in person over the last few days, this is what happens in communities of humans – and there are various almost tribal elements at play as communities form into ‘stronger’ and ‘weaker’ elements. Why should this be different when we age or become unwell or a memories begin to fade? We don’t stop being human.

As a service and as a profession, we need to have plans that are as strong and protective for older adults experiencing bullying as we do for children as often there aren’t the forceful parents around to protect and defend. It is left to us, as professionals, to take that advocacy role.

There also has to be a broader understanding that things don’t always happen in the way we would like them to and more care homes and placements need solid guidance and frameworks for managing and working with communities where sometimes people don’t get on or choose to be and particularly where were a very different power balance elements at play due to differing physical and mental health needs and differences of dependencies – dislike can lead to bullying within the environment if it is not addressed.

Bullying is about power differentials. That doesn’t cease to exist when we leave the playground or the workplace. It is the unfortunate aspect of community building and the human condition and it can’t and mustn’t be swept under the carpet.

One day I want to see the same resources, organisations and policies around bullying within care homes and sheltered housing communities as exist around bullying in schools.

Closing Care Homes

Community Care reports that the CQC yesterday released figures stating that 42 adult care services (that would be care homes and home care agencies) have been closed over the last year following action taken by the registration authority.  A further 51 services were closed following ‘poor’ ratings.

The Guardian breaks down the figures a little more minutely. And the figures deserve examination.

Those 42 services comprised of 34 care homes and 8 agencies.

Of the ‘further 51’, that includes 39 care homes, 11 care agencies and 1 nursing agency.

The total amount of residents who have needed to move places of residence due to these closures is 1600.

How is this not a national scandal on the front page of every newspaper?

It may or may not be obvious (probably not, come to think of it) but I do haul around searches for care homes and poor practice in care homes including ones that have been forceably closed – that is active searching – and maybe 3 or 4 might have been on my radar. So that’s an awful lot of highly vulnerable people who have been subject to incredible disruption, often linked to abusive practices in these care homes that have completely slipped beneath the public radar.

The Guardian lists the reasons for these closures as being

• verbal and psychological abuse of residents;

• medicines not being managed safely, leaving people at risk of not receiving vital medication;

• lack of medical and nursing care;

• staff not legally able to work in the country;

• poor sanitary conditions;

• lack of staff training.

Unfortunately, verbal and psychological abuse of residents is always a potential danger in work with vulnerable people. Residential homes can be a rich ground for potential abuse and sometimes the ‘wrong’ people are attracted to the kinds of work which can allow for abusive power-plays. It is despicable, it should never happen, but it has and it will, unfortunately. The only way to stamp on it really is strong regulation and good management.

All the other issues though seem to point to potentially money-saving measures related to staffing –  illegal immigrants will invariably be paid a lot less than ‘legal’ employees. Poor medication management points to poor training. Training costs.

Lack of medical and nursing care? Medical and nursing care costs.

Poor sanitary conditions? Cleaning up costs.

Lack of staff training? Training costs.

Do we see a theme here?

It is a very pertinent theme as we move towards an NHS which will increasingly draw on private enterprise.

This announcement and these figures are in advance of a new regulation system that comes into place on Friday. I’m fortunate to have a very good friend working in CQC as an inspector.  We go back to when we worked together as care assistants in the same residential home. Now, that makes me feel old but I raise it only to show how strange it is where our careers take us – anyway, I use her as a sounding board about my day to day frustrations and equally have a neat little insight into some of the behind-the-scenes changes in the various regulatory bodies that have become the CQC. It sounds like a mess, to be frank.

I lost any faith in the regulatory system a while back – not because there aren’t good people working there – indeed, taking my friend as an example, I would be hard pushed to think of anyone with a higher moral compass as a practitioner and she couldn’t be more focussed on providing good outcomes but the constant flux in the system (and yes, retraction of staffing levels) does have an impact both on quality and on staff morale.

At the ‘sharp’ end we have abusive systems in residential homes which are able to rattle along without sufficient oversight and regulation because there aren’t the people to provide the level of supervision needed.

I don’t want to colour the past in roses unnecessarily. I know there were problems, certainly with the physical structures of homes but with private companies, the motivation to ‘get better’ and ‘improve’ is not sufficient to force their hands. It only occurs when the delivery is so very poor that they are actually losing money.

There was an interesting quote from Cynthia Bower, the Chief Executive of the CQC in the Guardian where she says .

“This is where we’ve been focusing our attention over the past year as we get the sector ready for a new registration system that will be even tougher when care is not up to scratch.

My ‘mole’ in the CQC would claim that this is a part of the problem – the focus on changing systems has taken people away from front line inspections and where I’d agree with her is that the desk-based inspection systems do not provide any protection to those the system is meant to protect.

I know the system is due to change but in my old fuddy-duddy way, I would say there is absolutely no replacement for spot inspections regularly, day and night, weekday and weekend, from inspectors.

A ‘good’ report one year is no more valid than a CRB check one day after it has been completed. Bad things can happen the day after an inspection takes place.

Yesterday I was talking to a family member about a problem that she raised regarding a residential home where her mother is currently placed. This is a ‘good’ residential home.

It isn’t an issue that could be termed to be ‘abusive’ but it shouts ‘poor staff training’ to me. One member of staff saying one thing can make a ‘good’ residential home ‘poor’.

I know it’s not fashionable and I can’t see it happening – not in the current climate – not ever, but when the staff were employed directly by the local authority, at least training, pay and conditions and supervision could be better enforced.

Of course, we can never roll back the privatisation of the care sector but it’s amazing how few lessons have been learnt from the difficulties faced. I suspect it’s because it is an aspect of people’s lives that no-one really wants to think about unless they are directly faced with it.

I suspect it is part of an ingrained fear of growing old and possibly internalised ageism which sees ‘the economically redundant’ elderly as being somehow peripheral to mainstream society and their needs, wishes, wants, desires and aspirations – even if those aspirations are about living out ones’ life with the necessary care given in a dignified and sensitive manner.

Older adults will never have the same voice as young families in drawing the attention of the exchequer.

Why aren’t we shouting about these residential homes that deliver so poorly? Why isn’t every single closure on the front page of the national newspapers? Why does no-one care about the ways we treat older adults in this society? How is this able to happen?

Money, guilt and fear, I suspect.

This is why I wanted to work with older adults initially and it remains the same ten years after qualifying. There is so much more work to be done. It can feel like swimming against a rising tide but if we don’t shout out and shout frequently, all will be lost for our futures.