Castlebeck and CQC – Brief Thoughts

Paul Burstow MP addressing a Liberal Democrat ...

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I don’t have time for a long post today, just a few brief thoughts that came to me as I considered the unsurprisingly critical report on Castlebeck by the CQC.

Of course it’s easy to be wise after the event but it leaves a bitter taste in the mouth when the CQC comes down hard on Castlebeck after it required a TV undercover programme to uncover the widespread abuse at Winterbourne View. Where is our faith in the CQC? Well, personally, I didn’t have any to begin with but this report is not a solution, it smacks of a desperation to gain any kind of public recognition of the CQC itself rather than a real attempt to improve any system of regulation.

Regulation costs. Good regulation costs. In the week that the Ofsted is planning two week, unannounced inspections of childrens’ services, I ask why services for adults have been allowed to be neglected?

Yesterday I heard Paul Burstow on the radio on my way home. Two things struck me, firstly that he didn’t seem to have any understanding of the difference between a hospital such as Winterbourne View and a care home. He  seemed to be happy to blame local commissioners for the quality of the placements that they commissioned in hospitals without an understanding of what had led to this situation – namely chasing the lowest prices.  He still is banging on about his so-called Excellence scheme which, if anything, will make things worse as I wrote here. The Excellence scheme is opt-in and it is for companies to pay to be a part of. That is not about excellence, that is about money-making.

The CQC should be demanding excellence from every single service it inspects. Every day. It doesn’t. It demands sufficient paperwork every couple of years, at most. That is how it inspects. Actually, the CQC doesn’t inspect any more. It does not have enough people to inspect, control and check.

We have allowed companies like Castlebeck to rake in millions of pounds of profits on the back of providing poor care to vulnerable residents and patients. We have allowed this because noone is calling the CQC and the government to account for destroying adult care services.

The CQC criticising Castlebeck – of course it will but remember this is on the back of one television programme with hidden cameras. What about the thousands of homes without hidden cameras? Where are the checks? Where is the scrutiny? Where is the excellence?

Light Touch Inspections, Winterbourne View and the CQC

There was a report on the Community Care website on Friday that the CQC were ‘calling time’ on their so-called light touch inspection ‘regime’ thereby rolling out potentially to annual inspections for adult services and care homes.

As the article emphasises

Bower said that the CQC had favoured a “proportionate, risk-based, light-touch” approach to regulation – in which services were left uninspected for up to two years in the absence of issues coming to light – but service users, providers and staff favoured more inspections.

“What people want, particularly people who use services, is for us to put our boots on the ground,” she said. “Inspections are a really positive quality assurance for providers.”

It’s hard to believe Bower would have been saying this if she had not been forced into the position by the Winterbourne View scandal where substantial abuse was uncovered.

A shame that she did not show more backbone and spirit in protecting the organisation that was handed to her to lead when all the cuts were coming hard and fast. It did not take a genius to work out that the only reason the so-called ‘light touch’ system was implemented in the first place was to save money. The problem is, that it has stripped the CQC of any credibility it might have had as a regulator.

And yesterday, this same CQC criticised Winterbourne View and it’s owners, Castlebeck had misled that self-same regulator about issues that where taking place and abuse that was taking place while they were inspecting the service.

Interesting to see the Independent highlight the issues which the CQC raised as criticisms of Castlebeck

Inspectors said they found people who had no background in care services had been working at the centre, references were not always checked and staff were not trained or supervised properly.

They added Castlebeck failed to meet essential standards, required by law, including:

:: The managers did not ensure that major incidents were reported to the Care Quality Commission as required;

:: Planning and delivery of care did not meet people’s individual needs;

:: They did not have robust systems to assess and monitor the quality of services;

:: They did not identify, and manage, risks relating to the health, welfare and safety of patients;

:: They had not responded to or considered complaints and views of people about the service;

:: Investigations into the conduct of staff were not robust and had not safeguarded people;

:: They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred;

:: They did not respond appropriately to allegations of abuse;

:: They did not have arrangements in place to protect the people against unlawful or excessive use of restraint;

:: They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings;

:: They failed in their responsibilities to provide appropriate training and supervision to staff.

While there is no excuse for such considerable failures, you’d think that a good regulator worth it’s proverbial salt should have picked up some of these issues through a thorough and robust regulation system.

Remember this is the same Bower who has promoted extensively the use of whistleblowing and family members as a ‘resource’ to augment their inspection processes. And then the organisation feigns upset when things are concealed to it.

How did we come to this? How did we, as a society, allow the organisation that regulates Health and Social Care to be stripped bare due to a resource-led decision and blunt its teeth so incredibly that people who depend on these services can have no confidence in its position to protect?

Money, cost, closed eyes and an ability to discharge responsibility for the care of those in our society who need particular protection has led for this situation to emerge.

Unfortunately I can’t go into details about some of the things I  have seen over the past week that makes me feel  much more strongly about these issues but suffice to say this – which, in itself – could even be too much.

I visited a care home which had an ‘excellent’ star rating. Yes, the stars are outdated but it is an easy way to check and remains so. There had been no inspections over the past year, at least, anyway. Excellent. And it looked it on the outside. My involvement was due to a large scale safeguarding investigation. Let’s just say it was very far from excellent and had been for a number of years, including when the last ‘excellent’ inspection rating had been given.

The inspections depend too heavily on self-reported data and too little on ‘feet on the ground’ and investigations skills. I sometimes wish I could try doing a really thorough, wholesale inspection of any given inspection service. I’ve worked in residential care. I know what I would look for. It angers and upsets me that self-reporting and the ‘light-touch’ were ever permitted for purely cost-related reasons.

But the CQC says it is increasing inspections – still it will not be close to previous levels. To see them criticise Castlebeck – all well and good – but it doesn’t take the responsibility for inspection and regulation away from them. It bears some resemblence to the social workers who are told they are more easily led by parents who conceal information from them. If the social workers are chastised for ‘believing’ why not the regulator.

It makes me angry. Maybe time to invest in regulation and inspection and demand better services that actually protect against, rather than mask poor care. It is ever more important.

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.

Personalisation and Professional Disillusionment

Yesterday, Community Care published the result of a survey they had undertaken about ‘personalisation’ among social care professionals.

The headline figures while wholly unsurprising, make for interesting reading where only 41% of respondents felt that service users would benefit from the implementation of personal budgets and 83% felt that cuts would impede the progress of the personalisation agenda.

To which my first thought was ‘only 83%’?

Anyone who has read some of my previous writing/ranting about personalisation will be pretty clear where I stand.

While the idea and the concept of introducing more person-centred support planning and opening up direct payments to a wider range of people is absolutely fantastic as a concept, the implementation has been dire.

There has been a complete side-lining of service user groups that don’t fit into the ‘easy’ mode – namely those with mental health problems, older adults and those who might not have capacity to involve themselves fully in the support planning process, the same figures and quotes that the government and her agencies roll out again and again about the man who pays for a PA to go with him to a football match instead of a day centre are so completely off the radar when the smaller pool of money available for care services exist that they are almost insulting to those for whom a) the thought of having enough money allocated to pay for two tickets to a football match would equal 7 showers a week – so it’s football or cleanliness and b) that group of people (because, yes, much as the government don’t want to accept it, they do exist) that actually WANT to go to day centres.

And so we plough on.

But even though I have had many criticisms of the way that personalisation and particularly personal budgets either managed centrally by the local authority (where the end effect is exactly the same for the service users in most situations) or delivered by direct payments (where someone has to have capacity and desire to take on the direct payment and employ assistants or have someone who is willing and able to do that for them) – there is more to the personalisation agenda and process which is in danger of being lost in the process.

Personalisation as a value base and an approach to work and social work in particular with people who need or who are eligible to receive services for care ties in perfectly with aims of re-addressing the power differential between provider and ‘receiver’ and the imbedded dichotomy between ‘giver’ and ‘taker’ in society.

That model of giver/taker which is bound within the welfare state system can create an imbalance and the potential to give back some of the ‘control’ and some of the decisions to the person who receives services may, in some way, redress elements of this balance. There is no way that my training and experience has taught me better than anyone else, what YOU as a recipient need. Yes, I learnt my theories and my models and understand that building social networks is important but if you prefer to do that at a coffee morning at the local museum instead of at a day centre that’s perfect. If you want your neighbour’s granddaughter to help with your personal care rather than an anonymous and frequently changing ‘carer’ from a local agency who is paid at mimimum wage and has a day full of appointments and who isn’t paid for travel time by her agency so she needs to cut short on some of the time – perfect.

But we already had that system with Direct Payments. Where is the difference?

Ideologically, the difference was that everyone would know how much money they were ‘getting’ – whether directly or managed and they would be able to be consumers. Our society tells us that money is power. Money creates consumers and the market will right itself.

Even, theoretically, when a personal budget is managed by a third party (and I include the local authority as a potential ‘manager’) you will know how much is ‘allocated’ to you so that you can ‘spend’ it in the way you want.

This doesn’t happen in practice though because local authorities need to save money and are still tied up into procurement contracts that make agencies unequal when ‘bidding’ for the funds that have been allotted via personal budgets.

I know this is getting a bit technical and complicated but it’s important to understand. I don’t think anyone can oppose ‘personalisation’ as an approach regarding empowerment and ideology.

The implementation, however, reeks of money-saving and penny pinching. It also has pushed the responsibility for services away from the local authorities and onto individuals and their carers.

You have £100 per week, find the care yourself – then we (the LA) aren’t responsible anymore.

I’m wholly in favour of contracting out assistance and advice on self-assessments and support planning to local voluntary sector organisations. My own LA tried that. We referred lots of people to them.  They withdrew because we were referring too  many people to them and the local organisations didn’t have the resources (or the contract) to undertake as many support plans as were being referred – but the idea is not one I have any problem with and in fact, I rather like it.

But this wasn’t offered to people who do not have the capacity to lead in their own self-assessment and support planning. The organisations couldn’t do that because they were not experienced in non-directed advocacy work – it takes longer.

It is hard to see through the budget cuts as well towards a future where, as Burstow as said he wants direct payments to be the ‘preferred method’ of delivery of personal budgets.  I don’t want to detract from the fact that this is and will be fantastic for some, perhaps most people, we move to a model where there is – again – a ‘one size fits all’ approach.

The true tragedy of the personalisation agenda is that is has and is coming to fruition during a period of cuts – the government (and the previous Labour government too) want to pull back the responsibilities of local authorities and with the criteria for accessing any support is rising rapidly it may well be that more and more personal budgets are delivered directly from peoples’ own savings or disability benefits (while they still exist).

I am fearful of the future for adult social care but I’m not necessarily unhopeful.

I think there is potential for change and development but unfortunately the ways I see of improving systems come at higher cost.  There has to be some major research and debate about the delivery of personal budgets and the way that personalisation encompasses people who lack capacity and lack advocates (family and friends) and how they can best benefit from this process – perhaps access to additional funds to pay for the trust fund type system of management we were assured would happen but in practice is not feasible for a relatively small sum of money as it costs more than it might deliver.

We need to see more about how support planning can work in the voluntary sector as, speaking personally, I genuinely don’t have time to do the process of support planning any justice as a part of my day to day job. It ends up being rushed because I can’t devote a couple of visits of a couple of hours to talk through and develop a truly person centred support plan.

The process of self-assessment needs to be reconsidered because while the idea is fantastic for some people – our self-assessment forms are biased towards physical disabilities and look scarily similar to a DLA form where people are asked to explain how they are on ‘their worst day’. That doesn’t really help with confident-building when you are working with someone who has very low self-esteem and depression/anxiety. The process of self-assessment in itself can and has been traumatic – let alone the person who is not able to engage with the assessment process due to a lack of mental capacity where questions about ‘dreams, hopes and wishes for the future’ while well-intentioned, can be hurtful and hard for families to listen to when they are asked to their parent who has advanced dementia.

I fear we have allowed a great conceit to be steamrollered into simply another ‘one size fits all’ approach to developing social care. It doesn’t have to be like this but that seems to be the government perception about what ‘personalisation and personal budgets’ are.

Choice is fantastic of course, but sometimes people want quality as well. It shouldn’t ever need to be an either/or. It does feel like it at the moment with the promotion of choice above all things.

So where are we going? Personalisation isn’t going away and nor should it. Personal budgets aren’t going away and nor should they.  Local authorities, however, might be going away – further and further away from social care and the responsibilities that they hold towards it.

We keep up with the advocacy and with the systems that are failing because we owe it to those who are reliant on these systems to make them work as best they can but we keep trying to pinpoint and pin down the flaws in the implementation with the hope that sometime, some day, someone will listen.

As professionals we don’t oppose personalisation. We have always been trying to use person-centred approaches. We just dislike injustice and inequity and that seems to be painted all over the current implementation and the frustration is that so few people (if any) in government seem to be aware.  Am I disillusioned? Yes, definitely. We were promised new ways of working in a more person centred way.

Desperate, no, not yet though as long as there’s some fight left in the belly to keep banging on and on and on about what personalisation SHOULD be and why it isn’t working yet. Not for everyone.

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.

A Vision for Adult Care – a few brief thoughts

I’ve only just had a chance to read the ‘Vision for Adult Care’ published yesterday and wanted to offer a view very initial thoughts although I haven’t any doubt that it will be referred to continually for many years to come.

Having read it my initial response was a little underwhelmed. I don’t know what I was expecting. Perhaps that was just it really, we knew exactly what to expect. There wasn’t anything in there that should surprise anyone at all.

We know that there needs and will be a genuine desire to push the personalisation agenda and move towards personal budgets where service users and carers have greater control over the budgets that they are assessed to need with services rather than directly provided and commissioned services being chosen ‘on their behalf’.

I have always attempted to care plan with rather than for people. That has been the policy for about 20 years arguably since the 1990 NHS and Community Care Act. What stymied the ‘choice’ element back then was the realisation that services have costs attached and ‘block contracts’ are cheaper and provide more services are cheaper costs to the councils. My understanding is that block contracted care with little choice in the provider was never the goal of the reform to legislation 20 years ago. That was supposed to, and did, open up the ‘social care’ market. It has just led us down this prescriptive path because the prescriptive path was cheaper than the choice and user-led path.

That should be the lesson for the government of the day – but enough with my cynicism.

I can wholly embrace the desire to move everyone to personal budgets and moreover, I absolutely welcome and appreciate the acknowledgement that having a personal budget is not the same as having a direct payment.

The language of social care seems almost designed in some ways to alienate and obfuscate so I apologise in my use of jargon.

Managed personal budgets seem to be a way that some local authorities have ‘dodged the issue’ of blocks to direct payments or when people have been reluctant/unwilling to move to direct payments. The government seems to have made, at least an attempt to understand this.

As the document says

We want people to have the freedomm to choose the services that are right for them from a vibrant plural market. That is why this vision challenges councils to provide personal budgets, preferably as direct payments to everyone eligible within social care within the next two years’

That ‘preferably’ offers the councils some get out within the target of ‘two years’ but it will be interesting to see what outcome measures (because there will be new outcome measures) are going to be taken up in my council, at least and what kinds of pressures and supports will be rolled out for that broader ‘direct payments’ issue.

I wonder how many people accept and understand that these ‘direct payments’ and ‘personal budgets’ are all means-tested and can all be charged. I mention that because sometimes in the press there doesn’t seem a complete appreciation of that. I say that as someone who has recently assisted to set up a direct payment personal budget to someone who is paying full cost. He is paying as much as he is getting back. Sounds nonsensical? Not really, because this way he is able to ‘buy’ into the support package and information that is given in the same way it is to those who don’t pay for their own support. Apparently, according to the government though, we don’t provide the same levels of support for full cost users, that is also rolled out as a goal for the future. I wholeheartedly welcome that. Access to support, information and care planning should and will be a universal service. I’ve always believed it is inherently unfair that people who are charged full-cost have sometimes been denied that support – indeed, I have personally provided it and argued successfully with my managers that I should wherever it has been possible but I am aware that too often the local authority has washed it’s hands of anything that it does not have a direct responsibility for – mostly due to cost rather than callousness. But back to the ‘vision’..

The paper sets out a number of principles

Prevention

‘empowered people and strong communities will work together to maintain independence’

Wonderful. No-one can deny statements like that. The vision specifically explains (quite rightly) that early intervention promotes better outcomes (and lower costs) in the longer term. This is what we have been saying for years – as the eligibility criteria have increasingly tightened. Therein lies the so-called rub. The way the ‘vision’ ducks this is by emphasising community support and action alongside paid care services. The ‘Big Society approach to social care’. Gulp. I honestly still find it difficult to understand ‘big society’. Does it mean more people doing voluntary and community work? I am sceptical even though I don’t want to be. My concern is that it means a greater pressure on family and friends as carers.  The vision mentions the ‘scheme’ in Japan where families ‘swap’ care responsibilities in different areas of the country. I worry that too great a reliance on informal and ‘free’ support will lead to un inequitable access to equivalent services for people that don’t have large support networks or live in supportive communities. Time Banks are also suggested as a way of providing support which is good, I like the idea but too great a reliance on hours given willingly may not be the best safety net.

I absolutely agree that commissioning needs to be closer to the ground. I see some of the craziest commissioning decisions being made and can’t believe anyone in those service areas have any clue about what  the local community needs or wants.

The vision does state clearly that ‘Carers are the first line of prevention’. Good. And it goes on to explain ‘Councils should recognise the value of offering a range of personalised support for carers to help prevent the escalation of needs that fall on statutory services’.

I have set up a lot of carers’ direct payments myself and have a few carers who manage them. In some ways, it is very easy to ‘sell’ direct payments to carers as there is a much greater degree of flexibility but there is actually very little money allocated to carers’ direct payments presently. I hope this ‘vision’ and appreciation of the longer term saving that carers are contributing that we will be able to offer them more money through direct payments themselves. Carers Allowance is some kind of evil joke that is, in my view, insulting. Carers Direct Payments potentially can ‘make up’ for it but the local authorities have to loosen the poor upper limits on the carers’ direct payments.

We are promised a forthcoming carers’ strategy. I await it will much interest.

Telecare and technology is also mentioned. We have been promoting this for a few years. It can be very successful but it cannot replace human contact.

Personalisation

I’ve mentioned this above and am very glad that the document acknowledges that ‘A personal budget alone does not in itself mean that services are automatically personalised’. In some ways, that has been my cry in what I thought was the dark. The document mentions the areas that have been slow to pick up in the roll out of direct payments, namely older adults, adults with mental health problems, adults with learning disabilities and adults who lack capacity.  Regarding one of the ideas for managing direct payments for people who lack capacity, one of the suggested ‘solutions’ is placing the control of the budget in the hands of ‘another suitable person’. Interesting. I wonder what this means – informal care and support, a trust fund type project, a professional. All have potential costs and as the criteria for eligibility tighten, the money itself will be less. Higher quality care and m0re choice with less money. Sounds perfect.

There aren’t really any solutions offered but at least acknowledging some of the difficulties is a start.

Interestingly, there is a line about increasing choice to people living in residential care which is a fantastic idea. I am very curious and excited to see how this might happen in practice.

Again, the examples offered in the Vision relate to people that have capacity, support and ideas.

There also seemed to be a suggestion that the IMCA (Indepedent Mental Capacity Advocate) role might be broadened. This is a joy to my cynical self. I  have worked extensively with our local IMCA service and I couldn’t praise them highly enough. I really really hope we can use them more but they will need to be paid.

Plurality and Partnership

The vision emphasises an idealised support ‘partnership’ between individuals, communities, voluntary sector, private sector, NHS and local councils. Probably in that order of preference.

We are told the aim is ‘a broad market of high quality service providers’. Absolutely fantastic. This is my vision for social care as well. I am just a little cynical about the high quality=low cost possibilities but I am willing to be proved wrong, indeed, nothing in the world would make me happier. I want to be able to advise and promote high quality care from many different providers. But that was what we were promised 20 years ago.  The vision promotes a move away from the ‘block contracts’, again, personally, I feel in general they have been negative and have limited choice but there has to be an acknowledgement that they grew out of a necessity to reduce costs.

Protection

Safeguarding concerns have often been raised about the roll out of direct payments and a potentially larger, unregulated workforce of Personal Assistants as well as issues regarding management of finances.

The vision seems to have a great deal of faith in CQC (Care Quality Commission) to inspect services where safeguarding concerns have been raised. Anyone else notice the slight problem here? That’s a bit like closing the door after the horse has bolted – I apologise for the cliche.

There is also the suggestion of a type of ‘neighbourhood watch’ scheme for people in communities to ‘report’ and ‘look out for’ people who might be being subject to abuse. Honestly, I hope this is happening anyway. Fine, it doesn’t do any harm but it doesn’t replace a strong safeguarding structure and culture. I noted there is a particular statement that

‘Local government should act as the champion of safeguarding within communities’ which suggests  that whatever the new ‘practices’ outside the local authorities will do, it won’t be safeguarding. There is a consideration to put this function on a statutory basis. Please, please, yes, yes. Vulnerable adults need the same protections as vulnerable children. This is long overdue and a real failing of the current safeguarding system that at times feels too toothless. It is very hard to get police involved sometimes where I can’t imagine there would be the same difficulties if we were talking about children rather than adults.

Productivity

The vision goes into greater detail about the financial package the local authorities and social care has been ‘gifted’. So be it. It is unprotected money and we all have doubts as to whether it will be enough but noone is getting any money at the moment. There is a focus on efficiency savings.

One of the elements that made me happiest actually is hidden towards the back of the document where it states that ‘The Department of Health will amend the ‘Payment by Results’ tariff from April 2012 so that the NHS pays for reablement and other post-discharge services for 30 days after a patient leaves hospital. From next April, Trusts will not be reimbursed for unnecessary readmissions to hospital’.

Hopefully, this will mean that discharge planning is more coherent and less rushed with the Trusts knowing there will be cost implications of readmission if they ‘get it wrong’. Good.

On the other hand, the vision wants councils to rip apart any remaining in-house services. I understand their point that this is potentially narrowing choice but often, certainly everywhere I have worked, it has been the best quality service when compared with private sector care services. This makes me sad. Goodbye, in-house support. I miss you before you have even gone.

People

And so we move to the social care workforce. Sigh. Yes, the government say ‘care workers, nurses, occupational therapists, physiotherapists and social workers, along with carers and the people who use the services’ and you get the impression they put the list in order to importance in their own minds’ eye.

The vision explains that

‘New and continuing professional roles will be developed for front-line social workers, occupational therapists, nurses and others’.

And then goes on to explain the problems there are with sickness and absence in the sector. I wonder if all the reconfigurations have been an issue about increased stress and uncertainty, never mind. I’m sure the government hadn’t considered that.

Interestingly there is mention of working with Munro’s review of children’s services in social work to allow social workers to have more ‘decision-making authority’. Huh? I thought the decision-making was to lie with the service users.

I am thrilled that there seems to be a linking of social work with community development. Seriously. I think this is absolutely the best area for adult social work to place itself and I am genuinely excited to think there could be a role for social workers in community-based growth. However, the skills sets may not quite be there and there will need to be some additional support given at first.

Generally, it’s a mixed bag that tells about lots of hope and plans as expected in a vision. There isn’t much suggestion or explanation yet but that will come with time. Some elements are clearer, some even foggier than they were before and my brief thoughts have been less brief than I imagined.

I find it very hard not to be cynical and I find it very hard to trust this government to be honest. There seems to be a worryingly high dependence on ‘free’ care provided by family and community and no explanation of where the support will come from when these community supports don’t exist.

But I do want the system to be better. I want everyone to receive a better service, not just those who are able to actively engage with the process of receiving a direct payment and I want the changes to work. I don’t care much for the government but I do care desperately for the sector.

A vision is nothing more than a promise until it delivers though. I want the central government, a government without  a mandate, to deliver on outcomes and promises as well as local government officers.

And with that, I sign off the longest post I have ever written for this blog – thanks for staying till the end (if you did). It terrifies me that the word count for one post I wrote in 40 mins is the same as the word count for the essay (currently taking a PQ module) that has taken me about 4 weeks to write… .. . . .

On Professional Conferences and Frontline Workers

The thought for this post came during a brief conversation with my sister yesterday. I was berating and ranting about how I have a feeling that ‘no-one ever listens to us’. The ‘us’ in question, just to give the conversation some context, was front-line, currently practising social workers.

The reason for my railing was the way that I have been following the National Children and Adult Services Conference 2010. Mostly my links have been maintained through a variety of Twitter feeds that I am following. Twitter is good for checking while sitting on buses or when you are hanging around because you’ve shown too little faith in London Transport and turned up 20 minutes early for an appointment.

The National Children and Adult Services Conference has had a lot of influential speakers – ministers, shadow ministers, heads of various services and quangos. I see (and maybe I’m wrong in this) no place for actual practitioners at events such as this. It costs £500 a throw and there’s no way on earth any local authority is going to let loose anyone who actually works in the frontline access conferences that have expenses such as those.

Instead, they create little silos of managers talking to policy-makers talking to consultants talking to reporters. About Social Care. About us. But not to us.

Yes, Hilton Dawson speaks, the Heads of the College of Social Work speak but where are the people who actually work in social care at the front-line? Not in the managers’ officers earning comfortable pay packets to commission utterly inappropriate services and push us into working in unintuitive ways. We have a lot of people in ‘social care’ who would wince at the actual day to day work.

A few years ago, when I was in a different team (I’m sure I’ve told this story before, so indulge me for a moment or two), one of the assistant directors in the borough was doing an ‘on the coal-face’ type exercise. For some reason, I can’t remember why, I was ‘volunteered’ by my manager to take him out with me on my visits. I think because she was fairly sure I wouldn’t say anything rude! The cases I had on the cards (already booked up by the time I knew he was coming) were bread and butter stuff. Very straightforward and non-complex pieces of work – one initial community care assessment and one review with a carer involved.

On the second visit, when we were speaking to the user and carer, I explained what services we could offer, he chipped in and was very sympathetic – he was (I say ‘was’ because he is in a different role now) a really pleasant guy – actually offering more than we would under our eligibility criteria because it ‘seemed rational’. Afterwards, I explained to him that we couldn’t offer the care that he had suggested because it was outside the budget allowed by the authority. This surprised him. He had an idea how rationing actually works on paper but when you are on the front line telling people that they can’t get a service that they desperately need. That was a ‘new’ experience for him. He saw the stress of the carer and wanted to help. Wanted the service to be available for them. It wasn’t though.

It’s what I do every day. I am the person who tells users and carers that their local day centre is closing down and the social contacts they have made will be dissipated as the council see it as ‘unimportant’. I tell the overstretched and undervalued carers that respite has been cut because eligibility criteria have changed.  I am the person who people complain to when they get the bills for their care services and explain how ineffective the agency care workers are. I am the person who sits with someone in tears as we try and battle through a Self Assessment Questionnaire which has no subtletly  and reads like another DLA form, putting a price and a cost on something as ethereal as disability – especially fluctuating disability. I am the person who tells people they can only access minimal services because the criteria of the council have changed.

Not Paul Burstow. Not Andrew Lansley. Not the people sitting in the room at the National Children and Adults Services Conference 2010.  They may be experts in organisations but they are not experts in practice. They do not speak for the social care sector, they speak for the managers of the social care sector.

Now my sister, who is a lot less hot-headed that I, gently reminded me that this is not something that is exclusive to the social care sector. This happens in all industries. Managers talk to managers.

I have to wonder where the expertise lies.

When I hear Paul Burstow make statements about personal budgets and everyone nodding along at how awful it is on the ‘front line’ without any of them ever having an experience of going into someone’s home and holding the hand of someone who is terrified by another form, another set of bureaucratic functions that seem to be further removed from the reality of needing care immediately.

When I hear Cynthia Bower, I wonder how she would feel sitting next to me this week as I attend yet another safeguarding meeting at one of the ‘supposed’ ‘Good’ residential homes that can’t even manage the very basics of care and have not had an actual inspection for a couple of years.

Yet, she is the ‘expert’ who is able to make all sorts of claims about improving services by taking away controls and checks. And the managers cheer because THEY don’t like being inspected.

Sure, I complain about performance indicators. A lot. The reason I complain about performance indicators is not because I don’t think we should have our work measured objectively. I do. I just think some of the PIs are utterly ridiculous and have no relation to the quality of work we undertake.

Back to the National Conference of Children and Adult Services. It’s fairly interesting some of the noises that have come out of the processes. I know there are practitioner events such as Community Care Live. Indeed, on 17th November there is a Children and Families Event – definitely worth attending if you are involved in that area of work and available.

I know the different conferences are aimed at different groups. It would be interesting to know if they say the same things.

My father was involved in the disability advocacy movement as a disabled man. He expressed heartily the need for user involvement in the development of services (quite rightly!). Similarly, we in the profession need to advocate for our own professional roles in relation to our managers.

My message, and I’m channelling him now is ‘speak to us and not for us’.

One day, I’d like to see the same people attending events like Community Care Live as attend the National Conference of Children and Adult Services.