Winterbourne View – Where were the Deprivation of Liberty Safeguards?

One of the many things that have been concerning me since the Panorama programme about abuse within the Winterbourne View hospital for adults with learning disabilities was aired was the way that the safeguards implemented under the Mental Capacity Act were, or weren’t used.

Bearing in mind that a number of the patients/residents would have been formally detained under the Mental Health Act, that still leaves some that surely should/would/might have been subject to the Deprivation of Liberty Safeguards.

Law books 2

Eric E Johnson @ Flickr

On The Small Places, Lucy, in a fantastic post that breaks down a lot of the issues, writes on this matter stating

Undoubtedly everyone on that ward was deprived of their liberty, but were they detained under the provisions of the Mental Health Act, the Mental Capacity Act Deprivation of Liberty Safeguards, or just unlawfully detained?  It’s not a question that’s taken up, but from a legal perspective it’s very important.  If they were unlawfully detained, police should look at charges of false imprisonment on top of other charges relating to assaults and neglect.  If they were detained under the DoLS, who wrote the assessment that detention was in their best interests?  Did they place conditions upon the detention, and ensure they were upheld?  Was this assessment lawful, or should families be looking at issuing proceedings for unlawful detention against those who commissioned the care?

We don’t have answers to this question and I’m going to wander into the realms of supposition and guesswork with little apology, after all, I am no journalist.

I am going to presume that there was a poor use of the Deprivation of Liberty Safeguards – and I make this assumption based on the following grounds.

Firstly, there is a very poor understanding and implementation of Deprivation of Liberty Safeguards (DoLs).  I am a  practising Best Interests Assessor and a a social worker in a team that is primarily responsible for older adult. I go to a lot of residential and nursing homes. I go to a lot of hospitals. I observe and sometimes I assess. I have seen poor implementation and understanding in my own experience and can’t even begin to count the errors in the knowledge of the basic  tenets of the DoLs procedure that managing authorities (residential homes, nursing homes and hospitals) have. It’s a job to explain to colleagues as well.

This isn’t necessarily through lack of training, although sometimes it is merely about the speed of turnover – the staff that were trained are no longer in situ,  but it is also about a way that the safeguards are perceived. It’s also because all the training was done prior to the safeguards ‘going live’ to ensure the procedures were in place  but there have been changes through case law and through practice so professionals are lagging behind on the legal procedural knowledge and with training budgets cut, it can led to dangerous and unlawful practice.

Managing authorities are generally  (not exclusively) reluctant to trigger them because somehow they see it as bringing more attention to the ways the organisation operates or they see it as some kind of criticism for the way that they manage care. It may be or it may not be. If there is a deprivation of liberty there needs to be a legal framework in which it operates.

I’d venture to say that everyone at every level in every residential care facility needs to have an understanding and knowledge of the law and the way it relates to people who lack capacity to make certain decisions. I wonder what understanding those who assaulted patients in Winterbourne had of the law.

Any number of times  I have been told that a managing authority will request an authorisation after a review or when the social worker tells them to which, in itself, shows a misunderstanding of the legislation which requires immediate action and requests for assessments as soon as (or actually prior to) a deprivation of liberty takes place.

With the issue of the Deprivation of Liberty Safeguards and the Mental Capacity Act more generally come the role of advocates. Independent Mental Capacity Advocates have a statutory role within the Mental Capacity Act just as Independent Mental Health Advocates have a role under the Mental Health Act. Were there any advocates involved with the patients at Winterbourne? If so were they given the access which is allowed legally?

I genuinely believe that alongside criticism of the CQC which I will probably save for another post, it’s worth looking at the role of advocates and the potential that they could have to prevent abuse and to protect people who are vulnerable to abuse. I wonder if there should be a more robust system of advocacy in place (hint – yes, I think there should) to monitor placements from the basis of each resident. Cost? Why, yes, it would. And therein lies the rub but in any discussion of improvement, I think the role of an independent advocate looms large.

So why didn’t the Deprivation of Liberty Safeguards, safeguard the patients at Winterbourne View?

My own supposition is because they were completely ignored and not used.

What might a Best Interests Assessor have discovered that a CQC inspector couldn’t? Well, each resident affected would have had to be interviewed, as would staff members and family members. Deceptive staff members and frightened residents would still have been respectively deceptive and frightened but additional questioning and listening could have potentially led to a breakthrough. There would have been an examination of care plans and methods (although as we discussed in the office last week – any home can present a beautifully person centred care plan on paper – it’s a matter of implementation) and there would have potentially been a route in for more ‘relevant persons’ representatives’ to visit and ensure the well-being of the person being ‘deprived of their liberty’.

In a sense, I do wonder how many other ‘Winterbourne Views’ there are out there. I think while the culture of the organisations and the role of power needs to be examined, there also has to be an understanding of the law as it stands and whether safeguards were used  – if they were, why didn’t they safeguard? and if they weren’t (which is my suspicion) why weren’t they? Surely that is for the management (and the government agencies which monitor the legislation) to answer.

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.

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.

The Sailor

H.M.S. Medway

Image by Adelaide Archivist via Flickr

Last week, I went to see an elderly man who has dementia. I’ve known him for a couple of years and have seen the progression of this dementia. Sometimes the progression happens at different rates. We’ve had a lot of time to chat, over the past couple of years though.

I visited him in the residential home in which he is now placed, where he said he never wanted to end up a couple of years ago.

Circumstances change though. No, it doesn’t feel good, it doesn’t feel comfortable but it is right for him now. He needs 24 hour care.

When I met him, it was to be our final meeting. The six-week placement review meeting. He occasionally remembers me as I’ve visited him more recently but this time the deterioration in his mental state was palpable and it cut like a knife.

As it was obvious my rudimentary questions were going over his head, the standard ‘Do you know what city this is?’.

His eyes flashed with grief and he drew a quiet ‘You know, I can’t quite remember’ From a proud and native Londoner, that dampened my heart.

I switched the conversation back to something I was sure he would want to talk about. He had proudly served in the Royal Navy during the war and the immediate years afterwards.

‘So tell me, was it the Merchant Navy or the Royal Navy you were serving in?’, I said ‘I can’t quite remember’.

His eyes lit up. ‘The ROYAL Navy’, he gruffly confirmed.

‘Tell me about your time in the Navy’, I prompted him with my memories of some of the stories he had told me.

‘Ah yes,’ he said, and proceeded to the very familiar stories that he had always enjoyed telling. About the war, about being one of the few to survive a number of sea assaults. About the people on his ship who had been killed. About his friends who returned and his friends who didn’t. About how he had pretended he was older than he was because he wanted to enlist at the start of the Second World War back in 1939.

But even these stories, which I had heard hundreds of times, were vaguer in the details. Sometimes I found myself prompting him and filling them in.

The conversation made him happy but it made me resolutely aware of the nature of memories and how they form who we are.

As I looked around his room in the residential care home which is filled with photographs of family, favourite paintings from home, I pondered at the brief echo of his life and sense of being that remains.

I picked up a photograph of him with his wife who died a couple of years ago. They had been married for over 40 years.

‘Who’s this?’ I said, first pointing at him.

‘That’s me’, he said, and he looked at me as if I had completely lost it. I smiled and nodded ‘of course it is’.

‘And who’s this woman?’ I said, pointing at his wife.

‘That’s Mary,’ he said, his voice softening. ‘She’s a fine woman. The best. I would have married her’. He stopped for a moment and it was as if his thoughts had caught up with him. He looked at me with stronger resolution and said quietly ‘I think I did’.

I looked at the fading picture of the couple who had raised a family together.

This spark of life and increasingly vague recollection that continues to hold on in the face of the loss of everything that might be related to the sense of self we have is what always grips me. He had, over the years, shared his memories of battles and wars long gone – of times that would never return and of a world that is slowly but surely slipping away. I don’t have any remaining parents or grandparents. When I heard their stories of the war I was young enough to think little of it and not realise, perhaps, the enormity of the changes that had happened in the world since they were young .

I feel honoured to be able to share and hold some of the recollections of those people with whom I work and it has enabled me to build up a strong picture of a London and Londoners both native and from all corners of world and the people that have inhabited this city and this country over the decades.

When the memories fly away, it is the family, friends and yes, even the grumpy social workers who will keep a hold of those memories and draw on them.

He thanked me as a I left and I thanked him.

‘Thank you’, I said and I meant it with all my heart.  Knowing him and working with and alongside him has made me a richer person and has granted me the gift of deeper understanding of who he is but also who we are as people.

This is why I love my job and that’s why I despair at some of the changes in social work that push contact time to the minimum. This job is best and most effective when the relationships can build and grew and can be built over time.

So when I go to review someone in a residential home, I know who they are and who they were. I know the individual from more than a piece of paper. Sometimes it is not possible of course, fast work needs to be done and the pressures of the job increase to the extent that these conversations about the past, the so-called idle chats about memories, might be lost in favour of task-based visits. Visit to assess. Visit to review. Rarely does ‘visit to build and develop a relationship and sense of identity of this person from their own mouth over a longer term period’ count on statistics.

It’s easy to see where the better service would lie but this is the price to be paid by the cuts in staffing.

Linford Park Nursing Home

Linford Park Nursing Home is in danger of closure after a  raid last week by police reports the Telegraph. The article states that

“The operation was intelligence led and targeted immigration offenders working illegally at the home,” said a UK Border agency spokesman.

He said 13 workers were found to be illegal immigrants. Two were released on bail while the rest were in custody last night.

According to the local paper, the Daily Echo,  during the raid concerns were raised about the quality of care and three members of staff were charged with abuse and neglect. Horrific stuff of course.

Staff were replaced by those drafted in by the local authority and some residents were moved. Of course, there are (quite rightly) outraged relatives who object to their family members being pushed and pulled into any available placement.

Although all I was thinking is ‘would they have been so quick to act if there were no immigration issues and all the issues were purely about quality of patient care?’.

I doubt it. And that is the sadness of the system of monitoring of residential and nursing care.

The systems to check and monitor care homes is woefully inadequate and getting worse. CQC is currently bound up in re-registering services and a friend of mine who works as an inspector told me in a conversation that they are being focused 100000% on re-registering rather than actually tackling issues that might come up in care homes on a day-to-day basis.

Calling for more staff in any government agency in these cut-driven days is foolhardy at best and idiotic at worst but if there is any agency that needs it – it is the ground work of the inspectors who can go on at the drop of a hat and without announcement check the quality of care which is being given to those who are often not empowered to speak out.

Briars Retirement Home

Yesterday, as reported in Community Care, Annette Hopkins (owner)  and Margaret Priest (manager) ,  of Briars Retirement Home in Southampton have been found guilty under the Mental Capacity Act of neglect on 10 and 4 counts respectively.

It’s an interesting case as the Mental Capacity Act introduced a new offence of ‘wilful  neglect’ of someone who lacks capacity and while sentencing for Hopkins and Priest is expected today, the maximum tariff under the Act is 5 years and/or a fine. I wonder if that will be on each count.

It’s very telling that this was only codified as a distinct offence in the 2005 Act.

Community Care explains that

Residents at the Briars Retirement Home in Southampton were found dehydrated and in pain and with gaps in their medication and food records. All of the affected residents lacked mental capacity.

Which is beyond shocking in itself and one has to wonder what if the press response would be louder if it were animals being kept in this condition. A telling indictment of the value that older and incapacitated adults may have in our society.

Trawling back through the Daily Mail website (I know, I know – bad for my blood pressure), I find an article from 2008 when they discuss exactly this case. The headline, bizarrely, is a quote from Hopkins – ‘We all make mistakes’. Yes, Hopkins, we might all make mistakes but we certainly don’t all wilfully neglect other human beings causing pain and dehydration.

The article does though, expound wonderfully, the duplicity of the Mail. The article quotes Hopkins at length saying

‘The problem is the heart rules the head,’ she added. ‘You think you can give that bit of extra care.

‘I thought we were a good care home. We have tried to do right but by trying we have done wrong.’

Of course, they also find family members of other residents who criticise the heartless council for moving other residents out as the home was happily closed.

Where does the problem lie? Possibly that residential care has been seen as a source of money for private companies. There are many very caring and very competent people in the field of residential care but there are also some people who seem to revel in working with some very vulnerable people.

The local website ‘This is Hampshire’ explains some of the litany of offences in more detail – and make the Mail’s defence all the stranger

Police told how the full disturbing catalogue of failures included how:
■ Residents were malnourished and dehydrated
■ The place they called home had a strong stench of urine and the floors were filthy and faeces-stained
■ Dirty bedding and incontinence pads were left lying on the floor, mixed with clean clothing
■ Medication would be handed out by unqualified staff and was sometimes given to the wrong people
■ Bosses were not qualified but claimed they were through years of doing the job
■ Staff didn’t have the right equipment to lift residents who needed to move
■ The wrong beds were used, leaving residents with severe sores
■ Some were so ill or incapable they should have been in a nursing home
.

The initial concerns were raised by district nurses visiting the home. It makes one wonder how effective the then-CSCI (now CQC) are in monitoring what is actually happening in residential services that might not have other people coming in and noticing some of the things that have been going on – this is, after all, an extreme case.

Interestingly, the Basingstoke Gazette, reporting from the trial claims that Hopkins told the jury

“It got to the stage where they (the CSCI) were saying if you don’t get it right, then you are out.

“But people were asking ‘How can we get it right if there is no one to tell us how?’ We were told that we had to do it for ourselves because each care home was different It wasn’t until another inspection that we knew whether we were doing it wrong.”

She added: “If only we had had more help, and it’s not that I am just saying that because I am here (in court) now. It had been going on for years.”

Which seems at best disingenuous. Surely her job is to KNOW what is right and as a professional she should have a care to exactly what is needed to run a safe and comfortable residential home or she should have no business in trying to do so. Maybe people manage to run homes very effectively without being told exactly what to do by the CQC. It’s hard to imagine that this was seen to be a credible statement – indeed, the guilty verdict indicates that it wasn’t.

More tellingly she said

the care plans were done for the benefit of the inspectors and that on a day to day basis there were procedures in place to ensure staff were well trained in the care required for each person at The Briars.

The fact that care plans should be considered to be done for the benefit of inspectors as opposed to the residents living in the home under her care says everything about the way the home was run and the attitudes of the management. Training obviously has a very different meaning in her eyes if it results in such poor management as occurred and resulted in the death and maltreatment of a number of very vulnerable people.

The problem is that there is a surplus of poor residential homes and it has been allowed to exist and continue to exist because older people or at least older people who might be in the council-funded, privately run care homes have a much quieter voice. The newspapers are happy to play along to the narrative of an oppressive social services department that barges in and asks awkward questions to the ‘caring’ home managers and owners.

There needs to be a far firmer, far more involved inspection process to weed out the worst offenders and ultimately to save lives but it won’t happen as long as the narrative of cuts in public services is taking place. The irony is that cutting social care budgets will increase NHS costs massively.

A Home to Fit

I have worked with Mrs G for about 18 months. She has a degenerating dementia and is becoming more physically frail. Unsurprisingly this is not an uncommon basic scenario that rears it’s head at work. Mrs G has no surviving family but she was a very active local politician – involved in lots of causes and has wide and varying groups of friends who have endeavoured to keep an eye on her and provide substantial care and support for her over the last few years. It just goes to show that sometimes the links of friendship can be just as tightly bound as those of family.

A conference of friends was called yesterday. There were a fair few people who all have an interest in her wellbeing. We talked about residential care. I first raised the prospect of residential care for Mrs G shortly after I was first involved with her. I felt that things were not going to improve and that she really needed more support than could be provided at home. I was wrong and happily so. Friends came out of the woodwork and banded together to augment a formal care package with lots of informal support.

As I spoke to Mrs G yesterday, she wasn’t really able to follow the conversation or the flow. She is a sociable person by nature who, I think, if we can find the ‘right’ fit of residential care home – may actually enjoy an aspect of it. I know exactly what type of care home I’m looking for – one with a bit of spirit to it and character. Preferably one that might have room for a cat as well. It isn’t an impossible call because I’ve known it to happen but I have to say the prospects aren’t looking too hot.

Sometimes I despair at the generic nature of some care homes. I know there is an optimum economic way of providing care to the most people at the lowest possible cost. I also know some care home managers that care enormously for the quality that they are able to maintain for those who use their services. It can seem like looking for a needle in the haystack at times though.

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