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.

Eligibility, Birmingham and Cuts

Birmingham was the first English town without ...

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While awaiting the details of the court judgement, there was an important ruling yesterday that Birmingham Council’s attempt to limit eligibility to social care services to those who have ‘critical’ care needs is unlawful.

Drawing out some of the definitions to what this actually means and could mean requires a look at the details of those who brought the case to court.

There were four defendents which the BBC explains include

a 65-year-old woman with severe learning difficulties who receives 24-hour care in a home paid for by the council

25-year-old man with a rare genetic disorder and severe learning disabilities who receives overnight respite care, also funded by the council

30-year-old deaf, autistic man with severe learning disabilities who is prone to self-harm. His specialist day care would also have gone under the plans

and

a 36-year-old woman with severe learning difficulties whose day care centre will close and who is also set to lose respite care

It’s useful to go back to the definitions of what ‘critical’ and ‘substantial’ needs are to understand fully the implications of councils moving the eligibility criteria from one stage to the next.

Critical needs exist where –

• life is, or will be, threatened; and/or
• significant health problems have developed or will develop; and/or
• there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or
• serious abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out vital personal care or domestic routines; and/or
• vital involvement in work, education or learning cannot or will not be sustained; and/or
• vital social support systems and relationships cannot or will not be sustained; and/or
• vital family and other social roles and responsibilities cannot or will not be undertaken

Whereas Substantial needs (those that Birmingham are stating they are no longer able to meet) exist where –

• there is, or will be, only partial choice and control over the immediate environment; and/or
• abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out the majority of personal care or domestic routines;
and/or
• involvement in many aspects of work, education or learning cannot or will not be sustained;
and/or
• the majority of social support systems and relationships cannot or will not be sustained; and/or
• the majority of family and other social roles and responsibilities cannot or will not be undertaken

A couple of things to be noted here. A differentiation is made between ‘abuse’ and ‘serious abuse’ so that one will be covered and the other won’t. What kind of ‘legal’ test would there be to determine when abuse counts as ‘serious’ or not? Can we see children in similar cirumstances being subject to a differentiation of level of care available depending on whether abuse is ‘serious’ or ‘not serious’? And who is doing the judging? Well, I can answer that last question. It is the social worker involved as I am asked as a matter of course to ‘band’ people according to these criteria.

The obvious glaring point is the lack of thought of any kind of preventative work that sticking so closely to the criteria will create. Where is the hope of creating those very creative personal budgets when only the very bare minimum of essential needs are being met.

I can’t claim anything other than relief that Birmingham case was challenged in court. These criteria and these levels of need look at people as lists of what they cannot do. That goes against everything that we know and the ways in which we practice by looking at strengths and looking at people as individuals. However, the reason the criteria were brought in in the first place was to end some of the ‘postcode lottery’ of care provisions and to bring consistency to who was offered what nationally. Of course, the problem remained that interpretations of these criteria vary so the consistency which is objected by ticking boxes (the only way the officials seem to know to apply it) depends, as mentioned previously on the social worker who is doing the ‘judging’.

Back to this case though, it was brought under the Disability Discrimination Act and hopefully the judgement will be available soon. Hopefully too, local authorities around the country will be leafing through it and realising that the wholesale and slapdash cuts that they are imposing are not legal.

As for the government of millionaires, none of them will be reliant on social care support from the council. They can buy in any support that they might potentially need and cannot understand the distress of those who are totally reliant on the availability of services.  They cannot understand the implication of their gung-ho ideological cuts and the thought of Cameron, Clegg and Osborne claiming ‘We’re all in this together’ sticks painfully in the throat.

Although I fully expect Birmingham to challenge this ruling, I hope that the case is held and that some of the trigger happy cutting is stopped and the very real effect of the cuts agenda is shouted out more loudly and more clearly – not just for those of us who are personally losing services but to raise our voices with those who cannot always shout so loudly.

That is what social justice is about and that is what social working is about.

Which Care? What Care?

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

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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.

Vacancy Rates

Community Care have published a special report into social work vacancy rates in the UK. The report finds that 1 in 10 social work posts in the UK are currently vacant according to information that they have put together following a Freedom of Information request.

There has been a big push towards social work recruitment over the last year, indeed, the article states that

In England, where the government has invested £11m in recruitment campaigns and at least £28m into the reform programme, vacancy rates have risen from 10.9% in 2009 to 11.3%.

I would expect it’s too early to see the benefits of these investments as a lot of the push was towards social work training so it may be interesting to see any changes in the amount of people applying to study social work degrees has changed but it’s still a very high rate.

The breakdown of figures shows that the highest vacancy rates are  in the East of England at 15.3%, running slightly ahead of London at 15%. The lowest vacancy rates are in Northern Ireland.

It’s interesting that Northern Ireland, Wales and Scotland have lower vacancy rates than England. England is less cohesive and there are more variable elements. The GSCC seems to have lost its way somewhat and there is less of a shared identity across the whole of England perhaps.

Social Work according to another article in Community Care, has a different status in Northern Ireland where it seems to be (or at least, that’s my inference from the article) more highly respected and sought after – meaning that universities can be more selective and that vacancies are more likely to be filled by competent applicants.

In Scotland, the example is given that the workforce may not be as mobile and that social workers are more likely to live and work in the same areas.

The problem is, well, one of the problems is that the higher the vacancy levels, the worst the strain is on the current workers and the more likely they are to burn out or leave – leading to the problem existing in a cyclical nature.

There doesn’t, from my brief glance, seem to be a definite trend as to whether the vacancies are in adult services or children services.

For example (using London as it is what I am familiar with)

Waltham Forest has vacancy levels at 47.8% in children services and 16% in adult services whereas Richmond Upon Thames has children vacancy rates at 26.1% and adult at 43.1%.

(come on Richmond, you must be able to do better than that !)

Those are just a few of the examples.

These figures don’t surprise me. We knew as much last year and this is not a situation which is going to solve itself within a year. The changes I, personally, have seen in the year – well, we’ve had people leaving our team whose posts are not going to be recruited to. Reconfigurations have meant that those posts have now ‘officially’ disappeared and therefore wouldn’t show up in any statistics on vacancy levels but they are vacancies because there are fewer people to do the same amount of work.

On a real level, that means quality slips, mistakes are made and increased pressure makes a less healthy and potentially more expensive (sick leave) workforce.

But this isn’t news to anyone. This is common sense.

Going back to the initial article and report there are a few things that worry me and I am speaking from my position as a social worker particularly in adult services.

Tim Loughton has written a piece for Community Care pledging to bring down vacancy rates in Childrens Social Work. He is the Parliamentary Under-Secretary of State for Children and Families. But – he has also been tasked with overseeing the social work reforms. Of course his priority will be seeing to the childrens’ services. That is where the political capital is to be gained.

Again, Community Care emphasises this explaining

English councils can now access a share of the £23m local social work improvement fund for children’s services promised in March.

Other programmes aimed at children’s services in England include the development of an advanced social work professional status, due to be launched by the Children’s Workforce Development Council next month. Keith Brumfitt, director of strategy at the CWDC described this as “a retention and reform measure to keep experienced people in frontline jobs so they can share their expertise”.

Where is the input regarding Adult Services – where in there any government minister showing an interest or pledging that social work in the adult sectors will be injected with cash or promoted or that our services are actually vitally important.

It shouldn’t need to be a competition but my worry remains that with the money and the focus on vacancies in childrens’ services, adult services which are suffering equally and more silently, will be slowly sucked dry of any expertise.

Community Care teams will be replaced by Support workers who validate self assessment questionnaires as they come in but the underlying principles, training and theoretical base is lost and Mental Health teams slowly replace social workers with ‘mental health practitioners who can come from a wide range of disciplines of which social work is one’.

Social Work has a lot going for it. It is a lot more than administration.

To me, this is the ultimate legacy of the NHS and Community Care Act and the advance of Care Management to the stage that there is no longer any need for a professional background to carry it out as it increasingly becomes more about ticking boxes.

Hope remains in the form of the Reform Board though and possibly developments attached to the establishment of the College of Social Work.

Things can only get better.

Refusing help

The tragic case of Stephania and Sam Wolf has been in the news over the last day. Without knowing anything but the most cursory details of this particular case, it raises some issues and dilemmas that I am very familiar with and wanted to explore for a moment or two.

There is the issue of the overstretched carer who has little external supports. Yes, help was offered but help was also turned away. One can also speculate about the pressures that being a sole carer in a small community might bring and how much effort was made by services to actively engage with people who might find their presence stigmatising. One can also speculate about the kind of help that was offered and whether our systems are limited both in the type of help offered (day centres, home carers for example) and also by the ways in which help is offered.

These are the problems that may be created when social workers are berated by the press and in the public perception. An unrealistic image is engendered of the profession and people who might benefit and need social work interventions feel that there is a stigma attached to having a social worker or social services involved. For me, this is far more important an issue for the College to address than whether I feel comfortable telling people on the bus that I’m a social worker.

As long as ‘the social’ is seen as something wrong, unpleasant or something of a punishment, it will make people from all client groups – adults and children – reluctant to engage.

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Now again, I want to emphasise that this is not a statement about this particular case, but there is a dilemma when a family member is a main carer of someone who may lack capacity to make a decision about their own personal care needs.

When would we, as social workers – as representatives of ‘social services’ challenge the carer as to whether they are acting in the best interests of the cared for and when does ‘refusing help’ need to be challenged?

This is one of the most troubling dilemmas as a professional. It is much easier to provide a service and to provide care when everyone agrees of course. When there is a clear capacitious statement by someone who may be entitled to a service that they do not wish for a service – again, that is clear, also  when there is blatant abuse it is a very clear judgement to make that the family member/carer is not acting in the best interests of the cared for – but when do we cross the line and demand services go in for the benefit of the person who might not be able to decide for themselves and whose family member is refusing help on their behalf.

Especially if the family member may be living in the same property. There is a risk of ‘upsetting the apple cart’ so to speak and ending up on the front page of the Sun or the Mail being accused of ‘dragging granny away from loving daughter’ or strong-arming services in.

A lot of times though,  services are refused, we can and often do have to walk away. People have the right to refuse.  Sometimes though, we need to assert the services more fully. Services don’t have to be removal to residential care – that is another myth that does enormous damage in the public perception of social care and often when services might be refused it is because people or their families are scared we’ll ‘put them into residential care’. Often I chuckle to myself that the last thing in the world we are going to do is put someone in residential care if they don’t need it as a  package of care at home is  infinitely cheaper.. but that’s not always as clear in thoughts and perceptions prior to arriving and being able to say this.

The problem with asserting roles and trying to engage slowly with a view to increasing or accessing services by slow introduction and the creation of a relationship of trust is the time factor that we are all subject to in our day to day work.

Fortunately, in the team I work in, being a CMHT, we are given more time to actively engage with users and carers and can often, even if it is over a period of months, gently prod towards a slow introduction of care services.

Just this week, I have finally, after working with someone for well over a year, persuaded her to give some formal care services ‘a try’. She could have done with those services for a good few years and granted the presence or not is a matter of quality of life rather than life and death but there is no way she would have agreed had we not had that previous relation of trust which had built up over time.

In the adult teams where I previously worked, there would be no time allowed for that. A refusal of services is one less assessment you need to do – and I don’t mean that to sound cruel, it isn’t meant to be – but just that the levels of workload don’t allow you to go back and try and catch anyone who might fall through the net.

Sometimes people don’t want what ‘professionals’ think they should have and that’s fine too. The Mental Capacity Act speaks explicitly about the right to make ‘unwise’ decisions although one persons’ unwise decision is another persons’ fully formulated plan. The provision of this clear statement is to ensure that professionals don’t become too prescriptive in making decisions about whether someone might have capacity or not. There are many decisions everyone makes on a day to day basis that aren’t scrutinised in the way that people whose mental capacity might be being questioned would be scrutinised and it is about shedding pre-made assumptions (apart, of course, from the assumption that everyone has capacity as a baseline).

But back to the Wolfs. If there is one thing that I hope can be taken from this it is that social isolation doesn’t just happen in big cities. It can happen in small rural communities too.

Keeping an eye out for neighbours and  acquaintances is worth more than formal care services.

Into the Deep End

While I’m still recovering at home, my thoughts are turning over a number of things as they come up and I suspect while I am still off work, I’ll be considering some more ‘memory’ posts to keep me on top of things.

After I qualified, well, actually a couple of months before I qualified as a social worker, I lstarted looking for work. This was before the GSCC registration when a DipSW/Degree were enough to start working immediately as a qualified social worker.

Agencies were literally snapping off our hands to work for them. There was a massive shortage of social workers in every field, in every area. Many people were recruited directly out of college. I decided to sign up with a social work agency. Partly because I was very impatient to earn money after a couple of years of part-time working and partly because I was far from resolved as to which area of social work I wanted to move into and I felt the agency option might leave me some greater flexibility.

Perhaps times have changed now – this was almost exactly 10 years ago – but at that point, when I explained to the agency and subsequently in the interview, that I was a freshly qualified social worker equipped with a lot of experience of hands-on care in the voluntary sector and one statutory (first) placement there was an understanding that support would be given. There weren’t NQSW programmes but there was a desperate need for bodies at desks.

I went to work in an inner city borough in London – not the same one I work in now. Process of elimination will determine that there aren’t THAT many boroughs that count as ‘inner city London’ but I’ve now made my way through a few of them..

I was working in an older adults’ team. It was a large team and a large office. Fortunately, for me at least, there were some familiar faces as that borough has some sponsored students on the same MA course as I’d been on so went into the office already knowing a couple of people which definitely helped.

I was struck by the friendliness and the willingness to help. Yes, I was a brand new, young (relatively!) agency social worker but honestly, the team bent over backwards to assist and answer all the stupid and not-so-stupid questions I had.

I immediately was grabbed by the upping of pace between placement experiences and ‘qualified’ experiences but as regards to training and access to support, I might have been employed through an agency but there seemed no obvious difference with those who were directly employed. The caseloads were very high and the output was expected to be high. As I learnt later though, and in different teams, it could have been a lot worse. I only had my placement experience to compare it to though as all my pre-course experience had been as a hands-on carer/support worker in residential homes.

In retrospect, I realise I was very lucky to have had a good team around me. There were a lot of things I was worried about. Manning the duty phones filled me with dread, probably for the entire time I was there.

I’d like to say my manager was fair but he wasn’t desperately. While team members were friendly, competent and helpful, he seemed to have an over-fondness with appearing to be doing the ‘right’ things to his immediate managers. Since then, I’ve realised one of the most valuable assets of a good manager is to be able to fight for the things that they believe it and stand up what is ‘right’ even if it is not something that fits in with the ‘higher management’ model.

The geographic area I covered was one of immense and obvious poverty. The high rise blocks rose as trees do in thick conifer forests. Sometimes there would be glimpses of true loveliness when reaching the top of a high rise and looking out at the view of the entire city as it pans out below you. Then there was the abject despair of the broken lifts and the graffiti in the stairwells. Graffiti would be the best of it. The vomit, the bloodstains, the urine and faeces – human and animal. But there were also some of the most beautifully kept houses I’d seen as well. Sometimes, in some areas, the stairwells became places to congregate and trade all manner of illegal goods and substances with the residue very obvious – discarded needles, used condoms. There seemed to be little dignity in the external presentation of some of the estates which often contrasted acutely with the dignity retained within the flats that I visited.

I have always been fascinated by stories and peoples’ stories. By trudging the streets (I don’t drive and mostly walked from visit to visit), I would pick up the history of the city and the neighbourhood, the familiar noises and smells. People would tell me their own and their families’ histories. There would be the histories of families who had been living in the same areas of the same city for generations and the recent arrivals from other parts of London, other parts of the UK and other parts of the world – each with a story about how they had arrived at the place they were.

One of the things that struck me was the way that all these stories intermingle in the same communities, sometimes crossing and sometimes taking themselves on different strands.

I had been leaving in various shared houses in various parts of town myself and the opening up to the true meaning of community was something that had been fairly new to me. I heard stories that I would never have been privy to in any other circumstance and the streets, as I trudged through them, took on different colours and hues. I knew, through my discussions and conversations which shops had been there for decades and which had been new arrivals. I knew where the old Bingo Hall and the old Dance Hall had been. I knew where the different community groups met and what support they provided for ‘their own’ and how to tap into these resources.

Covering duty scared me at first as I was unsure what I might come to expect and thought I was expected to ‘know everything’. Fortunately, I had many experienced people around me who didn’t mind my constant questions too much.

I remember when the first service user that I had been working for a while, died. I had been trying to arrange a residential placement for her. I had been coordinating with family members and had been to see a number of homes. We organised the move and within two days, she had died. I remember the abject sadness that welled over me. I pondered the influence of the move and the way it had happened. How anything might have changed. Discussions with more experienced colleagues helped me to think through the matters logically and I know, particularly now, working with older adults, you do see death up close, but it is still something that touches one profoundly, especially when you have spent time building a relationship with the service user and the family.

Things worked differently then as well. Care management as a model which had developed from the NHS and Community Care Act 1990 and was still at it’s earlier stages – services hadn’t necessarily been pushed to large block contractors at the same levels as they were subsequently. FACS hadn’t been introduced and each authority had their own guidelines. When I drew up care packages, I would have to cost each one on a different form before submitting it. Computers were still shared and forms could be handwritten. It seems so archaic in a lot of ways.

Some ‘new’ databases were just being rolled out but few people used them, certainly not as many as the managers wanted. There was some resistance to change.

I learnt a massive amount there though and took some very strong lessons with me. I made a lot of mistakes but fortunately none with grave implications. I learnt to love working with older adults and relishing the richness that a long experience of life can bring and what can be shared as a result. I saw my share of loneliness and heartbreak but also the joy of kindness and community that is brought to other lives.

It was a good place to start.

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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