Sadness, Sympathy and Self

Sometimes, some days feel filled with sadness. I had one of those days this week. I don’t like to use the word ‘hardened’ but to put it this way, in over 10 years of frontline social work practice in some of the most deprived areas of the country and in the inner city, I’ve seen a fair bit of what society has to throw in terms of crumbs to those who are some of the most vulnerable members of it.

I look at the high rises that skirt around the cities and I see hundreds of lives being lived, families existing and stories being told. Some with hope and pride. Some with desperation and despair. All different, all a part of this community and society we live in. Poverty is real. Despair is real. The two don’t have to go hand in hand though.

I have a strong stomach and don’t bat an eyelid at all sorts of things when I walk into a house. I’ve probably seen worse.

In some ways, human misery is a part of my trade. Not always, of course, because there are the wonderfully reassuring smatterings of hope but difficult social circumstances and social deprivation run a theme through my career.

Although I often emphasis that mental ill-health is certainly no respecter of social class or financial assets, it is sometimes the level of deprivation and the difficulty and shame of poverty that I see that reminds me of the way that this political class intentionally ignores and isolates some members of the community.

Perhaps the most difficult part of  my job is wrapped up in the AMHP (Approved Mental Health Practitioner) role. It is a mirror into my ethical compass and while I enjoy the aspects that were involved in training and the support and development and even community feeling I have with other AMHPs, the process of making a decision about someone’s forced detention in hospital or a forced medication regime is never one that can be taken lightly and I don’t think it is one that should ever be ‘enjoyed’.  It is power, writ large. It is control.

Sometimes people thank you retrospectively for ‘making the right decision for me at the time’ but more likely that isn’t going to happen.

This week, I carried out a Mental Health Act Assessment in a hospital. That is very far from unusual. When I read the background and the circumstances, when I conducted the assessment and made the application for detention, which I did, I was overcome with a feeling of sadness for the action that I had taken and for the life that it predominantly affected.

For obvious reasons  I won’t go into details – anyway, even if I did they would possibly sound fanciful and unrealistic. To people who think that I have a ‘difficult’ job, I would say I  have had a walk-on part among some fine and very strong people who have had to contend with sickness, pain and family circumstances that have rolled all the dice against them in the lottery of life.

And when I sign the papers and write up the report, I don’t forget. I think, I reflect and I try to learn. What could we have done to prevent this situation from having occurred? Sometimes the answer is nothing but sometimes there might have been a different path, a different action or different guidance that might have led to a different outcome.

Sometimes, some days, I just feel overcome with sadness. Sadness at the injustices that are meted out by life, fate and circumstance. Sadness at the way that this society perpetuates and builds on those injustices of circumstance. Sadness at my role my own complacency in accepting that we have created such an unequal and unfair society.

In a community where people who live on state benefits are treated with an intention to humiliate and scorn and where the government not only condones and supports this, it tries to create further barriers between the ‘haves’ (with ‘have’ meaning working tax-payer) and the ‘have-nots’ (meaning those who depend on the state for income) it sickens me as I know that the rhetoric of ‘choice’ and  ‘community capacity building’  are empty words which mean nothing without the world of privilege. By privilege I don’t mean money, necessarily, but include the privilege of having family or friends around, the privilege of being well enough to build up networks of support, the privilege of being a part of a community. There is so much more to privilege that cash assets or income.

Sometimes I want to shout against the system that I am a part of. The social care system in this country is not ‘fair’ – it reeks desperately of unfairness and the pushing of ‘choice’ in very narrow terms onto a wide range of people who in reality have no choice whatsoever further marginalises and discriminates against poverty, incapacity and isolation.

But I continue in my job. I go into work and ‘buy into’ the system. In my own defence, I fight as hard as I can from the inside and I don’t forget the names, the faces and the stories of those whose lives touch mine.

I remember, I note and I learn and sometimes, that just fills me with sadness – but when I stop feeling that sadness, I stop learning, growing and trying to create a better world. One person at a time. In spite of the system I work in and with rather than because of it.

Goodbye Southern Cross, Hello Open Public Services

So Southern Cross – the largest private care home provider in the UK will be closed.

What of the 31,000 residents who live in their properties? Well, the government has given us its assurance that they will be ok so that’s alright then.

Or not.

Goodbye, Hello

m kasahara @ flickr

On the day that the Open Public Services White Paper was published  (which can be found here – pdf) – which couched in the comfort of positive words like ‘choice’ , we would do well to heed the warnings of the way in which social care was sold off in chunks, from public to private and reflect on whether it is better to allow care homes to ‘fail’ in order to prove that the strongest will rise to the ‘top’.

The problem is that Southern Cross WAS the strongest. It did rise. It also speculated on property and ownership transferred away from the core business base of providing care and homes for those who needed both.

But on a more pressing issue, what will happen to those who live in Southern Cross homes and work for Southern Cross homes.

As the Independent says

Analysis by the GMB union revealed the names of 80 landlords who own 615 of the homes, many of which are subsidiaries of larger companies registered overseas. This makes it much harder to obtain financial information about the companies as rules governing accountability and transparency, especially in “tax havens” such as Jersey, Cayman Islands and British Virgin Islands are significantly more lax.

In addition, the GMB was unable to trace more than 120 landlords, which mean thousands of people are living in care homes where the identities of the owners and directors are unknown.

In the absence of full company accounts and other relevant information, such as the names of directors, it is “nigh on impossible” to assess whether they are suitable to run care homes funded in large part by public money, according to Andrew Craven, GMB statistician and researcher

At least the ‘Department of Health’ spokesman says

“Whatever the outcome, no one will find themselves homeless or without care. We will not let that happen. Today’s announcement does not change the position of residents. The Care Quality Commission will continue to monitor the services provided… We have been in constant contact over the course of discussions and remain ready to talk to all parties.”

That’s reassuring. Or not. Would that spokesman or anyone in the Department of Health want that level of uncertainty lying over their head or the heads of one of their parents? The residents of the homes will not know who their landlords are or whether they are fit to run care homes at all. Of course no-one will find themselves homeless – it will be the local authorities, the elected local authorities who will have to spend and fret themselves out of this one – nothing to do with the Department of Health’s reassurances – unless the Department of Health is going to compensate those local authorities for the time and cost they spend to ensure the welfare of residents of Southern Cross homes that may close.

As for the CQC, I think we have established that it is unfit for purpose and unable to regulate a care industry that has grown too large and too costly to be regulated efficiently. How about an idea? The Department of Health invests very heavily directly in the CQC so that they can provide at least twice-yearly, unannounced inspections together with a host of lay visitors attached to every single residential and nursing home?

No, the Department of Health is weedling out of this crisis as it will weedle out of the cost of ensuring that the residents of Southern Cross Care Homes are not made homeless.

Now, I want to link some of these issues to the Public Service White Paper that was published yesterday and particularly one or two sentences I picked out.


In the context of rolling out more extensive ‘choice’ in other areas of government, the paper says

‘We will ensure that individual service providers are licensed or registered by the relevant regulator for each sector (e.g. the Care Quality Commission) so that those choosing services can known that providers are reliable, without stifling cost”

Does that not lead to a tiny little shiver down ones spine? The CQC is being held up as a reason to trust in this extension of ‘choice’.  Has noone mentioned the cost of good quality regulation, either.  It’s worth reading this post at The Small Places for more consideration of the way the CQC regulates social care services. The CQC has failed to regulate and the care sector is failing to deliver on personalisation so far. The care sector has had time to learn as well. We had direct payments for many years and before that the ILF (Independent Living Fund) which allowed payments to be made directly to adults with disabilities to choose care. The system should be sophisticated enough by now to deliver good quality, equitable services but it has taken many years even to reach this point. There’s a long long way to go.


“The wider public sector has much to learn from local authority successes in commissioning, for example, in adult social care”.

See, look at us, government, we’re a success! Success. This is the end-result of success. Adult care commissioning is not a success. It has not extended choice unless of course (and I think I’ve found the key) success is based on the principle of privatisation and provision of contracts to the those who deliver at the lowest cost regardless of quality. That is the adult social care ‘success’ that the government is lauding in the Open Public Services White Paper.

We are dazzled by words such as ‘choice’ and ‘open government’  but they have no meaning outside ‘lowest cost’ and ‘discharge of responsibility’.

Think of Southern Cross. Think of Adult Social Care. It’s coming to our homes, our hospitals, our high schools and our highways.

So much for my week of positivity!

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.

Law Commission Report on Adult Social Care – some thoughts

I’ve not had much time to look through the Law Commission Report into the proposed changed in Adult Social Care Law but to say it’s been long needed is an understatement. Adult Social Care Law is a hotch-potch and a mess. A couple of weeks ago, I was talking to a student who asked for some help with her law revision and she put it very succintly to me when she said it was much harder to understand community care legislation because it was ‘all over the place’ as compared to legislation related to work with children or in the mental health fields.

Hopefully, there is an upcoming reassessment and improvement in the way that community care legislation and legal duties are delivered through a single Act. That was the purpose of the Law Commission Report.

There are 12 parts to the report and I’ll briefly look at each section and make no apology for summarising the bits that I, personally, will find useful and interesting. The report in full and in summary can be found here. Among all the links, there is also an audio version available.

Part 1 – Introduction

Unsurprisingly, this explains the background to the report namely that adult social care legislation is currently spread across disparate Acts of Parliament and there are some pieces of legislation that remain ‘on the statute book’ but are not currently in use/useable (s47 of the National Assistance Act!)

Usefully, this section does introduce an initial brief definition of ‘Adult Social Care’ as being

the care and support provided by local social services
authorities pursuant to their responsibilities towards adults who need extra support. This includes older people, people with learning disabilities, physically disabled people, people with mental health problems, drug and alcohol misusers and carers.

The introduction continues to explain the timetable for the change process and some of the policy developments (most notably ‘personalisation’ and the move towards personal budgets in social care) that are taking place in the context of this review.

Part 2 – Defining Adult Social Care

While a brief definition was given in the introduction, this second section explains the need for a more robust definition of what or rather, who, comes into the definition of ‘adult social care’ in legislation.  This ‘definition’ will go beyond who receives services from social services departments and will include those who are not eligible for services so as well as duties regarding assessment and provision of services, there is likely to be a duty around providing more general information and advice.  This comes from splitting into two the principles of provision of social care – the universal (where the advice, information and support would come in) and needs identified following an assessment.

Part 3 – Structure of the Reform

This talks about the need for a consolidation of social care legislation. Currently, the suggestion is that there will be one single ‘Adult Social Care’ Bill which will cover both England and Wales (although this depends on how far Wales may diverge post-election).

As for the details of legislative powers and guidance, there are going to be three ‘levels’

– Primary Legislation

– Statutory Instruments

– Statutory Guidance

This seems to make sense and is particularly uncontroversial but I was particularly pleased that there will be a Code of Practice introduced (the Statutory Guidance). Those of us use to working with the Mental Health Act and the Mental Capacity Act will have a good understanding of how Codes of Practice link to primary legislation and I think they have been enormously helpful in explaining the legal issues to laypeople and practitioners.  It is actually specifically mentioned that the role of this Code of Practice will be similar to that in the MHA and MCA.

Part 4 – Statutory Principles

These ‘principles’ are familiar to those of us who work with Mental Health (and Children’s) legislation whereby there will be some underlying guiding principles and ideas to pull through the whole legislative framework.

There is an interesting discussion in this section about the way that the content of these principles had been considered when open to consultation. One of the principles (and the ‘main’ one) will be about a general aim to promote and contribute ‘to the well-being of the individual’ but the Act will also encompass some of the ways that this can be done by ensuring the individual in question is included in the process.

There is also a principle (unsurprisingly) about safeguarding adults from abuse and neglect and using a ‘least restrictive’ principle which will be familiar from the Mental Capacity Act. I am interested in how a ‘least restrictive’ principle will work in the context of people who do not lack capacity but I expect the issues will become clearer in the passage of time.

Part 5 – Assessments

Ah, the Assessment – that ‘core legal right’ at the heart of the Act and what will be the ‘gateway’ to services however they are delivered. Firstly the term ‘community care assessment’ was criticised as being old-fashioned. To be honest, we don’t use the term in any context except a legal one anymore anyway.

It is agreed that the threshold for accessing an assessment should be low and and that the assessment itself could be seen as a ‘service’ in its own right – the comparison is made with having a GP check up.

The local authority would be able to flag up voluntary sector services for people who did not meet the eligibility criteria and would be a source for advice and information as well as services.  The paper also talks about clarifying the position of people who refuse assessments so they might be able to access information and advice without having to have an ‘assessment’ of any kind.

The threshold for a fuller assessment will be met when a person may have needs that could be met by service provision so there will be a change of language in the law however there is a (quite right) determination that the threshold will remain low – because you might not know  if the need could be met until you have assessed!

There are a number of more specific guidelines mentioned about the way assessments should be conducted and who might conduct the assessments and how they would be undertaken. Generally, there are likely to be statutory instruments covering some of these issues and the details will follow, no doubt. There will be some scope for specialist assessments to be requested in certain circumstances where the user might have specific needs.

There was some mention of this being a reserved task for social workers but that was dismissed quite summarily (because there wouldn’t be enough social workers, I presume) and will be a matter for the statutory instruments!

There will also be further specific guidance about the scope and place for self-assessments in the process.

Part 6 – Eligibility

This is quite a complex one but basically, the recommendations include codifying what is, in effect, current practice – namely that the social care needs identified through an assessment are measured against eligibility criteria and if the individual meets those criteria as determined, the local authority arranges or provides services to meet those needs.

There would be in indication in the Code of Practice regarding the levels of eligible need and how the councils would interpret them.

The law is not going to specify where the line should be drawn by the local authorities regarding setting the ‘thresholds’.

Interesting discussion in the document about duties under s21 of the National Assistance Act. I won’t go into details because I don’t have time but it looks like the duties will be recommended to be retained.

Part 7 – Carers Assessments and Eligibility

Unsurprisingly, there will be a consolidation of duties under various carers’ legislation to provide a carers’ assessment. I’m shocked when I hear of the number of people who are not being offered carers’ assessments when they should always be as a matter of course. Hopefully, this will be an imagining of a long distant past.

The ‘cared-for’ person needs to have at least some social care needs for the carers assessment to be ‘triggered’ and not only ‘medical’ needs. This is a bit of a blind spot in my view but the document recognises this and feels that any changes made in regard to this have to be done as a matter of policy by the government.

The requirement to provide a carers assessment will though apply to any care provided and not be limited to those providing ‘substantial’ care as it is as at the moment.

It is proposed that rather than the carer needing to request an assessment, the local authority will have a duty to provide which is far better as I see it.

Part 8 Provision of Services

There is an discussion in this section about whether or not to define what ‘services’ actually are in the context of that which can be provided. It was felt by the commission that there should be some kind of list involved and that there was also a need to specify preferred outcomes of the provision of services. The list will take the form of categories of support in the context of those which will provide the desired outcomes.

The recommendation which explains it far better than I can annotate, explains

Community care services (however named) should be
defined in the statute as any of the following provided in accordance with the
well-being principle:
(1)  residential accommodation;
(2)  community and home-based services;
(3)  advice, social work, counselling and advocacy services; or
(4)  financial or any other assistance.

The statute should set out the following list of outcomes to which the wellbeing principle must be directed:

(1)  health and emotional well-being;
(2)  protection from harm;
(3)  education, training and recreation;
(4)  the contribution made to society; and
(5)  securing rights and entitlements

I actually really like the idea of including the outcomes. I think it adds significant clarity to the position and scope of provision of services overall.

It’s also interesting that social work services are seen as a discreet ‘service’ as opposed to advice, counselling and advocacy. I wonder if that is a shoe-in for a different type of social work with adults in the future. We can but hope.

Carers’ services will follow similar guidance as above.

A care/support plan must also be provided in written form for the user and carer (if necessary) that should include assessed needs, eligible needs and desired outcomes. I see in my future more paperwork but actually, if it is going to be an improvement, I’ll welcome it with open arms!

Direct payments will be retained in their current form and interestingly there is a proposal to introduce them to allow for payment for residential services.  I am not necessarily opposed to this however I do think there are some practical issues that are a concern. I’ll have to come back to this though in a post of its own!

None of the existing provisions for services that are being provided free of charge (for example those subject to s117 aftercare) will be affected by this and they will continue to operate in the current form.

Part 9 Adult Protection

There will be a specific role for the local authority to lead on safeguarding processes regarding adults at risk of being abused. In fact, the term ‘vulnerable adult’ will be replaced by the term ‘adult at risk’.  The document states:-

We, therefore, proposed that an adult at risk should be defined as a person aged 18 or over and who:
(1) is eligible for or receives any adult social care service (including carers’
services) provided or arranged by a local authority; or

(2) receives direct payments in lieu of adult social care services; or

(3) funds their own care and has social care needs; or

(4) otherwise has social care needs that are low, moderate, substantial or
critical; or

(5) falls within any other categories prescribed by the Secretary of State or
Welsh Ministers; and

(6) is at risk of significant harm, where harm is defined as ill treatment or the
impairment of health or development or unlawful conduct which
appropriates or adversely affects property, rights or interests (for
example theft and fraud).

Quite a broad definition but contrary to be beliefs of some, does not include everyone over 65!

Harm will be defined as

(1)  ill treatment (including sexual abuse, exploitation and forms of ill
treatment which are not physical);

(2)  the impairment of health (physical or mental) or development (physical,
intellectual, emotional, social or behavioural);

(3)  self-harm and neglect; or

(4)  unlawful conduct which adversely affects property, rights or interests
(for example, financial abuse).

but significant harm will be a judgement process.

Section 47 of the National Assistance Act will be repealed which is unsurprisingly and there will be another commission to look specifically at what it should be replaced by. This is, perhaps, where compulsory powers of entry will come in.

Adult Safeguarding Boards will be put on a statutory footing and there is some additional guidance on how they will operate.

The qualification that Guardianship can only be used for people with learning disabilities when there is abnormally aggressive or seriously irresponsible conduct’ will be removed which I think will allow for better protection for people with learning disabilities in the longer run.

The other sections of the report, I’ll cover very briefly

Part 10 Ordinary Residence and Portability

There is some clarification on the rules about residency in a particular authority and the principle of being able to take the assessment between different local authorities is, quite rightly, introduced.

Part 11 Overlap Issues

This part clarifies some of the areas where there are different pieces of legislation and particularly where there would be a crossover between health and social care issues but also with housing issues, forensic services and with childrens’ services.  There is some guidance about clarity regarding continuing care guidelines and how direct payments might work if they are extended into healthcare (which is likely).

It also recommends that adult social care teams can assess 16 and 17 year olds .

Part 12 Other issues

This includes a look at the right to advocacy which the report says should be retained as far as it already exists but not extended.

The local authorities will retain their registers of people who are blind and partially sighted and have discretionary powers to maintain other ‘registers’.

There will be a continued review about a proposed definition of ‘a disabled person’.

So that’s all! Well, it’s been interesting to read through. Generally it seems like a substantially positive review and I think it will improve the way that services are delivered and at least make it clearer. There are parts of the review I’d like to explore in more detail – particularly the safeguarding arrangements and some of the items in the overlap issues like continuing care but I’ll have to come back to them.

I’d be interested to hear other thoughts about the process!

Personal Budgets in Practice

Recently, I’ve been working with a service user and his carer (daughter) to put together a  support plan or rather two support plans – one for him and one for his daughter . The two live together and without his daughter’s presence, there is no doubt at all that the man, G, would be in residential care so the personal budget is relatively substantial.  G has advanced dementia. His daughter who is a strong advocate for him and a devoted carer has given  up her job in order to care for her father. She receives carers allowance which is a pitiful £55.55. Think about that – for constant care (yes, she gets respite but that is sparse and shrinking).

As for creativity with G’s support plan, it isn’t particularly, because he has quite specific personal care needs and there is no scope for much creativity regarding tasks apart from the ability to potentially employ someone from outside the usual agencies.  Oh, we can choose the time and the ‘blocks of care’ but the type of care needed is specific so we can’t ‘skip a shower one day so there’s more time for a bath the next (seriously, that was suggested in one of the training sessions I attended!)’ as health reasons determine the need for regular visits. G’s support plan is, what we call a ‘managed personal budget’. That means that a virtual budget is assigned to G and I make the arrangements for agencies to cover the specified hours. I don’t get a choice of agencies. The agencies that are employed are those that have won ‘bidding’ contests with the local authority and are party to block contracts.

This ‘counts’ as a ‘personal budget’ for the purposes of the local authorities’ ‘figures’ even though the effect is exactly the same as it was prior to the ‘personalisation agenda’ – no, wait, there is a difference. I have three times the amount of paperwork to complete. Am I working in a more ‘person-centred’ way – well, I hope that I was ALWAYs involving service users and carers in care planning. That’s not to say that direct payments haven’t been enormously liberating and positive for a lot of service users. I absolutely don’t believe that everyone should have ‘managed’ personal budgets but it is a fallacy to believe the ‘hype’ that this personalisation agenda has brought the same benefits for all service users.

So we move to the idea that Burstow promotes that all support plans should be delivered by direct payments. We discussed delivering this package via direct payments, when I promoted even a slither of interest, I invited someone from our direct payments team round to meet the family (because they can ‘sell it’ better than me and can answer all the detailed questions about implementation and finances that sometimes I can’t) and we stalled. Why? Because G’s daughter felt genuinely stressed and frightened at the thought of employing someone directly – the agencies that accept the direct payments amounts are limited and don’t include her preferred agency and if she went with the preferred agency, her father would lose vital necessary hours of care.  She has little enough time to herself as it is and spending more time managing and planning her father’s care processes was something she felt that we should be doing.

Her father has very poor cognitive functioning to the extent that communication is very difficult.  The direct payment option, was, she saw, a way to push more stress onto her as a carer.

This is a reality that some of those who are implementing the wonderful new world of everyone receiving direct payments type personal budgets really have to address.

However I do have a more positive story to follow up on. That is that she, (M’s daughter) has a carer’s personal budget for herself which is delivered via a direct payment. While I won’t go into the details about what has been provided, you’ll have to trust me on this as I say we have been able to be incredibly ‘creative’ with the support planning of the carer’s personal budget and it will have an immediate positive effect on her quality of life. So all’s well that end’s well.

Generally, I have had a lot of success with carer’s personal budgets being implemented and I think that has been because the money provided (although not very much) is money in addition to the core care needs for the cared-for person.  There is a scope for more interesting ideas of things to use the money for.

It’s hard to see how more creativity can be instilled without more money and as long as the figures allow ‘managed’ personal budgets to be ‘counted’ we won’t have a real idea of how ‘ground-breaking’ these programmes are.

I don’t know the answers to these problems – I hope some of those consultants who are paid multiples of my salary and can spend all their days in discussions and consultations are able to come up with some genuinely practical responses rather than the usual ‘try harder/work harder/involve users (as if we don’t do all this already’.

Let’s see.

And on a final unrelated point, I saw a link to this blog yesterday on Twitter. It is written by the 18 year old son of someone with Alzheimer’s and I found it excellent and insightful.

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


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;
• involvement in many aspects of work, education or learning cannot or will not be sustained;
• 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.

Weekly Social Work Links 11

I am going to have to do a quicker than usual ‘round up’ this week because I’m heading off to the March this morning.

But it has been a fantastic week in terms of the richness of posts.

I’ve already written a post about why I am marching today but this post by SocialJerk about the situation regarding housing in New York opened my eyes. This is where we are heading.

On the subject of housing Malcolm Payne writes about the ways that the social work role is described in literature provided for housing staff and he raises a lot of the issues of the confusion about the definition of the social work role and the issue of  why ‘social worker’ is often confused with ‘local authority social worker’ in the UK.

Ladybird writes about the ‘ripple effect’ of the cuts in her own service.

A Social Worker’s View talks of the problems raised by a shortage of condoms in Kenya. Something to bear in mind from my often anglocentric world view.

The Masked AMHP and the next stage of his explanation of the tribunal process ‘When Detained Patients Appeal’ series and the story of what happens in a tribunal.  Sometimes I forget how alien some aspects of my job may seem to others. I haven’t ever written about tribunals. Perhaps one day I’ll pop up with some of my own thoughts and experiences.

How Not to Do Social Work has a time for decisions and contemplates burnout. A potential hazard of the trade.

And Nectarine on Going Mental  raises the issue of noise in the office. I feel her pain.

While Social Worker Mom asks when it’s no longer healthy to work with a particular client.

A Case Manager’s Verse talks about issues regarding communication via email at work. Many interesting points raised that I hadn’t considered and some I had but hadn’t quantified.

Jamie Middleton writes about the importance of pets to someone’s mental wellbeing.

JaeRan Kim writes another thoughtful post about treating difference and perceptions about mainstream integration and the place of disability culture when moving towards fully integrated societies. Food for thought.

Dorlee at Social Work Career Development has a great interview with an art therapist about her work.

Nancy Smyth at Virtual Connections has a post about the use of Second Life and a PTSD (post traumatic stress disorder) simulation. I remain a little uneasy about this kind of simulation. I haven’t had any experience of using second life and remain generally sceptical but it is interesting to read about these programmes and how they may be used. Maybe I’m just being a fuddy-duddy!

Speaking of which, I’ll sign off with an post from the Social Work Tech Blog about using a ‘Social Work Digital Toolbox’ and there are some useful ideas there if you have an iPad or want to justify the acquisition of one ‘because it would be good for work’.

To sign off though, I’m going to link to this video of the Andrew Lansley Rap.