The Challenges of Social Care Inspection

The appointment of Andrea Sutcliffe as Chief Inspector for Social Care at the Care Quality Commission is a highly commendable one. Not only is she knowledgeable about the care sector (see for example http://www.guardian.co.uk/social-care-network/2013/jul/15/what-good-homecare-looks-like) but she also has her own personal experiences to draw upon (http://www.whentheygetolder.co.uk/finding-care-for-older-relatives/) and that combination, along with her naturally open approach, bode well for the future inspection of social care.

Yet that future is strewn with challenges that Andrea first needs to tackle. The general perception of social care is not great and trust in the Regulators has been severely dented over recent weeks. The first challenge will be defining a model of inspection that will ensure poor provision is identified and stamped out yet this model must also reflect the nature of the care sector and the huge variations within it.

Yesterday, for example, the new Chief Inspector for Hospitals, Prof Sir Mike Richards, outlined a model which he frequently referred to as ‘an army’, 20 or more inspectors marching into a hospital to inspect all aspects of care provision and ensure the meeting of standards. Unfortunately, in social care that will not work as, in many instances that many inspectors would outnumber both residents and staff!

The variation in social care is completely different from that of hospitals. Social care covers care homes and home care, it covers care and support for the elderly and care and support for those with learning disabilities, it covers large care providers with 100’s of homes as well as micro providers with just a few beds. Finding a model of social care inspection that fully encompasses the variation while ensuring consistency is, in itself, a challenge.

The Care Quality Commission has recently stated that it intends to have more specialist inspectors and social care could really benefit from this approach. For example recent reports have highlighted training and development issues with Health and Social Care staff and having learning and development specialists as part of the inspection process can help raise awareness of the importance of staff development, encourage providers to focus on training and development and help identify failings where providers fail to implement staff training and development. Similarly specialists in infection control or nutrition could have a significant impact.

One thing that would be good to see, and may well happen given Andrea’s former job, is a focus on best practice information and its application both by providers and inspectors. Resources, for example, from the three main national bodies, Skills for Care, National Skills Academy for Social Care and, of course, the Social Care Institute of Excellence should be routinely be embedded in care practice and those who inspect should also be fully familiar with this in order to ensure inspections are informed. One challenge has always been getting best practice information through to all providers, it is easy for providers to say they don’t have time to look at these things or, in the worst cases, believe they know what they are doing and don’t need any advice. If providers know their inspectors will look at this then they are far more likely to make to time to look at and use this information.

The regulatory framework has increasingly moved toward an outcome based approach, if providers and inspectors do not access the knowledge of what excellent outcomes look like then that system fails.

Undoubtedly, Andrea Sutcliffe has a challenge ahead, one that I am sure she will meet head on, and, ultimately, social care can only benefit by having such an effective leader at the helm.

Health and Social Care Training: The Real Issues

“There is no minimum standard of training for healthcare assistants before they can work unsupervised, an independent report has found” http://www.bbc.co.uk/news/health-23246066

Actually that’s not true!

Back in March Skills for Health and Skills for Care launched the National Minimum Standards for Healthcare and Social Care workers – see http://www.skillsforhealth.org.uk/about-us/news/code-of-conduct-and-national-minimum-training-standards-for-healthcare-support-workers/ . In addition the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 state quite clearly the Health and Social Care providers must ensure employees are “appropriately supported in relation to their responsibilities, to enable them to deliver care and treatment to service users safely and to an appropriate standard, including by receiving appropriate training, professional development, supervision and appraisal” (Regulation 23)

So, the issue is not whether those standards are in place but how those standards are applied, implemented and inspected.

The first area that needs real scrutiny is the induction process.

Imagine that time when you first started in a new job, there is always an element of nervousness as you enter a new environment, have to learn new routines and adapt to working with new people. Now imagine how much information you are likely to retain when you are bombarded with DVD’s or reading material which is supposed to make you competent in the role you are about to undertake!

While we have, in social care, the Common Induction Standards, it has to be remembered these only form a part of the induction process. Induction must be as much about ensuring that new employees learn about the workplace, its routines etc. and how the induction standards apply to the workplace and the individuals receiving care and support there. A tick box approach to the induction standards will not work and there needs to be a greater understanding by managers and leaders in the home of the importance of mentoring new employees to ensure the induction standards are embedded in work practice.

Learning and development must not stop after a successful induction. Professional development is a regulatory requirement and continuous training is important. Even if you have been on endless health and safety courses the chances are going on another will spark something in your mind that you had forgotten or prompt you to think about a bad habit you have got into and encouraged you to change it. Training, aside for giving us new information, can also make us think about how we do things right now, it brings us into ‘conscious competence’, always a good thing to do on occasion.

Supervision and appraisal also serves the same purpose. It helps us question why we do things in certain ways and can make us consider better ways of doing our work. Too often supervision and appraisal are seen as a means to be critical of an employees work but they should be seen as a means of encouraging employees to think about their own role and how they perform it.  

The key issue is to ensure that those responsible to managing and leading staff are sufficiently trained themselves in staff development.

One of the vital areas of training, often overlooked, is the quality of training itself. Certainly I have stopped using training providers because of the negative feedback I had from staff (the usual complaint is ‘they were just reading from a script’ – how can a trainer engage learners when they a focused on reading their lines?) yet how many providers actually get feedback from staff about the quality of training. It is important that providers do this, not only to ensure the quality of training but also to ensure they are not wasting their money!

There are schemes in place which accredit training in social care the principle one being the National Skills Academy for Social Care, and whilst their list is somewhat small at the moment, it would benefit all those who provide social care training to apply for accreditation (here’s the link https://www.nsasocialcare.co.uk/training-providers ).

Given that standards and regulation already exists the obvious question is how are these actually regulated and inspected. If there are issues over training and development why are these not picked up in the inspection process? It can only be speculated that the inspectors themselves are receiving insufficient training into what to look for and what questions to ask about training and development. One of the proposals from the Care Quality Commission’s consultation on inspection is the introduction of ‘specialist’ inspection teams – personally I hope that includes specialist in training and development to ensure standards and regulations are adhered to.

The training and development regulations and standards are there, the issue is how these are applied and inspected, if we can improve this we can improve the general quality of care across the board.

The Confusion of Westminster

Last week we had an announcement that £3.8 billion will be given to social care yet official sources cloud this. For example the Department for Communities and Local Government describe it as;

“£3.8 billion, including £2 billion of new NHS investment, to improve adult social care and join up with health services. This will help older and vulnerable people to stay healthy and remain at home thereby avoiding unnecessary hospital admissions or emergency visits to A&E. To stimulate real change, £1 billion of this funding will be paid when local results are achieved.”  (https://www.gov.uk/government/news/eric-pickles-hails-council-tax-5-year-freeze-and-38-billion-for-social-care)

In other words the money is for preventative health support to reduce the need for admissions in hospital.

Obviously this has to be welcomed by preventing a health issue becoming a health crisis the pressure on Accident & Emergency departments can be eased a little and, more importantly, being healthier should lead to a better quality of life for those who need social care services.

But what it does reveal is the ignorance of those in Westminster about what social care is.

Eric Pickles demonstrated this with his quote on the DCLG website saying;

“For the last 30 years all too often the care home, social services, and the local GP haven’t been working together to prevent unplanned hospitalisation of elderly or vulnerable people.”

The last set of statistics from the Health & Social Care Information Care show that care home residents only account for 14.6% of council funded care recipients. How, one wonders, does Mr Pickles think the new investment will help the 85.4% of social care users who are not in care home?

If the role of preventative health is to be transferred to social care then considerably more money will need to be ploughed into the sector. Social workers and social care workers are not health professionals and if it is to be their role to work with the health of an individual then they will need significant training in order to do so effectively. If however the onus is on health professionals then the money is not for social care it is simply transferring health funding!

Following on from the spending announcement we have learnt that the Care Bill will set the ‘substantial’ criteria as the benchmark for individuals to access care funding from the state.

The current ‘substantial’ criteria mentions health briefly, the majority focuses on personal dignity, daily living and family and community life and when the Care Bill final goes through there will be a significant increase in funded care users as many councils are currently only funding those with ‘critical’ needs. Therefore councils will need a staffing infrastructure to cope with this increase if current social workers are not to be totally overloaded with paperwork, especially if they also have to assess health needs!

Westminster seems to be clueless about social care and solutions to support people to live life in the way they want to is lacking as Ministers continue to confuse social care and health.

Social care should be about supporting people and bringing together the services they need. Health is just one of those services. A person’s health needs will vary over time and, where social care support is involved, it is social care’s responsibility to ensure the individual is able to access those health services, but social care also has a responsibility to ensure the individual is supported in every aspect of their life, from adaptations in housing to maintaining community links.

Social care is ever more important in society and demand for social care services will grow as the population ages. We need a social care service that is fit for now and the future and that cannot happen until those in Westminster recognise that they need to recognise the true importance of social care.

The Time to End Poor Care is NOW

The morning after yet another Panorama expose on appallingly bad care the media response is, as usual, distinctly underwhelming. No loudly broadcast calls for the resignation of senior civil servants, no demands for inquiries into the care system, in fact, nothing.

One particularly difficult issue with social care is that it is far too easy to spread the blame and for nobody to take responsibility.

Commissioners, Regulators and providers can all blame each other and the Government can blame all three! Yet, ultimately, the responsibility for regulating social care lies in Westminster and it is the responsibility of politicians to ensure safe, quality care is available to all.

Yes appallingly bad care exists but good quality care also exists. The quality of care is solely dependent on the care provider and good care providers have to struggle in a system that treats both good and bad care equally. Both are allowed to thrive in a system that is, currently, more focused on money rather than quality and the needs of individuals.

Of course bad care providers are to blame for the care they provide and such providers need to be shut down and banned from providing care services again yet the system allows them to carry on. Regulators can be blamed for not spotting the bad care being provided yet they are constrained by the regulations they regulate and inspections can only provide a snapshot of care provision and inspecting home care in particular is challenging. Commissioners can be blamed for buying services based on price rather than quality and, perhaps, they rely on information provided rather than going out and inspecting the care services they are commissioning services from.

But all of this can only happen because of the framework in which everyone operates.

Contrast this to the NHS and the calls for action following the Mid-Staffs enquiry. Those who stoutly defend the NHS and campaign for better quality do so because the NHS is a single, national, entity yet few of those people so stoutly campaign the fragmented social care system.

The ultimate responsibility for social care lies with Westminster, it is no use politicians blaming other elements within the system because it is the system itself that is broken and urgently needs to be reformed. There increasingly needs to be a system that promotes and rewards good care providers whilst ensuring those who provide bad care are eradicated.

We are promised a new care rating system soon, which is welcome, but it must, obviously, be one that can be trusted, one that will influence commissioning and one that reflects the care individuals need rather than what bureaucrats believe is essential in terms of paperwork!

Yet beyond this we also need a system that has real accountability. The ability of all parties to pass blame on others MUST STOP NOW. Ministers must admit their responsibility for social care services, commissioners must accept they have a responsibility to ensure the services they are commissioning are quality services, regulators must accept their responsibility to rigorously act and eliminate poor care and care providers must be held fully accountable for any failures in their duty to care.

The time to end poor care is now and this has to start with ending the blame game and all those responsible for social care to stand up and shoulder that burden.

Me, Food & Social Care

Apparently I am an overly fussy pernickety eater although I would prefer to say I have a truly sensitive palate which means that there are many foods that are not palatable to me! Many have tried to test and trick me but always have failed.

It is not something that has any significant impact on my life and I doubt I am the only person like this.

Yet what if someone with a similar palate found themselves suffering with dementia and placed in a care home. Without knowing the persons likes (because the dislikes will be far too many to mention!) it would be easy to try and give the individual just what is on the menu. Personally if that happened to me I would simply not eat what was in front of me, but how does that act get viewed by the care provider? Am I being awkward? Am I refusing to eat? The more I insist that I will not eat what’s in front of is my behaviour becoming ‘challenging’?

If I have no relative’s to speak up for me to explain my eating foibles what happens next?

If I am refusing to eat what is in front of me yet I don’t have the capacity to express that how can I be sure that my behaviour is interpreted correctly? And how will my non-eating be reacted to?

If I lack capacity then someone will make a decision in my ‘best interest’ under the guidance of the Mental Capacity Act. Obviously it would be in my best interest to eat yet if I were forced to eat something that tasted extremely bad to me the more likely my behaviour would become more challenging and I would probably be labelled as such and because of my limited likes it attempts to try different foods would also probably fail and lead to more ‘challenging behaviour’.

This is, of course, hypothetical yet there are, undoubtedly, many people in similar situations, it may not be with food but with other aspects of daily life.

This is why carers and families are so important in the social care system. Social care professionals need to understand the person who needs care services and, where individuals are unable to articulate their needs, listening to carers and families is vital in providing quality personalised care.

The quality of social care is not just about now, it is about the future and the quality of care we want to receive in the future if we find ourselves needing care services. Quality services can only be achieved by understanding the individual and, equally important, their individuality. By the time care ‘professionals’ become involved in a person’s needs it is likely those needs have already progressed to a point where understanding individuality becomes more difficult making it ever more important for those professionals to engage with carers and families to truly get to understand what makes the person needing care service tick.

Carers and families have a responsibility too. As someone they love begins to deteriorate through age-related conditions they should prepare that information to ensure they are able to pass it on. Obviously, as individuals, we also have a responsibility to make sure those things are known in case we need social care services in the future.

In reality the real onus is on those paid to provide social care services to ensure they are providing personalised care based on the information given to them by the individual, their carer’s and their families.

If I ever need social care services I want those people providing those services to understand all of my needs and provide care based on those needs. Undoubtedly you do to. So let’s focus on moving toward that for the benefit of those who need care services now.

Social Care - It's Not Rocket Science

How long has the debate around integrated care been going on? It’s a constant theme running through the social care debate yet one that remains fully unresolved and one that seems difficult to achieve but why?

It’s not rocket science!

Take, for example, the space shuttle. That feat of engineering consisted of 2.5 million component parts, including more than 200 miles of wiring! Thousands of scientists, designers, engineers and manufacturers managed to come together to create a single machine that enabled regular space travel. Even so that would not have happened without the thousands of others who also played a role. The astronauts who flew the shuttle were also products of a system that selected, trained and developed them to ensure they were capable of operating such a complex machine. Then there were those on the ground who made sure the launch and landing were successfully achieved.

Yet we struggle to give individuals the integrated care and support they need!

The component parts of providing integrated care are considerably less than those needed for space travel and the cost considerably less!

Yet bringing together social care, health, housing, benefits and employment for the benefit of an individual seem to be an impossible task for the bureaucracy of the U.K.

Obviously because social care is so low on the bureaucratic pecking order it means that the other elements needed for integrated care tend to take precedent. Social care is a small part of the Department of Health and Housing and Benefits sit within in two other Whitehall departments. At the level of the Whitehall bureaucracy focus is on departmental achievement and policy formation with little or no consideration to the individual yet by changing focus to achieving integrated care for the individual departmental achievement and policy formation could actually improve.

With the space shuttle, the goal was achieving manned space travel that could benefit the space programme by being reusable. All those thousands of people involved in the project came together to achieve that goal, integrating their role into that single achievement. Obviously there were disasters yet overall that particular programme was a success.

Those in Government should learn that if the goal of social care is the life of the individual we can begin to make social care the Primary service under which all other elements needed to provide effective integration are mustered and directed by social care services.

Completely effective social care means having a fully integrated service whose goal is the needs of the individual, why is it so hard after all it’s not rocket science.

The Sense of Adventure

Do you like to think outside the box, push outside you comfort zone, expand your horizons or perhaps extend the frontiers of your knowledge?

It seems to be a naturally occurring part of human nature to seek out new experiences and find ways to enhance our lives by discovering new things. Obviously we all do this in completely different ways. The adrenalin junkie will take to extreme sports to conquer the elements by seeking outrageously dangerous thrills, excitedly relishing the physical and mental challenge they have set themselves. Others may take joy in food, the adventure of seeking out a new restaurant, savouring the ambience, sounds and aromas surrounding whilst eagerly anticipating the new tastes they are about to experience. Others could simply be avid readers who regularly and enthusiastically, seek out new authors to stimulate their imagination and mind.

Essentially, within all of us, to a greater or lesser degree, there is a need to have new experiences to keep us from become to stale and bored with life.

Yet, when it comes to providing social care, what do we do to stimulate and expand the experiences of social care workers to keep them interested in their work and to stimulate them to encourage them to expand their horizons when it comes to how they deliver care services?

Outside of social care, many businesses go beyond general training with such things as ‘team-bonding’ activities and whilst these may have become something of a joke or simply an excuse to have a good time the principle behind the idea is a sound one. It is something different in the workplace and should, if well planned and designed, give sensory experiences that go beyond those normally experienced in the workplace.

Unfortunately regular classroom training does not usually provide the extra sensory aspect, in fact much social care training is done simply to comply with regulations rather than truly benefit the care workers. Additionally training only forms a part of the learning process and without the other elements training becomes little more than a chore, especially if it is one of those courses that has been done year after year!

Add to this the increasing pressure in care services, to do as much as possible in ever decreasing time-slots, little time is left for workers to engage in personal growth through work and take the importantly essential opportunity to reflect on the work they are doing and what they could do to improve that work.

And now to completely flip the coin – what about those we provide social care services for?

There is this public perception of older peoples’ homes being rows of old-fashioned arm chairs filled with elderly people who just sit there between getting up and going to bed. While there a many homes where that may be the case there are many that provide excellently managed activities which stimulate and stretch the minds and senses of those they care for.

There is some great work around at the moment focussing on raising awareness of loneliness amongst older people who may have no family and only see carers for brief visits. But loneliness is not just about having no-one around you. You can be lonely in a crowded space, just like those people who are left to sit around all day in those poor care homes. Loneliness is not necessarily being alone but about being engaged or stimulated in some way. In social care we need to ensure that those we provide care and support are stimulated and engaged and given the chance to have new experiences or re-live the thrills of past exploits.

Cognitive decline does not necessarily mean a loss of all the senses!

We all have a sense of adventure laying somewhere within us and that naturally stimulates our need to seek out new experiences which in turn helps us keep fresh and stops us becoming bored. Social care must be about providing those who need services with a good quality of life and that sense of adventure is an important part of that quality. Similarly we need to keep social care workers engaged and stimulated as this obviously helps in retaining staff and encouraging them to fully immerse themselves in the quality of care they provide.