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 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.

Back to Basics after Winterbourne View: Social Care Training

The Governments final report on Winterbourne View says a lot about the need for staff training but within all of that there is an important phrase that applies right across the social care spectrum and that phrase is “properly trained”.

While there could be some debate about what ‘properly trained’ means it is essential that all care providers reflect on the standard of training that they are providing for their staff. Under the current economic climate it is quite possible that providers are focusing on the cost rather than the quality of training.

Skills for Care and Skills for Health are charged with producing minimum training standards by January but it is unclear as yet whether these will be tick boxes for providers or fundamental changes in the way training must be monitored or delivered yet in either instance care providers should take responsibility for the quality of the training they provide for their staff and this can be done in a number of ways.

Firstly talk to staff. How did they feel about the training, were they engaged with the training or was it just a chore that just had to be done? I know, from personal experience, have conversations like that are useful, once I was informed that a training session was pointless because the trainer just read everything from a book and obviously did not know much about the actual subject. Needless to say that training provider was not used again but without seeking that feedback in the first place the company would probably have continued using the same trainer.

Naturally it would be obviously more useful if care providers could have some assurance about the quality of training providers before they booked them. This is easy for certain courses such as First Aid and Food Hygiene where trainers are accredited by the Chartered Institute of Environmental Health but for other training the route to quality is much less clear.

Yet there is some help, the National Skills Academy for Social Care has started a list of endorsed trainers (available here) and of course word of mouth through local trade associations is a good way to identify recommended trainers. Hopefully the endorsement/registration of trainers in social care will expand to help providers in identifying trainers who can provide appropriately qualified trainers to meet the needs of their particular service.

It is also, perhaps, important that care training providers look at how they can improve their own service by , perhaps, ensuring that the model of care set out in the Winterbourne View report is embedded in any training they deliver and by seeking recognition from the National Skills Academy for Social Care so that providers can trust that they will receive quality training.

Care providers have further responsibility though. Ensuring staff are ‘properly trained’ is not just about what happens in the classroom setting, that training has to be turned into practice and that aspect is the responsibility of the management of the care provider. How aspects such as infection control, medication, mental capacity, adult protection etc. are applied to those the provider cares for can only be done at the point of care delivery and it is essentially vital the staff development activities work hand in hand with formal training.

Unfortunately, when the sector changed from the National Minimum Standards to the Essential Standards of Quality and Safety many of the training standards were lost as the new standards were required to cover hospitals, dentists, ambulance services etc. as well as social care but hopefully the new standards being worked will fill some of this gap.

There can be little doubt that training and the quality of training will be high in the Care Quality Commission inspection agenda and ultimately training provision is the responsibility of the care provider and it is essential that training provided for staff is high quality training that engages and leads to better outcomes for those they provide services for.

Personalisation and Being Human

You would probably agree that there is a part of you that enjoys time alone to relax and reflect yet at times you enjoy the company of others and, if you were being honest with yourself you do, perhaps, enjoy the attention others give you.

Perhaps, at times, you feel that you are not using your full potential in some aspect of your life and that those you are with fail to understand how much more you can offer and improve yourself.

Maybe there is a hidden part of you, one that you can’t reveal to anyone that holds a regret in life, a choice made wrong which, on one hand, is seemingly trivial yet on the other is one that has lived with you for a long time.

We are all the same, and the above holds true for most of us but the degree to which it applies may vary, yet they are fundamental part of our make-up.

Yet do we pay enough attention to these aspects of being human when delivering social care?

Personalisation is the key to delivering good quality social care yet the key to personalisation is understanding what it is to be human and understanding how we tick. Unfortunately the basic training of care work does not include this aspect of understanding which is so vital if quality care is to be universally delivered.

Core training consists of health & safety, infection control, food hygiene, etc. The Skills for Care Common Induction Standards go further but beyond induction training how much training do the majority of care workers get in understanding the individuals they are working with.

There is, of course, a tendency to stereotype people who need social care services (as in all aspects of life) using generic labels such as ‘learning disability’ ‘dementia’ ‘old’ and so on. Such labels have their uses and stereotyping is a human trait which allows us to form our own identity but in delivering care services and treating people with dignity and respect such labels represent just one aspect of who the person is. Although this one aspect may have significant impact on other areas of their life the person who needs social care services is still a person with the many individual quirks, nuances and subtleties that make us all slightly different but with the same underlying aspects of what it is to be human.

Obviously the immediate tool for learning about a person in order to provide personalised care and support is communication. Effective communication is essential, especially about listening to the person about their likes and dislikes but it needs to go further to understand a person’s desires  dreams and hopes. For example if we want to promote a person’s self-esteem we have to understand what that means to the individual, self-esteem involves personal beliefs and emotions not merely the likes and dislikes which are the standard part of any care plan.

Being a person is a complex thing and delivering quality, personalised care and support relies on understanding the individual not merely their personal preferences but also their values and beliefs which form their individuality. Those responsible for delivering care and support services are those on the front line of care and it is essential that their training includes more than the safety and physiological aspects of life.

You would probably agree that if you needed social care services that you would want services that understood what you needed, delivered by people who know when you need company or when you need to be alone, people who knew how to motivate you yet understand when you may be pushed too far, people who understand what dignity and respect mean to you. Isn’t only right then that we should apply this principle to all social care users.

Skills, Social Care & Society

Very soon the whole social care consultation merry-go-round will start once again with the emergence of the White Paper. When the Government  publish this  undoubtedly the focus, once more, will be on who pays for care services and how they do so, leaving out HOW MUCH such services really cost.

Part of the debate on social care is about providing quality services but there is little discussion how this is achieved and how the front line care workforce is trained to deliver that quality and why training is so important to achieving the best possible outcomes for those who rely on care services.

Everyone sitting in an office right now knows about Health & Safety at Work, to most it is something that is fairly abstract but rigorously enforced by the ‘Health & Safety Police’ in a manner that appears somewhat obsessive. Yet in social care health and safety is a lot more immediate and is not only about the workers but also about the people they support and care for. Slips, trips and falls, for example, become a much greater hazard for those who are frail and have problems with mobility, it is not just a case of worrying where computer terminal wires trail but all small lumps and bumps in the flooring become potentially hazardous.

Care workers, therefore, have to have a  greater awareness  of health and safety than the average worker and, of course that level of training costs.

One of the favourite things in social care is to compare the workforce (in terms of pay conditions etc) with the retail sector. I have often questioned this comparison but the issue of training helps illustrate why the comparison is a false one, particularly moving and handling. Obviously both jobs involve manual handling, lifting etc but in a supermarket the only handling involves inanimate objects. How much more complex the need to be able to handle people, to help them in and out of bed or the bath, how to use the more complex equipment, such as hoists, which need to be tailored to the individual.

Care workers, therefore, have to have a  greater awareness  of moving and handling than the average worker and, of course that level of training costs.

The same applies to many of the basic training elements in many workplaces where care workers have the additional element of having to take into account how that knowledge applies to those they work with.

Beyond that the care workforce is expected to have additional knowledge that is, generally, only otherwise found in the health sector. This includes infection control and ensuring that the risk of infection is minimised, they need to understand the concepts of cross contamination, the hazards of handling bodily waste and how to deal with contamination if it occurs. Care workers need awareness of medication, how to store it, deliver it and record its use and care workers need to understand the signs and symptoms of adult abuse and what to do if they suspect abuse has taken place.

Society also expects care workers to deliver dignity and respect to those they provide services for. While the words dignity and respect are often bandied about very little is said about what this involves and the principle skill is communication and care workers need to be trained in the complexities of communication in order to listen to and understand the needs of the individual to deliver the best possible service.

Social care is often portrayed as a generic service where care workers are transferable. But, in fact, care services are far from generic, older peoples services are vastly different from learning disability services or mental health service or physical disability services and aside from the general skills listed above there are also specialist skills needed by the care worker dependent on the service they are working in. Knowledge of dementia is an essential skill for working with older people but not in many other services, (although in learning disability services dementia is an issue that is probably needs more consideration as the population ages), knowledge of autism and epilepsy is needed in learning disability services where these conditions are prevalent and, of course, knowledge about specific learning disabilities need to be known in order to provide the best possible service.

Overall then the care workforce  needs  extensive skills and knowledge to deliver the best quality care. This sometimes fails, as demonstrated by Winterbourne View and Ash Court but this cannot be surprising in a society that undervalues care workers and fails to see the importance in ensuring care services are funded sufficiently to allow the full spectrum of  specialist  training to match the  specialist  service that care workers are expected to deliver.

When the White Paper is  published  and the consultation process around the proposed draft social care bill starts they needs to be a greater examination of what we expect the social care workforce to deliver, the skills and knowledge that are needed to deliver quality care and how much investment is needed to ensure these skills are in place.

Improve Dementia Care Sooner Rather Than Later

Dementia is a disease, or rather the generic term for a group of diseases that are classified as degenerative diseases of the nervous system. The World Health Organisation classifies these diseases, Alzhiemer’s Disease, for example, is listed as “a primary degenerative cerebral disease of unknown etiology with characteristic neuropathological and neurochemical features. The disorder is usually insidious in onset and develops slowly but steadily over a period of several years” in the WHO International Statistical Classification of Diseases and Related Health Problems 10th Revision, more commonly known as ICD-10.

Given that the various types of Dementia are a disease it seems surprising, yet deeply disturbing, that the NHS is failing to provide adequate care for those who have dementia http://www.bbc.co.uk/news/health-16206169

One of the reasons could be that care for those with dementia in the UK falls under the social care remit rather than the health care one. Therefore the expertise in supporting people with dementia is detached from front line health care.

The problem is, perhaps, exacerbated by the fact that few people access hospital services because of their dementia. The reason for being hospitalised is for other health reason, yet it has to be born in mind that these reasons can be related to the dementia, for example a cut or burn could be the result of failing to remember something, so true, holistic care needs to take into account all aspects of the persons health.

One of the answers being touted is training for NHS staff, while this can only help it may not be enough to solve the problem. Training imparts knowledge but that is all, how that knowledge is used in practice is a completely different matter. To ensure that the knowledge gained through training is used effectively their needs to be both good staff development and effective leadership at all levels of the NHS. And to achieve this, managers and supervisors, at all levels, need both effective leadership and communication skills along with a knowledge of dementia themselves.

An additional area highlighted was communication between hospital staff and relatives of the person with dementia. This is an important area to be addressed. Dementia is a disease that can have a great impact on a family, the worry about a loved one can be tremendous, along with the guilt of feeling inadequate in caring for them. If this is made worse by a) poor care & b) poor communication then it is not only the patient that the hospital is failing.

Again the solution is better knowledge, better practice and better communication skills.

Perhaps it is now time to take a fully integrated approach to health and social care. Why not have social care specialists on elderly wards? Why not recognise that social care is best placed to provide the support for people with dementia in hospital. This is particularly important in ensuring there is sufficient after care when the person leaves hospital, especially if they are returning to their own home.

The numbers of people with dementia are predicted to rise sharply and unless action is taken soon the situation will only get worse, so let’s hope we get action sooner rather than later.