INTRODUCTION

A WAY OF THINKING ABOUT THE STANDARDS AND THEIR OUTCOMES


As you may have guessed from the title, this small book is about putting the National Minimum Standards (NMS) into practice. Our practice (what we do) produces "outcomes" - results for residents. Beneath the heading of each standard is the outcome. Have a look.

For instance, Standard 23: "Residents' own rooms suit their needs." Simple and sensible, isn't it? (Actually it says "service users", but I'm going to avoid that phrase.) It's what we're aiming for. We want each resident to have a room that suits their needs. And that's what the inspector should be making a judgement about, and will probably need to talk with the resident and or their relatives in order to make a sound judgement.

Of course, if the room doesn’t meet the resident's needs - say it's too small - the inspector can then use the room sizes set out in the standards to make a requirement or recommendation. To take this example a little further: most proprietors or managers of care homes know of one or two residents who would choose a small room, just enough to have what they want in it and no additional "responsibilities". But, if the resident becomes more disabled and needs to have their bed with space either side so that they can be helped from both sides, or if they start using a wheelchair, then they will probably need a bigger room, if and when one is available. You may be well ahead of the inspector, because you want residents to have rooms that "suit their needs", and by the time the inspector comes, the resident may have moved to a larger room. My point is that these standards are your standards, and those of you who had been running your home for several years before the standards were published, had probably already found ways of putting your own high standards into practice.

The set of standards on which the book is based is for Care Homes for Older People, but, in my view, the standards for "younger" adults are basically the same, and I do hope the some of the readership will be people providing services for other client groups.

This guide is more about a way of thinking; it's not an instruction manual. Once you get the hang of owning the standards and using the outcomes, you don't really need instructions or directions. So, I discuss each of the standards and offer a view, a perspective - a way of looking at them - and some suggestions and ideas to challenge you. Your constant touchstone is the question: "what's best for this resident?" within the bounds of what you can practically achieve.

How the book is set out
The book is structured in the same order as the standards themselves. Each chapter deals with a group of standards, from Choice of Home to Management and Administration, from Standard 1 to Standard 38. (All the main standards are included, but I have left out Standard 6 (Intermediate Care) - I explain why at the end of Chapter 1.

I have seasoned the chapters with "useful tips" and "challenging ideas". Some of you may find that the seasoning is a little strong - too much pepper? - and, certainly, I have not held back on expressing my idiosyncratic ideas about "doing it differently". In putting these ideas before you, I hope to stimulate you to challenge your own - and established - practice and thinking. I take full personal responsibility for these challenges, but I do assure you that they are the product of my own real practice, not just plucked out of an excitable imagination!

At the time of writing, inspection is once again in a period of change and uncertainty. The standards themselves are going to be reviewed, and we hope that this publication will make a contribution to that review. The Commission for Social Care Inspection (CSCI) has set out some sensible and positive changes to their practice in "Inspecting for Better Lives" (November 2004), but CSCI is to be merged with the Healthcare Commission, a process which itself will produce more changes.

One proposal from CSCI is to increase the proportion of unannounced inspections. This may mean that no established home has to spend hours preparing, and filling in forms and questionnaires prior to announced inspections. The work involved with inspecting should belong solely with the inspector, not with the home. Everything in the standards and anything that's in an accurate inspection report, should be being done in a good home anyway.

Remember the standards are yours.  Inspectors didn't invent standards, nor do they own them; their job is to check that homes meet the standards. And, if your home produces good results for residents and thereby meets the standards, all well and good - 'nuff said!

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CHAPTER 1

CHOICE OF HOME: STANDARDS 1 - 5

A place to hang your hat

Any old place I can hang my hat is home sweet home to me.
William Jerome, 1901.

Although I don't often wear a hat, for me this old song conjures up an appealing image of comfort and familiarity – that homely, lived-in quality. It takes only a couple of words to connect us with our feelings of home, but they are not the same words and images for all of us. This is why each care home – in order to provide choice and to be a real home - should be unique and have its distinct identity. Within its walls there must be the opportunity for residents to create their own homely space, both in their private rooms and in the areas they share with others.

In this chapter I’m going to tease out the essentials of the first group of standards, Choice of Home (1 – 5), and how you, as a manager or proprietor, may produce the stated outcomes, in other words, get the right results for residents.

For what you’re aiming to achieve, look at the outcomes under the headings of information, contract, assessment, meeting needs and trial visits. Then look at the introduction to this section and at the standards themselves.  Although we may quibble with some of the language (I’m afraid “service user’ still grates with me), the overall purpose of this set of standards is crystal clear. From the point of view of the manager and proprietor we might say, “We want residents and their relatives to choose our home because it suits them and will meet their needs.”

Of course, this begs the question of what sort of home it is and that is dealt with in all the later standards (and chapters): care, the life of the home, complaints and protection, environment, staffing and management.

But, given that your home exists and is open to new residents, how do you provide the information needed and agree an honest contract for accommodation and care? From one viewpoint this will simply be a matter of good business and from another it will be the start of the care provided. Both are important, so we should aim for a combination of the two. Whatever kind of home it is, full and clear information and a fair contract are essential, as is forming a friendly and individual relationship.

Information
Standard 1. Outcome: prospective residents "have the information they need to make an informed choice about where to live."

A statement of purpose and a brochure that are read by no one but inspectors would not meet the standard – even if they passed the inspection! Homes achieve this outcome in different ways. The standards seem to imply that there should be several different publications, but it’s confusing for everyone if there is a proliferation of material, that gives the same information over and over again, at great length and written in jargon.

One way of providing the necessary information for prospective residents is to have a short, simple leaflet for people to take away, and a display folder containing all the information set out in Standard 1.2. Each item of information in the display folder could be made available to anyone requesting a copy. It needs to be in a form that can be easily and regularly updated. Selected items from the folder can then be assembled into an individual guide or handbook for each resident. The folder can be kept in the reception area of the home for residents and visitors to have a look whenever they want to.

Useful tip: always remember to sign and date every piece of information - and notices, of course. Information goes out of date and if you don't know who wrote it and when, it's easy to get old and new information muddled up.

One of the items to be made available to residents is the latest inspection report, so that must also be written and presented in a way that is easy to read. If it isn’t, send it back and ask for a report that meets the standard (“in plain English and in a language and/or format suitable for residents”). Can you imagine the great effect it would have on inspection reports if everyone did this? CSCI are working hard to improve inspection reports, but you can help them by insisting on reports written in plain English.

Challenging idea: like the rest of the information you supply, your inspection report must be suitable to be read by residents and relatives. If it isn't, send it back and ask for one in plain English.

A glossy brochure is very costly and often not suitable. Keep it simple. Avoid the phrase “service users” and similar gobbledegook; ordinary readers will wonder who they are! Pictures are helpful to most people but can be expensive, so cut your coat according to your cloth.

At the point when residents and relatives are looking at different homes, they are also worrying about fees. They want to know how much your fees are and who is going to pay them. And if they are likely to be "self-funding" (paying for themselves) they desperately need independent guidance and help. There are various organisations that offer help, but not all give good advice. NHFA (co-sponsors of this publication) are amongst the best known and most trusted. (See chapter 8) NHFA will provide you with literature and a free advice line for residents and relatives.

Contract
Standard 2. Outcome: each resident "has a written contract/statement of terms and conditions with the home."

The contract is an agreement between the home and the resident. Standard 2.2 makes it clear what should be in the statement of terms and conditions, but you must keep the document concise. Remember it’s invalid if the resident or their representative doesn’t understand what they’re signing up to. It’s also worth remembering that the contract encompasses everything contained in the information folder, so you can’t just shove things in there because they sound good but you aren't actually providing what you've promised.

Look at the report and model contracts suggested by the Office of Fair Trading (OFT, May 2005). and encourage residents and relatives to use the advice provided by such organisations as NHFA, Counsel and Care, and the Relatives' and Residents' Association.

Needs Assessment and Meeting Needs
Standards 3 and 4. Outcomes: no resident "moves into the home without having had his/her needs assessed and been assured that these will be met" and residents "and their representatives know that the home they enter will meet their needs."
Unnecessary and unsuitable placements have long been a terrible problem for residents and for staff trying to work with them. Unprincipled proprietors (not you of course) and lazy community care managers would collude to ‘dump’ people into homes where they would be unhappy and neglected because the home could not meet their needs. Knowing the pressures there are for this to continue, managers of care homes must insist that a proper assessment takes place and that the home is chosen because it can meet the resident’s needs. As a manager it does you no harm at all to be demanding; your reputation for good practice will spread very quickly and all residents will benefit from it. Of course, this assessment provides the starting point for the care plan (see chapter 2).

Soon enough, every new resident will be coming to your home on the basis that they have chosen it and they know that their assessed needs will be met.

Challenging idea. Many years ago when I was manager of a big local authority home, social workers used to abandon new residents in the entrance hall, sitting in wheelchairs, clutching their notes – that was ‘an admission’. I quickly became very unpopular in the department because I demanded assessments, residents’ involvement, proper introductions, and the right not to accept residents if we could not meet their needs. I dug my heels in and wouldn’t budge. I had to stand up to most of the department all the way up to the director, all of whom thought I was being unreasonable and high-handed. It was a case of "back me or sack me", but it wasn’t long before proper assessments were being made and residents were involved and making their own choices. Managers do have the power to change practice and raise standards. These new standards have been hard won so don’t let them slip.

Trial visits
Standard 5. Outcome: residents "and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home."

The subject of trial visits brings us back to ‘a place to hang your hat’. As a manager, one of your most important skills is the ability to notice things and to notice how you’re feeling about them.

Useful tip: Every time you come into the home, do so as if for the first time. How does it feel? What’s the impression? Does that entry into the home express what the home is really like? Every time you hear the doorbell ring and a member of staff answers it, notice what happens. If it isn’t the way you want it to be, it is your responsibility to get it right.

For a prospective resident nothing matters more than those few moments: crossing the threshold, the greeting and welcome you get, the look and smell of the place, the atmosphere in every sense.

Nearly everyone wants to visit, have a meal, spend some time, and meet staff and other residents before committing themselves to giving it a longer trial. But they may be reluctant to ask, so encourage them to make a visit; invite them to a meal. Occasionally, and for various good reasons, it's not possible. When that’s the case, you (or a senior member of staff) should visit the prospective resident where they are, and in doing so you take the home and its atmosphere to them.

As the manager, if you are satisfied that the atmosphere truly reflects the home and its care, then don’t worry if sometimes a prospective resident is looking for something different and chooses not to come to your homely, lived-in place; that’s what “Choice of Home” is all about. They’re not looking for a place to hang their hat; they’re looking for a home run like a good hotel with staff in uniform. And that's fine; the same standards apply, but they are implemented in a different way.

(You will have noticed that I've left out Intermediate Care (Standard 6), not because it's not important but because it's a specialist area which would require a whole chapter to itself. I've seen intermediate care done very well and I think it's an excellent, much needed, development, but I've no first-hand experience of it. And that's another good reason for not writing about it, because all of this book is based on my own real experience.)
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CHAPTER 2

HEALTH AND PERSONAL CARE: STANDARDS 7 - 11

Drive with care
Led by principle, practice makes perfect

The National Minimum Standards make a pretty comprehensive practical text in managing care. These standards flow from principles, and, if you have a firm grasp of principle, you could have invented most of the standards yourself.

No one learns to drive by following a book of instructions. You learn by doing - by driving under supervision - but before you get behind the wheel, you must understand that a car is a lethal weapon. Being a safe and considerate driver is first a matter of principle and attitude, and second a technical skill.

The manager of a care home is the driver of a vehicle on which the health, welfare, and happiness of a large number of people depend. However good you are technically, without the principles you’ll be a lousy driver.

Standards 7 – 11, (the care plan, health, medication, privacy and dignity, and dying and death) require staff to understand and share the principles behind the standards. Too much current training consists of instruction in technique without sufficient discussion and understanding of values.

Care plans
Standard 7. Outcome: The resident’s “health, personal and social care are set out in an individual plan”.
Each resident comes to your home with an assessment. (If a self-funding resident makes an application to your home and has not had a social services assessment, you must make an assessment yourself or arrange for one to be done by a qualified person.) The assessment outlines the resident’s needs, and the care plan says how those needs are going to be met. So, the care plan should look very much like the assessment, and each time it’s reviewed, the resident’s needs are reassessed.

Care plans can easily become over-complicated, unwieldy and jargonised. Keep them simple and short - and handy. Here a principle is that residents (and/or their relatives, friends or advocates) must be able to understand and be in control of their own plan. It’s not the staff’s plan or the manager’s – or anybody’s but the resident’s. There must be the opportunity to include all the areas that are in the resident’s assessment, but there may be areas for which a resident doesn't want or need to have ‘a plan’.

Ideally the resident's plan is kept in their own room. Like some other valuable and confidential items, it should be reasonably secure in the room, but don't let difficulties about confidentiality keep the plan out of reach of the resident and/or their relatives - or, obviously, the staff who are caring for the resident. Some residents keep their care plans in their wardrobes or bedside cabinet. This is a good idea. With encouragement, you might find that one or two residents would like to have the plan right by them and may refer to it constantly. As with so many bits of paper in the home, care plans are literally useless unless they are used. Be flexible and imaginative, but think it through from first principles starting with "Whose plan is it and what is it for?"

Challenging idea. It's the resident's care plan, no one else's, so it should be available to and used by the resident and their relatives. Therefore it should be kept in their room along with all the other private and personal possessions and information. Now all you have to do is to work out how best to make that happen.

Health care
Standard 8. Outcome: Residents’ “health care needs are fully met”.
The standards list hygiene, pressure sores, continence, exercise and activity, falls, nutrition, registering with a GP, provision of chiropody and dentistry etc., hearing and sight, and entitlement to NHS services. (The details of how you meet these needs will be set out in the resident's care plan.) Consistency and gentle attention are often the keys to improving aspects of health, so staff must be reliable and must have the time to give residents the attention they need.

Challenging idea. There are still too many homes where incontinence is not only regarded as inevitable but is created by the way care is provided. Incontinence is an individual problem and must be tackled in individually ways. If your home has "toilet regimes", "bowel books", and stocks of pads for general use, you are almost certainly responsible for making people incontinent and keeping them that way. Think it through and attend to it individually; it's the only way.

Remember that living in a care home (including a care home with nursing) does not reduce individuals' rights to full NHS and GP services. A resident's relationship with their GP should be as direct as it was before they came into the home. Watch out for GPs evading this responsibility and relationship. While there are some excellent GPs with patients in care homes, there are still far too many who regard such patients as a nuisance and not deserving the attention they give people living in their own homes.

Yes, it’s your job to organise the home in such a way that residents can stay as healthy as possible. But, don't forget that you may choose to smoke, eat junk food, take too little exercise and risk your own health. Residents too should be able to choose to live an unhealthy and risky life. Your duty is to offer the opportunity to stay as healthy as possible, while accepting that not everyone will want to do so. For example, if meals are good in an attractive dining room where the atmosphere is congenial, and the garden is pretty and well-tended, most residents will want to get to the dining room, and some may like to take a walk in the garden, so exercise becomes just a part of ordinary, pleasurable life, not a chore. However, at the same time, you may be increasing the risk of falls, simply because people are moving around, and decreasing them because people stay mobile and their circulation is improved.

Standard 8.7 appears to demand that residents’ “psychological health is monitored regularly”. I think you should take this with a pinch of salt – very bad for the heart – first, because monitoring psychological health sounds like a job for a psychiatrically trained professional, and, second, because it could be an intrusion and infringement of rights. But having taken your pinch of salt, and bearing in mind your principles, of course you’ll want staff to notice if someone is upset, down in the dumps, or disorientated, and that you will pay the resident extra attention or get them special help if needed. And look out for the depression that often follows a move into a home and can last for many months. As with other serious (and usually multiple) losses, the loss of your home and the move can cause deep depression. Psychological health is frequently linked to physical health. This is an example of why you should be careful to be guided by the principles rather than by the “instructions” of the standards.

Medication
Standard 9 Outcome: Residents “where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines.”

This outcome is poorly worded. Principle and practice, not policies and procedures, protect residents. We’ve probably all known homes that have a standard medication policy and procedure that’s not followed in practice. Lots of homes routinely take tablets out of their original packaging and put them into little pots well before giving them to residents. Relatively few homes really encourage and support residents to be responsible for their own medication. And research continues to reveal that drugs are being widely misused and wrongly administered in hospitals and care homes - too many, too much, too often, not reviewed regularly, and sometimes used for the convenience of the home rather than for the wellbeing of the resident. Observe, review, and question.

Useful tip: Keep residents' medication securely in their own rooms. This obviously applies to residents who are managing their own medication, but it can also apply to those who need help to take and remember their tablets. Apply exactly the same methods of recording and administering except don't do it from the drugs trolley do it from the resident's own little drugs cupboard. The dining room drugs "round" always has a somewhat institutional and public feel to it; this way you can make it a much more private and individual affair. Some pharmacists will install individual cabinets free (on loan) and all the documentation to go with them.
Have you ever thought what a potential source of cross infection the traditional drugs trolley is? No one washes their hands between each resident’s medication administration, so you are taking infection from each resident and to each resident, and mixing it with infection from every other resident THREE TIMES A DAY! Why go on doing it like that?

As manager, your grasp of principle, your determination to put it into practice, and your vigilance will help to protect residents and ensure that their medication is used for their health rather than for the smooth running of the home.

Privacy and dignity
Standard 10. Outcome: Residents “feel they are treated with respect and their right to privacy is upheld.”

Imagine the scene in a home: it’s time for an early morning cup of tea. A member of staff knocks on one bedroom door and waits for an answer before going in with tea. At another door she knocks and walks in before she gets an answer; and at another she goes in without knocking. She passes one door altogether and she goes into the next with a glass of juice in her hand. At the sixth door, she knocks, calls to the resident and uses her pass key to enter.

This scene is open to interpretation, but I think it will be obvious to most of us that such practice meets the standard – or certainly achieves the outcome. An inspector, concentrating on outcomes and practice, who began the inspection early enough to witness this work, may judge such sensitive, individual care as "commendable".

Unthinking rule following doesn’t lead to good practice. If staff believe that there’s a rule saying that they must knock at every room and wait for an answer, they won’t actually do it most of the time because that’s not what every resident wants. But, when the inspector calls, if they don't have confidence in their practice, they try to follow the rule. On the other hand, if they are acting on principle, they will have the confidence to enter bedrooms in the way each resident chooses. They’ll know the minutely detailed preferences of every resident in all matters of personal care.

The same goes for how staff address residents. A mark of a good home where residents are respected may be that some residents are known by their title and surname (Mr Miller) and others are known by their first names or even chosen nicknames (Bill or even "Dusty", if that's what Mr Miller likes and is used to). Different staff may use different forms of address, so, those who know Dusty well, use his chosen nickname, but those who are not so intimate and friendly, or haven't known him for long, will call him Mr Miller. Just like ordinary life - which, of course, it is.
 
So, as a manager, you’ll encourage your staff to think things through, using principles as the starting point. You want them to have a strong sense of their own privacy and dignity, and therefore to be keen on respecting other people’s. The way you relate to the staff will be crucial in this process.

Challenging idea. You're the manager (or proprietor); you're in the driving seat, but you can't drive and read other people's instructions at the same time. You want your staff to understand why they do things, and not just follow instructions. So challenge yourself and others. Question conventional wisdom. If something has always been done in a certain way, it may not still be right for your home and your residents now. Practitioners invent good practice by finding new ways of working and by thinking differently.

Dying and death
Outcome: Residents “are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.”

In a good home, where most people stay until they die, there will be nearly as many deaths as admissions. Of course, some residents will die in hospital, and others may need to go to a hospice to receive specialist "end of life" care, but if they do have to leave the care home to die, keep in touch. Sometimes you, or other staff, will be the person's only regular visitors, and, as you would do in the home, keep an eye on the basic care that's being provided in hospital (which is not always up to scratch). Is the patient (resident) being helped with eating? Are they getting enough to drink? Mouth care? Washing and keeping their hair brushed and comfortable?

Above all, find ways for yourself and staff to spend time just sitting quietly with residents when they are dying. Most people (not all) don't want to die on their own; be with them.

Managing dying and death well is one of the most demanding aspects of your job. You will help staff and the family – and sometimes other residents – to stay involved yet not overwhelmed. The death of a resident who has been well cared for is not a failure.

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CHAPTER 3
DAILY LIFE AND SOCIAL ACTIVITIES: STANDARDS 12 - 15

The time of their lives

You get a good feeling when you go into some care homes. Admittedly, the furnishing, decoration and layout make important contributions to this feeling, but it's more than that. If the building looks cared for it may well mean that residents will be cared for too, but it doesn’t always follow. The most important element of how a place feels is what goes on between people – the social relationships, the conversation, the ambience. This is created from many tiny components. It is so complex and intricate that it’s impossible to force or to fabricate.

In this chapter I’m concentrating on the third set of standards (12 –15) ‘daily life and social activities’. How does a care home become a living community in which residents can have the time of their lives?

No, I’m not pretending that most residents don’t feel a sense of loss about the home they’ve left behind. I’m not trying to underplay the effects of increasing disability and dependency, and of sickness and death. Indeed, if, as a manager, you delude yourself into thinking that all is jolly, harmonious, and fun all the time, you are creating a ghastly emotional prison for everyone.  I mean that, in a home for older people, having the time of your life is living the last period of one’s life: living rather than merely existing or being kept alive.

Living through the loss of your home but enjoying the opportunities offered by being looked after and not having to struggle through every day. Meeting people and making new friends – and even one or two new enemies, if you’re that way inclined. Looking forward to a good meal - not only the food, but the company. Joining in activities and outings, and feeling you have a contribution to make. The pleasure of getting to know some of the staff and other residents with whom you share interests, or a sense of humour, or who like your stories or gain from your experience. Welcoming your own visitors and being able to offer them something – ‘tea or coffee, or would you prefer a drop of rum or Scotch?’ Taking part in happy occasions and sometimes in sad ones. This is a life to be lived.

Social contact and activities
Standard 12. Outcome: residents "find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs."

My goodness, that’s a high aspiration for any of us anywhere.

Care homes cater for a wide range of characters. Some are loners who would prefer to stay in their rooms, listening to the radio, watching TV or dozing, venturing out just once a day for a main meal perhaps. Others like constant company and want to be where the action is, sitting near the front door, joining in anything going. They regard their rooms merely as a place to sleep whereas others use their rooms to the full. Some residents like to invite their neighbours and friends in, as you would to your own house or flat, and they get invited back.

None of the ordinary social intercourse between residents requires "programming" or "managing", but it is dependent on the manager and staff creating the right atmosphere. With the best intentions, a member of staff can block a burgeoning friendship between residents by misinterpreting contact. “No, that’s Nora’s room, Nellie, not yours; you mustn’t go in there;” the result being that Nellie feels thoroughly told off and never visits her friend Nora again.

I’m always a little suspicious of ‘activities programmes’ and I’ve been to many a home where programmes are posted up on the wall only because the inspector expects to see it there. Homes that have no programme as such but where there’s a lot going on are more convincing. I’m not so cynical that I believe all programmes are a sham, but, as with most written material in a home, I’m more impressed by the reality than the write-up. Sometimes ‘activities’ seem as if they are a bit like compulsory games at school, with quizzes and crosswords as programmed activities rather than something a couple of residents and a domestic worker do from their newspaper at coffee time. And this is where good management comes in.

Challenging idea: Hand over control of activities and social events to the residents (assisted by friends, relatives and staff). This will work better if you also hand over control of the voluntary funds. Don't expect residents to take the initiative if you hang on to the purse strings.
With the residents and relatives in charge, planning activities, outings, special events etc. and fundraising becomes an important activity in itself. Collectively they become a strong group and will help you with all sorts of other aspects of running the home.
Wouldn't it be fun to say to the inspector, "No, I don't organise any activities; I have nothing to do with it. You'd better ask the chair of the social club if you want to know what they get up to."?

The society and culture of a home grows from small, important, social exchanges, and the manager and staff create the fertile seedbed in which these relationships germinate and blossom. A sensitive and creative manager encourages the domestic worker to take half-an-hour over a coffee break, doing the quiz or crossword, or giggling over the horoscope, with a small group of residents. It’s an ordinary part of life in the place, not an "activity". But, as with Nellie being told off for visiting Nora, the domestic worker can easily get the message that she mustn’t "waste time" with the residents.

Similarly, you won’t get far in creating a multi-cultural home if you rely on the occasional Caribbean or Irish evening, while at the same time ignoring the individual cultural backgrounds and potential contributions of residents and staff. For example, if you have someone coming in for a music morning and some of the residents and staff are gathered enjoying singing old songs, remember that part of the common culture of British people who were young - or youngish - in the 50s is popular songs of that time including Calypsos and spirituals. Don't trap people in what's narrowly perceived to be "British" popular culture; you're likely to have both residents and staff with a lot of old and new songs and other important aspects of diverse cultures to offer each other. Make use of all the talent and different backgrounds that you've got, but make it all part of everyday life in a lively place. (The same goes for food, but we'll come to that later.)

Community contact
Standard 13. Outcome: Residents "maintain contact with family/friends/representatives and the local community as they wish."

If you manage to foster a lively community within the home, links with the community outside will grow. The residents’ families and friends will feel that they are welcome and appreciated. Staff living locally will be proud of the home. Churches, mosques, temples, shops, businesses, pubs and clubs, and other organisations will regard the home as an asset to the neighbourhood, not somewhere shut away and isolated.

Useful tip: A home near to where I live has an art exhibition every year. Drawing and painting is one of the normal pastimes of the home. They have original artwork everywhere, some of it top class, and the annual exhibition draws in the outside community and gives the home a distinctive reputation and identity.

Take care that this open and active community spirit doesn’t become overwhelming for those residents who prefer a quiet and secluded life. This is the point of "as they wish" in the stated outcome for this standard. After all, the home is there for its residents first, and links with family, friends and the surrounding community must be geared to the real needs and wishes of each and every resident. 

Autonomy and choice
Standard 14. Outcome: the manager  ‘conducts the home so as to maximise residents’ capacity to exercise personal autonomy and choice.’

Think of this in terms of control – residents’ control over their lives. Coming to live in a care home should increase control for each resident. With staff on hand, it’s possible to regain control in areas where choice was previously impossible. For instance, if you’ve got someone to help you to get up and get dressed, you can decide what to wear. Your choice of clothes is no longer limited only to those you can manage to put on yourself, or to those you can reach in the wardrobe.

But in a lot of homes, the experience is a loss of autonomy and choice.

Challenging idea: Look at the details of the building and your practice. Can residents move freely around the building - and in and out of it - without being blocked by locked doors and "baffle" locks? Are staff doing things for people that they could perfectly well do for themselves? Are there taxi numbers, bus and train timetables, cinema and theatre programmes, TV and radio schedules on display? Are there drink making facilities? Do residents have the same range of choices that you have for enjoying themselves and relaxing?

Contrary to some widely held assumptions about people with dementia, all residents can make decisions and can gain control of important details of their lives, and build all these small choices into the substantial satisfaction of ‘autonomy’- in other words running your own life again. If you ever catch yourself saying or thinking "They (residents who are mentally infirm) can't make decisions," give yourself a thorough ticking off! Because with that attitude, you'll never achieve Standard 14.

Meals and mealtimes
Standard 15. Outcome: residents "receive a wholesome, appealing, balanced diet in pleasing surroundings at times convenient to them."

Nothing is more important than meals and mealtimes, but much of what I would say is implicit in what I have written about the previous three standards.

The food’s got to be good: high quality ingredients, plenty of fresh fruit and vegetables, well cooked, and attractively presented in quantities that each resident can finish, then have more if they want to. Many older people - not all - like to finish the food they've been given. It's therefore dispiriting to face a plateful of food, knowing that it's too much, and failing day after day to finish it.
Put at least some of the food on the table so residents can help themselves and each other (control). Don’t rush people. Make each meal an occasion and a pleasure.

The layout, furnishing and decoration of the dining room matter greatly. You can make it posh, "silver service" - the place to have "a meal out" - or you can make it much more homely - "a meal at home". And you can combine the two: the main meal whether it's lunch or evening "dinner" can be formal and posh, and the other meals informal, flexible and homely. There are several possibilities. An increasingly common practice is for most residents to have breakfast taken to them in their rooms, so some people like to have breakfast before they get dressed and ready for the rest of the day.

Useful tip: Instead of serving breakfast from a trolley, set out all the food, juices, tea and coffee on a table, as they do in some hotels. Some residents will be able to help themselves, and those who can't are in a much better position to choose with staff serving them from the attractive display.

Avoid getting into an - all too common - pattern of sandwiches or heated-up frozen snacks (such as sausage rolls) for "tea". Ring the changes; experiment; introduce new tastes. If you do have sandwiches sometimes, make them special, attractive and varied.

Introduce different sorts of foods from different cultures, but for goodness sake don't do it just because you feel you have to demonstrate how culturally diverse and sensitive the home is. Provide a  range of foods because most people (yes, including older people) like to try new things and some of them will both like and be very used to all sorts of different cooking and ingredients. Do make sure you can provide proper vegetarian, Halal, or Kosher meals whenever required, and encourage all residents to have a taste. Think also about tea, coffee and other drinks - have different sorts on offer - and avoid that disgusting cheap squash that has never been near a piece of fruit.

I’ll end this chapter with a controversial piece of advice. Mealtimes can be a real trial when there are too many people to help and the atmosphere becomes tense - not good for anyone. You want to establish a calm climate for residents so they can unwind and be sure that they'll get the food they want. If they can relax, they will become less demanding, and staff will be able to help them in a methodical and reliable way.

It’s rare to see staff eating with residents, and I’ve heard all the dozens of reasons why this is not possible, but it is and it transforms mealtimes. Some residents require a lot of support at mealtimes, not only with eating but also with relaxing, chatting and enjoying the meal. They need someone sitting with them throughout the meal, not dodging in and out to "feed" them. It requires careful planning, but I promise you that if you work at this and make it a normal part of your good practice, mealtimes will improve.

Challenging idea: At every meal, have a member of staff sitting at the table with a group of residents, not only helping them with their food, but taking a full part in the meal - talking, eating, and making it a pleasant, social occasion.

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CHAPTER 4
COMPLAINTS AND PROTECTION: STANDARDS 16 - 18

A stitch in time saves nine

If you see something going wrong, put it right before it gets worse. If you suspect that someone’s safety or liberty is at risk, find out what’s going on and nip it in the bud. If someone complains about anything, no matter how apparently trivial, look into it immediately and sort it out. Sounds simple, doesn’t it? Unfortunately it’s not, but making it more complicated doesn’t help anyone - least of all, the residents. 

I can claim long experience of “Complaints and Protection” (Standards 16 - 18) in a wide variety of social care settings since the mid-60s. I’ve seen most sides of the various systems designed to respond to and correct complaints, and to protect people who use care services. As a manager, registered person in control, inspector, independent complaints investigator and as a complainant, relative and advocate, my experience gives me little faith in the systems we have set up.

Generally, systems and procedures for “dealing” with complaints are just that: their underlying purpose is to protect the organisation from complainants. The more sophisticated these systems have become, the more impenetrable, defensive and long-winded they have grown.

I regret to say that one result of the legislation on complaints and protection (NHS and Community Care Act, 1990 and Care Standards Act 2000) has been to increase bureaucracy. First we had local authority inspection units and complaints units, and then the National Care Standards Commission (NCSC); and the next year we got the Commission for Social Care Inspection (CSCI). Soon enough, that will change too. In addition, most large provider organisations have created their own complaints and quality assurance systems. Some local authorities have set up parallel systems to test the quality of services they commission. All these organisations are inevitably to some extent parasitic, feeding off the time, energy and money of care providers - resources that should be going into care. And some of what goes on in these expensive systems often has little to do with the welfare and protection of residents in care homes. (It looks as if CSCI are going to achieve a better balance . . .  fingers crossed!)

It’s rare for a complainant to have the determination and stamina to pursue a complaint. They are unlikely to succeed unless their complaint provides ammunition for the organisation they have complained to. A complaint can be hijacked for other purposes: for the regulators to have a go at a care home; or for an employer to discipline a difficult member of staff, or an excuse to close down a team or section. And, of course, complaints can occasionally be made for very dubious reasons: a disgruntled member of staff or a vindictive, disturbed resident or relative. But they all have to be heard, taken seriously and investigated.

A fundamental redesign is urgently needed, but is less likely to happen because we have set up complaints systems in which a large number of relatively well-paid people have a vested interest. The whole set-up is currently geared to the big social care organisations, those that can afford to establish specialist sections to engage in this unproductive activity. The individual resident or relative and the small care providers must find a way to use the standards on complaints and protection as they were intended. Here’s how.

Complaints
Standard 16. Outcome: residents “and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon.”
Well, yes of course, in a good home staff will be alert to the subtle messages from residents – such as they don’t like some kinds of food or they’d like to go to bed later, even if they don’t say so. Or they object to the way one of the night staff speaks to them, but who do they tell?

You must have a “simple, clear and accessible complaints procedure”, and you must keep a record of each complaint and the action you have taken. As manager, you need to demonstrate that you want people to tell you about anything they’re not happy with. And don’t leave staff out of this, because there’s no quicker way to stifle residents’ complaints than blocking your ears to those of staff.

So what might your complaints “procedure” look like? How about something like this?


Suggestions and complaints
Please tell us what you think about the home and the way we do our job.

You can tell us or write to us – either way, we will listen and take notice of what you say, and we will always respond to you and thank you for letting us know what’s on your mind.
If you’re not happy with our response you can go to any or all of the following:
The manager – (name)
The registered person – (name and contact details)
The inspector  (name and contact details)

We know the home will never be perfect, but – with your help – we want it to be as good for you as possible.

Signed:  . . . . . . . . . . . . . . . .
Date:  . . . . . . . . . . . . . .  . .



Although you'll need to set out a clear, step-by-step process, including how to appeal, does it have to be any more complicated than this? It’s no good just distributing such notices and thinking the job’s done – that would be the superficial, procedural approach. Staff need to be trained and residents and relatives spoken to, but do keep it simple and direct. At every meeting – even handover meetings – you could check if there are any complaints or suggestions (and encourage staff to chip in). You might also, as some homes do, have a complaints and suggestions box – just another way of encouraging people to comment.

Once complaints and suggestions become a normal part of life and work in the home, you’ll find that the whole culture changes. This is one significant way in which residents will take part in running the home. Complaints will be prized as triggers for positive change. And, what’s more, if you get a good flow of comments from residents and relatives, you can incorporate this into the home’s “quality assurance” system (see Standard 33 in chapter 7).


Rights
Standard 17. Outcome: residents “have their legal rights protected.”

There are just three short paragraphs devoted to this standard. You’ll get it right if you bear in mind the principle that residents in a care home have exactly the same legal status as you do. They can vote; they are free to come and go; they are free to take their own decisions about all aspects of their lives within the same constraints that we all face. But, remember, most residents have come to the home because they need help with various aspects of the lives. So, just as some may need assistance to get up and dressed, some will also need help with getting a postal vote, if they want one. Residents who have no relatives or friends involved may want an ‘advocate’ and you should try to get one for them. Age Concern and other organisations provide advocates but they are in very short supply.

Challenging idea:
Many homes now have locks or key pads on the front door which prevent residents coming and going. This is an infringement - a restriction - of people's liberty, and, once installed, we tend to forget that we have taken away a fundamental right and have, in effect locked residents in.  We also forget that such locks are a serious risk if there was a fire, because most front doors are also emergency exits. There may be residents or special circumstances when residents' safety takes precedence over their right to freedom of movement, but you should regard the use of "baffle locks" as a temporary arrangement to reduce risks for a particular resident at a particular time. Such locks should not be a permanent measure, effectively imprisoning all those who can't open the door without assistance. (See also chapter 5, Standard 22.)

I believe that if you are the sort of person who values and exercises your own rights, you are likely to guard other people’s as well. If you disregard the rights of staff, some of them will inflict the same attitude on residents.

Protection. Standard 18. Outcome: residents “are protected from abuse.” Inspection was started to achieve this outcome. A series of scandals led to the 1984 Registered Homes Act and the 1990 NHS and Community Care Act (under which inspection units were set up). But as with everything else in the home, it is for you, the manager, to take the lead in protecting residents from abuse by your vigilance and the open culture that you establish. Don't put your faith in policies and procedures, or in the fact that inspectors fail to pick up signs of abuse. (The example of locked doors is "abuse", but it goes unnoticed. It becomes "institutionalised" because we have stopped noticing it, thinking about it, and challenging it. See also the challenging idea at the end of chapter 2.)

Staff, residents and relatives (and any visitor) must feel that they can talk to you about any concern. Abuse can come in many different forms, in the most unlikely ways, from the most unexpected people. Twenty years of regulation should have rooted out those homes that are institutionally abusive (by regime and culture) – although we must remain on our guard. Like overburdened relatives, staff can become abusive through stress and isolation. They believe that they are doing their best and they lose their self-critical faculties. This is why staff meetings, supervision, and an open and critical culture are essential.

It’s hard to believe that someone you thought highly of and who truly cares for the wellbeing of residents could become an ‘abuser’, but it can happen. If you notice the signs early – impatience, tone of voice, demeanour – not only will you be able to prevent abuse to residents, you will also help good, committed staff to carry on doing a job they love to the benefit of many more residents in the future.

As manager, you need to be in constant, close contact with residents. You may meet with them as a group every couple of weeks, and you may visit and talk in private with each resident (especially those who don't come to your meeting) at least every month. And the same goes for staff, because they are often the ones who know that a resident is unhappy, or notice that another member of staff is failing to treat a resident with the respect or care that they should. You will be meeting staff individually in regular supervision (see chapter 7, Standard 36). In addition you should make it clear that you will listen to staff and they can speak to you at any time in confidence about poor practice or abuse.

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CHAPTER 5

ENVIRONMENT: STANDARDS 19 -26

Think differently

Some of the very best care homes I know fall below the "letter" of the national minimum standards on “environment” – and one of the worst I know exceeds them. How can this be?

More than any other, this set of standards (19 – 26) appears to have precision and to be measurable. In 2002, it shouldn't have surprised any of us that government and the new regulator (then the National Care Standards Commission - NCSC) capitulated to sustained pressure to relax these standards. Yet, in my opinion, this was due more to the limitations and inflexibility of inspection practice (and a failure to recognise the importance of outcomes) than to the shortcomings of the original standards.

If the original standards were justified, how can I say that a good home might not meet them? Because no home – and certainly no building – is ever perfect, nor does any amount of physical luxury or modern equipment make up for a lack of true person-to-person care and high standards of hygiene. On the other hand, a neglected and inadequate building cannot provide a good enough environment for its residents. Any house that is still the same as it was a hundred or even fifty years ago could be of interest to the National Trust but is unlikely to be much use as a home of any sort. Our standards have changed. Think how expectations and regulations – and standards - have progressed in the lifetime of residents in a care home for older people.

The first old people’s home I managed was opened by Mary Wilson (the then prime minister’s wife) in 1964. It accommodated 120 people and was part of the move to close the huge old institutions where everyone slept in dormitories with no private space or possessions. In this “new” home the largest rooms had just four beds in them, which, to people moving from their 30-bed ‘wards’, in the mid-60s meant luxury, space, and privacy! But, by the time I got there in 1982, those new standards had become hopelessly outdated and the place was a run-down institution of the worst kind. It was dirty, demoralising and over-crowded. We fought the local authority to reduce the numbers so that we could use five of the big bedrooms for small dining rooms and convert all the other multi-occupied rooms, including sixteen two-bedded rooms, into single rooms.

With the publication of Home Life in 1984, we were given strong backing for our campaign because, we argued, our local authority could not ask private and voluntary homes to get rid of multi-occupied rooms and, at the same time, tolerate them in their own homes. Home Life helped us with most of the other improvements we made, particularly with staffing levels (see chapter 6).


Standard 19. Premises. Outcome: residents “live in a safe, well-maintained environment.”

To achieve this outcome you need an overall awareness of the general state of the home and its grounds, and an eye for detail. Planning, organisation and vigilance are vital. Yes, a programme of upkeep and decoration – planned maintenance - is crucial. Make improvements as money becomes available and opportunities arise.

Ignoring a frayed carpet in a corridor is foolish and could lead to a fall that could prove fatal. Encourage staff to notice hazards and take action; urge them to look after the fabric and the expensive equipment, but you must be alert yourself.

Useful tip:
Go round the whole building and garden every day you're there.
Be renowned for your eagle eyes - your obsession with detail.

Notice if a fire door has been wedged open or tied back with an old duster and rectify it immediately, and let the staff know that it must not happen again. If you leave it, negligence sets in and it could spell disaster. Nip it in the bud. If the door really needs to be held open, then you will have to invest in an electro-magnetic holder that will release the door to close when the alarm is activated.


Shared facilities
Standard 20. Outcome: residents “have access to safe and comfortable indoor and outdoor communal facilities.”

Spend time with residents in the sitting room and garden. Is there enough space? Is it comfortable and attractive? Can residents get into the garden to enjoy it? Do you feel like avoiding certain areas? Go on, sit in that nasty, smelly old armchair with its cracked, brown vinyl upholstery. Don’t wait for the inspector to tell you it has to be replaced – be your own inspector; they’re your standards and this is a chair you can’t tolerate any longer. You would be ashamed to have it in your own sitting room, wouldn’t you?


Lavatories and washing facilities
Standard 21. Outcome: residents “have sufficient and suitable lavatories and washing facilities.”

Challenging idea:
I would like to do away with all separate lavatories for staff. If we had no staff lavatories, we would have no more dirty, uncomfortable, and dangerous lavatories for residents. If a toilet is good enough for residents, it’s good enough for staff – and visitors. (This is why inspectors should discipline themselves never to use staff or visitors' lavatories.)

Imagine how vulnerable most residents are when confronted by a dirty lavatory, a wet floor, no lock on the door, no paper, no soap or towel? You can just go somewhere else, but most of the residents can’t. Dirty, unattractive, ill-equipped lavatories have huge, but largely hidden, consequences: incontinence, constipation, falls, infection, depression and a loss of self-respect.

Apply the same sort of thinking to bathrooms. Most people enjoy the bathroom as a place to relax and to take care of themselves. Can residents do that in their bathrooms or are they merely “cleaning stations”? One of the most common sights in a care home is bathrooms used to store equipment and supplies that shouldn't be there and make the rooms cluttered and uninviting - and difficult to use. 


Adaptations and equipment
Standard 22. Outcome: residents “have the specialist equipment they require to maximise their independence.”

Here again, you can spend the earth on equipment and alterations, and residents can be less independent than they were before. How many hoists are lying idle or used indiscriminately and without training? Some major items will be required but the most significant increases in independence for residents come by changing attitudes and making small adjustments. Close, sympathetic, observation, and not jumping in and doing things for people will show you how moving a chair, changing a door handle, or providing a resident with suitable crockery or cutlery can make all the difference.

Look under the stairs. Are you keeping redundant and unused walking frames and wheelchairs there - just in case you might need them? Apart from a couple of wheelchairs for occasional use, you shouldn't keep specialised equipment that has once been prescribed for or owned by individual residents. Send them back to the supplier if they were on loan, or get relatives to take them away if they were owned by residents. And don't keep a 'stock" of specialist equipment; it should all be individually prescribed and designed to meet precise needs.

Challenging idea:
Why assume that residents need their tea pouring for them, when they’ve been pouring their own for the last sixty years? Teapot too heavy? Get a smaller one or a tipping teapot stand. That’s maximising independence.

The use of "baffle locks" and coded keypads is now widespread in care homes, and they severely restrict independence. They have usually been installed to reduce the risks of residents "wandering" or getting out of the building unnoticed. Sometimes - and in specific circumstances - this is justified, but remember that you are, in effect, locking residents in, so you must review such precautions very regularly. How long ago was the lock installed? Is the resident still with you and still at risk, or has everyone just got used to it? Do the risks of wandering outweigh the psychological risks of effectively locking residents in? Or is it time to leave the door unlocked until the risks to another resident make it necessary to use the key pad again? (See also chapter 4, Standard 17.)


Individual accommodation: space requirements
Standard 23. Outcome: residents’ “own rooms suit their needs.”

Above all others, this has been the contentious standard, but look at the outcome. So simple; so right. I have known many residents who wanted a small, sparsely furnished room with no pictures on the walls. But they usually wanted such a room because of their current state of mind. Some, later, would want to decorate the room and then move to a larger one. Others remained determined to live a hermit’s life until it ended. But, I think most of us would agree that a pokey little room would fall far short of “suiting our needs”. I believe the original standards were very reasonable, but only if used in conjunction with the stated outcome.

Individual accommodation: furniture and fittings
Standard 24. Outcome: residents “live in safe, comfortable bedrooms with their own possessions around them.”
I have seen several examples recently of rooms that have been so comprehensively furnished (to the minimum requirements) by the home that there is no room for residents’ own furniture. It’s not easy for a resident to insist that they want their own furniture when there’s nowhere to store what the home has already provided. Don’t be bullied by inspectors over this. Residents should have what they want in their rooms, not what the inspector thinks they should have. (But don't use this as an excuse not to provide adequate furniture.)
 

Services: heating and lighting
Standard 25. Outcome: residents “live in safe, comfortable surroundings.”

This standard demonstrates how important it is for the manager to spend time with residents – particularly in the dining and sitting rooms. Sit down; eat with them; talk with them. Experience for yourself; observe residents and ask their opinion. You will see if the heating and lighting are safe and comfortable, and if they can be adjusted to suit particular residents in particular circumstances. Some residents with poor eyesight will need bright, powerful, lighting to read by - and you should provide it.

Occasionally, you'll find that a resident would prefer to take risks that this standard (and others) is aimed to protect them from. For instance, a resident may want very hot water in their own basin or bathroom, or they want to open their window wide to have a nice breeze blowing through the room. Normally their hot water supply will be limited to 43-C and their window will have a restrainer on it to prevent it being fully opened. You'll assess the risks with the resident, and make the necessary adjustments so that they can have very hot water and plenty of fresh air . . . and then, if asked, you'll tell the inspector the reasons.


Services: hygiene and control of infection
Standard 26. Outcome: “the home is clean, pleasant and hygienic.”

Enthusiastic cleaning staff make a huge difference to a home. (And their often unrecognised contribution to the social life of the home is also crucial.) Care and nursing staff need to think about hygiene in a comprehensive way. It's little use attending to someone's ulcerated legs without carefully washing and drying swollen feet, and then, it's just as idiotic to put those feet in shoes that are full of dirty flakes of dead skin - a perfect breeding ground for infection.

All staff – led by the manager – should take a pride in the place. You must support and value the domestic workers and don’t leave a mess for other people to clear up. Cleaners should be in charge of their own areas and be recognised as important members of the team. Dirt and stink set in fast, so clean up immediately rather than leaving it to the next day when the domestic worker comes in. If one of your cleaning staff is away, make sure someone else does their job. As always, the manager sets the tone.

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CHAPTER 6
STAFFING: STANDARDS 27 - 30

A quart into a pint pot
(Most of this chapter is highly contentious. I challenge much of the accepted consensus about staffing, training and qualifications. Staffing is the most costly element of care in care homes, and the persistent underfunding of care ensures that staffing remains inadequate despite the requirements of the national minimum standards. In my view, the effects of underfunding are exacerbated by diverting some of the existing funding (and much time and effort) into a fundamentally flawed system of training. Anyone who questions the value of training (as it is), may expect to be subjected to the collective disapproval that greeted the boy who dared to say the emperor had no clothes!)

I'll start with an open secret. With local authority fees at their current levels (2005), very few homes can get enough staff on duty to meet the stated outcome of Standard 27. The low level of fees paid by local authorities ensures that staffing in care homes nearly always falls short of the National Minimum Standard (27.1): “staffing numbers and skill mix . . . are appropriate to the assessed needs of the service users, the size, layout and purpose of the home, at all times.” Generally staffing is inadequate in numbers, qualifications and training – and, of course, many care staff are very poorly paid. It’s a national scandal that residents and their relatives, and staff and their dependants have to suffer these inadequacies, and it’s a disgrace that this scandal was created, and appears to be ignored, evaded and colluded with at the highest levels of government and the national inspectorate. Until this issue is faced and fees raised to a sustainable level, care homes will always struggle to provide an adequate service to residents. The fact that many homes do manage it is a great tribute to the commitment of providers, managers and staff.

Outsiders to care homes rarely grasp the harsh realities of staff numbers and costs. A typical view from outsiders is “We were told there are fifteen care staff but we never see more than three on duty at a time.”  Well, they wouldn’t. What they don’t realise is that allowing for training, holidays, handovers, staff meetings, supervision, and a few days’ sickness a year, you will have to employ six people to get just one person on duty every hour of every day throughout the year.

Take a home for fifteen residents, all of whom are physically frail and some of whom have dementia. The residents need at least three, sometimes four, care workers on duty during the ‘waking day’ and two at night. Add a manager and a deputy, a couple of part-time domestic workers, a cook and kitchen assistant, and some part-time admin hours, and, if paying half-decent wages, your staffing costs alone will be in the region of £400 a week per resident. Without all the other costs of running the home adequately, which could be around £150 - £200 a week per resident, on their own, staffing costs are more than most local authorities pay. So, how on earth do we pour this quart of care into the pint pot of staffing?


Staff complement
Standard 27. Outcome: residents' "needs are met by the numbers and skill mix of staff."

Most of us who have actually done this work will recall times when we’ve been short of staff and somehow managed to get everything done and meet the residents’ needs. It’s exhausting but it can be very satisfying. And we may think back to times when there have been plenty of staff around but residents have been neglected. We’ll also remember ‘trained and qualified’ staff who were useless. Equally, we’ve worked with someone new into the job – or, indeed, someone who’s been in it for years – with no formal training, and they were great to work with because they were thorough and reliable, and enjoyed their work.

I’ve seen staff who light up a room with their presence, who are so sensitive and responsive to residents’ needs, so skilful in the organisation of their work, that they're doing the job of two or even three less capable people. I recall one who was previously a laundry worker and one a hairdresser. However, I’ve often seen mealtimes at which several residents were waiting to be fed by one worker who went round from one to another and, standing up, spooned liquidised food into their mouths. It could have been done so much better, but the fact remains that to do it properly two more people were needed. Moreover, when you are always so short of staff, standards and morale drop; poor care becomes routine and it takes remarkably determined staff and management to reverse the trend.

So, adequate staffing is not just a matter of numbers: two can be better than four, but those two have to be excellent. Such dedicated people are few and far between, and their commitment and energy is not inexhaustible.

Making the best use of staff resources.
A mean and unimaginative employer will respond to staff shortages by cutting back essentials such as supervision and handover time, by using agency staff, or by imposing supposedly time-saving routines and discipline. But go-ahead and creative proprietors and managers, facing the same problem, will encourage and support their team to find better ways to use their limited time. Through supervision, meetings and handovers, the team will reflect on and re-organise their work. They will realise that imposing supposedly time-saving routines on residents not only fails to meet residents’ individual needs, it creates unnecessary work. For instance, routine ‘toileting’ is counter-productive for everyone, resulting in the misery and indignity of incontinence for residents and soul-destroying extra work for staff. Whereas teams which discuss these issues and are determined to find a better way, will have the commitment and discipline required to help each resident to the lavatory when they need to go, rather than when the staff routine dictates that they should (which for most residents will either be too late or too early). (See also chapter 2, Standard 8.)

A resident can relax if she knows that at breakfast someone will come and sit down at her table, and give her their full attention for ten or fifteen minutes, helping her with her food. Because it happens every day and it’s always done in the same unhurried and considerate way, that resident will look forward to a peaceful, pleasant meal. She won’t be so anxious that she spends most of the mealtime in a tizzy, possibly calling out for help and disrupting the meal for everyone else. The whole atmosphere at breakfast time is transformed because staff have thought it through and planned together how they are going to manage their work. You won’t succeed in establishing teamwork like that if you cut back supervision and handover time because you are short of staff.

Useful tip: The creative manager will value domestic workers as full members of the team, and will encourage them to be involved with residents. Given respect and encouragement, someone who was just a ‘cleaner’ becomes an invaluable additional team member, organising coffee mornings and doing all sorts of little, special things for residents. She has status and thrives on the variety and scope of her job.

So, as the manager, you use your scarce staff resources to the full. If residents can trust the staff and rely on them, some of their constant, urgent needs actually diminish. Instead of desperately trying to grab attention in the hope they might get a little, they can relax because they know they are going to get help.  Confident, well-organised teams are focused and fulfilled, even though they are still working very hard and could always do with another pair of hands.

Learning on the job

My experience of training as a care worker and manager

Like most people, I started in this work untrained and inexperienced; in fact I started not as a worker but as a resident. As an eighteen-year-old, new to London, I was given lodgings in a hostel, and I worked as an assistant in a secondary school. The hostel turned out to be a probation hostel, where I shared an attic room with three other young men all of whom had been in or had just avoided being in prison. Many of the hostel residents had been in care as children. I learned a lot, fast.

I learned by experience – about myself, about “care”, about institutions – and it still influences my work more than forty years later. Afterwards I worked with children and older people for several years still with no formal training. The work was hard (an 80-hour week was common) and very challenging, but with supervision, discussion, and reading, I kept learning. By the time I was twenty-five, I was deputy manager of a large children’s home – still unqualified. But then, with the support of my employer, I did my ‘in-service’ course and qualified as a residential child care worker, and became manager of the home. By this time I was supervising staff and students, and running training sessions both within the home and on college courses.

Later, I did the Bristol University post-qualifying certificate in residential social work (a rare and brilliant course); the advanced course in consultation at the Tavistock Clinic; a master’s degree in public policy; a diploma in counselling, and so on. I’m still training, teaching and supervising, but I also need to go on learning – it’s never too late! Most of my qualifications are not recognised now. It’s not easy to equate them with NVQ levels, and why bother? I don’t feel I have anything to prove to people who have comparatively little experience of the work and, though their training is recent and recognised, it is unlikely to be broader and deeper than my own. I'm not alone! There are countless other well-experienced managers who are in a similar, if not identical, position.


For care home staff and managers the ‘learning by doing’ experience is common and strong. We take a pride in having survived and done a good job in spite of all the difficulties. However we can also get stuck with this pride if we don’t open ourselves up to go on learning and developing professionally.

A lot of trained staff appear to have stopped thinking. Frequently I come across qualified nurses and managers who claim to be expert in their fields but whose practice is institutional, unimaginative and frankly ignorant. Their attitudes and practice are at least twenty years out of date, yet their training is much more recent. I see their effect on staff and residents and I wonder who filled them with "answers" and taught them stop thinking.

Yet, I have many friends and colleagues who were ‘unqualified’ but were superb care workers, and taught me a thing or two. If you work alongside such people and you’re willing to learn, you’ll learn. You will imbibe what you cannot assimilate on any taught course. The purpose of professional or vocational training is to integrate experience and skills with knowledge, ideas and theory. Simply swallowing facts and theory doesn’t qualify anyone to do anything other than to regurgitate them. But nor will any amount of experience on its own and without questioning, analysis, reflection, and understanding, qualify you to do anything other than to repeat it. 

Qualifications
Standard 28. Outcome: residents “are in safe hands at all times”.

I’ve always found this a strange outcome. Is there a direct correlation between the three brief standards on qualifications - (28.1, .2 and .3) 50% of staff to have NVQ level 2 and all trainees to be registered on a certified training programme – and residents being “in safe hands”?

Originally the whole idea of National Vocational Qualifications (NVQs) was to enable practitioners to gain a qualification by proving their “competence” to an impartial, independent, assessor. Gaining an NVQ should not be dependent on attending any particular training course. An experienced and competent care worker should be able to apply for an assessment, provide evidence of their competence, and be awarded their qualification. Of course, it’s highly unlikely that anyone could achieve the level of competence required without a good deal of “training” (see below).

Training and NVQs have become rather like standards and inspection: the organisations that have been put in charge of these vital processes have hijacked them, and designed them to fulfil their own organisational needs rather than "qualify" the workforce to meet residents' needs. Just as any well-run care home should pass its inspections without doing anything extra simply for inspection, so should any competent care worker be able to get their NVQ level 2 without doing anything extra simply to “qualify”. Yet the bodies that design, administer and award NVQs have created a lucrative bureaucracy. They’ve set up a long, complex and costly assault course for candidates to negotiate before they get their certificates. Of course care workers are proud of getting an NVQ, and so they should be, but that doesn’t mean it’s the right process or that the qualification itself means that residents “are in safe hands”.

I realise that this is heresy and everyone who has taken the oath of allegiance – all the candidates, assessors, trainers, verifiers, training providers– will want to burn me at the stake unless I recant.

Here it is, written in the good book: 50% of staff will have to have NVQ Level 2 so that “service users are in safe hands at all times”. I don’t believe it, and I don’t think most of you do either. (Mind you, as more care workers and managers get their required qualifications, the more they will subscribe to this mistaken belief. It's a self-fulfilling prophecy.)

Staff training
Standard 30. Outcome: “staff are trained and competent to do their jobs.”

That’s a sensible outcome, and makes Standard 28 unnecessary. If staff are competent to do their jobs, not only would the home meet this standard, but, if they applied for NVQ assessment at the level appropriate to their jobs, they should qualify.

The training standards specify that there should be a training and development programme (30.1); that all staff have induction (30.2) and foundation training (30.3); and that everyone receives a minimum of three days’ training a year and has an “individual training and development assessment and profile”.

There’s a wonderful range of opportunities for training and staff development in a care home. Think about everyday work, handovers and staff meetings, supervision, in-house training sessions, external events and courses. Then think about your induction and foundation programmes. You’ve got it made!

Link your programme with everything else. Make training and development part of the home’s mainstream culture. Involve everyone – residents, relatives, ancillary staff. Expect every member of staff going on an external course to bring their learning back to the team, and to use it. Have a regular training spot at staff meetings and make professional development part of every supervision session.

A care home is the best possible setting for “action learning” – learning together from experience through re-telling, reviewing, reflecting, analysing, and proposing ways forward. This is how a good home is run, how good staff gain confidence in themselves and each other, and how practice moves forward. This is how staff are trained and become competent.

And recruitment?
Standard 29. Outcome: residents “are supported and protected by the home’s recruitment policy and practices.”
Recruitment is a huge problem in care homes. If you manage to establish the sort of staff development culture I’ve described, it will help to attract good staff and to keep them for a while. However, in a small organisation, where wage levels are not the best, and there are limited opportunities for promotion,, your emphasis on staff development may mean that some of your best staff stay only until they can get a better paid job on the strength of the experience and training they’ve gained with you.

Do try to recruit your own staff. If you’ve got a personnel section (or, in the current grandiose jargon, a human resources department), let them do the donkey work, but don’t let them choose people for you. You should be at the controls of the recruitment process.

Of course you must protect residents with CRB checks and by following up references, but you can never be certain, so use your induction and probation periods to the full. There’s little point in going through all the palaver of recruiting a new member of staff only to let them drift and lose them in the first few weeks.

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CHAPTER 7
MANAGEMENT AND ADMINISTRATION: STANDARDS 31 - 38

Jack or Jill of all trades


Standard 31. Day to day operations. Outcome: residents “live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully.”

 “Fit to be in charge”? It’s an all-rounder’s role. You should be able to do all the other jobs in the place: cooking, cleaning, caring. You need to understand how things work: the boiler, the washing machines, the lift. You’ll also be familiar with finance and quite complex administration. Rotas, employment law, medicines, nutrition, teamwork, dementia, health and safety, risk assessments . . . there’s no end to it. And, of course, you’ll know the standards (your standards, remember) backwards.

Challenging idea:
When I was manager of a very large home, it was considered to be a 9-to-5, Monday to Friday job. I spent my first three months working shifts and doing every job in the home, but even after that I continued to work at least one shift every week with the care staff. I varied the shift (sometimes early, sometimes late, and occasionally a night shift) and worked different days with different teams. I knew the place, the practice and the people through and through, and they knew me. I didn't expect anyone to do something I wouldn't do or hadn't done myself.

You have to be practical and resilient. You’ll be able to think on your feet and respond to events and emergencies.

“Of good character”? Being of good character is more than just a matter of references and CRB checks, important as they are. It’s a question of integrity, of being honest, honourable, sound, and principled. Reliability is a much under-rated virtue and it’s central to the role of being a good care home manager. Residents, relatives and staff need to be able to rely on the manager without becoming over-dependent on her or him. Another difficult balance to maintain.

“Able to discharge his or her responsibilities fully”? Yes, but this is not only about the manager; it is about the organisation that employs her. Managers are sometimes caught between what they know they should do to meet the residents’ needs and the restrictions placed on them by their employers or proprietors, and by local authority fees which don't cover the costs of care. Too often, managers are asked to make bricks without straw, and when the bricks fall apart they get the blame.


Ethos
Standard 32. Outcome: residents “benefit from the ethos, leadership and management approach of the home.”

Ethos means the distinctive character, spirit and attitude of a home, and it is inextricably bound up with the way the home is led and managed. It is the heart and soul of the place, the atmosphere, the sense of welcome, warmth and inclusiveness. This is possibly the most elusive quality and the hardest to achieve. A home can meet nearly all the other standards and still fail on this one. It is the ethos that helps residents to feel “at home” and relatives at ease, and enables staff to commit themselves to the place and its work.


Quality assurance
Standard 33. Outcome: “the home is run in the best interests” of residents.
This is a standard that needs careful thought and interpretation. You may already be using a ready-made quality assurance system – and I’ve seen them used well – but I am suspicious of the “quality” culture, which can encourage window dressing to the detriment of the real, everyday experience for residents. Would such a system fit the ethos of your home?

We know as consumers and users of countless other service industries that quality assurance can be misused. It can simply be a way of showing that the home has a “high customer satisfaction rating” (by asking questions designed to elicit the "right" answers), and that doesn’t prove “the home is run in the best interests of the residents”.

My advice is to keep it simple. If you read the standards carefully (which of course you do), you’ll have noted standard 33.2 (annual development plan). The obvious way to structure your plan is to use the format provided by the standards. (It may well be that the self-assessment tool that CSCI are proposing will provide an ideal framework for this planning, reviewing and quality assurance process.) As an inspector (pre 2002) I used the new standards (just published) in inspections. In homes where there was an active group or committee of residents (and relatives) I asked them to make their own inspection report and then I used that in the overall report.

Useful idea:
We used to have a comprehensive annual review of the home. Residents, staff, relatives and other stakeholders took part. It was published and distributed. Out of it came an annual plan that included financial planning. We posted our aims and a running financial account for all to see. This was more than twenty years ago. Nothing's new - it wasn't our idea, we just adapted it to our needs. Take the initiative; be inventive.

In this publication I have repeatedly recommended that you make the National Minimum Standards your own. I don’t see the advantage of setting up additional frameworks for planning, practice and reviewing when you’ve already got the standards. Use the outcomes in the standards to involve residents and relatives with reviewing the home (quality assurance), influencing the way it’s run, and becoming familiar with the standards. 

Here’s an example:
Standard 15: “The home should provide a wholesome, appealing, balanced diet in pleasing surrounding at times convenient to you.” Then you could have a “not met, met, or commendable” scale to tick and room for comments. However you design your reviewing or “quality assurance” system, make it straightforward and interesting, and involve relatives. Publish the results quickly so that residents can see that their comments make a difference and that they are being heard. You could have a very productive and lively residents’ meeting on the strength of each survey (Standard 12: Social Contact and Activities - see how the standards are connected?).


Financial procedures
Standard 34. Outcome: residents “are safeguarded by the accounting and financial procedures of the home.”

This standard has been controversial because some proprietors - understandably - questioned the need to inspect the finances of their business and the competence of inspectors to do so. But the intention is to protect residents against dodgy companies that could be tempted to exploit residents or may suddenly cease trading. The CSCI need the powers to investigate but this should be done with discretion and suitable expertise. The standard does mean that the manager must understand the finances of the home, and gives them a way of alerting CSCI to any concerns they have.


Service users’ money
Standard 35. Outcome: residents’ “financial interests are safeguarded.”

This may sound like the previous standard but it’s different. This is about the handling and control of residents’ own money. The principle is that no matter how much you trust the provider of a service, you don’t put them in control of your dough. Nor should they want to be - or accept being - in control of it. (See also chapter 3, Standard 14.)

It used to be normal – and very bad - practice in care homes for residents to hand over their pension books. Almost everyone colluded with this: local authorities, social security, the post office, managers and proprietors, residents and relatives . . . and inspectors. My impression is that at last, after years of effort, the tide has turned, and it is now widely accepted that residents or their chosen representatives must be in control of their own finances.

However, it is still common for homes to control personal allowances and to miss opportunities for residents to find ordinary pride and pleasure in paying their way.

Useful tip:
Lots of residents look forward to having their hair done, and would like to pay for it in the way they used to. But many homes still deprive residents of the significant satisfaction of handing their money over, because the hairdresser is paid directly from residents’ money in the office. (See Standard 14: Autonomy and choice.)

Small cash sums can be used so creatively. Don't defend bad practice with the excuse that such sums could be lost. They could be, but compared with residents losing their autonomy and self-respect this is no risk at all.


Staff supervision
Standard 36. Outcome: “staff are appropriately supervised.”

The standard requires six supervision sessions each year for care staff, covering practice, philosophy of care, and career development. All other staff and volunteers must also receive supervision. So . . . supervision every couple of months at least. That's what you would do anyway isn't it?

As always, my advice is to start with the minimum, and when you get that established, build on it. And don’t forget that, as manager, you need supervision too. If you’re not getting it, demand it.


Record keeping
Standard 37. Outcome: residents’ “rights and best interests are safeguarded by the home’s record keeping policies and procedures.”

To me this is one of the dud outcomes. Policies and procedures in reality never safeguarded anything; it’s the practice of them that counts.

Challenging idea:
In a care home recently, I saw seven separate record books recording everything from doctors' visits to bowel movements to bed changes. None of these books was necessary; none was consistently filled in; and all the information should have been recorded on the residents' individual care record. 
Be wary of falling into the classic bureaucratic trap of trying to solve problems by keeping more records. Try to make a single record in the right place.
Make a simple audit of all your record keeping. Cut out duplication and such awful institutional records such as baths and bowels books. If you've still got them, give yourself a thorough ticking off, and get rid of them now!

Adequate record keeping is essential for good care and the proper running of the home, but the task can seem overwhelming. Most staff will need support to enable them to see it as a simple part of everyday work. Residents’ care records so easily slip into repetitive phrases - “all care given”, “no problems”, “pad changed” etc. – that are more a superficial record of what work was done rather than how the resident is and what they did. Encouraging staff to write these records differently helps them to think and act differently; to see things from the resident’s point of view.

Useful idea:
Suggest that staff sit with residents and ask them how the day has been and contribute to what’s written (see Standard 37.2). The knack is to integrate record keeping with practice, while, of course, maintaining confidentiality.

Safe working practices
Standard 38. Outcome: “the health, safety and welfare of residents and staff are promoted and protected.”

This is a heavy but unavoidable responsibility for the manager, especially in small organisations that don’t have health and safety specialists on tap. You will achieve this outcome if you manage to establish a vigilant and safety conscious culture in the home. You and your team will notice, record and take prompt action to rectify hazards. And don't forget the hidden risks to residents and staff from stress and emotional damage, as well as the more obvious physical risks.