On this page you will find articles
that John Burton has written. The articles will be changed regularly.
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Articles on this page (posted 10.7.08)
Is your care home up to standard?
If you can keep your head . . .
when all about you are losing theirs
Policy, politics, management . . . and the CSCI
Truth will out
CSCI - a Titanic failure
Beware the train set mentality
Why do so many managers approach their work as if they were playing with a train set?
Look at it this way
My work as an independent consultant takes me into care homes of all sorts. I spend most of my time with residents, staff and managers, and sometimes with relatives. I also meet with “outside” managers, those who work at organisations’ headquarters.
Caring Times for May 08.
John Burton.
jb@johnbbrixton.demon.co.uk
www.standardsforpractice.co.uk
Standards and quality
3-in-1
Standards, quality and complaints
Is your care home up to standard?
Who are the best judges of whether standards are met or not? Inspectors? Managers? Staff? No, the residents and relatives are the best judges of standards in care homes, but until now they have had to read the National Minimum Standards (NMS) if they wanted to know what the official standards were.
The NMS are generally well written and relevant. They cover all the important areas of care and they are still serviceable after six years of use. However, they were not written primarily for residents and relatives; they were written for proprietors and managers, and serve as a common basis for inspection.
I have written - and Counsel and Care have recently published - a version for residents: Your care home – is it up to standard? A guide for residents and their families. And with each guide there is a satisfaction survey and a complaints, compliments and comments form. Three vital tools in one small folder, designed to be given to and used by every resident.
Do we really need yet another guide?
At inspections, homes are often found to provide inadequate information, infrequent and insufficient “quality assurance”, and an ineffective complaints system. You need all these to complete your Annual Quality Assurance Assessment (AQAA) successfully.
The purpose of the pack is, first, to inform and empower residents (and relatives), and, second, to help you (the home) to use the National Minimum Standards in a positive way that meets the demands of the inspectors (for information, “quality assurance”, and a complaints system). I have avoided using the phrase “quality assurance” in the pack because I feel that people have become somewhat suspicious and cynical about it, regarding it more as a tool of the provider than as a support for the “customer”.
Whether it’s Tesco’s or Sainsbury’s, or the local authority asking for feedback, I’m always doubtful about their motives, and I can see that they design their forms to get us to say what they want to hear.
The great advantage to both residents and the home is that “Your Care Home” is an independent publication produced by a nationally recognised and respected charity. The pack is easy to read and use, plain and simple. If you write your own guide, there will always be the danger that its underlying purpose is to elicit the “right” responses (for your organisation).
Providing a copy for each resident as soon as they arrive at the home (or even before) says “We are going to do our very best for you; we are open to criticism and we need your feedback – complimentary and critical. We have nothing to hide and we’re proud of what we do, but we know there is always room for improvement.”
How to use the pack
I recommend that all residents are provided with the pack and that you have spare copies to give to residents and their relatives “on demand”. Ideally you would have copies available on display and preferably near to a small lockable letterbox ready to receive the replies to the survey and any completed complaints forms. (These letterboxes are now readily obtainable from hardware/household/DIY shops at a very reasonable price.)
I suggest that you encourage new residents to complete the survey within four weeks of arriving at the home, and every six months subsequently. You may want to ask residents (and relatives) to give you six-monthly feedback through this survey, say in April and October, so that you have the surveys all at the same time. But try not to restrict the times of feedback.
Make sure that you always give residents a full summary of the survey results so they’ll know the message is getting through and it’s worth doing. For example: “Our residents’ survey has told us that many of you would like to have supper half an hour later in the evening, so from Monday June 30th we will serve supper in the dining room from 7 p.m. instead of 6.30 p.m. We will still bring supper to your room, if you prefer, from 6.30 p.m.” Your can imagine how pleasing that would be for residents who have asked for the change, and, of course, how it may impress relatives, visitors and inspectors!
You will need to keep a permanent record of the feedback from the survey. You may consider setting up a computerised record as well as keeping a written record. Your inspector will want to see it, and, of course, you can send them the survey results with your self-assessment. And you will need to check that letterbox every day!
Used well, the Your Care Home pack will encourage everyone – residents, relatives, and staff – to think differently and positively about the home and the standards. In designing and writing this pack, I tried to get away from the sort of “compliance” and bureaucratic “minimum standards” way of thinking and embrace a more inclusive, collaborative, open, and positive attitude to the standards.
A guide for managers and staff?
I’m considering producing a parallel publication to complement the pack: “Your Care Home – a guide to the standards for managers and staff”. This guide would help you to put the NMS into practice in the way they are set out in the residents’ guide.
Some readers may recall that about five years ago I wrote a whole series of articles in Caring Times on “Putting the Standards into Practice”. I’ve often used those articles with managers and have been pleased to know that they are practical, sensible and helpful. I always encourage managers to challenge standard – or standardised - practice. In other words, always think about the standards from the resident’s point of view, rather than assuming that what the organisation has always done or what the inspector has always asked for is automatically right. Standards are for practice not for inspection, and we make progress by listening to residents and meeting their needs, not by following orders from above.
I would be very grateful for any feedback and suggestions that would help me to plan this new book. Which standards pose the most difficult problems for a manager? Are there some innovative ideas and practices that you have tried out and found to work well for residents?
Of course, I learned a lot from my own practice as a manager, but I have learned just as much from colleagues who I’ve worked with over the years and from their interesting and varied care homes.
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1. Your Care Home – is it up to standard? – a guide for residents and their families
This small guide for use by residents and relatives (and friends/advocates) sets out all the National Minimum Standards (NMS) that apply directly to residents. In plain words, it tells residents what the standards are and enables them to check whether their home is “up to standard”.
2. Your Care Home – is it up to standard? – satisfaction survey.
This concise (one sheet of paper) survey is designed for residents to give you regular feedback on the home. It follows the order and layout of the guide and will provide a comprehensive “quality assurance” tool for the home (as required in the NMS and by the new inspection process).
3. Your Care Home – complaints, compliments or comments.
This simple complaints form is designed to encourage residents to make a complaint (or give a compliment or any other comment) easily and quickly without feeling overawed by a bureaucratic complaints system or process.
The Your Care Home pack, priced £5.99 per single copy or £4.99 if ten or more are ordered, is available from
Counsel and Care, Twyman House, 16 Bonny Street, London NW1 9PG
There are discounts for bulk orders.
Telephone: 020 7241 8555
Fax: 020 7267 6877
www.counselandcare.org.uk
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Caring Times for March 08.
John Burton.
Management and public policy
If you can keep your head . . .
when all about you are losing theirs
A local authority I used to work for is advertising for a “Director of Personalising Services” (at £90,000 p.a.). Will they never learn?
Apart from the ugliness of the word, there’s nothing wrong with “personalising” services; indeed, it’s all the rage right now. This sudden enthusiasm for making social care “personal” is mystifying: what else could it be? In the 70s social care was often referred to as “personal social services” which rather begged the question that if such services were not personal, were they impersonal? Of course, the answer then in too many cases (when nearly all social care was provided by local authorities) was a resounding “yes”. Things haven’t changed all that much in the last 30 years of perpetual but superficial change imposed from outside. Now, too much social care, though “delivered” mostly by private and voluntary agencies, is still impersonal, and won’t be fundamentally changed by yet another government-driven “agenda” of “personalisation” . . . unless those in power can learn from their mistakes, or from how change is managed in good care homes.
Real change grows from the ground up, not from the top down. And, to extend the horticultural theme, most plants need a whole range – and balance - of nutrients and conditions in which to flourish. So it is for care homes.
Ten years ago “New Labour” proclaimed that it was going to “join up” government. What did it do? It appointed “tsars” and tried to change society by setting targets and monitoring “performance” in specific areas. Often the areas selected were precisely the wrong ones and defied common sense. Trains failed to stop at stations in order to meet the performance criterion of arriving at the final destination on time. Politicians and policy-makers believed they could fix things by “driving through” their “robust” policies and procedures. It’s a mechanistic and formulaic approach that ignores the complex, dynamic nature of human relationships and the whole purpose of providing a service.
Ministers told us they would get rid of “silos”, meaning that they would demolish the isolated, exclusive monoliths of government, and then they set about creating nonsensical, grand commissions and outfits such as the “Number 10 Delivery Unit”! We were presented with idiotic advertisements for “Anti-Social Behaviour” and “Child Abuse” co-ordinators, and “Dignity Champions”. The words make little sense, but if you refused to adopt them you became unsuitable for appointment, and open to accusations of somehow promoting the social ills that these policies were intended to cure.
Care homes are inundated with so many directives and demands from above that it is very difficult to remember what exactly it is that we were meant to be doing in the first place. The remarkable thing is that the majority of homes do stick to the task and manage to be “caring and homely”. How is it done?
The “whole” home
Nowhere is care potentially more personal and individual than in a care home. But nowhere is it more important to understand and integrate the “whole” place. Everything (and everyone) is connected with everything else. Change one thing and it affects everything else in the home.
Outsiders tend to think narrowly about their own particular specialism whether it’s training, finance, safety, staffing, maintenance, medication, reminiscence, activities or inspection. They all have their targets. So, each time someone “up there” imposes their own “agenda” on care homes, the home has to adjust to accommodate it. Of course, some of these outside initiatives can benefit the home and the residents. Most homes attempted to get hold of some of the “dignity” grants; it would have been foolish to turn the opportunity down.
I see the evidence of these failed and forgotten initiatives in many homes: unused “reminiscence” or “sensory” rooms; impractical, complex care planning systems; training and supervision programmes that are no more than a set of tick-boxes; and those horrible white-boards with the date and “The weather is SUNNY” scrawled on them (often the wrong date and the wrong weather!).
The care home manager has to think about the whole home and the whole task, and integrate all the dozens of different aspects of running the home so that residents’ individual and shared needs are met.
The home that is run from the outside in (or from the top down) soon becomes institutionalised as the manager’s attention is drawn to outside demands and away from the “primary task”.
In the last few years, NAPA (www.napa-activities.co.uk) has adopted a whole home approach. Activities are no longer what take place in one room run by one person two afternoons a week; they are woven into the life of the whole home. Led by the experience and expertise of people like Sylvie Silver and Sally Knocker, NAPA now promotes activities as a way of life rather than an add-on. Life is full of activity: relationships, meals, newspapers, conversations, cleaning, laundry, shopping, clothes, games and outings of course, art, television and radio, garden, pets, having a drink, watching football, knitting, writing a letter . . . yes, all the things we all do.
When you go into a care home with this sort of whole life/whole home philosophy, it feels normal. People are going about their business, some on their own, some with others. They talk to each other. OK, staff are often busy and sometimes in a hurry, but when they are with residents they relate to them; they take their time; they listen. They are likely to think that residents are more important than any official visitor be they an outside manager, inspector, or doctor. The motto of such a home might be “Residents First”.
“If you can keep your head when all about you are losing theirs” (Kipling’s “If”) you have the makings of a great care home manager. There is always a lot to do and there are many pressures and demands on the manager from within the home. But when you get ministers, civil servants, heads of dozens of assorted think-tanks and charities, publicity-hungry, drama-queens (and –kings) – outsiders all – jumping on the latest policy bandwagon and driving it slap-bang into your care home, you have to have a cool head and a clear sense of direction, otherwise you’ll be knocked off course.
Specialisation is the enemy of normality. Government policy deliberately segregates people by age, by physical and intellectual disability, and by physical and mental health. In effect, we also segregate people by class, education, and wealth, although this is never declared as a policy objective. For years, the accepted policy has been to segregate people with dementia and separate them from the “normal” society of a care home. Yet, we know that there are thousands of people with dementia living a good life in care homes that are not specialised “dementia units”, but where staff are often much more expert in their care than in some of the ghastly specialised “homes”.
The more specialised a home becomes, the more likely it is to become institutionalised. The residents are cut off from normal relationships and life, and very quickly they descend into social, emotional and mental atrophy. But this is as a result of national policy that has promoted the specialisation and segregation widely regarded as good practice.
It always takes a long time for bright politicians and policy wonks to catch up with what is obvious to everyone else on the ground. Look at the sudden revelation (headline news on the day that I write this) that local authorities are leaving ¾ million desperately needy people unsupported because the result of national and local government policy has been to provide care only when their needs become life threatening, which is, by definition, too late. It took The Commission for Social Care Inspection four years to reveal what half the population already knew.
And this brings us back to the “personalising of services”. The thinking goes like this: if we (the government) give people the opportunity (and money) to choose (and buy) their own support services, they will make better decisions and get a better service, cheaper, than all our efforts for the last (nearly) thirty years of Community Care, commissioning, care management, and getting rid of the Home Help service. Well, to start with we (the local authority) will need to fork out £90k to get a world-class specialist in personalisation. That should do the trick.
As this latest wind of policy blows around our ears, we need to keep our heads, remember who we really work for and concentrate on the primary task.
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Caring Times for January 2008 John Burton
jb@johnbbrixton.demon.co.uk www.standardsforpractice.co.uk
Policy, politics, management . . . and the CSCI
Truth will out
At the time of writing – at the fag-end of the old year - the Government and Labour Party appear to be writhing in terminal agony. It may be the sharp and unexpected beginning of a long, slow, decline, or it may just be a hiccup and Labour will bounce back.
A lot of luck and chance is involved with politics, and a lot of skulduggery. Generally, we reap what we sow and, to some extent, we make our own luck. Gordon Brown was lucky as well as cautious as Chancellor, and seems to have been unlucky as Prime Minister. His caution is not such an asset now. Blair was bloody, bold and resolute (as was Thatcher) but Brown gives the impression of dithering, not knowing in which direction to take the country, and he is being destroyed by “events, dear boy, events”. He’s a static target and he doesn’t seem to be able to regain the initiative.
Shame and scandal
The government enact laws in an attempt to stamp out corruption in politics, and then find themselves wriggling in shame as they are impaled on their own rules. The media sniff out the merest whiff of scandal and hunt down and destroy indiscriminately. Those who have made honest mistakes find themselves tarred with the same brush as the real crooks who have schemed and lied their way to the top.
This government is good at talking about climate change, but it has actually done very little. We have had White Papers proclaiming new policies on resourcing preventative care but the reality is that fewer people are getting the help they need when they need it. These days you’ve got to be in a pretty bad way to qualify for social care of any sort.
Diverting blame
We are involved in this whether we like it or not: as individuals and communities, and as social care professionals. For many years government has dithered over the funding of social care while passing ever more legislation to regulate and control it. Disproportionate effort and resources have gone into systems designed to divert blame away from those in power, pointing the finger at the little people. Such systems do not improve care; they undermine it. And, I’m sorry to say, that more and more good people simply go along with it.
The mainstream media are interested in care homes only when there is a scandal of neglect or abuse. When a story breaks, blame is almost always directed at individuals rather than institutions, organisations, and government bodies, who very quickly get organised to demonstrate their innocence. Sometimes, it is the very same people who have worked hard to change bad practice who are identified as the perpetrators.
Injustice
In my work, I have seen this injustice repeatedly. Twenty-five years ago, the powerful central management officers in the local authority I worked for then were more concerned with victimising a low-paid domestic worker for allegedly “stealing” a loaf of bread, than in facing up to their responsibilities for reforming a disgracefully abusive institution that they had starved of resources and attention. To get a change of approach, I had to threaten to expose their dishonesty and neglect. But my willingness to blow the whistle then meant that I had no future with that employer beyond the five years I spent creating a care home that they could be proud of. In our line of work, you risk your future by speaking truth to power.
More recently, I have seen good people hounded out of post because they have insisted on maintaining high standards. I failed to prevent a bunch of ignorant, meddling, and subtly racist committee members from expelling one of the best managers I have ever worked with. I have seen care workers accused of neglect and abuse because, while doing their best in the face of overwhelming need, they have transgressed and been caught out not following procedures that were impossible to comply with.
And this brings me – you’ve guessed it – to the Commission for Social Care Inspection.
Inspection
CSCI have been successful – so far – in keeping the lid on what’s really going on inside the organisation, but the truth will out. There are rumblings, at last, from Unison. Leaks are beginning to spring; they will turn into trickles, and I’m hoping that soon we’ll have a flood of protest.
The whole purpose of star ratings is to reduce the workload, thereby reducing numbers of inspectors and inspections, and, of course, costs. The ratio of inspectors to care homes is dropping, and inspectors therefore are under huge pressure to move homes up the star rating scale. The more homes that have two and three stars, the fewer inspections that have to be carried out. Individual inspectors’ judgement is being overridden in order to cut back on inspections.
Pressure on inspectors
Homes with one star (and some that don’t rate even one) will have no more inspections than they used to have: a maximum of two a year. The pressure is also on for homes that are adequate or poor to be closed or to move up to two stars. There is no time to make more than two inspections a year, so this is the real driver for closure or improvement. Pushing a home to closure will mean no more inspections. Just one satisfactory inspection is enough to reduce inspections. There is no recognition by CSCI that improvement takes time, whereas standards in a home can very quickly deteriorate.
If you keep an eye on those homes that have had problems in the past, you’ll see that some still haven’t been re-inspected for a year or more. CSCI claim that the self-assessment system will provide a good measure of quality and homes do not therefore need such frequent inspection. We all know that is not true. What home is going to tell CSCI that standards have fallen through the floor and they need inspecting urgently?
CSCI themselves should know how inaccurate self-assessment is when things aren’t working well. Just look at their own annual reports.
What does this feel like for the dedicated inspector who does the job because they believe in it? Terrible. A lot have resigned in disgust, but there are still some left. Sooner or later the truth will out.
Three principles of effective inspection
The Commission has never grasped the essential principles of effective inspection:
1. First and foremost, inspectors are the publicly appointed guardians of standards – their job is to check safety, care and homeliness. Standards can and do slip, so inspectors must follow-up complaints and check homes frequently.
2. Inspectors must be out there with the residents and staff. You can’t inspect merely by reading paperwork.
3. Inspectors must collect their own information and not ask the home to do anything extra solely for inspection purposes.
Advice to social care organisations
Keep your distance. Of course, while CSCI still operates and continues in its determination to launch the star ratings (and thereby to cut inspections and inspectors), providers will want as many stars as they can get. But the truth will out. As the leaks begin to turn to a torrent, and brave inspectors blow the whistle, and as stories of poor standards in two- and three-star homes begin to hit the headlines, it would be wise not to be seen as an enthusiastic ally of CSCI.
We need independent, honest, regular inspection, but good providers do not need inspectors to tell them what their standards should be. They are your standards. Uphold them; practise them, and trust residents and relatives to be the best judges of your “quality”.
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Caring Times for November 2007 John Burtonjb@johnbbrixton.demon.co.uk www.standardsforpractice.co.uk
Inspection
CSCI - a Titanic failure
The Commission for Social Care Inspection (commonly known as “Sea Sky” or, with the obsession with stars, perhaps it’s “See Sky”) is a Titanic failure and is now worse than useless when it comes to doing the very things it was set up to do. The great hulk is holed beneath the water line and it’s going nowhere but DOWN.
I see the star ratings as distress flares being fired from a sinking ship . . . or are they the explosions as the boiler blows up?
A legalistic deception
Mike Rourke, the Director of Inspection, Regulation and Review at Sea Sky, speaking on File on Four (BBC Radio 4) in September, claimed that the Commission cannot investigate complaints from residents and relatives.
Yet, in a glossy little booklet, distributed to thousands of care home residents last year, under the heading of “Protection from harm and abuse”, Sea Sky relates the following comforting, but misleading, anecdote:
When I visited my mother she was very upset by the way she had been treated by a member of staff, and had bruises on her arm where they had bathed her. We made a complaint to the Commission for Social Care Inspection, who carried out an investigation that resulted in the member of staff being dismissed.
When local authority inspection units were being set up fifteen years ago, it would have been unbelievable if they had denied responsibility for investigating complaints. Even five years ago, when the late (but not much lamented) National Care Standards Commission started work, if our new national inspectorate had told us that complaints from residents and relatives were not within their remit, we might have asked “Well, if you don’t investigate complaints, what exactly do you do?”
But, here we are in late 2007, with our reformed, revitalised and thoroughly modernised regulator, facing this disgraceful abdication of public and moral duty.
Apparently, at around £100 per year per resident, the Commission found that they could not meet the demands of the Regulations to inspect homes twice a year, so they got the Regulations changed, giving them the option of inspecting some homes as infrequently as once in three years. I assume that their clever lawyers discovered that they didn’t need a change in the Regulations to stop investigating complaints. No, they claim that the law never required or empowered them to do so in the first place.
Star struck
So, while the CSCI have been busy reducing their core task (inspecting and investigating complaints) how have they been fulfilling their promise of “inspecting for better lives”? Yes, they’ve set their sights on “the stars” rather than getting on with the essential business of plain old, time-consuming, feet-on-the-ground, inspection.
The stars above are the only focus of the little group of powerful officers occupying the bridge of the good ship Sea Sky. When they “consulted” on their proposals for quality ratings they didn’t ask whether or not they should embark on this ludicrous idea in the first place. They merely asked what form of rating was preferred. In spite of claiming overwhelming support for star ratings, they received approval from only a tiny handful of “users” for this irrelevant and dangerous wheeze. Most of the support appeared to come from sycophantic and overawed fellow “professionals” and providers.
What inspectors think of Sea Sky
Judging by what I’ve heard from inspectors themselves, star ratings are all to do with personal obsessions at the top of CSCI, and nothing to do with the protection of residents in care homes.
I quote from a letter I received from a recently resigned inspector: “ CSCI generally fails in its core function . . . it is bedevilled by meaningless inspection targets, is self-serving, risk aversive and seemingly obsessed with trying to reach out and operate in a political climate.”
“. . . inspectors who try to operate with a proactive, measured zeal in order to protect the vulnerable, often feel cut off at the knees in a target orientated, systems-led malaise. These inspectors usually leave the CSCI. Others who remain generally seem more motivated by completing inspection caseloads and often subscribe to the prevailing culture that shortfalls in care homes are not really the CSCI’s responsibility – only that of the care providers. It leaves a bad taste in one’s mouth knowing that often those who are supposed to protect the vulnerable do not.”
Dangerous inconsistency
Whenever I see news of the CSCI taking action against a care home, I look up the inspection reports. You have to move fast, because the reports are removed from the website quite quickly, and you can see why. A recent example was of a home that would have received two stars at the very least according to consistently good reports, but suddenly the CSCI moved in and closed it. How quickly things change!
Other homes appear to have been bumping along the bottom, well beneath the standards for several years, and yet the CSCI appear to have taken no effective action. I thought the whole point of a national inspectorate was to achieve consistency.
I’m helping a neighbour to find a care home (with nursing) locally. So, of course, I’ve been looking at a lot of inspection reports. But many have not had an inspection for well over a year and we all know things can change fast. My neighbour said she didn’t know what to think after reading the reports, and when she went to visit a couple of homes she couldn’t square the reports with what she saw. I rest my case, m’lud.
Three principles of effective inspection
The Commission has never grasped the essential principles of effective inspection:
1. First and foremost, inspectors are the publicly appointed guardians of standards – their job is to check safety, care and homeliness. Standards can and do slip, so inspectors must follow-up complaints and check homes frequently.
2. Inspectors must be out there with the residents and staff. You can’t inspect merely by reading paperwork.
3. Inspectors must collect their own information and not ask the home to do anything extra solely for inspection purposes.
What should providers do?
While the captain and senior officers of this doomed ship repeat the order “Full speed ahead. Follow those stars. This ship is unsinkable”, what should providers do?
• Keep well clear of a sinking ship, otherwise it will drag you down with it.
• Stick to your course – your task. Keep steering your ship towards your destination – good care. Use the National Minimum Standards as your map (they are your standards, not the CSCI’s) and use your good principles and your good experience as your compass. You work for your residents and not for the Commission. Whatever happens to inspection in the future should have no major influence on the course that you steer. Just go on doing a good job.
• If the star rating system survives (and there’s still no certainty that it will) it’s only sensible and natural to want three stars for your home. Anything less may be damaging for you. But do not be diverted from your course by chasing stars to the detriment of your primary task (running a truly caring and homely home). If you’ve got a good inspector - as some of you will have - you will get your stars anyway.
• Keep your quality assurance system simple and resident centred. You want to find out what you are doing well and what needs improvement, and you want the residents’ (and relatives’) honest opinion. The reason you should want to involve the residents and relatives and find out what they really think is so you can run a better home for them, it is not to please inspectors or to chase star ratings.
(Some parts of this article featured in John Burton’s presentation to The East Sussex, Brighton and Hove Registered Care Home Association Conference on October 16th.)
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Caring Times for September 2007 John Burton
jb@johnbbrixton.demon.co.uk www.standardsforpractice.co.uk
Management
Beware the train set mentality
Why do so many managers approach their work as if they were playing with a train set?
Alan Johnson has promised us no more reorganisations in the health service. We’ll see if he remains Health Secretary for long enough to see it through. Constant churn and change have bedevilled the National Health for many years now. As each new politician takes up post, they feel they have to make changes. They impose new solutions which turn out not to be solutions but a new set of problems. They treat this huge organisation as if it was no more than a malfunctioning machine that needs new parts, more fuel, and constant redesign.
The same is true for education and social care. No organisation can work if you keep chopping bits off and grafting other bits on, and then keep pulling it up by its roots to see if it’s still alive.
The essence of management
Effective management is not simple, but the principles are.
When you’ve decided what is the real purpose – the primary task – of your organisation, the task of management is making the best use of available resources to get the job done. In services like education, health and social care the wellbeing of people is your primary task, and people are your main resources in achieving the task.
Why then do so many managers treat their responsibilities as if they were children (most often boys) playing with a new train set?
Playing trains
As a boy I had a model railway. Gradually I added more details and features: a farm, a village with a school, a church, and a little country station where there were milk churns, crates of poultry, and tiny people for ever waiting for the train but never boarding it. A branch line and a mainline . . . all the fascinating miscellany of a pre-Beeching, 1950s railway.
I made little houses, trees and hedges, and a tunnel for the trains to chug through. Every now and then I would change the layout. The village and farm were moved; the whole landscape and road network were transformed, but still the trains went round and round even if it was in a different direction through new countryside.
One of the characteristics of such a set-up is its inherent pointlessness. The trains never actually go anywhere, no matter how often they arrive and depart. The purpose of a model railway is play not travel, but play is how children learn, and I took my railway very seriously.
In modern parlance, I was the Chief Executive of my model railway. I was the – not so fat – controller, stationmaster, signalman, engine driver, fireman and guard. But my passengers were tiny, static figures who never set foot in a carriage; I just pretended that they did.
Care homes are not train sets
A worrying characteristic of some managers at or near the top of organisations running care homes is that they appear not to have grown out of their train set phase. A care home has nothing in common with a model railway: the people are real; they need care and the building has to function as a home.
I attend a few care exhibitions and conferences, and I’m always struck by the predominance of technical “solutions” on display. The message is that if you buy this or that appliance, this or that computerised system, this or that range of furniture, your home will run like clockwork (back to the train set).
Excellent as some of this high tech. hardware is, none of it can solve your people problems . . . and, remember social care is only about people. Computerising your rota and payroll may help you with a particularly complex aspect of your administration, but it can’t decide for you who is the best member of staff to work with a new resident when they first come to the home: to welcome them, to settle them in and to introduce them to the home. Train set management is just not up to the task.
That salesman, looking so smart in his white shirt, silk tie and dark suit trousers, who spends the day messing up a piece of carpet and - hey presto! - cleaning it up in next to no time, can’t solve incontinence problems in your home. He can sell you an appliance that will deal with some of the consequences but his super-duper shampoo/vacuum is no substitute for careful, individual, thoughtful, planned, reliable and sensitive attention given by a whole team working collaboratively for each resident. No, he sells train sets and – I’m sorry to say – too many managers think that train sets are analogous to care homes.
Management decisions
Some organisations elevate and value the technical and administrative functions of management above the softer, more complex and risky functions. This is a mistake. After all managers only exist to take risky decisions. Management is all about uncertainty not certainty. Key management decisions are difficult choices and have no guarantee of success. Management is the exercise of discretion: you weigh up the pros and cons; you consider the risks; and you decide.
Our current culture of management in social care tends towards the “train set mentality”. Managers are encouraged to buy ready-made solutions rather than to see working with difficulties, thinking things through, and working out what to do as the very essence of real management. The misuse of standards in inspection has put too much emphasis on formulaic, imposed, “right” answers rather than fostering a more organic and developmental approach to management.
Two extremes
I work with managers with many different styles. At one extreme is the chief executive type who knows very little about care (or “homes” for that matter) – yes, often a man – who can’t wait to start playing at management. He has a fixed idea of what the care home should be like; he can’t let it develop and evolve. He must buy new gadgets and hardware. He may feel himself to be in competition with other similar managers and he wants to show how he can use his power. So he invents new slogans and targets: “We will be the best in the area . . . the county . . . the country!” He wants four stars from the inspectors and will throw a tantrum if he doesn’t get them. A colleague (but to him a competitor) has just installed a new phone system in his homes, so our CEO wants one too, irrespective of its suitability for the residents. His ambitions are all superficial and short-term; they have very little to do with the care of the residents and a lot to do with a little boy and his train set.
At the other extreme is a manager who doesn’t care a fig for “things” and possibly lets herself down a bit by concentrating so exclusively on care and the quality of relationships. Of course, this is the right side to err on, but it may become difficult for outsiders to understand or to appreciate how good her home is. Some technical and administrative improvements will help, as will some honest criticism mixed with recognition of the really good work that the home is doing.
I have found that the first manager rarely changes because he lacks the maturity to think about what he is doing and why he might be doing it. But the second manager is much more amenable to change because her principles are sound: her first concern is the people she works for and with, and she sees technical and administrative assistance as useful tools rather than intrinsically desirable possessions. She probably never had a train set!
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Caring Times for June 2007 John Burton
jb@johnbbrixton.demon.co.uk www.standardsforpractice.co.uk
Look at it this way
My work as an independent consultant takes me into care homes of all sorts. I spend most of my time with residents, staff and managers, and sometimes with relatives. I also meet with “outside” managers, those who work at organisations’ headquarters.
My first visit usually spans a day, normally from before breakfast to after the evening meal, although sometimes I may stay overnight or even work through the night. What I see does not only tell me about the home itself, but it also tells me a huge amount about the organisation that runs it.
Initial contact
Experienced consultants know that the initial contact with the “client” (someone asking for your help) reveals a lot. Frequently a senior (outside) manager will at first couch their enquiry in terms of what they want you to “do” to staff or homes that aren’t performing well: “A magic wand would be best, but we’ll settle for a cattle prod.” Or perhaps the problem is a negative inspection report: “Can you fix this home for us so that we get three stars instead of one?” “Could you run us up a silk purse out of this sow’s ear?” “Oh, and how long will it take?” A classic fix is seen to be team building or some other form of training. No amount of training will fix short-staffing and an undervalued, uninspired team.
Senior managers who are not prepared to have their own practice and attitudes examined and linked with the level of performance they see in others, soon get my drift and they seek out a more compliant consultant who will adopt their point of view. But, fortunately for me, there are enough managers who already understand that they are a crucial part of a whole system, and that, if we are going to develop better practice in the care homes, we will have to work with all levels of the system (including theirs) to achieve real change.
The practised eye
When an antiques dealer is sizing up a piece of furniture, they look at how it was made. They turn a chair upside down; they pull out the drawers of a tall-boy to examine the wood and joints; then they stand back and look at the whole thing to see if it’s all of a piece – does it look “right”?
Many other experts have the same approach to their trade, but in social care we seem to be more easily taken in by what’s on the surface. We tend to think more about appearance than substance. And, of course, it really does matter where we are looking from – our point of view. The people who know what’s going on in a home are the residents and the staff because they experience it every day, and it is all too rare that outside managers and inspectors look at a home from ground-level.
Good inspection
At one of the homes I work with, the manager has consistently found the inspector to be thoroughly understanding and helpful. Between them, they have created the sort of trust and professional respect that is too often missing in this relationship. I don’t mean collusion or turning a blind eye to shortcomings; I mean that the inspector truly understands how the home works, what the manager’s job is and the challenges she faces. The home manager feels she can contact the inspector for advice without being misunderstood or provoking an unwarranted reaction. The inspector has got the measure of the home (and the organisation that runs it): she has met with the residents and eaten with them. She has confidence in the manager and recognises the big issues (such as racism) that the manager is confronting (and making progress with). She sees the details and she sees the whole picture.
But this is an experienced and committed inspector who can distinguish between complaints motivated by racism and those that are about poor care. She is fully aware of what’s going on beneath the surface and that the remarkable improvement in the home is inevitably a gradual process. Changing the attitudes and “culture” of a home (and an organisation) doesn’t happen overnight, nor is it a matter of writing new policies and procedures or of superficial training exercises. The manager who is committed to this sort of long-term change can be destroyed by a lack of understanding from inspectors and outside managers.
Edicts from on high
For a long time, in my articles for Caring Times and other publications and at conferences, I have argued that we won’t make much headway in changing social care for the better by making new laws and regulations, by setting up more grand bureaucracies and commissions, and by edicts from on high. At the same time, I have always advocated the use of National Minimum Standards and quiet, committed, regular, inspection.
One way of viewing the work of The Commission for Social Care Inspection (CSCI) and its predecessor is that they have indeed set out to “improve social care and stamp out bad practice” but they have largely failed. When I see a newspaper or broadcast account of neglect and abuse at a care home, I look up the inspection reports on the CSCI website. Sometimes the Commission has already removed the home and its reports, so one can’t see what’s been going on, but if the reports are there it is often difficult to understand how the home continued to exist. These reports make dismal reading: requirements ignored for years; wild fluctuations in the assessments of the standards; a succession of different inspectors making requirement that have little to do with the deeply entrenched problems of the home; and a strong impression of disconnection between the demands of the standards and regulations and the dreadful reality of daily life for residents.
I have experienced this failure at first hand as a relative. The CSCI appear to be saying all the right things but there is very little connection between what they say and what they do.
Self-assessment
As most readers will know by now, care homes are now obliged to make an annual “quality” assessment of their service. In other words, it is now official: the Commission for Social Care Inspection have handed over a major part of their work to the very people they are meant to inspect.
But, when looked at from another angle (that of the residents, staff and public) the CSCI have been practising self-assessment for years. (Bob Ferguson made a similar point in May’s Caring Times.) They write an annual report in which they tell us (and their paymasters, the government) just how well they are doing and that, due to the Commission’s good work, everything is getting better. For example, they tell us that the prospect of star rating has already led to a rapid improvement in care. According to Chief Inspector, Paul Snell “Already, more than two-thirds of providers given an indicative rating of ‘poor’ a year ago have now improved the quality of their service.”
Hmm . . . from down here (on the ground) I would make the following observations on this supposedly dramatic claim:
1. If providers had failed to improve a poor service in a year, they and the CSCI should be in trouble; so why claim this is some sort of triumphant vindication of star rating?
2. How long had these providers been poor and what has the CSCI been doing about it before the threat of stars transformed them?
3. What about the third of homes that haven’t improved? Are we to conclude that their continuing poor care has nothing to do with inspection or star-ratings?
4. It is the CSCI themselves who say that homes have improved and we are presented with this “evidence” to prove that inspection and star rating are effective. As the Commission gets smaller and employs fewer inspectors, it has to find a way to do fewer inspections and it’s essential for them to show that fewer inspections are needed. Why should we trust the evidence?
With the new self-assessment forms, the CSCI is returning to “paper-based” (or computer-based) inspection. “Real” inspection – being there, in the home, with the residents – is being reduced in favour of “virtual” inspection. Send in your self-assessment on time, and as long as you’ve filled it in correctly, you should be all right for another year. Very like filling in your tax return. And you can bet your boots there will be plenty of consultants who see an opportunity for a lucrative little number – completing your assessment for you.