Beyond Winterbourne

Yesterday, the Department of Health published ‘Transforming Care : A national response to Winterbourne View Hospital’ (PDF)  the ‘final report’ about learning and developments following the case which highlighted, via a BBC Panorama documentary, the systematic abuse which was embedded in the running of a private hospital for people with learning disabilities ‘with a stated purpose of providing assessment, treatment and rehabilitation’.

The failings were found not only in operation of the hospital  but in a complicated and confused health and social care system which on the one hand seems to have been moving away from ‘institutionalisation’ over the past few decades while on the other hand commissioning services which embed institutionalisation and powerlessness into failing and very expensive systems’. The case of Winterbourne View also highlighted the failure of the regulator, the CQC, to respond to information provided by a whistle-blower and of local authorities and commissioning NHS Trusts to actually quality assure the services which are being provided.

Another related report which was also published yesterday (PDF)  came from Family Mosaic – a housing association which provides supported living services which highlights its own failings in terms of poor care and proactively looks at new policies and ways to turn this around. In a way, the Family Mosaic document – is a testament to an organisation which wants to learn pre-emptively and the organisation should be applauded for producing it.

I want to look at some of the issues in both these reports as I think they are  linked,.

Lessons from Winterbourne View

The introduction to the report sets the context of Winterbourne View Hospital – a placement for 24 adults with learning disabilities. The report explains that 48 patients had been referred there since its opening in 2006. The average cost of a placement was £3500 per week and

‘13 were referred by commissioners within 20 miles

12 were referred by commissioners within 20-40miles

14 were referred by commissioners between 40-120 miles

9 were referred by commissioners over 120 miles’

14 separate English NHS commissioning bodies had acquired places there plus some unspecified (presumably a problem with exact data) from Wales..

You’d think that maybe there’d be quite a lot of quality assurance going on with all that money streaming in.

Both the Serious Case Review and this report pick up on the amount of lost opportunities in terms of communication between agencies – between commissioners and between primary and secondary health care services. There has been a lot of confusion – not least from the Secretary of State about the position of Winterbourne View but that fact that it was a hospital and received detained patients (rather than a care home which it has been incorrectly yet frequently referred to) means some of the responsibilities and monitoring processes would be different.

The police, hospitals, commissioning bodies, local authority (who was responsible for safeguarding alerts), CQC Inspectors and Mental Health Act Commissioners seemed to have failed to ‘join the dots’.

While the Serious Case Review goes into detail about what went wrong, this report is more interesting in terms of what is going to happen next.

What is happening as a result

Immediately the CQC changed some of the systems for pulling in whistleblowing information and started an inspection programme for learning disabilities settings.

There was to be (and is to be) a focus on more local settings where possible as distance from family and familiar settings is crucial. Where it is not possible the placing authority should remain in close contact and plan moves back to local areas as soon as possible. A long term distant placement is not an option.

Hospital the report states, which should be obvious I guess, is not a long term placement and should only be used for the minimum time necessary.

If it is necessary at all.

The report talks about the need to listen to people with learning disabilities and their advocates as ‘not listening’ was a big failure. It’s important that listening is beyond hearing what someone might say as well – particularly if there are communication difficulties. It’s important that those who don’t have families to advocate for them are heard as well. Fortunately the report touches on the need for strong advocacy services to be developed.

What will happen

The Department of Health has set a timetable for June 2014 for a ‘rapid reduction in the number of people with challenging behaviour in hospitals or large scale residential care’.  These numbers will be monitored by the DoH.

I am interested when the report talks about ‘people with challenging behaviour’ if they are just referring to people with learning disabilities. My hope is that they aren’t and this will apply equality to those people who have more advanced dementias and may display behaviours which could be interpreted as challenging due to communication difficulties

There is an emphasis on ‘personal care plans’ being developed which partly shows the failing of the personalisation agenda to date as it has completely passed by swathes of people with the highest needs. Maybe there’ll be some attempt to ‘catch up’ now. Let’s hope.

Interesting to that the report nudges the CQC to consider the ‘model of care’ delivered in terms of regulation and compliance. .Personally I’d see that meaning that these larger institutions inherently carry a ‘higher risk’ but it will be interesting to see how that develops.

Interesting that the report focuses (rightly) on the involvement of ‘families and self advocates’ in driving quality and change. My only comment would be a plea for the Department of Health not to forget those people who have very high support needs and who are, due to their cognitive impairments, not able to ‘self-advocate’ and who do not have family advocates. There is a gap here and often these people are at high risk of abuse due to the lack of ‘supporting voices’. There must be a way for formal advocacy to speak on their behalf.

Strengthening Corporate Responsibility

The report also looks at the organisational failings of Castlebeck and the lack of responsibility taken by the organisation itself.  The report urges the CQC to take more enforcement action organisationally if necessary and there has been a move to appoint ‘Corporate Compliance Managers’ – presumably to hold large organisations to account.  The Department of Health will also be looking at the way the CQC are able to ensure the ‘fit and proper person; test which is applied to registration can apply to organisations – whether a board member is nominated to be responsible. However the powers do not exist in legislation for the CQC to check more than one appointed person. This is something that strays into the ‘to be decided’ part of the action plan but no doubt will be an interesting space to watch.

Improving Practice

The report highlights good practice in the hope it will be modelled  more broadly. A voluntary register for people working in adult social care is being mooted. Personally I favoured full regulation of the social care workforce but that’s likely to be too costly to organisations who are working on minimum wage payments to many staff whom they don’t necessarily want to professionalise even though the work is crucial. The low status of social care work is inherent in the attitudes of employing organisations. Training is important though and so is modelling of good care. While compassion doesn’t cost, environments in which it can flourish are better sustained when staff aren’t under constant pressure and are treated, themselves, with respect.

Whistleblowing mechanisms are mentioned and tightened where they haven’t been already.

Particularly interesting to me as a (now) ex-AMHP and BIA was mention of the Mental Health Act and Mental Capacity Act. The report confirms that 73% of the people are Winterbourne View were detained under the Mental Health Act. They should have had statutory protections of appeals and access to IMHAs. It also makes one wonder under what grounds the other 27% were being detained. Was it –really- ‘informal’? Were DoLs ever used? If not, were there any questions asked by those visiting about why or why not?

One of the most interesting ‘key actions’ to me is that

‘The Department of Health will work with CQC to agree how best to raise awareness of and ensure compliance with Deprivation of Liberty Safeguards (DoLs) provisions to protect individuals and their human rights and to report by Spring 2014.

I have a particular interest in DoLs – their use and their lack of use so will certainly be keeping a VERY close eye on this. I’ll try not to be cynical. I’ll really try.

Family Mosaic’s proactive report

Family Mosaic’s ‘No Going Back’ report (PDF) unfortunately has faded into second place in this post but it almost deserves more than one post to itself however the themes link in so tightly with the Winterbourne View Review.

I’d recommend that both reports are read together and it is commendable that Family Mosaic as a provider organisation have looked proactively at how they can do better in terms of challenging institutionalisation and poor practice among their own staff.

The report looks at the history of ‘deinstitutionalisation’ and the move to Community Care principles but also where the failings have crept back and cultures where care may be delivered in different settings but where the quality has been in question and abuse has resulted.

The organisation provides examples of poor and indeed, abusive care in its own settings to look at how to improve and what to offer in terms of building a better culture of delivery of care.

One of the interesting aspects they consider is the lack of ‘whistleblowing’ so that staff who might witness poor care and who have been on the requisite training may not feel they are in a position to report it or may not recognise it when they are involved in the delivery.

The report focuses on aims and action points for the organisation as a whole including a more open policy towards whistleblowers and those who raise concerns internally.

It explains clearly basic expectations for delivery of services to service users by staff and all in all, it is a fantastic piece of work by Family Mosaic who should be commended.

Conclusion

These two documents offer a way forward for delivery of care and attitudes towards those who need care. I wish we had a Winterbourne View type document and review of care for older people, particularly older people with dementia and hopefully when the document refers to ‘people with challenging behaviour (a term I don’t really like to be honest’ it isn’t only referring to those in learning disabilities settings – however I fear it is.  We need to have a wholesale reappraisal of large institutional settings for care delivery – be they hospitals for people with learning disabilities or 90 bedded nursing homes for people with dementia. Age/cognitive ability/family involvement/means to self-advocacy cannot determine ones right to dignified and high quality care.

Family Mosaic have presented a good model that moves beyond care for those with learning disabilities – I hope more providers take notice and take a proactive response.

However, there will be costs and if the government is truly intent on building better services across the board and for all sectors, there has to be an understanding that the money will have to come from somewhere.

I hope it will happen. The right noises are being made. I just hope the results are equally satisfying.

The ‘Red Tape Challenge’ does Health and Social Care

We all knew it would come in time. This wonderful government idea to slash all that awful ‘red tape’ that stops people doing what the government otherwise would stop them doing finally arrives at Health and Social Care.

I had a brief look at some of the provisions detailed as ‘red tape’ for which the government is asking for comment and quite frankly, I am horrified.

What I might see as essential protections, they are presenting as ‘red tape’ and asking for feedback about potential abolition.

This is a consultation so it’s really important that as many people as possible to contribute and in the joyful spirit of openness, the website allows up to see the live commenting on others. I wonder how those with less technological access or knowledge are able to comment quite so openly about some of the provisions up in the air.

But openness and accessibility only seems to go so far and for the government departments responsible they seem to be after whipping up public distaste of ‘red tape’ although actually, we really do need to move from the idea that bureaucracy is necessarily bad.

There is a separate website entirely to focus on ‘ regulatory enforcement’ and where it might be unnecessary.I feel robust regulation (and thus, enforcement which has to follow as a result) is essential. The big problem with social care and health regulation since the CQC was established was the ‘light touch’ type approach which had been taken and the ‘back office’ regulation and not enough enforcement.  I really really hope that it is not cut back further. I want to see more regulation and stronger enforcement, not less of it.

But back to the ‘red tape challenge’. I want to share some of the provisions ‘up for discussion’ that the government has classed as ‘red tape’.  I’m solely concentrating on what is up under ‘Quality of Care and Mental Health Regulations’ as I felt that was the area I knew best. The numbers refer to the list of these ever so demanding provisions in the Excel list here.

39 is that oh so burdensome (!!!) regulation that requires the Care Quality Commission ‘to monitor and access for monitoring purposes, people who are deprived of their liberty’ and necessity to report this to the Department of Health.

40 is a nice one about requiring people ‘who assess Deprivation of Liberty’ to have an enhanced CRB.  – clearly unnecessary because.. er.. people who lack capacity and may potentially be subject to DoLs aren’t likely to be vulnerable, right? I think there’s an issue about effectiveness of CRBs in general but a bit worrying that that’s considered ‘red tape’.

43 is much more worrying as it is the obvious ‘red tape’ which introduced IMCAs as a safeguard for ‘those who have noone to speak on their behalf’ making them mandatory in abuse and review situations. RED TAPE??

55 is another ‘good one’ which ensures that IMHAs are ‘of an adequate standard’ because clearly, that is unnecessary (!?!)

Obviously there are many many more – I’ve just, for reasons of time, picked out a few that interest me personally but do have a look at them and COMMENT.

I’m frankly insulted that some of these provisions are even considered to be ‘red tape’  but as there’s an open consultation, it’s important that as many people as possible who know and understand the implications of removing them, to contribute.

If the government want to know what ‘red tape’ is in terms of adding unnecessary burdens, I’ll gladly explain about how useful (or not) it is to spend time recording how much time I spend on ‘smoking cessation’ work or time spent ‘clustering’ people according to diagnosis into tiny little tick boxes which are, clinically, unhelpful in order to get the ‘Payment by Results’ systems which will never work well, up and running. THAT’S red tape.

But it seems to be red tape that potentially infringes on the rights of those who might be least able to protect their own that they are classing as ‘red tape’ here.

Contribute to the consultation and let’s tell them how important some of these provisions are.

Oh, and someone should tell the Department of Health that the GSCC doesn’t exist anymore as they seem to have forgotten on their Professional Standards page (published this week!) but we know how much interest the Department of Health has in social work and social care so shouldn’t really be surprised.

Pic by Martin Deutsch@Flickr

Exposure and the CQC

Last night, ITV examined the state of residential care and regulation of the sector in Exposure. While I watched the programme through the lens of someone who has had significant experience of the sector, I’ve also followed the birthing pains of the Care Quality Commission avidly so some of the information given wasn’t ‘new’ to me. I probably didn’t approach the programme as an ‘average viewer’ might.

There were a few issues raised that I think useful to explore. The programme seemed to rightly raise the void of inspection that took place through the initial years in which the CQC was established. The organisation was established with less money than it’s predecessor bodies, the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.  While focusing on registering services, the CQC dropped the ball on maintaining inspections and relying on previous ‘good and excellent’ reports to step back on regular on-site checks.

An ‘excellent’ service can fail very quickly if there are changing in funding and personnel in a home, for example and the lack of attention to frequent unannounced inspections was something that was highlighted in this programme.

However while not resolving the organisation of responsibility, this focus has changed and the CQC has stated that regular, unannounced inspections are taking place now.

The website has long been a gripe as far as I’m concerned. There seems to be less information with each iteration and the scope and searchability isn’t as helpful as it used to be. The CQC website remains the only one I have come across at work which has become progressively less user friendly  with each iteration  (and yes, I have always given feedback on the changes when it’s been an option!). The lack of reports from both predecessor organisations (for example, not being able to access CSCI reports or reports when an organisation has changed hands – as was highlighted in the programme) is a big issue. As members of the general public, we can determine how useful or not historic information is but we have to have access to it. More information is better.

Reports need to be very easily understandable and clear about what is expected and what good and bad care look like. They are better than they were. People liked star ratings because they were easy to understand. They were abolished but the star ratings remained on the website for a long time afterward which was poor information in the extreme. While the government excellence scheme was shelved, I think there’s a real desire for people to have an understanding beyond a care home being compliant or non-compliant – people want to know if St Matthew’s Home in Hull is better than St Francis’ Home in Bridlington and a TripAdvisor type comment site won’t always provide an independent and authoritative understanding of that. I’m not sure if it’s the place for the regulator but it was in the past and understanding what good care looks like as well as bad is something that Behan, the new CEO of the CQC has stated he wants to work on.

The footage of Cynthia Bower at the select committee was positively painful and her links with Mid Staffordshire made her a particularly poor choice of CEO initially. They could never establish any credibility in the sector with that background and proved that she was not up to the task. The only concern was how much damage she did in the meantime.

I do have more hope with the new CEO, David Behan and some of the changes that have taken place but the programme showed the need for a strong and authoritative regulator within health and social care.

The problem is that all these cuts happened in the regulator as commissioners like local authorities were hammered by substantial cuts which – certainly in my experience –  have seen monitoring units slashed. You see the monitoring teams – they were the so-called ‘back office’ which were cut but the input that had on day to day care is significant.

The only way forward is for commissioners (local authorities/NHS and yes, private funders), regulators and providers to work very closely regarding responsibilities and tie information in with each other but most important to make that sure those who use the services and local communities, families and advocates can understand and know cohesive lines of communication with organisations responsible for developing and regulating good care.

It doesn’t help for organisations to be siloed when life is more complex and while I would never want to absolve those government bodies like the CQC of their responsibilities, I think the structures and information streams need to be better regarding lines of responsibility.

If the organisation isn’t able to do its job properly due to cuts, it needs to return to the government and tell it.

I have become more hopeful that there will be a change in culture in the regulator with a change in leadership. Use of more and more ‘experts by experience’ and experienced specialist professionals in inspections is also a positive move but it’s not good enough to stand still.

As Barbara Young said in the programme, the CQC needs to the a regulator for people and particularly for people who have their voices quietened by organisations which can display power in terms of delivering care. It isn’t good enough to rely on families complaining as many people in residential services don’t have families who visit. Proactive regulation needs to happen alongside proactive safeguarding investigations by local authorities and proactive monitoring. Organisations which provide care can’t resolve their own responsibilities to provide quality care. If money is cut by local authorities, it has to be challenged and challenged hard before quality slips rather than afterwards as an excuse.

There is room for hope though. I do think the CQC consultation is positive and the move towards regular unannounced visits is a good one. It should never have been otherwise but we can’t change the past.

If we want a regulator that works, it has to be given the tools and the resources to regulate in a way that we want and expect it to. That costs. So be it, it is a necessary cost.

I want a responsive, responsible, proactive and mostly a listening regulator. I’m willing to give them time seeing that some progress has been made, but there really does need to be a change noticed in the reports that feed back to Parliamentary committees and published reports next year.

A Culture of Care?

I can’t help it but I’m somewhat unimpressed and uninspired by claims that Castlebeck’s transformation is nearly complete (As reported by The Guardian).  I’m sure Mr Sullivan has done a sterling job in dragging the remains of homes such as Winterbourne View towards acceptable standards but the very fact that such poor standards of care are evident in contemporary care is a shameful indictment on our society.

It riles me not only that such abuse took place in the first instance, but that it wasn’t picked up by the care provider.  Would the abuse still be happening if it were down to Castlebeck to identify it and take action?  I shudder to think that the answer might be a resounding “Yes”.  Also to think what else may be happening within care homes across the UK where vulnerable adults don’t have the benefit of family involvement or carers with the insight to blow the whistle on abuse … or Panorama!

 Having worked with numerous residential and nursing homes, it is not hard to see how totally dependant some vulnerable members of our society are on those paid to provide good quality care:  Care that is monitored and regulated and where safeguarding policies are in place to ensure that those who can’t speak up for themselves are protected from abuse… Really?

I can’t help but recalling one particular home, the manager was sitting in a very well equipped, spacious office when I arrived congratulating herself at the marvel that were her new, glossy brochures. Showing prospective families just exactly how decent the home was with its ample garden blooming with flowers and general good cheer.  Carers smiled on the front cover in a manner that exuded quality, person-centred care from more carers than one could possibly need whilst care-free residents tucked into their gormet meals.

Sadly, the reality was very different:  Insufficiently trained carers that didn’t have the time to answer a call-bell that had been rung for the umpteenth time as the room’s occupant continued to lie in urine soaked sheets.  Then there was the missed opportunity after missed opportunity to spot pressure wounds that were silently getting progressively worse – out of sight, out of mind.  All the time, the owner continued to congratulate herself and confidently sell the homes’ services to prospective new residents and their families.  Oblivious to the reality that was unravelling the other side of her plush office door.

Of course, such business’ need to be well run but when business comes before quality of care something needs to change.  Whole cultures need to change because if the underlying ethos of a home’s manager is developing a thriving business, how can the ethos of carers within that home be anything different … such as caring perhaps.  Whilst I’m all for serious case reviews and learning from past mistakes, I’m not convinced my ministers’ exclamations that, “We must learn from this so that these things must never happen again!”   I fear that they will happen again … and again until the whole culture of care changes to one of … well, care.

I can recall perhaps just a handful of small care homes where the managers rota themselves on shift so they know what’s going on and can identify any training needs.  Where more money is spent on care than on prtraying a good image to prospective new residents.  They may not be glistening with a new coat of paint every 6 months or benefit from TV advertising but they are run with an underlying ethos of care and respect and reflect far more the brochures that are displayed elsewhere, but they don’t have their own glossy brochures.  All they have is a good reputation which gets them by more than adequately.

Consulting on the CQC

I’ve been generally critical of the CQC (Care Quality Commission) since it’s establishment. I’ve been particularly critical of what I have seen to be the failings of a regulator for health and adult social care services where I have felt that there has been an impact, by the lack of robust regulation, on the lives of people who use and need the services which are provided.

My main concerns have been about a move away from regular announced and unannounced inspections and a move towards desk-based inspections. However the CQC has been re-evaluating this approach and with a new Chief Executive in David Behan and an outgoing Chair – I wonder if it’s time for me to evaluate my own attitude to the regulator for health and adult social care services in England.

I could never understand how Cynthia Bower was appointed in the wake of the Mid-Staffordshire scandal. It seemed to be a strange appointment. Starting a new agency by merging the functions of the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission was always going to be hard. This combined with new responsibilities to regulate services in different ways seemed to have led the eye to be taken off the ball as far as current standards went with the focus being on bringing new regulatory frameworks in amid low staffing.

As far as social care is concerned (and that’s the area i know best) this move away from  regular on-the-ground inspection of services combined with cuts in funding both to the organisation and to local authorities who might have had their own, more robust, monitoring teams, led to concerns about quality in the services being provided.

However, the CQC seems to be moving on in terms of re-establishing consistent and regular unannounced visits to services and there seems to be a shift in terms of the priorities which they are placing on promoting quality of care over merely meeting the lowest acceptable standards.

I read through the consultation for the strategy of the CQC between 2013-2016 (and, incidentally provided feedback because it is, after all, a consultation!) and it left me more hopeful that the sector might be developing a regulator that it needs.

Six ‘priorities’ are laid out for the next three years.

1. Making greater use of information and evidence to achieve the greatest impact

In this section the CQC acknowledges the move back to regular unannounced inspections and explains the way that information gathered relating to risk has fed into the way that inspections are conducted and that this needs to continue and strengthen in the future.

‘Building an evidence base’ about what works in regulation includes looking at overseas models. Obviously, I’d welcome a fuller evidence-based approach with the caveat that sometimes past excellence can change to present mediocrity by one new member of staff and there will always be some random elements at play in this sector – an area where I think the CQC has failed in the past by simply judging future potential risk by past performance.

The CQC is increasingly going to look at regulating different services in different ways with the same (presumably) framework as inspectors are professional regulators rather than experts in specific sectors. GPs and Dentists need to be monitored in a different way from a nursing home, a large general hospital or a private ambulance service. It seems to make sense.

Using information from different sources is also crucial. The CQC report mentions this. I expect they would feed heavily from local authority complaints in the field of social care and the information we (as LAs) get regarding care providers and particularly our contracting team which monitor quality and complaints. If someone from the CQC came into our LA and spoke to social workers directly about different home care providers and residential homes, I expect they might get a broader view.

2. Strengthening how we work with strategic partners

Here the CQC mention the changes coming in the NHS and the need to link with organisations such as ADASS, Monitor, presumably new Clinical Commissioning Groups and professional organisations.

I hope there will be a strong voice for Social Work in the form of the College of Social Work in feeding information back to the CQC. I might be on a bit of a theme here but I think the CQC can learn an enormous amount about adult social care from social workers and I think they really need to utilise the knowledge we have of local areas and areas around quality. While I will contact the CQC with major concerns/complaints about residential homes, I’m not asked to feedback about niggles or, for that moment about fantastic services. I’d love to see these links work not just at a managerial level but between inspectors and social workers in the locations they regulate.

3. Continue building better relationships with the public

For a regulator to have public confidence, the public have to know what they do, what they are responsible for and what they are not responsible for. The CQC can do their best but if people don’t know about it or have different expectations, they are unlikely to get the message across positively.

New ‘Healthwatch’ organisations will promote local links and input into inspections and the CQC is building on its ‘Experts by Experience’ programme building people who use services and carers of those who use services into the framework. I watched a video from an inspector where she talked about using an ‘expert by experience’ and referred to a carer of a person with dementia who helped her in an inspection of a residential care home. I’d hope that people who have dementia and may have cognitive impairments are also built into the process of being experts by experience. It is vital that users and carers are involved and different models built to encourage this involvement but that assumptions are not made that because someone may  have a cognitive impairment that they cannot speak for themselves.

Improving access to reports would also be good. Improving the searchability of the CQC site would be a massive bonus. It’s become increasingly difficult to search and find information and seems to constantly take steps backwards in terms of usability.

I think it would be helpful if there were comment forms under each service for public to send information from the website directly to the relevant inspector. Inspectors could have a greater visibility online and using broader social media to communicate with the public – not just through PR people.

I want to know what inspectors do every day. I’d love to see a regular blog from an inspector (without needing to mention any specific services but just with broad themes – generally frontline blogs are more interesting than management blogs!)

4. Building relationships with organisations providing care

This is an area I probably have less experience in. It explains that the organisation wants to provide quality reports and improve the feedback given to providers by inspectors. It’s often about links and nurturing positive links over time but not allowing that to impede judgement when there are problems.

5. Strengthening the delivery of our unique responsibilities under the Mental Health and Mental Capacity Act

As an AMHP (Approved Mental Health Professional) and a BIA (Best Interests Assessor) I have a particular interest in matters relating to the Mental Health Act and the Mental Capacity Act.

I feel particularly the CQC have disappointed me (I know that will upset them!) about their knowledge or rather their lack of knowledge about Deprivation of Liberty Safeguards. I think good and thorough knowledge of DoLs should be a core question in every single inspection in every residential and nursing home and hospital in which they may apply. I  have come across too many home managers who really should know better show an appalling lack of current knowledge about DoLs and believe that there are many many unauthorised deprivations of liberty that inspectors should be able to challenge homes and hospitals about.

Personally, I’ve made a number of third party referrals for assessments under DoLs and that’s just by people either allocated to me or situations I come across when visiting people in care homes or hospitals – there must be many many more that go unchallenged because the law is so fluid and complicated and I don’t have any faith that the CQC and those representing them on the ground know it.

I’d like to see better links between inspectors and Best Interests Assessors after all, we (should) have significant expertise in applying the DoLs and perhaps we could shadow inspectors and ask the questions that they don’t know to ask until they are trained up at least.

This is three years too late.

6. Continuing our drive to become a high-performing organisation

This section is about building a learning organisation and working out ways to measure progress. I know the organisation works with ‘professional regulators’ but I think something has been lost in not using people with expertise in health and social care to carry out inspections and to rely on generic ‘auditing’ experience but I can’t see that changing.

I do think there are hopeful signs though in these new priorities and wish the organisation well – we need a good, strong regulator that has the faith of the sector and I feel we will need it all the more as the NHS changes.

I am increasingly thinking that more link, better conversations and more co-production are the ways forward for the CQC and for health and adult social care in general.

Do feedback on the consultation though – we need lots of voices. The CQC say that they welcome feedback through social media – so this is my own response!

photo by vivido @ Flickr

Winterbourne View – The Serious Case Review

Yesterday the Serious Case Review written by Margaret Flynn about Winterbourne View Hospital was published. It catalogues the series of circumstances which led to those scenes seen on BBC’s Panorama programme and it makes important and salutary lessons for everyone involved in health and social care.

It is a well-written, detailed report which catalogues a series of holes in the process of provisioning, commissioning, managing and monitoring a long stay hospital for people with learning disabilities but the most important lessons can easily be extrapolated out to many other areas of residential, nursing and long stay hospital care.

In summarising my own reading of the report, I have added some of my own thoughts as I go but I do recommend going to read the full version. No doubt I’ll be reflecting on it more over the next few days/weeks.

Introduction

This sets out the background to the airing of the programme on 31 May 2011 and the scope of the serious care review (SCR) which covers the period between January 2008 – when South Gloucestershire Council received their first safeguarding referral to 31st May 2011 when the Panorama programme was aired.  It explains the terms of reference of the report and some of the specific incidents seen on Panorama which caused concern.  This included illegal restraints procedures and

‘notions of a hospital, nursing, assessment, treatment, rehabilitation and support were emptied of meaning and credibility’

The Place and the Personnel

Winterbourne View opened in December 2006 after a ‘feasibility’ study by Castlebeck Ltd which had assessed that there was a need in that particular geographic location for this kind of service. As seen in the programme the placement of a hospital on a business park seems unbelievable but according to the ‘Statement of Purpose’ quoted in the report, there was local access to ‘amenities and a main bus route’ – one does wonder how much this was important to those in the hospital as opposed to those working at the hospital.

Families were not allowed into the bedrooms of those living there which rings many alarm bells to those of us in the sector but may not have been seen as something unusual if you don’t know how these things should operate.

Learning disability nursing and psychiatry were the only disciplines employed in the so-called ‘multi-disciplinary’ teams. The report explains the structure of the service and staffing which was heavy on support workers, which in itself isn’t surprising however a ‘hospital’ employing no occupational therapy, for example, is particularly surprising.  There was a very high turnover and sickness rate among staff which in itself is a sign of there being something particularly wrong in the structures.  12 hour shifts were the norm which may have suited the service and staff more than those who use the service and there was certainly a lack of detail regarding day time activities and timetables for those who lived in Winterbourne View.

I do wonder where the input from care managers/care co-ordinators were in terms of monitoring care plans and ensuring their were adhered to. My gut feeling is that with out of area placements, there was less impetus to be able to monitor these. Commissioners didn’t seem to make many demands that the operating guidelines for Winterbourne were met in terms of providing a therapeutic and rehabilitative environment.

Chronology

This section details the concerns raised and is an analysis of what was actually happening at Winterbourne along a timeline.  Unsurprisingly there are a string of concerns raised that when seen along a timeline can build a picture of a hospital and an organisation that is not fit for purpose.

Part of the concern as a whole is that the dots were not connected in terms of the series of incidents and concerns to build a coherent picture of what was happening. Whilst it’s ‘easy to be wise with hindsight’ it’s important to remember that we have systems which are supposed to protect vulnerable adults which should include collating and using information, concerns and reports to build cohesive pictures of what is going on – that’s even without the whistleblowing which took place.

It makes very difficult reading – all the more so in the context that it was not sufficiently investigated, not internally, not locally and not by the regulator nor police. The key worry that ran through my head is that this may have continued had it not been for both the intervention of determined ‘whistleblowers’ and the involvement of a BBC journalist. That’s a very very worrying lesson that needs to be acted on.

The Experiences and Perspectives of Patients and their Families

The author of the report spoke to six families in particular and explains their perceptions, experiences and understanding of what was happening at Winterbourne View.  The report gives life to some of those who lived at Winterbourne View and humanises them in a way, it seems that the service itself never did – with hopes, aspirations, character and personality.

One patient said

he had been in ‘loads of worse places than them, all over the country’ and that he had been abused in lots of care homes

And if there’s a key lesson to learn it is that Winterbourne View is not an anomaly and shouldn’t be seen as such.

The patient recollections of abuse and treatment at Winterbourne is very powerful. It evidences the importance both of listening and humanising approaches within residential care and hospital care. The importance of being near families and the disruptions of constantly changing placements seems to be the nature of life for some groups of people who have particular care needs and I wonder where the power in commissioning is coming from to look at different models.

When families raised concerns that their children had brought to them these reports were often disbelieved or families were not given the full details of what was going on.  It also raises the importance of visiting and monitoring – particularly for those who may not have families.

Importantly the report says

A family expressed anger that service commissioners making spot purchases to meet the needs of individuals do not know what they want to buy; they do not seek assurance that the service they believe they are buying is delivered; and they do not follow up on what is being provided.

Perhaps more importantly in terms of lessons to be learnt globally

‘As families recalled some of their distressing experiences, it was clear that they had no collective experience of being regarded as partners deserving of trust and respect or even of collaborating with paid carers.

There has to be a shift in the conceit of ‘paid professionals’ or ‘paid support workers’. We have to work with, alongside and for those whom we support and their families as otherwise we should be nowhere even close to a position in social care. Respect, listening and remembering whom we are serving  is the crux of the profession and that seems to have been lost somewhere.

Agencies

Castlebeck Ltd seemed to have a ‘limited executive oversight’ of Winterbourne View with the geographical distance from their head office in Darlington providing significant lapse in responsiveness when concerns were raised.

Interestingly they seem to place some of the blame directly on the CQC and problems with the transition from the Healthcare Commission to the CQC. While no CQC apologist this seems to be a very complacent and worrying dereliction of duty from the organisation that was paid to provide a service which should include self-monitoring.  The SCR looks at Castlebeck’s own analysis of their failings but finds it lacking with attempts to discharge responsibility for the things that went wrong. As it says

Overall Castlebeck Ltd’s appreciation of events leading up to transmission of Panorama is limited, not least because they took financial rewards without any apparent responsibility. The recommendations fail to address corporate responsibility at the highest level

Which is sad, but unsurprising.

NHS South of England also produced a report about commissioning of care and treatment at Winterbourne View.  Out of the 48 referrals made to Winterbourne View, 13 came from commissioners located less than 20 miles away and 9 of those 13 were from commissioners less than 10 miles away.

Worrying is that there were some placements made with few checks and some not even reading the most recent inspection reports.  Interesting that of the 48 English patients (the experiences of Welsh patients – not being the responsibility of the NHS in England were not counted in these figures) 35 were admitted under a section of the Mental Health Act, 13 were admitted informally and 6 were detained after being admitted informally. Unfortunately there are no details regarding the Deprivation of Liberty Safeguards but it would be interesting to know more about those ‘informal’ admissions legally.

NHS South Gloucestershire PCT was the ‘coordinating’ commissioner being where Winterbourne View is located. They produced another report.  Hospital records were also accessed but there seemed to be no linking of information together and agencies not speaking to each other seems to be a major problem and continuing concern.

South Gloucestershire Council also provided a Safeguarding Review.  South Gloucestershire received 40 safeguarding alerts between October 2007 and April 2011. The system locally to follow up some safeguarding alerts seemed to be flawed in terms of not receiving relevant and necessary information requested back from Winterbourne View.  Many of the alerts ‘tail off inconclusively with no clear decisions and no rationale for decisions’.  Each alert was dealt with discretely and the pattern was not allowed to emerge.

Avon and Somerset Constabulary were also involved as there were a number of assaults reported and they also provided a report. There were some flaws in the sharing of information between the police and the local council.

CQC also compiled a report.  The SCR picks up on some confusion in language in terms of the CQC and notes the importance  to note that Winterbourne View is not a care home but is a hospital. The CQC admits that it’s creation has had a significant impact on inspection of services – something we all knew – but it’s good to see them acknowledge this finally rather than paint the biased hue of everything ‘being better’ under the new regime.

The lack of specialist inspectors is a particular factor that the new systems of regulation have lost. Apparently ‘professional regulators’ is a better way of doing things rather than those with specific knowledge of particular service areas. Perhaps this isn’t quite the right way to develop regulatory services.

Findings and Recommendations

The report finishes with a summary that is robust. Winterbourne View is a particular snapshot which has been able to take place due to a series of circumstances that put the spotlight on the services. These spotlights aren’t often shined into the world of long stay hospitals and residential care. But for a BBC programme, it might never have been picked up. That’s a lesson in itself.

Castlebeck Ltd didn’t provide a poor service because it had no money. It provided a poor service because it didn’t see any reason not to.  There were no reasons to question itself or what it was doing. Those questions weren’t being asked by any of the agencies responsible for protecting those who lived in Winterbourne View.

The recommendations are that the Clinical Commissioning Groups, Local authorities and NHS Commissioning Board should be looking more closely at the services they commission, where they are commissioning them and aim to cut down in-patient services.

The report emphasises

‘Commissioning is a professional activity that should be led by trained specialists who know and develop the market according to public policy’

This made me sigh as it seems in my own experience that we are moving backwards on this. I see fewer specialist commissioners who know their areas and more general commissioners who come from non-health or care related backgrounds and with little understanding of the sector or the needs locally of those who use the services they commission.

The report strongly criticises the commissioning of long stay hospitals for people with learning disabilities as perpetuating the ‘out of sight, out of mind’ type modelling for care services.

Recommendations include a more robust use of the Mental Capacity Act 2005 and particularly that

‘The Department of Health should assure itself that CQC’s current legal responsibility to monitor and report on the use of Deprivation of Liberty Safeguards provide sufficient scrutiny of the use of DoLS’

There was a lesson in poor multi-agency working which needs to be worked on actively and there is a recommendation that those who are subject to provisions of the Mental Health Act or Deprivation of Liberty Safeguards as well as all who make a complaint have access to independent professionals, whether social workers, Best Interests Assessors, IMCAs or IMHAs or more than one. Advocacy is crucial to prevent abuses.

As far as the CQC is concerned, the report explains that the ‘light touch’ regulation, enamoured by the CQC doesn’t work with settings like Winterbourne View. The CQC has been too reliant on self-reporting and trusting providers are complying.

There’s a recommendation that the ‘

Mental Health arm of the CQC should have characteristics akin to HM Inspectorate of Prisons in terms of standards’

That would be an interesting and useful development but I doubt the current CQC is set up to provide a robust monitoring procedure.

Conclusions

I haven’t been able to cover all the points of the SCR. It is worth reading in its entirety. It concludes by emphasising that services like Winterbourne View should not exist as they create no aspirations and hope.

They are not therapeutic environments and were created to provide a funding stream to the private company rather than to improve the quality of treatment and care to those who need them.

Commissioning should look at what exactly is being commissioned and what is needed to achieve the end result of an improvement of quality of life.

I look at this report and it is an excellent report, and I despair. I recognise parts of it but it is a particularly appalling litany of pain, distress and human suffering that could have been identified earlier. We relied on a television programme to identify these issues when there were so many people who should have identified this sooner.

No one comes out of this well apart from the whistle blowers who tried to make a difference.

Good services can and do exist but we need to be very clear about expectations of services and what we expect a hospital built on an industrial estate and factoring in amounts of income possible can achieve as opposed to services which truly exist in local communities.

It’s an awful situation but the SCR offers an opportunity to learn and do things differently. Let’s listen more and better across the whole sector and remember that this job is always a matter of partnership and never should be one of dictation. We have to do things better.

Winterbourne, South Gloucestershire Council and Responsibility

Winterbourne View and the systematic abuse of those people with learning disabilities who were placed there uncovered by BBC Panorama programme last year has had significant repercussions.

That countless attempts by whistle-blowers  were ignored until the BBC took up the mantle that should have been taken by the regulating authorities was a particular failing in the system that should protect those who are most dependent on robust and good quality care.

The CQC was actively moved into ‘defensive’ mode and instituted a number of new inspections of similar type facilities around the country. I’m not sure that anyone in the CQC took particular responsibility for a lack of response to the initial concerns raised.

I saw this story on the BBC this morning that two managers at South Gloucestershire Council have been dismissed.  The two dismissed were a team manager, Kevin Haigh,  and the council’s safeguarding manager, Brian Clarke  – as the story says

It is understood that a-year-and-a-half before the whistleblower came forward and the programme was filmed, Mr Haigh and Mr Clarke were alerted to other allegations of serious abuse.

In their defence, a Unison statement reads

‘We believe that there may be wider failures in safeguarding procedures in South Gloucestershire in relation to Winterbourne View which go far beyond the involvement of any two individuals.

Which is a fair point but I think that there has to be some level of responsibility taken within a local authority when safeguarding procedures fail so badly. Particularly concerning to me are two issues – firstly why it takes a BBC documentary to uncover abuse that had been flagged up clearly and secondly, knowing about how safeguarding investigations are conducted, how this was able to ‘slip past’ what are, in my experience, fairly robust procedures.

Either way, whilst I don’t welcome scapegoating, I think it’s right that those who are responsible for management within public services take responsibility  for things when they clearly don’t work to protect those who need safeguarding.

As for the serious case review, which is due to be published later this year, I can only hope many lessons are learnt so we become less reliant on the press and more able to rely on robust preventative work by commissioning authorities and inspection regime to stamp out institutional abuse and/or to spot it as a priority.

A look at ‘Caring for our future : reforming care and support’

A rapid chase through the Care White Paper

The government published it’s long overdue Care White Paper yesterday. There’s been time for a significant amount of coverage to push through to the media and I don’t want to repeat information that’s out there but rather provide a response/analysis from where I am and where I see it. There is a good summary on Community Care though.

It’s a hotch potch of a document. The words are pretty but there’s an underlying tone of ‘saving taxpayers money’ which shines through from every good intentioned statement. Saving money isn’t a bad thing but I wonder how much the intention is to change the way the market in care is delivered in line with the NHS Bill and how much is to actually change the philosophy behind the process of care. I doubt the government’s good intentions.

The White Paper divides into eight chapters. So I’ll follow that pattern in my review of them.

Chap 1: The Case for Change

Here, the paper itself sets out the current difficulties in the system as it is at present which is reactive to crisis rather than focused on prevention. I can’t help feeling a little cynical in noting even the current system wasn’t intended to be this way, but has developed as such due to the pressures on funding.  The government line is to prove the point about crisis response but that’s not really been the agenda all the time.

Believe it or not, there was a time we met ‘low’ needs and while accepting there is a financial limit, the demonisation of the system is hardly a true reflection of what was envisaged and more should be learnt about the ways that systems imposed develop into a ‘race to the bottom’.

So the paper suggests that the answers will be found by providing more services sooner in the process of ageing or a disabling condition.  We will have more support for carers and will be promoting communities to provide support within themselves.

People need more information, without doubt, and that will be provided. That’s hardly revolutionary but too much has been down to local differences – the old ‘postcode lottery’ arguments. This will be clarified so people can move around the country and know what they will be able to expect.

Interesting that the ‘opportunities from reform’ all seem to revolve around financial benefits. It’s a valid benefit and opportunity but an interesting angle so

‘Promoting people’s wellbeing and independence’ will ‘limit future demand for care and support and help to ensure taxpayers’ money is used for effectively’.

Support for carers will enable them to ‘remain in the workplace’ which will ‘support economic growth’. So THAT’S why they are so keen to support carers – don’t want anyone to think that ‘caring’ without pay for a family member isn’t a valid and essential economic contributor.

and ‘Supporting businesses to grow’ – which is maybe what choice is all about.

I’m not against these agendas but I think the framing in economic terms is very very interesting.

Chap 2: Our vision for care and support

Understandably and quite rightly there is a high proportion of ‘control’ wanting to be distributed from top down to users in this section of the White Paper which is all well and good. It’s been (rightly) the movement of travel and needs to go further. As someone who works with people who have not been able to benefit fully from the ‘choice and control’ agenda, I was particularly looking for things that would help and support the people that I work with here.

There’s a lot of focus on promoting communities in being active and enabling to those living in them. There’s a need to promote better information streams – quite rightly – the system is enormously complex and I spot a little line on page 19 about ‘supporting the transformation of the social work profession’.

So the role and place of the local authority to provide care and support will be changing as it says

‘instead of purchasing and providing care and support, authorities will increasingly be expected to take a leadership role in a local area’. That should be interesting.

Chap 3 ‘I am supported to maintain my independence for as long as possible”

So in looking at prevention of isolation and needs the White Paper turns to communities to look for support, quite rightly. There’s a lot of potential here and social isolation is specifically targeted with some wonderful local models explained in terms of the way they work with isolated people to bring them into communities.

Not everyone wants to be a part of a community and there are some people communities tend to be less eager to support but it’s a great initiative for some people and there will be a lovely new Outcome Framework which will identify measures of loneliness for us to work on while local authorities managers and accountants look at ways they can meet targets at low or no cost.

Commissioners will be ‘encouraged’ (whatever that means) to draw on community support networks rather than moving people into ‘formal’ services. I read that along the lines of finding services that are provided at low or no cost but perhaps I’m a cynic.

There’s a line here too about social work pilot schemes which will  ‘liberate’ (I’m VERY suspicious of the word ‘liberate’) social workers from case management. It looks like a push towards more community based social work but I have some concerns. Firstly, case management is only bad if it is implemented badly as a process rather than as a collaboration. Poor case management can have an enormously detrimental effect on someone.

I’m not convinced by social work pilots but will wait for the outcomes of these pilots to see before I make a final judgement. I like the idea of more community work but am worried at what cost it may come in terms of privatising delivery of service and moving responsibilities for provision away from a democratic mandate.

I do like the idea of connecting care homes with their local areas. That is enormously positive and where I’ve seen it happen locally, it has made a big difference. It does seem like a lot of ‘use volunteers’ as the answer to problems but honestly, that’s not a bad thing where there are volunteers. I just wonder if all communities will be as engaged and where there is such a great reliance on community to provide support, what will be done in those areas that aren’t as supportive.

As regards housing, there will be significant investments in housing for older and disabled people. I hope this will encompass people in mental health services and is not limited to those with physical  health needs. There is a muddle over extra-care sheltered accommodation which is described as a way to meet low level needs but also as an alternative to residential care. Oh, I mean a ‘cost effective’ alternative to residential care. Missed the key point there.

Chap 4 ‘I understand how care and support works and what my entitlements and responsibilities are’

Information, information, information. It’s crucial in order to make choices and the government sets out ways, particularly websites, that will provide more information about services and facilities to all rather than just those eligible for them.

Interestingly the NHS 111 number will roll out support for social care. I wonder how this will work as a national helpline when provisioning is so different locally and there will be an extension of services like NHS Direct and NHS Choices into the social care sphere. Look forward to seeing that. I genuinely hope it works.

Local authorities will also be obliged to provide more information online but also in other formats, to those looking at services and providers but it looks like there is intended to be a default move online for many access points – including self assessments online as ‘they provide a better customer experience’. I wonder how this marries with the issues around the digital divide. There will be paper and telephone options available at least.

There will be a national eligibility framework and it seems (although this will only be confirmed later) that it may well be set at ‘substantial’ under current FACS guidelines although there will be a move to a new framework of assessment and eligibility.

People will also  have more options about who assesses them.

‘Our ambition is for many more providers to offer assessment services’. Good business opportunities there and a role for the social work pilot schemes.

Carers will have an entitlement to assessment (which exists) and to the provision of services (which doesn’t at present). I’m glad to see that.

Chapter 5 ‘I am happy with the quality of my care and support’

There’s an interesting diagram on this chapter on page 38 with circles of ‘roles and responsibilities in care and support’ around the ‘service users and carers’ at the centre, with Government, Commissioners, Providers and CQC around them. Interesting that there is no place for social workers. I expect we come into ‘commissioners’ but sad that the profession doesn’t seem to have a place around this diagram and is not even mentioned.

There is talk of better regulation by the CQC with inspections annually (scandalous that they were ever anything but in my view).

Looks like they’ll be a return to some kind of rating system too. Strange that just disappeared.

Statutory Safeguarding Adults Boards will be convened by local authorities with police and NHS organisations inputting to them. There will be further consultation on powers to access someone who might be at risk of abuse or neglect.  Personally, I’d like to have seen more on safeguarding.

Commissioning on quality is emphasised (good) and there seems to be a desire to look at some kind of outcome model to judge this. There’s also an acknolwedgement of the failing of some private care homes such as Southern Cross and

‘Local authorities have a duty to provide accommodation to anyone – publicly or self-funded – who has an urgent need for care which is not otherwise available’ and noone will be left homeless if a provider were to fail.

I don’t doubt that would be the case anyway but more public protection for private companies failing can only lead to additional costs.

Chapter 6 ‘I know that the person giving me care and support will treat me with dignity and respect’.

Here there’s an emphasis on building skills in the social care sector. I don’t believe people go into this field of work to be oppressive or uncaring but the system dictates it and a bullying workplace leads to poor and dangerous service delivery to people who have higher needs.

The government claims to be committed to the plans of the Social Work Reform Board and that the College of Social Work will play a heavy role in improving standards of education and training in social work in universities.

The White Paper supports the position of Principal Social Workers in Adult Services and part of that role will be coordinating feedback from frontline practitioners. I look forward to having one locally as I have a lot to feedback.

Chapter 7 ‘I am in control of my care and support’

Ah, personalisation, that bittersweet word which means everything and nothing. Everyone entitled to care and support will have a personal budget – I genuinely thought that was already on track and didn’t think it was anything new. And look

‘We will push further with our ambition to support as many people as possible to enjoy the benefits of a direct payment’.

I hope that support is extensive and looks beyond the current models which have served some exceptionally well but many others very very poorly.

I won’t mention the ignorant way that advocacy is included in the White Paper which evidences a lack of knowledge by those who wrote the paper but will merely reference Martin Coyle’s (from Action for Advocacy) blogpost which says it all.

There’s some more in this section about integration between health and social care which is becoming more distant in practice rather than more evident.  Use of the term ‘care coordination’ is confusing as it is a generally used term in mental health services and has different technical meaning to the way it is used in the White Paper in terms of physical health. That has already caused us many confusing conversations locally as to someone having two care coordinators – one for physical health and one for mental health – which kind of proves the point about duplicating work and having unfathomable systems. The terms should really be clarified and separated if necessary.

Chapter 8 ‘Making it Happen’

A draft bill was published alongside the White Paper. I haven’t read it yet. I wonder that some organisations seem to have thrown their lot in wholeheartedly with the government which makes me a little nervous. I want to support positive change but I don’t want to be blinded by good intentions and words that lead to little that changes the lives of those who have the most need for support.

Interestingly the ‘financial context’ is stuck at the back of the White Paper like a growing tumour. There are mealy mouthed words about the government putting money into social care but while taking away in the other hand, from local government, they have contributed directly to the ‘crisis management’ only model that they criticise.

Conclusion

I see little if anything revolutionary in this paper. I see nothing that explains a change in the direction of travel and means of delivering social care. I see some positive signs and some acknowledgement of difficulties but we were moving down the path of personalisation at a rate that it could only continue. While there was mention of personal budgets for residential care, I saw nothing about ISFs and developing ways of promoting choice for those who are excluded from communities and who may lack capacity. I saw nothing about changing legislative frameworks. I saw a lot of gaps, not least, the massive funding gap.

Nice words though, fluffy and helpful and a lot of the language of ‘choice’ (where possible), ‘community’ (where free) and ‘market’.

These things are always filled with the right words. I think a lot of opportunity to restructure and rethink adult social care has been lost although there are some springs of hope – there aren’t by any means enough.

Pic by wintersoul1 at Flickr

Panorama and Ash Court – Towards Improvements

I watched Panorama last night. The programme, as explained yesterday, focused on the abuse by care workers at Ash Court of an older woman with dementia whose daughter filmed her secretly on a hidden camera in the home.

The footage of the abuse was sickening and involved both physical and psychological (neglectful) abuse by those employed to care for her. Most indicative was the lack of regard that the care workers had for Mrs Jane Worroll as a human being as we saw the treatment dehumanising her.

It was clearly uncomfortable viewing and links are being made with Winterbourne View but there are vast differences and this time, although I almost surprise myself, I think it’s important to defend the role of the Care Quality Commission in this case.

With the Winterbourne View Panorama expose there were whistle blowers and the regulator should have taken action as a result. With the situation at Ash Court, there was a hidden camera and while some of the cultures could have been known to exist within the home itself, it’s clear that the regulator did not have a way of knowing what was happening before it happened.

As they say in the statement that they make on the programme that what they (the CQC)

cannot do is to identify and stamp out deliberately concealed abuse. By its very nature, concealed abuse takes place away from the eyes of managers and inspectors and can even take place, as in this case, in a well run care home. Abuse of vulnerable people is a criminal matter, and is rightly handled by the police and the courts.

That’s the big difference between Ash Court and Winterbourne View. The disappointment in Panorama is that it tried to merge the agendas of both and while there is a common narrative to both programmes about abuse of those who have power of those who do not, the solutions and causes are different.

I mentioned on Twitter during the programme about the discrepancies of procedures and powers for adult safeguarding and safeguarding of children.

Personally I see ‘safeguarding’ and ‘abuse’ as the use of power by someone against another person who has no power. That might be as a result of physical ability, mental capacity or understanding or just some of the institutional structures in place. Whether the person who is abused is 6, 65 or 85 shouldn’t have any sway within the processes. What I’d like to see is a unified process that deals with the effects of abuse and the power differentials – rather than provide so many more hoops to jump through and weaker processes when the person to whom the abuse happens is over 18.

The effects may be different according to the stage in the life cycle but they may not be. The criminal act is around the abuse of power and the abuse within the relationship that takes place along with the eventual effect.

I’m sure those with more knowledge than me will come back to attack my somewhat simplistic judgements and thoughts on this but it’s frustrating working within an adult safeguarding process that lacks so many of the potential teeth when we see some of the abuses that take place and see so few taken to court due to unreliable witnesses or lack of scope for action.

Another disappointment of Panorama (although unsurprising as they wanted to squeeze out all the ‘abuse’ footage for shock value and only had 30 minutes) was the lack of attention to some of the systemic problems that have led to warehousing of older adults in institutions when they need residential care. The pay of the staff was mentioned but pay is not the only consideration.

I worked quite happily at a very low wage as a care worker myself for a number of years but what matters as much as pay (although pay helps) is the value placed on the members of staff. Staff who are not respected and who are treated as expendable and with little respect are more likely to pass that feeling of powerlessness on to others. It isn’t an inevitable link – you get good staff in bad homes and bad staff in good homes – but it’s more likely that if staff feel linked to and attached to those whom they care for and those for whom they work – they are more likely not only to pass on that feeling of respect but to feel vested in the organisation for whom they work.

Too often care work is seen as ‘easy’ and care workers are seen as ‘replaceable’. Organisations like Forest Care (and many others I know) bring staff over from the Philippines en masse to carry out these roles or put staff on zero hour contracts and push out unionisation. Organisations have to regard staff better – and pay is one of those aspects but not the only one – in order to create cultures of care and compassion. The other aspects are good and robust supervision, including peer supervision and giving staff responsibilities and a stake or voice into the organisation they are working for. Whistleblowing has to be easier and better regarded. Complaints improve care and processes and they should not be feared.

Local authorities and the government needs to be willing to pay more for care and for monitoring inspections which don’t need to simply come from the Care Quality Commission. If LAs push prices down to rock bottom quality will suffer. Some people do need 24 hour residential or nursing care and it shouldn’t be accepted as being ‘sub-standard’ as default. It doesn’t have to be.

Panorama didn’t shock me, unfortunately. It saddened me. I hope it doesn’t become just another blip in the process of change. I want the processes and structures to be pushed to positive change. Blaming the CQC won’t do that – changing the expectations and systems might.

As for hidden cameras in residential care homes and in people’s own homes – I see it increasing and have a sense of discomfort about some of the rights to privacy that are impeded however finding and challenging abuse is important. Would Mrs Worroll’s abuse have been discovered without them? Unlikely unless one of the care staff attending her raised concerns with their own manager. I may be tempted to use hidden cameras myself if I had a family member in a similar position but that’s the key – it’s only those people who have family members who will have recourse to such action – what we need to do is find the reasons these abuses happen institutionally and act on them.

Of Hidden Cameras, Care and Panorama

Tonight’s  Panorama is focusing on care of the elderly or rather, lack of care. Maria Worroll was placed by her mother in a care home in Camden which had an ‘excellent’ rating by the CQC (Care Quality Commission).

Jane Worroll, Maria’s daughter, noticing something amiss and perhaps having concerns, set up a hidden camera in her mother’s room to observe how her mother’s treatment. Mistreatment and abuse were filmed and it led to a conviction by a care worker, Jonathan Aquino, under the provisions of the Mental Capacity Act (2005) and a jail term of 18 months.

There are a few key points to take into this and to note. Prior to June 2011 (when the filming took place), the previous assessment and inspection by the CQC was in 2009. It was an unannounced inspection and as described above, the outcome found the home was excellent.

There were a couple of ‘compliance’ visits after the incidents films came to light but the important thing to note is that an excellent care home can provide appalling care if there is one abusive care worker. Similarly a care home which may have a poor inspection report can provide excellent care if there are caring and good quality care staff. Historical reports of care by regulators actually tell us little about the quality of the care today, at this moment, as staff in these care homes tend to be transient and low paid.

There is an issue about management culture of course. I have seen a switch in manager making both a very positive and very negative effect on residents in these homes. While more regular ‘spot’ inspections – perhaps by lay visitors as well as official regulatory bodies – may be one answer, it may not root out the individually abusive members of staff. A much better way to do that is to firm up whistleblowing procedures and supervision procedures for care workers – perhaps more peer discussion and supervision as well as managerial supervision.

As for the effects I see, I am no longer surprised by the increase in surveillance by family members which is a definite increased trend that I’m seeing. While there may be issues of privacy, the concerns of families are very real.

Until our care systems can provide better qualities of regulating and monitoring care – and not only from the CQC but from commissioners – whether they be local authorities or privately funded – there will always be these questions that linger at the back of the mind.

I expect I’ll be watching tonight, if I am able. I think I know what I’ll see but it is important that these incidents come to light so that changes in the systems can be made. This is one incident but it is very far from isolated. Our society needs to deliver the type of care and the methods of monitoring of care and the financial provisions for care that are not age-dependent. Until we do so, I can only infer that the systems of social care in this country are inherently ageist.