What makes residential care good?

I was asked this morning on Twitter what I felt made a ‘good care’ in a residential home. Sometimes it’s hard to elaborate in 140 characters so thought it would be useful to explain my thoughts in a little longer form.

I’ve worked in social care for a number of years, either as a care worker/support worker in a couple of residential homes (and as a ‘bank’ carer in even more) and as a social worker in adult and mental health services.

I’ve been into a lot of residential care homes and I’ve seen massively varying standards  from the home the time I left a home with such heavy concerns that I left a message for the CQC inspector on my way back to the office to the homes I would both be happy to live in myself and would be happy for any of my family members needing care to move into immediately.

So how do I judge what is ‘good’ (and these aren’t necessarily in order!) – especially in the time limited fashion that often involves me walking in and out in an afternoon.

Culture – which can be hard to quantify but you know it when you see it. From the decor and the welcome you receive when you walk in or when you call on the phone to the small interactions you might see in the lounge area and the amount and type of items you might see. Is the lounge empty except for a few paperbacks that look untouched and are mostly large saga-type romances with little variety? Are the (as there was in a home I went to earlier this week) lines of VHS videos stacked up next to the TV? (without a video recorder, incidently)? These things show care, or lack of it to the details.

Feedback – I listen to people who use the services. Communication can be at different levels and there are sometimes people in care settings who don’t want to be there but often users respond to kindness and listening to the feedback of those who use the services and family/friends who visit is vital to understanding the quality of the service. Of course, it’s useful to read the official reports but they are so rare now and often out of date – while issues around quality of care can change quickly, that we need to look in other areas and understanding how well homes respond to individuals and their needs, wishes and wants is fundamental.

Staff – How am I greeted, that’s one this but more importantly are the interactions I see between staff and residents and not necessarily the residents I’m there to visit. Is there eye contact, is there any touch involved? Are the staff sitting in the lounges responding in conversation rather than requesting things are done/not done? Is there any interaction between residents? How is this facilitated? What is the staff turnover like? I might ask the member of staff showing me round how long they have been working there, do they enjoy it? Often they’ll say yes, anyway, but sometimes you get a glimmer of something else.

Size – I have an issue with stacking up older adults in large residential homes in a way that we wouldn’t in other user groups. We have residential and nursing homes now with 50+, 90+ residents. There can be good care in these places but are they ‘homely’? Are they able to meet individual needs? Or is it a hark back to institutionalisation and long stay hospital type settings. It feels like it is about cost and age discrimination. I would be happy to care delivered in small settings. Large doesn’t necessarily mean bad and small doesn’t necessarily mean good but do we really think there is a justification for 100 bed ‘units’ in the current day. The only justifications are cost and economies of scale. I don’t think that’s good enough.

Individualised responses – are the residents individuals? Can they pursue different activities if they don’t want to sing music hall songs? What if I resident moves in who prefers Led Zeppelin to Knees up Mother Brown (real story, incidently!). What if they wanted to do things or go places that weren’t on the ‘programme’? Yes, individualisation can cost but it doesn’t need to – it can be able to things that don’t necessarily raise a charge. How is this done? I want examples in every home of how individual needs are met.

Those are some of my initial thoughts. I’d welcome thoughts from others about what and how they make judgements about what good care in a residential setting involves.

Thanks for Bill Mumford for inspiring me to write!

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Four Seasons, Private Equity and the Care Sector

Money Talks - Do you listen?

Both the Guardian and the Financial Times report on the possible imminent buy out of Four Seasons by ‘Terra Firma’ – a private equity company. Guy Hands, who chairs the company is described by the Guardian as

the tax exile and private-equity baron best known for his disastrous debt-fuelled takeover of EMI

Comforting.

Four Seasons Healthcare is a large provider of nursing and residential care homes in across the UK. As it says on the front page of their website

We are the leading independent healthcare provider in the UK. We own and operate over 500 care centres and nursing homes, employing around 30,000 people. Our care homes and nursing homes are unique and we’re proud to offer consistently high standards of service and care.

Seems like a perfect investment opportunity for a.. er.. private equity company, right?

Maybe I’m being a little disingenuous. Having an A level in Economics doesn’t give me a significant understanding in financial models of support however what is blatantly obvious is that the sector as a whole (and we’ll push Southern Cross into the mix here as well) have over borrowed on assets which haven’t produced the intended profits.

The further link with Southern Cross is the irony (or maybe it isn’t) that Four Seasons took over a number of Southern Cross homes when they went under.

The Financial Times explains that Four Seasons is looking to refinance a £780 million debt and is ‘likely to raise £525 million of new debt’.

These kinds of fantasy figures have little in the way of substance to me. But that’s a lot of money and I do wonder at the amounts of money knocking around in these health and social care sectors.

Last month Terra Firma bought a Gardening Centre group for over £200 million.

The type of business is of little interest to the company putting the money in. It is purely and simply a business opportunity. This is one of the reasons I shudder at the leaking of health and social care into the private markets. The reality of financing, refinancing and profit making can be cut throat but for the people who live in these nursing homes it’s worth remembering that they are possibly the last years of the lives of people at stake rather than lilies and tomato plants.

Four Seasons has a deadline of September 2012 to refinance the debt it has. It is currently owned by a consortium of banks. A private equity company will be no worse nor better than what exists now unless it is able to offer the company more financial security (which I presume it is) but the interesting part, for me, as an outsider to the world of equity and financing is that this is not the first very large healthcare company to be switching hands and talking in terms of millions regarding profit in health care.

The Matlock Mercury (in the East Midlands) has a story which raises concerns by the GMB union when Southern Cross staff were transferred to Four Seasons and they asked for a response from the CQC. They write

Recently the Care Quality Commission said as follows: “The large health and care organisations are not overseen financially by anyone.

“The Care Quality Commission (CQC) require that a provider is financially stable, but it is outside of our remit to carry out financial audits or financially background checking of any service provider.

I can appreciate that. The CQC is pushed but isn’t it worrying that there is no-one at all overseeing whether service providers are ‘financially viable’? It doesn’t need to be the CQC – but perhaps – as we move towards a situation where more and more health care services are moving into private hands – it should be someone..

This is the future of the NHS. It is already here. Profits will be pushed to shareholders and companies are accountable to those shareholders rather than the people who use and need the services provided.

Tomorrow, this will be the hospitals.

picture by w4nd3rl0st at Flickr

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.