Race To The Bottom Commissioning

Writers are obsessed not just with words but with wordcount. That innocuous, humble figure in the drop-down menu or nestling innocently in the bottom left hand corner of your screen should be a record of achievement. Instead, too often it’s a curse, an ever-tightening straitjacket on the creative flow. Blogging at least allows me to stretch out a bit as opposed to a commissioned piece for another site or magazine, but there’s lots of evidence to show people seldom read to the end of the article or  even past the opening paragraphs. If you’ve reached this point, you might well be in the minority.

Lately I’ve been a victim of the oppression of wordcount for a very different reason. Creativity has no place in the dark murky world of contract compliance and tenders.

These form an increasing proportion of the workload of any independent provider in fostering and residential work. I understand why they have appeared. After all, I’m old enough to recall the old days when social work had no systems for measuring its effectiveness, the days when we just knew and that got us nowhere. However, the last few months have taught me that while it appears we have swung to the other extreme with compliance coming out of every orifice, not only are we no nearer to truly demonstrating effectiveness, it is stifling innovation and good practice that children and young people need more desperately than ever before.

Two weeks ago I completed a tender for an authority in the southeast. I wrote 12,098 words. As each question was limited to 500 words, you can see how much ground they wanted to cover, except that this document, clearly designed by committee, was intensely repetitive. There are only so many ways you can say you are child centred, needs-based, work in partnership and strive to keep children safe.

Anyway, there were four lots to this tender for different groups of children but the responses were similar, so that’s 48,392 words in total, half a decent novel in another world. For this sought-after tender there would be at least 40 providers going for it, which means the authority will have to read and digest 1,935,680 words. The responses  must be processed to ensure the quality threshold is achieved, graded on a scale of 1 to 5 then compared to rank the providers in a tiered system.

My 48,392 words does not include any of the policies and procedures that were requested, nor any of the considerable business, insurance and financial information. Then this whole quality exercise counts for only 40% of the tender because 60% is price. This imbalance between quality and cost is common – one tender went 70-30 in favour of price.

This modern approach to commissioning is an exercise in futility. I simply do not believe that all my words will be read, let alone systematically compared with the other 1,887,288 that have been submitted. It cannot possibly be done.

I resent the fact that quality is less significant than price. More and more, authorities are looking to the bottom line of the balance rather than good practice when it comes to children’s futures. I accept that they don’t have as much money and that the cuts are not their fault. However, this is not the most effective way of using their scarce resources to provide a child centred service.

I’ve said before how prices can be kept down in the sector – you provide a placement without extra services like contact, therapy and other forms of support. Yet carers as well as children need those packages of care as the demands of fostering are ever more complex. A price-based approach does not encourage that.

With the contract comes compliance. Fine, I understand why this is important. However, what happens in practice is that each authority wants very similar information but in a slightly different form. The 5 outcomes are the same, the info they require ever so slightly different. In passing, you can work out the problems affecting every authority by the nature of their requirements. A heavy emphasis on, say, staff checks or allegations means they’ve had a real problem in the recent past.

The lack of consistency means providers have to collect different statistics for every authority. Providers are of course inspected by Ofsted but this seems to be irrelevant when it comes to the tenders and perish the thought that Ofsted might want stats that are in any way similar to those required by authorities. Ofsted for example uses ethnic monitoring categories that do not match with any other I have come across.

All of this costs money. Providers will have to pass on the costs of extra posts and databases in one way or another, and goodness what the local authority staff costs are in processing 1,935,680 words.

Three other southeast tenders are between 3 and 5 months late because authorities are unable to reach a conclusion. Two face legal challenges because they request information that breaches data protection legislation. Some simply do not realise that having a policy for everything does not guarantee better quality. One organisation was censured for not having a child protection policy on gangs, but what do they expect. “For children and young people we do all we can to keep them safe but if they join a gang, sod ’em.” It’s reached the stage where I would be tempted to submit that.

Forgive the ranting. It’s helped me let off a bit of steam. I’ve just spent the day on a Section 11 audit for a council in East Anglia. It’s about safeguarding and that’s important, really, I get it, but question whether this is the right way to go about it. Self-assessment. Frankly unlikely that I’m going to give a score of anything less than perfect. ‘Do you have a policy on such and such?’ Answer: “Yes I do have a policy on such and such.” It will keep them happy because this is the fourth one I have filled in and everyone has been happy with that answer so far. Doesn’t say how good this provider is or the difference good safeguarding and risk-management makes.

The Fostering Regulations require that organisations send their child protection policies to every authority they work with or could work with. I know another provider who sent out 42 responses and did not hear back from one of them, not even an acknowledgement. Utterly futile.

It has reached the point where I don’t know what piece of legislation it is Section 11 of and I’m past the point of caring. 1,974 words, if you’re interested. I’m hacked off – you can tell, can’t you – because it’s a waste, of precious resources and of my creativity and innovation as a practitioner. I have several ideas stillborn because there is simply no time. Putting them into action would improve the well-being of children in care far more than any of the compliance mechanisms do.

But if by some chance you’ve bucked the stats and reached this far, have a look at two recent pieces that are considered, definitely non-ranty but point out the consequences. “Commissioning services drives up costs” from Public Service Europe and “race to the bottom commissioning” from the Third Sector. Commissioning is important. It needs to focus on value and quality. There must be a better way. That’s 1213 words I wanted to write.

Moving On and Looking Back

Forgive me for the slightly self-absorbed post. Blogging by its nature can be the epitome of self-absorption but I attempted to write with a look to the wider world, particularly in the sector I know best, social care. I put this in the past tense as this will be the last post I write.

When I started writing, I had the voice of a social worker and AMHP (Approved Mental Health Professional) in a Community Mental Health Team. I was trying find that voice amid the policy and processes that we found ourselves, as practitioners, caught up in and trying to extend outward some of the frustrations and observations garnered from the ‘frontline’. It felt and it feels like that policy happens from afar, away from the homes I visited, the wards we attended, this was my world and it felt like a completely different world from the one defined by officials in the Department of Health when they remember ‘social care’ is a part of their remit.

I believe wholeheartedly in social work as a profession and social workers as professionals but I became frustrated at the lack of professional leadership. There is no doubt that the last year of my professional life has been one of the most challenging. I’ve worked in social care for 20 years (gulp – I look younger, I promise!) as anyone can imagine, I’ve seen many changes in that time. ‘Reconfigurations’ were nothing new to me. Working with change and in organisations that change frequently is one of my fortes but the most recent one was the most painful by far. While parts of my job, I loved – particularly when I was able to work with and alongside individuals and families and walk with them through some of those moments of crisis – working in an organisation and delivering services which were being ripped to pieces was difficult. Defending organisational decisions became impossible. The fight was still there inside me to promote and present a better way of working and honest interactions with everyone who needed our service, I saw waiting lists grow and discharges of people who I felt would benefit from more support. I saw the effect of the programme of cuts in the NHS in a very visceral way. I was and am very lucky. I have been able to walk away. I find myself in a job that excites and interests me and presents many new challenges. The same ease with which one can move on cannot be said for those who are reliant on the support of social care services and I remain acutely aware of my privilege in being able to.

I found a different (but related) job and thought I’d be able to continue writing with the passion I never stopped having but I can’t. The situation has changed and the voices need to be heard from the frontline I’ve stepped back from. I have become the person I resented for so many years. As a social worker, I always had a hint of scorn for those who took the ‘desk jobs’ and moved away from the direct work with people who use the services we provide but I’ve become one of those people.

In defending myself to the old me, I’d say that changing the world can happen in different ways. I am no less committed to the same ethical standards of making the world of health and social care better for those who use services. I am seeing that social work and social care happens in many different places. Is it an attempt at justifying my decision to leave social work behind? Yes, probably but that’s something I’m reflecting on a great deal at the moment.

I have been disillusioned by the time I spent working in the statutory sector as a social worker. As a parting salvo as I head off into the sunset, I want to reflect on a couple of themes that revolve around social care at the moment.

Kneejerk funding decisions lead to more expense, both in terms of quality of life and finance in the longer term. I’ve seen panic cuts both at a national and local level. The problem with panic cuts is that the things that are easily destroyed cannot be built back up in the ‘good times’.

‘Choice and control’ the buzzwords of change ring very hollow to me now as I saw in both the NHS and the local authority, the way that data and information is manipulated to meet performance targets that are meaningless to people who use services. Choice is one of the most nefarious words in the sector in my opinion. ‘Choice’ is very much defined by what organisations allow to be chosen and the confidence, communication skills, advocacy support of the individual doing the ‘choosing’. I railed against processes that favoured ‘he who shouts the loudest’ but it was to no avail. Presented by the government as a panacea of positivity, I have seen the downside of ‘choice’. It has been the creation of a two-tier service in adult social care that provides those who are able to choose with fantastic opportunities but those who may not have the capacity/support to choose are left lagging behind, in poorer, oft forgotten services. With funding drying up and fewer third sector organisations able to pick up the slack, there is a massive void of support which often falls on family and friends – the ‘informal’ support networks that the government still feel able to criticise.

Dementia care is a particular interest of mine. Professionally I have worked in the area for a number of years. Dementia is moving further forward in terms of government policy making and the so-called ‘dementia challenge’ which is currently trying to increase diagnosis rates. That’s all well and good and I won’t enter that conversation but I will say this. In order for dementia to be better understood by the public it has to be better understood by the government agencies who are supposed to be providing the information. There is a horrendous lack of information about the role that supportive social care services play in improving the quality of life for people with dementia. As I worked alongside a ‘memory clinic’ which had been decimated by cuts, I laughed hollowly at the words of the government ministers about increasing diagnosis rates in primary care and for hospital inpatients. See my first point about panic cuts and lack of cohesion. Reading some of the Department of Health missives you’d be at a loss to think they ever discussed any of their plans with anyone with a current social care background. Perhaps the new Chief Social Worker (or one of them anyway) will provide a sticking plaster to this but it’s very apparent at the moment that there is no cohesive, current social care voice in the government department and it makes some of their policies woeful. The level of ignorance even of government ministers who clearly haven’t been briefed by people who understand social care would be embarrassing if it weren’t desperately sad.

Lastly about Social Work itself. I retain my social work registration and will now until 2014 at the very least. I suspect far beyond that as I don’t want to give up my registration. I am very proud to be and to have been a social worker. The ethics and values of the profession can really shine a light and guide many of our colleagues in allied professions and we shouldn’t be shy of realising our own worth. Often I hear social workers talk of status and comparing ourselves unfavourably to nurses, teachers, doctors, psychologists etc. We shouldn’t need to constantly compare. We have a fine profession with its own knowledge base, standards and codes. Having worked in a multi-disciplinary mental health team (and I think being an AMHP helped with this as we are known to be a stubborn and independently minded bunch) I never felt anything but an equal to the other professionals I worked alongside (and challenged – psychiatrists – I’m talking to you ;)). We do need to ‘sell ourselves’ more and we can’t rely on waiting for ‘good press coverage’. Do the job, however hard, with the ethics and values at the heart and remember why we are there – it isn’t to promote organisational will but to walk alongside and guide. Sometimes there are difficult, coercive decisions to be made but reference to values and ethics become all the more important there. The nature of a job that sometimes has a coercive function is that ‘hearts and minds’ will never be particularly straightforward. I didn’t become a social worker to make friends or to swan in adulation of my ‘goodness’. I went into it because I felt it gave me more opportunities to make a positive difference in someone’s life. More often than not, certainly over the last couple of years, it became more about saying what wasn’t possible than what was – but if I could deliver that with as much humanity and empathy and transparency as possible, it could be a start.

Many thanks to Zarathustra for this space and for the support he has offered to me.

And thanks to everyone for reading, commenting and responding over the last year or so. My reasons for stopping are work-related but not in a bad way. I just think my voice has changed now and it’s important that those ‘on the ground’ have the way left open to them to find it. I won’t say I’ll never write again, I may at some point in the future, but if I do it won’t be anonymously I will, though continue to knock around on Twitter I expect!

Goodbye

Exporting Care

Location, Location, Location

Yesterday I read this article in the Guardian. It reports that in Germany there is an increase in Germans being placed in residential, retirement and rehabilitation units in eastern Europe where the costs are lower.

As the article says

Germany’s chronic care crisis – the care industry suffers from lack of workers and soaring costs – has for years been mitigated by eastern Europeans migrating to Germany in growing numbers to care for the country’s elderly.

But the transfer of old people to eastern Europe is being seen as a new and desperate departure, indicating that even with imported, cheaper workers, the system is unworkable.

But before we are too quick to castigate Germany, I think it’s important that we look at what happens in this country.

Until one month ago, I was a local authority employed social worker, seconded into an NHS Trust (as I was a mental health social worker) working predominantly with older people. I made a lot of residential and nursing placements. I worked in an inner London borough.

The amount of local placements we had came nowhere near meeting the needs of the local community. Yes, there has been a push towards caring for people longer at home – perhaps it was a feature of central London, perhaps not,  but many of the people I worked with did not have family around them. The cost of housing had pretty much seen to that in terms of ripping communities apart.

Still, there are pockets of close communities even amid the high towers of the financial centres of London. Among the office blocks and fancy shopping streets, there are communities that have evolved over the decades, centuries even and those tourist spots visitors see, they are ‘home’ to many people who might not wear the smartest suits or have the fanciest accessories.

We ‘converted’ some of the residential provision locally into ‘extra care sheltered’ provision – see, that would be good, that would ‘keep people at home’ for longer.

So where are we now?

The chances of getting a placement in the local area are very slim to zero. We had waiting lists months long for some of the residential provisions in the area. The wonderful ‘extra care sheltered’ housing provision realised soon that they could not manage the needs of those who needed 24 hour residential support or maybe the criteria for residential care moved higher but they have not truly become an alternative for someone who needs a residential placement. They have become a safer environment with a constant ‘warden’ for those who may otherwise have had sheltered accommodation.

So there are fewer residential and nursing placements for people who are local to the area. If a family shouts and hollers enough they may get someone on the ‘waiting list’ for a place. Who knows when that place will come up. We don’t like saying it explicitly  but places in residential and nursing homes usually come up for one reason and that’s a death or a deterioration in physical health and noone wants to think about that.

What does a local authority do then?

It moves people out. It is more likely to move out people who have no family support and no ‘links’ to the area. You see, living somewhere for 70+ years isn’t seen as ‘link’ enough if your family and friends aren’t there. Anyway, even if they don’t want to move you out, if there are no beds, there are no beds.

So while we aren’t moving people to other countries, that’s only really by virtue of us being an island. We aren’t that much better than Germany in this respect. We are moving people to unfamiliar settings and localities on the basis of cost alone.

Commissioning Quality

How are these decisions made? Well, to absolve myself from responsibility, I’ll say it wasn’t my decision. I did and do rage against it. I raised it internally as the ways these decisions are made are purely on the basis of finances of local authorities to make placements.

Currently, in inner London we are placing frequently in outer London but soon it will be the Home Counties and further and further away from familiarity. I wonder how consistent this is with the Mental Capacity Act which demands previous preferences are taken into account. This can be ridden over roughshod if there aren’t any local placements at the right cost.

So we move to commissioning. There has been a race to the bottom in terms of providing services and placements at the lowest cost. Property is a massive cost in central London so cheaper land can push down general cost but at what price to autonomy and preference?

There has to be a way for commissioners to be accountable for the decisions they make. Families can push and make complaints on behalf of those who are not able to make decisions for themselves but there really needs to be, in my opinion, some external scrutiny of commissioning decisions made by people who really understand the social care sector. Yes, councillors can scrutinise but how many understand the needs of those who are not pounding on their doors making complaints about council services? Who understands that those who have the quietest voices or who have noone to advocate for them may be having their rights ripped away from them?

I’m not sure of the answers. All I know is that I wish the commissioners would have listened to their social workers. I wish there were a stronger, formal system of advocacy which would raise these issues with people who commission services and I wish there were an understanding in central government of the impact that geography makes on the cost of social care.

There may be cheaper and more available placements in South Yorkshire but that doesn’t mean the answer is placing Londoners there. I fear it may well be in the future.

We can’t become too complacent. Germany today may well be Britain tomorrow.

Does God Need A Make-Over?

There has been much in the media of recent about the rather fraught view of religion by other parts of society. On this occasion, I’m thinking in particular of the Church of England’s (and to be fair, most other Christian denominations) response to gay marriage and of course the well-publicised vote on whether women should be allowed to become Bishops in the Church of England.

I find it an interesting discussion for a number of reasons not least because I am a Christian and an Independent Social Worker so find myself asking whether the two can co-exist without being at loggerheads for much of the time.  On the one hand, they appear to be best friends; after all principles such as compassion, self-less giving, openness and honesty and shared between the two.  Prior to being a welfare state wasn’t welfare provided by family and caring neighbours? On the other hand they appear to be poles apart and the (media’s interpretation of) views of Christians have become the very definition of inequality and discrimination: Being reported as an outdated, irrelevant religion whose demise is imminent.

All this has led to the media and bloggers alike asking whether God has become irrelevant or in Katy Campbell’s blog questioning whether God requires a bit of PR to continue in contemporary society.

I think a part of the problem is that people are confusing religion with the Christian’s view of God.  For a Christian, God created everything in the beginning, has always and will always co-exists as Father, Son (Jesus) and Holy Spirit.  Whilst Christians identify that individuals can have a relationship with God who is perfect, religion is largely man-made and often where the problems exist. The problems don’t necessarily lie in the fact that people believe in God or any other god for that matter.

Does God need a make-over? If you ask a Christian they would say that to suggest that he does would be to acknowledge that he isn’t actually God so in itself is an absurd question.  Does the Christian church need a make-over to bring it in line with contemporary society and more in line with Biblical principles?

Another issue is the Bible which is of course the Christians’ book of choice. A Christian will tell you that it is one of the means through which someone gets to know God. It has itself been under scrutiny of recent particularly when discussions about gay marriage have been raised.  The reason being that the Bible sets out a clear framework for marriage; Christians believe that it is an institution ordained by God and a union between a man and women. That is why most Christians will be against gay marriage. Not because they are homophobic but because it is contrary to the foundation of their faith.

So, perhaps the issue isn’t that God requires a make-over or that the foundations of the Christian faith should somehow be remodeled because to suggest such a thing is surely questioning whether any religion is valid.

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.