A Confident And Skilled Workforce In Social Care

An article published in Workforce Matters (Issue 2: December 2012)

How will the adult social care workforce of the future be affected by public health changes in England? Vic Citarella, Director of health and social care consultancy CPEA, talks to the CfWI.

Vic Citarella is cautiously optimistic about the transfer of public health to local authorities in April 2013. But he believes it will take time before more integrated services and commissioning have an impact. To start with, the majority of people working in social care are unlikely to notice any difference. But with directors of public health championing the need for preventive investment, the benefits of integration and more long-term thinking, there should be positive outcomes for both people who use services and the social care workforce.

“The changes in public health are part of a wider picture of change, which includes personalised care, more emphasis on prevention and adult safeguarding,” he said. “In future, we will expect people in the social care workforce to work across health and social care and to be trained in new areas. This will include making the most of people’s strengths through self care and taking into account components related to their particular conditions, including medication and assisted living technology. A shared approach to training, support and supervision will have to be part of a more integrated approach.”

Inequalities in education and training will need to be addressed, said Mr Citarella. The healthcare and social care workforces are of a similar size, at around 1.35 and 1.56 million, but there has been comparatively little investment in training for social care. If people working in social care are to be trained in areas such as dementia and end-of-life care, the cost will be significant, but will lead to savings and benefits in the longer term.

New organisations such as consumer champions Healthwatch may also help to develop the skills, competence and confidence of the social care workforce.

“Greater integration may be an opportunity for people working in social care to be more innovative and challenging. Sometimes they can see ways of doing things better, but are not in a climate where they can raise issues. If they are all part of the same infrastructure there will be a place for this type of discussion. We may see a more confident social care workforce which is less deferential to medical professionals.”

More personalised services might also mean a more personalised workforce. If social care workers are employed directly by service users or their families, they may take more individual responsibility for their own training, development and practice. With greater choice in the system, they may follow the service user across commissioning boundaries, making workforce planning a challenge.

With many volunteers, community groups and individual carers working alongside paid social care staff, there is a shift towards a more enabling role.

“There is move towards refocusing the paid social care workforce on supporting carers and developing community capacity and networks of volunteers. Investment in self care and assisted living technology also makes the resources go further. There’s an emphasis on ‘doing with’ rather than ‘doing to’.”

There is a huge opportunity for the public health sector to help improve the health and wellbeing of the social care workforce, said Mr Citarella. Directors of public health could play a central role.

“There are high levels of stress and ill health in this workforce. Public health could be more sensitive to the welfare needs of an individualised and isolated social care workforce of over a million people. Occupational health ought to be high up the agenda.”

Planning for the future social care workforce will not be easy, however. “Many people don’t yet understand the complexity, fragmentation and diversity of the social care workforce. Thanks to organisations such as Skills for Care we now know a lot more about this sector than before, but workforce planning will still be a challenge.”

Want to know more about our work in social care? Contact rhidian.hughes@cfwi.org.uk.

CPEA Works With Care Providers in a Safeguarding Workshop

In October 2012 CPEA Ltd worked with SARCP (Staffordshire Association of Registered Care Providers) to run a workshop on working together to keep people safe. The day was attended by many providers and health and social care agencies from Stoke and Staffordshire. Vic Citarella, company Director of CPEA Ltd chaired the day and speakers included the Chair of the local Safeguarding Boards and safeguarding and other social care professionals. Claire Crawley from the DofH provided an update of progress at a national level to agree a definition of safeguarding. Pat Bailey, from CPEA, reminded us that the role of the registered manager is to champion, lead and protect and it is important to raise the profile of the manager as lead professional, responsible and accountable. Reviewers and regulators will not embed good practice as this is the key role of managers and a basic fundamental if we want to improve practice.

Citation, a company providing HR support, demonstrated the differing advice available from CQC, within No Secrets, The Government Guidance on protecting vulnerable adults and employment law. Essentially in a case of harm or risk of harm CQC advice, and generally the local authority, is to suspend the employee immediately but employment law warns against a knee jerk reaction, that suspension isn’t always appropriate and investigation should take place in a timely manner. It is the employer’s responsibility to suspend staff, based upon their investigation, and also their duty to report conclusions to the relevant professional bodies. The role of a good employer is to undertake any actions in a proper and proportionate manner and Claire Crawley said we need responsible and capable providers to do this.

A major concern amongst providers is the suspension of contracts and that this should only happen when there are serious risks and then local authority representatives need to tell providers what they are doing and why. Sarah Hollinshead Bland, Commissioner Adult Safeguarding in Staffordshire County Council explained that contracts are often suspended during large scale investigations and placements can re-commence when the investigation has concluded and required improvements in practice can be sustained.

Key messages from the day were

• The Safeguarding framework is about improving wellbeing and Adult Protection investigation is just one aspect of the safeguarding process. Many practice concerns are now falling into safeguarding processes and this was on the increase. Managers said if they tried to argue they were told they were failing to act. Social workers couldn’t cope with this increase in activity and whilst they were dealing with safeguarding they were not carrying out personalised assessments and reviews.

• Those investigating safeguarding/abuse allegations, however important they perceive their investigative role, are not outside the general law and have to have proper regard to and for those who face allegations and natural justice whereby there should be no bias against the accused, that there is a right to be heard, to know the case against you, what the evidence is, what statements have been made and a fair opportunity to correct or contradict.

• There are occasions when negotiation is appropriate; that not all bad practice should lead to safeguarding scrutiny. Remember – residents in care homes can be subject to more abuse by poor safeguarding procedures and actions.

Janet Pearson, Director, CPEA

Margaret Flynn Provides Notes From A Department Of Health Stakeholder Event On Positive Behaviour Support

What is restraint? An array of interventions, some of which are coercive, the merits of which may not be known. The ways in which restraint is perceived differs markedly – with many professionals broadly asserting its necessity – typically by citing extreme examples –  and people with learning disabilities and autism and their families questioning its necessity.

Which principles should underlie physical intervention? The following elements of principles should underlie physical intervention:

• The context should be known i.e. there are risky environments, risky management decisions, risky managers and practitioners and risky practices. The latter would include, for example, undertaking a physical intervention without any knowledge of a person’s biography.
• The traumas people are known to have endured should not be reinforced by any form of a physical intervention e.g. people who are known to have been sexually assaulted should not be placed on the ground and immobilised by body weight
• People’s experiences of being subject to restraint, for example, should be known – are they doing to their peers and staff what they have endured in previous settings?
• Individuals should never be restrained when they are naked or partially naked. Furthermore, when naked or partially naked, they should never be immobilised by body weight
• Any intervention has to be part of an agreed and positive approach
• Chemical restraint, physical restraint, mechanical restraint and/or seclusion should not co-occur

What data is required? Every incident of physical restraint should be recorded as a patient safety incident. What is the point of counting incidents if nothing other than the fact of a physical restraint, for example, is known? Information concerning physical interventions requires a single route.

How we get from where we are now to where we want to be? The NHS Commissioning Board should issue a series of edicts, i.e. Thou shalt…

• Adopt a life-span approach to people with learning disabilities and autism, referencing this in their service specifications
• Put a moratorium on building new secure services or extending such services in the knowledge that if there is a building it will be filled
• Ensure that the Care Quality Commission does not register units which are outwith national policy i.e. Assessment and Treatment units
• Review and challenge the use of the mental health legislation as it impacts on adults with learning disabilities and autism on a locality basis
• Discontinue the office function of long distance commissioning in favour of investing in effective and credible local supports – if Winterbourne View Hospital patients and their families had known the telephone contact details of individual commissioners – it is unlikely that they would have had to resort to calling the police
• Promote the piloting of micro-commissioning – with people with learning disabilities and autism, their families and their local authorities
• Only invest public money and commission services from agencies which are owned by accountable individuals i.e. not opaque corporate bodies
• Ensure that a service’s Statement of Purpose cites “positive behaviour support” and that this is reviewed by the Care Quality Commission
• Cease to believe that (i) compliance with minimum standards results in a safe and valued support service which requires neither monitoring nor evaluation and (ii) that professionals know everything

Margaret Flynn, contributor and note taker, November 2012

Positive Behaviour Support – Thoughts In The Light of Winterbourne View SCR

There is no doubt that the lives of Winterbourne View Hospital patients were undercut by terrible treatment which resulted in them feeling blamed and abandoned and being physically harmed. It appears that an excessive emphasis on people’s labels and perplexing behaviour has taken us too far from making sense of their biographies and the complexity of their lives – and from the basics of caring about them and attending closely to their needs and caring for them with capability, respect and compassion.

The Serious Case Review relied on a BBC broadcast of May 2011, information from the hospital’s ex-patients and their relatives and information from a range of agencies, including Castlebeck Ltd, which owned Winterbourne View Hospital. These thoughts rely solely on what we have learned about the circumstances of adults with learning disabilities and autism who have been placed in hospital settings offering “assessment and treatment.” We believe that the practice of physical restraint at Winterbourne View Hospital is a bracing indictment of inadequate management (remote and long distance) and inattentive commissioning.

We suggest that five sets of observations clear a path to viewing the circumstances of adults with learning disabilities and autism in secure settings. We believe that they point to the necessity of developing very different service responses. We begin with a single tragedy:

1. During July 2006, Derek Lovegrove died as he was being restrained. He was a blind and deaf patient with learning disabilities at Cedar Vale Hospital. The Deputy Coroner observed that “…the system was there, the policy, the care plan – but no one seemed to check that it was followed.” Cedar Vale Hospital was owned by Castlebeck Ltd. After the Inquest they stated, “We will take time to fully consider the proceedings of this past week to ensure that any lessons which must be learnt are learnt and acted upon.” Five years before the exposure of the violence associated with restraint at Winterbourne View Hospital, Castlebeck Ltd could have led the way and distanced themselves, and perhaps other services, from the practices associated with Derek Lovegrove’s death. However, during 2009, Castlebeck still had not learned the lessons. A Heathcare Commission visit found shortcomings in Cedar Vale Hospital’s management of serious incidents and patient restraint. The sequel to the BBC Panorama’s expose of May 2011 was broadcast in October 2012. This gave coverage to a recording of a Castlebeck Ltd employee training Winterbourne View Hospital staff in methods of physical restraint. He recalled an occasion when instead of restraining a patient, he “kicked him in the bollocks.” The programme advised that this trainer had been “suspended some weeks ago.” Thus the “learning the lessons” claim apparently did not impact on either the training or practice of harmful means of physically restraining adults with learning disabilities and autism. Heartlessness and amnesia appear to go hand in hand.

2. All policies concerning physical restraint emphasise that it should be the “last resort response.” Castlebeck Ltd’s own policy concerning physical restraint was no exception and yet it bore no resemblance to the practice filmed by an undercover journalist. It was the first line response. We came across no examples of physical restraint being the intervention of last resort. The practice of wrestling patients to the floor and lying across them occurred on a daily and routine basis and yet was not identified as constituting abuse by any professional. Chance determined that there were no tragedies at Winterbourne View Hospital given the filmed evidence of restraint practices and those promoted by Castlebeck Ltd’s own trainer. Records attested to the excessive and harmful use of restraints which involved wrestling adults with learning disabilities and autism to the floor and immobilising them with bodies and objects. These incurred physical pain and injuries, some of which required the attentions of Accident and Emergency services. Even patients who were naked or partially clothed were physically restrained on the floor by staff. It does not appear that exceptions were made for patients whose early lives had been compromised by sexual assaults. Neither was any attention paid to patients’ care plans. As an NHS commissioner observed, “…it is…documented that a mask was used on two occasions. This approach is not written in care plans as being agreed to.”

3. Restraints as practiced at Winterbourne View were pre-emptive. Staff physically overwhelmed patients using whatever means they wanted. Patients were ill-served by their imprecise label of “challenging behaviour.” Staff responded to patients as if self defence was their principal priority.

4. The volume of physical restraints which wrestled patients to the floor and held them there – sometimes for many hours – were under-reported by hospital staff and described in records in fictional terms. Inadequate as these records were, no one took any notice of them. Oblique references to patients “having an unsettled day” and “re-directing patients” were euphemisms for unknown numbers of staff pinning patients onto the floor.

5. It appears that adults with learning disabilities and autism who are patients in hospitals, assessment and treatment and secure services are outwith the protection of legislation. During 2009, it was with some prescience that a Public Protection Unit investigator urged Winterbourne View Hospital to install CCTV cameras. The investigator noted that in view of two incidents, “in which two service users had their teeth knocked out by carers during a restraint situation, both patients appear to have been punched in the face…restraint is usually carried out by two or more people so any allegation of improper or criminal conduct is countered by two people’s word against the victim – the victim always unlikely to make a good witness in a criminal prosecution…no doubt something your staff are aware of…” After the initial Panorama broadcast, staff emphatically denied all allegations made by Winterbourne View Hospital patients which were not captured on film – and even those which were filmed were described by the staff concerned as “horse play…play-fighting…sparring…boxing games…playing.” Accordingly, the Crown Prosecution Service relied solely on film footage provided by the BBC. The Serious Case Review confirmed that Winterbourne View Hospital patients lacked any means of asserting or protecting their rights. They were scandalously silenced.

These findings buttress our concern that adults with learning disabilities and autism have been disproportionately disadvantaged in secure service settings where they may be subject to violence on an unknown scale. Winterbourne View Hospital has taught us about the arbitrariness of cruelty under the guise of restraint and the lamentable lack of interest of all professionals, most particularly Castlebeck Ltd and the commissioners of this service, in ensuring that patients were protected and safe. Such stark findings led us to conclude that there is no place for the practice of getting adults with learning disabilities onto the ground and pinning them there. This form of restraint, as imposed on adults with learning disabilities and autism, in these settings, should not be countenanced.

Margaret Flynn and Vic Citarella