Cameras in Care Homes – Mixed Views in the Profession

Cameras in Care Homes – Mixed Views in the Profession, according to Andy Merker, Vic Citarella and Janti Champaneri

Last week, The Times told us that research into use of cameras to protect people in care homes had found the following proportion of stakeholders are in favour of their adoption:

• 90% of families with relatives in care

• 66% of staff

• But less than 50% of residents

The research, conducted by care home provider HC-One, came in the wake of CQC’s announcement that it is to issue a public information sheet for families and companies who want to film inside care homes.

Then, later in the week, respected commentator Roy Lilley wrote this in his blog: The CQC\’s Andrea Sutcliffe, inspector of care homes, is savvy enough to know she can\’t deliver 24-7 safe care for your Granny. She\’s given up and given permission for StreetWise relatives to sort it out themselves. She\’s handed her job to the relatives.

There\’s guidance on the way that StreetWise relatives neither want nor will be bothered about. It is a bureaucrat’s answer to a burgeoning problem that StreetWise families will sort out for themselves.

Roy’s conclusion is well worth including here:

If the law required CCTV in every care home, with the memory device only accessible by the client or family, we could make Andrea redundant tomorrow – and knowing her as I do [I am sure] she wouldn\’t mind at all.

The terms of the CCTV debate

A couple of days after all this I met with Andy and Janti to discuss the promotion of the embryonic Social Care Support Network at the Lahore Fort restaurant in Sparkhill, Birmingham (a venue chosen as we are thinking of hosting a Social Care Curry Club meeting as a way of giving the network some impetus).

Over a great buffet (a bargain at £9.95) inevitably, bellies perhaps slightly bulging, our conversation turned to this whole ‘cameras in care homes’ debate. And I have to say that in some respects it doesn’t matter what we concluded as the important thing was we debated the issues with as much relish as we tackled the buffet. Still, this is what we agreed:

We recollected that the Social Care Association had written a Parliamentary Briefing on the subject of care home CCTV in the late 1980s. Nostalgia then kicked in about the heyday, from our perspective, of professional debate. The policy, in the written piece, had been shaped in the cauldron of meetings, in actual formal debate and with postal interchange of comments.

Moving on, we thought the position emerging was a damning indictment upon CQC – and perhaps the regulator needs to look at what it is they are really measuring in terms of quality services. For those on the front line, the difficulty about good quality care is that it is what occurs at the interface between the carer and the service user. Frequently, this interaction involves deeply personal activities and/or issues for which we would usually require the utmost privacy/confidentiality. So ironically with most cameras in care homes currently sited in public areas few actually abusive interactions are captured – as perpetrators present themselves as all sweetness and light in such areas of the home.

Atrocities

Another aspect we discussed: the strength of the request for this kind of surveillance does not seem to be reflected quite so much by service users, in comparison to their relatives. And perhaps this is the more worrying aspect – the way in which social care has failed spectacularly to provide a guarantee of safe care sufficiently strong to secure the confidence of relatives.

The reality is that for most service users, support workers need to become involved in these intimate moments, and the difficulty is that abusers can use this mask of privacy to hide what they are doing. So atrocities can (and do) occur. And, of course, there is always the issue of the blind spots that cameras cannot see – which determined abusers will quickly work out.

Furthermore, it is not just deliberate criminal abuse that must be eradicated but any and all offences against dignity and respect – the insidious neglect that characterises poor social care practice. Here cameras could be a conscience, a training aid, a form of communication, as well as a reassurance to relatives that their concerns are either unfounded or are being properly addressed.

CCTV becoming ubiquitous in care settings may ultimately be the way that things may need to go.

However, the challenge has to be in what circumstances the tapes/disks would be accessible and in what ways would these tapes/disks be safeguarded from unauthorised viewing? Over our excellent repast we agreed that the kind of double key security one finds in safe boxes in hotels — with one held by the hotel, the other held by the guest — may be one way of ensuring controlled access. Perhaps CQC should be present when such tapes are viewed?

But there are definite thorny issues about the service user, and indeed the worker, giving informed consent. It is possible we will have a scenario where the camera comes to replace the call-bell, in itself a source of discontent in many care homes. Residents and workers will work out together why cameras are useful, what concerns they address and how they enhance personal and safe care. In dialogue with relatives they will then utilise them accordingly; we agreed that is a convincing scenario.

On our way out of the restaurant, we briefly turned to domiciliary care – surely we can have whatever cameras we want in our own houses, can’t we? Would the safeguards need to be different in these settings? Are there any guidelines that we could pinch from the experiences of Big Brother? (Perhaps more of the Channel 4 reality TV version rather than Orwell’s nightmare vision?)

In any case, we think this is a significant and professional topic for debate. We also believe that this issue does need to be actively considered by practitioners, as well as residents and their relatives, to develop a beneficial and safe way forward.

Saying farewell to the patron of the Lahore Fort we queried whether there might just be an upstairs room for a social care practitioners meeting prior to partaking of a buffet. A professional network facilitated discussion followed by all the curry you can eat, including pudding, seemed to us an offer practitioners simply couldn’t refuse.

Toothpaste, Vinyl versus Latex and ‘DNACPR’

Helping out at a home owners and registered managers’ event recently I noticed three interesting topics were animating discussions.

One: toothpaste as a hazardous substance. This started off as a tale told to emphasise another ludicrous CQC inspector going over the top— until somebody posed a personal care scenario where toothpaste could really be potentially harmful. It is worth weighing the benefit of toothpaste to basic dental hygiene against the possible dangers to eyes from misuse, we learned.

Next: the relative merits of latex and vinyl gloves was in terms of practicality versus cost discussion. It centred on a contractual requirement to use only latex. Apparently both makes of gloves meet the same standards for infection control purposes. So, if this is the case, why the insistence on latex given vinyl is half the price? We speculated on the added sensitivity to touch of the latex and contractor ignorance of how and when gloves are used. However according to one home owner there were potential savings of £1,000 per year – and it’s a matter of personalised practice for another?

Three of three: DNACPR stands for ‘do not attempt cardio-pulmonary resuscitation’, which came up discussing the 5 key questions CQC will ask of registered social care services. In true workshop fashion, the questions were allocated around tables for discussion, and the table that had: Are they responsive? came up with a really helpful description of how the practitioners in their care home respond to situations when possible resuscitation may be a matter of choice – and may be potentially more harmful than beneficial. Clearly, caring and common-sense make it not only responsive to the resident and their relatives but importantly professional. On a personal level it gave me useful information that I could have done with several months ago, when my father was terminally ill.

So what did these three vignettes teach us at this event – besides, that is, the subject matter of the day (the Care Act and CQC Fresh Start)? We learned that it is often the little things, the details, which make the biggest differences in people’s life — indeed, they are often the crucial difference between harm and benefit.

CQC – A New Start

Janet Pearson, CPEA Director attends a consultation meeting: CQC – A new start

CQC has been re-invented, with the aim of being a strong independent regulator on the side of the people who use services. It’s moving away from the previous pass/fail approach to one of helping services to improve, ensuring that they are safe, effective, caring, responsive to people’s needs and well led. Sir Mike Richards is Chief Inspector for hospitals and Andrea Sutcliffe was appointed for social care recently, while a third Chief Inspector for general practice will also be appointed.

CQC has been consulting on how it inspects the NHS and independent acute hospitals and as a result anticipates new legal powers to award ratings for hospitals and re-introduce them for social care. The reformed regulator’s new approach to regulation will therefore be based on:

• Registration – a more rigorous test with named accountable leaders

• Surveillance – continuous monitoring to identify failures and risk of failure using local and national information sources and qualitative information from people(hopefully including Healthwatch)

• Expert inspection teams, with longer inspections for hospitals possibly spending 5 days on site rather than the current 1 day format and more time talking to people

• Simple clear standards based on three levels – the fundamentals of care, expected standards and high quality care

• Ratings to help people choose between services – outstanding, good, requires improvement and inadequate

In terms of the new legislation, the new regulations become law in April 2014 and changes to inspections for adult social care, mental health and learning disability services, including ratings will commence in 2014 – 2015 (and 2015 – 2016 for community health care and ambulance trusts). Inspections of acute hospitals are commencing ahead of the legislation and 10 trusts have already been identified for early inspections.

The model of three levels of care will apply to all services though specific expected standards will be drawn up for different service areas when the Chief Inspectors are in post. At this stage CQC are consulting on the suggested Fundamentals of care – based on the Francis Review of Mid Staffs NHS Trust:

1. I will be cared for in a clean environment

2. I will be protected from abuse and discrimination

3. I will be protected from harm during my care and treatment

4. I will be given pain relief or other prescribed medication when I need it

5. When I am discharged my ongoing care will have been organised properly first

6. I will be helped to use the toilet and to wash when I need it

7. I will be given enough food and drink and helped to eat and drink if I need it

8. If I complain about my care, I will be listened to and not victimised as a result

9. I will not be held against my will, coerced or denied care and treatment without my consent or the proper legal authority.

The fundamentals read as a ‘bill of human rights,’ however missing in many people’s eyes is the key point of person centred approaches, of people being treated with dignity and respect and working in partnership with professionals to co-determine treatment and support plans.

At the consultation strong views were expressed about obvious omissions of user and carer involvement and that the focus of questions was not right. The audience was not confident that CQC is really listening. CQC was however interested in opinions regarding the length and frequency of hospital inspections and whether these should be announced or unannounced.

The new ratings will be based upon standards found at inspections.

The three levels are represented in the diagram below.

More details on the consultation can be found in the CQC report – A new start. www.cqc.org.uk/inspectionchanges

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

Let Me Know

Whatever your question the answer is the workforce. A turn of phrase oft used by the former Chief Executive of the, already lamented, Children’s Workforce Development Council gives rise to a few questions of my own.

Question: How will a 25% saving be made on social care budgets that are 80% spent on workforce costs?

Question: When policymakers say we must focus on early intervention and prevention what do they actually mean in practice?

Question: Do personalised services imply a personalised workforce?

Question: Is safeguarding becoming ‘job creation’?

Question: Why is what should be safest service (residential care) the most regulated and that which poses most potentially harmful risks (privately employed personal care arrangements)the least regulated?

Question: Should compliance inspectors at CQC and their opposite numbers at OFSTED rejoin the social care workforce?

Question: What is going on with the College of Social Work?

Any questions? There remain plenty of organisations to address them – too many some say – but sadly not one with a specific set of answers around integrated children’s services.

One thing that is certain is that, thanks to the National Minimum Dataset, we now know more about the social care workforce than ever before. Surely it is time to start using that data to start answering a few questions and stop the often devastating swings of the pendulum that see workforce initiatives follow scandals and crises – only to wither away during times of ‘other’ priorities.

The social care workforce has enough inbuilt dichotomies and paradoxes of its own – paid/unpaid, regulated/unregulated, professional/vocational, relationship/task, adults/children even life and death – to have to deal with the us and them of politics. The sooner policy makers really permit a sector-led approach to answering the workforce questions the sooner we will all secure improved benefit from the 2 million plus people working to care and support adults and children in the UK.

Guest Blog from John Burton at The Association of Care Managers: In Defiance of Compliance

A care home that is run simply to be “compliant” is unlikely to be a good place in which to live or work. Compliance is alien to the ethos, principles and good practice of the social care profession and residential social work 

 

Compliance, the principal tool of measurement used by the Care Quality Commission, has no place or validity in the life and work of a care home. It is a negative and submissive concept. Nothing ever grew and developed, no initiative, no advance was ever made by compliance. Compliance is static and change is dynamic. The notion of compliance could only be of use to check important but secondary technical services to the home, and such checks should be made by suitably qualified and experienced technicians. For example, the lift must be properly maintained, medication managed well and accounted for, and food stored and prepared safely, but such compliance is not the primary purpose of a care home. 

 

Those of us who were trained and qualified as residential workers or residential social workers – trained to practise, manage and lead – received a thorough grounding in such areas as human growth and development, loss and change, social psychology, group processes, community and institutionalisation, leadership, ethics, ageing and society, social work methods, social policy, counselling, dependency and power relationships, family and individual therapy, etc. etc. We were encouraged to enquire, to challenge, explore, and debate ideas. We thought, read, and argued. We were not taught “compliance”. Courses differed and, of course some were better than others, but I very much doubt if any residential social work course ever mentioned “compliance”.

 

No, I’m wrong. In the early 70s, when I did my qualifying training, the word compliance described a worrying aspect of, for example, a child whose infancy and early years had compelled them to keep their heads down and to find a way of surviving the hostile and persecutory world around them. These days, we might take compliance in an eighty-year-old resident of a care home to indicate that they may be being abused, bullied or medicated, and they had attempted to avoid further pain and humiliation by withdrawing into themselves and being “quiet”, compliant and unnoticed. “No trouble.”

 

“The creativity that we are studying belongs to the approach of the individual to external reality . . . Contrasted with this is a relationship with external reality which is one of compliance, the world and its details being recognised but only as something to be fitted in with or demanding adaptation. . . in a tantalising way many individuals have experienced just enough of creative living to recognise that for most of the their time they are living uncreatively, as if caught up in the creativity of someone else, or of a machine.” D.W.Winnicott, Playing and Reality.

 

Care homes are caught up in what the machine of CQC has created – compliance. We will break free of the constraints of compliance only if we start acting like professionals and leaders of our care communities. We must stop acting like quiet, frightened, compliant children, anxious to please by fitting in with the rules and restrictions imposed on us. We must grow up, join forces in taking responsibility for our own profession, and lead the development of care homes as highly valued local centres of care and support.

 

Over ten years, the national regulators have turned social care upside-down. Instead of the needs of users instigating the form and operation of care services, and those services, led by the registered managers, being designed and managed at a local level to meet those needs, the regulators have imposed their misinformed and blinkered design for care. This top-down approach has in turn spawned a new layer of quality-assurance, management and consultancy which is now seen as essential to prove to the regulators that providers are compliant. And this self-perpetuating arrangement flourishes alongside the cosy pretence of personalisation. Compliance-centred is the very opposite of “person-centred” care.

 

It seems extraordinary that while those at the head of this appallingly wasteful and dysfunctional system have had the advantages of sophisticated management training and mentoring, they seem incapable of understanding their part in it.

 

According to Paul Hoggett (University of the West of England), social work/social care professionals need the capacity . . .

• to tolerate and contain uncertainty, ambiguity and complexity without resorting to simplistic splitting into good/bad, black/white, us/them, etc.
• for self-authorisation, that is, the capacity to find the courage to act in situations where there is no obvious right thing to do
• for reflexivity, that is, to take oneself as an object of inquiry and curiosity and hence to be able to suspend belief about oneself; all this as a way of sustaining a critical approach to oneself, one’s values and beliefs, one’s strengths and weaknesses, the nature of one’s power and authority, and so on
• to contain emotions such as anger, resentment, hope and cynicism without suppressing them and hence to be both passionate and thoughtful. 

What do we think Tom Kitwood would have made of this compliance culture? Would it not fit perfectly with his description of a “malignant social psychology”? Is it not understood at any high level in Government, Department of Health or CQC that the malignant effect of compliance does not merely “filter” softly down to the way residents in care homes are treated, it is – albeit unwittingly – aimed directly at them and blights their lives.  

 

When senior members of CQC are cornered, and when they cannot bully their way out of the corner, they resort to the excuse that they have no choice and are merely following the orders given them by government but are short of resources, and “give us time – we’re a young organisation”. Such excuses are a betrayal of professional ethics.  

 

As social care professionals and leaders, registered managers must take their cue from their own professional standards. We must support each other, learn from each other, and always put our clients first.  

 

John Burton, ACM

johnb225@btinternet.com