Adult Care Blog

Social care apprenticeships in action

2012-02-10T14:31:49Z

It may have passed you by but we are just coming to the end of Apprenticeships. Workforce development body Skills for Care has reported that 40,000 new apprenticeships were started in social care last year. It has produced a useful guide to apprenticeships, with information for employers and potential apprentices.
But if you don't want to read through all of that here are a couple of videos of apprenticeships in action in social care, courtesy of learning disability provider New Boundaries and the Field House care home in Shropshire. More videos are available from Skills for Care.

Mental Capacity Act medical consent queries answered

2012-02-10T11:34:42Z

Mental Capacity Act - Agony Aunt (mp3)

The above comes courtesy of the Social Care Institute for Excellence and captures its Mental Capacity Act expert Rachel Griffiths talking about one of the main issues that comes up in her work helping providers implement the Act: whether staff can sign medical treatment consent forms on behalf of service users.
I presume you all know the answer but have a listen if not. Here's the advice in written form.

Winterbourne View care staff plead guilty to abuse

2012-02-09T13:45:48Z

Three Winterbourne View care workers today pleaded guilty to the ill-treatment of residents at the now closed learning disability hospital in Bristol, reports the BBC.
Wayne Rogers, 31, Alison Dove, 24 and Holly Draper, 22, pleaded guilty to nine, seven and two counts of ill-treatment under (I think) the Mental Capacity Act at Bristol Crown Court today.

This is not the end of the road. The three are due to be sentenced on 16 March and eight further defendants are due to be dealt with next month as well.

Share your positive stories of personalisation in mental health

2012-02-09T10:21:51Z

Mental health has always been one of personalisation's "problem areas", with risk aversion and the health-social care funding divide resulting in low take-up of personal budgets.
Well, a King's College London research project has been launched to see how this picture can be changed and it is now looking for examples of good practice of personalisation in mental health. This blog post from KCL social work lecturer Martin Webber gives the lowdown on how and what to share.

This initial phase of research will lead to a "gold standard" for personalised care in mental health, which will be shared on a website.
This all sounds like a really great project that could hopefully help social workers in mental health move forward with personalisation.

Nice video shows user and carer leadership in action

2012-02-09T10:07:19Z

This video may cheer you up if you have a spare few minutes - it collects some short clips of carers, parents of disabled children and service users talking about things they have achieved in their communities off the back of In Control Partners in Policymaking courses. These provide training in support planning, influencing policy and organising support groups for users and carers locally, among other things.

How social workers can narrow inequalities in death

2012-02-09T09:38:08Z

A report this week revealed that people in more deprived areas are more likely to die in hospital than those from more affluent places.

In this guest blog, National End of Life Care Programme social care lead Tes Smith argues that social workers have a key role to play in narrowing these inequalities in death.

Fairness is much in the news at present, not least in the shape of the stubborn gap between rich and poor. As in life, so in death it seems. This week, the National End of Life Care Intelligence Network identified that people living in deprived areas are 7% more likely to die in hospital than those residing in the most affluent areas.

Surveys consistently show that most of us would prefer to die at home or in another community setting, such as a hospice, rather than hospital. Reducing the percentage of deaths that take place in hospital is a key objective of the Department of Health's national end-of-life care strategy.

A small fraction of the gap identified in this week's report - one seventh - can be accounted for by differences in factors such as the cause of death and life expectancy. Individuals affected by some conditions that affect more people in deprived areas, for example chronic obstructive pulmonary disorder, sometimes prefer to be cared for in their final days and hours in hospital.

However the report does raise issues around equity of access to housing and care services that allow people to exercise choice over where they are cared for and, ultimately, where they die. Social care professionals can do something about that.

Social worker role

Yes, death might come after months or even years of high tech medical interventions - whether pharmacological, surgical or technological. However, social care services often have regular contact over a long period with an individual as they become more frail - and with their family or informal carers.

We can liaise with services such as housing and occupational therapy to ensure the individual's home is both decent and equipped with any aides and adaptations needed to support them in their final days, weeks or months.

More powerfully however, we can support individuals nearing the end of life and their carers so they can access the services that will allow them to die at home or in a hospice if that is their wish. This can involve putting in place a package ranging from transport services to specialist pain relief services and community nursing.

With our assessment, communication, co-ordination and care planning skills we should be working with health colleagues in hospitals and the community. We can advocate on behalf of clients who might lack either the verbal skills or self-confidence to effectively pursue such care packages themselves and co-ordinate the delivery of services. With ethnic minorities over-represented amongst the most deprived in our community, there might be language barriers that we can help overcome.

Sharp elbows

The broader social care profession should be working with specialist palliative care social workers in hospices and hospitals to champion the interests of those whose voice might otherwise be lost.

When asked why he thought his new National Health Service would survive, Nye Bevan is said to have replied that the 'sharp elbows of the middle classes' would make quite sure they and their families had access to high quality free healthcare.

Perhaps it is part of the social care professional's role to play the sharp elbows of those less able to voice their wishes and preferences for care in this age of choice. Care provision at the end of life might be a good place to start.

The cost of separating mental and physical healthcare

2012-02-09T00:00:06Z

There's an interesting report out today from the King's Fund about the costs (to patients and the NHS) of treating physical and mental health problems separately given the large number of people with long-term conditions who also have mental illnesses.

It finds 46% of people with mental health problems have a long-term condition and 30% of people with a long-term condition have a mental health problem, amounting to 4.6m people.

However, the report says: "A separation of mental and physical health is hard-wired into institutional arrangements, payment systems and professional training curricula. As a result, co-morbid mental health problems commonly go undetected among people with long-term conditions, and where problems are detected the support provided is often not effectively linked or co-ordinated with care provided for physical problems."

The result is poorer patient outcomes and significant cost to the NHS and the wider economy. What's worse is that people with these co-morbidities are disproportionately found in deprived areas, where they lack access to services and resources.

The report has some interesting ideas for bridging the gap:

Greater involvement of mental health specialists in primary care.
Much greater investment in liaison psychiatry services in acute hospitals to identify people with mental health problems.
Training for physical healthcare staff in basic mental healthcare.

There is less about the role of social care professionals in this report, beyond stating that they have a role to play, particularly in relation to people with dementia and long-term conditions.

It would be good for this to be fleshed out as social workers and other care professionals have a crucial role in identifying people with co-morbidities, taking a holistic view of their condition and co-ordinating their support. Hopefully, this is something that can be addressed.

We all want to liberate adult social work - but how can we do it?

2012-02-06T12:38:29Z

On Friday, The College of Social Work held a summit on the future of adult social work attended by senior managers, civil servants, academics, social work representatives, users and frontline practitioners.

There was a remarkable degree of consensus about what needed to happen: practitioners needed to be liberated from bureaucracy, rationing and risk aversion to exercise professional judgement to better support service users.

But there was less clarity about how we should get to this point.

No Munro review for adult social work

Children's social work has had its own inquiry - the Munro review - to address the self-same issues of bureaucracy and the erosion of professional judgement. But no such review is in the pipeline for adult social work.

The College is keen to influence the forthcoming White Paper on adult social care in a more social work-friendly direction. And the signs on this front are good.

Care services minister Paul Burstow said last week that social work would be at the heart of the paper, with an emphasis on community development, not care management. His message was echoed at Friday's summit by DH official Glen Mason but there was no more detail on what the White Paper would say.

No reserved tasks for social workers

Indeed, Mason was clearer on what the White Paper would not say: that there would be no legislation to establish specific roles and tasks that only social workers can do. This was in response to one summit attendee who felt that such provisions would help carve out a status for adult social work, drawing on the experience of statutory child protection work in raising status.

This means that, whatever the White Paper says about social work, it will be up to individual organisations - particularly local authorities - to put this into practice.
Mason said he felt that most directors of adult social services understood the importance of social work.

However, some in the audience did not share his optimism, particularly in relation to directors who did not have a social work background.

(Image from Rex Features)
]]> Do directors and local authorities support social work?

Indeed, Adi Cooper, the director at Sutton Council, said that the fact that she was a social worker had been helpful in enabling her to champion the profession in her local authority, including through annual professional conferences and a pilot in community social work.

And, she said candidly, social workers are expensive, when compared with non-qualified workers. They need to prove their value for money to directors who are having to maintain levels of adult social care in the face of massive cuts from government.

She is clear that they are value for money, but other directors may draw a different conclusion. Moreover, as social work consultant Vic Citarella told the summit, there is a lack of clear evidence that social work input leads to improved outcomes for service users, particularly in relation to older people.

Management problems

Also, if directors are signed up to a positive vision of adult social work, why are many of the current barriers to this vision problems of local authority management?

This situation has led many to look outside local authorities for sources of liberation. The time when the summit most came alive was when we heard from two of the social work practice pilots, which are delivering social work for adults at arms-length from their respective councils.

Do social work practices offer liberation?

Naomi Mungroo, of the First Point practice in Surrey for deaf and hard of hearing clients, explained how her practice had been freed up through being outside the local authority.

For instance, one client of hers was placed out of county and visiting them involved a day out of the office. Now Mungroo is communicating with this client through Skpye every two weeks, something that would not have been permitted when she was directly employed by the council.

Not only was the management chain far shorter at First Point, she said, but there was real accountability to service users, who sat on the practice's non-executive board.

"If you have people attending your meetings and they want something done, two months later they will say, 'where is it?'," said Mungroo.

What service users want

This point chimed with the messages of two presentations from service user leaders, Sue Bott of Disability Rights UK and Peter Beresford of Shaping Our Lives.

Bott said that focus groups that she had conducted with service users had identified a number of qualities they wanted to see in social workers: respect, honesty, reliability, the ability to treat the service user as an equal and life experience.

Significantly, they also wanted social workers to stand up for them and not to be part of the system, which Bott suggested might be best offered outside of the local authority, including through practices.

However, there are only seven social work practice pilots and they are yet to be evaluated; as Cooper pointed out, liberating social work will need to take place within local authorities if it is to succeed.

Moreover, some unions see them as a backdoor to the privatisation of social work with adults and a recipe for eroding the terms and conditions of practitioners.

Personalisation and social work

And what of personalisation? As Community Care and Unison's annual survey on personalisation found last year, the implementation of self-directed support in several areas is adding to the bureaucracy that social workers face in their working lives, while failing to deliver promised choice and control to service users.

The College has already expressed its misgivings about the issue. Reversing this trend across local authorities will be critical to ensuring the vision articulated at the summit is realised.

But this will involve those charged with taking forward personalisation in England - notably the Think Local Act Personal (TLAP) coalition - and social work representatives (including the College) agreeing on what practitioners' role should be if service users are to truly direct their own support.

TLAP programme director Martin Routledge had a go at this in a blog post last week, which argued that while some people would not need social work input to direct their own support, others - those in crisis or lacking in capacity - would need significant support for qualified professionals to make personalisation work.

Do social workers want to be liberated?

Adi Cooper raised one further challenge. While most social workers are hungry to be liberated, some may not be able or willing to escape the strictures of care management to exercise their professional judgement in an autonomous fashion, she said.

The erosion of social work skills that has been attributed to care management cannot simply be reversed by an injection of autonomy.

Glass half-full or half-empty

But perhaps we should take a glass half-full approach on this.

After all, there does seem to be some commitment to changing adult social work for the better from government; we have a new champion for this part of the profession in The College (while the British Association of Social Workers continues to bang the drum for adult social workers); and most other parties can coalesce around the vision of a liberated profession, working positively alongside service users to enhance their independence and well-being.

Let's hope all can come together to make this vision a practical reality.

(Image on Flickr from Pimlico Badger)

Sector-led scrutiny in adult care: where's the transparency?

2012-02-06T11:57:01Z

Since care services minister Paul Burstow scrapped annual assessments of council adult social services in November 2010, performance management of councils in this area has rather disappeared without trace at a national level.

It's not that it isn't happening: we have a Promoting Excellence in Councils' Adult Social Care Board, whose role is to keep track of performance in all councils and work with authorities to drive improvement. It embodies "sector-led improvement" (i.e. local authorities taking responsibility collectively for improved performance) and includes representatives from the Local Government Association, Association of Directors of Adult Social Services, the Care Quality Commission and the Social Care Institute for Excellence.

But while there is a short paragraph on the board on the LGA website, you'd be hard-pressed to find out much about its work online.

This is in stark contrast to the previous system in which the Care Quality Commission produced an annual report on local government performance in adult social care, with separate reports and performance scores for each council.

The sad thing is that sector-led improvement work is happening. The LGA is conducting peer reviews of councils, where people from within local government go and assess performance in an authority, and there is more targeted support for councils that have been previously deemed to be falling short.

But finding information on progress and the outcomes of peer reviews is next to impossible (well, I've found it next to impossible). Again, this would not have been the case in respect of inspection reports when we had a national system of annual assessment.

At a local level, councils are supposed to be producing local accounts of their performance to provide citizens with a means of scrutinising what is going on. Here are a few that have been published for 2010-11 - Stockport, Hackney, Rotherham - to give you a flavour.
In all cases of published local accounts, I have no doubt, there has been a transparent process locally, where the report has been published prominently, scrutinised by backbench councillors and had input or a critique from the user-led local involvement network.

However, what we don't know is whether all councils have published such a report, or whether any independent judgement has been reached on their quality i.e. the extent to which they involve a genuine self-assessment, rather than a public relations exercise.

I'm not calling for a return to national assessment of council adult social services by the independent regulator. Well, not necessarily. I just think that the system of sector-led assessment needs to prove itself to be something other than a way of making performance assessment cheaper. And for that, we need much more transparency, nationally.

Disabled face hostile climate in wake of benefits assault

2012-02-06T11:50:03Z

Charities are warning that disabled people are facing abuse on the streets and accused of faking their conditions due to the government's cuts to benefits for the group, reports The Guardian.
Some are declining to use disabled parking bays lest they accused of not being worthwhile recipients of support for their impairment, with people with less visible disabilities at particular risk of abuse.

Here's a reminder of those cuts to benefits and services for disabled people (though one of the 10 listed here - the cut to mobility benefits for people in residential care - has been dropped), illustrating just how stark they are. The government has an opportunity to make concessions after a number of its benefit cuts, in the Welfare Reform Bill, were overturned by the House of Lords; however, ministers just reimposed the cuts in the House of Commons.

And there seems to be no let-up to the twin narratives that there are many thousands of people claiming or applying for sickness benefits who should be looking for work, and that disability living allowance is just too expensive and going to people who aren't really that disabled.

However, the disability movement has been fighting back with a vigorous campaign, illustrating the difference these benefits make to people's lives and the genuine need of claimants. For those of you with a bit of time on your hands, here's a recent dispatch from that campaign: an e-book written by leading campaigners against both the Coalition's reforms to welfare and those of its Labour predecessor.

(Image on Flickr from Byzantine_K and taken from Disabled People Against Cuts poster)

Does David Cameron understand the CQC's role?

2012-02-02T16:32:18Z

Totally missed this but a thoroughly damning report was published last month into adult social services at Wirral Council.

It was into the events surrounding the council's overcharging of several learning disabled service users, which was exposed by social worker Martin Morton, who was later forced to resign.

I've stuck a bit more on the report at the bottom of this post, but the man on my left was quizzed about it at prime minister's questions yesterday by Wirral West MP Esther McVey.

Cameron accepted McVey's call to look into the report (or, rather, to get care services minister Paul Burstow to do so).

But what's interesting is what he went on to say about the Care Quality Commission:

"The Care Quality Commission, which has had a difficult birth, clearly has a really important job to do in ensuring that its inspections are thorough and targeted in the areas where they are most needed."

The Wirral report concerns a local authority adult social services department's failings. In November 2010, Cameron's government took the decision to end CQC assessments of local authority adult social services departments, replacing it with a sector-led assessment system led by the Local Government Association and the Association of Directors of Adult Social Services, among others.

So while we might all agree that the CQC has an important job to do, it's unlikely to be in ensuring Wirral responds to this report. So the question is, does Cameron know what he's talking about?

Damning CQC inspection

Ironically, Wirral's adult social care failings had been exposed by the CQC before Cameron's government stripped it of these powers, following an inspection in 2010 that found it was performing poorly on safeguarding.

There is an exception to what I've just said, which is if the LGA, Adass and the CQC decide collectively that problems at Wirral Council are so serious - and that sector-led intervention cannot make a sufficient difference - that an emergency CQC inspection is warranted.

But somehow I don't think Cameron was opening the way for such an intervention with his comments. I think he was just a bit loose with his tongue and not very well briefed. (Apologies prime minister if I'm wrong).

]]> Report findings

Klonowski's report identified a series of failings. Here are a few:

"The council has not yet learned how to embed a culture whereby whistle-blowing concerns are investigated in a robust manner without fear of reprisal for the whistle-blower."

"The [report] has set out a large amount of information, which in a number of
instances have highlighted where the actions/lack of action on the part of senior
managers gave her cause for serious concern and need to be reflected upon."

"The failure of the [department of adult social services] during the period covered by this review has put vulnerable adults, who were either supported by transitional housing benefit/supporting people or under the "care" of the providers covered in this report via community care assessments, at greater risk, and to quote Mr Morton made them "pawns" in this whole saga. A totally unacceptable situation that needs to be learned from at member, senior officer and middle manager level."

I could go on.

The important thing is that Wirral has accepted all of the report's recommendations.
Council leader Steve Foulkes has said: "I do not ever want to find the council in the position where staff are penalised for identifying failings or feel unable to speak out, or where the needs and rights of vulnerable people are compromised."

Let's hope so.

I'll let you know if I hear anymore on this story - like what the Department of Health may do and any more dispatches from Wirral (a council meeting is addressing the issue on 13 February).

(Image on Flickr from World Economic Forum)

Have your say on Mental Health Act stats

2012-02-02T11:37:49Z

To state the obvious, there are few more significant statutory interventions than the use of compulsory powers under the Mental Health Act, and one concerning trend in the last couple of years has been the rising use of these powers.

All of this means that how information is collected in relation to the use of these powers is of vital importance, so it's worth putting away any aversion to statistics and responding to a consultation on this topic from the NHS Information Centre.

This is looking at the case for scrapping the existing standalone data collection on Mental Health Act powers (or KP90 to its friends) and instead collecting this information instead through the Mental Health Minimum Dataset (MHMD), which collects a host of other data about the use of specialist mental healthcare.

As I understand it, the key advantages of the change are:-

Better information about the care pathways taken by people detained under the Act or placed on community treatment orders and about how long people are detained. Information on this could help improve the commissioning and design of services in local areas.
Breaking down the use of compulsory powers under the Act by employment status, diagnosis and, crucially, ethnicity, rather than just gender, as the KP90 collection currently does.

So it's worth answering the consultation questionnaire if you get a moment.

Key lessons on mental capacity assessments and best interests decisions

2012-02-01T12:09:41Z

We reported yesterday on calls to enhance guidance and training for professionals on best interests decision making under the Mental Capacity Act, but I thought it would be worth trying to pull out some of the key lessons from the study in question.

About the research

The research seems pretty solid and is based on an online survey, and telephone and face-to-face interviews with social care, health and legal professionals about best interests decisions they have taken under the Act.
It comes courtesy of charity the Mental Health Foundation, which has done a lot of work on how professionals can apply the Act (for example), and two of the country's major research centres into the two key client groups involved, the Norah Fry learning disability centre at Bristol University and the Bradford Dementia Group.

Though its focus was on best interests decisions, many of the most interesting findings relate to assessments of capacity. (Do see our guide on conducting a capacity assessment, which is based on work by the Mental Health Foundation).

Lack of understanding of MCA

A major finding was that the principles of the Mental Capacity Act were not being adhered to in a significant minority of cases. While people should be presumed to possess capacity, not assumed to lack it on the basis of disability, diagnosis or age, and have the right to make unwise decisions, about one-quarter of best interests decisions followed apparently flawed assessments of capacity related to perceived unwise decisions or to someone's disability, age or diagnosis. Though this finding was based on an online survey - and so may not reflect the complexity of cases - these issues remained when researchers probed deeper through interviews.

Impairments dominating assessments

Researchers found in some cases conclusions were drawn about a person's lack of capacity because of their inability to communicate verbally or respond to the presence of other people.
"In all these cases, it seemed that the impairment did dominate, and that practitioners had some difficulty in adhering to the principle of presumption of capacity," said the report.

Lack of capacity based on lack of 'insight'

An assessment that someone lacked capacity was in some cases based on the finding that they lacked 'insight' into their care needs, particularly in relation to people with dementia. So, for instance, if professionals believed that a person would be better off in a care home and the person disagreed, this apparent lack of insight translated into an assessment of incapacity to decide. But the research points out that 'insight' is not a word mentioned in the Mental Capacity Act code of practice and that lack of insight in this sense does not equate to a lack of capacity. In one striking passage, it says: "Whether a person with dementia accepted a particular course of action recommended by professionals (frequently admission to a care home) influenced whether an assessment of capacity was initially undertaken and, in turn, if a finding of capacity was made."

Making best interests decisions

Some interesting findings on this:

Best interests decisions in social care were most frequently carried out through a series of multi-disciplinary team meetings. Typical features of successful practice were good chairing and organisational skills, clarity in defining the decision to be made, and an overriding concern for engaging the client at the centre of the process.
Social care decisions more often related to safeguarding and changes of accommodation, rather than care reviews, direct payments or care planning.
Though best-interests decision makers should consider the person's expressed wishes, feelings and values, the researchers only found a few cases where these had been influential in the decision.
Outcomes for people were not just based on their best interests but on resources and available services. As a result, for instance, temporary admissions to care homes for people with dementia were often made permanent.

Recommendations

The research makes a number of significant recommendations. Here are a few key ones:-

Revising the MCA code of practice to clarify the distinction between a lack of capacity, on the one hand, and unwise decisions and lack of 'insight' on the other.
The code should include case examples that reflect the complexity of the cases experienced by practitioners, as well as examples of successful good practice.
Pro formas for conducting mental capacity assessments and best interests decisions should also be added to the code.
Providers should carry out regular audits of compliance with the MCA by staff.
Care homes should hold weekly reviews of assessments of capacity and best interests decisions.

Hopefully this research should provide a springboard for practice, guidance and training improvements in relation to the MCA. Do have a read.

Philanthropists told: "mental health charities need you"

2012-02-01T00:00:27Z

In these straitened times, effective charities, like their less effective counterparts, are struggling to keep hold of public funding, putting a greater premium on private donors.
But where should philanthropists be putting their money in relation to social care services?

A report out today provides a guide to investing in employment support for people with mental health problems. It comes courtesy of New Philanthropy Capital, which researchers the effectiveness of charities. NPC says this is an area that private donors have neglected in the past, leaving government to take the lead, but says philanthropists have real potential to make a difference.

It looks at the case for investing in four services, providing donors with an idea of which charities are potentially most effective, costs, risks and returns. One service that comes out well, in terms of relatively low risk for high return, is individual placement and support, under which employment advisers are placed in mental health teams to integrate treatment and employment support and service users are, ideally, placed in a job and supported to retain it. (This piece has a bit more about IPS).

However, no charities examined by NPC delivers IPS so may need support to develop the model. Which is where private donors come in. Bill Gates, can you help?

(Image on Flickr from IssacMao)

Update your adult safeguarding knowledge

2012-01-30T13:35:35Z

Just to let you know we've got a conference on safeguarding adults at risk in Birmingham on 21 March.
We ran a similar conference last year in London, which went really well - lots of good debate and interesting insights into issues including latest policy, the role of the Care Quality Commission, serious case reviews, the deprivation of liberty safeguards and managing within constrained budgets.
Be great to see as many of possible of you there.

Anyone interested in serious case reviews specifically may want to also attend our forthcoming conference on SCRs, in London on 29 February. This will look at how to conduct effective SCRs, best ways of learning and disseminating lessons and an introduction to new reviews of domestic violence killings. Do go along.