Why We Need to Support Practitioners In Best Practice In Hospital Discharges

The headlines on hospital discharge make for depressing reading. Prolonged stays in hospital are associated with worse health outcomes and increased care. Ten days of bed-rest in hospital, is the equivalent of 10 years of muscle ageing for people 80+. The numbers of people waiting in hospital for support on discharge have significantly increased over the years with around £820 million a year delayed hospital stays (National Audit Office).

Levels of demand on health and social care services are rising while Adult Social Care departments have had their budgets significantly cut. There is sector wide recognition that more funding is required, and this sense of urgency has permeated government ranks. The system needs more investment but this is not a single fix. Much closer and integrated working between all organisations involved in hospital discharge will help to reduce delays and there have been some excellent initiatives nationally. Many programme managers and project managers have been recruited through Sustainability and Transformation Partnerships and Better Care Fund Plans to identify with senior managers local solutions to the complex issue of hospital discharge.

However, my experience working for many years in this area has been that information on new initiatives and knowledge around best practice in hospital discharge is not always being cascaded down to those directly responsible day to day for supporting hospital discharge, in part because of challenges to release staff from frontline practice. Often those working directly with people have no idea about the vision and plans for better integrated solutions to hospital discharge let alone are invited to be part of the conversations about best practice in hospital discharge.

My experience is that many practitioners are not made aware of some of the pilots and new services set up to support hospital discharge. Indeed, working with Adult Social Care Departments and NHS acute and community organisations over the past few years on hospital discharge it’s clear that many practitioners and their managers are still unaware, for example, of NICE guidelines and recommendations around hospital discharge, reablement and intermediate care and best practice evidenced nationally by organisations such as NHS Improvement, the Kings Fund and the Social Care Institute for Excellence.

A National Audit Office report published in May 2016 stated that “Health and social care providers have made limited progress in adopting recommended good practice”.

Basic good practice recommendations such as starting discharge planning early, identifying blocks to discharge early in the admission and making sure the person is informed and in control are still not consistently adhered to. Often those facilitating discharge are not supported to work together with their community colleagues to ascertain how people were being supported before admission or to ensure they are properly supported on discharge. Far too many assessments and decisions for long term care and whether people will benefit from reablement and rehab, for example, are still being made in an unfamiliar hospital environment despite the push for discharge to assess models.

A couple of weeks ago I was charged with delivering training on recording delayed transfers of care to front line local authority workers. They were clearly very committed and passionate about providing good hospital discharge support. What they wanted was to know about the technical aspects of the legislation, so they could “challenge” their NHS colleagues on numbers of DToCs. What they needed was to understand the impact on health and wellbeing of those people delayed in hospital while they “challenged”. They needed to be empowered to develop closer working relationships with their NHS colleagues both operationally and in understanding each other roles and remits and increasing their knowledge and skills around best practice in integrated working and hospital discharge.

Without staff being supported to develop in line with evidence-based practice, ways of working will remain static with staff from different organisations continuing to practice inconsistently and separately despite the best efforts of the senior managers and project managers to “integrate” services.
Change has to come from the bottom up as well as at a senior operational or strategic level, with health and social care front line workers being given the skills, knowledge and forums to learn together about evidence-based practice in hospital discharge and intermediate care services. Nothing will change otherwise and no matter how much money is invested and how many great initiatives are piloted, and many people will continue to experience poor hospital discharges.

Claire Collins

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Positive Risk Taking – Trish O’Hara

Most of the choices that people make in life naturally involve some element of risk. Avoiding risks altogether can limit life opportunities, and impact negatively on quality of life.  People want choice and control for themselves and safety for those they care for. This is because risk is a concept that tends to have negative connotations, but people take considered risks all the time and gain many positive benefits.

People perceive risk differently, including people who use services, practitioners, and families. This can be difficult for social care practitioners and confusing for individuals and families. Therefore, adopting a balanced approach at a practice level can be a challenge. Balance and proportionality are vital considerations in encouraging responsible decision making.

In our work streams we have been considering:

  • What skills do staff need to properly develop positive risk taking in their practice?
  • How can learning programmes be developed that inspire and motivate practitioners to take a bold approach to positive risk taking?
  • What systems need to be in place to enable a responsive approach to positive risk taking?

Getting out of bed, and all that it entails – getting washed, dressed having breakfast, and taking the bus to work – carries risk. Though, staying in bed could still involve both psychological and physical risks.

Back in the mid 80’s the social care sector often ignored risk assessments.  There were risk assessments in place for health and safety of the building and staff. However, what was lacking was person centred risk assessments to support  the people using our services to positively live their lives.

I recall us supporting  extremely complex individuals to go to Glastonbury music festival.  We did this without a risk assessment, and this was back in the day when you could speak to Martin Eavis directly to get free tickets.   They were the days of ‘try it and see’.

By the late 80’s risk assessments were firmly and quite rightly in place to ensure staff were confident to support people to try new things, and live as full as life as possible.  Managers who would start a sentence ‘Yeah,  let’s try that,  let’s do a risk assessment’ with a smile.  It was as if doing the risk assessment itself was the incentive to make it happen.   Over time, I noticed that the sentiment of risk assessment changed.  The managers started to say, ‘oh no,  you  had better risk assess that’.   It seemed like the idea that risk assessment had become  a way of limiting people. The intention changed. Risk assessment should be used as a tool to support  empowerment, and innovation. It should also be used to listen to  those that need care and support.

Finding time to embark on meaningful co-production,  ensuring the person is an equal partner in the shaping of their services is likely to mean that people will be faced with more choice. Where people are faced with more choice this is likely to lead to options that introduce more risk.

So what is stopping our services effectively undertaking positive risk assessments, what are the barriers?

People perceive risk differently.   For instance,  it you ask nurses what is the main risk for older people in care homes,  they are most likely to say,  falls.  If you ask social workers,  they are likely to be concerned with risks to adequate housing or benefits.  If you ask their family, it is likely to be that they  are concerned that their loved one is treated badly. If you ask the person themselves,  they may be more concerned with losing their identity and/or purpose.  We come to the table with a bias based on role and relationship.

Getting the balance right requires professional competence,  partnership working and understanding that safeguarding is about improving quality of life as much as safety, and can only really work if we keep it personal.

Because risk assessment is considered a skilled endeavour,  we often see managers or team leaders completing the risk assessment from beginning to end from inside of an office,  rather than inside the life of the person.   Key-workers need to be trained to understand risk assessment and be part of the process, as they are often the people who know the person best.

There is also a real fear of being accused of neglect.   Staff also struggle to understand that what may be important FOR the person may be in direct conflict with what is important TO them.   A disproportionate response that infringes the rights of individuals to make their own,  albeit at times,  unwise decisions.   Often there is a lack of a working knowledge of the Mental Capacity Act and what it means to deprive a person of their liberty. A general lack of knowledge when and where to apply the law.

Ultimately,   risk is part of life and arguably the most successful people take many of them.   It is impossible to self actualise without taking risks.  It’s the only way to face the challenge of Everest.    Many of us would make it to the top if we were given the chance to do it at our own pace (maybe years),  using our own methods,  with the right people and with the adaptations required to help us along the way.     We would find our own peak and reflect on our own troughs knowing where we are,  where we have been and where we are going.

We will continue to challenge practice in our work streams, and get practitioners to really believe that positive risk taking is a fundamental core of practice.

Trish O’Hara

 

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Whose Responsibility is It? – Risk Reduction and Dementia (Bartle and Behrens)

Whilst attending a Dementia Partnership Board Meeting (our first in this area) to review their priorities, prevention was discussed. A member raised the point we should determine what we mean by prevention and suggested in some areas the evidence base was weak. The board had a range of stakeholders, and was inclusive and committed to developing meaningful changes. However, within this local authority, like many others, there had been funding cuts to the person responsible for ‘prevention’.  Reducing funding for risk reduction may save funding in the short term, but has long-term implications; possibly higher costs to both health and social care. So, whose responsibility is it to mitigate risk reduction in dementia. The individual, public services or is it everybody?

Three years ago, we developed our first resource: Dementia and Risk Reduction – see below.

It was developed from an excellent document produced by WHO in 2014, highlighting the international priority of risk management in dementia. Since then, our organisation has addressed these priorities through our work streams: training and consultancy and in the development of resources

During this time, we have debated whether to utilize the term ‘risk reduction’ or ‘prevention’ in the messages we give, as these words are sometimes used interchangeably despite having different meanings.

Since we have been highlighting modifiable risk factors on our programmes, our role appears to have evolved from simply being educators in social care to activists in health promotion. Sharing with our participants information for them to share with their clients, and which they may choose to act upon within their own lives.

In July 2017, The Lancet published a long-awaited paper on the ‘Dementia Prevention and Care’ by Gill Livingtone and colleagues (http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(17)31363-6.pdf):  A comprehensive review of the current evidence on modifiable risk factors in dementia care. For anyone working in dementia care this document will prove to be valuable; It is not a paper that you can skim read, it is succinct and relevant in many domains.

Risk reduction, for dementia, may be considered on three levels:

Level 1 (primary): Interventions targeted before symptoms present

Level 2 (secondary): Interventions targeted at individuals who develop Mild Cognitive Impairment (MCI)

Level 3 (tertiary):  Interventions targeted at individuals living with dementia and their carers. These interventions aim to slow the progression of the disease and potentially alleviate some of the burden, enabling people to maximize strengths.

Level 3 is where most of our work is targeted.  We educate front line care staff on strategies supporting people to maximize their potential, which includes enabling people to stay in control. When supporting individuals, this could be making changes to the social and physical environment and considering the relationship between health and social care factors. This area of work may not be viewed as risk reduction in the traditional sense, but it plays a fundamental role.

Level 3

In the publication, many interventions are sighted ‘care’. However, these interventions may be considered as ‘risk reduction’, carrying the same level of priority as level 1 and 2. Within Level 3, we can consider risk reduction more broadly in terms of reducing the risk of increased levels of care, hospital admission or admission to care homes; all of which have a significant impact on the individual and society, including a financial impact.

 

A number of ‘evidenced based’ interventions were sighted in the recent paper including (but not limited to):

  • Timely diagnosis
  • Cognitive stimulation therapy
  • Cognitive training
  • Cognitive rehabilitation
  • Environment adaptations
  • Assistive Technologies
  • Communication, engagement and person-centred care
  • Medication (moderate effect)
  • Carer support, education, and CBT
  • Sensory stimulation
  • Optimal end of life care
  • High intensity exercise
  • Safeguarding
  • Optimising hearing and sight loss

 

We develop resources for many of these interventions and raise awareness of them within our day to day training.

However, we must be careful about framing dementia only as a condition to be ‘managed’ as it is both stigmatising and limiting; it reduces opportunities for self-management and self-determination. Rather, a ‘management’ narrative is perhaps necessary to assist systematic support to ‘managing’ the complexity of dementia.  However, we need to be aware of different perspectives: dementia is multi-dimensional.

Perhaps as part of the risk reduction agenda for level 3, we need to consider:

What does dementia bring to individuals and communities? How can we reframe ‘loss’ as an opportunity? What can we learn about the positive power of vulnerability? Do diminishing cognitive skills lead to not being ruled by reason, but instead the heart, and if so what benefits might that bring? What does living in the moment, having insights and opportunity bring?

What personal resources are available to individuals to challenge the standard paradigm in dementia? Some of the negative connotations associated with dementia stifle opportunities. If we had a more inclusive society, how could this facilitate opportunities in individuals to develop personal resources, resilience, and capacities?

 

What, then, is the role of local authorities in using this evidence effectively in their work?

Level 1

  • Incorporate risk reduction strategies into the work with services that support people over a life time, such as learning disabilities (who have an increased risk of development of dementia). This includes risk screening people in their care and ensuring that training incorporates risk reduction
  • Where children are in the LA care a strategy should be in place to stimulate a life time love of learning (to build cognitive reserve).
  • Work with allied health services to support health checks for diabetes screening, weight management and hearing checks.
  • Consider specific modifiable risk factors (vascular) to BAME communities with targeted interventions.
  • Ensure that accessible information is available to the general population on risk factors and prevention strategies. Provide information accessible information to BAME communities
  • Make funding available to tackle social isolation in dementia and develop ways of measuring how effective this has been. Enforce NICE guidelines for Home Care, that relate to measuring outcomes, however, consider tackling loneliness as part of this.
  • Develop more integrated models of work. Work which is under way – however, skills development running to catch up.

Level 2

  • Work to embed risk reduction strategies in core training. Many individuals working in care and support services are already working with individuals that have MCI. L&D commissioners should ensure this is incorporated into their training programmes.
  • Ensure appropriate opportunities are available to people with MCI for engagement and to enhance cognitive skills through day centres, luncheon clubs, and community activities
  • Develop effective integrated working between health and social care providers to identify and address health factors in a timely fashion
  • Consider multi-model interventions which enable effective, integrated working between health and social care

Level 3

  • Consider inclusion and self-determination as risk reduction enablers
  • Offer comprehensive training opportunities to services to maximize on ‘evidenced based’ interventions. We are very fortunate in Hertfordshire as our local authority has long invested in this. We have developed over 17 different educational programmes which have targeted the list of evidence based interventions, together with tackling broader social psychological factors. Over the years we have trained over 13,000 people to think more broadly and to BE proactive in their work.
  • Develop their services to better support informal carers, recognizing the benefit and value of this in both economic and moral terms.
  • For commissioners consider the services you do business with. Ask whether the services you currently work with properly understand their role within risk reduction? How many have inclusive models of work? Put funding behind front line voluntary sector services and build the social enterprise model so we can work at a primary level in our communities
  • Develop co-production, tapping into the talents and assets of individuals living with dementia. As a very smart chap (Chris Mason) living with dementia said recently ‘If we get things right for those living with dementia in the community we get things right for everyone’.
  • Develop appropriate courses, and measure the impact training has in reducing unnecessary admissions to both hospital and care homes. Some residents only require short term treatment in hospital: for example, antibiotics, fluids, or x rays, but then may become ‘stuck’ in hospital leading to increased risk of hospital acquired infections and falls.
  • In our work, we have been commissioned to work on a Vanguard project that successfully reduced admissions to A&E from care homes. The programme included training aimed at supporting practitioners to detect the early signs of delirium -perhaps from a chest or urinary infection – and consider risk factors which may lead to falls, such as visual perceptual challenges and the physical environment. The programme also explored how positive psychology may impact on wellbeing.

 

In summary, we will leave you with this thought from the Dementia, Prevention and Care Paper:

 

Dementia, especially Alzheimer’s, is a clinically silent disorder starting in mid-life, whose terminal phase is characterized by dementia

 

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Mental Health Awareness Week #MAW2017 – Read Sarah’s Story

Mental Health takes many forms and affects us in many ways, and it doesn’t discriminate between race, religion, colour or gender. It can gradually creep up on us or hit us like a truck. No 2 people will suffer the same.

 

I have struggled with mental illness for half of my life now.

I remember aged 17, being in the bath after another argument with my parents, thinking how easy it would be to just stick my head under the water and end it all.

 

Every teenager has their struggles and will say that their parents just don’t understand them, but this was especially true of mine. Even now, 15 years later, I still look back on my teenage years as a very traumatic time.

 

From the age of 18, I spent 7 years in an emotionally abuse relationship. It started with the odd accusation here and there, until eventually, it became an every day occurrence. Every time my phone pinged, he demanded to know who it was. If the person wasn’t female, then clearly I must be cheating. When I was 25, we finally separated and I was left alone with a house and all the bills to pay for.

 

My counsellor recently told me a saying that they use in her sector: “The road is full of potholes”. This was very true of this point in my life, only they weren’t potholes, they were an abyss that I was circling and about to fall into at any moment.

 

I recall driving home from work one afternoon and all I wanted to do was drive my car flat out into a brick wall. I knew then that I needed help, so I made an appointment with my doctor and was prescribed antidepressants and signed off work for 2 weeks. I will never forget my manager’s reaction to that note: “you could always just rip it up and get on with it”. Words failed me and I hurriedly left the office and didn’t return for 2 weeks.

 

Things got a little better as the tablets started to take effect but it wasn’t just the feeling low, it was the insomnia, the numbness and the anxiety that can accompany Depression. I didn’t sleep properly in weeks and this only hampered my recovery.

 

Over the following months, I became stronger and began to like living on my own, it was then that I very unexpectedly met my husband.

 

Within a few months of meeting him, I had weaned myself off the antidepressants and I felt amazing. We were married 9 months after meeting and shortly after we were posted overseas with the military. Moving away was the fresh start I needed, we made some great friends and had our two children.

 

So how can I still feel sad?

A question I have asked myself so many times. After all; I have the perfect marriage to my best friend and soul mate and we have two healthy and wonderful children.

So what can I possibly have to feel depressed about?

The answer is nothing. But Depression doesn’t need a reason.

 

My latest battle with Depression really started last year. I knew I was struggling so I went to the doctors and requested to go back on antidepressants. But as the year went on, my mental health continued to decline and after the loss of a close friend to cancer last July, things just got worse.

 

The thing with Depression though is that it doesn’t just affect you, it affects everyone around you. I became less and less tolerant with my children and I withdrew from my husband- some days feeling so angry with him just for sitting down on the sofa next to me. I wanted to scream at him, even though he’d done nothing wrong.

 

My husband thought it was all his fault that I felt this way, like he wasn’t enough to make me happy anymore. But it wasn’t anything to do with him or our children. The truth is; I still don’t know what caused it.

 

It wasn’t just my home life that was suffering, but my job too. I struggled to complete every day tasks and made so many mistakes.

I’m very fortunate to have a boss who understands and helped me to get back on my feet. I now know that if I’m having a bad day, I only have to let her know and she will support me as much as she can. This makes all the difference to my struggle.

 

By September last year, things were back at their very worst. I didn’t have the suicidal thoughts that I’d had previously because of my children, but I knew I needed more help. The doctor had doubled the dose of my antidepressants but this was not helping, so I sought a counsellor. I found her listed on the Counselling Directory website and instantly liked her from her photo.

 

I’ve lost count of how many sessions I’ve had with her, but every single one has helped to get me back on track and feel better. We’ve been through the ‘nitty gritty stuff’- the abuse etc. but I have left every session feeling a million times lighter.

I don’t have regular weekly sessions anymore, I just go when I feel like I need a bit of support or help. For me now, it’s a bit like an MOT for my brain when I need it.

 

Mental Health takes many forms and affects us in many ways, and it doesn’t discriminate between race, religion, colour or gender. It can gradually creep up on us, or hit us like a truck. No 2 people will suffer the same.

 

I’ve been lucky to make many new friends since my eldest started school last year, and I have been very surprised to learn how many of those other parents have been effected by their own mental health- some just the once, for others it’s ongoing. And it always seems to be the parents who are (sometimes rather annoyingly!) always happy. It just proves that, despite appearances, you never know what personal battle someone is fighting.

 

Don’t ever be afraid to ask for help; more people understand than you realise.

 

 

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Why we changed our organisation from a ‘for profit’ organisation into a Social Enterprise.

I started to write this blog at the start of the year. Normally this is a time most people take stock and ask how can we BE and DO better?  However, within our social care sector, this reappraisal is not new, but rather ongoing, and insidious.  We are constantly being asked, how we can DO better. For many services this has resulted in cutting back, and prioritising profitability.

However, what is the impact of this?  Is there a hidden cost of dwindling social care funding, creating highly competitive, low cost, low value services? Has this disproportionate focus on the turning a profit  taken us away from more ethical aspects of our work, as we forget to ask how can we BE better? Surely the test of how we can ‘BE’ better as a social care service lies within the ‘social impact’ that we have, not in the profit that we accrue.

About twenty years ago after a relatively short career in social work I became a proprietor of a social care business at the age of 27, and when I look back over the last two decades I see the factor which drove me to business was the freedom to BE the person that I wanted to be. Because of this, I get immense pleasure from my work, and my collaborations. I spend time working with the individuals that I chose, and I have the opportunities to learn about, and develop what I determine as critical, interesting and applicable. I am motivated, engaged and free to be innovative. My values are at the heart of my business, sometimes at the expense of profit.  Over the years my values have evolved. As a young entrepreneur, I was always interested in creating and sharing, however now I am more concerned about how these collaborations impact on our communities, collectively and positively.

Despite being a ‘for profit’ organisation, we shared our resources, widely and openly (with no material gain), and attempted to reach out to individuals and organisations through our work. Whilst we have had many supporters, we have also been met with some alarming responses: individuals proactively unfollowed us, and actively excluded us. It was disappointing and deeply demotivating. There appears to be a lack of trust in our sector: driven possibly by competitive, anti-collective forces.   Consider though what the possibilities might be for our sector where we are able to foster trust, and build alliances beyond the competitive limitations of market forces. What if we all shared common goals, the communities that we serve? What if there was a less of a ‘me’ mentality and more of an ‘us’?

The growth of a market was stimulated, in part with the introduction of the Community Care Act, and has relied on competitive forces, creating best value. However how effectively does this model work now, in this current climate? In 2012 the government introduced the Public Services Social Value Act in an attempt to get commissioners to consider the social impact of their buying power. However, this only applies to high value contracts. So what of all the other services, or individuals, purchasing services in their community? Whilst these services are regulated by ‘CQC’, many are driven by profit, and may not always be making their decisions in the interests of ALL of their stakeholders.  If we are to really make a ‘shared society’ work, should we not ‘expect’ that ‘social enterprises’ are afforded preferential treatment at a local buyer level? In 2015 there was a review of the implementation of the Public Services Social Value Act suggesting that the Act be extended to contracts below the public spend threshold. It is my view this could be extended further than suggested.

In the health care market we have already seen many services become ‘social enterprises’.  Health has long had an expectation that it should service all ‘stakeholders’, as since the introduction of the NHS it has been free at the point of delivery.

However, that is not the case for social care:   the expectation remains many providers maintain a ‘for profit’ status. Many business minded individuals identify opportunities in a growth market, particularly in the community, where the there is a growing need to support individuals with more complex levels of care. The question is, how sustainable is this in the current market? Does the ‘social enterprise’ model work better in this climate, and if so – should commissioners consider this as part of their market shaping strategy as part of a long term goal for smaller, as well as large organisations? Could this be applied across all types of services, particularly training services like us, whom should be embodying an example, as advocates of ‘best practice’.

So, as a proprietor what are your driving values? To make a profit or make a difference? Whilst on the face of it, it may be a little more complex than that, determining the overriding priorities will help to properly focus priorities on outcomes. As an education provider in social care we aim to buck the trend, and embody this change.

‘Social Enterprise’  is a more comfortable fit for us: synergy with stakeholder expectations and our activities. Through raising awareness, we aim to provide better insights into the experience and needs of the individuals we support in the social care sector.  From a business perspective, it seems to make sense as it is through trading, we may have a bigger impact in society.

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Press Release – 3 Spirit UK accredited for creating genuine social impact

PRESS RELEASE – 06th Feb 2017

3 Spirit UK  accredited for creating genuine social impact

 

Hertfordshire based 3 Spirit UK has been awarded the Social Enterprise Mark, which proves they are in business to benefit society, community and the environment.

 

The Social Enterprise Mark is only internationally available social enterprise accreditation, enabling credible social enterprises to prove that they are making a difference.  Only organisations which can prove they operate as a social enterprise, with the central aim of using income and profits to maximise their positive social and/or environmental impact taking precedent over a requirement to maximise personal profits for owners and shareholders are awarded a licence to display the Social Enterprise Mark.

 

Applicants must meet robust qualification criteria in order to be awarded the Social Enterprise Mark, and are re-assessed each year to ensure they continue to meet the criteria. Subjected to an assessment process which is overseen by an independent Certification Panel, 3 Spirit UK’s governance documents and accounts were scrutinised.  As a result, 3 Spirit UK has earned the Social Enterprise Mark guarantee that profits [or surpluses] are used to

  • to improve the quality of care for vulnerable people through education;
  • to support the rights of vulnerable groups through access to education;
  • to prevent and delay further deterioration in the health and wellbeing of a person living with dementia through access to education and/or tools.

 

3 Spirit UK joins other social enterprises that have been awarded the Social Enterprise Mark, such as the Age UK Enterprises, Eden Project, Big Issue, and the Phone Coop.

 

Government data estimates that there are 70,000 social enterprises across the UK, contributing over £24 billion to the economy and employing around 1 million people.

Social enterprises plough the majority of their profits back into activities that benefit people and planet, rather than just lining shareholders pockets.  However, some businesses are taking advantage as there is no legal definition for them. The Social Enterprise Mark CIC is the guardian of genuine social enterprise principles, and it safeguards these through the independent accreditation process.

 

The 3 Spirit UK aim is to foster a collective responsibility in the social care sector to champion human rights, and to improve the wellbeing of the most vulnerable in our communities. Through education and collaboration, they aim to empower both front line services, and corporate strategists to maintain an ethical and moral ideology in every facet of their work. This is achieved in two different strands of their work:

  • by providing education to the health and social care workforce, and directly to vulnerable groups.
  • by providing services tools and/or consultancy to improve the impact of their work, to create efficiencies that improve wellbeing.

Over the last four years 3 Spirit UK has been dedicated to researching and developing innovative learning opportunities. This has involved engaging with a wide variety of stakeholders by utilising social media and other platforms to share ideas.  In this process the aim has been to develop resources that engage the workforce, and work well in overstretched and underfunded services. In a very challenging social care market 3 Spirit UK has aimed to identify strategies and resources to help services balance competing priorities, focusing on what good care and support, and to determine how to meet individual outcomes for wellbeing.

 

Caroline Bartle said, “We’re really proud to have been awarded the Social Enterprise Mark.  3 Spirit UK is absolutely committed to supporting sustainable businesses and consequently helping local communities to thrive and prosper”. “Over the last two years 3 Spirit has been engaging with research that identifies factors that impact on the wellbeing of individuals living with dementia. This research shows that there are several lifestyle factors which may delay the onset and progression of dementia. A broader amount of research indicates that many people living with dementia in our communities are amongst the most loneliness, which is harmful to health. To improve outcomes, we have been reviewing the evidence base, and attempting to come up with a tool that provides solutions in practice; the Home Spirit Tool. We are hoping that the mark will demonstrate our commitment to meeting wider social goals through the application of this tool”

 

 

Lucy Findlay, Managing Director, Social Enterprise Mark CIC, advised:

 “As the only way to independently assess and accredit genuine social enterprises, the Social Enterprise Mark guarantees businesses use profits for purpose not for the pockets of shareholders.”

 

 

 

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Dignity Action Day – Macro to Micro

Tomorrow is DIGNITY ACTION DAY. Follow the #DDA2017 for all the great working going on today to raise the importance of dignity in our services.

Over the last few months in developing our leadership courses we have been thinking a lot about the work that leaders do in inspiring and facilitating dignity in the workplace. The way staff are treated within the work place has an impact on their ability to deliver optimum care, and offer dignity. If we are going to tackle dignity in the workplace, should we not be looking at the bigger issues? Cuts in funding, and poor commissioning practices impact on dignity on the front line. The support that is provided to staff is influenced by the status that we bestow upon our care sector, which is STILL the most undervalued and underpaid role in our society.

 

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Benefits of Providing Access to Exercise in Social Care Services

Over the last few years, we have had the opportunity to work in a more integrated way with health services in our course development. Supported by health and social care practitioners we have been considering how health and social care interact; the cause and effect, the impact and outcomes on a practice level within specific domains.  This interlocking enables us to develop new insights and tools. Within this we have been considering:

 

  • What are the individual and collective benefits to services of receiving more support for exercise for people living in with dementia?

 

  • What are the potential barriers to providing exercise in care homes and/or community settings?

 

  • What priority is given to this and what training is available to facilitate this?

 

Health and Wellbeing is identified in the Dementia Care Skills Education and Training Framework (section 6), as a key area for education and development for staff working with people with dementia both at tier one and tier two. Section 6 includes health as well as psychosocial activities as expected, and exercise is explicitly mentioned in the first outcome. We have interpreted the outcomes to a more meaningful and measurable course outcome, with exercise linking to many other aspects identified within this section, including but not limited to falls and pain management. Alongside my health colleagues we have debated and developed the merits and outcomes of this course which is set to be a very practical and holistic look at front line integrated interventions.

 

The Context

 

Over the last few years there has been some exciting research emerging about the impact of exercise on dementia. Alongside which we have started to see exercise offered in front line services as part of prevention strategies. In addition, policy and legislation changes such as the Care Act 2014 have outlined their vision for prevention, of which exercise must feature. Organisations like Age UK have offered chair based exercise, and exercise has been targeted by some authorities as an intervention to reduce the risk of falls and other health outcomes.

The emergence of more collaborative working between health and social care has stimulated the growth of such initiatives; pooling funding to improve health outcomes with prevention. However, what is emerging from the research is that exercise potentially has much wider benefits than reducing the risk of falls, particularly in terms of its application to dementia. Mental health services and local primary care services have offered exercise on prescription for many years as a valid form of treatment for depression, so exercise may potentially offer a valid treatment for some of the neuropsychiatric disorders which often are associated to dementia for example; depression, apathy, hyperactivity and agitation. Exercise may also enable improvements in cognition, and some research seems to suggest that exercise may act directly on the pathology of dementia. What is very clear however is that exercise has far reaching impacts both for physical and mental wellbeing.

 

Some Definitions

 

Exercise is planned, structured and repetitive movement which aims to improve or maintain physical health. Physical activity is any movement which contracts skeletal muscles and increases energy expenditure. The main types of exercise are aerobic, strength, flexibility and balance. Aerobic exercise increases breathing and heart rate. Strength exercises make your muscles stronger. Balance exercises can help prevent falls and flexibility exercises help you to remain limber and improve the range of movement.

 

The Barriers

 

However, accessing and maintaining activity where comorbidity is present can be a challenge. If a person is older when they develop dementia they may also experience barriers to accessing and maintaining exercise. For example, pain, fear of falling, arthritis, sensory loss, or respiratory problems. A person may also have restricted movement and some rigidity and quite possibly not be mobile. Good assessment, including pain assessment should be completed to develop a plan that is appropriate to that individual alongside advice from the GP. However not all people developing dementia are older, so this could exercise may be an excellent targeted intervention for younger people with dementia? A study in the Netherlands is currently researching the impacts of exercise in early on set dementia (EXERCISE-ON study) the authors  (Hooghiemstra et al 2012) suggest that certain dementia characteristics such as apathy may lead to sedentary and socially impoverished lifestyles, and by targeting these interventions in a timely fashion they can have far reaching impacts.

 

Together with co-morbidity barriers, we need to consider the challenges dementia brings in potentially engaging in exercise. For example, difficulties with coordination,  motor skills, visual perceptual challenge and memory difficulties.  These difficulties will require us to have a considered approach to the support systems needed to overcome these challenges.

There is such a wide variety of exercise available to us therefore it is about identifying strengths, and identifying suitable exercises that engage these strengths. This might include walking, dancing and/ or using music. Music can powerfully evoke memories, impact on motivation as well as provide rhythm and structure to support difficulties with memory. It is therefore an excellent method of exercise.

 

The Benefits

 

Exercise may improve thinking skills.  A Chinese study (Lam et al 2012) found that mind-body exercises such as Thai Chi could improve cognition as well as have additional impacts such as improving balance and strength. Exercise is targeted as a potential primary  prevention strategy to delay / reduce onset of dementia once someone has been diagnosed with mild cognitive impairment. The wider impacts of exercise on health outcomes are well documented, despite this many services fail to see the importance of it, and more specifically their role in supporting and enabling exercise.

 

Some studies have been completed to look at how effective exercise is in care homes at reducing the incidence of depression. Depression impacts on quality of life and pharmacologic treatments are not without their side effects. Some studies have found no evidence that moderate exercise in a care home had an impact on depression (Conradsson et al 2010). In contrast  Edris et al (2009) had more success in providing a three week exercise plan, as found that it reduced levels of agitation. Agitation and depression are not directly comparable, and clearly variables will differ within this context. However, reducing incidences of agitation could have a direct impact on staff costs associated to working with challenge. Researching the impact of exercise on depression within a care home is a complex task, as the social environment, beyond the time of the exercise will potentially impact. Separating these variables in research is bound to be a challenge.

 

Conclusion

 

Despite the barriers, both in research and in delivery opportunities for people living in care homes to exercise must continue to be a priority. Factors to be considered include: building design, access to outdoors, effective pain assessment and management, and education on the benefits of exercise. There may be a wider impact on these enablers, including improved mood, better sleep and potentially improved nutritional intake.

 

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Bibliography

 

 

Ahlskog, E.J., Geda, Y.E., Graff-Radford, N.R. and Petersen, R.C. (2011) ‘Physical exercise as a preventive or disease-modifying treatment of dementia and brain aging’, 86(9).

Aman, Edris et al.(2009) ‘Supervised Exercise to Reduce Agitation in Severely Cognitively Impaired Persons’, Journal of the American Medical Directors Association , Volume 10 , Issue 4 , 271 – 276

 

 

Baker, L.D., Frank, L.L., Foster-Schubert, K., Green, P.S., Wilkinson, C.W., McTiernan, A., Plymate, S.R., Fishel, M.A., Watson, S.G., Cholerton, B.A., Duncan, G.E., Mehta, P.D. and Craft, S. (2010) ‘Effects of aerobic exercise on mild cognitive ImpairmentA controlled trial’, Archives of Neurology, 67(1), pp. 71–79. doi:

 

Conradsson, M., Littbrand, H., Lindelöf, N., Gustafson, Y. and Rosendahl, E. (2010) ‘Effects of a high-intensity functional exercise programme on depressive symptoms and psychological well-being among older people living in residential care facilities: A cluster-randomized controlled trial’, Aging & Mental Health, 14(5), pp. 565–576

 

 

Duzel, E., van Praag, H. and Sendtner, M. (2016) ‘Can physical exercise in old age improve memory and hippocampal function?’, 139(3).

 

Hoffmann K, Frederiksen K, S, Sobol N, A, Beyer N, Vogel A, Simonsen A, H, Johannsen P, Lolk A, Terkelsen O, Cotman C, W, Hasselbalch S, G, Waldemar G, Preserving Cognition, Quality of Life, Physical Health and Functional Ability in Alzheimer’s Disease: The Effect of Physical Exercise (ADEX Trial): Rationale and Design. Neuroepidemiology 2013;41:198-207

 

Hooghiemstra, A.M., Eggermont, L.H., Scheltens, P., van der Flier, W.M., Bakker, J., de Greef, M.H., Koppe, P.A. and Scherder, E.J. (2012) ‘Study protocol: EXERcise and Cognition in sedentary adults with early-oNset dementia (EXERCISE-ON)’, BMC Neurology, 12(1), p. 75.

 

Littbrand, Hã., Lundin-Olsson, L., Gustafson, Y. and Rosendahl, E. (2009) ‘The effect of a high-intensity functional exercise program on activities of daily living: A Randomized controlled trial in residential care facilities’, Journal of the American Geriatrics Society, 57(10), pp. 1741–1749

 

 

Lam, Linda C.W. et al (2012) ‘A 1-Year Randomized Controlled Trial Comparing Mind Body Exercise (Tai Chi) With Stretching and Toning Exercise on Cognitive Function in Older Chinese Adults at Risk of Cognitive Decline’ Journal of the American Medical Directors Association , Volume 13 , Issue 6 , 568.e15 – 568.e20

 

Lowery, D., Cerga-Pashoja, A., Iliffe, S., Thuné-Boyle, I., Griffin, M., Lee, J., Bailey, A., Bhattacharya, R. and Warner, J. (2013) ‘The effect of exercise on behavioural and psychological symptoms of dementia: The EVIDEM-E randomised controlled clinical trial’, International Journal of Geriatric Psychiatry, 29(8), pp. 819–827.

 

 

Schwenk, M., Dutzi, I., Englert, S., Micol, W., Najafi, B., Mohler, J. and Hauer, K. (2014) ‘An intensive exercise program improves motor performances in patients with dementia: Translational model of geriatric rehabilitation’, Journal of Alzheimer’s Disease, 39(3), pp. 487–498

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