Professional Curiosity and Safeguarding Adults

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Lack of professional curiosity is increasingly being highlighted in Safeguarding Adults Reviews (SARs) nationally as a contributing factor to serious harm or deaths.

What is professional curiosity?

Professional curiosity is the exploration and development of a deeper understanding of what is happening with an individual or those around them. This is achieved through a robust understanding of an individual’s history, good communication skills, proactive questioning, application of legislation, identification of patterns of concern, ability to hold difficult conversations and respectful challenge. The primary feature of professional curiosity is the avoidance of making assumptions and taking information or a situation at face value. There are many barriers an individual may experience which will reduce the likelihood of them disclosing abuse or neglect directly. Therefor professional curiosity will enable the practitioner to more readily identify signs and indicators.

Professional curiosity is not something that can or should be turned on and off or used at particular times. Rather, it should be seen as a way of life, a way of professional practice and a way of being – so that a curious approach permeates all aspects of the practitioners’ interactions (Research in Practice Professional curiosity in safeguarding adults December 2020).

However, it is accepted that there are many barriers to effective professional curiosity. It is important that organisations and professionals are aware of these and take steps to reduce them to enable the development of a culture that supports the maintenance of professional curiosity

Barriers to effective professional curiosity Disguised compliance

The appearance of a caregiver, family member, or organisation cooperating with services in order to avoid raising suspicions, to alleviate the practitioner’s concerns, and, ultimately, to eliminate the professional’s involvement entirely.

The ‘rule of optimism’

Practitioners rationalise new or escalating risk despite there being clear evidence that there should be concern.

Not identifying accumulating risk

Viewing each incident in isolation without context or consideration of an individual’s history and not considering the risk in relation to the cumulative effect of recurring incidents.

Normalisation

The perception that actions become ‘normal’ or ‘natural’ and are an accepted part of an individual’s daily life. This leads to a lack of professional challenge or questioning.

Professional deference

Practitioner’s perception that another professional is of ‘higher status,’ hence, they are unwilling or afraid to challenge that professional’s view.

Confirmation bias

The search for evidence that supports or confirms the practitioner’s existing view and rejection of any evidence that may challenge their existing view as incorrect.

Knowing but not ‘wanting’ to know

Having a sense that something is wrong but not being able to form the feeling into a reasoned evidence-based view.

Diagnostic overshadowing

Attributing all the evidence in an individual’s life to their diagnosis rather than taking a broader view, considering relationships, environment, trauma, coercion, poor levels or inappropriate support etc.

Remote working

An additional barrier to professional curiosity is remote working and it is important to recognise and act in relation to this when connecting remotely with both people who are at risk of abuse, neglect, and other agencies. It is important to consider that remote conversation can:

Alter relationships
Create a barrier to successful communication
Create a reduced ability to read the non-verbal content of a conversation
Create a wish to terminate the conversation as soon as possible due to anxiety, unwillingness or ability to use the required technology
Enable difficult conversations to be terminated more easily
Reduce ability for the professional to see the ‘whole’ picture and assess accumulating risk
Reduces awareness of who else may be present during a conversation but out of sight

In addition, remote working limits opportunities to model good professional curiosity by more experienced practitioners. When you are in ‘earshot’ of a conversation you can learn how to ask good questions.

There are additional barriers that practitioners need to be aware of:

Poor supervision and management support
Complexity and pressure of work
Preconceived ideas and values
Lack of openness to new knowledge
Fear of respectful challenge
Fear of holding difficult conversations
Lack of confidence in managing tension
Discounting information that cannot be proven

Organisational values that foster effective professional curiosity

The values of an organisation will have a significant impact on the likelihood that professional curiosity will thrive. Ensuring the workforce:

Have time and capacity
Approach practice from a strength-based perspective
Ensure those with lived experience are actively involved in safeguarding
Display competence in relation to recording which is supported through effective processes and procedures
Are provided with good supervision and management support.
Are legally literate and have a robust knowledge of safeguarding
Are provided with effective training which provides positive impact at a service and organisational level and links to increased competence

To find out more about how to cultivate professional curiosity at a strategic level join our Level 5 Safeguarding Adults accredited programme.

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Dignity Action Day – Macro to Micro

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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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Home Truths to Home Spirit

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Last week the Kings Fund and Nuffield Trust produced a report, ‘Home Truths’, demonstrating the impact of the local authority spending cuts over the last six years on social care. The report highlights the combined pressures on services, such as maintaining Fundamental Standards (CQC), working towards achieving the Living Wage, dealing with contract cuts, as well as coping with significant staffing shortages. Cumulatively these pressures have meant that many services have fallen short of demand and for some there have been serious failings. However, for the majority, the shortcomings are visible in delayed discharges from hospital, which has a negative fiscal impact.

The report highlights some of the strategies adopted by services to compensate for these cuts. For example, some providers are relying more heavily on privately funded clients to subside their local authority contracts. Some are actively identifying options for support in the wider communities and using volunteers to bolster their service.

The report warns that the social care sector will not cope against the continued planned cuts and additional sector pressures, and recommends three possible options to address the dismal outlook:

achieving more with less
a different offer
long term reform

Whilst the latter two can be debated over the longer term by politicians and senior social care figures alike, providers need to be getting on with the ‘what can we achieve for less’ more imminently. There is an urgent and critical need to think outside the box about how we can do things differently.

As part of the ongoing strategic review many services have been actively reviewing their resource input against their outputs and outcomes in an attempt to get more for less. Good business strategists understand that the skill lies in leveraging resources effectively to create a comfortable operating profit. This isn’t always about cutting back but rather doing things differently. Training is one example of a resource that can be manipulated for different outcomes. There has been a growing reluctance to spend on training, with more services opting instead to develop independent capabilities or deliver E learning in the hope that this widens the profit margin. However, in reality some of these ‘cutting corner’ decisions can impact on quality, leaving services ill prepared to ‘fire fight’ issues such as safeguarding incidences, health and safety concerns, complaints and/or poor service outcomes. Many of these matters often rear their ugly head at a time when services are logistically challenged, forcing the focus on resources toward just covering the job instead of on maintaining and improving outcomes.

On a more strategic level, within our local area some excellent joined up thinking has been going on. Integrated projects have developed, which have been supported by the pooling of NHS funding (Better Care Fund), aiming for smarter working through integrated practice. Our organisation has been involved in one of these projects, working with care homes to reduce hospital admissions. Hospitals are very disabling places for people living with dementia, and poor outcomes are typically observed; economic and individual. Clearly there is a lot of work to be done to upskill staff to ensure that there is a timelier reporting of health concerns through better quality observations, and ensuring that preventative measures are put in place to avoid unnecessary admissions.

One of the areas that has seen the largest cut in funding is community based services, such as support at home (homecare). Spending is down a whopping 30% despite policy objectives to support more people in the community. This is a significant cut in comparison to residential and nursing services which were only cut by 4 – 6%. Home care services now are delivering more hours for less money. So what solutions are there available for our home care services?

This key question has been the driving force behind the development of Home Spirit, a platform developed for home care providers. The platform equips services with the tools to literally think differently, be proactive and add value to their service.

The portal consists of a number of tools. The person centred planning tool has several potential domains which are selected by the client, and are based on their specific identified outcomes. It is easy to use and prints and uploads reports, making sharing easy. It avoids duplication, or having to write anything out so saves time. It can be completed on mobile while at the client’s home, and, with an easy to use navigation system, it has sensory appeal. The tool helps agencies to reduce operational costs in assessment and reporting. It can highlight risks easily, both those that are determined by the individual as well as the care agency. The report can be produced in a shorter version (similar to a one page profile) which informs busy workers in a simple snapshot HOW to provide the support. At £19 per month for as many reports as required, it is also excellent value.

The environment audit is intended to be a proactive tool. It may reduce hospital admission and risk of falls through environment assessment. It can be used by families and individuals to identify potential assistive technologies (a requirement of the NICE Home Care guidelines 2015), which include health monitoring options, safety and activity monitors, and leisure and communication technologies. These technologies now have a much wider scope and can promote human connection and tackle loneliness. Loneliness has been linked to poor health outcomes, leading to additional financial burdens on community and NHS services. Tackling loneliness through supported use of assisted technologies is only one of the many benefits that can be introduced by the tool. The environment audit tool also makes simple recommendations for environmental adaptation to improve independence. The environment tool will also make recommendations around how an environment can be adapted around a specific task for a person with dementia, and therefore informs and educates, offering a tailored support plan.

The ‘still my life’ post diagnostic tool is completely FREE to access and helps families to plan together to take proactive steps to manage the condition; this aims to reduce anxiety. One of the first questions asks the person to consider the difficulties they face and what actions they plan to put in place to mediate these challenges. The design of the tool aims to encourage people to rehearse their own strategies, helping them recall them with more proficiency, as well as have very clear goals on how to compensate for their difficulties. Another question prompts the person to consider aspects of life that they appreciate and value (positive psychology), this can have a direct therapeutic value. One of the questions guides individuals to complete appropriate legal planning. Local authority resources spent making ‘best interest’ decisions could be avoided by documenting decisions in a timelier manner. The planning tool provides accessible guidance on how these measures can be put into place. The tool also asks individuals to consider early interventions for nutrition and sleep. As 72% of people living with dementia are also living with another condition (co-morbidity), early strategies to support sleep and nutrition can have a positive effect, reducing risks of delirium and inappropriate admissions to hospital. The post diagnostic planning tool can be easily downloaded and completed on paper. This additional tool is potentially an asset to home care providers, as providing access to this resource as part of your service shows that you provide added value. Perhaps more importantly a tool like this provides hope, and motivates families and individuals to think proactively.

The circle of support tool helps to identify communities of support to build upon existing community networks and engender a sense of belonging and affiliation to the wider community.

The learning resources (infographics) available through the portal support staff, through bite-size learning, to observe better, develop better relationships, and improve reporting. The flexible resource reduces the need for staff to be removed for training at critical pressure times. Community services are now working with higher levels of need and the skills sets required are reflective of this. Appropriate investments need to be made in knowledge management. The resources available on this portal are specifically designed to work well in busy environments.

Therefore, while services are scratching their heads considering their next move to survive this hostile environment, we have been actively developing a solution. The benefits of the Home Spirit tool are potentially far reaching and offer a legitimate opportunity to services to do things differently and to achieve more for less.

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Deprivation of Liberty – Are we spending public monies wisely?

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Deprivation of Liberty – Are we spending public monies wisely? Trish O’Hara April 2015

I for one, am fully aware of the necessity of adhering to Article 5 of the ECHR and delighted that Lady Hale pointed out that however golden the cage, it is still a cage.
But, the new threshold following the Cheshire West ruling :-
Continuous supervision and
Lacking capacity to consent to remaining
And how it falls within the Human Rights legislation:
The objective element: i.e. that the person is confined to a particular restricted place for a non-negligible period of time;

The subjective element, i.e. that the person does not consent (or cannot, because they do not have the capacity to do so) to that confinement;

State imputability: i.e. that the deprivation of liberty can be said to be one for which the State is responsible.

seems to have created an unprecedented amount of paperwork for those who, perhaps, need to be focused on emergency situations in hospital.

I am fully behind the new ruling for those living in residential care homes, nursing homes and hospices but am not sure this is money well spent on those in Intensive Care Units and in transportation from one hospital to another. It seems to me that those completing the assessments – such as Section 12 doctors and Best Interest Assessors are in the lucrative situation of charging £250 or so to assess people who are sick in hospital for a week or so. The nursing staff having to make applications, to spend time with the assessors – all of which is time away from using their expertise in keeping the person alive. I am aware that on many occasions, assessors have gone out to complete an assessment and the person has either gained capacity or indeed died or been discharged. I expect the assessors are still paid for their time and yet more public money is swallowed by this over-zealous interpretation of the ruling.

Of course, when a patient is resisting treatment and needing restraint, there needs to be protocols in place to ensure it is to maintain the life of the person, but can this not be regulated within ordinary hospital procedures?

Public monies are a dwindling resource as services face further cuts. Surely, there needs to be a common sense approach to deprivation and when it is necessary to authorise it.

I understand that new guidance is due to be published in 2017 which I hope recognises the paper driven exercise that often seems both pointless and expensive.

Yes, all patients should be informed and asked to sign consent for a time when they may not have capacity, following an operation and yes the MCA is a wonderful piece of law that protects the rights of all of us. But, the idea that a person who has suffered perhaps a head injury in a road accident and needs to take an ambulance for numerous hours to a specialist hospital needs a DOLs seems to me to be wasting peoples time and money.

I am not sure there is enough emphasis yet on getting this right where it needs more attention, time and money spent.

Are there enough home care providers who are involved in supporting a deprivation in a persons own home, not registered, trained in understanding liberty?

Do families understand that deprivation of liberty may be seen as false imprisonment?

Do enough care homes understand the right for people with capacity to make unwise decisions?

Do enough supported living services realise that they may need to apply to the court of protection if they are depriving a person of their liberty?

Surely, these are the areas of real concern. And where assessment and monitoring is most needed.

I await 2017 publication with much anticipation.

TrishFollow Us

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Wellbeing is Outcome by Trish O’Hara

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Wellbeing is Outcome – by Trish O’Hara March 2015

So the opening chapter of The Care Act is all about wellbeing. I presume every agency has wellbeing in their mission statement. We talk about wellbeing all the time in services today. It is the main driver of our delivery. It is how we are measured. It is the point. And yet, in my experience, practitioners struggle to define it.
Let’s be honest, care packages are created on the back of need, not want. Budgets mean that only ‘need’ is eligible. Any social worker who thinks their assessment processes are person centred must accept that their assessment processes are purely needs led. Person centred planning is aspirational and dreams led – it’s about want not need. What is important for the person is often in direct conflict to what is important to them. Whilst a person’s care package is based on need – the service providing said package is then measured on outcome. This means the provider must know how to move on from the initial assessment and turn the process on its head – still making sure that the person is in receipt of the service they are paying for.
This is not easy.
In essence, the budget meets the persons needs – but your service will be measured on the persons wellbeing and outcome.
So let us define outcome focused practice;
Input The resources required to provide agreed service
Activity The action plan that delivers said service
Output The service is evidenced as delivered
Outcome How this makes the person feel
An example to help us as follows;
Colin is a man with Down Syndrome and a mild to moderate learning disability. Colin has had a life long dream of meeting Elvis in Vegas. Colin lives with 5 others in a registered care home. Colin has the capacity to make his own decisions in the main and chooses to eat very surgery and fatty foods. Colin has diabetes and is about 5 stone overweight which is putting a great strain on his heart and effecting mobility. Colin often refuses his medication and has uncontrolled epilepsy with several seizures per day. Colin is very gregarious and friendly, often singing Elvis songs and making people around him feel good. The staff at his care service have spent years attempting to support Colin to make ‘better’ decisions about his diet and medication. He ignores them. Colins mum is very involved in his care and is worried about his health.
It is when Colin begins a person centred plan – using PATH that his life changes.
Starting with the dream – Colin is in Vegas meeting ‘an’ Elvis.
Colin has a hotel room and a ticket to an Elvis concert
Colin is on the plane with a ticket, passport and visa
Colin has saved £3500
Colin has permission from his GP and insurance to fly

We can see there are a myriad of barriers to this trip. We can see that there a many risks.
Colin tells the staff his dream – staff work from the dream to support Colin to take control over his life.
Colin is excited about going to Vegas. Colin takes his medication without fail and even agrees to a blood test. Colin actively involves himself in healthy eating and manages to lose 3 stone. Colin chooses to walk from the bus the final mile to the day service every day – this was his idea. Colin no longer drinks fizzy drinks. Colin is offered money from his mum and his uncle toward the trip. Colin saves and budgets toward his trip. Colin goes to see Elvis impersonators in the UK. The GP agrees that Colin is now fit to fly. Colin flies to Manchester to see family who he had lost touch with and to see how flying felt. Colin gets a passport.
Let’s use the language to describe events.
Input:          Staff time – Actions plan creations – Appointments with health professionals
Action:       Nutrition Plan, Exercise Plan, Budget/Savings Plan. Colin begins to shop, cook and eat according to plans – along with medical appointments, taking of his medication – controlling his epilepsy and blood sugars.
Output: Colin goes on his dream trip to meet an Elvis in Vegas
Outcome:    Colin has outcome long before output – Colin takes control of his health, his diet, his life. Colin loses weight, becomes more active, controls his seizures and enjoysa full active life in his community. Colin makes plans, budgets and makes decisions.
It is often presumed that outcome comes after output, but as you can see by this example, often outcome arrives before output. In fact, Colin may never get to Vegas, (although I jolly well hope he does) – but still the outcome comes pouring in.
Staff have been working on Colins health and diet for years – but never before had Colin engaged in it. Colin needed to be heard. Colin wanted a trip to Vegas to meet Elvis, which was seen as impossible – Evidently, people believing in Colins dream and supporting him to work toward it – meant that he felt in control, empowered and made his own great steps to achieve his dream. The outcome is clearly filled with evidence of wellbeing.
It is this example that helps us think about what we measure. Output is not where we stop and is not what we measure. Wellbeing is outcome – and it is wellbeing that must be documented as evidence that we are providing the services that the person is paying for – Not need.Follow Us

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The Mental Capacity Act and Safeguarding

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Blog by Trish O’Hara 24 January 2015

The Mental Capacity Act continues to be pivotal in safeguarding
Following The Care Act and The Care and Support Statutory Guidance (Oct 2014), it is clear that if we are to understand safeguarding, we must first fully understand The Mental Capacity 2005.
I was also pleased to see that the Fundamental Standards thread The MCA throughout and The Care Quality Commission have The MCA at the centre of their inspection process.
In 2005, I was thrilled to see the principles of The MCA and truly believed there would be a radical change in practice almost overnight – But it’s 2015 and some services are still failing to uphold the principles fully. Whilst, I understand why it is hard for providers to support an individual in their often ‘unwise’ decision making, and realise it challenges the tradition of care and the instinct for care providers to feel they have the right to stop a person making poor decisions – I find it is a constant revelation in the training room.
When I pose the idea that an individual with diabetes may want to eat 12 doughnuts, it is still considered neglect by the service providers to ‘let’ the person do so. I spend much of my time reminding people that they start with The MCA. Does this person have capacity? In line with the first principles of the Act, we must presume capacity unless we have proved otherwise – and our duty of care is to provide information, education, opportunity and choice to said person with capacity, who may continue to eat doughnuts and it is clear that the law protects their rights to do so. The evidence of our information, education, opportunity and choice is vital and of course the risk assessment. In fact, it would be neglect to deny the person the right to make their decision. Of course, if the person does not have capacity then the decision would be made in their best interests. This of course, is where the final principle of the Act takes main stage. Are we using the least restrictive approach? I am not sure it has been challenged enough. My hope is that the ‘new style’ CQC inspections will find a way of monitoring the 5th principle in action.
It is with all this in mind that I continue with the 6 key principles of safeguarding. The order of which is vital –
Empowerment
Prevention
Proportionality
Protection
Partnership
Accountability
The Mental Capacity Act can clearly be seen in these principles. Starting with empowerment and prevention is a clever way to remind us who is at the centre of any decision and then our proportionate intervention which may need us to protect, if an individual is unable to make the decision – But, when we are protecting, it is essential we understand our responsibility to work in partnership and be accountable for our actions.
I love these principles – They make everything so clear.
And then ‘self neglect’ as a type of abuse – spoils it.
The empowered person, with capacity, makes unwise decisions that may be judged as self-neglect by others. Are we really to see this as an abuse? Is that useful? Especially, as the definition of abuse used in the Statutory Guidance, describes abuse as involving another person or persons. At what point are providers to consider self-neglect as abuse? I can imagine that will be when the individual is making lifestyle choices that the provider does not agree with or like. I am fairly convinced that the contributors who created the principles are not the same group who decided upon the changes to the types. It may have been more useful for us all, if they were.
As long as we truly recognise that in order to safeguard, we must uphold and understand The Mental Capacity Act – (DOLs), and we will all be on the right track.
Safeguarding is everybody’s business – so is understanding The MCA.Follow Us

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A is for Abuse

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A is for abuse; A is for action
Nov 2013

CAROLINE BARTLE discusses the startling prevalence of abuse of older people with dementia and why, despite increasing awareness, we are still a long way from tackling this serious problem… read moreFollow Us

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A is for abuse; A is for action Nov 2013

A is for abuse; A is for action
Nov 2013