An apprenticeship means learning on the job, at any age. Apprenticeships are not just for young people. In the health and social care sector older apprentices often have great life experiences to contribute.
For apprenticeships of a higher level, individuals can already be working in the sector, and need to do an apprenticeship to advance career opportunities. However, to complete an apprenticeship, the learner is required to complete 20% “off the job” learning.
This 20% is likely to include the following activities:
Attending virtual classrooms
Contributing to forums
Completing assignments
Guided reading
Reflective diaries
Shadowing other members of the team
Participating in audits
Feedback/learning sessions with some of the people the learner supports
Meetings
We specialise in the delivery of Higher Apprenticeships in the Care Sector.
Face to face delivery has always been the preferred delivery model in social care for very good reasons. To teach ‘care’ an interpersonal approach is required. Our impact assessment demonstrates that there is greater impact where the delivery is actively able to model ‘care’, to demonstrate inclusion and share experiences in a powerfully reflective way, person to person. Our impact work also demonstrates that there are sometimes unintended consequences to passionate delivery, where the learner is not only moved to feel confident and capable, but also inspired to make a difference.
Face to face delivery provides an aesthetic experience, one which utilizes sensory experiences, positive communication styles and human connection to improve impact. Care can also be very ‘practical’ in nature (beyond the obvious topics such as first aid and moving and positioning) and therefore, can benefit from face to face delivery. Teaching ‘care’ is also a reflective experience both for the learner and the facilitator which is evoked more naturally within a face to face setting.
In the past couple of months COVID-19 has caused a significant shift in the way learning is delivered. Social distancing has forced us to re-evaluate the delivery model, with some very surprising outcomes. The challenge for us has been how we maintain the organizations ability to impact practice, within an online platform. How could we affect the way people feel and inspire people to make a difference in their work through the medium of a computer?
How do we develop rapport with people and negotiate practical commitments for change? And how do we really listen to the way people feel and offer safe spaces where people can share their experiences?
Last week we were delighted to learn we were provided a grant by Ufi for digital transformation. This also provides access to a community of practice to re-imagine our practice. We called our project ‘Transitions’ but is best described as a rebirth. The pace of change has been rapid. COVID-19 has forced everyone to adopt remote delivery. Without COVID-19, it would have taken years to encourage people to adopt this type of learning and get to the point where we are now delivering the number of webinars we are doing in the space of a few weeks. It has forced people into the digital era almost overnight. In addition to this, the workforce we support are now having to adapt to new ways of working, new laws and challenges, balancing rights and responsibilities. Rapid recruitment is required, including the training of volunteers. Training is needed now, but the sector is currently not ready to embrace new ways of working. Some of the challenges we have experienced include:
Services reluctant to let people train in their home environment, worried that they will not engage fully
Individuals reluctant to use their own personal mobile devices
Lack of equipment including head sets
Lack of digital skills, e.g. ‘what is a mouse?’ 😊!!
Lack of commitment from employers to transition working practices
People accessing without headsets in shared offices
Confidentiality when training in learners’ own homes
Skilling up the trainers to wear two hats in their delivery, IT extraordinaire and outstanding trainer
Security issues with specific webinar platforms requiring our team to rapidly develop skills to use multiple platforms that meet different client requirements
Fear of the unknown, no experience in alternative delivery methods
Challenges with delivery have included:
Enabling learners to feel safe
Meeting a range of learning styles
Reasonable adjustments
Keeping the course interactive and managing contributions
Developing rapport with learners
However, despite these challenges great opportunities are emerging, such as:
Course Preparation – sending information ahead of a course enables learners to be more engaged
Social Learning – peer collaborations, often across services
‘Flipped Learning’ – courses that were delivered over a full day are now split over two half days with a case study in between to reflect on
Collaboration – across the training and delivery teams reducing duplication and encouraging innovation
Greater accessibility and an ability to reach a much wider market
Leveraging resources – multimedia platforms leading to broader accessibility
Maximising constructivist approaches – optimizing problem based scenarios/ case studies by drawing from a broader audience
The ability to match trainers’ skills to client’s needs – previously there were geographical restrictions with face to face delivery
We would do well to remember the context of social care within this technological transformation. We recongise that much of our work relates to sensitive subjects, so in addition to onboarding around technology, we also need to consider confidentiality and emotional safety. But we also need to recognize that part of enabling people to feel safe and included, means supporting them with digital capabilities and the confidence to use new platforms. With a greater focus on visual teaching practices we need to ensure that we adopt positive images and deliver a broad range of cultural representations to make our material relevant and inclusive. We need to consider how to use technology to integrate activities which powerfully advocate human rights, deliver progressive strength-based ideologies and promote justice. We need to embrace those technologies that enhance the human experience, to share powerful stories that have a sustainable impact. We must be committed to the person’s voice and that our technologies are accessible to experts by experience and enhance, not hinder their contributions. We must exploit those technologies that capture and highlight the great contributions that individual care and support staff make to people’s lives. Finally, we must continue to maintain data protection, protect our learners from being exposed to negative online experiences and continually strive for safeguarding both for our learners and broader communities.
However, social care learning is not a single point of delivery. Knowledge management practices require a much more strategic approach to interface what we need to deliver in social care to get good outcomes. Our organization has invested heavily in the development of techniques to improve impact of vocational learning in social care. Our focus has always been on outcomes of our work, not necessarily the evaluation forms, nor just learner outcomes, but instead the impact for our communities: the organisations and the individuals they support. The strategies we adopt to improve the reach of our work includes measures before (in organisational needs assessment), during (communicating expected impacts) and after (staging resources and providing tools). We have historically relied on technology to achieve the before and after but have been reluctant to move to blended approaches in delivery. However, Social Distancing has a sliver lining, the impetus to take these bold steps to integrate our impact work with equally as impactful online delivery through the medium of ‘Virtual Classroom’.
What is clear is that ‘care’ is still about people. So, we must remain focused on the people and how technology can be used to enhance facilitative relationships. I am excited about the use of new technologies, particularly how these may leverage our impact by utilising teaching strategies which encourage reflective practice and collaboration.Follow Us
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
There is an estimated 1.2 million Lesbian, gay, bisexual transgender (LGBT) older people in the UK, many of which will have dementia with services often failing to meet the specific needs.
The public sector equality duties require organisations to eliminate discrimination, advance equal opportunity and foster good relationships for all those using services. However so often the opportunity for older people to even ‘mention’ their sexuality is supressed. It is the role of all social care organisations and leaders of services to raise hidden issues that silently trample on human rights. It is essential to push boundaries and to enable the people we work with to honestly reflect on their practice.
The subject of sex is too often ignored when thinking of people in their 60’s, 70’s and 80’s plus. Many practitioners lack the confidence and skills to know how to raise the subject. Whether we were born in the UK or moved here in our lifetime, we are still terribly ‘British’ when it comes to the subject.
Some people from the LGBT community have already struggled with higher risk of mental ill health, suicidal thoughts, self-harm and substance misuse and a lifetime of waiting for law to catch up with common sense in order for their rights to be upheld. It was only in 1973 homosexuality was removed as a mental disorder from DSM and 2013 before same sex marriage was recognised in law.
It is estimated that only 53% of people from the LGBT community have ‘come out’ to a health professional – the remainder may include those that feel their lifestyle choices are nobody else’s business, but it is possible that many may fear discrimination and keep their mouths and closets firmly shut. How can we ever tailor services to meet the specific needs and preferences of people from the LGBT community, if they do not feel safe to become visible?
For individuals living with dementia memory problems mean that often individuals have to experience ‘coming out’ twice, into services which are often not prepared, willing or skilled enough to support these needs. The vital work in reminiscence can bring a persons’ history to the fore, often resulting in the person finding themselves as well as others understanding them better. However what if, by bringing a person back to a childhood when they were a different gender results in difficult memories?
The rise in HIV in men over 50 continues, with a much later presentation for health care, and a higher mortality rate than their younger counterparts. Older men reporting that unsafe sex is still common place. From this we can presume that unsafe sex is as prevalent across all over 50’s and may have an effect on STI’s in the whole community. It feels necessary to raise this issue as specific health and social care needs arise from this information and not to only associate HIV to the LGBT community, but also to consider safe sex in our older population. More specifically what role do older people services play, or should play in supporting safe sex?
Older people from the LGBT community remain more likely than both heterosexual peers & younger generations and to be single & live alone. They are also less likely to have children, which means they are more likely to have a greater need of formal care & support. It would also suggest that where a person with children may be less likely to need residential care, and those without may have a greater need and sooner. So this would mean that out of the estimated figure of 1.2 million of LGBT older people, many may be living invisibly in our care homes. In data collected by CSCI (now CQC) in 2008 only 7% of care homes and 8% of domiciliary care providers reported carrying out specific work around equality for LGBT, with less than 1% of care homes who had done any specific work around sexual orientation & assessment or care planning. With no preparedness or any provision to acknowledge LGBT, it seems living in a care home is similar to living in their closet. Clearly much work is needed to advance this practice.
We need more LGBT friendly care homes, or specific care homes that understand what a gender neutral pronoun is. These flag ship services will embrace all people, regardless of their sexual orientation. More broadly much work is needed around older people and sexuality. Challenges faced with being older; ageism, physical and mental frailty pose problems for meeting sexuality and intimacy needs. A basic and fundamental human need for all regardless of age or sexual orientation. This is essentially about coming back to our core social care roots; promoting person centred care, dignity and inclusion.
Good Practice:
Include sexuality & gender identity in assessment.
Consider marketing strategies: use same sex couple’s photos in marketing.
Consider using appropriate language such as gender neutral pronouns.
Carry out training in sexuality and older people as standard practice
Consider culturally sensitive reminiscence: Trans gender is different in childhood
Appreciate not everyone has conventional model of ‘family’
Consider physical building constraints to privacy
Put pressure on stakeholders to make LGBT and dementia a research and commissioning priority
Further resources: NATIONAL CARE FORUM, VOLUNTARY ORGANISATIONS DISABILITY GROUP –Dementia Care and LGBT Communities a Good Practice Paper (2016)
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.
Issued in 2014/15 identified a number of safety concerns in the Adult & Social Care sector i.e.
“A range of factors affect the safety of services, including a failure to investigate incidents properly and learn from them so they do not
happen again, ineffective safety and risk management systems and, in hospitals and adult social care, concerns with the adequacy of
staffing numbers and mix, alongside skills, training and support.”
In Adult Care Services specifically contributory factors were staffing levels, understanding and reporting safeguarding concerns, and poor medicines management. It was noted that “adult social care providers struggle to recruit the staff they need. Vacancies and turnover in the sector are high. For nurses, vacancy rates can be as high as 20% in domiciliary care and 11% in residential care.”
Additionally based upon an analysis of the inspections carried out 1 in 10 of adult social care services were rated as inadequate!
The CQC’s comments in relation to those inadequate ratings were “there were a range of governance issues that undermined the organisation’s quality and safety – from poor data quality (such as inaccurate care plans and medication records) or a lack of staff meetings, to little or no responsibility for complaints or mistakes.”
In relation to these concerns, of the inspections undertaken, there has been an increase in CQC enforcement actions to 7% in 2014/15 from 4% in 2013/14.
In contrast the observed outstanding services have management that ensure their staff receive continuous development and training. One inspector commented that
” It was how the people were supported. There were high levels of staff training; the training was just immense really, with staff doing refresher training throughout the year.”
These observations and data, particularly regarding vacancies and turnover, suggest that more effective risk management and quality training would be a substantial contribution to ensuring that care is always safe.
The HSE, following a review, have now recognised that there are aspects of health & safety training that can be covered by online training. Their guidelines are to be updated and will include advice to employers to ensure that the online training is fit for purpose. There are elements of Health & Safety training which must be classroom based i.e. first aid
My experience of training managers in the residential and domiciliary care sectors identifies, quite clearly, the challenge of developing effective risk assessments. Overcoming this challenge by using quality training companies not only assists these organisations in meeting their legal requirements but also minimises the risk of HSE sanctions and penalties that have been substantially increased in terms of fines and custodial sentences.
Since the first Dementia UK report in 2007 on the economic impact of dementia there has been a slow, but more recently accelerated, awakening on the potential impact of dementia on our communities, with some liking it to the threat of global warning. As a result, there has been increasing investment in research. With this has come a growing evidence base for the application of non-pharmacological treatments, accelerating opportunities to improve practice and individual outcomes. However, bringing this new research, ideas and practices to front line staff has been a slow burning process. Although I am pleased to say that many of our clients have moved beyond the realms of ‘dementia awareness’ as the only training staff get.
Very early in my career as a social worker I was thrust into the depths of dementia diagnosis. Newly qualified, I was eager, motivated and interested to learn, to forge my sense of professional identity. I quickly got a job in Islington with a team known at the time as ‘Mental Health Care of Older People’. Based in the hospital, and led by a confident and dynamic psychiatrist, I sat amongst a very diverse (multi-disciplinary) group of professionals. What I learnt very quickly is that dementia is a fascinating and complex condition that requires a multiple perspective in order to truly get it’s measure. I couldn’t help feeling, though, that in this group I struggled to find an identity, to understand my professional worth; and truly the worth of the social model. I felt at the time (about 20 years ago!) there was a strong leaning towards medical interventions, some effective, and some fraught with difficulty and undesirable side effects. At this time there was a limited evidence base for non-pharmacological treatments, so many looked to medical treatments.
My occupational training in Islington compelled me to learn more, so I began personally to pursue the possibilities for good dementia support. For the first few years I read widely; I’m ashamed to say in the last 20 years I have never once picked up a novel. I am fascinated instead by the challenges and opportunities available in good dementia support; things like, the way the condition and the battle against it humanise us, connect us, and teach us the importance of meaningful connection. It also reminds us of the dangers of disconnection, demonstrates to us that there are strong correlations between our mental wellbeing and our physical health. The interplay between neurological challenges and the social world has always fascinated me, and the creative ways we can communicate and connect. After grappling with the topic for a number of years I soon started training in dementia care, and was soon asked to author a training manual for the first ever dementia care knowledge sets. By this time, I had a much firmer idea of my professional identity, and the role and power of the bio-psycho-social model of support that had challenged me in my earlier years.
For a while my learning went down a rather formal route; I studied at Bradford, which was a great way to benchmark my ideas and my work. However, I learn most from ordinary experiences, feedback from my training groups, and what I see in my own limited direct practice experience. There is a growing collective consciousness of the experience of dementia, led by many people living with dementia like the brilliant Tommy Dunne @TommyTommytee18, and Chris Roberts @mason4233. This has added another dimension to what we believe the possibilities are. This is tacking stigma and showcasing HOPE. Whilst learning about the lived experience of dementia is critical, dementia does not happen in a vacuum, it touches lives and services in so many ways. Therefore, to be a good dementia care educator we must widen our radar. It’s important to learn from all of those people, not just the academics or people living with dementia, but also family carers, front line support staff and other trainers who are often the catalyst for change. Teaching and training in dementia care and support opens you to all that and good trainers will use those opportunities to refine and enhance their message.
Having a good grounding in your subject, the practical underpinned with the theoretical, is a good start but you now have to convey the message in an effective manner and target the training appropriately. All organisations differ and individual group skills levels differ. A good dementia care trainer will ask not ‘these are the courses I can offer’, but will instead say ‘let’s have a look at what is happening in your organisation and see how we can work together to fill the gaps’. It’s about working together, combining skills, and celebrating successes.
Regulation is important in our society, and organisations like CQC work hard to ensure that staff are appropriately trained. However, their legacy has left a box-ticking approach to mandatory training. CQC make clear in their standards now that prescriptive mandatory training is no longer a requirement but rather staff should receive the training appropriate to their role. Despite this, many organisations lack the ability to audit skills and plan training based on need. Done incorrectly it can become a very expensive business. Troubled with poor staff retention, and persistent cuts, our sector needs targeted and fit-for-purpose training.
So the challenge is developing a course that will have an impact. In my years doing this I feel I have developed a recipe.
Knowing the sector and wider policy drivers is important, and understanding relevant occupational standards to scoping a course that is properly benchmarked.
Ensuring that your content is evidence-based ensures that the course is credible.
Knowing how to share human experience in a powerful way that people relate to; often this means bringing in experts by experience.
Understanding how to weave the key underpinning factors in social care: human rights, communication and recording, safeguarding, dignity, positive risk taking and safety. Person centred planning is critical in getting transition from classroom to practice.
Developing good accessible learning resources. Despite the commercial sensitivity I think it’s always good to share.
Develop content that encourages collaborative, integrative work with health. Giving people the opportunity to contrast medical and social interventions in scenarios helps us to identify which is appropriate, and to value each intervention. Sometimes medical interventions are required so that social interventions are made possible and vice versa.
Providing practical tools that help to bridge the gap between research and practice.
Using case studies that reflect the diverse society in which we live and ask the right questions to push boundaries.
Using the right language. Inappropriate language gives poor messages. For example, ‘wandering’, ‘challenging behaviour’, ‘suffering with dementia’.
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.
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