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Delivering safe care
How can it best be assured?

One of the five key questions addressed and reported on by Care Quality Commission (CQC) in its inspections of health and social care services is, ‘Is the service safe?’. The safety of people in care is affected by a whole range of things, but the first thing in most people’s minds, when thinking about safety, is whether the person receiving support is being abused – physically or verbally.

Of course, everyone wants to know that the right medicines are given at the right time, that a doctor will be called if needed, that the staff are able to transfer people safely, that they won’t be scalded in the bath etc. However, the thing that keeps families, and often clients themselves, awake at night is concern about the attitude and behaviour of staff.

Seven organisational elements

What can and should providers do about this very real concern? There are seven main organisational elements which contribute towards a provider’s ability to deliver safe care. Of these, the first two listed below are absolutely core and essential priorities. The other elements can all play a part, but these two are pre-requisites, without which there can be no assurance that safe care is being delivered.

The seven elements are:

  1. Staff core values.
  2. Local management.
  3. Organisational culture.
  4. Training, supervision and communication.
  5. Incident reporting and review.
  6. Audit.
  7. Policies and procedures.

Some points relating to the other five elements are included in the panel. However, in this article I want to reinforce what I believe are the two main issues.

Staff core values

Any organisation is only as good as the staff it employs. This is a truism. The people who directly deliver care and support are generally:

  • The largest single group of staff within an organisation.
  • The least well-paid.
  • The least well-educated.
  • The least experienced.

None of these factors is the fault of the staff themselves, rather the system in which they work and the values of our wider society, which don’t recognise the importance of their role in terms of pay and status. Addressing these broader issues is not within our gift, although we should all do what we can to pressurise leaders and policymakers to act. However, given these realities, what can we do to minimise the risk that we will end up with people in caring roles who really don’t care?

Minimising risks

There are many things that contribute towards an organisation’s ability to recruit and retain staff with the values required. However, I suggest there are four important practical steps that managers, and particularly those making recruitment decisions, should take:

  1. Use values based recruitment. All the effort in the recruitment process should be towards establishing whether the applicant has the right values. This is much more important than their education or experience. Of course, it’s also more difficult to assess in an interview process, but there are ways in which, through questioning and observation, people’s acceptance of the value of all human beings, irrespective of their age, abilities etc. can be tested. Their reaction to stressful situations can also be explored in a variety of ways.
  2. Training and supervision. In the early stages of a new employee’s work, it is critical, not only that adequate training is given, but that there is close and regular supervision by someone whose own values are not open to question. Supervisors need to observe directly the work of the new employee, and also get feedback from others with whom the person has worked – including, where possible, clients and their families. Some people have an ability to ‘put on a show’, but not many people can keep this up at all times and an inkling of concern, expressed by colleagues or others, should raise alarm bells and ensure close monitoring is maintained.
  3. This is really part of the wider culture of the organisation, but whatever the overall policy and practice, it is critical that, at a local level, there is a clear understanding about the values expected and the obligation on all staff to uphold this and report even the slightest issue of concern. What is perhaps even more important, is that when issues are raised, however trivial they may appear and whoever they are raised by, they are followed up actively and immediately.
  4. Discipline/dismissal. Staff are quite rightly protected from unfair dismissal through employment law, but this can sometimes lead to managers being overly cautious in taking formal action when areas of concern are identified. However, it is critical – and particularly where issues occur early in someone’s employment – that robust action is taken where there is evidence that someone has displayed attitudes or behaviours that are inappropriate. A clear message needs to be given to the individual concerned and the wider workforce. Act early, nip issues in the bud and take no unnecessary risks.

Knowing how hard it is to recruit and retain good staff, it is tempting to compromise both in the recruitment process and in supervision and/or discipline. Managers will be under pressure to maintain staffing levels and avoid use of agency staff. This can drive compromise against an individual’s better judgement, and could lead to them thinking, ‘will I end up with anyone better if I don’t take them’, ‘I’ve got more confidence in someone I can monitor directly than with agency staff’, ‘I’ve advertised three times for this job and there are no better candidates’, for example.

Yes, this will mean some risks have to be taken on occasion – isn’t all recruitment a risk anyway? However, take risks around ability and experience, rather than around values. Where the risk is taken on appointment, ensure that supervision and monitoring is even tighter than it would otherwise be.

Local management

Whether or not a provider has the right culture, provides good training, policies, reporting systems, and the myriad things that make an organisation ‘Good’, it is the quality, approach and values of the local manager that really makes the difference. It has been said by many, including by me on numerous occasions, ‘Show me a good manager and I’ll show you a good service’.

There is lots of evidence to support this assertion. Nowhere has this been better demonstrated to me than during my time with Castlebeck, where I was Operations Director after the Winterbourne View abuse scandal. The CQC’s review of the abuse concluded, ‘There was a systemic failure to protect people or to investigate allegations of abuse,’ and this reflected on the overall organisation as well as the individual service.

However, the organisation still had some excellent services. Those services were managed by competent and committed managers, who often had to battle hard to support their service users and their staff in difficult circumstances. Where there were problems – and this was not just at Winterbourne View – it was evident that whilst there were organisational failings, some of the responsibility lay with weak local management. Again, the CQC’s review stated, ‘There was a lack of leadership and management and ineffective operation of systems for the purposes of monitoring of the quality of service that people receive.’

Priorities

Whilst many factors can contribute to the delivery of safe and, particularly, non-abusive care, staff core values and local management issues are paramount. For organisations looking to ensure safe care for their residents, my strong advice would be to prioritise values-based recruitment, effective supervision, and invest in and support the best management at service level.

Other important factors contributing to the delivery of safe and non-abusive care and support
  • Organisational culture. An organisation should put people before profit, take a long-term view, and value and support the frontline workforce. Owners, directors and managers need to share and live the core values that underpin safe care.
  • Training, Supervision and Communication. Structured and effective training is important, although it will minimally impact on people who don’t start with the right values and beliefs. Equally important is regular and structured supervision, including observation and feedback from others. Perhaps the most neglected is effective communication on a regular basis between the Board, local managers and all staff.
  • Incident reporting and review. It is essential that there is an open and honest culture where all incidents are reported, recorded and reviewed. Lessons need to be learned both from individual incidents and, at a service and organisational level, from the close monitoring of trends to identify things such as individuals who feature regularly in incidents, and patterns in particular locations, at certain times of day or with specific managers or shift leaders etc.
  • At both a service and organisational level, safeguarding and similar issues need to be subject to structured audit, just like the finances are. The safety of care is just as important as health and safety.
  • Policies and procedures. Organisations need comprehensive policies to evidence externally that they have the right approach and systems in place. However, their impact on local, frontline staff should not be over-estimated. Policies and procedures need to be available for reference, but requiring people to read policies has minimal impact when compared with training and supervision.

Colin Young is Managing Director of Nomad Care Management Ltd, developers of CareGuard. He was previously Chief Operating Officer with Leonard Cheshire Disability and Operations Director at Castlebeck Care. Email: colin.young@careguard.uk.com

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