Dundee City CouncilResponding to Harm in

Care Settings

Brief Overview of Practice in Dundee

• Context

• Current Practice

• Early Indicators of Concern Pilot

• Developments since Pilot

• Future Considerations

Current Practice-Process for Responding to Care Home Concerns CMHT 1 CMHT 2 CM1 CM2 Hospital

Arrange placements, review and respond to concerns individually

Service Manager

Review Team

Provider ForumProvidersLANHSContractsCare Inspectorate

Liaison Provider Review Officer-LA

Individual Reviews Service User Relatives Provider Review Officer-LA + or – NHS

ConcernsService UserRelativesReview Officer-LAProvider+ or – CI+ or - NHS

ASPService ManagerReview OfficerService UserRelativesProviderCI+ or – police+ or - NHS Team Meetings , Database

Head of Service , Service Manager, Contracts Officer, Review Manager

Providers

Current PracticeWhat we know

• The value of having a core team having an overview of all care homes

• The value of having good communication between all stakeholders including informal and formal networks/relationships/processes

• The value of having a core management team who have a good overview of the care homes and a process by which to respond to concerns

Quality of Staffing – Notable increase in Grade 4 (41%) and Grade 5 (44%) and decrease in Grade 3 Adequate (12%) and Grade 2 (3%).

Quality of Management & Leadership – Considerable increase in Grade 4 (49%) and Grade 5 (41%) and decrease in Grade 3 Adequate (10%). No service graded 2 Weak or Grade 1 Unsatisfactory.

0

19

44

23

14

003

12

4144

005

101520253035404550

1 2 3 4 5 6

%

Grade

Quality of Staffing

Dundee 11/12

Dundee 12/13

37

48

21 21

00 0

10

49

41

00

10

20

30

40

50

60

1 2 3 4 5 6

%

Grade

Quality of Management & Leadership

Dundee 11/12

Dundee 12/13

Quality of Care & Support – Notable increase in Grade 4 Good (36%) and Grade 5 Very Good (28%) and decrease in Grade 2 Weak (17%). No service graded 1 Unsatisfactory.

Quality of Environment – Considerable increase in Grade 4 (47%) and Grade 5 (36%) and decrease in Grade 3 Adequate (11%) and Grade 2 (3%).

4.5

33

17

29

15

1.50

17 17

36

28

2

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6

%

Grade

Quality of Care & Support

Dundee 11/12

Dundee 12/13

0

9

50

19 19

30

3

11

47

36

3

0

10

20

30

40

50

60

1 2 3 4 5 6

%

Grade

Quality of Environment

Dundee 11/12

Dundee 12/13

What we Know

• We had good knowledge of the Care Homes in Dundee and the common themes of concerns

• We had a consistent process within the Review Team however no formal processes/thresholds to enable consistent approach to Care Home Concerns across all teams/professionals

• There were a large number of other professionals outwith SW in regular contact with Care Homes who had or potentially would have valuable observations , experience and knowledge similar to our own with no formal process to share this outside ASP procedures

Can we use research to help practitioners

Reflect on their concerns in Care Settings ?

9

Dundee Older People Tool1.Concerns about management, leadership and organisation

There is a lack of leadership by managers, for example managers do not make decisions, set priorities or ensure staff doing job properly.

The service/home is not being managed in a planned way, but reacts to problems or crises.

Managers appear unaware of serious problems in the service. The manager is new and doesn't appear to understand what the service is

set up to do. A responsible manager is not apparent or available within the service. There is a high turnover of staff or shortage of staff. The manager does not inform Social Services that they are unable to meet

the needs of specific service users. Positive observation of practice

2.Concerns about staff skills, knowledge and practice  Staff appear to lack the information, skills and knowledge to support older people

with dementia. Staff appear challenged by some residents' behaviours and do not know how to

support them effectively. Members of staff use negative or judgmental language when talking about

residents. Record keeping by staff is poor Communication across staff team is poor Positive observation of practice 

3. Behaviours, Interactions and Well-being of ResidentsOne or more of the residents Show signs of injury through lack of care or attention. Appear frightened or show signs of fear. Behaviours have changed. Moods or psychological presentation have changed. Residents' behaviours change - perhaps putting themselves or others at risk. Positive observation of practice

4. Concerns about the service resisting the involvement of external people, isolating individuals and lack of open-ness

Managers/staff do not respond to advice or guidance from practitioners and families who visit the service.

The service is not reporting concerns or serious incidents to families, external practitioners or agencies.

Staff or managers appear defensive or hostile when questions or problems are raised by external professionals or families.

Positive observation of practice5. Concerns about the way services are planned and the deliver of

commissioned support There is a lack of clarity about the purpose and nature of the service. The service is accepting residents whose needs they appear unable to meet. Residents' needs as identified in assessments, care plans or risk

assessments are not being met. The layout of the building does not easily allow residents to be supervised

and adequately supported to socialise and engage safely with others. Agreed staffing levels are not being provided. Staff do not carry out actions recommended by external professionals. The service is "unsuitable" but no better option is available. The resident group appears to be incompatible. Positive observations of practice

6. Concerns about the quality of basic care and the environment The service is not providing a safe environment. There is a lack of activities or social opportunities for residents. Residents do not have as much money as would be expected. Equipment is not being used or is being used correctly. The home is dirty and shows signs or poor hygiene. There is a lack of care of personal possessions. Support for residents to maintain personal hygiene is poor. Essential records are not kept effectively. Residents' dignity is not being promoted and supported. Positive observation of practice

Comments: Reported to: Action Taken:

Worker Name: Role: Date:

All concerns/information to be passed to Agreed Person for recording once any actions complete as required/appropriate .

Early Indicators of Concern ToolOpportunities

• To validate what our experiential knowledge had told us re concern/harm in care homes

• To offer formal consistent guidance re awareness of potential contributory factors to harm in the care home setting

• To act as a vehicle to formulating concerns and process and act on them in a meaningful way, individually and as a contribution to the ‘bigger picture’ for ALL practitioners

Challenges from the Pilot

Exercise

Case Example

• Management• New Owner• Concern re approach to

individual care needs• Resident absconded• Poor reporting• Drug errors• Thefts• Response to relatives

concerns

Working Together to Support and Protect People in Care Settings

Staff and Management of Care Setting

Health Colleagues

Care Inspectorate and other Regulatory and Advisory BodiesAdvocacy Services

Social Work Staff

Contracts Staff

Service User Family/Friends/Representative

Early Indicators of Concern-Visitors/staff/residents-Guidance

Early Indicators of Concern-SW-Procedures EIC Database

ASP Contract/Quality Monitoring Large Scale Investigation

Good Model of Partnership Working in Response to Care Setting Concerns in Dundee

Microsoft Word Document

Microsoft Word 97 - 2003 Document

On-going Work

Formal training for ALL staff is being supported by SW Workforce Learning and Development on :-

• The Early Indicator of Concern guidance for visiting professionals• The Early Indicator of Concern procedures for SW staff• The Early Indicator of Concern Database • The relationship between Early Indicators of Concern-Adult

Protection-Contract Monitoring-Large Scale Investigations.

• Identified 2 care homes-1 LA and 1 private to consider a tool/s that service- users/visitors and staff could use themselves to consistently and pro-actively recognise/communicate and act any concerns

Final Thoughts

• The tool and procedures are to support not replace professional judgement

• The objective is to offer practitioners/stakeholders

a way to organise their thoughts so that they can act more confidently and effectively in supporting improvement and protection within care settings

Final Thought

Pro-active rather than Reactive

Awareness-Information Sharing-Action

jillian.low@dundeecity.gov.uk