Workshop that highlights the work done with the University of Hull to identify early indicators of concern in care settings which may, if unresolved, affect the safety and well being of residents. Further development has been undertaken to develop these early indicators into good practice guidance, which assists staff members and other relevant stakeholders to work in a preventative way and promotes good partnership working. Contributed by: Dundee City Council

1. Dundee City Council
Responding to Harm in
Care Settings

2. Brief Overview of Practice in Dundee
• Context
• Current Practice
• Early Indicators of Concern Pilot
• Developments since Pilot
• Future Considerations

3. 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 Forum
Providers
LA
NHS
Contracts
Care Inspectorate
Liaison
Provider
Review Officer-LA
Individual Reviews
Service User
Relatives
Provider
Review Officer-LA
+ or – NHS
Concerns
Service User
Relatives
Review Officer-LA
Provider
+ or – CI
+ or - NHS
ASP
Service
Manager
Review Officer
Service User
Relatives
Provider
CI
+ or – police
+ or - NHSTeam Meetings , Database
Head of Service , Service Manager, Contracts Officer, Review Manager
Providers

4. Current Practice
What 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

5. 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
00
3
12
41
44
0
0
5
10
15
20
25
30
35
40
45
50
1 2 3 4 5 6
%
Grade
Quality of Staffing
Dundee 11/12
Dundee 12/13
3
7
48
21 21
00 0
10
49
41
0
0
10
20
30
40
50
60
1 2 3 4 5 6
%
Grade
Quality of Management & Leadership
Dundee 11/12
Dundee 12/13

6. 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
3
0
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

7. 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

8. Can we use research to help
practitioners
Reflect on their concerns in Care Settings ?

9. Dundee Older People Tool
1.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 Residents
One 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 practice
5. 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
9
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.

10. Early Indicators of Concern Tool
Opportunities
• 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

12. Challenges from the Pilot

13. Exercise

14. Case Example
• Management
• New Owner
• Concern re approach to
individual care needs
• Resident absconded
• Poor reporting
• Drug errors
• Thefts
• Response to relatives
concerns

15. 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 Bodies
Advocacy Services
Social Work
Staff
Contracts Staff
Service User Family/Friends/Representative

16. 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

17. 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

18. 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

19. Final Thought
Pro-active rather than Reactive
Awareness-Information Sharing-Action
jillian.low@dundeecity.gov.uk