Early indicators of concern in adult care settings E40


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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

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  • Intro:-Context of Placements Current PracticeThe Early Indicators of Concern PilotFuture considerations following the PilotMy reference will be Older People as this is my area of experience and responsibility however a similar Pilot was being tested in our Learning Disabilities Service focussing , not only on Care Homes but also supported housing services and included an integrated Health and Social Work Service. Unfortunately due to unforeseen circumstances the progress has been slower in this area however the principles and initial pilot proposal was very similar in both service areas.
  • However I think we manage this challenge quite well as this diagram shows . We have good relationships and forums with most of our stakeholders, enabling us to share information in an open and honest manner. As starting point ,individual reviews and response to concerns are by the teams making the placements and they are supported and guided by the service manager re more significant concerns. We are fortunate that although we do not have a formal process for sharing concerns between ALL teams yet; having the same service manager responsible for all the Care Homes placements enables information from all the teams to be considered collectively when making decisions regarding a service. In the Review Team as well as a having similar processes to the other teams we also have a number of other forums in which we gain and share knowledge of our care homes , including:-Our providers forum which is seen as a partnership improvement network ,Our informal liaison roles in which each Review Officer is allocated a home encouraging relationship building, support and information sharingIndividual Service User Reviews which enable us to focus on individuals care needs and provision Individual Responses to concerns andFull Adult Protection Processes These forums enable us to build a good knowledge base of our care homes from a wide range of stakeholders.In the Review Team we then share any relevant information from each of these forums at our team meetings and record the information on our team database .This information is then used to raise awareness of any issues in individual care homes, offering a context for future visits and or an opportunity to have a discussion with providers ,care inspectorate , contracts section , service manager and head of service as appropriate depending on the concerns being raised.This information has proven to be very useful alongside CI reports and feedback via our Contracts Officer , giving a wider context to inform decisions re services e.g.reduction of quality payments, action plans, embargo’s etcWe have been able to express a view on whether a poor grade has been expected as part of concerns or appears to be a blip in a generally good service .We have been able to ‘track’ staff who have caused concern and move around services encouraging safe recruitment and good reporting to professional bodies
  • So from our current practice we knew:- above
  • So when we were approached by the Scottish Government to be involved in the Abuse in Care Pilot we thought it would be a great opportunity to-next slide
  • Essentially what we did was ask each practitioner to use the tool not to ‘inspect’ care homes but to reflect on any concerns they had in the course of their contact with a service ,act appropriately and we asked them to record this on a database. For the purpose of the Pilot we were not specific re how and when action would be taken , leaving this to professional judgement, in keeping with established practice and professional responsibility.The database was monitored and considered as per existing processes by the review Team manager and contracts officer.
  • As with many practice issues , what on paper appeared to be a straightforward process quickly became much more complex and challenging and although practitioners outwith the original process are beginning to think about and contribute to the bigger picture of service concern ,the quality of the information received via the new database is variable making it difficult to analyse and use it as anticipated.
  • Concerns were being raised re management arrangements in a particular homeChange in ownershipPoor response to managing care needs-challenging behaviourPoor reportingDrug errorsTheftsPoor response to relatives concernsResident abscondingThese concerns were raised by individual workers across 3 teams ,via CI complaints and by the care home staff and involved a number of residents over a period of mths. The individual concerns had been addressed individually however from our existing processes we were able to collate that information and move away from individual concerns to a more collective perspective/concern of the service and take action accordingly. This involved working with the existing manager, new owners and the CI to agree action plans and an embargo of the service until the service improved .
  • I hope throughout this Presentation I have demonstrated how via the 4 Quality Themes I would contribute to ensuring a Good Quality of Life for Service Users at Menzieshill . However I understand this would be an on-going Process of Continuous Improvement Involving Key Stakeholders..
  • When we started the Research in Dundee we used the term ‘Abuse in Care’ from the original Research and quickly re-named our Tool-Early Indicators of Concern.As Dave says the tool itself does not evidence Abuse, we are saying some or patterns of concern from the Tool, may indicate a risk and by being Proactive rather than reactive ,being aware, sharing information and taking action sooner, we may be able to reduce the risk of actual harm occurring.
  • Early indicators of concern in adult care settings E40

    1. 1. Dundee City Council Responding to Harm in Care Settings
    2. 2. Brief Overview of Practice in Dundee • Context • Current Practice • Early Indicators of Concern Pilot • Developments since Pilot • Future Considerations
    3. 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. 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. 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. 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. 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. 8. Can we use research to help practitioners Reflect on their concerns in Care Settings ?
    9. 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. 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
    11. 11. Challenges from the Pilot
    12. 12. Exercise
    13. 13. Case Example • Management • New Owner • Concern re approach to individual care needs • Resident absconded • Poor reporting • Drug errors • Thefts • Response to relatives concerns
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. 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
    18. 18. Final Thought Pro-active rather than Reactive Awareness-Information Sharing-Action jillian.low@dundeecity.gov.uk