Could self-management work in care homes?

This blog is co-authored by Helen Sanderson, founder of Wellbeing Teams and Alex Fox, CEO of Shared Lives Plus.

Social care’s inspectors, CQC, consistently find that smaller care homes are, on average, better than big care homes. John Kennedy’s JRF research into older people living in care homes found, unsurprisingly, that relationships are key: people want where they live to feel like a real home.

The number of small care homes is reducing, however, because the economics of running a small care home are increasingly difficult. Care home businesses are consolidating as the pressure increases. This shouldn’t inevitably mean that each individual service gets larger, but care homes for older people with 100 beds are commonplace. This may create economies of scale for those businesses, but it may equally create dis-economies of scale, as the markers of great value in care can become harder to achieve in services which reach institutional scale: feeling connected and human both inside the service and with the wider community. Where those businesses are hierarchical, it can also be harder to foster the trust in workers, personal sense of responsibility and autonomy that create transformational support relationships in social care. Some of the largest businesses have financing and ownership models which feel a long way from the idea of ‘community’ or ‘social’ care, and appear to have been used partly as vehicles for risky property speculation. We have seen some huge care provider bankruptcies affecting thousands of older people and there may be more on the way.

So, given that half a million people live in care homes is there a way to create the high value and quality of small care homes, with the economies of scale on things like training and registration which larger businesses can enjoy, but without the added costs of large management infrastructures and profit-hungry big business models?

One approach is the household model, where a care home is divided into small, self-contained households with a focus on creating a family like atmosphere. Dementia Care Matters supports care homes to use this approach and become Butterfly Care Homes. One Butterfly Care Home in Nottinghamshire reports a 43% reduced incidence of falls and 1.7% reduction in staff sickness.

Belong villages have a similar household model. Each Belong household is grouped into an ‘extended family’ sized community for around 12 people, with bedrooms that lead into an open-plan shared communal space, and a kitchen.

In both Butterfly Care Homes and Belong Villages team members often have greater autonomy than traditional care homes. Could self-management take this further?

One of the most promising and widely-talked about ways of organising care and support teams is the Buurtzorg community care model from the Netherlands: recruiting people who are able to work as part of small self-managing teams, supported by coaches rather than a traditional line management structure, with use of tech and data to track activity, payments and outcomes. This model can create better-paid, more fulfilling and autonomous roles, in which people have the time to build consistent relationships, and get better outcomes, at lower overall cost where people can move to independence, because of the better outcomes and vastly reduced need for management infrastructure.

A new briefing paper from the RSA boldly suggests that self-management could save social care. The paper describes five case studies from the UK. One of these case studies is Cornerstone in Scotland, who have drawn inspiration from it to completely reimagine what a large support business looks like around a self-managing rather than hierarchical management structure. The Wellbeing Teams model, which provides integrated, holistic community care on Buurtzorg-like principles, has already been awarded ‘outstanding’ by inspectors, CQC, as has a Buurtzorg UK team. Building-based care services have been slower to experiment with the self-managing model, perhaps because people who are attracted to a devolved, relationship-based way of working have tended to have more affinity for community-based care, but the model’s benefits are arguably most needed in the part of our sector which is most at risk of institutionalisation.

A fully scalable self-managing approach to care homes would perhaps look something like this:

  • Small, ‘home-sized’ care homes or using a household model, with teams recruited who had the skills and aptitude to self-manage, sharing responsibility rather than leaning on a traditional management structure.
  • Those small, largely autonomous businesses networked within a franchise-like structure, with a centrally-developed IT and finance system to track activity, outcomes and payments.
  • Coaches supporting each team and communities of practice for teams to share their challenges, innovations and learning.

Self-management wouldn’t be a panacea for the care home industry: self-managing teams in care homes would also need to adopt the most personalised and empowering cultures and approaches. The best care homes have strong links with their local communities. Few people want to volunteer for a large, faceless company, but where a care home feels genuinely like part of the community, there is huge scope for added value through volunteering, forming Community Circles and the invaluable benefits to health and wellbeing of feeling part of a community, not removed from it. This would fit particularly well with a mutual model of ownership, in which residents, families and perhaps even the wider community had a stake, as well as workers.

Often when we talk about reforming and personalising social care, we focus on models which are the most community-embedded, or, like Shared Lives, seen as the most innovative. But we need to gains of personalisation to reach the whole of social care: they can’t be reserved for the lucky few. There may be models of self-management in the care homes industry which we haven’t included here, so we would be grateful to hear of any examples we have missed. And if you are in the industry and just hearing about or starting to consider this radical transformation, we would love to hear from you. We will be happy to add links to this blog, but most of all we would love to start a new conversation.

Imagine having another 8 minutes of social interaction a day

CMM reports that “Just ten minutes of social interaction a day improves wellbeing in dementia care”, according to a study by researchers at University of Exeter Medical School, King’s College London and the Social Care Institute for Excellence (SCIE). “The Wellbeing and Health for people with Dementia (WHELD) programme trained care home staff to increase social interaction from two minutes a day to ten, combined with a programme of personalised care. It involves simple measures such as talking to residents about their interests and involving them in decisions around their care.”

This is important work by the universities and SCIE, but how heartbreaking that a study is required to prove the need to people with dementia to have just ten minutes a day of social interaction, and that previously they could expect just two. What would the wellbeing and health of people with dementia be like if they received an hour a day of social interaction? What would any our wellbeing be like if we could look forward to just ten?

This is why we need socially-based models of support like Shared Lives and Homeshare, and why people consistently report that they are happier and healthier within them. We need as much investment in researching the groundbreaking impacts of these smaller, social models, as we have currently into tweaking existing models which can seem to offer people so little.

Little miracles

I’m grateful to Anne Watts for getting in touch to share a little about her inspiring lifestyle, built around caring for others, which she writes about in her blog (eg The Blue Dictionary and The Woman from Belgium) and books which you can find here: www.annewatts.co.uk . Ann’s way of living has elements of both Shared Lives and Homeshare. It seems extraordinary, but I wonder how many others live in this way or as Anne suggests below, would be willing to? Anne says of Shared Lives:

“Like all the best ideas, it is simple, straight forward and provides fertile ground for the little miracles of healing and kindness  that carers see every day, and  you certainly do in your work.

My back ground is in nursing (50 years of it – and going strong). Since returning home in 2000 I saw how there were great yawning gaps in the caring profession, not being adequately addressed, just tinkering around the edges over the ensuing years.

The inadequate warehousing of the vulnerable in society; those with mental health issues, the disabled and the elderly – were unacceptable and I wondered what I could do to help in an effective manner.

Beginning with an elderly relative who was frightened of going into hospital or a care home, I moved in and cared for her within the stable, secure and much loved home she had shared with her recently deceased husband. She flourished, became her old self, had a quality of life she began to enjoy again and died peacefully at home, with family around her, two years later.

Immediately I was inundated with requests from people to care for their parent etc. And have done this now for some 10 years.

I am paid in free board and lodging and minimal expenses. In return I live in, shop, clean, cook, drive, and re introduce people to life again. No more sitting alone all day, waiting for a carer to rush in at any given time to give very basic hygiene care.

With a live in carer who can see the life not being lived clearly, there are drives into the countryside, walks, picnics, visits to old haunts, nutritious food, whizzing down the aisles of the supermarket choosing long forgotten favourite foods to enjoy.

Watching someone come back to life is the greatest remuneration there is.

99 year old Eileen had shared many a holiday with her husband in Spain. Since his death (they were married 72 years!) her life had shrunk to sitting alone, waiting to die. Her family were afraid when I suggested taking her back to Spain for one last holiday-“what if she dies on the plane ” etc.”

So, I took her to Sainsbury’s, she chose olives, tapas, red wine and we had regular Spanish picnics in her garden. She always blossomed into the giggly young bride she had once been as she told me all about the times she and her beloved Frank had enjoyed in Spain.

I drove her down to Cornwall to attend her grand daughter’s wedding. She loved it and we stayed three days. She was still talking about the champagne a few days before she passed away 8 months later.

Living life right up to the moment you die – that’s what it’s all about.

Now I live in Oxfordshire, caring for an 80 year old gentleman for whom Parkinson’s Disease is tightening it’s grip. The worry and stress of fearing admissions into hospital have dropped from his face, and the certainty that he is now safe in his own home has given him a new lease on life.

So, I am living the Shared Life ethos in reverse I suppose. I do not have a home of my own, having lived my life helping others in so many ways, but now can offer my skills in this manner. I have been overwhelmed and shocked at the response and requests I field whenever it becomes known that I am ‘available’. The need is all around us – as you well know.

But they can be addressed, a step at a time.

I just wanted you to know I’m out here – and there will be many others who can do what I am doing. Keeping elderly folk out of hospital beds, and fretting about nursing home costs/standards of care and loss of independence.”

www.annewatts.co.uk

 

Are we ‘warehousing’ older people?

A Daily Telegraph report based on recent care home research says that smaller care homes are being replaced by what it describes as large ‘care warehouses’ after a wave of closures. Smaller care homes are finding it increasingly hard to cope with cuts and don’t have the same economies of scale of larger operations, nor the property market investment strategies of the really big corporates.

What the Telegraph report didn’t mention is that the last annual CQC State of Health and Care report was unequivocal in drawing a correlation between better care and smaller settings:

CQC data
CQC data

This isn’t to say that every small care home is great and big ones awful: there are examples of larger services which people enjoy living in and in which they receive great care. But it does suggest that, despite the particular quality challenges faced by smaller homes (eg it’s harder to cope with staff turnover in a small team; there is no corporate training/quality regime to draw on etc), there are elements of providing a caring, safe and perhaps above all, homely, environment, which are inherently easier in smaller settings.

This is certainly the experience of the smallest regulated care settings: Shared Lives schemes, which are limited to a maximum of three people and are homely by virtue of the support offered taking place in an ordinary family home. CQC also says that Shared Lives outperforms even the smallest end of the care homes sector:

CQC data
CQC data

There has been lots of talk (including recommendation 7.3 in the NHSE report by Sir Stephen Bubb), post-Winterbourne View abuse scandal, of CQC refusing to register new institutions for people with learning disabilities to safeguard safety and quality, because the evidence is clear that these kinds of facilities are fundamentally incompatible with community living.

If that’s true for people with learning disabilities, why is it not even discussed when it comes to building ‘warehouses’ for older people?