Behind the facade, beneath the surface – where registered managers need to look and what they need to know
JOHN BURTON writes for CT Extra
John Burton Independent Social Care Consultant <www.standardsforpractice.co.uk>
Head of the Association of Care Managers (ACM) <www.caremanagers.org.uk> August 2012
The manager of a care home is expected to build and maintain an acceptable facade of “service delivery” that complies with regulatory standards. However, truly caring relationships and a sense of community and homeliness are the product of social and emotional, ethical and intellectual analysis and leadership at a much deeper and more complex level.
The important but nevertheless secondary issues of policy and procedure, “quality”, standards, and regulation have taken precedence over the “primary task” (caring and homeliness) that is the sole legitimate purpose of any care home. As the leader of the home, the registered manager has to be exceptionally clear sighted and determined. She or he must stick to the primary task and resist the pressure to gratify external demands at the expense of attending to the needs of residents. When the home is performing the primary task, the facade will no longer be false, and legitimate external expectations will be honestly met.
We are formed by our experience. To what extent is a matter of debate, but there is a general acceptance that our early infancy and childhood have a profound influence on how we live, work and relate to others as adults. Those who live in, work in and lead care homes are vulnerable to and driven by unconscious forces, individually, collectively and institutionally. Like the hospital in Isabel Menzies’ classic study, the “social system” of a care home is an institutionalised “defence against anxiety”. If we are aware of our unconscious world – why we are feeling and behaving as we do; why the whole team is feeling and behaving as they do – we are less at the mercy of our instincts and emotions.
If the manager of a care home is aware of and understands the unconscious forces beneath the surface of the home, the more she or he can support, lead, and enable the staff to give care (give of themselves). To do this the manager must also be supported with the same level of awareness and understanding from outside. Every hour of every day of every year Managing a care home (for people of any age) is a job like no other in the extraordinary demands it makes on the manager.
The organisation (home) cares for people whose high levels of need and dependency require exacting attention and commitment from staff while evoking reflex emotional responses such as love and hatred, desire and disgust which can threaten to overwhelm both individuals and the home itself, and against which individuals and (most significantly at a management level) the whole home will find ways to defend themselves to survive. Care is given day and night every day of the year. Each instance of support encompasses a complex interaction at an emotional level. Even when it appears that staff show no empathy and withhold their human compassion, they are of course attempting to defend themselves against the emotional demands of the job. It isn’t easy to receive care (particularly intimate physical and emotional care) and it isn’t easy to give it. To do it well each person has to have a well practised skill and an understanding of and sensitivity to what’s going on emotionally for themselves and the person in their care. These are not isolated, one-off episodes of care; they are linked, repeated, planned or ad-hoc, cumulative, demanded, relaxed or tense, willing and reluctant, routine or urgent.
All the hundreds of instances of social, emotional and physical support (to name only some of the elements of the care relationship) that occur in the 24-hour life of a care home require highly sophisticated organisation and culture, designed and led to sustain the psychological health of the home, to enable a staff group (in all, probably as numerous as the residents themselves) to give care, knowing that they will get emotional support. Such a home has a very different “feel” to one that prioritises “service delivery”, “compliance” and “quality assurance”. Delivering a service or giving care? The phrase “service delivery” expresses the problem that I am confronting in this article, and the facade we erect to disguise, deny, and defend ourselves against the true nature of the work. Really caring homes are designed and led to perform the primary task – giving care. The whole organisation of such a home is built around giving care.
Every action, every process, every record made, every meeting and training session, every visit or intervention by an outsider must be judged against the question of whether it supports, enables and enhances the primary task. If it doesn’t, it is at best redundant and a waste of time, money and energy, and at worst it gets in the way and subverts the primary task: it is anti-task. The manager who has the insight, determination and courage to eschew the “service delivery” model, thereby challenging him- or herself, the staff, the proprietors, the commissioners, regulators, policy makers, and even government, is too often isolated, exposed and undermined. Those who collude with and depend on the facade have opted for safety and distance from the task. They “deliver a service” as if care was an object or a discrete procedure rather than a give and take, up and down, constantly renegotiable, person to person relationship.
Breaking the collusion – taking authority
In July 1982 I began leading the reform of a 120-place local authority care home. The place was a disgrace and there were many other care homes like it all over the country. Nothing in subsequent scandals of institutional care (including recent examples such as Winterbourne View and Stafford Hospital) has been any worse than what was going on in this home. Outsiders denied responsibility and blamed the managers and staff. I spent my first three months working shifts with every member of staff, doing all the jobs in the home, experiencing this hell at first hand, and writing a review. I took the review to the director of social services. I told him that either he gave me the authority and resources (that had been promised at my interview) to lead real change both inside the home and in the department that was so abusing it, or I would publicise the scandal in the local paper and wider media. I was given the authority to make the major changes that were achieved over the next few years. (Such change takes years not months.)
Leading as the manager of a care home involves taking authority and challenging the collusion that maintains residential care in its despised – and when not despised, patronised – position. Like the councillors and senior managers, like the union bosses and personnel section, the policy and research section, the trainers, social workers, doctors and district nurses, and like the mayor on his Christmas visits, most people knew what was going on, but held their noses, shut their ears and closed their eyes. No one would accept responsibility and accountability. Many of us (care home managers) understand how neglect and abuse are a product of a social care “delivery” system that ignores the primary task while maintaining a sophisticated defensive facade of legislation, regulation, top-down policy and detached management.
We already knew what the admirable Serious Case Review on Winterbourne View has revealed to a wider professional and public audience. We knew that what the Panorama programme (on Winterbourne View) showed was the gross and criminal result of management lies and neglect in pursuit of unearned profit, combined with the failure of all the outside organisations that were accountable to the patients/residents to be true to their primary task (and their own publicity). What was most powerfully conveyed by the close examination of the role of each outside organisation was their despicable collusion (presumably an unconscious process) with Castlebeck’s lies about the “care” that they were “delivering” for £3,500 a week. (Perhaps a prosecution under the Sale of Goods Act 1979 would have been appropriate?) Had any of these organisations understood and been aware – as care home managers must – of the ever present possibility of such collusion, and if there were staff within them who had the courage to challenge it, the scandal of Winterbourne View would not have happened. As it was, it was left to honorable and brave employees and an undercover journalist to put a halt to the abuse and collusion. (The initial attempt, during and immediately following the programme, of the Care Quality Commission to excuse and defend themselves and to divert the blame, illustrates the nature of this collusive facade.) What has been learned from evidence to the Mid Staffs Public Inquiry and what will emerge more coherently in the report (due on October 15th) is that the appalling failure of care and management at Stafford General Hospital resulted from a collusion which went right to the top of the NHS and beyond to MPs and ministers. It took a change of government to allow the full investigation of catastrophic failure at Mid Staffs. The first inquiry revealed what had gone wrong with the care provided by nurses, doctors and managers within the hospital, but those with wider responsibility refused to allow themselves to be examined, and continued to attempt to cover up the truth – to maintain the facade – during the inquiry.
The questions that Government and policy makers, senior managers and regulators – indeed the whole social care establishment – have to ask themselves are:
a) Can I/we face the music? Can I/we accept responsibility and be accountable? Can I/we stop sheltering behind the facade and attend to the primary task? (After all this is what we are asking of care staff and their managers every hour of every day of every year.)
b) And, if we can, if we have the courage, how do we go about it? Recognition and support for care home managers While there are many care home managers who do take the lead and run truly caring and homely residential (and “nursing”) homes, most are isolated and unrecognised, and they succeed in spite of social care policy, not because of it.
Last year the Social Care Association (SCA) and the Association of Care Managers (ACM) launched a campaign to get recognition for registered managers’ leadership role in developing residential care. SCA produced a comprehensive guide to “The Role of the Registered Manager”, meanwhile ACM campaigned to improve regulation and reduce the bureaucratic demands that get in the way of the primary task. Likewise, the Care Providers’ Alliance appointed Denise Platt as their “Red Tape Champion”. With the support of the National Care Forum (NCF) and the National Skills Academy for Social Care, SCA and ACM met with Paul Burstow (the social care minister) with the message that, if the Government is genuinely intending to “transform” social care and care homes, it needs to focus its efforts and resources on the managers and staff, on leadership and practice.
The National Skills Academy surveyed more than a thousand registered managers to discover a body of overwhelmingly committed professionals who are frustrated by lack of time for the primary task and by budgetary and bureaucratic obstacles. In addition, nearly half the respondents identified a conflict of priorities as a main barrier to the job. About a third said that regulations, fear of mistakes, and contradictory advice got in the way of managing good care. Well over two-thirds of those who took part in the survey “would welcome a membership body for registered managers”. The survey report goes on to say (page 43) “It is perhaps felt that it’s only by establishing an official membership body that registered managers will be able to exert a greater collective influence on their own career development, the role that they play in the sector, and the broader perception of adult social care.” There are at least two professional associations already: the SCA, which has been in existence in one form or another for more than 60 years, has a long history of developing professional practice and supporting managers and social care workers through publications, conferences and seminars; and ACM, which is a much more recently formed association specifically for registered managers. Together, these two bodies have a wealth of experience and shared knowledge, and launched the initiative which led to the National Skills Academy survey. These two associations, their members and the thousands of managers who are not members could form a professional body with the experience, knowledge and authority to lead a revolution in residential care. Andrew Lansley called for the “liberation of the NHS” ; care homes need liberating too, and that will only happen when registered managers are able to lead it.
The first step (proposed by SCA, ACM and the National Skills Academy) is to launch a series of local meetings to get registered managers together, sharing their experience and ideas. They will need support and commitment from outside but a professional association must be led by the members. When care home managers get together in “learning sets”, they learn from and support each other; they share experience and think their way through problems together; they innovate and gain confidence; they value themselves and their profession; they learn the techniques of “action learning” and can pass them on by using them with their own teams; and the homes they manage flourish. This has most recently been demonstrated by the inspiring work that the My Home Life project has been doing using action learning sets with care home managers all over the country.
What is missing, as yet, is the combined commitment and support of the policy makers, providers and employers, commissioners and regulators to enable registered managers to take the lead (take authority) in their own career development, the development of residential care, and the broader perception of adult social care. Yes, it has to be said, the courage to change is required from the very people and organisations that have unwittingly colluded to cultivate the conditions in which neglect and abuse can grow. This change needs the commitment of those who have put registered managers in a position where they have no time for the primary task, where homes are underfunded, understaffed and unsupported, where bureaucracy, inept regulation, fear of making mistakes, contradictory advice and conflicting priorities prevail. Real change will not happen without a self-critical reappraisal from those who ordain the direction of policy and currently control care homes from the outside. The manager – the leader – of a well run care home has to have the “capacity for self-authorisation, in other words the courage to act in situations where there is no obvious right thing to do.”
Much as those who set out procedures, standards and regulations would like to think otherwise, caring is full of dilemmas and there are no pat answers. And this is why the manager of the care home must also have the “capacity to contain uncertainty, ambiguity and complexity without resorting to simplistic splitting into good/bad, us/them, etc.” Two further professional qualities are required of the care home manager: “the capacity for reflexivity, that is, to take oneself as an object of inquiry and curiosity and hence to be able to suspend belief about oneself; all this as a way of sustaining a critical approach to oneself, one’s values and beliefs, one’s strengths and weaknesses, the nature of one’s power and authority, and so on.” And “the capacity to contain emotions such as anger, resentment, hope and cynicism without suppressing them and hence to be both passionate and thoughtful.” These qualities are foremost amongst the areas of discussion and development that are worked on when managers get together in learning sets. (All passages quoted in the above paragraph are from Paul Hoggett, Professor of Social Policy and Director of the Centre for Psycho-Social Studies at the University of the West of England.)
Requirements for the good management of residential care
• Primary task – clearly and concisely stated (not a long waffly ‘statement of purpose’).
• The manager must have full authority to lead.
• The manager must be honest in all ways.
• The manager must engage directly and support staff in engaging directly with residents.
• Residents must be able to take a real part in the running of the home. The resources needed
• Adequate staffing – in numbers, training, and supervision – adequately paid with good conditions of employment, and the staff must be organised (rotas, meetings, teams etc.) within a structure that has been designed (and is regularly adjusted) to carry out the primary task.
• Adequate finance – tied to real income – and a budget controlled within the home.
• All the parts of the home – staff, buildings and equipment, catering and finance etc. – must be integrated and managed from within the home as a coherent whole.
The function of outsiders:
• All outside management, administration and monitoring of the home must be tested against the question: “Is this necessary to perform the primary task of the home?” Superfluous outside activity should cease.
• Checking that homes are caring, homely and safe should be the task of truly independent inspectors who should be familiar and accessible to the residents, relatives and staff. They must have the power to investigate and prevent abuse, and they too will concentrate all their efforts on assisting the home in performing its primary task.
• All other outside bodies connected with residential care must serve the same overall function as the homes do – responding to the needs of residents. They too must be judged by what difference they make to the lives and well-being of residents.
• And finally, given adequate resources to do the job, each manager, each member of staff and each home should stand or fall on the same test: “Is this home doing what it was designed to do and what it says it will do? Does it provide the care which residents need? There is little in these requirements that is controversial. Achieving the “liberation” of care homes (to perform their primary task) will be led by registered managers (and some even manage it now). It is the responsibility of those at the top to create the conditions for change and to channel the available resources back to the primary task.
We are asking a lot: the courage to be self-critical and self-aware; the determination to bring about change even when it is painful and will mean loss of power and even jobs. Take down the facade; look beneath the surface; create the conditions for change and, with your support, the registered managers will take the lead.