Dignity, Risks and Responsibility in Residential Homes for Elderly People Herbert Laming Chief Inspector, Social Services Inspectorate,
Department of Health, Richmond House,
INTRODUCTION to congratulate Counsel and Care and the Royal for organising a Seminar on this subject. It Health of Society is not only timely, but it is of immense importance to the current and future residents of homes, and to the future of residential care in this country. I hope that you will not take it amiss if I say that I have a slight quibble about the wording of the title of the Seminar. It seems to me so easy to slip into talking about ’the elderly’ as if they are an homogeneous group with the same needs, hopes and resources. Because of that I
I would like
think it is important that we talk about elderly people and keep trying to highlight their separate identity. I mention that also because I believe the nature of residential care in this country is changing rapidly. It is not just that people are living longer and therefore have very different needs from residents of previous generations who were by and large much younger and much more ambulant. It’s not just that people are surviving with many more severe disabilities some with multiple handicaps, and therefore needing much more intensive and more personal help. It is also and perhaps most importantly, the fact that many more people are being helped to live in their own homes or in sheltered housing. The result is that when people take up residence in a home, they are in most instances very much more frail, more likely to be confused, more likely to experience incontinence and more likely to have a range of disabilities. It is therefore important to recognise that the characteristics of the clientele have changed and are continuing to change. Therefore the structure of buildings needs to change so that people who may be confused or may have impaired hearing or limited vision are going to feel secure rather than overwhelmed by being part of a big bustling centrally directed institution. It is not just the buildings. The staffing needs to change both in terms of numbers and skills. It is necessary to have staff who understand what it is like to lose some bodily powers, to lose some of one’s physical functionings and to have intermittent periods of confusion or even dementia. The first point I wish to emphasise is that residential services need to be properly planned, properly managed and adequately staffed. They need to be based upon good systems which include everything from information about the services, through referral procedures, mission arrangements and include the large and small things which together add up to ’quality of life’.
79 Whitehall, London SW1A 2NS
The Children Act (1989) and the accompanying guidance draws attention to general principles and good practice. These relate extremely well to the principles set out in the report chaired by Lady Wagner entitled ’A Positive Choice’, the document produced by the Centre for the Policy for Ageing entitled ’Home Life: a code of practice for residential care’ and the Social Services Inspectorate (SSI) documents on ’Homes are for Living In’ and ’Caring for Quality’. There is therefore a huge body of knowledge available about the ingredients of good practice. It is worthwhile just highlighting a few elements to illustrate those things which together help vulnerable people maintain their dignity and their self-esteem when they move into residential care. Firstly, we must ensure that momentous decisions about long term care are never made at a time of crisis. It may be necessary to arrange short-term care at such a time, so that big decisions are made in an atmosphere of calm and consideration of the options. Before people give up their own home and move into a residential establishment, they need to have full information about the home, the life style and what it might mean for them. It follows that the individuals must, so far as is possible, be involved in the decision-making process. Furthermore, if at all possible the individual should have a period of preparation which might be thought of as a ’trial period’ when issues are being considered and no final decision has yet been reached. And during this period they need counselling and support. I would suggest that the way admissions are organised speaks volumes about the philosophy and the standards of practice in the home. Moving into residential establishment is a momentous decision and many people understandably fear that they are giving up all control of their own lives. Living with strangers can be a curious experience for any of us, but it is much more demanding if one is old and frail, fearful and faced with the prospect that it might be for the remainder of one’s life. In other words people need time to understand that moving into a residential establishment can be a really good experience that can enhance the quality of life and give security. The move can give them a sense of well being and at the same time remove the loneliness, isolation and fear that many experience living in their own homes. But people need time and support in making that decision. This is particularly so when we consider that the average age of admission into homes for old people is now over 82 and that many residents are disabled in some way. However, it needs to
192 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
a~
be emphasised that because someone is no longer able to do everything for themselves it does not mean that they can do nothing for themselves. One of the biggest challenges in residential care is trying to ensure that each resident continues to
operate at the maximum of their abilities and that wherever rather than precipitate
possible we preserve independence greater dependency.
DIGNITY
’
The title of the Conference identifies dignity as one of its main themes. I have taken the liberty of re-ordering the title so that I can focus first on dignity because I suggest that it so underpins good practice that if we can get this bit right the rest will almost certainly fall into place. In other words the policies, the procedures and the practices’ need to be based upon a commitment to ensuring a life style for each resident which enhances their sense of worth, supports good morale and makes them feel valued as a human being. Dignity was one of the 6 elements identified in the Social Services Inspectorate report ’Homes are for Living in’ (HMSO, 1989). The others were: ~
privacy
~
choice
~
fulfilment
ful living within a group are not at the expense of individual freedom and rights. Great progress has been made in recent years in helping staff to recognise individual need within a group situation. It is important that we go on helping staff to develop confidence, sensitivity, and judgement so they know how and when to intervene. In particular that they know when to do things for residents, and when to let residents do things for themselves. In
independence and rights. Dignity was defined simply as a recognition of the intrinsic value of people regardless of their circumstances. But as Samuel Johnson pointed out in the 18th century, ’there is a wicked inclination in most people to suppose an old man decayed in his intellects. If a young or middle-age man, when leaving a company, does not recollect where he laid his hat, it is nothing; but if the same inattention is discovered in an old man, people will shrug their shoulders, and say, his memory is going’. All too easily that leads to sweeping generalisations about older people, undermining their individuality and even leading to talk of a second childhood. Treating people in their later years as if they are children certainly does not add to their sense of dignity. What is important is that they should feel that the home in which they live does not operate to meet the convenience ~
~
of the staff or administration. It must operate in ways which ensure that well-being of the residents is at the centre of the decision making processes and day by day practices. Furthermore, it recognises that every resident is different, has a different background, different motivation, different aspirations, different resources, different life experience and maybe a different culture and different religion. Respecting the intrinsic value of each individual necessitates knowing each person and ensuring that the way in which authority and power is used in the organisation actually promotes participation and partnership rather than always makes decisions on behalf of others. It is not easy to preserve individual identity whilst operating in a group situation. It requires great skill to ensure that those compromises which are necessary to achieve success-
this connection staff need time, because we all know that it is much easier and quicker to do things for a frail or disabled person than it is to help and support that person doing things for themselves. Standing by and encouraging an elderly person with a shaking hand to try and make, pour and drink a cup of tea, requires much more skill than the staff member making the tea and helping the person drink it. Wherever possible our approach ought to be about finding ways of working with residents, rather than doing things for residents and making them the recipients of our decisions and actions. There are many ways of denying adults dignity. I need not go through them all, but they are about denying residents privacy. Going into their rooms without knocking and’asking their permission. Or not ensuring that residents have their own personal space, and their own personal possessions and being able to keep some of their possessions secure and private. There are many other ways such as the inappropriate disclosure of personal information and the denial of choice. Not being able to guarantee that a resident will always in all circumstances have their own clothing and not someone else’s. Of being thoughtless about leaving someone too long in the toilet or not properly looking after their dentures or their spectacles or ofpressurising residents into passive compliance in order to secure a quiet life. In truth the fewer choices a person has in life the more they depend upon others to defend those choices and to protect their best interests.
RISKS AND UNREASONABLE RESTRAINT In no aspect of life can risk be eliminated. It can be minimised and it needs to be properly managed. A balance needs to be achieved between enabling an individual to achieve their hopes and wishes and at the same time not allowing them to operate in a way which exposes them or others to unreasonable danger. In other words, it is reasonable to allow a resident who is capable of doing so to go out for a walk on their own, even though there will always be risk associated with it. Where as it is unreasonable to allow a confused resident to wander out in the street unsupervised. There are, of course, different levels of risk, but I am sure that most of us are concerned about those areas where there is a potential for serious harm. The danger is that understandable concern, and indeed proper care, will lead to over-protection and unnecessary restriction. At its worst, restraint can be used when it is positively against the best interests of the residents. For example, whilst it is perfectly reasonable to use cotsides on a bed at night in order to protect an elderly person who may be in danger of falling out of bed, it
193 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
...........-.1-~.---,
would be unacceptable to tie that person into a chair. Similarly, it may be essential for the outer doors of a unit to be locked in order to prevent residents walking out into the road, or indeed to prevent intruders, but it would be unacceptable to lock a resident in a room. The more disturbed a resident is, the more personal care they need and that clearly presents a problem for management which needs to be addressed. Where unreasonable restraint is used this may not reflect issues primarily about the residents, but may reflect stress in the staff, frustration, lack of support and lack of supervision. Because risk needs to be it is necessary for every establishment least 4 well established features which are:
properly managed, have an
to
policy, which recognises risk as feature of social care, but which also sets out a clear statement to managers and staff as they carry out their
1. A succinct statement of a
responsibilities.
.....................................................................
Local authorities are now well advanced in setting up local inspection units and I am sure that more will be said about this.
CONCLUSION The Government’s Citizen’s Charter reinforces in averypowerful way much that I have said. It places the citizen at the centre and its aim is to bring about a different philosophy which is to ensure that services work for users rather than the other way round. The Government is looking to all providers of services to apply the messages of the Citizen’s Charter in their local situations. In addition the Government has increased the money available for training of staff this year to a record sum of £29m. The Government is committed to a high standard of residential care and it is a challenge to us all to ensure that in all homes the judgement about standards is based upon the quality of life of each resident. We need to encourage and support each other as we aim to achieve together that very worthy goal.
2. A strategy for managing risk, which requires a regular review of the design of the building, adequate staffing rotas and a proper system of training and support to staff. 3. Practice guidelines which set out clear statements on risk indicators and clear guidance to staff about what is acceptable and what is unacceptable. 4. Risk taking can only be successful if it is done within a
proper framework of staff supervision and support. Individual members of staff should not be expected to make decisions which may expose a resident to an unreasonable degree of risk without proper support and
supervision.
RESPONSIBILITIES Everyone in the field of the planning, managing and operating residential care has responsibilities, but so also have relatives, residents and a’whole range of other visitors to residential homes. It is always difficult to know what goes on behind closed doors and every organisation that provides residential establishments, needs to have in place, systems for ensuring that as far as possible concerns of residents are heard and acted upon. The most dangerous situations occur when homes are seldom visited or when there is a conspiracy of silence and as it were, everyone looks the other way. We carry moral responsibilities, as one human being to another, professional responsibilities and also managerial responsibilites. In all of this it is essential that there is open communication. The Community Care legislation requires authorities to have in place a Complaints Procedure, but that Complaints Procedure needs to be set in the context of reinforcing a message to residents that ’we value your opinion’. It is clearly undesirable for things to be left unattended until a formal Complaints Procedure has to be invoked. On the contrary, it is very important that residents feel that the home is for them, that they can exercise choice about the way in which services are provided and that they can express opinions about how things might be done differently so that their quality oflife would be improved.
194 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
Department of Health, Richmond House,
INTRODUCTION to congratulate Counsel and Care and the Royal for organising a Seminar on this subject. It Health of Society is not only timely, but it is of immense importance to the current and future residents of homes, and to the future of residential care in this country. I hope that you will not take it amiss if I say that I have a slight quibble about the wording of the title of the Seminar. It seems to me so easy to slip into talking about ’the elderly’ as if they are an homogeneous group with the same needs, hopes and resources. Because of that I
I would like
think it is important that we talk about elderly people and keep trying to highlight their separate identity. I mention that also because I believe the nature of residential care in this country is changing rapidly. It is not just that people are living longer and therefore have very different needs from residents of previous generations who were by and large much younger and much more ambulant. It’s not just that people are surviving with many more severe disabilities some with multiple handicaps, and therefore needing much more intensive and more personal help. It is also and perhaps most importantly, the fact that many more people are being helped to live in their own homes or in sheltered housing. The result is that when people take up residence in a home, they are in most instances very much more frail, more likely to be confused, more likely to experience incontinence and more likely to have a range of disabilities. It is therefore important to recognise that the characteristics of the clientele have changed and are continuing to change. Therefore the structure of buildings needs to change so that people who may be confused or may have impaired hearing or limited vision are going to feel secure rather than overwhelmed by being part of a big bustling centrally directed institution. It is not just the buildings. The staffing needs to change both in terms of numbers and skills. It is necessary to have staff who understand what it is like to lose some bodily powers, to lose some of one’s physical functionings and to have intermittent periods of confusion or even dementia. The first point I wish to emphasise is that residential services need to be properly planned, properly managed and adequately staffed. They need to be based upon good systems which include everything from information about the services, through referral procedures, mission arrangements and include the large and small things which together add up to ’quality of life’.
79 Whitehall, London SW1A 2NS
The Children Act (1989) and the accompanying guidance draws attention to general principles and good practice. These relate extremely well to the principles set out in the report chaired by Lady Wagner entitled ’A Positive Choice’, the document produced by the Centre for the Policy for Ageing entitled ’Home Life: a code of practice for residential care’ and the Social Services Inspectorate (SSI) documents on ’Homes are for Living In’ and ’Caring for Quality’. There is therefore a huge body of knowledge available about the ingredients of good practice. It is worthwhile just highlighting a few elements to illustrate those things which together help vulnerable people maintain their dignity and their self-esteem when they move into residential care. Firstly, we must ensure that momentous decisions about long term care are never made at a time of crisis. It may be necessary to arrange short-term care at such a time, so that big decisions are made in an atmosphere of calm and consideration of the options. Before people give up their own home and move into a residential establishment, they need to have full information about the home, the life style and what it might mean for them. It follows that the individuals must, so far as is possible, be involved in the decision-making process. Furthermore, if at all possible the individual should have a period of preparation which might be thought of as a ’trial period’ when issues are being considered and no final decision has yet been reached. And during this period they need counselling and support. I would suggest that the way admissions are organised speaks volumes about the philosophy and the standards of practice in the home. Moving into residential establishment is a momentous decision and many people understandably fear that they are giving up all control of their own lives. Living with strangers can be a curious experience for any of us, but it is much more demanding if one is old and frail, fearful and faced with the prospect that it might be for the remainder of one’s life. In other words people need time to understand that moving into a residential establishment can be a really good experience that can enhance the quality of life and give security. The move can give them a sense of well being and at the same time remove the loneliness, isolation and fear that many experience living in their own homes. But people need time and support in making that decision. This is particularly so when we consider that the average age of admission into homes for old people is now over 82 and that many residents are disabled in some way. However, it needs to
192 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
a~
be emphasised that because someone is no longer able to do everything for themselves it does not mean that they can do nothing for themselves. One of the biggest challenges in residential care is trying to ensure that each resident continues to
operate at the maximum of their abilities and that wherever rather than precipitate
possible we preserve independence greater dependency.
DIGNITY
’
The title of the Conference identifies dignity as one of its main themes. I have taken the liberty of re-ordering the title so that I can focus first on dignity because I suggest that it so underpins good practice that if we can get this bit right the rest will almost certainly fall into place. In other words the policies, the procedures and the practices’ need to be based upon a commitment to ensuring a life style for each resident which enhances their sense of worth, supports good morale and makes them feel valued as a human being. Dignity was one of the 6 elements identified in the Social Services Inspectorate report ’Homes are for Living in’ (HMSO, 1989). The others were: ~
privacy
~
choice
~
fulfilment
ful living within a group are not at the expense of individual freedom and rights. Great progress has been made in recent years in helping staff to recognise individual need within a group situation. It is important that we go on helping staff to develop confidence, sensitivity, and judgement so they know how and when to intervene. In particular that they know when to do things for residents, and when to let residents do things for themselves. In
independence and rights. Dignity was defined simply as a recognition of the intrinsic value of people regardless of their circumstances. But as Samuel Johnson pointed out in the 18th century, ’there is a wicked inclination in most people to suppose an old man decayed in his intellects. If a young or middle-age man, when leaving a company, does not recollect where he laid his hat, it is nothing; but if the same inattention is discovered in an old man, people will shrug their shoulders, and say, his memory is going’. All too easily that leads to sweeping generalisations about older people, undermining their individuality and even leading to talk of a second childhood. Treating people in their later years as if they are children certainly does not add to their sense of dignity. What is important is that they should feel that the home in which they live does not operate to meet the convenience ~
~
of the staff or administration. It must operate in ways which ensure that well-being of the residents is at the centre of the decision making processes and day by day practices. Furthermore, it recognises that every resident is different, has a different background, different motivation, different aspirations, different resources, different life experience and maybe a different culture and different religion. Respecting the intrinsic value of each individual necessitates knowing each person and ensuring that the way in which authority and power is used in the organisation actually promotes participation and partnership rather than always makes decisions on behalf of others. It is not easy to preserve individual identity whilst operating in a group situation. It requires great skill to ensure that those compromises which are necessary to achieve success-
this connection staff need time, because we all know that it is much easier and quicker to do things for a frail or disabled person than it is to help and support that person doing things for themselves. Standing by and encouraging an elderly person with a shaking hand to try and make, pour and drink a cup of tea, requires much more skill than the staff member making the tea and helping the person drink it. Wherever possible our approach ought to be about finding ways of working with residents, rather than doing things for residents and making them the recipients of our decisions and actions. There are many ways of denying adults dignity. I need not go through them all, but they are about denying residents privacy. Going into their rooms without knocking and’asking their permission. Or not ensuring that residents have their own personal space, and their own personal possessions and being able to keep some of their possessions secure and private. There are many other ways such as the inappropriate disclosure of personal information and the denial of choice. Not being able to guarantee that a resident will always in all circumstances have their own clothing and not someone else’s. Of being thoughtless about leaving someone too long in the toilet or not properly looking after their dentures or their spectacles or ofpressurising residents into passive compliance in order to secure a quiet life. In truth the fewer choices a person has in life the more they depend upon others to defend those choices and to protect their best interests.
RISKS AND UNREASONABLE RESTRAINT In no aspect of life can risk be eliminated. It can be minimised and it needs to be properly managed. A balance needs to be achieved between enabling an individual to achieve their hopes and wishes and at the same time not allowing them to operate in a way which exposes them or others to unreasonable danger. In other words, it is reasonable to allow a resident who is capable of doing so to go out for a walk on their own, even though there will always be risk associated with it. Where as it is unreasonable to allow a confused resident to wander out in the street unsupervised. There are, of course, different levels of risk, but I am sure that most of us are concerned about those areas where there is a potential for serious harm. The danger is that understandable concern, and indeed proper care, will lead to over-protection and unnecessary restriction. At its worst, restraint can be used when it is positively against the best interests of the residents. For example, whilst it is perfectly reasonable to use cotsides on a bed at night in order to protect an elderly person who may be in danger of falling out of bed, it
193 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
...........-.1-~.---,
would be unacceptable to tie that person into a chair. Similarly, it may be essential for the outer doors of a unit to be locked in order to prevent residents walking out into the road, or indeed to prevent intruders, but it would be unacceptable to lock a resident in a room. The more disturbed a resident is, the more personal care they need and that clearly presents a problem for management which needs to be addressed. Where unreasonable restraint is used this may not reflect issues primarily about the residents, but may reflect stress in the staff, frustration, lack of support and lack of supervision. Because risk needs to be it is necessary for every establishment least 4 well established features which are:
properly managed, have an
to
policy, which recognises risk as feature of social care, but which also sets out a clear statement to managers and staff as they carry out their
1. A succinct statement of a
responsibilities.
.....................................................................
Local authorities are now well advanced in setting up local inspection units and I am sure that more will be said about this.
CONCLUSION The Government’s Citizen’s Charter reinforces in averypowerful way much that I have said. It places the citizen at the centre and its aim is to bring about a different philosophy which is to ensure that services work for users rather than the other way round. The Government is looking to all providers of services to apply the messages of the Citizen’s Charter in their local situations. In addition the Government has increased the money available for training of staff this year to a record sum of £29m. The Government is committed to a high standard of residential care and it is a challenge to us all to ensure that in all homes the judgement about standards is based upon the quality of life of each resident. We need to encourage and support each other as we aim to achieve together that very worthy goal.
2. A strategy for managing risk, which requires a regular review of the design of the building, adequate staffing rotas and a proper system of training and support to staff. 3. Practice guidelines which set out clear statements on risk indicators and clear guidance to staff about what is acceptable and what is unacceptable. 4. Risk taking can only be successful if it is done within a
proper framework of staff supervision and support. Individual members of staff should not be expected to make decisions which may expose a resident to an unreasonable degree of risk without proper support and
supervision.
RESPONSIBILITIES Everyone in the field of the planning, managing and operating residential care has responsibilities, but so also have relatives, residents and a’whole range of other visitors to residential homes. It is always difficult to know what goes on behind closed doors and every organisation that provides residential establishments, needs to have in place, systems for ensuring that as far as possible concerns of residents are heard and acted upon. The most dangerous situations occur when homes are seldom visited or when there is a conspiracy of silence and as it were, everyone looks the other way. We carry moral responsibilities, as one human being to another, professional responsibilities and also managerial responsibilites. In all of this it is essential that there is open communication. The Community Care legislation requires authorities to have in place a Complaints Procedure, but that Complaints Procedure needs to be set in the context of reinforcing a message to residents that ’we value your opinion’. It is clearly undesirable for things to be left unattended until a formal Complaints Procedure has to be invoked. On the contrary, it is very important that residents feel that the home is for them, that they can exercise choice about the way in which services are provided and that they can express opinions about how things might be done differently so that their quality oflife would be improved.
194 Downloaded from rsh.sagepub.com at UNIVERSITAET OSNABRUECK on May 26, 2015
