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Review of the culture & clinical safety at Castlebeck

Debra MooreManaging DirectorDebra Moore Associates

+Do we use this a chance to do something different?

“Her death has become one of those major modern occasions where there seems to have been a collective sense of empathy for a stranger’s fate. She has become an embodiment of the betrayal, vulnerability and public abandonment of children.

The inquiry must mark the end of child protection policy built on a hopeless process of child care tragedy, scandal, inquiry, findings, brief media interest and ad hoc political response. There is now a rare chance to take stock and rebuild”

Peter Beresford

Professor of Social Policy, Brunel University

+Personal and professional

+What do I know?

+My response to Winterbourne View

+I choose action

“You have many choices. You can choose forgiveness over revenge, joy over despair. You can choose action over apathy.”

Stephanie Marston

+Abuse - is anyone, anywhere safe?

For 10 years, Gordon Rowe raped, kicked, punched, drugged, starved and neglected the adults with learning difficulties who lived in his residential homes in south Buckinghamshire. (Longcare Inquiry)

One on occasion she attended the hospital at around 6 am to find her mother in a side room calling ‘please help me, please help me’. The patient was covered in dried faeces and was completely naked. She ran down the ward to find the staff ‘chatting and laughing’. She assisted in washing her mother and it was ‘awful’. Her ‘hands were absolutely caked’ and it ‘was dried and it was up her arms and it was round her neck’. The patient died later that night. (Mid Staffordshire)

One person interviewed was raped, age 7, by a family friend; then abused, aged 10, by her foster brother who had Downs Syndrome; and then, at age 14, sexually abused by her cousin. (Lemos & Crane)

In October 2007, Pilkington, then 38, drove herself and her 18-year-old daughter, Francecsca Hardwick, to a layby …the then set the Austin Maestro on fire, killing them both…an inquest heard how the family had been kept virtual prisoners in their own homes by youths who threw stones, flour and other objects and kept up a relentless stream of abuse

+Abuse - is anyone, anywhere safe?

“appalling examples of discrimination, abuse and neglect across the range of health services” Death by Indifference

“People with dementia are the most vulnerable in society and it is shocking that this study has found that they are being subjected to abuse in their own home” Alzheimers Society

Inspectors for the Care Quality Commission - which regulates home care in England - found that 217 companies were employing workers who were not properly qualified. One company in Birmingham employed 23 carers with criminal convictions for offences including theft and assault. One carer in Coventry locked a vulnerable person out in the garden while another put a carrier bag over a care user's head.

Scotland Yard, which is co-ordinating the investigation into Savile's alleged offences, says it is following up 340 lines of inquiry, following complaints of abuse and sexual assault by him. It is also in contact with 14 other police forces. In total, officers are in contact with 40 potential victims.

+In Winterbourne View

What do all these scandals tell us about the setting conditions for abuse?

What is the recipe for disaster?

Lack of voice in terms of service users/families/advocacy Lack of respect for the individuals and their families Unclear purpose and values Mix of service users with widely differing needs Boredom – lack of activities Institutional and impoverished environments Geographically isolated services Low staffing levels and high use of bank/agency staff Poor training and staff development Lack of management supervision and appraisal Closed inward looking culture Poor incident reporting systems and low level governance Weak management and low visibility Lack of clinical/nursing leadership Poor whistleblowing procedures Failure to act on complaints/concerns Poor intra-agency reporting and liaison

Where could we see all this happening?

+Methodology of the review

Site visits to 12 hospitals between June and August 2011 Winterbourne View not included as subject to on-going police

investigation Assessment of services against Confirm & Challenge Outcomes

Framework Review of literature and government policy Interviews and observations with people who use services and their

families Observation of key meetings – service user forum and staff meeting Confidential Interviews with staff across all departments including

housekeeping, administration, nursing, clinical and training Confidential Interviews with Executive Team Analysis of documentary evidence – rota’s, MDT and CPA minutes

and notes, nursing and clinical notes Summit with key stakeholders to inform recommendations (Sept

2011)

+Findings and recommendations 9 key areas 1. Assessment, care planning and therapeutic interventions

2. Multi-disciplinary team working

3. Planning and delivering person centred care

4. A meaningful day

5. Environment and facilities

6. Workforce and staff training

7. Organisational structure and culture

8. Commissioning

9. Clinical governance and patient safety

+Assessment, care planning and therapeutic interventions – key lessons

Ensure a clear purpose and focus for in-patient provision – ‘short term psychiatric assessment & treatment’ with the aim on returning people to the community

Agree admission criteria and a proper care pathways with individual outcome measures and discharge planning from the start

Ensure there are the resources and expertise to deliver specialist interventions – therapies and programmes

Create a meaningful day – combat boredom!

Promote healthy lifestyles

Invest in person centred care planning – INVOLVING PEOPLE & FAMILIES!

+Multi-disciplinary team working – key lessons

Be clear about the role of each person and support activities that bring them different professional groups together such as training

Ensure that the MDT is visible within services and spend time with direct care staff – accountability

The role of named nurse & key worker need to be defined and accountable

Listen and respond to the views of people and families – don’t confuse!

+Planning & delivering person centred care – key lessons

Really connect with PEOPLE AND FAMILIES

Increase opportunities to hear the voice of people who use services and their families

Support people and families with knowledge and information - expert patient/expert carer skills

Ensure materials are accessible and enable people and families to engage fully in assessment and care planning processes

Ensure people know their rights!

+A meaningful day – key lessons

Building skills

Person centred active support

Positive Behavioural Support

Intensive interaction

Communication

Meaningful occupation and employment opportunities

+Environment and facilities - key lessons

Smaller environments – better compatibility

Involve service users and families in setting and monitoring environmental standards

Remember the ‘healing’ aspect of the environment

Space for therapeutic activity

+Workforce and staff training- key lessons

Induction – first point of contact – emphasis on values, rights and safeguarding

Robust preceptorship, induction and clinical supervision

Rolling programme of training prioritising person centred thinking and approaches, care planning and HAP as well as clinical skills

Training needs analysis and effective staff matching vital – KSF linked to appraisal

Involve people and families at every stage

Look outwards – network, network, network

+Organisational structure and culture- key lessons

Patient care and outcomes must be focus of Board level discussion and communication

Robust management supervision and clear accountability

Staff who are related should not work in the same team

Managers need development and training

All meetings need to be purposeful, strengths based and appreciative

High visibility - Management by wandering about!

+Commissioning- Key lessons

Focus on patient experience and quality of care

Use of multi-media to see what the life of the person is like e.g. video diaries

Undertaking regular population needs analysis aggregated information from care plans, HAPs, patient exit interviews, family carer surveys etc.

Ensuring manager understand commissioning landscape and expectations and work in partnership

+Clinical governance and patient safety- Key lessons

Be clear about expectations – agree the Quality Strategy – clear outcomes and accountability

Weave achievement of quality targets into appraisals of all staff

Ensure people and families are involved in all aspects of setting and monitoring standards

Robust governance systems and data

Board reporting

ZERO TOLERANCE

+In summary

My report contains nothing new – it is, sadly, an echo of other reports detailing failings across the NHS, Social Care, Independent Sector and in people’s own homes

How many times do we have to say it?

We need to stop blaming each other and get on with changing things…!

We need to create the conditions for person centred care to flourish

+A personal ‘call to action’

“It is all built on trust, so I trust you to look after my son”