Last year I started to talk to John Kennedy about policies, procedures and paperwork. This started when I was preparing for my CQC interview to become a registered manager with Wellbeing Teams and had to show a range of policies and procedures. This blog brings together conversations with John about paperwork and asking some fundamental questions about Care Plans.
Drawing on our own experiences of working with and talking to managers and care workers in care homes and homecare services. We wanted to share some thoughts in the fairly certain knowledge you are going to put us right! But sometimes the obvious is the thing that is so cleverly hidden, and it’s never wrong to ask questions but we still feel like heretics!
We have been particularly trying to understand what factors create the right environment for values driven, relationship-centred care to flourish. We keep visiting ‘outstanding’ care homes and the much rarer, ‘outstanding’ organisations, We’ve been trying to uncover their secret.
Care Plans – what are they for?
Combining our experiences has highlighted this area that comes up over and over again in conversations. The sheer volume and complexity of the paperwork in care. Do we know what it’s all for and is it actually doing what we think it is? Is it actually effective? For example we have been ruminating on the purpose of Care Plans. A fairly common line read in inspection reports is:
“There were gaps in all care records looked at. Care records were not regularly updated and some contained inaccuracies. Care plans were not always put in place when people moved into the service. This meant staff did not have the information they needed to provide safe care and support to people.” This is a direct quote from a recent report.
Whilst visiting and talking to care homes (really good ones too) they speak of the forensic attention to detail that inspectors and quality compliance folk demonstrate whilst going through Care Plans, leading to longer and more complicated documents detailing every little thing about an individual’s needs. This process takes up a significant amount of care staff time; writing, reviewing, updating and auditing.
The theory is that the care plan is like the old ‘Haynes’ manual for cars and is the ‘instruction manual’ for an individual’s care. It is the way that care staff know how to deliver the right safe care to an individual. We’ve heard it said that, if for example, a care home had a Norovirus outbreak and staff were off sick then the Care Plans would instruct agency staff in how to deliver the care.
Who are they for? Staff or inspectors?
It all sounds very plausible and sensible until you reflect on the practicalities. If this is the case then it needs also to be true that care staff regularly read Care Plans? When we’ve posed this question to managers and owners their eyes drop to the floor they splutter a bit and then reply, ‘well no of course not’.
When pressed they indicate that in all practical senses the main purpose of the care plans is to please the inspector. In one ‘outstanding’ care home they hinted that they had a member of staff whose only job was to keep care plans up to date, neat and tidy in a filing cabinet, for the inspectors eyes only.
When you reflect even a small 40 bed care home would present quite a logistical and capacity problem to staff if they regularly read all the Care Plans. Care homes are very busy and the idea that at 7:00am the morning shift is going to sit down to read 40 care plans before beginning their duties feels unlikely. Even less credible is the idea that a care home with sick residents, from Norovirus and a patched together staff team, would have any time or inclination to read 40 Care Plans. All the anecdotal evidence we have uncovered very much points to Care Plans being ‘for them’ and incidental to the actual delivery of care.
It is probably a truism that there is a correlation between good care and good care plans. Because good care homes manage to do all they are asked to do well. But is there a causation? When ice cream sales go up so do drownings! They are correlated, but eating ice cream doesn’t cause drownings. Both are influenced by hot weather! Is there a causation between good care plans and good care? Or is it that it’s the ‘weather’, the ‘culture’ that the best organisations create that is the causation?
Are Care Plans evidence-based practice?
We’ve searched about a bit to try and find any academic research or evaluations that demonstrate a causation. We’ve found a couple of US studies which indicated that written care plans were not effective in communicating care needs.
Why is this important? Well because care staff and especially managers spend an inordinate amount of time writing and reviewing Care Plans. This means they are invariably behind a desk and not out and about on the floor providing care, leadership and investing in relationships. It feels to us that anything that care staff have to do that is not directly engaged with the people they care for has a significant opportunity cost. If there is no evidence that a task is effective surely we shouldn’t be doing it?
Since they were introduced into care homes in the early 90’s Care Plans and associated paperwork almost appear to have become the most important aspect of a care homes activity. Because they can be checked whilst the actual quality of care and relationships are more difficult to evaluate?
Can anyone provide us with another evidenced narrative to challenge our thoughts? Have there been any studies or evaluations of written Care Plans in care homes? What was the evidential basis for their introduction?
We can definitely see a need for ‘one page profiles’ detailing essential information like allergies, specific risks; choking, falling etc These could be succinct and clear documents easy to access and understand and therefore often read. What we can’t understand are pages and pages of detail which are time consuming to keep up to date and paradoxically can actually bury the essential information that everybody needs to know. By making the paperwork so complex are we actually increasing the risk? Too much complexity can lead to priorities being blurred
We continue to test this question when speaking at conferences or engaging with providers. No one, who actually works on the floor, has yet challenged us and said “oh no the staff read all the care plans diligently”. The response to the question “Do your staff read care plans? Do the care plans direct the care? Is invariably a snort, a guffaw and a shaking of the head.
Do Care Plans get in the way of care?
In 2014 the Joseph Rowntree Foundation published a report on excessive paperwork. The most depressing finding was the perception of staff that it was their paperwork that was the defining indicator of the quality of care they provided. They felt valued more for their paperwork than their caring skills! This seems to be completely the wrong ‘culture’ to be promoting kindness, empathy and good relationships. It’s a culture that encourages distance and an ‘industrial’ ethos. One that only the most ‘outstanding’ and brave of providers can stand up to.
In March 2016 the Dept of Business, Innovation and Skills published the results of a consultation on paperwork in care. It makes an interesting read. The same message; too much paper is leading people’s hearts and minds away from the core
Perhaps the time has come for a wholesale re-evaluation; a reinvention of what the ‘system’ requires of care workers. One where there is evidence behind the bureaucracy and one where the true ‘opportunity cost’ of the systems demands are factored into the ask.
Paperwork is required, it is essential but it needs to be effective. Where paper demonstrably supports good care and isn’t in competition for care workers time, energy and empathy. What do you think?