Co-production

In traditional homecare the first conversation is usually called the assessment. The purpose is to find out what the person’s needs are, and to do a risk assessment before the service starts. The conversation will be dictated by the paperwork.

How can we change this conversation from needs and risk, to what matters to the person, and learning about their priorities? Can we have paperwork that is person-centred, and yet still fulfills the expectations of regulators? This is what we are exploring with the new team of Wellbeing Workers. We want the first meeting to be a conversation, and the paperwork seen as the record of a conversation, not a form to fill in.

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Does this sound familiar? Jean was recruiting for carers for a homecare team. She shortlisted five people and invited them to come for interview. Out of the five, only one person turned up. The person who did turn up said,

“I don’t really want the job, but the job centre expects me to come for interviews.’

Like Jean, I was worried whether people would turn up. Yesterday was our  recruitment day for the new self-managed Wellbeing Worker team we are establishing in Lytham St Annes, for Caring Hands. This is a new way or working in home care, and we have been trying a very different way to recuit people. Yesterday was the day to find out whether this had worked.

We have 60 people expressing interest, 30 people had a 15 minute telephone call with Geraldine the registered manager, to talk about the role and received recruitment packs and given the date for the recruitment day. Knowing that people not turning up is such a big issue we asked people to phone to confirm their attendance by 16th August. Ten people confirmed that they would come – but would they really turn up?

The day due to start at 10am, at St Anne’s Community Centre. With fifteen minutes to go there were only 3 applicants in the room. Then everyone else arrived – nine in total – carrying foil covered trays, and plastic bags – bringing their lunch to share. Bringing a lunch to share was not the only thing different about how we wanted to recruit people for this new team. This is what we were trying:

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1) Recruiting for values

We intentionally did not ask for CV’s for people, or asked people to fill out application forms. We wanted to meet people as they are, and learn about them, and their values through the process of the day. One of the ways that we did this was to use the resources from Skills for Care, and created sets of ‘Values Cards’. We used these in small groups for people to share their answers and values with their potential team-mates – as well as us, listening in.

2) Focusing on Head, Heart and Hands

Ali Gardner explained in her blog how we are looking for people to use their head, heart and hands in this role, and therefore we wanted to reflect that in the recruitment process.

Head – We wanted people to tell us how they would ‘use their head’ to respond in different situations. One of the ways we explored this was through scenarios, explaining in turn what they would do if confronted with a particular situation.

Heart – Working in a self-managed team involves brining your whole self to work, sharing who you are and what matters to you. It is also about working ‘from the heart’ in a compassionate way with people we support – and each other. We wanted people to both feel comfortable sharing about themselves, and learning about each other too. We started gently with a warm-up exercise and built on this to ‘human bingo’,  and then answering the values questions took the personal sharing to a deeper level.

One-page profiles are a key way to communicate what matters to you. At the telephone conversation part of the process, Geraldine explained how we use one-page profiles and we asked everyone to bring their draft one-page profile with them to the day (and provided information about how to do this in their recruitment pack). The recruitment pack included the one-page profiles of the recruitment team, so that people could ‘meet’ us through our one-page profiles before they came. All nine people bought their one-page profile, and during the day there was an opportunity for personal reflection, to add to their one-page profile and share this with the whole group.

We also wanted to see how people could, through conversation, learn what matters to the older people they would be supporting if successful. We used the ‘What Matters to Me’ booklet, and people working in pairs finding out what mattered to an older person (part of the recruitment team) through conversation.

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Hands – As home care is a role that requires people to use their hands, two sessions directly explored this. When we were designing the day, we thought about people helping each other to eat as part of the recruitment process. Whilst we can see benefits to that, we were also conscious that you would know what the recruitment team were looking for, so could we approach this another way? In the end we decided on hand massage. We thought that expecting people to do something they have not done before (only one person had experience of hand massage), following instructions, and connecting personally through physical contact would help use learn more about people. People also used their hands to build structures from spaghetti!

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3) Looking at team working

Being part of a self-managed team requires learning about team working in a deeper way. We covered this three different ways – in the scenario section there were scenarios related to being a self-managed team; we used the marshmallow and spagetti exercise, where people have to build a structure together in 18 minutes, and we had an exercise where people had to give feedback to another person. The concept of bringing lunch to share was also part of this – working together and sharing skills and lunch.

4) Thinking about this as ‘finding a match’

I explained at the beginning of the day, that we were looking for a good match between the role and people. To show that we were serious about this, we include a section where people interviewed me and Geraldine (the registered manager) about the role and what it entailed.

5) Co-producing the process and decision-making

We have a team of us organising and delivering the day, and making the final decisions. This included two older people, the registered manager, and the Community Circle Connector. We are setting up the Doncaster team in October, so Becky, the registered manager for the Doncaster team came along to see what the process was like. I asked my colleague Michelle to join us, as she leads on teams and organisations within H S A and used to be a home care manager herself. Caring Hands are working in partnership with Community Circles, to ensure that we can focus addressing lonliness and isolation as important elements of well-being.

The two older people – who introduced themselves to the group as Amy and Freda, were equal decision-makers in who was invited to join the team at the end of the day. Their role was particularly important in the session where people demonstrated how they would learn about what matters to an older person.

 

Today, five people from the group of nine are being offered jobs as part of our first Wellbeing Workers team in Lytham, the first self-managed home care team. People gave wonderful feedback about the process at the end of the day. This is not a surprise if you are being considered for a job of course, and  our evaluation partner, Joe McArdle from Chester University, will be following this up so we can learn more.

What would have been different, if these same nine people had come for a half hour interview?

One woman, lets call her Maria, presented really well in all of the scenarios and values questions, but it was only in the hand massage, and the ‘what matters’ conversations that we noticed how she spoke over people, always had a ‘bigger story’ and struggled to listen. If I had been only interviewing her I would have given her the job, and then struggled to let her go through the probation period.

Two other people, lets call them Jo and Karen, expressed how they loved the concept of the self-managed team but were not sure how much hands on care they really wanted to do. We talked about this a lot during the ‘interview us’ section, and this helped them both realise that this role was not for them. If we had just done a half hour interview I think they would have decided to give it a go, and learned within the first two weeks that this was not really the role for them and left.

 

I am encouraged by what we are learning, but will everyone accept the jobs, and still be here in 3 months time? I will let you know.

 

PS 5pm Just heard that everyone has accepted the jobs. Phew.

 

 

 

 

 

 

 

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Last week was Dementia Care Matters 20th anniversary conference. Gill and I were invited to give a keynote and I know it sounds cheesey, but it really was an honour. Not just that, it resulted in a significant change to my personal mission in relation to care homes. Before I say more about this, a confession. Gill is one of David’s biggest fans, and whilst I absolutely saw David as a kindred spirit in his values, and admired him, I felt in a bit of competition too. Now, I am most definitely moving from any sense of competition to collaboration. This is what has changed my views – four areas that matter and what this means to me.

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At a time when we see more shocking reports about how poor some home care services are, and the impact of the cuts, it can be hard to keep believing that we can do more, and do better. Better communication with families may just seem like the icing on the cake. Yet the longest research into happiness published recently confirmed what we knew; that relationships are central to happiness. Here are some ideas of how we can do this, and how organisations are taking this forward.

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Four years ago I was presenting at a Laing and Buisson conference on care homes. My presentation was  towards the end of the day, talking about the importance of relationships, choice and control. Every presentation before me, without fail, focused on showing amazing dementia-friendly designed buildings and talking about good, respectful care. I felt like I was in the wrong place, with a different tribe who valued different things. However, after the conference I was asked to help to review one of these new flagship care home, lets call is Marble Manor. Two months later I travelled south to meet the people who lived there, the manager and staff. My first impression was that the building looked incredible, and as I walked in, it felt as sumptuous as a four star hotel. The bedrooms were warm and welcoming, and also had the slightly sterile feel of a hotel bedroom. At lunchtime I was invited to eat at the  dining room, which equaled many of my local restaurants, with a wine menu too.

When I met the people who lived there, they were cutting up coloured paper to make Christmas decorations. One staff member moaned to me that,

“The walls are all newly decorated, so we can’t put these decorations up. I don’t know where we can display them.”

Out of earshot of the staff member, one of the people who lived there muttered to me,

“This felt like being at primary school all over again.”

I asked how people spend their time. There was an activities programme, like the Christmas decorations, that people could choose to take part in. This was extensive with music appreciation evening, and trips out. At Marble Manor, you have a beautiful buildings and gardens, and you can choose which of the activities on offer you want to do. Can we go further than this?

I volunteer at a local care home a couple of times a month.  If Marble Manor looks like a four star hotel, this one, Bruce Lodge, probably looks two star, but they have focused on choice, control and relationships. They wanted to see how far they could go in enabling people to have more choice and some control oIMG_7718ver what they did, where, who with, when, and how they were supported. Here is an overview of how they did this.

What: People in the care home did not have an individual budget, and did not have any resource that they could control. Without any additional resources, they decided to give each person a ‘budget’ of two hours a month to decide what they wanted to do and who would support them to do it. When I shared this at a conference, my colleagues in learning disability services were politely derisive and challenged whether 2 hours was even worth it. When I share this at conferences with colleagues from older peoples service they wonder how Bruce Lodge could have possible done that. At Marble Manor they told me that this was not necessary as people could have staff time whenever they wanted it. This was not the reality when you spoke to people who lived there. They felt fortunate if staff spent time with them, and it was at the staff’s discretion. At Bruce Lodge it was an entitlement, and the person was in control of when and how they used their ‘budget’ of time.

Where: People could use their time to go where they wanted, and we proactively encouraged people to go out. If they could get there and back within two hours they could do it. People at Marble Manor went out when a relative took them out, or when there was a group outing.

When: People could choose then they wanted to use their time. People could also choose to use their time in different amounts, learning knitting for half an hour a week, going out for an hour twice a month, or swimming and tea and cake afterwards once a month.

Who: People could choose who they wanted to support them for those two hours, and if they were not able to do that, the manager matched then to a staff member who shared that interest. This was one of the biggest challenge – moving from roles (“you are the key worker so you do it’) to matching people based on relationships and shared interests. This short film shares how this was achieved.

How: Obviously, having choice and control over how you spend two hours a month is not enough. At Bruce Lodge everyone had a one-page profile describing what matters to the person and how they want to be supported. The ‘how you want to be supported’ became the job description of the staff. Here people were starting to direct their own support, on a day-to-day basis. This was reviewed with the person and their family.

This was how one care home worked towards involving people in decisions about their life, in how they wanted to be supported (and recording this as a one-page profile), in how they wanted to use their time (a ‘budget’ of two hours a week) and who they wanted to support them. I look forward to two hours a month just being the beginning, and getting to two hours a day. This may sound unaffordable in the current climate, without extra funding. The manager at Bruce Lodge achieved this within their current resources, and in Flintshire, we are working with commissioners and home care providers to go from achieving this in one care home, to all the care homes there. If you want to know more about the ‘how’ you can read about it here.

It is no surprise that older people want choice and control over their lives. This is at the heart of personalisation and the vision for care fir for the twenty-first centruy. The conference was four years ago. I hope that at the next conference I go that that is focussed on care homes, that we talk more about  choice, control and relationships in care homes, as well as excellent buildings and good care.

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There was a disturbing but not surprising article in the Guardian last week on how the ‘Silent majority’ of older people do not complain about substandard care. It reported that more than half of over-65s, who have faced problems did not complain as they feared it might impact treatment, ombudsman finds.

This is not just older people. When I was in hospital a few years ago, a volunteer came to my bed in the 6 bedded bay to see if he could ask me some questions about the quality of my care. As he pulled the chair next to my bed and got out his clipboard, I could see two nurses making the bed opposite mine, and the consultant was with the patient at the end of the bay.

“Did everyone introduce themselves to you?” he asked.

The answer was no. But I hesitated. Could the nurses hear me?

I speak at international conferences, have a PhD and yet it is hard to be powerful in your pajamas and say what you really think. It is hard to be honest when you don’t know what people can hear and what would happen if the answers were not favorable. So I completely understand why over half of older people do not complain.

We need to find other ways of helping people share what is not going well and how things need to change. One approach worth considering is Working Together for Change. This is a proactive way to routinely hear from patients or people receiving care, about what is working and not working from their perspective. Not only that, you co-produce the analysis and the actions with patients too. Here is an example of how one hospital, in Bispham, near Blackpool used it.

 

As part of their commitment to working in a more personalised and person-centred way Spiral Health introduced Working Together for Change and are using it every 6 months to inform their development. This means that the person responsible for quality asks every patient to share with her two things that were working well, and two things that could be improved, about a week into their hospital stay.

It often took persuasion to share something that was not working, for the same reason the article describes. What was different however, was that this information was collected from everyone, routinely, and no one could therefore be identified as a “troublemaker”. The other difference is that people were asked about what was working too. Some post hospital stay surveys may ask similar questions, but the difference here is that Cheryl, the quality lead, did something with the information immediately. This included sharing compliments with staff, as well as trying to directly address, wherever possible, whatever it was that was not working. Patients were also asked for two suggestions that they would like to see in the future in the hospital.

The information was aggregated on a six monthly basis with the information from all of the patients who had been on the ward during that period. Patients were also asked if they wanted to be involved in looking at the information, understanding and acting on it. It was not fed into a computer somewhere, it was analysed by patients, and staff, together.

I helped to facilitate the first time they used the Working Together for Change process. We brought together patients, therapy assistants, senior nurses and therapists, and managers for a day. As this was the first time we had used the process, we had data from 12 patients, but this was enough to start with (now it can be done with 100’s). We started by looking at all the ‘working’ information, and clustered it into themes. Three of the top ‘working well’ responses from patients at Bispham hospital were that the ‘staff were excellent’, that ‘the teamwork in the unit was good’ and that patients felt ‘calm and slept well during their stay’. The same process was used to find the top ‘not working’ and later, what was important in the future. The three top ‘not working’ responses were “I don’t like the food – it’s awful”, “I am hurried for meals and then have to wait” and “It took too long for someone to come for me”.

 

The comments about the food were not a surprise, however this time, the patients, staff and managers thought together about what the causes were, what success could look like, and what they were going to do next. As a result the unit’s menus were altered and the whole meal-time experience improved. There are 8 steps to the full process and you can read more about how it was used in a hospital here.

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The same process has been used in a care home, hospice, home-care, schools, commissioners, and by national social care providers. Leonard Cheshire is using the process to inform their national strategy, and other leading social providers like Dimensions have been using the process for several years. Commissioners in Flintshire about starting to use it to gather information about care homes, and to inform their strategic planning.

To help patients and people share what is not working may need a different approach where we ask everyone, and build trust by showing that we do something with the information, and patients can be part of analyzing and acting on it if they want to be. This does not mean that people will not complain, but using something like Working Together for Change may mean that we can address issues before they become complaints and create more of a culture of continuously asking what is working and not working and acting on it together.

 

 

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