Health and Social Care Committee
Inquiry into residential care for older people
RC79 – British Association of Social Workers Cymru
BRITISH ASSOCIATION OF SOCIAL WORKERS CYMRU: SUBMISSION TO THE INQUIRY INTO RESIDENTIAL CARE FOR OLDER PEOPLE IN WALES.
BASW is the largest professional association for social work in the UK, with offices in England, Northern Ireland, Scotland and Wales. We promote the best possible social work services for all people who may need them, while also securing the well being of social workers.
By joining the Association, members commit to the values set out within the Code of Ethics.
BASW also comprises the BASW Social Work Trust, a registered charity; Venture Press Ltd, a publishing company and provides financial support to the Social Workers Benevolent Trust and Social Worker Educational Trust. BASW maintains strong international links through its membership of the International Federation of Social Workers.
The IFSW definition of social work:
The social work profession promotes social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. Utilising theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.
SUMMARY OF EVIDENCE.
1. Admission to residential care is often associated with hospital admission as policy and practice can reduce the possibilities of older people returning to their own homes.
2. Older people who appear to be self-funding may be denied an assessment of need despite the legal right under the 1990 NHS and Community Care Act.
3. People who are self-funding may find themselves placed in care homes by relatives with no access to independent advocacy.
4. The assessment framework focuses on deficits in order to evidence eligibility rather than assisting the development of person-centred solutions.
5. The pressure to complete assessments and move people out of hospital often leaves little time for exploring individual’s choices and assisting them to make the best decisions.
6. There has historically been a view that social work skills are not required by older people. The replacement of social workers by care managers underlines this.
7. Once in care homes, there is little chance that residents with concerns about the care they receive will be able to share them unless they have supportive family or friends.
8. Although residents of care homes are referred to as living in their home, this is not an accurate description of the situation as residents have few rights.
9. Concern about the impact of home closure on residents has been raised but residents of care homes are often admitted to hospital and may have to move to specialist residential care or nursing care. The full extent of this has not been quantified.
ENTERING RESIDENTIAL CARE
Admission to residential care often occurs after a crisis at home or, more frequently, an admission to hospital. Research shows that hospital admission negatively affects older people and prompt discharge is in their best interests. However, prompt discharge can mean that decisions are not optimum for the individual. The Commission for Social Care Inspection found that following the introduction of the Community Care (Delayed Discharges) Act in 2003 rates of discharge to residential care ranged from 5% to 33% of older people requiring support. The research also found that once in a care home, there was very little chance of leaving.
The process of decision making when planning discharge from hospital is affected by a number of factors. Of major importance is access to information in order to make informed decisions. This information may not be available. Medical or nursing staff are known to inform relatives that the patient has to go into residential care, despite having little understanding of alternative care options in the community. Patients who are obviously going to be self-funding may be denied an assessment, ignoring their right under the NHS and Community Care Act 1990. Instances of relatives being given a list of care homes and left to choose are not unusual. The choices made, which usually do not actively involve the older person, may not be based on the needs of the individual It can also mean that people are forced into a care home against their wishes with no advocacy available. The force is not physical but the desire not to be a burden can be very strong.
THE IMPACT OF POLICY AND PRACTICE ON OLDER PEOPLE
The policy of reducing Delayed Transfers of Discharge rightly aims to reduce the inappropriate use of hospital beds and the damage an extended stay can cause older people. However, efforts to reduce delays because there are no beds available in the residential home of an individual’s choice by encouraging the selection of other homes can result in people moving to homes that are difficult for relatives to visit or where the care is known to be poor. While moving to the home of choice is possible, this will involve further upheaval for the older person.
When an individual does have an assessment of their needs, the focus is often on their deficits as the Unified Assessment Framework evidences eligibility for services. The hospital environment accentuates individual’s difficulties, particularly when people have dementia. The result can be that decisions are made without an understanding of how a person would function if they returned to their own home. The relentless pressure to complete assessments and arrange care packages do not allow time for the development of creative solutions.
The contrast between services to children and those for older people is rarely commented on. Children who have to leave their homes are ‘looked after’ whereas older people are ‘placed’. It is considered good practice for social workers to carefully consider the future plans for children and help them to adjust to the changes. Social work with older people has historically had a low status. In fact the necessity for qualifications has at times been thought to be unnecessary. The role of ‘care manager’ was created to implement the care management cycle of assessment, arrangement of care and review. There is little connection with the IFSW definition of social work above.
Once in a care home there are few safeguards for residents. Those people who are on local authority contracts should have their needs reviewed annually, but this may not happen because of the need to prioritise new referrals. The CSSIW inspectors talk to residents when inspections are carried out. However, residents may be reluctant to share concerns with people that they have not met previously and don’t know they can trust. In addition many residents may have limited communication because of cognitive or physical impairments.
Residential homes are referred to as the ‘home’ of residents. This is misleading as residents have few rights associated with living in their own homes. Choices about furnishings and behaviour are limited by considerations of safety and routines. The manager of the home has to ensure that the individual resident’s needs can be met in the home. Once this is no longer the case, the resident will have to move. The owner of the care home may decide, or be forced, to close the home and residents have no option but to move out.
Concern has been expressed about the impact of home closures on the residents. However, the residents of care homes frequently move. Admission to hospital is common, sometimes on a number of occasions. This may be associated with the high levels of physical frailty of residents but it can also be the result of inadequate skills within the staff team or fears that failure to send someone to hospital may be seen as neglect. Residents also move onto nursing care or into specialist dementia care. The full extent of these movements has not been quantified.
RECOMMENDATIONS.
1. No one should move to a care home without the opportunity to consider the possibility of alternative options, preferably out of a hospital environment.
2. Advice should be available that will inform choices about the selection of a care home.
3. Older people should be entitled to a skilled social work service that will promote their rights and choices.
4. Investment in the prevention of avoidable hospital admissions will benefit older people by maintaining them in their own homes.
5. Support for residents in care homes should be improved to protect their rights and promote well-being.