Total Eclipse

In the main, people working in care choose to do because they want to be caring. But sometimes they don’t support people to live the lives they want to lead. Perhaps it’s the surprisingly ordinary, possibly even dull nature of an ordinary life which leads to workers talking up worries.  Leading to a reframing of the ordinary act of asking another person for advice or help can be turned around and become a problem to worry about, evidence of a dependency, a vulnerability the person needs protecting from.

A recent Community Care article highlighted the case of a Local Authority which breached a man’s human rights by forcing him to stop his sexual relationship with his wife when they asked for help.  Like any other ordinary couple they wanted to start a family.  But when they asked for help professionals began to worry.  Despite the couple having been married for years, a decision was suddenly taken that the learning disabled husband lacked the capacity to consent to sexual relations with his wife.  In attempting to turn around the implications from this hugely intrusive decision, the Local Authority was to arrange access to sexual health education  but then somehow failed to provide him with the education he needed.

https://twitter.com/CommunityCare/status/899307540470804482

The couple were kept separated for a truly shocking amount of time because the workers involved failed to understand their role in upholding their rights.  They had been married and lived in a mogonomous relationship for years. Just pause for a minute and really let that sink in.  Years.

Lucy Series has written a brilliant analysis of the issues – https://thesmallplaces.wordpress.com/2017/08/23/the-price-of-protection/amp/

However, equally brilliant (as always) was Mark Neary’s take on the case –

Mark’s timely reminder that married life is in the main outstandingly ordinary in nature, challenges the values behind the professional decision taken in this case to singularly focus on one aspect of the couples relationship when deciding not to support their request for help with fertility treatment but to instead force them to sleep apart for over a year.

The facts of this case aside, for spcial workers it is another prompt to be careful to avoid the “protection imperative”, that moment when professional worries eclipse clear and objective reasoning.  See Justice Baker in the case of CC v KK & STCC

Professionals and the court must not be unduly influenced by the “protection imperative”; that is, the perceived need to protect the vulnerable adult…. There is a risk that all professionals involved with treating and helping that person – including, of course, a judge in the Court of Protection – may feel drawn towards an outcome that is more protective of the adult and thus, in certain circumstances, fail to carry out an assessment of capacity that is detached and objective.”

If you think the community care report is of an “unusual case” you may be disappointed.  A self advocate recently described how he and his partner were subjected to 360 questions by professionals when they decided they wanted to become parents “because we have learning disabilities”.

There are many aspects to being a parent.  The right to experience all that goes with being dad or mum is a hugely important part of being human. Perhaps there is more we can do to make accessible information to those who want it beyond that which covers to act of potential conception.

In case you find yourself facing a similar scenario the link below will take you to accessible information and resources on sexual health and other things – http://www.btm.org.uk/resource-category/health/

And here is the RiPfA case law summaries on working with parents with learning disabilities – https://www.ripfa.org.uk/resources/case-law-summaries/?platform=hootsuite

Article 8 ECHR right to a private and family life

Human Rights Act 1998 right to marry and have children; right to respect for a family life

UNCRPD right not to be discriminated against in marriage, family and parenthood

Care Act 2014 the general principle of wellbeing takes into account relationships

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Ten thousand whispering and nobody listening

cat 1

I received my social work qualification in the post just two days before I started my first ever social work post. New social workers, in the days before we defined Newly Qualified Social Workers, were just called a new social worker. The fact that you were newly qualified was never  discussed. I was a social worker. I bought a new shirt for the occasion of my first ever day in the profession. It would have been ironed had one of the children not delayed me by being sick in one of my wedding (now work) shoes.

I met my first line manager in the first hour of the first day. She talked a lot and I was to listen. In fact she even passed me a notepad and pen as she commented that she was surprised I was not noting some of the things she was telling me. In truth I wont have been listening. I can’t listen when people give me instructions. If I get lost and ask people for directions I never listen to a word they helpfully try and give me. As much as I need their assistance I instead find myself concentrating on the kindly direction givers accent or slight whistle when they pronounce anything with an ‘s’ in it or I notice the expression of their passengers face. Whilst nodding and saying ‘yes, turn right’ after they’ve said it to give the impression I am listening I am wondering where they going themselves or where they have been. Now that I would listen to. But directions and instructions far less so. I expect my new superior was telling me about fire alarms that probably wouldn’t go off and the ritual of car parking or maybe even how to pay the tea club. I smiled and nodded and I remember noting something down in the pad she had given me. It will have likely to have been the last one I heard her say in order that it looked like I was listening. My guess is that it said something like ‘ok’. It may as well as said ‘turn right, yes’.

I remember my first ever social work client from that day. She was called Jean. She talked and I listened because she was talking about herself, her life, her ambitions, her present situation and her desires. Jean spent a lot of time talking about her cat. There were no instructions attached to Jean talking, and so I just listened. I asked questions from time to  time, but crucially I listened and Jean just spoke. On my lap I had a Community Care Assessment. This, my boss explained, was where we wrote down relevant points about peoples lives to do ‘The Assessment’. I had heard a lot about assessments in my first morning as a social worker. They were described as the cornerstone, the purpose and the focus of our role. In truth I hadn’t had much in the way of training on assessments at university. There was some mention of Care Assessments and Care Plans but in three years of training, 24 separate 3000 word assignments, two 8000 word portfolios based on two practice placements I rarely mentioned assessments. My training was about our approach, our understanding of people, relationships, the dynamics of relationships, empowerment, advocacy and rights. Maybe I was on the sick on the day they did ‘assessments’? Either way, assessments were a form and forms came with instructions. I wouldn’t have listened.

Half way through week one the boss was clear that my work with Jean needed reviewing. I was invited in to the meeting room and asked to explain where the discharge planning was up to. With my paperwork in hand I began talking about Jean. I had completed the assessment through recording what I had heard Jean say. So half reading from the assessment document and half through memory I talked about my conversations with Jean. I talked about her background and her family, I talked about her husband Bob and his job and how when he retired he died shortly after robbing Jean of the retirement that they planned. I talked about how Bob had helped choose the new carpet that she had tripped on, causing the fracture that led to her fall and how she laughed at the thought that he was getting his own back. I talked about the grandchildren in Australia and how the letters and photographs kept Jean going as well as the 3am phone calls from her granddaughter Laura due to the time difference and how excited Jean felt when she was due a 3am call. I talked about Jeans cat and how when Bob had died and her daughter had gone to Australia it was the main focus on Jeans life. I listened to Jean talking about the life that Jean once had, the life she was planning to have and the life she had now. After I had talked about Jean I waited for the boss to speak. There was a long pause and then she spoke. ‘You may have well as assessed the bloody cat’. She went on to explain that what I needed to assess was the support Jean needed, not Jean herself and certainly not her long lost husband, far flung daughter and bloody cat. I needed to listen to how many times she needed the toilet during the night. I needed to hear if she now thought she needed to be in a residential home. I needed to hear how the care package was going to get her back home. I needed to listen out for who manages her finances and how much money she has. I was genuinely perplexed. I wasn’t trained to do that sort of listening. I didn’t like that sort of listening. That wasn’t the social work I was educated in and in truth I didn’t even recognise that it was social work. But this was my job.

I didn’t speak to Jean again or get the chance to listen to her. Our conversation was converted into an assessment by an experienced social worker. Apparently with a half decent nursing report and a functional assessment from the OT we could just about throw together an assessment that would help Jean be discharged as quickly as possible. The assessment documented that  Jean needed four calls of home care a day. The calls would start anytime between 7am and 11am. Lunch was between 12 and 3. Tea from 3.30 to 7 and bed every night by 10pm. No mention of Bob or little Laura in Sydney or even Audrey next door. On the box that documented whether or not Jean had got any pets it said in bold capital letters NONE.

 

 

All life is an experiment – I am not vulnerable!

friendship

I once worked with a young woman called Emma (not her real name) who had a mental impairment and would sometimes go into town alone, whereupon two young women would sometimes meet up with her. Emma would withdraw £200 from the ATM which she would share with these people. After an hour or so, the two women would desert her. The care home staff where Emma lived wanted to prevent Emma from going out on her own, they said it was ‘mate crime’ and that Emma was being financially abused.

I met with Emma and put this to her. She said, “I know they are not my real friends, they only want my money. I’m not daft.” I asked what would she do if it happened again? She said, “The same probably. It’s worth £200 to me because it feels like I have friends, I can pretend to have friends even if it’s just for an hour.”

Emma’s story made us feel sad and angry that people would take advantage of her and we wanted to protect her. But she did not want us to do that. She had the mental capacity to make the decision and, putting it bluntly, she did not care how we felt.

I also worked with a man who was nursed in bed at home but his son – frustrated with his dad’s deteriorating health – would shout at him. We wanted to stop the son from shouting at the older man, possibly apply to the court to prevent him from visiting altogether, but the man told us and the police to do nothing. He acknowledged it upset him when his son lost his temper but he loved him and wanted him to be around. In time, he died at home with his son visiting him to the end. As social workers with both children and adults know well, from the perspective of the person a not-very-good family is usually better than no family.

Had the legislation been available, we could have over-ridden their decisions to protect them. They would have been protected from abuse, so we would feel better, but would Emma or the older man feel better? If a capacitous person wants our support then we give it; if they don’t, we must walk away, no matter how upset or concerned we are.

I am reminded of that much quoted speech by Sir James Munby (‘When is Safeguarding Abuse?”) in which he says that if local authorities are to justify intervention then what follows must be better than what went before. I have no doubt the intention of the Vulnerable Adults Bill is not to wrap all people in cotton wool, but to take what Sir James calls a proper balance in supporting those “less well equipped” to deal with risk than others.  If you want to find out more try the brilliant Lucy Series @thesmallplaces – https://thesmallplaces.wordpress.com/2014/11/14/what-good-is-it-making-someone-safer-if-it-merely-makes-them-miserable/

However the proposals for a Vulnerable Adults Bill concern me because, although I have little doubt that while the courts would continue to respect the right of an individual to make an unwise decision, where such is to be over-ridden that must be by a higher authority than a council employee. Indeed, I don’t see why the inherent jurisdiction of a judge sitting in the High Court does not already meet this need. And as I see it, treating people who are vulnerable because of their disabilities differently from all other people is discriminatory.

In practice then I fear such an Act would be used against people, not to support people, and there would be little consistency in its application by health and social care workers. The culture of paternalism and protection is still deeply embedded in some quarters. For example, I have been challenged many times about the outcome of a capacity assessment I have completed, but not once when I said the person lacked capacity to make the decision, only when I said the person had capacity. That is absurd; the assumption of capacity unless proven otherwise should be well established but it is not, even ten years on.

I doubt those drafting the Bill would want this to happen but in practice many people with dementia (or not!) in hospital making the natural decision to return to their home would be deemed ‘vulnerable’ by ‘concerned others’ and needing protection. The ward staff would want this because they would not want to be held responsible in the event something bad happens to the person. This paternalism exists now in spite of the law preventing it. In my experience some professionals are not afraid so much of something bad happening to the person, they are afraid of something bad happening to them as a consequence of something bad happening to the person!

I tell social workers all the time that if they do what the MCA says then Section 5 of the Act will protect them from liability. But how could a social worker trying to defend the right of a person to make an unwise decision deal with such ward staff or police officers or concerned neighbours telling them that they must do something and citing the new law? Who among us wouldn’t be more worried about their job than the rights of the relevant person? The MCA is already intentionally used against people so what then would be the chances of a person unfortunate enough to be objectively considered ‘vulnerable’ appearing on the radar of health and social care retaining their autonomy?  See the case of Fluffy the Cat if you don’t believe this to be the case – https://ukhumanrightsblog.com/2015/01/29/what-price-liberty-damages-dols-and-a-cat-named-fluffy/

By the way, in time Emma found a real friend and moved out of the care home and into a shared flat and those two women lost their free money. What she had needed was support from her social workers, not for her social workers to decide what was best for her.

Ian Burgess, BIA and MCA Professional Practice Lead, on behalf of the Adult Principal Social Worker Network in England

 

Lymbery, M (1998). Care Management and Professional Autonomy: The Impact of Community Care Legislation on Social Work with Older People. The British Journal of Social Work 28, 836-878.

Munby, Lord Justice (2011). Safeguarding and Dignity: When is Safeguarding Abuse: Keynote address by Lord Justice Munby to the Rotherham, Doncaster and South Humber Mental Health NSH Foundation Trust’s AMPH and Social Care Conference.

 

 

 The Liberty Safeguards – the door is open for better social work

liberty or death.png

On the 13th March 2017, the Law Commission published their report on Mental Capacity and the Deprivation of Liberty Safeguards.  The overdue report finally arrived a week after news broke of the death of Rusi Stanev, aged 61.  The ruling on Stanev v Bulgaria by the European Court of Human Rights in 2012 was a catalyst for change.  Just two years later Lady Hale referenced his case in setting the acid test for determination of what constituted a deprivation of liberty in her summary of the landmark Supreme Court ruling which has come to be known as Cheshire West.

The Cheshire West ruling was a large boulder thrown into the relatively tranquil sea of adult social work.  The waves which it has generated continue to disperse and rebound across the profession, disrupting the comfortable care management function which has defined adult social work since the Community Care reforms of the 1990s.  Cheshire West was a wake up a call to adult social work, reminding the profession of its roots as an academic discipline that promotes social change and development, social cohesion, and the empowerment and liberation of people based on principles of social justice and human rights.  The role of Best Interest Assessor became a hugely desirable qualification for adult social workers who saw the opportunity to reconnect with their values as the person whose professional role was to uphold people’s human rights.

The widened the definition of deprivation of liberty in 2014 has, however, triggered unprecedented demand on Local Authorities. Almost overnight we experienced a 10 fold increase in the number of requests for the Safeguards to be authorised from hospitals and care homes where a deprivation of liberty was taking place.  In the last 18 months further pressure has mounted on adult social work services as deprivations of liberty are also being identified in supported living settings for adults with learning disabilities.   As social workers we are relearning report writing skills as we prepare to present cases to the courts, increasing our legal literacy with case law that references the UN Convention on the Rights of Persons with Disabilities and reclaiming our sense of professional identity and pride in our profession.

So, we have approached the Law Commission Report with optimism and a sense of hope.  The report (which includes draft legislation) reflects 3 years of work on the part of the Law Commission to review how fit for purpose the current Deprivation of Liberty Safeguards scheme in light of the clarity given by the Supreme Court in 2014 on what constitutes a deprivation.  Their finding is that there is a compelling case for reform of what has become an overtly technical process which is subject to increasing managerial concerns about levels of demand and the cost which Local Government is baring in administrating the scheme.  They observe that the numbers of requests for authorisation have reached levels which make it impossible for Councils not to routinely breach statutory timescales for completing assessments and putting the safeguards into place. Their solution is to replace the DoLS with a new scheme which they are proposing is called the Liberty Protection Safeguards.

Here is where a first pause is required. As a proposed response to reduce the level of technical fog around the current DoLS – already the name of the new scheme is causing confusion with parent and carer groups questioning what the difference is between a protection and a safeguard.  Our view is that names matter hugely.  As symbols of intent which send signals across the system a name is a powerful object.  Our preference would be to simplify the name and set out as we intend from the start.  Let’s drop the protection bit and simply call the new scheme the Liberty Safeguards because that is what they are. We know what images the word protection conjures up in the post Care Act world of health and social care; where we challenge those who self-neglect, ignore the spirit of making safeguarding personal or give barely a passing nod to our responsibilities under Article 8. If we call anything in adult care ‘protection’, then really do expect the worst because there is a swathe of the public sector that think that protection means good old fashioned, ‘lock em up and love em as best you can’ care. The best protection is self protection or sponsored protection where people’s rights are upheld with the same vigour and singular desire as we ourselves feel when it comes to protecting ourselves and our loved ones. If public protection is genuinely such a concern that the word protection must explicitly feature in there (and having read the first few bars of the heart-sinking entitled proposed Vulnerable Adult Bill) let’s at least try and agree on what it is we are trying to protect.  Our role as social workers is to protect people’s right to liberty.  So if we can’t drop the word, let’s at least move it to call them the Protection of Liberty Safeguards.

Going back to the detail of the scheme, our Liberty Safeguards would apply in much wider contexts including hospitals, care homes, supported living, shared lives and private and domestic settings. The new scheme will cover any situation where Article 5(1)(e) is potentially engaged. The specific arrangements that may be authorised are:

  • arrangements that a person is to reside in one or more particular places;
  • arrangements that a person is to receive care or treatment at one or more particular places; and
  • arrangements about the means by which and the manner in which a person can be transported to a particular place or between particular places.

Interestingly, the Law Commission also propose that whereas the DoLS scheme only applied to adults over the age of 18, the new Liberty Safeguards would apply for 16 and 17 years olds. This is a sensible change which reflects best social work practice in preparing young people for their transition into adulthood.

It is also proposed that the role of Local Authorities as the Supervisory Body be revised and replaced with a new Responsible Body requirement.  In a pragmatic nod to the drive towards integration the Responsible Body duties would be shared across health and social care depending on where the deprivation of liberty is taking place with hospital trusts and CCGs taking responsibility for their cases.

There are other significant changes which it is worth finding out more about from the various commentators who have written about the report.  However, our personal favourite is the blog written by Mark Neary.  The ruling on the unlawfulness of his son Steven Neary’s deprivation of liberty in 2011 is one of the most significant cases in adult social work in that it made the connection between Article 5 and Article 8 ECHR, the right to a private and family life.  If Article 5 is the technical aspect of the current DoLS scheme, Article 8 is the heart and soul made manifest in Mark and Steven’s relationship. If you ever get chance to hear Mark speak, please take the opportunity.

Whilst, we recognise and welcome the requirement to make explicit the relationship between the proposed Liberty Safeguards and the UN Convention on the Rights of Persons with Disabilities by upholding people’s wishes, feelings and beliefs when authorising the Safeguards, we are underwhelmed by the missed opportunity to emphasise the significance of Article 8 rights.  It makes us wonder whether the current obsession with interference with Article 8 rights to justify disproportionate responses to so called self-neglect has leaked into the thinking of those working on the report.

The Law Commission also recommend that the role of Approved Mental Capacity Professional be introduced building on the current Best Interest Assessor role.  As a long term advocate of the AMCP role we remain convinced that role is a lifeline being thrown to the adult social work profession and it should be grabbed with both hands. It is a role most naturally suited to social workers with adults because since 2014 we have rapidly embraced and consolidated our expertise, knowledge of and passion for human rights and the Mental Capacity Act (2005). AMCPs as the safeguard of people’s rights and well being. What greater opportunity can there be for all those social workers who came into the profession saying at their interview to get on the course that they wanted to make a difference?

So do the Liberty Safeguards provide a last chance saloon challenge to adult social workers?  We think they do.  But we also think that if better social work is to become our reality, social workers will need to be really brave. In embracing the social work role as the Law Commission envisage it, and making the most of the potential to elevate our professional by leading on human rights through social work, we may need to be prepared to cast off other roles that we have had bestowed on to us that don’t suit us, or that we don’t do well or moreover where the person themselves needs to be the only voices heard.  At the beginning of the Law Commissions consultation process we asked ‘Are We Human or Are We Care Manager?’ and questioned where social work sits, nearly 30 years on from NHS & Community Care Act. By the end of the consultation we think that yes, we can see the door which is open to us.  This 3 year process has generated overwhelming evidence that the answer to the question is that social work is human rights and that it is ready for the challenges of ensure that Article 5 loophole is dealt with. However, social work is not the answer on its own and can only wish to be a small part of the solution. As Mark Harvey said in his blog describing a new Bohemian social work movement:

 ‘we are not the custodians of society, we need to learn to be part of it, in fact we need to ask humbly if we can come and play again. Then and only then on an equal footing can we work alongside people and create opportunity, not risk averse application that does unto’.

To truly step up to the plate and play the role the new proposals need us to, we need to really ask ourselves – what sort of social worker are we?  Are we really ready to step away from the trappings of care management, which was a role no one else wanted but we ended up with in the post Community Care scramble of 1990. Our role as all things to everyone, assessor, support planner, broker, discharge facilitator are perhaps best rested with the individuals we support, the communities that they come from and families that are best suited to help deliver real meaningful outcomes because of their love for the person. Social workers, put down your RASs (they never worked anyway), step up to the challenge of the Liberty Safeguards and deliver human rights based social work and maybe not all the other things between.

The milkmen of human kindness

nsw

Firstly, if you haven’t read Mark Nearys fantastic book ‘Where Have All the Milkmen Gone’ then we think that’s a good place to start. Mark totally gets it when it comes to social work for Steven. He doesn’t want someone who thinks they know Steven and Mark better than Steven and Mark know themselves. He doesn’t want an admin officer for a social worker or someone who can broker care (although he does want the awful bureaucracy removing!). Mark doesn’t want someone who can interpret other professionals jargon. Mark isn’t looking for a mate for him or Steven. Nor is he looking for someone to relay decisions made by the great and good at panels in locked away towers. Mark wants someone alongside Steven. Someone batting for him. Someone who when Mark isn’t there is absolutely going to advocate for his sons wishes, feelings values and beliefs in a way Mark knows Steven wants. Crucially, Mark and others, want someone on behalf of the state (Local Authorities  or NHS – it shouldn’t matter) who totally get and love the fact that Mark and Steven love each other. The thought of standing in the way of their relationship should be as abhorrent as the feelings generated when you hear Mark talk about those who separated Steven from his dad. Whether it’s the principles of the MCA, the Articles in the UNCRPD or the Well Being principle in the Care Act, the overriding ethos is that the state should not interfere with the family life. Our role is to promote it, protect it and if possible to enhance it… And then get out of the way very quickly!

However it still looks like we are a million miles away. More evidence is coming to light of the routinised institutional nature of human rights abuses which are taking place in the name of so called care and treatment.  #underlockandkey was the latest in a series of reports on what is becoming an all too familiar story of families heart breaking distress.  There is an ever expanding list which is compelling and which identifies consistent themes including:

So, we change the size of our institutions from big asylum to small group home, and the uniforms are all but gone but the practice is frozen in time.  We continue to debate about how it isn’t enough to just build new types of institutions  – and we agree that a bigger shift is needed in mindsets if learning disabled people are to genuinely experience their full range of their human rights. Medical training still appears to over emphasise that clinical autonomy is the more important in decision making than the views of the person.  This has to change. Social Work training is grounded in human rights and individual autonomySocoal Work could potentially be the challenge needed. Since the early 1980s we’ve been talking about Social Workers becoming a named person providing advice and advocacy for people.

So many people have a named social worker and have done for years. But what’s changed?

Whether we are named Social Workers or not we are in the heart of a culture which families who are brave enough to speak to the press about their experiences are telling us is immersed in the ways of the old institutions. We no longer chase the doctors coattails, walk along wards or dormitories in large Victorian buildings but are we still effectively perceived by people and their families as still prowling the corridors, ensuring compliance and often crushing the hope they have of a loving family life.

The  Department of Health’s vision for adult social work  is the most recent attempt t0 define a role for a Named Social Worker. 6 Local Authorities are piloting the role as describe here – https://lynromeo.blog.gov.uk/tag/named-social-workers/

Social Care Institute for Excellence are reporting here on the outcomes so far from the pilot http://www.scie.org.uk/social-work/named-social-worker.  It is still early days,  but from our involvement this feels like something important is being tested.

Social work is at a crossroads. What do we want the Named Social Worker to be? More importantly, what do people with a learning disability and their families and supporters want their Named Social Worker to be?

Self-advocates have told us that they want their Named Social Worker to be there for them. They didn’t see the social workers in the heroic role of fighting medics to prevent admission to an ATU. People with a learning disability that we support don’t know what an ATU is right up until the point where the options have been exhausted, the ‘risks’ seemingly too great and the door locks behind them. The people we spoke to wanted a social worker to be, well, a social worker. The kind of social workers we think social workers want to be; a really good one. One who can speak about love without feeling embarrassed.

For ‘Named Social Workers’ read ‘good Social Workers’ or moreover,  Social Workers who are legitimised to be exactly what they have trained to be compassionate, kind and on the person’s side. Social Work has a unique role and position within the system and it is designed to be the safeguard against people being marginalised. Social work is steeped in an education of social justice, empowerment, human rights and an unequivocal and unashamed approach to helping people to remain as independent as possible and close to the loving support of their families and friends. Ensuring that is our unique role. The only safeguard that is needed is to keep people safe from the system intervening into family life. Whether social workers are ‘named’ or not, they need to be really good social workers regardless.

ethics-and-justice

Winter – Part 3

Each year the headlines going into the NHS winter seem to forecast a bleaker outlook.  

Whilst the 1st October still feels very autumnal, the build up to this years NHS winter is underway.

Which is worrying if you are responsible for arranging services for people who will need some extra support from adult social care to help them home from hospital.  In adult social care we rely on so called winter monies to fund out of hours, home care, intermediate care and transitional beds, all of which get people out of hospital and back to their communities so they can complete their convalescence and recovery.  This winter however the signs are that these funds won’t reach social care.  The NHS winter is biting and hospitals are needing every penny health commissioners can find.

This is further destabilising fragile social care providers, many of which are small local businesses who are really struggling to make things stack up.  As reported by the Kings Fund & Nuffield Trust social care providers face huges pressures in terms of retaining staff, maintaining quality and staying in business.

social-care-for-older-people        Social Care for Older People (home truths)

Our experience is that small, local providers are full of caring, passionate people who are trying to make social care work despite the challenges.  People like Mark, whose story from 5.05 minutes into this video about what happened on Boxing Day 2015 when the River Calder broke its banks left me speachless when I first heard it.

Mark and his team faced the worst that winter could throw at them.   But driven by deeply held convictions that it was their job to care, they are made social care work in the most challenging of circumstances.

Going into this winter we are anxious, but we haven’t lost hope.  People have an incredible capacity for caring and to find humour and happiness in the bleakest of circumstances.

winter-okie-aged-80

So going into the social care winter 2016 here are our suggestions:

1.  Remember why you work in the social care sector.  You care.  If you didn’t you could earn more somewhere else.

2. Nevet forget you are a guest in people’s lives and this is a huge privilege.  The minute it stops feeling that way it is time to move on.

3. Create space with your friends and coworkers to talk about the people you are here to serve and support.  Every person is a bright spark of colour in your life.  Sharing those sparks might catch a fire to keep you and your colleagues warm during the darkest of days when the pressure is on.

Someone to Safeguard

The referral was pretty bog standard these days. The neighbours didn’t get Elsie’s permission for any of her details to be referred to Social Services. In truth it had never crossed their minds they’d be asked for this. When pushed by the call centre about the issue of consent they said that they didn’t think they needed her consent and that this was a matter that ‘the Council must take seriously for everyone’s sake’. And then behind the thinly veiled threat to act the neighbour stumbled upon four little words. Magic words. Words that suddenly change the meaning of everything and words that seemingly come with their own legislation, procedures, judges and juries. ‘It’s a safeguarding issue’. And boom, there it is. Elsie, aged 87, never known to the Council, never having failed to pay for council services or any other tax that propped up with welfare state that she didn’t really partake in, was known. Consent overridden. Case opened. Within moments Elsie had an electronic file. Elsie had a Reference Number. And Elsie would receive an automated letter thanking her for contacting the Council and she would receive a call within the next seven days. All done within five short minutes from the start of the phone conversation. Within ten minutes Elsie was on waiting list of other Reference numbers waiting to be allocated to a Social Worker and sat on the computer screen of the Manager. Whether Elsie used services or not, from that moment on to the day of her death, nothing was clearer – Elsie was a Service User and there was a record to prove it. There was, as far as everyone was concerned, someone to safeguard.

The social workers went in twos to the address. No-one was quite sure why. The referral mentioned that Elsie had got cats but there wasn’t any belief that the cats were dangerous. Perhaps the second social worker was there because social workers love cats. The referral said the house was ‘dirty’, ‘things everywhere’, ‘cluttered’, ‘soiled pads in the garden’ and Elsie, although not seen for some weeks, was wholeheartedly felt by the neighbours to be dirty herself. ‘She’s self neglecting’.

Having knocked at the door and getting no response the social workers pushed slightly at it and the door opened. A cat ran out and then back in again. No sign of Elsie in the hallway. The social workers called her name, walking gingerly through the hallway, past a sideboard with some framed pictures of a moustachioed man with the ‘Geraldo, King of Swing’ emblazoned on them. Calling out her name and holding out their ID badges the social workers continued inward.

Elsie was in the kitchen. She smiled when she saw the social workers and beckoned them in still further. The social workers introduced themselves and whilst doing so Elsie kept on smiling before raising her hand as if to stop the second social worker saying their name. Elsie bent forward and placed her right ear up against what looked like a radiogram from footage used to show listening to the broadcasts of Prime Minster Churchill telling them they wouldn’t surrender. Almost trance like Elsie’s smile remained fixed as she listened to the radio. Elsie probably listened to the radio for a full three minutes, to the social workers, observing the cats, the newspapers (one from May 1991 with a picture of Paul Gascoigne on) and moving their feet on the sticky floor tiles, the three minutes felt like a lifetime.

When Elsie moved away from the radio she asked the social workers ‘who are you again, love?’. The social workers explained who they were and said that they were there to see if ‘she was alright, you know, see how things are’. Elsie said she was fine and asked if the neighbour had asked for them to visit. ‘She’s lovely, like that. Looks out for me’. Elsie explained that she had lived in the house all her life. Her parents, who she said ‘died recently, in 1971 and 1975’ had left the house to her. The social workers listened. They wanted to be respectful, they had questions of course (and they had lots of boxes to tick) and had already decided that things ‘weren’t right’ but they listened nevertheless. Half way through talking Elsie’s eyes suddenly lit up. ‘John!’ she said. Within moments Elsie was back to the other side of the kitchen, head propped up against the radio, same expression on her face, which now to the social workers seemed almost rapturous. This time a longer a wait. Five minutes. Elsie broke her concentration just once, to beckon the social workers to sit down. Neither did. Elsie didn’t notice or care.

Elsie said that John worked for the radio. He was in his late forties and his job was a ‘broadcaster’ and that each day John ‘either announced the news or introduced big bands… sometimes both’. Elsie said that John was based in London and he still lived there. She said John sometimes slept in the radio station and sometimes broadcast during the night, but not usually. The social workers continued to listen but really wanted to talk about the cats and Elsie’s ‘daily routine and keeping clean’. More in an effort to wrap the conversation up about John and move on to the matters at hand, the self neglect, one of the social workers asked a question. ‘John sounds lovely. Is he someone you have actually met and know’? And with that the tone of the conversation changed. Elsie explained that John had spoken to her on the radio for over 60 years. He was her man friend and he was engaged to marry her. Her betrothed. John had promised Elsie that one day he would drive up from London in a white Bentley car and marry her. Their plan was to live in London and take Elsie away from all this, including the cats. Elsie said the social workers could have the cats if they wanted them.

On walking to the door with the social workers Elsie thanked them for coming but they had to go now as John liked to ‘talk to her alone’. Elsie smiled as she shut the door behind them. The last thing the social workers heard Elsie say as the door closed was that John was her man and ‘was not for sharing, goodbye’.

The social workers weren’t inexperienced. One had just become an Approved Mental Health Professional and the other had worked with older people for years. But as they walked to their cars and drove back to the office the silence between them spoke more than any words of completed boxes on the safeguarding form. ‘What was all that about?’
Safeguarding referrals can be complex. The social workers knew that. They also knew that to ‘help’ Elsie they had to get to know her, build up trust etc. So the visits continued throughout the next week. On each occasion Elsie spoke to the social workers but continued to ignore any questions about her health, her wellbeing, her cats and the state of her house. Most questions were met with ‘I know love. John’ll see to it’. All conversations were interspersed with long periods of Elsie listening to the radio and smiling with occasional, knowing nods and some ‘ah’s’ aimed at the social workers as if ‘John’ was further confirming plans that would need to be relayed to the social workers. For the most part the social workers just heard the hiss of the untuned radio. For them there was no voice, no programme and without doubt there was no John. However what bothered the social workers more than this was that there was no progress. No getting Elsie to see what state she was in. No getting Elsie to consent to sorting the house. No getting Elsie to realise the safeguarding issue. The self neglect. The abuse.

Safeguarding doesn’t allow for stalemate or for someone to continue to be abused. It identifies the abuse and through a list of ‘outcomes’ it makes the social workers do something. For the social workers things needed fixing for Elsie. She had a choice. Either Elsie worked with them to ‘improve the situation’ or they would ‘Refer to other agencies’. The case notes were clear. Elsie wouldn’t engage. She lacked capacity to make the decision. It was all in her best interests. The risks were unmanageable. The hoarding was a fire risk. The cats were underfed and the RSPCA would be cross. She needed safeguarding. If only she could see it! She was a problem. The problem needed fixing.

The social workers didn’t seek Elsie’s consent to refer to other agencies. In Elsie’s case the ‘other agencies’ was the Mental Health Team. Elsie was visited by a Community Psychiatric Nurse, who within hours visited again but this time with the Psychiatrist. The social workers received a call ‘How has this gone on so long? and ‘she’s in a terrible way, totally delusional, paranoid ideation’ and is ‘refusing all treatment because of this bloody John thing’. The next call was to the AMHP. Pink papers in the bag, the Mental Health Act Assessment was to take place that evening.

The Ambulance couldn’t stay and eventually the police were called. 87 year old Elsie was escorted out of her property by two young police officers. One of the police officers had to switch the radio off during ‘the incident’ in the house. He at least had the foresight to give the radio to Elsie and reassured her that she ‘could hold it’ in the back of the car. It was the only bit of humanity Elsie ever witnessed either that evening or throughout her entire dealings with the ‘support’ agencies.  Section 2 completed. Safeguarding outcome achieved. No more self neglect. Someone had been safeguarded.

The first thing Elsie did on the ward was to find a plug for the radio. John was there. Reassuring her and helping her to stop crying. And that’s how things stayed for a number of weeks. The medication was taken, Elsie complied. The nurses moved on to the next person, Elsie listened to John. There was no more worry about Elsie from the neighbours, the problem had been fixed. No more self neglect, no more self to neglect. Elsie’s care plan said ‘needs all cares’. And that’s what she had. All cares attended to and a continued love affair with John.

The discharge planning never once considered home. Home was where the ‘multi-disciplinary team’ had felt that the bad thing happened. Home was where the cats had had to be removed and where the social workers had found Elsie’s love letters to John, which had ensured merriment on the ward due to the details that she went into about her feelings for him. The self-neglect would re-start at home and why risk things? Elsie was happy enough. Everything was fixed, apart from the John thing.

The Care Home never fully read the care plan about Elsie and the new social worker had not really written much up about John and what had happened at home. The radio didn’t go with Elsie to the Care Home. Elsie noticed this on her first day at the home. However instead of asking for the radio Elsie screamed for 8 hours. In the end she was given medication. The Care Home didn’t call the hospital or speak to the psychiatrist about how distressed Elsie was. They made one phone call that day, which was to the social worker requesting more funding ‘due to the screaming’ and the impact this was having on other patients and staff.

Over the next 3 months Elsie moved into two different care homes and was returned to hospital following a fall. The radio was never switched back on.

Elsie died in a care home. It was four months, five days and 6 hours after the phone call from the neighbour.

Lord Justice Munby stated ‘what is the point in making someone safe if it merely makes them miserable’. In ensuring Elsie was miserable, we were unfit to even ensure her safety. John did exist for Elsie and we never saw that. John was the risk management plan. John stopped Elsie self neglecting, not the other way around. Elsie was the expert in her own situation and had an 87 year start on the rest of us who tried to study her and fix her within weeks. John was her flickering light of hope which we extinguished in the name of safeguarding people from themselves. I hope she saw John again somehow.