Care Management Matters May 2019

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MAY 2019


New methods changing the landscape

Improving your rating

How to handle CQC inspections

From the ashes

How safe is debt financing now?

Are you family-friendly?

Maintaining residents’ relationships





Congratulations to everyone at Belong Wigan Care Village for achieving CQC Outstanding!

Here’s what CQC said about Person Centred Software’s system in their inspection report... Registered Manager using Dashboard Monitoring The Person Centred Software system allowed them to monitor any changes identified and highlight any concerns which allowed them to discuss changes in need with relevant health and social care professionals, ensuring that care was reviewed promptly, and any changes could be put in place immediately. Carer using Electronic Evidence of Care “Person Centred Software is great, its continually open so we know what is needed and never forget a need or to make a record of interaction.”

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Activity Coordinator using The Gold Standards Framework The activity coordinator told us they would immediately visit this resident to ensure their last wishes could be kept: “If I see [the butterfly] I make it my job to spend time with them”. Relative using the Relatives Gateway A relative used the Person Centred Software portal: “I’ve read [my relative’s] notes on the Relatives Gateway and keep up to speed. I know how he is, it’s there in black and white.”

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In this issue 05

Inside CQC Joyce Frederick, Deputy Chief Inspector for Registration at CQC looks at work being done to review Registering the Right Support.


CMM News


Business Clinic This month, the panel looks at Nymbl, a system to aid falls prevention.


Rising Stars 2018 Nadine Webster is Home Manager at Cedar Lodge.


Celebrating excellence Countrymen UK at Future Roots are the focus of this month’s Markel 3rd Sector Care Awards story.


Event Review A review of the Surrey and Sussex Social Care Showcase 2019.


What’s On?


Straight Talk Julia Jones, Founder of John’s Campaign discusses the importance of involving family in care settings.






From the Editor



Can we cut out the middle man? New ways to recruit in social care Neil Eastwood from Sticky People takes a look at new ways providers can reduce the use of agencies when looking for temporary staff.


Shaking off the past: A brighter future for UK care service funding How can you make your service appealing to investors? Jackie Bowie of JCRA explores the preconceptions of lenders and borrowers and shares her tips.


Devil in the detail: Making CQC inspections work for you How can you get the most from the inspection process? Neil Grant uses guidance given to CQC inspectors to help you prepare.


Unlocking talent: The role of the nursing associate Organisations across England are being urged to offer opportunities for apprentices. David Sines explores the role of the nursing associate and how it can benefit the sector. CMM May 2019


EDITORIAL Editor in Chief: Robert Chamberlain Editor: Angharad Burnham Content Editor: Emma Cooper


PRODUCTION Lead Designer: Holly Cornell Director of Creative Operations: Lisa Werthmann Studio Manager: Jamie Harvey Creative Artworker: Ruth Clarry

ADVERTISING 01223 207770 Advertising Manager: Daniel Carpenter Director of Sales: David Werthmann Senior Sales Executive: Aaron Barber





Joyce Frederick Deputy Chief Inspector for Registration, Care Quality Commission

Neil Eastwood Founder, Sticky People and Care Friends

Jackie Bowie Chief Executive Officer, JCRA

Madeleine Starr MBE Director of Business Development and Innovation, Carers UK




Robin Wells Co-Founder, Care Software Providers Association

Claire Sutton Digital Transfer Lead, National Care Forum

Nadine Webster Home Manager, Cedar Lodge




Professor David Sines CBE PhD Strategic Advisor, Health Education England (London)

Julie Plumey Director, Future Roots

Julia Jones Co-founder, John’s Campaign

SUBSCRIPTIONS Non-care and support providers may be required to pay £50 per year. 01223 207770 Care Management Matters is published by Care Choices Ltd who cannot be held responsible for views expressed by contributors. Care Management Matters © Care Choices Ltd 2019 CCL REF NO: CMM 16.3

CMM magazine is officially part of the membership entitlement of:

ABC certified (Jan 2017-Dec 2017) Total average net circulation per issue 16,336


CMM May 2019

Neil Grant Partner, Gordons Partnership LLP

From the Editor Editor, Angharad Burnham looks at some of the sector’s pressing issues for providers and how the articles in this issue can help. There’s no two ways about it. Recruitment in this sector is hard. Despite work to improve it, there's still stigma around being a care worker. Government’s campaign to attract more people to work in social care ran through February and March, and I was delighted to attend an exhibition of photography taken during this time. The images weren’t a portrayal of the public's idea of social care – people changing bedpans or care home residents watching television – but showed the scope of being part of this sector. People were being supported to collect eggs from hens, attend interviews, go to the beach and generally have a good time. Government’s campaign has been criticised for showing an idealistic image of working in care, and there is a huge amount more skill and intricacy involved than the posters suggest, but this is a start, and I look forward to seeing statistics on the impact it has had.

FINDING SOLUTIONS Whether the campaign has brought more CVs to your desk or not, recruitment is still an issue that needs to be tackled. Focusing on the growing area of digital solutions, this month Neil Eastwood has looked into the companies that claim to be an alternative to agencies. Online platforms that give providers access to temporary staff, and temporary staff access to shifts, without the high cost of agency fees, could help to resolve some of providers’ most pressing issues, but are they the answer? Read Neil’s thoughts on page 20. While the cost of agency staff is a big problem for providers, retaining staff is also an issue. A lack of necessary funds means this sector can’t always keep up with competition in terms of pay, and as raised by John Kennedy in CMM’s March issue, a new generation of social care workers is needed – and they come with demands.

One possible solution is to explore apprenticeships. We asked David Sines of Health Education England to provide his insights into this route and he’s shared his knowledge on how the nursing associate apprenticeship role can help with recruitment and development of staff – plus how it can aid retention. His article begins on page 41.

BEING PREPARED Another pressure which providers can always reluctantly rely on is inspections from the Care Quality Commission (CQC). Many providers who are doing fantastic work

find this a major stress point and don’t come out with the rating they want or feel they and their staff deserve. Neil Grant from Gordons suggests that the key is in preparation. He’s put in Freedom of Information Requests to CQC to find out what guidance they give to inspectors before they knock at your door, and has used this to create a bank of tips and suggestions, which he’s shared with us in his article on page 36. Enjoy the issue and don’t forget to provide feedback and your thoughts on any of our articles on the CMM website, where you can also claim CPD points for reading previous editions.

Email: Twitter: @CMM_Magazine Web:

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Daily Record Management | Care Planning | Management Insights

Almost two years have passed since CQC published Registering the Right Support in June 2017 following consultation. The guidance explains how providers should comply with the national service model and best practice when developing services for people with a learning disability and/or autism. The policy is applied across registration and inspection; both to support us in making decisions about applications to register or vary registration, and in the judgments we make during inspections about the quality of care being provided to people using services. Over these two years we have learnt about providers’ and inspectors’ experience of applying Registering the Right Support in practice. This is why we have decided to carry out a review of the guidance to ensure its principles are clear and its aims are achieved. The extent of the review and the subject(s) it covers will be determined by a scoping exercise we are undertaking with stakeholders. As part of this, we will consider guidance and recommendations published after Registering the Right Support and whether they should give rise to changes to guidance. As a result of our ongoing regulatory work, we and stakeholders have identified issues which we anticipate may form part of the review, subject to the scoping exercise. These may include further clarification on the definitions of campus and congregate settings and issues around supported living services. We will make any changes to Registering the Right Support we consider appropriate following the review taking into account stakeholder views. We have learnt a lot through our use of the guidance at CQC. One stand-out lesson is that where providers, commissioners and CQC work together with people who use services and their families around transforming care, the principles of Registering the Right Support are applied successfully. This has led to us registering many services in line with best practice – making a difference to the people now being supported by those services. At the heart of all of this is the experience of people who use services. Registering the Right Support is part of the response to the catastrophic failures of care at Winterbourne View and we are all very clear that the guidance exists to support the development and delivery of services that lead to better

Inside CQC J O Y C E


Joyce Frederick, Deputy Chief Inspector for Registration at the Care Quality Commission (CQC) looks at work to review Registering the Right Support.

outcomes for people. All of us working in the health and social care sector share a responsibility to learn from these failures and play our part in ensuring it does not happen again. During this scoping review, we want to hear about your experience of reading and using

“We want to understand whether any changes are needed to make the guidance even more effective for all.” the guidance and any ideas you have for how it could be improved. We’ll also be speaking to people who use services and their families, commissioners, inspectors and national health and social care organisations to ensure we’re

hearing from everyone who has a stake in ensuring learning disability and autism services support people to live good lives. We want to understand whether any changes are needed to make the guidance even more effective for all. Sign up to our newsletters to hear about opportunities to get involved. As well as reflecting on the guidance, we are also supporting providers to apply the guidance today. Our pre-engagement service for Registering the Right Support enables providers to discuss their proposals or development ideas with CQC before submitting a registration application. We can help providers interpret the requirements set out in the guidance and advise on the likelihood of registration – although we are only able to decide whether to grant registration once we have an application and have conducted an assessment. If this sounds like a service that could support you with your ideas, read the guidance then get in touch.

Joyce Frederick is Deputy Chief Inspector for Registration at the Care Quality Commission. Share your thoughts and feedback on Joyce’s column on the CMM website CMM May 2019


Not everyone will read this. But everyone SHOULD read this. An evaluation to understand the impact of the PASSsystem on 101 care businesses was commissioned by everyLIFE Technologies in 2017 and completed in 2019. The evaluation was led by both the Social Care Institute for Excellence (SCIE) and York Consulting. The evaluation has demonstrated evidence based on feedback from business owners, care managers and care workers that the PASSsystem brings significant tangible benefits in terms of managing risk, efficiency, accountability and quality of care. To read the full report or request the executive summary of the SCIE / everyLIFE evaluation: Go to Or

Proven to: ■ better manage risk ■ realise business efficiencies ■ aid delivery of high-quality care ■ demonstrate accountability to services users, families and regulators

APPOINTMENTS NCF The National Care Forum (NCF) has announced the appointment of Liz Jones as its new Director of Policy.


The status of EU staff after Brexit The Department of Health and Social Care (DHSC) has confirmed the status of EU staff after Brexit if the UK leaves with or without a deal. Health and Social Care Secretary, Matt Hancock has confirmed that the qualifications and registration of EU staff will be recognised in the UK, whether we leave the EU with or without a deal, so health and social care workers with professional qualifications from EU institutions can continue to practise in the UK as they do now. This means up to 104,000 social care workers and 63,000 NHS staff who qualified in the EU will have their training and experience accepted by all regulatory bodies for the health and social care sectors, including: • Health and Care Professions Council. • General Medical Council.

• Nursing and Midwifery Council. • General Pharmaceutical Council. • General Dental Council. The confirmation also means that employment contracts will not need to be changed if the UK leaves the EU without a deal, and staff won’t have to re-apply for their current positions after exit day. Matt Hancock said, ‘Every day across the health and social care system, our EU colleagues and friends make a difference to millions of lives, and this vital legislation means they will be able to continue work here, whatever the Brexit outcome. ‘My priority is to make sure high standards are maintained across the healthcare system and patients continue to receive the high-quality care they deserve – this legislation helps ensure that will continue to be the case.’

Danny Mortimer, Chief Executive of NHS Employers and Chair of the Cavendish Coalition of social care and health organisations commented, ‘We have been clear that we must continue to embrace the vital contribution of our talented colleagues from overseas in caring for our patients and communities. ‘We very much welcome the news, as will employers and staff, that the UK will recognise the qualifications of EU professionals in a no-deal situation.’ Government is encouraging EU workers to apply to the EU Settlement Scheme that re-opened on the 30th March. The scheme is now free and those who have lived in the UK for five years or longer can apply for ‘settled status’, whilst those who have lived in the UK for under five years can apply for ‘pre-settled status’.

Skills for Care guide to improvement Skills for Care has launched a new online guide, Guide to improvement, to help social care employers to identify, plan and implement improvements across their service. The guide offers a comprehensive toolkit to help organisations deliver high quality care and support, and meet regulatory standards. At the beginning of 2019, 17% of regulated adult social care

services in England were still delivering care that didn’t meet the Care Quality Commission’s fundamental standards. To avoid having to implement costly interventions, organisations need to act quickly to make sure that they meet these fundamental standards. Even when a service is already achieving the Care Quality Commission’s fundamental standards, continuous

improvement is a key part of achieving and maintaining a Good or Outstanding rating. The Guide to improvement aims to help adult social care employers to identify what their service needs to improve and develop an action plan to implement the required changes. Providers can download the guide for free from the Skills for Care website, www.skillsforcare.

Care England has appointed Daniel Casson as its first Digital Development Executive. Daniel has been Head of Business Development at Jewish Care since 2007.

THE KING’S FUND Sally Warren has been appointed as the new Director of Policy at The King’s Fund.

CARE INNOVATION HUB Navin Mayani has taken on the role of Chief Executive Officer for the Care Innovation Hub.

ANCHOR HANOVER Anchor Hanover has strengthened its Executive Board with two new appointments. Kate Smith joins as Executive Director for Business Services and Simon Glucina is Executive Director for Transformation.

BOROUGH CARE Borough Care has welcomed Lee Omar to its Board of Directors in the role of NonExecutive Director.

RETIREMENT VILLAGES GROUP Retirement Villages Group Ltd has appointed Will Bax as its new Chief Executive from April 2019.

CENTRE FOR AGEING BETTER Health and work expert, Professor Dame Carol Black has been appointed Chair of the Centre for Ageing Better. CMM May 2019



Funded Nursing Care rate for 2019/20 Government has announced the NHS-funded nursing care rate for 2019-20, which will increase by 4.7% to £165.56 from April 2019. The higher rate of NHS-funded nursing care will also increase by 4.7% from the current rate of £217.59 to £227.77 per week for 2019

to 2020. This is only relevant for people who were already on the higher rate in 2007 when the single band was introduced. These rates have been based on an independent study of the costs of providing nursing care, undertaken by LaingBuisson. The

findings of this study have been combined with a 3.1% efficiency expectation of care home with nursing providers, and an expectation that no more than 10% of nursing hours are delivered by agency nurses. Professor Martin Green OBE,

Chief Executive of Care England, has reportedly announced that he is not satisfied with the rate, saying, ‘At long last the funded nursing care rate has been announced. It is not what we were hoping for and we will be considering next steps.’

Good practice for complaints guide The Local Government and Social Care Ombudsman has issued a guide on good practice for complaints. The guide shares lessons from complaints to help providers improve services. Based on the Ombudsman’s experience of investigating complaints about independent providers, the guide gives real-life examples of common problems the organisation sees and suggests practical ways to avoid them. Caring about complaints: lessons from our independent care provider investigations looks


CMM May 2019

at complaints around a lack of clear information about fees, charges and contracts; problems with billing and invoices; ensuring people’s belongings are looked after properly; and handling challenging behaviour from friends and relatives. Michael King, Local Government and Social Care Ombudsman, said, ‘Since 2010 we’ve been the only independent route to redress for the thousands of people receiving care from independent providers. ‘In that time, we have

investigated thousands of complaints, and have upheld a high proportion of those we investigate. ‘And although we see poor practice, we also see good examples of care providers making practical changes as a result – and it is this good practice we want to encourage. Care providers can learn a lot from the complaints we receive and resolve, and by working together hopefully we can improve the system for everyone. 'We believe caring about complaints and learning from

them is a sign of a mature culture and good leadership – as well as being a cost-effective way of improving, especially when resources are under pressure.' The guide also shows how the Ombudsman works in partnership with the Care Quality Commission and includes a copy of the single complaints statement, Quality Matters, which was produced in partnership with organisations including Healthwatch England last year. The statement helps providers set out what people can expect when making a complaint.


Social care in the Spring Statement The sector has responded to the Chancellor's announcement of further delays to funding and reform of social care in the Spring Statement this year. A three-year Spending Review will now align with the Autumn Budget, over two years since Government announced its intentions to publish a Green Paper. The Voluntary Organisations Disability Group (VODG) is calling on Government to rethink and bring forward much-needed reform. VODG argues that Government must urgently reverse years of chronic under-funding in the sector. A clear policy direction for social care is vital, along with a fair financial settlement that would guarantee the sector’s future. Dr Rhidian Hughes, VODG Chief Executive, said, ‘The case for a clear policy direction for social care is clear and is something VODG has argued for powerfully and repeatedly. While Brexit is a priority for Government – and will

have an undoubted impact on social care – it is not an excuse for it to drag its heels over social care. Government’s inability to produce the long-awaited Green Paper has a human impact because older and disabled people rely on social care. Ministers are effectively leaving a vital national support system in limbo instead of giving it financial resource and strategic direction it urgently needs.’ Other organisations have also responded to the lack of any mention of funding or reform for social care in the Spring Statement. Lord Porter, Chairman of the Local Government Association said, ‘The Government acted on our calls to find extra one-off funding for councils this year in the last Autumn Budget, including for social care, potholes and high streets. With councils still facing a funding gap of more than £3bn in 2019/20… The money local government has to maintain the services our communities rely on is running out

fast and huge uncertainty remains about how local services will be paid for into the next decade… ‘Brexit cannot be a distraction from the challenges facing our public services. If we truly value our local services then we have to be prepared to pay for them. Fully funding councils is the only way councils will be able to keep providing the services which matter to people’s lives, continue to lead their local areas, improve residents’ lives, reduce demand for public services, and save money for the taxpayer.’ Commenting from Independent Age, George McNamara, Director of Policy and Influencing at the charity, said, ‘It’s desperately disappointing and frustrating that the Government has yet again decided to kick the can of social care funding down the road. We are in the scandalous position where people are dying every day because they are not receiving the social care that meets their needs.’

Helen Walker, Chief Executive of Carers UK, has commented on the failure to mention social care in the Spring Statement. She said, ‘Another opportunity has passed and once again the Government has failed to deliver the funding for social care services that unpaid carers and those they support desperately need. ‘Without immediate investment in care services – as well as plans for sustainable long-term funding – the pressure on families providing unpaid care is only going to increase. We know that carers are already under a lot of strain... ‘The Government’s upcoming Spending Review must ensure better financial support for carers and enable them to have a break. Carers have already waited over two years for the Government’s Green Paper on social care so it is imperative that this too has their huge contribution to our society and the economy – worth £132bn a year – at its heart.’

The Platinum plan is more than just a set of chemicals, its about creating the highest quality of living within a care home, without breaking the bank. The Platinum plan includes: • Comprehensive documentation • Safety data sheets • Risk assessments • In-house training • Products which comply with British Standards

CMM May 2019



Renewed concerns about mental capacity reforms

Public against robots in care

A group of social care organisations has raised concerns about mental capacity reforms, following detailed analysis of Government's Mental Capacity (Amendment) Bill impact assessment. Professor Martin Green OBE, Chief Executive of Care England says, ‘Following a poorly drafted impact assessment that eventually accompanied the Mental Capacity (Amendment) Bill on its passage through Parliament, the Government agreed to re-write it. The second version of the impact assessment is full of loop holes and anomalies being open to chaos and confusion. The very suggestion that care home managers will need only half a day’s familiarisation training indicates just how out of touch the Department of Health and Social Care is.’ The analysis identifies a range of concerns about mental

Results from a survey of over 2,000 people have shown significant resistance amongst the UK population to Artificial Intelligence (AI) being used to provide care. This resistance comes in spite of the current skills shortage facing the sector and the potential for robots to address this and save money. The research, carried out by Randstad saw 83% of respondents saying they don’t think robots should be used in the care industry and only 17% in favour of AI helping to fill the skills shortage. A recent report, also carried out by Randstad, shows the UK lagging behind the rest of the world in terms of positive attitudes to AI in the workplace. Digitalization at Work, published in November 2018, showed that only 48% of UK citizens think AI will positively affect their job in the next five to ten years, compared to 59% globally and 88% in China.

capacity reforms that Voluntary Organisations Disability Group (VODG) says could result in: • Dilution of human rights, with the mechanisms for upholding liberty being opaque and illogical. • Significant new responsibilities for independent and voluntary sector social care providers, and a wide range of responsible bodies for organisations to report to depending on types of care. • Additional financial costs being passed onto providers, with no comparable diversion of funding away from local authorities. Care England has announced that the Liberty Protection Safeguards (LPS), for example, will be operated by a bewildering range of responsible bodies, in a far more complicated system than the one being replaced. There is also a very confused context for the proposed new work for care home managers;

if the person is in a care home and aged 18 or over, the local authority must decide, essentially, whether an individual care home manager is ‘up to the job’, and Care England states there is no clear information on how authorities will do this. VODG Chief Executive, Dr Rhidian Hughes, said, ‘This new analysis highlights deeply flawed assumptions underpinning Government’s mental capacity reforms. We continue to urge Government to work with the sector to get this Bill into much better shape in order to understand the human, social and financial consequences that arise from its proposed approach.’ The analysis is published by the Association for Real Change, Care England, Registered Nursing Homes Association, National Care Association, National Care Forum and the Voluntary Organisations Disability Group.

CQC fees for 2019/20

£7.5m sheltered housing scheme

The Care Quality Commission (CQC) has confirmed what it will charge health and adult social care providers in England this year. The changes in CQC fees for 2019/20 took effect from 1st April 2019. This follows public consultation on CQC’s proposals for the fees, which took place between 25th October 2018 and 17th January 2019. After consideration of the responses, the main decisions are: • An increase in fees for the community social care sector by £1.5m as part of the final year of a four-year trajectory to full chargeable cost recovery. • A decrease in fees for the residential social care sector by

A major landmark in Ashford Borough Council’s modernisation plan for its sheltered housing schemes has seen the re-opening of the Danemore scheme in Tenterden. The new-look Danemore sheltered housing scheme provides 34 homes for affordable rent for older people, together with four chalet bungalows which will be sold on the open market. The scheme includes a large communal lounge and kitchen, laundry room, guest suite, buggy store and cycle racks.

£0.8m to better align the cost of regulation with the fees collected. • An increase in fees for the dental sector by £0.6m to better align the cost of regulation with the fees collected. CQC states that this scheme ensures it completes its aim of recovering all costs for all sectors, as required by HM Treasury. This means that the regulatory costs are paid for by provider fees, as opposed to being subsidised by funding from Government. Additionally, this scheme addresses issues in sectors where CQC needed to balance fees recovered with the cost of regulating those sectors.

DC Care DC Care has successfully sold Belvedere Park Nursing Home in Coventry. The home provides support for 25 people who might have mild dementia or require nursing care. The business has 12

CMM May 2019

been acquired by Anand Patel, a new entrant to the care sector. Mr Patel undertook specific care sector courses and obtained the necessary qualifications to support him in the acquisition of the business.

A treatment room provides hair dressing, a nail bar, a podiatrist and chiropodist massage chair and a foot spa. Natural daylight is maximised in each home and the shared spaces. The scheme has been devised in recognition of the need to make provision for an increasing ageing population – around 40% of people within the Ashford borough will be aged over 50 by 2026. The new facility was built by Westridge Construction Ltd, with architects, PRP also involved.

Sentimental Care Ltd Sentimental Care Ltd has agreed a £5.4m re-finance package with Barclays, including additional funds to invest and develop its residential care home portfolio. Sentimental Care Ltd delivers care home services across three residential homes including two located in Somerset – Hamilton

Park, Taunton and Horton Cross, Ilminster – as well as a home in the Brecon Beacons, which is to be extended. The funding package will allow further investment in the group’s care homes by increasing the number of beds by 18 as well as improving facilities for its residents.

A law firm with a different perspective Preparing for inspections is vital – and ensuring your submissions are the best they can be is no small part

Providers must aim high and sell their services before and during inspections more than ever if they are to achieve Good or Outstanding ratings with CQC. Crucially, evidence must be at hand to demonstrate creative and innovative working, the essential ingredients of excellence. At Gordons, we can assist you in preparing submissions to go to CQC, highlighting your towering strengths, in order to distinguish your services and get you the ratings you truly deserve. | 01483 451900 |

Care Home Guides For registered managers and care home owners FREE TO ACCESS

Business in Focus

Business in Focus

Business in Focus

Care home communications

Fair trading for care homes

Web layout for care homes

A guide for registered managers and care home owners

A guide for registered managers and care home owners

A guide for registered managers and care home owners

Making sure your business complies with consumer law

Making sure your business complies with consumer law

Making sure your business complies with consumer law

This guide was produced as part of a business advice project by the Department for Business, Energy and Industrial Strategy and the Chartered Trading Standards Institute.

This guide was produced as part of a business advice project by the Department for Business, Energy and Industrial Strategy and the Chartered Trading Standards Institute.

This guide was produced as part of a business advice project by the Department for Business, Energy and Industrial Strategy and the Chartered Trading Standards Institute.

Three new guides have been released by Business Companion - the free government-backed website written by trading standards experts to help you understand the laws that affect your business - covering key issues in care home management: Care home communications, Fair trading for care homes and Web layout for care homes.


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State of ageing in Britain A report on the state of ageing in Britain has shown that a significant proportion of the population is at risk of poverty, illhealth and hardship in later life. The State of Ageing in 2019, compiled by the Centre for Ageing Better, is warning that people in their 50s and 60s could face substantial inequalities in health, work and housing as they age. The charity is therefore calling on Government, businesses and charities to think about changes that can be made now to ensure the next generation of older people can experience a good quality of life and can make the most of living for longer. The research brings together publicly-available data to reveal vast differences in how people experience ageing, and considers varying factors such as where they live, their financial circumstances and what sex or ethnicity they are. An average 65 year old can

expect to live just half of the remainder of their life without disability. However, those in less affluent parts of the country are more likely to die earlier and be sicker for longer, according to the report's data. As more people live longer, greater focus is needed on tackling the causes of preventable ill-health and disability including poor diet and low levels of physical activity, says the Centre for Ageing Better. The charity is calling on Government to require all new homes are built to be accessible and adaptable as standard and to commit to improving the condition of existing housing. Employers must do more to support people to keep working in fulfilling jobs as long as they want, says the charity, especially those managing health problems or caring responsibilities, so that they can save more money for their later life.

Care of people with autism: consultation The Department of Health and Social Care (DHSC) is asking autistic people, their families and those caring for them to share their views on how care of people with autism in England can be improved. This call for evidence is part of the cross-government review of the national autism strategy, which will be refreshed and launched later this year. The strategy will be extended to cover children as well as adults, so it is improved for people of all ages. People with autism, their families, carers and professionals can all take part in the online survey. Government is asking for people’s views on: • How autistic people feel within their local communities and whether members of the public understand their needs. • Whether autistic people, their families and carers receive the right support for all their needs at the right time. • How much autistic people are

supported to develop their skills and independence. • Where progress has been made, and where it still needs to be made. • What the key priorities should be for the future. Suggestions for improvement in specific areas could include: • In school through support to access the curriculum. • At hospital through timely diagnosis. • Within the community through respite care or support to enter the workplace. There will also be face-to-face sessions with groups of people with autism, including children and young people. Supporting people on the autism spectrum or with learning disabilities is one of the four clinical priority areas in the NHS Long Term Plan. The consultation will close on 16th May 2019.

IN FOCUS Health and care workforce: Closing the Gap WHAT’S THE STORY?

Nuffield Trust, The King’s Fund and the Health Foundation have published a joint report, Closing the Gap, discussing the need to support the health and care workforce to prevent collapse of the sector. Projections in the report show that without decisive actions being embraced in the upcoming NHS workforce plan, nurse shortages will double to 70,000 by 2023/24. The authors warn this deterioration would mean the goals of the NHS Long Term Plan will be impossible to achieve. Among the recommendations for urgent measures is radical expansion of nurse training, with cost of living grants of £5,200 a year and a tripling of the number of people training as postgraduates. The measures outlined in the report are needed to prevent the health and care workforce crisis from worsening dramatically. Experts from Nuffield Trust, The King’s Fund and the Health Foundation calculate that these solutions can only be fully implemented if there is a £900m increase in the annual budget for training and developing health and care workers in England by 2023/24.


Closing the Gap states that, even with grants and expansion of postgraduate training, bringing 5,000 more students onto nursing courses each year, and actions to stop nurses leaving the NHS, the number of nursing roles required cannot be entirely filled domestically by 2023/24. To keep services functioning, 5,000 nurses a year must be

ethically recruited from abroad, meaning Government will need to make exceptions to the salary restrictions in the Immigration White Paper and fund the visa costs incurred by NHS trusts. On social care, the authors say the proposed migration system after Brexit is not appropriate, and Government will have to go back to the drawing board to come up with a new route into the UK for care workers. The report also notes that the NHS should be careful that pay policies to attract new staff do not pull those staff out of social care services. A comprehensive overhaul of social care funding is also needed immediately, says the report.


Glen Garrod, President of the Association of Directors of Adult Social Services, said, ‘Adult social care derives its strength from the many people who work in it... ‘This report rightly highlights that a comprehensive overhaul of social care funding is needed immediately to stop staff leaving the sector due to lower pay and conditions. This runs the risk of being exacerbated by pay policies for NHS staff such as increased training and bursaries, potentially attracting people with some of the same skills and qualities needed in social care. ‘In the last year, social care has shown how vulnerable it is with both national and local providers struggling to run a viable business and retain essential staff. Social care is fragile and critically needs the people working in it to want to continue and for others to be able to join.’ CMM May 2019



Report into benefits of retirement communities A new report has shown the benefits of retirement communities for older people, including improved physical and mental health compared to living at home. The independent study, commissioned by the ExtraCare Charitable Trust and conducted by Aston and Lancaster Universities, looked into how healthily people were ageing compared to when they were living in their own homes. It showed that residents living within the charity’s retirement communities: • Were more physically active than

they were in their homes (75% increase in exercise). • Benefited from a reduced risk of falls (18%). • Were less anxious than when they lived at home (23%). • Had an increased walking speed. • Were ‘never or hardly ever’ lonely (86.5%). • Had improved autobiographical (24%) and memory (17%) recall. • Could delay or reverse the onset of frailty. The study follows the charity’s 2012-2015 research with Aston

University, which revealed a 14.8% reduction in depressive symptoms amongst residents after three years, and annual NHS savings of 38% per person. The latest study by Lancaster University, led by Professor Carol Holland, includes additional measures for loneliness, resilience and quality of life. This latest research has helped inform the development of a resilience tool to measure how resilient residents are in terms of physical and cognitive health. The tool will launch this Spring and will

be used to reassess residents who have already been identified as frail to determine if personal goals and targets are helping them to become more resilient. There are plans to roll the tool out to other retirement housing providers later in the year. 19 villages and schemes were included within the research, with more than 160 residents involved. For the second report, data from the participants was collected at 24, 36, 48 and 60 months. The full report is available on the ExtraCare Charitable Trust website.

Julie Morgan, said, ‘The Welsh Government is committed to supporting older people, and those requiring care, to live the lives they want to lead. I’m delighted to say that we are fulfilling our pledge, two years earlier than we originally planned, to allow people to keep up to £50,000 of their own savings

to use as they wish, without having to use this to pay for their care.' The capital limit increase and the maximum weekly charge for non-residential care (introduced in Wales in 2011) both seek to reduce the impact of charging on people who rely on care and support to help meet their daily living needs.

Capital limit increase in Wales The Welsh Government has announced a capital limit increase, so that people in residential care can retain more of their money if they need support in a care home. The Deputy Minister for Health and Social Services, Julie Morgan has confirmed the introduction of a £10,000 increase in the capital limit

used by local authorities in Wales who charge for residential care, raising it to £50,000. The allowance in Wales is the most generous across the UK and is now more than double England’s and Northern Ireland’s upper allowance of £23,250. In Scotland the upper limit is £28,000.

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CMM May 2019


Keeping Active in Residential Elderly study A group of care home residents is taking part in a University of Birmingham study, Keeping Active in Residential Elderly, to see whether exercising while seated can improve the health and wellbeing of frail older adults. The Keeping Active in Residential Elderly study is being conducted by the Physical Activity and Nutritional INfluences In Ageing project research group at

the University of Birmingham. Participants are exercising using specialised chair-based physical activity and resistance training machines, which are adapted and designed for frail older adults. Residents living in Olivet Care Home and Sheltered Apartments in Birmingham, run by Christadelphian Care Homes, have volunteered to participate in the study. They will be measured before and after

the study to assess their physical, psychological, cognitive, emotional and social health, as well as their immune function. They were selected at random to either take part in the resistance training group or a ‘control’ group which will receive their usual regular care throughout the duration of the study. Over six weeks, those in the resistance training group

will complete three to four training sessions per week, with each training session lasting approximately 35 minutes. There will then be follow-up measurements six weeks after the sessions have taken place to assess if there have been ongoing positive health benefits, and interviews with the participants and care home staff to get their opinions on how they felt about the intervention.

interoperability, e.g: • Sharing of information across the health and social care system to support efficient access to care. • Real-time alerts that notify providers when someone using their service has been admitted to or discharged from hospital and other appropriate flags. • Removal of fax machines through the use of appropriate and secure messaging platforms.

2. Use of data for the prevention of escalating social care needs and for early intervention, e.g: • Predictive modelling for adult social care demands and needs across a population. • Using data to highlight those whose environmental, health and social indicators mean that they are at higher risk of losing their independence.

Funding for digital projects Funding for digital projects has been announced for organisations that provide and commission adult social care services. Organisations are invited to bid for a share of £4.8m to enable them to roll out their projects on a wider scale. The funding for digital projects in adult social care is managed by NHS Digital and supports Matt Hancock’s vision for interoperability and openness, open standards and appropriate

infrastructure. Applications can be made by not-for-profit adult social care providers, local authorities and academic organisations based in England. Partnerships and consortiums are welcomed and encouraged. Applicants for the funding for digital projects will likely comply with two main themes: 1. Use of standards to support whole health and care system

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Deprivation of liberty assessments in Staffordshire The Local Government and Social Care Ombudsman (LGSCO) has criticised Staffordshire County Council’s decision not to conduct deprivation of liberty assessments for some vulnerable people. In May 2016, Staffordshire County Council decided it would stop carrying out any deprivation of liberty assessments except those it classified as high priority. At the time it made the decision, it was aware it would not be complying with relevant legislation and statutory guidance, but made the decision because of a lack of finances, according to LGSCO. The council created its own guidance for ranking Deprivation of Liberty Safeguards (DoLS) requests into three priority bands. This was based on guidance issued by the Association of Directors of Adult Social Services, but Staffordshire used an adapted version which resulted in fewer requests being categorised as high priority. At the end of June 2018, the council had a backlog of 3,033 DoLS requests for which it had not carried out the relevant assessments, with some dating back to August 2014. Michael King, LGSCO, said, ‘We issued a focus report in 2017

highlighting the problems we were seeing in this area, and although we believe Staffordshire’s response is at the extreme end of the way councils are dealing with DoLS issues, I would urge others to look at how they are carrying out assessments to ensure they comply with relevant law and guidance. ‘Resource constraints can never be a legitimate reason for not carrying out the assessments required by law or statutory is not acceptable that the only way low and medium priority applications are resolved is because the people involved move away or die. ‘Because the council does not assess the majority of requests we simply do not know if there are people waiting in the backlog who are wrongly being deprived of their liberty... ‘Its decision may also have had an impact on those providing care – for example, when care providers need to liaise with the emergency services for someone they don’t have the right authorisations for. ‘I now commend the council’s attempts to review its policies and tackle its backlog of requests and ask it to take on board my recommendations.’

Larchwood Care closes five homes Larchwood Care has announced the closure of five of its homes, but says the remaining 50 homes in its portfolio are not affected. Brookes House in Brentwood, Copper Beeches in Liss, Mountwood in Andover, Wickwar in South Gloucestershire and Withy Grove in Preston will all be closing on or before 31st May 2019. Notice has been given to local commissioners and residents, and families and staff have been informed. Tony Stein, Chief Executive of Larchwood Care, said, ‘These five homes have been losing substantial amounts of money over an 18

CMM May 2019

extended period of time and their continued operation has become unsustainable for the company. ‘There are a number of external sector-wide factors that have contributed to this decision, including the inadequacy of fees paid by commissioners, high operating costs and, low admission rates… ‘We will work closely with social services, CCGs and others to support residents and their families at this difficult time…This has been an incredibly tough decision to take and all other options have been considered.’

Call for free personal care Independent Age is once again calling on local councillors to back the call for Government to introduce free personal care for over 65s – something that is available in Scotland, but not in England. The social care system costs local government billions of pounds every year, but according to a report from Age UK, it is not meeting the needs of over 1.4 million older people. The older people’s charity says that free personal care for older people can: • Provide a social care guarantee. • Provide better value for money for the taxpayer. • Reduce the need for residential care placements, which are funded at high cost by local government. • Support family carers to spend more time providing emotional support. • Enhance the integration of health and social care. A recent YouGov poll found that 74% of adults in England aged 18-64 want free personal care for all older

people, and 69% would be willing to contribute more to fund it. In addition, there is growing parliamentary support for free personal care. A recent ComRes poll for Independent Age, which surveyed 116 MPs in England, found that three quarters of them (74%) agreed that free personal care, paid for through a social care contribution, should be provided to all older people needing it. This reinforces the recommendations of the influential Health and Social Care and Housing, Communities and Local Government select committees’ joint report setting out the case for free personal care to be introduced, paid through a social care contribution. With more than two years having passed since Government announced it would produce a Green Paper on adult social care, the charity has written to council leaders across England, calling on them, their fellow councillors and prospective council candidates, to join the growing support for the introduction of a free personal care guarantee for older people as part of the social care reforms.

VODG position statement on sleep-ins The Voluntary Organisations Disability Group (VODG) has published a new position statement on sleep-ins, calling for Government to take decisive action. VODG has warned that the lack of clear regulations for the payment of overnight support will drive the social care market to move in uncoordinated ways and lead to ‘inconsistent commissioning and provision’, and its new position statement outlines the association’s ‘grave concerns’. VODG is also urging Government to set a new rate for sleep-in payments, after full consultation with workers, employers, commissioners and other stakeholders. The Group has consistently warned Government that case law is at odds with how sleep-in

support is commissioned. The group is adamant that commissioners must not use the recent Court of Appeal judgment to cut fees for overnight support. VODG makes several recommendations to resolve the sleep-in confusion, including that: • Government must consult widely with workers, employers, commissioners and other stakeholders and clarify what hard-working staff are entitled to, and precisely how it, and commissioners, will fund this. • Commissioners and providers must work together. • Government must confirm that the current legal position means employers will not face HMRC retrospective action to recover under-payment of national minimum wage for sleep-in work.

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New ways

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CMM May 2019

If there is one area of social care where we can all agree innovation is desperately needed, it is in recruitment. Here, Neil Eastwood from Sticky People and Care Friends looks at the upcoming trend of using technology to cut out agencies when looking for temporary staff.

Finding enough new staff with the right values is now the top risk for care providers by some margin. Yet despite this, employers have had little in the way of highimpact, innovative tech focused specifically on our sector. In fact, I would argue much of the recruitment technology that has seen widespread uptake in social care in the past 15 years has made things worse, not better. A prime example of this is internet job boards, which can overwhelm recruiters with volumes of unsuitable applications generating high rates of interview no-shows and uncommitted new starters, most of whom leave within a year. Another more recent technology that promises much is applicant tracking system (ATS) software. There are now over 300 ATS systems on the market, but a number deliver a poor candidate experience by requiring login details to be created and asking for far too much information from the applicant too early in the process. This is a critical flaw in the world of social care recruitment, where quality applicants have so much choice. Employers tell me of poor after-sales support from certain vendors and the challenge for busy managers of updating the ATS software regularly. In many cases then, the expected benefits of applicant tracking systems are not yet being fully realised. These are both examples of recruitment technology that wasn’t built for social care employers. The field narrows considerably when you look for purpose-built solutions for a sector which is, by its nature, riskaverse. We definitely lag when it comes to adopting novel ways of doing things. The care market is also very fragmented, with thousands of mostly very small businesses spread right across the country, so if you are a hardpressed recruiter or manager, advances can pass you by. Equally, many start-up recruitment tech companies are much more likely to target lucrative markets that have money to spend, such as the financial sector and corporates, rather than


CMM May 2019




cash-strapped social care providers. But perhaps things are finally changing. There is an emerging trend to build bespoke mobile-centric platforms, such as apps, specifically for social care recruitment. Putting the smartphone as the main interface for users of your new service is a clever move in a sector where most of the workforce does not sit at a desk and heavily relies on their mobile phone as their primary means of communication.

TEMPORARY STAFFING IS LEADING THE WAY It is perhaps no surprise that one of the first recruitment innovations to gain traction in our sector is addressing one of the biggest sources of cost and frustration to residential care providers – temporary agency staffing. It is often said that a deep unhappiness with the status quo is the trigger for innovation. Some of the most successful recent techbased products and services have been created to address markets where traditional suppliers had become too powerful and this is a perfect example. It is likely that readers who regularly have to book or pay for temporary nursing or care staff from an agency have had a poor experience. Temporary staffing suppliers have a bad reputation. A number, certainly not all, are guilty of opportunistic pricing as well as sharp practice. Of course, the availability of short-term staff is critical to nursing and residential homes, given recruitment and retention challenges as well as unexpected absence, but many managers feel taken advantage of and there has long been a desire to find a better way to source short-term labour. In response to this desire, we have seen the emergence of temporary staffing platforms

dedicated to the care sector which create a digital marketplace to bring self-employed workers, particularly nurses and care assistants, together with residential care settings seeking short-term staff. These include Florence, the longest-established and focused mostly on nurses, as well as other more recent entrants such as Roostr. They have strong appeal to both the manager (moneysaving, convenience, speed, direct contact) and the worker (higher rates of pay, more choice, more control, a direct relationship). They also bring transparency to both the buyer and the seller and remove overhead cost and, in many cases, excessive profittaking.

SCALING CHALLENGES Despite the strong concept, building an online marketplace is fiendishly hard – you need to quickly establish both buyer and seller communities to a scale that ensures one side or the other doesn’t get frustrated and leave the platform. This is a particular challenge in care where over 70% of frontline staff live six miles or less from work. The way to overcome this is to initially limit the geography you serve and focus on building volume in a concentrated area before moving on to establish the next market, and certainly both Florence and Roostr are smart enough to have done just that. Another challenge is to ensure an excellent user experience for both the manager booking staff and the self-employed nurse or care assistant. If finding shifts takes too long or it’s difficult to check the suitability of prospective workers, users will quickly desert. For many residential homes, processing payroll and adapting to another set of terms aside from the traditional staffing agency can be a barrier. For goodwill to be

maintained, self-employed staff will expect to be paid promptly. Employers may find this a big difference from longer payment terms that may have been negotiated with agency suppliers. If workers are made to wait too long they will be reluctant to come back. Marketplace platforms that directly connect buyers and suppliers also risk what is called dis-intermediation – the temporary worker and manager deciding to drop the platform once a relationship is formed. To be successful, these online platforms have to find solutions to these risks. Uptake of this type of technology is largely driven by word of mouth – prospective self-employed nurses or care staff will seek out feedback from other temps they know or meet as well as checking online reviews from colleagues. Equally, many employers will want some reassurance before signing up. Here, the companies may face their biggest challenge: resistance to change. Although providers can expect savings of up to 30% on typical agency costs, there is a familiarity to dealing with an established supplier. Despite the downsides, a middleman also takes some of the perceived risk away. In our highly regulated sector, could a fear of nobody to fall back on if things go wrong hold back adoption?

CONSIDERATIONS FOR PROVIDERS If I were a registered manager contemplating this method to source temporary staff, I would first find the platform or platforms that offer good coverage in my area, then seek feedback from colleagues who have tried them out. The organisations supplying the solution should always be able to provide several contacts of clients who would be happy to give their feedback, but asking at

registered managers’ forums and online via the growing number of Facebook groups for managers would be my advice. Also check with your finance team that they are able to process payments in the method and timeframe expected. It is not necessary to make a wholesale change from current suppliers to an online-based marketplace platform. Shifts can be booked on an individual basis, so once a relationship and trust is established between each self-employed worker and the manager, and the process of booking and paying is bedded in, this can be built on by transferring additional shifts away from the agency supplier over time.

THE START OF A REVOLUTION? Overall, I am a big fan of this type of innovation, especially since it brings competition into a one-sided market where suppliers have far too much power. But this use-case is only really relevant for residential settings, not so much homecare providers, who traditionally don’t use temporary staffing agencies and have little requirement for nurses. It also addresses only temporary staffing needs and not permanent recruitment. It is unlikely that many of the workers who have chosen to be selfemployed and use this method to seek work will be enticed to a permanent position with a particular care or nursing home, so the direct contribution to reducing vacancy rates is likely to be negligible. While helping employers to reduce burgeoning agency costs is a very welcome development, I anticipate this is just the tip of the spear in the application of mobile phone-centric technology to support providers find the new staff they desperately need to support the vulnerable in our communities. CMM

Neil Eastwood is Founder of Sticky People and Care Friends and Author of Saving Social Care. Email: Twitter: @StickyNeil Have you tried a new recruitment platform? What are your thoughts on this latest innovation? Share your thoughts and feedback on Neil’s article on the CMM website 22

CMM May 2019

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Shaking off the past A BRIGHTER FUTURE FOR UK CARE SERVICE FUNDING Financial risk and debt advisory specialist, Jackie Bowie of JCRA, unpicks the preconceptions of lenders and borrowers in the care sector and discusses how you can make your service appealing to investors.

The sector’s historic use of debt financing is chequered. Around ten years ago, large private equity investors began to identify the sector as one with good growth potential, driven by an ageing population. Private equity funds started to invest in very large care groups and built sites across multiple regions in the UK. However, the return on investment from these assets does not tend to benefit much at all from economies of scale, and the running cost of a care home, for example, can be very ‘localised’ to each individual site. This made it difficult to discern


CMM May 2019


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whether an individual service would be a viable investment.

A TROUBLED PAST One way for these equity investors to extract capital value was to enter into sale and leaseback agreements, where the underlying property asset, for example a care home building, was sold, often to a specialist property investor, and then leased back over a very long-dated, inflation-linked lease structure. This allowed large, one-off capital injections to come into the business, but at the same time left the operators with often onerous, high, fixed lease costs. When revenue started to come under pressure, there was no flexibility in these leases and operators were forced to succumb to their lessors under the burden of the high cost of servicing debt. The fate of Southern Cross is one notable example, where expensive leases could not be paid, so the landlords made a call on the assets. The financial problems of Four Seasons Healthcare Group, which are down to different circumstances, although still debt-related, have also been well publicised, and this has added to some lenders’ concerns about lending to the care sector, making debt raising more difficult for some. During the pre-financial crisis years – up to 2007 – bank lenders (mainly the UK clearing banks) had a strong appetite for lending to care home owners and operators. Much of their lending was focused on smaller, mainly family-owned businesses with a handful of localised assets. These businesses did not have the same sale and leaseback structures as their larger competitors and, on the surface, their financial reports would not have looked to be overly stretched in terms of debt levels; in financial terms, their level of ‘gearing’ would have been low. However, it was during this time that the bank lenders started to sell large amounts of financial derivatives – contracts that require payment of a fixed rate of interest over a long period of time – and many care homes entered into these. They were positioned as safe risk-management tools (to limit risk from rising interest rates), but in reality, many of them were very complex, structured products. Once interest rates started to fall (2008 onwards), the financial costs

for owners and operators began to soar. There was no opportunity to exit these contracts, as their termination penalties were prohibitively high. In some cases, the termination penalties were higher than the actual underlying debt. For example, one borrower had a loan of

“Given this history of debt financing, it is no surprise that both borrowers and lenders are approaching debt with some trepidation.” £25m, and a fixed-rate derivative, which, if cancelled early, had a termination penalty of £28m. What came next was a slew of lawsuits against the banks. These lawsuits were driven by the Financial Conduct Authority (FCA) investigation into the banks’ sales practices, and those found at fault were issued with an instruction for how compensation had to be calculated.

MOVING ON Given this history of debt financing, it is no surprise that both borrowers and lenders are approaching debt with some trepidation. However, the debt financing market has moved on in the last three to four years and there are now many more choices of suitable debt sources that come with much lower risk. Furthermore, lenders are now attempting to evaluate borrowers on their own merits and not treat the sector as one homogenous group. The presentation of your business in terms of its operating metrics and financial status is critical to ensure the debt structure and the cost of debt are optimised to your particular situation. Operating metrics, acquisition opportunities, capital expenditure plans, and the mix of private pay versus local authority clients in your service will all be scrutinised when assessing your business. The cost pressures facing the sector are well-documented and, when combined with constrained revenues, are forcing operators to

> CMM May 2019




undertake detailed analyses to forecast their financial performance and demonstrate to lenders that they have some resilience.

KNOW THE MARKET Analysis of key organisations across, for example, the not-for-profit care sector, reveal operating margins (before accounting for debt and investors being paid) of around 12% on average over the past four years. The range of profitability in the not-for-profit care

“New investors and lenders who are not carrying any pain from previous losses have entered the market, and they are keen to make successful equity investments and debt offerings.” sector is broad, with some organisations showing negative operating margins, to organisations with margins of around 40%. This range is further impacted by the differences seen in cost of capital – the cost of debt and the amount paid to investors – and the different types of funding that operators have in place. The cost of interest and capital repayments, including debt and operating leases, can take up over a third of available cashflow (the average for the whole care sector over the last four years). The way the sector operates means it is left very exposed to adverse changes, such as increasing staff costs or reduced payments from local authorities, as well as potentially rising interest rates, to name just a few. Borrowers need to be able to demonstrate to lenders how they are managing these risks and demonstrate their strength against industry benchmarks. While large private sector care groups can access a wide range of

funding sources due to their scale and diversity, charitable groups have been more restricted to bank debt or some type of leasing product. The growth of the socially responsible investment market has opened other avenues, in particular the bond and private placement market, where borrowers can raise mediumto long-term funding. Access to this market can be direct; charities can use the Retail Charity Bond (RCB) platform, which issues a bond in the charity’s name and then lends the proceeds to it. These 7- to 12-year fixed-rate bonds are sold to a wide range of socially responsible investors (SRIs) as well as institutional investors and can be bought by retail investors via their stockbroker, substantially widening the charity’s potential supporter base.

A HOPEFUL FUTURE Overall, there are still many headwinds facing the social care sector, and some tarnished reputations remain from past troubles. However, as an industry that serves such an important social purpose, ensuring its financial viability should not only be the focus for owners and operators, but also advisers, financiers and Government. Funding markets have changed materially since 2014/15. New investors and lenders who are not carrying any pain from previous losses have entered the market, and they are keen to make successful equity investments and debt offerings. Structuring your business plan and sensitising the assumptions (cost of debt, inflation assumptions, wage costs, revenue mix) to evidence your adaptability will give lenders confidence. Due to the much broader source of finance available now compared to before the financial crisis, debt structures can be better tailored to each individual circumstance, with flexibility built in to accommodate potential shocks. The sector has realised there is no one-size-fits-all approach, and it is now beginning to shake off the misjudgements of the past and reset expectations for the future. CMM

Jackie Bowie is Chief Executive Officer of JCRA. Email: What are your experiences of using investors and lenders? Are you thinking of approaching a lender to fund your service? Share your thoughts on the CMM website where you can also provide feedback on this article 28

CMM May 2019

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STRIKING A BALANCE: MOBILE APPS TO REDUCE FALLS Falls prevention is an important and growing area of providing services in adult social care, particularly in older people’s care provision. Nymbl has developed a system to support people and providers in this area. Research shows that a third of people over the age of 65 fall at least once a year. Falls cost the NHS over £2bn per year and over 4 million bed days. The emotional impact of falling frequently leads to reduced mobility, fear of falling again and social isolation. An ageing population and increasing demands on services means that finding a solution to this issue is critical. Nymbl is a balance measurement and improvement programme with apps and an intelligent portal designed to reduce the risk of falls in older people. The idea was born when Caroline Owen Jones and Tom Virden met retired spine surgeon, Dr Jean-Pierre Farcy who wanted to communicate his clinical experience as widely as possible with the people who needed it most. Part of the knowledge he wanted to share was around the importance of balance as an indicator of a person’s state of health, as well as the ability to predict someone’s future state of health. He knew there was an opportunity to use smartphone technology to deliver the dual-task interventions, combining isometric poses with cognitive load, that had proved successful amongst his patients but needed support to see this vision through to reality. Caroline and Tom together with Jim Cook, Ed Likovich and a team of experts in technology and science, created Nymbl.

HOW DOES IT WORK? With funding and grants, the team developed two mobile apps. One of these, Nymbl Pro, evaluates 30

CMM May 2019

balance based on CDC Steadi protocols and Dr Farcy’s expertise, and the other is for balance training. Health and care providers use Nymbl Pro, a balance evaluation app, to assess a person’s current abilities. This assesses the person’s strength and static and dynamic stability. The user is then given a numerical baseline score which they should see improve over time as they train. Once they have established their baseline, the user will move onto either the Nymbl Training app or take part in Nymbl Classes, or both. The training app allows a person to carry out dual-task training exercises in their own home. It progresses the person’s training levels based on their performance and engagement with the app. If the user prefers to engage in group activities, they can attend a Nymbl Class, which focuses on dual-task training as a shared experience. Nymbl has found that the average engagement in traditional balance classes is less than 10%, whereas a Nymbl Class boasts more than three times that figure. The person’s progress is trackable remotely, so family and professionals can see engagement and improvements. The app also has an intelligent alerting system, which can provide warning if someone is at a high risk of falling. This approach improves outcomes at an individual level, encouraging intervention before emergency situations arise.

A DIFFICULT SECTOR The roll-out of Nymbl has seen some challenges. ‘We are fortunate

compared with many other businesses in that the problem we are addressing is universally agreed upon and we were very quickly able to show the effectiveness of our solution,’ says Caroline, Nymbl Co-Founder. Chief Executive Officer, Ed Likovich goes on to describe the difficulty of targeting the social care sector, saying, ‘One challenge is the adoption of technology in this market, but the company’s progress has been helped by the increasing penetration of older adults owning smart devices in their home, passing the 50% threshold in 2018. ‘A further challenge lies in designing apps in a way that older adults understand and are comfortable with. 'There was a pervasive market belief that older adults were fearful of technology. What we found through focus groups is that the fear was based more on the complexity of the interface and the fear of breaking the device. We initially had three buttons and we found that it produced anxiety. Moving to a single button design brought dramatic results, for example a greater than 90% adoption by those who tried using it.’ The design of the apps was pivotal in ensuring engagement, and the Nymbl team have paid close attention to the experience of the users. Caroline says, ‘Working in older adult focused design is more than interface, even the colour palette matters for those with macular degeneration, requiring careful design regarding contrast, font size, leading and tracking. Many of the conventions, common across all IOS/Android

apps, are well understood in the younger population but entirely foreign to older adults. This means every aspect of the client engagement with the technology has to be thoroughly interrogated.’

ENCOURAGING PARTICIPATION The results from users so far is promising. Studies into user engagement conducted by Imperial College London have found that more than 25% of those offered the programme started using it. At 21 days of participation, the users can expect improvements in their balance and postural sway area reduced by 37%. At 30 days, studies amongst care home cohorts show a 28.3% numerical baseline score improvement, resulting in a 50% reduction in the number of people at an increased risk of falling. Participation tends to be sustained, with 87% of independent living and care home residents completing at least three days a week of training, and at six months, over two thirds of those community members are still participating. Nymbl’s aim for the future is to continue to develop and improve balance and prevent falls, particularly in older adults who don’t go to the gym. CMM

OVER TO THE EXPERTS... How can Nymbl be applied in different care settings? What are the drawbacks? How does it differ from systems that are already being used?

COULD MAKE A HUGE DIFFERENCE In an ageing society, technology can make a huge amount of difference to people requiring a bit of extra support at home, as well as benefitting the family members or friends looking after them. A fall can have a huge impact on a loved one’s confidence and independence. Carers tell us that the risk of their loved one falling when they’re not around is what worries them the most, so prevention technologies have a key role to play in providing much needed support and reassurance. Being able to see how a loved one’s balance is progressing, or being notified that they are at a higher risk of falling than usual, would be extremely helpful in falls prevention. This kind of technology can help to relieve worry when carers go about other daily plans, like going to work, staying in touch with friends or simply taking a much-

needed break to recharge. As well as allowing carers more freedom, it can also give loved ones peace of mind knowing they are being supported from a distance. Falls prevention devices are just one asset in a range of technologies that can help make life easier for carers and enable those they support to live independently for longer. Tools that monitor medication or gas detectors, for example, could help reduce unplanned visits or hospitalisation. Devices that allow you to control the home environment can be useful if a loved one has difficulty controlling appliances, reaching for curtains or using doors. Other technologies like remote monitoring and alerts, remote healthcare and technology to improve physical health can all help.

Madeleine Starr MBE Director of Business Development and Innovation, Carers UK

A STEP TOWARDS IMPROVING CARE QUALITY Falls are one of the major factors contributing towards the increased level of hospital admissions amongst older people. The NHS says that people over the age of 75 are most at risk of being admitted to hospital as a result of a fall. The use of smartphone apps by residents and care workers provides an opportunity to prevent falls and hospital admissions. By using smartphone technology, Nymbl can attack the problem at its source and enable people to improve their balance whilst encouraging exercise. The key to Nymbl’s success will be the ease of use of the app. Smartphone apps have already proven their success by making monitoring fluids in real-time a reality. Care homes can see which residents have not had sufficient fluids and take appropriate action, reducing falls caused by dehydration by up to 33%. The use of smartphone

technologies, such as Nymbl, clearly demonstrates the vast opportunities which are available for preventative care – improving the quality of care for those in independent living or a care home. It is important that we promote the growth and use of digital technologies in the social care sector and ultimately improve the quality of care delivered, but as Nymbl has found, this can be difficult. Our Association aims to help with this, by promoting this message to the NHS and central Government so that providers can be supported to adopt technology. Innovative apps like Nymbl will make a real difference for both care workers and those in social care, reducing hospital admissions and improving people’s quality of life, and it’s important we get the message out there.

Robin Wells Founding Director, Care Software Providers Association (CASPA) and Director, Person Centred Software

A PERSON-CENTRED SOLUTION The main difference between Nymbl and more traditional balance trainers is the integrated, person-centred approach. If technology is done right, it is person-centred. Good technology and digital solutions used in health and social care should have a positive impact on the people receiving support, their family and professionals involved in their care. Nymbl has considered the ability of its users when designing the system and has carried out research to ensure that the user experience (UX) is positive and does not cause anxiety. They have designed it from the start with the end user in mind. Importantly, Nymbl has also incorporated evidence-based faceto-face classes into its offering, with Nymbl Classes also being available. These have themselves shown higher engagement than traditional balance classes. Initial results show promising participation and baseline score improvements

and high levels of continuing participation after several months. Nymbl has the potential to be implemented in a variety of settings from residential care, to homecare, supported living to respite day care, especially if it is used in conjunction with group Nymbl Classes. It has the potential to improve not just balance and falls risk, but also feelings of loneliness and isolation. Current falls prevention strategies are often piecemeal and don't offer an integrated approach. Nymbl offers users, their family, and those involved in their care the opportunity to collaborate in improving a person’s balance and reducing their chances of falls. A key challenge for Nymbl will be encouraging widespread access to the Nymbl Classes to ensure that even the most geographically isolated users can benefit.

Claire Sutton Digital Transformation Lead, National Care Forum CMM May 2019



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Nadine Webster is Home Manager at Cedar Lodge, run by MHA.

CAREER HISTORY I always knew I wanted to be a nurse. I started my training in December 1990, had my son in 1992, qualified in 1993 and got married in 1995 – it was a busy time! I was part of the last intake before Project 2000 and nurses were over-recruited. I did my nurse management training on a children’s ward which was the area I’d wanted to specialise in, but there was no position available when I finished this training, so I took a job in a local care home with nursing instead. I thought it would be a dead end, but it was so exciting and it worked around my children. I was even offered a position on the children’s ward when one came up, but I turned it down to stay in social care. I saw that I could make a difference to older people and loved my work. I moved around between homes to gain experience – mostly small, private organisations – and was often offered more senior positions but always turned them down to prioritise my family. Eventually, I was working at Abbey Park in Coventry, a care home with a fast response and end of life unit. I thought I’d only be there for about a year, but I was promoted and started to manage the fast response unit, going on to become the deputy manager. I then moved to Cedar Lodge, where I’ve worked for two years. MHA is the best organisation I’ve ever worked for – the senior management team listen to and care about both the staff and the residents. Here, I’ve been able to grow and learn and I can lead rather than ‘manage’ my team so that they can grow and learn with me. It’s the complete opposite of what I always thought I’d wanted to do, but I can’t imagine not working with older people now.

ORGANISATION I am Home Manager but I prefer to think of myself as a home leader. Cedar Lodge is a 47-bed home providing residential, dementia and nursing care. We have a variety of residents who all have different levels of needs, from those who just need daily support to people who have quite advanced dementia and physical health needs. It means that residents can stay here and don’t need to move as their health declines; it also means we can accommodate couples with differing levels of need, and we actually have three married couples living with us at the moment. Everyone mixes together and we try to have a really inclusive environment. We bring anyone who wants to come on our outings, and the activities are put on so everyone can join in, however able they are. We also have a dog who everyone loves. We are always looking for new ways to improve our service and make the residents’ lives more fulfilled. We


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have music therapy sessions, an in-house hairdresser who comes twice a week and a regular GP. We hold relatives meetings and take their feedback and implement it. Even if it sounds strange, we love getting negative feedback and we really encourage it – it’s the best way for us to improve where it matters most to our residents and their families.

CURRENT ROLE I’ve been in this post for almost two years. I was Interim Home Manager when I first came to the service and was promoted to Home Manager in September 2017. I used to think people were crazy when they wanted me to move up in a company. I often thought I couldn’t do it, but once I became a deputy, I realised I could be a manager if I wanted. I was ready for the challenge, so I was glad when I was offered the home manager position, but I did doubt myself at first; it’s such a huge thing to be responsible for all the staff, the residents and their relatives too. I sort of knew what to expect when I took on the role, having been deputy for a while. I was aware of the challenges and the new tasks, like audits, chairing meetings and the general business side of things. Being familiar with the home also meant I understood the specific challenges it faced. We used a lot of agency staff when I first took over, and I knew I needed to tackle this. I implemented the use of MHA’s employee referral scheme and I am proud to say that we now use no agency staff except in very extreme circumstances. I also took over at a time when the admin manager was on long-term sick and my deputy manager was on annual leave for five weeks, so that was hard. But I have a really good team and they share responsibility. I couldn’t do this job without them. The role is more rewarding than I’d expected. I feel like I’m part of a big family and Cedar Lodge is my second home. I can honestly say that I love my work. Talking to residents and seeing a smile on their faces is such a great feeling. It’s so nice to know that you are making a difference to people’s lives, especially when someone compliments you on something you’ve done well or that they’re grateful for – it proves that you’ve done something right. Switching off is truly a hard part of the job, but MHA has recently sent all of their managers on a leadership and development course, Engaging Leaders, which has been so useful for me in this role. Just having techniques to switch off before I go to sleep makes such a difference. The other difficult part of the job is losing residents. They’re people you’ve developed relationships with, and often with their families too. It does change a home a bit, when someone who was there is suddenly gone.


CMM May 2019

RISING STARS I didn’t know about the Rising Stars programme until I found out I was nominated. My line manager nominated me and didn’t tell me. I got a call saying that I had been selected for the programme and I actually thought it was a prank until I realised it was the head office number. I couldn’t believe it. As far as I’m concerned, I just come to work and do my job; I didn’t think I was doing anything special or worth such a lovely accolade. The programme has given me the opportunity to experience things I would never have had the chance to otherwise. We’ve been to the House of Lords and had media training with Altura where we were taught to read from a screen, how to sit and how to present yourself. The year has flown past and I would absolutely recommend that others apply for the programme. I’ve been to my mentor’s own care home, and have really had my eyes opened to other areas of the sector. I always come away from our meet-ups with new ideas to take back to my home.

FUTURE CAREER In the future, I’d love to see Cedar Lodge achieve an Outstanding rating and I want to continue to nurture my team and watch them grow. At first, I was worried when I wasn’t at the home and I’d often call to make sure things were OK, but now I know I can trust them to get on with it and do a great job. Eventually, I might want to move somewhere bigger, but I know I want to stay with MHA. I am trusted and respected here and that’s hugely important to me.

ADVICE My advice is to sometimes have a little word with yourself. If you think you can’t do something, take a moment to realise that you can. Remind yourself why you’re doing this job and remain open and honest. Don’t ask anyone to do things that you wouldn’t want to do and never sweep issues under the carpet – deal with them proactively. For managers at every level, it’s important to recognise the capabilities of your staff. Develop them and encourage them to believe in themselves so they can grow. CMM Nadine is part of the second cohort of Rising Stars. This innovative programme, developed by National Care Forum and supported by Carterwood and apetito, is designed to identify leading lights within organisations who will shape and form the care sector in the future. More information about the programme, the candidates and future opportunities can be found at


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Devil in the detail Making CQC inspections work for you Following last month’s look at how CQC ratings differ across regions and sectors, Neil Grant from Gordons Partnership LLP offers his insight into how providers can get the most from the inspection process and prepare themselves for the inspector’s visit.

The key components of regulation by the Care Quality Commission (CQC) are registration, inspection, compliance and enforcement. While the emphasis given to inspections has waxed and waned over the years, it is clear that they will remain an essential feature of CQC regulation. For one thing, CQC is obliged to set out the minimum frequency of inspections linked to its performance assessment of services. Currently, this is six months for Inadequate services, twelve months for Requires Improvement services and two and a half years for those rated Good or Outstanding, calculated from the publication date of the inspection report. All CQC inspections in adult social care comprise two main elements: compliance with legislation and ratings. The two are distinct; in terms of public perception, ratings have become the dominant partner. However, if CQC wishes to take enforcement action against a service, it must identify a breach of compliance with statutory requirements, so


CMM May 2019

the compliance aspect will be particularly important to those care services that are at risk of enforcement action. A Good rating is seen by CQC as the minimum standard nowadays and those services that fail to attain this rating are becoming the subject of increasing regulatory scrutiny and intervention. Commissioners and lenders will also be concerned by an Inadequate or Requires Improvement rating. Providers need to be ready for inspection day in order to demonstrate the strengths within their services and how they are addressing any shortfalls.

FILLING IN THE PAPERWORK In planning an inspection, CQC will review the Provider Information Return (PIR) submitted by the provider. This form is the provider’s opportunity to set the scene, presenting positive information about the service, so far as is possible. In time, CQC intends to replace the PIR with Provider Information Collection (PIC). CQC sets out the importance of this provider submission in its internal guidance document, Planning Inspections: ‘The PIC…collects essentially the same information [as the PIR] but will be accessible to providers as a live online portal rather than an annual submission. The provider is prompted to complete the PIC every three months as a minimum, but [it] is available as a live record they can update at any time. ‘The PIC gathers key information from providers about their service. As well as providing important information about the quality of a service it also gives indicators about how well a service is led and managed. A detailed accurate PIC can indicate a well led and well managed service [my emphasis]. Well led services should have the information requested in the PIC readily available under their own quality management arrangements (as required by regulation 17). Poor quality information or failure to submit a PIC can indicate that a service is not well led.’ The starting point must therefore be to spend time pulling together a comprehensive and accurate PIR/PIC. You may also wish to consider carrying out a review of your service as part of the PIR/PIC preparation using CQC’s Key Lines of Enquiry, prompts and sources of evidence, perhaps employing external consultants. Some people call


CMM May 2019




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these ‘mock inspections’. Any actions resulting from the review or mock inspection can be put into an action plan and implemented in advance of the inspection. This is evidence of effective governance, employing the same assessment framework as CQC: the single, shared view of quality.

PREVIOUS INSPECTION REPORTS CQC will use your last inspection report as an integral part of their inspection planning. As CQC’s Planning Inspections guidance states: ‘The previous inspection report is a vital source of information for inspection planning. Previous reports: • Highlight areas that need to be followed up on inspection, including breaches, poor ratings, or recommendations we have made. • Show the service’s history, and whether it is responsive when concerns are noted. • Show whether the service sustains good quality care or only resolves problems when CQC has identified them.’ You will need to ensure that any compliance issues and any other criticisms of your service emanating from the last inspection have been addressed, as these will be reviewed when CQC returns. If the manager of a service changes, it is crucial that the new incumbent is aware of CQC’s concerns and is confident that they have been and/or are being addressed.

THE START OF THE INSPECTION First impressions in life count for a great deal and it is no different with inspections. The lead inspector will introduce themselves to the manager or other senior person on duty and will explain the type of inspection to be undertaken, whether it is comprehensive or focused. The lead inspector may well ask some open questions at this point. CQC’s internal Evidence Gathering guidance sets out the type of questions that may be asked and it’s useful to be familiar with and prepared for these: ‘Make it clear at the start of your site visit or other contact with the provider or manager that you are looking for evidence of a ‘good’ service. It may be useful to ask them the following questions: • Tell me how you are providing a good service? Do you have evidence to show this? • What achievements are you most proud of? • What have you done recently that has made a major difference to the people who use your service?

• How have you made sure your service is inclusive and respects the equality, diversity and human rights of people who use the service and the staff who work there? • How do you gather information and feedback from people who use your service, their carers and families, and care staff? • What is your biggest challenge? • What plans do you have to improve the service? ‘These sorts of questions start inspection contact in a way that shows we are ‘looking for good’ and focused on encouraging improvement. You can look into their answers during site visit and other inspection activity, and use them to develop your evidence gathering plans responsively.’

A RIGHTS-BASED APPROACH You will have noted that one of the questions the lead inspector may well raise is in relation to equality, diversity and human rights. CQC’s whole regulatory framework is human rights focused. It has adopted what it calls the FREDA principles: Fairness, Respect, Equality, Dignity and Autonomy. In addition, there is the Right to Life principle and an additional principle around staff rights and staff empowerment. In February 2019, CQC published Our human rights approach for how we regulate health and social care services. Providers and managers should familiarise themselves with this document, as well as other publications such as Equally Outstanding, Quality Matters and Developing People, Improving Care. You will also want to be able to demonstrate to inspectors that you are meeting the requirements of the Equality Act and Human Rights Act, be it in terms of lesbian, gay, bisexual and transgender rights or ensuring that staff are free from the risk of violence, harassment, discrimination and abuse. Linked to this, CQC inspectors will look at compliance with the Accessible Information Standard, which dictates that everyone should be able to access information in a way that is suitable for them. Inspectors will review documentation and speak to staff to ensure this standard is both understood and implemented. As CQC advises its inspectors in its guidance document, Gathering Evidence: ‘It should be possible to see whether providers are meeting the requirements to “identify, record and flag” people’s accessible

information requirements through looking at assessments and care plans. When selecting care plans for tracking, you should ask that the plans include a sample of people who require information or communication in a different format due to disability, impairment or sensory loss. ‘In order to see whether needs are being “shared and met”, it might be necessary to talk to staff and people using the service, or through observation.’

MENTAL CAPACITY This is a key area that services often fall down on. Without fail, CQC will look at compliance with the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) requirements as it has a statutory duty to monitor them. Concerns are frequently identified in inspection reports about an absence of decision-specific mental capacity assessments and a failure to record best interest decisions fully. Issues that often arise around DoLS include a failure to notify CQC of an authorisation or a withdrawal of a DoLS application, so it’s essential that providers are up-to-date with this. CQC will also be expecting providers to chase local authorities for authorisations, notwithstanding the current backlog of around 125,000 applications.

MAKING THE MOST OF IT Providers and managers should ensure they get the most out of the feedback session at the end of the inspection. The lead inspector should allow you time to respond to their feedback and ask questions. They should also record your responses in their notes. This is your opportunity to try to head off issues and/ or identify matters to take up with CQC after the inspection. After the inspection, hold a debrief session with staff and establish if there are any issues you need to respond to CQC about before the draft inspection report is received. Finally, you should supply any additional information to CQC before your report is issued, as a matter of priority. In doing this, you can have an impact before the report is drafted. Don’t wait for it to arrive several weeks down the line, by which time memories will have faded. Always do yourself justice by ensuring you are an active participant in the inspection, not a passenger or spectator. CMM

Neil Grant is Solicitor and Partner at Gordons Partnership LLP. Email: How do you prepare for a CQC inspection? Has CQC commented on anything you’ve done particularly well? Share your experiences and feed-back on Neil’s article in the comments section of the CMM website CMM May 2019


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CMM May 2019



NURSING ASSOCIATE Organisations across England are being urged to offer opportunities for apprentices, but how can this be done in the social care sector, and what are the benefits? Professor David Sines from Health Education England explores the role of the nursing associate and the goals it aims to achieve.

In 2018, Skills for Care published The State of the Adult Social Care Sector and Workforce in England. A range of key issues were identified regarding challenges faced by a dynamic social care workforce facing increasingly complex local populations. The report noted that the Department of Health and Social Care would be bringing forward a Green Paper, which would


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inform the design of a national strategy for the care workforce. This strategy would be put together using workforce intelligence sources and evidence from national and regional policy makers. However, the Green Paper has not (as yet) appeared, but in the meantime Skills for Care and Health Education England are working together to co-design local workforce solutions. These will reflect the changing nature of our care systems in England as they continue to become more and more integrated. Emergent workforce solutions require the future-proofing of both the supply and the design of flexible career progression pathways for care workers. The aim is to enable staff to acquire greater confidence and ability, and to support them to apply their skills across a range of health and social care settings. It will also provide innovative solutions to enable the whole of the care workforce to reach their full potential. User demand, personalisation, new technology, pharmaceutical advances and longevity amongst the population are among the reasons a new approach to workforce design and delivery is required. Not to mention Government’s commitment to introducing integrated health and social care systems that are supported by the development and deployment of well-trained care staff across a range of local services. At the centre of this vison for the creation of a more closely aligned health and social care workforce is the need to reduce dependence on the in-patient healthcare system and to develop new ways of working with an aging population; a population that presents with increasingly complex health and social care needs and which rightfully stakes its claim to be actively engaged in the design and delivery of the care and support that it requires.

focused’. The report acknowledged that health and social care assistants made an essential contribution to the care sector in England, but advised that there had been underinvestment in providing local access to training and development to ensure that staff were ‘working to high, consistent standards wherever they work’. Skills for Care’s 2018 State of Care report agreed that staff should be able to access training to develop the right values, skills and knowledge to enable them to provide high quality care and support. Evidence of the appetite for additional training and career development possessed by members of the social care workforce has been confirmed by Skills for Care who have reported that approximately 50% of care workers held a relevant adult social care qualification at Level 2 or higher, whilst 37% had engaged with the Care Certificate. Skills for Care and Health Education England have been investing significantly to design new career pathways and work-based learning opportunities in the social care and health sectors. Part of this is developing new apprenticeships that are available to current and aspiring social care staff. Apprenticeship routes enable employers to work alongside education providers to offer training for their workforce against approved, benchmarked performance standards. The training leads to the award of a nationally-recognised vocational qualification which evidences proficiency to practise. The nursing associate apprenticeship provides one such example of how employers can work with education partners to co-design and deliver workplace learning solutions.


Following the 2015 Shape of Caring review, Government announced the introduction of the new role of a nursing associate. The person in this role would be trained to work across a range of health and social care settings. The aim was to increase the

In 2015, Health Education England’s Shape of Caring review identified a gap in support workers’ skills and knowledge and confirmed the need to develop a workforce which was more ‘community and public health42

CMM May 2019


competence and skills of a new cohort of trained and regulated care workers. They would be equipped with the knowledge and skills to support people with highly complex needs, including those with longterm health conditions, learning disabilities and cognitive/mental health disorders. The first ‘test site’ nursing

“Apprenticeship routes enable employers to work alongside education providers to offer training for their workforce against approved, benchmarked performance standards.” associate programmes commenced in 2016/17, followed by national roll out in England in 2017. The Nursing and Midwifery Council has been responsible for regulating and admitting qualified nursing associates to a designated part of its Register since February 2019. With the ongoing radical change required by health and social care agencies and the necessity to deliver greater levels of out-of-hospital care, this new role was needed to support people at home, in care homes – with and without nursing – and in hospital. The nursing associate offers a nationally-approved ‘higher skill set’ than that provided for care workers currently. The nursing associate programme is delivered as a full-time Level 5 Apprenticeship as an ‘earn and learn’ programme over two-year period. It enables the trainee to be educated with the knowledge and skills required to provide high-quality, person-centred care. The training is provided in the same way as any other apprenticeship model to foundation degree or equivalent – in partnership with a designated


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“This new role is set to make a significant contribution.”


university on a day release basis. Trainees acquire knowledge and both practical and critical thinking skills to enable them to make a substantive contribution to social and health care assessment and delivery. Apprentice nursing associates spend 50% of their two-year training programme working and learning in their home base (including residential, community and homecare settings). The remainder is spent on day release attending their university programme and gaining as much experience as possible in different health and care settings. The role offers greater flexibility to the social care workforce in terms of career development and should provide opportunities for staff who are unsure of their educational ability, but still wish to advance their careers with their current employer. From an employer point of view, apprenticeships can enhance the competence, capability and capacity

of your staff so they are better equipped to respond to the needs of people using your service. Staff may be more satisfied knowing that there is a career path for them, and this could help your recruitment and retention figures.

THE FUTURE OF NURSING ASSOCIATES In 2017, 2,000 trainees were recruited to the nursing associate programme within 35 health and care test sites. Key findings to date suggest that current trainees have been motivated by a desire to improve the quality of care and safety for service users and have shown themselves to be highly motivated and conscientious learners who are keen to build on their experience of working in care and health settings. University leads and employers have reported a consistently high level of enthusiasm and commitment shown by trainees and have noted

a relatively low attrition rate of 7% (Traverse, 2018). Our social care landscape is changing in response to the complex needs and demands placed upon it by our local populations. New workforce solutions are required to bridge the gap that currently exists between our health and social care systems. The nursing associate is a regulated role, but it is shaped and adapted to the needs of local employers and service users. As such, it is a ‘facility independent’ role, requiring practitioners to function lawfully within their defined scope of practice. This new role is set to make a significant contribution, not only to enhancing opportunities for flexible career progression for members of the social care workforce, but also in providing greater assurance to members of the public with regard to the safety and effectiveness of the care that they receive. CMM

Professor David Sines CBE PhD is Strategic Advisor to Health Education England (London). Email: How have you used apprentices in your organisation? Have you engaged with the nursing associate role? Share your thoughts and experiences on the CMM website where you can also provide feedback on this feature CMM May 2019


Celebrating excellence Markel 3rd Sector Care Awards

It quickly became apparent that the club was not only for men who worked the land. There are many men who enjoy the outdoors – some were regular gardeners, some holidayed in the countryside, some were footballers or cyclists and some just like being outside.


Countrymen UK at Future Roots won the Contribution to Sector Development Award at the Markel 3rd Sector Care Awards.

Countrymen UK is a lottery funded project that evolved from Countrymen’s Club at Future Roots in Dorset in 2012. The Countrymen Club started as a result of my dad having Parkinson’s and being isolated from peers. He was unable to access a work environment unsupported – he was a farmer and had always loved feeling the seasons’ rain, wind and sun, but it seemed that all day care opportunities were inside and mostly attended by women. Dad had never been a ‘group’ man and would never have sat inside talking, although he could talk while he worked – a lot. The Countrymen Club was initially formed for men who worked on the land who needed support to access the countryside and a work environment. The men had various diagnoses, from dementia to stroke, depression or just feeling lonely. The fact that the men’s conditions were left at the gate and no-one knew what was ‘wrong’ with one another became an important aspect of the club; they just knew one another’s strengths. 46

CMM May 2019

We are asked so often why we don’t have women in the club and we did try but it changed completely. The men became dependent on the ladies making decisions, putting their hats and coats on for them, and the banter stopped. The men were very polite, not as they were on a general day, and the women tended not to enjoy the club when the weather wasn’t good, saying things such as, ‘I had to go out in the cold for the last 60 years, I don’t want to now.’ The men also often say they have never made decisions in the home, with their remit always being making decisions about the outdoors – so while their wives chose when to put the kids to bed or when to have tea, the men chose when to wash the car or paint the fence. Once these decisions are taken from them, because they are no longer able to carry out the tasks, they don’t have the opportunity to make choices, so part of the club is around giving men this independence back.

REWARDING ACTIVITIES The men are never herded around; they have an element of freedom. We have a mix of experienced workers and volunteers who accompany the men and support them to do what they like. They can see the animals or just wander around. Some will collect eggs, or apples if it’s that time of year. We hold the club from 1.00pm so that there is no rush getting ready, the men can come for lunch and are fully engaged and occupied all afternoon, resulting in more restful evenings and better sleep. Activities change depending on what the men want to do, but we have found animals are amazing in breaking down barriers and settling anxiety. Brushing the animals or sweeping leaves has a similar effect. We also play outdoor games – there is so much

competitive spirit; the men love to play horse shoe skittles, football, anything – and they will cheat to win. At the end of each session, sometimes the men read poems or they sing, not traditional war songs but Radio 2 songs they would have had on at work or in the car. It is good to see their faces once they start, although initially they might be resistant to public singing.

A GROWING VENTURE We have had one evaluation so far and the comments from the men and carers were really special. it showed the importance of socialisation and the meaningful environment, some men still feeling they are going to work and retaining the identity they want to keep. Because of the success of the Countrymen Club at Future Roots, the decision was taken to share the model with other care farms and gardens throughout the UK, giving birth to Countrymen UK (CUK). CUK is based on a social franchising system and the initial target was ten care farms and gardens becoming franchisees by the end of 2020, a target that was exceeded within the first 18 months of the project. This early success has meant that CUK can now recruit even more franchisees and a new target of 15 care farms and gardens has been agreed. Franchisees are spread throughout the UK, from Cornwall to Inverness. Some are early start-ups, while others are already experienced in care farming and have been running groups and activities for young people and adults for many years. Franchisees receive a range of services, which include an operational manual, support and training to establish and develop their own Countrymen Club, as well as access to promotional opportunities and marketing materials. Training courses cover both business development topics and Countrymen Club operations. Project Manager, David Drysdale, said, ‘Our slogan, “Getting back to being you” reflects our belief that farms, gardens, forests and other green spaces help men to retain their identity and have a positive impact on physical, mental and social wellbeing. The Lottery’s Accelerating Ideas Programme has recognised the significance of this and has funded this stage of the project until the end of 2020.’ Part of the project is to carry out research through a system of monitoring and evaluation and CUK has the support of the University of Essex in devising the research and analysing the data that’s being collected. Around 200 men and their carers are expected to participate in the study and a final Project

Report on Monitoring and Evaluation should be available by early 2021.




Being a finalist in the third sector awards was something really special for a small organisation like ours. Going up to London and experiencing the whole occasion was amazing; to win was totally unexpected and we were slightly in awe of everyone there. The award has given us more credibility with people who don’t know us across the country, and I am sure that the fact we so quickly achieved our initial target of ten farms delivering Countrymen UK groups was a direct result of winning this award. CMM

Julie Plumley is Director at Future Roots. Email: Twitter: @Countrymenuk1

The Markel 3rd Sector Care Awards is run specifically for the voluntary care and support sector. Visit www. to see 2018’s winners and find out more about this year’s event. Sponsorship opportunities are available. With thanks to our supporters: National Care Forum, Learning Disability England, The Care Provider Alliance, Association of Mental Health Providers and VODG. The Contribution to Sector Development Award was sponsored by

CMM May 2019




Health and adult social care professionals from across the Surrey and Sussex areas attended the Surrey and Sussex Social Care Showcase, the region’s biggest free business and training event for the care sector, at Brighton Racecourse on Wednesday 6th March. Now in its thirteenth year, Showcase 2019 attracted over 700 visitors. For the first time, the event welcomed professionals from the health sector, giving the opportunity for all the region’s major adult social care and health networks and partnerships to be represented. This year’s topical Showcase theme of ‘Stepping up to the Challenge’ reflected the enormous pressures currently facing the whole of the adult care sector and aimed to help providers respond accordingly. Showcase’s informative and stimulating seminar programme proved once again to be a big draw for care providers and their staff. Amongst the care industry leaders speaking throughout the day were Sharon Allen from Skills for Care, Debbie Ivanova from the Quality Care Commission (CQC), Keith Strahan from NHS Digital, Kathryn Evans from NHS England and Vic Rayner from the National Care Forum. Speakers also came from national bodies including Association of Directors of Adult Social Services (ADASS), National Institute for Health and Care Excellence (NICE), the Care Association Alliance and National Activity Providers Association (NAPA) as well as business support organisations. Speaking to a capacity audience, Debbie


CMM May 2019

Ivanova provided an update on current and planned regulatory changes and future initiatives at CQC, along with news of forthcoming publications due this spring. Delegates also enjoyed a lively question and answer session with Debbie. Describing her seminar topic as a romp through the latest policy agenda impacting social care, Vic Rayner gave delegates an insightful overview of Brexit, the NHS Long Term Plan and the social care Green Paper. Sharon Allen told delegates about the national recruitment campaign, the Skills for Care Innovation Fund and the progress of integrated care across the board – touching on some issues of interest to local providers along the way. The issue of how to recruit and retain highquality staff proved an ever-popular seminar topic for providers faced with the challenges of operating in a region distinguished by relatively low unemployment combined with a high cost of living. Sticky People’s Neil Eastwood shared brand new research and tips on how providers could supercharge their recruitment and retention efforts. Rated a five-star seminar in delegate feedback, Grant Payne’s fully interactive workshop on how to manage stress in the workplace encouraged delegates to jump up out of their seats and take part. Practical business and legal advice on Liberty Protection Safeguards, data protection, CQC inspections, Competition and Market Authority guidance and consumer law also proved popular

Showcase seminar topics. Commenting on another successful Showcase, Erica Lockhart, Chief Executive of Surrey Care Association and one of the organisers said, ‘As we are currently collaborating on a great number of joint projects to improve delivery of care across the board, we felt it was important to include our colleagues from the health sector and we are delighted so many came to join us at Showcase. ‘The shortages of nursing and care staff and pressure on council finances are some of the biggest challenges facing local health and social care providers today and we all need to work together to ensure a sustainable long-term future for our sector.’ The Showcase’s extensive exhibition area also offered a ‘one stop shop’ for products and services from over 50 training providers, property and IT companies, legal and business advisers, care associations and suppliers to the care industry. Local charities were well represented too. The Deputy Lord Lieutenant of West Sussex, Mr Neil Hart, officially opened Showcase 2019 and the Mayor of Brighton and Hove, Councillor Dee Simson, also attended. The Surrey and Sussex Social Care Showcase was free of charge for health and social care professionals from Surrey, East Sussex, West Sussex and Brighton and Hove and was supported by Surrey Care Association, East Sussex County Council, Brighton & Hove City Council and West Sussex County Council. CMM


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C O - F O U N D E R

Julia Jones, Founder of John’s Campaign takes a look at the importance of involving family in care settings and how this can be achieved.

When John’s Campaign announced it would be accepting ‘Carers Welcome’ pledges from the residential sector as well as from hospitals, Andrea Sutcliffe, the then Chief Inspector of Adult Social Care in England, was quick to express her support, saying, ‘Good homes don’t just concentrate on the person living in the home, but also on the people who matter to them. The best homes welcome family and friends, value their insights and treat their feedback as the gifts to inspire improvement that they are…we want to see an open and inclusive culture and a key aspect of that is for residents to be able to be surrounded by the people they love when they want to be.’ Professor Martin Green of Care England added, ‘There is really good evidence that people who maintain their relationships have much greater wellbeing, and better quality of life.’

J O H N ’ S

Perhaps this is so obvious that it doesn’t need saying. Yet, if it’s true, we need to look harder at the inequalities between people who remain supported by a network of external relationships throughout their life in residential care and those whose friends or family say goodbye in the reception area and are not seen again until the funeral. It may be tempting to attribute these instances of abandonment to the individuals involved – we don’t know the inner history of other people’s past lives and relationships – but a more constructive approach might be to consider whether an institution can create its own culture of family involvement. Look again at Andrea Sutcliffe’s language: the best homes ‘welcome’ and ‘value’ families and friends, treat their feedback as ‘gifts’, are ‘inspired’ by them. These words represent positive actions; things that can be done by managers and staff. But this isn’t just an exercise to keep the regulators happy, such homes are surely the places which we would choose for ourselves and our own families. Hospitals which have adopted the principle of welcome and partnership with family carers have co-incidentally found a range of additional benefits in areas such as safeguarding, reduction in the use of anti-psychotic medications, improved nutrition and hydration and fewer complaints. These win-win outcomes could also apply in social care. The primary focus of John’s Campaign has been on welcoming the families of people who are living with dementia. However, a recent presentation from Romaine Lawson of Apple House Care outlined how establishing a ‘familyfriendly’ ethos and offering strategies for relationship support and development could be transformative in homes for younger adults with learning disabilities. Participants of the presentation discussed the idea that a well-managed admission to residential care could help salvage close relationships that had been damaged by the stress of physical caring and the hurt of distressed behaviour.


An admission which has successfully included families from the outset also offers a better chance that they will be positively involved at the end of the person’s life. There are many reasons why friends and family fail to visit – or become progressively more reluctant. It’s upsetting. They don’t feel needed. It’s boring. Reflective conversations at admission time can be very helpful. Instead of telling family carers what activities your organisation provides, ask them what they and their relative like to do together. Listen to their answers, then discuss how they can manage this within the new environment. Don’t offer to take over anything they can continue for themselves. The family carer may be at crisis point, stressed and exhausted. They may simultaneously yearn for help and feel guilty accepting it. Discover what have become the intolerable aspects and reassure them that you will be taking responsibility for these. But do all you can to remind them of the areas in which they are expert and irreplaceable. Most people like to feel useful. ‘What would you like to continue to do for your mother?’ is a good question. The answer may be ‘Nothing. You’re getting paid to look after her now.’ Or it could be helping with hair and nails, helping at lunchtime, being there for her at sun-downing time. You can do more than accept these offers; you can explain how these will contribute to her overall care. You can express your gratitude. Family carers’ distress needs understanding and comfort; not just at the beginning and end of their relative’s time with you but throughout. Some hospitals have introduced carerawareness training to develop staff members’ confidence and skill providing this. Some care homes offer access to targeted support such as intervention by Admiral Nurses. Peer support can be particularly effective and as your culture of welcome develops you may notice your family visitors begin sharing each other’s troubles. Then you can congratulate yourself. CMM

Julia Jones is Co-founder of John’s Campaign and author of Honoured Guests, freely downloadable from the Care England or John’s Campaign websites. Email: Twitter: @JohnCampaign 50

CMM May 2019

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