I've spent a big chunk of my day off working on careplans on Birdie. These take upwards of 2hrs to write initially, we then review these as needed (they are "live" & update instantly on the staff app), today I spent 90mins reviewing just one.

This, along with some recent NVQ4 units, has got me thinking about person centred care & how the "person centred" bit is usually the last step in the process for those receiving care at home. To understand why, we need to look at how a person might come to be needing care.

Here in the UK people needing care at home tend to have care allocated to them by social services. This is either post hospital stay or as "admission avoidance", where the request has come from a GP or a district nurse. These clients are contributing to the cost of their care.

The cost will be decided after a financial assessment, the amount / number of hours is a separate assessment, both of these will be carried out by a community social worker with input from family, occupational therapy & physios who will provide any equipment needed.

In the current climate, it is not uncommon for clients to never meet a social worker in person. A package of care will then be put out to brokerage, whereby private care companies will bid to take the package on (councils will have an upper & lower price cap).

Once a company has been allocated the package they will go to meet the client & carry out their own assessment. It is only at this point that the client gets to have much of a say.
This process is sometimes called the "professional gift".

CQC (care regulator) stresses the importance of "person centred" care, that the client should have as much choice as possible, yet this is almost impossible under the current structure. Clients have little say in who cares for them or the time of calls.

Often a social worker will specify via brokerage the ideal times that the client would like along with a basic list of care needs, but as we are often going in blind, not knowing exactly the needs of the client until we get there. Unfortunately we often find a lack of equipment,

inadequate call times (wrong time for the client or not enough time to carry out the tasks), or unsafe working environments. With a lack of SWkrs, DNs, OTs & PTs, reduced contact with GPs, care homes & hospices having a shortage of inpatient beds & an aging population, this will

only get worse. The system is at full stretch & creaking at the seams. Those who need care at home are struggling to get their basic needs met, let alone having "person centred" care.
Yet nobody knows how to fix this.
The whole care system here needs a ground-up rebuild ASAP.

So, having looked at home care, let's look at how person centred care works in residential settings for the elderly.
It doesn't.
Although clients may choose the home they move to, they still have no choice when it comes to the people caring for them or the timing of care.

Many residential care settings are lovely places with caring staff, plenty of equipment, lots of great activities, beautiful grounds, big rooms & good food. But these cost. Lots. If you're one of those wealthy enough to self fund you could be paying as much as £20k pa, or more!

For those needing council funded beds options aren't as good. Staff are stretched, there could be a shortage of the correct equipment, little outside space, less choice with meals, activity budgets don't go as far & rooms are smaller.
So here we find a 2 tier system.

Now let's look at alternative funding in the community.
Some clients needing longer term care are given the option of "direct payments". They will be given a budget to use on care as they see fit. They will be able to choose a care company & decide how many hours care & when.

This is overseen by a social worker who will also assist & guide the client with commissioning care, but does give the client more control.
Then we can look at the best model in community care.
The PA.

A PA (personal assistant) is employed directly by the client & funded by direct payments. The client can specify exactly how, by whom & when they need their PA to support them. PAs can be sourced by social workers who will advise & support the client while overseeing the budget.

The client is responsible for everything that any other employer would be (PAYE, holidays, training, H&S).
This explains why not many clients take this option up. Employing an outside company is easier, but limits choice.
Once again we see that "person centred" care has limits.

I will add more here, but I'm tired now and I deserve a gin...

Next topic will be adults with learning disabilities. I'll expand on this tomorrow. Hold on to your hats peeps, you'll be amazed and infuriated at the same time. But first I need sleep to get through another shift in the morning, I already know it's going to be a tough one.

Right. Learning disability care.
Let's start with the oldest of those being supported in residential care.
There are 2 types of residential care for adults with learning disabilities, long stay hospitals & group homes.
As I'm community based we'll start with the group home.

Older people living in group homes were likely to have been in care since childhood. They were also likely to have been in the institutes (sometimes called asylums). They would have been told as children that they were not able to leave & that they couldn't live independently.

Conditions that they experience will range from mild learning differences, autism of any variety, non-verbal communication difficulties, coupled with physical disabilities or epilepsy. These institutions were in operation until the 1980s.

Then along comes Thatcher. Her government tried to close these down and brought in "care in the community". This meant the slow phasing out of the institute model, enabling people to live more normal lives. In practice this didn't work very well.

People were moved from large closed hospitals to "group homes", usually same sex, were they still didn't have any rights & couldn't leave unaccompanied. When I came into care in the 2000s this was beginning to change for the better, but still had a long way to go.

My 1st placement was in a "locked unit". The chaps we supported had severe learning difficulties & epilepsy, were non-verbal & were deemed at risk from the wider community, they didn't leave the house unless they had staff with them. They'd all been in care since childhood.

So, having never had the opportunity to earn themselves how was their care paid for? This was a complex mix depending on each persons health needs with NHS CHC "continuing health care" meeting part, some funding from benefits & some from council social care budgets.

Each person was allowed to keep a small amount of their benefits (at the time it was £80pm) for personal use (clothes, toiletries & treats), with funding being provided for a short break (usually 4nights) each year.

With the changes brought in by more recent governments there's a push towards moving people on from these units into their own home, this can be ordinary rented homes, maybe shared with another person, or flats within specialist complexes. This is known as "supported living".

Unless someone has complex health needs the funding for this is no longer met by the NHS. The entire cost is met through benefits & council social care budgets. In some ways this has improved this slightly for the client. They are able to have choice.

For the 1st time they are able to have a choice in where they live, who they live with & who supports them. If only in a small way as brokerage still has a hand here & companies bid for the contract.

Clients will have a care package tailored to their needs. Often this will entail 24hr support in some way. 1 chap I worked with was 1-1 24hrs in his own home with 2-1 support in some circumstances, another was 1-1 8am-10pm in a supported complex with shared night care.

Although they aren't able to pick the company who manage their staff team, they will have input into which staff members support them. They will have choice in their day to day lives in a way they won't have had before. This is a step in the right direction.

This is where we return to "person centred care". In many circumstances this is where it's working. The person receiving support has input, the package is adapted to suit as time passes, the team have the best interest of the client at heart, but this takes hard work & time.

Those in "long stay" facilities aren't so lucky. Although staff teams will do their best, those living there are not there by choice. Some will be there after a period of crisis, some will be there because there's nowhere else for them to go.

They are often a long way from home, at times they may be subject to chemical or physical restraint & don't have much choice in their day-to-day lives. Many people here will suffer worsening mental & physical health outcomes, which negates the aim of their admittance.

This makes it harder to find them a community placement nearer to home. Sadly most end up in these facilities because family or paid support relationships have broken down, the person has had a period of mental health crisis or simply because there is no placement available.

The aim since "Winterbourne" has been to close these units, as the institutions were closed, but with a lack of funding for specialist community support this is a long way off. In the meantime people continue to be cared for miles away from their loved ones.

I'm stopping for today, I'm off to play with this fluffy girl, I'll continue another time