Loneliness is something I fear.

I’ve got better at being alone, sometimes I even crave my own space, but I’m scared of feeling lonely. It’s always something I’ve associated with getting older. My nana passed away recently, she was 85 years young. Her health had deteriorated over the last year and she was not as able to get out. My nana attracted people; prior to her physical health decline she’d come back from town and tell stories about this person she’d met whilst waiting for the bus, or this person she’d met in the hairdressers, or someone she’d had a cuppa with when taking a few minutes to sit down. She had one of those faces that said ‘talk to me.’ We often laughed at just how many people would talk to her and tell her the most interesting of stories that she didn’t always know whether to believe!

When my nana couldn’t get out as often she’d hang on for every visit from family or friends; she’d say ‘oh you’ve only just got here do you have to go?’ after a 3 hour visit. She could pull on every heartstring to keep you there, saying to my son ‘oh Dan you’ll have your own life and friends to see won’t you, you’ll not want to stay with your old grandma.’ So he’d stay another hour or two..!

All of this was because when things got more difficult physically she didn’t get as many opportunities to get out and see people. She got lonely.

While I could understand how people can become lonely as they get older, it surprised me to see in the State of Ageing report that actually the loneliest people are aged between 25 and 34 years, closely followed by those aged 35 to 49 years. Looking at the government’s loneliness strategy ‘A connected society: A strategy for tackling loneliness’ and particularly at the illustration about certain life events that leave people lonely it became clearer as to why this might be. Amongst other thing people can become lonely because they enter a period of ill health, because they are living with a disability, because they take on a caring role, or because they suffer a bereavement. Things that could happen to any of us…

So what can we in the health and social care sector do to help with this? Future proofing as I do, I want to ensure that communities are thriving and inclusive of everyone who lives in them, I want to ensure that care provision is of a quality I would hope to experience when I need some care and support, and I want to feel part of something bigger than just me, in my house, wishing someone wanted to talk to me.

Well first of all I think we need to work in a more joined up way. Why is the NHS doing one thing while Local Authorities do another and Care Providers try to ensure they are up to date with all of them? GP’s have started social prescribing; surely to ensure this is successful there needs to also be some communication and links with Voluntary Sector Organisations and Care Providers, to know what is available locally to support people and promote community engagement.

Do we really know the people we support? Do we hear what their interests are; know what people want to do, and what would make them feel less lonely? For many people meeting up with one person they really like once a week would be less isolating than sitting in a room full of people they have nothing in common with 6 days a week, so day centres or activities that have no meaning to them might not be an answer.

Are we supporting people to make the best use of their personal budgets to ensure they get support to live their best life? If socialising is important to someone then how can we ensure they get the opportunities they need to meet people doing things that they like to do? Is our role sometimes as introducer to activities that someone would like to attend but doesn’t have the confidence to visit alone for the first few times?

Do people living in a care home have real options and opportunities to engage with their local community? Does the community see residents as part of its fabric? Do people feel valued where they live?

There are so many things we can do, but we need to talk to each other to make it happen. It all starts with some communication. How many people did you speak to today, or did you smile at? Did you know them all? Let’s challenge ourselves and our teams to talk to one new person each day; to learn something new about people they already know each day, or to think of ways to involve people they support in new activities or opportunities. If you find yourself sat on a bench have a look around you, lift your head out of your phone. Maybe say hello to someone. Be kind. Just like my nana would have done.

‘Co-production is not just a word, it’s not just a concept, it is a meeting of minds coming together to find a shared solution. In practice, it involves people who use services being consulted, included and working together from the start to the end of any project that affects them.’ Think Local Act Personal (2011)

Co-production done well can be life changing.

Harnessing the experience, information, skills and knowledge of people who use services to inform delivery of those services is going to influence the quality of delivery in a positive way. It creates opportunities for people working for a service to see those using the service as people first, and it helps us all to see a little bit of what the world looks like from a different perspective.

Co-production isn’t easy. Enabling people to participate, contribute their thoughts and be involved ‘from the start to the end of any project that affects them’ takes real commitment and passion on behalf of the service, it takes time and patience, and sometimes we have to hear things that aren’t comfortable!

The benefits of co-producing training, policy development, service plans are many; we took some time to reflect on our experiences and share an example of co-production in practice.

Brightening Minds Training was invited to deliver a program of person-centred approaches training to the care and support team of a national charity. This organisation really promotes taking a person-centred approach when supporting individuals to live their lives. They wanted some training that would underpin that approach, helping people to think about how they can ensure the support they provide really puts the person at the centre and responds to their wants and needs.

The training plan was created by someone who receives care and support alongside an experienced trainer. They sat together and wrote a draft; they worked through the draft and presented it to the rest of the training team; they adapted the training plan based on feedback from the team. This was a true co-production.

Working together with people with a care and support need gave us a perspective when we were producing the training plan that we would otherwise not have had. In turn that helped us to build in exercises that would really enable people to reflect on their own lives, wants and preferences and how that might influence the care and support they provide, and then to consider how they might continue to challenge themselves and their teams about what really person centred support is and the positive impact that support can have on people’s lives.

We included videos in which some of our colleagues who receive care and support describe examples of great experiences of person-centred support, and some not so positive experiences, as well as tackling subjects such as positive risk taking, and helping people to think about what is possible in their lives.

The training is delivered by an experienced trainer and someone who has experience of receiving care and support. We have worked really hard to grow the confidence of people when co-facilitating training. Again, this has taken some hard work and some time, but seeing the impact on course participants when people talk about their real-life experiences shows how worthwhile and meaningful this approach can be.

The feedback from training has been incredibly positive; every course participant has had something positive to say and overall the most common responses mention the value of having that ‘expert by experience’ present at the training, sharing their experiences and helping them to think a little differently. What’s more the organisation has fed back that training they value is training people talk about afterwards; and they talk about our person-centred approaches training. People can’t wait to go back and put what they’ve learned into practice, or to celebrate the great things they are doing already in their services with the rest of their team.

We’ve learned a lot through co-production; sometimes you just don’t know what you don’t know! If it isn’t your experience then why would you?

Co-production is not asking people to answer questions that are based on or driven by your agenda; it is not inviting someone along to an event to share their opinion and doing nothing with that opinion, and it is not the same as consultation. It’s more than that; it’s the contribution of people who use services being embedded in the absolute fabric of what you do, it’s a commitment not just to hearing people but to using what you hear to produce something that benefits them and others. And when you get it right it’s magic!

We’ve been spending some time this week writing a positive approach to managing risk and safeguarding children policy for a social care provider wanting to offer a short breaks service for disabled children and adults.

Of course, Brightening Minds always want to do a great job for our customers. This task always gets us thinking about what does a great job of writing a policy actually look like? What content is useful and what is it that will help the provider and its team be the best they can be?

We thought back to our operational experiences working as social workers, nurses and managers for the health and social care sector and also our time spent as operational leads for domiciliary care and residential care providers. When working for these different services we knew we had a responsibility to follow what the organisation’s policies and procedures said, yet found they were so complicated, full of technical jargon and lots of complicated phrases that we sometimes found it difficult to understand how they applied to our job, let alone being clear about what we needed to do.

We are all agreed this needs to change!

Let’s start with the simple question…what is a policy and procedure?

We understand a policy is a guiding principle used to inform others about what is important in an organisation and describes the standards to be achieved in the work undertaken. A procedure describes a series of steps to be followed to ensure a service is provided in a way that achieves what is important and achieves an organisation’s standards.

A policy and procedure should always describe the standards that are expected from our staff when we make decisions and the actions we must take when we are providing a care and support service to our customers.

We believe an effective policy and procedure is kept as simple as possible, written in everyday language with both customers and team members being able to understand them. Policies and procedures need to make a positive difference to what staff do when caring and supporting others. We know we have to comply with the Accessible Information Standard with all organisations that provide NHS care and / or publicly-funded adult social care being sure that people who have a disability, impairment or sensory loss get our information in a way that they can access and understand. The Accessible Information Standard (DCB1605 Accessible Information)

Top tips to consider when writing a policy and procedure

• A good place to start is to think about your organisational values and how they inform your policy, then describe it.

• Research and understand what is required to make your policy compliant with the relevant law and current good practice guidance?

• Does it reference what law, good practice guidance and research has informed them.

• Understand what will make your policy compliant with standards expected of us by our regulatory bodies and reference it.

• Question whether what you have written is clear to your staff and is clear about what is expected from them. Does it clearly describe what your staff need to know in understandable ways and help staff understand what action to take?

• Do they help your customers understand what they can expect from your organisation and your staff when receiving care and support?

• Involve your staff team or customers in their development to help make sure it has in it what makes a real and positive difference to customer’s lives

Once you have the policies and procedures you want, make sure they are regularly reviewed and you have a record that your staff have read them, understand them and are able to explain how they inform the care and support they give to people.

The test of an effective policy is that it has a positive impact on your service delivery. It’s not just that you have them, but rather they make a positive impact on the way you provide safe and effective care and improve the quality of people’s lives.

Do you need help with writing a policy, one that is useful to your service and helps your staff and customers understand the standards of your service? Contact us on 01423 561119, or email hello@brighteningminds.co.uk for more information.

'CQC are coming, CQC are coming...' said in the style of Henny Penny 'the sky is falling'; it's often the way Providers feel when they hear the news that the inspector is calling.

Sometimes we don't even know the inspector is going to call; we might have an idea, we might know they are due, but when the day will be we just don't know.

So thinking about that what will help us to feel prepared, confident and ready to showcase the quailty of our service whatever the day and whoever comes to call?

Here we have put together some top tips particularly focused around 'Well-Led' for you to consider.

1. Use the information CQC give you.

CQC’s website is a really useful (if sometimes challenging to navigate) resource. The CQC has produced detailed information about the areas that its inspectors are looking at, and specific questions that they should be able to answer when inspecting a service. Becoming familiar with the two particular CQC documents will give you insight into what the inspector is looking for, and different sources of evidence to demonstrate this:

http://bit.ly/cqckeyprompts will take you to CQC’s Key lines of enquiry, prompts and ratings characteristics for adult social care services. This really useful document helps you to consider where your service is currently and check that you have the basics in place, and look at what other things you can do to enhance your service delivery to provide even better support to you customers.

http://bit.ly/cqcevidence is a document that suggests some possible sources you can use to describe and evidence your organisational compliance and the quality of service delivery around each specific key line of enquiry.

When you look at these documents they can seem large and overwhelming so maybe take heed of top tip number 3 when formulating how to approach this!

2. Identify where you are currently in quality of service delivery, where you want to be and how you are going to get there.

Where do you rate your organisation as a service provider currently? Have a think, and be really honest with yourselves, maybe ask your team for input. Look at what CQC say a good social care provider will be doing and consider if this describes your service.

Next think about where you would like to be and why. What are the challenges in your way to achieving this?

Remember that we can always improve so being really honest at this point about what some of the challenges or weaker areas are is a great basis for a conversation with your inspector about how well you know your service and what you are doing to make it even better.

3. We are always stronger together…this is a team responsibility and needs a team approach.

Share out the responsibility of this inspection process just as you share out the responsibility for care and support delivery. If you are employing people and trusting them to deliver a service in your organisation’s name then why not seek their cooperation in making this service the best it can be!

Involve the team in identifying your current position; perhaps use the ratings characteristics referred to in tip 1 in a team meeting or supervision to make a baseline assessment of the service currently. Then talk to people about what they think you could all do to provide an even better service.

What are people most proud of about their work? Enable people to speak about the great things they do to instill a culture of positivity and to celebrate the great things the team does already.

Perhaps allocate roles around the key lines of enquiry to ensure everyone takes a lead on one area to feed back to the Registered Manager. Remember this is about everyone’s participation and input!

4. Know your service, and tell people what you know!

You are the experts in your service, in the people it serves and the staff who deliver the service. The CQC inspector’s expertise is in the key lines of enquiry and applying those to what they see, hear and understand about a service.

If you aren’t explicit about what your service does and how that makes a difference to the lives of the people you support, how will the inspector know? They might do some digging and exploring to find out, but make it easy for them by having examples to talk about, and by sharing information about the great things you do (appropriate sharing of course) with all the stakeholders of your service and all of your partners.

If everyone who ‘shakes hands’ with your service or receives a service from you feels positive about it then the continuous message an inspector receives will be positive.

5. Use your incidents to continuously improve your service.

We dread them, we lose sleep over them, and we hate the paperwork they create. However reality tells us that sometimes things go wrong. One of the best and most helpful things an organisation can do is honestly report every incident and then use this honest report to grow and improve.

Celebrate the staff member who reports the most to encourage people to report! (I may be being over exuberant here but we need to be more positive about incident reporting.)

6. Value your values!

Time for a bit of research. Ask 10 people of all different roles or contact in your organisation what the organisations values are. Could they answer? If so fabulous, now how do they relate to the key lines of enquiry? If not then here is another development opportunity.

Your values are there to guide your service and to give confidence to people receiving the service of what they can expect you to do. However if we are to work to the values we really need to know them.

Find creative ways to embed these values; map them to the key lines of enquiry and build your supervisions, audits, team meetings, training and service planning around them. Sing them, act them out, rap them, be as creative as you like. But make sure everyone knows them, and knows what they mean for their role in the organisation.

7. Impact impact impact! The ‘so what’ question.

When talking to people about your service, when auditing your service, when managing your team, when describing what it is you do, how often do you ask yourself ‘so what’?

We think it’s a really helpful question in enabling you to refocus on why you are doing what you are doing, whether it is truly beneficial or just a process, and who it impacts on and how.

What difference does the support you provide make to the people you provide it to? What is your impact and how do you measure it?

Following an incident what improvements or changes have you put in place? What was the impact of this change? So what?

8. A portfolio of your achievements will give you organisational confidence.

Having evidence to back up and inform the conversation you have with your CQC inspector is really valuable, and preparing a portfolio of useful evidence and information is one way that you can do this.

Gather feedback from customers, families, commissioners, other disciplines and other services that you partner with. Show your complaints and how you use them to inform service improvement, dissect an incident report and investigation, and use all of this information as evidence of how well you know your service.

We find case studies can be helpful in making the link between what you do and the impact it has. An inspector isn’t going to have time to look through years of care and support plans for someone, so if you can capture some information about the support you have provided and the impact it has in a case study it gives a snapshot of some really positive work.

We have a suggested template for a case study for you to follow available here: http://bit.ly/bmtresources

F

Picture the scene..It’s 20.30 on a cool spring evening and I’ve broken down on the A1. 20 miles from home and 430 miles into a 450 mile round trip. I’m a tad fed up; there may be a little ‘bleep’ word or two, and I might have fallen out with Agnes, my trusty and elderly Vauxhall Astra. (Bear with me I promise this is going somewhere.)

I ring my breakdown service provider. A helpful and pleasant customer service person tells me that I am a high priority due to being a woman travelling alone and on the side of the motorway at night. That means someone is going to be with me within an hour. Thank goodness.

No sooner have I put the phone down than the recovery man himself rings me and we work through where exactly I am on the motorway. He’s 20 minutes away. Yay! However towards the end of our conversation he says ‘oh sorry Clare, they’ve actually cancelled the job and I’ve to go somewhere else. It must mean there’s someone closer to you though. Take care.’

2 hours, a dead phone, trench foot, 3 nettle stings and a stream of bad language later arrives a recovery driver from another firm. Turns out I’ve been demoted in terms of importance, and then passed on to another subcontractor working on behalf of my service provider.

He says he can only take me to a place of ‘safety’ and then I’ll be dumped to await the original recovery firm. What did confident, mighty, feisty me do at this point folks? Well I cried….

Put your violins and tissues away; I made it home and lived to tell the tale. And cancelled my breakdown provider the next day… But not before reflecting on their values and telling everyone I know (and many people I don’t with the power of facebook) about my shoddy experience.

Courtesy, Care and Expertise is the promise they make to the people who use their service. So why would I describe my interaction with them as powerless, out of control and overwhelmed?

Moving to healthcare: the industry is different but the sentiment is the same. How would I have felt if I’d been in need of care and support and treated so carelessly and made to feel so unimportant? Surely the impact would have been greater because this is about my life and my quality of life.

So how does an organisation with a focus on its values deliver a better quality service?

Well quite simply everyone knows what we are striving for. If the people you support, their families and friends, the team you work with, and all of your stakeholders know and understand the organisations’ values then everyone knows what they can expect and what is expected of them.

Values support us in recruiting the right people. We can teach people the skills they need to undertake the physical aspects of a role, but it’s helpful to understand what they find important in their approach to supporting people, and to see if their values align with ours.

When those right people are part of our team values help us to support them in their role and grow their skills and knowledge. Why not build your staff supervision around your values? When encouraging staff to talk about what they are most proud of relate it to the values for example to reinforce the organisations’ aims.

Values help steer us. Before changing the way we do things or taking on a new service have we thought about how it fits with our values? If the two don’t fit don’t make them.

Measure and evidence your impact by reflecting on your values. Think about the difference you make for the people you support. What do they say about the support you give them and what difference does your support make to their lives? How is this reflected in your values? Describing how your values map the key lines of enquiry will ensure that while your values are central to your organisation and your mark of quality, you are also delivering a service that is compliant with the characteristics that CQC measure it against.

Ok I know we aren’t living in a perfect world, and I realise that values aren’t the solution to every challenge. But if we are going to put the effort into creating them, use them to describe the service we want to provide, then let’s make sure we get the basics right like ensuring everyone knows what they are and what they mean. Ensuring the people that receive our service, work for our service and liaise with our service know that we mean what we say, and we work hard to achieve it.

Let’s be the best we can be, not the disappointing breakdown service. I think there’s value in that…

Here at Brightening Minds we spend time with managers in the adult health and social care sector who want to provide great leadership and direction to their valued employees. Their aim is to provide excellent care to people they support. Conversation often turns to how difficult it can be to keep up to date with all the information 'out there' to support providers across the domiciliary, residential and nursing sector to deliver good and outstanding services to their customers. It seems that the combination of having an awareness about currently available resources and limited time to immerse yourself in even one or two of these useful and essential documents, whilst knowing these are directly relevant to your service delivery, can result in a sense of being overwhelmed, feeling anxious and often isolated and lonely in your job role. It is a constant nag in your mind that can sap your energy.

These feelings are certainly not ones that result in us behaving as confident and effective leaders of our services, the type of leader that we would want to be for our well thought of staff teams who want to be effectively supported by their managers to be the best they can be.

We gave some thought to this at Brightening Minds and came up with a solution that we believe will go some way to address this challenge faced by many managers. We consulted with providers across the sector about what would be a useful way to support them to be effective managers, with increased confidence in what they say and do is informed by up to date research, legislation, current guidance and good practice, that they can easily apply with their staff teams when delivering their service every single day.

Brightening Minds Resource Bank was born. Our people at Brightening Minds act as a sector filter, identifying resources, signposting their relevance and explaining how current resources may be applied to services to ensure compliance. More than that, this enables you to be the confident and effective provider you want to be. Brightening Minds Resource Bank will save managers time; time being one of the most precious commodities when being responsible for service delivery in a rewarding yet challenging sector.

The Resource Bank forum enables managers to share tricky and challenging issues with each other and all of us at Brightening Minds. This will give us the opportunity to co ordinate working together, for the benefit of the whole sector through the sharing of operational expertise to find realistic solutions that are practical and maybe even innovative!

Brightening Minds Resource Bank aims to support managers to deliver effective and quality leadership to their staff teams, resulting in their employees feeling well supported and enjoying job satisfaction in their health and social care role. In turn a team that functions effectively will deliver the highest quality care with the greatest and most positive impact for the people they care for. How could CQC not want to celebrate that with you?

I love food.

People who know me are not remotely surprised by this statement. Food is important to me for so many reasons. I use food to socialise, cooking for friends, meeting friends for dinner. I use food for comfort, when the England rugby team were out of the world cup I commiserated with chocolate. Food can be a reward or motivator for me, I’ll run (well walk fast) if I know it earns me a few extra carbohydrates to refuel, you get the picture. So if someone told me I couldn’t eat anymore due to a risk that I might choke I imagine I would be devastated. What would I do when I saw my friends? What would I turn to when I needed a sweet fix?

This situation can be real life for the people in our care.

Person centred is not a new term in care provision. It’s what we all aspire to achieving; ensuring that people are cared for in the way that they choose, whilst also ensuring their needs are met. But what makes the difference between an ideology and actually delivering person centred care and delivering it well?

While we are self-caring and independent we are at the centre of our own lives. We make decisions, some of those decisions might be unwise, (that last Bacardi was the last thing I needed on Saturday evening, but oh how I wanted it!) but the beauty of being human and of consenting age is our right to choose. Obviously not every decision is made purely around us, we have families and friends and we often make decisions based on our responsibilities to them rather than purely what we would like to do. Ultimately though we are masters of our own destiny, and as daunting as that can be sometimes imagine how life would be if we didn’t have that freedom.

How would it feel if your body wouldn’t do the things you wanted it to and that restricted the choices you could make? Or if you were reliant on someone else to support you with everything you did. Imagine if you could make choices but struggled to communicate them to other people. What would it be like if people who didn’t know you were making decisions on your behalf?

So how do we ensure that the care we deliver really does put the person at the centre, and what are the challenges to achieving this? Reflecting on my experience of working with people to develop care and support that is truly person centred leads me to sharing a few of my thoughts, although I can guarantee I don’t have all the answers.

Communication is key.

Finding out what makes a person them is key in delivering person centred care and for that good communication is essential. It is also one of the most difficult things to get right. We already know that there are many views around verbal and non-verbal communication and I’m not looking to challenge them or to present an alternative. How someone communicates will be individual to them; it may involve verbal communication and observations of body language, or you may employ communication boards, symbols or signs. The important thing for us is that we learn to understand the way someone communicates and use this understanding to create a conversation.

Good communicators will use their ears and mouth in the correct proportion and will have a variety of questioning techniques ready to keep the communication channels open. They will be gently inquisitive rather than interrogating and keep their opinions out of this conversation. This is not to say this conversation isn’t two way, it can be really helpful to give a little of yourself in order to receive something back but it’s important to consider what it is that you are giving. Let’s not start a debate when we are trying to encourage people to open up to us about the most important details of their lives!

Finding the appropriate pace of the conversation is crucial. I used to be frightened of pauses and silences; in my own company I often talk to myself just to break the silence, so to be with someone and there to be no talking was terrifying! But I was taught and now do believe that silences allow thinking time, and that might be just what it is. Check in if you need to, ask if your question was clear, but just hang fire a minute or two and give the question chance to land and an answer time to formulate. Good questions provoke thoughtful responses.

What is right for you is not right for everyone!

Seems obvious perhaps as we are discussing person centred approaches, but when we challenge ourselves to think about it there is a real risk that we will make decisions and offer support based on what we think is best for someone in our care, rather than what is right for them. Life experience programs us with our own set of values and approaches to everything that we do. We form our opinions from a combination of what has been instilled in our upbringing, our lived experiences, from what we have tried, what works for us and what hasn’t worked for us in the past. However our well intentioned approaches can sometimes be no more than that; well-intentioned but not hitting the mark for the person they are intended for.

I have a friend who has support for a couple of hours a week with making appointments, managing emails and letters, and ensuring finances are running smoothly. For the purposes of this example let’s call him John. He is independent with all other areas of his life but he finds these specific areas challenging and needs direction and focus to undertake them. John had employed a new support worker, Bill through an agency to help him with these specific tasks and we were talking about how it was going. Well it wasn’t working out he explained as Bill had been told that his role was to advocate choice; there appeared to be a mismatch in what this meant to Bill and what it meant to John. When Bill arrived they would discuss the plan for the next couple of hours and as they commenced each task he would ask things like ‘what would you like to do about this letter?’ and ‘what should I do with this appointment?’ John said that if he could answer all of those questions then he wouldn’t need assistance!

So whilst Bill was working really hard to ensure that John was in the driving seat and that his role was enabling rather than leading, John had already made a choice that what he wanted and needed in a support worker was someone who would say ‘you have these bills to pay, and these appointments to make’ and then support him to do that. Giving him all of these different options was actually creating anxiety for John, albeit unintentionally. Of course I can see where Bill was coming from. This approach of telling someone what they need to do often conflicts us with what we expect the support role to be but that is what a person centred approach embraces. It’s what ‘right for me’ actually means to that person, not what we interpret it to mean.

Important to and important for are not the same.

A fabulous yet simple tool I have used time and again is something I first found from Helen Sanderson Associates and it’s a simple list template with ‘important to’ in one column and ‘important for’ in another. The things that are important to a person are often not the same as what is important for them and their safety but in order to create a plan of care that really meets someone’s needs exploration and cohesion of both areas is essential.

Often what is important to someone sits alongside what is important for them, however on occasion there may be conflict and it might be necessary to draw on other skills and support such as risk management and the expertise of other professionals. Let’s return to my opening story to consider what that might look like.

In this example I talked about how important food is to me, and how challenging it would be if I was to be told I could no longer eat due to a risk that I would choke. Using this example it is important for my safety to have my nutritional needs met and reduce the risk of choking. Clearly in this scenario we have a conflict.

So what can someone supporting me do in this situation? Well hopefully they will communicate with me rather than dictate to me, they will present me with the options and the risks, allow me to consider them and make a decision. Perhaps with the input from other health professionals we will come to a creative compromise where I can still engage in trying small amounts of food whilst undertaking all of the experiences that I associate with food because that is the decision I am able to make, or perhaps I’ll tell you thanks for your advice but it’s a risk I’m willing to take.

If my ability to understand the risks is impaired hopefully I will have some support with this decision, taking into account my previous wishes and my love of food and all it means to me, balancing that with the risks of eating even small amounts of food. Then together we will create a plan for what happens next. Together; with me at the centre. This plan won’t be set in stone, it will be something we can try and something we can review but it’ll be built around me and based on consideration of what is important to me as well as what is important for me.

That will be person centred care. It is hard work to get it right, there is so much to take into consideration, and it extends beyond just my crude example but please remember that I know me, so to know how to care for me…well I’m the best person to ask.

I’ve started running. (I’ll allow a moment for the laughter to subside…)

I’ve got to 3 weeks (8 runs) in and my left knee has stopped participating. Every time I move it it shouts at me, and it has no further plans to participate until I develop some supportive muscles around it.

In truth the pain started at the end of week 2 when I was 6 runs in. My mum said ‘Stop running Clare, look after that knee. Don’t put too much pressure on it.’ I thought to myself ‘I’m 30-bloody-6, I’ll run if I want to.’

Should I have listened to my mother? Perhaps…

Why didn’t I? Because I’m stubborn, because I’m 36 and because I didn’t have to! I have no medical conditions that affect my understanding. I can retain, use and weigh information given to me and I can make my own decisions based on this information. I have the capacity to make decisions about my life. Thank goodness for that!

A few recent events have made me think about how we view capacity, what we understand it to mean, and how difficult it can be sometimes to allow people to make their own decisions when we feel that we know best!

Recently someone I know was admitted to hospital following what some would say was a series of unwise decisions. At the point of admission he was acutely unwell, but as memory tests and questioning demonstrated he nonetheless had good understanding of the reasons for admission, the care required to aid recovery, and could consent to the care offered by the medical team.

Over the next few days my friend’s family and close friends came to visit, all very concerned and all with their own opinions on his situation and events leading up to his admission.

I find it incredible how rapidly situations can change when someone needs some care. From being at home making day to day decisions to being in a care setting with someone deciding what is best for you can happen extremely quickly. One day I was talking to my friend, asking what the plan was for his hospital admission. He didn’t know further than the next intervention. Talking further it appears that this wasn’t due to the lack of a plan, but because the Doctors had been consulting with his family rather than with him. He was only hearing the parts they chose to discuss with him. Additionally, when an intervention was required while visitors were present, the hospital staff would explain what they needed to do and why regardless of who was present at the bedside.

‘Why didn’t he challenge them?’ you might be thinking. Well he felt too exhausted to start challenging people; it was enough to get through each day and to try and recover without arguing about who should be privy to what information and who should be making what decision. He wasn’t happy about what was happening but as he explained it was one of those ‘choose your battles’ moments.

Of course there’s nothing to say that his family were making decisions that he wouldn’t have agreed with or made himself; they felt that they were acting in his best interests and doing what was right by him. The point is that if you are capable of making a decision about your life, treatment or future then you are entitled to make it. Just as my mum gave me an opinion and I chose to ignore it, my friend should have been given the full information about his condition and allowed to choose the plan for his treatment.

What is it that makes us think it is ok to make decisions for another person then? As parents it’s always going to be a challenge not to jump in and offer an opinion or make a decision on your child’s behalf no matter their age; after all you did have a legal responsibility to do that for the first 16 years of their life and old habits die hard! This is an important point for health professionals to consider when approaching consent and capacity. Our parents want the best for us, but their best is not necessarily our best, and we don’t always make the same decisions that our parents would make for us. Therefore health professionals must be absolutely clear that they have our consent to disclose information to our nearest and dearest. If there is a question around capacity to give consent a full capacity assessment must be undertaken and the principles of the Mental Capacity Act (2005) adhered to.

Hearing about my friend’s experience of being a patient and his feelings of disempowerment around the plan for his treatment made me concerned for people who have difficulty with independent decision making in certain areas. We make hundreds of decisions every day, from what to have for breakfast or how to spend the evening, through to larger decisions like where we want to live or which job to apply for. Not having the capacity to make some of the larger decisions does not automatically mean an inability to make any decisions. Thinking about the impact for my friend, if he is not party to the discussions around his treatment then isn’t there a risk that he will be removed from his own recovery?

I urge you to think about some of the decisions you make each day and about how it has made you feel when someone offered an opinion on one of your decisions that you perhaps didn’t want to hear. Imagine how it would feel if their opinion became your reality. Now think of how wonderful it is to be human, to be an independent thinker, to have the right to make your own decisions; and where you can make every effort humanly possible to support other people in exercising their right to make their own decisions.

Sometimes I refer to myself as a ‘risk averse Nurse’ and I’m jokey as I say it but there’s a serious undertone.

I remember the first time I heard that people with complex health needs were being cared for in their own homes by unqualified staff. Aargh! My pulse started to race as ‘RISK’ flashed through my brain repeatedly! Defining ‘complex need’ I mean things like support with enteral feeding or caring for someone with a tracheostomy tube for example.

As a student nurse and many times in my qualified career I have been to lectures on and had clinical supervision sessions surrounding accountability and the role of the Nurse. At times I have felt terrified into trying to remove the risk from every situation. As a Nurse I am accountable for every decision I make, and rightly so. But this has been instilled in me with such vehemence that on occasion I’ve been at risk of not taking a person centred approach. No scrap that. It was person centred, but the person at the centre was me protecting my PIN!

I see this in other nurses regularly; we don’t want to take risks. Much of that is sensible, it could be your life in my hands and I’m not going to put you at risk. But if my determination to keep you safe restricts your freedom and your decision making then this is clearly not right either.

Taking a moment to think this through, how risky is it to be cared for at home with a complex need, by a carer? First of all unqualified does not mean not qualified to care for, it means not qualified as a registered nurse. Thinking practically I had to learn to be a Nurse and let’s face it recruitment is increasingly challenging across the sector, impacting on the availability of Nurses to support people at home. Would it not seem a practical solution then that specific care interventions are taught to people who have an interest in a caring role and other outstanding qualities that enable them to be the right person for the job?

That in mind my attention turns to how carers are trained and monitored in care delivery, and who is responsible for ensuring they are competent in the skills they are using. Both the Care Quality Commission (CQC) and the Nursing and Midwifery Council (NMC) have expectations that care staff are deemed competent prior to independently undertaking care skills delegated to them. Neither body however defines what competence looks like, the qualifications required of the Nurse delegating these care interventions or the frequency that competence should be reassessed.

Whilst CQC regulates care providers and the competence of care teams it offers no regulation of care for those people in receipt of a direct payment, so who is responsible for ensuring care staff employed in this way are delivering safe and effective care?

I often hear that an assessment of competence only reflects one moment in time. Whilst this is true my challenge is if we never make this initial assessment how do we know someone ever achieved the required level of understanding in the first place?

As nurses when we train someone to undertake a care intervention we retain the professional responsibility of appropriate delegation of that intervention. One could argue that regardless of whether I deem someone I have trained competent the very fact that I allow them to undertake the intervention means I consider them competent. Re-enter risk averse Nurse. There is great reluctance among Nurses to deem carers competent due to the risk and responsibility it carries, but this must be balanced with a consideration of how risky it is not to.

I’m presenting a whole load of issues here and perhaps it’s time to think of some potential solutions. What is the key to safe and effective care delivery using this model of care?

Firstly, a robust approach to risk management is essential. Consider where the potential for harm is both for the person receiving care and the people delivering care. Identify who might be harmed, and what you can do to reduce the risks of the hazards occurring. Discuss the risks with the person or family receiving care, invest in risk reduction as a team approach.

On the same theme, we must recognise (and accept) that we are only ever going to be able to reduce risk, we will never eliminate it. Training carers to competently deliver safe and effective care is a necessary standard to reduce the risk of harm to someone in their care, not a way of challenging nurses to put their PIN on the line! The very fact that carers are human and caring for other humans means that we will never eliminate risk.

The facilitation of honest and open communication will enhance the quality of care provision. Encouraging those receiving care and care staff to raise concerns, questions and report incidents without risk of being chastised will promote learning and lead to the development of safer care practices. In addition effective communication between the commissioners, consultants, specialist nurses and community teams is essential when delivering care. In order to consistently meet someone’s needs and preferences the multidisciplinary support team must be up to date as to what these are.

Nurses who are delegating care skills, training carers, and ensuring people living at home are receiving the care they need in the way they want, need to feel safe and supported as practitioners. It can be a lonely life out there as a nurse training carers to deliver life sustaining support. Surely a sensible risk reduction strategy would be for regulatory care bodies to collaborate around the training requirements for specialist carers, for the Nurses training them and for the commissioners purchasing the care provision.

I suspect we would all, commissioners through to care providers, welcome clarity around what skills can be delegated to specialist carers and what remains the role of the Nurse as well as what level of competence people receiving care can expect from their carer whether employed by them directly or through a registered care provider.

In today’s world where people with complex health needs are rightly being offered increased choice about how and where they would like to live, some structure around the expectations of those supporting these choices will offer clarity and create robust and sustainable care provision in the community. Until that day comes I’ll keep going, fighting my aversion to risk and offering support to nurses, organisations and individuals to ensure their carers are delivering safe and effective care.

For further information on delegation of skills you may find the following information helpful: https://www.rcn.org.uk/professional-development/accountability-and-delegation

http://www.personalhealthbudgets.england.nhs.uk/_library/Resources/Personalhealthbudgets/Toolkit/MakingPHBHappen/TrainingandDeveloping/PersonalAssistants.pdf

The RCN produced a document called ‘Managing children with health care needs: delegation of clinical procedures, training and accountability issues’ in 2008 which looks at clinical procedures that may be undertaken by non-qualified staff, delegated by Nurses following training and competency development. A link to this document is available here: http://www.ncb.org.uk/media/523631/rcn_guidance_april_08.pdf

If you are a nurse working in a community setting and overseeing or delegating care skills to health care assistants, assistant practitioners and support workers/personal assistants we would really like to hear your views. Please visit https://www.surveymonkey.co.uk/r/HVMFPRW and take our anonymous 10 question survey.

Clare Flynn is a registered nurse who currently works with organisations and individual employers to develop and deliver training and competency frameworks for carers providing complex care in community settings. Previously working in commissioning for people with complex health needs and as a Clinical Lead Nurse for a care provider she is passionate about supporting Nurses to ensure they are effective in managing risk and delegating skills safely.

They tell you to think of a title that has a kick and makes people want to read it. I'm well aware this blog title might put some employers off action learning, but bear with me, read on and it (should) become clearer!

Have you ever had a challenge or an issue that you didn't know how to overcome? 'Just one?' I can hear you thinking.

Me too.

Take a moment to think about how you approached it. How stressful was it? Who helped you, if anyone? Perhaps you couldn't tell anyone.

I've had a number of challenges across the years, both professionally and personally. (and I am ever more surprised at how many years there have been, I still feel like I'm 16!) I've often been reluctant to talk about them because I didn't want advice. I wanted someone to listen, perhaps explore, but not to tell me what to do. I'm not saying there's not a place for advice by the way, just that it's not always what I need.

Well hello and welcome action learning!

I'm part of a social enterprise in one of my roles, and that has given me the opportunity to take part in an action learning set. Put together with a group of relative strangers who share a common goal of creating social change we have worked together, supported each other and learned or acknowledged things we never knew or 'noticed' about ourselves. These people now know more about some elements of my character than many people I hold close. And because of the trust we have created in our action learning set they hold that 'stuff' confidentially.

Right get on with it Clare, what is action learning?

Action learning involves working on real problems, focusing on learning and actually implementing solutions. It is a form of learning by doing. http://ifal.org.uk/action-learning

An action learning set very basically is a small group (ideally 5-7 people) who come together and bring a current live issue to work on. Each person takes a turn to be the 'issue holder', presenting their issue to the 'set members' and being supported to work through this issue by being asked open questions and given time to consider the answers. The issue holder then creates some actions or next steps to follow up with and report back on the next time the group meets.

‘I could do that with my friends or family over a coffee' some people say. Perhaps you could. Or perhaps your friends would be tempted to give advice. Perhaps they would hear and accept your perspective on the issue and not challenge you to think around it in any other way. Perhaps open questioning is something they have limited experience of. What would hold you to implementing any actions you come up with from talking to your friends?

And I don't know about you but my mum is my greatest critic and my greatest fan. She's wonderful...and she's full of advice. She tells me what to do about things I don't consider to be challenging so oh help me what will she say if I am struggling?

To be clear there are no judgments of your issue in action learning. Your fellow set members aren't there to advise you on how to solve or resolve your issue. That's for you to do.

Your fellow set member's role (and your role as a set member) is to ask open questions that allow you to explore your issue, giving you time and space and a safe place to consider where to go next. So back to my title, I gave up my job after an action learning set! Nobody told me to and I don't advocate anyone else doing it, but the questioning around my issue helped me to realise that I had a decision to make; that I was struggling to grow my business, and the social enterprise I am involved in as well as work almost full time for someone else. In context, my action learning opportunity was related to the social enterprise and my self employed role rather than my role as an employee.

So talking of employees let's take action learning into an organisation for an example.

What are the issues for an organisation? Perhaps it's something about ensuring the highest quality service or output. Who is responsible for this? Every member of the organisation. Everyone has a part to play. So gather 5 or 6 people from different departments, it might be the CEO, and representation from every department. Set the overarching topic area, and invite each person to consider what issues they have within the context. Set the boundaries or 'rules' of the group and get ready to get going!

There are facilitators out there who will run the action learning sets for you to get you started. I love it so much that I am one, but there's nothing to stop you having this support for an agreed number of sessions and then carrying on yourselves afterwards if you so choose.

Through action learning you will learn to really listen to people, to question in a way that benefits and enables the issue holder's learning as well as wider group learning. You'll learn about who you are, what motivates you and what makes you effective. You might become emotional, top tip ensure there are tissues. You might be elated sometimes or irritated with yourself at others. But if you engage and be an active participant I can guarantee you will get something from it!