Voyage Care Voice – S2E5: Amanda Griffiths sits down with Debbie Ivanova from the CQC

After a successful pilot season of Voyage Care’s first ever podcast, we are excited share our second season with everyone! Relaunching as Voyage Care Voice, our podcast will be showcasing real people with real insights.

In this season, we’ll be focusing on how important quality is in the social care sector. This week, we’re lucky enough to be joined by Debbie Ivanova from the Care Quality Commission (CQC) for a special extended episode.

Debbie is Deputy Chief Inspector for people with a learning disability and autistic people at the CQC. She’ll be chatting with Amanda Griffiths, Director of Quality at Voyage Care, about her role at the CQC, the effects of COVID-19, the CQC’s Quality of Life tool, and the importance quality.

Great quality care and support

As the leading provider in the sector, we are truly committed to providing the best quality care and support possible. We constantly look for ways to improve the care we deliver, so it enables the people we support to live the lives they choose; lives which are fulfilling, meaningful and happy. To learn more about our great quality care and support, please visit our commitment to quality area.

Care Quality Commission (CQC)

Take a look at some of the important publications Debbie mentioned in this episode:

Can’t listen right now?

Read the transcript of the podcast below.

Amanda:

Hello, I’m Amanda Griffith, the Quality Director at Voyage Care. Welcome back to season two of our podcast where the theme is quality. Today’s episode is with myself and Debbie Ivanova, Deputy Chief Inspector for people with learning disability and autistic people from the CQC. Here we’ll be discussing all things CQC, COVID-19, and of course, quality.

Amanda:

So, Debbie, thank you so much for joining me today. It is really good to have the opportunity to almost demonstrate that there doesn’t always have to be a schism between provider and regulator. Because, actually, for many people, we all have the same aims and objectives, and that is to see the delivery of great care. So I’m sitting here as a quality director at Voyage Care with many years, probably too many years, of experience within social care, although, I wouldn’t change a thing. Many people that will be listening will know who I am, especially for the Voyage Care listeners. But it’d be really good if you could introduce yourself and just tell us a bit more about who you are and about what your role is. That would be really great.

Debbie:

Thank you, Amanda. Really good to join you today. I’m Debbie from CQC, and my job is as Deputy Chief Inspector for people with a learning disability and autistic people. This is just a one-year post to actually look at how we change our regulation of services for people with a learning disability and autistic people. But I’m a social worker by profession, but started my exciting career working as a care assistant in a service for the children with a learning disability. I’ve managed homes for people coming out of long stay hospital and moving into the community before I became a regulator. For the last 25 years, I’ve mainly worked in regulation, but I did spend three years working in Bulgaria and in Albania and a little bit in Macedonia, really trying to get people to think about how to organize their care for people with a learning disability in those countries too. My passion is about working with people and really supporting them to live the best lives they possibly can.

Amanda:

So you’ve done it straight away there, Debbie, so a point in which you said Albania. Interestingly, probably six months before the pandemic, I had a really long trip to Albania and visited with some people who are delivering LD services down in Sarandë and trying to get them off the ground. So there’s a real common shared theme, and I might pick your brain a bit more about that at some point.

Amanda:

I think you are the only other person I’ve spoken to ever with any experience of social care in Albania-

Debbie:

Nice.

Amanda:

… so it’s really made me smile now. So that’s really interesting. I think what I want to do first is I want to try and explain where we come from as an organization. I’ve been here eight years, and I think one of the most valuable things we did as an organization was creating a document which underpins everything we do, which we refer to as our quality framework.

Amanda:

It’s not a policy, it’s not a procedure, it really just sets out what we believe. And for us that identifies that we define quality pretty much in line with what Lord Darzi did back in 2008. And that was such a good definition. It stands. So we say that quality is an equal mix of care and support which is safe, it’s effective, and it delivers a great experience. And then underneath that, we set five goals which encompass our competent caring staff. We know there are issues at the moment around that. We absolutely have a goal of involving the people we support. We have a very clear goal around measuring positive outcomes, and we’ve done some specific work around that.

Amanda:

The key thing that I look at all the time is positive assurance. What does our data, what do our outcomes, what do our staffing issues, what do they tell us about the quality? And then the final thing is we are always looking to ensure that we’re delivering that kind of consistent quality care and support for every single person that we’ve supported. It’d be really interesting to understand perhaps, do you personally have a definition that you hold dear as defining what quality care for people with a learning disability or autistic people would have? And is there a formal line, a short and jaunty formal line from the regulator?

Debbie:

Okay. So all of those things you’ve talked about have to be really important, don’t they, in quality care for people that we’re involved with supporting and looking after? But I guess I’d want to start by saying I think the fundamental principle is that autistic people and people with a learning disability are as entitled to live an ordinary life as any other citizen. So I think what that means is we expect health and social care providers to really guarantee people those choices, the dignity, the independence, and the good access to local communities that most of us take for granted.

Debbie:

I think we also want services to be really ambitious. And it’s a word you will hear me use probably quite a few times today because I think it sums up what I really think we should be trying to do. We want services to be ambitious with people about their lives. We want services to become really person-centred and making sure that that ambition is tailored to each person’s needs and aspirations. So focusing on understanding people, getting under what they really want, and supporting them to live good lives of their choosing rather than only thinking about what’s the best way to keep people safe or the best way for meet peoples’ care needs. Perhaps put simply, it’s not only about what is important for the person but what’s important to the person and how do we get to the place where we’re confident we know that, and that the ambition we have for that person is good enough.

Amanda:

That’s a really great way of describing it. It’s really interesting, actually, because at the end of the day, it takes a lot for an organization to get to that place culturally, that you are always challenging back and saying, “What does that person want themselves?” I think, yeah, that we were on a great path doing that. One of the things that we found really difficult with the introduction of COVID and the regulations was that made it a little bit more difficult, because for people who don’t have that intellectual ability to understand the restrictions, et cetera, I think that really impacted on the lives of people being supported, especially in residential homes. I think it was a difficult one. I know that for me there were great frustrations in the early days. What was coming out in terms of guidance and all had a significant slant on older people and homes for older people. I don’t know, did you find that there were changes in that approach with that more direct instructional view around guidance, et cetera, throughout the COVID? I suppose it’s around how did you cope with that as a regulator, the fact that we had very clear instructions that could not be interpreted?

Debbie:

Yeah, it has been a really difficult period of time. For me, working during COVID has meant that I was in regular touch with a whole wide group of stakeholders, but also with the Department of Health and Social Care, to try to make sure that we kept thinking across the whole of social care so that we didn’t just focus on older people but what does this mean? What did these rules mean for people with a learning disability? How do they to translate into good practice taking into account people’s human rights, taking into account the fact that we’ve got to really think about what are the reasonable adjustments that need to be made to enable people to live their lives?

Debbie:

You’re absolutely right, it was very, very difficult. And that’s why we changed the way that we were inspecting a little bit during COVID so that we could really move slightly away from a focus on inspections to a focus on supportive conversations. Certainly at the beginning of COVID when we were doing our emergency service framework, we actually had 20,000, I think, conversations with providers over that period of time. And then, of course, we moved into our infection prevention and control methodology, which we did, I think, about 6,000 of those inspections, really looking at how services were using the guidance both around how staff should behave, but also how to use visitors, how to make sure the service is kept to the standards that were expected during COVID. All of those things are slightly different from our fundamental approach, which is much more about what is people’s real experience of care.

Debbie:

But I suppose what I think we also tried to do is recognizing that COVID could, because of those variables that we’ve talked about, end up creating more closed environments, which can lead therefore to more closed cultures. We also wanted to strengthen our approach to identifying those closed cultures, and of course, in the light of the reviews that were done after Whorlton Hall and Glynis Murphy reports that we had, and our own out-of-sight report into the situation of people who are restricted and secluded within all types of services, hospitals and care homes and supported living. We know the real risks that there can be for people when closed cultures develop. So we needed to make sure that we were still balancing that and getting under the cultures whenever we could. It’s really those things that led me into the post that I’m in now looking at, specifically, how do we regulate services for people with a learning disability.

Amanda:

Thank you. I was really delighted when I saw that this post had been created, personally speaking, because it puts somebody at the helm. There’s always been changes relative to the sector in which we work, but to have a person is a personal touch. It makes a difference to know there is a person or there is somebody with the responsibility for the area. I think, it’s for a year, it would be really good to see that continue. Because I think, also, it shines a lot on the importance of this sector of social care. I think it’s been a very positive move.

Amanda:

I think you’ve already talked to me a bit about how the role of CQC changed during the pandemic. And interestingly, those ESF calls at the very beginning, in the main, and although there would’ve been a few very small exceptions, our managers all found those incredibly supportive. They were very nervous because it’s a change and people don’t like change, but I think, credit where credit’s due, a majority of managers that we spoke to and anybody that… At this time while we’re still in a bit of a state of limbo, I speak to every manager who has a visit or a call. I speak to them before, and I speak to the after because we went into this in March last year and everything just went up in the air, didn’t it? It’s very difficult. We forget that managers don’t like change as much as the people we support don’t like change. But yeah, it’s worthwhile, giving you that feedback, those ESF calls in the early days were pretty supportive for most managers. They found that it was really useful to have an inspector call them up and to have that conversation. It really was so. That’s worth saying.

Debbie:

Good to hear.

Amanda:

You already said before, actually, that I think it has been a difficult time for people we support. And it was very sad that some of the changes which would’ve made life easier for some of the people we support, things like clear masks, they weren’t authorized. We couldn’t get insurance clearance for them until really late in the day. But I know that looking at what our teams have achieved, some of the activities and what they’ve actually done within the confined of their four walls, same as all of us being held in our own home for the sake of preventing the spread of infection, there have been positives. Is there anything that you’ve seen as a regulator around there have been some positive outcomes as a result of this and as a result of COVID?

Debbie:

I think one of the main things that we talked about in our provider collaboration review, which was published in July 2021, was around the challenges. But we did find that despite those challenges, which I think were all very clear what they were, there were occasions where we found people with a learning disability generally were positive. One was about how well-informed they were about the pandemic and people understanding why they weren’t able to see their friends and family in the way that they had done before, and also how to keep safe. We found that there’s been, I suppose, quite a good development in some of the adjustments that were made to make sure that there was a really good range of communication techniques and strategies, Easyreads, online information, lots of good little videos that were online that helped people to understand what was happening. So there were some good things that had been done to really keep people informed and reduce anxieties.

Debbie:

The other thing that I think, and, and you’ve alluded to it a little bit there already, what we saw was that providers trying to prevent and minimize disruption to services that people turn to digital technology a lot more. I think this did two things. First of all, I think it improved collaboration between services. So there was a lot more better conversations going on between different parts of the sector. And actually, some people who hadn’t been able to be really involved in reviews before, it got a lot better collection of people together who felt more confident to speak in that setting.

Debbie:

But it also, I think, gave people with a learning disability who had access to digital services and the skills to use them a broader range of activities. Sometimes there were more social groups they could get involved in, more educational tool tools and resources. I was reading a great story about a service that had bought some virtual reality games and had used those throughout the whole of COVID to really give people experiences of going to places and doing things that they’ve never done before. And they are now looking at exploring how they use those as a learning technique going forward to really get people to try out new things and to experience more choices. So there were some good things there.

Amanda:

Yeah. I think working in social care, unless we are able to be continually looking for the positive, sometimes it would be easy to think everything is an uphill battle. But yeah, I agree with you, I think that it has challenged fundamentally the way some providers work and the way they operate. I know for us, if there was one real positive that came out of the whole of the situation going back as far as last March, that is our communication is like it never was before. As you say, we’ve utilized the technology, we’ve utilized the ability to be speaking to people immediately. And also, the references you made to things that like Easy read, whenever there’s been a change to guidance or any type of change to the way services have to operate fundamentally, one of the first considerations has been, so how do we communicate this to the people that we’re supporting?

Amanda:

We’ve been very fortunate having things like the behavioural support practitioners. So at the point at which masks were mandated, so good. And we will take that learning on forward that actually every bit… I mean, you always do communication well as a provider, but it really made us realize it was just that little bit more that we could do. And that was around utilizing the technology that was available for us to get it out there quickly, to be more reactive to change, and to be able to track that change better. I don’t think it’s all been negative. It’s been a hard time, it’s been a very hard time, but I don’t think it’s all been negative.

Amanda:

It really does feel like lots of change. For us as a provider, it feels like there’s an awful lot of change going on at the moment. I mean, at the tail end of last year, we’ve had the Right Care, Right Support, Right culture has landed, the final iteration of that. And then we were really delighted when your new Quality of Life tool for inspecting the services that we deliver arrived. And it’d be really good if you could tell us a bit more about that and about where that came from. What was kind the embryo of that? How did that grow and develop?

Debbie:

Okay, so it’s probably best putting this in the context of the work that I’m doing at the moment. Because as I mentioned before, my role came about because of our out-of-sight report, because of the Glynis Murphy and the Whorlton Hall. And of course, since then, we’ve also now had [inaudible 00:18:44] Cawston Park and the awful things that happened to the three young people who were living in that service. What we’re doing is constantly look at how can we really regulate better? How can we really get under what care is like for people in a service? The work that I’m leading is focused on three areas. I’ll tell you those briefly, and then I’ll go a bit more into the one about inspection and talk about the Quality of Life tool a bit.

Debbie:

What I’m doing is making sure we use that policy you’ve referred to, Right Support, Right Care, Right Culture, which, of course, was the development from registering the right support, which was there before, but making sure that we use that across all services. So across hospitals, across social care services, whether that be residential, supported living, to make sure that we only register the right services and to make sure that all of the services that are operating are measured according to those standards. Because we want people to be able to say, “I use services that support me in the way I want to live and where I want to live.” So the first of my areas is all around that. We’re particularly looking at working with commissioners, looking at working with those people who are in planning departments, as well as providers, to really understand what that means, what Right Support, Right Care, Right Culture means in terms of devising new services, thinking about how that could be delivered.

Debbie:

We don’t want any more big hospitals being set up. If we are going to have a new generation of services that are about where people need that crisis treatment, then they should be small. They should be in the community. They should be services that are really focused on the least disruption to people that can possibly be, but giving them the real support they need within their local area. So the first one, therefore, is very much focused around that and working with our registration colleagues and working with external people to think about what are the right services and how do we make sure those are the ones that are registered.

Debbie:

Then the second one is much more about looking at the regulation of services. This one, I want people to be able to say, “I won’t be asked to move into a service that isn’t safe, and I won’t be expected to continue to live in a service that doesn’t meet my needs.” So how do we do that? How do we actually look at getting under what that means? The new approach that we’re using is very much about… It’s within our current methodology, but it’s adding to it some things that we think will really help because of all the learning that we’ve done from those reports. First of all, we make sure that there is always a team that includes the right people. Now, bear in mind, we are only piloting this at the moment, so this won’t be the experience of all of your services. The team that we’re putting together should always have somebody that is from either adult social care or hospitals teams that has knowledge of people with learning disability.

Debbie:

What we also make sure is there’s an expert by experience involved in those inspections, that the focus is on observation and spending time really listening and talking to people. That’s where the focus is. And the focus is on actually getting under what does the care look like for those people in that service? The Quality of Life tool that you’ve talked about is one of the ways of doing that. It was first developed in order to address those recommendations from Glynis Murphy, and was developed with a number of people, including one of our university colleagues who have actually helped us to think this through. There was a big piece of work done, and you’ll see all of these are now on our website. But the tool that we’re actually piloting at the moment within our service is a shorter version of a big piece of work. The purpose is to improve our ability to consistently identify and take action in services that aren’t meeting the needs, aspirations, and skills development of people with a learning disability or autistic people.

Debbie:

The tool looks at how well people’s care plans are actually delivered in practice. It’s about moving from that, “What does it say? What does it say in the person’s communication plan or their positive behavior support plan or their care plan about how they want their care to be delivered? And is that actually happening?” So the version of the tool that’s been piloted, and I want to be really clear that it is a pilot, we’re evaluating and extending the pilot at the moment, but it is still a pilot, that version has been published on our website and has that broader framework that the tool was based on. But we haven’t got to the end of this journey yet. We’re still looking at how well can it be used? How easy is it to use? How are our inspectors actually using it as a tool within those inspections? When we’ve concluded that, obviously, we will update the tool and let people know what it is that we’re going to use going forward.

Debbie:

The third bit of our work is about making sure that we influence pathways and wider healthcare of people with a learning disability and autistic people. And there’s two particular things we’re looking at doing here. One is looking at going into hospitals, acute hospitals, and looking how people are supported. You will be aware of some of the awful leader reports that have shown how people with a learning disability are not given the treatment that they should be to make sure that they get that full life. And still, far too many people are dying far too young. We want to get into acute hospitals and really have a look at where are some good practice, what’s the good practice that we can highlight so that other services can learn. We are also looking at how do we increase accessibility of GP services and dentists for autistic people. So those pieces of work, they’re fairly in early stages at the moment, but to really focus on the pathway and the ways that people can use other bits of the system not just the places where they live.

Amanda:

I really like what you’ve said about the third part of your work, Debbie, because actually, it’s almost as though you are fully aware of some of the biggest challenges that providers face. I think at times in a cohort of systems, so we have social care, we do have inpatient services, we then have local authorities, we then have CCGs delivering community care. It’s not that any of those elements are not doing what they do correctly, but the flow across them is not always advantageous to the people who we are supporting. And sometimes, it’s at that point that things break down. That communication, that sharing of information, and actually, the sharing of a desire to do what’s best and what the person that we’re supporting wants doesn’t always happen. I think everybody is in incredibly pulled in so many directions. I just think, yeah, pathways is absolutely necessary.

Amanda:

I think that’s been really evident throughout the pandemic. There is so much a provider can do. But actually, when there is formal guidance, it does make it incredibly easier. So that is music to my ears. The accessibility to GPs and dentists, absolutely spot on. We are still seeing great difficulty at times in pockets. It’s not the whole picture. It’s not the larger picture, but there are elements where it is incredibly difficult. When you are tracking cases, you can see that it’s not for want of people trying to access healthcare, it’s just that the system is so pulled in so many directions. And actually, sometimes processes have not been formalized for other agencies. And then it, it’s just a synopsis between the different elements who all have a responsibility in delivering care and support people. So I’m really happy at that.

Amanda:

I’m also really happy, and I know that many of my colleagues were really delighted when the website went live with the Quality of Life information. Any provider worth salt will always be looking to change and learn. And when we’re all learning and going in the same direction, it goes back to what I said at the very beginning, we all have the same objectives. At the point at which people are not sat there with that objective of making sure that the care that is delivered is just brilliant for the people who need it and the support is appropriate and still just brilliant for the people we support, while there are people sat in the seats making that happen, then we can only improve, can’t we?

Amanda:

I know that some of the logistics and some of the mechanics and some of the processes we have to, and the hoops we have to jump through, they’ve increased greatly over the 38 years I’ve been in social care. But something underpinning all of that, there are still so many people with a great desire to see things done properly, and you find a way through it. But it does help when there is a way and it’s pulled together and there is something formally you can follow and that it’s a standardized approach. You can deliver it in a person-centered way, but when it’s very clear what you should be achieving and what’s acceptable and what isn’t, I tell you, Debbie, it makes life much easier for providers. It really does.

Debbie:

I’m sure.

Amanda:

So thank you for that. This is a really poignant question the next one, because actually, we had a first inspection for our new Prader–Willi service. What we’ve done is once we’d got to the point that we were assured, and I’m talking about in the period of time that I’ve been in this role and working with the organization, we did a lot of work about getting to the point that we hit a place where everybody’s compliant and we know that. Because compliance is only the bare minimum, isn’t it? There is so much more above that. The real joy of life comes between being a good service and being an outstanding service. That’s where you want to be; either at outstanding in terms of an assessment by the regulator or working towards it.

Amanda:

And once we’d done that, we’ve then since drilled down and we’ve created very clear specialisms taking that very specific evidence-based research and guidance from the industry leaders. So we’ve done autism. We have a specialist behaviour support specialism. We have our brain injury specialism. And our most recent one is Prader-Willi. We opened a brand new Prader-Willi specific service, and it came in as an outstanding on its first inspection, which is quite an achievement for a brand new service. It’s just delightful to see it. I know that the people living there, they’re happy, and that’s what matters. But have you got any tips with where we are at the moment? And I know it’s really difficult to get an inspection that would be looking to move someone to outstanding, but for the whole learning disability and supporting autistic people, what tips have you got for managers in any organization for achieving an outstanding rating at the moment?

Debbie:

Well, first of all, I’d just say congratulations, that was great to hear. It’s very unusual to come straight in at an outstanding rating, so it must be a really good place. So well done. Now, what I’m going to say next is probably going to sound a bit funny, but hopefully, it will make sense. It’s not about having hens. And the reason I say that is that sometimes we think that people try and find a formula for achieving outstanding. I remember so clearly, we had a service and we talked about it, and it said that it was outstanding. And one of the reason that it said that it was outstanding was because it had hens. The people in the service were going out and they were gathering the eggs and they were looking after the chickens. We then found about eight services around it all started to have hens because they thought that was the way to get to be outstanding.

Debbie:

I suppose what I really think is at the bottom of what makes an outstanding service is the exact opposite of that, which is actually, what is outstanding for these people in this service? What is the ambition? Back to that word again. What is it that for each individual person in this service is going to give them that real life of their choosing? That’s what makes a service outstanding, having that real ability to focus in, get under what it is for each of those person in terms of their support, in terms of their care, but most importantly, I think in terms of the culture of the service. Use Right Support, Right Care, Right Culture, it does give you lots of the hints and the ways to doing that. But perhaps one of the things I can do, which might help you a bit, is give you a few questions which I think, certainly as managers and leaders and as staff, is a good thing to think about.

Debbie:

How much are people in control of their lives? What can they do? How do they change the things that are happening around them? How is the service organized to people’s ambitions rather than the functioning of the service? How many times is it possible that people can do things, for example, go to a concert late at night, go out to the pub and stay there until it shuts? How do you make sure your staff are working in a positive culture where the expectations are really high about respect, about really valuing individuals? How do you get that culture which she doesn’t accept anyone being spoken to, talked about, written about in a way that isn’t demonstrating their equal value? How do you demonstrate and check on this? As a provider, as a manager, as a shift leader, how do you know what’s happening on a Friday night, on a Sunday afternoon? How do you know that there aren’t peaks forming within the staff? What are you doing about really making sure that happens? How are you making sure that when you recruit staff they’ve got those values that you want to be there?

Debbie:

What was the last thing you changed as a result of someone speaking up? What was the last thing you implemented because an advocate brought your attention that something wasn’t quite right for the person in your service? Those are the kind of questions that if a service can answer really well and can demonstrate that they’re doing all those things, that’s what’s going to help to push people into that outstanding place where they’re really clearly not only meeting people’s rights and needs, but aspirations and doing it in a way that shows the value of each individual.

Amanda:

They are some fantastic questions there, Debbie. They are really good. But I have to say, I do like that quote, “It’s not about the hens.” And I think that it’s something that people in social care should know. It should be on one of those chalkboards in everybody’s kitchen, “It’s not about the hens.” And I’m with you on that because I know exactly what you’re talking about there. People think that it is a tick box and a list of, “You do this, you get outstanding.” Actually, you have to make it about the people that you’re supporting.

Amanda:

I remember one of the very first things I did when I came to Voyage Care was we wrote the capacity and incapacity policy. I didn’t want to just write an NCA policy because it’s about understanding some people have capacity, some people don’t have capacity. I took lots of advice and feedback writing there. And probably the most important section in that policy document is around unwise decision-making and the fact that people have a right. I learnt a lot writing that. I came here from older people’s care. I’d worked in older people’s care for decades, and I came here, and I’ve stayed, and I love it. I think probably I’m the wrong sort of nurse. I think I should have been an LD nurse because it’s just taken over my life and I love it. But I remember that light bulb moment of I allow… Oh, well, I did allow because they’re not teenagers anymore. I allowed my teenagers to go off out on their dirty Thursday into town or their Friday night, and they would make unwise decisions during that time.

Amanda:

But yet, we were focusing and concentrating on not letting people with capacity to make decisions to really make them. And so, we did a lot work around how do we evidence what we’ve done to give people the information they need to weigh it all up but to still live a life? I’m not talking about, “I’m going to go and sit on the train tracks,” but just things that people leading ordinary lives do every day, because we all take risks every day. I think that when you have a mechanism in place for that and you have that focus in your mind that the care and support you’re delivering will be as safe as you can make it and you’re meeting all those requirements, that was one of the biggest learnings I had, that actually for people with a learning disability and for autistic people with capacity, we cannot be jailers or prison warders. We have to support them to lead a fulfilled life, and you have to put the framework in around it. But that’s me waffling, but I think that’s been a big learning for me over the years.

Amanda:

So the next question I’ve got for you is, and I don’t know whether you can help me with this, but have you got any really good examples of really good quality and care and support that you’ve observed or heard of recently, Debbie?

Debbie:

Well, I think I’d like to draw your attention to the Home for Good report that we’ve published in the September just gone, because the thing that’s exercising me the most at the moment is how we move the people on who really have become stuck in our hospitals. That report includes eight best practice case studies which demonstrate that good community support can be provided for people with a learning disability, a mental health need, or autistic people within the settings that we are working in. If you look at that report and look at somebody like Andy’s experience. Andy is 30, he is autistic. He has a learning disability and an anxiety disorder. In a seven-year period, from the age of 18, he’s been sectioned twice and spent six of those years in several specialist hospitals. When he’s in a hospital, when he’s under section, he tries to strangle staff, or he may rip radiators from the wall when his anxiety spirals. He’s not an easy person to provide care for.

Debbie:

But Andy’s support service was designed for him from scratch to meet his needs. One of the actions the provider took, and I think this is something that’s really important, we talked about pathways before, is that his support service is designed alongside the multidisciplinary team so that there was really regular contact in the community. And this team were there to support with his requirements and to help the staff who are providing the day-to-day care to make sure that they continue to get it right. The provider recruited his team using a values-based approach and made sure that those people reflected Andy’s interests and aspirations. So they were people who would be able to work with him and help him to succeed in his new home. And it worked.

Debbie:

So 18 months after he was actually referred, he settled in his home. It doesn’t happen quickly. I think that’s a really important message. It takes a long time to get this right. He’s now really been able to reduce his medication and live a much, much fuller life. I think what we’re seeing is where we do have that combination of the individualized approach and that ambition that is founded on that real respect for the person, you can do some great things. We can find services that will work for everybody, but it can’t be done by fitting people into services very often. It is mostly by developing the service around that person.

Amanda:

Yeah. I read the document and I read all of the scenarios and actually did take some real learnings from that, Debbie. It was incredibly useful. One of the things that we’ve done, as I said to you before, is we’ve introduced a specialist behaviour support specialism. What’s really important, especially for a provider, is that you continually review and you take the learnings. As we work on a day-to-day basis with people moving from secure settings into community settings… And that is quite a big ask, isn’t it, to go from a lot setting into your own property with either a tenancy or a license to live there and the freedoms that that can bring if people do have that element of freedom? It’s a completely different change. You’re right, it is about putting that person at the centre.

Amanda:

I’m long in the tooth, I say it to so many people. I’ve been around the block several times. Actually, you feel quite ashamed when I think over the years how transitions have been made. We know so much more now, and I think it is only right that every provider is undertaking those transitions safely, but with the person that they’re supporting right bang in the middle of it. It goes back to what you said at the beginning, we can’t just do things to people. So it’s really important. No more are we in the situation where we just say, “That’s where you go in, and that’s it.” We have to have that agreement. It does my heart good. I’ll be getting to retirement and thinking there’s still so much more to do, but we have come a long way, I think, as an industry. And also in your approach as a regulator, we’ve come a long way in my lifetime, and I think we should be proud of that.

Amanda:

We’re not where we want to be, and we probably haven’t done it as quickly, but we shouldn’t forget the changes that we have made and that every day we have got the opportunity to make changes again. However, saying that, I think one of biggest issues at the moment in that continuity of care across settings, so that moving on, it is really difficult with staffing at the moment. It really is. I think I’m hearing from many colleagues from different providers and across the industry of people not being able to move people on, people turning down packages. I do believe that will impact on quality of care. But what’s your thoughts on that? Do you think there is any solution to this kind of… Well, it is just a crisis that we are in at the moment, isn’t it? That seems to have come out of nowhere. It’s as though that the last four, five months everybody has hit the same place in terms of staffing, haven’t they? Do you think there’s a solution to it?

Debbie:

It’s a tricky one, isn’t it? I think you’ll recognize that in our State of Care report that we’ve just published we talk a lot about this, the challenge of the workforce. Perhaps there’s a few things I’d like to say. I mean, firstly, it can’t be said enough that we do really appreciate this sort of hard work and the dedication that all colleagues working across social care have done throughout the past year, because it is phenomenal. There has been so much energy gone into making sure that people are kept safe and people are kept as well as possible, and making sure that we keep our commitments up to people. We do see that, and we do really appreciate it.

Debbie:

We also understand that the impact of working under that sustained pressure can’t be underestimated. we know how the negative effects on health and social care workers of anxiety, stress, exhaustion, and burnout are real and need to be addressed and so important that providers have good things in place to actually support their staff through these next months which may be just as tricky. I think it’s absolutely right that we acknowledge those challenges, but perhaps one of the solutions is to try to change the focus a bit. Because I think what we’re in danger of doing is getting everyone to think, “Oh, poor social care, it’s a terrible place. So hard to work there.” I’d like to get us to start to think about changing the focus from the challenges to the victories, highlighting what’s really good about care and the good practice that we see, the good outcomes that you’ve achieved, and making sure that’s what’s flagged out there in a much stronger way.

Debbie:

My story is that working in care is fabulous. I’ve loved it. It’s a career for me that started being a… I was paid £3,000 a year as a live-in care assistant, and it set me up to a career that has just been fantastic. I am still as motivated to make that difference as I was in those days. I’ll tell you a little secret here, I almost got sacked for whistleblowing in my first job because people were being restrained by being tied into beds at night. I was so, so angry about it coming out of university, had no qualifications or knowledge about working in care. But I just knew, my values told me what was good care and what wasn’t good care. And then I built on that with my learning, built a career.

Debbie:

It is fabulous, and we’ve got to get that message out there. We’ve got to really get people to understand that this isn’t a difficult dead-end job, that this can be such an amazing work to do. Some of the people I’ve met, some of the people with learning disabilities that I’ve lived with working in services have just taught me so much. Yeah, they have given me an insight into how you can make the most of your life in a way that probably no one else has done so. It’s not a solution, but my suggestion is that we try to reframe this conversation and we make it much more about how wonderful social care is, not how difficult.

Amanda:

Yeah. It’s a difficult one, isn’t it? I don’t think there is a clear solution at the moment other than we just have to commit to what we’re doing and keep on voicing how great it is. I’m like you, Debbie, I can’t imagine ever having done anything else with my life. In fact, it’s been my life to the point that my family completely know. I make time for them, but when I’m working, my priority is what are we doing? Are we doing it right? And are we doing the very best we can? I’m grateful, as I’m sure you are, to so many people across the industry that have that approach, but I do worry about the future. And that’s just kind of a statement.

Amanda:

I know that I talked before and I know I’ve said that I’ve been around a long time. Over your career, what’s been the major changes? What have you noticed in terms of the stance on quality care for people and disabilities? I mean, the very fact that you are in that role at the moment, that is a move forward, and it is a great change and for autistic people. But for you personally, what have you noticed in terms of the approach around quality care and support for people with learning disabilities over time?

Debbie:

You said earlier that it’s been quite gradual some of these things, and I think there has been that slow movement of acceptance that some of the models of care that we used to have are just not good enough anymore. I think fundamentally underneath that is that recognition of people’s human rights and that full acceptance that people with the learning disabilities have the same rights that the rest of us do. And therefore, what we should be doing is looking at how we support them to live the lives that are the most fulfilling for them.

Debbie:

I think that’s where probably things have changed. If people are now able to live longer lives, it’s really important that those are better lives as well as longer lives. And that does take us into that focus on what it should be like for each individual. I reckon it’s taken a long time to come. I mean, some of the reports go back for a long time, don’t they? We’ve talked about time for change, now is time and the building the Right Support initiative that’s now six years old, and we are still kind of working towards getting people out of those hospital settings.

Debbie:

I think that quality is now seen as much more about designing services around people than designing services for people. So it’s back to that message again. I do start to wonder if this generation will look back and will say, “My goodness me, we were putting our older people into huge surfaces of 100 beds. Was that really what we would want?” I guess I think people’s expectations are at the bottom of a lot of these changes. So if you get that recognition that this is about people’s rights, and then you think about what would I want, what are my expectations, what are the kind of things I would want from my life? I think that’s what takes us into the right direction for the kind of services that we want for now and in the future.

Amanda:

Yeah, no, I agree with you. Interestingly, I had that very same conversation with… Somebody I haven’t met had asked me just over a quick call with them last night about the delivery of care services for older people, and we had that same conversation about we’ve put people in to these… I’m not going to say institutions, I think that they’re not. I think there are some really great quality providers out there, but I do think some of the principles around care and support that we apply for people with a learning disability actually would fit very nicely around people with dementia. I think they would fit very well. I guess it’s one for the future. It’s one to watch, isn’t it? And that brings me quite nicely then to my final question. What do you think quality looks like in the future?

Amanda:

I’m asking you here for some pointers now. Where do we need to be looking? And how can we strive to keep meeting the changing quality standards? I am very hot on making sure that as soon as something lands, I’m a great believer in get the gap analysis done. How much of this are we doing? And then where have we got the gap? And then how do we change it, and how do we communicate it out? And how do we monitor that change has been demonstrated, and then more importantly, sustained. Because the changes even over my eight years at Voyage, I could write a book on the changes that we’ve rolled out on the back of things that have come from the wider industry. There is so much, and at times I don’t think we realize how much we change things and how the delivery of care and supports change, and it just keeps happening. But what do you think? Is there anything priority for the future that you’re aware of that’s coming down the line out there?

Debbie:

We are working to develop a new understanding of quality across health and social care through the work we’re doing in our strategy and developing our regulatory model, which is happening at the moment. What we’re trying to do is bring a much more unified and consistent understanding of quality through our strategy. Because what we’re trying to do is develop a single assessment framework for provider regulation that will go across all types of services. Now, I think it’s right that we do that because that will help us to really make sure that we have the right standards across all services. But then underpinning that, what we’ll have to make sure is that there’s that specialist understanding and specialist knowledge that we found so important in learning disability services.

Debbie:

One of the things that I can give you a bit of a heads-up about is what we’re doing is exploring how we use what’s already there, existing materials, particularly having a real focus on I and we statements. So we’re looking at the work that’s being done by TLAP, Think Local Act Personal, and using those statements to really make sure that we focus on outcomes and what people want. We’ve done some initial scoping around this, but we are now starting to build up that momentum and think about what would it look like if we have that series of I and we statements across all of the work that we do. And I suppose my hint then for the future really would be, if you think about the differences between what your parents would’ve accepted in care… I mean, our parents’ generation, I think… well, my parents certainly, were very grateful. They were grateful for most of the things that were given them. They were grateful coming out of the war with having enough money in their pockets, having enough food to eat. I don’t think our generation are quite as grateful.

Debbie:

I think we’re a bit more demanding. I think we won’t accept some of the things that the previous generations have. If we constantly think about, “What would I want in this situation? What is it that I am going to be satisfied with when I am being cared for?” I don’t think you can go far wrong, because I do think that we have now built up some really high expectations of what care should be like and how it should support us to live our full lives, not just to end our lives in a setting where we are supported to maintain the care that we need.

Amanda:

That’s really useful. I guess for anybody that reads and is linked to things like TLAP and the other people who drive the change, there should have been no shock that these I statements and we statements were coming down the line, should there really? We should have already been looking at these. Yeah, fortunately, I’m glad that they have been well and truly on our radar for a while. I think it’s probably going to be a positive move. The only thing that I’d say is sometimes change is difficult for an organization. I think with the whole issues of what we’ve been through, it’s very trying for a provider at the moment in how do you direct an organization to slightly change. Because it’s not a big change, but it is a change of approach and a change of thinking, isn’t it?

Amanda:

But from my point of view, I do think it’s the right thing to do. I, for one, welcome them, Debbie.

Debbie:

That’s great.

Amanda:

So think about how we introduce it later. I’m embracing them. We’ll work out how we get them over the line with everything else that’s going on at the moment. You know what? The day that I say I can’t do something is the day that I’ll retire and go and live somewhere else. I’ve come to the end of my questions, so that wasn’t too bad, was it?

Debbie:

Not at all. It’s been really great to talk to you. Thank you, Amanda.

Amanda:

Thank you.

Amanda:

Thank you so much for listening to this podcast. If you want to hear more, you can catch up with this and other podcasts on the Voyage Care website.

Make An Enquiry