White Christmas

White Christmas

The care home had given notice and were very clear on the telephone call that came through that in their opinion there was nothing more they could do. Betty was a problem. Wandering. Absent Without Leave. Absconding. Leaving other vulnerable people at risk whilst staff had to go find and recover her. She had been found in the launderette, in the local church and once in the local pub. All places of her old life. The life she had left behind when she had entered the care home. The duty logs carefully recorded and logged each successive incident of risk, using words which captured their increasing sense of frustration to describe Betty’s ‘behaviours’, which they had passed on to social services as they increased the number of telephone calls which they had made to check out how their referral was progressing through December.

By December 22nd things were reaching fever pitch and the Matron had got involved. As the Team Manager I handled a really difficult phone call with Matron insisting that I take action. I reminded her that this close to Christmas there were very few spaces in other care homes due to pressures from the hospital and given Betty had been with them so long could we not work together to help make things work? No. Was she sure the situation could not wait until the new year? Very sure. Matron was adamant that I needed to look into options for Betty as she was really very confused and more concerning, she rarely ‘did as she was told’. Betty was wondering all over the town after she had been told not to. Most alarming to Matron, last week Betty had ‘absconded’ and been found by staff wondering the streets of town looking for her late husband, Ronnie. When Betty had been told her husband had been dead for 10 years, she had become very distressed, crying, need a lot of calming down. Matron was concerned, upset even, she had Christmas to think about and this meant that she would be dealing with reduced staffing levels, a sickness bug and increasing number of relatives visiting the home. But it was really the staffing levels that concerned her. Two to one staffing was not cheap over Christmas, and whilst she would usually try to accommodate the increase if I would authorise an increase in fees to the home, it was unlikely that she could afford to commit that level of staffing to manage Betty and her behaviours.

On the afternoon of 24th December, two of us were the last ones in the building, running the Duty Social Work desk, when a panicked call came through from the home. Betty had gone missing during the night. She had been returned by police who had brought her back freezing cold and extremely confused. Matron was clear. The home was at their wits ends, Betty was a huge risk to herself, the GP agreed and the impact Betty was having on resources was leaving other vulnerable people at risk. Matron demanded that we arrange an emergency placement in a home which provided specialist support for people with dementia. Faced with the risk that Betty would end up in hospital if we did nothing, at risk of all sorts of harm from infection over the Christmas period, confused and alone, we rang Betty’s daughter in Tenerife and spoke to her about what may happen to Betty that afternoon. From the sunny shores of Tenerife ‘permission’ was granted to ‘move her somewhere nice’. DoLS sorted st the stroke of a pen. So a move that afternoon, Christmas Eve, was in the offing. All in time for Christmas.

Both of us went to the home, just in case we needed a driver and someone to chat to Betty. We knew we’d certainly need two to handle Matron. When we arrived at the home Betty was the first person we saw but neither of us recognised her. She watched us walk from the car down the snow-covered path to the home. Her gaze haunted, searching our faces as though looking for someone. We rang the door bell and waited to be let in by the matron, admiring the wreath on the front door, shivering from the cold.

The care worker who answered the door in her purple uniform had tinsel in her hair. She looked relieved when she saw us. “Oh, thank god you are here, follow me, Matron is expecting you”. We were ushered into the Matrons office before the door was slammed behind us before we had chance to say hello to Betty or anyone else. The Matron was ready for us “Do you want a cup of tea. We have mince pies, help yourself to Quality Streets”. “Thanks” we said and did as offered noting that the toffee ones were missing from the tin, presumably already eaten. Matron had her script and was not to be distracted or diverted “She is 89 but you probably know that. Been with us for about 5 years. Her daughter put her here for respite as she was at breaking point. We had to go back to Panel to make the decision permanent as she needed care. Was very underweight when she first arrived. We’ve sorted that out. She was self-funding for a year, her daughter sorted the finances. But once the money ran out and she moved onto your rates we had to move her as you wouldn’t match the amount we charge for the room she was in. She was no bother at first. Kept herself to herself. You could talk to her and that. Not now. All you hear is her talking about her husband Ronnie but as I say, it’s been ten years since he died. The photos are all over her room, they seemed devoted from what her daughter says…”. Matron paused to root round the Quality Streets. A moment of displeasure on her face as she realised that her favourites (the toffee??) weren’t there, then settling on a coffee cream. “The thing is, we cannot continue with her. It’s taking the girls all they can to stop her disappearing. I’m down to two staff from this afternoon. We just cannot keep her. Her meddies are there and I’ve spoken to the home where she’s going. It’s got a locked door, so you got that bit right. Is she going in your car? Could she go now? It’ll probably be for the best. I’ll get someone to fetch her”. My colleague and I exchanged glances, a mutual decision made, this is dreadful but let’s get this done, Betty needs to be somewhere where she is welcomed. We followed Matron bustling toward the lounge, rounding up a staff member who was tasked with gathering together Betty things. Within 10 minutes Betty’s whole life had been packed. 89 years reduced into fitting into a suitcase and a plastic bin bag.

Betty was compliant because in truth she didn’t know what she was complying with. Yes, she’d get in the car. It was the same colour as her daughter had. And Betty listened as we talked about driving her to the new home “My Pamela has got a car just like this. Do you know her?”. We asked Betty if she would consider a new place to live? Yes, she was ok with that too. “Until Pamela comes. She’s in Worksop. I’m going to live with Pamela”. Excitedly Betty climbed into the front seat and the one suitcase and half-filled black bin bag, a lifetime of experiences bundled in the boot. “Now then gentlemen. Just one thing. We need to pick up Ronnie on the way please”. We smiled and carried on and wished we were taking Betty back home to Ronnie.

The journey took about thirty minutes via two small market towns at the foot of the hills. Streets were quiet with the occasional shopper heading in and out of shops to grab a last-minute gift or jar of cranberry sauce. The radio in the car was playing in the background. And then, from no-where the radio DJ became the umpteenth that day to play White Christmas. Time stopped.

“Aww. This is a favourite of my Ronnies, is this one” Betty said. And started singing. Softly to herself.

Every traffic light we paused at Betty thought she saw Ronnie. She unbuckled her seatbelt as we stopped for a pedestrian crossing, she opened the door and leapt out shouting “He’s there! Ronnie love, I’m here, it’s me, it’s me Betty, get in”. A young man of about 20 pushing a pram and smoking a cigarette looked up with alarm and swerved to quickly get passed. Betty’s face fell, dejected. She looked confused and got back into the car. Moments later she turned to the social worker on the back seat and said, “That wasn’t Ronnie you know. He wouldn’t be pushing a pram nowadays and our Pamela wouldn’t fit in it, yer daft apeth.. And he never smoked”. Betty went back to singing. “Where the treetops glisten and children listen. To hear sleigh bells in the snow”. From my front drivers seat, in the rear view mirror I caught sight of my colleague in the back seat next to Betty, who was gently holding her hand, tears in his eyes.

The deal was concluded quickly enough. Within an hour Betty was literally signed, sealed and delivered. The new care home, a dementia specialist unit with lock doors a plenty, were very welcoming. She won’t be at risk here, we were reassured by the nurse, we have special key pads to keep residents safe. The nurse was most interested to hear about Ronnie and assured Betty, whilst leading her down a dimly lit corridor, that Ronnie would be there to see her soon. We said goodbye to Betty but by then she was already half way down the corridor towards the lounge. There was no transition for Betty, no endings, no time for her to adjust and realign to her new situation. Just a sharp new beginning in another room full of armchairs, forgotten lives and the unwatched television in the corner.

Dreaming of a White Christmas whilst living your last.

Winter – Part 3

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

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

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

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

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

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

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

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

winter-okie-aged-80

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

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

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

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

Winter ‘blocking’

Looking back on the chaos last year, as hospital after hospital declared major incidents, this year all is quiet, almost eerily so. Have things really improved, or is it that:

We will have to wait for the likes of @RichardatKF at the Kings Fund to tell us what is really going on however in the meantime, despite the lack of noise in the system, nothing feels to have changed on the ground.  If anything, the pressures seem to have increased.

Adult social workers are used to being on high alert at this time of year and being warned that winter is on its way, although, usually, the first warning we get to be ready comes around the beginning of July… At Christmas, whilst others celebrate, adult social workers experience their busiest time of their year.

Under intense pressure, good people can behave badly and poor organisational culture, usually hidden, can be exposed during winter. In the midst of heightened anxiety, consideration of human rights, issues of consent and evidence of compassion can be the first things to go. Issues of choice and control, foremost in social work values, are at risk of being overridden and drowned out, replaced by the dehumanising language of the day: ‘patient flow‘; ‘through-put’; ‘bed-blocking‘; ‘units’ and even ‘creaking gates’. These have all been used in the last three weeks to describe those who became ill over Christmas and needed help from our hospitals. Take these headlines which are typical of any particular month you want to put the phrase ‘bed-blocking’ into google….

The resulting massive pressure is transferred onto social workers and social care commissioners, to shunt poorly people in need of medical care, therapy and compassionate nursing, out of hospitals into care homes without any consideration of their capacity to be involved in decisions about how their care needs were met. The issue, of course, is not that people should be in hospital, it is that they should be moved to the right place in a way that gives them time and support to make the right choice. The impact of local government pressure on the social care market, however, has left it fragile and wary.  The market is at risk of a major failure this year facing pressures on all sides from squeezed public finances and raised thresholds of complexity as people who would previously convalesced in hospitals find themselves in ‘transitional’ or ‘intermediate care’ beds.

The dilemma of the care home setting is sensitively caught by Alan Bennett in the wonderful monologue he wrote for Thora Hird, The Last of the Sun. They are places where families hope for the best for their family members, whilst at the same time wanting to look the other way and not be made too aware of things that might upset them.  The decision to move into a care home is underplayed by hospitals under pressure to reduce lengths of stay and so called ‘delays to transfer of care’.  The reality is that the person is being made to choose to move from their home to the place where they will live out the rest of their life in a matter of a few short days.  This is a timescale that most of us would baulk at if told we had to move house and make the decision that afternoon ready to go the following day, never to see our homes or most of our possession again.  The best of our local care homes stand firm faced with the extreme high risk associated with this chaotic approach to hospital discharges. These homes resist the temptation of an income source in an effort to ensure that people remain safe and that discharges remain coordinated and appropriate. However, for the most financially challenged homes, those whose situation places the quality of care at the edge of acceptable levels of safety, it is a difficult temptation to resist, the offer of a new admission with the income the person would bring to fill a vacant bed and  delaying the decision of the home closing.

If ever there was a test of social workers and social care commissioners’ conviction and values, it happens during winter. The pressure to discharge at all costs, with no real thought given to the long-term impact on the individual, can feel immense. We try to stand firm and insist on being given another 24 hours to clear a safe discharge pathway through services designed to get people home with support.  But without genuine protection for social care the pathway for discharge will close down.

The weeks following Christmas always highlight social work at its most stretched but arguably also at its best. Social work, working alongside health colleagues but crucially operating outside of the health hierarchy, can provide the necessary challenge to ensure that even at times of crisis, human rights are upheld and that the most vulnerable of people experiencing the most uncertain of environments are afforded the same human rights as us all.

Edited from the original published in Community Care February 2015 http://www.communitycare.co.uk/2015/02/17/adult-social-work-stretched-also-best-hospital-crisis/