CARE HOME DIARIES PART 2 ‘The Good, the Bad and the Ugly’

If you missed Part 1 it’s here. But in the second part of this short series, I get a job at Hill View House just as I start to think of social care as the new slave trade. Well, I still do. A bit.

No, of course Hill View House isn’t the real name of where I work, and we won’t be identifying any staff or residents by name or detail. But let’s just say I liked Hill View as soon as I walked in for my interview. For starters, it smelt nice. As anyone ‘in the know’ will tell you, this is usually a good sign for a care home. If you need nuclear-grade breathing assistance just to get through the front door of a care home, chances are it’ll be more than just your nose telling a bad story for the rest of the place.

I’d wanted to get back to some ‘hands on’ work but had let my my registration lapse some years ago and couldn’t go back as a qualified nurse.  So I’d been to visit a local agency  shortly before interview at Hill View. Their office reminded me of the shabby old car hire place my Dad used to run in the 70’s. Dust hung in the few shards of light that lit the shelves full of old ring-binder files with labels like ‘Helf & safety 2010’. A few wan faces looked up from their PC monitors to gaze at me for a moment. “Male, middle-aged. Looks a bit weird for this sort of thing” they probably thought before staring back at their spreadsheets.

I quickly learnt from the chap I’d agreed to meet that there “wasn’t much work for agency staff any more.” The sales pitch didn’t get any better. I would have to pay for a uniform. I’d have to pay for a CRB check. I’d have to attend 5 days of mandatory training, which is good of course. Apart from the fact I wouldn’t get paid to attend. And I’d have to do 2 ‘shadow’ shifts with another agency worker before flying solo. Yep, you’ve guessed it. In my own time. It was a very quick chat. I didn’t quite say ‘You’re [bleep] having a [bleep] laugh’ but let’s just say the agency manager wasn’t too unhappy to see me darting off into the fresh air and daylight muttering something about modern day slave labour and the taking of piss.

So back to Hill View. It was immediately clear that Hill View was a home for people with varying degrees of dementia. The more mobile residents looked bustling and alert, free of the slump and dead eyes of the Haloperidol fugue* I’d seen elsewhere. Other residents were clearly long immobile, coming toward the end of the long, terminal journey of Alzheimer’s or one of the other dementias. While I waited I could see staff engaging with people who were, in all probability, beyond comprehension of speech and certainly incapable of chatting about the weather. But carers chatted away nonetheless, knowing full well that this would only ever be a one-way conversation. With six months of these conversations under my belt I now know how difficult this is. I didn’t back then then, but it another thing I liked about Hill View.

Fortunately they seemed to like me too. With one brief but successful interview I was a relief care assistant, and with 5 days induction training and a CRB certificate to my name I was ready for my first shift and that dark Saturday morning with Ted and a very experienced care assistant called Hannah. 

Next week: CARE HOME DIARIES PART 3: ‘Pictures on a Bedroom Wall’ where dementia makes my jaw drop

CARE HOME DIARIES PART 1 ‘Unfashionable, Unseen, Unmentionable’

Introducing a series of posts from the front-line of dementia care

It had been twenty years since I’d last dealt with bodily fluids that didn’t belong to either small children or one of the dogs. But here I was at 7am on a Saturday morning helping to wash and dress a chap called Ted. Ted has severe Alzheimer’s Disease. He cannot walk or talk, and needs constant assistance to do just about everything.

Before this, my last encounter with Alzheimer’s had been twenty years ago. I was training to be a Registered Mental Nurse and what was then known as ‘Psychogeriatrics’ really wasn’t the most popular placement for students. Hardly surprising for a specialty sounding like a David Lynch movie and promising little more than a seven hour shift full of old people’s bits and an ocean of human waste.  But I finished my placement through gritted teeth and carried on toward a career with mentally disordered offenders and far, far away from the ravages of dementia.

So wiping Ted’s bum on a Saturday morning while normal people were having a lie-in could reasonably be described as a culture shock for one who normally earns a living travelling up and down the country running courses, or sitting at home bashing away at a laptop. But in six months as a relief care assistant I’ve learnt an incredible amount.  About life. About death. About people. And a lot about dementia.

There was a time when dementia was, as it seemed to us student nurses, the unfashionable, unseen and unmentionable of health care. But more recently the blogosphere, social media, a smattering of telly and a renewed interest in the harm that can come to a group of people who are just about as vulnerable as it’s possible to be has made dementia a great deal more visible than it has been in the past. It is now something most people are aware of, even where they haven’t been touched by it themselves.

But there remains one perspective pretty much invisible to the dementia story. Not those of the sons and daughters of sufferers, many of whom have provided moving and hugely educational accounts of Alzheimers, Vascular, Lewy Body and all the other conditions which form the umbrella of ‘dementia’.

There are around 18000 nursing and residential care homes in the UK. They will be staffed by a team of mainly unqualified care assistants, primarily female and paid minimum or near minimum wage, In many cases they will have had just about enough training to tick a box and satisfy the CQC inspector, and may often have little command of English.

Theirs is pretty much a silence broken only by the odd hidden camera expose of physical abuse, verbal hostility or theft, or the ever growing focus on care home scandals where residents are left starving, dehydrated and rotting in their own excrement. If they work in people’s own homes as domiciliary carers, they don’t turn up, or when they do, spend barely any of the allotted (and paid for) time with their clients. We hear some pretty terrible stuff, but how often do we hear the care assistants’ side of the story?

Most people working on the front line of dementia care aren’t big on talking about what they do. From my own experience, this certainly isn’t because they’re inarticulate or have nothing to say. They’re just too busy putting in enough minimum wage hours to pay the gas bill. So this is a carers-eye view of a degenerative brain condition which ranges from the mild early-stage to the severe, terminal condition we rather clumsily lump into the term ‘dementia.’  It won’t always be easy reading and there will be mention of things we British would never normally mention, but I’m lucky to work in the sort of home where good things happen as well.

Connor Kinsella
JCK Training

Next Time: CARE HOME DIARIES PART 2: ‘The Good, the Bad and the Ugly’ where I get a job at Hill View House just as I start to think of social care as the new slave trade. Well, I still do. A bit.

Physical Restraint: The Story Behind the Stats

As Mind publishes survey data and calls for a ban on face-down restraint, The Stuff of Social Care looks at the issue from the point of view of those doing the restraining

It’s been a long time since I last took part in physical restraint, but for many years I did work in environments where the need to prevent harm was part and parcel of a nurse’s working day.

For the most part we relied on the first resort. Talking, listening, reasoning, observing. Using a rapport that may have been built up over a period of time, and developing skills that were fundamental to working with highly distressed, agitated people. For most of my nursing career I was lucky enough to work in well-staffed forensic units where staff and patients knew each other well, and where the very thought of an agency or locum nurse was unimaginable.

But at times the last resort was unavoidable. Most of the trained, professional staff I worked with would much rather not use physical restraint. Like me, they would loathe the idea of holding down another human being to inject them with powerful drugs. But when all else has failed, or extreme harm was imminent, or where leaving a severely psychotic man or woman unmedicated would almost certainly leave them more terrified, confused and at risk than they already were, then I for one would not lose any sleep restraining that individual.

By the time I had qualified as a nurse, physical restraint had gone from the often chaotic bundle of arms legs and torsos of my student days toward a set of techniques called Control and Restraint (C&R), a Home Office approved means of managing physical aggression. I along with my colleagues attended regular training in C&R. We turned up at sports halls in trackies and trainers spending hours and days learning and practising the management of physical aggression.

A major (and rather unpopular) part of the training involved role-playing ‘the patient’ and being subjected to the procedures oneself. C&R was based on a 3-person team immobilising the patient. It used a certain amount of discomfort and even short bursts of pain to contain violent people, a fact which we as the role player would be only too well aware. Some of the techniques we learnt involved immobilising the patient face-down on a floor or bed. The reasons for this were that a) the person on their back can fight back much more effectively than if they are face down, and b) saliva and teeth make very potent weapons when they belong to a person who really, really doesn’t like being held down on a floor by several nurses. A key part of the 3-person team was the ‘head’ man or woman, whose job was to ensure minimum discomfort for the person on the floor and protect their airway.

But apart from the actual physical techniques, a fundamental of the training was that physical restraint was absolutely a last resort once every other strategy had failed, or where danger was imminent.

There are those who believe that physical restraint of the mentally ill is little more than state-sponsored thuggery, or who wonder whether restraint is necessary at all. Well, physical restraint is a necessary part of mental health care at times. That’s an undeniable fact, but it’s easy to see why and how restraint gets such a bad press, and why bodies such as Mind need to spend time, money and effort surveying it’s use.

We need go little further than Winterbourne View to acknowledge the presence of thugs masquerading as care professionals. From the very first emergence of the lunatic asylum, the opportunity to get paid for wielding power, authority and physical dominance over others has always proved attractive to a certain type of psychopath.

But there are much deeper and wide-ranging reasons why physical restraint may be over-used or abused. Mental health care certainly needs a sensible, contextualised and much broader discussion about physical restraint per se, and the reasons behind it’s use and misuse. The ‘face down’ issue is perhaps something of a narrow lens, and when 22% of staff report not having had face-to-face training in the last 12 months, we need to ask why that is.

I have a few observations. Questions about restraint are far from being a solely modern phenomenon, but for those whose 7.5 hour shift seems incomplete without a dose of adrenalin-pumping action and a ‘good decking’, current conditions have never been better.

Beds are disappearing. Only the very sickest of the sick have access to hospital treatment. The most distressed and disturbed are funnelled into smaller and smaller pockets of in-patient chaos, often provided by companies with shareholders and profit margins to maintain and gladly filling the gaps left by the running down of NHS in-patient psychiatry.

I would hope that such critical care would be delivered by the sort of skilled, well trained staff I described earlier. This all too often isn’t the case. Many of our most severely ill patients are being cared for by agency and locum staff with bare minimum training, a lack of experience and often poor communication skills. Many will barely know the names of the people in their temporary care.

This is where the ‘jump on, grab a limb and for f*** sake make sure they’re still breathing’ model of managing potential and actual aggression is practised today much as it was in the dungeons of Bedlam.

Right at this moment, someone, somewhere is in a psychiatric unit posing potential or actual danger to themselves or others. People with mental disorders can and do become violent, and staff are needed to contain the violence and minimise that risk. Hopefully they are with staff who can reassure, listen and diffuse aggression with empathy and skill. They are trained to use restraint safely and appropriately, and to be able to make decisions as to when and how it is used.

Mind’s survey results suggest this is all too often not the case.

Welcome to the Re-Boot!

The Stuff of Social Care blog has now moved to the newly refurbished JCK Training website. It will look a little odd until I finish the integration process, but in the meantime the blog itself is fully functional so please feel free to dig around! Now that the JCK Training website is almost fully re-booted, more content will be on here very shortly indeed, and I for one can’t wait to get blogging again! see you soon.

Connor Kinsella