How do we deal with the care home abuse problem?

I’m starting writing this just before a Panorama programme featuring video’ed evidence of violence against an elderly lady in a care home is aired on British TV. If you don’t have the stomach to watch it, there is an article written by the victim’s daughter on the Daily Mail’s site here and a BBC write-up, including criticism of the Care Quality Commission that aired today, here. The CQC had earlier been criticised for taking its eye off the ball regarding abuse at the Winterbourne View secure unit; Worrall picked the home for her mother after reading an excellent report from the CQC, which gave an approving report after the abuse had been revealed, claiming that the abuse was an “isolated incident”. (You can watch the programme here in the UK for a year after transmission.)

This is, of course, not the first time violence against care home residents has been exposed — last year, a Panorama special exposed violence and cruelty against residents in a secure unit for people with intellectual disabilities and “challenging” behaviour, and reports of low-paid, foreign care workers being employed to provide lacklustre care have circulated for years. The main complaint has always been that the care workers are underpaid and poorly trained, and indeed the recordings of Maria Worrall’s “care” showed female carers complaining about the pay (and of a bad atmosphere in the ‘home’) while washing Ms Worrall. People have told me that most care workers are skilled and treat the residents well, but a few don’t, and the pay rates were “shocking”. However, 30 years ago, the pay rates might have been enough to live on, which is less likely to be the case now, hence the increasing reliance on foreign workers.

I’ve had my own share of unpleasant and violent experiences at the hands of untrained and probably underpaid “care” workers when at boarding school in my early teens (the school was a special school for secondary-age pupils with high academic ability and behavioural problems. Several of the teachers appear to have been scraped from the bottom of the barrel and would not have got a job in a normal school, but there were some seriously bad apples among the care staff who were obviously untrained and unqualified and seemed to have been recruited down the pub, and there were some who were violent against boys, often in public (there were also incidents of violence among pupils, including from prefects, which did not result in any punitive action). The three most senior teachers also behaved violently or threateningly to pupils on more than one occasion, so the culture of violence went right to the top of the school and it was not all the care staff’s fault, but no attempt was made to provide qualified care staff.

In response to the Winterbourne View scandal last year, I wrote that we need to raise the calibre of people employed to care for vulnerable people, whether they be elderly, disabled people or youths with challenging behaviour. There is no standardised system of training for non-nursing carers and no requirement for them to receive any, and it does not have the respectability of nursing or prison work; all that is required is a criminal record check. The exposure of the impersonal and lacklustre care, and outright abuse, that went on in various institutional care settings in the late 20th century was a major factor in their being largely eliminated: long-stay hospitals, psychiatric hospitals, children’s homes and villages, special boarding schools like mine (of course, another major reason was that it was realised that separating people with these conditions from their families, and from society, for years or decades was wrong in itself). We are now left with smaller institutions with home-like affectations, mostly for the elderly and some people with disabilities.

I have heard it suggested that they should just all be closed and people should be looked after in their own homes. I do not think this is feasible, and it probably is not desirable for many people. Some old people’s homes are well-run and the residents enjoy living there and enjoy having things done for them that they previously struggled to do on their own. While many adults with physical disabilities would want to live with their families (especially families they had started), others would not (particularly if the disabled person distrusted their family); while some like living alone, supported by carers, others would find that a quite lonely prospect, and it’s not usual in many cultures. Some families might find it particularly difficult to care for a relative with dementia at home, particularly if conditions are cramped or their behaviour makes living with them extremely difficult. There have been a few incidents of bad home care which proved almost lethal (such as the nurse who turned off someone’s ventilator, leaving him brain-damaged), or was compromised by budget restrictions (such as the case of Elaine McDonald last year). The person who said it today is a physically disabled adult who had an unpleasant few months in a nursing home a few years ago and reported at the time that she was constantly bored, deprived of contact with her peer group and the outside world, and offered no meaningful activity; she also said that there was some abuse and that nonetheless, the care home got a strong “dignity” rating while she was there. However, while that home may be awful, not every physically disabled adult who has been in a care or nursing home (even one who did not want to be there in the first place) reported that their experience was like that. My boarding school experience was dreadful, but far from universal.

Care homes are here to stay, and there are things that can be done to make sure that abuse is eliminated as far as possible. We need to have a preponderance of English-speaking staff, as well as sufficient members of staff who speak whatever other languages residents may speak. We need to drastically reform the CQC, which obviously has had its eye off the ball for years, giving glowing reports to institutions where abuse is easily discovered. We need basic facility standards, such that nobody who does not want to is forced to share a room. We need to make sure there is no barrier to the involvement of family and friends, no barrier to surveillance, and no restriction on internet use by residents — while we remember that not everyone in a care home is able to use the internet or has family that are able or willing to closely supervise their care, so there must be some agency that makes sure such people are advocated for. Finally, we need to raise the calibre and status of care staff, introducing mandatory training and qualifications, and make sure the care workers’ wages are enough to live on. Caring, both in people’s homes and in institutional settings, is a vital job and its importance should be clear to those in it and those hiring. People who are vulnerable have the right not to be abused, and there must be acccountability at all levels.

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