Since the Care Quality Commission (CQC) changed its inspection process, few learning disability care homes have achieved an outstanding rating. But both of Resolve Care’s homes have the distinction. Owners Anne Graham and David King talk to Dan Parton about how they did this.
It sounds so obvious when said, but like many things in life, it belies a complexity that is hard to achieve: “You have to want to care for people,” says Anne Graham. “There are other organisations in the sector where it’s about profit as opposed to wanting to give people the best chance in life.”
At Resolve, the emphasis is purely on giving the residents the best possible life. All of the residents have autism and/or a learning disability and a history of offending behaviour – in some cases, serious offences. All have been in hospital or prison and most have had limited opportunities and meaningful life experiences.
This is something that the CQC has recognised, as David King remembers: “We were obviously euphoric when we found out we were going to get [the outstanding rating],” he says. “We got a press release from the deputy chief inspector at the CQC, and one of the things that stays with me from that is it said: ‘the staff at Resolve should feel very proud of the work they do. I would recommend all other providers ask Resolve about how they achieve what they do.’ That’s what we want to share.
“I’d like to think that scrutiny is increasing on care services now. The CQC seems much more tooled up to regulate than they have done for a long time. We felt that they got under our skin when they came – there were things previous inspections have not looked at. Previously, some of the things being asked – they just wanted to see blank forms and the procedures we followed and it seemed like a box-ticking exercise, rather than focusing on how the service was delivered and the care and support service users received. So services could fly under the radar as long as the boxes had been ticked. They dig deep now, they went right into [case management system] Eclipse. They were really impressed with the records we had.
“This reflects on us and the staff team because you feel you have earned the outstanding rating, because you feel they have examined and inspected everything that they need to.”
Feels like home
The philosophy behind Resolve underpins everything they do. For instance, Highview and Low House, Resolve’s two homes situated just outside Bishop Auckland in County Durham, have bright, clean and tidy living areas. The furnishings are modern, yet homely. They don’t have the feel of a care home. This, says King, is one of the aims of the service – it is the service users’ home and the building should reflect this. Each service user has had their say on how their room and the communal areas were decorated. They are also involved in doing DIY maintenance around the home, as and when it is needed.
“If you look at the environment, everything is bespoke: this is because we believe service users’ have a right to this – many grew up in horrible, dirty, deprived environments – now they can have somewhere lovely to live in,” says Graham.
An understanding of the service users’ background – which is often one of lengthy trauma and abuse – is important to King and Graham so they can develop and train staff to get to know them as people and not judge them for past experiences and instead ensure that they have meaningful lives and do not revert back to offending behaviour.
“You can talk about the term ‘rehabilitation’ but rehabilitation is going back to a previous state,” says King. “The previous state of our service users’ was chaos and dysfunction, so we’re toying with the term ‘habilitation’ as ‘rehabilitation’ is taking them back to a dreadful time in their life, but this is something fresh and new.
“It is getting people to understand that if you are exposed to dreadful experiences in your formative years, then the chances are your adult years aren’t going to be a bed of roses. We need people to make the link that as far as protecting children and understanding why adults turn into what they do has a lot to do with how they’re brought up and the experiences they have.
“Some of the service users come out of hospital and they are absolutely petrified that the community at large knows who they are and what they have done, which creates a barrier straightaway. It is like there is no humanistic link between the service user and community – you’re not the same as me, you’re not real.
“But we provide opportunities to get them to engage in so many social environments as an equal and we believe that reduces the chances of reoffending as the community see them as people the same as them.”
Engaging with the community is fundamental. Resolve’s model of care means that from 9am to 4pm Monday to Friday (excluding holidays), the residents are involved in meaningful occupations. This includes such things as voluntary placements in the community at a local luncheon club and similar activities such as receiving football coaching, taking part in a dog walking project, working at a centre for older people and working at a recycled furniture project. The residents also have time to indulge in passions, such as fishing, working with horses and building models.
“One service user has a football season ticket,” says Graham. “We have to have two-to-one support and the risk assessment was unbelievable. But we don’t say ‘no you can’t do it’ we have to find a way to do it.”
King adds: “We think about how can we make it happen with the least risk possible. At a lot of places the default answer for anything with a modicum of risk is ‘no’, whereas we think ‘is there a way we can?’
“It is easier for them to watch the telly. But there are no TVs on during the day, except sometimes when they have an hour for lunch they put it on. But it is cultural for us to understand that Monday to Friday the staff and service users need to be contributing somewhere, because how are the service users ever going to develop skills if they ever want a job, if they’ve never done some of the basics?”
This means the service users have genuine engagement with their local community. “Out of that they are accepted as equals in the community and it isn’t tokenistic,” says Graham. “They don’t get sent to day centres where they sit colouring. It has to be purposeful and what they’re interested in because they have to want to do it, to get up and be motivated.
“When we go into the community, 99 times out of 100 it will be a positive experience, which will have someone in the community say ‘we had one of those lovely lads in today’.”
But it took a long time – and a lot of perseverance – for Resolve to get to the stage where its residents are valued in the community.
“When we were first looking for community placements for our service users, no one would have them,” says Graham. “We would ring charity shops asking ‘do you need any volunteers? We have a gentleman with a learning disability.’ They would reply ‘oh, we don’t need any at the minute’ so it took a long time. But once they get to know our service users it is ‘can they come in and do an extra day?’, but it is getting that foot in the door.”
This has been crucial to the residents’ development, adds King. “There are many places where there might be some kind of community living going on, but that involves going to a club once a week and doing the shopping – people don’t engage with the community other than that. They may live in a house in the community but they are just [stuck] in that house – it’s like a mini-institution.”
However, the emphasis has to be on structure and limited choices. Given that many service users have spent a large proportion of their lives in hospital or prison settings – where choices were not given – giving them unfettered choice would create more problems because the service users wouldn’t know what to do with it and it would increase anxiety and therefore risks to them and the community, King says.
Although that doesn’t mean that new experiences are not introduced. “We know what they enjoy doing as we have a good understanding of them, but we also introduce things that they have never done,” says Graham. “We had one service user who would spend most of his time in his bedroom on the hospital ward – he wouldn’t come out and engage – but with our structure he is doing something every day. This includes going bowling and asking to go roller-skating – he’s in his 50s – but before he would only wear jogger bottoms, he wouldn’t even put on trousers. But now he’s like a different man; he stands proud, he is trying new things and is more sociable, communicative and less anxious, he even asked to buy new clothes that aren’t leisure wear.
“This is not to say that there are never difficulties in the home. Although there are few at times we have to support service users to stop and think when they present as disinhibited or risky. We are able to this because we have good relationships with them where know they are and feel respected and see this as supportive and not punitive.”
Relationships are key
Relationships are key to the Resolve way of working, and growing trust, especially between staff and service users, is central to this.
As Graham emphasises, some of the service users have come from “terrible” family backgrounds, where they have suffered lengthy abuse and neglect, and then gone into the care system and had awful experiences there too. “They’ve been let down time and again – reinforcing how they can’t trust anyone,” she says.
King adds that developing trust and an open relationship with each resident is a cornerstone of the service. “If we can’t develop a relationship, how are they going to confide in us with worries they have that might lead to them engaging in risky behaviours again,” he says. “They have to trust us to be honest enough to say things.”
Graham adds that they do not judge the service users. “You hear some of the things our service users have done and it is horrible but at the same time you have to balance what’s happened to them and not judge. It is saying ‘how we are going to prevent it happening again.’”
King says that when service users were in previous settings, if they disclosed to staff any concerns about thoughts or feelings they may have had, it would have resulted in the withdrawal of whatever privileges they had, as they were seen as been riskier. As a result, they would not say anything if they did have thoughts, and so keep their privileges. But this meant their increased risk was not addressed.
“We have to get them to trust in us enough to share what their worries and concerns are so we can put in place enough support so they don’t have to miss out on things,” says King. “But it is that first stepping stone of getting them to manage their own risk, and that’s so hard to do.
“What we do is two-pronged. We are very focused on the management of risk – protection of the services users, staff team and the public – but equal to that is giving the service users a quality of life. If you don’t get the balance right along the way someone might get hurt. If we give someone the best quality of life possible while putting that effort in to make sure that everyone is protected, it just seems a reasonable way of approaching things.”
Graham adds: “It is important the service users are involved in decision-making and their care. They are involved in the writing of the care plans; they are agreed before they try new things. Before they do any activities they sit with a member of staff and they know where they are going, what they are doing – so if they are going shopping there will be a list so they know exactly what they are doing. They also discuss with staff what support they would want to have should they experience a difficulty in the community. In doing this, service users’ anxieties are reduced and it also enables new experiences to be introduced at their pace.”
The team at Resolve also understand that contingency plans are necessary in case things don’t go as planned – and the service users are also involved in this. This means that if plans do have to change, the service user doesn’t need to ask for help or question what’s happening. In doing this, service users are not subjected to unwanted attention from others in the community which promotes more positive community engagement and acceptance.
“When we come back from a trip we have a debrief and talk about what went well for service users but also what difficulties they may have had and how we could put that right next time, and that’s revisited in the next briefing when we go out,” adds Graham. “That gives them more control over what they’re doing.
“Some of the people we support are unlikely to be able to ever manage their own risk – that’s why they have staff with them – but it is about having the relationship so that service users feel comfortable to ask ‘will you help me’?”
Of course, to develop strong relationships with residents requires a stable and dedicated staff team, and another strong part of Resolve’s philosophy is in recruiting people who fit the service users. “When we interview people we’re not bothered if they have worked in social care before, we’re bothered about their values and how they care for people,” explains Graham. “We can teach them and enrol them on Diplomas but it is about the culture and how we speak to each other and respect each other – service users and staff team.”
King adds: “We have learnt that knowledge, skills, experience, qualifications are – not to sound disrespectful – almost irrelevant to what we do. In fact, sometimes it is better bringing in someone who has no experience because they don’t have these ingrained poor value-based practices that we steer clear of.
“We have learnt that when bringing support workers in who spend the vast majority of their time with service users we have to find people who are as closely aligned to our values as possible.
“There is so much drive and determination behind it [Resolve] because you can have all the ideas in the world but if you cannot implement them and get them in place and get people to follow you on that journey it is a waste of time.”
Graham says that on occasion they have had candidates who have come across amazingly well in an interview, but when they start working they haven’t had the right values to fit in.
“We’ve heard [staff] say things like ‘it’s ridiculous that we can’t have staff cups’ or ‘we have to share a toilet with them’ so we get rid of them quickly,” she says. “We have a 6-month probationary period, buddy books, and we mould people into what we want.
“It is still not nice getting rid of a member of staff, but we focus on what’s right for the service users and we’ll just say ‘this isn’t the right environment for you’.
“We don’t even put new members of staff on Eclipse initially because we don’t want them to know all about our service users because everything is on there – their offending behaviour, relationships with their family – so we don’t let them on it until we feel confident that it is going to work.
“Sometimes they [service users] are quite embarrassed about what they have done – they think people are going to judge them, because they’ve always been judged and we want them to be seen as people and not what their offence was.”
King adds that there is a great core staff team at Resolve, but they are now focusing on ensuing that turnover of staff is as low as possible, and the service users will play a full part in this.
“When we talk about ‘team’ we include the service users in that. This is their house, they contribute to everything, everything we do is working shoulder-to-shoulder,” he says.
Graham adds: “We have a core team but move some others on. As long as the service users are involved in this process and they don’t believe it’s because they did something wrong because we don’t want them to feel rejected, then that’s OK. I would rather move a member of staff on who’s not right than keep a team together. That’s not what we are about. In some services you need to ask the question, who is the service for – the staff or the people they care for?”
Using technology to minimise admin and maximise face-to-face time
Staff are able to spend the vast majority of their time with service users because King and Graham have sought to streamline other areas, such as record-keeping and administration, as much as possible. They have been able to do this by using an online case management system called Eclipse. Eclipse, which is operated by OLM Systems, has a range of benefits for managers and service users – and impressed the CQC inspectors, according to Graham.
“Eclipse gives you lot more time,” she says. “The support workers use it on their tablets to update records so they don’t have to go off into an office to type up their notes, they can do it while they are watching the telly [with the service user]. Team leaders would have to spend a lot of time in the office if they didn’t have their tablets, because you couldn’t sit with someone’s paper file out as it is all confidential information and some of our service users are good at reading.”
Graham adds that it also saves space. Resolve do not have paper records, so they don’t have to be kept in bulky filing cabinets, where it can be possible to lose files. It also means that accessing records is much quicker to do.
In addition, the Eclipse system is secure – more so than paper records. No longer can records be accidentally left out where someone can see it, for example. “It is safe and secure and only those people who need to see it get to see it and that is based on our authorisation,” adds King.
Eclipse is also useful for evidencing what the service provides for commissioners and purchasing authorities and how funding is being allocated. “When we do case notes in Eclipse – what staff did, when they went out, when they came back – we are evidencing all the time, so if commissioners come in they can see where every penny of their money is being spent,” says Graham. “It can be pulled through into a report so there is a paper trail. If we say we have taken people somewhere we can show that. We can upload photographs, which is also evidence that this has really occurred.”
The ability to upload photographs to Eclipse also has benefits when staff and services users are discussing care plans. “Our service users sign their own care plans and they do planning on them which is pictorial. Some of our service users can read and have written ones, but the majority prefer the pictorial ones.
“They all also have memory books. We had those before we had Eclipse but now we can upload photos directly from our iPhones into the system so that’s better for them as they are safely stored if they ever want copies.
“It is about the service users having photos of what they’ve done, so you can say ‘what did you do the other day?’, they might say ‘nothing’, but if you have photos it can stimulate conversation.”
King adds: “We now have a medium of keeping records where we can have photographs and videos in – you cannot do that with a paper file.”
But while Resolve is focused on the care and support provided to service users, it is a business, and this cannot be lost sight of. However, they say their focus on providing the best possible service has also led to profitability.
“We are a business and profit cannot be a dirty word – we have to generate money to provide a service – but the profit, sustainability and viability side is almost secondary to the attention to detail that has made the service what it is,” says King. “That came as a by-product, almost.”
Graham adds: “I think by concentrating on doing everything right and not being good business people in the beginning – I’m a social worker and David’s a nurse – our focus has always been wanting the best outcomes for the people we provide a service for. But by doing that, that made us a better service and people wanted to buy into it, so we have probably done it the right way. It has increased our sustainability because we do it right, and we did it right because we wanted to, not because we wanted to be a massive organisation.”
They have also been careful to only advertise residential places within the northeast. “Winterbourne View showed that having someone placed 200 miles away from their local authority region makes maintaining family contact or any reasonable level of contact with someone who is close incredibly difficult,” says King. “With us, it isn’t a barrier – we will transport our lads to Newcastle to meet family whether that is weekly, monthly or whatever is needed to keep those relationships going.”
This explains that while King and Graham have had success with their two care homes, they are not planning to expand much further – they want to retain the close focus they have on the service users they support.
In the short to medium-term, the focus is on developing the service users’ skills, with the hope that some may, in time, be able to move into a more independent supported living setting. With another CQC inspection on the horizon too, they want to keep on developing so that their hard-won outstanding rating is retained.