Scrolling through old files on my laptop (it’s raining!) I found this blog, written eight years ago (when I was a mere 75 year old) and forgotten.  With care homes receiving so much attention because of the death rates linked to the Covid-19 pandemic, it seemed to resonate.

I have been depressing myself reading the report by the Care Quality Commission into the ‘care’ of the elderly and infirm in so-called care homes.  I have an increasing interest in anything to do with old age – retirement, ageism, aches and pains, pensions, downsizing, reading obituaries – since I am now 75 which means, I suppose, that I qualify for the elderly category, even though I don’t feel old and am in stubborn (clearly unsustainable) denial.  Thankfully, I am not yet infirm but I am conscious that if I stay alive (that’s all you have to do to get old!) I probably will become so.  Not many old people manage to die fit.

Care for the vulnerable is a central duty of any civilised society and the CQC report indicates that we are falling woefully short.  18% of 13,134 residential care homes were not meeting minimum standards (that’s minimum standards) ensuring the care and welfare of their customers.  That increases to 28% of 4,672 nursing homes that care for the frailest people.  David Behan, the CQC chief executive, is quoted as saying, ‘Critical is the creation of a culture that focuses on people, not on the organisation, and where staff have the skills to deliver the care’.  The report concluded that care was too often mechanical and that staff needed to focus more on individuals’ needs rather than just seeing a series of tasks to be completed.  Apparently, staff often talked over residents as if they weren’t there and failed to ask them what they wanted.  To quote Mr Behan again, ‘Unacceptable care is where everybody is treated the same. We’re not all the same, we don’t have the same needs, and it is therefore essential that people are treated as individuals and their care and support is personalised to them’.

So, one size does not fit all.  Doesn’t this sound horribly familiar?  Even old people, it seems, are diverse.  I have always claimed that diversity, whilst a fact, is a damned nuisance.  How much easier everything would be if we all had the same needs, instead of endless variations on a theme.  At a stroke we’d be released from the laudable, but probably unobtainable, quest to make everything personalised.  We could settle for mechanistic procedures designed to meet common needs, be they learning needs, customer needs, welfare needs, care needs – any needs.  But we are stuck with diversity which, whilst irksome, certainly makes life more interesting.

The reason why the CQC report has depressed me is not only because I’m 75 (probably reason enough!) but because it is identifying a problem for which I can see no viable solution.  Bridging the vast gap between what we’ve got now and what we want seems a bridge too far.  Sadly, the old and infirm, often muddled and physically incapable of looking after themselves, have little to commend them to younger staff.  No wonder staff talk over old people as if they weren’t there.  Why bother to ask someone with dementia what they want when you’ve tried it before and didn’t get a sensible answer?  When my father was in an old peoples’ home for the last six months of his life (it probably hastened his end), he used to complain that he couldn’t make out what the foreign staff said to him, that they often left his food on a side table just out of reach and that one carer seemed to delight in running his shower a tad too hot.

The question I’m wrestling with is whether caring for old people is more than having good systems and procedures.  I always remember the quality guru, Dr W Edwards Deming, saying, ‘If you put good people into a bad system, the system always wins’.  Perhaps devising robust systems and procedures that shape the caring behaviours of staff is the first priority?  Then, as a second priority, we could start working out how to get staff to have the right attitudes and start really caring.

As ever, I’m left wondering whether the problem is best tackled as an attitudinal one or a behavioural one?  Most people I talk to – including my wife who was a nurse and health visitor – are adamant that attitudes come first and behaviour second.  But I’m not so sure.

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