MAKING A REALITY OF ‘A POSITIVE CHOICE’

RETHINKING LINKS BETWEEN RESIDENTIAL CARE SETTINGS AND COMMUNITIES

Des Kelly OBE | Trustee | The Residential Forum | November 2018

This short paper revisits a
programme of work which is almost 30 years old to celebrate the 30th
anniversary of the publication of the Wagner Report Residential Care: A Positive Choice (1988), HMSO. However, as far
as is possible, it looks to the future of residential care services rather than
the past.

image

The review was commissioned by Rt
Hon Norman (now Lord) Fowler, Secretary of State for Health and Social
Services, in December 1985. There was widespread agreement, at the time, that
residential care services were in a demoralised state. The final report A Positive Choice sought to promote a
fundamental change in the public perception of residential care and its place
in the spectrum of community care services. It argued for residential services
to be part of a spectrum of ‘care in the community’, and further:

“We believe that giving primacy to the views and wishes of services
users will, inevitably, alter the context in which residential services
operate.”
(p3)

Much has been written since (and
there have been many more reports into the state of residential care) but as
Richard Clough outlines in the Foreword to Residential
Care: A Positive Future
(2008) which was published to coincide with the 20th
anniversary of the Wagner Report, it is remarkable how successful the committee
was in getting its recommendations implemented.

So, what is the proper place of
community in our concerns to ensure a consistently positive experience and a
positive outcome for people receiving support in care settings? The Wagner
Report states:

“It should not even be necessary to speak in
terms of ‘links with the community’ – residential establishments should so
clearly be a part of the community they exist to serve.”
(p51)

The report devoted a chapter to
discussing residential care provision as a community resource. Of course, in
the 1980s the composition of the care sector was rather different as was the
population of people living in homes. A much greater proportion of care homes
were operated and managed by local authorities – a situation which has
effectively been reversed with the expansion of the independent sector. The
loss of local accountability is not inevitable but as care providers have
expanded beyond one local authority area it has resulted in greater
responsibility on local management (i.e. the Registered Manager) to maintain
positive community presence and relationships. In addition, the levels of need
have significantly changed with a much greater likelihood that people move into
residential care for specialist care and support, perhaps most evidenced by the
high proportion of people living with dementia in care homes. Nevertheless, the
idea of the care home as a resource for the community including family carers,
protecting the array of community contacts or networks and continuity of
personal relationships remains, rightly, a powerful aspiration.

This was precisely the rationale
for ‘A Window in Homes’ which was one of a series of programmes of
action-research commissioned and funded by the Department of Health under the
banner of the ‘Caring in Homes Initiative’ (CHI) to follow-up recommendations of
A Positive Choice. The CHI was a
three-year programme of research and development which also considered quality
assurance systems, information for users and training for care workers. It
seems incredible to be reflecting (from 2018) on a DH-funded programme of
development with such wide coverage which also included an independent
evaluation of the four main strands of work. The aspirations espoused by the
Wagner Report (and the subsequent work of the CHI and the Wagner Development
Group, which led in turn to the formation of the Residential Forum) are undoubtedly
as pertinent now as they were 30 years ago.

In leading ‘A Window in Homes’
the Social Care Association sought to reflect the value of the community
resource aspect of residential care arguing that people who live in care homes
should have every opportunity to enjoy the same leisure, educational and other
facilities offered by the community as all other citizens. Policy guidance
although sharply differentiated between residential services and community
services acknowledges links as desirable for both individuals and institutions.
In this spirit, a ‘sense of belonging’ has both individual and collective
meaning. This was also highlighted in the evaluation of the programme by Penny
Youll and Christine McCourt-Perring published as Raising Voices: ensuring quality in residential care (1993), HMSO. The
relative isolation of some care homes was a concern that informed the ‘A Window
in Homes’ work.

The experience which subsequently
emerged at Winterbourne View Hospital might serve as a stark
reminder of what can happen if care homes do become isolated both physically
and from families. The Window in Homes programme observed that, at the time,
almost all the literature on residential care and community involvement was
either descriptive or prescriptive. The action-research was thus exploring a
relatively new set of ideas and there were few existing frames of reference or
previous studies on which the work could be based. The evaluation of the
programme noted that social opportunities outside the care home are as
important as outsiders visiting the home. There were questions raised too about
the seeming benefit of smaller homes and care providers – which arguably
remains a barrier for some care homes in certain communities. The Residential
Forum has been pleased to see new initiatives such as Care Home Open Day,
greater emphasis on intergenerational cooperation and support for art activity
adding to awareness about residential care services.      

Whilst the rights of individuals
have been made more explicit and there are procedures intended to safeguard
independence and privacy; regulations, standards and systems of inspection have
developed; information about services have improved; staffing and training have
received some attention – all recommendations of the Wagner Report – many
challenges still remain for the sector. The quality of care is variable;
qualifications and training have stalled; recruitment and retention are significant
issues for most providers … and the reputation of the residential care sector
is still a problem. Although there has been some investment into the sector,
perhaps best evidenced by better design and more new build facilities,
commissioning practices continue to put primary focus on price. The idea of positive choice as the experience of
residential care services is not yet realised and the notion of community
involvement, whilst better than 30 years ago, remains more an objective than reality.
Policy statements about the value of forms of integration have wide support but
are yet to become mainstream. The future for residential care services is at
best uncertain.  

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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