Written evidence submitted by The Relatives & Residents Association (RTR0138)

28 January 2022

R&RA

The Relatives & Residents Association (R&RA) champions the rights of older people needing care in England. We provide information, advice and support to empower older people and their families/friends, and use their unique perspective to raise awareness and to influence policy and practice.

Introduction

R&RA welcome this inquiry and the opportunity to outline the impact of workforce problems on older people using care services. Recruitment and retention is one of the most pressing challenges faced by the social care sector. It is vital that there are sufficient numbers of social care workers with the right skill mix to ensure older people have a good quality of life. Put simply, the quality of care depends on the workforce, both in terms of quantity and the quality of that workforce. Our helpline hears daily about the impact of staff shortages, of poor management and of lack of training across the sector. These are having devastating consequences for people using care services, putting their safety, dignity and wellbeing at risk. We urgently need a long-term workforce strategy – similar to and learning lessons from other sectors and other countries – and investment to match.

Staff shortages

Inquiry question:

What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

Long-standing strains on the sector have now reached crisis point. The shortage of care staff and high vacancy rates have long been a problem and warnings from the sector during the pandemic about the worsening crisis have gone unheeded.

This is preventing people from accessing the care and support they need and hampering care providers’ ability to deliver safe, dignified care which respects rights. People are waiting longer for assessments, and even when identified as having care needs face delays and difficulties in getting support. This is putting untold pressure on relatives and friends to step in and fill the gaps which in turn impacts on their own mental and physical health. It is also adding to pressures on NHS services when they are already stretched to breaking point.

Our helpline also hears that staff shortages are preventing delivery of dignified care – helpline clients are being told that providers can only do the bare minimum. This is very far from the quality care older people should be able to expect. When people make the (often difficult) decision to get support for their care needs, at the very least those services should offer safety and dignity. We are concerned that the staffing crisis in care is putting people’s safety, dignity and other rights at risk and that this is going unnoticed, behind closed doors.

We hear daily about the impact this is having on people using care services. Our helpline clients share their concerns about care standards falling, leading to distressing, degrading conditions.

A care home resident was found in distress by their relative, left unchanged with faeces also over the bedding and on the walls. [Example from anonymous helpline client]

Staff shortages and a lack of access to health services can lead to detrimental impact on older people’s mental and physical health.

A care user was found by a relative to have missing teeth and others in a bad state of repair which staff had not noticed. [Example from anonymous helpline client]

Concerns about neglect and older people being left without basic support are common, including:

dirty or missing dentures, which can cause infection, reduce people’s ability to eat and lead to wider health problems
missing mobility aids, which can act as a form of restraint by preventing people from moving around freely and independently
missing or incorrect spectacles, which leads to loss of independence, isolation and ability to engage in the life of the care setting/their community
broken or missing hearing aids, which prevent people from communicating and forming relationships but also from engaging in discussions and decisions about their own care

All of the above can lead to isolation and deterioration of mental and physical health and lead to cognitive decline, particularly for people living with dementia.

The loss of a resident’s hearing aids was left unreported and not acted upon by staff until raised by a relative. [Example from anonymous helpline client]

Lack of time to support care users also leads to ‘everyday’ infringements on rights, such as being dressed in other people’s clothes. These lead to a subtle erosion of people’s dignity, having a disproportionate impact on their wellbeing, identity and sense of belonging.

We are concerned that a ‘perfect storm’ is brewing to exacerbate staff shortages at a time when relatives and friends of those in care have had their access restricted due to the pandemic. This has left care users without their support networks at the time they need them the most. Relatives and friends play a vital role in supporting care users, assisting with communications with care staff, helping plan appropriate care as well as spotting potential issues and concerns with care, particularly abuse and neglect. When they are kept away, the care user loses their advocate, confidant, perhaps the only person they would tell about concerns with their care or treatment. Relatives and friends should be seen as essential to the person’s care as bathing and dressing – the Care Act does not differentiate between the importance of personal care and supporting relationships.

Recommendation: support from relatives/friends must be recognised as an essential part of care

We must never again see people in care separated from the essential support of relatives/friends
Face-to-face meaningful contact with family carers is a prerequisite to basic care and must be recognised in law with a duty on regulators to monitor and enforce

Manager shortages

The single biggest determinant of quality of care is the quality of local management. Good local leadership is vital for a positive culture, to ensure basic care standards are met and maintained, and that staff feel supported to remain in post. Poor or absent management is having a detrimental impact on care user’s wellbeing and quality of life.

A relative called our helpline distressed that they couldn’t visit their parent because staff lacked knowledge about Government visiting guidance and were not being supported by the manager who was overstretched as a result of managing several care homes. [Example from anonymous helpline client]

Recommendation: care staff should have a nationally recognised career structure, with adequate rewards

This would help to nurture talent and encourage care workers to progress up to management positions, bringing the experience and skills developed throughout their care careers
Paying care managers adequately would help encourage them to stay in post

Retention of staff

Inquiry question:

What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

High turnover of staff has long hampered the sector. It not only leads to the poor outcomes identified above by staff shortages, but also to lack of consistency of care. At its heart, good care is about knowing the person’s needs and wishes, about building relationships with them and the relatives/friends they want to support them. This consistency and familiarity is particularly important for people living with dementia and an ever-changing series of new faces providing intimate and personal care needs can lead to confusion and distress.

Lack of familiarity with care workers and over-reliance on agency staff led to a resident refusing support with personal care and developing problems with hygiene. [Example from anonymous helpline client]

The pandemic has had a significant effect on the morale of the social care workforce and there is an urgent need to build resilience post-Covid-19. It is likely that particular support is required around care worker’s mental health and wellbeing.

Recommendation: steps must be taken to ensure the social care sector is as highly valued as the NHS

Care is a crucial public service – care staff should be valued as highly as NHS staff for their vital work
Social care workers must:

be registered
have mandatory qualifications
have a nationally recognised career structure
be adequately rewarded for providing care which is a crucial public service

A long-term strategy on workforce is urgently needed
Social care reform needs to build a sustainable workforce which recognises and values the professional contribution they make
Additional resources must be invested to build a sustainable professional workforce and ensure safe, high quality care
Leadership is needed from the Government to ensure this becomes a reality in the fragmented care sector
All steps should be taken to raise the profile and status of care work in the immediate-long term, including growing the next generation of social care professionals via care careers promotional campaigns in schools and colleges, graduate schemes and intergenerational work to raise awareness of life for older people needing care

The care workforce, even larger than the NHS workforce, is of huge economic importance to the country. Investment in the workforce will not only be good for the staff and for people using care, but will bring benefits to local communities and the country as a whole.

The pandemic has highlighted the disparity between the social care workforce and the NHS workforce. The social care sector must never again be an afterthought.

Recommendation: the status of care workers needs to be aligned with staff in the NHS

Adequate sick pay must be provided
The provision of free PPE must be protected
Care workers must be recognised as keyworkers for the vital role they undertake
Policies should focus on the people who need support, not on protecting institutions

Recommendation: there needs to be a better understanding of the care sector and the needs of people using care by the Government and its agencies

The pandemic response to date demonstrates a lack of understanding about the vulnerabilities of the sector, how care services operate and the reality of living and working in care settings
There needs to be better alignment between social care and health care to ensure people are at the heart of services and their holistic needs are met – older people should not be defined by their age or their health conditions
We are concerned about the lack of any reliable system of central government oversight of older people using care services

Training

Inquiry question:

What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?

There is a widespread lack of knowledge of care users’ rights amongst care providers. This is due to a lack of training on human rights and care providers legal duties under laws such as the Human Rights Act, Mental Capacity Act and Equality Act. Our helpline hears that staff have little training and on-going support to understand how conditions such as dementia, sensory impairment and pain may affect a person, and how to recognise and engage with more subtle forms of communication. This leads to care users’ rights not being respected or protected. The Government seem unaware of this knowledge gap, making references to these laws in guidance for providers during the pandemic with little recognition of the lack of knowledge of them amongst care workers.

The lack of training and skill development is also a lost opportunity for the sector to nurture and develop talent, building this from the ground upwards to feed into management structures and support the progression of care workers. This in turn would help with retention issues and demonstrate that care is a skilled profession of high value to society.

Recommendation: the knowledge gap in the care sector must be closed

Social care workers must be properly trained, with accredited, transferable training
Care staff must undergo mandatory training on the Human Rights Act, Equality Act and other laws protecting rights
This training should focus not just on understanding the rights and their legal duties, but also on how to use those laws in practice to improve services and care user’s quality of life
Training on these laws should also be mandatory for others working in social care, including social workers, inspectors, health practitioners, Commissioners etc.

Jan 2022