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Expert Comment: Neglect in care homes

086 Dr Joe Greener Tuesday 6 May 2014

Dr Joe Greener, Lecturer in Social Policy and Social Work, looks at the recently broadcast Panorama documentary Behind Closed Doors: Elderly Care Exposed.

Last week Panorama aired a documentary looking at ill-treatment and neglect in elderly residential care homes. The disturbing and distressing programme was difficult to watch and showed just how degrading and dehumanising elderly residential care in the UK can be. Older people left for hours without being taken to toilet, call bells going unanswered, residents left in soiled or soaked pads and even deliberate acts of abuse by certain care workers. However what the documentary indicates most clearly is that there is a need to take profit motives out of the care sector, implement transparent regulatory processes and begin to give higher value to this type of work. Punitive measures aimed at frontline staff will never tackle the root cause of the problem in an industry which remains largely driven by private profit interests and is by consequence shrouded in mystery. 

Firstly, what the programme failed to emphasise is just how difficult, disempowering and low paid care assistant work often is. A social care research institute from King’s College estimated that between 150,000 and 220,000 care workers in the UK are paid less than minimum wage. Indeed, despite continual calls from a range of professional bodies and academics to up-skill care work, the industry has not undergone any form of real professionalization. While training requirements have been formalised and providers are now legally expected to provide courses on various aspects of the job, care work remains demanding and low paid. Often pay rises through promotion (i.e. the move up from care assistant to senior care assistant) amount to an increase of 20p an hour. Often workers are at the top of the pay-scale when they are earning between £6.50 and £7.50 an hour.

In the Panorama documentary academics from the University of Worcester highlighted the need for more training as a measure to improve standards in the care industry. Yet it is often impossible for workers to put the training they already received into practice. Much of the time in the care industry the instruction delivered by care companies is meaningless. In courses concerning personalisation, incontinence and moving and handling certain standards of practice are delivered to workers that are impossible to implement within the daily pressures facing them in the workplace. Incontinence care is a prime example of this – despite policy being that workers should ensure that all residents are toileted frequently the short staffing levels means this is virtually impossible in many of our homes and hospitals. More to the point, care providers often use training courses as a means of legal protection from the responsibility for inadequate provision. Many companies for example have claimed that once staff receive training management can no longer be held accountable for failings. This shifts responsibility for care away from managers, policies and the overall organisation of the work towards the frontline staff.

A further issue not dealt with in the documentary is that many care workers employed are migrants from developing world countries who are subject to harsh treatment both through immigration policy and disreputable employers. Oxfam in 2009 found that many migrant workers were facing highly exploitative employment relations including wages below the legal minimum, various means of pay docking and excessive hours. Currently care companies find migrant labour highly desirable because of the vulnerable situation that Home Office policy puts these workers in. Workers are often unable to leave an employer without jeopardising their immigration status.  

Unfortunately, it seems now that the only way to hold these companies to account is through secret filming in individual care homes. The regulatory body – the Care Quality Commission (CQC) – is evidently not fit-for-purpose in terms of being able to hold this industry to account. It would be erroneous to assume that the homes featured in the documentary are in anyway exceptional – in actual fact much academic evidence suggests that abuse and neglect is widespread across the country (see Mandelstam’s 2011 book How We Treat the Sick for example). In the documentary, one the featured homes, The Old Deanery, received a decent grade from the CQC and then shortly after Panorama clandestinely filmed an assault occurring.

It would be unfair to be overly critical of this documentary as it does contain some analysis of the pressures facing care workers in their day-to-day work. However, it does not go far enough in providing an evaluation of the social care market and fails to highlight the effects of a particular type of privatisation which has taken hold in this industry. Once again the response of the company in light of the exposé by Panorama was to sack seven workers rather than to make any real commitment to better whistleblowing procedures or higher staffing levels. The mistreatment of our elderly people is endemic and emerges from economic and political processes at the heart of how the care industry operates. There are few reasons to expect the private sector companies which are dominant in this sector to take firm action to ensure good quality care. Owning up to the extent of the malpractice would only damage a company image and inputting reliable measures to greatly reduce the incidents of abuse impacts on profit margins. In addition, the actual functioning of social care markets departs significantly from how competition is conceived to operate within neo-liberal ideological discourses promoting privatised care. Elderly people who rely on these homes cannot be understood as empowered consumers who have the ability to choose between establishments. Often it is councils which make the decision about what care is available anyway and this is always constrained by local budgets.   

Also, the commissioning of care has meant that brutal forms of cost-reduction have become the only process by which companies are able to secure contracts and increase profits. Most of the funding for elderly care comes from cash strapped councils who are unwilling and unable to pay more for these services. This is not to suggest that the private sector providers should be absolved of blame. Many of these companies have ruthlessly attacked the living standards of residents and working conditions of employees in order to increase the pay of directors. 

Nevertheless there are a number of reforms which could greatly improve the quality of care for elderly residents. In the first instance the government should strive to professionalise the care industry workforce with a real commitment to increasing wages and implementing a proper career ladder. This would make care assistants feel valued for the work they do and would provide real opportunities within the industry. Furthermore if adequate professional bodies were to emerge then these could provide appropriate legal protection meaning frontline staff may feel empowered to whistle blow on poor practice. Secondly, removing the profit motive from the industry would have a massive effect on the institutional context within which care takes place. The bottom line would be quality care not profits. This would halt the constant race to the bottom which seems to define the sector at the moment and would take the process of care delivery out of the hands of secretive profit making institutions.  

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