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The Future for the Workforce in Residential Care

Introduction

The workshop, which was the fifth to be held by the Residential Forum, was attended by 31 participants from various parts of the United Kingdom. Their interests, expertise and experience covered a broad range of issues pertinent to residential care, and there were representatives from all sectors.

As has been the convention in the past, comments made within the discussion groups have not been attributed to individuals, but the report aims to capture the essence of discussions, based on the feedback presented in plenary sessions..

The Residential Forum was grateful to receive financial support from the Social Care Institute for Excellence and Skills for Care to enable the event to take place.

2          Theme

Previous workshops explored a wide range of themes addressing the challenges posed by modernisation, group work and supported living services for working age adults,  services for children and young people and people with learning disabilities, as well as residential care for older people.  The Workshop took the theme of The Future for the Workforce in Residential Care.  It has been a thread running through discussions and presentations at previous workshops, because a safe supported competent workforce is vital to the future of the sector, and, more importantly, is vital to the quality of care provided.

It is well recognised within the sector, and must be acknowledged by those outside it, that the quality of care experienced by those who need it is only as good as the person delivering it.

3         The Key Issues Outlined

Looking constructively to the future of the workforce in residential care, demands an honest and careful appraisal of the past: how did we get here, and what have we learned so far?

Four key issues were identified:

Residential care is often perceived as a `Cinderella` service, with a great deal of hard work by staff, for pay that is disproportionately low for the levels of responsibility and impact on quality of life for service users  attached to even the humblest of tasks and roles.

Residential care, within the general spectrum of care provision, like the `elephant in the room`, is large but rarely mentioned. Despite being, paradoxically, both admired and respected and giving cause for anxiety, personal experience as well as professional issues can often lead to denial of the real importance and value of residential care.

Residential care can in some instances appear to be a `policy free zone`. Dilemmas arise from lack of clear policy and raise questions as to whether it is better to do nothing than to get it wrong?

Without a clear steer, there is a danger that staff who have low self esteem and are resigned to low pay and low status, perpetuate a vicious circle that in turn affects people who use services. Stigma and discrimination shown towards service users cannot be challenged effectively by workers who are disempowered and  demotivated. High quality services are unlikely to be delivered by workers who, lacking support and confidence in their own  value and abilities, fail to see the correlation between having their own needs met and being able to meet the needs of others. The vicious circle has to be breached.

The Agenda for Change and Modernisation

In addressing these key concerns, several themes have emerged:

Modernisation in both public and private sector service provision has prompted debates about residential care, that demonstrate the urgent need to re-frame the over-simplistic perception that is still held in some quarters that residential care is bad/domiciliary care is good. The reality is that in an increasingly diverse and complex sector-within- a –sector, what matters most are the outcomes. There is a need to maximise the benefits and positive outcomes, and minimise the negative outcomes, without dismissing or failing to recognise that most interventions have some degree of inherent risk.

A commitment to person centred care and optimum outcomes for individuals, coupled with an honest appraisal of what residential care can best deliver, would assist modernisation and make modern services accessible to those who need them. If we are to achieve this, it needs to be evidence-based, and although there is good research around, it is far from exhaustive. Much more needs to be done if services are to be changed and improved, and it must include and increase the involvement and voice of service users as well as workers. Commissioners also need to re-address their practice, and look at a continuum of services, and the implications of long-term needs.

Services need to be seen as part of an increasingly broad spectrum that takes account of

The Management of Change

The challenge is to develop a workforce that can deliver services to meet these increasingly complex needs and expectations. It is important to acknowledge these key factors and concerns, and work constructively with them, utilising the undoubted skills, competence and commitment that already exist in residential care and building on them.

Developing the workforce to meet future challenges is not only about training. Although training and qualifications are important in establishing and maintaining a competent workforce, it only works when they are part of a wider and comprehensive strategy that has

Understanding the Workforce

There are significant differences within the residential care workforce, and  these have to be taken into account when looking to the future. In the  Childrens’ and Young Peoples` services there are, generally, senior staff with a balanced age range, appropriately qualified, and with a fairly normal rate of turnover comparable to that in the business sector. There is no large cohort of staff nearing retirement age. The majority of care staff are younger, predominantly female, in the upper 70% of achievers. 60% are likely to be qualified, and have a planned work time of 2 – 3 years.

This is not the case for staff working in older people`s services, who tend to be older themselves. Although the majority are qualified and there are stable turnover rates, a disproportionate number of senior staff are due to retire relatively soon.

Care staff at less senior levels tend to have an older age profile (except in services for people with disability) and are almost exclusively female. Typically they are lower achievers, 40% qualified, and although there may be a core of stable staff, there is, overall, a higher level of both internal turnover and loss to the sector. Moves are often made for very small amounts of money, suggesting that other factors may prompt change and `churn`.

To address these issues, and to meet workforce needs in the future, the sector needs to consider:

The profile, then, of the workforce of the future will be

Supporting and Developing the Workforce

The challenge is to establish human resource and management systems and the supervisory skills required for such a mixed workforce.

This is particularly tough in the face of, for example, European Union directives and other requirements and constraints associated with part-time working, which are in some contexts at odds with the value placed by service users on consistent staff teams and familiar faces.

Investment in the workforce (to VQ levels 3 and 4) is not being sustained by some of the smaller organizations – meaning that possibly only the larger organizations will have workforces equal to the  complex tasks the sector faces in the future. Investing in training, pay and conditions to attract, retain and develop staff to meet complex needs may well be something small organizations will find difficult. Economic diversity has, in many respects, been a strength within the sector, but looking to the future, it may be that less is commissioned from smaller organizations.

Key questions were raised at this stage of the workshop, asking

Is it possible to provide the sort of residential care required under current staffing conditions?

Is it possible to imagine re-balancing how residential services are organized to take a greater account of the nature and mode of work people are willing to do (and thereby expand the `pool` of staff willing to work)

Would an increase in commissioning income produce higher investments in staff or would there need to be additional checks?

A significant block on workforce development is the shortage of people with residential experience to support learning. What options are there for dealing with this?

The recurrent message is that increasingly complex needs will require a workforce with complex and diverse skills. Another factor is that the workforce is not homogenous, and increasingly with the separation in Social Services provision, skills for work with children will be different from those required for work with adults. Residential care is not valued as highly as it deserves in either branch, with the consequence that workers in these services are not valued highly either.

The Challenges of Recruitment and Retention

The paradoxical situation of needing a highly skilled workforce but not valuing what they do is not new, but contributes to the problems of recruiting and retaining staff. One of the problems highlighted by small organizations in particular, is that whilst they recognize the need to train staff to meet complex needs, and the value of continuing staff development, investment in training may not appear to be cost effective when staff turnover seems high. The question was raised as to whether it is in fact possible to provide the sort of residential care required, now and in the future, under current staffing conditions.

A major factor in developing the workforce is the link between management and services. The better people are managed, the better their commitment, and better commitment leads to better services. In a sector where 52% of services providers are corporate – about 6 major companies – it may be that these are the organizations that are better able to invest in training and development for their staff. This may however  be a threat to small providers, who may not survive.

It is interesting to note that staff turnover rate in the sector has improved, but still around 36% of staff leave within 6 – 12 months, and 55% in the first 2 years. Research into where people go suggests that 48% move to another job in the care sector. The fact that they (and their skills) are not lost to the system, is positive, but clearly the larger corporate organizations will be better able to accommodate `churn` than the smaller independent or not-for –providers. From the information available it appears that reasons for leaving are

Some staff are lost because there is not always a clear career pathway in some organization. Entry age barriers also mean that the sector is losing out on a potentially useful resource, but predominantly the problem lies in retention rather than recruitment difficulties. The quality of leadership in organizations and whether or not staff feel valued are major influences on staff movement. Approximately 92% of managers have VQ s at level 4, and the majority (67%) of care staff have at least a VQ  at level 2. It would be helpful if funding schemes could be rationalized and more easily accessible. Perverse features in the current system for providing training for qualifications, with different funding streams, have emphasized the inequalities between local authority providers and those in the independent sector. Chasing funds requires excessive amounts of managers` time. To some extent, the financial burden of investment and training can be reduced if small organizations join consortia or partnerships that can tap into Local Authority or other statutory resources. Helping small organizations to enhance their business management skills and improve practice would also be a positive action.

4        Values

Social care values underpin the motivation of workers in the sector. It is often an empathy with social care values, and specifically the values embodied in good practice in the Residential Care segment of the care sector, that steer people into this area of work in the first instance, and influences retention as their career progresses.

Staff need to be able to translate their understanding of those values into the way they relate to residents. Attitude and ways of working, trying to understand things from the residents` point of view is fundamentally important to the quality of care experienced by service users. There is, however, very little theoretical underpinning to support this, and values and attitudes are hard to quantify or measure. Having the confidence, abilities and skills to practice creatively and intuitively as well as operating with professional competence enable staff to deliver good care.

The feeling of being `cared for` is a key issue for residents, and it goes far beyond being kept safe, helped to manage behaviour, or being on the receiving end of care tasks, however competently those things are delivered.. Training, supervision, leadership and management and good practice must all keep core values at the heart of what they do, and help to create not only a learning culture , but a culture concerned that promotes positive outcomes.

Good practice, based on sound values should itself be valued, but as in most parts of the care sector, residential care has often suffered from negative and stereotypical images. The status of the profession and roles within it needs to be expressed much more positively. Managers have a key role in promoting good values, inspiring and motivating staff.. They, too, need support themselves to be able to do this effectively. Motivational leadership is vital at all levels.      

5        Future Challenges

Reframing social care and redefining services
Care services provided by and expected from the residential care sector have become increasingly complex

Theoretical and Evidence base issues
There is a paucity of theoretical underpinning to validate good practice and no real research-based vision of the workforce. One of the problems is to find ways of strengthening the evidence base without losing some of the already clear messages about employment and workforce. It is difficult to measure values and attitudes, but these are
key aspects of good quality services.
 
Leadership for Modernisation and Change Management
Strategic issues have to be addressed as part of the modernization process. Issues about pensions, pay, conditions of service and adapting to the changes required under European Union directives affect both individuals and organizations.  Employers are still not strong enough in leading on strategies that develop the workforce. . Managers have a key role in implementing change, and may not themselves be receiving appropriate support to do this.   

New Models of Regulation
It often appears that nobody is taking an overview of residential care, but the service is regarded by many as `over-regulated` at present. External pressures on staff have been demotivating, and the demands of, for example, Government targets and limitations put on ways of working, often serve to deskill workers and deny them opportunities to work creatively. This is limiting and discourages flexible outcome based work.. There are problems in recognizing success, and defining the conditions that promote good residential care. There is a feeling that Government only understands simple messages, and the messages from this sector are often complex.    

Raising Status
The fact that the care sector as a whole, and residential care within the sector,  is seen as a low status service is not a new problem, and one that continues therefore to impact  on workers and consequently on people who use services. Successful change management must address this as a serious issue because it has a negative effect on recruitment, retention and staff morale. Comparisons were made about the ways in which commercial organizations promote what might be regarded as low-status jobs, and what can be learned from them. Tesco was a frequently cited example of an organization with good HR policies that offer something extra to the job itself, whether it is family friendly patterns of working, promoting employee well being and opportunities for personal development.

It is also important to recognize the link between status, gender, ethnicity and confidence with regard to jobs and roles that are perceived as having low status.      

Migrant workers
The sector has increasing numbers of migrant workers. Problems arise not only when language barriers make it difficult to communicate with residents and their families, but can make it difficult to understand and implement policies and procedures. There may be  cultural differences in the way care is provided and different expectations about  relationships and status of different professionals, work ethic, and conflict resolution.   

Difficulties in practice
Major problems, quite different in nature,  were  identified  in both adult and children`s services. This illustrates, paradoxically, the co-existence of both negative and positive results of the separation of adults` and children`s services, and the increasing complexity of both.

Adults
In adult services, dementia is becoming more prevalent, making group work an unrealistic option in many settings.  People in residential care for older people are living longer, and there is an increasing requirement for  end-of-life care not dissimilar to hospice care. Staff need to empathise with residents, to understand the need for balance between risk and quality of life issues, because good quality residential care is much more than simply managing behaviour.

Children
Residential work with young people has been affected by a number of factors. The move towards smaller homes and an increase in turnover of residents has altered the group dynamic in many homes and limited the stability and resilience of the group to provide a variety of relationships, experience and opportunities for learning social behaviour. There is a greater use of one-to-one counselling, but perhaps less opportunity for children in residential care to  make secure attachments. This is not new, but reflects the fact that residential child care has been influenced for decades by external factors, for example  the non-resident shift pattern resulting from the introduction of a fixed working week and changed working practices introduced in  the 1970s .    

Recruitment and Retention
Some problems were common to both adults` and children`s services, the most significant being that of high staff turnover in services where consistency and stable relationships are valued highly by residents but difficult to achieve.

Some good staff are lost, because there is no clear career pathway or opportunity for progression. While there are clear patterns of advancement in field social work to chief officer level, residential workers often hit a ceiling that impedes their progress. This may be because their experience is often limited to the homes where they work, and they may not be perceived as having enough breadth of experience for general management roles.

Entry age barriers prevent some potentially good workers from making the choice to embark upon a career in residential care, and if they look to other areas of work they are unlikely to opt back in to the care sector later. 

There is competition for staff within social care because, for example, care staff can hire themselves out as personal assistants funded by direct payments.
    
Valuing the Contribution of Residential Care

If the earlier part of the seminar looked at the future of the workforce, the future for the workforce, for the individuals within it, was the central theme of the second day.

The consequences of residential care being under-valued, and the undervaluing of staff themselves was a clear (and familiar) message emerging from the first day`s work. Understanding the impact on staff, and the consequent effect on people who use services, was the focus of plenary sessions, and a prelude to discussion and feedback about ways forward.

When staff feel undervalued they feel the need to safeguard and protect themselves. If they do not feel safe, cared for and valued, there is a recognizable impact of care they are able to give to others. De-motivated, stressed workers are likely to work inefficiently (and sometimes unsafely), experience health problems that can lead to poor sickness absence rates within organizations and the consequent increased stress on other workers carrying extra workloads to cover for absent colleagues.

One of the The Eden Alternative`s `Golden Rules` states

            As managers do to staff, so do staff do to residents.

One of the ways in which staff respond to negative feelings is by adopting  a professional Accommodation Syndrome ( Tony Harrison). Secrecy and denial are followed by a feeling of helplessness and the belief that everyone is coping. This leads to accommodation – trying to avoid acknowledging the issues for fear of appearing weak, working harder, but inefficiently, until the dam bursts and there is delayed disclosure of the underlying problem. This may in turn be followed by retraction and denial and a retreat back into secrecy.

If staff are to deal well with the pressures and demands of their working lives, this is done better by staff who are engaged with colleagues, the organization and the valued underpinning the work they do. Staff could be regarded as operating at one of three levels of connection: engaged employees, not-engaged employees, and actively disengaged employees. There is a danger that disengaged staff undermine engaged staff, but conversely of course that enagagement enhances performance.

It is important for staff to recognize and acknowledge the real difference they can make to service users` and colleagues` lives, and that the social dimension of motivation is
significant. Levels of staff well-being can be measured by their perception about whether and their work are respected and valued, and Gallup Q12, a management tool to assess staff engagement using 12 questions, was cited.

Other measurable factors, both support and overlap with the questions in the Gallup tool. Although soft data is hard to obtain and analyse, it can be extrapolated from some of the more measurable hard data. For example levels to which staff feel supported and cared for can be illuminated by looking at supervision systems and how they operate. Absence- through- sickness figures and financial performance are often indicators of the level of staff morale.

Good leadership and management can motivate staff groups and teams in a number of ways, by giving staff a sense of being valued and respected, supported, cared about, motivated and enthusiastic. Morale is likely to be high where people feel that they are a valued and respected member of a team. It also contributed very favourably to staff`s sense of well-being if they felt they had a reasonable workload and realistic expectations placed upon them.
 

Staff Wellbeing/Staff Care

A sense of/feeling…

                                   

Ways Forward

The foregoing issues raised in both plenary sessions and feedback provided indications for ways forward for the Residential Care workforce in the future, and suggestions for the role the Residential Care Forum might play in shaping it.

One of the most important needs is to address the question of status. Identifying what workers and organizations are proud of, the aspects of service that residents value highly, and celebrating them, is a place to start. Analyse what works and why, by identifying successful features and approaches, and the conditions in which services flourish and produce positive outcomes. Having identified success, it is important to share and promote it.      
  
Each discussion group produced ideas and project outlines for developing this, which included

The Story of Our Place – A scheme based on `appreciative  enquiry` and providing all stakeholders in a residential care service (staff, residents, relatives, managers) with a platform for a narrative and holistic approach to judging positive outcomes. Looking at the way individual narratives interact, based on a non-threatening way of learning through gentle questions and opportunity for expression, could offer useful insights into what are regarded as positive outcomes and how to change practice to accommodate and achieve them.

Leadership and Management Programmes – It was agreed that there is a need to invest in managers and let them design programmes, identify topic areas (for example finance, performance management) to enhance their ability to lead effectively and motivate staff . Much could be adopted from public sector, and other sources (for examples Adair`s 3 part model). It might be regarded as a challenge to find ways of retaining expensively trained managers, but there is an argument for making a virtue out of change, which can be energizing, and managers are not always lost to the sector. There is also a moral justification for example if they are lost to the NHS, where they still contribute to the overall spectrum of care.

 It was acknowledged that there are already management programmes and vocational qualifications, and that these and the Skills for Care vision statement needs to be translated into something practical. Benefits for residents can be assessed for example by looking at occupancy and waiting lists that demonstrate that people are `buying the product`.

Residential Forum Leadership Role.- The Forum is well-placed to influence policy in areas outlined throughout the seminar. Issues were presented under four headings.

Workers as the `Unit of Currency` in the Workforce. A new approach to old ideas is called for, to invest in the worker and the workforce. Induction and Lateral Development need to be interactive – where `inductees` are able to give as well as get, ask questions, and challenge practice enable both individuals and organizations to grow. New staff are able to contribute from the beginning – making the sector more appealing to young innovators and potential leaders. Successful and sustained investment is as much about organizational culture as individual development. The empowerment of basic grade workers is linked to the empowerment of service users and enriches the lives of both.

 

The Residential Forum

Established in 1994, the Residential Forum seeks to promote high standards in residential care and to contribute to improving the quality of services and practice.  The Forum encompasses all parts of the residential sector - statutory, voluntary, not for profit and private.

 

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