IDENTIFYING AND OVERCOMING BARRIERS TO WORK-BASED LEARNING AND INNOVATION IN THE ADULT SOCIAL CARE SECTOR CASE STUDIES FROM THE UK LAPIS RESEARCH PROJECT LEARNING FOR ADULT SOCIAL CARE PRACTICE INNOVATIONS AND SKILL DEVELOPMENT

Project no: 2020-1-UK01-KA202-078960 APRIL 1, 2022

This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein.

Case Study 01:

The UK government aims to innovate in social care use of digital technology and is supporting the ways in which care homes use iPads as a tool to engage patients and staff. This innovation was born during the first Covid-19 lockdown when visits to care homes were suspended. iPads enabled patients to video call families and friends and keep in touch with their wider community. However, since then, some care workers have introduced residents to the latest craze, TikTok, and are using this to improve the wellbeing of patients, as well as showing the wider world what life is like in a residential care home, helping to break down stigma and increase knowledge among the younger generations. An example of how care workers use TikTok comes from Teal Beck House in North Yorkshire where TikTok Friday offers residents a chance to create videos to popular songs, including a rendition of Dolly Parton’s hit, 9 to 5 which went viral, with over 400,000 views. A similar initiative in the West Yorkshire town of Dewsbury has led to a massive 4.1m views of the residents performing Sia’s hit, Cheap Thrills, with residents also taking part in TikTok challenges, which help add excitemtnt and interest to their days, Resident, Theresa Thornton, 94, who has lived at Ashworth Grange since 2015 said: "Filming the videos has become a real highlight of my week! I feel really relaxed in front of the camera and love to give the team suggestions for what we can do next!". The residents love seeing themselves on video and enjoy hearing the positive comments posted about their videos. This innovation not only brings fun into the lives of older people, it is also breaking down stigma around what older people can do, and life inside care homes. Digital technology offers the care sector many ways to innovate, and some of these are much more creative than perhaps the UK government envisaged when it invested in iPads for every care home in the country!

Case Study 02:

“It's a million miles apart, completely different. We’ve got a colleague who's gone through all their training in the NHS. There you get paid to go in and do a training course. We can't afford to do that apart from the induction training.” Our respondent is a highly experienced care leader running a domiciliary care organisation based in several UK towns. Care work requires dedicated, well-trained staff, and our care leader explained how her organisation devised their own core training programme of 21 units as a means of ensuring care workers had training beyond the required UK Care Certificate. This process is expensive as staff are paid for training (shadowing) when they first start, although some of the learning has to be done online and unpaid (in contrast to This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. the NHS, where all training time is paid). The rationale for the organisation providing more extensive training than is required by government is that care workers are dealing with vulnerable and frail people who may have several health problems presenting at the same time and require personalised care from a care worker with a range of skills. However, with many years’ experience in s our respondent is adamant much more training is needed to enable care workers to deliver the best care to service users. However, there is a significant barrier. Comparing the care sector to the NHS (our two cities)1 she observed how the care sector is viewed as ‘dirty work’, and explained the perception that NHS staff look down on the sector despite relying on it in order to ensure patients can be discharged safely from hospital. “You try and get your local NHS people too (to share knowledge). At one time when we first started out District Nurses would come in, and do things like catheter care training, stoma training, all of those things. They would come in to you free of charge, and do that training for you. Now you can't get a District Nurse through your door. For love nor money. It is not something they will now do, and the NHS, and I know it's horrible thing to say, the NHS are very snobby in relation to carers. And it's almost like they think we are only there to do the dirty work until it suits them.” The ideas of care work as ‘dirty work’ is itself widespread within and beyond the sector, it acts as a barrier to recruitment and retention of staff and to accessing training. Our respondent explained there were theoretical programmes of health and social care, but training providers were not developing other accredited learning programmes because although there was a need for training employers cannot afford either the cost of the programme or the cost of providing cover while staff undertake training. The rates paid to care organisations do not allow for wages comparable to the NHS (or larger supermarkets) and our respondent feels the pricing of care is held down to uneconomic levels because there is a perception the work is low-skilled, ‘dirty work’. In the past the NHS had provided free training for care staff taking on patients with complex health-related problems, such as dressings, catheters or stoma care, or had sent a district nurse to manage this care in the patients home. However, cuts to funding and then Covid-19 have meant such training or This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. support is no longer provided, with the care agency calling in vain for support with complex issues and sadly, when support is not forthcoming, having to give notice on contracts and leave. Within our respondent’s organisation there is much good practice in training and development, including working in partnership with their preferred external training provider to develop their 21 core units induction programme to the organisation’s high expectations of early career skills and knowledge, but a great need for further, more advanced training in order to equip staff for their complex job. Excellent initiatives such as regular personal development reviews and the in-house production of brief guides to issues such as skin care, nutrition and other complex care issues do support staff but cannot replace ongoing training or the need for a wider pool of tailored qualifications.

Case Study 03:

“If [funded] time slots were given for the training to be delivered, management could allocate time for this when completing the rotas.” Our respondent is a care home manager with over 14 years’ experience, leading care workers, an administration team and nursing staff as well as working with other specialists who visit the home regularly to provide aspects of care to over 40 residents. Staff at the home do almost all training online. The home uses the standard framework of the UK care certificate for all staff but tries to take account of prior learning. Time for learning is limited due to lack of staff, issues such as unexpected staff absences preventing staff from leaving their primary duties and the requirement for staff to do learning unpaid and at home, which can be difficult for staff to fit in round their home responsibilities. One aspect that cannot be taught online is lifting and handling. The manager arranged for experienced staff to become accredited trainers so they can deliver this learning in house. The organisation has been able to access local civic authority training for some staff in the identification of sepsis and took advantage of an opportunity to have the ‘Dementia Bus’ This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. visit the site, enabling staff to gain experience (although not training) in living with dementia. “The dementia bus offers a virtual reality experience, which is medically and scientifically designed to show someone with a healthy brain what dementia might be like.” The manager offers staff twice-monthly opportunities for discussion about all aspects of work during which they try to discuss training needs and some staff are taking NVQ qualifications in health and social care. During meetings staff are able o identify the types of learning they would find useful, most particularly wanting greater insights into dementia care, and the differences in types of dementia (vascular, Lewey’s Bodies etc), understanding what sorts of creative activities would help support their residents and computer skills, which are important as all training in this organisation is online, as is record keeping and even some staff meetings. “The staff are always keen to learn and develop new skills. Learning while at work would work well for the staff …so completing this while on duty would mean they are already within the building and not having to give up their time on their days off.” Barriers to training and development opportunities are time and budgets. The manager is confident that in areas where she has expertise she could plan and deliver training, although ideally training should be to an externally validated standard and offer staff the chance to develop a portfolio of qualifications. However, training outside of that mandated (the care certificate) and essential for health and safety (lifting and handling, recording and administration of medications) is unfunded and so difficult to find time for it is almost nonexistent.

Case Study 04:

This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. “In the main, as we recognise, it can be quite difficult to see if training is actually being applied in practice, I think that actually ensuring training is applied could probably be added on to sector challenges/barriers.” Our informant is a practising occupational therapist with experience working in a variety of settings including undertaking competency assessments, mental health, assessing and supporting patients with frailty and dementia and working in the community. She is currently also establishing a training company for adult social care to address gaps in knowledge and understanding. “I'm looking at developing my own training company, because I've seen gaps in knowledge, for example, when it comes to the Mental Capacity Act…people don't know how to apply the different healthcare acts… [care workers] need to know how to apply it in practice, not just learn about the history of how it came about.” Our respondent feels organisations are often attracted to the cheapest training options because margins are so tight, there is so little time, and staffing to cover for training is such a problem. However, she has found problems with training that is poorly targeted, not delivered by people with relevant expertise, which makes the training poor value for the trainees and the organisation. Acknowledging the lower status of care work as opposed to health-related roles based within the NHS our respondent points to the need for care staff to have outstanding soft skills, particularly communication and empathy, and that these skills should be prioritised in recruitment and training and developed and assessed through work-based learning. “Actually, it's OK to have different learning abilities. Not everybody is going to be able to sit there and write a 10,000 word essay …we've all got different skills that we can utilise. And actually, it's the proactive skills that are more important when we're working in social care. Can you actually engage with a person with dignity? This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. With respectful communication? Can you actually problem solve a situation in a safe way? And that's maybe not going to be in the typical training routes.” Our respondent set out a clear vision for innovating in training and in practice, through involving all staff in thinking about how practice can be improved, and engaging staff in the identification of training needs. She identified how training could be innovative, with modular and synoptic elements covering specific conditions and co-morbidities, leadership, communication, network building, resilience and many other elements with different approaches to learning available to suit differing organisational needs. “Most of all, giving flexibility to work with each organisation to fix THEIR [training] needs - if it is end of day 1 hour sessions, full days, half days, half hour hand over boost, workshops, on hand on shift consultancy alongside staff etc. Working WITH the organisations in a tailored way, just like we SHOULD be tailoring our clients/service users/patients care. This sector has a really challenging time juggling budgets and time, let’s make it more accessible and engaging for all.”

Case Study 05:

“I think as a domiciliary care provider, and as I'm speaking for everyone that's in supported living, everyone outside of the care home… I still think we're left behind on a broad national scale.” Our respondent works for a larger domiciliary care provider in England, and her role is in developing the organisation in the broadest sense. She works on building relationships with the NHS, other care providers and training organisations. She is responsible for a wide range of staff training and development and for cross-organisational interactions in support of clients. Key issues in domiciliary care focus on lack of opportunities for progression from a This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. ‘left behind’ service, leading to a shortage of workers and lack of foundational skills from care work in professionals supporting care work organisations. The point was made that social workers or occupational therapists have almost never worked in care and then progressed to their professional status, which means they have little real-world experience of care work as understood by care workers or people receiving care. Furthermore, there is a significant disconnect between the teaching of Health and Social care in higher education and the requirements of domiciliary care, which our respondent reports are not discussed as a career option, nor as part of the curriculum, leaving those with higher qualifications unaware of care as a career option. “We took on an apprentice from a local university… he said “Oh dom. care - it never got talked about”. And I did Health and Social Care at university, and dom. care was never mentioned. It's not talked about. We talk about career progression within the NHS, and we talk about career progression as a social worker, as a midwife, but it's never as a support worker.” Larger organisations which have been successful at tendering are able to overcome fragmentation to a limited degree through gaining access to events and networking opportunities (forums) organised by the care commissioners (e.g. the Country Council or Care Commissioning Group) which are not open to other providers. This enables them to learn and to share learning with their staff, meaning there are more learning opportunities available. “Now they're [care commissioners] trying to initiate more task and finish groups. And I joined probably about 6 different groups with different domiciliary, care and support providers, and we meet either every month or every other month, and there seems to be more working together than there was pre COVID” Despite there being more opportunities for collaboration there is no shared provision of training as there is in the NHS. Our respondent noted the significant need for soft-skills training and for training in topics of specific use to domiciliary care such as financial This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. management, communicating with medical professionals and counselling skills. She pointed out that if younger people were to be recruited into care they would not have these skills (having lived at home and relied on parents for support themselves) and would not be able to fully support clients. As with other respondents she noted the need for specialist training too, in medical-related areas. “Well, [fragmentation] affects everything, doesn't it? If you've not got that kind of work in partnership together, you've then got clients ultimately being really unwell and really poorly. It's then affecting the NHS in England and it's affecting policy procedure standards, costings, funding’s and it's becomes a domino effect.” To overcome fragmentation there needs to be a clear set of core training (maybe based on the Care Certificate Standards) and of high status, with a route to progress, like you can progress in the NHS. There also needs to be a well-designed package of additional elective training which is part of the same package, accredited, with national standards and funding for time, cover staff and trainers, shared across all providers. It will raise standards.

Case Study 06:

“And the political arena has to step up. To take on board that it very much needs to be integrated. We've got to be much more on a level playing field, and everybody can come.” Our respondent has more than 30 years NHS experience and leads a unit which aims to provide NHS support for Home Care Services in a large region of England. Her team includes registered nurses, occupational health and physical therapists, and administrator, plus open vacancies for Pharmacist, Assistant Practitioner and Speech Therapist. Although her team provides advice on training to home care services and builds networks to enable sharing good practices the team does not provide training to care workers, although training in clinical practice and communication were priorities she identified and worried were not being addressed. In her experience training for care providers is expensive, patchy, difficult This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. to access and not always of good quality. Ideally she would like staff working in the care sector to have the same opportunities for high-quality, validated training as provided within the NHS for Health Care Assistants, registered nurses (care homes will usually employ one or two registered nurses), and other staff (such as occupational therapists, administrators and managers). “I think it's certainly [lack of] access to good quality training, clinical skills training, particularly. I'm finding that that's what a lot of the homes come to us with, whether we know where they can get training from or to source that training (for them).” Within the NHS when staff encounter a problem they can quickly get advice and support, they know who to turn to, a doctor, therapist, pharmacist, dietitian etc is available to help. The care sector really struggle to access reliable and timely expert information when they encounter something unfamiliar, and this can lead to patients deteriorating and then needing hospital in-patient care when it could be avoided, integrating the services would save money in the longer term, through better training, support and consistency of service standards. “We've got to be much more on a level playing field, and everybody can come. The carers have got to be much more confident in in the work that they are doing [through training] and they do a valuable job, but the public needs to re-evaluate perceptions, and it is very sad they don’t, because they do a wonderful, wonderful job.” An example of how the playing field could be levelled was exploring how to give care providers access to specialist nurses (Parkinson’s disease or Multiple Sclerosis for example), to provide information sessions for care staff, and then provide an easy route to referral to specialist nurses when needed. Currently such a system is not in place, but if it were it would be a step towards integration of care and health services. A key barrier to integration though remains public (and by extension, political) perceptions of the care sector. This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. “But there's a lot of stereotypical views out there that [are] just not valid at all, around the actual public perception of social care and, actually, sadly the social carers perception of their own work as well.” Integration of services will require political will, public backing and changes in attitude in both the health and care sectors, but, if it can be achieved the investment in time and money will pay dividends in improving the quality of care and reducing the need for expensive health interventions.

Case Study 07:

Undertaking an independent review of a disparate landscape of disconnected care provision and an unrecognised, largely invisible, frontline workforce, Camilla Cavendish proposed a set of recommendations in 2013 under the title The Cavendish Review, in which the British journalist and former Head of the Policy Unit for David Cameron, saw “an opportunity to create a “Certificate of Fundamental Care”… (that) will reduce complexity, duplication and confusion by linking explicitly to the nursing curriculum…” and noted the certificate “will be the foundation stone of a series of national competences which emphasise what is common to health and social care, and what is common to registered nursing and support work, rather than what is different. For the airline industry has demonstrated that common goals and a common language, (and) training junior and senior staff together, are a cornerstone of safety.” In the Review Cavendish pointed out “it is time to start seeing… support workers as a strategic resource, to both the NHS and social care.” The review proposed that “Eventually, it (the Certificate) should be open to volunteers and unpaid carers, who are shouldering so much fundamental care.” In the UK a care certificate is now a compulsory element of training for all care workers. Whether the certificate has drawn groups of differing levels of care sector professionals together in training opportunities, and helped cement a This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. “cornerstone of safety” in the care sector is open to debate, but from a care worker’s perspective what actually is the Care Certificate, and how does undertaking it work in practice? “(We have) an opportunity to create a “Certificate of Fundamental Care”… (that) will reduce complexity, duplication and confusion…” 1 Our respondant is an experienced care worker, having worked at one other organisation for 8 years previously. She shared with us what it was like starting at the new agency and how difficult it was to get her previously gained qualifications and experience recgonised. She took part in only one morning’s induction training when she started her new job as a bank domiciliary care worker at a local agency, and straight away the alarms bells started ringing. She had already completed the Care Certificate at her previous job in 2015 when it first came out, but her new manager – the person who was meant to assess her said it was agency policy to undertake the certificate again, as it wasn’t “a proper qualification”. Our respondant took this to mean it wasn’t accredited, so as such she guessed it was difficult for her to prove that she had actually done it, even though she had kept her original Skills for Care workbooks. Our respondent was concerned that her new manager didn’t seem interested that she had done the certificate previously, and they didn’t discuss how the training to achieve the 15 standards would fit into a larger arc of learning and professional development. She was given a workbook to complete and link to an online course to do at home. Then, she was told, her manager would sign it off “no problem, because she was experienced”. Naomi started to worry as it wasn’t a Skills for Care workbook like her first one, and she didn’t recognise the name of the training company at all. She wasn’t given the chance to ask questions per se, but did manage to quickly ask was it the same at the agencies’ other branches, but the manager didn’t seem to know. The online course took about 8 hours in total, and this didn’t compare with the 12 weeks of supervised working through all the standards with the co-worker she was shadowing and regular assessment meetings with her manager, that had taken place in at her last company, when she was full time. This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. “Things seemed so different at the new company, it was like it (the Care Certificate) was a different course altogether. I was worried that despite my manager accepting I had experience, having to do the same training again just seemed a waste of everyone’s time.” Our respondent shared that she felt she needed to discuss things with her manager properly to make sure that she had achieved the necessary standards successfully, but it was difficult to fit in a meeting around all her new shifts, and her manager never seemed to be available. She felt in her last job she had really benefitted from the training that doing the Certificate had provided, but in this role the connection wasn’t that strong. The online sessions had been pretty basic, and she didn’t really learn anything new. She looked online again to see what other care workers experiences had been with their Care Certificate training, and it seemed she wasn’t alone. Like her, some people had really good stories and some not so much, it just seemed to depend on the company they worked for, and how good their manager was at training them. “It was such a shock going from my first company into my new job. I just thought I would be able to take the certificate with me, as that was supposed ot be the point of having it. But having to do it again, and the training at the new agency just didn’t compare. I just don’t think the care certificate works like it is meant to.” Contributory to this issue is currently many different training companies offer care certificate training packages online for very low sums, and in 2017 Health Education England, and its two main training partners Skills for Care and Skills for Health, issued a joint statement warning about training and e-learning providers charging for training and assessment materials when all these were freely available from any one of their websites. As the Care Certificate is not externally assessed, quality can be variable across different settings, and HEE has also issued guidance for care companies, as it is the responsibility of the employer to make the assessments in the workplace and using the tools provided. It would appear that what was set out with the best of intentions to be a universally recognised certificate of skills, knowledge and experience, has become an opportunity for This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. sharp practice training organisations to exploit busy and less informed care team managers, and in fact has created both duplication and confusion for care workers in their already limited training opportunities. That the certificate lacks portability and transferability undermines the very thing it intended to do, and it is unsurprising that our respondant felt it didn’t do was it was meant to do. Recent conversations with Skills for Life representatives has lead to the understanding that the Care Certificate will undergo a review in the near future, as it is recognised to be failing. Using this opportunity to introduce accreditation, and regulation of the training providers, will go someway into developing the certificate in line with the ideals of the original Cavendish Review.

Case Study 08:

In addressing the well-being of an elderly gentleman living alone, a comprehensive approach was adopted. A detailed care assessment was conducted, ensuring a nuanced understanding of his needs. Equally important was evaluating the support provided by his daughter, recognising the challenges she faced while balancing caregiving with full-time employment. A joint assessment involving both father and daughter was considered, delving into the impact of her support on her professional life and his social isolation. To combat his seclusion, collaboration with local community organisations was initiated, offering avenues for social activities and companionship. Simultaneously, formal services were evaluated, striking a balance between familial care and professional support. This approach emphasised the significance of evaluating not just the individual’s needs but also the capabilities and challenges faced by the informal caregiver, ensuring a holistic and supportive framework for both. Case Study 09: Efficient communication networks and rapid implementation of practical measures played pivotal roles in reducing delayed discharge for an older patient recovering This project has been funded with support from the European Commission. This publication [communication] reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein. from surgery. A specialised re-enablement team was established, bridging the gap between hospital care and home support. This streamlined approach allowed for swift discharge, acknowledging the crucial role timing played in the patient’s recovery. The case of an active elderly lady, facing a sudden change in her circumstances due to illness, showcased the importance of prompt discharge. By ensuring her home was adapted for her needs and providing specialised training for caregivers, she could return home swiftly, avoiding institutional care. The synergy between hospital teams and external social care services proved instrumental, underlining the effectiveness of a well-coordinated approach to post-hospitalisation care. Case Study 10: A domiciliary care provider embarked on a transformative journey to enhance person-centered care. A meticulous revision of care plans involved multiple stakeholders, including social workers, care workers, service users, their families, and medical practitioners. Central to this process was clear leadership at the senior management level, overseeing the comprehensive rewriting of care plans. Transparent and effective communication was paramount, ensuring that the revised plans resonated with the actual needs and desires of the service users. Regular monitoring and updating of care plans became standard practice, guaranteeing their continuous relevance and effectiveness. This initiative not only streamlined care processes but also fostered an environment where service users and their families felt heard and supported. By prioritising individual needs and involving stakeholders in the planning process, the organisation successfully transformed its care approach, ensuring a person-centred, comprehensive, and continuously evolving support system for its clients.