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One size really does not fit all

Updated: Sep 9, 2021

This is Cyril, one of my grand-dogs. he is a rather sweet, but hugely energetic cocker spaniel/retriever cross. He's now ten months, so his needs have changed a bit since he was this tiny. He needs a strong arm to hold him back from crashing into everything in his excitement at the idea saying hello to other people and dogs. He does have excellent recall and can be happily off lead in most places, returning at first whistle. Cyril likes chewing things and chasing balls. He needs to be occupied, or his behaviour can become destructive. He needs lots of praise and rewards.

This, meanwhile, is Storm, a very well-trained, four-year-old working cocker spaniel. He had to go the groomers before being part of the bridal party, as he is a bit of a smelly mud-sponge who is happiest when using his finely-honed search and retrieval skills in a dense thicket of brambles. He can be slightly protective of his human and sometimes wants to assert his dominance with a slight warning growl when approached and on-lead. Usually, he is very keen to receive attention and fussing, even from heavy handed toddlers. Storm needs reminders that he is not in charge, to rein in his tendency to dominance. He also needs plenty of exercise and time off lead for the zoomies.

....and this is Flirty (we didn't choose the name). Flirty is a retired, working English Setter, who came to us from the grouse moors. She is the loveliest natured dog, affectionate, quiet, gentle and award winning (before she came to us). Unfortunately, she was bred and trained to set - to seek and point towards game birds. She has no off button; the scar on her nose is from running though barbed wire after pheasants when she escaped for a four and half hour jolly across the South Downs.

We've had to adapt how we care for her and provide for her needs. She has a GPS tracker because if she does get out of the garden and onto open land, she will cover twenty or thirty miles very rapidly. There is no off button with Flirty. She has to be run every morning for ten miles or so - but on a harness rather than off lead. She doesn't mind seagulls either and will happily try to cross the Solent, using doggy-paddle, if those pesky seagulls are taunting her. It makes trips to the beach 'interesting' and she needs close monitoring when next to open water.

We've both developed stronger left arms but have also discovered secure dog fields - places she can be off lead, chase pigeons and run freely. It feels like the least restrictive option. We have considered her needs and preferences and adapted how we provide care; watching her sprinting around the perimeter of a six-acre field whilst we enjoy a coffee is preferable to constantly nagging her to stop pulling or, indeed, chasing her across open countryside worrying she'll get hurt. Providing care that meets her needs is as nice for us as it is for her.

What's this got to do with health or social care?

I guess the opening statement has to be that I am not comparing humans to dogs - although both species have a very clear need for care that meets individual needs and preferences.

The Care Quality Commission has published their report, Out of sight - who cares? A review of restraint, seclusion and segregation in services for autistic people, people with a learning disability and/or a mental health condition. It makes clear links between staffing levels, personalised care, a culture that encourages staff to listen and respond to the individual needs of each person and lower need to restrict people and deny then the freedoms they are entitled to. Enforcement action has been taken where there are breaches of people's human rights. The full report is available using the hyperlink below. Clearly it is not only specialist services that need to consider how they are ensuring care provided meets people's needs and preferences and is carried out keeping those people are the very heart of how services are delivered. It applies to acute hospitals, community services, care homes for the elderly and those with disabilities and mental health services. No service can hope to become outstanding if their care is institutional and their pathways inflexible,

The Commission is looking a more in-depth inspections for services where people are more vulnerable and the culture is more closed, where people with learning disabilities, autistic people and people with mental health problems live to ensure the Commission staff 'get under the skin' of the services and truly see what is happening: how; people experience care.

There will be a greater emphasis on observation of care using the short observational framework for inspection tool. Care homes for the elderly can also become quite closed, with few outside visitors, little time outside the home for residents and minimal engagement with the local community.

A good activity programme is not a timetable of bingo, singalong and watching football on television. A good programme understands what each person enjoys and considers how to help them continue to participate in those activities or try new ones . Activities should not be simply things to fill the day with, they should stir memories, encourage active engagement, promote movement and mobility, allow social contact and help people retain (or learn) skills and independence. Rarely is that possible with a 'one-size fits' all programme delivered by a lone, part-time activities coordinator.

Providers might do well to understand their own services, to know where they are providing high-quality, truly personalised care and where improvements can be made. That self assessment and in-depth knowledge of each service is key to identifying where to focus improvement work to bring about changes and improve the lives of people using services - as well as improving the working environment for staff and reducing the higher costs associated with poor care delivery and low aspiration. Even acute hospitals would do well to consider what activities are available for their patients, particularly their frail elderly patients who are often left dozing in their chairs simply because nobody is encouraging any engagement or offering activities. The very good trusts do have activities, they take people out for walks around the grounds or to the coffee shop, take people to the church service, offer hand massage and nail care, have board games like domino's and much more.

Distressed behaviour is much less likely to be experienced by the person and the staff where care is personalised and individual needs are met. Agitation or disruptive behaviors in the confused elderly people (or others with cognitive impairments) are often reasonable responses to inappropriate or unfamiliar situations or personal interaction with the people providing care. Think about how frightening an accident and emergency department must seem to to someone who is already a bit muddled but is now in pain, frightened and alone. It's not hard to see why that person might scratch or lash out at someone trying to remove their clothing or take their blood pressure, is it?

Now imagine the same person in a quieter area, with the same nurse providing continuity and an increasingly familiar presence, with some of the strangeness removed through having a known person with them and being left in their own nightwear, if possible. Imagine how much calmer they might be if their usual carer or the nurse they have become familiar with can stay with them in the anaesthetic room. It's possible - children have parents with them, children wear their own nightwear to theatre, after all.

Within my Towards Outstanding book series is a care home development guide, which includes a self-assessment framework to enable that deep understanding of the quality of care provision. The book explores the qualities and practices that lead to ‘Outstanding’ ratings in residential care and provides a wealth of resources for assessing and managing any service for continuous improvement.

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