When Poor Practice Becomes “Just How We Do Things Here”

“We've always done it like that.”

I think most of us who have worked in care for any length of time have heard that one. I've probably said it myself at some point, although hopefully not too often!

It doesn't necessarily mean what somebody is doing is wrong either. Sometimes there is a perfectly good reason for doing something a particular way. It's when nobody can really tell you what that reason is that we perhaps need to take notice.

I've been thinking quite a bit recently about how poor practice actually develops in care services. We tend to talk about it after something has happened, usually when there has been an adverse inspection outcome, but how did that practice become acceptable in the first place to result in a requires improvemnet or inadequate rating?

Someone starting their first care job can complete all the induction and training we ask them to do, but they're also going to learn an enormous amount from the people working alongside them, thats certainly how I learned in my first ever care role.

They watch the experienced care worker who seems to know what they're doing. They see what happens when things get busy. They notice what people bother with and, probably more importantly, what they don't.

If everyone takes the same shortcut, why wouldn't they assume that's the right way to do it? And if the manager knows it happens and doesn't challenge it, that reinforces it even more.

We can have a beautifully written policy saying one thing while everyday practice is teaching people something completely different. We probably don't need to think too hard about which one will have the biggest influence.

Most shortcuts don't start with somebody deciding to provide poor care

Quite often people are just trying to cope. You're short staffed. Someone has phoned in sick. A resident isn't well, another resident has fallen. The phone is ringing, the manager is helping on the floor and the thing you planned to do at two o'clock isn't going to happen.

So you move it to tomorrow. That's normal, anyone who has managed a care service knows there are days like that. But what happens when tomorrow is just as busy?

The supervision gets moved again, the competency assessment can wait until next week and we will catch up with the records later.

Nothing disastrous happens. Everyone gets through the day, so it happens again.

After a while, something that started as a temporary workaround can become the normal way of working without anybody ever deciding that it should.

Then somebody new joins and learns that version of the job.

“But they're really caring”

I've been involved in investigations where people have said, “But they're really caring.”

Sometimes they absolutely are.

And this isn't just something we see internally when things go wrong.I had a look at some recent CQC findings while I was writing this. In one service rated Inadequate this year, CQC said people and relatives generally felt safe and inspectors observed staff being kind and caring. At the same time, inspectors found significant problems with training and management oversight. Only 12 of 47 staff had received falls prevention training despite many people being at high risk of falls, and patterns and trends in people's risks weren't being identified and acted on.

Caring staff and poor care aren't necessarily opposites.

People can genuinely care about the residents they support and still be working in a service where the systems, skills, oversight or leadership around them aren't good enough.

That doesn't mean we ignore individual accountability. If somebody knew what they were supposed to do, had been trained, was competent and simply chose not to do it, that needs dealing with, but if I discover that five people are doing exactly the same thing, I'm going to be asking more than who did it. Because at that point I don't think I've just got a problem with five individual members of staff, I've potentially got a problem with what the service has come to accept.

What are we walking past?

Leaders set standards in all sorts of ways, and not just through policies, meetings and supervision. What we walk past really does matter.

You don't have to formally tell somebody that something is acceptable. Sometimes seeing it repeatedly and saying nothing does exactly the same job.

The same applies when somebody tells us they're struggling. If people repeatedly get the message that everyone is busy and they just need to get on with it, there is a fair chance they'll eventually stop telling us. I'd much rather have somebody say, “I don't know,” or “I'm not confident doing this,” than copy what everybody else seems to be doing.

Are we actually joining things together?

Another recent CQC report gives quite a sobering example of this.

One person had experienced 30 falls in 12 months. The falls had happened and information about them existed, but CQC found that provider-level leaders and the registered manager had failed to identify and effectively monitor the pattern to make sure improvements were made.

Thirty falls.

It would be easy to look at each one individually. Was the person injured? Was the falls risk assessment reviewed? Was the family informed? Was the incident form completed?

All perfectly reasonable questions, but somewhere along the way somebody also needs to ask why this person has fallen 30 times and whether there is anything else we should be doing.

The same principle applies much more widely. A manager covering a couple of shifts might not worry me. An increase in agency use might have a perfectly reasonable explanation. A few overdue competencies need addressing, but they don't necessarily mean a service is unsafe. Neither does an increase in incidents on its own.

But if the manager is regularly covering shifts, agency use is creeping up, staff are leaving, competencies are overdue and incidents are increasing at the same time, I want somebody to put those things together.

That's what good governance should be doing.

Not giving us six separate reports telling us six separate things are happening, but helping us understand whether they might be connected.

Because by the time poor care is obvious, whatever contributed to it has been building for quite a while.

The question isn't “Who did it?”

When something goes wrong, of course we need to establish who was responsible. Individual accountability matters. But we also need to ask what allowed it to happen and whether we could have seen it coming.

If we only deal with the person at the end of the chain, we might solve the immediate problem while leaving everything around them exactly as it was. Then we shouldn't be too surprised if we find ourselves dealing with something very similar again.

I'm talking about this in the next episode of Beyond the Audit, which I'm recording ready for September. The wider episode looks at how good people can sometimes end up delivering poor care, because I don't think the answer is always as simple as finding the person who got something wrong.

Sometimes it is about the individual. Sometimes it's competence, leadership or pressure. Sometimes several fairly small things have been allowed to become normal over time.

So perhaps rather than another checklist this week, have a look at what actually happens when things get busy. What are people doing because “that's how we do it here”?

And would you be comfortable explaining why?