Early Indicators of Concern in Care Services

Executive Summary

Aim

The aim of this project was to develop an information-led process that might help health and social care practitioners to examine and clarify their early concerns about care services. Such a process, it is envisaged, could enable practitioners to intervene at an earlier stage to prevent the significant deterioration in service quality that is associated with abuse and neglect.

Objectives of the Project

The project focused on two service user groups in particular; people with learning disabilities and older people with significant care needs. Two central questions were explored in the course of the project:

• First, what are the early indicators of concern or warning signs that health and social care practitioners notice when they visit service users in staffed settings such as care homes and group homes?
• Secondly, how can information and knowledge of such early indicators be used to enable practitioners to share their concerns about a service more effectively?

In respect of people with learning disabilities, the project aimed to build on existing research which had suggested that practitioners are able to identify early warning signs or early indicators of concern about services at an early stage (Marsland et al 2006).

Specific project objectives were:

• Validating the original research findings in the context of Dundee and to contruct a process or guidance tool that is appropriate to the needs of local health and social care practitioners.
• To begin to analyse and evaluate the implementation of the newly adapted process in the local context

In respect of older people the project aimed to establish whether similar early indicators of concern could be identified and applied for residential care services (including nursing care) for this second client group.

Specific project objectives were:

• To replicate some aspects of the original research to identify early indicators of abuse and harm in staffed services for older people.
• To use these indicators as the basis for a practitioners guide or toolkit that is appropriate to the needs of local health and social care practitioners.
• To begin to analyse and evaluate the implementation of the newly adapted process in the local context.

Outcomes

Services for People with Learning Disabilities

The project found that the early indicators identified by staff in Dundee could indeed be grouped under the six areas of concern identified in earlier research:

• Concerns about management and leadership
• Concerns about staff skills, knowledge and practice
• Concerns about residents' behaviours and wellbeing
• Concerns about the service resisting the involvement of external people and isolating individuals
• Concerns about the way services are planned and delivered
• Concerns about the quality of basic care and the environment

Where abuse and or harm was known to have occurred, practitioners reported that they had observed or noticed a number of different indicators across a number of the six areas of concern, prior to the actual discovery of abuse. This suggests that concerns or problems do not occur in isolation and therefore practitioners should be most concerned when they find a service exhibiting a range or pattern of concerns.

The project group used these indicators and six areas of concern to construct a one page matrix of examples and a recording sheet for practitioners (see Fig 1). In addition, a simple process for recording and sharing concerns, in a multi-disciplinary context was created. Training was delivered in respect of the information and recording process, to a range of health and social care practitioners in Dundee.

Older People's Services

Analysis of the research interviews and focus groups in Dundee produced sets of indicators that were remarkably consistent with the findings for people with learning disabilities. These indicators were found to correspond with each of the original six areas of concern described above. There was some variation or difference in the kind of individual indicators of concern identified, but the areas or domains were found to be the same (see Fig 3).

The project group again used these early indicators to construct a one page matrix of examples and an accompanying recording sheet for practitioners. Training was delivered in respect of the information and recording process to a number of health and social care teams across Dundee.

In addition, the local authority developed a computer based information gathering system to accompany the information and process that had been developed. This system enabled practitioners to record their concerns (early indicators) about whole services which had not previously been possible for most of the teams concerned.

Implementation of the Process or Early Indicators tool

Six teams across the two service user groups took part in a trial or pilot of the information and process, following on from the training by the project team. During this trial period individual staff reported that they found the information and process to be helpful and further stated that the six areas of concern identified, resonated powerfully with their practice experience.

However, the trial period or pilot also identified two main barriers to the successful implementation of any process based on the early indicators. First, across joint health and social care teams there was discovered to be significant ICT compatibility problems which prevented many staff from being able to share any information collected electronically with colleagues. Contemporary practitioners need information recording, sharing and collating systems to be computer based, user friendly and readily accessible to all.

Secondly, it became apparent that any wide scale implementation of the early indicators tool or process would not be possible without the development of robust procedures, guidance and training. Such procedures, guidance, and training are currently being developed by Dundee City Council in partnership with other relevant agencies.