Early Indicators of Concern in Care Services

b) Older People's Services - Care Homes (Residential and Nursing)

The objective in this second component of the project was to replicate some aspects of the original research conducted in respect of people with learning disabilities. Subsequently, as above, the objective was to construct a process or guidance tool that is appropriate to the needs of local health and social care practitioners. As above, the original project objectives are listed in full below:

Older people - staffed services (residential and nursing care and sheltered housing support)

With regard to older people, the objectives will be to replicate some aspects of the original research and to construct a process or guidance tool that is appropriate to the needs of local health and social care practitioners. In other words, to identify early indicators of abuse and harm in staffed services for older people and to use these indicators as the basis for a practitioners guide or toolkit. As above, an additional objective will be to begin to analyse and evaluate the implementation of the process in the local context:.

i) The researcher(s) will undertake semi-structured interviews (5-10) with health and social care practitioners who have experience of supporting a person who was (subsequently) proven to have been harmed or abused. These interviews would seek to identify early indicators of abuse in staffed services for older people in Dundee.

ii)The project group will undertake 2 focus groups with local health and social care practitioners (not those interviewed above) to identify local observations in respect of "early indicators" of abuse and/or harm in staffed services for older people.

iii) The researcher will review any existing documentation and/or study evidence in respect of early indicators of harm or abuse in staffed services for older people. For example, this might include locally held "files of concern" for specific services and published research evidence.

iv)The researcher (and associate researchers) will analyse the evidence gathered and establish the emerging indicators of potential abuse, for older people's services.

v) The project group will work with local health and social practitioners to produce a process or tool(s) that will complement existing service monitoring and safeguarding systems, using the evidence gathered. The basic format or structure to this process is likely to mirror the comparable process developed in respect of people with learning disabilities (above).

vi) The project group will design and deliver appropriate training to the relevant health and social care practitioners, including providers of services.

vii) The project group will begin to monitor the application of the newly constructed and implemented Abuse in Care process in Dundee. In essence, this stage is about finding out how staff are beginning to use the process that has been developed.

Research Undertaken - Older People's Services

• Semi-structured interviews were undertaken with Care Managers from Dundee within social services. These Care Managers have experience of supporting a person in residential or nursing care who was (subsequently) proven to have been harmed or abused. The interviews were open in that the findings from the original research were not used as a basis for the interview schedule. Evidence from the Dundee interviews has been combined with interviews from a parallel (simultaneous) research project being undertaken in England. This second project was conducted using the same research methodology and targeted health and social care participants with comparable roles.
• The project group undertook a focus group with local health and social care practitioners (not those interviewed above) to identify local observations in respect of "early indicators" of abuse and /or harm in staffed services for older people. Though these practitioners were employed as Care Managers by the local authority they were either nursing or social work qualified.
• Locally held, "files of concern", for specific services were identified and reviewed in respect of early indicators of harm or abuse in staffed services for older people.
• Thematic analysis of the evidence gathered was undertaken and the indicators of concern for older peoples' services have been compared with the existing (original) research findings for people with learning disabilities.
• Contemporary research literature was examined and compared with the Early Indicators of Concern that have been identified in Dundee. For example, we examined the themes identified in the recent research project undertaken by Professor Dawn Brooker within the PANIOCOA research initiative. Findings from the Brooke study and other studies in Germany (Goergen 2004) and Norway, (Juklestadt 2003) and an inquiry report in Ireland (O'Neill 2006) indicate findings which are broadly consistent with the six groupings identified within the Abuse in Care research (Marsland et al 2006).

Research Findings - Older People's Services

• The examples provided by both the interviews and the focus group suggest that the early indicators for older people in staffed settings are remarkably consistent with the original research findings for people with learning disabilities. As with (a) above, examples were provided that corresponded with each of the original six groupings and 'new' groups of indicators were not forthcoming.
• There was some difference revealed in what might be termed the manifestation of such indicators in older peoples' services. For example, across the three sources of evidence it is clear that one emerging indicator has been the fact that services do not update care plans and therefore care staff do not take the appropriate measures for individuals. Whilst this inaction on behalf of senior staff can clearly be positioned within the original grouping of Concerns about management and leadership it appears that this kind of specific problem is more commonly reported in older peoples' services than it was in learning disability services. It may be that since older people's services are, on average, larger than learning disability services it may be more time consuming for senior staff to ensure that care plans are up to date.
• As in (a), above, participants in the focus group agreed that the original six headings did reflect their discussions in Dundee and their observations of underlying (or pre-existing) concerns. In respect of indicator significance, it was again clear that it is not possible to identify one clear primary indicator, or group of indicators. This again suggests that the indicators of concern may not occur in isolation but be evident as combinations of difficulties.

Applying the Research Findings - Developing a Process or Tool Based on the Early Indicators for Older People's Services

As with the parallel learning disability strand, described above, the early indicators were used to construct a two part framework. Again, one part was a memory aid and one part was a recording form. The six areas of concern were the same as for people with learning disabilities but some of the individual indicators were different, for older people's services (see Fig 3).

An information and training session was designed based on this two part framework and a member of the project group delivered sessions to a number of local authority and / or joint health and social care teams in Dundee.

Developing a Computer Based Recording System

In addition to this training, the project team developed a computer based data gathering system that was accessible to local authority staff. This system enabled practitioners to directly input the early indicators of concern that they had seen or noticed in services that they visited. The system also enabled staff to view the concerns identified by other practitioners, perhaps from other teams or visiting different service users.

Fig 3. Early Indicators of Concern - Older People's Services