The seven key principles to reform social care

Jeremy Hunt speaking at BASW’s World Social Work Day event. Picture: Joe Newman

The social care industry has been looking for some time to gain an insight into the governments thinking on the future of social care. It may well be that this week we were given some insight.

Jeremy Hunt, Health and Social Care Secretary speaking to the British Association of Social Workers conference in Westminster, said we need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition.

Too many people experience care that is not of the quality we would all want for our own Mum or Dad. “We need a relentless and unswerving focus on providing the highest standards of care – whatever a person’s age or condition. This means a commitment to tackle poor care with minimum standards enforced throughout the system, so that those using social care services are always kept safe and treated with the highest standards of dignity and compassion.”

He went on to say that fixing the broken social care system “will take time” and acknowledged there had been “stalled reform programmes” in the past as he set out plans for reform. Giving his first speech since his department was given full responsibility for social care in January, Mr Hunt said the solution will be found in embracing the “changes in technology and medicine that are profoundly reshaping our world.” Setting out the seven key principles to reform social care which will be detailed in a Green Paper to be published in the summer.

Seven key principles

One of the Green Paper’s key principles will be a sustainable funding model. Other principles set out in the Green Paper include: the quality and safety of services, the integration of the health and social care systems, control for those receiving support, valuing the workforce, providing better practical support for families and carers and ensuring greater security for all. The new system of funding social care will be capped. Asked directly if that meant there would be a cap on what any individual had to pay, he replied: “Yes.” But his remarks disappointed those who had hoped for a tax-funded system that would give social care parity with the NHS. He insisted the element of personal responsibility envisaged in the original National Assistance Act 70 years ago would stay.

The health and social care secretary said: “The way that our current charging system operates is far from fair.” This is particularly true for families faced with the randomness and unpredictability of care, and the punitive consequences that come from developing certain conditions over others.

“If you develop dementia and require long-term residential care you are likely to have to use a significant chunk of your savings and the equity in your home to pay for that care. But if you require long-term treatment for cancer you won’t find anything like the same cost.”

Hunt acknowledges that the principles will not succeed unless the systems we establish embrace the changes in technology and medicine that are profoundly reshaping our world, he said. “By reforming the system in line with these principles everyone – whatever their age – can be confident in our care and support system. Confident that they will be in control, confident that they will have quality care and confident that wider society will support them.”

The need for action now

Hunt is under pressure to do something now. This month Sir Stephen Houghton, the leader of Barnsley council in South Yorkshire, said the postcode lottery was turning a historic economic divide into a serious social one. “If you happen to live in a poorer area you’re more likely to receive lower-quality care in old age or if you suffer from a long-term disability. People should be entitled to the same quality of service no matter where they live,” he said.

Hunt acknowledged “the daily pressure” faced by local authorities and said: “We need to recognise that with 1 million more over-75s in 10 years’ time they are going to need more money, and we are going to have to find a way of helping them to source it.”

Niall Dickson, chief executive of the NHS Confederation, which represents organisations across the healthcare sector, said: “Warm words are always welcome but let us hope this speech represents new thinking in a government which like the rest of the political class has been understandably distracted by Brexit. The signs are that the Secretary of State understands what is needed – but the challenge of convincing his cabinet colleagues remains.”

Jeremy Hughes, Alzheimer’s Society chief executive, said: “Jeremy Hunt’s seven principles must not be wishful thinking for those impoverished by having dementia. The Government must now commit the funding to make good on these principles. “Without the necessary funding, vulnerable people will continue to struggle needlessly. By 2021, a million people in the UK will have dementia, and we need urgent action to create a system that can meet that challenge.”


The seven key principles that will form the framework of the Green Paper due to be published in the summer of 2018 should be given a cautious welcome. After all, it could be argued that the reneged promised cap on social care frees cost this government a large majority at the last election. However, it is just possible that the pressure of the Government to deliver on these principles this time may result in a solution to the problems of social care for fear of losing the next election. I have no doubt that Jeremy Hunt is sincere in trying to achieve change, but he cannot do anything without the support of the Prime Minister and her colleagues. This issue should be above party politics. Let us hope that the Jeremy Hunt principles lead to much needed action.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The importance of hand hygiene in social care settings

Hands are the most common way in which microorganisms can be transported and subsequently cause infection. In order to prevent the spread of microorganisms to those who might develop serious infections by this route, hand hygiene must be performed effectively.

There is considerable evidence that Service User contact results in contamination of health care professional’s hands by pathogens that cause health care associated infections (HCAI). Effective hand hygiene is recognized as the single most important procedure for significantly reducing/preventing infection, leading to improved morbidity/mortality rates.

A recent study in France has shown that good hand hygiene practice was particularly valuable during periods where infections were active within the community. In the UK this winter we have seen increased pressures on our health services as a result of the influenza outbreak (the so called Australian Flu).

In France during January to March, France like the UK experienced a widespread influenza outbreak. Care homes that took part in the study which had implemented additional measures reported a 30% lower mortality rate than the control group.

It seems prudent then to continue to raise awareness of social care staff in the UK to the importance of effective hand hygiene in social care settings.

In most care settings, staff receive training in infection control including hand hygiene. But over time, staff can become complacent and underestimate what poor hand hygiene can cause to vulnerable Service Users.

In 2017 the World Health Organisation ran a campaign designed to improve hand hygiene and highlighted:

The 5 moments of hand hygiene at the point of care:

1.       Before Service User contact

2.       Before Clean/Aseptic procedures

3.       After body fluid exposure/risk

4.       After touching a Service User

5.       After touching a Service User surroundings.

Correct technique for hand hygiene:

Bare Below the Elbow.

The Department of Health (2007, 2010) state that hand hygiene is not performed effectively if sleeves and cuffs are close to wrists.

Bare Below the Elbow means:

  • No long-sleeved clothing (or capacity to fold above elbow)
  • No wrist watches
  • No bracelets or wrist bands
  • No rings except one plain wedding band
  • No nail varnish, false nails, nail jewellery or nail extensions
  • Natural nails must be kept short and neat

Hand decontamination using an effective technique, will ensure that all surfaces of the hands are covered. Clinical staff must use the Ayliffe (6 steps) hand hygiene technique. Lancaster university have produced a video on how to use the technique.

Protection of Service Users

An audit should be carried out to ensure alcohol hand gel units readily available. They should be easily accessible and available in sufficient quantities if they are to be used effectively. Consideration should be given to the provision of additional dispensers if needed, or pocket-sized bottles of hand rub where required to supplement these, particularly during outbreaks. The Service should also ensure that sinks are equipped with a suitable hand sanitiser and paper towels to ensure hands can be washed thoroughly.

Regular spot checks should be undertaken to observe staff practice that ensures staff are sanitising their hands between all episodes of personal care. The spot checks should also include checks on hand washing technique and knowledge of when gloves and other personal protective equipment (PPE) should be used.

Staff Training

Although Infection prevention and control training (including hand hygiene) is a mandatory requirement for care staff. The manager should ensure that regular refresher courses are made available to staff to ensure the continuation of best practice.


There is a great deal of evidence that the failure of care staff to carry out correct handwashing techniques can have serious consequences in the spread of infection and on the lives of Service Users. The World Health Organisation, NICE and a whole raft of research including the French study show how important it is that care staff follow the correct procedures for handwashing.

Given the pressures that care staff are under it is easy for them to become complacent when carrying out correct hand washing techniques. It is the duty of managers to ensure that staff are following best practice and have the resources available to carry out the task. Increasing staff awareness of the importance of hand hygiene along with refresher training will help to prevent contamination and infection.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Can robotic seals reduce stress and anxiety in people with dementia?

The use of robotics in social care services is gaining traction. You only have to look on eBay and Amazon and you will find PARO the robotic seal.

Developed in Japan and modelled on the features of a baby harp seal, PARO is the most common therapeutic pet-type robot used in studies with people with dementia. The therapeutic version (version 9) is an autonomous robot that is similar in weight to a newborn baby, and has 5 sensors that are processed by artificial intelligence software to enable PARO to respond to the user and the environment. Typically, active during the daytime, PARO can move its tail and flippers, open and close its eyes, and make sounds similar to a real baby harp seal.

Paro has been around for some time invented in Japan in 2005. So, it’s taken some time to get established. It is now used in health and care services around the world

It is claimed that the robotic seals reduce stress and anxiety, scientists have said.

The cuddly animals respond to touch and speech. The devices look like toy seals.

They have built-in sensors and their artificial intelligence allows them to “learn” and respond to the name given to them by service users. They can also react to being stroked and spoken to by wriggling, turning to the person, opening their big eyes and squeaking.

Research has shown the seals can reduce stress and anxiety, promote social interaction, facilitate emotional expression, and improve mood and speech fluency.

But although they were shown to enhance the wellbeing of people with dementia, there were concerns about meeting the infection prevention control requirements as they can be hard to clean.

Hygiene and cleaning tests were carried out over nine months by the University of Brighton’s School of Health Sciences on a 10-bed dementia ward run by Sussex Partnership NHS Foundation Trust. The results show that PARO was maintained within acceptable limits for NHS Infection Control.

Lead researcher Dr Penny Dodds, who recently moved from the university to the charity Dementia UK, said: “To our knowledge, this was the first testing of the infection prevention and control aspects in the world and we are delighted with the results.

“We have demonstrated that, under controlled conditions, PARO was safe within the hospital setting for an acute care dementia unit. It is hoped that this can allay concerns from those who have been hesitant about using PARO in the NHS.

“It is anticipated that PARO will receive Medical Devices Status in the UK shortly and the distributor is preparing PARO for the UK market – we could be seeing PARO on wards throughout the country in the not-too-distant future.

“The successful research means we can now offer our cleaning testing protocols for use. This work is ongoing and the next stage will be to see if a weekly clean can be reduced to 15 minutes.”

Dr Dodds said there were similarities to using pet therapy but PARO is easier to supervise.

“Unlike real pets, PARO always behaves, has rechargeable batteries, is always available – and PARO should last about 12 years,” she added.

“The most important aspect is the improvement PARO makes to a patient’s quality of life.”

Dr Doug Brown, chief policy and research officer at Alzheimer’s Society, said: “It’s great news that PARO has sealed the deal, bringing these robots one step closer to supporting people with dementia.

“With no cure for dementia and no new treatments for over 15 years, it’s important to develop innovative ways to support the 850,000-people living with dementia today.

“These novel seal robots can boost social engagement, improve mood and reduce agitation in some people living with dementia. Although it is vital that they are used alongside human contact, and never replace it.”


Staff working with people dementia are always looking towards innovation to help them improve the quality of life for service users who suffer from this disease. Paro the robotic seal is one such innovation that is claimed to reduce stress and anxiety. One could argue why not have dogs in the care facility. The trouble is they are unpredictable, they can transmit disease, and most importantly, they go home at the end of the day.

There is however an ethical question we have to address when we choose to use robotics. What happens to our moral character and our virtues in a world where we increasingly have more and more opportunities to transfer our responsibilities for caring for people to robots? Where increasingly, the quality of those robots encourages us to feel more comfortable with doing this, to feel less guilty about it, to feel in fact maybe like that’s the best way that we can care for people. I would suggest there is no substitute for compassion.

Albert Cook BA, MA & Fellow Charted Quality Institute

Managing Director
Bettal Quality Consultancy

Concern about residential care contracts

According to a recent ‘Which Report’ care home residents are unwittingly signing contracts which could see them kicked out within 24 hours, ‘Which’ has found.

The watchdog warned that vulnerable older people and their families could be subjected to unfair terms because they don’t understand what they are signing.

The Government said it was considering changing the law to protect people from “unscrupulous” providers.

In the course of their research ‘Which’ contacted 50 care homes posing as a family member looking for care for elderly relative. Just four homes agreed to send a sample contract, three of which contained clauses which could be unfair to residents, including the right to end a contract with 24 hours’ notice for “detrimental behaviour”.

Another contract said the home could charge a resident up to a month’s fees following their death, a practice which the Competition and Markets Authority has previously said is illegal.

In a separate poll of 500 people who had recently signed care home contracts, only half said the provider checked that they understood the document they signed, and a third of those who said no checks were carried out said they did not understand what they had signed up to.

Transparency and Care Governance

The lack of transparency in care home contracts is damaging to providers of care home services. I have no doubt that regulations will be brought in to protect Services Users from unwittingly signing contracts where they do not fully understand what they are signing up to.

Why does the social care industry have to wait until they are forced to follow acceptable best practice? The solution of the problem I would suggest is in their own hands.

There is no getting away from the inclusion of charges within a legal Condition of Services Contract. However, the same information could be included in a separate supporting document called a ‘Care Homes Charges for Services’. This would:

  • enable Service Users to plainly see what they were signing for and not confused by the complexity of trying to understand the true meaning of charges hidden in the body of the legal contract;
  • enable managers and staff to explain more easily to Service Users the charges which would be in singular focus.
  • enable care home providers to demonstrate to service users and regulators their commitment to transparency regarding charges for their services and care governance.

Alex Hayman, Which? Managing Director of Public Markets, said: “It’s unacceptable that care homes are making it difficult for people to get hold of contracts and the terms and conditions they are signing up to when making such an important life decision.

“Far too many care home residents are hit with unexpected fees or contract terms –which can have far-reaching and devastating consequences for vulnerable people and their families at an already distressing time.”

Andrew Boaden, Senior Policy Officer at Alzheimer’s Society, called the findings “absolutely appalling”.

He added: “The findings from this investigation are deeply saddening and shameful, but unfortunately unsurprising. Around two thirds (70 per cent) of people living in care homes are affected by dementia.

“And all too often families of people with dementia have called us at their wits end, as their loved one suffers at the hands of bad contract clauses.

“Some have told us harrowing stories of people with advanced dementia evicted at a month’s notice.”

Minister of State for Care, Caroline Dinenage said: “We know it can be distressing for care home residents to face upheaval, that’s why we expect people receiving care to have easy access to information and certainty about their circumstances.

“We’re taking action to tackle poor consumer practices – on Monday we will publish our response to the recent Competition and Market’s Authority report where we will outline stronger consumer protections.

“If improvements aren’t seen we will look to change the law to protect care home residents from unscrupulous practices.”

A CMA spokesperson said: “It is extremely important that care home residents, and their families, can be confident they will be fairly treated, especially during the difficult period after a family member has died.

“That is why we are currently investigating a number of care home providers, to determine if they are complying with consumer law, and have recently consulted on new advice on the charging of fees after a resident’s death.”


The ‘Which Report’ clearly shows a lack of transparency and care governance on behalf of care home providers making people Service Users fully aware of charges for their services. There is clearly a solution which I have outlined. Is it not in the best interests of Services Users and providers to be transparent about what they charge for their services?

Albert Cook BA, MA & Fellow Charted Quality Institute

Managing Director, Bettal Quality Consultancy

NHS Alert on the risk of Oxygen Cylinders 

The design of oxygen cylinders has changed over recent years with the intention to make them safer to use. Cylinders with integral valves are now in common use and require several steps (typically removing a plastic cap, turning a valve and adjusting a dial) before oxygen starts to flow. To reduce the risk of fire, valves must be closed when cylinders are not in use, and cylinders carried in special holders that can be out of the direct line of sight and hearing of staff caring for the patient.

Ensuring oxygen continues to flow

An unintended consequence of these changes is that patient safety incidents have occurred where staff believed oxygen was flowing when it was not, and/or they have been unable to turn on the oxygen flow in an emergency.

This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.

In a recent three-year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported to the National Reporting and Learning System (NRLS). Six patients died, although most were already critically ill and may not have survived even if their oxygen supply had been maintained. Five patients had a respiratory and/or a cardiac arrest but were resuscitated, and four became unconscious. Other incident reports described patients experiencing difficulty breathing and low oxygen saturations that required urgent medical attention.

Incidents involved portable oxygen cylinders of all sizes on trolleys, wheelchairs, resuscitation trolleys and neonatal resuscitaires, and larger cylinders in hospital areas without piped oxygen. A typical incident report reads: “Patient arrived on coronary care unit with oxygen saturations of 72%. Oxygen in situ and set to correct rate on the flow dial but unfortunately [the valve] was not opened and the patient was not therefore receiving oxygen. Peri-arrest on arrival, [crash team] called condition improved. The registered nurse continued to check that the cylinder was not running out but failed to notice not turned on as indicator green.”

Insights from local investigations include:

  • prioritising training for staff groups and clinical areas where the risk is high.
  • reinforcing theoretical training with regular opportunities to practise operating the cylinder controls.
  • linking safe operation of cylinder controls with other key safety issues, including fire hazards and how long a full cylinder will last on various flow rates.
  • placing laminated guides close to the point of use. These can easily be prepared in advance to be immediately available when needed.

NHS Improvement and the Medicines and Healthcare Products Regulatory Agency (MHRA) are supporting the distribution of training materials and resources for different manufacturers’ designs of oxygen cylinder via the Medication Safety Officer (MSO) and Medical Device Safety Officer (MDSO). The MHRA will continue to work with industry partners to improve oxygen cylinder design. The Healthcare Safety Investigation Branch (HSIB) is also currently conducting an investigation into this safety issue.

Staff training

The manager should ensure all staff responsible for using oxygen cylinders receive training regularly and can demonstrate that they understand the controls on the cylinder. Providers should recognise hands on practice is the most effective way of ensuring competence so give staff the opportunity to handle and operate the controls on a regular basis.


Although evidence from this NHS Alert relates to patients in hospital settings, the safety issues highlighted when staff are using oxygen cylinders may be equally relevant to where they are in use in care homes or community settings.

Safety is of paramount importance to all aspects of care. This alert asks providers that use oxygen cylinders to determine if immediate local action is needed to reduce the risk of these incidents, and to ensure an action plan is underway to support staff to prevent them.

Managers of social care services can do well to learn from the insights into local investigations and ensure their policies and procedures take account of the guidance given in this NHS Alert.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy