Agency use

Agency use is strongly misunderstood by care homes. It is seen as the place to focus in order to curb expenditure, and is often blamed for poor financial performance. It is undeniably a contributing factor, however there is more to consider when aiming for appropriate recruitment. For me, agency use will always be a vital part of running a care home, although this can be tempered with the use of bank staff, overtime, and overstaffing.

When analysing cost of agency temps compared to regular staff costs, let us look at the figures. For each hour, minimum wage is currently £8.72. Add general employers’ costs such as training, NI contributions, Pension contributions, making circa £9.85ph. Also add on 11% holiday costs (5.6 weeks per year, adjusted hourly), makes £10.93ph, assuming the role is gapped. In reality, if agency is used, costs will be higher. Most agencies work for between £12 and £14 per hour. So the conservative true cost to an employer using agency is circa £2-3 per hour. Let us assume £3ph. This doesn’t account for the training, supervision, appraisal, HR management, and potential SSP/SMP (although I concede the latter may be reclaimable) payable to an employee. Agency use is therefore about 20% extra on top of

Now let us make a few assumptions. Annual leave accounts for 11% absence of staff, and sickness probably equates to around 3% (although it surely feels higher!). So are we better to hire 11-15% extra staff? I think it is generally a good idea to have a 10% leeway, however you cannot forecast sickness, and there are times of the year where people will be more or less inclined to take annual leave. This means there will still be times where we are requiring agency, and other times that we are overstaffed.

Where the extra staff come in useful is attrition. It can take 6-8 weeks from point of contact to starting a shift, as DBS wait times, training, induction, shadow shifts etc. This means that a staff member with a 4 week notice period (in the unlikely event they actually work it) will still leave us short staffed for the 2-4 weeks it takes to hire a replacement.

Having a strong bank of staff who will pick up work as and when required on a casual worker basis is a good answer to agency use, but this cannot be too large as we need to be able to actually offer shifts to these people, and they can turn down shifts quite easily. Overtime payments can incentivise staff, and I’d argue £1-1.50 is a good range, as it is both financially viable, and supports continuity of care for residents.

So my advice is pragmatic. We won’t (and shouldn’t) strive to eradicate agency use completely, as to do so would require a level of staffing that would be financially crucifying. Instead, aim to find a solid, reliable agency who can provide a few good, strong workers on an ad hoc basis. Look after each other, invite them to home training, supervise them, and integrate them fully into the team.

Death: what is our role?

People die. It is, ironically, a fact of life. When one of our residents die, we usually will have seen it coming. You see a decline in mobility, reduced appetite, reduced urine output, a lack of motivation….. but quite often family can be blind to all of this. Quite often I will encounter families pointing the finger towards my care staff for not ‘getting someone up’, or giving enough support feeding. Most of the time this is borne, I believe, out of guilt. Misplaced guilt. There is still an unfortunate phrase that is too often uttered: “I am putting my mum in care”. This conveys a decision, ownership… care is a terminal destination in most cases. For family to ‘put’ someone there…. well, that just makes them feel as though they have given up, failed as a family. Nothing could be further from the truth. This setting should be a home.

It often seems as though our job is to prolong life as much as possible; indeed, should a resident refuse to drink (a common occurrence), then we are scrutinised over how much we have offered, how we have prompted the intake, what medical assistance we requested, how we have documented the decline… most of my complaints come after a resident has passed away. Family feel that guilt- the feeling that they are responsible-  families will argue with each other, misplacing the blame, until they find that the best way to unite is to find a common enemy: the care home.

I recently had a death of a former resident, and received a call from the family shortly after, and the sentence spoken has stuck with me: “We were not expecting it”. They must have been the only ones. My assistant suggested they were wearing blinkers. So it made me question, should we as home managers be telling families in a more open and honest way that their loved one is reaching the end of their life? On the one hand, forward planning is essential, and the more time they have to come to terms with this the better, it may remove the idea that the death is due to our errors or omissions. On the other hand, what if we get it wrong? I’m not paid for a clinical opinion.

My grandfather has recently been in hospital twice for sepsis. He is over 80, has vascular dementia, is hoisted, and has a reduced fluid intake. He doesn’t have long left. If he makes the year I would be amazed. I have been absolutely clear on that with my mother, and she gets it (being an ex registered manager herself), but I know it will be a huge shock to some of the family. It shouldn’t be. Family shouldn’t be getting stressed and arguing over his care. A little bit of stoicism carries a lot of weight.

My opinion is that we should be open and honest about declines we are seeing in residents, and encourage end of life planning from admission. Natural death is nobody’s fault, and our role should be to make our service users comfortable as nature takes its course.

A day with an Amazon delivery driver

So today I spent my time sat in the passenger seat watching someone deliver parcels for Amazon. I’ve done this once before and I have to say it seems an awful job…

What I gather, from quizzing the driver’s limited knowledge, is that Amazon sub contracts the delivery of parcels to smaller transport companies. I accept that some working practices- such as having the drivers work on a self employed basis, hiring their vans out at circa £200 per week- may be down to the individual transport companies. But my concern is levied mainly at the outlandish delivery expectations from Amazon.

Amazon provide an app which sets out the route and delivery addresses for the drivers, and has them scan the parcels prior to delivery and then click how it has been delivered (to occupant, neighbour, safe place etc). This reminds me of an eMAR system used to administer medications in care homes. If nobody is available to receive a parcel, the drivers are expected to attempt a redelivery.

The routes that Amazon set are ridiculous- notwithstanding the awful sat nav that I have seen try to take you through dead ends and the wrong way up one way streets- the routes are that large that, coupled with time restraints, encourages illegal and unsafe driving. In order to deliver on time it is common practice to park on double yellow lines and speed, in the full knowledge that failure to do so could lead to losing their job.

Today, the company are taking on a route in a more remote location, and have a much smaller, more manageable number of parcel drops. The problem is, Amazon track this and steadily increase the number of parcels being delivered if they notice the drivers taking lunch breaks etc- the reasoning being if they manage twenty parcels in one hour, that can be replicated for 8 hours in a row. This doesn’t account for traffic, redeliveries, awkward roads etc.

Economically this is gold standard- drivers are paid per route, not per parcel, and so the greater the output, the greater the rewards. At the expense of the drivers. I am all for freedom of contract, and free business, but a responsible company like Amazon should really be looking into the business practices of both themselves and sub contractors. Amazon would defend this criticism, diverting the attention to their sub contracted delivery company, but for me that is not an acceptable defence.

This takes me back to a care agency I used to use for temporary care workers- we would see many foreign faces being literally bussed into the care home, with stories of withholding wages and multiple back to back shifts. Again, theoretically these workers can manage their own rota and turn down work if it would leave them too tired- and the rates we were getting as a home were fantastic… but the reality was these care workers could not turn down a shift for fear of losing all of their work. It was an awful situation for them, and not one we wanted to support as a care home.

Good job too- the agency made headlines weeks after we ended our relationship as they were being investigated for human trafficking offences.

I now exclusively use an agency who are slightly more expensive, but completely open and transparent with me about everything from their recruitment, back office processes, and even their books. We have a strong partnership with them, and I have taken them to my current care home with me… and they have subsequently won business from every home in our group.

Money is not everything.

New direction

It’s been a while since I’ve posted on here. I think my initial intention was to write largely around my studies, as a gentle addition to my CV. Poor idea; no motivation to post, and the topics were pretty dry.

So now I’m going in a different direction. Over the past few years a lot has changed. I left the military, finishing my final couple of years teaching bomb disposal at the world’s premier IED disposal school. It was an honour, and I loved the job. Unfortunately, the company (or institution?) was very role based in its culture, which prevented the meritocracy and autonomy I craved. I believed that I would find salvation in a law firm, where meritocracy was the name of the game. After a summer vacation scheme at Mills & Reeve I noticed that I was right- it was a meritocracy. Unfortunately, the autonomy wasn’t there.

My father at the time had recently moved from being a CEO in the not for profit sector, to being the registered manager of a nursing home catering for advanced dementia patients with challenging behaviour. I had a clinical background, having worked on private ambulances for a year previous, so why not give it a shot? I spent 8 months as a unit manager, which I am sure will be expanded on in later posts, and managed to help turn the home around, getting their first “Good” CQC rating in 7 years.

I leveraged that short success for my first registration, and I now manage a residential care home in Bolton.

So let’s see where this goes!

Substantive Justice vs. Formal Justice

Most people would agree that the role of law is to achieve justice, however justice is a term which can only be defined subjectively; it relates to an individual’s moral standpoints. A utilitarian may argue that justice is served when the greatest good is done for the greatest number, whereas a Marxist may assert that justice is done only when all is equal in terms of wealth distribution. Justice may be easier to define holistically if its antonym ‘injustice’, in meaning that which is unfair, is appreciated. It is useful to categorise justice into ‘substantive justice’ and ‘formal justice’ when attempting to comprehend its nature.

Substantive justice pertains to the need of law itself to be just, whether created through legislature or legal precedent. What is considered just may vary from person to person, yet the prevailing moral leaning of society will often dictate whether a law is seen as just

Formal justice is concerned with ensuring that legal principles are applied in a fair way. This means there must be a following of legal rules; all like cases should be treated alike and, conversely, unalike cases should be treated unalike. A lack of bias is essential when a judge is hearing a case, and procedure must be applied evenly and equally to all.

Substantive justice and formal justice differ in that formal justice’s jurisdiction lies in the procedural domain of following rules, whereas substantive justice seeks to ensure that the rules themselves are fair. Formal justice is concerned with treating like cases alike, and substantive justice must specify what counts as alike. Formal justice is easier to apply rigidly if one asserts that all laws, whether fair or not, if applied equally to everyone, are therefore just. Substantive justice, on the other hand, has the complex task of ascertaining exactly what is fair.

There can be conflicts of justice when the two try to operate side by side. Before 1991, there was no offence of rape within marriage. The case of R V R [1991], which created the offence, showed considerable substantive justice for society as a whole, however formal justice may not have prevailed. I recently read a blog postwhose address I fail to recall, which commented on an aspect of the works of A.V. Dicey, which pertained to legal procedure, saying that “in principle no law should have retrospective effect”.

We expect law to be fair and just in its principles and in the way that they are applied. We do not just expect substantive justice, or formal justice; we expect something entirely more complex and incredibly difficult to achieve: a synergy of the two.