The Clydebank ramp and professional reasoning

Many people will have seen the recent news stories about an access ramp installed outside a council property by West Dunbartonshire council. It’s been discussed and commented on in various newspapers, including The Grauniad, The Mirror, and The Clydebank Post, which gives a slightly different take on it.

Unsurprisingly, given the dimensions and appearance of the ramp, it’s attracted a lot of negative attention. I make no bones about it: the ramp is very very ugly. Comments have ranged from the well-meaning but misguided “there must have been another solution, it’s obvious” from people who know nothing about disability adaptations, to the downright nasty (as per the Express and the Daily Fail websites) which I’m not going to repeat here because – well, because why would you?

Given the complete lack of understanding of this issue displayed by so many people, I thought it might be helpful to go over the kinds of things OTs and technical officers have to consider when they’re looking at major adaptations like this.

Building regulations require gradients of no more than 1:12 for powered wheelchairs, 1:16 for attendant-propelled and 1:20 for self-propelled, plus there needs to be a 1400mm resting platform at the door and at the bottom, and more resting platforms every few metres. If they had relaxed building regs for this ramp, it would have been shorter, but much steeper, and possibly unsafe and/or too difficult to use. Remember that the small girl now will eventually be a heavier teenager, and will require a larger, heavier wheelchair. Look at the pictures of the property and the garden – there are three sets of four or five steps each from the pavement to the house, with longish platts between them, then a right-angled turn to the right, with a couple of steps up, and then a right-angled turn left to the front door with a step and probably a high threshold (uPVC doors have high thresholds) to get into the house. There’s a big height difference between the pavement and the door – it should be obvious that the ramp is going to have to be very long.

They will have looked at

– the little girl’s needs, now and in the longer term, and her expected lifespan
– her type of wheelchair (pictures on one of the news websites, it’s a power chair which might not be suitable for a stairclimber attachment)
– family as a whole – siblings, parents, other carers, location of other family support – how physically able are they? how much care do they do? what are their lifestyles? how often will the little girl be going out? who takes her out? will it always be family or paid carers? Six years from now, does she want to go out independently with her friends? Will she need a bigger, heavier chair later that nobody could push up a shorter but steeper ramp? Is it better for the family to stay in that house because it’s close to family support than move to another part of town?
– proximity to hospital and school – good reasons not to move to another house
– adaptability of interior of the house
– access rights and needs of whoever lives in/owns the first floor flat above – if the shared access is jointly owned by the council and an owner occupier above, the o/o might have refused permission for a steplift
– availability of other suitable housing – houses in hilly areas will generally have steps at the door
– feasibility and cost of all possible solutions – stairclimbers, steplifts, vertical lifts.
– impact on the property. When no longer required, semi-permanent ramps can be removed in a couple of hours with minimal impact on the garden. Lifts require more structural work, before installation, and if it’s a vertical lift, after removal. Something’s holding that hill up, after all.

Stairclimbers require trained operators. Family members and/or paid carers would have to be trained to use it, if the girl has a wheelchair suitable for use with a stairclimber. This would restrict who could take her in and out, whereas most people would manage pushing a wheelchair up a ramp. And I really wouldn’t want to be taking someone up and down those steps using a stairclimber on an icy day.

Looking at the layout of those steps, it would need either four separate steplifts, or three and ramping from the door to the top of the path, or one steplift with a very very very long track plus ramping from the door to the top of the path. The last steplift I did was four years ago, covered 6 straight stairs and cost £12k. You’d be looking at at least £40k to do those steps. Steplifts and vertical lifts get stolen, get vandalised and break down. Do you want to be standing in Clydebank in the pissing rain in January in the dark with your daughter, unable to get into your house because the lift has broken/been nicked/been destroyed? And I don’t even want to think about the massive structural work that would have to be done to dig out the ground and shore up the hole to put in a vertical lift.

Having looked at the photos over and over, and drawing on my 14 years experience of doing major adaptations, I can’t think of anything else they could have done to that property that would have worked. Obviously we were talking about it at work today, and OTs and technical officers alike were in agreement that there was almost certainly nothing else that could be done to the property. But we all did wonder why the family hadn’t been rehoused. I think the Clydebank Post article sheds some light on that. It reads to me as if the family had been waiting to be rehoused to a ground floor property for a while and were offered this one on the understanding that they could manage the steps. It’s possible the little girl was mobile when they moved in and her use of a wheelchair has been a later development. It’s possible that they were offered and accepted the property on the understanding that rehousing or adapting the access would be offered if and when the little girl became unable to do the stairs. And it’s also possible that West Dunbartonshire’s housing policy says that if you refuse 3 properties they’ve offered you, you lose your priority and go to the back of the queue, so they felt they had to take it. I couldn’t find anything on their website which says so, but it’s pretty common in housing policies. But as mentioned above, there could be very good reasons for the family wishing to stay in that property.

What I don’t understand is why the woman is saying she didn’t realise what the ramp would be like. I accept that most people don’t know much about the building regulations applying to ramp installations, but surely it must have been discussed with her. Surely it was pointed out during the assessment and when they were looking at possible options. Mind you, I’ve done bathroom adaptations where I’ve taken plans out, gone over them at length, explained very clearly “this is where your bath is now, the bath will be removed, the floor will be relaid with a fall towards the drain, the shower will go in this area where the bath used to be, the floor will be a wet floor so there won’t be a step for you to worry about…” only to have people complaining at the end of the job that they wanted a shower cubicle and they’re pissed off we removed the bath. So it is possible that it was explained and the family just didn’t take it in, especially seeing as most people are not familiar with the drawings ramps.

But as for the nonsense about the gate – garden gates open inwards. There isn’t a housing developer in the land who would fit a gate so that it opened onto the public pavement.

The trouble with the private sector is it gets to walk away (and it operates within the patriarchy)

Local authority social work departments have a legal duty to assess the needs of people with disabilities, and to provide services to meet assessed needs (in line with their eligibility criteria). They have no obligation to provide all of the required services internally; it’s acceptable to contract with external agencies to provide services on behalf of the local authority. Over the past few years, the free market has been invited in to social care services, under the mistaken belief that agencies would be falling over themselves to provide good quality care at reasonable prices.

Agency care workers regularly report not being given travel time to get between clients and not being paid for travel time, although travelling between visits is obviously part of their working day. Add to this the low wages, shift work, early starts, late finishes, weekend and public holiday work (yes, people still need help to get to the toilet on Sunday mornings and Christmas Days), the physical demands of the work, the psychological demands of remaining pleasant, polite and professional while a confused person rants at you or a family member yells at you because you’re ten minutes late having had to travel from your last visit on the other side of town, and the general dealing with pee, puke and poo, and you can see why many people decide it’s not for them and go off to other forms of employment. Care work is not easy work. Not everyone can do it or do it well. But it’s always been viewed as women’s work and therefore  it is under-valued (although not always under-appreciated) and underpaid.

This article states that

Turnover for domiciliary care staff working with older people has reached 28%, up from the previous year’s [2011] figure of 24%. Turnover for care home workers is slightly lower at 20%, but still represents an increase from 18% in 2011. The National Care Forum released the figures in their annual staffing survey, based on data from 40 organisations employing a combined total of more than 55,000 staff.

The most common reasons for people leaving their jobs were personal reasons (14%), dismissal (9%), and ill health (5%). The report showed the overall care workforce is ageing, with 46% of staff aged 46 and above. The NCF said this represented “a steady increase over the last three years”, while the proportion of the workforce aged 16-35 stands at 33%, compared to 34% in 201.

In 2011, Skills for Care published a report called Workforce Insight 2 –
Understanding Turnover and Retention in the Social Care – Research Report Findings 2011. This report states

Separating social care providers by ownership type, as in figure 3, we see that third sector providers exhibit turnover rates slightly below the regional average, private providers exhibit rates slightly above the regional average and statutory providers and other providers exhibit turnover rates which are markedly below the regional average; some 8% points lower, a difference of more than 50% in real terms.

Whilst exploring the differences between service types, we
discovered that whilst care homes with and without nursing were seen to have turnover rates slightly below the regional average, domiciliary care services were seen, on average to exhibit markedly higher levels of turnover than other forms of social care provider.

Whilst this insight accords with the prevailing wisdom, that domiciliary care providers have exaggerated levels of turnover, it is worth noting that in the case of the West Midlands sample there were a higher percentage of domiciliary care services which experienced no turnover incidents compared to other service types. Specifically, 33% of all services reported experiencing no turnover, whereas 36% of domiciliary care services experienced no turnover. This suggests that the high turnover ‘problem’ experienced by domiciliary care providers is actually experienced most acutely by a small number of providers.

Identifying these providers and supporting them to address their difficulties should be an important objective for Skills for Care and its local partners.

The report goes on to say that care workers have double the staff turnover than managers, and senior care workers have a slightly slower turnover than managers. They suggest that the high turnover among care workers could be linked to limited opportunities to progress from care worker to senior care worker, and new employees taking entry level care worker posts and leaving after realising the work is not for them.

Skills for Care also compared turnover in rural and urban areas, and found that (unsurprisingly) care workers tend to stay in their jobs when there are few other jobs to go to, but turnover is higher where other jobs exist. They say

This is significant not only because it helps to highlight the relationship between local labour market conditions but also because it suggests that social care remains something of a second choice occupation in those labour market areas where there is a choice of alternative occupations.
Having observed greater levels of job shifting behavior (and so higher turnover) in areas with higher job densities we can further hypothesize that mean wages of social care workers in these areas will also be higher as employers seek to encourage their employee not to seek work elsewhere, this would be particularly marked in lower-status
social care roles where the ties to a role may be weaker.

Returning … to our rural/urban categorisation we can see that average wages for care worker roles and senior care worker roles are indeed higher in rural areas than in urban areas. Registered manager roles are marginally more in urban areas; a likely reflection of the fact that managerial skills are more readily transferable and therefore more highly valued in the urban labour market than the rural labour market.

This report says that in England, 19% of homecare workers’ time was spent travelling. It also says that across the UK, roughly 80% of the care at home workers are female. And if they’re not being paid for travelling time, and travelling time make up 19% of their working time, they’re losing out on a fifth of what they should be earning.

No wonder the turnover is so high.

And when the turnover gets high, care agencies can’t meet their commitments. In my part of the world, I had been aware for a couple of months that one agency appeared to be having difficulties. Service users and their families were complaining that their allocated care workers were being chopped and changed. One woman told me her mother (who has dementia) received 29 different carers in the past two weeks. The agency acknowledged they were having difficulties providing staff, and we heard rumours of precautionary suspensions to investigate disciplinary allegations contributing to the staff shortages, a manager walking out without notice, and a management team being flown in from another part of the UK to take control. One of my service users asked me to reduce their care package from 2 workers for an hour morning and evening to one worker for 30 minutes morning and evening (because of an improvement in function and reduction in disability). That information was passed to the agency in early October, by phone and electronically. A month later, they were still sending in two workers for an hour, and said they had no idea they’d been asked to reduce the service. Disorganised doesn’t seem to be adequately descriptive.

And then on Monday, late in the afternoon, the agency in question emailed my employer with a list of people they are supposed to provide a service to, saying they were unable to cover the visits for the foreseeable future, and asking the council’s own homecare department to step in and cover, immediately. How on earth is a homecare department, reduced over the years as work has been outsourced to private agencies, supposed to cover several hundred hours of visits with only an hour’s notice before the first workers were due?

The home care managers and others have been working flat-out this week to find cover for the people abandoned by the agency, from within their own resources and from alternative private providers. Obviously, it hasn’t been possible to provide care to everyone at the times they usually get, or with workers they know, or in some case, to provide care at all. Families have been asked to help where they can, and I’m not aware of anyone who has been left with no care at all, but if everyone has been covered, by workers or by family, it’s been through good fortune and a lot of very hard work. It’s entirely possible that if this happened again, vulnerable people could be left with no care, because when you’re asked to provide 500 care hours, and you can only find the workers to do 350, something’s gotta give.

I’m astounded by how understanding the service users and their families have been. Yes, there have been grumbles, but on the whole even the grumblers have been reasonable and understanding in a situation where rants and shrieks and formal complaints would be understandable. One family member said to me “but the agency have just put the council in the same position the agency were in – trying to cover care with no workers to do it.” Really, they should be bellowing from the rafters their outrage that such a thing could happen.

Councils shouldn’t be outsourcing huge amounts of care provision. Of course there will always be people whose needs are best met by specialist agencies, such as specialist mental health providers, but the bulk of bread-and-butter home care should be kept in house, where the staff can be trained, paid and treated properly, and the service and staffing levels can be managed properly.

Where councils insist on contracting out their responsibilities, they should be specifying that the workers must be paid at least living wage, must be paid for travel time, must have access to a decent pension scheme, must have regular, good quality training and must have regular supervision – and the contract price should be one that allows for that. And if councils say they can’t or won’t do that, the whole of society should be asking why not? If we truly value the vulnerable people we have responsibilities to care for, shouldn’t we be doing everything we can to minimise the chances of their care provider walking away and leaving them without care? Shouldn’t we be doing everything we can to ensure that people with dementia have continuity of carers? Shouldn’t we be making sure that the people who look after our most vulnerable people aren’t driven out of their jobs because they just can’t afford to live on what they’re paid? Shouldn’t the men who go to work and make decisions rather than stay at home and care for their dependent relatives decide to value the work the women do to care for those relatives, rather than paying lip service to how much they appreciate it?

Something weird happened today

My boss and I were off to see a client and when we arrived at his house, there were two big suitcases and a carrier bag standing on the pavement outside his neighbour’s. They were still there when we came out, an hour later. One small black suitcase with a slightly open pocket stuffed full of grundies, one very full large black suitcase, and sitting on that, one Museum of Scotland carrier bag containing (so far as we could see without poking around in it) a coat, a scarf, some body lotion and a Sade tape. ??? The three bags were tied together with a mini-usb lead.

The neighbour was out so our client phoned him, and he said he didn’t know anything about it. We didn’t really know what to do, so I rang the police, and they said they’d send someone round to collect it, so we humpfed it into the client’s house for the polis to pick up when they have time.