How do you run a care home?

ViewsMay 10th, 2012

Punished by results: the dementia care home punished for excellence

In my last posting, I talked about understanding the cost in the flow of work, rather than just in the transactions.  In this article is an example of how focusing on transactional costs can have a potentially devastating effect on people’s lives.

Janet Bell and Jackie Smith have been running Spring Mount, a home for people living with dementia, for 24 years.  In that time Janet, Jackie and their team have delivered unparalleled performance.  Outcomes for residents stretch belief (when we visited, 4 residents were playing air guitar to Status Quo in the hallway!) and total system costs are unspeakably low.  The morale of those at Spring Mount is beyond compare.

This is all being achieved because Janet, Jackie and the team have rejected the myths governing dementia care:

Myths Governing Dementia Care

Dementia makes people…

– Less sociable & unable to enjoy new relationships;

– Sexually uninhibited & unable to understand sexual responsibility;

– Unable to make a positive contribution to group living;

– Unable to self-determine & make choices;

– Wander aimlessly;

– Unable to learn new things;

– Violent & aggressive;

– Lose their personality;

– Dependent on medication for control.

Their work has impressed the teams behind these Panorama reports and, years earlier, the team behind a similar programme for World in Action.  Back in 1999 the Nursing Times had been pretty blown away too.  Which begs the question, “Why aren’t others seeking to ‘do dementia’ the Spring Mount way?”

The answer is illuminating…Spring Mount’s unit cost to their local commissioner is £575 per week.  Other residential homes in the area charge £460 per week.  The commissioner thinks that Spring Mount is expensive.

However, the commissioner’s comparison doesn’t acknowledge that in its 24 years of operation Spring Mount:

– Has never had a placement break down;

– Has only once required the use of agency staff;

– Has never used anti-psychotic drugs for any of its residents;

– Has earned such confidence from the social workers who place there that they do not feel the need to review their placements;

– Has enabled such full and active lives for residents that their consumption of other health and care resource is demonstrably different and vastly reduced compared to other care settings (yes, that does mean that Spring Mount residents don’t turn up in hospital with Urinary Tract Infections).

Perhaps most striking of all though is that the commissioner’s comparison is to residential settings which would be utterly inappropriate to the needs of Spring Mount’s residents.  To a person, if Spring Mount were to close tomorrow its residents would all be moved to nursing care at a cost of at least £650 per week.

Spring Mount is cheap (that is, cost effective) but the commissioner cannot see it because of their frame of reference.  The consequence: the commissioner is now making it increasingly difficult for social workers to place there.  For the first time in 24 years Spring Mount has empty beds and no waiting list.

This is borne out of a particular way of thinking about the design and management of work:

Conventional Thinking:

– We must manage residents behaviour, cost & risk

– Cost and risk lie in activity and in residents behaviour;

– We must manage activity to control cost, leading to:

– Targets, functions, roles and responsibilities, focus on transactional and unit cost.

We must manage activity to control risk, leading to:

– Inspection, procedures, protocols, specifications, standardisation, policy, schedules, benchmarking, etc.

– We must manage residents behaviour to control risk, leading to:

– Managed spaces, visiting hours, anti-psychotic drugs, etc.

Resulting Ethos:

– Overt structures for control

– Extrinsic motivation – carrots and sticks.

Spring Mounts Thinking:

– We must provide a community in which our residents and their families can live well with dementia.

– Cost lies in any failure to provide and enable this community to thrive (if we get it wrong, costs are borne by us and other parts of the health and wellbeing system);

– Overt methods of control will destroy this community;

Providing this community means:

– Acknowledging and enabling the contribution which every resident, family member and staff member can make;

– Enabling risk taking and a positive attitude to risk.

Resulting Ethos:

– Control is implicit, discrete, purposeful, control as a consequence of solving problems which impede the community.

– Intrinsic motivation – pride in a job well done.

It is as Einstein said, “We cannot solve the problems we have created with the thinking that created them”.

As you can see from Spring Mount, people are thinking differently about the design of our health and wellbeing systems.  There is an alternative.  As a leader the place to start is by explicitly understanding how you currently think about the design and management of work.  From this, you can decide if you want to challenge that thinking before you start redesigning anything.  If you do challenge that thinking, the results can be extraordinary!

Change thinking.  Change Lives.

This article is an taken from: where more articles on Health and Wellbeing can be found.


Simon Pickthall worked in the public sector in Wales for many years before forming Vanguard Consulting Wales.  He has been fortunate to have worked with many leaders in Wales to help them understand their organizations from a Systems Thinking perspective –  and improve them as a consequence.  Simon was privileged enough to work on the Munro Review of Child Protection, and is committed to helping the public, private and third sectors deliver social justice.  [email protected]


Image originally from BBC

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