Changing social care: an inclusive approach
Case study: Age Concern Sheffield
Age Concern Sheffield is an independent organisation dedicated to supporting and improving the quality of life for older people in Sheffield, particularly the vulnerable and isolated. As a local organisation it feels it is best placed to understand and respond to individual vulnerable persons’ needs. As part of a national federation of over 400 organisations, Age Concern Sheffield can also create an impact on national issues. Age Concern Sheffield has a Support People Contract to deliver tailored one-to-one support to older people at risk of losing their homes. Age Concern Sheffield services include a home visiting advice service to help older people access their entitled benefits as well as day services to reduce social isolation and facilitate older people’s participation in worthwhile and enjoyable social activities.
There are six centres in the Sheffield city region with approximately 40 employees that support more than 100 people whose ability to continue living independently in their own homes is threatened by either dementia or poor physical health.
Age Concern Sheffield comprised a range of services run by committed staff who had been in their jobs for a long time. The organisation had grown steadily and achieved much, but the staff grew increasingly dissatisfied and wanted more information about what was happening within the service and greater flexibility and skills to provide the best services they could to people who use services. Over the past several years, Age Concern Sheffield has explored and trialled different mechanisms of staff feedback, consultation, training and job roles to ensure its structure and mechanisms are adequate and appropriate and enable people who use services to maintain their independence. Changing management structures and internal procedures now ensure that staff are able to target their services to reach more people in less time and provide a more effective and comprehensive service when they do reach people.
The following sections review the information gleaned from our director interview and the staff and service user focus groups with Age Concern Sheffield, focusing on three key themes: (1) leadership and purpose; (2) employee involvement; and (3) stakeholder involvement. Each theme comprises a series of sub-themes and we provide relevant examples from Age Concern Sheffield as illustrations. Refer to the knowledge review, practice review and analytical report, 'Improving social and health care services', for a full review of the themes.
1 Leadership and purpose
Our knowledge review revealed that the presence of an effective and passionate leader can help to drive service improvement. This section details the role of leadership in Age Concern Sheffield’s improvement initiatives.
Leaders need to establish a clear sense of purpose and ideology to enable change and improvement
In Age Concern Sheffield, the purpose had always been to improve the quality of life for older adults, yet the most efficient and effective ways of arranging and managing the organisation to enable staff to reach more people and provide a better and more nuanced set of services were less clear. The previous director was struggling in an increasingly vulnerable organisation. The new director arrived to a service that had grown steadily, but had remained relatively unchanged over 23 years. The staff were very dedicated to what they were doing and knew how to do their jobs, but were dissatisfied with the current state of the organisation as they felt a disconnect between their jobs on the front line and the larger purpose of Age Concern Sheffield. There were no meetings or discussions between the different departments, nor were there forums for exchanging ideas, learning or monitoring. Although the director’s experience gave her a good sense of some of the improvements she could make, she engaged in extensive consultation with staff members, the board and volunteers, and continues to systematically review each service Age Concern Sheffield provides.
The new director was specifically chosen due to her previous experience in leading organisations through change. She was also strongly aligned with the need for people who use services to be at the centre of any service delivery. Having clarified the underlying purpose with staff, she then had to identify what specific components of the organisation needed to change to ensure that its ensuing activities supported its purpose. She carried out consultations with staff to tap them for their expertise as well to identify their needs in the change process. The agreed sense of underlying purpose came first and mechanisms that enabled necessary changes such as funding were subsequent.
Leaders create the conditions to enable change and improvement
All staff interviewed acknowledged that the arrival of the new director had been the turning point for change and that the leader had enabled that change. Beyond clarifying the purpose and ideology of the organisation, the director created the conditions that allowed it to shift in the desired direction. Specifically she engaged in the following activities:
- giving front-line staff more responsibility to allow them to affect the outcome of their day-to-day jobs
- creating a senior management team
- creating cross-team committees for information and management exchange
- engaging staff
- engaging resistance
- engaging external key stakeholders
- reviewing processes
- being accessible.
Respond to issues, but do not compromise on direction
One staff member at Age Concern Sheffield contrasted the more formal style of the previous director with the current directorship and claims the environment is ‘a lot more relaxed now’. Yet, this certainly does not imply that the current leader is an easy target for opposition. The director was clear that one of her primary roles was to respond to issues raised by staff, people who use services or members of their organisation, but that in doing so she must also not compromise on the direction of travel. The director of Age Concern Sheffield said, ‘Leadership is key. You need to work with people but do not appear weak. Do not be afraid to say this is my vision.’ The director recognised that it was necessary to make discussions and disagreements acceptable:
Staff want to know what is going on and what the parameters are. It’s important to start with mutual respect and from the point of view that I respect what you’re doing, what you’re doing is valuable and vice versa. Beyond that we may have a disagreement. Disagreements are kind of taboo; people find it difficult to deal with them. There’s a desire for everyone to reach a consensus or pretend there’s one when there isn’t.
Make it part of the culture that it’s okay to have differences. It’s okay to discuss, but it’s not okay to get aggressive, and then it’s okay for a decision to be made that not everyone likes. We have some way to go on this, but we’re getting there.
Communicate underlying purpose and ensure actions are consistent with this purpose
Communication of the underlying purpose and ideology to others was key to the change process at Age Concern Sheffield. Communication involved capturing the values that already existed and ensuring that everyone was aware of them and engaging in observable behaviours that indicated their dedication to the new purpose.
Staff consultation initiated a two-way communication process. Methods used by the director to communicate with staff included the following:
- meetings with each employee
- group consultations with staff, including brainstorming exercises
- newsletters in the pay packets of all employees and volunteers
- personal telephone conversations
- group meetings and consultations
In Age Concern Sheffield, the director captured the values that employees associated with the organisation and the way they wanted it to be using one-to-one interviews. She analysed the responses and fed the results back across the organisation, predominately via e-mail. The resulting documents also included targeted actions based on the staff’s suggestions and needs.
However, while Age Concern Sheffield reported general success with its chosen methods of communication and consultation, it highlighted that its methods were not foolproof. All methods of communication need to be field-tested and consistently monitored to ensure maximum reach.
Stakeholders need to be on board with the underlying purpose
The director engaged a core nucleus of supporters to move her purpose and vision forward. Part of this engagement involved capitalising on the enthusiasm of the staff to build support and propel the improvements.
As a first strategy, the senior management had extensive consultation sessions with members of staff. The director set up one-to-one sessions between herself and each employee. The feedback and key messages from these meetings were reported back to all employees and plans for the future were developed using the evidence from these staff engagement exercises.
The director acknowledged there were limits to her abilities to ensure the values were spread throughout the organisation. Even where staff had been specifically encouraged to shape the underlying purpose, there was recognition that not everyone would be comfortable working in that environment. As the director commented:
There’s lots of opportunity and options to help people come on board…Ultimately, people know I can sack them if their performance is not satisfactory. There is an expectation that people will come to work and they should stay...you need to put effort into making sure that people’s expectations are appropriate.
In these instances she commented that there were procedures in place to dismiss those individuals who were not able to work in the same direction as the organisation. In some instances this also meant that board members left.
2 Employee involvement
The director recognised that employees were the key deliverers of their services, and thus real improvements could not happen without them. The Age Concern Sheffield director recognised that good practice involving employees in change and improvement programmes builds on staff expertise and how they do their job. Effective involvement meant ensuring that employees had ownership of the changes and improvements. The employees were encouraged to view continual change and improvement as part and parcel of their work and were readily engaged in the process of clarifying how the purpose should be carried out in day-to-day practice.
Engage employees – give them responsibility
An integral part – and outcome – of the change and improvement process for all of the organisations was employee engagement. There was recognition that if employees were given responsibilities in governing the direction and developing the specific actions that encompassed the improvement programmes, they would be more likely to take ownership of them.
One of the key improvements suggested by staff in the one-to-one consultations was to give them more responsibility, including how they organised their own time and resources and, in some cases, how they used their budgets. Despite requesting more responsibility, the reality was often a frightening experience for staff as they could no longer ‘pass the buck’. For example, one member of staff found the scope of being able to ration her department’s budget both exciting and anxiety-provoking at the same time. There was realisation that the responsibility for allocating resources now rested on her shoulders and she could no longer rely on the excuse that she could not do something she wanted because she did not have adequate funds. To facilitate the new staff roles, the director recognised the need to support people in this process. For example, when renegotiating contracts, the new HR manager wanted to try new processes to redefine job roles (i.e. create new job descriptions, move from sessional to fixed contracts etc.). The director needed to empower her to do this by giving her the necessary permission and information to enable her to use her initiative to complete the task. In other instances the director acted as a mentor to staff in their new roles, particularly those moving up to form a senior management team. To ensure that she supported the staff, she initially found herself more involved in operations than she would like to have been. Staff were generally positive and excited about being given more responsibility. A staff member said, ‘I enjoy my job a lot better now. I have always enjoyed my job but it is a lot more interesting having more responsibility.’ Structures were set up where people could interact and learn from each other and communicate better; this was intended to provide more support for everyone.
Establish a structure that allows engagement
The organisational structure of Age Concern Sheffield is hierarchical. This does not mean that staff have no say in organisational improvements, however. Following consultation exercises with employees, the directors circulated documents encompassing the feedback and explaining how it would contribute to the next stage. As a direct consequence, various interdepartmental consultation groups are in the process of being set up to allow for cross-fertilisation of ideas. One such group will be a sounding board for new policies and procedures. This process also avoids ‘reinventing the wheel’ by making learning and communications more efficient.
In Age Concern Sheffield, staff commented on how they felt their contributions were valued and taken seriously. When asked about what aspects of their job were good and made them feel satisfied, the following staff responses illustrate the importance of how small things contribute to the overall impression of an organisation:
Very rarely two days are the same. There are new things starting and coming up, new challenges and directions and also the feeling that my contribution matters. Also being asked about what I think of the way things are done, even in my induction they asked me what my impression was: what did I think about it, how did you think it was, did you think things had improved. Even at that stage I was being asked to contribute. I got the impression even at that stage that if I said ‘I wonder if it could work’ that it would have been noted. So it’s being asked for your ideas.
It’s very similar in my job, the encouragement as well. We have meetings and are asked to put across how we think it could improve and how we think it could get better.
Get communication channels right
Communication methods need to be accessible and ‘user friendly’ for all. Simply going through the actions of communicating without verifying that everyone receives the message is an ineffective – and exclusionary – method of spreading information and ideas. In Age Concern Sheffield, it was necessary to ensure that computer access was expanded within the organisation so that all employees could take advantage of electronic communication. This system included IT training, intranet and newsletters.
Flexibility in communication was also reported to be important in Age Concern Sheffield. The director had introduced critical event audits (CEA) as a way of exploring the key actions, events and circumstances that occurred when service delivery did not go as expected or was unsuccessful. As part of this process it was necessary to gather attendees who were willing to share their experiences on the front line for audience critique. To do this, it was essential for the organisers to communicate that the purpose of the CEA was to create a learning experience for all attendees, not to blame or incriminate people. In this instance, the director saw that it was necessary for her to be flexible in her approach. She thus employed a variety of techniques based on the lessons learned from the first couple of attempts at conducting CEAs. First, one-to-one sessions were required with the key personnel involved in the critical event and, in some cases, their line managers. Second, an external facilitator was brought in to help make the tone of the event more neutral, rather than seem castigating. Finally, results of the CEA were written up by one of the participants and distributed widely. This final stage was implemented to ensure that the outcomes were fully disseminated. Wide dissemination – and reiteration of the positive tone of the event – was thought to help garner support for future CEAs. Effective communication about the reasons behind CEAs should help to ensure employees feel thoroughly involved in the process and that they can contribute to and learn from the outcomes to help the organisation deliver better services. Each time the organisation held a CEA, it learned from it and used employee feedback to improve it.
Work with resistance
Resistance to change and improvement is often framed in a negative light. The director of Age Concern Sheffield was adamant that resistance could be beneficial to the improvement process. As part of the consultation process, the director organised away-days for staff to get involved with planning the improvements. Ensuring those with dissenting opinions were involved in the process meant they had a platform to air their views. The director used this opportunity to understand potential barriers:
Sometimes changes have been brought about because people who are often seen as ‘difficult’ often have astute ways of looking at things...They know the barriers that you’ll have, so you can use that to learn what the barriers are likely to be and then see how you can get round them...Give people a platform to air their views. You might not agree with them but it’s important to hear them.
One exercise used during the away-days to help the director constructively establish views was to ask staff to conduct SWOT analyses (identifying Strengths, Weaknesses, Opportunities and Threats). In some situations she employed external people to interview staff and volunteers to get their perceptions of barriers and opportunities.
While some degree of resistance or dissent was expected, there were instances of resistance that were unhelpful and indicative of a lack of commitment to the organisation and its improvements. One example from Age Concern Sheffield that was seen as particularly unhelpful was when some employees chose to deliberately disengage from the change programme. Specifically, there were two or three staff members, known to object to the change programme, who did not turn up to the initial staff away-days. The director directly challenged this behaviour. She made it clear that it was acceptable to hold and express dissenting views, but only if you were involved in the consultation process. In this instance, with extra attention and support, these colleagues were persuaded to take part in the process and make a valuable contribution. While it was important to give staff time to come on board, the director recognised that it was equally vital that the process did not lose momentum – and potentially the enthusiasm of other staff. Not everyone will initially agree with the changes and improvements, particularly if something they suggest is not heeded. The director argued that the goal of leaders in these cases is to allow staff to air their views and try to get to the underlying issue at hand, but also to encourage staff to participate in some of the improvements before disengaging from the whole process.
Give staff support to adjust and adapt to improvements
The improvement initiative at Age Concern Sheffield resulted in changes to existing staff roles and the creation of new posts. Age Concern Sheffield used personal coaching to help some members of staff assess how they could best develop in the new organisation. The director believed that personal coaching was a valuable tool and should be available to a range of staff, not just senior management. Where the improvements involved renegotiating contracts and job descriptions in Age Concern Sheffield, staff were given opportunities to engage in role plays with a trained actor to help them assess their own preferences for the new roles and where they felt they needed development.
Similarly, to help people adjust to improvements in service provision and organisational structure, all new staff in Age Concern Sheffield were required to shadow other staff members for two days. Following the success of this induction technique, shadowing was universally rolled out so that all members of staff now have the opportunity to shadow others or have someone shadow them, reinforcing an atmosphere of mutual sharing, respect and cross-departmental learning. One staff member said:
Quite a few people have shadowed me and I have got quite a lot out of the person who is shadowing me because of the department they have come from. So you do find yourself interlinking, once someone has shadowed you, you tend to ring them and say ‘I know you do this now’, it is really a good thing to do the shadowing.
The director of Age Concern Sheffield recognised that people often found it hard to find time to make improvements or think about how to make improvements, particularly when they felt that time constrained them from doing everything they would ideally like to. The director explained her response when staff questioned how they were supposed to find time to make improvements:
Everyone says that. It’s true because they haven’t been sitting there twiddling their thumbs. So, approach it like that. The starting point is mutual respect. Let’s look at how you’re spending your time. Also, how can we marry what you’re trying to achieve with the change that needs to be brought about? Staff are genuinely committed to providing a good service and respond well to being asked. Work with the motivation that they’ve already got. Then explain that we don’t have to do this perfectly. It’s okay to make mistakes. It’s okay to do it good enough. There are practicalities. I always think that people can rearrange their priorities. If it’s going to help them do what they want to do then they will. It’s getting people to shift their perspectives. They don’t think at the end of the week, I’ve done it all. It’s nice but it’s not realistic. At the end of the day, I’ve done as much as I can possibly do. You have to feel the pay off and that pay off is that they’re making real changes.
The staff at Age Concern Sheffield also commented that it is important to work in a safe environment where development could be discussed with peers and managers:
I think it is about working in a safe environment where you feel you can approach your line manager and say if you don’t feel confident in an area.
I do think approachability of more senior people is a lot better now. You just feel more comfortable with the people. The last manager was a lovely person, but it was just an image that was portrayed around her I think. I remember when I came for my interview I was told I must address her as Mrs X and it really stuck, every time I saw her after that I would still say it. Whereas things seem to be a lot more relaxed now.
The director of Age Concern Sheffield highlighted that while improvements and alterations can be rewarding, they can also be frightening and challenging. Supporting staff through improvement involves being approachable and creating a supportive environment for people to develop in. While all involved need to be aligned with the underlying purpose of the organisation, they also need the opportunity to see how they can best contribute to moving the organisation in the right direction.
3 Stakeholder involvement
In this context we refer to stakeholders as governing boards, people who use services or member organisations. In Age Concern Sheffield, as with all of our case study organisations, the people who use services and high quality service delivery were central to the improvement initiatives. This section will review some of our findings on effective stakeholder involvement from Age Concern Sheffield.
People who use services should be at the heart of change and improvements
The situation at Age Concern Sheffield showcases how traditional forms of service user involvement are not always the desired state. Staff found formalising feedback and engaging involvement from their elderly users difficult. For example, when asking their service users what could be improved, staff reported that people who use services generally said that ‘everything was fine’ because they were worried their service would be taken away if they said anything to the contrary. An initial attempt at using questionnaires to systematically capture feedback did not work. The director is now looking into alternative ways to obtain feedback in a way that works for the service user population, but that is still systematic enough to be useful to the organisation in meeting its statutory requirements. For example, a condition of Department of Health funding is that projects are evaluated for their effectiveness; one part of this is assessing the quality of the service from the users’ points of view:
Doing this will involve visiting people and asking them personal questions. For confused, isolated and depressed people having someone ask personal questions about the quality of your life is deeply threatening. Clients don’t want this; they just want tailored stuff to help them live their lives. A lot of stuff we’re required to do is counterproductive. I don’t want to add to this. We need to develop a new way of involving customers that doesn’t involve asking them all sorts of questions. For example, can we use face-to-face staff as interlocutors for life stories – techniques such as narrative gerontology or grounded theory – use some academic things with practical applications so we integrate service users’ views systematically.
Our service user focus group confirmed that most of the users of the particular day centre were content with its offering. Yet, more or better involvement was warranted or even desired in several cases. First, some users felt that changes to the provision happened too quickly: ‘There’s one thing one day, then something all together different another day. To try and keep up with it all, it’s difficult.’ Second, there was some appetite for further involvement in research initiatives such as focus groups under the condition that, ‘If we can get something done out of it. If good comes out of it’. Finally, some users claimed that they would be happy to engage in involvement initiatives if they ‘got them out more’. These examples suggest that there does seem to be some room for better communication and sharing of information with older people who are users in general, and greater involvement for users in research when it engages the users and they can see a means to an end.
Organisations need to work in and with the communities they serve
In addition to people who use services, the director of Age Concern Sheffield was keen to ensure the engagement of other key stakeholders from the wider community. She works hard to engage with board members and other local community organisations to ensure the necessary support is available for Age Concern Sheffield but also that Age Concern Sheffield is aware of community-wide changes. Negotiating the intricate web of stakeholder involvement requires a great deal of effort and persistence but the director of Age Concern Sheffield is convinced of its importance for service delivery.
Age Concern Sheffield was involved in several forms of evaluation, both formal and informal. As the improvements were ongoing, the evaluations were not simply one-off in nature.
In addition to the CEAs previously discussed, Age Concern Sheffield is also in the process of establishing formal methods of evaluating the quality of the services they offer. The organisation aims to make their evaluation informative rather merely a ‘ticking the boxes’ exercise or something for a positive external image. Age Concern Sheffield is in the midst of establishing various assessment teams including one focused on quality, another on new service implementation and another on finance. These groups are to set clear goals and objectives that tie in to the larger business plan (which was originally distributed to all employees and was based in large part on the one-to-one meetings between staff and the director). The organisation is also establishing a performance management framework that assesses outcomes relevant to staff and to the larger organisation. These key performance indicators are being developed in concert with staff.
The director at Age Concern Sheffield also uses more informal methods of evaluation such as ‘external critical friends’. A critical friend is someone the organisation trusts and who is ‘on their side’ with experience and ideas. For example, she has used this technique with the finance team, when implementing the new IT system and during recruitment.