Changing social care: an inclusive approach
Case study: TerraBlu
TerraBlu Ltd (TB) is a private sector provider of domiciliary care founded in 2000 by director Richard Gould to provide care for children with disabilities. Since then TB has extended its services and now provides care at home to older people, adults and children with disabilities in the South East of England, west Kent and East Sussex. TB is an approved provider to Kent County Council.
TB employs 80 people and provides around 2,000 visit a week to clients in their homes 365 days a year. Understanding what clients want and getting their feedback and input to services is seen as central to ensuring the best quality of support. TB has a focus on providing high quality care to help clients retain their independence.
In addition to providing care at home TB also organises social events and signposts clients to other services such as gardeners or technical equipment support. Seventy five per cent of TB’s clients are older people. Funding for their services comes directly from clients either from their own money or via Kent County Council as part of Individual Budgets or Direct Payments.
In March 2008 TB was awarded three-star status (highest level, representing excellent quality) following an unannounced assessment by The Commission for Social Care Inspection.
In 2007 TB changed its organisational structure with three aims: to improve as an employer; to further improve the quality of the care provided; and to enable the business to continue to grow without compromising on the quality of service offered. The drive to improve as an employer came predominantly from staff turnover levels of over 70 per cent. The other two objectives came from a realisation that the company had essentially worked on a crisis driven agenda, where key management responded to the latest particular client ‘crisis’.
The next sections review the information gleaned from our interview with TB’s director, focusing on our 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 TB as illustrations. We conclude our case study with a summary of TB’s efforts at evaluating its improvement programme.
1 Leadership and purpose
The changes that began in TB in 2007 were as a result of a clear recognition by the director of a need to adjust the business model and improve the employee experience while keeping client service at the centre of all the work. The following section details the role of the leadership in the change process.
Leaders need to establish a clear sense of purpose and ideology to enable change and improvement
TB was originally set up with the ambition of providing care for children with disabilities. The business was set up on traditional models of domestic care with a small informally structured and managed team. The company had now outgrown this structure in which management didn’t have time to think about the broader issues of employee well-being or new ways of working, since it was caught up constantly in the day-to-day issues of the moment. Employees outside a small inner circle felt neglected; this had resulted in a high turnover rate of staff.
The director set a new direction for the company with a change of business model and a shift to making TB an employer of choice. The desire to provide high quality care for clients had always been central to TB and remained so. However, the director also realised that achieving high quality care required engaged and motivated employees who felt their employer cared about them. To establish what was fundamental to a good employee experience the director turned to the staff to understand what they needed.
With guidance from his mentor, the director set about establishing how to make the changes and engage staff. The shift in direction of the organisation required new skills for staff and an internal restructuring to allow for formal growth:
Good leadership is about listening and building a consensus and then setting a direction, and to support people to move towards this direction, but you need that interaction, engagement of the employees … you build that by creating a structure that you can listen to each other … leadership needs to energise people and bring them along towards a common goal. In TB it’s informal and fast changing. You need to talk to people to do it.
However, the director felt that the underlying purpose of delivering excellent service is not one that always energises people. He believed that all staff accept delivering high quality service as the right thing to do. Yet, because delivering high quality care can be unrelenting on the support worker, it often exhausts rather than engages them (and their families). In consultation with the staff he established that what energised employees was being clear about goals, using terms such as ‘I want us to be … ’ or ‘let’s be … ’. The message for change that met staff needs was ‘we want this to be the best place you can work in homecare’.
Leaders create the conditions to enable change and improvement
To grow effectively while achieving a high quality of care in a larger organisation, TB had to move away from an informal structure and management style. The director used his experience from working previously in the army and business to build smaller teams and push responsibility and accountability down the organisation. These methods were uncomfortable for some employees but the director believed these processes were essential to ensure a profitable business, high quality of care and employee engagement.
First, the director established a senior management team that could take responsibility and control for delivery and standards of care as well as pastoral supervision for staff. Several models of hierarchy were tried with managers responsible for different groups before a final structure was agreed, focusing on responsibility for geographical regions. The purpose was to cascade leadership throughout the organisation. Core to the success of the model is empowerment of employees from the management team through to the frontline staff. Instead of a traditional model of having responsibility solely for the administration of care delivery in an area (e.g. developing a staff rota, undertaking client assessments and completing associated paperwork and follow up), care coordinators now have responsibility for leadership of their teams. This additional responsibility involves leading, motivating, developing and mentoring staff in their teams and is a big challenge:
Social care is generally about delivering statutory objectives, delivering wider social objectives, but I’ve realised that we need good social care skills and something more, which is this ability to motivate others and to take responsibility for delivery throughout the organisation.
The director reskilled and recruited staff where necessary to fit the new focus of the organisation to deliver good social care and to support and motivate employees at the same time.
Respond to issues, but do not compromise on direction
For some employees the changes were uncomfortable as they were in contrast to many traditional models of social care with small informal businesses and workers almost working their own client franchises. The director worked with staff where possible to address concerns but ultimately retained and recruited staff that were fit to deliver the new business:
Sometimes you work it out and you meet at the common ground and engage that person. But sometimes you don’t and if you don’t then I’m afraid it’s not the right environment for them and you part ways, sensitively and supportively, but you part ways.
Part of TB’s new direction is empowerment of its employees and holding people accountable for their actions. However, doing this means managers have to be tough and not accept behaviour that does not fit with the desired organisational approach:
We’ve bought in this fabric of empowerment and accountability, but there is a flipside, which is that you are accountable. Some people don’t like this and leave. As an employer you have to accept this, even though traditionally it has been a struggle to recruit sufficient support workers to cope with demand.
Sometimes TB meets resistance to its approach from those in the wider community. The director is very clear that as a leader you need to set a direction and be ready to go ahead with or without support:
You can listen and you might get support but you won’t always. You need to be sensitive to listen to others who say you might possibly be off course. One to one meetings can even add to your momentum, but you don’t stop in your tracks because of lack of support. Change only happens if you stand up and change.
Communicate underlying purpose and ensure actions are consistent with this purpose
Communication within TB is done through a variety of mechanisms recognising the need for fluid communication across the whole organisation and with clients. Newsletters are produced throughout the year, separately to clients and employees, communicating themes and the direction of the organisation. Team meetings are also used as a weekly form of communication so that messages from the director and management are cascaded down. Communication is not simply top down from the director and management team – team meetings are also used as a way to feedback to the senior team. The director also accompanies staff on home visits to receive feedback from clients but also as an informal way of understanding staff concerns and ideas. Acting on feedback and ensuring actions are consistent with communicated intentions has been a central part of the improvements in TB. One of the central pieces of the change was to ensure staff felt valued and cared for as feedback from staff indicated this was poor prior to 2007. Ensuring staff feel cared for by their care coordinator and the organisation meant the director had to communicate the standards expected and that actions reinforced the communications to staff that TB was valuing them. For example, weekly team meetings had to be held, cancellation was not an appropriate option and mentoring needed to be a priority for managers:
The comment we got from employees was often, ‘I don’t want to call my care coordinator because he’s/she’s so busy, calling around, dealing with this or that important issue. I’ve felt that my issue wasn’t important enough’, and not because their care coordinator has said they felt their issues were not important enough but just because when they call the care coordinator, he/she was stressed, you know in a rush and whatever, and so we’ve still got to work on that, trying to get care coordinators to make time for your staff and make time to listen. Reinforcing the mentoring and making sure the care coordinators have time for their employees has been fundamental.
Not having time to care for employees was not an acceptable option for the director. For him it was essential that employees were looked after and therefore managers had to find time to do so:
It’s just my style, some people will like it some will not. In this environment people who say ‘I can’t do A because I’m already doing B’ don’t survive, they get upset. People who say ‘I can’t do A, because I’m doing B at the moment, but if I do B different I can do A or listen I’m not sure if I should be doing A or B can you give me some direction’ – those people thrive.
Stakeholders need to be on board with the underlying purpose
The director worked with employees and clients on the reason for the changes and how to go about effectively making transitions. It was important that everyone understood and was working towards toward the same goals. This meant stepping up to new responsibilities and new ways of working. The director also recognised that for others there needs to be a ‘calm backwater’ for those who have good care skills and are happy for the organisation to change but do not want to take on extra responsibility or upskill:
You need to keep people energised and engaged. You also need to make sure you develop calm backwaters for people who are happy to do a good job but they don’t want to lead or develop their career, that’s absolutely fine. They still need to be on board with the changes but they might not want to stretch themselves further.
The director also believed that to ensure improvements are continuous and do not stagnate the message to staff and communication of the common goal needs to be continually refreshed. To that end each year TB gets staff ideas on how best to communicate and take action to make TB the best place to work. The director also inputs his ideas on what is needed to ensure this happens.
2 Employee involvement
Engage employees – give them responsibility
One of the important transformations within TB to restructure the business was to increase the personal responsibility of employees for outcomes throughout all levels of the organisation. The aim was to empower employees to be able to take action wherever they felt it was necessary to do so in order to achieve high quality care for their clients:
I want to move from a sort of cottage industry type organisation to being a more professional scale company in which you can objectively measure quality assurance, you need to cascade down that leadership within the organisation and it means actually letting go of something, still measuring them and holding people to account, but letting those responsibilities cascade down, that has been a brilliant thing.
Initially the director was concerned that relaxing control of the day-to-day at the top would mean standards of client care would fall but he has found the opposite to be true:
I had been worried about it that we were going to lose a level of quality but it was the right advice to push control of some things down to the care coordinators. And by doing that and reinforcing their standards it’s been great, it started a real group of engaged people at different levels in the organisation.
Establish a structure that allows engagement
TB has a variety of structures to engage staff in the process of improvements:
- weekly team meetings that discuss client and company issues
- yearly week away at a ‘care academy’ for members of staff from different levels to undertake training and to work on ideas for new initiatives to make TB a better place to work and deliver excellent care to clients
- staff forums
- social events with clients
- unplanned contact where director ‘drops in’ on home visits with staff
- new initiatives proposed and enacted by individual employees.
Engaging staff also means ensuring managers are encouraged and held accountable for supporting teams so that engagement is more than words and is actually done in reality. For example, the director asks his senior care manager about staff mentoring and welfare issues in their weekly meetings and requires updates on progress being made on actions.
Not all the ideas happened easily. For example, the staff forums took time to get people engaged and willing to take part but the director believes these have been a valuable way of hearing opinions from vocal and quieter employees.
TB also set up informal social events with employees to help people interact and engage with each other across teams. This helps people to get to know each other and exchange feedback.
TB does not have time to undergo large formal consultations with staff, but does need to consult and engage staff.
Get communication channels right
TB has a series of regular meetings that enable communication to go throughout the organisation. Given the disparate nature of homecare, structured small meetings had to be developed to allow information to work throughout the organisation in small groups. Both client and company issues are discussed in these meetings and the director personally holds managers to account on actioning issues that are raised:
In weekly team meetings we talk about all the stuff going on in the company. I hope we have a good dialogue, it’s a demanding job and a demanding environment, but I hope it’s fun. Meetings allow us to support each other and feel part of the same organisation.
Work with resistance
‘I think people often resist because you haven’t enthused them in the direction you’re going.’
Smaller forms of resistance were encountered on specific new measures. For example, the director wanted to set up an ‘employee of the month’ scheme but not everyone agreed, feeling it was against the team spirit of social care. Now the scheme is in place it has been a great success with over 80 per cent positive feedback from employees.
Some employees were also negative about taking staff away for a training week due to the time involved and the cost of going off site. However, since these schemes have been put in place they have delivered on making staff feel valued and involved in the business:
What I find is often the case with resistance is actually you haven’t taken time to listen to the person. And so you do that, you talk it through in a very open way. I think openness is very important, openness and transparency, and giving people personal confidence. If people are not confident and empowered they don’t feel open, but if you do support them and you do give them responsibility and you’re open with them, it helps to unlock what’s at the heart of people’s resistance.
Give staff support to adjust and adapt to improvements
Making the improvements involved lots of changes to the organisational structure, to the jobs that nearly all employees were doing, to the composition of the client base and to the culture of the organisation. To ensure high quality service it was important that the staff were engaged and motivated. Taking people through such major improvements meant the director and management team needed to communicate with employees and allow new, fresh ideas to flourish. The new responsibilities for many employees required a different skill set to those they had acquired through their technical social care training.
The director set up training days for the care coordinators for them to learn how to lead their teams. The training days he devised look at models outside social care to see what leadership works and what can be applied to social care work. Looking outside stretches employee thinking and helps them to be creative. The course is one mechanism to help to build the personal confidence of TB leaders as a key part of successful leadership. Traditional training for social care workers focuses on technical skills and expertise which are essential elements but it does not provide leadership training. The training course developed by the director is designed to cascade leadership skills throughout the organisation.
Ensuring both clients and staff have what they need to do an excellent job is an ongoing process and the director takes a hands-on approach. For example, he regularly attends home visits with frontline employees. This provides him with an opportunity to get direct feedback from the clients but also allows him to spend time with the employees and learn about large and small things that are affecting their opportunities and abilities to deliver high quality care for their clients:
I go out on care rounds. I do nothing in particular on these rounds; I put gloves on and get in the way a bit but it’s valuable for two things. One is that clients will tell me at seven in the morning what they really feel about our services, and this is great feedback to me. The second is that in between calls I’m getting feedback from a number of staff about whether they feel supported or not, and if they are not I will come back and tell the care coordinators.
3 Stakeholder involvement
People who use services should be at the heart of change and improvements
TB refers to clients and not ‘people who use services’. The director acknowledged that this is in contrast to the normal social care terminology. For TB, ‘people who use services’ suggests passive recipients. ‘Client’ in contrast reflects the important active and central status of those for whom the care is provided.
Ensuring clients are involved in the delivery of their care is important. The director’s home visits on a regular basis provide him with the best form of feedback from clients. Staff also organise social events for the clients which provide an opportunity for informal feedback and engagement with clients. Clients can also nominate any employee for ‘employee of the month’ as a way of incorporating their responses to positive activities or actions employees are taking:
Consultation with clients is fundamental. You need to be confident enough to be open, to listen and respond where you can to key messages. Sometimes you need to change direction in response to these comments. You need to involve clients in a variety of settings. Listen to what would materially improve their quality of life.
TB also runs client forums. These are a more formal way of getting feedback from clients but the director has found them very useful. Clients who wish to are invited to join these forums that are held quarterly for one hour. Clients who are particularly vocal and have strong opinions are encouraged to attend. The forums are held in a central location and taxis, if required, are sent to clients’ houses to collect them. Opinions from less vocal clients are encouraged but are often gathered from home visits or social events instead.
Organisations need to work in and with the communities they serve
TB as a business sometimes find itself kept at arms length by social services and the voluntary sector because it is a private sector company, despite the fact that independent providers supply some 70+ per cent of homecare in England. TB works at engaging with other organisations delivering similar care in order to try to provide a joined up service to their clients, but positive feedback from clients suggests they are managing to deliver a good service at present without joining up.
TB considers its most important community to be its clients, employees and their families. The director believes that one of the best ways to deliver a better service to clients has been to think of them as part of the TB community so that they are an extension of the goal of being an employer of choice. Some great examples of the success have been clients and staff volunteering to help out in initiatives such as social events, and relatives of clients then joining the company as employees.
‘I wanted the company to keep caring at its heart, but evolve away from informal networking to be a professional company that had measurable processes.’
Evaluation has been planned into the improvements to ensure that the organisation can see what changes are being made. Evaluation measures used by TB include:
- regular staff supervisions
- client and staff forums meeting quarterly
- retention rates
- client annual survey (run in the past by Age Concern as an independent third party)
- anecdotal feedback from employees at regular social events.