How long for lunch?

Setting the scene
A few years ago, I was asked to do an assessment of some one's care needs.  The person in question had learning disabilities and lived in an hospital in the North East where he no longer resides.
The assessment was to figure out if the person in question was safe to be allowed to "re-enter" the community and live in supported accommodation. 

We were commissioned by the organisation who were to provide the supported living in the community.  They  were very concerned, as the story they were hearing from the Hospital was that he was an extremely difficult person and only staff at the hospital could cope with his extreme behaviours.  They weren't clear what theses behaviours were, but it was clear that they felt he was very dangerous.

The assessment
When we arrived at the hospital to do his assessment things became clearer and more murky at the same time.  The behaviours that were dangerous were constantly referred to, but no one could actually explain what these behaviours were.  All we were told was that it took on average 5 people to control him when he displayed with these behaviours and all of them were fully trained in control and restraint.

In our effort to find out why he was being restrained we asked a series of questions (none of which seemed to be answered in his notes or the care plans of the hospital).

• When is he being restrained most commonly?
• What immediately precedes the restraint?
• What happens immediately after the restraint?
• What systems are in place for ensuring that this restraint is necessary?

The responses we received were quite random.

• Some staff said he was totally unpredictable and it could happen at any time for any reason.
• Some staff said he was restrained for "non-compliance".
• Some staff said they never restrained him, so didn't really know when or why.*

The interesting statement that came out of this was the "non-compliance" rationale.  We then asked, what they meant by "non-compliance" and typically the answer was.  When he was told to get out of bed and refused.  It then transpired that every morning, he had to leave his bedroom (which was then locked for safety reasons) and go down stairs to the main area.  If he refused to leave, he was "warned" and if he refused again he was restrained on his bed.

Apart from the quite surreal catch 22 situation of being restrained in a room you've been told to leave, no one could tell us why he had to leave his room for "safety reasons".

This caused so much concern that we started looking at other rules that were enforced for "safety" reasons.
The main ones that seemed to happen revolved around food and drinks.

First example
Lunch was started at 11:40am and finished between 11:55 and 12:00 noon.  Staff stood over the patients and told them to hurry up.  They had essentially 15 minutes between walking in the room eating two courses, orange squash and then tea before they were ushered out again and the staff would then lock up for "safety reasons".  Now, I'm not saying that there are no safety reasons for locking up the dining room but what was interesting was that the patients had 15 minutes for lunch (and a majority of the incidents revolved around lunch time) and the staff had 45 minutes for lunch (strangely starting at noon).  When we suggested that it might be better if everyone had an hour and they all ate together, I was looked at with bewilderment and told that as I wasn't a qualified nurse, I probably didn't understand.  They were of course correct on both counts!

Second example
The other big example we encountered of food based control was when you could have a cup of tea.
While observing the person we were looking to support all the staff and patients were in the main sitting room.  All the staff were watching TV at one end drinking coffee and tea and all the patients were at the other end of the room either sitting or walking around.  When one of the patients came over and asked for a cup of tea, she was told "it's not two o'clock yet, go away".  When she started crying he said "she's always like that"


There were plenty of other examples of enforced rules which seemed to have no reason or purpose other than to make the life of staff easier and interestingly all the staff seemed to think they were doing an amazing job. 

We (as an organisation)were in a very difficult position unfortunately as these staff had a massive say on whether three of their patients were going to be released from their hospital and allowed to move into the community, also we needed their support to actually gain access to these three patients.  Fortunately all three eventually moved to the community and I managed to get hold of the new Nurse Manager of the Hospital who was an old acquaintance and report what was happening.  I'm pleased to say it was dealt with well.

Leadership
We as an organisation are an advocate of coaching and leadership training.  What was interesting in this particular hospital is that we did at least 5 days of observations in total.  Night shifts, day and weekends.  The nurse managers office was next to the main sitting room and not once in that entire time did either myself or my colleagues observe that manager enter the room or speak to a patient.  In fact the only time we saw them was when she informed us that we were wasting our time as he was too difficult for people who "didn't know what they were doing" to manage.

Conclusion 

So, when we watch Panorama and wonder how people can hit those in care, remember, it's not just the violence towards the vulnerable which can be abusive, it's the simpler things like refusing tea or forcing people to eat quickly or indeed forcing people to do things not for any other reason than it's better for you.
It's also poor leadership, bizarre rules and regulations with no purpose and the demeaning of people through the use of control.

*interestingly the staff who never restrained him had a very good relationship with all the patients and would often be seen by the other staff as being weak and "giving in".