• Care home policies on oral health and providing people with support to access dental services
• Oral health assessment and mouth care plans
• Daily mouth care
• Care staff knowledge and skills

CQC, during their discussions at the Regulation of Dental Services Programme Board and with other stakeholders across adult social care and primary care, highlighted that awareness and take-up of the NICE guidelines were still low.

CQCs review included dental inspectors attending 100 routine planned inspections of care homes alongside inspectors from their adult social care team. They spoke with managers and senior staff members as well as people who use services, and their relatives, to find out about their experiences of care.
Smiling Matters is a report of what was found in those homes, conclusions and recommendations for action.

In Apple House care homes, we have used the report to raise awareness of the importance of clear guidance within our own homes to ensure that access to regular dental check ups, care plan guidance and daily mouth care is and continues to be an important part of a person’s person-centred support. We have found that staff training is crucial and this goes hand in hand with the understanding of creative support plans which reduce barriers to people receiving oral healthcare. An area of action will be to include how people find this experience within our annual service user survey to gain the views of the people we support. An area of excellence was found to be specialised training received by members of staff which has been rolled out to the teams. The report has been discussed and communicated throughout the organisation at senior, team and service user meetings.
One of the recommendations from the CQC report is:
That NHS England and local commissioners:

• Work with the care home sector to avoid lengthy waiting times for appointments and treatment and provide emergency appointment times. 

• Work with GP practices and other primary care contractors, such as community pharmacists, to establish local arrangements to signpost people to dental provision. 

• Provide adequate capacity to provide routine and emergency treatment to people in care homes. This should be linked to a clear, measurable outcome around avoidance of GP appointments and A&E attendances resulting from dental crises.

You can read the full CQC report ‘Smiling Matters: Oral health care in care homes’ here.

Romaine Lawson, Director of Operations, Apple House care home group.

What is Autism?

Autism is a lifelong developmental disability that affects an individual’s behaviour and communication. People with autism may lack social awareness, emotional reciprocity and the ability to sustain conversations. Autism Spectrum Disorder (ASD) is characterized by severe and persistent deficits in social communication and interaction (American Psychiatric Association 2013). In the UK the Autism Act (2009) led to the government producing statutory guidelines for autism. With a clear pathway of diagnosis, where everyone has a right to an assessment. 

Most parents notice some symptoms of autism when their child is two or three years old but these symptoms can change as the person gets older. The characteristics may be different in girls than in boys so diagnosis can be difficult. There is also a lack of a genetic or medical testing and the impairment may also be accompanied by other conditions such as epilepsy, ADHD and learning disabilities. People with autism may also have a co-morbid mental health condition such as anxiety or depression.

Features of Autism

Wing and Gould (1979) identified a Triad of Impairments with difficulties with social communication, difficulty with social interaction and difficulty with social imagination. People with autism may find it hard to keep eye contact due to an overload of speech, facial expression and body language data to process. They may also be unaware of personal space and may be unaware of non-verbal cues in communication.

They may also exhibit restricted or stereotypical patterns of behaviour and can be hyper (over) or hypo (under) stimulated by their environment. This can result in obsession with a particular topic, self-stimulating behaviours such as finger clicking, hand flapping, and an overload of emotional and sensory information, resulting in ‘stimming’.

According to Martin (2009) Baron-Cohen’s theory of mind can be considered as the fourth impairment for people with autism. As they will find it hard to imagine a world from someone else’s perspective and understand that other people have different thoughts and feelings independent from their own. This can be misinterpreted as a sign of rudeness as they may not be able to see things from another person’s perspective.

Working with autism

These difficulties can have the effect of preventing someone with autism feel the close bonds of relationships, and over compensatory rituals and routine can provide them with a feeling of safety and reassurance. So it makes sense that people with autism find routine very reassuring, although it is important to note that people with autism can adapt to change they just need support with time and preparation given to them so it is not just a sudden change that can make them feel overwhelmed.

Practitioners have advocated the importance of early intervention with environmental stimulation appropriate to a child’s needs is necessary for developing creative thinking in children. As many people with autism may need help with sensory processing to help them balance and regulate environmental stimuli. For instance some people may be sensitive to light or noise while they may need extra tactile stimulation. So in some cases it can be about thinking of the senses as a ‘graphic equaliser’ where people need help to balance their sensory input.

Strategies to encourage social interaction and communication can include the use of visual aids to help promote understanding and reduce anxiety. Carol Gray developed the use of ‘Social Stories’, while pictorial story boards can be useful. TEACCH promotes structured learning environments that encourage visual based engagement and communication. Also helpful is the use of a temperature gauge so they can communicate their feelings.

Creative strategies to help to attune and develop interaction and communication with people with autism. As often for two way verbal conversation can be too overwhelming due to the fact that they struggle to cope with verbal, nonverbal and body language, all at the same time. Arts Therapists encourage use creative mediums such as art, drama and music to engage and aid communication and interaction. Working together on an art object or creating a performance can be a less intrusive way of building a relationship for a person with autism. It may also meet their sensory needs and be a way of discharging emotion with directed movement and action.

Autism and Social Camouflaging

Hull, et al (2017) discusses social camouflaging, which is how people of all genders manage the way others perceive them in social situations. They suggest that people with ASD struggle with this have and it takes a lot of mental effort minimise their social soothing behaviours in public and this can cause stress and anxiety. A person who may seem to be functioning well in society may actually struggle to maintain this.

They also point out that this may account for less girls being under diagnosed with autism as boys will more likely to exhibit externalizing behaviours such as hyperactivity and conduct problems. While girls are more likely to internalise these difficulties leading to difficulties in emotional wellbeing.

This explains why often people with autism can struggle with mental wellbeing and emotional regulation, compared to the ‘neurotypical’ population. So it is useful to help them with coping strategies and when they do feel distress. Ccording to Connoer et al (2018) adaptive cognitive strategies can be successful with anxiety, but they are less successful at helping someone deal with destructive feeling and aggression. As over thinking and rumination can be a maladaptive response.

References

Conner, C. White, S. Beck, K. Goltx, J. Smith, I. Mazefsky, C.(2018)  Improving emotion regulation ability in autism: The Emotional Awareness and Skills Enhancement (EASE) program. Autism, 1–15. Sage Journals.

Hull, L. Petrides K.V. Allison, C. Smith, S. Baron-Cohen, S. Lai, Meng-Chuan Mandy, W. (2017) “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions.  Journal of Autism and Developmental Disorders. DOI 10.1007/s10803-017-3166-5

Martin, N. (2009) Art as an Early Intervention Tool for Children with Autism. Jesssica Kinsgley Publishers

Wing L. and Gould J. (1979) Severe Impairments of Social Interaction and Associated Abnormalities in Children: Epidemiology and Classification. Journal of Autism and Developmental Disorders 9 (1) 11-29

A postscript from Apple House HQ:

Huge thanks go to Andrew Wright, qualified art psychotherapist and valued member of the Summerwood staff team, for kindly sharing this detailed and interesting article he has written for our blog. We are incredibly fortunate to have such a talented and creative team member. We have Andrew’s full permission to share the above article but Andrew remains the copyright holder of the work and no sharing or use of his work is permitted without authorisation from the copyright holder: Copyright: Andrew Wright 2020.

Our teams are working hard to ensure a safe and peaceful Christmas can and will be enjoyed for all the people we support.

We have seen the introduction of Lateral Flow Device tests (LFD) and our staff are busy attending the webinars and training to ensure that these can be delivered in a timely manner. You can see more information regarding these tests here https://www.gov.uk/government/publications/coronavirus-covid-19-lateral-flow-testing-of-visitors-in-care-homes

Our teams have gone over and above this year in their commitment to our company and we can’t thank everyone enough for the extra effort we know the pandemic has made everyone make. We have all had to adapt how we think, what we do and how we see our family and friends. Frontline workers have been recognised for the work they do and this is long overdue. We want to see the celebration of our wonderful carers and managers applauded by the country as much as we do each and every day.

We have been keeping our readers up to date with the latest Governement guidance where possible. Please bear in mind that this is fluid and changes to meet the latest decisions taken centrally. For the latest guidance please go to the gov.uk site.

— Romaine Lawson, Director of Operations, Apple House Care Homes.

T and M enjoyed an afternoon tea, sat in the garden basking in the British sunshine, with chocolate cake, strawberry cupcakes and fizzy elderflower cordial. Once everybody’s tummies were full the afternoon entertainment began with Bob filling the air with the beautiful sound of the Scottish bagpipes.

M and T watched in amazement as Bob played for them. Bob, M and T then went out into the front garden so Bob could play for our lovely neighbours who all gave a round of applause for Bob.

A truly memorable day I’m sure you will agree.” — Sally Fox, Manager, Corner Cottage care home.

Jane Montrose, Managing Director of Apple House care homes, said of Bob, “I can’t thank Bob enough for helping to make Corner Cottage’s VE Day celebrations so memorable. He put a great deal of effort into looking just right in his Scottish finery complete with bagpipes and it was much appreciated by all. I’m sure the neighbours had an absolute treat that afternoon too!”

Historically, care homes and nursing homes followed the hospital model of rigid visiting times.  This in turn meant that families may not have been considered to be intrinsic in the planning of care pathways or, in fact, in the individual’s life inside a care environment.  Today, things are changing for the better but there is always more work to be done.

Apple House care homes embrace an ethos of inclusion.  Families and loved ones have a hugely crucial role to play and, as such, are our partners and never an inconvenience.

Apple House are proud to have signed up to John’s Campaign who champion family inclusion in care settings, and to have been featured in their blog. These are just some of the ways in which we include families of the individuals entrusted to our care:

• Decision making: From the moment that we receive a referral for a placement at our homes we establish communication with the individual’s family unless they do not wish to be involved in the assessment process.  This means that we invite the family and the individual to the home for an initial look at the facilities offered and to meet our team.  An open line of dialogue is created so that families feel empowered to ask any questions and to express concerns or wishes.  Often close family members advocate on behalf of their loved one or have worries about how the individual will adapt to their new home environment.  After all, change is scary for all of us and we understand that.  Only by being fully informed can families and their loved one make a decision that is right for them.
• Partnerships: We believe that families and friends are an invaluable source of information.  No-one knows an individual as well as those closest to them.  Insights and preferences, life history, hobbies and matters that are important to the individual can sometimes be shared with us more fully by family members, especially if their loved one finds verbal communication to be a challenge or if their memory is poor.  Memories are precious and we would like to learn about the memorable moments that are important to the person – all of this makes the individual who they are today. Working in partnership with families as well as the individual in care planning produces a more holistic and comprehensive pathway.
• Approachable: Communication is key.  Three words that summarise the entire partnership between ourselves and the loved ones of the individuals we support.  It is essential that strong communication is in place to form a bridge between families and staff teams.  That bridge helps to avoid rocky roads where anxiety and disharmony could take hold.  After all, it can be stressful and emotional entrusting the care and support of someone you love into the hands of others.  By us being approachable–letting families know that we are there to support them, that they can talk to us at any time–we hope to alleviate concerns, discuss expectations and to be friendly and flexible.
• Flexible: The people who live at Apple House homes are not living in our workplace.  We are working in their home.  They are free to invite their families and friends into their home for a cuppa or to enjoy their gardens with them.  We minimise rules about visiting to, for example,  the need to sign in which is a legal requirement, and to the consideration of others living alongside the individual.  There will always be a warm, genuine welcome from staff.  We have an ‘open door’ approach to visiting, just as we all expect within our own homes outside of care.
• Homely:  We work hard to ensure that Apple House homes are exactly that – homely!  To achieve this, we choose furnishings for our public areas such as lounges that are not clinical or generic in style.  We encourage the displaying of items and pictures that have meaning to the individuals who live there.  Our gardens are created and maintained with the help of those individuals who are able and wish to, for example our chickens are cared for by residents who collect the eggs and bake with them.  There are sensory areas and places to simply sit and be.  Where we are required to display certificates of registration, fire, health and safety etc, we endeavour to do so discretely.  Individuals are encouraged and empowered to decide how they wish their bedroom to look (and we’ve certainly painted some wild and varied colours!).
• Communication: We understand that it is not always possible to visit and so we ensure that alternative means of communication are accessible.  These include Skype video calls, email and telephone calls between individuals and their loved ones.
• Participation: Invitations are extended to families to events within the homes that are varied and regular.  These include invitations to birthday celebrations, BBQs, seasonal parties, special activities such as visiting owls and birds of prey and charity fund-raiser coffee mornings.

This list is not exhaustive – there are so many diverse ways of ensuring that we are family friendly.

–– Jane Montrose, Managing Director.

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Romaine’s varied career began as a care assistant and continued through to managing learning disability satellite homes and founding a school for disadvantaged children in The Sacred Valley of Peru. Romaine joined Apple House in 2005.

On receiving her award, Romaine said, “I’m so honoured to receive this award. Every single person here tonight also deserves this recognition for the wonderful work they do.”

The Hampshire Care Awards is an annual event organised and hosted by Hampshire Care Association & Hampshire Domiciliary Care Providers, to celebrate outstanding individuals and providers of adult social care across the County.

Redcroft’s registered manager and team created an entire cookery book in Braille, as featured here on our blog. Working with an individual for whom cookery is a loved pastime, all of her favourite recipes are now fully accessible to her in her own Braille cook books!

The Daily Echo said of the awards, “Now in their third year, The Daily Echo Proud to Care Awards are an amazing opportunity for our readers to tell us about all those locally that are doing a fantastic job in care, both paid and unpaid. The judges were very moved by the stories they read in the hundreds of nominations received and found it very difficult to choose who to shortlist and the final winners.”

Sharron Eyears, registered manager at Redcroft, told us “I collected the Proud To Care Award For Innovation on behalf of Redcroft.” She added, “I am so proud to be the leader of such an outstanding, dedicated and caring staff team who go the extra mile without thinking about it.”

Also a finalist in the awards for the ‘Carer Award’ was Dawn Salmon of Apple House care home. Dawn’s nominees, family members of people she supports, submitted wonderful commendations about Dawn including: “Dawn gives 200% to the service her colleagues and the people she supports and is so deserving of this wonderful recognition as an award finalist.”

At the most basic level, stress is our body’s response to pressures from a situation or life event. Some common features of things that can make us feel stress include experiencing something new or unexpected, something that threatens your feeling of self, or feeling you have little control over a situation. [Mental Health Foundation]

In the following article, Jayne Jackson, registered manager at Apple House care home, writes an open and very insightful reflection on how stress plans can and do have a profoundly positive impact for a gentleman she supports:

Our care plans are person centred and very individual to each of the people we support.
I was looking at environmental risk assessments & policies for stress. This centred around how we could look after staff’s health and what they/we could do to help in their day-to-day working environment, which we know at times can be stressful.This prompted me to look at the people we support [in relation to stresss]. We looked at easy read documents and set up a meeting.

The easy read document comprised general things to help lower stress/anxieties. We wanted our support plans to be personalised to suit the needs of the individual.

We worked with each person individually and discussed what we could do to help them stay settled and reduce their stress levels.

For one individual this was a massive achievement as in the past just discussing and writing information could cause him to experience high levels of stress.

We worked very closely over many years with the gentleman to help him learn to trust us. We use the phrase ‘it’s good to talk’ and this person now quotes this phrase.

This plan would not have worked for this person if they did not sign up to it.

He spent time with us, we listened to him, we built ‘his’ support plan. It is important that the person has ownership over ‘their’ plan. When he is feeling stressed we refer to the plan and this keeps it fresh in his mind. We all stick to the plan; this is key in keeping his well-being stable.

This plan cannot work without the individual being involved, it is not a paper exercise, it is a live tool.

The stress support plan runs alongside others that all interlink. He is now beginning to recognise when he is feeling troubled, or finding things difficult and, with our support, he is starting to work them out.
The individual works with us. We ensure he has time to reflect, to identify what is worrying him.

Breathing exercises, conversation and space are used; usually after 10 minutes he feels able to talk about what is happening. We must ensure that the person and staff have clarification that they have settled as this prevents further stress. A physical change can be seen within him – his body language and speech will return to pre-stressed levels, and he appears calmer. This is not just a one-off thing as this may happen a few times a day, or weeks may pass without presentation of stress.

Because of the trust we have built, continuity of the team and knowing and respecting the individual it could be said that he has a better quality of life. Sure, there are stressful days for him, we all have those, but learning to cope with them is what we support him to do.

I cannot tell you how proud I feel of him and the team; it is lovely to see the person more involved in day to day things, and by doing this it also helps him to have a renewed sense of purpose and to feel valued, staying focused forming part of his routine.

This individual wrote an additional support plan with staff which was linked to additional stress; he took it to a meeting with his psychiatric team and asked them to sign up to it which they did.

He then wrote to his link mental health team and asked to be discharged. We supported him in writing a letter and discussed the benefits, including self-esteem, that he would feel. His mental health team told us they never thought they would see they day this gentleman would be signed off [from their care].

This is a massive achievement for him!

Due to the hard work and commitment of my staff, their link team and the individual himself, he has stayed settled for over a year following years of mental health decline.

In our compliment folder, the person’s mental health team praised Apple House. They commented how well we had supported the person when they had deteriorated in their mental health and suffered episodes of depression and mania, they had never see this person doing so well. This was signed by the person’s community nurse. This person was told if they remained stable for the next year they would be signed off.

Jumping forwards a year, well its happened, he has been discharged!

We look forward to maintaining his wellbeing and will continue to encourage him to further develop and reach his personal goals.

— Jayne Jackson, registered manager, Apple House care home, Bournemouth.

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Not only are we beyond proud of Redcroft, but we are equally proud of our very own Dawn from Apple House care home who is a finalist in the Proud To Care Awards category of Care Home Worker! Dawn gives 200% to the service, her colleagues and the people she supports and is so deserving of this wonderful recognition as an award finalist.

Well done all of you and we look forward to the finals event next week!

— Jane Montrose, Managing Director.

Here are a few snapshots for which we have received kind permission to share.