With a growing population living longer placing unprecedented pressure on the health system, there is a recognisable need for change in delivery of healthcare and a shift away from care in hospitals. David Whelan visited a day centre in Belfast, to discuss the realities of supporting older people to continue living in the community.
A part of the Belfast Trust, City Way Day Centre in Sandy Row caters for 125 service users per week, facilitating around 45 over 65s per day and a further five younger severely physically disabled people.
Referrals to the service tend to come from a variety of health professionals including the likes of social workers, community psychiatric nurses, care managers and integrated care teams and a broad profile of the older service users includes those with a physical disability, sensory impairment, dementia or mental health issues.
The catchment area for the service is also quite broad, three buses facilitate the transport of users – many of whom only attend for one day a week, with those with complex needs attending more – from the likes of Stranmillis, Finaghy and Malone.
I begin by asking Manager at the centre, Jill Cowan, to explain how the service works: “The aim of the service is to provide person-centred, community focused day support for older people and people with physical disability who are vulnerable, at risk and with complex needs. We embrace choice, independence, health promotion and support for carers.”
Cowan explains that an important stipulation is that the centre provides social, rather than medical care. In essence this means that City Way does not undertake the administration of medicine. “Our main focus is to support people to live independently,” she explains. “One outcome of the service we provide is that unlike a physical disability service, for example, we have a lot of throughput. We are continually assessing the changing needs of our users.”
The centre aims to provide a structured but variable programme for its users, while also providing the wrap-around support to maximise individual potential. She explains: “We aim to encourage acceptance of physical limitations and changes to lifestyles, enhancing the quality of their lives and maintaining independence in the community.”
Below management level, the centre is currently staffed by five day-care workers and three care assistants, most of whom are part-time. Each day-care worker has a caseload of around 40 people, with responsibility for reviews, assessments and care plans, working in association with families, the users themselves and healthcare partners.
While it’s evident to see why facilitating an ageing population to live longer in the community is beneficial to the health service, Ann Scott, a service user at City Way three days a week, explains that there is also huge benefits for users like herself.
The former nurse talks openly about her battle with depression when her health meant that she could no longer work. However, in City Way, she has found a network which is having a positive impact on her mental wellbeing.
“I’m getting an awful lot from my time here. As a nurse, I was used to meeting and interacting with a lot of people on a daily basis. When I didn’t have that, I struggled but the centre allows me to get back some of that interaction. I’m also taking on a lot of new skills and re-visiting skills that I maybe haven’t used or explored in a long-time.”
Carrie McAllister, Senior Day Care Worker at City Way, believes that Ann’s previous role as a nurse has seen her become a caring companion and friend to many of her fellow service users, including her ability to relate to other’s state of wellbeing and her understanding of the positive effect engagement with the service can have.
McAllister states that Ann’s story is not unique, many of the service users bring skills from their earlier lives or jobs such as cookery, arts and music; and these skills are fostered and users supported to bring maximum benefit to both the individual and the centre’s users as a whole.
Around a year ago, the Trust facilitated the creation of a service user council, bringing together representatives of a number of day care centres, which City Way currently chairs. As Cowan explains, the aim was to: “Ensure that the voice of the user is heard and that opinions are being sought for the development of the service.”
The service user council is a replica of the in-house user group at City Way, which meets frequently to discuss a range of issues ranging from food, to facilities, to outings. The group issues invites to a range of its partners involved in the overall delivery of care and encourages discussion on improvements.
Ann, who is a member of both service-user groups believes that the existence of such collaboration is essential to ensure that the service is not acting or seen to be acting with a “top-down” approach to decision-making.
As an active service user, she is engaged in an extensive range of activities in any one day including the likes of quizzes, games, ballroom dancing, pet therapies, drama and even Tai Chi. However, undoubtedly, not all users are as engaged as Ann.
Cowan agrees: “Understanding how we engage those service users who are unwilling is a key ask we have of our staff. The answer is that while it is acceptable for services users to decline engaging in service activities, it’s not acceptable for us to give up trying. We recognise that no two people are the same and we structure our care and our activities to best suit the individual.
“Good person-centred care allows us build trust, establish relationships and tailor activities to an individual to encourage participation and to empower them to improve their wellbeing.”
McAllister, who has responsibility for planning the core-day for service users recognises the importance in offering diversity in activities to meet the needs of the broad spectrum of personalities to use the centre. While the centre has been recognised for its ability to do so, she also appreciates the many benefits that come with working in partnership with other organisations to ensure there is a constant stream of opportunity for users to improve their physical and mental wellbeing.
Turning to the challenges of delivering the service, Cowan highlights that those challenging trends identified for the health service are also visible within the centre, where the profile of user has changed slightly to one of an older age group and with more complex needs.
To that end, she says that the centre and her staff manage a lot of risk: “It goes back to the core issue of ensuring users can be independent in the community for as long as possible. To ensure that risks are well managed we have very strong lines of communication between the staff team on a daily basis.”
Another challenge identified is that of catering to the diversity of service users. While facilitating people from a whole spectrum of society is beneficial, in the form of behaviours, religions and culture through to physical mobility and mental capacity, striving to ensure that this wide spectrum is stimulated, challenges, engaged and comfortable is crucial and challenging.
“A day care centre is not a community centre,” stresses Cowan, “users are here because they need support. There is a clear link between people’s mental and physical health and we believe that ensuring that the user’s mental health is improving will have benefits for their physical wellbeing.”
Given the intensity and importance of such a role, I ask Cowan if keeping staff motivated is ever an issue: “I think our staff are very proud of what they do and they get satisfaction in seeing service users happy and well cared for. We, as managers, recognise the importance of ensuring staff are valued, that there are opportunities for career progression and that they feel safe within the structures they are working.
“Another element which we encourage is the use of their skill-set to improve the service. We recognise that each of our staff bring with them their own unique challenge and try to ensure that they feel comfortable to use these skills.”
Constant development and training for staff is one element of extensive administration work which is also undertaken in the centre to ensure that the centre is not only being guided by and working within the objectives of the Trust but also that staff are ahead of the range of policy and legislative changes which impact on service delivery.
In addition, the centre provides support and information for careers, as individuals and through Carers Groups, which meet in some centres. McAllister describes how the centre provides not only respite for carers but also supports them through connecting them with others facing similar challenges.
Looking to the future, Cowan says that the service user council has been a key development to ensure that the service continues to modernise to meet the demands of the service user.
“We aim to continue the delivery of the many benefits that day care offers to service users, modernising it to meet the need but also ensuring that the service is sustainable going forward,” she concludes.