# The Care Certificate: all 15 standards *The full underpinning knowledge for the Care Certificate and the Level 2 Adult Social Care Certificate, taught properly and free.* ## Production summary - Modules to record: 15 - Total script: 10322 words, about 69 minutes of finished audio - Voices: Amara (host) and Nadia (practice educator) - Level: Induction, entry level ## Accreditation wording that must appear in the description - **The CPD Certification Service** (planned): Application scheduled. Until it is granted, the CPD hours shown are our own declared study hours and are not third party accredited. - **Skills for Care** (aligned): Mapped standard by standard to the published Care Certificate framework. Alignment is our own mapping and does not imply endorsement by Skills for Care. > Do not upgrade any of these words in a description or a thumbnail. Aligned is not accredited, and planned is not approved. --- ## Standard 1: Understand your role **Runtime** about 5 minutes. **Words** 790. **Starts at** 00:00 in the full course recording. ### Learning outcomes to state on camera - Describe your main duties, the limits of your role, and why those limits exist - Explain how your employment contract, job description and agreed ways of working fit together - Identify the standards that govern adult social care in England and who enforces them - Recognise when a task is outside your role and say so safely ### Script `[CUE 1]` *Open on a single word on screen: BOUNDARY. Hold it while the presenter speaks.* **AMARA** [00:00] Nadia, I want to start with something that sounds obvious. What is my role? Because when I asked three care workers that this week, all three of them gave me a list of tasks. **NADIA** [00:13] And that is exactly the problem. Washing, dressing, meals, medication prompts. All true, and all beside the point. A role in care is not a list of tasks. It is a boundary. **AMARA** [00:26] Go on. **NADIA** [00:27] Inside that boundary you are trained, supported, insured and accountable. Four things. Step outside it and you lose all four at once. And here is the part people forget: so does the person you are caring for. Your protection and theirs are the same protection. `[CUE 2]` *Three stacked cards animate in: Contract, Job description, Agreed ways of working.* **AMARA** [00:45] So where is the boundary written down? Because nobody hands you a map on day one. **NADIA** [00:51] Three documents, and they are not the same thing, which is where the confusion starts. Your contract of employment is the legal relationship between you and your employer. Your job description is what you were hired to do. And your agreed ways of working, which is your service's phrase for policies and procedures, tells you how. **AMARA** [01:14] Which one do people actually breach? **NADIA** [01:16] The third one, nine times out of ten. When an inspector says a worker went beyond their role, they very rarely mean somebody did surgery in the lounge. They mean somebody did a task the right way for a different service, or the way they were taught in a different country, and not the way this service has agreed and written down. `[CUE 3]` *Regulatory map: CQC, Care Act 2014, Skills for Care, NMC, arranged around the person.* **AMARA** [01:41] And above all of that, presumably, sits the law. **NADIA** [01:44] It does. The Care Quality Commission registers and inspects services in England against fundamental standards written into the Health and Social Care Act 2008 Regulated Activities Regulations 2014. I want you to hear the word floor there. Those standards are a floor, not a target. The Care Act 2014 gives local authorities their duties around wellbeing and safeguarding. And Skills for Care sets the workforce standards, including this Care Certificate. **AMARA** [02:12] Now can I ask you about the bit I think is genuinely hard? Everybody says keep professional boundaries. But you are in somebody's home, you know their grandchildren's names, you have seen them cry. It does not feel like a transaction. **NADIA** [02:29] No, and it should not. Good care is warm. That is precisely why this line gets crossed by kind people with entirely good intentions, rather than by bad ones. `[CUE 4]` *Split screen: working relationship on the left, personal relationship on the right, with the record and manager test in the middle.* **AMARA** [02:40] So how do I know when I have crossed it? In the moment, on a shift, not in a classroom. **NADIA** [02:48] Use a two part test. Would you write it in the record? And would you be relaxed if your manager read it back to you? Accepting a cup of tea passes. Accepting a hundred pounds does not. A lift in your own car that is not in the care plan does not. A friend request does not. **AMARA** [03:11] That is a useful test. Is there a pattern in where it goes wrong? **NADIA** [03:17] Five things, and it is nearly always one of them. Gifts. Money. Keys. Lifts. Social media. Add lending or borrowing and you have the complete set. Every one of those has a policy in your service, and I would find yours this week rather than the week you need it. `[CUE 5]` *Five icons appear one at a time: gift, cash, keys, car, phone.* **AMARA** [03:37] Right. Last thing, and this is the one I would panic about. Somebody asks me to do something that is not my job. A dressing, say. What do I actually say? **NADIA** [03:49] Not that is not my job. That is a terrible answer, because the person still has a sore leg after you have said it. **AMARA** [03:59] So what instead? **NADIA** [04:00] Three moves. Acknowledge the need. State the limit in one plain sentence, no jargon. Then commit to a specific next action with a time attached. Like this. I can see that is sore. Dressings are the district nurse's job rather than mine, so I am going to ring them now, and I will tell you what they say before I leave. `[CUE 6]` *Three step graphic for the refusal script: Acknowledge, State the limit, Commit with a time.* **AMARA** [04:24] That is not a refusal at all, is it. **NADIA** [04:28] It is a referral. And it is probably the most professional thing you will do this week. New workers come to harm far more often by agreeing to something they should have declined than by declining something they should have done. **AMARA** [04:44] One more. What if a colleague tells me it is fine, they do it all the time? **NADIA** [04:51] Then it is still not delegated. A clinical task is only delegated when the registered professional accountable for it has delegated it to you personally, you have been trained and assessed on that specific task, and it is recorded in the care plan. Reassurance from a colleague in a corridor is not delegation. It is just a colleague in a corridor. ### Sources for the on screen credit - The Care Certificate framework, Skills for Care - Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, legislation.gov.uk - Care Act 2014, legislation.gov.uk - Fundamental standards, Care Quality Commission --- ## Standard 2: Your personal development **Runtime** about 4 minutes. **Words** 627. **Starts at** 05:16 in the full course recording. ### Learning outcomes to state on camera - Agree a personal development plan and explain what makes one useful rather than decorative - Use supervision and appraisal deliberately instead of passively - Give and receive feedback in a way that changes practice - Reflect on an incident using a structure you can repeat ### Script `[CUE 1]` *Regulation 18 text on screen, with the five duties highlighted one by one.* **AMARA** [05:16] I will be honest, Nadia. Personal development sounds like the soft module. The one you click through. **NADIA** [05:22] I know. And it is the one that turns up in the background of serious incidents more often than almost anything else. It is also a legal duty, not a perk. **AMARA** [05:35] Whose duty? **NADIA** [05:36] Your employer's. Regulation 18 requires them to give you support, training, professional development, supervision and appraisal. If you are not getting it, you are entitled to ask for it, and I would ask in writing. `[CUE 2]` *Side by side comparison: a vague objective in grey, a specific objective in gold, with behaviour, evidence and date labelled.* **AMARA** [05:50] And my side of it? **NADIA** [05:52] Honesty about what you cannot yet do. Which sounds easy and is not, because admitting a gap feels like admitting you should not have the job. But care work is unforgiving here. A worker who quietly says nothing about never having used a stand aid is not being modest. They are creating a risk that will land on somebody's shoulder. **AMARA** [06:16] Let us talk about development plans, because mine has said improve communication on it for about two years. **NADIA** [06:23] That is the commonest failure and it has one cause. Aspirations instead of actions. Improve communication. Be more confident. Nobody can do those, nobody can check them, and they will still be sitting there next year. `[CUE 3]` *Supervision prep card: three empty lines that fill in as the presenter names them.* **AMARA** [06:37] So what does a real one look like? **NADIA** [06:40] Three parts. The behaviour, the evidence, and a date. Listen to the difference. Improve my communication. Now properly. By the thirtieth of September I will have completed the dementia communication module, used Talking Mats with two residents, and had one observation from my senior confirming that I gave one instruction at a time and waited. **AMARA** [07:02] The second one is longer, but I can see how you would know if you had done it. **NADIA** [07:10] That is the test. Could somebody other than you tell whether it happened. The first one is a wish. The second one is a plan. `[CUE 4]` *Feedback contrast: character judgement crossed out, behavioural description ticked.* **AMARA** [07:20] Supervision next. What is it actually for? Because mine sometimes feels like either a telling off or a cup of tea. **NADIA** [07:28] It should be neither. It is a scheduled, recorded, protected conversation about your practice, your workload, your wellbeing and your development. Usually every six to eight weeks. **AMARA** [07:39] How do I stop it drifting? **NADIA** [07:41] Walk in with three things already written down. Something that went well and why. Something that unsettled you. And one thing you need. Three lines in your phone. That turns an hour that drifts into an hour that produces a decision. `[CUE 5]` *Four question reflection wheel, each segment lighting as it is described.* **AMARA** [07:58] Feedback is the bit I find hardest. Giving it to a colleague who has been there fifteen years, particularly. **NADIA** [08:05] Then make it about behaviour, never character. You are impatient is an insult with a job title attached. When you asked Mrs Ali three questions in a row without pausing, she stopped answering. That is information. She can use it tomorrow. **AMARA** [08:22] And receiving it? **NADIA** [08:23] Harder. The instinct is to explain yourself immediately. Try three moves instead. Ask one clarifying question. Say thank you. Decide later. You are completely allowed to disagree with feedback after thinking about it. You are not allowed to be unreachable by it. `[CUE 6]` *Closing frame: a reflection with a name redacted, showing what not to write.* **AMARA** [08:40] Last one. Reflection. I have never known what I am supposed to write. **NADIA** [08:45] Four questions, five minutes, and you can use it for the rest of your career. What happened, in facts rather than feelings. What was I thinking and feeling at the time. What do I now think was going on. And what will I do differently, specifically, next time. **AMARA** [09:04] And that counts as evidence? **NADIA** [09:06] For supervision, for your development plan, and if you go on to register as a nurse or a nursing associate, for revalidation. One rule though, and it matters. Reflect on your practice, not on the person. No names, no initials, no room numbers. That is data protection, not just good manners. ### Sources for the on screen credit - The Care Certificate framework, Standard 2, Skills for Care - Regulation 18: Staffing, Care Quality Commission - Effective supervision in adult social care, Skills for Care --- ## Standard 3: Duty of care **Runtime** about 5 minutes. **Words** 678. **Starts at** 09:26 in the full course recording. ### Learning outcomes to state on camera - Define duty of care and explain how it is created - Work through the tension between duty of care and a person's right to take risks - Apply the statutory duty of candour when something goes wrong - Respond to comments, complaints and incidents in the way the regulations require ### Script `[CUE 1]` *Definition on screen with the word OMISSIONS highlighted in gold.* **AMARA** [09:26] Duty of care. I hear this phrase about ten times a week, and almost always as a reason to stop somebody doing something they want to do. **NADIA** [09:37] Which is close to the opposite of what it means. So let us straighten it out. A duty of care is a legal obligation to take reasonable care to avoid acts, or omissions, that you could reasonably foresee would be likely to harm someone. **AMARA** [09:55] Say more about omissions. **NADIA** [09:56] That is where most breaches actually live. Not reporting a bruise. Not passing on that somebody has not eaten for two days. Not recording a fall you watched happen. Every one of those is a breach of duty of care on its own, and none of them involved doing anything. `[CUE 2]` *Balance scale: duty of care on one side, right to choose on the other, refusing to settle.* **AMARA** [10:16] And what is the standard I am judged against? Because I am not a nurse. **NADIA** [10:22] What a reasonable worker with your training, in your circumstances, would have done. Not the best worker in the country. And not what looks obvious afterwards with hindsight, which is the unfair one people fear. **AMARA** [10:36] That sounds fair, actually. **NADIA** [10:38] It is fair. It is also demanding, because it assumes you know what your own training covered. Which is another reason not to sit quietly through a session you did not follow. `[CUE 3]` *Mental Capacity Act section 1(4) quoted in full on a plain card.* **AMARA** [10:51] Right. Now the one I want to push you on. Mr Davies has capacity, he drinks, he smokes, he has refused the hospital bed, and he lives at the top of a very steep flight of stairs. Everybody on the team is frightened. What am I supposed to do? **NADIA** [11:10] Legally? He may do all of that. **AMARA** [11:13] Even though we can all see how it ends? **NADIA** [11:17] Even then. That is not my opinion, it is section one, subsection four of the Mental Capacity Act 2005. A person is not to be treated as unable to make a decision merely because they make an unwise one. Take that protection away and you have taken it away from yourself too. `[CUE 4]` *Five step risk enablement flow, each step ticking in.* **AMARA** [11:38] So my duty of care just evaporates? **NADIA** [11:40] No, and this is the bit people miss. Your duty is not discharged by overriding him. It is discharged by doing the work. Is he genuinely informed. Have the risks been discussed with him and written down, ideally in his words. Has everything that can be reduced been reduced, so a rail, a lifeline pendant, a different route to the bathroom. And is there a review date. **AMARA** [12:07] So it is a process, not a permission slip. **NADIA** [12:11] Exactly, and it has a name. Positive risk taking, or a risk enablement plan. It is what good services do instead of blanket bans. A blanket ban looks safe on paper and is very often unlawful. `[CUE 5]` *Regulation 20 checklist: in person, promptly, facts, apology, in writing.* **AMARA** [12:25] What happens when something does go wrong? Because it will. **NADIA** [12:29] Then the duty of candour applies. Regulation 20. If there is a notifiable safety incident, the provider must tell the person face to face and quickly, give the facts as known at that point, explain what will be looked into, apologise, and follow it up in writing. **AMARA** [12:48] I have watched people freeze at the apologise part. They think it means admitting fault. **NADIA** [12:54] Then let me say this as plainly as I can, because it stops good people doing the right thing. An apology is not an admission of legal liability. Section two of the Compensation Act 2006 says so in terms. Say sorry. `[CUE 6]` *Closing card: An apology is not an admission of liability. Compensation Act 2006.* **AMARA** [13:10] Last thing. Complaints. Nobody likes them. **NADIA** [13:13] Regulation 16 requires an accessible system that is actually acted on. And inspectors read the complaints log very carefully, because a service with no complaints is almost never a service with no problems. It is usually a service where complaining feels pointless, or risky. **AMARA** [13:30] So what do I do when somebody complains to me directly? **NADIA** [13:35] Listen without defending, which is the hard half. Acknowledge it. Do not promise an outcome you cannot control. Record it the same shift, not at the end of the week. And tell the person what happens next and when. Most complaints that escalate did not escalate because of the original problem. They escalated because nobody came back. ### Sources for the on screen credit - The Care Certificate framework, Standard 3, Skills for Care - Regulation 20: Duty of candour, Care Quality Commission - Mental Capacity Act 2005, section 1, legislation.gov.uk - Compensation Act 2006, section 2, legislation.gov.uk --- ## Standard 4: Equality and diversity **Runtime** about 5 minutes. **Words** 705. **Starts at** 13:58 in the full course recording. ### Learning outcomes to state on camera - Name the nine protected characteristics and the four forms of prohibited conduct - Explain the duty to make reasonable adjustments and give care examples - Recognise unconscious bias and its effect on care decisions - Challenge discriminatory practice safely and effectively ### Script `[CUE 1]` *Nine protected characteristics appear as nine tiles, filling the screen.* **AMARA** [13:58] Equality and diversity. In most places I have worked this was a poster on a wall and a form you signed. **NADIA** [14:06] Then let us do the version that changes what happens on a shift. Start with the law, because it is short. The Equality Act 2010 protects nine characteristics. Age. Disability. Gender reassignment. Marriage and civil partnership. Pregnancy and maternity. Race. Religion or belief. Sex. Sexual orientation. **AMARA** [14:24] Nine. And in a care home you would meet all of them. **NADIA** [14:29] All nine, and frequently several in the same person, which is the part the training posters never show. `[CUE 2]` *Four quadrants: direct, indirect, harassment, victimisation, each with a care example.* **AMARA** [14:36] The Act bans four things, is that right? I can never keep them apart. **NADIA** [14:42] Then let me give you one care example of each and they will stick. Direct discrimination is treating somebody worse because of a characteristic. Refusing to allocate a carer to a resident because of the carer's race. **AMARA** [14:57] That one is obvious. What is indirect? **NADIA** [15:00] A rule that applies to everybody but disadvantages a group without good reason. Here is the one I see constantly. All personal care between seven and nine in the morning. Several Muslim residents pray at those times, so they consistently miss breakfast. `[CUE 3]` *Bath round timeline showing the indirect discrimination example.* **AMARA** [15:16] But nobody designed that to exclude anyone. It is just the rota. **NADIA** [15:21] Correct, and it is still indirect discrimination. Intention is not part of the test. That is the single most useful thing in this module. **AMARA** [15:31] And the other two? **NADIA** [15:32] Harassment is unwanted conduct related to a characteristic that violates dignity or creates a hostile environment, and again the test is the effect, not the intention. Victimisation is punishing somebody for complaining, or for backing up somebody else's complaint. `[CUE 4]` *Accessible Information Standard: five verbs animate in, identify, record, flag, share, meet.* **AMARA** [15:48] You said disability works differently. **NADIA** [15:50] It does. For disability the Act goes further than telling you not to discriminate. It puts a positive duty on you to make reasonable adjustments. And for service providers that duty is anticipatory. **AMARA** [16:03] Meaning I have to have thought about it before the person arrives. **NADIA** [16:08] Before they arrive. Which in practice is deeply unglamorous. A hearing loop that is switched on and actually works. Easy read. Large print. Longer appointment slots for somebody who needs processing time. A quiet room for an autistic person who cannot cope with the lounge. `[CUE 5]` *Assumption montage: four quick scenarios, each ending with the unasked question on screen.* **AMARA** [16:26] Is there a specific rule, or is it just be reasonable? **NADIA** [16:30] In England there is a specific one, the Accessible Information Standard. It requires you to identify, record, flag, share and meet communication needs. Five verbs, and every one of them is active. Noticing does not appear on that list. **AMARA** [16:46] Can I ask you something uncomfortable? In your experience, how much discrimination in care is actual hostility? **NADIA** [16:53] Very little. Almost all of it is assumption. `[CUE 6]` *Closing card with the challenge script in quote marks.* **AMARA** [16:56] Give me examples. **NADIA** [16:57] Assuming the older woman with the Yorkshire accent would not want halal food, and never asking. Assuming the man with a learning disability cannot choose his own clothes. Assuming the confident son is the decision maker because his mother is quiet. Assuming a same sex partner is a friend, and sending every update to a brother who has not visited in six years. **AMARA** [17:22] That last one is bleak. **NADIA** [17:24] It happens weekly. And the fix is not moral, it is procedural, which is good news. Ask instead of infer. Write down the answer. Check again when things change. Bias lives on unasked questions. **AMARA** [17:38] Final thing. I hear something discriminatory from a colleague who has been there twenty years. Realistically, I am not going to start a confrontation in the middle of a lounge. **NADIA** [17:50] You do not have to. New workers freeze here because the only two options seem to be silence or a row. There is a middle route. Name the behaviour, not the person, in the moment, in plain words. I do not think we should be saying that in front of residents. **AMARA** [18:10] That is it? **NADIA** [18:12] That is it. It is not an accusation, so it is very hard to turn into a row, and it makes clear the behaviour was noticed. If it continues, it goes to your manager. If it is your manager, it goes through whistleblowing. And if a person you support is being harmed by it, it stops being an HR matter altogether. It is safeguarding, and it goes down that route. ### Sources for the on screen credit - Equality Act 2010, legislation.gov.uk - The Care Certificate framework, Standard 4, Skills for Care - Accessible Information Standard, DCB1605, NHS England --- ## Standard 5: Work in a person centred way **Runtime** about 5 minutes. **Words** 719. **Starts at** 18:40 in the full course recording. ### Learning outcomes to state on camera - Explain what person centred care means in law and in practice - Use life history and 'what matters to you' to change how care is delivered - Identify and respond to pain and distress in people who cannot tell you - Support choice in a way that survives a busy shift ### Script `[CUE 1]` *Regulation 9 text, with appropriate, needs and preferences highlighted.* **AMARA** [18:40] Person centred. Two words so overused I am not sure they mean anything any more. Can you give me a definition that survives an actual shift? **NADIA** [18:50] Here is mine. The person's own priorities decide how care is delivered. And where they cannot decide, their history, their values and their behaviour are used to work out what they would have chosen. **AMARA** [19:04] And that is a philosophy, or a rule? **NADIA** [19:07] A rule. Regulation 9. Care must be appropriate, meet the person's needs, and reflect their preferences. It is the first of the fundamental standards, and everything else in care is a means to it. `[CUE 2]` *Life history examples as three short vignettes with the misreading and then the truth.* **AMARA** [19:20] Where do I start on a shift, though? Because I have twelve people and four hours. **NADIA** [19:27] Start with life history, and stop thinking of it as a nice extra for the noticeboard. It is clinical information. **AMARA** [19:35] That is a strong claim. Justify it. **NADIA** [19:38] Gladly. A man who worked nights for thirty years is not agitated at two in the morning. He is awake at his normal time. A woman widowed in a hospital side room may become distressed at the smell of alcohol gel, and nobody on shift will have the faintest idea why. Somebody who ran a household of six will not accept being fed without protest. `[CUE 3]` *Behaviour to pain flowchart: new behaviour, movement related, check the obvious, scale, escalate.* **AMARA** [20:04] And if we do not know any of that? **NADIA** [20:07] Then here is the sequence. The distress gets recorded as behaviour. The behaviour gets a medication review. And a person ends up sedated for a problem that we created at handover. That is not a hypothetical, it is one of the commonest harms in the sector. **AMARA** [20:26] Is there a tool? **NADIA** [20:27] Several. This Is Me from the Alzheimer's Society, and the Getting To Know Me formats many trusts use. But the tool is not the point. The point is that somebody reads it, and that what is in it actually appears in the care plan. A beautiful life history in a folder nobody opens has changed nothing. `[CUE 4]` *Abbey Pain Scale and PAINAD named on screen with a caption that a validated tool beats a guess.* **AMARA** [20:50] You told me before that there is one thing in this standard that matters more than the rest. What is it? **NADIA** [20:58] Pain. Untreated pain is one of the commonest causes of what gets written down as challenging behaviour, particularly in advanced dementia. **AMARA** [21:06] How would I even know, if the person cannot tell me? **NADIA** [21:11] They will show you instead. Resisting personal care. Striking out during transfers. Guarding a limb. Rocking. Calling out. Refusing food. Or going very quiet, when quiet is not normal for them. `[CUE 5]` *Two shirts held up: the small numbers principle demonstrated rather than described.* **AMARA** [21:23] Quiet as a sign of pain. I would have read that as settled. **NADIA** [21:28] Most people do. So carry this rule into every shift instead. Assume pain until you have excluded it. Behaviour that is new, or behaviour that only appears during movement or personal care, is pain until proven otherwise. **AMARA** [21:43] And then what? I cannot prescribe anything. **NADIA** [21:46] No, but you can check the boring things and you can escalate. Constipation. Urine infection. Pressure damage. Teeth. Shoes that do not fit. Then use a proper observational scale rather than a guess, the Abbey Pain Scale or PAINAD, and ask for a medical review rather than accepting the label of challenging behaviour. `[CUE 6]` *Closing card: four high leverage choices, name, clothes, waking time, food.* **AMARA** [22:07] Right. Let me be difficult with you for a minute. All of this takes time. I am short staffed. Offering somebody a genuine choice is slower than not offering one, and everybody listening knows it. **NADIA** [22:21] That is a fair objection and I am not going to pretend otherwise. Two things make it survivable. The first is to offer real choices in small numbers. An open question to somebody with dementia produces anxiety and often no answer. Two options held up produces a decision in about three seconds. **AMARA** [22:42] And the second? **NADIA** [22:43] Front load choice into the parts of the day that set the tone. What to wear. What to be called. When to get up. What to eat. Get those four right and you will spend less of the rest of your shift managing distress that you caused at eight in the morning. Person centred care is not slower overall. It is slower at the start and much faster by lunchtime. **AMARA** [23:11] That is the first time anyone has made that argument to me in terms of time. **NADIA** [23:18] It is the only argument that survives a real rota. The dignity case is true and the time case is what gets it done. ### Sources for the on screen credit - The Care Certificate framework, Standard 5, Skills for Care - Regulation 9: Person centred care, Care Quality Commission - This Is Me, Alzheimer's Society - Abbey Pain Scale, British Geriatrics Society --- ## Standard 6: Communication **Runtime** about 5 minutes. **Words** 676. **Starts at** 23:27 in the full course recording. ### Learning outcomes to state on camera - Identify communication needs and preferences, and record them so others act on them - Adapt your communication for sensory loss, dysphasia, dementia and English as an additional language - Use non verbal communication deliberately rather than accidentally - Explain when and how to use interpreters, advocates and communication aids ### Script `[CUE 1]` *Four icons for the pre confusion check: hearing aid, glasses, dentures, lamp.* **AMARA** [23:27] Communication feels like the module everyone assumes they are already good at. **NADIA** [23:32] Which is why it causes clinical harm. When communication fails in care the consequences are not hurt feelings. People go without pain relief because nobody understood them. People get recorded as refusing care when they were asking for a different carer. People get labelled confused when actually they are deaf and the hearing aid battery is flat. **AMARA** [23:55] That last one cannot be common, surely. **NADIA** [23:58] It is extremely common. Before you decide anyone is confused, check four things. Hearing aid. Glasses. Dentures. Lighting. A very large proportion of apparent confusion is unaddressed sensory loss, and it gets written into a record where it follows the person around for years. `[CUE 2]` *Accessible Information Standard, five verbs animating: identify, record, flag, share, meet.* **AMARA** [24:15] Is there a legal duty here or is this just good practice? **NADIA** [24:20] There is a duty in England, the Accessible Information Standard. Identify the need, record it, flag it so it is visible, share it with others providing care, and meet it. Note that a need sitting in a file nobody opens has not been met. The standard is about action, not documentation. **AMARA** [24:40] Let us talk about adapting. Because I have heard people adapt in a way that made me wince. **NADIA** [24:48] Then you have heard elderspeak. Higher pitched, sing song, calling a woman of ninety sweetheart. Slower and simpler is fine. Talking to an adult as though she were three is not, and I promise you she can tell. `[CUE 3]` *Split screen showing elderspeak versus respectful adaptation, same words, different delivery.* **AMARA** [25:03] Give me the dementia list. The things that genuinely work. **NADIA** [25:07] Approach from the front, at eye level. Say who you are every single time, and do not test whether they remember. One instruction at a time. Then wait, and wait longer than feels comfortable, because processing can take many seconds. **AMARA** [25:23] How long is longer than comfortable? **NADIA** [25:25] Count to ten in your head. Most people give up at three and fill the silence with a second question, which resets the whole process. Use gesture and demonstration alongside the words. And do not argue with a false belief. Respond to the feeling underneath it. `[CUE 4]` *A ten second on screen counter demonstrating the wait after one instruction.* **AMARA** [25:44] Example? **NADIA** [25:44] She says she has to go home, her mother is waiting. Do not say your mother died in 1987. Say tell me about your mother. The feeling is that she is needed somewhere and she is anxious. That is the thing you can actually help with. **AMARA** [26:02] Interpreters. Realistically, if a resident's daughter is standing right there and speaks English, why would I not use her? **NADIA** [26:10] Because she may edit. She may have an interest in the outcome. In a safeguarding context she may be the source of the problem. And she is not bound by any professional standard, so nobody can hold her to accuracy. `[CUE 5]` *Interpreter seating diagram: worker facing the person, interpreter to the side.* **AMARA** [26:26] So when must it be professional? **NADIA** [26:28] Consent. Diagnosis. Safeguarding. Complaints. End of life discussions. For the weather and the football, family is fine. And one absolute rule: never use a child as an interpreter. Not for a moment, not for convenience. **AMARA** [26:42] Anything practical about how to use one? **NADIA** [26:45] Speak to the person, not to the interpreter. Keep looking at the person while the interpreter is talking. Say what did you eat today, not ask her what she ate. It sounds small and it changes who the conversation belongs to. `[CUE 6]` *Body language contrast: standing over a chair, then seated at eye level.* **AMARA** [27:02] What about my own body language? I never think about it. **NADIA** [27:06] Then it is communicating for you without supervision. Standing over somebody in a chair signals authority. Sitting at their level signals time. Doing the task while facing away signals that they are a job rather than a person. And watch your hands, because rushed hands read as rushed whatever your voice is doing, and rushed reads as unsafe to a frightened person. **AMARA** [27:31] Last one. A daughter rings and asks how her mother has been. What do I say? **NADIA** [27:37] Answer the relationship rather than the question. I am not able to share that, but I can let her know you rang and she can call you back. You have not breached confidentiality, you have not been cold, and you have put the decision back where it belongs, with her mother. ### Sources for the on screen credit - The Care Certificate framework, Standard 6, Skills for Care - Accessible Information Standard, DCB1605, NHS England - Dementia: assessment, management and support, NG97, NICE --- ## Standard 7: Privacy and dignity **Runtime** about 4 minutes. **Words** 614. **Starts at** 27:58 in the full course recording. ### Learning outcomes to state on camera - Explain what dignity means in the specific moments where it is usually lost - Maintain privacy during personal care, continence care and at end of life - Support choice and independence rather than doing things the quick way - Recognise institutional practices that strip dignity without anyone intending it ### Script `[CUE 1]` *Five step door sequence animating: knock, name, wait, enter, explain.* **AMARA** [27:58] Dignity is one of those words that is easy to agree with and hard to pin down. Where is it actually lost? **NADIA** [28:06] Almost never through cruelty. That is the thing people get wrong. It is lost in small operational decisions that nobody records. The door left ajar. The commode in the lounge with a screen that does not quite reach. The conversation about somebody's bowels held across them as though they had left the room. The meal cut up without asking. The towel that does not quite cover. **AMARA** [28:33] None of which anyone would defend if you pointed at it. `[CUE 2]` *Personal care room diagram: door, curtain, screen, and the towel coverage rule.* **NADIA** [28:37] None. And that is why the fix is noticing rather than caring more. Everybody in the building already cares. **AMARA** [28:45] Is there a regulation? **NADIA** [28:46] Regulation 10. Treated with dignity and respect, including privacy, support to be autonomous and independent, and involvement in the community. It is very short and inspectors use it constantly. `[CUE 3]` *Language swap card: nappy crossed out and pad shown, changed crossed out and supported shown.* **AMARA** [28:58] Take me through a personal care episode properly. What should it look like? **NADIA** [29:03] Start at the door. Knock. Say who you are. Wait for an answer. Enter. Explain why you are there. Five steps, and I want you to do all five even when the person cannot answer you. **AMARA** [29:18] Why, if they cannot answer? `[CUE 4]` *Three protected tasks illustrated: eating, washing the face, getting to the toilet.* **NADIA** [29:20] Because you do not actually know what they take in, and because habits do not survive being switched on and off. The carer who knocks for everybody is the carer who knocks when it matters. **AMARA** [29:34] And inside the room? **NADIA** [29:35] Door and curtains, both, not one. Expose only the part you are working on and cover it again before you move on. Keep saying what happens next. Offer the flannel so the person washes what they can still wash. And ask before touching, every time. `[CUE 5]` *Institutional habits montage, each frame ending with the phrase nobody notices any more.* **AMARA** [29:53] Continence is the one I would find hardest to get right. **NADIA** [29:58] It carries the most risk of humiliation and the biggest reward for getting it right. Two absolute rules. Never discuss continence in a shared space. And never use the word nappy, or changed, about an adult. Pads are pads. Adults are supported. **AMARA** [30:14] Now let me push. Independence takes longer. If I let Mrs Okafor wash her own face it adds four minutes, and I have eleven other people. `[CUE 6]` *Closing card: The first fortnight test.* **NADIA** [30:25] You are right, and I am not going to pretend the arithmetic away. Doing it for her is faster today and expensive over months, because function that is not used is lost, and in later life it does not come back easily. **AMARA** [30:42] So what do I do with eleven other people? **NADIA** [30:45] Be targeted rather than heroic. Pick the tasks where independence matters most to that particular person and protect those. For most people it is eating, washing the face, and getting to the toilet. Protect three things properly instead of protecting everything badly. **AMARA** [31:02] That is manageable. Last thing, and I want your honest answer. What do you see in services that everybody has stopped noticing? **NADIA** [31:11] Talking over somebody during a transfer as though they were furniture. Referring to people by room number, or by condition. Communal clothing that comes back from the laundry and goes to whoever it fits. Blanket bedtimes. Bowel charts on a wall. Care plans written about a person in the third person and never once shown to them. **AMARA** [31:34] Some of that I have seen and said nothing about. **NADIA** [31:38] Everyone has, and here is why. You are only able to see it for about a fortnight. So if you are new to a service, write down everything in your first two weeks that would horrify a visiting relative. Keep that list. In two months you will have stopped noticing, and that list will be worth more than any audit the service ever commissions. ### Sources for the on screen credit - The Care Certificate framework, Standard 7, Skills for Care - Regulation 10: Dignity and respect, Care Quality Commission - Dignity in care, Social Care Institute for Excellence --- ## Standard 8: Fluids and nutrition **Runtime** about 5 minutes. **Words** 754. **Starts at** 32:03 in the full course recording. ### Learning outcomes to state on camera - Recognise dehydration and malnutrition early, including the signs that get missed - Support eating and drinking safely, including for people with dysphagia - Explain the IDDSI framework and why thickened fluids are prescribed - Record intake accurately and escalate concerns in time to matter ### Script `[CUE 1]` *Call bell timer counting to forty minutes, then a resident pushing a glass away.* **AMARA** [32:03] Fluids and nutrition sounds like the gentlest standard on the list. **NADIA** [32:08] It is the one that appears in coroners' findings. Dehydration and malnutrition in care settings are common, preventable, and regularly behind enforcement action. I would treat this as a clinical safety module, not a catering one. **AMARA** [32:22] Why do older adults dehydrate so easily? **NADIA** [32:25] Three reasons stacked. Thirst sensation declines with age, so the warning system is quieter. Many are on diuretics. And a large number deliberately restrict fluids. **AMARA** [32:35] Deliberately? Why would somebody do that? `[CUE 2]` *Dehydration signs board, with new confusion and unexplained fall highlighted.* **NADIA** [32:37] To avoid needing the toilet. Because they cannot get there alone, or because last time they rang the bell it took forty minutes and they felt like a nuisance. **AMARA** [32:49] So the person is choosing dehydration over asking for help. **NADIA** [32:53] Routinely. And that is why the answer to dehydration is very often not a jug on a table. It is answering the bell. I would like everybody listening to sit with that for a second, because it reframes the whole standard. **AMARA** [33:09] What are the signs I should be catching? **NADIA** [33:12] The ones that get missed. New confusion. Drowsiness. Dizziness on standing. Dark, strong smelling urine, and less of it. Dry mouth and tongue. Sunken eyes. Constipation. And a sudden unexplained fall. `[CUE 3]` *MUST components diagram: BMI, unplanned weight loss, acute illness effect.* **AMARA** [33:25] A fall is a dehydration sign? **NADIA** [33:27] Very often, through postural drop. Somebody stands, the blood pressure does not keep up, and they go down. It gets recorded as a fall, a falls risk assessment gets updated, and nobody addresses the cause. **AMARA** [33:41] Let us do malnutrition. What am I looking for? **NADIA** [33:45] Weight loss in an older adult is never just ageing and should always be looked into. Services use a screening tool, usually MUST, which puts body mass index, unplanned weight loss and acute illness into a risk score. **AMARA** [34:00] I would not be the one completing that. `[CUE 4]` *Full IDDSI 0 to 7 ladder with drinks on one side and foods on the other.* **NADIA** [34:03] No, but you generate the data it runs on, and that is the point. Rings and clothes becoming loose. Dentures that no longer fit. Food left consistently. Somebody who only eats at one meal a day. Food refused only when a particular texture is served. All of that belongs in the record and at handover. **AMARA** [34:25] What actually helps, practically? **NADIA** [34:27] Small and often beats three big plates. Fortify quietly, so full fat milk, cream, cheese, butter, milk powder stirred into what they already eat rather than a supplement drink they will not touch. Protect mealtimes, meaning no medication round and no cleaning across the meal. And check the environment. Is the plate visible against the table. Are the dentures in. Is the person sitting upright. **AMARA** [34:53] Now dysphagia. This is the part that frightens me. **NADIA** [34:56] It should command respect. Swallowing difficulty is common after stroke, in Parkinson's, in advanced dementia, in head and neck cancer. And food or fluid going into the airway causes aspiration pneumonia, which is a leading cause of death in those groups. `[CUE 5]` *Positioning illustration: ninety degrees, and a crossed out slumped position.* **AMARA** [35:13] Explain IDDSI to me, because I have seen four different local systems. **NADIA** [35:18] That was exactly the problem it solved. IDDSI is one numbered scale from zero to seven, covering drinks and food together. Drinks: zero thin, one slightly thick, two mildly thick, three moderately thick, four extremely thick. Foods: three liquidised, four pureed, five minced and moist, six soft and bite sized, seven regular. **AMARA** [35:38] And who sets the level? **NADIA** [35:40] A speech and language therapist. And I want to be very clear about the status of that. It is a prescription, not a preference. Giving the wrong consistency is a medication error in every practical sense. **AMARA** [35:55] What if the person asks me for a normal cup of tea and they have capacity? `[CUE 6]` *Red flag list appearing one line at a time with a stop sign.* **NADIA** [36:01] Then you do not quietly pour it, and you do not simply refuse either. You escalate it. A person with capacity can decline a prescribed texture, and that is a real decision that deserves a proper conversation with the therapist, a record, and a review. What it must never be is a decision made alone at a bedside by whoever happened to be on shift. **AMARA** [36:27] Last thing. Positioning. **NADIA** [36:28] Upright, ideally ninety degrees, and stay upright for twenty to thirty minutes afterwards. Never feed anyone lying flat or slumped. Do not stack spoonfuls, and check the mouth is empty before the next one. **AMARA** [36:42] And when do I stop? **NADIA** [36:44] Coughing or choking during or after. A wet or gurgly voice. Watering eyes. A change in colour. Drooling. Food pocketing in the cheek. Any of those, stop and get help. And if somebody has repeated chest infections in their history, treat that as a swallowing red flag until a therapist says otherwise. ### Sources for the on screen credit - The Care Certificate framework, Standard 8, Skills for Care - IDDSI framework, International Dysphagia Diet Standardisation Initiative - Malnutrition Universal Screening Tool, BAPEN - Nutrition support for adults, CG32, NICE --- ## Standard 9: Awareness of mental health, dementia and learning disability **Runtime** about 5 minutes. **Words** 692. **Starts at** 37:05 in the full course recording. ### Learning outcomes to state on camera - Distinguish delirium, dementia and depression, and explain why it matters urgently - Apply the five principles of the Mental Capacity Act 2005 to a real decision - Explain what a Deprivation of Liberty Safeguards authorisation is and when it is needed - Recognise diagnostic overshadowing and the health inequality it causes ### Script `[CUE 1]` *Three column comparison: delirium, dementia, depression, across onset, attention, consciousness.* **AMARA** [37:05] This standard covers three very large subjects. Where do you want to start? **NADIA** [37:10] With the three Ds, because getting them confused is doing active harm right now in a lot of services. Delirium, dementia and depression. **AMARA** [37:19] Tell them apart for me. **NADIA** [37:21] Delirium is acute. Hours or days. Attention and consciousness fluctuate, so the person is bright at eleven and completely away with it at three. It is a medical emergency. Dementia is chronic and progressive over months and years, and consciousness is clear. Depression can look exactly like cognitive decline in an older adult, and tends to produce I do not know rather than a wrong answer. `[CUE 2]` *Delirium causes wheel: infection, constipation, pain, dehydration, medication, retention.* **AMARA** [37:48] What causes delirium? **NADIA** [37:49] Almost always something simple. Infection, particularly urine and chest. Constipation. Pain. Dehydration. A medication change. Urinary retention. Which is the good news, because nearly all of it is reversible if somebody acts. **AMARA** [38:02] So what is my rule on a shift? **NADIA** [38:05] Any sudden change in cognition is delirium until proven otherwise, and it needs medical review today. Not at the next routine visit. Not on Monday. Delirium carries significant mortality, and the commonest failure is recording it as having a bad day. `[CUE 3]` *Five MCA principles as five cards, turning over one at a time.* **AMARA** [38:21] Let us do the Mental Capacity Act, because I hear it quoted constantly and usually wrongly. **NADIA** [38:28] Five principles and they are worth memorising. Assume capacity. Take all practicable steps to help the person decide before concluding they cannot. An unwise decision is not incapacity. Anything done for someone lacking capacity must be in their best interests. And choose the least restrictive option that still achieves the purpose. **AMARA** [38:48] How is it wrongly used? **NADIA** [38:50] As a blanket label. He lacks capacity, full stop. That is unlawful. Capacity is decision specific and time specific. A woman may lack capacity to decide where to live and absolutely retain capacity to decide what to wear, what to eat, and whether to have a flu jab. You assess the decision in front of you, at the time it needs making. `[CUE 4]` *Two stage capacity test flowchart with the four functional abilities.* **AMARA** [39:15] And the test itself? **NADIA** [39:16] Two stages. First, is there an impairment or disturbance in the functioning of the mind or brain. Second, does that mean the person cannot do one of four things. Understand the relevant information. Retain it long enough to decide. Use or weigh it. Or communicate the decision by any means at all. **AMARA** [39:37] By any means at all. That is doing some work in that sentence. **NADIA** [39:42] It is. Blinking counts. A squeeze of a hand counts. Before you decide somebody cannot communicate a decision, you had better have tried more than asking them a question in a busy room. `[CUE 5]` *Cheshire West acid test on screen: continuous supervision and control, not free to leave.* **AMARA** [39:56] What about DoLS? Every service says it differently. **NADIA** [39:59] Start with the test, which comes from the Cheshire West case, and it is two limbs. Is the person under continuous supervision and control. And are they not free to leave. If both are true and the person lacks capacity to consent to those arrangements, that is a deprivation of liberty and it must be authorised. **AMARA** [40:21] Even if they seem perfectly happy? **NADIA** [40:24] Even then. That is the bit that surprises people. The judgment was explicit that a gilded cage is still a cage. Contentment is not consent, and a good placement still needs lawful authority. `[CUE 6]` *Diagnostic overshadowing illustrated: a symptom arrow deflected by a diagnosis label.* **AMARA** [40:37] Who authorises it? **NADIA** [40:38] In a care home or hospital, through the Deprivation of Liberty Safeguards. In supported living or a person's own home, it needs a Court of Protection order instead. **AMARA** [40:49] Last part. Learning disability. What do I most need to know? **NADIA** [40:54] One phrase. Diagnostic overshadowing. People with a learning disability in England die on average many years earlier than the general population, and the LeDeR reviews keep finding avoidable causes. A big driver is that when something new happens, it gets attributed to the learning disability or to autism instead of being investigated. **AMARA** [41:14] Give me the concrete version. **NADIA** [41:16] A man with a learning disability becomes withdrawn and stops eating. That is not a behavioural episode until physical causes have been excluded. Constipation. Toothache. Reflux. An ear infection. Check the body before you reach for the behaviour chart. And make sure the annual health check is actually happening, because it is the single most protective thing available and it is frequently missed. ### Sources for the on screen credit - The Care Certificate framework, Standard 9, Skills for Care - Mental Capacity Act 2005 and Code of Practice, legislation.gov.uk - P v Cheshire West and Chester Council [2014] UKSC 19, UK Supreme Court - Delirium: prevention, diagnosis and management, CG103, NICE - LeDeR annual report, NHS England --- ## Standard 10: Safeguarding adults **Runtime** about 5 minutes. **Words** 761. **Starts at** 41:42 in the full course recording. ### Learning outcomes to state on camera - Name the ten categories of abuse and recognise the signs of each - Explain the six safeguarding principles and the duties under the Care Act 2014 - Report a concern correctly, including when the concern is about a colleague or manager - Explain making safeguarding personal, and whistleblowing protection ### Script `[CUE 1]` *Ten categories as ten tiles, each with a one line sign.* **AMARA** [41:42] Safeguarding. Everybody has done this training and yet the same scandals keep happening. Why? **NADIA** [41:47] Because the failure is almost never a knowledge failure. It is a reporting failure. In nearly every inquiry, from Winterbourne View to Mid Staffordshire, people knew. They did not feel able to say. **AMARA** [42:00] Then let us do the knowledge quickly and spend the time on the hard bit. The categories. **NADIA** [42:07] Ten of them, from the Care Act statutory guidance. Physical. Domestic, which includes coercive control. Sexual. Psychological or emotional. Financial or material. Modern slavery. Discriminatory. Organisational. Neglect and acts of omission. And self neglect. `[CUE 2]` *Organisational abuse vignette: a rigid rota timeline with no choice points marked.* **AMARA** [42:21] Why does knowing the list matter, if I would recognise abuse when I saw it? **NADIA** [42:27] Because people report what they have a name for and stay quiet about what they do not. Organisational abuse is the clearest example. Nobody is hitting anyone. Everyone is up at six because that suits the rota. Everybody is in bed by seven. No choice about anything. That is abuse, and without the name for it, workers just call it how things are here. **AMARA** [42:52] Financial abuse is another one I would struggle to spot. **NADIA** [42:56] Look for the pattern rather than the incident. A new person suddenly very involved in the finances. Bills unpaid despite an adequate income. Money disappearing in small amounts. Pressure about a will. A relative who insists on being present at every conversation about money. And a person who has become anxious about spending anything on themselves. `[CUE 3]` *Six principles wheel with empowerment and proportionality highlighted.* **AMARA** [43:19] You mentioned six principles. **NADIA** [43:20] Empowerment, prevention, proportionality, protection, partnership, accountability. And the two that get trampled are empowerment and proportionality, because the instinct when somebody is at risk is to take over. **AMARA** [43:32] Making safeguarding personal. What does that actually mean? **NADIA** [43:35] Asking the adult what outcome they want, and recording it in their own words. It sounds small. It changes safeguarding from something done to a person into something done with them. `[CUE 4]` *Making safeguarding personal: a quote box being filled with the adult's own words.* **AMARA** [43:47] But what if what they want is to do nothing? A woman with capacity says her son takes her money and she does not want anything to happen. **NADIA** [43:58] Then two things are true at once, and you have to hold both. She can decline an intervention. And you still report it. **AMARA** [44:08] That feels like a betrayal of her. **NADIA** [44:10] I understand why it feels that way. But your duty to report does not belong to you to waive, and there may be others at risk from the same person. What you control is honesty. Tell her you have to pass it on, tell her who to, and tell her what she wants will be recorded and will carry weight. What you must never do is promise to keep it secret, and if you can, say that before she tells you. `[CUE 5]` *Reporting flow: same shift, manager, then around the manager to the local authority and police.* **AMARA** [44:43] Right, the mechanics. I have a concern. What do I do? **NADIA** [44:47] Report it the same shift to your line manager or safeguarding lead. Record what you saw and heard in facts, with her exact words in quotation marks. If the concern is about your manager, you go around them, straight to the local authority safeguarding team, and to the police if a crime may have been committed. **AMARA** [45:10] And what must I not do? **NADIA** [45:12] Do not investigate. Do not question the person over and over, because repeated questioning contaminates evidence and can make a prosecution impossible. Do not confront the alleged abuser, which puts you and the person at risk. Do not wash clothing or bedding, and do not clean the area. `[CUE 6]` *Closing card: Report the concern, not the conclusion.* **AMARA** [45:31] Here is the honest question. I am on a sponsored visa. My manager is the problem. Everyone tells me to speak up. What actually protects me? **NADIA** [45:42] The Public Interest Disclosure Act 1998, which protects a worker who makes a qualifying disclosure in the public interest from dismissal and from detriment. That is real law, not a poster. **AMARA** [45:54] Is it enough? **NADIA** [45:55] I will be straight with you. It is protection after the fact rather than prevention, and for somebody whose visa is tied to a sponsor the fear is rational. So use the routes designed for exactly that. The local authority safeguarding team, the CQC, and a whistleblowing helpline, all of which take concerns from workers directly and none of which require you to go through your employer first. **AMARA** [46:22] And if I turn out to be wrong? **NADIA** [46:26] If you acted in good faith you are protected. And I want this to be the line everybody remembers from this module. You are not required to be sure. Report the concern, not the conclusion. Deciding whether it is founded is somebody else's job, and they are paid to do it. ### Sources for the on screen credit - Care Act 2014 statutory guidance, chapter 14, Department of Health and Social Care - The Care Certificate framework, Standard 10, Skills for Care - Making Safeguarding Personal, Local Government Association - Public Interest Disclosure Act 1998, legislation.gov.uk --- ## Standard 11: Safeguarding children **Runtime** about 4 minutes. **Words** 606. **Starts at** 46:46 in the full course recording. ### Learning outcomes to state on camera - Explain why adult services staff have child safeguarding duties - Recognise the four categories of child abuse and the signs of each - Respond correctly to a disclosure by a child - Explain think family, contextual safeguarding and the duty to refer ### Script `[CUE 1]` *Think family diagram: an adult at the centre with a child in the household attached.* **AMARA** [46:46] I work with adults. Why is child safeguarding in my induction at all? **NADIA** [46:51] Because you will meet children constantly. In the homes you visit. As visitors. As the children of the adults you support. And as young carers. Working Together to Safeguard Children is explicit that safeguarding is everyone's responsibility, and everyone includes you. **AMARA** [47:08] Young carers. Tell me more, because I think I would walk past that. **NADIA** [47:13] Most people do, and it is the most common thing missed by adult services. A twelve year old doing personal care for a parent. Managing medication. Missing school. Interpreting at medical appointments. That child has a legal right to an assessment under the Children and Families Act 2014, and very often nobody has ever asked. `[CUE 2]` *Young carer checklist appearing as a home scene with tasks labelled.* **AMARA** [47:35] What would make me notice? **NADIA** [47:37] Ask yourself who does this when I am not here. If the answer is a child, you have found a young carer. And there is a wider principle behind that, called think family. An adult's mental illness, substance use, domestic abuse or learning disability is often the context in which a child is at risk, and the care worker in the house may be the only professional who ever sees the inside of it. **AMARA** [48:06] Categories. There are four. **NADIA** [48:08] Physical, emotional, sexual, and neglect. Neglect is the most common in England and the one most often described afterwards as having been visible for a very long time. `[CUE 3]` *Four categories tiles with pattern based signs rather than single indicators.* **AMARA** [48:19] What signs actually mean something? Because children get bruises. **NADIA** [48:23] They do, and that is why the pattern matters more than the incident. Injuries that do not match the explanation, or do not match the child's developmental stage. A child who is persistently hungry or dirty. A child who is watchful, or frozen. Sexualised behaviour beyond their years. A child who has become the carer. And a child who is never, ever allowed to be seen on their own. **AMARA** [48:50] Is there anything that is a concern in itself? **NADIA** [48:54] Yes. Any injury in a baby who is not yet independently mobile. Babies who cannot roll, crawl or cruise do not bruise themselves. That is a serious concern every single time, with no exceptions. `[CUE 4]` *Non mobile baby rule on a plain card, held for several seconds.* **AMARA** [49:08] Now the moment I would most fear. A child tells me something. What do I do in the first minute? **NADIA** [49:16] Listen. That is mostly it. Do not interrupt. Do not lead. Do not ask why. Reassure them that they were right to tell you. And do not promise confidentiality. **AMARA** [49:27] Surely I need to understand what happened before I report it. **NADIA** [49:32] No, and this is the single most damaging instinct a well meaning adult has. If you question a child, or ask the same thing twice, or suggest an answer, you can render that evidence inadmissible. The child then has to tell the whole story again to somebody trained, and sometimes a prosecution collapses. `[CUE 5]` *Disclosure response script: the three things to say, then the three not to say, crossed out.* **AMARA** [49:53] So give me the words. **NADIA** [49:55] Thank you for telling me. You have done the right thing. I have to tell somebody who can help. Then write down their exact words as soon as you possibly can, in quotation marks, and report it immediately. **AMARA** [50:10] What must I not say? **NADIA** [50:12] Are you sure. Why did you not tell anyone before. And above all, I will keep this between us. Never that one. `[CUE 6]` *Referral route map: safeguarding lead, MASH, police first if immediate danger.* **AMARA** [50:21] Where does the referral go? **NADIA** [50:23] Your safeguarding lead, and the local authority children's social care, usually through the multi agency safeguarding hub. If the child is in immediate danger, police first, always. **AMARA** [50:34] Do I need the parent's permission? **NADIA** [50:36] Not where seeking it would put the child at greater risk. And the threshold for referral is much lower than people assume. You do not need evidence. You need a concern. ### Sources for the on screen credit - Working Together to Safeguard Children, Department for Education - The Care Certificate framework, Standard 11, Skills for Care - Children and Families Act 2014, young carers, legislation.gov.uk --- ## Standard 12: Basic life support **Runtime** about 5 minutes. **Words** 709. **Starts at** 50:48 in the full course recording. ### Learning outcomes to state on camera - Perform the initial assessment sequence safely - Describe adult CPR to current Resuscitation Council UK guidance - Use an automated external defibrillator correctly - Explain DNACPR and ReSPECT, and what they do and do not mean ### Script `[CUE 1]` *Warning card at the top: this module cannot certify you, book a practical session.* **AMARA** [50:48] Before we start, be honest with me. Can I learn CPR from an audio course? **NADIA** [50:54] No. And I want that said clearly at the top rather than buried at the end. You can learn the sequence, and understanding it genuinely matters. But compression depth, rate, hand position and opening an airway have to be practised on a manikin and assessed by an instructor. **AMARA** [51:14] So what is this module for? **NADIA** [51:16] So that when you attend the practical session you already know what you are doing and why, and so that you can walk into an emergency with a sequence in your head instead of panic. Book the practical. Repeat it annually. And if you ever see a provider selling an online only basic life support certificate, no employer should accept it. **AMARA** [51:40] Right. Take me through the adult sequence. `[CUE 2]` *DRAB sequence animation: danger, response, airway, breathing.* **NADIA** [51:43] Danger first. Is the area safe for you. And I mean that seriously, because a second casualty helps nobody. Then response: shake the shoulders, shout, are you all right. Shout for help early, earlier than feels natural. **AMARA** [51:58] Then airway. **NADIA** [51:59] Head tilt, chin lift. Then breathing: look, listen and feel for no more than ten seconds. And here is the thing I most want you to take away from this whole module. **AMARA** [52:12] Go on. **NADIA** [52:12] Agonal gasping is not breathing. In the first minutes of a cardiac arrest, people often make irregular, noisy, gasping sounds. It looks like breathing to somebody frightened, and it is the single commonest reason bystanders do not start CPR on somebody who could have survived. `[CUE 3]` *Agonal gasping demonstration with a caption reading this is cardiac arrest.* **AMARA** [52:30] So if I see gasping? **NADIA** [52:32] Treat it as cardiac arrest. Call 999, phone on speaker, send someone for an AED, and start compressions. **AMARA** [52:40] Give me the numbers. **NADIA** [52:41] Centre of the chest, heel of the hand. Five to six centimetres deep. A hundred to a hundred and twenty per minute. Let the chest come all the way back up between compressions, because filling matters as much as squeezing. Thirty compressions to two rescue breaths if you are trained and willing. **AMARA** [53:02] And if I am not willing? Being honest, with a stranger, I might not be. `[CUE 4]` *Metronome at 110 beats per minute with a depth gauge showing 5 to 6 centimetres.* **NADIA** [53:08] Then do compression only CPR, and do not feel a moment's guilt about it. Compression only is vastly better than nothing, and hesitating over breaths is worse than skipping them. **AMARA** [53:20] The defibrillator terrifies people. What if I shock somebody who does not need it? **NADIA** [53:26] You cannot. The machine analyses the rhythm and will not deliver a shock unless one is indicated. Switch it on and it talks you through it, in plain English, written for people with no training at all. **AMARA** [53:40] Anything practical to know? **NADIA** [53:42] Pads on bare dry skin as pictured. Do not touch the person while it analyses or shocks. Go straight back to compressions after a shock, do not wait to see what happens. Take off any medicine patches, keep the pad off a pacemaker lump, and only shave chest hair if the pads genuinely will not stick. `[CUE 5]` *AED pad placement diagram, including patch removal and pacemaker avoidance.* **AMARA** [54:04] Choking. Quickly. **NADIA** [54:05] If the cough is ineffective: five back blows between the shoulder blades, then five abdominal thrusts, and alternate. If they go unresponsive, start CPR. And anyone who has had abdominal thrusts needs medical assessment afterwards, even if they seem fine. **AMARA** [54:21] Last thing, and it comes up constantly. DNACPR. **NADIA** [54:24] A DNACPR means one thing. Cardiopulmonary resuscitation will not be attempted if the heart stops. It means nothing else at all. **AMARA** [54:33] But I have seen it treated as meaning do not bother. `[CUE 6]` *DNACPR card listing what it does not mean, each line ticking away.* **NADIA** [54:37] So have I, and it kills people. A DNACPR does not mean withhold antibiotics. Or food. Or fluids. Or pain relief. Or hospital admission. Somebody with a DNACPR who develops a chest infection gets treated for a chest infection. **AMARA** [54:53] And ReSPECT? **NADIA** [54:54] A broader form that records recommendations for emergency treatment overall, of which resuscitation status is only one part. It is designed precisely to stop the do not bother problem. **AMARA** [55:05] Who can put a DNACPR in place? **NADIA** [55:08] It is a clinical decision, and it must be discussed with the person, or with those close to them where the person lacks capacity. And it must never be applied on the basis of age, disability or learning disability alone. Blanket application is unlawful, and it was the subject of a national CQC review after exactly that happened at scale. ### Sources for the on screen credit - Adult basic life support guidelines, Resuscitation Council UK - The Care Certificate framework, Standard 12, Skills for Care - Protect, respect, connect: DNACPR decisions review, Care Quality Commission - ReSPECT process, Resuscitation Council UK --- ## Standard 13: Health and safety **Runtime** about 5 minutes. **Words** 707. **Starts at** 55:32 in the full course recording. ### Learning outcomes to state on camera - Explain your duties and your employer's under the Health and Safety at Work etc Act 1974 - Apply the principles of safe moving and handling, and refuse an unsafe manoeuvre - Handle substances, sharps, fire risk and lone working safely - Report accidents and near misses, including under RIDDOR ### Script `[CUE 1]` *Section 7 duties on screen, employee side highlighted.* **AMARA** [55:32] Health and safety has a reputation as the box ticking module. **NADIA** [55:36] And musculoskeletal injury is the biggest cause of sickness absence in this sector. People leave care work with backs that never recover. So let us treat it as the module about whether you can still work in ten years. **AMARA** [55:52] Start with the law. Who owes what? **NADIA** [55:55] The Health and Safety at Work etc Act 1974 puts the main duty on your employer, to ensure your health, safety and welfare so far as is reasonably practicable. But section 7 puts duties on you too. Take reasonable care of yourself and of anyone affected by what you do or fail to do, and cooperate with your employer. `[CUE 2]` *Manual handling hierarchy as three descending steps: avoid, assess, reduce.* **AMARA** [56:18] So if I go along with an unsafe practice? **NADIA** [56:22] Then part of it is yours. And the flip side of that is the bit workers rarely get told. You have the right to refuse work that is unsafe, and to report it without detriment. Refusing an unsafe manoeuvre is a lawful act, not insubordination. **AMARA** [56:40] Let us get concrete. Moving and handling. **NADIA** [56:43] The hierarchy first. Avoid hazardous manual handling where reasonably practicable. Assess what you cannot avoid. Reduce the risk so far as reasonably practicable. That order matters, because most services jump straight to lift carefully. `[CUE 3]` *Hoist checklist: plan, sling size, LOLER date, staff numbers.* **AMARA** [56:56] And on a shift? **NADIA** [56:58] Use the equipment in the handling plan. Use the number of staff in the handling plan. Check the equipment and the sling before use, including the LOLER inspection date. And never improvise. **AMARA** [57:11] Here is the real world though. It is a two person hoist and there is one of me, and she needs the toilet now. **NADIA** [57:20] Then it does not happen. I know exactly how that sounds. But a two person hoist with one person is how people end up on the floor with a fractured hip, and how you end up with a back injury and no job. Get the second person, or the person waits and you escalate the staffing as an incident. `[CUE 4]` *COSHH storage scene with an unlabelled bottle crossed out in red.* **AMARA** [57:44] Which feels like failing her. **NADIA** [57:46] It feels like it. It is actually the only version where she does not get hurt. And I would put in writing that it happened, because a service that is short enough for that to arise needs the incident report far more than it needs your heroism. **AMARA** [58:05] What else goes wrong with hoisting? **NADIA** [58:07] Slings. They are person specific and size specific, and the wrong sling is a fall waiting to happen. And never drag anybody under the arms, never let somebody hold on to your neck, and never manually lift a fallen person from the floor if a hoist is indicated. `[CUE 5]` *Progressive horizontal evacuation floor plan with fire compartments shaded.* **AMARA** [58:26] Substances next. **NADIA** [58:27] COSHH. Cleaning products, disinfectants, some medicines, clinical waste. Each hazardous substance has an assessment and a safety data sheet, stored locked and labelled. One rule I want to underline. Never decant into an unlabelled bottle. That is how somebody drinks thickener remover out of a lemonade bottle. **AMARA** [58:46] Sharps? **NADIA** [58:46] Never resheath a needle. Dispose at the point of use, into a bin that is not overfull. And report any injury immediately, because post exposure prophylaxis is time critical. Hours matter. `[CUE 6]` *Near miss iceberg diagram: one accident above the line, many near misses below.* **AMARA** [58:59] Fire. What is different in a care setting? **NADIA** [59:02] You usually do not evacuate the building. Progressive horizontal evacuation is the norm, meaning you move people into the next fire compartment through fire doors. Which is exactly why wedging a fire door open is not a small sin. That door is the plan. **AMARA** [59:20] Reporting. Do near misses really matter? **NADIA** [59:22] They are the cheapest safety information you will ever get. Same lesson as an accident, no injury attached. And some incidents go further, under RIDDOR, to the Health and Safety Executive. You will rarely be the one submitting it, but you are the one whose report triggers it. If you do not write it, it does not exist. **AMARA** [59:45] Last one. Lone working. I am in somebody's home and something feels wrong. **NADIA** [59:50] Then leave. Not after the call, not once you have finished. Leave. You can escalate from the pavement, and you can go back with a colleague. Follow the check in system, keep your phone charged and on you, and know the route if somebody does not answer the door. Nobody has ever been disciplined for leaving a house that felt unsafe. ### Sources for the on screen credit - Health and Safety at Work etc Act 1974, legislation.gov.uk - Manual Handling Operations Regulations 1992, Health and Safety Executive - RIDDOR 2013, Health and Safety Executive - The Care Certificate framework, Standard 13, Skills for Care --- ## Standard 14: Handling information **Runtime** about 4 minutes. **Words** 619. **Starts at** 60:15 in the full course recording. ### Learning outcomes to state on camera - Apply UK GDPR and the Data Protection Act 2018 to care records - Record in a way that is factual, timely, legible and defensible - Explain when confidential information may lawfully be shared without consent - Recognise and report a data breach ### Script `[CUE 1]` *Special category data card with health and care data highlighted.* **AMARA** [60:15] Handling information. I suspect most people think this means do not gossip. **NADIA** [60:20] That is about a third of it. The rest is the law and the record. UK GDPR and the Data Protection Act 2018 govern personal data, and health and care data is special category data, which means extra protection. **AMARA** [60:35] What matters day to day? **NADIA** [60:37] Data minimisation, accuracy, and confidentiality. Plus the Caldicott Principles, which apply specifically in health and care. `[CUE 2]` *Caldicott principle 7 on screen, held long: the duty to share is as important as the duty to protect.* **AMARA** [60:44] I have heard of Caldicott but never actually read them. **NADIA** [60:48] Two are worth knowing by heart. The eighth says inform people how their data is used, which is the most ignored. And the seventh is the one that surprises people. The duty to share information for individual care is as important as the duty to protect confidentiality. **AMARA** [61:06] That is the opposite of what most training implies. **NADIA** [61:10] It is, and it is the correction that inquiry after inquiry has demanded. Failing to share has killed people. Confidentiality is not a reason to keep a district nurse in the dark. `[CUE 3]` *Recording contrast: conclusion in grey, observation in gold, side by side.* **AMARA** [61:23] Let us do recording. What is the standard I should write to? **NADIA** [61:28] Assume everything you write will be read by the person it is about, by their family, by an inspector, and possibly by a court. That is not paranoia, it is just what happens. **AMARA** [61:41] That would change how I write. **NADIA** [61:43] It should. The core rule is facts and observations, not conclusions and opinions. Aggressive is a conclusion. Shouted, pushed the door, and said get out, is an observation. Refused personal care is a conclusion. Said not now, I am cold, and turned away, is what actually happened. `[CUE 4]` *Error correction demonstration: single line, initial, date, original still readable.* **AMARA** [62:02] Why does the difference matter so much? **NADIA** [62:05] Because the conclusion travels. Aggressive goes into a handover, then into an assessment, then into a placement decision, and six months later somebody is refused a service by a person who never met them. The observation lets the next reader draw their own conclusion, and it also happens to be true. **AMARA** [62:25] Practical rules? **NADIA** [62:26] Same shift, not the end of the week, because memory fades and late entries look defensive. Sign and date. No gaps. Never overwrite. If you make an error, one line through it, initialled and dated, with the original still readable. Never falsify, never backdate, and never write up care that did not happen. `[CUE 5]` *Everyday breach montage: bus seat, phone camera, open screen, lift conversation.* **AMARA** [62:47] When can I share without consent? **NADIA** [62:50] Where there is a risk of serious harm to the person or to others. Where a child is at risk. Where there is a legal obligation or a court order. And in defined public interest circumstances such as preventing or detecting serious crime. **AMARA** [63:07] How much do I share? **NADIA** [63:09] The minimum necessary, with the people who need it, for the specific purpose. And record what you shared, with whom, and why. That last part protects you. `[CUE 6]` *72 hour countdown clock for ICO reporting.* **AMARA** [63:20] Breaches. What actually counts? **NADIA** [63:21] Far more than people think. A handover sheet left on a bus. A photograph of a wound sent over a personal messaging app. A rota emailed to the wrong address. A care record left open on a screen. A conversation in a lift. **AMARA** [63:38] And if I realise I have caused one? **NADIA** [63:42] Report it immediately. Not tomorrow. Serious personal data breaches have to reach the Information Commissioner's Office within seventy two hours of the organisation becoming aware, so every hour you sit on it is eating somebody else's deadline. **AMARA** [63:56] Social media. Where is the line? **NADIA** [63:59] Well before where most people think it is. Never photograph a person, a wound or a record on a personal phone. Never post about a person even with the name removed, because jigsaw identification from small details is one of the commonest routes to a regulatory referral. A shift, a town, a condition and a birthday is a name. ### Sources for the on screen credit - UK GDPR and Data Protection Act 2018, Information Commissioner's Office - The Caldicott Principles, National Data Guardian - The Care Certificate framework, Standard 14, Skills for Care - Records management code of practice, NHS England --- ## Standard 15: Infection prevention and control **Runtime** about 4 minutes. **Words** 665. **Starts at** 64:22 in the full course recording. ### Learning outcomes to state on camera - Apply standard infection control precautions consistently - Perform hand hygiene to the correct technique at the correct moments - Use personal protective equipment correctly, including donning and doffing order - Explain the chain of infection and where each link can be broken ### Script `[CUE 1]` *Chain of infection as six links, each one breaking in turn as the interventions are named.* **AMARA** [64:22] Infection control is the training everybody has sat through most often. What do people still get wrong? **NADIA** [64:29] Gloves, mostly. But before the rules, let me give you the reason behind them, because rules without reasons get skipped at half past six on a bad shift. **AMARA** [64:40] Go ahead. **NADIA** [64:41] Infection needs six links in a chain. An infectious agent. A reservoir where it lives. A portal of exit. A mode of transmission. A portal of entry. And a susceptible host. Break any one link and the infection does not happen. **AMARA** [64:58] So every rule is breaking a link. `[CUE 2]` *WHO Five Moments diagram around a bed, with moment five, surroundings, highlighted.* **NADIA** [65:00] Exactly. Hand hygiene breaks transmission. Isolation breaks transmission. Catheter care protects a portal of entry. Good nutrition and vaccination reduce host susceptibility. Safe waste disposal removes the reservoir. Once you can see which link you are breaking, the rule stops being arbitrary. **AMARA** [65:17] Hand hygiene. Everybody knows this one. **NADIA** [65:20] Everybody knows it and compliance in audits is routinely well under a hundred per cent. The World Health Organization Five Moments are: before touching a patient, before a clean or aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching their surroundings. **AMARA** [65:38] That last one, surroundings. People miss that. **NADIA** [65:41] Constantly. You straighten a bed rail, you touch a table, you go to the next person. That is transmission. `[CUE 3]` *Soap versus gel comparison card naming C. difficile and norovirus.* **AMARA** [65:48] Gel or soap? **NADIA** [65:50] Soap and water whenever hands are visibly soiled, and always after caring for anybody with diarrhoea and vomiting. Alcohol gel does not reliably kill Clostridioides difficile spores or norovirus. In an outbreak, gel alone gives you false confidence. **AMARA** [66:05] How long? **NADIA** [66:06] At least twenty seconds, all steps of the technique, and then dry thoroughly. Drying is not the optional bit at the end. Damp hands transfer organisms far more readily than dry ones. **AMARA** [66:18] Bare below the elbows. Is that real or is it a uniform preference? `[CUE 4]` *Donning and doffing sequence animation with hand hygiene steps between.* **NADIA** [66:24] Real. No wrist watch, no stoned rings, no long nails, no gel nails. Cuts covered with a waterproof dressing. All of those harbour organisms and all of them stop you washing properly. **AMARA** [66:36] Right. Gloves. You said this is the big one. **NADIA** [66:40] The commonest error in every service I have ever audited is the same glove worn for more than one task, or more than one person. Gloves worn continuously are not a barrier. They are a transport system. **AMARA** [66:55] That is a horrible image and I will remember it. **NADIA** [66:59] Good. And gloves are never a substitute for hand hygiene. Clean your hands before you put them on and after you take them off, every time. `[CUE 5]` *Glove misuse illustration: one glove travelling between three people.* **AMARA** [67:09] What is the order for putting PPE on and taking it off? **NADIA** [67:14] On: apron, then mask if needed, then eye protection if needed, then gloves. Off: gloves first, then apron, then eye protection, then mask, cleaning your hands between the steps and at the end. And take it off in the room, not in the corridor. **AMARA** [67:32] Why does the doffing order matter? **NADIA** [67:34] Because you are removing the most contaminated thing first, and working towards your own face last. Do it backwards and you wipe a contaminated glove across your own eyes. **AMARA** [67:46] Isolation. Anything beyond follow the sign? `[CUE 6]` *Isolation review reminder: a door sign with a review date attached.* **NADIA** [67:48] Yes, and it is a point of principle. An isolated person is at real risk of loneliness, low mood and physical deterioration. So isolation must be reviewed and it must end when it is no longer needed. I have seen signs left on doors for weeks because nobody owned taking them down. **AMARA** [68:09] And outbreaks? **NADIA** [68:10] Two or more linked cases and you report, so the health protection team can act. For diarrhoea and vomiting the forty eight hour rule generally applies before returning to work or ending isolation. **AMARA** [68:23] You mentioned antibiotic resistance. What can a care worker actually do about that? **NADIA** [68:28] More than you would think. Report accurate symptoms rather than conclusions. Cloudy or strong smelling urine on its own is not a urinary tract infection. Asymptomatic bacteriuria is very common in older adults, and treating it causes harm without benefit. So describe what you actually observed, and let the clinician decide. ### Sources for the on screen credit - Five moments for hand hygiene, World Health Organization - Infection prevention and control, NG139, NICE - The Care Certificate framework, Standard 15, Skills for Care - National infection prevention and control manual, UK Health Security Agency --- *Copyright WAJD Group. Built by WAJD AI.*