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									Think Tank Notes

Considering the emerging commissioning issues in the care workforce
for staff with English as a second language

11th October 2005


Judith Clark (Ashley Homes), Nicky Hone (CSCI), Jenny Cangy (CSCI), Naira
Mnatsakanova (Watford and 3 Rivers PCT), Peter Buckle (English Community
Care representative), Karen Licence (Royal Borough of Kensington and
Chelsea), Nigel Hart (London Borough of Waltham Forest), Keith Sumner
(Peterborough PCP), Ken Fairbairn (Peterborough PCP), Sue Bennett
Peterborough PCP), Judith Whittam (CSIP – Change Agent Team),
Muhammed Aslam (Southwark Council), Lionel Took (Workforce
Development Team), Sue Farrow (Suffolk CC), Nigel Walker ( CSIP Better
Commissioning and Integrated Care Networks - Chair)

1.    Outline of this paper.

This paper reports on the issues raised by commissioners, providers and
others regarding the employment in care services of significant numbers of
staff for whom English is a second language.

2.    Introductions.

Ken Fairbairn (Commissioning Manager with Peterborough Care Partnership)
opening the proceedings and described the background to his concerns and
issues as a commissioning manager (see Powerpoint presentation 1 attached
to this event). Peterborough PCP wished to be pro-active in their market
management and face many issues similar to other commissioners, including
how to develop the relationships with the independent sector and the issues
that arise. This includes the issue of staff for whom English is a second

Sue Bennett (Training Manager with Peterborough Care Partnership) (See
powerpoint presentation 2) introduced the PMS Pilot Project that has been
developed alongside providers in Peterborough since 2003. This outlined the
market and numbers of people in care and caring in the Peterborough area
and the risks that seemed to be there for service users as a result of the
numbers of staff for whom English was their second language.

3.    Establishing the issues.

It was recognised that the nature of the workforce in the care sector was
changing. The job was perceived as unattractive and low paid by many British
workers. The point was made that qualified social workers also had a
significant representation from overseas and that pay may not be the only
factor. Commissioners and providers recognised the need to try and ensure
that a proper career pathway, including training opportunities, was presented
to those who wished to learn and progress, including staff from overseas.
Establishing standards within contracts is one thing but monitoring these and
acting on it is more difficult.

It was also recognised that the nature of some areas of the British workforce
was altered as a result of membership and expansion of the European Union.
Responses to the staffing crises in Health services had also encouraged staff
to move out of residential, nursing home and domiciliary care services into
better paid employment (often with increased terms and conditions) in health
and prompted interest in overseas recruitment. This was not likely to change.
Economic migration had been a pattern in Britain for many centuries. Further
expansion of the EU would probably increase the overseas workforce. The
population changes of the next 30 years would not allow for some areas of
work, care being especially vulnerable, to develop unless migrant workers
entered the employment market. There would be insufficient people of
working age to provide a care infrastructure. It is therefore timely to consider
the best ways to promote good practice in this area.

It was noted that it was not only overseas staff who may have English as a
second language. Some significant numbers of staff who are British citizens
may also have difficulties in communicating fully as a part of their job. Even
when people are British born and have English as their first language there
can be difficulties in communication if written and reading skills are not good.
This needs recognition when consideration is being given top both recruitment
and training issues, but was not the main focus of this meeting.

Any approach to dealing with immigrant workers may need to bear in mind the
issues within the indigenous population too, especially where these related to
training and training methods or issues of contractual or regulatory standards
of communication. On the positive side many staff do wish to improve their
English and do so in their own time.

Typical difficulties discussed by the group included:-

      Staff not understanding residents. Even when the English spoken by
       staff was reasonable regional accents and colloquialisms could get in
       the way (“spending a penny”).

      Staff not comprehending instructions or medical words and phrases.
       This was especially worrying when staff felt they could not admit their
       lack of comprehension. (It was reported that in one recent training
       session in Peterborough the 14 staff present spoke nine languages as
       first languages excluding English.)
        Staff not being able to keep accurate written records. It was noted that
         this may be especially dangerous where it included medical notes or
         medication records.

        Staff not being able to communicate with each other where several
         nationalities, of whom all had English had a second language, worked
         together and only had imperfect English to communicate with.

        People using services becoming isolated due to staff from the same
         cultural group talking to each other in their native language thereby
         excluding them. (It was noted that some providers had made this a
         disciplinary offence).

        Cultural differences may prevent staff from providing services in a way
         that is required or preferred. This is a similar issue faced when British
         staff provide services to others from different cultures.

        When staff where also given accommodation in residential or nursing
         homes as a part of their jobs this could also exclude them from mixing
         with the local population and improving their English further, especially
         if residing with others from their home country.

There are implications for quality if we accept that we need to develop our
workforce for those whose English is a second language. We may need to
address the issue with people entering care homes and there is a need to be
very open with workers about their ability to say they don’t understand and to
welcome and respond positively to this.

4.       The scale of the problem and role of providers.

It became apparent during the discussion that no-one knew the scale of the
difficulties or how many staff had English as a second language. But with half
a million staff employed in care services this could be a significant number.
Within this number however standards if English could vary widely and it was
important to recognise when English was “good enough” rather than a barrier
to good service provision. It was also important to recognise that the problems
faced should not become racist in nature but be a topic that could be openly
discussed and recognised in order to gain understanding and improvement.

The role of independent providers was discussed and the point was made that
a fair price for care had still not been achieved in many places. This could
disadvantage providers who paid the cost of recruitment and training. It was
recognised how important it was to use properly accredited and reputable
overseas recruitment agencies. It was also agreed advisable to have some
standard test for agreeing an acceptable level of understanding of language at
the time of recruitment. Some agencies invested in full inductions for potential
staff in their native country, before being brought to Britain. This helped to
ensure people wanted to and could do the job. Whilst it was good practice not
all providers did this.
Some further discussion took place regarding the cost of this training and the
necessity to pay and incentivise staff to attend training in order to ensure that
they gained the right training and skills. This should include payment for
attendance at training, an obligation not all providers met. It was agreed that it
was not only necessary to encourage staff to attend training sessions but to
ensure that the learning was internalised. Some monitoring of outcomes from
training was necessary to ensure money was not wasted and improvements
were gained.

There were also issues about staff conversing in their own language to the
exclusion of service users. Some providers treat this as gross misconduct.
However there can be problems in promoting the use of English if providers
also house staff from overseas so that they do not mix and practice English
within the community.

It was also important to consider the difference between competence in caring
and being able to speak English. It can be very useful to speak a different
language when working in areas where residents speak different languages
themselves. The issue therefore becomes one of good enough English
standards to communicate with and understand service users, to undertake
learning and to keep suitable and adequate records.

There are some difficulties too in recruiting from specific communities to
provide care to others from that community. Some places are engaging with
religious and community leaders to try and improve this. Developing a proper
career pathway is important as a part of this so that communities do not feel
they are being asked to place people into positions within society that are
poorly paid and of low status. A joint approach from commissioners and
providers is important.

5.     Issues of Regulation

From the regulatory point of view some work was being carried out, largely at
a local level, to try to ascertain the nature of the current workforce, although
there was sometimes reluctance on the part of providers to give full
information on this. It was not thought that any formal work was being
undertaken to consider strengthening regulation in this area. Current
regulatory requirements discuss ability to communicate but are open to some

It was not known within the group whether regulations covering overseas
recruitment agencies covered areas of language competence.

There was at least some evidence of a growing number of complaints
regarding communication difficulties, although this was anecdotal. It was also
sometimes necessary to check out whether complaints could be racist but it
was felt that cross-checking of complaints received could assist in keeping
this under control. It was also recognised that there may be an issue of
service users who are challenging or abusive to staff and support needed to
enable staff to deal with this. This was not necessarily exclusive to overseas

There were sometimes tensions between the regulators, providers and
commissioners when contracts and specifications set targets above the
Minimum Standards (although the Minimum Standards were recognised to be
just that...minimum). Providers often felt under pressure to meet staffing levels
set within the standards and sacrificed quality responses to enable this. At the
root of this problem could be financing or a lack of well developed
relationships between commissioners, independent providers and the
regulators. Difficulties needed identification and discussion between all parties
to improve the response. Raising price of care may not be the answer at a
local level but well targeted interventions could help, for instance specific
training provided via commissioners rather than being included in the costs of
care, or funded recruitment campaigns that were joint and across many

Inspectors and commissioners voiced concern over domiciliary care staff who
worked in a more isolated fashion without direct supervision or other staff
being able to observe their practice or comment on it. In these cases
complaints were the only way that poor practice or communication difficulties
might be uncovered. Food preparation issues and the handling of medication
were among the main issues of concern.

6.     Some current developments and possible ways forward.

“Skills for Care” are currently reviewing requirements regarding workforce
skills through developing Learning Resource Networks in sub-regional areas.
Commissioners and providers need to identify local groups and gain input.

National policy development on workforce development may assist as this
develops. The “Options for excellence” review of workforce (feeding into
Green Paper/White Paper developments) had a particular consideration of
overseas worker issues as part of the framework. International Social Work
group will also feed into this. Lionel Took agreed to place this paper within this
framework for consideration. Nigel Walker will also place this into the that
framework through the CSIP route.

Main route of obligation in this area is through CSCI and the NMS and there is
a review of these currently. Commissioners and providers may wish to ensure
that CSCI consider the issue of overseas workers more thoroughly.

Training grants are given via DH to LA’s. These are no longer ring fenced but
can be made available to the independent sector. Providers need to ask
locally what’s happening to this money and how they can gain access to it.
Commissioners may wish to use it across the sector as a central pot to build
skills and a single approach that providers are obliged to use. “Skills for Care”
training grants can also be bid for locally...but oversubscribed by seven times
last year. Learning Skills Councils also have money available but approaches

A voluntary code for domiciliary care via UKHCA addresses some issues of
overseas recruitment.

How do we incentivise providers to take up opportunities that are there?
(Peterborough will be thinking about this in the near future and if anyone
would like to think with them that would be welcomed! E-mail keith.sumner@ ).

It was felt that there may need to be an inspection of induction programmes
by commissioners in order to measure the outcomes of training rather than
seeing training as being provided to tick boxes.

Commissioners present also wanted to promote more fully information on the
expectations people should have when receiving services. It was recognised
that such information needs to be made more generally available. The OFT
commented on this in their recent report The wider use of websites by LA’s
was discussed. Ken Fairbairn commented on the information available on the
website run by Elderly Accommodation Counsel ( )

It was agreed that it would be useful to know if any commissioning authorities
had developed good protocols regarding overseas recruitment with their
providers. Nigel Walker will post a question across the network once this
paper is on the web with a reference for people to read these notes to prompt
possible further discussion and response.

(notes written by Nigel Walker and approved by group members) October 2005

( A separate issue was raised at the end of this meeting regarding “live-in” staff who may be
recruited abroad and live in the houses of those that receive a service. It was recognised that
these people may escape normal checks and balances if the agency is not registered as
providing dom care or the individual is privately employed (or employed via Direct payments).
It may be that this issue needs to be picked up separately in the future.)

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