With this Workshop, our 26th major event, the Sussex Gerontology Network's Sheltered Housing Group celebrates its 1 10th anniversary. The first workshop, held in November 1991 was titled The Quality of Life in Sheltered Housing: the levels of community activity. During the decade the Workshops have brought together residents and managers (scheme and line) to discuss issues of common concern. Recurrent themes have been the participation of residents in scheme management, the promotion of residents' independence and the delivery of care and support.

This Workshop drew the largest number of participants to a single event ‑ 130 representing nearly 50 organisations, Registered Social Landlords and Local Authorities. Most of our participants have come from within a 150 mile radius of Brighton ‑from Gloucester, the Midlands, Cambridge; but to this event we welcomed a small group from Belfast, our most distant participants so far.

Participants to this Workshop were pre‑circulated with a Briefing Paper setting out the issues for discussion; this is reproduced in part in the first section of this Report. In the morning session four speakers discussed their own approach to these issues; their presentations are summarised below.

In the afternoon session, small groups of participants listed the 'grey areas' experienced by themselves and suggested rules for Good Practice. These were brought together in a final plenary session.

Themes arising from the Workshop are presented as a Guide to Good Practice; these are for discussion and do not necessarily represent the views of individual speakers.

THE ISSUES

Gone are the days when the warden was expected "to act literally as a 'good neighbour' and to knock on the doors of designated older people, offering to collect pensions or shopping or offer other similar assistance to that which might previously have been available informally through family or local networks." (Parry and Thompson, 1993, p.8). Well, not quite. In 2001 one can still find job descriptions which read, as this example from a small housing association illustrates, "The role of the Scheme Manager is to benefit and support the communities within sheltered housing as fully as necessary, being of assistance to all tenants equally and a friend and neighbour to all...".

During the 1990's a new trained professional appeared on the scene, especially in the larger and specialist housing associations, "with a job description focussed on housing management rather than good neighbour and caretaker responsibilities, and replaced direct care‑giving with a services liaison role" (Thompson and Page, 1999, p.39).

‑ As professionals, scheme managers are constrained in the performance of their duties: ‑ By management seeking to provide explicit and uniform standards of performance ‑ By legislation and regulations, e.g. health and safety, designed to protect them and their residents ‑ By fears of litigation over in injuries caused or suffered j ‑ By lack of insurance cover for injuries or damages incurred

But whilst professional scheme managers are resident in their schemes they remain neighbours. Is it possible to be both a neighbour and a professional? Where do the boundaries lie? Herein lie the 'grey areas' which can cause so much anxiety and stress amongst scheme managers, stress which employers should, under their responsibilities for the health and safety of their workforce, strive to mitigate.

What is a neighbour? In our culture the word is highly emotive.

Primarily a neighbour is someone who lives nearby; we do have 'neighbours from hell'; but generally, in our language and culture the term has a positive resonance. 'Neighbourly' is defined in the dictionaries as ‑ friendly, kindly, social; never as hellish! This derives from our Christian heritage in which the second New Testament Commandment is 'to love thy neighbour as oneself, illustrated by Jesus' well loved parable of 'the good Samaritan' (Luke 10:33) related in answer to the question 'who is my neighbour?' Retold today the story might describe a victim of a street mugging; a doctor and a social worker pass by, probably muttering to themselves 'not in my job description' or 'my insurance does not cover such situations'. With luck, help will be offered ‑ perhaps from the most unexpected or unqualified source.

Consider the following case study ‑ supplied by one scheme manager from her own experience and corroborated as typical by many others.

A resident develops an acute urinary infection. Her GP prescribes antibiotics and sends the prescription to the pharmacy. The pharmacist, in an act of good will, personally delivers the medicine to the scheme ‑ but at 6.30pm on a Friday evening. The resident is unable to take the medicine unaided. The scheme manager is on‑site but off duty; the resident has no family or carers living nearby. The scheme manager phones for a social worker and for a nurse but neither can attend before midday on Monday; it seems essential that the medical treatment begins without delay. The scheme manager is forbidden by her employer to administer medication; what should she do? She could ask another resident (perhaps even more frail than the patient) to help; or she could ignore the rule‑book and give the help needed. One could elaborate upon this all‑too‑common scenario.

The differing nature of the medication tablets or pills: one must ensure that the confused person takes the correct dosage at the specified times. ‑ liquid: a person with severe arthritis or palsy may not be able to hold a spoon steady. ‑ injection: one would expect this to be given in the surgery ‑ but diabetics, for example, normally self inject their insulin.

The qualifications of the scheme manager the scheme manager is a trained nurse with considerable nursing experience before taking up her present post; she is no longer on the nursing register or covered by medical insurance. ‑ the scheme manager works part time both as a mobile warden and as an agency employed nurse. ‑ the scheme manager has received appropriate 'in‑house' training. What should the scheme manager do In the six afternoon small workshops participants ‑ mostly scheme managers and residents listed the 'grey areas' that they most frequently encountered. These are listed below systematically but not in any order of importance ‑ though the personal care issues came high on all lists.

Personal care

	help in administering medication and eye drops
	personal hygiene e.g. incontinence, catheter insertion
	lifting after falls
	administering first aid (one scheme manager said that she had been issued with a first aid box ‑ but for her personal use only!)
	standing in for other professions when they fail to attend for such tasks Domestic tasks
	changing light bulbs, plugs, batteries
	carrying refuse bins to basement collection point
	use of pass key
	making a cup of tea or light meal for a resident
	doing shopping, collection pension or prescriptions

In some of the above situations the scheme manager may be expected to act in an emergency; but what constitutes an emergency? Some scheme managers have received formal training in some of the tasks; (one participant claimed to have a 'certificate in light‑bulb changing'!)

Scheme events

	handling money: the scheme manager is prohibited from handling funds for residents' activities, yet (s)he is expected to facilitate them
	the scheme kitchen does not meet the required standards for preparing full meals; should the scheme manager cook the celebratory meal in his/her kitchen or must an outside (and expensive) caterer be hired?

Rights to information about residents

how much may/should the scheme manager be told about a resident's care package?

what information about 'problem' residents (alcoholics, paedophiles, the mentally ill) should/must be disclosed to scheme managers? They believe they need to protect other residents. They may need to protect themselves. (It was argued that a scheme manager injured by a resident whose past violent behaviour had not been disclosed would have a strong case against their employers under health and safety law).

How many times each day does a scheme manager work within these 'grey areas'?

A LEGAL PERSPECTIVE

Jo Bridgeman, Lecturer in Law, University of Sussex.

Jo Bridgeman's interests lie in the law of tort ‑ of civil obligations ‑ especially as it relates to the care of children; there has been very little work undertaken on the specific legal issues relating to older people. There are obvious parallels with the law relating to older children in that a balance must be reached between fostering their independence and ensuring that they can exercise their decisions with safety.

The tort of negligence: a negligent action is one brought by an individual who has suffered harm as a consequence of the breach of a legal duty imposed by law; only where the standard of behaviour falls below that set by law will there be liability. The primary function of the law is to compensate, as far as money is able to do, the person who has suffered harm by the action or inaction of others; the law, may, also have a deterrent effect resulting in changed behaviours.

There are three elements of negligence; each must be present to constitute grounds for action:

there must be a duty imposed by law a recognised standard of care must be breached harm must have been caused

The last element is significant; there is no liability if no harm has been caused; neither does it follow that there will be liability for all harm caused. In setting the boundaries of liability the law distinguishes between physical harm (to the person or property), economic loss, psychological injury etc.

What is a duty of care? It is a control device to limit liability. If an action causes harm (as for instance where a scheme manager drops a pan and bums a resident whilst preparing a meal or misses their footing, injuring the resident they are lifting) there is no problem over duty. Negligence imposes a duty to act carefully if one does act ‑ it does not impose a duty to act. Jo quoted a judgement (Stovin v Wise [ 19961) in which the Court noted the parable of the Good Samaritan and explained why English law would not impose on the priest and the Levite a duty to act. "There are sound reasons why omissions require different treatment from positive conduct. It is one thing for the law to say that a person who undertakes some activity should take responsible care not to cause damage to others. It is another thing for the law to require that a person who is doing nothing in particular should take steps to prevent another from suffering harm from the acts of third parties ... or natural causes."

We do have a duty to act when we have responsibility for others, arising from an undertaking to others (re. for instance their health) or an assumption of responsibility. The law relating to children provides examples where parents or carers have a duty to act, e.g. if a child is in danger of drowning a passer by has no duty to act ‑ but a parent or carer has. (Hence the legal actions arising from deaths or injuries in school outings). Similarly, a medical doctor has no duty to stop in the street to help someone in distress ‑ but as soon as he does start to help he has a duty to act with care.

In the case of the scheme manager is there a duty to act? There is a duty if an undertaking has been given, or if, by their actions the Scheme Manager has led the resident to rely on them. What a resident has been told about the scheme manager's duty and role is thus very important.

In those cases where the law imposes a duty of care, the next question is whether the standard of care set by law was met. The standard set by the law is that of the 'reasonable man' engaged in the activity in question. Ultimately it is a matter of common sense or an intuitive judgement. Expected standards will differ ‑ for instance as between parents looking after children, and professionals.

Jo cited the case of a child scalded in the bathroom whilst the mother went to fetch a towel. In such cases judges are sympathetic to the realities of life in the home. In this case, Surtees v Kingston‑Upon ‑Thames Borough Council (199 1), the court "should be wary in its approach to holding parents in breach of a duty of care owed to their children ... The studied calm of the Royal Courts of Justice, concentrating on one point at a time, is light years away from the circumstances prevailing in the average home. The mother is looking after a fast moving toddler at the same time as cooking a meal, answering the telephone, looking after other children and doing all the other things that the average mother has to cope with simultaneously, or in quick succession, in the normal household. We should be slow to characterise as negligent the care which ordinary loving mothers are able to give individual children given the rough and tumble of home life."

In the case of a professional worker: "Where the situation involves the use of some special skill or competence ... the test is the standard the ordinary skilled man exercising and professing to have that special skill ("Bolam v Friern Hospital Management Committee" [1957]). When dealing with either parents or professionals the courts will take account of the complexity of the situation and of the multiple pressures acting upon. the individual. "...Where there are questions of assessment of the relative risks and benefits of adopting a particular medical practice, a reasonable view necessarily presupposes that relative risks and benefits have been weighed by the experts in forming their own opinions." The judiciary has reserved the right to determine that the professional opinion is not reasonable but will only do so in the rare case where it will not "withstand logical analysis." (Bolitho v City and Hackney HA [ 1999]). Thus we must ask when deciding to engage in an activity: what are the chances of an accident occurring or what precautions are necessary to prevent harm when acting? How serious are the consequences of such an accident? What are the likely consequences of not acting? What are the benefits of one's actions? What would be the cost of precautions taken to avoid the accident?

In reaching a judgement as to whether the individual took sufficient care, reference to generally accepted practice will be indicative that the actions were reasonable.

Referring to the case study presented as a workshop briefing, Jo argued that the scheme manager should weigh the risks in administering the medicine (very slight) with those of delaying. The law does not not require one to act; one's procedural manual forbids it. But if one does decide to help in administering the medicine the chances of being found in breach of negligence are very low. (The scheme manager would be responsible for ensuring that the medicine was given as directed, they would not be responsible for the nature of the prescription given by the GP).

Jo reiterated the importance, in all such situations, of making one's decisions after evaluating risks and benefits; the courts will take into account the degree of emergency, the pressures of other forces and such mitigating factors. (One form of pressure regularly experienced by scheme managers comes from close relatives whose wishes may not necessarily coincide with those of the resident).

Jo concluded by referring to the criticism made of the current system of negligence litigation in the Report of Bristol Royal Infirmary by Professor lan Kennedy; although this dealt specifically with the care of children in a hospital setting its conclusions are relevant to all health and care professionals.

The law of negligence is surrounded with uncertainty which is detrimental to both providers and recipients of care.

In the context of Sheltered Housing the uncertainty could be addressed by an agreed set of guidelines to be drawn up by both management and those carrying out the tasks discussed and acceptable to all professionals. These guidelines will assist in decision making and will define the scope of common practice.

Another criticism made in the Kennedy Report is of the way that the law identifies an individual to blame. This fails to acknowledge that we all act within systems. In seeking an individual to blame we ignore the fact that it might be the system that is at fault; punishing the individual does not change the system.

The law focuses on the competing interests of individuals; it creates an adversarial battle between claimant and defendant. But these individuals often have to maintain an ongoing relationship; the law does nothing to foster such relationships.

The fear of clinical negligence results in a culture of silence and blame. There should instead be:

	an administrative system which provides compensation for harm
	institutional and individual quality assurance systems
	procedures for training and continual professional development.

These criticisms of the clinical negligence system are equally apposite in relation to other professionals providing care and suggest an alternative legal framework ‑ one which fosters positive relationships.

A MANAGEMENT PERSPECTIVE

Dave Morris, Policy and Strategy Manager, Anchor Retirement Housing.

Dave Morris worked for 22 years in local government and for the last 12 years has been with the Anchor Trust ‑ an association with over 700 sheltered housing schemes. Recently he has been involved in the training of scheme managers and now is responsible for the long term business strategy, especially compliance and regulatory approaches, leading to the preparation of procedural manuals. He is a member of EROSH's steering group and represents both EROSH and Anchor on a DTIR/DoH Supporting People group.

Until two years ago sheltered housing providers worked within a very light touch regulatory mode ‑ they could do much as they wanted. Now we have Best Value and Supporting People and increased regulation from the Housing Corporation particularly over rents and service charges. There is now greater emphasis on achieving value for money and continuos improvement. Local authorities and their Social Service departments will be commissioning bodies, their contracts specifying services to be provided. Detailed service specifications will be required and monitoring systems put in place. Quality both of the services themselves and the buildings within which they are delivered will be controlled. From April 2002 the contracts will describe the work of the scheme manager, detailing the tasks to be covered by the Supporting People grants.

Providers will no longer have a free hand. Social Services will be looking for improvements in service ‑ or they will look for an alternative provider. Performance indicators are being drawn up by DTLR. Five yearly scheme reviews will be instituted; in addition there will be internal annual reviews and ongoing negotiation and contracts.

There is much concern about how this will work in practice; Anchor, for example, works in 230 local authority areas; some may favour the extension of sheltered housing provision whilst others consider the closure of some schemes.

Government backs these changes; it wants to see outputs, to see where its money is going. It has in fact already spent £140 million in putting in place the structures for Supporting People.

Anchor is preparing for these changes and is working with DTLR to get the best deal for sheltered housing. With drivers such as Best Value and Supporting People staff need to know what is expected of them.

Why do we have documented procedures? Staff must be aware of the standards expected in the delivery of a service, reflected in Best Practice. But the amount of legislation to be pulled together in the procedural manuals is immense. Only too often scheme managers receive notice of some new requirement ‑ but no explanation of a reason for its implementation. Manuals are a cornerstone for ensuring that scheme managers are given the backing they need to provide a quality service; but scheme managers are usually working on their own ‑ contact with line managers can often be difficult, especially at weekends when crises are likely to occur!

Documented procedures identify individual staff procedures, clarify roles and helps to establish consistency. Often a housing association will have three or four schemes within a locality all working with similar contracts but employing different practices. Documented procedures provide a benchmark against which to measure performance and improvements in it. There needs to be more dialogue and clarity between sheltered housing providers and social services about expected standards.

Best Value is sought but often the measures cited are vague (as too in National Service Frameworks).

Thus documented procedures establish best practice and provide evidence  to external bodies that systems are in place to manage service delivery effectively and reliably.

When no-one else is around staff should know what to do. But in many caring situations that are no real answers; good employers will support their staff when problems arise ‑ poor ones will not.

To sum up, the advantages of documented procedures lie in helping staff to manage processes and situations confidently and to check that they are acting according to the requirements of their own organisation, the law and regulation.

But there are disadvantages.

Manuals can lead to processes becoming over bureaucratic; if too prescriptive, initiative can be stifled; if poorly written they can be misinterpreted. Too few senior staff may be available to train scheme managers. It is very difficult to cover all possible situations within the manuals. Good associations are moving towards empowering scheme managers; but the manual can be seen as a stick with which to beat staff, threatening them with disciplinary action rather than urging them to improve service delivery.

Once developed, manuals may lie un‑revised; they become obsolete and seemingly irrelevant ‑leading to staff doing 'their own thing'. They need to be constantly revised with scheme managers fully involved in the review process. Good neighbour or professional? In many crisis situations the scheme manager is first on the scene, the resident may be in a distressed state and in need of assurance of a personal nature. Most other professionals and informal visitors would provide this help; the onus is all too often placed on the scheme manager in the absence of others. A procedural manual should provide information about how to get help for residents and promote their independence and should set limits about what is and what is not reasonable to undertake. The manual should reflect what goes on 'in the real world'. It should provide a step by step guide to help to deal with situations, giving guidance on a range of situations and educating others about the boundaries of the scheme manager's role. In conclusion, Dave reiterated the new contexts of performance standards and monitoring, being established by local authorities and their social services departments. They 'grey areas' must be addressed ‑ in some situations adequate protocols may be devised and ambiguities resolved; but in others there will be no 'right way'; scheme managers must be empowered to make their own decisions. In very few instances will something go badly wrong.

INSURANCE PERSPECTIVES

Ortho Barnes, Director FARR Plc.

FARR Plc act as brokers for some 200 housing associations (many of whom were represented in this workshop) ranging from the larger to the smaller ones. Ortho Barnes himself is chair of a housing association with a considerable stock of sheltered and supported housing.

Insurance has become a major issue in the past decade. Why? Risk Management Stipulations: the Housing Corporation imposes tight controls on housing associations. Driven by internal audit, direct costs are measured but not added value. Increased numbers of regulations are imposed. Corporate responsibility: in a culture of increasing litigation and recognising their responsibilities under health and safety legislation Boards err on the side of caution in attempts to minimise risk. Individual discretion becomes limited. Escalating insurance costs: liability costs are increasing by 33% per annum, due variously to inflation, recession, etc. Income uncertainty: whilst staff and insurance costs are rising, future income under Supporting People is uncertain; one tries therefore to limit all costs. False economy: housing associations are not good at looking at the added value provided by services rather than at direct costs alone; the cost of better and increased services may well be offset by reduced costs of future illness etc. Mythology: beliefs that one is not covered for certain activities, or is personally liable for injuries caused are mostly rubbish.

Typically a housing association will buy the following profile of types of cover. Employers liability: protecting the employee against injury sustained at work e.g. through falls, back injury, through lifting, etc. Stress is a new major form of injury arising from a nil percentage 8 years ago to 25% of cases today. Public liability: injuries to third parties, either scheme residents or outsiders. Scalding is a common example ‑ but it ought not to happen; measures should be taken by management to ensure that it does not happen. Other types of injury are now being encountered; if a school can be sued for providing poor teaching, why not a sheltered housing provider for poor care? Personal accident: direct payments are made according to the nature of the injury irrespective of any employer's liability (though this may exist too). But people with higher risks tend to have lower care because of the costs involved. Disparity between office and care staff is a common anomaly with housing associations and local authorities.

Attacks on staff by residents are covered by personal accident insurance ‑ which all employees ought to have. Legal expenses: increasingly housing associations are purchasing this cover; employee claims are rising 50% annually and many do not have the staff to deal with them. Fidelity: e.g. a resident has money stolen; the frequency may be high but the risks are low since the sums involved are small (in contrast to large scale fraud). Employers are however seeking strict procedures to govern the handling of money by scheme managers.

Of these types of cover, employers liability is, by law, compulsory. Fidelity cover is obligatory only for Industrial and Friendly Societies. Public liability is not required by law but is taken by all associations. Good practice demands cover for personal accident. Legal expenses cover is increasingly taken. Orlito then summarised the types of claims encountered.

	costs of claims for lifting and manual handling amount to 50% of all claims
	third party/public liability claims amount to 25%; with proper supports most of such claims should be avoidable and managements will try to minimise the cost.
	routine employers liability cases ‑ slipping or tripping, account for 15% of costs.
	costs of personal accidents are low because the benefits are small, even though the incidence may be high.
	65% of costs thus arise from employers responsibilities to employees - not to the residents.

Ortho defined the real costs ‑ to a medium sized scheme ‑ of various categories of worker. These costs are actually quite low; (scheme managers should not be told that cover is too expensive!).

Under employers liability: a clerical worker £ 12 pa, a scheme manager £18, a care assistant, £42 and a labour operative £84 (i.e. cover for care assistants is higher because of the lifting involved).

Personal accident rates range less widely: clerical worker, £20, scheme manager £25, care assistant £30, labour operative £50.

Public liability would cost approximately £1 per unit for general need housing to £6 for special needs housing (due to the high duty of care to residents). The cost for sheltered housing would fall midway between the two (largely because of the number of visitors to a scheme).

In conclusion

Direct costs are rising, but accountants are not calculating added value in measuring their real costs the increased concern with risk management and new legislation overwhelms senior management and results in even more complex procedure manuals the need to retain a good level of services in a time of rising costs will come to a head with Supporting People; there is a need to introduce standard procedures.

And finally there are too many myths around, about what scheme managers can or cannot do. Suggestions that certain activities might not be covered are not usually true ‑ the scope of employers and public liability policies is very wide. Policies cover all activities on behalf of one's organisation ‑whether one is on duty, off duty, on call, etc. Insurers will almost invariably meet claims. Insurers will however challenge a housing association if it believed that an inaccurate description was given of an activity carried out by its staff, resulting in an imperfect risk assessment. The insurer will probably meet the claim ‑ but will increase the premiums in future.

THE TRADE UNION PERSPECTIVE

Gary Smith, Regional Organiser, GMB.

Gary Smith has in recent months worked closely with Brighton and Hove City Council sheltered housing scheme managers in their negotiations with the Council consequent upon a restructuring of sheltered housing.

 Are scheme managers a politically vulnerable group of employees? Yes. they are lone workers and may suffer injury in physical tasks or experience assault in interacting with residents (the client group increasingly manifests challenging behaviours). they are at risk from falls, back injuries, often when the professionals expected to perform a task do not appear. they are open to allegations (both from residents and their relatives); investigations, especially involving the police, are distressing.

Gary asked participants if they knew the extent to which they were covered by insurance if they were never able to work again if they were off work, sick, for a lengthy period (some employers gave full pay for six months, half pay for six months, others only gave statutory sick pay). Are scheme managers insured for personal injury and accident? Much poor practice exists.

If you have an injury at work to whom do you turn? procedural manuals are often very lengthy with copious material on health and safety. Have you been instructed in its use and provisions.

Some employers are only too ready to find in the small print something that you did or did not do which aids them in limiting their own liability and putting the blame on you.

If you have an accident or injury you are probably covered by your employer's

insurance and thus will not be personally liable for damages or compensation. But again the small print may be used to initiate disciplinary action, perhaps leading to loss of job and home. Who protects the scheme manager against the employer, anxious to be seen to have done the right thing and to place blame elsewhere?

In the case of a police investigation, the scheme manager is likely to be suspended.

The investigatory process is neutral but the suspension produces feelings of guilt.

Who will represent and support the scheme manager? Employers often have very good procedures but these are poorly transmitted to staff. Employers have a habit of saying to staff "We have our procedures, you should have known better."

Staff need training in relevant skills and in applying policies to specific situations.

Failure to give proper training is tantamount to an attempt to evade liability.

Employers often seem more concerned to protecting their own interests than to looking after those of their staff.

A Trade Union can:

	offer it's members benefits e.g. insurance and legal assistance
	enable members to have a voice in their work
	raise issues, e.g. stress, and articulate concerns
	represent its members when they face trouble in disciplinary situations

Today one has the right to be represented by one's trade union even if the employer does not formally recognise the union.

The role of the Trade Union is to be pro‑active; in issues involving health and safety, for insurance, not just to limit litigation but also to reduce the risks experienced by workers.

TOWARDS GOOD PRACTICE

The following themes emerged from the Workshop and are presented for discussion among sheltered housing providers, staff and residents.

Increasingly, stress is being cited as a major cause of work‑related illness, absenteeism and probably of accidents The scheme manager's role is, by its nature, very stressful; frail residents inevitably generate frequent 'crises.' The stress is aggravated by the late or non‑arrival of relevant professionals GP, ambulance, nurse, social worker, etc. the scheme manager is alone in coping with an emergency The stress may be further aggravated by procedural manuals which appear to prohibit some activities which seem, through common sense or compassion to be appropriate. It is the duty of an employer, under health and safety legislation to minimise stress in employees.

Managements defend, justifiably, the need for procedural manuals. where a contract has been entered into for service provision, the nature of that service must be clearly specified where a similar service is provided in various units or locations, uniformity of performance is expected.

But staff are likely to see the manuals as instruments of control. they seem designed to protect the management against claims for breach of duty they enable blame to be attributed to the individual worker, with threats of disciplinary action and possible dismissal or of personal liability for financial damages. the manuals are often overly prescriptive and do not recognise the sympathy shown in the courts or the liabilities accepted by insurance companies. 3 Manuals must deal with situations that exist in the 'real world'. E.g. probably the most flagrant breach is the prohibition of administrating medicine when it is known that most scheme managers will, in certain situations, do so Manuals must be clearly written and easy to use Manuals must be drawn up and accepted by management and all staff involved (and residents too?); staff must feel free to question or challenge any item that seems not to accord with natural, everyday practice.

4 The systems within which scheme managers work must be comprehensively explained to other professionals (to ensure collaborative working) to the residents (for they will experience stress in situations of uncertainty) 

5 Scheme managers and similar staff must be given comprehensive training in the content of their procedural manuals in making assessments of the risks and benefits incurred in any action within a 'grey area'. 

6 Scheme mangers must be given confidence to feel empowered, to feel trusted by their management in making decisions in difficult situations; they must feel that they have easy access to and support from their line managers they should have access to a trade union for advice and support 7 Scheme managers should understand the nature of insurance cover provided by insurers.