Sara Livadeas explains how being prepared to go against the grain has reaped success during two momentous years as CEO of The Fremantle Trust.
Sara developed her crusading spirit for provide better quality care while working as a volunteer at a hospital for the ‘mentally handicapped’ in the 1980s.
“I wanted to put something back into the community and I was really appalled by what I found,”
“There were male-female segregated wards, people didn’t have their own clothes or their own bedrooms and they were shouted at by staff.
“It was a horrible place. It was a bit like the old asylums and it was one of the last ones to close. I knew what I was seeing wasn’t right but I didn’t have a frame of reference to hang it on so I became really interested in what was going on with people with a learning disability and how they were cared for.”
Having begun her career as a psychology assistant, Sara decided to train as a social worker.
“It sounds very grandiose but I wanted to put things right that I could see were wrong at that time,” Sara explained.
“I worked for a long time on supporting people with a learning disability to move out of hostels and into their own accommodation in supported living settings.”
Having joined Oxfordshire County Council, Sara climbed up the career ladder to become Deputy Director for Adult Social Care commissioning services for older people and people with a learning disability.
Twenty years later, Sara took her first step into the provider side of care with The Orders of St John Care Trust (OSJCT) where she worked for three years as Strategy Director.
“I was basically in charge of building care homes, which was amazing because I didn’t know anything about that when I started,” Sara confided.
After three years, Sara left the OSJCT and wrote a book on how to open a care home while working
“There was loads of information on how to close a care home but nothing on how to open one,” Sara noted.
It was at this point she was approached by The Fremantle Trust and successfully applied to become their CEO.
“I did have a desire to become a chief executive because having worked in a local authority for so long the mantra was always that care homes are bad and institutions are bad and care at home is good,” Sara said.
“That was the local authority policy but we were spending half our budget on residential and nursing homes. I wanted to see if I could deliver really good and outstanding care and whether it was doable or not.
“I think that if we’re going to carry on supporting end of life in these big institutions then they need to be as good as they can be and I wanted to see if I could do it and that’s why I went to Fremantle.”
Having taken up her position in January 2019, Sara found there were quite a few legacy issues at the charity.
“It was a bit of a turnaround situation to be honest,” Sara explained.
Sara took the decision to end the contract for the Buckinghamshire-based Trust’s Barnet services shortly after joining.
“It wasn’t working for us and it wasn’t working for them,” she noted.
The CEO adopted a threefold strategy in addressing the Trust’s care quality issues.
“It was getting the right people doing the right things, getting the culture right and putting the systems and processes in place to support people to get it right,” Sara said.
“We are very much on a journey. The organisation is under invested. I don’t believe the local authority is paying a fair price for care and all of the surplus that was generated was being swallowed up to pay down an old local government pension deficit at a rate of a million pounds a year.
“Without that money we could not invest in things like infrastructure and technology and training as well as changing the culture.”
The Trust operates under a long-term contract with Buckinghamshire Council.
While noting some initial care quality issues at the charity, Sara said its underlying fundamentals were strong.
“Our homes are 100% en-suite and in good locations,” Sara highlighted.
“We’re often in the heart of market towns which is obviously really good for staffing because people can walk to work.
“Also there are a lot of hospitals in Buckinghamshire and I think that really helps our nursing care because it means we can recruit nurses as they live in the area and our nursing homes are good and well regarded.”
Sara said the Trust’s existing values of being kind and part of the community were sound, adding she had some “non-negotiables”, including the visibility of senior people.
“I would always say to anyone that I recruited that it’s really important you spend at least 50% of your time in services getting to know the customers, the residents and the employees, and really modelling the sorts of behaviours that you want other people to do such as spending time with the people who use our services,” the CEO said.
In an innovative move, Sara and her leadership team put on uniform and worked shifts at the Trust’s homes.
“I wanted to model the behaviour such as spending time just sitting and chatting with residents because we’re very task focused and I wanted that visibility and to listen to what people were telling us, that’s a really strong non-negotiable for me,” Sara explained.
The CEO revealed she was an unapologetic magpie when it came to stealing best practice from her peers.
“I spend a lot of time copying my peers so I look around for good people and see what they’re doing and then I copy them,” Sara said.
“I’m not ashamed to copy what other people are doing because I think it’s really good for us to learn from each other.”
She cited former WCS CEO Christine Asbury as someone she admired for being innovative and leading by example.
With Sara having just written the charity’s corporate plan, begun building relationships with Buckinghamshire council and having started to get the right people doing the right things, she was faced with the onset of coronavirus at the end of February last year.
“The last year has been quite different from the one I had planned,” Sara reflected.
“We could see the pandemic coming and so we did a lot of planning. I used the skills I’d learned working in a local authority on planning for an emergency.”
To help combat the recruitment and retention challenges posed by COVID, the Trust created a new support worker role.
“We were really flexible and really fast tracked recruitment,” Sara explained.
“We looked for people who had been furloughed or had lost their jobs in other sectors.”
The Trust created 49 support worker roles. Of these, 65% came from outside the sector, 35% came from hospitality, 16% from businesses, such as admin and marketing, 13% from retail and 10% from leisure and fitness.
The new recruits included an actor from the West End, a teacher and a driving instructor, with a notable increase in male applicants amongst the fresh intake.
“It was just brilliant because it brought in all this new talent and a different way of looking at things,” Sara said.
Twenty eight of the new recruits have stayed with the Trust and progressed into other roles.
“When I first joined the Trust I stayed in a care home and I was really impressed with the range of skills and abilities care teams had because I could see with my own eyes what a range of stuff they were doing,” Sara explained.
“It was the same during the pandemic. Colleagues really stepped up and showed us the range of skills that they had.
“We had trained care workers validating deaths because we couldn’t get GPs to come out to the homes during the peak of the pandemic. We pay our staff Real Living Wage but that’s a lot less than what GPs are being paid.”
While noting that some GPs had “washed their hands” of her homes at times during the crisis, Sara said Buckinghamshire council had been supportive.
“They passed over the money that they got from the government,” she noted.
“There was no funny business in terms of passing over the Infection Control Grant and other monies. We also received a tax deferment from HMRC that was worth around a £1m which helped quite a lot with cash flow.”
The Trust took on a number of contracts from the NHS for people being discharged from hospital, some of whom were recovering from COVID, and agreed an additional temporary contract with Buckinghamshire council due to a rise in vacancies during the pandemic.
“On the one hand, our relationship with the NHS and local authority has improved and the level of respect has increased but at the same time we feel under constant scrutiny,” Sara said.
“They have a very ‘Big Brotherish’ approach to monitoring what we’re doing. We were criticised on one occasion for our infection control procedures by somebody who hadn’t set a foot in our care homes.”
The CEO said the Trust had recruited a nurse expert to specifically work on infection control procedures.
“I’m really impressed with our infection control procedures and policy,” Sara said.
“We do physical audits to see if staff are donning and doffing PPE correctly, for example.”
While taking hospital discharges during the crisis, Sara opted against creating designated settings under the DHSC’s programme.
“I do believe that the idea to extend the capacity of the NHS by effectively engaging with nursing homes to support people with COVID is a really good one and it’s part of the solution going forward to be able to increase and decrease capacity quickly but the conditions the CQC put around designated settings were so stringent,” Sara commented.
“That’s why there’s been such as dearth of applications.”
The CEO noted that NHS funding had been “precarious” for the discharge to assess and rehabilitation services the Trust had offered.
“You sometimes have to move people around to create this service and when the funding tap keeps being turned on and off it’s impossible for providers to plan with any certainty,” Sara noted.
“If the government and NHS would just listen to providers, we could jointly craft a service that would meet those needs rather than the commissioners stipulating what it should be and then being surprised when nobody can deliver it.”
Sara said the Trust had effectively counteracted the risk of people being discharged without being tested in the early stages of the pandemic by caring for them in isolation.
The CEO added that PPE supply had been good thanks to the Trust’s effective planning.
“We were lucky because we have a big budget so were able buy PPE in bulk for our homes,” Sara said.
“We were ahead of the government on PPE and caring for people in isolation.”
Sara took the time to write to every single family member who had lost somebody during the pandemic regardless of whether their death was COVID related and to invite them to get in touch if they had any unanswered questions.
“I think it all happened so quickly for a lot of families so reaching out to them was one of the things I wanted to do,” she explained.
The Trust’s leader admitted to have been reluctant to lock down at the beginning of the pandemic.
“I was a bit of an outlier at the start because I thought if someone had told me my daughter had to go into hospital there is no way I would accept not being able to see her,” Sara said.
“I was pushing for visits to continue the whole time but I had my Trustees and my Care Director saying there was a risk and everybody else was locking down.”
In the end, Sara bowed to the inevitable and her homes were locked down to all but end of life visits and special circumstances.
Regular communication has been key for Sara in her effective handling of people’s concerns during this emotionally charged period when they have been unable to see their loved ones.
Sara wrote to all families and friends ahead of lockdown to inform them they would not be able to see their loved ones during lockdown and ensured they were kept in touch through the Trust’s website and phone and Zoom calls.
“We tried lots of different methods of communicating with friends and relatives but were taken a bit by surprise at the start because we didn’t have a database of contacts,” Sara confided. “We are better at it now though we’re still not perfect.”
Sara and her leadership team keep families up to date with any change in government policy. The CEO communicates with family members monthly with her home and service managers providing weekly updates. Employees are also kept regularly updated with changes in policy.
The homes were once again opened up for garden visits as early as possible with the return of summer.
“I absolutely knew it was the right thing to do and I encouraged my home managers to be open as much as possible,” Sara noted.
“Throughout the pandemic we’ve been ahead of the government on our visitor policy and allowed visits inside with screens and increased infection control while restricting the length of visits.”
Although new government guidelines restrict residents to one visitor, Sara said the Trust would be keeping its two person per resident policy with more allowed in exceptional circumstances.
“If more than one person wants to visit and if a child wants to come with them we allow that,” Sara explained.
“I’ve said to the relatives and friends that I am not going to be policing whether they touch each other. They’re adults and they can make that decision themselves. We give advice but we are not going to be policing whether people give each other a hug and the chances of getting coronavirus from a brief hug are so low anyway.”
When asked if she was worried about a lack of insurance coverage on visiting, Sara said she believed her home’s infection control procedures were safe and every individual situation was risk assessed.
“I’m not worried about an insurance challenge because I think we can explain and defend the decisions that we’ve made to keep people safe,” Sara stressed.
Turning elsewhere, Sara noted that regular testing had significantly reduced staff absences.
“Testing has really helped us because it means people don’t need to be off when they haven’t got coronavirus and you can pick up asymptomatic staff and send them home,” Sara said.
“A lot more of our residents have actually recovered from coronavirus than we previously knew and that gives us confidence.”
CHP was interested to learn that Sara did not follow the accepted wisdom regarding staff vaccinations.
While significant numbers of care staff continue to decline COVID vaccinations for non-medical reasons and leading providers such as Care UK and Barchester have adopted ‘no-jab, no job’ policies, Sara revealed she was once again inclined to go against the grain with a more relaxed and inclusive approach.
Talking to us in early March, she revealed that around 60% of her employees had been vaccinated.
“We’re encouraging everybody to have the vaccine and setting an example by having it ourselves but I think the priority is to ensure that residents are vaccinated,” Sara stressed.
“Obviously I want our employees to be vaccinated but the bottom line is if the residents are vaccinated then they’re protected. I wonder if we’re getting a bit too hysterical about care workers not being vaccinated because if the residents are protected we may be focusing on the wrong thing.
“I am a bit more relaxed about this. I started off thinking ‘no vaccine, no job’ but the more I think about it the more I think it’s less of an issue if the residents are protected. I think societal pressure will eventually bring all employees on board.
“Compelling people to do things is never really a good idea because they’re resisting for a reason and you’re just going to increase their anxiety so dialogue is much better.”
Sara takes a similarly inclusive approach with regard to home working for non-frontline staff.
She runs twice weekly conference calls for those working from home.
“It’s just a well-being check and to keep people updated,” Sara explained.
“I also remind people to take breaks, set boundaries between their workspace and their home and reach out to their colleagues for support.”
Sara has kept a dialogue going with the team about when they want to come back to the office.
“If people feel in control, they’re much more likely to go along and do the right thing,” Sara added.
She has also been eager to ensure that the fantastic efforts of her employees during the pandemic have been recognised and rewarded.
In another innovative move, the CEO wrote to Doug Gurr, the chief exec of Amazon UK, asking if he would like to recognise her employee’s contribution during the pandemic.
The Amazon chief responded by sending ‘goody boxes’ to the Trust’s 1,400 employees which were delivered to services with a personal ‘thank you’ from Sara and her senior team.
In terms of broader recognition and incentivisation for care staff, Sara said the sector would have to be professionalised with people being paid and trained properly.
“People’s skills need to be recognised so the pay and training needs to increase and the career structure needs to improve,” Sara said.
“We need to reward them properly,” the CEO added, noting she had introduced the Real Living Wage when beginning her tenure.
In terms of wider reform of the sector, Sara noted social care’s glaring omission from the Chancellor’s Budget in March as well as how he had subsequently described the sector as a “problem” needing to be fixed.
“If you’ve got the DHSC running a recruitment campaign and at the same time you’ve got the Chancellor describing social care as a ‘problem’, then the government really needs to get its act together in terms of messaging,” Sara said.
“Who’s going to want to work in ‘a problem’ and who wants to invest in ‘a problem’? It’s going to knock the confidence of the people who use the services and it’s so undermining to describe the sector that way.
“Social care enables people to live the lifestyle of their choice at all ages. It enhances their quality of life and sometimes it enables them to try out new things, even at the end of life, so it’s a very positive type of support.”
Sara noted the societal need for a reset in terms of how people think of old age and how they are going to be supported.
“People go along in their lives with the mindset that they are not going to get old and it’s not going to happen to them and then they get old and they take the blinkers off and look around and they realise that the services that are there to support them are wholly inadequate by which point it is way too late for them to influence what’s available to them,” Sara said.
“People need to engage now with what they want in their own later life and what they want for their friends and relatives if things are going to improve.”
The Trust’s CEO said she was doubtful whether reform would be implemented this year while noting the importance that eventual reform is not just about funding.
“Reform needs to be much more than capping the amount that private payers pay in their lifetime,” Sara stressed.
“There doesn’t just need to be more money, there needs to be a consideration of what social care is for, what we want from it, including suitable housing, preventative services, equipment, support for carers, housing with care and keeping people at home. All of that needs to be part of the story.”