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Culturally appropriate care
Context
In May 2021, the CQC published guidance on culturally appropriate care, in this article I will focus on how this links to the regulations and key lines of enquiry (KLOES) and look at culturally appropriate care in practice. Culturally appropriate care can also be called culturally competent care. Cultural competence can be defined as the ability to understand, appreciate, and interact with people from cultures or belief systems which are different from your own, this has been a core component of phycological thinking for at least 50 years. Culture is evidenced in human behaviour and relates to thoughts, communication, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group. Competence means having the capacity to practice effectively when working with families from any ethnic, religious, or cultural background. Culturally competent practice acknowledges and aims to understand the meaning of cultural identity within everyone’s life. It requires that all organisations and professionals within them develop cultural knowledge and that the design and provision of services respond to culturally specific needs.
The CQC guidance expands this definition to encompass, ethnicity, nationality, religion, gender, sexuality, and disability. Culturally appropriate care is underpinned by a human rights approach to care and to service delivery. In a nutshell, culturally appropriate care is about ensuring equality of opportunity for all.
The CQC point out that culturally appropriate care has increased importance during the COVID-
- have less contact with people that understand and affirm their culture.
- have no opportunity for contact with their culture or community outside their home.
- spend more time with people who do not share their culture
- experience more life events that have cultural significance
Culturally appropriate care and The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
A care service which fails to demonstrate effective culturally appropriate practice may be in breach of three regulations, these are:
Regulation 9: Person centred care – a failure to meet a person’s cultural needs would be a breach of
9 (1) the care and treatment of service users must—
a. be appropriate,
b. meet their needs, and
c. reflect their preferences.
Regulation 9 (3) explains what care providers should do to meet the requirements of Regulation 9
Regulation 10: Dignity and respect – a failure to meet cultural needs would constitute a failure to treat the person with dignity and respect and would be a breach of Regulation 10 (1) and 10 (2)
Regulation 11: Need for consent – this is slightly more tenuous, Regulation 11 (1) says that care and treatment of service users must only be provided with the consent of the relevant person. To do this; care providers must communicate with the person in their preferred manner and a failure to embrace culturally appropriate care would constitute a breach of Regulation 11.
The CQC can prosecute in cases of a breach of Regulation 11 and can take other enforcement action in respect of a breach of Regulations 9 and 10
Culturally appropriate care and the KLOEs
This topic impacts on all the KLOES, most of the impact is on the Responsive and Well Lead KLOES. Key themes which emerge are:
- Involve people in discussions about their care.
- Listen to their wishes and preferences
- Plan services to deliver care and support in the way people prefer
- Embedding culture into all aspects of communication
- Staff training and learning
- The culture of the service
- Leadership and management competencies
- Involving staff in the development of the service
More information on how culturally appropriate care impacts on the KLOEs and hence CQC inspections can be found on the CQC website.
Culturally appropriate care in practice
Some examples of culturally appropriate care in practice include.
Cultural competence – define what this is in relation to your service. One way to do this is via the assessment process. Consider all aspects of culturally appropriate care.
Effective communication – The Accessible Information Standard requires providers to assess, record, communicate and meet the communication needs of those who use their services. Culturally appropriate care means thinking beyond language.
Involving people – we must recognise that the experts of their cultural needs are the people themselves. Care providers must engage with staff and people wo use the service to seek their expert opinion, learn from them and value their views.
Person centred care – it is vital that services provide staff with the underpinning knowledge so that they can be truly culturally competent to deliver person centred care. Remember that this is more than an awareness of ethnicity, staff need to know and understand all aspects of the person who they are supporting, this includes national culture, regional culture, ethnicity, religion, disability, belief.
Care planning – ensure that cultural needs are identified and accommodated as an integral part of every aspect of care planning and reviews.
Cultural awareness and values -
Examples of culturally appropriate care
Religion and spiritual needs
We recognise that supporting people to maintain religious and spiritual practice is a core component of wellbeing. Some examples of how providers can do this include:
- Provide staff with training so that they understand the significance of customs, practice, prayer, dress, objects.
- Ensure that individual needs are specified in care and support plans and that these needs are met in practice with tangible evidence.
- Address potential issues of conflict between cultures in a proactive and positive way, there is no place for discrimination in social care whether that is overt or covert. Religion and belief are one of the protected characteristics under The Equality Act 2010.
- Establish links with religious leaders so that staff can learn about a person’s religious and spiritual needs but also the person can be supported to maintain their faith.
Food and drink
It is so easy to make assumptions about food and drink preferences, for example that all South Asian or African people like spicy food. If they have lived in the UK for some time they may prefer “British food”. However, it is important that we meet people’s nutritional, and hydration needs and ensuring that these meet their personal and cultural preferences is vital to wellbeing. Some examples of good practice include:
- Ask people what their preferences are.
- Learn about specific practices and restrictions which are consistent with religion, for example, do your staff know what terms like Kosher and Halal mean in practice and how not to offend people inadvertently?
- Involve people in meal planning, remember that you provide individual person-
centred care rather than “one size fits all” care. - Ensure that all staff including catering staff in care homes understand and subscribe to meeting people’s food and drink needs.
- Consider how food is presented and how it is eaten, it may be polite in British culture to eat with a knife and fork but in some cultures, it is polite to eat with the hands or a spoon.
- Remember that in some cultures, it's polite to refuse food and drink the first time they're offered. This means you might need to offer more than once.
Healthcare
Some of the main challenges are around animal products in medication and religious observance such as Ramadan. As with other cultural needs these must be identified on a person specific basis, planned and risk assessed, and these needs must be met. In respect of Ramadan the timing of their medication may need to be changed, to do this a GP may need to review any changes to make sure they're safe. Some other examples include:
- Consider how complimentary remedies may contraindicate with prescription medication and consult with healthcare professionals about this.
- When supporting people to make healthcare decisions, always take mental capacity into account. If the person lacks the mental capacity for such decisions when making best interests’ decisions, you must consider cultural needs.
Clothes and personal hygiene
Our appearance is part of our identify and it is a core component to self-
- Listen to the person and if required involve their family and friends to establish how the person would like to dress and be presented.
- Ensure that staff understand the importance of traditional dress and how to support the person to dress in garments which staff may be unfamiliar with. The local community can prove to be a tremendous resource in this respect.
- Remember that in some cultures, how people dress in public is different from how they dress in private. This might be important if you are arranging a video call between a person and their family. It also varies according to personal preference.
Personal and shared space
Our personal space is our safe space, it is where we feel comfortable. The same is true of those who use care and support services. It is important that we do not judge people by our values and beliefs. Some other examples are:
- Think about how shared space is laid out and decorated, most care homes are designed for a British clientele, but if the service provides services for people with different cultures, then the décor and layout must incorporate their needs as well.
- Use of CCTV may infringe people’s feelings about their privacy, for example, Muslim women may not wish anyone to look at images which show them without a headscarf.
End of life care
understanding people's wishes at the end of their life is always important. It can be particularly important if the person using the service and staff do not share the same culture. Remember, there are no second chances, so we must get this right first time. Some examples include:
- Involve people and their families to ascertain the persons needs and include these in advance care plans and end of life care planning.
- Identify specific requirements, for example, in Jewish and Islamic faiths, burial needs to take place quickly. This is another reason why it is important to have a plan.
- If prayers and rituals will bring comfort to people, plan how these will be facilitated.
- Ensure that staff do not accidentally offend people and their families by their lack of knowledge about religious and spiritual needs.
Conclusions
These are just some examples of culturally appropriate care in practice. It is vital that providers of care and support services embrace this aspect of service provision and ensure that they identify and meet the needs of all people. A failure to do this would mean that not only has the person been discriminated against, which is unlawful, but also the requirements of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 have not been met. In the previous issue, my article on this subject identified that this would result in breach of regulations 9,10 &11 and impact on the responsive and well lead KLOEs.
A culturally competent professional can understand the world view and culture of a person. They should develop an understanding of the cultural diversity today, and gain knowledge of the impact of relevant historical influences on the lives of people who use services. For example, the impact of war and social unrest in the country of origin. Professionals should also recognise that different people from the same geographical area, cultural or religious group may have different language, beliefs, and values. They should also recognise the importance of asking individuals and families about their experiences and what matters to them and not make assumptions. Services that fail to demonstrate that they have embraced and embedded culturally appropriate care into practice will be in reach of regulations, this will result in an adverse CQC inspection and enforcement action. Often, only small changes are needed to make a big difference to people. The most important things to do include asking people, understanding culture and preferences and being curious about the things that are important to people.
