Last reviewed 29 February 2016

Jef Smith looks at the subject of terms of address within care, a topic that continues to cause issues even though most guides to good practice state that users of health and social services should themselves have the right to determine how they are addressed.

Last September, the CQC criticised staff at a home in Yorkshire for using what it felt were inappropriate terms of endearment. Under the section of the report dealing with the question “Is the service caring?”, inspectors wrote as follows:

“throughout our visit we heard staff using terms such as ‘sweetie’, ‘darling’, ‘handsome’ and ‘love’ when speaking to and about people who used the service. Although the language was meant to be friendly it could be regarded as demeaning and patronising.”

Taken in context, that comment could certainly not be regarded as unbalanced. It was noted that some relatives “thought that staff usually spoke respectfully to people” but that others mentioned “occasions which they had witnessed when staff had spoken inappropriately”.

There were other examples which suggested that privacy was not always scrupulously observed; residents, it was reported, “were not always supported with their personal care which meant they were left in an uncomfortable and unhygienic state”. The lack of curtains in a shower room meant that “body shapes could be seen from...a communal area”. Residents “were expected to be in their rooms by 11pm at night and were not permitted to be out of their rooms until 8am the following morning”. It is true that “staff knocked on people’s doors before going into their rooms”, but should this elementary requirement for privacy still need to be stated? All in all, the grading for this area of the home’s performance as “Requires improvement” can hardly be seen as unfair.

Nevertheless the press reaction to the report produced what CQC itself called “shock, horror headlines”, with many stories dismissing the inspectors’ reaction as bureaucratic and unfeeling, even inclined towards promoting an atmosphere which “would be cold and unwelcoming”. One older person was presumed to speak for many when they said: “The use of the word ‘love’ is part of our heritage”.

There is indeed an honourable place in social care for an intimacy between service giver and service user, but workers have to be sure that genuine closeness does not tip over into inappropriate familiarity or, worse, condescension. As so often in our craft, the balance is a delicate one to strike. As is so often the case in our profession, the balance is a delicate one to strike.

It is often good advice, when considering issues of dignity, to ask how one would feel when placed in a similar situation, but in this case I’m not so sure. I dislike my fishmonger calling me “darling” and I bridle when an allotment colleague addresses me as “young man”, but I rejoice when called “pet” or “hinny”, words which are rare in London but for me recall three happy years spent in County Durham. For many women a whole range of terms and manners of delivery feel sexist; remember the outraged reaction when the Prime Minister paternalistically told Angelina Eagle MP to “calm down, dear” during Prime Minister’s Questions.

The CQC’s view

Commenting on the Yorkshire case, Andrea Sutcliffe, CQC’s chief inspector of adult social care, made some similarly personal points. In one of “Andrea’s blogs”, her short weekly articles published on the CQC website, she told readers that she doesn’t mind being called “Skippy” by some old friends or “love” by almost anyone, but understandably she hates her first name being abbreviated to “Andy” or her second to “Sooty”. What these examples show is that our reactions to the names people use to address us are very much geared to our individual feelings.

As Ms Sutcliffe went on to point out, “If it’s all about choice for me in my daily life, how much more important for people who may need to rely upon others for care and support?”. One generally applicable rule is to be guided by what people say they want for themselves, and for this to happen you have of course both to ask them and to abide by what they tell you; and don’t forget they may change their minds over time as relationships develop.

Alan Bennett relates how in his mother’s care home, staff insisted on inappropriately abbreviating her name even after he’d corrected them (she had dementia so wasn’t altogether able to answer for herself). The staff would justify the practice with a sort of “we know best” attitude, like that of old-fashioned nurses telling you what was good for you. This is the sort of would-be superior stance for which there is emphatically no place in modern social care.

Ironically, the CQC ended up quite welcoming the media attention generated by their Yorkshire report. Debbie Westhead, CQC’s Deputy Chief Inspector for the North, who took the brunt of the press and public outrage, weathered the storm with considerable aplomb. She recognised that “managers and staff using affectionate terms of endearment to address people” is “part of the compassionate and person-centred care approach that we expect providers to deliver and that people simply deserve”. Her reservation was that it is vital that “individual wishes and preferences are always understood and responded to appropriately.”

The fact that such a basic point still needs to be made is, however, a pretty severe judgement on the care industry. The use of terms of address touches on a whole range of fundamental service user rights — independence, dignity, privacy and choice, to name a few — so should it really have required a government inspector to point out this elementary principle?

The Code of Conduct for Healthcare Support Workers and Adult Social Care Workers in England, published by Skills for Care and endorsed by the Department of Health, is full of phrases like “always act in the best interests of people”, “treat people with respect and compassion”, “helping them to be in control and to choose the healthcare, care and support they receive”, “promote people’s independence and ability to self-care”, “assisting those who use health and care services to exercise their rights” and “always gain valid consent”. Taken together, the primacy of respect and choice to good care seems very clear.

The bigger picture

There are, of course, still critics who dismiss the discussion about terms of address and endearment as trivial compared with some of the much more serious issues thrown up by poor practice and active abuse. However, this is to ignore the essential interrelationships between diverse aspects of care.

The North Yorkshire cased showed how issues around relatively trivial seeming points of respect, such as terms of address, can be symptomatic of a larger attitudinal problem. A home that did not respect its residents enough to check how they would like to be addressed is one which also thought it unimportant that residents did not have complete privacy when they showered and that denied them access to communal areas between bedtime and breakfast. All of these practices were symptomatic of the same lack of respect and were insidiously reinforcing each other.

There is an interesting way in which the issue of names can be inverted, which is this: how would service users prefer to address you?

We should all take care when introducing ourselves in a professional capacity to service users. Some will indeed be happy with, even encouraged by, the immediate show of warmth that using one’s first name can imply, but others may feel they are being pushed into too early a intimacy and are obliged to reciprocate when really they would have preferred to hold back for a while.

Everyone is different, and those differences have to be carefully navigated, which was precisely the point made in Ms Sutcliffe’s blog. Or may I call her Andrea?