/ Health, Home & Energy

Is the care home sector working well?

elderly care

The Competition and Markets Authority is undertaking a thorough review of the care home sector to make sure it works in the best interests of those who rely on it, as Douglas Cooper of the CMA explains.

We launched our market study in December last year to look at issues affecting the 430,000 older people in care and nursing homes across the UK.

As part of this study, we’re looking at a range of issues including:

  • How people find the experience of choosing a care home
  • How care homes compete to attract residents
  • How well care homes are complying with their obligations under consumer law
  • Whether the current regulation and complaints systems give residents adequate protection

We want to be sure that the care homes sector is working well for residents and their families.

Home to care home

Care homes can provide a safe, warm and caring environment for older people to be looked after when they’re no longer able to cope at home.

But choosing a care home is a big decision, which often needs to be taken in stressful or upsetting circumstances, and can have a huge financial impact on families.

In particular, we want to know that residents and their families can get the information they need, when they need it, that they understand any contracts they sign once a home is chosen, and that they are treated fairly by the home during the time they need it.

We’re also looking very closely at reports of potentially unfair practices and contract terms being used by some care homes.

We will assess how widespread these concerns are, how they’re affecting residents, and whether they are likely to breach consumer law.

Playing fair

We’re now a few months into our study and have already received a wealth of useful information and well-informed opinions.

We’ve heard from consumer groups and charities about various concerns around potentially unfair practices and contract terms being used by some care homes, including:

  • Hidden charges where residents face additional fees for services they didn’t know weren’t covered within the weekly fees. Examples might include charges for accompanying residents to medical appointments or entertainment.
  • Fees being increased at very short notice and without clear explanation.
  • Care home residents being charged large deposits/upfront payments without being clear what these cover.
  • Unreasonably long notice periods to leave the home.
  • Residents in receipt of local authority funding being asked directly for top-up payments for additional services by the care home, but it may not always be clear what they are being charged for.

We’re also looking at complaints and redress systems to assess whether these work effectively for residents and their families or if they are difficult to use and deter people from complaining, for example through fear of retaliation against them.

We’re taking a detailed look into how common these practices are.

We haven’t yet formed any view about whether they break any consumer law or other regulations.

But if we do find there are problems, we can take action, including launching enforcement cases or making recommendations for changes in the rules that protect residents and their families.

Help needed

We want to gather further information and that’s why we welcome the launch of the Which? care home reporting tool, where your comments will be treated confidentially.

We want to hear about the experiences of residents and their families who feel they may have been treated unfairly by a care home.

This will feed into our study and help inform our conclusions when we publish our final report by the end of the year. We’ll also be ready to publish our interim report in May this year.

This is a guest contribution by Douglas Cooper of the CMA. All views expressed here are the CMA’s and not necessarily those shared by Which?.

What’s your experience of the care home sector? Have you or an older relative/friend ever been treated unfairly by a care home’s practice, contract or complaints procedure? Or, if you’ve ever worked in the sector, what sort of problems did you encounter?

If you’d like to share sensitive personal experiences in the comments below, please choose to do so using an alias, and omit anything identifiable.

Comments
Guest
Mary says:
18 March 2017

I worked in a hospital where amongst our patients are from care homes and it’s appalling to see the sort of care home staff who accompany patients. Some of these staff are not properly trained in providing care and support. I remember one who just spent the whole time on their phone and not bothering that his patient was nearly sliding off his wheelchair and another incident where the staff haphazardly pushed the wheelchair and banging the patient’s bandaged foot on the examination bed and then retreat outside and leave us to soothe the patient who was crying in pain. It made me think that if they are acting like this in the presence of proper healthcare staff, what more when they are alone with the patient? It also makes me think the lack of criteria in recruiting the kind of people to work in this type of environment. I see my parents in every elderly patient that I meet and it breaks my heart every time I encounter those who seemed unhappy and helpless in their predicament and I’m unable to give them any help aside from raising a clinical incident whenever I witness a blatant ill treatment of them by the accompanying care home staff. Having witnessed these, I’d like to see that the management of every care home (both private and council run) be transparent in their accounts and practices and that residents (privately paying or funded by the council) should be given equal quality care and their families should be given updates when necessary. Also, the care home management should give support (emotional and professional) to their staff because this work area, like the rest of the healthcare sector, is both physically and emotionally draining. It angers me how unscrupulous people prey on those who cannot defend themselves and get away with it and it seems almost every council is willing to pay for a white elephant such as paying a celebrity to light up the Christmas lights than to spend its money on their vulnerable constituents.

Guest
marion says:
18 March 2017

My mother was in a generally decent care home however some of the staff were not kind enough to residents. A really good system of cctv and other methods of monitoring these vulnerable people is so needed.

Guest
Nick Monaghan says:
18 March 2017

Care Homes should be part of the NHS,Free and run on the basis of need not profit for owners.

Guest
Audrey says:
18 March 2017

I completely agree with this comment

Guest
Malcolm Cook says:
19 March 2017

Question: why are care company homes and home visit care companies in business? Answer: because they all make profits for their directors. Suggestion: if all such companies were closed down with staff kept in place then all such businesses could be administered by the NHS….with all profits going not to the directors but to the NHS.

Guest
Lonicera B says:
24 March 2017

I agree but as I understand it they closed down nearly all the Council run homes.

Guest
Alan says:
18 March 2017

My mother-in law had dementia – the local authority placed her in a private care home which asked us for top ups. The LA said they would not pay and we had to. Legal advice from “Help the aged” said otherwise, quoted the relevant regulation, and the LA caved in.

Profile photo of duncan lucas
Guest

Alan -think about it -a council has its lawyers they must know the law and advise the councilors and those running the council who advise the employees paid for by your taxes to be obtrusive and “economical with the truth ” , you know what that means don’t you ? Its one thing a shady business trying to get money out of you by fraudulent means its quite another when its your own local council- Complain to your MP-now !

Profile photo of John Ward
Guest

I suspect that a lot of local authority managers are shooting from the hip and not consulting their legal department. They probably don’t want inconvenient legal advice because it will interfere with their budget management and upset their self-determined care priorities. If they can squeeze top-ups out of families that leaves more money for other cases; I can see the logic of that but it is not right. The council should be demanding more funding from central government but that is difficult and unrewarding whereas it it is easier to screw a bit more out of the client’s family. Local councillors don’t have much influence over day-to-day management of their authority’s social care responsibilities in my experience. Unfortunately MP’s can only ask questions – they have no power over local councils. Thank goodness for Age Concern and other dedicated organisations that keep the pressure on. I hope the CMA review will take note of Alan’s points and address them.

Guest
Malcolm Cook says:
19 March 2017

Local councils authorise and/or appoint care homes and home visit companies, I imagine most also have a ‘care department’ hence, it should be a responsibility of the care department of councils to oversee the administration of all care companies and ensure the wellbeing of care clients. However, I doubt very much if those employed in council care departments have much knowledge or experience of hands-on care….to my mind, incompetence rules – hear nothing, see nothing, do nothing. Perfect for the care company directors and managements, but not so good for the clients of such. It’s high time a Care Register was instigated, only those who have NVQ2 status may be listed and a concerted care training programme launched.

Profile photo of Ian
Guest

I think another problem is that councils have been cutting staff and resources for years, so many local authority managers are simply overwhelmed. They should know the regs, certainly, but it’s possible they’re just fighting rearguard actions and saying the first things that come to mind.

Profile photo of John Ward
Guest

I agree with you, Malcolm. Ever since the CQC came into existence I suspect that local authorities have taken a back seat on supervising care homes. They probably form workable relationships with those that happen to be within their catchment and have acceptable fee levels but don’t spend much time looking for problems as that would give them even more headaches.

Is there any form of independent review site for residential care homes [along the lines of TripAdvisor]?

Guest
Andrea says:
18 March 2017

My lovely Nana died last year whilst in a care home. She had Alzheimers and was 99 years and 11 months old.
Family had so much stress during the two years she lived in the home. At every visit we found her care plan ignored. She was very frail and thin and felt the cold terribly. They put her in t shirts and left her near open windows. Her wedding ring was stolen whilst in the custody of staff. The police couldn’t prove who did it. One summers day she was left in the sun and had heat stroke. Mum and I found her and put her to bed and sought medical help. She was a very smart lady who laterley would be foundsaqww without her teeth, hearing aids or glasses, unable to hear or see or chew her food. We couldn’t get her good basic care and the staff just thought we were a nuisance. Other residents who had no visitors, received similar treatment. The place stunk of urine. We found other residents in situations of distress and had to find staff to assist them. Nana fell 6 times in two years, each time hurting her head and having stitches. The last fall she had led to a bleed on the brain and she subsequently died. The fall was totally avoidable, but Nana had no glasses on, no walking stick and no staff with her in the communal lounge. No one knows how long she lay on the cold floor before she was found. When the coroners inquest was held, the care staff lied on oath, with identical statements prepared by a London barrister. The day before the inquest, masses of notes appeared about Nana, that had never been on her file, about checks the care home had done. I didnt have time to go through them all. They had months to backdate records. Staff denied even speaking to family on the day of Nana’s fall, on oath. the CQC were informed of what happened but after the inquest never got back to us. They are not fit for purpose. CCTV would have proved the care staff’s negligence but wasnt installed. I would take my own life rather than end up in a care home.

Profile photo of duncan lucas
Guest

How many more heart-rendering stories like Andrea posted before any action is taken ,we need more than words or is it a case of -not producing for the Nation ? then “goodnight Vienna ” , speak to Andrea.

Guest
Denise says:
21 March 2017

Hi Andrea

I can simpathise with you, and have experienced some of the same treatment with my Mothe who had vascular Dementia,

The care home she was in, made a serious drug error, Nearly resulting in her death. I did not find Safeguarding and Cqc of any help. The whole experience was horrendous. My mother also ended up with a haematoma on her left leg, bruises all down both arms, again this was not dealt with in a professional manner.

I had to pull the staff up on numerous occasions on different things. Lack of training and language barriers were a major issue.

The week before my mother passed away, the Deputy asked Staff to sit my mother out in a armcahair, she had been in bed for five months, and was at the end of life care. This broke my heart and to this day I will never forgive them for their lack of care.

I believe these homes should be more strictly regulated, and monitored more.

Pray I never end up in a home.

Guest
Eve says:
27 March 2017

Andrea, Im so sorry that you had to experience this.
I briefly worked within a care home until January of this year.
I left because the standard of care is certainly not fit for purpose.

This was a Bupa home. Profit before care.

So many incidents on an ongoing basis. Person Centered Care they promote. Rather stuck in a corner all day with infrequent pad changes. Bupa is a downright disgrace.

Profile photo of VynorHill
Guest

This ‘conversation’ is disturbing. There are so many instances of bad practice above and the worst part of it all is that those who suffer this wrong doing are those who can do little to put things right. Bad news travels faster than good, and those content with what is provided seem either to be in a minority or happy to let others write here. So far I don’t see more than one actual owner writing to defend the sector, though I might have missed an entry or two. The other worrying problem is that demand is likely to increase exponentially in the coming years and we really need to get things right now in preparation.
Around me in a fifty mile radius are ten care homes. Two of these offer a minibus, a therapy programme and communal activities. The other eight simply give the basic address and contact number. None of the ten has an inspection report to read. None indicates whether there are any vacancies and none go anywhere near costing their provision, though this is a complex issue and it may not be possible to include it on an introductory web site. To choose something suitable one would have to visit all ten, look for personal recommendations and work out a possible balance sheet of expenses for each. This is reminiscent of the stress of finding and buying a new house. and the knowledge that if you get it wrong it’s not just bricks and mortar you are dealing with.

Profile photo of duncan lucas
Guest

When I worked for BT there used to be a training school in Otley (Yorks ) I lodged with a BT approved landlady , I liked it and a year or two later I phoned her back to reserve a date , she told me she no longer did it as there was not enough money in it and had turned it into an “Old Folks Home ” . That was back in the 70,s .

Guest
Audrey says:
18 March 2017

I have not personally been involved in arranging a care placement but I often hear comments from people who have and they are often given the wrong information by councils and advice workers such as ‘house must be sold and proceeds used to pay for care’ when it is still lived in by the spouse or a carer/relative over 60

Profile photo of rosealee
Guest

I worked in the care sector as a professional for over thirty years. I left in 2008 and it was in crisis then and very underfunded. The situation has just been left to deteriorate as no Government has wanted to address the issues. All there appears to have been is consultations and discussions on long term care. I fear this will not get resolved as no politician or their family member will have to endure some of the treatment mentioned on these blogs. As is often stated a country is judged on the treatment of its elderly,and in a lot of cases we fail miserably. However, the UK likes to take central stage around the globe where money seems no object. Strange how parliament gets it so wrong with its own citizens. The unfair system whereby a person with their own property however modest has to sell it to fund care,whereby a person without has the state pay. I only hope that WHICH will keep the pressure on Government. It needs this as a t the moment as all the news is dominated by Brexit or Donald Trump

Guest
christine Hemmings says:
18 March 2017

My experience of my mum being in a care home was horrendous. We had to go everyday to ensure that Mum was ok. Often tablets would be found on the floor, dropped by staff or residents, night buzzers were pulled out of the wall to stop residents buzzing, toileting was done on a time basis not on a need basis. The staff took breaks together so no staff were available for periods of time. I could go on and on ! The CQQ were a waste of time. What is the point of informing homes when they would be visited. This home in particular would just prior to a visit attempt to put everything in order until the visit was over. then everything went back to normal. Social services were no help whatsoever, despite them agreeing with the points we raised eg Mum never having a proper bath or shower due to shortage of staff, nothing was done.
We couldnt move her due to the fact that Mum needed hoisting and turning in bed each night. Many care homes refused to take her due to this. Obviously because it took 2 staff to deal with her. Mum was 99 when she died an I can only hope that the Government takes more control over all care homes. No one should have to experience the 3 years that we had to endure .

Guest
nigel says:
19 March 2017

We chose a home for my Dad who had dementia. We began to suspect that all was not well, but persevered with it and made numerous suggestions and complaints.
Eventually the truth (or part of it) of what was really happening to these vulnerable patients came out . CQC and the Police were involved.
It emerged that some patients, including Dad, had been verbally abused, humiliated and subjected to degrading treatment by night shift staff, Other staff knew what was happening but were intimidated and kept quiet. Thankfully, one plucked up courage to expose the events. For others it was much, much worse. A patient died after severe sexual abuse. A new management team were installed and the place was ‘rebranded’. We were assured that this was a completely fresh start. One staff member had been jailed. Others sacked.
We stayed with it on the understanding that this was a fresh start, because this was a convenient home for my Mum to visit Dad and take him to the seafront in his wheelchair, which they both enjoyed.
Things did improve , from appalling to just second rate. All the time we were trying to get things improved. Eventually they said Dad needed nursing care and we moved him to a better home in another town 20 miles away. It was much less convenient for Mum and the family but we felt that the level of care improved.
Unfortunately he was not there long before he died but we feel his last months were probably more comfortable and less stressful for him.
Readers may wonder why we stayed with the home, but remember these things came out over time and for a long time we thought it was just sloppy care and lack of funds and ‘the system’. When the storm broke everyone became involved; CQC, Council, Police, and we were assured this was a new start.
In a way the blame does lie with the system. Pushing care of the sick and elderly out to the private sector inevitably results in cost cutting and poor care is the result. It is not always the fault of the owners though as they are expected to make a silk purse from a sow’s ear. As a previous contributor said, councils spend on frivolous things while old people are given second rate care.

Profile photo of duncan lucas
Guest

It just gets worse Nigel, my sympathy towards your dear departed Dad . How could people call themselves “human beings ” animals wouldn’t behave like that , personally I would feel like putting them up against a wall in front of a firing squad . If it was America the whole lot would be jailed for a long time , the company sued for every penny it had and the owners home-car- shares etc sold off, but this is “feel sorry for the perpetrators” not the victims UK protect the “business image ” at all costs, so tell Nigel its “just one bad apple ” .If I was in charge of this country I would have zero sympathy for any of those vile “carers ” . I blame the advertising industry for portraying old people as “Cash Cows ” and making them feel guilty for having worked all their lives and saved their money NOT spent it on stupid advertising products. This is one “old fart ” who will go down fighting.

Guest
John says:
19 March 2017

I have not had direct experience myself of being in a care home. Being now 81, I have visited an acquaintance in a care home , and talked to people of their experience of care homes in the area.
Generally, if I should need to go into a care home (and as I have had a good life so far), I now feel I would like to take a peaceful exit, rather than be a burden to myself, relatives and the public purse.

Guest
Angela Mary Brace says:
20 March 2017

I have experience of poor care for my epileptic brother but he is now in an amzing home called Fern Lodge in Braintree.
Sadly a 92 yr old friend is in a care home at Heybridge where, I quote, when asked what else there was for tea for 6 people all on the NHS enablement plan ‘That is all that was left over from lunch’. (left over for the dementia unit across the campus) He is still there and is putting wt on probably because we and his family and friends have suppleneted his tea. Lunch and breakfast are OK. He is going to reside elswhere.

Guest
Niece Chris says:
20 March 2017

My aunt was in a care home. On a visit, to her, one of the residents collapsed. The staff did not know what to do and as a trained first aider I took over. I was appalled that they seemed to be ignorant of even the basic recovery position.

Another aunt went into a nursing home. She complained that she could not understand what the carers were saying as Engish was not their first language. Staff ignored the buzzers while they watched TV. My 98 year old aunt fell on several occasions while trying to get to the toilet, as help had not arrived. She died after a fall in the toilet. When I spoke to the undertaker her rings had disappeared from her fingers but there was no evidence of how or when this happened, post death.

It is my opinion that staff are inadequately trained.

Profile photo of Beryl
Guest

Latest News – care firms have cancelled contracts with 95 UK councils, saying they cannot deliver services for the amount they are being paid. Watch Panorama tonight 20:30 – 21:00.

Reading through the above comments only strengthens my belief in everyone having the right to choose, when life no longer has any quality left, as John so fittingly depicts it, “to take a peaceful exit.” My recently deceased sister struggled on at home with both rheumatoid and osteoarthritis during her final years rather than go into care and, although the arthritis didn’t kill her, the number of pain killers and other pills she swallowed on a daily basis no doubt contributed to the stomach injury that finally ended her life. With only a 50/50 chance of surviving surgery, she decided against it, said all her goodbyes to everyone and just passed peacefully away in hospital. For her it was a blessed relief.

My niece, a retired nurse went to great lengths to find a suitable care home to accommodate her mothers needs and with her medical background and past nursing experience was able to determine whether the care provided and general attitude of the staff reached the standard she knew her mother deserved and would require.

I have had cause to officially complain about the poor standard of care at at least one care home in the past and was instrumental in the successful execution of its closure. It was an extremely stressful experience involving opposing highly qualified professional medical practitioners, the CQC and the local Mental Health Trust, all of which took some lengthy persuading that the written report I had submitted was evidential and substantial. It was a privately run care home, mainly funded by the NHS.

Modern scientific medical advancement is prolonging elderly people’s lives but the provision of care is unable to meet the ever increasing demand. My sister chose to keep her independence and remain in her own home rather than risk moving into the ‘care” of the kind of people who think profit takes precedence over vulnerable elderly people’s lives.

Profile photo of duncan lucas
Guest

The problem you have Beryl is the vociferous PC Brigade and their insistence on making it a crime to take your own life their argument being- modern drugs alleviate any pain . As your post points out she was in so much pain that she took large doses of painkillers which I know can cause stomach perforation /hemorrhage, once that has happened the stomach and the stomach contents leak onto the vital organs of the body you have a short time to get surgery. Having worked in hospitals it may “shock ” some of the PC group to know that if there is no chance of long term survival and the patient is in extreme pain the doctors “help ” the patient to die . One of my aunts was dying of cancer she was on a drip of strong painkillers , her daughters response as she watched her mother die was — quote- “she did not know she was dying ” . I want this group to post on Which and tell those posters here who have relatives who died in pain and suffering , not just physical but mental WHY they should suffer indignity /extreme pain / acute suffering just to satisfy their “ideals ” NOT of those dying . Its all very well when they were looked after TOTALLY by the NHS but now its private enterprise running on profit not Humanitarianism .

Profile photo of Ian
Guest

Not sure it’s entirely the PC ‘brigade’, Duncan; there’s a lot of concern around right to die with regard to unscrupulous relatives. I’ve just had a very close and old friend die, slowly, of lung cancer, but he wasn’t dependent, or in a care home. He was diagnosed last September and things happened quickly – far too quickly – from then. His mind was as sharp as ever when he passed away, and a startlingly high intellect combined with outstanding comedic timing meant he was fully aware and able to joke about his impending demise. He told the Chemo nurses “You know, you’ve really put the fun back into Lung Cancer..” and his devoted daughter was with him until he died.

He wanted to live and if he hadn’t I’m sure his daughter would have accommodated his every wish. But not all have relatives as devoted as she was.

Profile photo of John Ward
Guest

Duncan – You have raised a very controversial topic and there are many feelings surrounding it that go way beyond political correctness. I don’t believe you have the right to challenge believers of certain approaches to pain, suffering and death to explain themselves. It is a fundamental principle for many that it is not for relatives, or even next of kin, to either prolong or to seek to curtail life when people are in the care of the physicians whether in the private or the public sector. Your approach tramples over people’s religious beliefs, their own moral and ethical attitudes, and their commitments to their loved ones. There are also many different opinions on the alleviation of pain and whether or not taking pain-killers [other than as prescribed] is a deliberate or a desperate act in a situation where the patient might not be in a state of free will.

Profile photo of duncan lucas
Guest

Believers of pain+suffering+death John ? -Whose ? their own no chance , they are sitting back making moral judgments on the dying while they are not in that position themselves . Do you not understand the thoughts and feelings of those who are dying in extreme pain ? I can provide 100.s if not 1000,s of people who are terminally ill and want to end it and they have to go abroad and die . how can a human being stand back and watch another suffer like this it takes a very clinical viewpoint , if a pet was in the same situation your neighbour would be phoning the RSPCA . Young people think they live forever and dont understand the full facts about death and suffering -I do I watched many die and its not nice , I nearly died twice and I have lived with pain all my life , not enough to kill me but enough to let me know the suffering of others I do not change my opinion ,have you not read the heart rendering posts on this ? I have to look after my wife 24/7 and have done so now for 18 years -no brake and any welfare benefit I got was taken off me by HMG to pay the IMF/World Bank etc -billionaires . Read up on those having to go abroad to end their extreme suffering. I have compassion on the suffering of humanity why make it worse for them?

Profile photo of John Ward
Guest

You have misquoted me, Duncan. I wrote about believers of “certain approaches to pain, suffering and death”. That covers a very wide spectrum and I don’t think it is suitable for this type of forum. No two situations are identical and emotional responses make it impossible to categorise and generalise. I think there are sensitivities that need to be respected and we need to be careful not to intrude on people’s grief. No one person’s interpretation of humanitarianism is more valid than another’s. I am not going to continue this dialogue because I think it could be painful for other readers. In any case this Conversation is about residential care homes and the treatment of elderly or poorly residents, not people in terminal phases who would usually be in a nursing home, hospice or hospital and in receipt of medical attention.

Profile photo of malcolm r
Guest

A great concern of mine is the seeming unwillingness of authorities to routinely evaluate care and care homes, listen to complaints, and for the CQC to be unable to do their job as extensively as we would like. Is this, I wonder, partly a wish to bury their heads in the sand rather than face up to deficiences that they would then have to deal with?

Putting care in the private sector involves the profit motive. Not a bad incentive in many ways as it encourages efficient, not wasteful, practice and should motivate those in the business. However, if councils are not prepared to pay what it costs they should not be surprised at the outcome.

I am generally not in favour of “nationalisation”, but wonder whether local authorities would be better off running their own care homes, and eliminating the profit a third party must make – thus reducing costs and giving them control. If only I could trust public servants to act properly, run such homes in a caring and efficient way. Past reports of bad practice – social services presiding over the abuse of young people for example – are not reassuring.

Profile photo of Ian
Guest

They used to run their own care facilities; but it became government policy during the early ’80s to ‘encourage’ private care homes and now it would take a great deal of money to reclaim the system which the government would be extremely unlikely to provide.

Profile photo of duncan lucas
Guest

Thats an honest answer Ian.

Guest
B. Michaels says:
27 March 2017

I just want to praise the care homes which looked after my father, who could be quite difficult to manage.

Guest
Gill Duval says:
29 March 2017

My mother, who had dementia, lived in Dover and when she needed full time care I wanted her to be near me – I live about 70 miles away- so that I could visit her regularly. Whatever I did , whoever I asked, care homes, local authorities etc. no-one would even consider letting her live near me. That meant, towards the end, I drove to Dover three times a week. I even missed her dying, as by the time I got down there, she was gone. I was even refused a priest being called to her as ” she hadn’t asked” but – SHE HAD DEMENTIA!

Profile photo of John Ward
Guest

It does seem that some of the people running care homes have had a total compassion bypass.