Exposure and the CQC

Last night, ITV examined the state of residential care and regulation of the sector in Exposure. While I watched the programme through the lens of someone who has had significant experience of the sector, I’ve also followed the birthing pains of the Care Quality Commission avidly so some of the information given wasn’t ‘new’ to me. I probably didn’t approach the programme as an ‘average viewer’ might.

There were a few issues raised that I think useful to explore. The programme seemed to rightly raise the void of inspection that took place through the initial years in which the CQC was established. The organisation was established with less money than it’s predecessor bodies, the Healthcare Commission, the Mental Health Act Commission and the Commission for Social Care Inspection.  While focusing on registering services, the CQC dropped the ball on maintaining inspections and relying on previous ‘good and excellent’ reports to step back on regular on-site checks.

An ‘excellent’ service can fail very quickly if there are changing in funding and personnel in a home, for example and the lack of attention to frequent unannounced inspections was something that was highlighted in this programme.

However while not resolving the organisation of responsibility, this focus has changed and the CQC has stated that regular, unannounced inspections are taking place now.

The website has long been a gripe as far as I’m concerned. There seems to be less information with each iteration and the scope and searchability isn’t as helpful as it used to be. The CQC website remains the only one I have come across at work which has become progressively less user friendly  with each iteration  (and yes, I have always given feedback on the changes when it’s been an option!). The lack of reports from both predecessor organisations (for example, not being able to access CSCI reports or reports when an organisation has changed hands – as was highlighted in the programme) is a big issue. As members of the general public, we can determine how useful or not historic information is but we have to have access to it. More information is better.

Reports need to be very easily understandable and clear about what is expected and what good and bad care look like. They are better than they were. People liked star ratings because they were easy to understand. They were abolished but the star ratings remained on the website for a long time afterward which was poor information in the extreme. While the government excellence scheme was shelved, I think there’s a real desire for people to have an understanding beyond a care home being compliant or non-compliant – people want to know if St Matthew’s Home in Hull is better than St Francis’ Home in Bridlington and a TripAdvisor type comment site won’t always provide an independent and authoritative understanding of that. I’m not sure if it’s the place for the regulator but it was in the past and understanding what good care looks like as well as bad is something that Behan, the new CEO of the CQC has stated he wants to work on.

The footage of Cynthia Bower at the select committee was positively painful and her links with Mid Staffordshire made her a particularly poor choice of CEO initially. They could never establish any credibility in the sector with that background and proved that she was not up to the task. The only concern was how much damage she did in the meantime.

I do have more hope with the new CEO, David Behan and some of the changes that have taken place but the programme showed the need for a strong and authoritative regulator within health and social care.

The problem is that all these cuts happened in the regulator as commissioners like local authorities were hammered by substantial cuts which – certainly in my experience –  have seen monitoring units slashed. You see the monitoring teams – they were the so-called ‘back office’ which were cut but the input that had on day to day care is significant.

The only way forward is for commissioners (local authorities/NHS and yes, private funders), regulators and providers to work very closely regarding responsibilities and tie information in with each other but most important to make that sure those who use the services and local communities, families and advocates can understand and know cohesive lines of communication with organisations responsible for developing and regulating good care.

It doesn’t help for organisations to be siloed when life is more complex and while I would never want to absolve those government bodies like the CQC of their responsibilities, I think the structures and information streams need to be better regarding lines of responsibility.

If the organisation isn’t able to do its job properly due to cuts, it needs to return to the government and tell it.

I have become more hopeful that there will be a change in culture in the regulator with a change in leadership. Use of more and more ‘experts by experience’ and experienced specialist professionals in inspections is also a positive move but it’s not good enough to stand still.

As Barbara Young said in the programme, the CQC needs to the a regulator for people and particularly for people who have their voices quietened by organisations which can display power in terms of delivering care. It isn’t good enough to rely on families complaining as many people in residential services don’t have families who visit. Proactive regulation needs to happen alongside proactive safeguarding investigations by local authorities and proactive monitoring. Organisations which provide care can’t resolve their own responsibilities to provide quality care. If money is cut by local authorities, it has to be challenged and challenged hard before quality slips rather than afterwards as an excuse.

There is room for hope though. I do think the CQC consultation is positive and the move towards regular unannounced visits is a good one. It should never have been otherwise but we can’t change the past.

If we want a regulator that works, it has to be given the tools and the resources to regulate in a way that we want and expect it to. That costs. So be it, it is a necessary cost.

I want a responsive, responsible, proactive and mostly a listening regulator. I’m willing to give them time seeing that some progress has been made, but there really does need to be a change noticed in the reports that feed back to Parliamentary committees and published reports next year.

A Culture of Care?

I can’t help it but I’m somewhat unimpressed and uninspired by claims that Castlebeck’s transformation is nearly complete (As reported by The Guardian).  I’m sure Mr Sullivan has done a sterling job in dragging the remains of homes such as Winterbourne View towards acceptable standards but the very fact that such poor standards of care are evident in contemporary care is a shameful indictment on our society.

It riles me not only that such abuse took place in the first instance, but that it wasn’t picked up by the care provider.  Would the abuse still be happening if it were down to Castlebeck to identify it and take action?  I shudder to think that the answer might be a resounding “Yes”.  Also to think what else may be happening within care homes across the UK where vulnerable adults don’t have the benefit of family involvement or carers with the insight to blow the whistle on abuse … or Panorama!

 Having worked with numerous residential and nursing homes, it is not hard to see how totally dependant some vulnerable members of our society are on those paid to provide good quality care:  Care that is monitored and regulated and where safeguarding policies are in place to ensure that those who can’t speak up for themselves are protected from abuse… Really?

I can’t help but recalling one particular home, the manager was sitting in a very well equipped, spacious office when I arrived congratulating herself at the marvel that were her new, glossy brochures. Showing prospective families just exactly how decent the home was with its ample garden blooming with flowers and general good cheer.  Carers smiled on the front cover in a manner that exuded quality, person-centred care from more carers than one could possibly need whilst care-free residents tucked into their gormet meals.

Sadly, the reality was very different:  Insufficiently trained carers that didn’t have the time to answer a call-bell that had been rung for the umpteenth time as the room’s occupant continued to lie in urine soaked sheets.  Then there was the missed opportunity after missed opportunity to spot pressure wounds that were silently getting progressively worse – out of sight, out of mind.  All the time, the owner continued to congratulate herself and confidently sell the homes’ services to prospective new residents and their families.  Oblivious to the reality that was unravelling the other side of her plush office door.

Of course, such business’ need to be well run but when business comes before quality of care something needs to change.  Whole cultures need to change because if the underlying ethos of a home’s manager is developing a thriving business, how can the ethos of carers within that home be anything different … such as caring perhaps.  Whilst I’m all for serious case reviews and learning from past mistakes, I’m not convinced my ministers’ exclamations that, “We must learn from this so that these things must never happen again!”   I fear that they will happen again … and again until the whole culture of care changes to one of … well, care.

I can recall perhaps just a handful of small care homes where the managers rota themselves on shift so they know what’s going on and can identify any training needs.  Where more money is spent on care than on prtraying a good image to prospective new residents.  They may not be glistening with a new coat of paint every 6 months or benefit from TV advertising but they are run with an underlying ethos of care and respect and reflect far more the brochures that are displayed elsewhere, but they don’t have their own glossy brochures.  All they have is a good reputation which gets them by more than adequately.

Consulting on the CQC

I’ve been generally critical of the CQC (Care Quality Commission) since it’s establishment. I’ve been particularly critical of what I have seen to be the failings of a regulator for health and adult social care services where I have felt that there has been an impact, by the lack of robust regulation, on the lives of people who use and need the services which are provided.

My main concerns have been about a move away from regular announced and unannounced inspections and a move towards desk-based inspections. However the CQC has been re-evaluating this approach and with a new Chief Executive in David Behan and an outgoing Chair – I wonder if it’s time for me to evaluate my own attitude to the regulator for health and adult social care services in England.

I could never understand how Cynthia Bower was appointed in the wake of the Mid-Staffordshire scandal. It seemed to be a strange appointment. Starting a new agency by merging the functions of the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission was always going to be hard. This combined with new responsibilities to regulate services in different ways seemed to have led the eye to be taken off the ball as far as current standards went with the focus being on bringing new regulatory frameworks in amid low staffing.

As far as social care is concerned (and that’s the area i know best) this move away from  regular on-the-ground inspection of services combined with cuts in funding both to the organisation and to local authorities who might have had their own, more robust, monitoring teams, led to concerns about quality in the services being provided.

However, the CQC seems to be moving on in terms of re-establishing consistent and regular unannounced visits to services and there seems to be a shift in terms of the priorities which they are placing on promoting quality of care over merely meeting the lowest acceptable standards.

I read through the consultation for the strategy of the CQC between 2013-2016 (and, incidentally provided feedback because it is, after all, a consultation!) and it left me more hopeful that the sector might be developing a regulator that it needs.

Six ‘priorities’ are laid out for the next three years.

1. Making greater use of information and evidence to achieve the greatest impact

In this section the CQC acknowledges the move back to regular unannounced inspections and explains the way that information gathered relating to risk has fed into the way that inspections are conducted and that this needs to continue and strengthen in the future.

‘Building an evidence base’ about what works in regulation includes looking at overseas models. Obviously, I’d welcome a fuller evidence-based approach with the caveat that sometimes past excellence can change to present mediocrity by one new member of staff and there will always be some random elements at play in this sector – an area where I think the CQC has failed in the past by simply judging future potential risk by past performance.

The CQC is increasingly going to look at regulating different services in different ways with the same (presumably) framework as inspectors are professional regulators rather than experts in specific sectors. GPs and Dentists need to be monitored in a different way from a nursing home, a large general hospital or a private ambulance service. It seems to make sense.

Using information from different sources is also crucial. The CQC report mentions this. I expect they would feed heavily from local authority complaints in the field of social care and the information we (as LAs) get regarding care providers and particularly our contracting team which monitor quality and complaints. If someone from the CQC came into our LA and spoke to social workers directly about different home care providers and residential homes, I expect they might get a broader view.

2. Strengthening how we work with strategic partners

Here the CQC mention the changes coming in the NHS and the need to link with organisations such as ADASS, Monitor, presumably new Clinical Commissioning Groups and professional organisations.

I hope there will be a strong voice for Social Work in the form of the College of Social Work in feeding information back to the CQC. I might be on a bit of a theme here but I think the CQC can learn an enormous amount about adult social care from social workers and I think they really need to utilise the knowledge we have of local areas and areas around quality. While I will contact the CQC with major concerns/complaints about residential homes, I’m not asked to feedback about niggles or, for that moment about fantastic services. I’d love to see these links work not just at a managerial level but between inspectors and social workers in the locations they regulate.

3. Continue building better relationships with the public

For a regulator to have public confidence, the public have to know what they do, what they are responsible for and what they are not responsible for. The CQC can do their best but if people don’t know about it or have different expectations, they are unlikely to get the message across positively.

New ‘Healthwatch’ organisations will promote local links and input into inspections and the CQC is building on its ‘Experts by Experience’ programme building people who use services and carers of those who use services into the framework. I watched a video from an inspector where she talked about using an ‘expert by experience’ and referred to a carer of a person with dementia who helped her in an inspection of a residential care home. I’d hope that people who have dementia and may have cognitive impairments are also built into the process of being experts by experience. It is vital that users and carers are involved and different models built to encourage this involvement but that assumptions are not made that because someone may  have a cognitive impairment that they cannot speak for themselves.

Improving access to reports would also be good. Improving the searchability of the CQC site would be a massive bonus. It’s become increasingly difficult to search and find information and seems to constantly take steps backwards in terms of usability.

I think it would be helpful if there were comment forms under each service for public to send information from the website directly to the relevant inspector. Inspectors could have a greater visibility online and using broader social media to communicate with the public – not just through PR people.

I want to know what inspectors do every day. I’d love to see a regular blog from an inspector (without needing to mention any specific services but just with broad themes – generally frontline blogs are more interesting than management blogs!)

4. Building relationships with organisations providing care

This is an area I probably have less experience in. It explains that the organisation wants to provide quality reports and improve the feedback given to providers by inspectors. It’s often about links and nurturing positive links over time but not allowing that to impede judgement when there are problems.

5. Strengthening the delivery of our unique responsibilities under the Mental Health and Mental Capacity Act

As an AMHP (Approved Mental Health Professional) and a BIA (Best Interests Assessor) I have a particular interest in matters relating to the Mental Health Act and the Mental Capacity Act.

I feel particularly the CQC have disappointed me (I know that will upset them!) about their knowledge or rather their lack of knowledge about Deprivation of Liberty Safeguards. I think good and thorough knowledge of DoLs should be a core question in every single inspection in every residential and nursing home and hospital in which they may apply. I  have come across too many home managers who really should know better show an appalling lack of current knowledge about DoLs and believe that there are many many unauthorised deprivations of liberty that inspectors should be able to challenge homes and hospitals about.

Personally, I’ve made a number of third party referrals for assessments under DoLs and that’s just by people either allocated to me or situations I come across when visiting people in care homes or hospitals – there must be many many more that go unchallenged because the law is so fluid and complicated and I don’t have any faith that the CQC and those representing them on the ground know it.

I’d like to see better links between inspectors and Best Interests Assessors after all, we (should) have significant expertise in applying the DoLs and perhaps we could shadow inspectors and ask the questions that they don’t know to ask until they are trained up at least.

This is three years too late.

6. Continuing our drive to become a high-performing organisation

This section is about building a learning organisation and working out ways to measure progress. I know the organisation works with ‘professional regulators’ but I think something has been lost in not using people with expertise in health and social care to carry out inspections and to rely on generic ‘auditing’ experience but I can’t see that changing.

I do think there are hopeful signs though in these new priorities and wish the organisation well – we need a good, strong regulator that has the faith of the sector and I feel we will need it all the more as the NHS changes.

I am increasingly thinking that more link, better conversations and more co-production are the ways forward for the CQC and for health and adult social care in general.

Do feedback on the consultation though – we need lots of voices. The CQC say that they welcome feedback through social media – so this is my own response!

photo by vivido @ Flickr

Winterbourne View – The Serious Case Review

Yesterday the Serious Case Review written by Margaret Flynn about Winterbourne View Hospital was published. It catalogues the series of circumstances which led to those scenes seen on BBC’s Panorama programme and it makes important and salutary lessons for everyone involved in health and social care.

It is a well-written, detailed report which catalogues a series of holes in the process of provisioning, commissioning, managing and monitoring a long stay hospital for people with learning disabilities but the most important lessons can easily be extrapolated out to many other areas of residential, nursing and long stay hospital care.

In summarising my own reading of the report, I have added some of my own thoughts as I go but I do recommend going to read the full version. No doubt I’ll be reflecting on it more over the next few days/weeks.

Introduction

This sets out the background to the airing of the programme on 31 May 2011 and the scope of the serious care review (SCR) which covers the period between January 2008 – when South Gloucestershire Council received their first safeguarding referral to 31st May 2011 when the Panorama programme was aired.  It explains the terms of reference of the report and some of the specific incidents seen on Panorama which caused concern.  This included illegal restraints procedures and

‘notions of a hospital, nursing, assessment, treatment, rehabilitation and support were emptied of meaning and credibility’

The Place and the Personnel

Winterbourne View opened in December 2006 after a ‘feasibility’ study by Castlebeck Ltd which had assessed that there was a need in that particular geographic location for this kind of service. As seen in the programme the placement of a hospital on a business park seems unbelievable but according to the ‘Statement of Purpose’ quoted in the report, there was local access to ‘amenities and a main bus route’ – one does wonder how much this was important to those in the hospital as opposed to those working at the hospital.

Families were not allowed into the bedrooms of those living there which rings many alarm bells to those of us in the sector but may not have been seen as something unusual if you don’t know how these things should operate.

Learning disability nursing and psychiatry were the only disciplines employed in the so-called ‘multi-disciplinary’ teams. The report explains the structure of the service and staffing which was heavy on support workers, which in itself isn’t surprising however a ‘hospital’ employing no occupational therapy, for example, is particularly surprising.  There was a very high turnover and sickness rate among staff which in itself is a sign of there being something particularly wrong in the structures.  12 hour shifts were the norm which may have suited the service and staff more than those who use the service and there was certainly a lack of detail regarding day time activities and timetables for those who lived in Winterbourne View.

I do wonder where the input from care managers/care co-ordinators were in terms of monitoring care plans and ensuring their were adhered to. My gut feeling is that with out of area placements, there was less impetus to be able to monitor these. Commissioners didn’t seem to make many demands that the operating guidelines for Winterbourne were met in terms of providing a therapeutic and rehabilitative environment.

Chronology

This section details the concerns raised and is an analysis of what was actually happening at Winterbourne along a timeline.  Unsurprisingly there are a string of concerns raised that when seen along a timeline can build a picture of a hospital and an organisation that is not fit for purpose.

Part of the concern as a whole is that the dots were not connected in terms of the series of incidents and concerns to build a coherent picture of what was happening. Whilst it’s ‘easy to be wise with hindsight’ it’s important to remember that we have systems which are supposed to protect vulnerable adults which should include collating and using information, concerns and reports to build cohesive pictures of what is going on – that’s even without the whistleblowing which took place.

It makes very difficult reading – all the more so in the context that it was not sufficiently investigated, not internally, not locally and not by the regulator nor police. The key worry that ran through my head is that this may have continued had it not been for both the intervention of determined ‘whistleblowers’ and the involvement of a BBC journalist. That’s a very very worrying lesson that needs to be acted on.

The Experiences and Perspectives of Patients and their Families

The author of the report spoke to six families in particular and explains their perceptions, experiences and understanding of what was happening at Winterbourne View.  The report gives life to some of those who lived at Winterbourne View and humanises them in a way, it seems that the service itself never did – with hopes, aspirations, character and personality.

One patient said

he had been in ‘loads of worse places than them, all over the country’ and that he had been abused in lots of care homes

And if there’s a key lesson to learn it is that Winterbourne View is not an anomaly and shouldn’t be seen as such.

The patient recollections of abuse and treatment at Winterbourne is very powerful. It evidences the importance both of listening and humanising approaches within residential care and hospital care. The importance of being near families and the disruptions of constantly changing placements seems to be the nature of life for some groups of people who have particular care needs and I wonder where the power in commissioning is coming from to look at different models.

When families raised concerns that their children had brought to them these reports were often disbelieved or families were not given the full details of what was going on.  It also raises the importance of visiting and monitoring – particularly for those who may not have families.

Importantly the report says

A family expressed anger that service commissioners making spot purchases to meet the needs of individuals do not know what they want to buy; they do not seek assurance that the service they believe they are buying is delivered; and they do not follow up on what is being provided.

Perhaps more importantly in terms of lessons to be learnt globally

‘As families recalled some of their distressing experiences, it was clear that they had no collective experience of being regarded as partners deserving of trust and respect or even of collaborating with paid carers.

There has to be a shift in the conceit of ‘paid professionals’ or ‘paid support workers’. We have to work with, alongside and for those whom we support and their families as otherwise we should be nowhere even close to a position in social care. Respect, listening and remembering whom we are serving  is the crux of the profession and that seems to have been lost somewhere.

Agencies

Castlebeck Ltd seemed to have a ‘limited executive oversight’ of Winterbourne View with the geographical distance from their head office in Darlington providing significant lapse in responsiveness when concerns were raised.

Interestingly they seem to place some of the blame directly on the CQC and problems with the transition from the Healthcare Commission to the CQC. While no CQC apologist this seems to be a very complacent and worrying dereliction of duty from the organisation that was paid to provide a service which should include self-monitoring.  The SCR looks at Castlebeck’s own analysis of their failings but finds it lacking with attempts to discharge responsibility for the things that went wrong. As it says

Overall Castlebeck Ltd’s appreciation of events leading up to transmission of Panorama is limited, not least because they took financial rewards without any apparent responsibility. The recommendations fail to address corporate responsibility at the highest level

Which is sad, but unsurprising.

NHS South of England also produced a report about commissioning of care and treatment at Winterbourne View.  Out of the 48 referrals made to Winterbourne View, 13 came from commissioners located less than 20 miles away and 9 of those 13 were from commissioners less than 10 miles away.

Worrying is that there were some placements made with few checks and some not even reading the most recent inspection reports.  Interesting that of the 48 English patients (the experiences of Welsh patients – not being the responsibility of the NHS in England were not counted in these figures) 35 were admitted under a section of the Mental Health Act, 13 were admitted informally and 6 were detained after being admitted informally. Unfortunately there are no details regarding the Deprivation of Liberty Safeguards but it would be interesting to know more about those ‘informal’ admissions legally.

NHS South Gloucestershire PCT was the ‘coordinating’ commissioner being where Winterbourne View is located. They produced another report.  Hospital records were also accessed but there seemed to be no linking of information together and agencies not speaking to each other seems to be a major problem and continuing concern.

South Gloucestershire Council also provided a Safeguarding Review.  South Gloucestershire received 40 safeguarding alerts between October 2007 and April 2011. The system locally to follow up some safeguarding alerts seemed to be flawed in terms of not receiving relevant and necessary information requested back from Winterbourne View.  Many of the alerts ‘tail off inconclusively with no clear decisions and no rationale for decisions’.  Each alert was dealt with discretely and the pattern was not allowed to emerge.

Avon and Somerset Constabulary were also involved as there were a number of assaults reported and they also provided a report. There were some flaws in the sharing of information between the police and the local council.

CQC also compiled a report.  The SCR picks up on some confusion in language in terms of the CQC and notes the importance  to note that Winterbourne View is not a care home but is a hospital. The CQC admits that it’s creation has had a significant impact on inspection of services – something we all knew – but it’s good to see them acknowledge this finally rather than paint the biased hue of everything ‘being better’ under the new regime.

The lack of specialist inspectors is a particular factor that the new systems of regulation have lost. Apparently ‘professional regulators’ is a better way of doing things rather than those with specific knowledge of particular service areas. Perhaps this isn’t quite the right way to develop regulatory services.

Findings and Recommendations

The report finishes with a summary that is robust. Winterbourne View is a particular snapshot which has been able to take place due to a series of circumstances that put the spotlight on the services. These spotlights aren’t often shined into the world of long stay hospitals and residential care. But for a BBC programme, it might never have been picked up. That’s a lesson in itself.

Castlebeck Ltd didn’t provide a poor service because it had no money. It provided a poor service because it didn’t see any reason not to.  There were no reasons to question itself or what it was doing. Those questions weren’t being asked by any of the agencies responsible for protecting those who lived in Winterbourne View.

The recommendations are that the Clinical Commissioning Groups, Local authorities and NHS Commissioning Board should be looking more closely at the services they commission, where they are commissioning them and aim to cut down in-patient services.

The report emphasises

‘Commissioning is a professional activity that should be led by trained specialists who know and develop the market according to public policy’

This made me sigh as it seems in my own experience that we are moving backwards on this. I see fewer specialist commissioners who know their areas and more general commissioners who come from non-health or care related backgrounds and with little understanding of the sector or the needs locally of those who use the services they commission.

The report strongly criticises the commissioning of long stay hospitals for people with learning disabilities as perpetuating the ‘out of sight, out of mind’ type modelling for care services.

Recommendations include a more robust use of the Mental Capacity Act 2005 and particularly that

‘The Department of Health should assure itself that CQC’s current legal responsibility to monitor and report on the use of Deprivation of Liberty Safeguards provide sufficient scrutiny of the use of DoLS’

There was a lesson in poor multi-agency working which needs to be worked on actively and there is a recommendation that those who are subject to provisions of the Mental Health Act or Deprivation of Liberty Safeguards as well as all who make a complaint have access to independent professionals, whether social workers, Best Interests Assessors, IMCAs or IMHAs or more than one. Advocacy is crucial to prevent abuses.

As far as the CQC is concerned, the report explains that the ‘light touch’ regulation, enamoured by the CQC doesn’t work with settings like Winterbourne View. The CQC has been too reliant on self-reporting and trusting providers are complying.

There’s a recommendation that the ‘

Mental Health arm of the CQC should have characteristics akin to HM Inspectorate of Prisons in terms of standards’

That would be an interesting and useful development but I doubt the current CQC is set up to provide a robust monitoring procedure.

Conclusions

I haven’t been able to cover all the points of the SCR. It is worth reading in its entirety. It concludes by emphasising that services like Winterbourne View should not exist as they create no aspirations and hope.

They are not therapeutic environments and were created to provide a funding stream to the private company rather than to improve the quality of treatment and care to those who need them.

Commissioning should look at what exactly is being commissioned and what is needed to achieve the end result of an improvement of quality of life.

I look at this report and it is an excellent report, and I despair. I recognise parts of it but it is a particularly appalling litany of pain, distress and human suffering that could have been identified earlier. We relied on a television programme to identify these issues when there were so many people who should have identified this sooner.

No one comes out of this well apart from the whistle blowers who tried to make a difference.

Good services can and do exist but we need to be very clear about expectations of services and what we expect a hospital built on an industrial estate and factoring in amounts of income possible can achieve as opposed to services which truly exist in local communities.

It’s an awful situation but the SCR offers an opportunity to learn and do things differently. Let’s listen more and better across the whole sector and remember that this job is always a matter of partnership and never should be one of dictation. We have to do things better.

Winterbourne, South Gloucestershire Council and Responsibility

Winterbourne View and the systematic abuse of those people with learning disabilities who were placed there uncovered by BBC Panorama programme last year has had significant repercussions.

That countless attempts by whistle-blowers  were ignored until the BBC took up the mantle that should have been taken by the regulating authorities was a particular failing in the system that should protect those who are most dependent on robust and good quality care.

The CQC was actively moved into ‘defensive’ mode and instituted a number of new inspections of similar type facilities around the country. I’m not sure that anyone in the CQC took particular responsibility for a lack of response to the initial concerns raised.

I saw this story on the BBC this morning that two managers at South Gloucestershire Council have been dismissed.  The two dismissed were a team manager, Kevin Haigh,  and the council’s safeguarding manager, Brian Clarke  – as the story says

It is understood that a-year-and-a-half before the whistleblower came forward and the programme was filmed, Mr Haigh and Mr Clarke were alerted to other allegations of serious abuse.

In their defence, a Unison statement reads

‘We believe that there may be wider failures in safeguarding procedures in South Gloucestershire in relation to Winterbourne View which go far beyond the involvement of any two individuals.

Which is a fair point but I think that there has to be some level of responsibility taken within a local authority when safeguarding procedures fail so badly. Particularly concerning to me are two issues – firstly why it takes a BBC documentary to uncover abuse that had been flagged up clearly and secondly, knowing about how safeguarding investigations are conducted, how this was able to ‘slip past’ what are, in my experience, fairly robust procedures.

Either way, whilst I don’t welcome scapegoating, I think it’s right that those who are responsible for management within public services take responsibility  for things when they clearly don’t work to protect those who need safeguarding.

As for the serious case review, which is due to be published later this year, I can only hope many lessons are learnt so we become less reliant on the press and more able to rely on robust preventative work by commissioning authorities and inspection regime to stamp out institutional abuse and/or to spot it as a priority.

A look at ‘Caring for our future : reforming care and support’

A rapid chase through the Care White Paper

The government published it’s long overdue Care White Paper yesterday. There’s been time for a significant amount of coverage to push through to the media and I don’t want to repeat information that’s out there but rather provide a response/analysis from where I am and where I see it. There is a good summary on Community Care though.

It’s a hotch potch of a document. The words are pretty but there’s an underlying tone of ‘saving taxpayers money’ which shines through from every good intentioned statement. Saving money isn’t a bad thing but I wonder how much the intention is to change the way the market in care is delivered in line with the NHS Bill and how much is to actually change the philosophy behind the process of care. I doubt the government’s good intentions.

The White Paper divides into eight chapters. So I’ll follow that pattern in my review of them.

Chap 1: The Case for Change

Here, the paper itself sets out the current difficulties in the system as it is at present which is reactive to crisis rather than focused on prevention. I can’t help feeling a little cynical in noting even the current system wasn’t intended to be this way, but has developed as such due to the pressures on funding.  The government line is to prove the point about crisis response but that’s not really been the agenda all the time.

Believe it or not, there was a time we met ‘low’ needs and while accepting there is a financial limit, the demonisation of the system is hardly a true reflection of what was envisaged and more should be learnt about the ways that systems imposed develop into a ‘race to the bottom’.

So the paper suggests that the answers will be found by providing more services sooner in the process of ageing or a disabling condition.  We will have more support for carers and will be promoting communities to provide support within themselves.

People need more information, without doubt, and that will be provided. That’s hardly revolutionary but too much has been down to local differences – the old ‘postcode lottery’ arguments. This will be clarified so people can move around the country and know what they will be able to expect.

Interesting that the ‘opportunities from reform’ all seem to revolve around financial benefits. It’s a valid benefit and opportunity but an interesting angle so

‘Promoting people’s wellbeing and independence’ will ‘limit future demand for care and support and help to ensure taxpayers’ money is used for effectively’.

Support for carers will enable them to ‘remain in the workplace’ which will ‘support economic growth’. So THAT’S why they are so keen to support carers – don’t want anyone to think that ‘caring’ without pay for a family member isn’t a valid and essential economic contributor.

and ‘Supporting businesses to grow’ – which is maybe what choice is all about.

I’m not against these agendas but I think the framing in economic terms is very very interesting.

Chap 2: Our vision for care and support

Understandably and quite rightly there is a high proportion of ‘control’ wanting to be distributed from top down to users in this section of the White Paper which is all well and good. It’s been (rightly) the movement of travel and needs to go further. As someone who works with people who have not been able to benefit fully from the ‘choice and control’ agenda, I was particularly looking for things that would help and support the people that I work with here.

There’s a lot of focus on promoting communities in being active and enabling to those living in them. There’s a need to promote better information streams – quite rightly – the system is enormously complex and I spot a little line on page 19 about ‘supporting the transformation of the social work profession’.

So the role and place of the local authority to provide care and support will be changing as it says

‘instead of purchasing and providing care and support, authorities will increasingly be expected to take a leadership role in a local area’. That should be interesting.

Chap 3 ‘I am supported to maintain my independence for as long as possible”

So in looking at prevention of isolation and needs the White Paper turns to communities to look for support, quite rightly. There’s a lot of potential here and social isolation is specifically targeted with some wonderful local models explained in terms of the way they work with isolated people to bring them into communities.

Not everyone wants to be a part of a community and there are some people communities tend to be less eager to support but it’s a great initiative for some people and there will be a lovely new Outcome Framework which will identify measures of loneliness for us to work on while local authorities managers and accountants look at ways they can meet targets at low or no cost.

Commissioners will be ‘encouraged’ (whatever that means) to draw on community support networks rather than moving people into ‘formal’ services. I read that along the lines of finding services that are provided at low or no cost but perhaps I’m a cynic.

There’s a line here too about social work pilot schemes which will  ‘liberate’ (I’m VERY suspicious of the word ‘liberate’) social workers from case management. It looks like a push towards more community based social work but I have some concerns. Firstly, case management is only bad if it is implemented badly as a process rather than as a collaboration. Poor case management can have an enormously detrimental effect on someone.

I’m not convinced by social work pilots but will wait for the outcomes of these pilots to see before I make a final judgement. I like the idea of more community work but am worried at what cost it may come in terms of privatising delivery of service and moving responsibilities for provision away from a democratic mandate.

I do like the idea of connecting care homes with their local areas. That is enormously positive and where I’ve seen it happen locally, it has made a big difference. It does seem like a lot of ‘use volunteers’ as the answer to problems but honestly, that’s not a bad thing where there are volunteers. I just wonder if all communities will be as engaged and where there is such a great reliance on community to provide support, what will be done in those areas that aren’t as supportive.

As regards housing, there will be significant investments in housing for older and disabled people. I hope this will encompass people in mental health services and is not limited to those with physical  health needs. There is a muddle over extra-care sheltered accommodation which is described as a way to meet low level needs but also as an alternative to residential care. Oh, I mean a ‘cost effective’ alternative to residential care. Missed the key point there.

Chap 4 ‘I understand how care and support works and what my entitlements and responsibilities are’

Information, information, information. It’s crucial in order to make choices and the government sets out ways, particularly websites, that will provide more information about services and facilities to all rather than just those eligible for them.

Interestingly the NHS 111 number will roll out support for social care. I wonder how this will work as a national helpline when provisioning is so different locally and there will be an extension of services like NHS Direct and NHS Choices into the social care sphere. Look forward to seeing that. I genuinely hope it works.

Local authorities will also be obliged to provide more information online but also in other formats, to those looking at services and providers but it looks like there is intended to be a default move online for many access points – including self assessments online as ‘they provide a better customer experience’. I wonder how this marries with the issues around the digital divide. There will be paper and telephone options available at least.

There will be a national eligibility framework and it seems (although this will only be confirmed later) that it may well be set at ‘substantial’ under current FACS guidelines although there will be a move to a new framework of assessment and eligibility.

People will also  have more options about who assesses them.

‘Our ambition is for many more providers to offer assessment services’. Good business opportunities there and a role for the social work pilot schemes.

Carers will have an entitlement to assessment (which exists) and to the provision of services (which doesn’t at present). I’m glad to see that.

Chapter 5 ‘I am happy with the quality of my care and support’

There’s an interesting diagram on this chapter on page 38 with circles of ‘roles and responsibilities in care and support’ around the ‘service users and carers’ at the centre, with Government, Commissioners, Providers and CQC around them. Interesting that there is no place for social workers. I expect we come into ‘commissioners’ but sad that the profession doesn’t seem to have a place around this diagram and is not even mentioned.

There is talk of better regulation by the CQC with inspections annually (scandalous that they were ever anything but in my view).

Looks like they’ll be a return to some kind of rating system too. Strange that just disappeared.

Statutory Safeguarding Adults Boards will be convened by local authorities with police and NHS organisations inputting to them. There will be further consultation on powers to access someone who might be at risk of abuse or neglect.  Personally, I’d like to have seen more on safeguarding.

Commissioning on quality is emphasised (good) and there seems to be a desire to look at some kind of outcome model to judge this. There’s also an acknolwedgement of the failing of some private care homes such as Southern Cross and

‘Local authorities have a duty to provide accommodation to anyone – publicly or self-funded – who has an urgent need for care which is not otherwise available’ and noone will be left homeless if a provider were to fail.

I don’t doubt that would be the case anyway but more public protection for private companies failing can only lead to additional costs.

Chapter 6 ‘I know that the person giving me care and support will treat me with dignity and respect’.

Here there’s an emphasis on building skills in the social care sector. I don’t believe people go into this field of work to be oppressive or uncaring but the system dictates it and a bullying workplace leads to poor and dangerous service delivery to people who have higher needs.

The government claims to be committed to the plans of the Social Work Reform Board and that the College of Social Work will play a heavy role in improving standards of education and training in social work in universities.

The White Paper supports the position of Principal Social Workers in Adult Services and part of that role will be coordinating feedback from frontline practitioners. I look forward to having one locally as I have a lot to feedback.

Chapter 7 ‘I am in control of my care and support’

Ah, personalisation, that bittersweet word which means everything and nothing. Everyone entitled to care and support will have a personal budget – I genuinely thought that was already on track and didn’t think it was anything new. And look

‘We will push further with our ambition to support as many people as possible to enjoy the benefits of a direct payment’.

I hope that support is extensive and looks beyond the current models which have served some exceptionally well but many others very very poorly.

I won’t mention the ignorant way that advocacy is included in the White Paper which evidences a lack of knowledge by those who wrote the paper but will merely reference Martin Coyle’s (from Action for Advocacy) blogpost which says it all.

There’s some more in this section about integration between health and social care which is becoming more distant in practice rather than more evident.  Use of the term ‘care coordination’ is confusing as it is a generally used term in mental health services and has different technical meaning to the way it is used in the White Paper in terms of physical health. That has already caused us many confusing conversations locally as to someone having two care coordinators – one for physical health and one for mental health – which kind of proves the point about duplicating work and having unfathomable systems. The terms should really be clarified and separated if necessary.

Chapter 8 ‘Making it Happen’

A draft bill was published alongside the White Paper. I haven’t read it yet. I wonder that some organisations seem to have thrown their lot in wholeheartedly with the government which makes me a little nervous. I want to support positive change but I don’t want to be blinded by good intentions and words that lead to little that changes the lives of those who have the most need for support.

Interestingly the ‘financial context’ is stuck at the back of the White Paper like a growing tumour. There are mealy mouthed words about the government putting money into social care but while taking away in the other hand, from local government, they have contributed directly to the ‘crisis management’ only model that they criticise.

Conclusion

I see little if anything revolutionary in this paper. I see nothing that explains a change in the direction of travel and means of delivering social care. I see some positive signs and some acknowledgement of difficulties but we were moving down the path of personalisation at a rate that it could only continue. While there was mention of personal budgets for residential care, I saw nothing about ISFs and developing ways of promoting choice for those who are excluded from communities and who may lack capacity. I saw nothing about changing legislative frameworks. I saw a lot of gaps, not least, the massive funding gap.

Nice words though, fluffy and helpful and a lot of the language of ‘choice’ (where possible), ‘community’ (where free) and ‘market’.

These things are always filled with the right words. I think a lot of opportunity to restructure and rethink adult social care has been lost although there are some springs of hope – there aren’t by any means enough.

Pic by wintersoul1 at Flickr

Of Hidden Cameras, Care and Panorama

Tonight’s  Panorama is focusing on care of the elderly or rather, lack of care. Maria Worroll was placed by her mother in a care home in Camden which had an ‘excellent’ rating by the CQC (Care Quality Commission).

Jane Worroll, Maria’s daughter, noticing something amiss and perhaps having concerns, set up a hidden camera in her mother’s room to observe how her mother’s treatment. Mistreatment and abuse were filmed and it led to a conviction by a care worker, Jonathan Aquino, under the provisions of the Mental Capacity Act (2005) and a jail term of 18 months.

There are a few key points to take into this and to note. Prior to June 2011 (when the filming took place), the previous assessment and inspection by the CQC was in 2009. It was an unannounced inspection and as described above, the outcome found the home was excellent.

There were a couple of ‘compliance’ visits after the incidents films came to light but the important thing to note is that an excellent care home can provide appalling care if there is one abusive care worker. Similarly a care home which may have a poor inspection report can provide excellent care if there are caring and good quality care staff. Historical reports of care by regulators actually tell us little about the quality of the care today, at this moment, as staff in these care homes tend to be transient and low paid.

There is an issue about management culture of course. I have seen a switch in manager making both a very positive and very negative effect on residents in these homes. While more regular ‘spot’ inspections – perhaps by lay visitors as well as official regulatory bodies – may be one answer, it may not root out the individually abusive members of staff. A much better way to do that is to firm up whistleblowing procedures and supervision procedures for care workers – perhaps more peer discussion and supervision as well as managerial supervision.

As for the effects I see, I am no longer surprised by the increase in surveillance by family members which is a definite increased trend that I’m seeing. While there may be issues of privacy, the concerns of families are very real.

Until our care systems can provide better qualities of regulating and monitoring care – and not only from the CQC but from commissioners – whether they be local authorities or privately funded – there will always be these questions that linger at the back of the mind.

I expect I’ll be watching tonight, if I am able. I think I know what I’ll see but it is important that these incidents come to light so that changes in the systems can be made. This is one incident but it is very far from isolated. Our society needs to deliver the type of care and the methods of monitoring of care and the financial provisions for care that are not age-dependent. Until we do so, I can only infer that the systems of social care in this country are inherently ageist.

It’s all about the training! CQC and Deprivation of Liberty Safeguards

Today, as Community Care reports, the CQC has published its annual report into the operation of ‘Deprivation of Liberty’ safeguards for 2010/11.

Deprivation of Liberty safeguards are a particular part of the Mental Capacity Act which allows a legal process of authorisation where there is felt to be a ‘deprivation of liberty’ in a care home or hospital related to someone who lacks the capacity to make a decision about whether they remain there or not. The process of decision-making relating to whether a Deprivation of Liberty is authorised revolves around the managing authority (the organisation which is potentially depriving the person of their liberty) and the supervisory body (the local authority or PCT (or whatever they are called now) where the person is or who is responsible for the care of that person (if, for example, they have been placed out of the local area the responsibility remains with the placing authority).  The decision is made on the basis of a number of assessments (six actually) which are undertaken by at least two people, one of whom must be a doctor and one of whom must be a ‘Best Interests Assessor’ (who can be a social worker, nurse, occupational therapist or psychologist).  The Best Interests Assessor, unsurprisingly, makes a recommendation not only on whether the deprivation is in the person’s best interest,  but whether the framework and care plan constitutes a deprivation of liberty at all.

So that’s DoLs in a nutshell. What have the CQC got to do with it? Well, amongst other things, monitoring these Deprivation of Liberty authorisations is another part of their work.

Care Quality?

Another day, another report. This time, Which? has done some undercover work into the quality of homecare delivered to older adults as reported by the Guardian.

The team at Which? asked 30 families to make notes and diaries over a week in January and feed back the information, some of it is horrifying but the sad thing is that it doesn’t shock or even surprise me. That’s the real shame of the system.

One elderly woman was left alone in the dark for hours unable to find food or drink. Another was left without a walking frame, leaving her unable to get to the bathroom, while one man was not given vital diabetes medication, the watchdog said.

Which? has not named the agencies which I feel is wrong. I hope they are going straight to the Care Quality Commission (CQC)  with this information because for a consumer organisation which is supposed to be behind us as consumers of care services (oh, it’s coming in health care too – just wait) I’m surprised they feel they need to protect the names of those companies involved.

The reason they do is that those companies will not be removed from their positions of providing care to those who have been subject to institutional abuse such as that meted out in the examples given, because yes, this is institutional abuse.

These companies are probably tied into long term extensive contracts with local authorities than are bound in law and allow for a certain level of ‘default’ that makes them difficult to replace.

So what should and can be done?

1) However admirable Which? is, the fact that we have to rely on  Which? and Panorama to do the job of council quality assurance teams and more importantly the Care Quality Commission is not acceptable.

2) Embedding advocacy into the system far more fully. These people monitored were the ones who had families to complete the diaries. What about those people without families particularly those who may have cognitive impairments. We have to replicate the ‘checking’ role that involved families have to those who don’t have family support and for me I see that as happening through greater advocacy.

3) Commissioning (again, apologies to Guilty Commissioner who I know does things differently). The people who buy into and commission these block contracts aren’t the people who use them. They award on the basis of cost where quality has to have a greater impact on quality of life and quality of care provision.

4) Politicians. People go to their MPs about Forests but not about social care. The people who need the changes aren’t the people who are most likely to be politically active and that’s why this area has slipped so far down the political agenda. Politicians of worth need to advocate for electors who might not be clamouring at their surgery doors. They need to think of those who may be disenfranchised and take the advocacy and representation role more seriously to affect change.

Let’s hope we stop seeing these reports soon but i remain sceptical.

Bye Bye Bower

Yesterday Cynthia Bower resigned at the Chief Executive of the Care Quality Commission. I remain amazed that she was ever seen as competent to run it in the first place but it’s easy to be wise in hindsight. Her departure is no surprise as the organisation has consistently been shown to be ineffective and unable to effectively or safely keep within its remit as the regulator of health and adult social care services in England.

As the Guardian states, at the time of Bower’s appointment by the Labour Government

Andrew Lansley, the then shadow health secretary, said at the time: “We have to ask whether it is right that the person in charge of the West Midlands strategic health authority at the time, Cynthia Bower, is now to be put in charge of the national regulator which heads up these investigations and which will be responsible for ensuring that this never happens again in Mid Staffordshire or elsewhere.”

Lucy at The Small Places refers to some of the closing statements at the Mid Staffordshire Inquiry which shine a light on the actions in the CQC at the time. She quotes Dame Barbara Young’s evidence – who had resigned as CEO of the CQC and was asked why – saying

I really believed strongly that we could only do a good job if we were on the ground locally inspecting with rigour and understanding what was happening locally in health core systems and in hospitals that were delivering services. And I knew that we were finding it quite difficult to ensure that that was the case with the resource we had. And I could see further restrictions in resources on the horizon, because by then it was clear that the service was going to share in cuts. And I could also see that that was going to happen at a time when the quality of care was going to be even more at risk than usual as a result of health core cuts in services.

So you’d be a regulator in a very difficult position, with government, accountable to government, but responsible really to the public, with less resource to regulate effectively, and services being more at risk And it just felt to me that that was not a job that my skills were best suited for.

Lucy, in her excellent post, points out, quite rightly that it was the Labour Government that was responsible for establishing the CQC in its current form. This goes beyond the party political. It is about creating a system which has allowed a more rigorous inspection regime to lapse faced with cost and faced with the potential to cause a political ‘stink’ when hospitals in particular might be found to be ‘failing’.

And where now for the CQC? Bower leaving was necessary but it looks as if the problems that run through the organisation are far more endemic than a change at the top. There needs to be trust restored in an organisation which is supposed to regulate services that we all depend on wholly.

My experience is more in the social care side than health and I see the dilution of regulation has happened over the years with poorer services, fewer inspections and inspectors with more experience in auditing paper records than inspecting care homes thoroughly ‘on the ground’.

Meanwhile, Paul Burstow calls for Dignity Codes for older people – who will be responsible for ensuring these ‘codes’ that apparently he wants care workers to sign up to are upheld? and his now cancelled so-called ‘excellence’ schemes which was unravelled and ratings sites – they all seem to be attempts to cover up the need for strong regulation and inspection because that would cost more money.

So Bower’s leaving is just an admission of failure and acceptance that she should never have been in that post to start with. She has barely displaying competence in ‘leadership’ but leadership is not just about one person and while the systems remain in place, we wait to be see if there will be any really useful changes in a regulatory body which has had such a difficult birthing experience.