Yesterday, it was announced that the government was going to set up a website, the details of which would be unveiled  in the Spring White Paper on Adult Social Care which could bring a kind of ‘Trip Advisor’ model of rating and commenting to providers of care homes and nursing homes.

Sounds good so far. I certainly welcome more open and accessible information for those who are choosing care homes but there are some real and obvious differences that need to be highlighted between the choices that are available to those who are picking hotels in New York City and those who are choosing care homes for Granny in Wallsend.

On a positive note, Burstow claims that these plans came from user-led discussion groups which shows that he is listening but there are some important points that have to be taken into consideration, lest this is seen as a way of trying to provide regulation on-the-cheap because the actual regulatory body – the CQC – is unable to carry out its function.
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National Audit Office CQC Report

In a timely moment (although possibly not for the CQC), the National Audit Office today publish a report into the workings of the Care Quality Commission (CQC). Yesterday the Public Inquiry in Mid Staffordshire wound up and before looking at the NAO (National Audit Office) report, it’s worth pulling a few quotes from the summing up in the inquiry as they make pertinent points.

The issue of what counts as an ‘inspection’ of a service

Right, so an inspection doesn’t mean what members of the public might think of as an inspection.  It may simply mean looking at the systems and the paperwork; is that right?
”Answer:  It may.”

This should be borne in mind when the CQC parade their ‘inspection’ figures around. An ‘inspection’ can be a form that is sent out to the provider for them to complete themselves.
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CQC – the insiders’ views

The Inquiry into the failings in the Mid-Staffordshire NHS Foundation Trust has been going on for a while now but yesterday there was some hefty evidence from two CQC (Care Quality Commission) ‘insiders’ which blasted open the so-called regulator and lifted the lid on the poor practice that some of us have suspected for a while.

I would urge anyone in health and social care who serves are regulated by this body, take a look at some of the evidence presented yesterday. I did and I hate to say that I wasn’t surprised but let’s just say it confirmed some of my suspicions.

The two witnesses who provided the evidence were Amanda Pollard – an inspector with the CQC and Kay Sheldon – a non-executive director at the CQC.

I want to look at some of the statements that they made in the hope that these issues are picked up on by a wider audience.  Both Amanda Pollard and Kay Sheldon are ‘whistleblowers’ in the finest tradition and should be heartily applauded for the stance they have taken. Continue reading

Is the CQC fit for purpose?

There was an interesting article in the Guardian yesterday about the Care Quality Commission which was set up as a new regulatory body for health and social care in 2009.

The CQC is headed by Cynthia Bower at a salary of £195,000 pa who was previously the Chief Executive of the West Midlands Strategic Health Authority – responsible for Stafford Hospital at the time it was found to have been providing substandard care.

How she was able to take post at the CQC is quite staggering to me, as an outsider but there she is, responsible for the regulation of health and adult social care services. You’d think it was the opening of a black comedy. Maybe it is.

There are some chilling facts that the Guardian have uncovered and they deserve repeating – over and over again – because the CQC is responsible for the regulation – not only of hospitals but of every care home and domiciliary care agency in England.
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Unannounced Inspections

I can spend a fair amount of time in residential and nursing homes because a part of my role is about both making placements in them and reviewing ongoing placements in them.

Over the years, I’ve seen many different types and different quality care homes and there are a couple of observations I can make very broadly.

Firstly that the quality of the inspection reports (as well as the frequency of inspections) has nosedived over the last few years. This isn’t all down to the death of CSCI and the arrival of the CQC as it was a pattern that was already happening but it does seem to have got worse progressively and unsurprisingly, this is linked to job losses and a reduction of resources allocated to the CQC. The reports seem to speak their own jargon-like language and sometimes looking at one it is hard to know (unless it is incredibly good or bad) what the issues actually are.

Secondly, there are many perceptions that people have of residential and nursing homes – not helped by media (don’t get me wrong though, I think the programmes that unearth poor and abusive practice have been very helpful to the sector) – that poor care abounds. While there is much more poor practice than there should be, there are also some gems which exist out there and provide very high quality and ‘caring’ care although the impression I get is that it is sometimes in spite of, rather than because of the way that care is organised.

Often the best care is down to individual home managers, individual care staff who have a particular approach rather than large, imposed management styles.

Yesterday, Lansley announced that there would be a rise in unannounced inspections in care homes. It’s important to note that the amount of inspections carried out will not increase but the amount of unannounced as opposed to planned inspections will.

Does regulation improve an industry and a culture? Well, not necessarily. I think there is something more deep-seated in the way that the care sector has been turned into profit-making businesses where individualised care is more expensive than warehousing of older adults in particular in very large institutions but that’s another story for another day.

Regulation can at least help to monitor some of the issues that may arise and while it is far from a panacea to cure all ills, I think that better and more frequent (unannounced) inspections are better than fewer, announced inspections as long as the inspectors are both knowledgeable about the legal aspects of the requirements of the home (I’m particularly thinking about the Mental Capacity Act and Deprivation of Liberty Safeguards here where I’ve found very little attention/knowledge from the CQC reports) and the inspectors aren’t afraid of pressure from providers.

It’s a step of course and while I can think of niggles/problems/answers – most of them involve more resources but the current situation where inspections are so rare as to be happening once every two years or less in some circumstances, does not provide a level of regulation that should be expected in such an important area.

I’ll certainly be keeping my eyes peeled for the results of these changes and I hope they will make things better.


CQC  – Care Quality Commission

CSCI – Commission for Social Care Inspection (predates the CQC which took over in 2009)

Deprivation of Liberty Safeguards – particular legal tenets relating to adults without capacity who are detained and deprived of their liberty in care homes or hospitals.

Hospitals and Respect

The Care Quality Commission has reported today on a series of unannounced inspections that it has undertaken in Hospitals over the Spring which deduced that, of the 100, 45 met the standards required for nutrition and dignity, 35 met both standards but needed to make improvements (which makes you wonder around the standards if they are not ‘absolute’) and 20 did not meet either or both of those standards.

The National Report is available from the CQC site here (PDF).

The headline reports have been covered well by the national press so I thought I’d read through the report to see what ‘dignity’ and ‘nutrition’ actually meant in terms of the inspections which were carried out.

The report explains who the survey was undertaken in that two wards in a particular hospital were chosen on one day of the year.

Regarding respect for the patients the issues most commonly found to be lacking where call bells which were either placed out of reach or not responded to, attention to language in that condescending or dismissive tones were used towards patients and attention to personal private space regarding curtains being pulled around beds, for example, was not well-respected.

Regarding nutritional intake the most common problems were that patients were not given the help needed to eat, interruptions during meals so meals could not be finished and a lack of monitoring of food intake.

The inspections were carried out by one or sometimes two CQC inspectors, a practising nurse and an Age UK ‘expert by experience’.  The inspections took place between 9am and 4pm including one mealtime.

It’s very easy to berate a lack of compassionate nursing and I have no doubt that issues such as the way that condescending language is used is a matter of staff skill and training. Unfortunately our society as a whole tends not to value the older person and the less able person.

I am shocked myself at some of the language I hear people use in reference to older people – even (perhaps this shocks me more) colleagues who work in other service areas who seem to think of ‘the elderly’ as a homogenous group of people who no longer have individual identities that we can relate to when they cease to be economically viable.

That is a matter of training, training again and instilling attitudes in a work culture. Management culture drips down to individual practitioners and staff, that’s one thing I’ve learnt from working in the care sector. You might get the odd ‘bad apple’ but if the work culture is positive, they will be routed out. If the work culture is bad, bullying will dominate and the bullying of staff invariably leads to the bullying and mistreatment of patients.

I do though think there is a fundamental ‘acceptability’ of ageism in our culture which makes these reports less surprising than they should be.  Thinking back to my own social work training, which focused heavily on children and families (it’s a generic qualification so it is important that all age groups are covered well) the amount of time we spent talking about the needs of older people was below a minimum acceptable standard (one lecture in two years and most people didn’t turn up to it as it wasn’t compulsory)  and the course itself seems to adopt an ageist approach by not covering the needs of older people to a sufficient or acceptable standard.

If that is what is happening in the universities that train our professionals then we have to work harder and improve and push respect far higher up the agenda.

The other issues relate to staffing levels and the costs of providing a well-staffed ward. While I think every professional who is registered by a body which oversees them has to remain responsible for their own actions there are systemic failures in a management culture which does not allow sufficient staffing to deliver basic respect, dignity and nutrition.

The report itself says

The key theme was around the lack of time staff had to spend with patients to attend to their individual care needs. Reference was often made to certain times of day or night when staffing was inadequate.

Equally in the section regarding nutrition it says

A lack of time to deliver care (due to short staffing, persistent high demand or excessive bureaucracy) can prevent staff from making sure that people’s needs are assessed and they are given the right support to eat.

Poor practice may also result if there is a culture in a hospital that does not place an emphasis on treating people with dignity and respect. This might explain why needs assessments do not seem to be a priority in some hospitals, and the habit of talking across (rather than to) patients by staff.

As we see from the post about the Stafford Hospital inquiry, blaming nurses is too simplistic. The management should not be able to get away with this. Why do they push these targets and maintain poor staffing levels? Because money is haemorrhaging and needs to be saved by the Trusts. The brutal truth is that the fantasy of efficiency savings remains a fantasy while people are not being fed properly in hospital and while management cultures do not focus on staff training and development but allow understaffed wards to operate.

It’s a useful, if somewhat depressing report but there have been similar reports over the years and the key thing is for the findings to be acted on and not filed away. The ‘usefulness’ of the report relates to the way it  might move beyond the news headlines and affect funding decisions and management decisions in all hospitals, not just those that weren’t forced to make changes.

It’s interesting to see the CQC be a little more proactive though, particularly around the need for unannounced inspections. Now, if it can manage it with hospitals, it should be able to manage the same with nursing and residential homes?