The announcement that the Care Quality Commission are proposing to extend the system used to drive up standards in hospitals ‘special measures’ to care homes makes for a good headline about the regulator being tough. I see that Andrea Sutcliffe, CQC Chief Inspector for Adult Social Care, makes clear CQC are “calling time on poor care”. This is understandable given that the regulator is also in the firing line by the media whenever poor care practices are revealed.
However, I’m a little confused as I thought CQC were already working towards a refreshed and stronger inspection regime. Today’s announcement by Jeremy Hunt to parliament appears to link to the extensive work done by the regulator in preparation for significant changes to inspection due to be implemented from October 2014. The five key questions about services: is it safe? effective? caring? responsive? and well-led?, developed as the framework for assessment, will lead to all registered care services (including care homes) being given one of 4 levels of quality rating.
The National Care Forum welcomes these changes as positive developments and has always supported a process of national quality ratings as being good for people receiving care services and their families, staff, providers and commissioners. We supported the original CSCI scheme and were delighted when the Nuffield Trust report recommended the re-introduction of ratings by CQC.
In our view quality cannot be inspected into a care service. Quality is the primary responsibility of the provider. NCF developed NCF Quality First - which the majority of our members already use - as a means of driving quality improvement for care and support services. NCF Quality First consists of 10 core elements with a commitment to the highest standards and continuous improvement, actively engaging people who receive services, relationship-centred care, community involvement, investment in staff development and training, accessible information, sound governance and financial integrity, evidence-based practice and learning, openness and transparency to help increase understanding of quality services and earn the trust of people receiving services and their families – as well as the public, commissioners and the media. It follows therefore that as we continue to develop NCF Quality First we have a zero tolerance of abuse and poor practice.
The term ‘special measures’ has become familiar through its use by OFSTED for so-called ‘failing schools’. The step from education to health services, as a means of tackling hospital trusts with poor standards, to care homes has a certain logic as they all provide public services. However there are significant differences between health and the adult social care sector. The obvious difference is that only a minority of care services are now in the public sector: 70%+ are private, around 20% not-for-profit and as little as 8% are operated by local authorities. As around half of people in care homes are funded by local authorities being put in ‘special measures’ could create additional difficulties quite quickly if this resulted in a lack of confidence and a fall in placements. In that sense there is a major difference between hospitals and care homes in the way they operate and are funded. I wonder - where will the expertise to help ‘failing’ care homes actually come from?
CQC rightly has significant powers over registered care providers - including the power to close care homes when there are concerns about quality and safety. Arguably, when CQC inspectors have sufficient concerns to intervene in the management and operation of a care setting and enforce changes, it is behaving it a way that is ‘special measures’ in all but name. They visit and inspect more frequently, may demand an action plan for change and if not satisfied with progress can issue an enforcement notice.
Of course it is in the best interests of people receiving care services, their relatives and providers that there is a robust approach to any shortfalls in standards. According to the CQC the use of ‘special measures’ in hospitals has led to improvements in leadership, safety, compassionate care and staff engagement.
Clearly we need a zero tolerance attitude towards poor practice. However there continues to be limited understanding of care homes and the services they provide: rising levels of needs, complexity and expectations; the on-going challenges of public sector funding; changing regulatory requirements and costs; staffing, management and leadership; each contribute to a complex set of dynamics.
There is now a wealth of research data on the essential elements for a positive culture within care homes. The work of My Home Life, the Eden Alternative and Comic Relief’s PANICOA initiative have all contributed significantly to our understanding of best practice. As a result there is a great deal of consistency about the importance of person-centred/relationship-centred practices underpinning the way in which services are provided.
I’m all for “restoring public confidence” by celebrating the best of what care homes do and I look forward to continuing to do this, in part by working with CQC to ensure that the system of inspection and regulation is strong and focuses on the things that really matter.
I remain to be convinced that simply using the label ‘special measures’ will contribute in any meaningful way to improving care home provision - we need a vision for the future of care homes not just slogans!
Des Kelly OBE | Executive Director | National Care Forum