Light Touch Inspections, Winterbourne View and the CQC

There was a report on the Community Care website on Friday that the CQC were ‘calling time’ on their so-called light touch inspection ‘regime’ thereby rolling out potentially to annual inspections for adult services and care homes.

As the article emphasises

Bower said that the CQC had favoured a “proportionate, risk-based, light-touch” approach to regulation – in which services were left uninspected for up to two years in the absence of issues coming to light – but service users, providers and staff favoured more inspections.

“What people want, particularly people who use services, is for us to put our boots on the ground,” she said. “Inspections are a really positive quality assurance for providers.”

It’s hard to believe Bower would have been saying this if she had not been forced into the position by the Winterbourne View scandal where substantial abuse was uncovered.

A shame that she did not show more backbone and spirit in protecting the organisation that was handed to her to lead when all the cuts were coming hard and fast. It did not take a genius to work out that the only reason the so-called ‘light touch’ system was implemented in the first place was to save money. The problem is, that it has stripped the CQC of any credibility it might have had as a regulator.

And yesterday, this same CQC criticised Winterbourne View and it’s owners, Castlebeck had misled that self-same regulator about issues that where taking place and abuse that was taking place while they were inspecting the service.

Interesting to see the Independent highlight the issues which the CQC raised as criticisms of Castlebeck

Inspectors said they found people who had no background in care services had been working at the centre, references were not always checked and staff were not trained or supervised properly.

They added Castlebeck failed to meet essential standards, required by law, including:

:: The managers did not ensure that major incidents were reported to the Care Quality Commission as required;

:: Planning and delivery of care did not meet people’s individual needs;

:: They did not have robust systems to assess and monitor the quality of services;

:: They did not identify, and manage, risks relating to the health, welfare and safety of patients;

:: They had not responded to or considered complaints and views of people about the service;

:: Investigations into the conduct of staff were not robust and had not safeguarded people;

:: They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred;

:: They did not respond appropriately to allegations of abuse;

:: They did not have arrangements in place to protect the people against unlawful or excessive use of restraint;

:: They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings;

:: They failed in their responsibilities to provide appropriate training and supervision to staff.

While there is no excuse for such considerable failures, you’d think that a good regulator worth it’s proverbial salt should have picked up some of these issues through a thorough and robust regulation system.

Remember this is the same Bower who has promoted extensively the use of whistleblowing and family members as a ‘resource’ to augment their inspection processes. And then the organisation feigns upset when things are concealed to it.

How did we come to this? How did we, as a society, allow the organisation that regulates Health and Social Care to be stripped bare due to a resource-led decision and blunt its teeth so incredibly that people who depend on these services can have no confidence in its position to protect?

Money, cost, closed eyes and an ability to discharge responsibility for the care of those in our society who need particular protection has led for this situation to emerge.

Unfortunately I can’t go into details about some of the things I  have seen over the past week that makes me feel  much more strongly about these issues but suffice to say this – which, in itself – could even be too much.

I visited a care home which had an ‘excellent’ star rating. Yes, the stars are outdated but it is an easy way to check and remains so. There had been no inspections over the past year, at least, anyway. Excellent. And it looked it on the outside. My involvement was due to a large scale safeguarding investigation. Let’s just say it was very far from excellent and had been for a number of years, including when the last ‘excellent’ inspection rating had been given.

The inspections depend too heavily on self-reported data and too little on ‘feet on the ground’ and investigations skills. I sometimes wish I could try doing a really thorough, wholesale inspection of any given inspection service. I’ve worked in residential care. I know what I would look for. It angers and upsets me that self-reporting and the ‘light-touch’ were ever permitted for purely cost-related reasons.

But the CQC says it is increasing inspections – still it will not be close to previous levels. To see them criticise Castlebeck – all well and good – but it doesn’t take the responsibility for inspection and regulation away from them. It bears some resemblence to the social workers who are told they are more easily led by parents who conceal information from them. If the social workers are chastised for ‘believing’ why not the regulator.

It makes me angry. Maybe time to invest in regulation and inspection and demand better services that actually protect against, rather than mask poor care. It is ever more important.

Which Care? What Care?

Lakeview Care Home. One of two modern care hom...

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Another day, another story of sub-standard care in residential homes in the UK. Today, the Guardian publish a story which relates to a Which? investigation

It explains some of the way the survey was conducted

In the most extreme case, a member of staff was witnessed dragging a resident towards the toilet by one arm, while another was repeatedly pushed back down into their chair by the head and shoulders when trying to stand up. Which? reported this to the health and social care regulator, the Care Quality Commission (CQC), which suspended admissions to the home immediately.

Anyone spot the problem with this? Yes, that’s right, the CQC waits for incidents like this to be reported to them and then subsequently take action. The CQC or any regulation or inspection authority should be the ones uncovering poor practice rather than being solely reacting to complaints that are made to them.

The Guardian goes on to say

The care homes were selected at random by Which? – one had previously been rated as poor by the CQC, two were deemed satisfactory, and one had been rated good – and the actors’ resulting diaries were analysed by a panel including an expert in inspection, an expert in activity and daily living, and a dietician.

Again shows a problem that has occurred since the scrapping of the ‘star’ system. Homes are still advertising the ‘stars’ and claiming to be ‘good’ or ‘excellent’ when it is outdated system demonstrating outdated inspection reports but still it is the first thing that people looking for residential care for family members.

It is very telling that a Consumer Organisation found the evidence rather than the official regulatory body.

But back to these homes and we’ll see the real fallacy in the ‘ratings’ and the inspections because despite the so-called ‘good’ inspections,

n three homes, residents sometimes had to wait 16 or 17 hours between dinner and breakfast without food, and in one home lunch was served just 1.5 hours after breakfast at 10am. For dinner one researcher was served a small sandwich and a chocolate-covered ice cream, despite them previously stating they didn’t eat chocolate.

There was a worrying lack of activity in all four homes. In one, residents constantly said they were bored, and in another not one of the advertised daily activities (including exercise, a quiz and a singing session) took place.

Does any of that sound ‘adequate’? Let alone ‘good’?

How is this allowed? Because the reduction of age and disability to irrelevance and unimportance in our society. Because care homes illicit a sense of guilt that we barely want to look behind what actually happens behind those closed doors.

This Which? investigation took four homes at random.

The CQC chair, Jo Williams is quoted as responding

The evidence Which? shared with us describes care that falls below what people using social care services have a right to expect – in one case so seriously that we acted immediately to ensure admissions to the home were suspended, and are now considering the best action for residents currently living there.

So this random sample of four included one home where the treatment and findings were so bad that it warranted an immediate suspension of admissions.

She goes on

“CQC listens to the views and experience of people who use services and look at what data tells us in order to identify possible risks, then reviews and inspects services. Seeing for ourselves what is going on in care homes is a key part of our regulatory regime – and almost all of our visits are unannounced. Where necessary, we require improvements against clear timescales or take enforcement action, following up to ensure these improvements have been delivered.”

Almost all of their visits are unannounced and they are ‘regular’ but tellingly, they are NOT frequent. Why is she not proud of the frequency?  The views and experiences of people who use services are important but how often will people feel safe in complaining.

Lest we forget, the Chief Executive of the CQC is a Cynthia Bower, who was Chief Executive of the  West Midlands Strategic Health Authority which was responsible for overseeing the Mid-Staffordshire NHS Foundation Trust where over 400 patients were found to have died due to neglect and poor care. How was she seen as able to take up the role of Chief Executive of the CQC? Not exactly a glowing track record on the regulation front.

Yesterday, Bower was facing the inquiry into the appalling levels of care in Stafford Hospital.

The Independent explains that

She told the inquiry, chaired by Robert Francis QC, that it had been “distressing to learn of the failings of care at Mid-Staffordshire Hospital and I offer my utmost and unreserved sympathy to patients and their carers and families. “I am deeply sorry for what happened and for the fact we had oversight of the NHS in the region at that time and we didn’t pick up failings in care.”

In addition to complaints, there were other alarm signals, such as reports of poor care from the Health Care Commission, the CQC’s predecessor, and of serious untoward incidents. But she said these were not enough to reveal what was going on.

“I wasn’t conscious at the time there was intelligence that we could have put together that would have said there were major failings of care,” she told the inquiry.

“I accept there were some issues we lost track of that would have generated more concern, but I don’t accept there were serious failings to put the pieces together.”

Ms Bower said the SHA did not have the capacity to have a detailed oversight of all of the region’s health services. She said the last NHS reorganisation in 2006 had caused a big upheaval and staff cuts of 60 per cent.

The first thing that springs to mind is ‘didn’t she learn anything about her role in the Stafford tragedy about the importance of GOOD regulation in the care system?’ The second thing is amazement that she should have been appointed to the CQC position anyway after such a horrific track record.

The government’s solution to this? To increase self-regulation and to out-source the so-called ‘excellence’ ratings for those care home providers that can pay.

The answer? Well, it would be more expensive but it would be more spot checking of the things that actually matter to the quality of life of users and residents in these services. How about a radical proposal that every care home is subject to the ‘excellence’ ratings whether they pay or not?

In some ways, nothing saddens my heart more than pounding on and on about poor quality care homes and poor quality inspection regimes – especially as I know that there are many very good care providers out there but unfortunately with a system of inspection which is so broken, those that are good are not recognised and those that are not good are not castigated and closed as quickly as they should be.

How have we ended up with a system that offers so little protection to some of those in our society who are in the most need of advocacy and support? By not caring enough about these stories.

Perhaps  more advocacy is a solution but it costs. Everything that is a potential solution costs. And that’s the problem.

But this is not something that can be swept under the carpet. These stories will return and I hope they do return to haunt those who are responsible for the destruction of the regulation system.

Because until they develop a conscience and a backbone, they will not go away. It’s just a matter of how many stories can remain hidden. And for how long.

Excellence Ratings for Care Homes

Yesterday, the government announced the unveiling of a new ‘gold standard’ or excellence rating for care homes. This is supposed to address some of the poor care that is delivered through local authority funded care.

I have my doubts. Not that I’m one to be necessarily cynical. But this time I am.

There are a number of reasons for my cynicism.

I believe the problem of poor care standards in residential and nursing care could be much more easily resolved than by a further level of ‘tick boxes’. All it needs, in  my massively oversimplified world, is more spot checks and random inspections – weekend and week day – day and night.

If a care home is doing its job and providing good care with adequate staffing, there should be no problem in well-informed inspectors and lay visitors popping in at any point and being able to speak to any resident or family member.

But this is too simple for the government.

The gold standard of excellence that they are introducing will be funded by the care homes and thus by possibly increased fees as these costs will filter down of course.

They will provide a new set of ‘tick boxes’ for homes to complete.

The Independent explains what the new system will involve

What will be rated?

* What may be included in the new excellence ratings

* Ratio of staff to residents

* Turnover of staff

* Activity programmes for residents and evidence that they are taking place

* All staff to be registered with the new Health and Care Workers Professions Council

* Minimum qualifications for staff

* Spot inspections and independent feedback from residents and their families.

Firstly, it’s important to note that these are issues that ‘may’ be included. Secondly, I thought that some of these issues were already a part of the inspection programme.  And if they aren’t they should be checked for ALL care homes – not just the ones that pay more to be part of the excellence scheme.

Basically, this ‘new’ system is a way of the government trying to add another layer of cost to what the CQC (Care Quality Commission – who are SUPPOSED to be regulating care homes)  should always have been doing.

The CQC claim that the new system will be owned by the CQC but administered ‘under licence’. Why under licence? Because it allows private companies to get their teeth in and allows more money to flow in. The CQC has proved that it is spineless, toothless and unfit for purpose.

The press release goes on to say

Chief executive Cynthia Bower said: “CQC’s role is to identify and react to signs that people may be at risk of receiving poor care. This means we can say we don’t see signs of risk at a provider, but this is not the same as saying a provider is offering ‘excellent’ care.

I say she’s plain wrong. The CQC does not identify poor care. They may react but they don’t identify. It is like pulling teeth from a dog to actually report poor care to them and the thought that they might actually, you know, physically walk into a care home and check the standards is living in a fantasy land where a community and country actually pay attention to the quality of care in residential homes. It should be a role of the CQC to define and award ‘excellence’ in care as a part of the current registration regime but under this new system, this role will be tendered out, at a price, of course – because, after all, what isn’t for sale in this country now – to private providers to ‘check’ and do the job the CQC should always have been doing –  but only for those who pay for it.

I don’t understand why the ‘star’ system was abolished (as it was last year) only to introduce another system at a higher cost. Why not judge ALL homes on this excellence standard rather than attach a higher cost to those homes that wish to ‘register’.

It all seems like a complete smokescreen to hide the toothlessness of the CQC (Care Quality Commission) and a way to garner more money from the independent and private care providers to pay for an inspection system that is not fit for purpose anymore.

Does no-one else see this? I’m amazed the government have the gall to get away with announcing this as if it is something new.

If they or anyone REALLY wanted to improve the quality of ALL people in residential care, they would fatten the CQC up with more inspectors and give the inspectors more leeway to inspect.

One of the worries of mine was also mentioned in the Independent namely that

At Christmas, the Care Quality Commission (CQC) carried out spot inspections of 234 health and social-care institutions, including nursing homes, which revealed significant lapses in standards in more than a third of cases. Ten reviews resulted in the highest form of censure, which could to lead to the commission withdrawing licences to operate.

After one review, a nursing home in Luton – run by Southern Cross, Britain’s largest care-home provider – was closed immediately because conditions were so bad. The commission found that 26 other institutions were not meeting required standards in all areas and ordered improvements.

So surely more and better spot checks are the way to unearth poor practice rather than another hoop to jump through at cost.

Why don’t the CQC just adjust some of their own criteria to include those elements raised in this so-called ‘excellence’ standard? Why does it need to be a separate and discreet system? Possibly because this way the government can raise money from it and farm out the inspections to private companies rather than relying on the toothless and frankly incompetent CQC to do.

Yes, I’m angry. I am angry because a real attempt should and could have been made to improve the quality of all residential care services nationally and it was fudged and obsfuscated. We are to be fooled by this ‘gold standard’ which is another way of saying ‘if you want our money for placements, you must pay’.

I see this system as being biased towards the large care providers. The Southern Cross/Care UK/Bupa providers at the expense of some of the small operations.

Some of the best service delivery I’ve seen has been in smaller one-man operations. I remember the care home I visited where the owner’s mother was a resident, her husband was the handyman and it felt like an extended family where the owner lived next door and spent most of the day sitting in the lounge chatting to the residents.

Would she be able to pay for an ‘excellence’ rating? Who knows – but the excellence and level of care was unmistakeable.

Should we be jumping in the air and celebrating a new excellence system? Maybe that’s what the government smokescreen wants us to do.

For me, the death of an effective regulatory system makes me sick to my stomach and makes me despair for the future care for older people in this country.

Johann Hari’s manifesto for change in care homes

A week or so ago, Johann Hari, a journalist and columnist for the Independent, wrote an article about his grandmother and the poor to verging on abusive care pathway that she experienced through devastatingly shoddy system that was and is not fit for purpose.

Today he writes again for the Independent proposing a series of changes across the sector which would improve the quality of service delivery.

I have a massive amount of respect for Hari and he writes very eloquently and passionately. I desperately hope more people listen to him than have listened to us, within and engaged with the sector who have been shouting, Cassandra-like, for so long.

His proposals are quite straightforward.

– Support elderly people to stay in their own homes wherever possible

This concurs with the evidence produced yesterday by the Alzheimer’s Society in a report published yesterday ‘Support.Stay.Save’ which concludes that while care in the home (rather than premature residential home placement) is a favoured outcome – the quality and training of staff is a serious issue – however if this were challenged, promoted and improved, there would be an eventual saving in the costs of placement in residential care.

Hari says’

There is a whole range of services that make this possible – from Meals on Wheels to home helps who are there to help an old man to shower in the morning and get into bed at night. We should be stepping them up, to keep anybody who possibly can free and independent. Instead, we are ruthlessly stripping them away.

and it is this that breaks my heart. We are tightening criteria, raising the bar to access support and increasing the cost of these services to those who may be responsible for their own costs. Hot meals on wheels delivery is not a default position anymore – they’ve been replaced by a fortnightly delivery of frozen food. This is a saving on paper to the local government but in the longer term denying this additional personal contact of a regular face delivering hot meals, is a much larger cost.

Councils have tendered out for the services at the lowest baseline cost. Care staff are provided on minimum wage, with little, if any, training and barely any dignity in their employment conditions so no wonder that corners are and have been cut. We need to provide the best possible rather than the cheapest possible.

They are better off with their families – so offer the care home funds to them first

Again, a seemingly obvious point. Hari states that residential care can cost upwards of £450 pw. Why isn’t that same amount of money offered in the home? It makes perfect sense. It makes perfect logical sense. Of course, some people will always need the 24 hour care. To be honest, we tend to fund increasingly higher packages of care in the home and it isn’t unknown for similar levels to be provided. I have one service user who has a package of virtually double that in her home (as a personal budget) but am frequently told that that is an unusual case and it’s only possible because a family member takes on a significant amount of care.

Local authorities do need to get over their aversion to funding overnight care in the home though. That would immediately make this more possible. Personal budgets theoretically should allow this point to be immediately actionable. In practice, it is not easy to squeeze the funds out of the interminable RAS (Resource Allocation Systems).

Make being a care worker a desirable profession

Hari says

Today, our elderly are looked after by people who are paid the same amount as street-sweepers, and have the same level of training..

This breaks my heart. I spent 7 years working as a care assistant in a residential home. I applaud this point. There were times when I met with friends from university and I was almost sneered at because of my job. Actually, scratch that ‘almost’.

‘When are you going to get a ‘proper’ job?’ I was asked. Eventually the pressure of that pushed me into social work. I am glad I did it but it is hard to understand where the sneering came from. Sure, money is an aspect of it but it’s wider than that. Sometimes the management seems to join in with this scornful and hierarchical approach to care workers – it’s important to remember that if a manager is not going to treat staff well and with respect you can be sure that residents will not be treated well either.

Increasing not only pay but conditions of service – decent holiday pay, sick pay and training – would make a difference. I’d like to see more of a line of career progression as well.

Retrospectively, I look back with a massive amount of fondness to those days. I was lucky to work in good homes where I was instilled with a good work ethic and values that supported resident’s rights. I know how easy it is as a worker to ‘go native’ within an organisation and agency if the work ethic and values are not good. It leads to spirals of dispirited behaviour.

I wish every social worker had had the experiences I had in hands-on care work. It was invaluable and it shapes a lot of my actions and values today. I doubt many do or will in the future. That’s more the shame.

Now, I am so proud that I was a care assistant in a residential care home. I wish I had been at the time.

Make every home publish its staff-to-residents ratio

Theoretically this should be possible. It should be easy to access. It makes a big difference. When relatives go to visit care homes I advise them to ask about this and perhaps ask the member of staff showing them round how long they’ve been there and what the staff turnover is.

Clarity would be a fantastic and simple indication of whether a care home runs on bare minimum or below minimum staffing ratios. Unfortunately the CQC doesn’t really help much here.

Hari says

Every parent knows how many pupils there are per teacher in their child’s school. Nobody knows how many carers there are per resident in their granny’s home. I asked at every home I considered: nobody would tell me. But this can make the difference between a good home and a terrible one.

I’m surprised that no home could tell him when directly asked. Maybe because sickness is not taken into account – some homes seem to constantly run below the CQC required level due to ‘unexpected sickness’. The CQC could monitor this with spot inspections. It doesn’t. Or only when things are literally falling apart. It makes me angry.

Impose minimum nutritional standards for the food

This makes sense again and a menu list can’t always indicate what the quality will be like. However, unlike Hari, I have seen homes that have delivered well on this front. I am sure I’ve been to many many more over the years though.

The ‘Scores on the Doors’ system of food hygiene ratings has been extended to residential and nursing homes so perhaps that is a start.

Well, the best start is for the person responsible to think ‘would I want to eat this every day’. No-one should be serving food they would not want to eat themselves.

Change the attitude

This is a broad brush that Hari paints.  The example he gives is a regimented imposition of bed times and morning times. There is something of the way that care homes are organised that sometimes some of the personal touches and individuality can be lost. This does differ in different care homes and there are as many attitudes as there are people. The key though is to emphasise individuality in choices and not to impose on others.

For me, it’s a matter both of training and staffing levels. Treat every resident as you would want a close family member of yours to be treated. It’s a very simple tenet and an easy one to remember. The difficulty is that not enough people will practice that way and so staff as well as residents are in danger of becoming institutionalised.

Stop the mass prescription of anti-psychotics to rebelling residents

This is self-explanatory really and to be fair (as Hari notes) it is one point that progress is definitely being made on. It is far less common now than it has been in the past. Quite rightly. Anti-psychotics can be dangerous for people with dementia.

Restore proper inspections of care homes

For me, this is a massive key to the whole process. The CQC needs to take responsibility for the decline in the standards and to restore spot unannounced inspections, day and night, weekend and weekday to EVERY SINGLE residential and nursing home in the country.

It is wholly unacceptable that there is a reliance on cheaper ‘paper’ inspections or ‘desk-based’ inspections and it is wholly attributable to staff being laid off by the CQC.

I have my sources (actually a couple of very good friends of mine whom I worked alongside in those days when we were all care assistants in the same residential home!) who work within the CQC and they have been given much larger caseloads and have less time to do more inspections.

Inspections need to put the providers on the spot and really and truly inspect. They need to check that what homes write about staffing ratios is really what is happening on the ground. We rely on them. They do not deliver.

As Hari says

In 2005, there were 50,000 physical inspections of care homes. This year, there will be a quarter of that number. David Cameron has called for “light touch regulation” of this sector, so homes are increasingly being asked to engage in “self-assessment”. That means they will be asked to fill in a few forms.

This, more than anything, makes me furiously angry. Light touch regulation DOES NOT WORK. It leads to increased abuse. I can give so many personal examples that I have witnessed. I will try to keep shouting until the system changes.

I wrote about this last November and have no doubt I’ll be writing about it again. And again.  And I’ll mention again because I think there’s a relevance that the Chief Executive of CQC is Cynthia Bower who was Chief Executive of NHS West Midlands when Stafford Hospital was delivering contemptible and appalling care. Hardly a CV that instills much confidence.

Make sure care homes that are shut down stay shut down

This raises the issue that care homes can fail and then just re-register and open under a new name which should be wholly unacceptable.

Again, I wrote about this last November when Private Eye and Compassion in Care were trying to gain more information about care homes that were closed down.

As Hari says in his piece, this was brought up by File on Four and Compassion in Care a couple of months ago.

Impose serious criminal consequences for elder abuse

There is a new law of wilful abuse of those who lack mental capacity which was introduced in the Mental Capacity Act 2005 but I agree with Hari in that the legislative framework for adult safeguarding needs to be as strong as it is for safeguarding children. Our hands are tied and the punishments do not fit the crimes.

It’s an excellent piece by Hari and I wholeheartedly applaud it. I hope more people will listen but we have to keep shouting as loudly as we can to improve the quality and attention of care for those who lack capacity and for all people who rely on others for support.

We all need to shout. Not just those of us who are directly affected or who have parents or grandparents who  might be affected (as we all may be eventually) but anyone who cares about living in a civilised society as well.

Perhaps its endemic of a society that wants to push the uncomfortable realities of ageing ‘under the proverbial carpet’ that has led to institutional abuse but our humanity is lost if we don’t stand up against it.

This is not a party political issue as significant damage was done under the last government but this government can’t get away with it either.

And thanks to Hari for raising these issues among a wider readership. I wish so deeply within my heart that this piece shocked me. Unfortunately, after many  years working in the care sector, I’m sad to say it doesn’t.

On Failing Care Homes

Today, the BBC report on a statement by Unison, who represent the inspectors who work for the CQC (Care Quality Commission), explaining how failing care homes will be able to thrive under the ‘cost-saving’ exercises which are the utterly despicable ‘desk based inspections’ that I’ve been railing against for over a year.

This is one of many areas that I don’t want to be right. I don’t want to be a ‘Cassandra’ type figure but I do want people to care and know that elderly and vulnerable people are not being protected by the current regime of inspection and that things are going to get worse unless there is a massive change in the way the CQC is run – remember the Chief Executive is Cynthia Bower, the same woman who was responsible for the West Midlands Strategic Health Board – which covered the Stafford Hospital whose problems we have become all too aware of. Hardly a glowing CV for someone appointed to a regulatory body.

The BBC article explains

Unison says the new system of written self-assessments will mean thousands of homes will avoid inspections altogether if they look good on paper.

But the Care Quality Commission, which introduced the system, said it would let inspectors focus on failing homes.

Which would be fine if they DID focus on failing homes. I  am, for the record, currently in the middle of a really unpleasant safeguarding investigation at a so-called ‘Good’ residential home. It only takes one day or one person for a ‘good’ home to turn into a really bad home. This is the point that is utterly and comprehensively missed by the ‘new’ system.

The BBC go on to explain

The new system replaces yearly automatic inspections for all homes.

It came into force in October and now means that homes which provide a good written self-assessment may not be inspected again, unless there is a serious complaint made about them to the commission (CQC).

For me, this is a horrific institutional abuse and dereliction of the duty of care that the state has towards adults who rely on us to provide high quality care for them. Firstly, I know for a fact this has been the system for way before October, as I have spoken to an inspector directly about care homes that I am worried about and have been told that they haven’t been ‘visited’. This is NOT a system that ‘came into force’ in October’.

And sorry, but when it takes a ‘serious complaint’ to trigger an inspection, we are setting such a low baseline for the standards of care that we expect. If they MUST move down this route and, if it wasn’t very obvious, I think it is a cruel and horrendous path to tread – then surely only those homes which provide faultless and outstanding care would be able to produce self-assessments, not ‘only those that don’t have serious complaints made about them’.

The CQC is not able to manage the work that is being generated for it – that’s the problem. It is purely and simply about cost-cutting.

According to the BBC article

Unison, which now represents about 700 inspectors, claims that the workforce numbers have halved since 2004.

And there we have it. The key to why the systems have had to change. It is not about providing a better service, it is not about more tailored inspection regimes – it is purely and simply about cost and cutting back the number of inspectors. They can’t spend two days inspecting every residential and nursing home because they don’t have the time to.

Paper-based self-assessment is as valueless as the paper it is written on. It is a completely inadequate system that produced poor quality care.

Can we rely on whistle-blowers? Perhaps but remember the people who often work in residential homes who we might rely on are often very poorly paid and this is a sector that relies very heavily on transient staff on minimum wages. Particularly the worst homes.

What about council’s own Quality Assurance teams? This is what I was told, informally, in conversation with an inspector. On the other hand, someone I know who works in our own council’s monitoring team tells me of potential job cuts they are being subject to. This is leaving a monumental gap in the checks and balances of the care home system.

Care is a big money business in this country.

Just last year, Andrew Lansley, the Secretary of State for Health under whose auspices the care sector lies, was given a donation to his private office of £21,000 by Care UK – one of the largest care ‘industry’ operators whose poor quality of care has been highlighted in the past in Panorama.

However this is not a party political issue. The previous government showed little care or interest in the proper regulation of residential and nursing care services but the further erosion of local authority budgets will lead to a worse system of regulation than we have ever had in this country.

This is scandalous in the extreme. Anyone from this government (and the last, to be honest) who claims they are protecting the vulnerable need only look to both the decimation of proper and thorough regulation of the care sector which has left the way open to abusive practices and the crushing of local authority budgets without ring-fencing which will lead to any back up checks and balances being slowly (or not so slowly) eroded.

No-one seems to care enough about these changes and what it means for quality and the CQC management seem to be able to get away with reassurances that ‘paper based’ inspections will be ok.

They won’t and they aren’t. I know. I worked in residential homes for years before I qualified. There is no such thing as over-regulation in this sector because the power imbalances are enormous and in some of the care homes, the residents, due to issues of capacity or through fear of consequences are not able to speak up about what is going on. We cannot rely on family members to be whistleblowers, it isn’t fair and it should be accepted that we can provide a good standard of care.

And, you know, not everyone has family.

And we can’t necessarily rely on social workers, like me, who go and review. Yes, I can and do pick up some aspects of care but we don’t have the powers to look at records about people we are not primarily involved with (quite rightly). We can raise concerns about individuals when we notice them but that is no replacement for a proper and stringent regulation regime.

We need inspectors, we need inspections and we need more of them. But they cost and it isn’t a price the government is willing to pay. But it should be.

Trouble at the CQC

A lot of people working within the social care sector have had misgivings about some of the changes that have been taking place at the CQC (care quality commission). The CQC is responsible for monitoring and registering care services (as well as health services,  but I’m going to concentrate on care services because it’s what I know best) since its inception when it pulled together various previous regulatory bodies and picked up their functions.

There are a lot of lessons to be learnt for the future within the CQC  as we draw to a point where lots of services across health and social care will be merging and we are pushed towards joint management. There is a lot to be wary of.

Private Eye has an expose’ piece in the current issue (dated 29/10-11/1, in the ‘In the Back’ Section p29). Unfortunately the piece doesn’t appear in full on their website so you will all have to go out and buy a copy (seriously, if you are concerned about the CQC it is definitely worth a read and to be honest, I can’t recommend Private Eye highly enough!).

I wanted to draw on some of the issues raised in the piece so forgive the lack of links for the time-being.

The investigation carried out by Private Eye was alongside ‘Compassion in Care’ which is a charity set up to counter abuse in care homes. The organisation was set up by Eileen Chubb, a former care worker who witnessed abuse and who lost her job because she was a ‘whistleblower’. The organisation campaigns for the vulnerable in care homes.

The report highlights a number of concerns related to the CQC particularly how they have either ignored and in one case ‘upgraded’ via the now defunct star-system homes in which proven maltreatment has occurred.

As the Eye says

‘Only last month we reported how – just two months before a hospital nurse described a care home resident as suffering ‘the worst care of neglect’ she had seen, the CQC had wrongly promoted what had been a failing home, run by care home giants Southern Cross, back up to a two-star ‘rating’.

I don’t have the time to relay all of the information and quite unbelievable lack of teeth of the CQC in the face of appalling care services as relayed by the Eye but it makes for frightening although worryingly not surprising reading to me.

Another part of the article refers to the leaked staff survey results published in Community Care and that backs up informal discussions I have with some good friends who currently work in the CQC.

The Eye states that

CQC Insiders were worried that attempts to push through registration for all homes and agencies ahead of the 1 October deadline was compromising safety in the homes themselves’.

This absolutely mirrors the conversations that I have had with CQC friends, including being told that they were told to concentrate on these registrations at the expense of visiting homes where issues may have been arising –much to their own chagrin.

The other concerning conversation I had with said friends was that the CQC seemed to be increasingly reliant on local authorities ‘quality assurance’ teams to check on the local residential, nursing and domiciliary services. We can only guess at what might happen to some of these teams as the local councils make massive cuts. I don’t know if they will be able to provide as strong a service as they might in less frugal times.

The Eye pulls up the report and interviews given by the head of the CQC last month stating that 34 homes and 8 agencies were closed after they took ‘enforcement’ action as a way to prove their ‘strong arm’ regulation as well as 51 other services which had closed after poor ratings.

This is an area that Private Eye has been investigating and has tried to push CQC to provide details of these ‘enforcements’ as there was nothing about them in the CQC’s annual report published in April 2010. Private Eye and Compassion in Care have tried to find details of the deregistered homes b ut the information  has ‘disappeared’ from the CQC website and they have been stalled in their attempts to investigate.

Cynthia Bower, the Chief Executive of the CQC in her previous incarnation was the West Midland Strategic Health Authority which was responsible for overseeing the Mid-Staffordshire Foundation Trust Hospital. It is quite staggering that the responsibility for protecting standard of care for those who are arguably some of the most vulnerable in society should be under her charge.

I’ve railed against ‘desk based’ assessments which were happening prior to the existence of the CQC where inspectors do not actually visit homes that have previously scored ‘well’ in inspectors but rather rely on ‘self-assessments’. It is a national scandal that we have no reliable and functioning way of monitoring care homes and that the CQC itself is relying on local authority quality assurance visits when it should be setting the gold standard itself.

The piece ends with the comment that while the CQC hasn’t responded to the piece, John McDonnell MP will be raising the issue in the House of Commons so hopefully they will respond to him.

I rail where I can but the difficulty I sometimes face is time and that often homes are able to ‘put on their best face’ for social workers when we visit. We have limited roles usually in reference to one particular resident.

I have to say that all the personal contact I have had with CQC inspectors has been exceptional – when I have picked up concerns at a care home and contacted them directly but it is clear that the time is not allowed in the same way that it had been previously.

We are back to penny pinching and cost-cutting.

Thank you to Private Eye and Compassion in Care for investigating these issues. They should be on the front page of every national newspaper rather than tucked away in the pages of Private Eye – but I have a lot of time and faith in Private Eye to be honest. They have some of the better investigative journalism in  my very simplistic terms. Go out and buy this edition, all the editions and subscribe!

We cannot let it lie.