Which Care? What Care?

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

Image via Wikipedia

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 Homes are still advertising the ‘stars’ and claiming to be ‘good’ or ‘excellent’ when it is outdated system demonstrating outdated inspection reports but still it is the first thing that people looking for residential care for family members.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.

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.