Yesterday the CQC published their report ‘The State of Healthcare and Adult Social Care in England’.
I have to try and put my criticisms of the CQC and their increasingly lax regulatory process to one side, although I couldn’t help a snigger when they claimed in their statement on the front page of the report to ‘Act swiftly to eliminate poor quality care’. Not exactly my experience when they rely on members of the public to actually alert them to poor quality care rather than carry out their own random and regular ‘on the ground’ inspections but it is the only report we have and there are some useful pointers in it.
The CQC inspection remit is very broad and obviously the quality of their inspections vary. This report relates specifically to the 2009/10 year.
The report covers four distinct areas – safe care, choice and control, person-centred services and standards of care. All the areas are very broad in their scope.
In summarising the report, I’ll look at it in those same areas and highlight some of the issues that arise. I will also focus on the areas in which I have a particular interest – namely adult social care and mental health but there are lots of pointers and lessons for healthcare outside this remit – I just don’t have time to comment on them all!
This covers physical safety such as safety from infection risks as well as safety from neglect and abuse.
The first ‘headline figure’ that the CQC lauds is that 80% of care homes met ‘safe working practice standards’. It does make you wonder about the other 20% though and add this to the fact that this is a self-reporting standard. Those care homes which met the ‘medication’ standard were 72% for older adults compared to 79% for adults under 65. I wonder what the variation would tell us about the different ways of management and attitudes towards older adults.
In the ‘maintaining dignity and care’ standard which includes responses by local authorities to safeguarding alerts, there was a growth in ‘better’ outcomes as there was an increase in local authorities performing ‘well’ as opposed to adequately (from 89 to 113). There were still 3 LAs performing poorly though on this fundamental duty. Unfortunately they aren’t named.
Safeguarding alerts increased over a third to 103,030 nationally across all client groups but the largest part of these referrals came in relation to older adults. No surprise there. No surprise at the increase either if you’ve been working in adult social care. We’ve noticed a real tightening up of the procedures and ways that we report and investigation abuse allegations. There was though a significant increase in the reports relating to adults with mental health problems (up 34% – same as older adults).
There was a fairly low response rate for users of Community Mental Health Team services (17,000 patients in all). Only a third were asked about physical health needs over the last year. I suppose I have a slightly different attitude as in an older adult’s CMHT we have a lot more interplay between physical and mental health so it’s something that might be more obvious for us to discuss.
Surprisingly only 56% of users had an out of hours telephone number to use.
There was a large increase in detentions under the Mental Health Act over the last year and the CQC report that only 21% of wards visited met the Royal College of Psychiatrists recommended 85% occupancy rate. 29% were over-occupied and 7% had a 125% occupancy rate. I’m not surprised by this. My own experience is that wards are closing at a fairly rapid rate and have been over the last couple of years. They cost a lot of money. This will get far worse and it is worth holding Trusts to account over this. I hope the CQC does this.
Choice and Control
This banner is about increased knowledge for users about options available to them as well as greater use of personal budgets to choose care needs and use of advocacy services as well to promote choice.
The number of residential care home places fell but the numbers of nursing home places rose nationally and particularly there has been a growth in provision of places for people with dementia. This is patchy at best across the country with the highest proportion of additional beds in the North East and the lowest in the South West.
I was concerned that the base figures of people on personal budgets was the indicator of how ‘good’ a council was at providing choice. My experience of implementing personal budgets is that all too often it seems like an empty ‘paper exercise’ in upping the councils’ figures for surveys such as this rather than a real and concerted change in mentality towards providing choice to those who require additional professional support to seize more ‘creative’ outcomes.
According to the report, which remember is dated 2009/10, only 3 councils are proposing to increase their eligibility criteria for services this coming year from substantial to critical and one was planning on reducing the eligibility criteria from substantial to moderate. I find that really hard to believe but figures are figures.
In relation to mental health service users, 48% of users said they definitely understood what was in their care plan. That’s a fairly shoddy figure! And 53% felt that their views had definitely been taken into account when putting together care plans. Perhaps we can see some of the potential difficulties for self-directed support in mental health arena when these figures are already so low but it is important to note that the low response rate of users is possibily another variant.
Regarding medication and information about medication 29% of respondents said they were not told about the side effects of medications that they were on.
Regarding inpatients both those detained under the Mental Health Act and those ‘voluntary’ patients, the CQC identified that the hospitals had been increasingly focused on security and ‘rules’ and that, more worryingly, more ‘voluntary’ patients were being held on locked wards and potentially were being deprived of their liberty. The report mentions that they were held neither under the Mental Health Act nor the Deprivation of Liberty Safeguards but the use of the Deprivation of Liberty Safeguards in psychiatric hospitals is generally not done. It may and should lead to a greater number of patients detained under the Mental Health Act for their own protection. I wonder if there will be any affect on numbers from this report.
A couple of interesting trends to pick up in this section which will no doubt, be a sign for the future. Firstly that less people as a whole accessed community care services – a fall by 4.7% from the previous year (that’s 83,930 fewer people). The report suggests that in the face of research showing an ageing population, it could be due to increasingly stringent application of criteria for assistance. Add this to the fact that people who benefited from help from grant-funded organisations (often those people who fall short of meeting the council ‘criteria’) also fell, there is a potential for a large unrecorded unmet need to be ‘falling through the gaps’ in service provision between the statutory and the third sectors.
Generally though there was satisfaction with the way that assessments were picked up and the involvement that people had in planning services.
The provision of telecare has grown over the last year, again, unsurprisingly – and I expect it will grow for many years to come and technology and care overlap in more creative ways.
Demand for the provision of ‘extra-care’ sheltered housing – which is sheltered housing with additional care services attached – was growing, sometimes beyond the provision of some local authorities. I see this as a potentially massive growth area and am often frustrated by a lack of provisioning particularly for those with mental health as well as physical health needs. If I were to be able to approach our commissioners with any one piece of information it would be that.
Worryingly only a quarter of councils demonstrated a strength in supporting people with complex needs and only seven displayed a strength in specialist services.
Regarding services for carers, there has been a large increase in carers taking up direct payments. This reflects my own personal experience as I have done a lot more carers direct payments this year and this amount grows every year however, the report worrying raises issues regarding money which was provided to improve the outcome for carers and was not ring-fenced and wonders aloud where this money might have gone. Sign of the times with the elimination of ring-fenced funding.
Standards of Care and Support
It’s interesting that the CQC explain how they judge that a care service is of a good quality or not. Their ‘evidence base’ is interviews of providers and users of services, information given to the CQC by the service, surveys given to staff, users and professionals (I have only once ever received such a survey), a key inspection (how often? Announced? I know a lot of services that haven’t been inspected for over a year), and information held about the history of a service.
My scepticism shines through because some services can ‘game’ the systems by having all the information required by the CQC written up perfectly but how they perform on simple human care levels differs enormously. I strongly believe that frequently (at least twice-yearly) unannounced thorough inspections are the way to truly judge quality.
Unsurprisingly the highest quantity of top level ‘excellent’ services were provided by the voluntary sector and the local authority. Private providers lagged behind. A sign of the times, perhaps as the government pushes the purchaser/provider split into the health service. Look to the care sector and be warned. Today it’s the care homes for your parents and grandparents. Tomorrow it will be your hospital services for you and your children. Perhaps then, we as a society, will care more.
Smaller care homes were more likely to be judged highly than larger care homes. Care homes for younger adults were more likely to be judged highly than care homes for older adults. No surprises here. But anger, a lot of anger. It’s about money, of course and there is less money available for the provision of care for older adults on a per capita basis. So larger homes and poorer quality care is the message given to providers.
The problem as well is the way that ‘good’ and ‘excellent’ are defined by the CQC as well though. I know poor ‘good’ homes and great ‘adequate’ homes. That was always the failing of the ‘star’ system but worse, to have no system at all and out of date ‘stars’ still on the website to give a wholly inaccurate view of what the level of care is like at any given home. The CQC should be ashamed of the way they have destroyed robust and transparent regulation and the previous government should be ashamed of how they allowed this to happen.
Finally and perhaps one of the most telling figures to take from the entire report is the one in the final sentence of the last page.
Only 16% of councils demonstrated low absence and vacancy rates and high recruitment and retention rates, which confirmed staffing issues continued to be an issue for 2009/10.
We can only imagine what the effect will be on these figures for 2010/11.
The use of these reports is that it brings to life the importance work that is done in local authorities and the effect that good quality support and provision has on peoples’ lives. Yes, of course service provision is essential and too frequently, commissioners are detached to an infinite level so they have little idea about what is needed ‘on the ground’ but often to, it is the human contact, the ‘being listened to’ and having views acknowledged that also makes a difference and that is dependent on quality staffing, quality training and having the time to spend with people.
My own experience in a pushed, under-staffed team is that I am spending less time instead of more time with people as I chase from emergency to emergency and the outcomes for those people who would otherwise had more intensive face to face contact is falling. This leads to sharper deteriorations, more likely readmissions or admissions to hospital that could have been prevented and eventually higher costs.
But with councils and NHS Trusts looking towards the immediate cost cutting of the next year and not at the longer term costs in 5, 10 years, this is the way we will go.
We shouldn’t be satisfied with delivering lower quality care. We aren’t. We need to speak up and speak loud and build links actively with user groups and carer groups and other professional groups to ensure that the government never forgot whom exactly they are betraying and to remind them over and over again that we aren’t going away.