The proposals amount to a step change in the depth, breadth, and consistency of inspections. They attempt to move away from superficial visits, focussing on minimum compliance standards and “tick box” approaches towards identifying excellence. The proposals also announce the use of “intelligent monitoring,” utilising a range of data to target homes that ought to be on the inspectors’ radar. The approach will also permit care homes to continuously upload and update their performance data, rather than relying only on the “big bang” of episodic inspections.
In May, I blogged on this site after watching a BBC Panorama exposé of neglectful and abusive care in three English care homes. I pointed out at the time that, although we can’t defend the indefensible, there are also many excellent nursing and residential homes delivering good care for some of our most vulnerable and medically complex citizens.
In August, in my King’s Fund blog, I took issue with comments made by NHS England chief executive Simon Stevens, who claimed that within his lifetime (despite rapid population ageing) we could somehow close down all 350 000 or so care home places if only we invested in “new technologies” and “support for carers.” I pointed out that such “magic bullet” thinking wouldn’t occur to anyone who spent their working life, as I do, looking after older people living with frailty or dementia. Of course, there is plenty we can do to enable more older people to remain in their own homes, but even in the world’s most age friendly societies, care homes are still required and older people and their carers sometimes make positive choices to enter them.
Besides which, in our current political landscape, far from providing more support for older people and their carers, swingeing cuts to local government support grants have led to many older people being deprived of even basic care and support. And we haven’t invested anywhere near enough in age friendly housing, communities, or in reducing social isolation. So let’s get real.
Once we accept that care homes are a necessary fact of life, then we can get serious about making them the best places to live that they can be. Much of what counts for residents relates to both person centred and relationship centred care. This means caring, well trained, and supervised staff, who put the older residents and their families’ individual needs, wishes, and stories at the centre—moving away from depersonalising approaches. Physical environment, food, range of activities, choice, and control are all central to this. City University’s “My home life” programme, the College of Occupational Therapists’s “Living well in care homes” programme, or the National Institute for Health and Care Excellence’s quality standards on mental wellbeing in care homes are all excellent examples of attempts to make these approaches mainstream.
The second key aspect—given that most care home residents have a combination of multiple long term conditions, frailty, disability, and in most cases cognitive impairment—is ensuring that they have full access to all healthcare inputs. This includes primary and community services, regular medication review, and adequate planning and support for care towards the end of life (as set out in the Gold Standards Framework programme and accreditation of care homes).
At the British Geriatrics Society, we have published three key documents about the healthcare of care home residents. “Quest for Quality,” which outlines their healthcare needs; “Failing the Frail,” which showed up systematic discrimination in fair access to healthcare; and “Care Home Commissioning Guidance,” which set out the components of good healthcare for residents.
Sadly, the commissioning of primary and community health services doesn’t fit under the remit of hospital, primary care, or social care CQC inspectors, and so I am still not sure who will vouch for the quality of healthcare that, by rights, commissioners should be assuring and providers should be delivering. It’s everyone’s responsibility and yet (at the same time) no one’s.
Quality improvement resources and communities of practice, such as those above, are crucial because even the CQC would admit that regulation and inspection alone cannot deliver quality improvement. Besides which, support for implementation and change isn’t its role or its mission.
In this context, it’s important to state that there is no neat, binary distinction between personalised empathetic care and the medical diagnostic model. Many of the problems which impair autonomy, safety, and dignity are amenable to assessment and treatment. For instance, poor mobility, depression, incontinence, falls, poor nutrition, noxious polypharmacy, or behavioural and psychological symptoms of dementia. It’s not a case of applying “either, or.”
So back to the new style inspections. The problems experienced by the CQC have been well documented—including numerous instances in the old regime of care homes passing inspections shortly before serious and scandalous failings were exposed; alleged bullying of whistleblowers; and the repeated attention seeking pronouncements in the media of its current chairman, who criticises frontline staff doing a job he’s never done himself, causing avoidable antipathy along the way. Moreover, institutions who passed with flying colours under the old regime may get mightily aggrieved with the CQC if the more detailed, new inspections find them wanting.
Rebuilding trust will take time. And there have been considerable teething problems with the new style inspections of hospitals as they get up and running—it’s still “work in progress.” However, the new regime is led by David Behan, who is steeped in social care and clearly wants to improve the quality of inspections. I recently had the privilege of meeting Andrea Sutcliffe, the new chief inspector for social care, and I am completely convinced of her competence and sincerity.
Of course, it’s one thing inspecting a couple of hundred acute hospital providers in England and another thing trying to keep tabs on over 25 000* care homes. Hence the importance of the “intelligent monitoring” to target efforts in those facilities most at risk.
The structure of the new style inspections mirrors that of hospitals, with overall ratings for institutions, and ratings under the headings of “well led,” “safe,” “caring,” “effective,” and “responsive to people’s needs.” And it’s unlikely that a care home would be “well led” if it was failing in other areas. At least there is now a mechanism designed to encourage confidential whistleblowing. Inspections will be informed by data that is systematically gathered in advance. And, crucially, instead of what were formerly superficial visits by non-specialist inspectors, we will now have inspection teams involving clinical or social care staff and “experts by experience” alongside the salaried inspectors.
Sutcliffe’s declared underlying principle for the inspections is to think about whether you would want your own older relative (or indeed, yourself) to be a resident. The “what would my mum think” test is a pretty good place to start. Before rushing to judgment, let’s give her and the CQC a chance, and give the new regime an opportunity to show its worth.
Professor David Oliver is the president elect of the British Geriatrics Society, a consultant geriatrician at the Royal Berkshire Hospital, and a senior visiting fellow at the King’s Fund.
Competing interests: None declared.
*This originally said 21 000 care homes, but was updated to the more accurate 25 000.