Q&A: Ask the Chief Inspector for Adult Social Care

gillybob

I am interested to know how the "inspection" of "in home" carers can possibly be carried out objectively? My grandma has carers going in to her three/four times a day. As her main carer I find this service (she pays a contribution towards this) invaluable as I hope it will enable her to stay in her own (rented) home for rest of her life. She will be 99 this year. It gives me the peace of mind to know someone will be looking in on her while I am at work or looking after my own grandchildren. However it worries me that my grandma does not like some of the carers who go in to see her. She moans that they only stay for 5 minutes (or less) and often don't even bother to take their coat off spending most of their time scribbling in their folder "to keep themselves right".Her night carer comes at 7.30 to put her to bed and she doesn't want to go to bed "like a child" however the company say that they have no other slots available. It's fine on the nights I can go but I can't be there every night at 9pm. I also worry that a couple of the carers are overly nice (sickly) when I am there. Grandma says "hmm you should hear her when you are not here". I appreciate that at her advanced age she can be quite challenging but I wonder how this type of service can possibly be inspected without the care provider knowing and therefore being on their best behaviour (so to speak). Surely if the carer is suddenly accompanied on a visit then they will know they are being checked up on.

Sorry for long winded post. I just worry.

Thank you for getting in touch and I’m sorry to hear your grandmother is not getting the care she needs at the best time for her.

As the chief inspector for adult social care in England, I’m very clear, as are all my inspectors, that people should get the care and support they need, when they need it. That’s why we ask all services – are they safe, caring, effective, responsive to people’s needs and are they well led?

Care agencies have a duty to make sure people receive care that is personalised specifically for them, based on an assessment of their needs and preferences. I would encourage you to raise your concerns with the care agency as without knowing the details of your grandmother’s care plan, I cannot imagine how her care needs can be met effectively and in a compassionate way in less than five minutes.

When we inspect home care services, we do give home-care agencies 48 hours’ notice for our scheduled visits (unless we are responding to concerns raised with us or when we are following up to make sure that improvements have been made). This is so we can be sure the manager or a senior person in charge is available on the day we plan to visit and can arrange alternative cover for their visits if on a rota.

I hope I can reassure you that this does not compromise the robustness of our inspections.

People using services, their families and carers are at the heart of everything we do at the Care Quality Commission. When we inspect we ask the questions that we know matter to them, we listen to their views and we take action to protect them when that is necessary. Through our inspection reports we try to provide clear, reliable information that allows them to understand the quality of care being provided by any given service they might be using, or considering using.

When we inspect we’re always thinking - is this a service that we would be happy for someone we love and care for to use? If it is we celebrate that; but if it isn’t, we will do something about it.

If you would like to read more about our inspections please visit our website – www.cqc.org.uk . You can also use the website to tell us about your experience of care as this helps us to plan our inspections and to focus on any issues you tell us about when we do inspect

loopylou

I worry about:
Announced inspections that give the provider notice and therefore time to prepare/cover up deficiencies.

Thanks for your question – it’s an important one, which others have asked too.

We usually announce our inspections of home care agencies 48 hours in advance. This is so we can be sure the manager or a senior person in charge is available on the day we plan to visit and can arrange alternative cover for their visits if on a rota. We want to make the most of the time that we are on site for an inspection without getting in the way of people’s care arrangements and so that means making sure we have the right information to help us focus on what matters most to people and that the appropriate people are available.

Inspection – i.e. what we see for ourselves – is a key part of how we regulate services but it is not the only way. We use a whole range of evidence to inform our visits and our judgements, including the views of people who use services and their loved ones – either directly or through those speaking on their behalf, such as community groups and local Healthwatch. Also, we consider information, such as safeguarding alerts and from current or former employees of the services, and look at records, from staff rotas to arrangements for staff training and supervision, to data on hospital admissions, nutrition, medicines and deaths.

Together, this helps us to create a clear and accurate picture of what the service is truly like for people. If the announcement of our planned inspection prompts a provider to make improvements, this is a good thing as long as it is maintained but based on the whole host of evidence we consider and the specialist training our inspectors receive, if there are underlying issues about the service, we will uncover them and hold the providers to account to make the required changes so that people get the care and support they deserve.

loopylou

I also worry about:

15 minute Dom care visits where the client has to make a choice between say being toileted or eating. I don't know of many/any fit, healthy people who can get up, washed, dressed and fed in such a ludicrously short period of time.

There is no leeway for responsive, person-centred care whatsoever, what are you going to do about this with the pressures already evident on care services?

How do you ensure that private care providers don't put profit above care?

Thank you for raising this issue – the debate about fifteen minute home care visits is certainly a hot topic, which we haven’t shied away from.
At CQC our focus and priority is on the people who use services and what care is really like for them.

My view is that if on a home care visit, someone has to choose between having a bath or having their breakfast – then the service is certainly not safe or caring, is not effective, can’t be responding to their needs and no well-led organisation should let it happen. If we find out that it is happening, then we will rightly criticise the provider.

I am often challenged that we are focusing on the wrong people – that it is the responsibility of local authorities commissioning 15-minute visits not the providers who say they feel forced to deliver care in that way. Of course, it can be the contract, but it can also be poor organisation of rotas and timetables, cutting corners to reduce costs, inadequate assessments of people’s needs and a lack of flexibility on the part of the provider.

If we rate services as inadequate or requiring improvement I would hope that providers will use our feedback to reflect on the reasons for poor services – and if it is within their own responsibility to sort, then they do just that. But if it is an issue they need to raise with commissioners, they can use our reports to explain why.

Ultimately though, people should not be in this business if they don’t care.

loopylou

How does safeguarding fit with the employment of many non-English speaking carers, who are barely trained for the job (this is from personal experience)?

Social care services are so important because at their very best they can transform a person’s life. They support people with a huge range of needs, including those with dementia, learning disabilities and people who lack capacity to make decisions for themselves. Strong communications skills are crucial for these staff. If care workers are unable to communicate effectively with those they are responsible for caring for and supporting, then I would question whether the service as a whole is safe, caring, effective, and responsive – this is what our inspectors are concerned about.

We know care workers play an essential role in providing people with some of the most personal and fundamental support and so we expect all providers to induct, support and train their staff appropriately to make sure they can do this. From 1 April 2015, the government has introduced the new Care Certificate, which sets standards for health care and adult social care workers in England – effective communication is a core principle within this and we expect providers to recognise this when they take on new staff.

loopylou

Councils cap the amount paid per hour of dom care (and care/nursing home) fees.
Dom care agencies are told that they will only be funded for 15 minute visits so are forced to cram as many visits in as possible often without allowance made for or paid travel time.
Result? Quality and meaningful support is sacrificed.

Thanks for sending in your question – it reflects the concerns I know many people have. When we look at a service we want to know if it is safe, caring, effective, responsive to people’s needs and if it is well-led. If the time for home visits means that people’s needs are not being met, we would reflect this in our inspection report and in the judgement we make about the quality of care being offered by that service. We will find this out by speaking to people who use services and their relatives, as well as looking at care plans and other records, to find out if people’s care needs are being met.

You may be interested to know that the National Institute for Health and Care Excellence (NICE) is currently consulting on draft guidance on how services should deliver personal care in people’s own homes, which includes proposals for commissioners on the length of visits. As the regulator, we encourage providers to look at evidence-based guidance that is considered to be best practice, which would include this guidance from NICE around length of visits, once it is published.

Coolgran65

My mother had dementia. Her carer visited 4 times daily.
Officially, to get mother washed and ready for the day, to toilet her, give her breakfast, all in 15 minutes.

Mother told the carer that she was already washed when she clearly was not, this went on for days/weeks and when I spoke to the Carer I was told that the patient wishes were paramount and accepted. Difficult when the patient has dementia and has no idea if and when she was last washed.

Meals on Wheels were delivered and put into the fridge. Mother would tell the carer that she had already eaten. The fridge was jam packed with uneaten food. Again the carer said that if the patient said they had eaten, then so be it.

There were many emergency admissions into hospital because of dehydration, blood sugars et al.

I worked full time and visited at least twice a week, a 40 mile trip. Mid week I'd wash mum's hair, take some shopping, bring back to my home the laundry etc etc.
At the weekend I'd do some cleaning in her house. Rubber sheets off bed and sofa etc to be washed down and discinfected. Scrub the toilet that was never flushed, the bathroom floor that was wet with urine.

I arranged for folk to cut the hedges, and do minor maintenance work.

Social Services determined that home care was giving my mother the ability to live at home. They would not listen to me.

Eventually I got an emergency call from the Social Services. Mum's social worker had called and mum answered the door wearing only a continence pad. How sad. Social services finally agreed that she was at risk at home.

Mother was always a difficult person and my brother who lived just 3 miles from her, called with her every few weeks, read the paper for a half hour and left.

All this is a long winded way of saying.... how can care in the home be monitored. And as in the case of my mother, it is not necessarily the carer being neglectful..... to what extent can they take the word of a patient suffering from dementia.

And at what point should the paid carer be reporting to the authorities their doubts that the home care is or is not working for the particular patient.

Visiting paid carers are in a position of trust and honour, families rely heavily on them.
Tell me how a visiting carer can be monitored.

The situation you describe sounds incredibly difficult and I can only imagine the stress and worry this has caused you.

I agree it’s so important that care workers have an understanding of issues about mental capacity and people’s ability to provide consent, but also of the need to keep people safe from the risk of self-neglect, such as malnutrition and dehydration.

The assessment of an individual’s person’s needs is key to this. It should be updated regularly, particularly if a person’s capacity is reduced, or fluctuating. When we inspect a service, we would check that staff know how to report and escalate concerns, about the risk of self-neglect.

In a situation like this, we would expect the care worker to raise this with their employer who has a duty to act on all information of concern, as do we, as the regulator. If people do not feel able to speak to the service provider, then they can contact us online www.cqc.org.uk/share-your-experience-finder or by calling us on 03000 61 61 61.

Mishap

And another:

How is it that these dreadful homes get good inspection reports?

I am sorry that’s how you feel and I will try to reassure you that our new inspection regime should mean this doesn’t happen. Previously we just looked at whether a service was compliant with a limited number of regulations. That was not as thorough and comprehensive as the approach we take now.

Now when we inspect a care home we ask five key questions – is the service safe, effective, caring, responsive to people’s needs and is it well led? Our inspectors specialise in looking at adult social care services and use specific prompts (which we call key lines of enquiry) to help them focus on what really matters to people. They involve Experts by Experience on their visits – these are people who have had a personal experience of care – who can really help us to find out what is happening in the service. We will talk to people using the service, their relatives and carers as well as staff. We may also observe practice and will look at records. A lot goes on during an inspection day!

After the inspection we will write a detailed report and reach a judgment about the rating the service should have – is it Outstanding, Good, Requires Improvement or Inadequate? The report itself is checked thoroughly to make sure that our findings and judgements are correct and proportionate. All our reports are on our website and from April, providers are required to display their ratings on their website or in the service itself.

We developed this new approach in collaboration with people who use services and their representatives, as well as providers, trade associations and other bodies. I really believe it is a reliable regime that gets under the skin of the service and tells it how it is. We will of course keep on thinking about how we can improve what we do.

If you have a concern about a particular care home, please get in touch with us. You can contact us online www.cqc.org.uk/share-your-experience-finder or by calling 03000 61 61 61.

Teetime

I'll add a question here. How much of an care home inspection is more than a paper based exercise? When I was a Nursing Homes Inspector under the old Act we looked in people beds, their wardrobes, tasted the food, went through the laundry, looked at the accounts, audited the care plans e.g. if it said someone had a bath we asked them ' when did you last have a bath' etc etc. my colleagues in SS when we did joint inspections did no such thing but sat in the office looking at paperwork like policies and procedures said they weren't supposed to 'intrude'.

Thank you for sharing your experiences.

I hope I can assure you that our inspections are not paper-based exercises. When we inspect care homes, we spend at least a day on site, speaking to people who use services, their families and carers, volunteers and staff, and seeing for ourselves what the service is really like. We also consider a range of evidence when we’re there, and can request more if we need to follow-up on any areas of concern. And just to let you know, I’ve certainly had lunch with residents when I have been on an inspection.

There is a lot of information on our website about what we do on our inspections which you may find interesting: www.cqc.org.uk/content/what-we-do-inspection.
 
I’d also encourage you to search our website to see if we’ve published inspection reports for care homes in your area so that you can see what our inspectors have examined on their visits.

alisonja18

So the current position among social care provided by local authorities is to push care in the home as it is less costly than residential care (the official line is it is where people want to be). Many people in this thread have commented about 15 minute visits, care workers less effective if unmonitored, choices between eating or maintaining continence.

My question is: how are CQC able to monitor this situation and what is their viewpoint on these comments? Are 15 minute visits sufficient? How can the boundaries between care at home and residential care be drawn so that people's care needs (and not finances) are at the forefront?

Obviously when asked where they want to be most people will say they want to be at home (the shadow of the workhouse endures), but does anyone ever go back after six months to check that this is still the case? That the person is not incredibly lonely, sick of choosing between food and continence? Do they offer the chance to look at residential homes before making their decisions so that choices are real and meaningful?

Thank you for sharing your thoughts with us. Many people have raised concerns about whether fifteen-minute home care visits are enough and have questioned whether finance or providing safe, high-quality and compassionate care motivates providers most. In a nutshell, my view is that if someone is having to choose between (say) a bath or breakfast because the time is too tight, then that is not a service I would want anyone I love to be receiving and I would expect it to change so that people can get the care and support they need.

Your comment about keeping people’s care needs under ongoing review is also really important, which is why we ask how responsive a service is. Care plans whether for home, or residential care, should be regularly monitored to see if they are meeting the care needs of the person receiving care. We check for this on our inspections.

moleswife

The European Respiratory Journal found, through a recent study, that indoor air quality in nursing and care homes is very poor as a result of domestic pollutants; this has a serious impact on elderly residents' lungs. This is the first study of its kind in Europe highlighting the damaging effects of heaters, building materials, furniture, cleaning materials, disinfectants and cooling systems. Lack of ventilation and indoor pollutants can cause lung diseases which are preventable and the body's ability to cope with harmful pollutants decreases with age. Should the UK not take the lead set by other countries in Europe by undertaking further investigations and conduct intervention studies to assess which prevention methods are the most successful?

Thanks for your question – I have to be honest and say I haven’t been asked that one before!

While indoor air quality isn’t something that we regulate specifically, we do require providers to make sure that the premises where they deliver care are clean, properly maintained and suitable for the purpose for which they are being used. This includes making sure that the care homes are visibly clean and free from odours that are offensive or unpleasant. If we notice unpleasant smells, this could be a sign of neglect and so it would certainly be something we would follow up on. Care homes are people’s homes and everyone has a right to be looked after with dignity and respect and in a pleasant environment.

Mishap

So....another question....in view of the overwhelming concern that the system is failing, what will be your first steps to rectify the situation?

And how can we help? - clearly the funding is inadequate. Should we be quizzing our election candidates about what their parties' policies are for improving this dreadful situation?

There is no room for complacency here - Andrea needs to hear this stuff.

Thanks for your question. The adult social care sector is certainly facing some tough challenges but I wouldn’t say that it is failing. Quite rightly, much attention is given to the instances when care services have failed people, and we have to make sure we are doing all we can to encourage them to improve or take action so that they stop providing such inadequate services. But we should also recognize that there is a lot of great care across the country, which we can celebrate. For example, as of Monday 20 April, we have rated 19 adult social care services as Outstanding and 1,715 as Good out of a total of 2,926. We are finding that good and outstanding services are focused on the individual, have clear and visible leadership, and have processes and staff that constantly explore ways to improve.

We’ve published a report on our website to showcase these positive examples www.cqc.org.uk/content/celebrating-good-care-championing-outstanding-care-1. Our aim is to update this every three months so that we can share learning, encourage improvement and inspire confidence across the sector.

In terms of what you personally can do, I’d like everyone to know about the standards of care they and their loved ones have a right to expect and to tell us when that care isn’t being provided – people’s experiences of care, both good and bad are so vital to our work, helping us decide where, when and what to inspect. You can get in touch with us, in confidence, via our website www.cqc.org.uk/shareyourexperience or on 03000 616161.

Jane10

My MIL was discharged from hospital (had a form of leukaemia) and cried all the way home. She had wanted to go to a care home and we had found one for her. The Doctor said she couldn't go to one as she was best living in her own flat. She dreaded living by herself even with us in to see her twice a day for several hours, doing all shopping and taking her out etc etc. She was so lonely we got a "care company" to provide someone to chat to her for a couple of hours a day while we were at work . Despite this she slumped into misery. Finally, she fell and had to be admitted to hospital. It was as though the old Gran had come back. She perked up and thoroughly enjoyed the comings and goings in the ward. She had been desperately lonely. She didn't want to stay in her own home. She wanted to live with other elderly people. The emphasis on "Care in the Community" was cruelty for poor old Gran. Please can you understand that just because its politically correct to promote the "care at home" lobby its not right for everyone.

I am so sorry to hear about her experiences of care and I agree; care must be focused on the individual’s needs – you cannot apply a one size fits all approach.

I recognise the severe impact that loneliness and isolation can have on older people who live in their own homes. We partner with The Silver Line, Carers UK and Relatives and Residents Association and other organisations that support those using care services to understand their experiences of care and use this information to inform our work.

If you do feel the care being provided for a loved one doesn’t meet their needs, you should be able to ask for this to be reviewed.

We always welcome your comments about the care being delivered – both good and bad experiences.

You can share your experiences of care with us by calling 0300 61 61 61 or online at www.cqc.org.uk/share-your-experience-finder

Mishap

gillybob - there are good homes; there is just no way of telling which is which by looking at the CQC reports.

Since last October, we have been rating care homes and other adult social care services as Outstanding, Good, Requires Improvement and Inadequate to give people clear information on how their services are performing.

These reports are available on our website, written in plain English, and our findings are described under the five questions that we ask of services: are they safe, caring, effective, responsive to people’s needs, and well-led. Our new inspections are much more thorough and really get under the skin of the service so I hope that this will provide people with a much better idea about the quality of care there is.

What’s more, as of 1 April 2015, the government has introduced a new requirement for providers to display their CQC ratings in prominent areas including on their own websites, as well as across premises, public entrances and waiting areas of care services. This is a positive move for openness and transparency and we hope it will help people to make even more informed choices about care for either themselves or loved ones.

littleowl

Reading all the above posts makes me shudder. My Mother is 86 this year and not yet ready for care. However, I know she is living on borrowed time and that one day I may have to face up to the question of 'care'. My question is, what confidence can I have in the CQC after reading all these posts about its failings? How can anyone trust the care of their beloved relatives to the people in these 'care' homes? I think they should be re-named SCARE homes because it seems that is what they all are.

CQC has gone through a lot of change over the last two years. We have looked at way we worked, listened to people’s views on how we should inspect and then introduced more robust methods of inspecting and regulating services based on what matters most to people.

One really important step (not least because I got the job!) was to create three separate directorates led by three Chief Inspectors so that our inspectors can specialise in Adult Social Care, Hospitals or Primary Medical Services. That means that they are much more confident and capable about looking at individual services and making a judgment about how good they are.

Inspections of these services are now expert-led and include greater involvement from members of the public, better use of information to identify risk, and more thorough visits. We also rate services to give the public and providers clear information on what is good and what needs to improve.

As an organisation, we are now clearer than ever on our purpose, which is to make sure people receive safe, high-quality and compassionate care, and to encourage improvement. We celebrate good care when we find it and hold providers to account when improvements need to be made.

We are an open and transparent organisation and we publish all of our findings on our website. You can read more about us on our website: www.cqc.org.uk/content/what-we-do

I hope this gives you the reassurance you are after that we are always on the side of people like your mother – we all want the very best for those we love.

One thing that I would add is that very often people do not think ahead and end up making decisions about care services at a time of crisis. I am really glad that you are thinking about this now and as well as our own website, you may find resources like the Social Care Institute for Excellence’s, ‘Find Me Good Care’ helpful. www.scie.org.uk/findmegoodcare

gillybob

I appreciate that there will always be "best times" for providing care in the home and that most elderly people will want to get up, eat and go to bed at similar times. So unless these providers increase the amount of carers available we are always going to have situations (like my grandmas) where she can either get up at 6am or 10am. There is no availability inbetween until, (in carers own words) "someone dies or goes into resedential care" Likewise her lunch has to be really early or very late as there is nothing available for the premium time of 12.30. On the days I am not able to make two visits myself (days when I have the grandchildren) she is being put to bed like a child at around 7-7.30 pm, which is far too early.

I am sorry to hear about your grandma’s situation. Person-centred care should be at the heart of her care plan including her preferences around mealtimes and when she would like to go to bed and get up in the morning. You and I would probably hate to have to go to bed so early in the evening, why does anyone think it should be different when someone is older?

Services should be responding to people’s needs and preferences in as far as is possible – the key question we would ask during an inspection is What has the service done to try to accommodate this lady’s wishes ?

I encourage you to raise this with the provider or alternatively, you can contact us by calling 0300 61 61 61 or by filling in our form at www.cqc.org.uk/share-your-experience-finder.