The role of arts and culture in care homes

In my role as a former principal inspector when looking for best practice in care homes an important consideration of any inspection, was always the range of activities provided for residents. If an inspector when visiting a home is shown to the resident’s lounge and is confronted with an exceedingly loud television with a large number of residents sitting in front of it, they will begin to ask the question what activities are being provided for residents. In their latest review of the Key Lines of Enquiry the Care Quality Commission are also placing a greater weighting on activities as an indicator of the resident’s quality of life.

The Social Care Institute for Excellence and All-Party Parliamentary Group on Arts, Health and Wellbeing. The Role of the Arts and Culture in Social Care Policy Briefing – July 2017, supports the importance of a range of activities for residents in care homes including art and culture.

The key messages from the briefing are:
• The arts can help keep us well, aid our recovery and support longer lives better lived.
• The arts can help meet major challenges facing social care: ageing, long-term conditions, loneliness and mental health.
• The arts can help save money in social care.

The All-Party Parliamentary Group on Arts, Health and Wellbeing (APPGAHW) has undertaken a major Inquiry into the role of the arts in health and wellbeing, with which the Social Care Institute for Excellence (SCIE) has been involved. The Inquiry yielded a substantial report – Creative Health: The Arts for Health and Wellbeing – providing strong evidence that creative and cultural activities can have a positive impact on people’s health and wellbeing.

The report found that in older people’s Services a growing body of evidence and practical experience that shows the engagement in the arts should be considered an integral part of healthy ageing. Social isolation and loneliness affect people of all ages. In older adults, social participation is more beneficial for health than giving up smoking. Around the country, community-based creative and cultural opportunities are being offered to older people as a way of overcoming social isolation and loneliness.

The research found:
• Participatory arts sessions in care homes yield improvements in residents’ wellbeing and the quality of care being provided by staff.
• Artists’ residencies in care homes prove popular with participants and carers alike, animating and personalising the care environment.

The All-Party Parliamentary Group support the proposal of artists’ residencies in every care home.
Chief Inspector of Adult Social Care for the Care Quality Commission (CQC), Andrea Sutcliffe, has pointed to the role of the arts in enabling people to live full and meaningful lives, identifying the best care homes to be ‘flexible and responsive to people’s individual needs and preferences, finding creative ways to enable people to live a full life.

We hope that this positive view will lead to more examples of care home providers securing culturally stimulating environments for their residents and staff and incorporating the arts into care packages.

An imaginative and holistic approach, which positively impacts on the wellbeing of residents, will make care homes more attractive to commissioners. SCIE has curated a digital resource, funded by the Baring Foundation, to increase their confidence and skills of care home staff in engaging residents in the arts.

Demand for older people’s dance classes now outstrips supply. Evidence is emerging that arts engagement helps to delay the onset of dementia. Musical training can enhance the plasticity of the brain, and visual art can improve cognitive functioning.

Engagement in creative and cultural activities can improve the quality of life for people with dementia and their carers. Arts on Prescription As part of a move towards place-based care, social prescribing seeks solutions to psychosocial problems in the community beyond the clinical environment. The most common outcomes of such community referral schemes are: increases in self-esteem and confidence; a greater sense of control and empowerment; improvements in psychological wellbeing; and reductions in anxiety and depression. Arts on prescription is a vital part of social prescribing, providing participatory creative activities that help to restore people’s wellbeing and reduce anxiety, depression and stress.

There is a great deal of evidence that the offer of a range of activities to residents in care homes is beneficial to their health and wellbeing. The Social Care Institute for Excellence and All-Party Parliamentary Group on Arts, Health and Wellbeing – The Role of the Arts and Culture report provides a description of what can be achieved in a care home setting. An emphasis on art and culture will not only improve the quality of life for residents, but provide staff with an added interesting element to their work

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

For more information about anything in this briefing or for a copy of the report, contact Alexandra Coulter:

Managing Health and Safety in care homes the plan, do, check and act approach

All managers of care homes are aware of the need for a systematic approach to health and safety. The Plan, Do, Check and Act approach provides the manager with an ideal systematic approach.

Plan: requires staff to say what needs to happen and say how you will achieve it.

Do: staff need to profile the risks that are identified and organise activities to deliver the plan, this will include the preventive measures required, and ensure there are systems and equipment in place to do the job safely.

Check: staff monitor the work to see if it’s being done safely and investigate the causes of accidents, incidents or near misses.

Act: staff review performance and take action on lessons learned, including those from audit and inspection.


The manager should say what they want to happen and write a health and safety policy that sets out arrangements for managing health and safety in the home to let staff and others know the commitment.

The health and safety policy does not need to be long or complicated, but it should clearly say who does what, when and how.

The manager should decide who will help to carry out their health and safety duties. This should be someone who is competent. A competent person is not someone who simply has the competence to carry out a particular task safely. In general terms, the definition of a competent person is someone who has the necessary skills, experience and knowledge to manage health and safety.

To help the manager to manage the health risks to employees, using an occupational health service can help identify risks, advise on suitable precautions and control measures, and provide services such as: health surveillance programmes; feedback and advice to employers following employee health assessments, e.g. pre-employment, following sickness absence, or rehabilitation and return to work; clinical services such as immunisations; employee information and training in the health aspects of their work.

The manager must consult with employees, in good time, on health and safety issues. This is a two-way process, as it allows staff to raise concerns and influence decisions on health and safety management. The consultation should include: risks arising from their work; proposals to manage and/or control these risks; the best ways of providing information and training.


The manager should make sure systems are in place to provide the tools and equipment to do the job safely and control the risks. Assess the risks and decide whether enough is being done to prevent harm to people. Decide what the priorities are and identify the biggest risks. The typical hazards found in a social care setting are all covered in the publication Health and Safety in Care homes.

Risk assessment is not about creating huge amounts of paperwork, it’s about: identifying the significant hazards; deciding who might be harmed and how. Evaluating the risks and deciding on precautions; recording significant findings; reviewing assessments and updating as necessary. Different risks need to be considered including: the common risks to everyone on the premises, e.g. risks from legionella, asbestos, electrical equipment, challenging behaviour and moving vehicles; common risks to service users, e.g. risks from falls from height or scalding, and general precautions capable of preventing harm to the most vulnerable; risks to workers arising from the tasks they undertake, e.g. moving and handling service users, responding to challenging behaviour, using hazardous substances, maintenance activities etc. risks to particular staff, e.g. expectant mothers, young employees, or those with pre-existing injuries which may impact on work; risks to particular service users, e.g. the risk of them falling out of bed or needing help with bathing or to move around safely.

Key points to consider when balancing risk include: concentrating on real risks that could actually cause harm; close liaison with the service user, carer and family/representative when carrying out risk assessments, which is essential to achieve outcomes that matter to them; how the risks flowing from a service users choice can best be reduced, so far as reasonably practicable, by putting sensible controls in place, e.g. when organising group activities, thinking how the most vulnerable can be protected without unnecessarily restricting the freedoms of the most capable.

The manager should provide clear instructions, information and adequate training for employees.

Everyone who works in the care home needs to know how to work safely and without risks to health.

Attention should be paid to: the induction and training of new employees (permanent and temporary), young workers, and nightshift employees.


Make sure the work is being done safely and risks are being controlled in the service. This is a vital, sometimes overlooked step. It will give the manager confidence that they are doing enough to keep on top of health and safety.


The manager and staff should learn from problems and successes, and make improvements. Plans should be revisited to confirm whether the health and safety arrangements are still appropriate and are achieving what they were designed to achieve. This should enable the manger to see: what has changed; and any new actions that are needed.

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy


CQC raises concerns about safety in nursing homes

The latest report of the Care Quality Commission published on 6th July is damaging to the social care industry. The report highlights that one in three nursing homes that has failed its official inspection in results described by the care watchdog as worrying and by the government’s care minister as “completely unacceptable”.

The Care Quality Commission said that of 4,000 nursing homes, which care for the most vulnerable people at the end of their lives, 32% have been rated inadequate or requires improvement and 37% have been told they must improve safety.

Inspectors making unannounced visits to care homes found medicines being administered unsafely, alarm calls going unanswered and residents not getting help to eat or use the toilet. Some residents were found to have been woken up by night-shift care workers, washed and then put back to bed, apparently to make life easier for staff.

Andrea Sutcliffe, chief inspector of adult social care at the Care Quality Commission, which carried out the inspections, said such practice showed a fundamental lack of dignity and respect. She admitted disappointment that only one in 50 of all care services had managed to achieve the top rating of “outstanding”.

The picture for nursing homes was the most worrying, Sutcliffe said. “Many of these homes are struggling to recruit and retain well-qualified nursing staff and that means that this is having an impact on delivering good services to people who have got very complex needs,” she said.

Of all adult 24,000 social care services in England, 21% have been judged “inadequate” or “requires improvement” in the first full checks of their kind by the Care Quality Commission – which have taken almost three years to complete. One quarter of those checked have been found wanting on grounds of safety.

Concern has grown because some services have been downgraded after re-inspection. Of more than 1,800 inspected more than once since 2014, 26% were subsequently relegated to “requires improvement” or even “inadequate” after initially gaining a rating of “good”.

Andrea Sutcliffe said that while re-inspections were often prompted by concerns raised by staff, other care professionals or users of the services, the number of facilities downgraded nevertheless underscored the fragility of the sector.

Caroline Abrahams, Age UK’s charity director, said it was troubling that a fifth of all services had been judged to need improvement and “pretty scary” that so many nursing homes had fallen below an acceptable threshold.

With a quarter of services deemed insufficiently safe, older people and their families were “now effectively playing Russian roulette when they need care,” she said.

Referring to the government’s manifesto pledge of a green paper on the future of social care, Abrahams said: “Taken as a whole, this report is a graphic demonstration of why older people desperately need the government to follow through on its commitment to consult on proposals for strengthening social care later this year.”

All registered social care services in England have now been inspected on grounds of safety, effectiveness, whether they are caring, whether responsive and quality of leadership.

While nursing homes come out worst, services grouped as “community social care” emerge best. These include sheltered housing with “extra-care” support and so-called “shared lives” schemes whereby people accept others needing care and support into their own homes.

Interestingly, by size, small care homes and homecare services emerge far better than large ones – three times as many large care homes, with 50 or more beds, being judged inadequate or requiring improvement than small ones with up to 10.

Andrea Sutcliffe said that although some big homes had proved they could provide outstanding care, smaller homes were often better at the personal touch and at retaining experienced staff.

Barbara Keeley, Labour’s shadow minister for social care, said: “This report confirms that the social care funding crisis caused by this government is now seriously affecting the quality of care across the country.

“It is deeply worrying that a quarter of social care services have safety concerns. Behind these statistics are thousands of vulnerable adults failing to get the medicines they have been prescribed, being ignored when they ask for help or having home visits missed.”

This CQC report paints a picture of a social care industry in crises. The safety of service users in nursing homes is of particular concern. There is undoubtedly problems with recruiting and retaining nursing staff, and the question needs to be asked can the safety of services users and the quality of care be raised in an industry confronted by a funding crises.

Never the less the safety of service users is paramount and even in this report that whilst 37% of nursing homes have problems with service user’s safety, why is it that 63% of the homes provide safe services?

We come back to the point; quality and safe care services are not solely dependent on money, but staff who are made aware of their duty of care and services monitored and audited to ensure that they are operating within the requirements of the fundamental standards.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Care Quality Commission new KLOES and inspections

The CQC is introducing new KLOEs, inspections and monitoring from November 2017. There are about 50 new Key Lines of Enquiry and about 50 other changes to them, plus many have been moved. Care home and domiciliary care services will need to modify many of their compliance activities to meet these new standards.

The changes to KLOEs and prompts are the result of feedback following consultation about the original KLOES which came into force in 2015. The news about the changes must give managers a feeling of de ja vu and here we go again. It brings to mind a situation I came across recently. As readers of my blogs you will know Bettal is a leading provider of quality management systems (policies and procedures) to the care sector, and our systems include more than 300 documents. One of our customers recently became alarmed when an inspector suggested that she should think about writing her own policies and procedures. As a former principal inspector, sometimes I wonder which planet some of the inspectors come from. I am all for managers customising our documents to address their culture and values, but if Bettal is doing its job correctly we will be providing managers with documentation based upon best practice and compliance to the Fundamental Standards.

There are two issues here. Firstly, does the manager have the time to write their own policies and procedures. Secondly, is it necessary if the documentation is shown to deliver quality services for service users and compliance to the Fundamental Standards.

Returning to the introduction of the new KLOES and inspections. CQC’s inspection teams will use the new updated framework to assess adult social care services, using the new key lines of enquiry (KLOEs) and prompts where they are appropriate. This replaces the previous separate versions for different types of service, published in 2015.

The consultation process found that many of the KLOEs and prompts were duplicated. CQC have designed the new KLOES to simplify the process for organisations that provide more than one type of service. They have merged the two previous versions for residential and community care, added new content to strengthen specific areas and reflect current practice, and made some changes to the wording to improve and simplify the language to aid understanding. They have also aligned, as much as possible, the wording of the KLOEs and prompts between the two assessment frameworks for healthcare services and adult social care services. To help providers to update their own internal assessment and training materials, they have mapped the changes against the current frameworks and highlighted them in a separate document.

CQC Principles

The consultation was based on a set of CQC principles which are designed to guide their approach to regulating in a changing landscape of care provision in the future, namely:

1.0 We will always take action to protect and promote the health and well-being of people using services where we find poor care.
2.0 We will hold to account those responsible for the quality and safety of care.
3.0 We will be proportionate, and will take into account how each organisation is structured and its track record to determine when and how to inspect.
4.0 We will align our inspection process where possible, to minimise complexity for providers that deliver more than one type of service.
5.0 We will be transparent about our approach and about how we make regulatory decisions.
6.0 We will not penalise providers that have taken over poor services because they want to improve them.
7.0 We will deliver a comparable assessment for each type of service, regardless of whether it is inspected on its own or as part of a complex provider.
8.0 We will rate and report in a way that is meaningful to the public, people using services and providers.
9.0 We will bring together inspectors who have specialist knowledge of different sectors to inspect jointly, where this is most appropriate for the provider.

Revision of characteristics that inform adult social care ratings

CQC have revised the characteristics that inform adult social care ratings to clarify how they relate to each of the KLOEs and associated prompts and to reflect what they have learned over the last two years of inspections under the new approach. They claim that this does not represent a shift in terms of the ‘bar’ that providers must reach for each rating. But it does mean that they can adopt a more a more targeted, responsive and collaborative approach and be clearer on what good and outstanding practice looks like.


The latest revision of the KLOES by CQC following consultation in the social care sector may well prove to be a positive move in the right direction. Especially, if it brings with it a reduction in the duplication of some of the prompts in the KLOES, and gives providers a clearer understanding about what inspectors are looking for in good and outstanding practice.

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy