Room for improvement in care homes NHS relationship

The relationship between care homes and the NHS is at the best of times a fraught one. Although care homes provide the majority of long-term healthcare to older people, they rely on primary care for access to medical support and referral to specialist services. Yet studies consistently show that healthcare provision for care home service users across England is unpredictable and uneven.

For the NHS, care homes are a conundrum; they provide care that used to be supplied by the health service, but are often perceived as a poor alternative that generates avoidable demand on hospitals.
So, what needs to be put in place to ensure more effective collaboration? In a recent study, researchers from seven UK universities tracked the care received by 232 care home service users over 12 months. A review of the evidence of what works, when and in what circumstances was carried out, and suggests that there are several key elements that contribute to effective cross-organisational working.


Somehow the NHS and the social care sector need to stop bickering over funding. The study found that when extra NHS provision was offered, either on a service users-by-service users basis or focused on a single issue – such as prevention of hospital admission – there could be unintended consequences. It could lead to a sense of “them and us” and mutual recrimination if the desired improvements in healthcare were not achieved.

In contrast, if the focus was on the care home as the provider of care to frail older people, there were more opportunities for NHS staff to discuss and plan with care home staff how additional investment or training from the NHS could improve service users’ healthcare. This approach clearly supported and sustained working relationships between the NHS and care homes.

Involvement of the right mix of people in design of healthcare provision

Ensuring that the right mix of people are involved in the design of healthcare provision from the outset, for instance, helps to develop a shared view about what needs to be done. Single care home teams, for example, or nurse and therapist specialists, can make an enormous difference to how service users experience healthcare. Yet by working apart from other services they risk being isolated, unable to access the relevant expertise to address the multiple needs of service users.

Access to specialist dementia care

As the majority of care home service users live and die with dementia, understanding the associated symptoms and behaviors of this condition in particular is crucial to working with care homes. The study found that access to specialist dementia care benefits service users, and improves the confidence and skills of NHS and care home staff.

Workload of Healthcare professionals

Healthcare professionals should not be expected to fit care home work within existing caseloads. They need protected time that allows them to develop experience and expertise working with social care. Ongoing investment in resources and services dedicated to care homes, as well as forging links with different services locally, would provide a way of working that can accommodate the different priorities of health and social care staff.

The achievement of greater integration in social care and healthcare

There is no one-size-fits-all answer for the NHS when it comes to working with care homes. The diversity of care homes in terms of size, approach, staff experience, proximity to other services and funding means it will always be context specific. But this is not an excuse for ad hoc and unequal healthcare provision.

To date, most of the research for answers has been driven by a healthcare agenda. This is not the starting point for service users and their families, who are interested in quality of life and quality of care. The study demonstrated the benefits of finding common ground but more work is needed to ensure care homes have an equal say on what matters for the health of their service users.
When NHS commissioners and healthcare professionals see care homes as an integral part of the health and social care system, and take the time to learn how to work together, there is a marked improvement in appropriate access to, and use of, healthcare. It is time, in short, for the NHS to see care homes as partners, not problems.


This study by points to inequality in the relationship between care homes and the NHS that needs to be addressed. The involvement of the right mix of people, the availability of dementia expertise, and the consideration of healthcare worker’s workload can bring about improvement. However, more focus should be placed on care homes to ensure staff have an equal say on what matters for the healthcare of their service users.

Acknowledgement: Claire Goodman professor of healthcare research at the Centre for Research in Primary and Community Care at the University of Hertfordshire,

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

CQC has increased enforcement action through new powers

In the past year, there is evidence that the CQC have used new powers that have resulted in an increase in enforcement action by 75% according to its 2016/17 annual report.

Enforcement actions rose 75% in the year to 1,910 compared with 1,090 in the previous year after the CQC received new powers to prosecute in April 2015.

The CQC carried out its first four prosecutions under its new powers. There were 1,271 enforcement actions in progress as of 31 March 2017, the majority of actions were warning notices (1,352).
Given the number of warning notices and the small number of prosecutions that actually took place, there appears to be a reluctance on the part of CQC to prosecute unless it involves the most serious of offences.

View of the Chief Inspector

The CQC Chief Inspector of Adult Social Care, Andrea Sutcliffe, has said: “This is not about creating a climate of fear – I would much prefer providers to deliver great care and improve when they don’t.
“But good providers and the public need to feel confident that when poor care is exposed, those responsible are held accountable so we can restore confidence in this vital sector and demonstrate quality does matter.”

A total of 740 providers were placed in Special Measures with 657 coming out, 470 of those did so because they had made substantial improvement.


The number of complaints received by CQC about the quality of care is quite alarming. There is evidence in this report that the major concern that leads people to complain in caring for service users is the safeguarding of their health and wellbeing.

The regulator received 76,634 contacts from people with concerns compared with 80,567 in 2015/16. Of these, 42% (31,826) related to safeguarding concerns, 0.2% (158) were safeguarding alerts, 49% (37,217) were complaints about providers and 10% (7,433) were whistleblowing.

Given that 10% of complaints came through the whistleblowing process suggests the there is evidence that those who have a concern are aware of how and to whom they should make a complaint.

There were 2,353 Mental Health Act complaints with 7,413 total contacts (including new complaints, enquiries and follow-ups to complaints).

Complaints about the CQC service

The regulator received a further 413 complaints about its service, down from 441 in the previous year. These included the tone and attitude of inspection staff during visits, the general competency of the inspection team around evidence collection, and potential bias and pre-conceived ideas of the service and looking for negatives, as well as administration and the handling of information about registered services.

The report suggests that there is hardly any improvement with a drop of only 28 complaints against the regulator during the year.

The CQC commented: “We encourage staff to learn from complaints and in some cases, we offer additional training and guidance.”

Oversight of the market

In its market oversight capacity, the CQC continued to monitor the financial sustainability of large, hard to replace adult social care providers. As of 31 March 2017, there were 51 providers in the scheme.

The CQC said care home providers were more resilient than domiciliary care providers but still experienced an overall decline in profit margins. It highlighted increased staff costs and the National Living Wage as the main pressures on providers.

The CQC’s revenue expenditure amounted to £226.2m in the year, representing a £12.4m decline on the previous year. Income rose by £40.6m to £149.6m following a fees consultation that will see most providers paying the full costs of regulation.


The CQC annual report hardly makes good reading for providers of social care services given the large number of complaints to the Care Quality Commission. However, the report provides no evidence of substantiation or satisfactory resolution to the complaints. The use of the CQC new powers as a means of effective enforcement action has resulted in an increase in enforcement actions, but limited use of prosecutions. Is it a case that CQC have to let providers know that where they are seriously concerned about a service they will use their powers to prosecute?

Safeguarding remains the central issue of complaints against providers of social care services, and there is evidence in this report that people are prepared to whistle- blow if they are concerned about the health and wellbeing of service users.

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

Health and Social Care Apprenticeships

There is a growing concern amongst the Health and Social Care Sector that there is an acute shortage of skills and skilled staff at all levels.

A new apprenticeship scheme has been developed within the Shropshire area and could be rolled out country wide if successful. Shropshire, with almost 24,000 people employed across the county, is an area which is experiencing major skills shortages at all levels. This serves as a model across different areas of the country where acute levels of skill shortages are prevalent.

The apprenticeship scheme allows people to enter the health and social care sector progressing through to high level careers such as nursing.

This plan will involve apprentices working towards qualifications such as senior healthcare, with the potential to progress on to healthcare – assistant practitioner level 5 and possibly nursing degree apprenticeships.

There are a variety of career paths available through the apprenticeships offered which include clinical health care, social care, available in residential and domiciliary care settings, dental nursing as well as more specific occupations.

It is not only health care but social care that will benefit from this initiative.

Social care needs people to be trained to work in settings such as adults with learning disabilities, care of the elderly and domiciliary care working to help people to be able to stay in their own homes. These are such important job roles helping people who are disabled or infirm to maintain a good quality of life.

The initiative is not aimed at replacing professionals but rather providing another pathway to achieving a role that requires much needed skills within the sector.

The apprenticeship allows for a seamless vocational route offering a structured career pathway for the apprentice. The vocational route is key where a sector needs skills now and in the future.

The key factor to the apprenticeship is that it allows mentors to pass on life-long knowledge, and for the student to learn from the best possible knowledge source.


The care sector is said to be in crisis. With uncertainty surrounding the continuity of our care services as we know them, this new apprentice initiative could well be a contributing factor in helping to ease the strain on care and health care were posts go unfilled because of a skills shortage.

If successful, this may be of significance in filling the shortfall of staff with skills specific to healthcare and social care.

Employers and organizations will be observant of the success of this new initiative. If successful, more areas of England may engage in this apprenticeship model and find success in filling the skills shortage gap through well trained and knowledgeable apprentices.

Stuart Cook
Bettal Quality Consultancy

Further reading:

Should Service Users home care plans be reviewed more frequently?

Reviewing Service User’s person centered care plans can be a time consuming but essential process. Under the Care Act, councils should review care plans no later than every 12 months.

However, a recent report by Healthwatch watchdog (2017), has said reviews of people’s care and support plans should be completed more frequently than once a year and should instead be a “continuous process. This applies particularly in cases where a person’s ability to do things for themselves might be changing rapidly.

Missed medication

The report looked at the experiences of people using home care services. It included information from 52 local Healthwatch organisations, and the experiences of 3,415 service users, their families and frontline staff, collected through events, surveys and site visits.

The report found that care workers were frequently unfamiliar with their clients’ care plans and when it was a staff member’s first visit, there was often not enough time to read the plan. In some cases, this was leading to “serious problems”, such as medication being missed.

A survey of 363 people in Newcastle, found one in seven had experienced medication being missed because of the home care provider. One in six respondents also said they felt the provision of medication was either “partly” or “never” safe.

The report recommended that automatic notification systems could be introduced to update staff about important changes to care plans, or prompts could be left around people’s homes as a reminder of their preferences.

Lack of time

The report also said local authorities needed to be more realistic in care plans about how much is achievable in the limited time available in most home care visits.
Comment: This is hardly surprising if a Service User is allocated less than half an hour support time.

It found that only half (56%) of 73 people responding to Healthwatch Blackburn with Darwen’s survey felt there was sufficient time to complete all tasks set out in the care plan.
A service user told Healthwatch Redcar and Cleveland: “Sometimes they give me a shower but they go over their time but most of the time they haven’t got time to give me one so I go a couple of weeks without one and that’s not right, I feel dirty.”
Comment: if care workers spend more than the allocated time with one person, they are likely to be late for their next appointment with another.

Home care workers in Torbay also reported “unrealistic staff rotas” that left them exhausted and having to carry out double-handed care tasks on their own.
Some Service Users also reported that staff lacked basic skills such as being able to boil an egg or make a bed, which resulted in poor care.

Neil Tester, deputy director of Healthwatch England, said: “We heard examples of compassionate care from dedicated staff, but people also talked about care that doesn’t meet even basic standards. Given the challenges facing the social care sector, it’s more important than ever than ever that people’s voices are heard.”

Margaret Willcox, president of the Association of Directors of Adult Social Services, said: “Most adult social care services in England are providing people with safe, high quality and compassionate care. That they are doing this in the context of rising demand and inadequate funding is a tribute in itself, but there is always room for improvement.”

Suggestions for improvement

Managers responsible for the services covered by this report may ask themselves, ‘are their service users satisfaction surveys working as intended’? Can they provide evidence that they are acting on feedback from Service Users? In the Bettal Quality Management System we have a spot check form which when completed by the service user along with a senior member of staff from the home care agency provides an ongoing opportunity for a home care service to learn about what service users feel about the service. Actions identified and taken can help to prevent the poor practice identified in this report.


Management and staff fully understand the importance of person centred care plan reviews, especially when there are changes in the persons needs and circumstances. But the central issue is the time allocated by commissioners to carrying out the task. Good care planning should identify changes to the persons needs that should be communicated to all care staff who provide a service to the person. While lack of time can be a cause for not delivering care and in particular medication, it should not be used as an excuse for poor practice.

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