New CQC inspection regime Adult Social Care Service

After months of consultation the CQC has at last published guidance to providers on how it monitors, inspects and regulates adult social care services. The new guidance I believe represents a major shift in the regulators approach to inspection. The guidance ‘How CQC monitors, inspects and regulates adult social care services’ November 2017, suggests a movement away from the frequency of inspection to more reliance upon information that is returned by providers.

Insight

CQC will use Insight to monitor potential changes to the quality of care. The CQC Insight system is designed to bring together information about a service in one place, and analyse it. This helps the regulator to decide what, where and when to inspect and provides analysis to support the evidence in inspection reports.

To monitor changes in the quality of care, inspectors will check CQC Insight regularly. If it suggests that the quality of care in a service has improved or declined, inspectors may follow this up between inspections or ask providers to give them further information or explain the reasons for the change. They may also decide to re-inspect the service, if there are significant concerns, or may carry out a focused inspection.

Provider information collection (PIC)

The provider information collection (PIC) allows social care providers to submit up-to-date information about the quality of care their service provides at a location. The PIC builds on and replaces the previous provider information return (PIR). PIC information is reviewed and analysed before being passed to inspectors as part of the regular updates they receive about the services they inspect.

Providers should be in no doubt of the importance that CQC place upon the provider information collection and must update the PIC at least annually. If they do not do so, their rating for the well-led key question will be no better than requires improvement at the next inspection.

Inspection

The biggest change to inspection is the frequency in which it is carried out.

A service will have a comprehensive inspection at the following frequencies:

  • Services rated as good and outstanding – normally within 30 months of the last comprehensive inspection report being published.
  • Services rated as requires improvement – normally within 12 months of the last comprehensive inspection report being published.
  • Services rated as inadequate – normally within 6 months of the last comprehensive inspection report being published.
  • Newly registered services and those no longer dormant – the first comprehensive inspection will normally be scheduled between 6 to 12 months from the date of registration.

Comprehensive Inspections

Comprehensive inspections take an in-depth and holistic view across the whole service. Inspectors will continue to look at all five key questions to consider if the service is safe, effective, caring, responsive and well-led. They will give a rating of outstanding, good, requires improvement or inadequate for each key question, as well as an overall rating for the service.

I guess that many of those services who are rated as outstanding or good will welcome the new frequency of inspections. Given they will only receive a comprehensive inspection every 30 months, providing there are no concerns with their provider information return. As a former principal inspector, I have real professional concerns about this length of time between inspections. Figures show that the duration of time the average service user lives in care home does not normally exceed much more than 2 years. This in effect means that there will be vast changes in the needs of service users over this period of time and a reliance on documentation to evaluate their quality of care. Nor does the approach take into account staff recruitment difficulties, and staffing changes.

Given that only 2% of Care services are rated as outstanding, it seems that fewer inspections are less likely to give the general public more confidence in the care sector. I think the CQC is in danger of forgetting that a service does just have to achieve quality but has to demonstrate how it can maintain it.

Summary

The CQC new guidance for providers of adult social care services shows a major shift from the importance of on- site inspection to a reliance on information gathered from providers. I remain to be convinced that fewer inspections will lead to improvement in the quality of services, given the ever-present changing social dynamic of a care service. CQC will claim that they want to place their focus on services that are underperforming. However, a question that is bound to be asked is: “will the new inspection regime be of benefit to providers and service users, or has it come about through a tightening of the resources that they now have available”?

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

 

New innovation to improve the lives of people with dementia

Manchester University Institute for Dementia are pushing the boundaries out to bring about new innovative thinking to improve the lives of people who suffer with dementia.

Imagine a pub designed for people with dementia, complete with old beer adverts, games of dominoes and darts, a DJ playing a selection of music from the 50’s and regular live entertainment, where people with the diagnosis can feel welcome and those who look after them can receive support.

A pop-up pub like this was set up in Salford recently by the university’s Institute for Dementia as part of Dementia United – the Greater Manchester partnership whose five-year improvement plan aims by 2020 to make Greater Manchester the “best place in the world” for its 30,000 residents with Alzheimer’s and similar conditions. It also wants to reduce dependence on health and care services.

This pub experiment is one of a number of innovations under the umbrella of Dementia United, led by the health and social care trusts enjoying their newly devolved status, and the Alzheimer’s Society. Its 41 partners, including charities, sports organisations and three universities, are working out how to tackle dementia from the perspective of those who live with it.

With 850,000 people living with dementia in the UK (1.3% of the population), according to Alzheimer’s Society figures, the eyes of the UK are focused on Dementia United.

Maxine Power, director of Dementia United, says: “This is a once-in-a-lifetime opportunity. Dementia is an area with a huge amount of activity, but it is like an orchestra without a conductor. Devolution brings clarity and a focus on care for people in the places where they live, rather than on organisations. Culturally that is a massive shift for our system.”

Dementia United goes way beyond pubs. It is about rejecting a model of care that health professionals agree is neither fit for purpose nor financially viable, and the opportunity to create a new one. Greater Manchester spends £270m a year treating and caring for people with dementia. The figure has not decreased in the past five years, despite many attempts to improve dementia care, and there are 20,000 hospital admissions for the 30,000 people in the area with dementia.

This is outrageous, says Power. She is adamant that in five years Dementia United will reduce that figure – mainly associated with unplanned hospital admissions and admissions to care homes – by 20%.

This will be guided by five pledges, to be implemented by 2021: improving the lives of dementia patients and their carers by questioning them about their individual needs; reducing variation in care quality (and a diagnosis rate difference between 63% and 90% across the city); the introduction of a key worker for each person with dementia; the redesign of services around users; and access to the best assistive technology.

Dementia United was set up in late 2015 as an “early win” under the devolution of Greater Manchester’s health and social care.

There is dementia knowledge in Manchester to back it. Its three universities formed a dementia research consortium in May 2016 and Prof Alistair Burns, the national clinical director for dementia, is based at Manchester.

Progress is being made. A measurement tool of “lived experience” has been developed, including numerical and qualitative measures of how people live their lives, which can be shared across Greater Manchester’s health systems. Work is under way on a dementia “dashboard” to allow inter-area comparisons and set standards. External evaluation methods of Dementia United are being developed jointly by the universities of Salford and Manchester.

Discussions are going on with Social Finance – a not-for-profit organisation bringing together government, the social sector and the financial community to tackle social problems – to build in additional financial support.

Assistive technology is advancing apace, with Manchester University’s dementia platform evaluating devices, such as watches with accelerometers to measure movement, to establish value for money. Everything in Dementia United must be supported by a business case.

George McNamara, head of policy for the Alzheimer’s Society, is working with Dementia United to make it a reality across Greater Manchester and is receiving inquiries from politicians worldwide, particularly the US. He says: “We are seeing the devolution of powers and funding on an unprecedented scale. What is significant is the scale and the marrying together of a number of political objectives and cultures into one vision.”

Patrick Hall, a fellow in social care policy for the King’s Fund, admires the ambition of Dementia United, but is concerned about its sustainability given the financial climate.

He says: “The locality focus in Dementia United is very welcome and anything that gives impetus to that for the care of people with dementia would be looked on by the King’s Fund very positively. However, it is being set up in the context of unprecedented cuts in social care and a decline in the number of community nurses. Only time will tell whether Greater Manchester has got the model right.”

Summary

Dementia services need innovation as an alternative to some of the existing practice This innovative approach to improving the lives of people with dementia is to be applauded. Especially, the pub experiment which offers the opportunity for people to continue as far as practical with a ‘normal life’.

It is sound practice to evaluate the experiment and share the learning with other services within the sector. Patrick Hall, a fellow in social care policy for the King’s Fund is right to add a note of caution. The proof of the pudding is the sustainability of any new innovation.

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

CQC Social care services state of care 2014-2017

This recently published report by CQC makes interesting reading for Adult social care providers.

In Angela Sutcliff’s (Chief Inspector CQC) introduction she acknowledges the efforts of over three-quarters (77%) of adult social care services which are rated good – this she says should be celebrated. According to Sutcliff these are services with leaders who inspire a positive culture focused on providing person-centred care – treating people as people and not just as recipients of care. These leaders motivate, develop and value their staff who work tirelessly and skilfully to support people to live their lives to the full, with dignity and respect.

The CQC initial programme of comprehensive inspections and ratings covered 33,000 care services in all across over a period of two and a half years.  However, quality across England is undeniably variable. The initial comprehensive inspection programme found only 2% of services were rated as outstanding. Sutcliff says, “While we make no apology for setting the bar high, this is considerably lower than we originally expected”. “It is clear that it is more difficult to achieve this highest standard of quality.

Readers will be aware that I have long argued in the past that the bar has been set too high and is counterproductive to those providers who need encouragement to improve the quality of services and reach the outstanding grade. I believe that it should be replaced by an excellence model, where the components of an excellent service are clearly identified. These should be free from ambiguity and measurable, and not rely solely on the judgement of an inspector.

Not only would this bring about more clarity it would result in the number of services who achieve the outstanding grading more realistic, without a drop in the definition of what constitutes a high quality social care service.

The report also found evidence of too much poor care: 2% of services are currently rated as inadequate, and 19% of services are rated as requiring improvement and are struggling to improve.

Background

Adult social care is the largest sector that CQC regulates, with a large number and range of providers, a strong private and voluntary sector, and wide differences in the size and types of services and care provided. The sector covers accommodation and personal care provided in residential care homes, nursing homes and specialist colleges (around 16,000 locations, with the capacity to provide care for around 460,000 people).

Personal care provided in the community for more than half a million people, of which the majority is care provided in people’s homes through domiciliary care services (around 8,500 services), as well as extra care housing, Shared Lives schemes and supported living services.

Challenges facing the sector

Adult social care services are facing a number of challenges. These include:

  • An ageing population with increasing needs.
  • The number of people aged 85 or over in England is set to more than double over the next two decades.
  • More than a third of people aged over 85 have difficulties undertaking five or more tasks of daily living without assistance, and are therefore most likely to need health and care services.
  • Difficulties in recruiting and retaining staff to care for people.
  • In 2015/16 the overall staff vacancy rate across the whole of the care sector was 6.8% (up from 4.5% in 2012/13), rising to 11.4% for home care staff. Turnover rates have risen from 22.7% to 27.3% a year over the same three-year period.
  • Potential changes to immigration policy resulting from the vote to leave the European Union could have serious consequences for the social care workforce. Around one in 20 (6%) of England’s growing social care workforce are non-British European Economic Area nationals – around 84,000 people.
  • Rising costs of adult social care. In 2015/16, the gross expenditure of all councils with adult social services responsibilities was £16.97 billion. Although this is 18% higher in absolute terms than in 2005/06, after accounting for inflation it is 1.5% lower than in that year.
  • Findings from the most recent Association of Directors of Adult Social Services budget survey have estimated that the National Living Wage will cost councils around £151 million plus at least £227.5 million in implementation and associated costs in 2017/18. This will affect both direct council costs and increased provider fees.
  • Concerns about funding to meet these costs and a reliance on those who pay for their own care.
  • Age UK estimates that an additional £4.8 billion a year is needed to ensure that every older person who currently has one or more unmet needs has access to social care, rising to £5.75 billion by 2020/21.
  • Some providers, particularly in domiciliary care, have withdrawn from local authority contracts where they felt there was too little funding to enable them to be responsive to people’s needs. Despite additional funding that has been made available for adult social care, only 7% of directors of adult social services are fully confident that savings targets will be met in 2019/20. The public have expressed concerns over the higher charges self-funders tend to pay, compared with state-funded residents.

Summary

This report acknowledges the valuable contribution made by 77% of adult social care providers. It also found that 23% are still failing to reach acceptable CQC standards. Given that only 2% of social care services in the sector achieve an outstanding grading, does little to promote quality of care in the sector in the eyes of the general public. The criteria for the award should be replaced by a model of excellence with components that can be subject to measurement.  The report outlines the serious challenges that are facing the industry in the future.

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

Musical activities improve cognitive abilities and memory recall of people with dementia

Musical activities have been shown to improve the cognitive abilities and memory recall of people with dementia

Staff in care homes are always looking for new strategies on how to engage with people with dementia. A recent report of people living at 17 care homes run by the Anchor Group has shown that musical activities can improve the cognitive abilities and memory recall of people with dementia.

A series of creative workshops held at Anchor care homes in Surrey, have revealed how the innovative adoption of dance, drama and music in care home activities can soothe and stimulate at the same time, bring back memories from the past and help to engage underused but still active areas of the brain.

The care home workshops, part of a six-month trial reveals a number of benefits for people living with dementia. The research funded by the older people’s charity Beth Johnson Foundation (BJF), saw the sessions boost residents’ mental health, self-esteem and self-confidence, after they started getting involved in drama, dance and music.

Based on the trial’s findings, a report ‘Experiences of Being’ was published by Anchor recommending the use of drama, music and dance in care homes to help those living with dementia.

Colin Hann, executive chair of BJF said: “Dementia is an area for more work and creative thinking and this report shows how the arts and drama can make an important positive contribution to those who have dementia. In the longer term let’s also work to find a cure.”

For six months, Anchor trialed the integration of drama, music and dance workshops into its dementia care, which was attended by 200 care home residents. The sessions saw positive changes in residents, many of whom experienced greater movement and physical exercise through the encouragement of dance or subtle actions using their hands or feet.

‘Props act as a stimuli’

In one session, while music played, a mixture of scarves, hats, over-sized glasses, wooden spoons and maracas were given to residents to try on, prompting conversations among residents and some role play.

The report stated: ‘The props acted as stimuli for the residents, with powerful and diverse reactions. The session ended with a ‘goodbye’ song, during which the props were collected and each resident was given a ribbon to wave or use in any way they choose to signify goodbye and thanks.’

‘Animated conversations’

One 96-year-old resident with dementia had never joined in with her care home’s activities but spent all day in her room, even eating her meals there alone. She attended a weekly one-to-one prop box activity, using boxes of beads, pictures and other small items and engaged in gentle hand movements set to music.

After attending, staff noticed the resident was enjoying the sessions and “now has animated conversations about her life when she was young – memories triggered by the items in the prop box.” The staff said the workshop has improved her confidence and self-esteem.

The One-hour workshop sessions were followed by a feedback and training session for staff at the care homes who gave their own input into how they thought the sessions could be modified.

‘Experiences of Being’

The success of the sessions has seen participating care homes introduce the workshops to the activities programme.

Anchor and BJF hope the results of the ‘Experiences of Being’ report will encourage everyone working with older people across the UK to consider the innovative use of arts-based activities in the homes of those living with dementia.

Jane Ashcroft, chief executive of Anchor, a not-for-profit care provider, said: “We’re keen to embrace innovative ways to enhance the lives of our residents and, with such positive results, this project has been a pleasure to be part of. I hope others learn from the report and are encouraged to introduce similar creative activities.”

Actor Linda Marlowe, who played Sylvie Carter a character with dementia in TV soap EastEnders this year, has also welcomed the workshops. To prepare for her acting role, she visited care home residents living with dementia. Ms Marlowe said: “I was there for three days spending time with the residents who had dementia to various degrees. This was invaluable in playing my role in EastEnders. I am now committed to promoting the use of drama and the arts to make a positive difference to help those who are living with dementia”

Summary

The report ‘Experiences of Being’ published by Anchor recommending the use of drama, music and dance in care homes to help those living with dementia, is a must read for staff working with people with dementia. Evidence from the workshops shows that the use of music and drama activities may contribute to improvement in the cognitive abilities and memory recall of people with dementia. In addition, the adoption of these activities by other care homes would add an enjoyable experience to staff and residents.