Putting the latest CQC report into context: the state of adult social care … and regulation. Things are not good.

There are three current reports in England that portray the reality of care home and domiciliary care provision. They do not make good reading.

Between January 2016 and April 2017, the Healthwatch network visited 197 care homes. These homes collectively provided care for almost 3,500 residents ranging from older people with dementia to those with severe learning disabilities. Some homes weren’t clean, with 11 reports recommending a deep clean. The décor of some homes was in a poor state, or the accommodation did not suit the needs of vulnerable people e.g.  wallpaper peeling off the wall in one home, with dead plants and rotten window sills.

Nine reports found that access to GPs was poor. Eight said it was difficult to get access to a dentist, and only one home told Healthwatch visitors that a dentist came to the home regularly

Forty-three local Healthwatch reports raised concerns about staffing, including staff numbers, turnover, and appropriateness of staff training, as well as worries that use of agency workers was affecting continuity of care.  The training undertaken by staff at one home was e-learning which, it seemed, did not need to be completed on the premises.

Meanwhile, the Competition and Markets Authority is currently conducting a market study on care homes, to see how the market works and whether people are treated fairly. Its initial findings suggest that people are struggling to get the information they need to make decisions about their care, often in stressful and time-pressured circumstances; that it is not realistic for many residents to move home if they are dissatisfied with care, so it’s essential that complaints systems function well. At the moment, they do not; They also found that some care homes may not be treating residents fairly with regards to consumer law; They observe that funding pressures and uncertainty mean that the sector does not have the right incentives to invest in meeting future demand, which is likely to increase substantially.

And now we have CQC’s State of Care report for 2016/2017. And what does it tell us?

    • 1% of services are currently rated as inadequate, and 19% of services are rated as requires improvement. (4,255 services). Last year it was 2% of services rated as inadequate, and 19% of services rated as requires improvement.
    • 42% of adult social care services originally rated as requires improvement and re-inspected did not improve their rating (1,880 adult social care services). Services rated as inadequate include care homes with the capacity to care for almost 9,500 people. Last year it was 38% retaining their rating of ‘requires improvement’ following re-inspection.
    • 23% rated good have been given a lower rating on re-inspection (719 adult social care services), compared with 26% last year.

The reality is that we are at standstill. Essentially, there is a core percentage of care services that are providing substandard abusive/neglectful care. We might as well be reading last year’s report. Thousands of older people are trapped in these situations – 9,500 in inadequate care homes – and thousands will be in this situation next year too. And the year after? And after that?

So, the question has to be asked as to whether or not Inspection and Regulation is achieving what we want? And the answer has to be that it isn’t. CQC tend to write their reports as though this process only commenced when it was formed in 2009, but this is not true. Regulation in this format was established by the National Care Standards Commission, which assumed its full range of responsibilities from 1 April 2002, fifteen years ago. And yet, we still have a fifth of care services failing.

Now, to be clear, we are not going to start attacking CQC or the people who work in CQC on this issue. There is enough noise being made by some small organisations, who have personalised the situation in quite an unpleasant way, without us joining in. And the truth is that the problem does not rest with CQC or its staff. The problem rests with Government failings, the weak legislation that underpins CQC, and the culture that has been created that inherently justifies poor care and neglect.

To put this in context, under the current English arrangements, a care provider cannot be prosecuted for failing to treat older people with dignity and respect or for having insufficient staffing. Nor can they be prosecuted for failing to provide safe care treatment unless this results in ‘avoidable harm’ or ‘significant risk’ of harm.  This is equally true in relation to failing to safeguard people from abuse or improper treatment, or failing to meet nutritional and hydration needs. CQC can take regulatory action in such cases, but this has questionable impact if 42% of adult social care services originally rated as ‘requires improvement’ and re-inspected did not improve their rating.

There are a number of key points to be drawn from all this, and the first is that not all these failings can be attributed to funding. This comes across most explicitly in the Healthwatch report, but also to some extent in the CMA one too. It is about attitude, approach and culture as much as anything and this needs to be fully understood if it is to stand out from the growing clamour for increased funding of the sector. Yes, there needs to be increased investment in social care and that is not in dispute. But equally, there are huge areas of concern that are nothing to do with money. These are about attitude, approach and what care providers can get away with it.

old man kissing old womanThe fact is that standards of care and health provision need to be re-defined to what is acceptable according to civil and human rights, not what is achievable by current market forces. The arguments that this is not financially viable or is unrealistic are unacceptable. Money can always be found when the political impetus is strong enough, and our experience has been that this is true for all Governments regardless of their politics. Social and health care provision should be constructed on what is necessary and not what is currently considered achievable – to date we have been in a race to the bottom, and that is helping no one. Care should be based on humanity, not on a minimum that is too often inherently degrading, abusive, neglectful or humiliating. We should challenge attempts at ‘grading’ abuse as poor-quality care, and reject suggestions that one form of substandard care is less harmful than another because it leaves no physical signs or because it does not negatively impact on the basic needs of food, lighting and heating. There are no acceptable or tolerable levels of neglect or abuse.

So, this isn’t about wiping away Inspection and Regulation. It’s about having standards that mean something to the people on the receiving end of them. It’s about robust inspection with adequate powers to take immediate action to protect, and it’s about adequately funding care provision – but not more of the same current state of social care. We need care provision that meets the needs of its users.

Is that too much to ask? The answer is simple. No. It’s not.