State of Care: an overview

CQC published their annual assessment of health care and adult social care in England the State of Care 2019/20 earlier this month.

It is divided into four chapters:

1. Quality of care before the pandemic
2. The impact of the coronavirus pandemic
3. Collaboration between providers
4. Looking forward, the challenges and opportunities ahead

The foreword clearly states that the professionalism and dedication of the people who work and volunteer in health and care has always been the system’s key strength and from March onwards this was never more obvious. They highlight that this is a cause for celebration as well as for reflection on how to ensure that all staff are recognised for their work, regardless of the sector in which they deliver care.

Another positive is them remarking that examples of front line changes from small home care agencies to large acute hospitals are a celebration of the dedication and resourcefulness of health and care providers and staff and that this illustrates their tremendous resilience, imagination and determination to think differently to meet the needs of people who used their services and keep people safe in a time of crisis.

The report was generated by inspection ratings of more than 31,000 services and providers.

Ratings in the report are as at 31 March 2020 (and all comparisons with the previous year are with ratings as at 31 July 2019).

They noted that there is wide variation in collaboration working in all regions. The differing levels of maturity of system working are noted to be due to a number of factors which could mean that the same initiatives (such as Primary Care Networks) might work well in one area but not in another.

There are case studies highlighted throughout the report including one that particularly caught our eye – Pimp my Zimmer!  There is also the example of a home supporting people to do hand washing exercises by adding glitter to water to represent germs. They found that with soap glitter comes off meaning all the germs had gone (and without soap the glitter sticks to your hands!).

The longest time for an NHS Trust to be in special measures has been 57 months.

There are some 23 pages devoted to collaboration between providers from pages 57 – 80 where some 17 key points are highlighted.

Here are the key points relating to the various parts of the sector

State of Care: mental health

• The overall proportion of services rated as inadequate rose from 4 per cent to 13 per cent. Almost all of this happened in independent services, where the proportion of services rated as inadequate rose from 5 per cent to 22 per cent. By contrast NHS services rated as inadequate remained at 3 per cent of the total.
• 71 per cent of mental health core services were rated as good and 11 per cent were rated as outstanding.
• There was slight improvement in the quality of acute wards for people of working age but 6 per cent were still rated as inadequate and 36 per cent as requires improvement.
• Inspectors highlighted difficulties in accessing CAMHS and poor access to secure mental health beds meaning adult prisoners remained in inappropriate custodial settings for prolonged periods awaiting transfer.
• However they also saw positives such as GP practices commissioning in-house mental health services and upskilling police officers to signpost people to appropriate local services.
• There was an increase in calls to CQC’s helpline about or from people detained under the MHA, often expressing distress or confusion about why people were more likely to be confined to their rooms rather than being able to move around freely. Of eight mental health services CQC inspected by mid-June (since pausing routine inspections) five were as a direct result of concerns raised by staff or members of the public.
• During the early stages of the pandemic there was a sharp fall in mental health activity (7,646 admissions against 9,933 in 2019).
• CQC are concerned about the risk of closed cultures developing in out of area placements.  As part of their work on closed cultures over the next year they will be working with people who use services ,families, providers, frontline staff and other stakeholders to improve the way they regulate services where there is a closed culture or a high risk of one developing.

State of Care: deprivation of liberty safeguards (DoLS)

• Despite legislation being in place for years there is still huge variation in understanding and practice and in the quality of training.
• Staff in hospital based mental health services for older adults did not always know when DoLS can be applied – assuming it should only be used if e.g. a person was actively trying to leave.
• Many providers did not understand what a good quality mental capacity assessment and best interests decision looked like.
• The type of service sometimes reflected the amount of positive risk taking that staff were prepared to make.
• Good quality training was often characterised by a focus on real life and practice based examples, rather than generic learning modules.
• From March to May CQC saw a sharp fall in the number of notifications compared with the same period in 2019. Notifications from adult social care services dropped by almost a third and in hospitals by almost two-thirds. There was however regional variation.
• They highlighted the Department of Health and Social Care April guidance.
• Given that a DoLS authorisation can last up to a year it may not be until March 2023 that DoLS is fully behind us. This underlines the importance of continuing to improve the way providers, local authorities and others work together to support the proper use of DoLS and to give careful consideration of how DoLS and Liberty Protection Safeguards (LPS) will work alongside each other in the first year of implementing LPS. They specifically state that the time ahead also provides an opportunity to consider what can now be done with the current DoLS system to ease the transition.

State of Care: social care

• The pandemic highlighted the unstructured relationship between government and a sector comprised of a collection of over 25,000 business, some which receive public funding and some of which do not. Covid-19 reinforced the need for more clearly defined expectations on both sides, with more extensive oversight and understanding of financial performance of businesses in order to target support.
• There needs to be a new deal for the adult social care workforce that reaches across health and care – one that better develops career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalism.
• 3 per cent of care homes have never been rated better than requires improvement (512 homes covering nursing and residential homes accounting for approximately 23,000 beds).
• 80 per cent of adult social care services were rated as good and 5 per cent were rated as outstanding.
• They have seen examples of systems to share data and medical records across providers and between sectors which has increased understanding of performance and demand.  However they are of the view that a lack of access to NHS digital systems can prevent adult social care providers from working with other partners.
• Adult social care organisations are not always involved as system partners and smaller organisations or those with workforce issues can struggle to engage with system working.
• Inspectors highlighted difficulties for people who need residential care with nursing.
• However they also saw positives, such as multidisciplinary collaboration including contracts between care homes and GPs to make GP access easier in residential care and nursing home settings.
• The number of deaths of care home residents occurring in England and Wales from 28 December 2019 to 12 June 2020 (registered up to 20 June 2020) was 93,475 (29,393 more than in the same period last year – a 46 per cent increase). Of those deaths 19,394 mentioned “novel coronavirus (COVID-19) which was 21% of all deaths of care home residents".
• 2612 calls from adult social care staff raising concerns were received in the period 2 March to 31 May 2020 (a 55 per cent rise on the previous year).
• They have not seen any clear relationship between care home ratings and the number of deaths due to Covid-19 in those homes.