In their recent wide-ranging review, ‘The State of Health Care and Adult Social Care in England,’ the CQC presented a number of conclusions that will have prompted nods of recognition from care management and professionals across a broad range of disciplines. There is surely almost universal agreement about one particular contention: that, in terms of funding and resources, the healthcare system is at full-stretch. It’s also fair to say that social care has experienced this squeeze as intensely as most sectors.
The review reported that detentions under Mental Health Act are up 9% this year and the number of working-age adults with long-term needs has increased. The pressures of higher demand have been exacerbated by workforce shortage, increased staff turnover (up by 4.7% between 2012/13 and 2016/17) and inadequate clinical information systems. As the review states, the £2bn from the Better Care Fund is welcome, but there is no doubt that social care providers are having to operate within increasingly tight budgets – the challenge for many is how to continue to improve in the face of these restrictions. For others, sadly, the challenge is simply a matter of survival.
The performance statistics are certainly a mixed bag. It is heartening to hear that many of the lowest-performing providers are making headway: 82% of those previously rated Inadequate have stepped up to Requires Improvement or better (the equivalent figure is 67% of inadequate in Mental Health). However, 23% of Good providers (and 24% of Good in Mental Health) have deteriorated to a lower rating. It suggest that increasing financial pressures are more acutely felt in maintaining high standards than addressing the basics required to rectify substandard service.
Certain statistics jump from the page: 89% of community Mental Health services are rated good or outstanding for learning disabilities or autism (compared to 66% for psychiatric intensive care units) and this is cause for real celebration. Caring and Responsiveness ratings are especially strong for learning disability providers and Responsiveness ratings are generally better with small providers.
On the flipside, it is regrettable that the report has found that progress on meeting the objectives of Transforming Care is patchy across England. Many care plans continue to lack evidence of active discharge planning and Heathcotes would certainly agree with the CQC’s assertion that fundamental to such planning is having building blocks in place to implement positive behaviour support.
Person-centred care is equally fundamental to the objectives of Transforming Care and, as long-term advocates of this approach, Heathcotes were pleased to note that its importance was a key theme throughout the CQC review. The report highlights that person-centred care shone through the evidence of successful providers. They engage service users as true partners in their care, consider their individual needs, reflect their voice and foster a culture which places them at the centre. We would wholeheartedly endorse the CQC’s assertion that service users should be viewed as people rather than recipients of care. Getting to know them as people – their likes, their interests, their passions – lays the foundation for their successful transition to a more independent setting. Tailoring activities to those likes and interests is one of the most effective ways to nurture positive behaviour.
In facilitating this dynamic it helps to find a good match between carer and service user and to maximise one-to-one support by that same carer over time. The benefits are two-fold: the carer gets to know the service user better and the continuity makes the service user more comfortable, so staff retention is an important objective for care providers seeking successful outcomes in the face of increasing pressures on resources.
The CQC’s report identifies the importance of living, learning and social experiences as well as the value of actively supporting engagement with the wider community. It’s another conclusion that we would strongly advocate. In tailoring activates to the interests of our service users, Heathcotes have always sought ways to increase their opportunity for citizenship and social inclusion. With many individuals the greatest developmental benefits can be gained from having such experiences beyond the residential care setting. This could be anything from a canal trip to a visit to the set of a famous TV show or a live football match. Sometimes activities involve a degree of managed risk but the potential reward is enormous in the recovery process.
The CQC report also highlights the need for a person-centred approach in the wider context of the care services framework. It points out the problem of a fragmentation of services which too often work in isolation, communicate poorly and focus on the priories or targets of their own service, rather than the service users themselves. The support framework requires a more joined-up approach which pools information more efficiently and centres on the multiple and complex needs of service users. At Heathcotes, we believe in collaborating as closely as possible with clinical professionals and one of our consultants has joined the company on full-time basis to become fully integrated within our support services.
Whilst there is much to agree about in the CQC review, we would express reservations about the implementation of ‘Registering the Right Support’ which advises that the number of number of beds provided by any given service should be limited to six. Should this guidance become legislation, it has the potential to make the care business untenable for some providers, negatively impacting on the market at a time when the sector is already fully stretched with the impact of the National Living Wage, auto-enrolment pensions, Brexit, staff turnover and local authorities’ continued imperative to bring down prices. There is no data to prove that services comprising between seven and nine beds cannot be person-centred and an extra two beds can make a service financially viable. The reality is more nuanced than a six-bed limit, a figure which has an arbitrary feel. It could force smaller, more creative providers out of the market and impact on the overall number of beds available.
Having sounded that note of caution, it is important to emphasise that the conclusions and recommendations of the CQC review are overwhelmingly sensible, insightful and useful in guiding sector-wide improvement. The challenges are considerable but, as the review highlights, the better providers are seeking to learn and improve in the spirt of collegiate learning and working together.