The CQC’s new framework focuses on safety and leadership. Owners and managers of services rated outstanding give their advice on acing an inspection.
When Maggie Candy became manager of Marlborough Court in south London in January 2012, the care home a troubled history. It had been embargoed several times by the local authority, preventing it from admitting any new residents. The home was bought by the Four Seasons Health Care chain after the closure of its previous owner, Southern Cross Healthcare.
Candy set about turning the home around, appointing a new deputy, involving staff and residents in decision-making and enabling residents to take part in community life. In August 2015, Marlborough Court received the top rating, outstanding, in a Care Quality Commission (CQC) inspection. “Staff treated people with dignity, respect and kindness. They were knowledgeable about people’s needs, likes, interests and preferences,” the report says.
The new CQC inspection regime, developed in response to a report into the failings at Winterbourne View, has been in place since October 2014. It provides four ratings, from outstanding to inadequate, and has “zero tolerance” for services where care is poor. In the words of the CQC’s consultation document, it will “always be on the side of people who use services”.
It’s a framework that Samih Kalakeche, chair of the standards and performance network at the Association of Directors of Adult Social Services, describes as “crucial in ensuring the quality of care we provide is fit for purpose”.
Services usually receive no notice of an inspection. On average, inspections last two days, but can be shorter or longer depending on the size of the service. There may be just one inspector or a team. Each service is evaluated on five key lines of inquiry that look at whether it is safe, effective, caring, responsive to people’s needs and well-led. Inspectors talk to managers, frontline staff, external stakeholders (GPs and nurses, for example), service users and their relatives to form a rounded picture.
Debbie Westhead, a CQC deputy chief inspector of adult social care, advises being “inspection-ready” at all times: “If was a manager in a care home, I’d be thinking, what do I do really well that I want to showcase and tell the inspectors when they call?”
Candy keeps a folder of relevant information to show inspectors: compliments, pictures, details of projects and managers’ newsletters. Home Instead Senior Care West Lancashire and Chorley, a home care service that received an outstanding rating, takes a similar approach, maintaining a CQC box containing policies, procedures and good news stories such as positive feedback from families.
Therese Timberlake, director of operations at Robert Owen Communities, which received an outstanding rating for its Domiciliary Care East Devon service, also emphasises the importance of evidence. She suggests keeping a record of how the service works with stakeholders – what surveys are carried out, for example, and how people are able to influence decisions.
Although frontline staff may be worried about an inspection, Timberlake told employees “not to fear the CQC but to see it as an opportunity to present what they believe they were achieving on a day-to-day basis”.
After a year using the new framework, the CQC’s biggest concerns “are about safety and leadership”, says Westhead, something highlighted in the organisation’s recent State of Care report, which mentions concerns such as poor safeguarding training and lack of evidence of risk management. It is crucial, she adds, “that an organisation is well-led and has a registered manager in place to lead the service and give clear direction”.
A service that is rated outstanding will, says Westhead, show “high expectations of what each person could achieve”. At Marlborough Court, CQC staff could see evidence of Candy’s philosophy that staff should treat residents as they would treat their own parents. She has found ways of making life more pleasant for residents: winning a grant to create a scented garden, for example, and bringing in children from local schools to ask residents about their memories of the second world war. Candy also runs armchair yoga sessions – an activity that is fun as well as healthy. “To be in a care home and bored would be the most heinous crime,” she says.
Merevale House, a small residential home for people with dementia, has also received an outstanding rating. Owner and manager Anne Fretwell’s belief that residents should be treated with dignity is reflected in the staff who work there: she recruits for personality, not for years spent in the sector, and residents help interview potential employees.
The CQC report highlighted the “laughter and good humour” present in the home. Activities, such as going shopping for food or walking the dog, are important and can arise spontaneously, says Fretwell: “People wear work belts, with things like bubbles, dusters, nail files, silly little toys, because when somebody’s got dementia, you can’t go away and look for something for 10 minutes. So you can file nails or blow bubbles – that can start the laughter off. Or if they’re getting agitated, we ask, ‘Shall we do some dusting?’ and pull a duster out.”
An outstanding rating is given only to those services that provide exceptional care. At Home Instead Senior Care West Lancashire and Chorley, for example, every care worker visit lasts an hour, and Robert Godson, who co-owns the service with his wife Gail, says the organisation’s approach is about going the extra mile. “We’ll run errands for them, we’ll take them to hospital appointments and dentists and hairdressers, rather than rush in and rush out and take the money.” Care workers also accompany clients to lunch clubs, day centres and singing groups.
Domiciliary Care East Devon, which supports people with learning disabilities, has a service that ranges from a few hours support a week to 24-hour care for those in supported living. The CQC report praised the strong leadership, the focus on continuous professional development for staff and the partnership working with other organisations. Timberlake was able to give examples to the CQC of helping service users to carry out particular activities, such as using assistive technology to help one man achieve his ambition of travelling alone from Exeter to Penrith in Cumbria.
The service’s approach, with its aim of balancing risk and independence, and its emphasis on responding to the needs of service users, epitomises the qualities CQC looks for. As Timberlake says: “One of the most important things is ensuring that everybody we support, no matter what level of disability, has a voice and that they are listened to.”