We are often asked by our customers to provide some guidance on improving quality assurance procedures for compliance purposes, in addition we are asked for advice on improving innovative Person-Centred Care.
They are often sceptical when it comes to looking at the comparison of CQC Ratings, Occupancy and Income. We at RedRoyal Consultancy Ltd carried out our own piece of research to produce some facts that would provide comparative figures.
Our research was conducted by using the CQC Reports, taking the first ten from each rating, Outstanding, Good, Requires Improvement and Inadequate. Using the reports, taking two figures, registration for the number of residents and the occupancy at the time of the inspection. Any report that did not clearly display both figures was disregarded, and we moved to the next report. A total of ten reports were viewed for each of the ratings to provide a small sample of Occupancy rates for each graded category.
The figures below were produced on the 21st March 2019 giving a clear indication that occupancy rates are closely linked to the CQC rating.
Table 1 indicates the Occupancy rate by percentage by CQC Grading.
Table 2 shows the numbers recorded by category.
Table 3 is a guide that provides an insight into the loss of potential gross income resulting from lower occupancy rates per resident, with a weekly charge of £500.00.
Table 4 shows the same loss of income based on a weekly charge of £500.00 per resident in Residential Care Home that is registered for 30 residents.
In this example the losses that correspond directly to the lower occupancy rates and accumulate to a massive £239.850.00. If a service is charging £900.00 per week this loss could be increased to £431,730.00. This in my opinion can be the direct cost of not investing in quality Person Centred Care, though this is not the subject of this research the CQC Inspection is based on the delivery of High-Quality Care that should be Safe, Effective, Caring, Responsive and Well-led.
Our research clearly demonstrates the links between CQC Ratings and Occupancy, as the CQC Rating is based on the standards of care delivered it should be assumed this is the direct cause of the reduced occupancy and income. Look at your potential customers, and the journey they take as they choose a care home for their loved ones?
Research will take place, they may compare Care Homes in the area and if yours requires improvement or is inadequate, and just down the road there is an outstanding Residential Care Home, which are they most likely to choose?
There is a clear connection between CQC Ratings and Occupancy rates which in turn are linked directly to the loss of potential income. In any business there is a need to continually evolve and develop which involves some continued investment.
For example take a quick look at our roads which are extremely well developed, yet with out continued investment they literally fall apart, I’m sure I don’t need to mention pot holes.
With some ongoing Investment, High Quality Reviews of your provision against recent developments, Innovative and Person Centred holistic Care for Health and Wellbeing, Outstanding is the basic standard that should be achieved by Residential Care and Nursing Homes.
Person-centred care for individuals with dementia
Person-centred care simply means putting the individual at the centre of everything that you do. Initially this means an in-depth assessment of care needs, their interests, abilities, history including a full life story, relationship needs, preferences, personality and anything that can affect the individual’s wellbeing. This should include favourite music, tea or coffee, make up, shower or bath, anything that gives a feeling of wellbeing and identity.
Person-centred care helps to keep individuals connected with positive activity and routines ensuring people with dementia can take part in the things they enjoy, this of course is why a detailed assessment and care plan is so important. This can be effective in preventing and managing behavioural and psychological symptoms of dementia by reducing anxiety, distress and confusion.
There are key points to consider with person-centred care.
Treating the individual with dignity and respect.
Looking at situations from the individual’s point of view and understand their experience.
Ensuring there are opportunities and support to try new things and take part in activities that give stimulation and enjoyment.
Family and carers should provide their knowledge and understanding of the individual as this is extremely valuable and, combined with the individual with dementia (where possible) should always be involved in developing a care plan based on person-centred care.
Changes in Behaviour
Sudden changes in behaviour are often caused by physical health problems – especially when the person seems to be more agitated, confused or distressed.
It’s always advisable to visit the person’s GP to rule out any physical problems including infection, pain or constipation reviewing all the individual’s medication.
Mental health problems including depression and anxiety, may also contribute to changes in behaviour. These can often be managed with medication and non-drug strategies. These can often include taking more time to understand the cause of the distressed behaviour and providing support in a different way. Changes of this nature requires regular review which must be reflected in the updated Person-Centred Care Plan.
Reducing behaviour that challenges
Meeting the needs of an individual with dementia can help reduce behaviours that challenge.
Some examples may include:
Maintaining relationships with other people
Giving encouragement to do things they enjoy or interests them
Changing the environment. For example, reducing noise and improving the lighting, using colour contrast for easy identification, changing handles for easy grip.
Keeping familiar, personal familiar items close to them, such as a favourite scarf or keepsake.
Keeping their bedroom comfortable – for example, making sure it isn’t too hot or cold and has familiar items.
Allow them to live in their experience. For example, if they believe they need to go and collect their car from the garage, don’t argue. Instead acknowledge them, agree and ask for more information and gently take their thoughts somewhere else.
When an individual’s behaviour becomes challenging, there are numerous ways to support them. You should always remember that the individual is having a hard time, not giving you a hard time!
The care worker should always consider:
1 The cause of the problem:
Is it the individual with dementia that is causing the problem?
Is it the interaction with other people?
Is it the person’s living situation?
Is the individual in pain?
Are they getting bored?
Are they comfortable and stimulated?
2 Look at the situation:
Where or when does the problem happen?
Does the person always act in the same way in the same place?
Is the behaviour triggered with the same person or in similar circumstances?
Look for patterns in the behaviour in the daily notes, everything that was going on at that time that could have triggered the behaviour and should written in the daily notes.
3 Look at how the individual is feeling when they behave this way:
They may be unwell, in pain or uncomfortable?
May be getting too much stimulation, confused, scared or frustrated?
They may be depressed, anxious, having delusions or hallucinations?
Lacking stimulation, feeling bored, lacking in social contact and becoming isolated?
4 Identify anything the person could be reacting to:
Use what you know about the individual from the in-depth assessment and Person-Centred Care Plan to explore the cause of the behaviour:
Antipsychotic drugs may be prescribed by a doctor in some circumstances, for instance if there is evidence of delusions or hallucinations and the person is severely distressed, or if there is a risk of harm.
The Person-Centred Cared Plan
The Importance of the (Pre) Admission Assessment and the Person-Centred Care Plan cannot be over emphasised, the care plan can only be as good as the information it is based on. If there are gaps in this information, with the best will in the world, the care will be lacking and can cause considerable distress, anxiety or depression as a result.
Care plan reviews are required on a regular basis, and should certainly reflect any recent changes in mobility, nutritional requirements, changes in health or behaviour. Care provision must be based on the needs of the individual today. Needs can, and often do change rapidly.
Reading the Headlines today it’s no surprise once again to see that a few Residential Care Homes have achieved some negative publicity. Of course there is a tendency to concentrate on the negative simply forgetting the excellent service that is provided overall, and the quality service that is delivered each and every day, by dedicated caring staff who’s work is on long shifts and short on pay.
When you consider the efforts put in to deliver a safe and effective person centred caring service, it often seems that the negativity is at complete odds. Yet here are the headlines again and again. I have just been reading some, which include the inquest into a resident who had fallen from a hoist while being transferred. Care Home Operators were fined £16000 with cost of £9500 after a resident received serious injuries falling down stairs. Yet another Care Home put into special measures and under Police Investigation after allegations of Abuse.
In one recent case in Northern Ireland a report was published stating in the findings that treatment of residents had been horrific, in this case the staff then endured physical attacks and death threats.
How on earth do things become so extreme? While every case is different, and of course accidents happen. Every effort should be made to prevent them, often this is the case as reputable providers take the steps that they deem necessary to prevent accidents and maintain very high standards of quality person centred care. Time and again, with one eye on the budget the possibility of not seeing the standards dropping is increased. A pound saved on staffing costs, training or maintenance can result in costing hundreds, or even thousands later. The cost in human terms can be severe. The whole process should remain in sharp focus, staff are your biggest asset without them you have no more than a building. Correct and robust employment procedures from the references, DBS, interviews and quality up to date training through to the supervision and support and disciplinary procedures should be second to none. As tempting that it may be to cut a corner, perhaps save a little on the training or start somebody before the references are returned such things should be avoided at all costs.
With the introduction of electronic management systems you could be forgiven for believing the all singing and dancing system ensures that you are delivering a high quality service, it provides you with reports ensuring that you can manage all aspects of service delivery from your desk top computer. Wrong! Does the system tell you how staff rushed through the personal care of Mrs H in room 18, or if they spent extra time ensuring her wellbeing? Does the system tell you that a tablet was dropped during the medication round and to save time it was picked up and administered contrary to procedure? Does the system tell you that the food when delivered to resident’s rooms is cold?
The management of the standards, policies and procedures is function that can only be completed satisfactorily with a hands on approach and very good communication from a competent and caring management team.
Recently RedRoyal was asked to assist a Registered Care Home in Norfolk, on arrival we could see that the communal areas were dirty and there was a distinct lack of organisation. Staff, if trained at all, were very poor at care provision and were poorly led. This lead to a lack of consistency and neglect of customers who were visibly sitting in soiled clothing and actively discouraged from moving and walking themselves. Often a resident would ask to go for a walk or, to the toilet as they need assistance to get up from the chair. The response was often “wait there a minute we are busy”. And this was a fairly standard response; the minute could and usually would in fact be considerably longer. Regulation 10 – Dignity and Respect. Regulation 18 – Staffing.
Much of the issue was apparently due to the staff shortages that the Service Provider was experiencing. I say apparently because this was the reason that most people would give for any and all of the poor standards, and the neglect and safeguarding concerns that were raised. Yet it was very clear to see that leadership and support was inadequate. Regulation 12 – Safe Care and Treatment.
Training was conducted sporadically and was of a very poor quality, some staff members had not been trained in many of the important areas after having being employed there for more than a year. One example of this was Moving and Handling training, one member of their night staff who was involved with transfers by hoist on every shift that she had worked there for more than twelve months and had not been trained to use the equipments correctly. This had led to examples where a single member of staff would hoist a customer with no assistance, often the same sling was being used for all the hoisting with no consideration to the difference in size, shape or weight of their customer. A new member of staff working nights with no care experience was inducted by shadowing another team member on the night shift. No training was given at all! Unfortunately by shadowing another team member the bad habits were being passed on as the’norm’. Regulation 12 – Safe Care and Treatment. Regulation 17 – Good Governance.
Another example of poor practice during hoisting would be the practice, adopted by the majority of their staff during the hoisting of an individual, while dangling in the hoist, their customers would endure some rough handling while their trousers or skirt would be jerked down to enable the less than caring care worker access to continence pads. It is no exaggeration when I say clothing would be jerked down as you can imagine the weight of customer against the sling would very often be holding the garment firmly in place. There was no thought for dignity or respect during this and staff would disregard customers when they would should “oh stop it”.
One poor soul who often resisted personal care and preferred not to be moved, either by standing to walk with assistance using a frame or simply moving from her bed to her chair in her own room suffered further as a result. Often this lady would be left in her bed, this would mean that she would often suffer from dehydration or malnutrition issues as a result. As shocking as this was, it resulted from being understaffed and those on shift would feel that they could not give enough time to ensure the lady consumed her food and drink. In addition this lady was then subjected to being hoisted, simply because staff wished to avoid the challenges due to her resistance to standing. With no assessment in place the lady did not have her own sling. Regulation 10 – Dignity and Respect. Regulation 12 – Safe Care and Treatment. Regulation 14 – Meeting nutritional and hydration needs
Records were generally maintained, and often the cases were completed by one person for all the customers. Clearly the person completing the records would not have dealt with all the customers and therefore the records were inaccurate and at times misleading.
None of the Care Assistants had knowledge of the Care Plan content! When asked about the diagnosis of one customer an experienced Care Assistant told me Mental Health, no mention of the diagnosis. Another Care Assistant told me Dementia, and a third said Learning Difficulties. Without such basic knowledge how on earth can care needs be met? None of the Care Assistants were aware of any Behavioural Programmes, and indeed risks were also largely unknown.
Infection Control was not apparent! Generally speaking the concession towards Infection Control was that staff would wear gloves and soiled laundry would be placed in sealed bags. That’s a start! Unfortunately that really was it. Care Workers would administer personal care in the customer’s room; the soiled items generally would be thrown to the floor to be moved when the Personal Care was completed. The soiled items would then be carried by the glove wearing Care Assistant to the storage bins. Soiled pads would be placed in clinical waste bins; soiled laundry would then be placed in sealed bags and placed in the appropriate storage bins. Of course waste could be dripped across floors; gloves would contaminate door handles, wheelchairs and hoists which were not subjected to any cleaning. In fact one of the slings was guilty of an extremely offensive odour. Regulation 9 – Person Centred Care. Regulation 10 – Dignity and Respect. Regulation 12 – Safe Care and Treatment. Regulation 17 – Good Governance.
Whistle blowing had become common place, and quite rightly so. Unfortunately the Management instructed staff to inform them directly of issues first. A member of staff raised concerns regarding medications some weeks later. Tablets had been found on a regular basis down the side of chairs and on the floor during cleaning. The Service Manager, while discussing the concerns informed all his Senior staff which staff member had raised the concerns, as the medication was administered by Seniors the staff member was subjected to bullying as a result. Regulation 12 – Safe Care and Treatment. Regulation 17 – Good Governance.
The above are just some of the concerns that we raised, as you can clearly see there were many areas of the service that were in desperate need of improvement. A standard quality Assurance Audit or Mock CQC Inspection can be a very positive tool to raise and maintain standards of Care within a service. RedRoyal Consultancy Ltd strives to raise the bar to ensure quality Care is delivered which in turn has a very positive impact on daily lives by providing a detailed action plan and support with each audit provided. Why be less when you can be Outstanding!