Delivering Integrated Care for Older People with Frailty

Care Talk, with the Kings Fund are hosting an exciting conference on 15th March looking at innovative ways to provide integrated health and social care to frail older people. This seems to be particularly relevant to the domiciliary care sector as we try to keep people at home and independent as long as possible.

As someone who is trying to coordinate integrated care for an elderly relative with multiple morbidities, I am keenly aware of the tensions between dignity and choice on one hand and keeping someone safe on the other.  I saw good integration in so far as the response in an acute episode was superb; the health care and social care has been excellent. Thereafter I have seen little evidence of integration and several examples of poor communication, one a visit from a social worker who knew nothing of the intervening activity resolving the acute health issue, and another where blood tests commissioned by the district team were not checked by the GP team. No criticism here, both teams have been superb, but clearly a communication and integration issue.

The day looks an exciting opportunity to share good practice and find useful ways to deal with this growing problem. The programme includes a presentation looking at ways in which the NHS are looking at new models of care and service redesign to embrace people with frailty. There is also a presentation around acute care for people with frailty. There will be presentations describing innovative new projects: a frailty pathway and the role of the voluntary sector; followed by an opportunity to work together in breakout streams and a closing panel session. I can't go but I certainly hope that the papers and outcomes from breakout sessions will be published. Innovation is certainly needed.


QSBD: What to do if you are faced with a Special Measures order

QSBD Solicitors A practical perspective on CQC Inspections and Enforcements was introduced by Mei-Ling Huang. Highlighting the business impact of a poor inspection, Mei-Ling suggested that providers should

Prepare thoroughly:

  • PIR is essential. prepare well and keep a copy.
  • Prepare an information pack with all your evidence against the assessment criteria
  • prepare your staff so that they answer with confidence about the standards and their role
  • Try "Mock Inspections" to remove the fear factor. (Care & Support West have an Independent Service Review Template that can help with this)

Seek legal help if:

  • a draft report is not accurate
  • you are on the 'cusp' of a rating
  • you have any 'inadequate' ratings
  • you receive a warning notice, notice of proposal to cancel registration, or notice about special measures.

Manage any judgements / enforcement notices proactively

  • seek help
  • assess the judgement against reality: look for uncorroborated hearsay and ensure that the assessor has evidence to support conclusions
  • gather evidence to refute judgement
  • prepare an action plan for improvement
  • manage your approach to CQC staff: DON'T get angry and defensive

Inadequate V Outstanding: Same indicators opposite ends of the spectrum

Andrea Sutcliffe, CEO of the CQC was the key note speaker at the Wiltshire Care Partnership and Wiltshire and Swindon Care Skills Partnership Joint Conference. She was clear that people were at the heart of good quality care: care users and staff and community. She contrasted Outstanding and Inadequate services and found the key indicator is the quality of leadership and the resultant culture with  Outstanding and Inadequate providers at opposite ends of the spectrum:

Management: Inadequate providers saw inconsistent management, change, churn, not focused on improvement, not learning from mistakes, not aware of or prepared to develop best practice. Outstanding providers were characterised by consistent management, a focus on improvement and best practice, open to suggestions.

Staff: Inadequate providers did not support their staff; outstanding providers made it a priority that their staff were happy in their work and supported to do a good job. 

Connections with the community: Inadequate providers were not open to their local community and made no attempts to develop links. Outstanding providers were vibrantly part of their community and used innovative methods to establish connections.

Justine Button, a local chief inspector from CQC reiterated the importance of leadership and emphasised these points and how important it is to have valid feedback from stakeholders and the importance of an 'independent critical friend'.

Stakeholder surveys can be a critical management tool to establish what staff, other professional colleagues and relatives feel about your service. Care2Improve gives you an independent view of these important perceptions.


More CQC evidence of themes behind assessments

At a recent care conference hosted by Care & Support West, association for care providers in the South West, Deputy Chief CQC Inspector Debbie Ivanova referenced the "State of Care" report 2015 .  Debbie pointed out that 40% services were classed as less than Good, with 7% inadequate. 

Interestingly, smaller organisations are seeing better results than large care providers. (small = <= 10, medium = 11-49, large >= 50 beds). Debbie Ivanova also referenced the themes emerging,  with safety and leadership proving critical factors determining the rating whilst performance against caring and responsiveness remained generally higher. 

When it comes to assessments, having evidence of good practice is essential. One third of providers had been assessed but a clear pattern was emerging .

Themes from "Inadequate" assessments

  • Management churn and change
  • No / Poor registered manager
  • Poor relationship between the manager and the owner / provider
  • Lack of staff supervision and staff development
  • Poor care planning / lack of personalised care
  • Poor oversight of care planning
  • Ineffective systems and poor risk management
  • Closed culture
  • Poor partnership working and community links
  • Unaware of best practice
  • Non notification of issues to CQC

Themes from "Outstanding" assessments

  • All stakeholders speak highly of the service
  • Effective registered manager
  • Leadership comes from the owner and the manager in a clear way
  • There is effective monitoring / Quality Assurance and Audit processes.
  • There is good staff development and recognition
  • Good oversight of care and staff communication
  • Active promotion of safe care
  • Continuous development and incorporation of best practice
  • Can Do Will Do attitude
  • Open culture
  • Links with local community.

BCC Forum: Advice from CQC inspector

BCC Main Provider Forum on Friday June 12th a CQC inspector reported that:

  1. Orgs that have no Reg Mgr in place (or fail to get one in place within a reasonable period of time) will not be able to obtain “Good” as a service rating and will always be rated as “Requires Improvement”
  2. And those that do not complete their PIR’s will not be able to obtain “Good” as a service rating and will always be rated as “Requires Improvement”

BCC Commissioning also reported that when a service is rated “Inadequate” by CQC their QA team will be informed and will make a judgement on whether to cease placements immediately.

  • The team will also visit the service and check on its CQC action plan and activities to improve the service
  • A set of guidance notes re this BCC checking process will shortly be available
  • I have asked BCC to alert C&SW in these circumstances so that we can support anyone who finds their service being checked and monitored by both CQC and the Council.

Notes from Caring UK Care Show, Bristol

On a boiling hot day, one very good reason to go to the Caring UK show was the air conditioned interior of the Bristol Pavilion conference suite at the Gloucester cricket ground off Gloucester Rd. Other good reasons were the two key speakers, whose talks are briefly outlined below.

Sue Burn CQC Inspection Manager: Care providers need a ‘critical friend’:

Sue recapped the fundamental standards, quality ratings and the improvement agenda which are the cornerstones of the inspectorate’s policy.

Talking about rating characteristics and what constitutes ‘Outstanding’ and what providers need to do, Sue suggested four critical reflective questions that a care provider should be asking:

  • Do I have a trusted ‘critical friend‘, someone independent who will tell the truth?
  • Are my staff really clear about our vision and our values?
  • Do I have ways in which to encourage and support staff to try out innovative ideas?
  • Do I really know what care users really feel about what it is like here?

What is clear is that these are essentially leadership and management issues and that focusing on professional management, with good processes and independent review and assessment is the only way to garner the ‘outstanding’ accolade.

Nadra Ahmed OBE, Chairman of the National Care Association: Leadership is major issue

Nadra set the scene by outlining how the current care system is a world away from how it was 2 decades ago. Apart from the legal framework and new commissioning practices by local authorities, a key difference is that people in the care system have greater and more complex needs. She recommended that people download and read the Easy Read Guide to the  Care Act.

For Nadra, the main challenges ahead were:

  • Leadership: with workforce a massive challenge, good leaders will attract and retain staff and motivate them to perform.
  • Innovation:In a time of austerity and budget cuts, providers who can provide good care at a reduced price will be those who can innovate
  • Integration: the transfer of budget from health to social care will be essential to resolve the bed-blocking issues in our hospitals. It is important to engage with CCGs and not just Local Authorities
  • Funding: the proposed changes only affect care and not hotel costs; people looking for care will need help and guidance. Good providers will know and understand the funding rules and will be able to advise.

Nadra finished by emphasising that there are opportunities to be had: growing demand, direct payment and different styles of accommodation all offer opportunities to the innovative provider.

Election Fall Out: the Social Care Dilemmma

The Conservative win in the recent election took many by surprise but what does this mean for the care sector?

According to the BBC ( these are the key pledges on Health and Social Care in the election:

  • Increase NHS spending in England by at least £8bn above inflation over the next five years
  • Seven-day access to GPs by 2020 & same day appointments for over-75s when needed
  • Integrate health and social care
  • Improve access to mental health treatments

The Guardian declared Social Care had been ‘the ghost at the feast’ of the election campaign with neither party making significant commitments, yet the NHS, guest of honour at this particular feast, cannot be fixed without addressing social care. The recent crises in the NHS with escalating demand have been a direct result of cuts in social care. Dementia costs a staggering £26bn per year, with around 2/3 of the bill shouldered by families via care fees and unpaid carers. Read more

According to Richard Humphries, Assistant Director, Policy, The Kings Fund (CMM May 2015: Politics and Social Care, p20) points out that the coalition made better progress in 5 years than the previous government did in 13:

  • Dilnott: Principle of a cap on care fees: protection from catastrophic costs
  • Care Act: a model of good practice and the most comprehensive and ambitious overhaul of social care legislation since 1948

However, whilst ring fencing health funding, the coalition has undermined their progress by allowing a 40% reduction in real terms to local government with sharpest reductions in community services such as home care. So, on the one hand, the provisions of the Care Act and Dilnott add extra safeguarding and support, and on the other hand, austerity measures mean that eligibility criteria has got tighter and funding more restricted. The Guardian cited these views from experts in the sector:

  • “social workers have had to deal with the fall out of the austerity agenda… it is time to … stop punishing the poor for the economic failures of the rich” British association of social Workers
  • “..there will be a £4.3bn gap and the effect of this on those most in need is simply intolerable” Independent Age
  • “We want to see a system that is protected by adequate funding and a sustainable workforce, is personalised, safe, good quality and aligned with health and our partners” Association of Directors of Adult Services
  • “Closer integration of care and health services .. is still rather more rhetoric than reality… that the context for developing new models and new ways of working is taking place against a long period of austerity will certainly add to the challenge” National Care Forum

Editor in Chief at CMM, Robert Chamberlain(CMM May 2015, p7) sees the public funding shortfall and points out that it is about managing expectations. Health may be free at point of delivery; social care is not, fewer people will get financial assistance and funded care will be for minimal packages.

“Isn’t it about time that the general public were told how it is going to be  in terms of social care funding”.  

We need to accept the current situation and people need to realise that the state will not provide and that people need to plan for potential costs in the same way they would plan for a pension.

Maximising the Value of Client Feedback

Do you truly know the real time and money cost of your current survey process? Assess your current effort levels and whether you maximise the value of the work you do.

How did you do?

12 – 16 You are doing great,  but it sounds like you are keen on improving. Take a look at how C2I can give you more time to focus on care and  how our unique analysis can improve business management.

6 – 11. Sounds like you could do with some help. Check your costs, we can give you more time, better value for money, plus our amazing analysis will help you to manage.

0 – 5. To meet the new CQC demands , you definitely need to do a better job of managing your feedback, Care2improve could revolutionise your feedback process, helping you to save time, money, get better results and help you manage.

Less than 0?  Care2improve could give you back your life! Call us now!

Don’t forget, our additional ‘Best Practice Follow Up Package’ is also available to really help you improve performance.

CINTRE Pilot Care2Improve for Care & Support West Offer

CINTRE is a regulated service for adults with difficulties. Their clients have complex needs, are demanding, not always easy to reach and often hard to place.

They have 2 residential units and an outreach unit. Their mission is to ‘Enable Independence’, enabling clients to have fuller lives.

When the partnership between Care & Support West and Care2Improve was first suggested, John Bennett, CEO at  CINTRE was keen to take on a pilot project.

“Cintre is responding to the sector call for further evidence in its work and recognised the need to provide further feedback from a variety of sources. Key to deciding what product to use was the ability to review services in a variety of locations and to have the flexibility and ease of use of a system to achieve this.
An on-line solution was sought and we have been encouraged by the model Care2Improve offer through Care & Support West. The model is straightforward and easy to use. The greatest challenge has been for us in bringing together the data we have to be able to issue the surveys, which we anticipated.
The survey will collate feedback from service users, staff, other professionals and the families and representatives of our service users. A good cross section of views and one we earnestly seek to drive our services forward.
Care2Improve have been incredibly patient and supportive throughout the mobilisation and we are now looking forward to our first set of results.”

Care2Improve worked with CINTRE to achieve the best balance of survey methods to meet the diverse needs of the stakeholders using a mix of postal, electronic and face to face solutions.

Question Answers Score
1. Do you always do your surveys regularly and at the time agreed? Always Mostly No Always = 2 Mostly = 1 No = 0
2. Do your surveys include feedback from staff, relatives and other professionals? Yes No Yes=2 No=0
3. How much time do you spend in design, layout and printing surveys? >2hrs 3-4hrs <4hrs >2hrs=22 3-4hrs=13 <4hrs=0
4. How much time do you spend inputting responses to a spread sheet? <3hrs >4hrs3 <4hrs <3hrs=2 3-4hrs=1 <4hrs=0
5. How quickly do you deal with responses? Always promptly Usually fairly promptly Delay them because of urgent things >2hrs=22 3-4hrs=13 <4hrs=0
6. What do you do with the responses? Scan them and put them in the drawer Read them and note key responses Analyse the data objectively 1=12 2=6 3=0
7. Can you easily derive clear, quantitative analysis in line with the 5 CCQC domains? Yes No Yes=2 No=0
8. How much time do you spend interpreting feedback and preparing reports? 1-2 hrs 3-4hrs A day A weekend 1-2 hrs=0 3-4hrs=4 A day=13 A weekend=22