The looming crisis in the provision of adult residential care across the UK is no longer big news.
Just last week, ResPublica warned of its likely collapse in England within five years. An estimated 37,000 beds will be lost and subsequent knock-on costs of care to the NHS will reach £3bn, said the think-tank. The Older People’s Commission for Wales has described the situation as “volatile and fragile”, Scotland’s 2014 Task Force for the Future of Residential Care has voiced similar concerns, while pressures in Northern Ireland mirror the rest of the UK.
Local authority spending on residential care in England alone has dropped by 17% since 2009 – a reflection of the minimum 40% cuts inflicted by Westminster on council budgets. Four Seasons Health Care – one of the largest providers – is set to sell off homes to make savings. Others too are getting out of the residential care market – with bigger bucks to be made from the sale of land and property, previously the refuge of the frail and elderly.
But what of the quality of care that remains? An alarming 41% of all adult social care services inspected by the Care Quality Commission since October 2013 have been deemed ‘inadequate’ or require improvement. Fewer than 1% were outstanding, though 58% were still deemed to be ‘good’.
CQC’s chief social care inspector Andrea Sutcliffe has voiced her own concerns about the quality of care, saying: “Stresses and strains in social care are impacting on quality. There are concerns about safety and leadership and many nursing homes are struggling.”
Unison shares CQC’s concerns. We have collaborated with Community Care on some important research to explore the link between the quality of residential care and staff training, looking at 300 recent CQC inspection reports and the training and support available to staff in the residential homes inspected. What emerged was alarming.
All of the inspections scrutinised were undertaken within the new approach established by CQC in October 2014 and covered homes for those aged 65 and over. The research examined where training had been identified as a problem by inspectors and where the training gaps fell. Breaches of Regulations 13 and 18 of the Health and Social Care Act 2014, covering safeguarding of service users from abuse and improper treatment and staffing, were also investigated.
Of the 300 homes inspected, 125 were deemed ‘inadequate’, 125 ‘required improvement’ and 50 were rated ‘good’. Training gaps were identified in 71% of all the homes told to improve – deemed ‘inadequate’ or ‘requiring improvement’. This figure was a shocking 91% in ‘inadequate’ care homes and 51% of those requiring improvement.
So where were the training gaps? The three largest occurred in the areas of dementia, safeguarding and Mental Capacity Act/Deprivation of Liberty safeguards.
Almost half (49%) of all the homes inspected were in breach of Regulation 18 – staffing – and a third (32%) fell short of Regulation 13 – designed to safeguard service users from abuse and improper treatment. More than a quarter breached both regulations.
Sixty-nine homes – more than a quarter of those regarded as inadequate or requiring improvement – had gaps in dementia training. And if that weren’t alarming enough, 66 of them were listed on the CQC website as ‘specialist dementia homes’ or supporting residents living with the condition. Yet one inspection report noted: “When we discussed dementia care with staff, we could not identify any recognition that people living with dementia require specialist care.”
Forty two per cent of all the homes in the inspections scrutinised had training gaps in the Mental Capacity Act, designed to protect those unable to make decisions about their own care. Almost a third (29%) failed to meet the training standard in the England and Wales Deprivation of Liberty Safeguards, which seek to ensure that the care provided does not restrict the liberty of residents. In one home, just three out of fifteen staff had training in both safeguarding standards.
Safeguarding training was also inadequate in homes required to improve. Seventeen out of twenty three members of staff in one home had received no training in the safeguarding of people.
Contrast the findings above with the inspection reports of ‘good’ homes and there is a noticeable difference: Only five of the 50 had training gaps and just one breached Regulation 18 concerning adequate staffing.
The implications of this research are not hard to work out and there have been too many reports of poor or neglectful care to count. Inadequate training – alongside inadequate staffing levels, poor pay and working conditions – must constitute a large part of the explanation for poor care. But who should shoulder the blame?
Most Unison members entering the world of care work – overwhelmingly women – do so because they really do care, because they want to make a difference to elderly and vulnerable people. Joseph Rowntree Foundation research reinforces that view, highlighting that care workers’ primary motivation is generally to clients, rather than employers.
Many have few qualifications and so are denied entry into nursing, but would love the opportunity to develop their skills and progress. Our research shows little chance of that in many care homes. As one worker – now undertaking nurse training – said:
“There was no routine training and it would just be a case of ‘watch this DVD again, re-do your e-learning’ … E-learning on the Mental Capacity Act for Christ’s sake! That’s really complicated stuff ...The lack of training left me stressed and angry and eventually with the dementia unit, completely burnt out. There was no training on how to cope either.”
David Cameron’s Challenge on Dementia 2020 promises to train 1.3 million NHS staff in dementia care. Yet his devastating cuts to local government threaten not just the amount of residential care but its quality through poor staffing levels and lack of training. Last week he railed against his own council – Oxfordshire – for cuts in local services. Perhaps it’s time he paid more attention to what his chancellor is up to!
