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What makes a care home outstanding?

28 September 2016

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 September 28, 2016
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Less than 1% of homes are rated as outstanding – all share three common attributes

 ‘If we want the best people to run our care homes we have to give them more status, better rewards and make their job easier.’

Around 80% of care homes for older people, in England, have been rated by the Care Quality Commission (CQC). So far, approximately 62% have been rated good, 37% as requires improvement or inadequate and just less than 1% are outstanding. Following up on my Care Home Inquiry, I have spent time reading the reports on those outstanding care homes and visiting them to try to understand their secret. What has enabled them to achieve this rare accolade? Outstanding care homes share three common attributes:

  • They have an outstanding manager who is well supported and valued.
  • They have sufficient resources to do the job well and these resources are invested in the service. An outstanding care home wholly reliant on state funding is an incredibly rare thing.
  • The provider organisation’s values and ethos are clear and effectively translated from the board room to the floor of the care home. Profit is never the raison d’être of these care homes.

The ratings concentrate on individual homes but what of the effectiveness of providers in ensuring consistently high ratings across their portfolios? Are there outstanding care organisations as well as outstanding care homes?

Small private providers run the majority of outstanding care homes; typically they have only one or two homes in their portfolio. A clear majority of larger providers, whether for profit or not, struggle to achieve consistency. When you find an outstanding care home in a large provider organisation you commonly find one rated as inadequate or at least some that require improvement, in the same stable. Providers with solidly good or outstanding ratings across their stock are very rare.

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To learn from these rare providers, I’ve visited and spoken to some of them to find out how they do it. What I found is that they work incredibly hard at ensuring adequate resources and an unflinching dedication to championing quality. But they are still highly reliant on recruiting good managers. They are aware that all their efforts in auditing, quality assurance and governance will have little effect if the manager is not well supported, confident and competent in their role. You can’t standardise care homes like burger joints. They need to be resilient in themselves.

The recent Skills for Care briefing on registered managers (pdf) highlighted that one in four care homes lose their manager each year and the figure is one in three for nursing homes.

More than half of all care home managers are over 50. Recent evidence suggests that managers are finding the role almost untenable as the complexity of their job grows and they face an external regulatory system increasingly adversarial and critical. In all but the very best organisations, they feel vulnerable and alone. The role of registered manager is a challenging one. Even a small care home will have a turnover in the millions, a significant workforce and more rules and regulators than you’d care to count. Even so typically salary levels are only in the mid £30k range. No other sector bestows so much responsibility on its management cohort with so little recognition or reward.

Inspection on its own will not improve the quality of care homes consistently across the sector. Yes it can provide the impetus for an individual service to improve but it doesn’t stop the previously good care home slipping into trouble. Inspection only weighs the pig, it doesn’t nurture it and help it grow.

One of the first outstanding care homes I visited, in mid-2015, was recently inspected again and rated as inadequate. It went from wow to awful in a matter of months. The primary reason was that the manager left. Neither the external regulators nor the parent organisation were able to prevent this decline.

We can’t continue to put all the responsibility of quality on to individual services. We have to recognise that care homes need to be supported, not just held to account.

If we want our care homes to be good, commonly and consistently, we should be recognising the fundamentals that underpin quality care. If registered managers are the fundamental primary keystone of quality why are we making their jobs so hard? Why are we driving them out? If we want the best people to run our care homes, we have to give them more status, better rewards and make their job easier.

This is why registered managers need a national professional body. It would set professional standards, provide support and development and crucially give this essential profession status at a national policy level. They are currently an unheard and unacknowledged voice. They need some power to balance their responsibilities.

Having just passed 50, it’s becoming rather personal. When I’m incontinent, vulnerable and frail I don’t want to have to trawl inspection reports to find one that’s good only to find it is not so good six months later. I want my local care home to be good, commonly and consistently. For this to happen we need to recognise the real fundamentals that will ensure quality.

Social care is crying out for leadership. There are many things we need to do to support care homes to be good. Investing in registered managers would be a positive start.

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