As the number of inspections continues to rise, many CQC-registered residential services for people with learning disabilities and/or autistic people have lost a previously Outstanding or consistently Good rating: did their standards really slip, or have inspectors been moving the goalposts?
As well as the regulations and statutory guidance that all care providers are expected to abide by, providers of services for people with a learning disability and autistic people have to meet the requirements of Right support, Right Care, Right Culture(RRR), published October 2020. The previous guidance was Registering the Right Support, published in June 2017. In the reports reviewed for this article, none of the services were meeting RRR at the most recent inspection but all had previously been meeting Registering the Right Support — so have the differences between the two caused issues for established services?
Thekey difference is that RRR is statutory for all relevant services, both old andnew, and has been described as the first time the CQC has adopted amarket-shaping role — something considered by some to be beyond their remit. Itintroduced the requirement that providers have identified a local commissioningneed for the service, but most will find that their local authority is happy tocorrespond with potential providers.
The principles behind RRR came from Building the Right Support (BRS), which is a national model issued by NHS England inOctober 2015 and itself part of the Transforming Care programme, the official response to the 2011 Winterbourne View scandal.
The most disruptive elements of RRR were probably the rules relating to the size, location and design of new care homes, which criticised “campus style” and“congregate” settings, and reportedly caused the immediate cancellation of many planned services. Although denying they had adopted a “one-size-fits-all”approach, even highly rated providers have claimed they have been prevented from expanding their current offering.
Providers of older services must ensure they are intimately familiar with RRR and BRS, and if their service is not in line with modern principles then this must be given serious thought. Much of RRR/BRS is uncontroversial and seeks only to ensure that people are safe and have basic human rights such as being able to access the community. Where a service works well in every other respect but finds itself non-conformist by being something of a campus or even an intentional community, that position may well be defensible. The provider must be able to demonstrate how the service has addressed the issues and is effectively meeting the real needs of the people living there, remembering that exceptional claims require exceptional evidence.
More information about RRR can be found in this introductory article, which includes links to the statutory and best-practice guidance that providers and managers must know and take account of.
The delay between abuse scandals and the programmes that result can sometimes give the impression that such issues are historical, but the poor treatment of people with learning disabilities and autistic people is an ongoing scandal. Some of the most vulnerable people in the country have even been moved from one abusive location to another, including Ben, a young man who had moved from Winterbourne View in 2010 to Veilstone care home, where he was abused for 17 months and which was only closed after a former resident went to the CQC in late 2011. Convictions of 13 staff and directors were not completed until 2017; Ben finally received compensation in November 2023.
Veilstone and its sister home Gatooma, owned by Atlas Project Team, were described as“isolated former farmhouses” and it is generally recognised that such homes are particularly at risk of developing a closed and abusive culture. However, all services are potentially vulnerable, especially those where people are unable to speak up about poor treatment or where there are not robust procedures in place to help those who do.
Amongthe Atlas convictions was founder Paul Hewitt, a well-known figure in mentalhealth who had previously helped formulate national policy on caring for peoplewith learning disabilities in the community, proving that even the mostwell-established, previously outstanding providers are at risk. Previous trackrecord and the skills and knowledge of a service’s leaders are not enough toguarantee it is safe from a poor culture.
Wehave further information for providers on closed culture risks in this article and this topic, and we also have a training presentation for staffand managers and resources for managing therisk. We also have information on employing relatives.
The registered manager (RM) is responsible for the day-to-day running of the service, and so a good manager usually runs a good service. This may seem obvious, but a common theme in reports for services of all kinds in which quality has declined is the loss of a good manager, combined with the lack of proper arrangements for the handover of managers. Sometimes their replacement cannot maintain the previous high standards for many reasons.
All services should ensure that the RM duties are clearly defined and that there are clear procedures and guides to follow to complete those duties, along with delegation plans. In most cases where an effective RM is leaving, they will have given and are working their contractual notice and so there should be plenty of time to organise a handover, but having good plan will also ensure the service isn’t left completely lost in cases of emergency leave or resignations. In smaller services another manager or senior might act up or the provider/director may step in to act as interim manager. In larger services and chains the RM of a sister service may support part-time, or there could be support from regional or operational managers. Whoever steps in, having clear direction and responsibilities for the role will make all the difference.
Unfortunately,if the acting manager does not have an RM’s grasp of what is needed, or iftheir eventual replacement is disappointing, then this can cause a rapiddecline in standards and give a very poor impression of the service. For oneservice reviewed for this article, their very positive 2020 report sang thepraises of the “passionate” RM, however by 2024 the “registered manager andprovider lacked knowledge”.
How we care for people evolves, as it should. Attitudes towards people with learning disabilities, mental health conditions and autistic people have only relatively recently changed to be more positive. It is well within the lifetime of many of the people we currently support that they were looked after in institutional settings — with these settings previously being referred to as“asylums”. Some may even have been medicated unnecessarily or punished for displaying some behaviours, and these practices re-emerge as a feature of failing modern services in some places. Examples in the reports sampled include controlling people’s access to the food people liked, using restraint and restrictions inappropriately, and using dehumanising and patronising language.
In several, what had previously been considered acceptable or even impressive was now critiqued — for example, one home is described in 2019 as having “bright”communal areas, but the most recent inspector thought the décor showed a lack of consideration for people’s sensory needs. Their focus on community work, including litter picking at a local park, had been a factor in their 2017 Outstanding rating and the report describes how beneficial this has been for one person. However, by 2023 the inspector worried because they could not demonstrate how this “met the person's needs and preferences or protected them from degrading activities.” (It’s not clear if it is the same person, or someone else that they are using the same strategies with.)
Even with the best will in the world, people can’t be an expert in everything and there will be times when the service managers or the inspection team misses something. For example, in one service’s most recent report the inspector queried the lack of locks on bedroom doors, but people’s personal security and door locks had not even been mentioned in2017 (when the service was Outstanding) or 2019 (when it was Good). The recent inspector also criticised the home for still looking in places like its previous incarnation as a hotel — it’s hard not to wonder what this amounted to and why the previous inspectors disregarded it in their considerations.
Another service (rated Good in 2019) was recently downgraded to Inadequate and one factor in the inspector’s poor opinion was it being “clear from the roadside people were living within a care setting”, and Street view shows someone had put up an obvious sign between the inspections! Whilst it is common practice for care homes for the elderly to have large signs, those for younger adults are expected to be discreet and avoid an institutional appearance. It appears that nobody at the provider pointed out this was a basic error or was not believed if they did.
Part of the role of the Nominated Individual (NI) is to oversee the RM and ensure there are no blind spots; services where the RM is also the NI, or where the provider is an individual, must ensure they have some sort of “critical friend” who can spot such clangers and be listened to. The importance of the NI being personally and honestly familiar with each service they are responsible for cannot be exaggerated.Larger providers should be cautious about depending on regional or corporate quality assurance assessments; it was identified at one declining service that six area manager reports had failed to identify issues and did not paint an accurate picture at all.
Lockdown left an indelible scar on the care sector. As well as the trauma of the pandemic, the CQC (and local authority commissioning quality teams) were unable to carry out their usual site visits and oversight of services. The move to arisk-based model of inspection meant that many Outstanding and Good services were left to their own devices, in some cases for five years or even more.Under the old assessment regime, even the most Outstanding services could expect to be inspected at least every three years.
As well as being a serious risk factor for the development of a closed culture, l ack of external oversight can cause even a usually tight ship to drift in many other directions. Services that have not had a site visit for several years should consider how they are ensuring they stay on course and make sure that the inspection team, when they do arrive, are not the first people in years to properly audit the service or challenge a provider’s resourcing decisions.
The“threat” of regular inspections is a vital part of the regulator’s power, and sadly the impression from some reports is that some providers have taken advantage, consciously or otherwise, of the lack of oversight to cut budgets and staffing levels. This will naturally have an impact on standards.
Of course, these days even the most scrupulous providers are having to make difficult financial decisions. The rises in essential costs, including food, fuel and wages, have not been matched by corresponding increases in the funding offered by commissioners. All kinds of care services are facing difficulties with recruitment and retention, but providers must realise that skimping on staffing, training and activities is a false economy and dangerous for people, staff, and the business. As well as care staff, administrators and care home domestic staff are also critical to the standard of care.
Most of the worst incidents of the past few years, and the resulting fines and punishments meted out by the CQC could have been avoided if the service had been properly staffed and resourced. All of the declining services reviewed for this article had issues with staffing levels and turnover, often alongside high levels of under-inducted agency staff. Staff were not being trained in the proper use of positive behaviour support (PBS) and restraint. Obvious, in excusable, poor practice like drag lifts and face-down holds were observed.In some cases, managers were having to perform care, domestic and admin tasks due to shortages, meaning that their supervisory and management roles were being neglected.
Once the dust has settled and the causes of the decline have been identified, providers must be willing to devote the time and resources required to recover the service’s previous high standards. Even where resources don’t stretch to an expensive consultant, the NI, director or other suitably senior manager can audit the service, gather feedback, and carry out their own mock inspections.
Plans to improve the service must be practical. For example, if staff are to take on extra tasks, then the impact on their current work must be considered and if new technologies are implemented then the time needed for training must be considered. They should involve the people living in the service as much as possible and in as many ways as possible.
We have many tools which will be of use to providers and managers working to improve their service. Those starting an audit and improvement plan from scratch will find our online inspection tool especially useful. We also have training materials and in-depth topics on People with LearningDisabilities: Developing Services and People with LearningDisabilities: Meeting Their Care and Support Needs.
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