The 2019 CQC State of Care Report was recently published on 15 October 2019. Overall CQC has concluded that the quality of care across the country is improving slightly but raised concerns about individuals continued difficulties in accessing the care and support they require. CQC’s analysis in relation to mental health and learning disability services and the adult social care sector are of particular interest.
Mental Health and Learning Disability Services
This year CQC has placed a focus on mental health and learning disability (LD) services and notes a particular impact on both quality and workforce pressures over the past year. CQC states that its inspectors have seen too many mental health and learning disability services with people who lack the skills, training, experience or clinical support to care for patients with complex needs. The report emphasises the increased demand on such services and acknowledge that this, along with challenges around workforce and access are at risk of creating a perfect storm. One of the main take-home messages resounding from the report in relation to these types of services is the fact that CQC remains concerned about the types of services available for service users. In particular, CQC comments on people spending too long in in-patient wards as a result of a lack of local, intensive community services. CQC notes that 14 independent mental health hospitals have been rated inadequate and put into special measures since October 2018 and calls for “a better system of care” for people with a learning disability or autism who are, or are at risk of, being hospitalised, segregated and placed in overly restrictive environments.
It is interesting to see the CQC focus on LD services this year, particularly in light of CQC’s extremely rigid application of its Registering the Right Support guidance (“RRS”) which has to date caused many frustrations for providers seeking to register these types of services. At Ridouts we have seen many providers struggle to register LD services as a result of CQC’s application of a rigid interpretation of the RRS guidance which fails to provide flexibility for the development of person-centred, service user focused services. Despite the guidance stating that care for people with learning disabilities and autism is complex and that there is no “one size fits all” approach when it comes to accommodation options, we have noted providers not being granted applications by CQC as they have been seen to fall outside of CQC’s prescriptive model. This has led to an increase in providers appealing to the Care Standards Tribunal as their only option to achieve registration.
CQC announced a review of its RRS guidance earlier this year “to ensure its principles are clear and its aims are achieved” however, we are yet to see its response to this. While it was not made clear what prompted this review, I believe it is no coincidence that the review was called at a time when more providers were being forced to pursue the resolution of their registration applications through the Tribunal. It will be interesting to see what comes out of the review, and it is hoped that the review will lead to CQC applying a more common sense, person-centred approach to registration decisions moving forwards which can help clear the back log of people waiting for appropriate placements outside of in-patient wards, helping address the concerns raised in the State of Care Report.
Adult Social Care
In adult social care (ASC), funding and workforce issues continue to contribute to the fragility of the sector with CQC stating the stability of the adult social care market remains a particular concern. CQC notes that there are fewer beds in nursing homes and care homes, and staff turnover has risen for the sixth year running. One of the main contributing factors to this is the fact that there is still no consensus on how adult social care should be funded in the future. Last years’ State of Care Report placed a spotlight on funding in ASC and said this should be an important element of the Government’s social care green paper. However, despite assurances, the green paper is yet to be seen and a large number of providers continue to receive inadequate funding from commissioners to cover the actual cost of care. The two factors are clearly inextricably linked – if you do not have the funds to pay quality staff at a rate that recognises their skills and contribution and investment in the improvement of a service is limited, then it is more likely that staff will experience job dissatisfaction and seek alternative employment.
Clear regional variations in the ability of services to recruit and retain staff are noted by CQC, as are regional variations to how services are commissioned. CQC has noted more evidence of joint commissioning approaches in some areas of the country which can help to address these problems to an extent (the Greater Manchester Health and Social Care Partnership plan is referenced as an example). However, it is noted that integrated approaches to commissioning are not yet widespread and some emerging integrated care systems appear to place less focus on social care than might be expected to deliver good system outcomes. Significant recognition and real action is required from the government to avoid a continued postcode lottery in quality of care and prevent the collapse of the ASC sector.
The prevailing message from this years’ State of Care Report is the need for more closely aligned joint working relationships between care services and organisations to help reduce unnecessary costs and improve people’s experiences of care. Failures in one area of the system can have a significant knock-on impact on other areas. As noted above in relation to the registration of LD services and ASC funding issues, CQC clearly plays a role in this process and it will be interesting to see how it responds to the issues highlighted over the past year while still exercising its regulatory powers – will we see a more understanding inspectorate or will it continue to ramp up its enforcement action against providers who (some through no fault of their own) have been found to fall foul of CQC’s standards?