Seasoned providers of adult social care services will be well versed in the challenges of recruiting and retaining staff. The latest Skills for Care report on ‘the state of the adult social care sector and workforce in England’, published in October 2023, has highlighted the continuing difficulties in recruiting and retaining staff in an industry that is woefully underfunded and undervalued. Its analysis demonstrates the value of the adult social care sector to the economy in England – it is estimated to contribute £55.7 billion per annum (more than the ‘accommodation and food service activities’ industry) – and seeks to identify solutions to the workforce issues highlighted.
Two key areas covered in the report include how CQC ratings can be impacted by the quality of a providers workforce and insight into key factors that impact staff retention.
How Can Workforce Investment Impact CQC Ratings?
The report analyses factors that could affect CQC ratings and noted the following were associated with higher CQC ratings:
- Lower staff turnover rates;
- Higher staffing ratios;
- A stable registered manager;
- Higher care worker pay;
- Higher levels of staff undertaking learning and development (e.g. take-up of the Care Certificate, training and qualifications).
The first three factors are considered in more detail below.
Staff turnover rates are not explicitly prompted for review through the CQC’s current inspection methodology but the existing Requires Improvement and Inadequate ratings characteristics for ‘Safe’ and Well-led’ (KLOEs S3 and W4) note turnover of staff ‘may be high’, indicating this is viewed as a red flag by the CQC. However, under the new assessment framework ‘staff vacancy and turnover rates’ are listed as a specific evidence category under ‘processes’ for the ‘safe and effective staffing’ quality statement demonstrating they are more likely to look at this in the future.
The current KLOEs consider factors that could be influenced by high staff turnover. For example, the familiarity of staff with service users, the provision of consistent care, the continuity of care delivery, the skill level of the staffing team and the maintenance of safe staffing levels (see KLOEs S3, E2, E4 and R1). Such areas have been translated into the CQC’s new assessment framework under the quality statements and evidence categories. Negative findings in any of these areas can influence the CQC’s views of quality and regulatory compliance which can impact ratings.
Safe staffing ratios have proven notoriously difficult to demonstrate through CQC inspection. Previous guidance recommending minimum staffing levels was scrapped when the CQC was created and benchmarks shifted to outcomes focused regulation. The CQC does not recommend any specific staffing calculation or dependency tools and providers are left to determine what ratios are appropriate for their service users. Providers may be asked to justify their staffing levels during inspection.
Examples of CQC inspector observations that have led to conclusions of insufficient staffing levels in care homes include staff not being present in communal areas, routine care tasks not being consistently recorded (e.g. repositioning records, leading to the conclusion that if it is not recorded it did not happen), call bells not being responded to promptly and service users not being given appropriate support to eat meals when required in a timely manner. These observations are usually corroborated by service user, relative and staff members comments on their views of staffing levels.
It is easy to see how higher staffing ratios can lead to better ratings. As long as the right staff are employed and supported by effective management, higher ratios usually result in happier staff, service users and loved ones who will speak more positively to inspectors about their experiences of a service.
Under the CQC’s new assessment framework there is a big emphasis on the collection of opinions from relevant stakeholders – three of the six main evidence categories are focused on feedback – so staffing ratios are likely to be even more influential to ratings decisions moving forwards.
As part of its new assessment framework the CQC is developing a new provider portal. Initial soundings indicate the portal is intended to be a two-way information sharing hub between providers and the CQC. Providers should therefore have the opportunity in the future to proactively supply evidence of positive feedback to the CQC outside of the formal physical inspection process. Providers should be looking to develop the ways in which they collect, record and analyse feedback with a view to sharing this information more regularly with the CQC.
Stable Registered Manager
The presence of a Registered Manager is directly linked to the Well-led key question. The vast majority of providers are required by law to have a registered manager in place and this is applied by the CQC as a condition of registration. The CQC’s existing guidance on inspection lists various ratings limiters, including one which limits a service’s ‘Well-led’ rating to no better than Requires Improvement if they have a condition of registration requiring a registered manager but they do not have one and satisfactory steps have not been taken to recruit one within a reasonable timescale. Through the existing CQC Insights process, the CQC will also look at the history of registered managers at a service to help determine whether there have been any potential changes to the quality of care and this may contribute towards a decision to inspect. With the CQC’s continued focus on risk-based inspections, this approach is likely to continue in some form under the new assessment process.
In the absence of a registered manager, or if there have been multiple changes to the registered manager position in a relatively short space of time, the CQC will be looking for assurances that the provider can demonstrate appropriate steps being taken to ensure effective management and continuity over time. Such steps may include the delegation of a temporary manager, other senior staff members stepping up to cover relevant responsibilities, additional provider oversight during any transition period and sufficient time and resources being allocated for effective handovers to be carried out between departing and incoming staff. These factors will influence the CQC’s view of leadership at a service, which is directly linked to ‘Well-led’.
Key Factors To Retaining Adult Social Care Staff
A new welcome insight from this years’ Skills for Care report is the identification of five factors that are key to retaining adult social care staff. This is of particular interest as staff represent the core of any social care service and, as noted above, turnover rates have been shown to impact the achievement and preservation of positive CQC ratings.
The five key factors identified by Skills for Care are:
- Being paid more than the minimum wage
- Not being on a zero-hours contract
- Being able to work full time
- Being able to access training
- Having a relevant qualification
The report notes that where none of these factors apply, care workers are more than twice as likely to leave their jobs than when all five factors apply – a 48.7% turnover rate compared with 20.6%.
During inspection CQC inspectors are likely to view staff training and supervision records when assessing the safety and effectiveness of a service. Such information is covered under the existing KLOEs and prompts and would fall under the ‘processes’ evidence category under its new assessment framework. Staff training records can be used to corroborate criticisms related to an alleged lack of detail in care planning records. For example, if the CQC note a specific medical condition has not been sufficiently described in a care plan, a lack of staff training in that area could be used to corroborate a conclusion of unsafe care provision. Additionally, if a staff member stated they felt they needed more training in the particular area this could be used as further corroboration, regardless of whether training records indicated they had received previous training. As noted above, feedback is a key evidence category under the new assessment regime and it appears the CQC may be placing an even stronger focus on what people say in the future. Therefore, investment in staff training and working with staff to identify potential training needs is key to helping boost both staff retention and CQC ratings.
A robust staff supervision policy that is more than a tick-box exercise is one clear way providers can help staff feel valued and supported. Seeking feedback from staff on challenges faced in their roles can help providers identify factors that may cause a staff member to leave before they go, thus improving retention rates. Feedback sessions can be held as part of, or in addition to, a provider’s regular staff supervision sessions. Additionally, setting out a clear career pathway and supporting staff members to gain relevant qualifications to help them progress can provide motivation and job satisfaction.
While factors such as the lack of funding and investment in the sector demonstrate obvious hurdles, providers should be continually reviewing opportunities to invest properly in their staffing teams. The Skills for Care report confirms there is a lot that can still be done outside of increasing salaries to help improve recruitment and retention of staff. Providers who can demonstrate a clear investment in their staffing teams are more likely to improve retention rates and achieve higher CQC ratings.