To say it’s been a tough year would be a shameful understatement. The health and social care sector has been tested like never before. Day after day we have been presented with harrowing statistics on how COVID-19 has tightened its grip on the world but amongst the bad news and escalating fear, we have seen innumerable examples of human kindness at its finest.
Social media has been awash with everyday people going above and beyond to help each other and these cases are indeed worthy of celebration. But what happens when being caring, compassionate and determined to go above and beyond is simply a requirement of your job? Here we find social care workers, earnestly and doggedly showing up to work day after day to deliver care to the most vulnerable people in our communities. These people have been the back bone of the social care sector for almost a year now and although many lives have been tragically lost to the virus in care services, this would have been far worse if not for the sacrifice and compassion demonstrated by many staff.
By now care providers will be reflecting on how their staff teams have performed and the dedication they have shown in their work. If the pandemic has shown us anything, it’s that good care staff are completely invaluable, but actually, this is nothing new. Now is the time to properly take stock of the importance of staff and the enormous impact that they can have on the success of a care business, not just in commercial terms but also from a regulatory perspective. To understand the importance of staff in a number of key areas will go a long way to meeting the requirements of a number of regulations and demonstrating to the CQC that you are a compliant provider.
The basics – Regulation 18 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 – Staffing
We’re all familiar with the requirements of Regulation 18. In accordance with that provision, a provider must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced persons must be deployed within the service and that those staff members are appropriately trained, supervised and supported.
At Ridouts we have seen hundreds of inspection reports that have cited staffing issues as a reason to downgrade a domain or suggest that a service is not safe. Often, the only evidence on which the CQC rely to arrive at this conclusion are innocuous comments from staff such as “I’m rushed off my feet” or “I wish we had a few more staff”. Judgments can be made without consultation with any documentation (most notably a rota or a staff dependency tool). All too often, the CQC take casual remarks like this as fact when actually, the simplest investigation would probably demonstrate that the numbers of staff working are appropriate and that the needs of the service users are being met.
Similar issues arise when inspectors ask staff about training that they have received. This is particularly common when staff are questioned about their knowledge of mental capacity or safeguarding. Staff can feel intimidated when questioned about their understanding or interpretation of certain areas of delivering care, especially something as complex as mental capacity, for example. A staff member may panic and immediately think that if they respond incorrectly then they, personally, will be challenged by the inspector or be subject to scrutiny. As a way of protecting themselves they may answer that they can’t remember or that they simply haven’t been trained on that subject, when in reality, they have. Again, an inspector may take such a response at face value and not consult a training matrix or staff records which contain certificates for relevant training. This can have a serious impact on your rating and can lead an inspector to conclude that the service is not compliant.
The best way to avoid such a scenario is to build “inspection confidence’ amongst staff. Mock inspections and spot checks will get them used to the “pressure” of the scenario. Staff should be encouraged to speak with pride about their gathered knowledge and get used to the feeling on being questioned by an inspector. Encourage them to showcase their skills with confidence.
In order to satisfy the CQC that Regulation 18 is being met, providers must keep clear and detailed records of staff training, a comprehensive training matrix and evidence of completed training. This can be provided to the inspector even if they do not ask for it and used to contradict inaccurate assertions made by an inspector or to give information that was not considered at all by the regulator.
Dependency tools and a clear rationale behind staffing levels are very important.
Infection Prevention and Control (IPC) inspections
Over the last 12 months staff members have been wading through an avalanche of ever changing guidance from Public Health England, Central Government and local authorities (to name a few sources). Guidance has changed alongside the dynamic pandemic and approaches to PPE, visitors and general infection control protocol have varied along the way. In recent weeks, Ridouts has seen a significant number of draft inspection reports produced as a consequence of an IPC inspection.
Many have demonstrated isolated errors by staff, for example, not wearing a face mask properly or improper disposal of PPE, which have resulted in a service being downgraded to “Inadequate” overall. Whilst there is no excusing failure to rigidly and attentively adhere to infection control policy and procedure, there is clearly a level of fatigue amongst some staff members, exhausted by what has happened and is continuing to happen, in recent months. Whilst disproportionate inspection reports can be challenged, (and they absolutely should be if a report paints an inaccurate or disproportionately negative picture of a service,) there is no guarantee that the CQC will amend its findings unless robust evidence is provided demonstrating that a finding is incorrect. In fact, the regulator will aggressively stick to reporting on what it found during that inspection, even it if was simply an unfortunate “one-off”.
On that basis, it is vital that providers remember to support staff wherever they can. Above we discuss mock inspections to build staff confidence but it is also imperative to closely and regularly supervise staff to ensure that their practice and understanding of guidance is up to date. Regular refresher training should also be offered in this area. Small issues can add up during an IPC inspection and it can be particularly cruel to see a service that has performed well during the pandemic have its rating reduced on the back of avoidable mistakes. In more than one case, Ridouts has seen “Good” rated providers who have had zero positive COVID-19 cases within the service, across an almost 12 month period, be penalised by CQC inspectors for momentary lapses in protocol during inspection. Focused IPC inspections have reduced their rating down to “Inadequate” and in some cases the CQC has taken formal enforcement action (particularly urgent action under Section 31 of the Health and Social Care Act 2008, as discussed by my colleague Caroline Barker in this article . Ridouts has intervened in several cases in the last 2 months, challenging decisions and proposals made by the CQC arising from IPC inspections.
Basic compliance with Regulation 18 (as discussed above) with IPC in mind can go a long way to ensure that your staff can demonstrate compliance and that they can feel confident that their knowledge base is up to date.
Whistleblowing and complaints
As providers will be aware, it is vital to create and develop a culture of transparency within care services. Having a clear and accessible whistleblowing policy will not only enable staff to draw the provider’s attention to any issue that may need to be addressed to ensure safe provision of care, but it will also negate the need for them to direct those concerns to external parties (e.g. the CQC) which could result in an inspection or further investigation. All too often are providers blindsided by problems because staff did not feel comfortable raising it directly.
Whistleblowing allegations feed directly into the CQC’s risk based approach to inspection and where allegations are made, the CQC is more likely to attend to inspect with those negative allegations in mind, thus prejudicing an inspection from the “get go”. Local authority safeguarding teams also rely on such allegations as the basis on which to investigate a service which can have a detrimental effect on the relationship with the commissioner both commercially and reputationally.
If staff are given the appropriate forum to raise concerns, deliver feedback or make a complaint directly to the provider, then this will only have a positive impact on the service and the people that live there. It will also demonstrate to staff that a provider takes their views seriously and wants to involve staff in bettering a service.
Keeping clear records of concerns and detailing how each has been resolved is essential evidence for the CQC, as are the minutes of any group staff meetings that are held where feedback may be sought. Not only will this help to develop a positive and supportive culture at the service, but it will also create evidence that helps to demonstrate a “Well-Led” service to the regulator.
Acknowledgement and reward
Small gestures of gratitude can go a very long way, particularly in the wake of such a challenging year. Whilst there is a hopeful conclusion on the horizon, it is not the time for our sector to take its foot off of the gas pedal, especially in the context of a reinvigorated, unsympathetic and at times disproportionally punitive regulator.
Although the sector continues to work hard, there are things that providers can do to boost morale, show appreciation and reward staff for their work thus far. Staff fatigue can be a huge factor in adverse inspections as can negative feedback from staff that feel underappreciated or ignored. As such, providers may want to think of innovative and meaningful ways to demonstrate appreciation to staff, in order to build trust, mutual respect and loyalty. Staff that feel valued will always go the extra mile.
It has been painful to watch the efforts of social care staff be largely ignored whilst the nation claps for the NHS, but this is not to say that praise and reward cannot be delivered on a micro level. Developing relationships in this way will have a positive effect in both the long and short term.
Conclusion
After over a decade of assisting, studying and analysing care services through my work with Ridouts, the influence of staff is undeniable. Staff conduct, attitude and investment in their work is a common denominator in all inspection reports, be it positive or negative. Staff will make or break a service. Careful and considerate management of a care service’s greatest asset is vital in driving a care business forwards, ensuring compliance and delivering good care.
