Elizabeth Kendrick: Enhanced health care in care homes

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Dr Elizabeth Kendrick, National Professional Adviser for Older People at the Care Quality Commission (CQC), discusses the CQC's latest work in ensuring safe, effective care and encouraging care home services to improve.

This presentation was recorded at our conference, Enhanced health in care homes, on 6 December 2016.


Thank you very much for inviting me today. I am going to talk to you about enhanced healthcare into care homes, and CQC’s approach to that going forward. I have got a lot of questions, because CQC is not there yet about how we would take this forward, so there are some questions for the audience as well going forward.

So I just thought I would give you some background. I am sure you all know that we are the independent regulator of health and adult social care in England. And that really places us in a very unique position in terms of we are regulating different parts of the sector, but we should be able to look at enhanced health in care homes and how the different parts of the system are working together to provide safe, effective, compassionate and high quality care.

So what do we actually do in practice? So we register people. So if you want to set up a service providing regulated activities, you have to register with the CQC, and then we monitor, inspect and rate.  And monitoring is going to have a really big role going forward with the CQC, and it is going to be about the relationships between the inspection managers and the providers, but it is also going to be about how the different inspection managers in the area work together.  Because CQC has actually got an integration task going forward, because we inspect in three different directorates.  We have an adult social care directorate who inspects care homes’ domiciliary care.  We have the PMS directorate who inspect things to do with general practice and dentistry, and we have our hospital directorates who inspect hospital services and community services.  And clearly with enhanced health into care homes there is an overlap between those three different types of inspections going forward.  And CQC is doing a bit of work at the moment about cross directorate working, and how we can actually change our culture so that the inspection managers and the inspectors work much closer together within a region, so we can look at a system in a better way.

And part of this has been through our thematic reviews. CQC last year undertook several thematic reviews, and people in this room may be most aware of the integrated care for older people which was published in July of this year. That looked at eight health and wellbeing boards, and looked at how services were working together around older people.  We found lots of examples of people doing integration work, but often it was on non-recurring funding, with very short timescales, not necessarily any time to evaluate what had been done by the project.  And we found that the health and social care landscape became increasingly confused and crowded by lots of small projects that were set up, and it was difficult for the professionals, not to mention the patients and their families, to actually navigate the landscape.  We also have enforcement powers where we find poor care.  We ask providers to improve and can enforce this if necessary.  And then we provide an independent voice, about the state of adult health and social care, and the independent voice published this year talked about the tipping point and the crisis in adult social care.

So we have already talked about what we do now. We do our ASC inspections where we look at care homes, and we look at that under a framework, and we look at PMS inspections. And as part of PMS inspections we look at older people, and how GPs are looking after their older people.  But we don’t specifically look as part of GP inspections, as to how GPs look after care homes, and clearly the relationship between the GP and the care homes can be really crucial.  As part of hospital inspections we look at community services, so we may well be looking at the district nurses, we look at dietician services, we look at physio, rehabilitation, but we are not necessarily looking at that in the context of what are they doing in a care home?

So we have already talked about the bits of the NHS England and Vanguards and that has been covered, so I am not going to talk a lot about that. But if we are going to take this forward, how are we going to look at what primary care are doing as part of the enhanced primary care into care homes? And what we are doing is, our next phase work going forward, we are going to take this forward as part of the older people part.  So in GP inspections at the moment, we look at how GPs look after older people, and going forward we will develop that, so we will look at what the enhanced primary care into care homes is as part of our older people population group within general practice.  And at the moment we are developing the prompts to go alongside that, so our inspectors are there, and can ask the relevant questions for this.

The MDT in-reach, we can look at that as part of our community services, and we are developing pathways to how we inspect community services. And so instead of looking at district nurses is one thing, looking at OTs/physios is a different part of community services. The plan for going forward is we may well look at a pathway for a patient across community services, and then speak to the different people involved in those pathways.

Re-enablement and rehabilitation. At the moment if you are in a care home, and you have a re‑enablement, rehabilitation part in your care home, that gets looked at in the same methodology as a normal care home. And quite a lot of the inspectors within CQC have found that really difficult to actually inspect, because the re-enablement rehabilitation side of the care home are actually trying to do something very different, and trying to get the patient home, than the people who are having long term care within the care home setting.  And if we approach that in the same way as an organisation, not only do our inspectors find it really difficult, but also the care homes find it really difficult to articulate what they are doing around that, but also to apply it to our inspection methodology.  We looked at inequalities in end of life care and our thematic review, so that was published in May of this year.  If you are interested in end of life care I would really encourage you to read it.  There are short summaries about end of life care for people in care homes, and also short summaries about end of life care for people with dementia.

And we learnt a lot about that, and in general we found that end of life care for people in care homes, and end of life care for people with dementia, was not as good as the end of life care that was provided for people with cancer. And that is not massively surprising, because there has been a big focus on end of life care for people with cancer, but there has been lots of recommendations that have come out of that. And we have made a big plea to our hospice sector as well to think about how they work better with care homes, and how they would work better about providing end of life care for people with dementia as well.  Workforce development is important as well, because CQC don’t want to be seen as an obstacle to people developing their workforce.  So one other thing is lots of myths exist around CQC.  So somebody told me that they couldn’t teach their care home staff to dip urines, because they would have to re-register with CQC as a nursing home rather than a residential home.  And those kind of myths just seem to grow and get exaggerated and it kind of goes round, and it’s not just one person who has brought that up with us, we would have to change our CQC registration if we trained our care staff to do nursing tasks.

And so there is really important myths that we need to bust out there, and I have also had so many people tell me in this job that they can’t possibly share information with care home providers, because CQC wouldn’t let them. And that is really not the purpose of the CQC, to stop you sharing information between different partners in the system. Telehealth and IT present us with an increasing challenge.  I am at the moment looking at inspection of digital primary care, and we have to define our methodology going forward for that, because actually inspecting, how can we ensure safe, high quality, effective care going forward when the doctors or the nurses who are providing that care, maybe actually all over the country, geographically spread from where the registered provider is.  How do we actually ensure when something is going on online that it’s safe, high quality, and effective care.  And we have got a digital strategy going forward, and we are going to start inspecting digital primary care from next April, and at the moment we are developing the methodology for that.  And the Vanguards who have a lot of digital IT also present us with challenges about how we develop our methodology for that going forward.

We don’t at all regulate commissioning, we do sometimes look at commissioning. So as part of our thematic work, we get a section 48 from the Secretary of State for Health and that allows us to look at commissioning, and that has really been very powerful in our thematic work. So we have found, not surprisingly, that those people who had a really good commissioning strategy for end of life care, that in their area there was much better end of life care than those people who didn’t have a commissioning strategy for end of life care.  CQC don’t normally comment on commissioning, but obviously they do as part of their thematic reviews.

So we have got a bit of work going on at the moment around cross directorate working. We have got this bit of work that is trying to bring different inspectors at a regional level together to talk about the intelligence that they are collecting, and to talk about problems within their system, and how they impact on the different parts of their system, and that is a really big bit of work for us going forward in the next financial year. We have already started the bit of work to enhance the older people’s population group in general practice, to accommodate the learning that we got from the About Enhanced Health Into Care Homes.  We had a really successful day in September which a lot of people in this room came to, and we brought together an internal advisory group from CQC, so inspectors who were there on the ground looking at care homes, inspectors who were there on the ground looking at medicines management, inspectors who were there on the ground looking at GP practices.  We brought them together in the morning, and we said ‘Okay how would you approach this new challenge about enhanced health into care homes?  How would you develop our methodology to actually incorporate that going forward?

And then a lot of people who I can see in the audience today came to an afternoon workshop which was an external advisory group to say what ideas have you got that we could take this forward? So we are enhancing the older people’s population group in general practice, but we are also looking at MDT working. And we are going to hopefully next year pilot a pathway approach to looking at care homes in the north region for CQC, looking at community services, working with their PMS colleagues, working with the care homes in a region.  We are also doing two place based activities in January/February next year, and place based activities are where we go and look at a system rather than look at individual providers.  We did Salford and Lincolnshire last year, and we are going to do that, and one of them is going to be around care homes.  We need to think again about this intermediate care, or re-enablement beds, and in general our inspectors felt that they should be looked at differently from normal care home beds, so we need different prompts to be able to assess them going forward.  And I would be really interested in people’s views in the audience as to whether you think that is a good idea or not.

So we had this internal and external workshop held in September, and the questions we asked was how can we address the challenges going forward, and what can we do differently? The outputs have been fed into the quality improvement groups, we have an adult social care quality improvement group, we have a hospital quality improvement group, and we have a primary medical services quality improvement group. And the outputs from that event were fed into the three different quality improvement groups.  End of life care is really going to be improved in our inspection methodology going forward, really looked at as part of the adult social care inspections, and also really looked at in terms of the primary medical services end of life care, is also going to be looked at.  At the moment we have got some national clinical fellows working with us, and one of them is working with the hospital director as well, to see how we can look at end of life care within hospitals in a more robust way going forward.

Oral health, somebody already mentioned the guidelines around oral health in care homes. And John Milne who is the national professional adviser for dentistry is very keen that we take this forward. So we look specifically at oral health in care homes as part of our inspections, and we are working out the best way that we can do that, whether it’s by incorporating an additional prompt within the care home sector, whether it’s by looking at this as part of dental inspections, we are doing that at the moment.  At the moment we are also doing a little bit of work about discharges from hospitals.  So how do we discharge people from hospitals, what kind of information do they provide to people on discharge from hospital, and is that the appropriate information?  And can we see evidence on our inspections that actually the information that is provided on discharge is appropriate and useful to the people who are actually receiving the patient home.

So we have developed a brief guide to discharging people from hospitals, it is going to be used by our hospital directorates, when they are talking to hospital discharge teams. And we are also going to flip that, and ask people at the other end what kind of information they are getting on discharge from hospital, and is that appropriate information, and is it useful, and timely and all that kind of thing. The place based work, we are doing two bits of place based work going forward, and one of them is specifically going to look at admissions and discharges from care homes to hospital.

So I have got some challenges for you as well. Part of our methodology going forward is how do we assess risk? So CQC is under financial constraints, the same as everybody else is, and could we develop a data set that told us about quality of care in a care home?  Could we actually look at developing a risks based strategy, or is it still about that individual relationship between the inspector and the care home staff, the care home manager?  So at the moment our inspectors have a portfolio of care homes that they look after, and they have relationships with that care home, but they also get intelligence.  So we have a big call centre in Newcastle where members of the public, relatives, health professionals, can phone up if they have concerns about a CQC regulated place.  And we also get intelligence through safeguarding alerts which come through as well.  But could we develop a data set that told us about quality of care in a care home, and how could we use that to develop a risk based approach to inspection going forward?

And then another really big thing for us is, can we look at wellbeing and preventing deterioration, because at the moment, we just look at the care as we find it, and we don’t necessarily focus very much of our inspection methodology on how we prevent deterioration. And clearly in a system that is tight, and a system that is under financial pressure, actually looking at how we prevent deterioration is really, really important going forward, and it is really important that CQC is being seen to support that, so we can act as a quality improvement tool within the system. So that is another bit of work, but that requires a kind of change of mindset and culture within the CQC, because we haven’t previously looked very much at how we prevent deterioration, and that requires staff training, and all kinds of things to go with it.  But that is a big bit of work that has been looked at as well.

So we have got a new strategy going forwards, that is because we are working in a changing environment. The Vanguards, not just the enhanced health into care homes Vanguards, are providing new complex systems that require different levels of regulation, and there is also how do we adapt and improve to stay relevant and sustainable for the future? And we know that there is more to do.  So we need to be a more targetive, responsive and collaborative approach to regulation.  How can we work better with our different partners in the system, but also our primary aim is to ensure more people get high quality care.  So we need to encourage improvement, innovation and sustainability in care.  There is this intelligence driven approach to regulation, how can we pick up on the intelligence we already have from our previous inspections, but also the rest of the intelligence that is out there in the system?  We want a single shared view of quality, so we want to say that the quality is a single shared view across our three directorates, so we can improve our efficiency and effectiveness as well.  That is my e-mail address, I would be really happy for people to contact me afterwards if you have any queries or questions relating to this, really happy to talk to people who are running Vanguards as well, who have different queries about CQC regulation.  And we have a Vanguard team who are dealing specifically with those queries who I can put you in contact with.

Thank you very much.


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