Good care but carelessness: what I found from shadowing a CQC inspection
Until recently my only experience of the inspection of care homes came from supporting my dad through life in three different care homes over nine years. As relatives we welcomed seeing inspectors in my dad’s care homes, in both good and bad times, although I felt frustrated at what often seemed like a lack of real action.
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My dad died in April 2012 and since then I’ve become involved in the Care Quality Commission’s co-production of the new methodology for inspecting adult social care. The meetings have been enlightening, but I wanted to shadow an inspection team to see what is really happening at the coalface.
The inspection I went to was of a 60 bed care home run by one of the largest providers in the UK. The home was split over two floors – frail elderly and dementia care – and had almost complete occupancy, with a registered manager in post, few staff vacancies and almost no use of agency staff.
The inspection team consisted of two inspectors, an expert by experience and a pharmacy inspector. The expert by experience was a woman with personal experience of care homes and working with people who have dementia. The inspection was unannounced, and I was an impartial observer who had no influence on the outcome of the inspection or the subsequent report.
During the day I shadowed the lead inspector as she spoke with the manager at the start of the visit and was given a tour of the care home. I spent time with the pharmacy inspector as she discussed medication practices with staff member and accompanied the expert by experience as she spoke with residents and relatives.
What struck me most about the inspection was how varied it was. The common perception is that inspections are all about checking records and, yes, records were checked, but the investigations didn’t end with whether paperwork had been completed correctly. The pharmacy inspector initially found few problems with the record-keeping relating to medications but she went on to speak at length with staff about their understanding of the medicines they were administering.
By having a pharmacy inspector on the team, it became clear that a high proportion of residents had prescriptions for benzodiazepines and antipsychotic medications, some of which had gone unreviewed for years. This was a joint failing between the care home and the GP. Moreover, due to gaps in training, staff members were unaware of the potential risks when these medications are given to people with dementia, including increased falls and even premature death.
While this was being uncovered, the lead inspector spent a large proportion of her day observing residents in the dining room over lunchtime using the short observational framework for inspection. The tool, developed with the University of Bradford dementia group, is a way of observing care to help the inspector understand the experiences of people who struggle with verbal communication.
On chatting with the inspector later, it transpired that she had observed a person having their cutlery taken off them and being fed, despite the person being able to eat independently, albeit slowly. On one occasion, a member of staff had put four spoonfuls of food into the resident’s mouth before they realised that person had not been swallowing the food, while another resident had their head held to make them either drink or have their drink spilt on them.
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While shadowing the expert by experience, I met some lovely residents who were largely happy with their care. Most people appeared well looked after, although they would have perhaps been less happy had they seen some of the care plans. Residents were often described through behaviours rather than being seen as a person, to the extent that one resident was described not by their name but as “it”.
But for everything we found on this inspection, will there be real action? In the feedback session the manager, who prided himself on being very hands-on, looked visibly shocked at what had been discovered and vowed to address every issue, which I felt was a genuine intention to improve. The inspector has since written a very balanced report and given a rating of “requires improvement”.
I hope that improvement has already happened. What I am certain of is that by being inspected, the eyes of the manager and his staff team were opened, residents were valued for their opinions and experiences and relatives were assured that quality is being monitored.
Inspection will only ever be a snapshot of a service, but by having a larger team and implementing a more thorough methodology, this regulation was far more comprehensive and insightful than any used in my dad’s time in care homes.