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WE SHOULD NEVER ACCEPT THAT IT IS OK FOR THINGS POST CRISIS TO RETURN TO THE STATUS QUO.

We as a society have lost sight of elderly people and allowed a broken social care system to remain unaddressed for very many years. So much so, that when a health crisis such as COVID 19 landed on our shores, care providers were ill prepared and as a result older vulnerable people have been decimated in their thousands. Covid 19 has disproportionately taken its toll on elderly people. Many older citizens have died in hospitals, in care homes and on occasions, alone in their own homes. Over the last few months we have witnessed a lockdown that has excluded families and friends visiting residents in care homes. That has been compounded by the absence of regulators and service commissioners during the same period. No one knows - other than staff - if residents have died alone, or in pain or even their actual cause of death. Often GP services were unavailable, ambulance transfers to hospital discouraged and it seems DNR (do not resuscitate) orders added to their care documentation. Their families have had to suffer in silence, experiencing terrible anxiety that arises from not being able to comfort their dying loved one.

The care home sector has been an integral part of the provision of social care. Some 400,000 registered beds exist in the UK to provide long term care for those who need it and the sector is a major employer of social care staff. Yet the care home market is generally denigrated and disrespected in so many ways. It is not a sector that is universally loved, and it is the persistent negative sentiment that often makes much needed recruitment that much more difficult. The motives of care providers are constantly questioned creating speculation and innuendo as to what happens day to day in the majority of care homes.
For many care providers it is not difficult at all to understand why the NHS is held in such high esteem, but yet completely baffling as to why the social care sector (and in particular, care homes) is perceived as the poor relation. Whilst accepting that public opinion may support the widely held view that quality social care and profit are not appropriate bedfellows, I nevertheless believe a fundamental misunderstanding exists as to the value care homes bring to their local communities and in particular, the quality improvements they can give to a vulnerable elderly person needing care.

""It's one thing to consistently call out poor practice and make critical observations as to how the social care system is failing, but perhaps it's time to draw attention to some options for sector renewal."

For very many years it has only been the scandalous headlines that have been broadcast across our media and in most cases for very good reason at the time. However, the vast majority of care home clients have a much more positive experience and indeed enjoy a lifestyle that living alone or being cared for by an exhausted family member could just not deliver. It should be remembered that 70% of all abuses perpetuated against older people occur in their own home.
If criticism was to be levied at providers, it is that they have by and large resisted real transparency and failed to embrace technologies that would allow for greater visibility around their services, care practices and financial returns. That gives the appearance of not wanting close scrutiny which in turn feeds the view ‘they have something to hide’. Families who want greater reassurance, are often left without explanation or evidence as to what has happened to a loved one.

Sector problems are many. Like most parts of the social care sector, stable funding is an issue, volatility in occupancy levels creates cost management stresses, declining pools of trained staff resource makes it difficult to contain staffing costs (creating an over dependence on agency personnel), sector sentiment tarnishes the image of working in care homes and generally average fee rates paid by local authorities are much too low. Many homes are paid a weekly fee that is lower than local hotel rates yet they have to provide so much more in terms of the resources required to deliver personalised individual care.
This horrible pandemic that has taken so many lives must surely now act as a trigger for change for all those associated with the provision of elderly care.

WE SHOULD NOT EVER ACCEPT THAT IT IS OK FOR THINGS POST CRISIS TO RETURN TO THE STATUS QUO. So, what must happen now?

Six Point Plan for Change

•An overhaul of the current regulator to move away from a ‘one size fits all’ approach and to create stronger powers of sanction. That should also include root and branch reform to embrace systems that ‘red flag’ concerns much earlier in a process. More emphasis on regulation by technology as opposed to a statutory visits programme
• A fair care home fees assessment process that acknowledges higher levels of dependence, the presence of co-morbidity and a needs complexity that requires additional funding support to ensure the very necessary extra resources are provided.
• The mandatory adoption of a technology ‘toolkit’ to ensure older people receive the care they and their families expect and to provide much greater levels of transparency for other stakeholders

• Minimum staffing levels relative to actual occupied beds. Those staffing grids should include skill mix requirements for care staff and expected numbers for housekeeping, activities, admin, catering and laundry personnel. They should also reflect the reality that trained staff availability is limited and create new supervisory roles for appropriately trained senior carers with revised levels of compensation.
• Government should consider undertaking new build publicly funded care facilities to inject additional competition into the sector and ensure providers collectively don’t have a price setting monopoly. Those public sector facilities can also lead on the quality agenda.
• Independently provided true cost of care analysis that includes a fair and reasonable ROI. Should be prepared on the basis of care categories and a range of care dependencies. Should also consider the possible economic relationship between fees optimisation and full occupancy maintenance via provider contracts.

Point by Point Review
1. An overhaul of the current regulator to move away from a ‘one size fits all’ approach and to create stronger powers of sanction. That should also include root and branch reform to embrace systems that flag concerns much earlier in a process.
• Clearly, the current regulatory and inspection regime hasn’t of late been effective. Indeed, it appears to have lost the confidence of the general public and it is perceived as toothless when material enforcement is required.
• The cost of delivering regulation and inspection should be fully met by health and social care providers and annual fees weighted for such. That however should not create a perception of infinite resources, as provider appetite and ability to absorb escalating year on year costs will be limited. Fee discounting should be afforded to those providers who accept technologies that permit the regulator to get information remotely, in such a way as to ‘alarm raise’ which then results in an inspection.
• The Regulator could embrace a corporate structure with its ‘notional shareholders’ being care commissioners, family representative bodies and Government. Annual quality accounts should drive decision making and Executives should be rewarded on the basis of budget adherence and quality accounts achievement. Regulators should not just be lifetime public servants.
• Inspection frequency should be reconsidered. If providers were mandatorily required to adopt surveillance, quality monitoring and care documentation technologies, inspection visits could be driven from the reporting of those tools. The outdated idea that every site is visited x times per annum regardless of care performance hasn’t proved to be robust. Further, often a provider is informed about a regulator visit beforehand. Ensuring a service is at the required standard on a particular day, isn’t indicative that very same service is at that performance level for the remaining 364 days in that year.
• In the age of technology, providers should be remotely monitored. Red flag technology could provide feedback to the regulator at a very early stage, which in turn would then lead to prioritising a site inspection. Companies should be engaged to work with CQC to develop monitoring platforms perhaps in the first instance for sanctioned homes.
2. A fair care home fees assessment process that acknowledges higher levels of dependence requires additional funding support to ensure extra resources are provided.
• A single Resident/Patient cost analysis tools should be embraced for use by all care providers and commissioners. Upon assessment of a potential care home patient, that tool should be utilised to determine the care category and the associated care component of the overall fee rate. A fee range should relate to a care category and be easily determined by any health or social care professional. It should for example specify the number of ‘care hours per resident day. That would ensure that care complexity is recognised and funded with providers incentivised to admit more challenging patients.
• Providers should retain the right to set the accommodation component of the fee charge albeit those providers with higher quality homes with additional resources, better levels of finish and presentation etc should have the ability to add an accommodation premium, much in the same way the hotel sector operates.
• Providers should have an option to provide extra services in excess of a standard service specification. Those services would be provided at a further charge. Families should expect to pay a ‘top-up’ for services in excess of a standard specification.
3. The mandatory adoption of a technology ‘toolkit’ to ensure older people receive the care they and their families expect and to provide much greater levels of transparency for their families and all other stakeholders
That toolkit could include;
• Third party safety monitoring by a team of healthcare professionals; Safety monitoring companies exist that place cameras in care homes and use them to support the provision of consistent high-quality care. Footage is retrieved by a professional healthcare team who assess content every single day and triage the response required, including the timeframe. Regulator access could be provided by those companies or indeed regulator training undertaken to permit regulators to operate a monitoring system as part of a virtual inspection process, (see Appendix 1 for a typical safety monitoring company summary)
• Independent third-party whistle blowing services operated via an app; A number of applications presently exist that would allow staff to report concerns on an anonymised/identified basis to a third party. That third party would then manage the raised concern directly with the care provider to ensure the matter was addressed. The whistle-blower can at all times get an update as to the management of their concern via an electronic dashboard. The independent whistle blower agency can in turn alert the regulator and other agencies if necessary.
• Electronic care planning documentation used by all care staff; To reduce paperwork and ensure very quick retrieval of care information, all providers should be encouraged to move to electronic care plan record keeping. That software provides ‘red flag’ alerting which regulators could use as an early warning sign that standards were slipping at a particular care service. Remote monitoring of food and fluid intake would also be possible.
• Agency Staff National Accreditation Programme that would allow all providers access to an electronic database to determine if temporary staff attending a site had the required qualifications, the necessary training and any current sanctions on their professional practice record. Providers would be required to submit concerns to an agency owner who in turn would have to update the record in the event of a determined sanction.
• National Care Workers training programme that has minimum skill set requirements before an individual can deliver care unsupervised. Staff would have to possess a set of core competencies before they could attend to vulnerable people. Part of that training would be site based and delivered by existing staff but external training around core values relating to working in aged care could be delivered by training agencies. Payment would be a care worker liability as essentially it would be an investment to improve job prospects.

4. Minimum staffing levels relative to actual occupied beds. Those staffing grids should include skill mix requirements for care staff and expected numbers for housekeeping, activities, admin, catering and laundry personnel
Minimum staffing grids relative to occupied bed numbers. No technology can ever be a substitute for appropriate numbers of trained and skilled care staff. Vulnerable people with care needs are dependent upon a care service having nurses and carers in sufficient numbers to ensure they receive a safe and professional standard of care. That means overall staff quantity and the skill mix of that staff group. Staff rostering technology combined with staff login/logout functionality would also ensure that an electronic record existed of all staff on duty at any point in time. That would allow the regulator to remotely monitor staff numbers if they so wished.
• Support Services minimum staffing; recommended staffing levels for catering, laundry and housekeeping services, activities personnel and administration will ensure that the overall patient/resident experience is positive. A number of UK polls involving care home residents have confirmed that the ‘food and meals experience’ is something very many older people in care look forward to. It is a big part of their day. Having activities personnel is also a priority to ensure older people are stimulated and living a fulfilling life. Families also wish to see their loved ones enjoying a community experience as opposed to sitting in isolation with limited or no interaction. Staffing numbers should be stored on electronic records.

5. Willingness to consider new build government owned and operated care facilities to inject additional competition into the sector and ensure providers don’t have price setting monopoly.
• A dependency only on third sector provision will allow providers in time to become price setters, to dictate the quality agenda and resist all calls for change, innovation and improvement as no other care provision alternatives exist. They may in time avoid admitting patients with complex and challenging needs if demographic pressures permit such, so publicly owned facilities will be needed for such patients.
• It shouldn’t be assumed that all providers are making gratuitous profits and that all costs associated to implementing change can be borne by care providers. If for profit sector is to develop facilities for challenging complex patients, fee rates should create an incentive to do so.
• The UK sector has been contracting from a supply standpoint because fees have not kept pace with cost inflation (specifically minimum wage pressures, declining numbers of available staff increasing dependency on agencies, reducing pools of nurses being trained etc) and at the same the dementia demographic has been increasing exponentially. Before this crisis it was clear demand was beginning to outpace supply and as a consequence price would have eventually in normal circumstances been expected to increase as a result.
• That said, UK austerity economics resulted in those needing care languishing in hospital beds under delayed discharge arrangements or alternatively remaining in their own homes without the care they need. Government owned facilities or provider incentives will need to exist to address such.
• For these reasons Government should reflect on whether or not it rapidly expands current state-owned provision to create the necessary sector competition. That would ensure insight exists in terms of the commercial reality of providing services in the aged care market, ensure bed supply exists to meet emerging demand for such and resolves hospital bed blocking by the challenging more complex older person needing more specialist care.

6. Independently provided true cost of care analysis that includes a fair and reasonable ROI. Should be prepared on the basis of care categories and a range of care dependencies. Should also consider the possible economic relationship between fees optimisation and full occupancy maintenance via provider contracts.
• True cost of care review; Some consideration should be afforded to commissioning an agency (PWC, KPMG, Deloitte, et al) to undertake a sector wide review of the typical cost of care. Having some insight to provider ROI will ensure some comprehension exists as to what is actually deliverable in terms of care standards and service delivery. Certainly, in the UK sector very significant fee variations exist in different parts of the country and as a result care quality is patchy with providers only developing new facilities in areas where fee rates allow for a sensible ROI. In other areas whilst demand is high, insufficient supply has meant that vulnerable people are left at home or in hospital beds.
Management of Supply; Providers currently face a number of stressors when operating care homes that effect their ability to provide consistently good standards of care. Fluctuating occupancy levels, availability of staff (with the consequence of having to depend on more expensive agency personnel), fee rates not being linked to client dependency, new competitors building more modern facilities in nearby vicinities, regulator standards forever changing with the associated additional cost expected to be met by providers etc
The following options should therefore be considered;
• Certificate of Need – As in parts of the USA, Government (via Local Authorities) should consider whether or not a new proposed development is permitted to proceed on the basis of need. Does the demand exist, should it proceed because it will improve the quality of accommodation available, do local labour markets offer sufficient staff recruitment options, is the proposed provider adjudged to be a ‘fit and proper person’ for the purposes of managing a vulnerable persons unit, are existing providers already struggling, has the applicant passed a financial viability test, what will be the impact on other existing local care providers? All these things should be indicators as to whether a new development should progress as any subsequent turmoil resulting for this new entrant will in the end be felt by the older people living in existing homes.
• Sector Stability via Contracting – Local Authorities could remove some stressors by making much greater use of contracting programmes, so essentially providers could have block contracting arrangements in place for some or all of their beds. Those beds would be paid for whether occupied or not. That should create cash flow stability, predictability around providers cost base and far better manpower resource management. Currently as occupancy moves up and down providers attempt to ‘flex’ staffing levels as that is their largest cost. That is necessary because they do not know how long a bed may be vacant. The benefit for the commissioners of block contracting is accessing pre-paid beds and having significant control who and when patients are admitted to homes under contract. It is also likely the block contracting reimbursement rates could be contained over the life of the contract.
• Dependency linked fee rates – It is obvious that older people needing care facilities have different levels of dependency. It should not be a ‘one size fits all’ approach to pricing or care home design. Care Homes should be encouraged to provide excellent services for those older people with more challenging behaviours for example, but at a fee that ensures that older person has the additional resources that they will undoubtedly need. Independently designed assessment tools are available in many countries to allow for objective assessment that once completed indicates the number of hours per patient day required to meet care needs, the additional resource requirements and any other support needs that may be identified for that individuals’ residency. Facilities should be designed to ensure they meet the actual needs of a range of vulnerable people. If a chronic shortage of ‘specialist care provision’ exists, providers should be financially incentivised to provide what is required, as opposed to ‘what is easy and higher margin’.

• Incentivise Excellence – Fees paid should relate to the development of higher quality facilities, for care inspection outcomes and other approved quality audit process findings. Providers who outperform expected standards should be financially rewarded via improved fees, contract awards etc. Those who embrace technologies that allow for remote independent third-party review, should be financially incentivised in an effort to encourage care companies to exceed expectations. League tables are another option, that can be publicised to create some competition in care standards. Whilst regulator reports are available and have some of that information, they are often unwieldy for families and older people to access. Care Homes should be required to display a ‘’for sale type board’ at their premises that has a ‘quality rating’. That would very quickly provide a visual guide as to the service quality outcome determined by the latest regulator visit.

Conclusion
Our social care staff and older vulnerable citizens have been at the frontline of this dreadful pandemic. Staff have heroically turned up every day at their workplace to provide care and support for societies most vulnerable. Yet, despite their very best endeavours thousands have died of COVID 19 in part because of their co-morbidities and vulnerability, but also because the sector was ill prepared as it was not a priority for Government.
Social care restructuring can no longer be delayed. Let this be the moment for real change when older vulnerable people are afforded the same respect and dignity that is provided to any patient in the NHS.

Government must now act to create an entirely new blueprint for the long-term care of elderly people. It is clear that over the last thirty years care systems and structures have not sufficiently protected vulnerable patients in their latter years, nor indeed have they promoted the delivery of consistent high-quality transparent care services.It is not enough to simply ‘tweak’ existing systems. That has been done so many times and yet the sector remains unstable, with older people not valued and social care staff held in low esteem.
It is entirely possible by implementing some or all of these proposals that there will never again be a Winterbourne or Whorlton Hall type scandal and that public confidence can be fully restored to create a relationship of openness and trust between care providers their service users and families.

If you would like to contact us on the above, please provide your contact details ccftv.cares@gmail.com and we will get back to you.