Concerns about services

There are many factors that can give rise to concerns about care quality. Care quality concerns may be:

• Care being delivered in an impersonal task driven way
• Care providers lacking robust systems that ensure people’s needs are responded to in a timely and caring fashion
• Poor environment and/or poor levels of hygiene
• Lack of stimulation
• Poor quality food and/or lack of choice
• Overly routinised care delivery e.g. everyone gets up at the same time
• Lack of appropriate levels of supervision and oversight
• Lack of training

This is not an exhaustive list. 

Causes of poor care quality are multi-factorial and could be related to any of the following examples:

• Issues relating to the effective management of the service e.g. manager recently departed or the manager may need more support or may appear to be struggling to address key issues
• Care delivery is not well organised
• Staff morale seems to be deteriorating and there appears to be a lack of commitment to providing a high quality and caring service
• Lack of commitment from the ownership
• Financial pressures
• Over reliance on agency staff
• Insufficient staff and/or recruitment problems
• Too few well trained staff
• Lack of robust audit systems in place to pick up on any developing problems or key audits  not being carried out

Issues may be identified by anyone who may be in contact / visiting either in a professional or personal capacity such as family members, social workers, district nurses, general practitioners. 

In many situations care quality issues are relatively isolated, of a minor nature and once identified can be readily addressed.  If you notice something that concerns you then it is important to tell someone such as the manager of the care provider.  The action you take should be proportionate and link to the harm level guidance.

Sometimes concerns are identified through routine audits and inspections.  It is the role of the CQC to carry out inspections of care services and rate them accordingly.  Sometimes, local audits and reviews may be also be conducted. 

The Quality Improvement Network (QIN) has been set up in Salford to help residential care services identify and address care quality issues.  The QIN meets regularly and includes a range of NHS specialist services including specialist nursing, specialist pharmacy input, the care homes GP practice, Adult Social Care, Mental Health, Public Health and CQC.  The QIN meets to share information about any care quality issues identified by any of the attendees and also to identify what support could be made available to help the service address the issues. This could include a visit from a specialist, some training input, and access to other resources or sources of support. The aim of this group is to help all residential services in Salford achieve a good CQC rating.

Where the care quality issues appear more complex or potentially serious, the QIN may recommend a more detailed examination of the issues and a more coordinated approach to the service. The QIN might request this if there were lots of local services raising care quality issues and/or following a poor CQC report.

QIN members would participate in a multi-disciplinary professionals meeting to share information and agree a consensus on what appear to be the main issues and options for providing focussed and effective support.  This may be followed by a meeting with the service manager and proprietor to discuss the situation, understand their perspective, identify help available, and seek their commitment to make the necessary improvements. 

In such circumstances the service will usually be asked to produce an action plan and this will be monitored and reviewed until the issues have been addressed. Further meetings will be arranged if felt necessary

Where there are serious care quality issues this can lead to more adult safeguarding issues particularly in relation to issues of neglect or physical abuse. These may be due to several separate incidents which are looked into and addressed on an individual basis or may present as part of a wider pattern that could amount to organisational or institutional abuse.  Issues be linked to a specific theme, for example an excessive number of medication errors or a range of concerns across a number of issues, e.g. unexpected patterns of weight loss, excessive numbers of unexplained falls, injuries due to poor moving and handling techniques, excessive numbers of service users with pressure sores etc.

Where the issues /concerns identified seem to be of a sufficiently serious nature to raise questions about the ongoing safety of service users, and whether what may have initially appeared as an isolated safeguarding issue is actually indicative of a pattern of poor quality care, then consideration will be given to addressing the wider issues via safeguarding processes. These are described in more detail in serious concerns about service guidance.

There is no clear dividing line between what issues can be defined as care quality and what issues are safeguarding. Professional judgement will need to be applied when deciding on whether to take a service through the safeguarding concerns process or keep it under the overall oversight of the QIN whose remit is around care quality rather than safeguarding.

• Rapid service deterioration especially where services have in the past come into serious concerns
• Change of ownership
• Frequent changes of manager
• Cost cutting measures affecting care delivery
• Poor building maintenance
• Under occupancy
• Poor staffing levels/low staff to resident ratios
• Recruitment issues or excessive use of bank or agency staff
• Proprietors who are frequently absent
• Insufficient training/supervision.
• Poor management of pressure relief/skin care/continence/end of life care.
• Inadequate documentation e.g. out-dated care plans
• Poor standards of hygiene/ infection control practices.

An inadequate CQC rating or a requires improvement rating where the service appears to requires improvement over most if not all 5 domains ( this may be linked with numbers of CQC improvement notices) ( NB An inadequate rating will not automatically mean a service is treated as a serious safeguarding concern as the issues may be more about care quality issues than safeguarding matters

It should be noted that any combinations of the above may indicate that a service may be in more difficulty than is initially apparent. Where these features emerge the following agencies should be kept informed so they are aware and able to evaluate in the light of any other information they may hold and coordinate further action where appropriate.

• Adult social care review team ( for residential care) or
• Integrated  area team ( if the concern relates to a domiciliary agency)
• Mental health and LD services if the service relates to their specialism)
• NHS Greater Manchester Integrated Care, if involved ( e.g. if is a nursing home)
• Any other key partner organisations involved usually CQC, infection control etc

Escalation to serious concerns can take place in a number of different circumstances. It could be a gradual progression where concerns about quality of care escalate as more information becomes available; or it could occur suddenly as a result of a single serious safeguarding incident or cluster of incidents.  Moving straight into the serious concerns process could be as the result of the following:

• A cluster of alerts about similar issues:
• Moving and handling.
• Pressure sores.
• Missed calls.
• Medication errors
• Excessive admissions to hospital.
• Individuals not properly nourished or hydrated.
• Patterns of discriminatory practice, e.g. bullying and harassment.

There is not a specific number of alerts which would automatically raise the level of concern to serious; professional judgment will be required in relation to numbers, type and degree of abuse. Other factors influencing a decision to initiate the serious concerns process include:

• Shared concerns from NHS Greater Manchester Integrated Care, Adult Social Care, Contracts, Public Health, regulatory bodies (Care Quality Commission), or other relevant people including whistleblowers or the general public or the Police.
• An individual case that is so serious or unusual that it warrants being handled by this part of the policy.
• Information from a whistleblower that has a clear foundation.

Where it is confirmed that there is good reason to bring a service into the serious concerns process the responsible team i.e. review teams or integrated teams will normally coordinate/manage the process making initial enquiries and arranging meetings.

Before a final decision is made on whether to take a service into serious concerns, the issue must be discussed with a senior manager (head of service or more senior). The head of service will need to consider who will need to be informed which will include the Director of Adult Social Services (DASS), lead member, Salford Care Division lead, commissioners, NHS Greater Manchester Integrated Care chief executive, the press office (as the issue could become an issue of wider public interest) etc. There will also be a need to keep these parties informed regarding progress to address the issues.

Where it is confirmed by a senior manager to bring a service into serious concerns the meetings will follow the same format as for individual safeguarding cases.

Where it is confirmed by a senior manager to bring a service into serious concerns the meetings will follow the same format as for individual safeguarding cases.

A Strategy meeting - Serious Concerns about a Service will decide if further investigation is required regarding the way the service is conducted and if there is such a requirement how this will be carried out i.e. reviewing of other individuals using the service: Care Quality Commission inspection; contract monitoring; Police investigation; or combinations of the above. CQC must be informed or invited to attend any meeting where there is an alert in respect of serious concerns about a service.

A Strategy meeting will then decide if further investigation is required regarding the way the service is conducted and if there is such a requirement how this will be carried out i.e. reviewing of other individuals using the service: Care Quality Commission inspection; contract monitoring; Police investigation; or combinations of the above. CQC must be informed or invited to attend any meeting where there is an alert in respect of serious concerns about a service.

At this stage any individual Adult Safeguarding processes already initiated will continue to ensure identified individuals are safe. Chairs of individual cases will often be invited to Serious Concerns about a Service meeting and will be an essential communication link between the two processes. Provider service managers and the Responsible Person/Nominated Individual (usually the proprietor) will need to be informed as soon as possible of the concerns resulting in entry to the Serious Concerns about a Service process. The information to be shared with provider services management/the Responsible Person, will be by the person designated to do so as agreed in the Part I of the initial Strategy Meeting. Part II of the meeting will usually include the responsible person/managers/proprietor or area manager over the service.

Special consideration will need to be made if it is anticipated there will be any pre-emptive action i.e. police arrests/interviews or Care Quality Commission unannounced inspection visit or seizing of documents etc.

If it is confirmed following the formal sharing of information that there are serious concerns either at the strategy meeting or at any subsequent formal meetings there are a number of options that may be considered to protect people still within the service, and reduce the risk of new service users being affected. These will usually include combinations of the following actions/options:

• Requiring the service to develop a realistic action plan with timescales.
• Making arrangements to monitor the action plan including follow up review and unannounced visits.
• Undertaking multiple reviews (in conjunction with the funded nursing team where nursing homes are involved) - this may be coordinated by the review team or led by an individual integrated team as appropriate to the situation/service.
• Informing any other Local Authority or NHS body funding people in the same service and recommending that they undertake their own reviews
• Arranging for other relevant NHS services such as the infection prevention and control team or the pharmacy support service to assess and/or monitor as appropriate.
• Arranging a joint NHS/CQC/adult social care public meeting with residents/relatives/proprietor, led by a senior manager, explaining what is happening, understanding how far they may be affected either directly or indirectly and engaging residents and relatives in monitoring/making choices about future placement etc based on factual information.
• Encouraging/supporting the Responsible Person /manager to make the required changes.
• Working in collaboration with CQC - in certain circumstances CQC will prioritise unannounced inspections and work cooperatively on enforcement action.
• Working in collaboration with the Police where appropriate.
• Making a voluntary agreement with the providers to suspend or limit new admissions into the service. This will require discussion (usually agreement with the service) but exceptionally may involve an element of compulsion subject to agreement at director level.  It also should be regularly reviewed so that as a service starts to address the issues , this is fairly reflected in terms of its ability to take new admissions once it is deemed safe to do so
• Voluntary of compulsory suspension becomes more likely if a service simply continues to fail to improve. It is also an option that CQC has the power to implement where it thinks fit and appropriate. The CQC also has the power to close down a service in exceptional circumstances subject to checks and balances. In the case of care homes this will require discussion with the Responsible Person.
• In the case of care homes the procurement team will arrange for other Local Authorities to be informed so they are aware of the voluntary agreement.
• The NHS Greater Manchester Integrated Care Funded Nursing Team will look to ensure no other NHS Commissioning services admit new service users.
• NHS Greater Manchester Integrated Care may decide independently to take its own action in relation to suspension of admissions or impose other requirements restricting new admissions.
• Where there is an agreed or imposed suspension there will be a clear expectation on the Responsible Person that the service will refuse any new referrals via any other sources such as self funders for the duration of a suspension.
• Where special circumstances arise e.g. a pre-booked respite care or an existing resident who needs to move from a residential to a nursing home bed and who does not wish to move elsewhere, the decision would be at the discretion of the chairperson who can decide to consult with other members of the multi-disciplinary team (the chairperson will usually be from the ASU but could be a team manager).
• Working in partnership with procurement/contracts/commissioning around possible suspension of contracts particularly in relation to domiciliary services where service users are dispersed and it is impractical to hold service user/relatives meetings:
• In some circumstances e.g. where breaches of the contract are involved it may be appropriate for the meeting to be chaired by the contracts manager/assistant director. This may be the most effective way to ensure the need for significant improvement actions are taken on board at the higher levels of an organisation. However, such meetings must also be attended by the adult safeguarding coordinator and minutes taken as per adult safeguarding procedures.
• Further follow up review meetings and meetings with relatives/residents to update on progress.