Last reviewed 4 July 2017

Three events occurring within the space of a couple of months this spring underlined the vulnerability of older people and people with disabilities who are depending on the compassion and vigilance of care workers. Jef Smith looks at the concept of “safe” in care homes, one of the Care Quality Commission (CQC) key questions that features prominently in the CQC’s new report on The State of Adult Social Care Services 2014 to 2017.

A fire which broke out early one morning in April at a care home in Hertfordshire resulted in two deaths, while a further 33 residents had to be rescued by firefighters from the collapsing and subsequently gutted building. “We had a number of people that were unable to get themselves out, you know, physically would not have been able to move even under normal circumstances,” reported the county’s chief fire officer. The fire service went some way to mitigating the effects of what was clearly an unsafe care service.

Also in April, the CQC brought to a conclusion the prosecution of the owners of a care home in York where a 98-year-old elderly resident had died after falling out of bed. The organisation, the court found, had failed to take necessary action to avert an accident which could have been prevented by following procedures relating to bed rail safety. This was the fifth prosecution of this type undertaken in the year since CQC was given special enforcement powers relating to health and safety; the fact that it led to fines on the provider totalling £100,500 shows how seriously the courts take such lapses.

Then, barely a month later, sentences were handed down to 13 directors, managers and care workers of the Atlas Project, an organisation running two care homes for people with learning difficulties in Devon, who were convicted of a series of crimes involving degrading abuse including the systematic use of excessive restraint. The offences were initially uncovered in 2011 and the affair has remained under wraps until now for legal reasons.

What these three sad stories have in common is that homes which as part of their mandate should have been keeping their residents safe for one reason or another, manifestly failed to do so. In a particularly ironic twist, it was revealed that a man at Veilstone, an Atlas Project establishment, had been moved there from the notorious Winterbourne View hospital, which was closed after evidence that similar abuse has occurred there. People become users of social care services because of their vulnerability, so for the trust that they have placed in so-called caring bodies to be so dreadfully betrayed is peculiarly perverse. It is a primary duty of care, perhaps the primary duty, to provide an environment and support which offers safety.

“Is the service safe?” indeed is the first question posed by the CQC in exploring the five qualities which it finds vital to any service it inspects. The others are: is the service effective, caring, responsive and well-led, but safety has pride of place in the list. What then does making a service safe really mean?

Getting an Outstanding rating for safety under CQC’s four-level grading system is noticeably more difficult than attaining the top score for the other qualities. Working through the inspection reports for a three-month period this spring, I found 10 homes rated Outstanding. It’s possible to be awarded an overall Outstanding rating by getting as few as two Outstanding scores on individual questions; in fact, of those 10, only three scored Outstanding on all five questions. In relation to safety, however, the significant point is that only the three homes with comprehensive Outstanding scores achieved Outstanding for safety. This suggests to me that even at the very top end of the quality scale, inspectors are extremely reluctant to award the ultimate accolade in answer to the question “Is it safe?”.

Rossall — an Outstanding home

It is rewarding to study the content of the inspectors’ findings in some detail. I chose to do this for a home called Rossall in Fleetwood in Lancashire, which in June was given the Outstanding rating on all five elements. “The building design optimised innovative systems” and “there were thorough risk assessments to mitigate each hazard”, wrote the inspector. “Very high staffing levels and skill mixes”, the use of “additional staff to adapt to people’s changing needs”, and “vigorous recruitment procedures” were all praised. Medicine management was characterised by “clear processes to meet high standards”. As for consumer feedback, “all the people we spoke with said they felt safe”. This summary identifies a number of factors worth studying in more detail — design and technology, staffing and recruitment, care records, and the management of medicines; the body of the report provides more details.

A safe environment

The systems employed for making the home’s environment safe for residents involve the latest technological innovations. These incorporate sensor lighting in bedrooms — illuminating en-suite facilities to minimise the risk of nighttime falls; safety strips on beds to warn staff of potentially dangerous movements — claimed an advance on alert mats which can themselves be a source of danger; and devices for alerting staff to incontinence episodes to reduce discomfort and pressure ulcers. Maintenance staff are trained to replace elements of the system or fix malfunctions, a speedier arrangement than waiting for outside help. All of this technology was carefully calibrated to respect residents’ dignity; the bed safety strips, for example, can be switched off if requested. Predictably, the emphasis on physical safety is as popular with relatives as with residents, all of whom had been consulted before installation.

A safe number of staff

Staffing is in a senseless innovatory; it is simply that the highest standards applied. For 32 residents, daytime care staff levels are for a minimum of 24, rising to 31 if circumstances require it; at night 18 staff are on duty. “Floating staff” are around “to empower people to have meaningful lives” and “to provide additional activities and engagement”. The generosity of these levels would be very difficult for most homes to match and fee levels doubtless reflect the very high staff salary bills. In this area, certainly quality comes at a price.

Recruitment procedures, however, show little that goes beyond what should really be regarded as good practice anywhere — meticulous documentation, scrupulous attention to references and criminal record checks, scrutiny of full employment histories, and verification where required of professional registrations. Unsurprisingly, “A newly recruited staff member told us they felt well supported on commencement in post,” adding, “The seniors speak with us regularly. They check how I’m doing and progressing and if there’s anything else I need.”

Safe care records

Care management again involves few innovations, just excellence in what most of us would quickly recognise as the well-established rules of good practice. Risk assessments are detailed, personalised and “utilised with a highly adaptive approach”. “Records cover, for example, door locks, medication, environmental and fire safety, call bell cords, nutrition, personal care, continence support and pressure area care” — nothing remarkable there surely. New risks are immediately recorded and fed through into the care plan and to day-to-day practice. Accidents and incidents are carefully monitored, and the duty of candour carried through with “in depth and transparent” analysis and reflection following any untoward incident to see that it does not occur again. As most residents have mobility difficulties, such diligence is essential to their welfare, as well as to their safety.

Safe medicines management

The same consideration calls for super-efficient medicines management and the inspectors were not disappointed. The home’s documentation incorporates consent, best interests and covert medicines protocols. In addition, senior night staff complete regular medication audits which show up any administration or recording errors. On-time medication is of course routine, but less predictable is the attention to monitoring and responding to pain, particularly for people who cannot easily verbalise. Use of the Abbey Pain Scale, a fairly simple system for totalling the pain indicators of people unable to communicate orally, enables staff “to quickly manage, relieve and assess the effectiveness of associated medicines”. Nurses on the staff, uniquely for the area in which then home is located, have been trained to provide intravenous fluids and antibiotics. As a result, many more residents are able to remain within their familiar surroundings at the end of their lives, an immeasurable quality gain.


Reviewing in this sort of detail just one element of an outstanding home’s inspection report proved for me an instructive exercise, one I would commend to any manager aiming to up their service’s grade — which of course should mean every manager. Naturally, achieving the sort of quality seen by Rossall is not cheap and depends on a financial model many providers can never hope to imitate, certainly not if they depend on local authority fees. This provider, for example, has agreed that one employee should train as a physiotherapist, an enviable luxury, about which the lucky staff member was predictably enthusiastic.

Should our society expect for its elderly anything less than what Rossall offers to a fortunate few Lancastrians? I think not, but if this sort of excellence is to become general rather than exceptional, a method of realistic funding for social care has to be worked out and implemented. One clue to a solution to the resource dilemma lies perhaps with a throw-away line in the inspection report. Having detailed the home’s high staffing levels, it adds, “The local Clinical Commissioning Group (CCG) confirmed hospital admissions from Rossall were consequently far below local averages.” Noting the way in which better care in residential homes can save money which would otherwise need to spent on health services is not of course original, but if a dependable way could be found of making the consequent reallocation of funds, we could be seeing many more examples of homes proving exceptionally safe environments.