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 home care, 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 services 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 services which as part of their mandate should have been keeping their clients 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 support which offers safety. The examples I have quoted happen to have extensive residential components, but the principles of professional responsibility, of course, apply equally to practitioners providing care services to people living in their own homes.

“Is the service safe?” indeed is the first question posed by the CQC in exploring the five qualities which it finds vital to any organisation 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?

Age Concern, Tower Hamlets — an Outstanding agency

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 recent inspection reports of care agencies scoring the coveted Outstanding rating, I could find only one Outstanding domiciliary care service whose inspection report had been published in the last three months which scored the top rating for safety. Ironically, this agency, Age Concern in the London borough of Tower Hamlets, got no more than Good for three other factors. What was it about the performance of this not-for-profit scheme that so impressed the inspectors in that area that it earned the Outstanding rating both for safety and for its overall performance?

Of course, gathering information on the quality of a domiciliary care agency’s work is much more difficult than a similar operation in a care home, hospital or even GP practice. The problem from an inspector’s point of view is that service delivery takes place in users’ own homes, in conditions in which it would be difficult to observe what actually goes on without intolerable intrusion on individuals’ privacy and dignity. The result is that there is a much heavier dependence on what the agency volunteers by way of information — through the Provider Information Return, care plans, staff files and other documentation, and interviews with managers, supervisors and front-line workers. Views are also obtained from local commissioning and safeguarding teams and, to a pretty limited extent — just two service users and two relatives in this instance — from recipients of the service. That’s a meagre base on which to make judgments, but there is little more that CQC or any other regulator could do to widen it significantly.

Bearing those limitations in mind, the summary at the beginning of the safety section of the Age Concern — Tower Hamlets report outlines four elements of the evidence they had collected — the comments of service users, the ability of care workers to take appropriate action if they had concerns about a client’s safety, the adequacy of staffing and the management of medicines. The recorded feedback from service users is very slight. One said, “Yes, I feel safe”; the other said, “I’m more than happy, I feel very safe.”

Documentation

Taking a look at the agency’s policies and procedures yielded a bit more substance. In particular, there was evidence that workers knew and understood the policies, being aware, for example, that they had a responsibility to pass on safeguarding concerns and showing that they could recite the various forms of abuse listed under official guidance. But again, anything less would surely have been reprehensible; such minimal achievements do not in themselves convincingly constitute excellence.

Checking risk assessments looks rather more helpful. These covered the physical environment — details such as the height of a client’s bed and the adequacy of lighting and ventilation — and areas such as manual handling and the use of potentially hazardous equipment like wheelchairs. A telling example is quoted about a service user who experiences delusions, where the employer advised workers to use diversionary tactics like making a cup of tea or encouraging the client — an avowed Christian — to pray.

Staffing issues

Staff recruitment was robust, with criminal record checks and references carefully followed up. Only staff with previous experience were accepted, though the experience of caring for a relative counted. Is any of this exceptional? I hope not because any agency which failed these basic tests would surely not deserve registration, let alone being listed as Outstanding. A rather more sophisticated administrative system was the use of an application called “Call Round” downloaded onto care workers’ mobile phones which provides information in the form of maps, daily work schedules and clients’ telephone numbers so that running late could be reported. (Phones were provided by the agency when necessary, and there were alternative arrangements for those unwilling to use the technology.) Geo-tagging enabled the service HQ to check times of arrival and departure, a facility in this context seen as a valuable safety measure rather than just a check on staff behaviour.

The limited number of handymen authorised to work in clients’ homes carry an ID, wear recognisable shirts, travel in marked vans, and also use the mobile phone app, providing additional layers of security and reassurance to service users. Delays to staff arrival times, both care workers and handymen, are minimised by sensible allowance for travel time, emphatically not general practice in the home care sector. The staff who were questioned knew what to do if a client failed to open their door. They had had first-aid training from the ambulance service and had access to a series of specially prepared one-page reference documents covering conditions such as chest pains, strokes, respiratory problems, burns and fractures. There were policies in place covering the key issues like accident reporting, infection control, dignity, and health and safety.

Medication management

The handling of medicines was given a similarly high priority. Care plans and records of medicine locations and medication administration where workers are involved were found to be well kept, up-to-date and effectively audited. In most cases, of course, these responsibilities are shared with families and the clients themselves, but there was evidence of a proactive approach to possible risks involving a person with dementia for whom a locked medicine cabinet was recommended.

All of this is as it should be, but does it really constitute excellence? On most counts, any agency falling short on, for example, record keeping, staff training, or supervision and support for the front line would be worthy of censure. The one point on which Age Concern — Tower Hamlets seems clear to go beyond everyday good practice is with its mobile phone app, although such things are becoming more popular in the industry.