It Ain’t Necessarily So – 19: Will care home ratings work for residents and relatives?
with JOHN BURTON
The foremost reason given by the Care Quality Commission for reintroducing care home ratings is that it will help prospective residents and their relatives to choose a home that best suits them. The regulator will grade the home on a scale from “inadequate”, to “requires improvement”, to “good” and to “outstanding”. The “star” ratings that the former regulator, the Commission for Social Care Inspection (CSCI), introduced and CQC continued with for a year, weren’t considered suitable although they were roughly the same as the new ratings. Stars had the advantage for residents and relatives that they are the common currency of quality.
Using – admittedly, carefully chosen – words for ratings has its problems. All the words except “good” are ambiguous. Surely an “inadequate” home “requires improvement”? And “outstanding” means remarkably different from the rest, and that could be outstandingly bad.
When people are looking for a suitable care home, at what point will they use the ratings? I think for those who browse the internet in their search for a home, the rating will be used at a fairly late stage, if at all, to select from a shortlist that has already been made. If you have got to the stage of making a shortlist and you have access to the CQC reports and ratings, surely you would read the reports. And, if you choose or reject a home, simply on the basis of the rating alone, that rating had better be accurate.
The other side of this issue is looking at the real reasons for going back to having ratings. I detect that the board and senior managers of CQC are secretly queasy about the ratings because they understand that they are making a rod for their own backs. Some ratings will be wrong, and some of those will blow up in their faces when poor care and even abuse are exposed at a home that has been rated good or outstanding. However, the Government has committed itself to ratings and CQC feels it has to comply. So, they are pretending that they are right behind ratings and will make the best of them.
Ratings do have advantages for the regulator. CQC can justify less frequent inspections of good and outstanding homes but, in the recent past, when some “excellent” homes were inspected after a gap of three or four years, the care was found to be atrocious. (It can happen the other way round: a good home that was unfairly saddled with a low rating keeps it until the next inspection.) A further short-term gain is that, as more homes become good and outstanding each year, they will inevitably demonstrate the “success” of CQC. It’s like schools with their exam results: they get better as teachers learn how to drill their pupils in exam techniques and, some would argue, as the exams themselves get easier. However, there is a limit to this “improvement”. There could come a time when there are so many “outstanding” homes that they no longer stand out, but, before then we will probably have had yet another politically driven change in regulator.
Government, CQC, and care providers have a vested interest in demonstrating and taking the credit for improvement. In this matter of ratings, they are in collusion. The larger providers believe they know how to get good ratings, and some divert time, effort and resources into chasing them instead of concentrating on their core task of good care.
Most residents and relatives would prefer the effort to go into care rather than care ratings, and would want inspectors to concentrate on checking that a home is safe, effective, caring, responsive and well led (CQC’s five questions) rather than agonising over the technicalities of awarding an accurate and unchallengeable rating.
We found a different way: Caring Times readers tell their stories
SB – manager, South London: No, ratings won’t work for residents and relatives. No home should be judged on the rating because it’s given on the day of the visit. It could change in hours – it could get better and worse.
The rating should be based on the experience of the people in the home: relationships with the staff and the other people who live there, daily support, medical support, food, activities, involvement, and how the home is run.
It’s not a beautiful building that should count: good care can be delivered in any environment. The service can only be good if the team on the ground is adequate and given the right training and mentorship. But if the manager doesn’t know how staff feel, they won’t get the support they need.
A true inspection should combine several visits at different times of day and night, and feedback from residents, staff and visitors. The inspector shouldn’t spend time on the paperwork that’s put together for inspection – tidy, nice and put in place – while someone is ringing the bell to be helped to the toilet and there’s no one to take her there.
How will CQC put all that inside a rating? Every home needs improvement in some way but that doesn’t mean that it’s not good. OK, if the place is bad, it has to be improved pretty damned quick, but actually if it’s that bad you can’t improve it that quickly! It takes time and very hard work.
And even when a home is outstanding, there will still be things that could be improved. Get the residents involved; get their opinion – that’s what people thinking of choosing the home should take notice of, not what CQC give as a one-off rating.