Safeguarding and quality in commissioning care homes
What is commissioning?Open
'Working together with citizens and providers to support individuals to translate their aspirations into timely and quality services which meet their needs; enable choice and control; are cost effective; and support the whole community.' (CSIP 2008)
The commissioning landscape is changing rapidly with renewed emphasis on personalisation, diversification of provision and better outcomes. The role for commissioners is rooted in a set of principles around enabling and empowering citizens and includes '… ensuring mechanisms are in place to protect people from abuse and undue risk' (CSIP 2008). Commissioning takes place at strategic, operational and individual levels. The underlying principles, however, remain the same. Whether a commissioner is making strategic decisions about local need or a social worker is working with an individual to find the right place for them to live, the point is that the service needs to meet the individual needs of the person -that includes enabling them to have choice and control and keeping them safe.
The Government has made radical proposals that will impact directly on health and social care commissioning. The Health and Social Care Bill proposes the abolition of PCTs and introduces GP commissioning through consortia. Health improvement functions will transfer to local authorities.
The Green Paper 'Modernising Commissioning' (Cabinet Office, 2010) (PDF) makes proposals to increase the drive to further diversify health and social care markets through new models of public service ownership. The aim is to promote shared ownership through employee and user-owned organisations and move away from large scale contract delivery. Chanan and Miller (2011) however have pointed out that the proposals confuse the running of public services with the aim of strengthening communities. Competition in social care markets may work against the need to ensure safeguarding as competing providers may be reluctant to develop communication and work in partnership. User-led organisations are likely to be more willing to facilitate risk taking than traditional services. Commissioners will need to be supportive of this whilst maintaining good safeguarding practice.
Commissioners need to ensure that safeguarding is not compromised by further fragmentation of social care provision and instability resulting from such sweeping changes. Responsibility for safeguarding is shared across agencies. Commissioners and providers need to ensure there is a shared understanding of responsibilities and good partnership working with the new consortia, the police, providers and other local partners through the local adult safeguarding board and in day-to-day practice.
- DH Safeguarding Adults: The Role of Health Service Practitioners
- Handout 1 - The IPC Commissioning Approach
- A Framework for Local Authority Commissioners was developed as part of the Putting People First agenda of the previous government and the drive to implement personalisation (DH, 2007). The framework offers a progressive approach to commissioning within the context of personalisation.
- The NHS information Centre offer another variation in the Commissioning Cycle.
Types of commissioningOpen
A number of places are purchased from a provider. This practice can work against the personalisation agenda as individuals are encouraged to take up places that are already paid for rather than choosing their own.
The Department of Health has asked local authorities to scale down their use of block contracts and avoid entering into new ones (Dittrich, 2008). However, block contracts have powerful benefits including security of income for providers and economies of scale for purchasers. These factors continue to ensure a place for block contracts in commissioning despite the policy shift towards personalisation and individualised service provision. Recent funding cuts and potentially increased administrative costs as economies of scale shift (Dittrich, 2008) are likely to further inhibit the progression away from block purchasing arrangements. If choice and control is to become a reality for people in care homes, commissioners will need to work to reduce block contracts. In the interim, where they cannot be avoided, contracts should include specific requirements to provide flexible, person-centred services. Commissioners should ensure that the impact on stability for providers and conditions of service for staff are addressed as block contracting practices are reduced.
Spot contracts (or spot purchasing)
A single placement is purchased by or on behalf of an individual, usually with support from family member, social worker or community health professional.
If councils are to be able to play an effective role in shaping the local care market they need to better record their contacts with all people requesting care and support. By ensuring that customer facing staff are recording all contacts (and providing people with accessible, accurate and appropriate information and advice) councils can monitor the current self defined needs of self-funders and the nature of these contacts.)Institute for Public Care, 2011
Self-funders are people who are not entitled to health or social care funding and who consequently pay for their own residential or nursing care. Estimated to be around 170,000 people, this group represent almost half of registered care home places in England (Institute for Public Care, 2011). Under the Human Rights Act, the local authority has the same safeguarding responsibilities towards these individuals as it has to those for whom it provides funding. All self-funders are entitled to assessment, information, advice and safeguarding services.
Self-funders may be at greater risk of abuse if they are unaware of their rights and if they lack support from family members to complain if there is a problem. It is important, therefore, that commissioners ensure that self-funders have equal access to support, information and advocacy. This should be provided by social work teams for people considering residential care and by care homes providing it. As this group may previously have no contact with the local authority these services should be promoted through other services, e.g. hospitals and GP surgeries.
Local Authorities will often have to pay for the care of self-funders when their own funding runs out. It is therefore in the interests of commissioners to ensure individuals are supported to make choices about good quality care. Self-funders represent an increasing proportion of social care consumers. Their needs, views and feedback represent a valuable resource for commissioners.
As yet, Direct Payments are not available to fund residential or nursing care. Despite this, commissioners should strive to ensure that individuals have a choice of care homes in the local area.
Where a commissioner purchases care provision outside of their local area, either through individual or block contracts, there may be uncertainty about safeguarding responsibilities. The commissioner retains the responsibility to ensure that safeguarding is central to the contract and quality assurance monitoring. In the event of a safeguarding alert, however, there should be clear agreement between the commissioner, the provider and the hosting authority as to safeguarding responsibilities. In such cases the Association of Directors of Adult Social Services’ cross boundary protocol should be followed.
What is safeguarding?Open
‘Safeguarding means protecting peoples’ health, wellbeing and human rights, and enabling them to live free from harm, abuse and neglect.’ (CQC, 2010)
Current policy for the protection of vulnerable adults is set out in No Secrets (2000) and is currently under review. Until recently, practice known as ‘adult protection’ has tended to focus on responding to abuse that has occurred or is suspected. However, the concept of safeguarding shifts the focus more on prevention and enabling people to protect themselves.
The Human Rights Act (1998) places a duty on public agencies to intervene proportionately to protect the rights of citizens (ADSS, 2005). People in residential and nursing homes may be particularly vulnerable due to cognitive impairment or communication difficulties. Commissioners and providers must ensure that abuse, harm and neglect of ‘adults at risk’ is actively prevented and that, should it occur, appropriate and proportionate responses are made.
Every local area must have its own multi-agency policy and procedures in place and these should outline an agreed understanding of the difference between abuse, neglect and harm and poor practice. It should be clear to providers when to report a safeguarding issue and when to address an issue through other means such as supervision, team meetings and staff training.
A multi-agency partnership approach to safeguarding is essential. All the partners, including commissioners, the police, the Care Quality Commission and local safeguarding teams, have a responsibility to work together and share information to protect people in their area. The multi-agency approach should address prevention as well as responding promptly to safeguarding alerts.
The definition of a vulnerable adult is currently set out in No Secrets (2000). The Law Commission review (2011) however has suggested the following revised definition of an ‘adult at risk’:
Adults at risk should be those who appear to:
- have health or social care needs, including carers (irrespective of whether or not those needs are being met by services)
- be at risk of harm
- be unable to safeguard themselves as a result of their health or social care needs.