Safeguarding and quality in commissioning care homes

Empowerment

Key points for commissioners

Commissioners include people who use services in all stages of the commissioning cycle – from service planning and specification to monitoring and evaluating service quality.
Commissioners ensure that there is a choice of flexible, person-centred services available in the local area.

Commissioners ask care homes to demonstrate (as part of the prevention of safeguarding incidents) that:

they include residents at all levels in the running of the home, including those who may lack capacity to make decisions
they support residents to make their own decisions and to be involved in decisions about how care and treatment is provided in the home
they are complying with the Mental Capacity Act 2005 – this includes ensuring that any decision taken on behalf of a person who has been assessed as lacking capacity (to make that decision), is made in their best interests
they provide personalised services that promote choice and control for the individual whilst ensuring their safety
residents and relatives have information on what they can expect from their service provider and information about complaints
support, advocacy and representation are available to residents
they empower residents to remain active, independent and linked to their communities
risk assessment and risk enablement processes are clearly defined and effective.

Commissioners ask care homes (as part of the response to safeguarding concerns) to demonstrate that:

individuals are supported during and after safeguarding investigations
in the event of an alert, the individual concerned is at the centre of the safeguarding process and, wherever possible, they remain in control and make their own decisions.

Commissioners work with local authority service managers to ensure that:

self-funders are offered assessment, information and advice
people using services are empowered to protect themselves – they know how to identify and report abuse, neglect and harm
residents and relatives are asked for feedback after they have made a complaint or experienced safeguarding procedures - did they feel listened to, do they feel safer? This is used to improve services.

Duties to empower people to make decisions and be in control of their care and treatment is underpinned by the Human Rights Act 1998, the Equality Act 2010 and the Mental Capacity Act 2005
DH, 2011

Care home providers are required to meet Outcome 1 (Regulation 17) of the CQC Essential Standards of Quality and Safety, ‘Respecting and involving people who use services’. People who are informed, in control of their lives and empowered to assert their views are less likely to be victims of abuse, neglect and harm and will be in a better position to speak out should it happen.

Personalisation

Through personalisation commissioning is both rejuvenated and wholly transformed.
DH, 2007

It is vital that commissioners develop their approaches in line with the aims and objectives of the personalisation agenda. Personalisation does not only apply to those who receive a personal budget - the principles can be applied across all social care services.

'At its simplest, personalisation, in the context of care homes, is putting the person who uses the service first in order to ensure that they can exercise choice and control over the way that services are provided. This is not a new concept for the best care homes. However, there is an expectation that health and social care services need to change to respond to the principles of personalisation as expressed in Putting People First. This requires services to be outcome-focused. Such services should ensure that peoples’ needs are met in ways they choose, and not according to how professionals believe things should be achieved.'
SCIE and the National Care Forum, 2009

Integrated personalisation and safeguarding

Safeguarding is promoting a more institutional approach of what not to do rather than encouraging a positive person-centred choice-sensitive culture in care.
Bowman, 2010

There is a danger that safeguarding practices may stifle personalised approaches to care. If service providers seek to protect people at all costs, they are in danger of infringing the rights of individuals to choose what they do. It is important to note that protective measures, for example, restricting someone’s movement in case they fall over, can be experienced as abusive by the individual.

It is important that personalisation is implemented in the context of safeguarding and vice versa. Those responsible for the development of both areas of practice should work together to achieve an integrated approach.

Risk assessment and risk enablement

Personalisation will have complex implications for safeguarding which will require a sophisticated and enabling approach to risk assessment. It is important that the social care workforce is supported to enable people to exercise choice and control whilst ensuring their safety and security. Risk assessment is a routine part of assessment, care planning and review but the increased emphasis on risk enablement presents new challenges. Social workers and care providers need to work closely with residents to ensure that the individual is enabled to make choices, even if those choices appear unwise and present an element of risk. If a person lacks capacity to make a decision, their close family or friends should be involved in making decisions in their best interests. Commissioners should include in their monitoring activities an assessment of the quality of risk assessment and risk enablement practice in care homes, including the outcomes for individuals.

If the care provider takes the view that a certain risk is too high, with a possibility that an individual who lacks the capacity to make a choice about their safety is being deprived of their liberty to reduce the risk, the provider must make an application to the local supervisory body.

Case study

Mrs Quin has dementia and lives in a care home. She often wakes in the night and tries to leave the building in her night clothes, saying she has to get to school. The staff have, in the past, been able to distract her and get her to help make a cup of tea and then she has forgotten about school. However, these incidents have become more common over the past two weeks, it has become harder for staff to distract Mrs Quin and she gets more agitated. On these occasions, the care home staff are concerned that frustrating her wishes in this way might amount to a deprivation of her liberty. They are sure her wish to leave is not made with capacity, and that refusing to let her do what she wants is in her best interests.

They refer to the local authority supervisory body to request a Deprivation of Liberty Safeguards authorisation to ensure that, if these restrictions do amount to a deprivation of liberty, they are in her best interests and proportionate. Trained assessors are appointed, who conclude that the restrictions on Mrs Quin’s freedom do amount to a deprivation of liberty but it is authorised for two months as being in her best interests.

See Deprivation of Liberty Code of Practice.

See the section on the Deprivation of Liberty Safeguards (DOLS) in the Legislative and Policy framework.

Involving people who use services

Recent research from the Joseph Rowntree Foundation on 'Involving users in commissioning local services' found that credible user involvement in commissioning is far from being achieved and that the skills, knowledge and practice of commissioners in this area are limited (JRF, 2010). The Department of Health (2007) recommend that citizens are involved in all stages of the commissioning process to ensure personalisation is written into contracts and person-centred services can be provided. The benefits of involving a wide range of stakeholders in the commissioning of services for older people have been demonstrated in a number of studies (Hughes et al, 2009). Commissioners should engage local groups of people who use services and carers and the voluntary organisations that represent them. They should also endeavour to involve people who are hard to reach by providing advocacy and support.