Safeguarding and quality in commissioning care homes
Key points for commissioners
- utilise the governance framework to promote good quality care and to gather intelligence from monitoring partners (e.g. Care Quality Commission (CQC)) to assess risk
- use information gathered during investigations and serious case reviews to inform future commissioning
- provide information to the local Safeguarding Board to assist the Board in its governance role
- identify services that are at risk of isolation from the wider community and address this - isolation presents a greater risk of abuse and institutionalised care as there are fewer people to notice and report it
- utilise feedback and complaints information from care homes
- give care home staff opportunities to give their views about the service to feed into the service monitoring process.
Commissioners ensure that care homes:
- incorporate safeguarding principles into recruitment, induction and supervision
- provide a safe environment and can demonstrate good practice on health and safety
- provide (or access) good quality training on quality standards and safeguarding for all care and support staff
- demonstrate good leadership and a culture of dignity and respect
- encourage staff to question poor practice, to develop learning and avoid a blame culture
- encourage connections with the wider community and access support (e.g. befriending) for people who are at risk of social isolation
- actively promote empowerment, providing education about risks and enabling residents to protect themselves
- properly support and monitor residents who may present a risk to others
- can demonstrate how they learn from mistakes
- can demonstrate good practice in administration of medication, falls prevention, pressure sore care, nutritional care and financial safeguarding.
There are many approaches to the prevention of abuse, neglect and harm in care homes. These include the empowerment of residents, promotion of quality services, good leadership, training and support for staff. SCIE has explored these issues in SCIE Adult Safeguarding: Prevention
The local authority has lead responsibility for safeguarding in its area. Safeguarding issues are more likely to arise in services that offer poor quality care. Commissioners should therefore take an active interest in the quality of all care service provision in their area, including the integration of health and social care, whether or not it is commissioned by them and whatever the method of funding.
The Association of Directors of Adult Services (ADASS) assert that ‘it is important not to rely only on single means of quality assurance but to be able to triangulate information from different sources to be able to evaluate effectiveness, both of partner organisations as well as the partnerships’ (ADASS, 2011).
Providers should not be overburdened by additional requirements to those relating to registration and regulation. It is therefore important that commissioners work to ensure that all monitoring activity is aligned as much as possible. Commissioners should gather information from all the stages of the commissioning process and all the activities carried out by stakeholders to inform their work.
What others are doing - ideas you could use
Set up a team of Safeguarding Adults Practice Officers
Durham County Council and County Durham Primary Care Trust have set up a team of Safeguarding Adults Practice Officers, consisting of two nurses and two social workers. The team works with residential and nursing homes to respond to safeguarding incidents that have occurred in care homes and to work proactively with providers to reduce the number of safeguarding incidents. The team works collaboratively with providers to share best practice, promote Dignity in Care principles, and to ensure care practices within care homes in County Durham are of the highest quality (The National Mental Heath Development Unit).
The governance framework
The mechanisms in place for defining services, setting standards and quality assurance should all consider safeguarding as core business. Commissioners should effectively utilise and coordinate the many strands of monitoring and quality assurance activity in order to assure quality of service and good safeguarding practice.
Joint strategic needs assessmentOpen
Joint strategic needs assessments must take into account the outcomes from people’s person-centred plans and how these affect all support and services across and commissioned by the local authority/PCT.IDeA 2006
Joint Strategic Needs Assessment (JSNA) is a requirement under the Local Government and Public Involvement in Health Act (2007) and underpins the processes for health and local authority commissioning.
The JSNA assesses local need with regard to health and wellbeing, which includes safeguarding. Local Area Agreements are developed to address the needs identified in the JSNA. The Health and Social Care Bill places greater emphasis on the JSNA with Local authority and GP consortia carrying out JSNA as part of the Health and Wellbeing Board; commissioners need to be central to this process. The Bill will introduce an obligation for health and social care commissioners to have regard to the JSNA in exercising their relevant commissioning functions (DH, 2010a).
The Public Services Bill aims to encourage commissioners to engage with social enterprise when planning public services. It proposes a requirement for local authorities to give greater consideration to economic, social or environmental wellbeing during the pre-procurement stage.
Local people should be part of the JSNA process to ensure that services are personalised, and that group and individual safeguarding concerns are addressed. Commissioners need to consider how to stimulate the local market to meet identified need. The assessment should consider the type and level of local need, for example some areas may have a high population of older people and may need to plan for the expansion of provision for dementia. The risks to local vulnerable people should be based on intelligence from the community and all local partners. There may be particular issues of crime and abuse locally that require specific responses and resource allocation. For example, there may be rogue traders targeting older people in the area or, with regard to care homes, there may be a spate of abuse allegations or complaints stemming from one home.
It is important, when analysing data, not to confuse an increase in safeguarding referrals with an increase in abuse. Such changes could be due to increased awareness or inappropriate referrals due to poor training. Data should always be analysed to ensure that judgements that inform commissioning decisions are transparent and have a sound evidence base.
What others are doing - ideas you could use
Map and analyse safeguarding referrals to help target resources
Haringey Council has recently carried out extensive mapping of safeguarding referrals. This has enabled it to analyse what the risks are and to target resources accordingly.
Local Area AgreementsOpenAreas of need and priority identified in the Joint Strategic Needs Assessment should form Local Area Agreements (LAA). Under the Local Government and Public Involvement in Health Act (2007) local named partners must cooperate to develop the agreement and agree local improvement targets. Commissioners, along with local safeguarding leads, should ensure that local safeguarding issues are considered in the LAA and targets are agreed to address those issues.
Clear and agreed outcomes for the individual ... provide a strong tool for contract monitoring; it is essential they are made clear at an early stage in the tendering process.IDEA, 2006
The service specification sets out the specific requirements of the service, in this case, the care home. Specifications are underpinned by the CQC Essential Standards of Quality and Safety but they should also take account of the needs and desired outcomes of individuals and address their safeguarding needs. The specification should form part of the contract between the commissioner and the service provider and should set out the methodology for service monitoring.
In addition to the needs of the individual, commissioners should consider including service requirements in the service specification. For example:
- adherence to local safeguarding procedures
- appointing a specified safeguarding lead
- having service-specific safeguarding procedures in place to fit with the local procedures
- ensuring residents and relatives know how to recognise and report abuse
- training all staff in safeguarding to an agreed standard
- having a whistleblowing policy.
The Improvement and Development Agency (now Local Government Improvement and Development) recommend that service specifications are linked to individual outcomes and priorities and that commissioners work with - and learn from - providers about what makes a clear and understandable service specification (IDEA, 2006).
What others are doing - ideas you could use
Appoint an independent chair to help you review cases
The Care Management Group (CMG) has a Safeguarding Board with an independent Chair. The Chair reviews every safeguarding case across the organisation to identify any lessons that need to be learned to improve practice and keep people safe.
CMG also does a lot of work to encourage people to express their views and grow in confidence so that they feel empowered to speak out if abuse is happening.
Local safeguarding adults boardsOpen
Multi-agency safeguarding boards are responsible for overseeing safeguarding activity in a local authority area. The board should ensure that safeguarding is integral to local health and social care provision ensuring policy and procedures are in place and providing training and information. The local authority takes the lead for the board but may appoint an independent chair. The board should be linked to other strategic partnerships and, in the future, health and wellbeing boards.
Membership should include:
- people who use services and carers
- the police
- health partners
- local providers
- voluntary organisations
‘Members from partner organisations should have a lead role in their organisation with regard to safeguarding adults and be of sufficient seniority that they can represent their organisation with authority, make multi-agency agreements and take issues back for action’ (SCIE, 2010). Intelligence from all sources on local service provision should be available to safeguarding boards. The ADASS advice note to directors recommends that safeguarding boards carry out annual reviews of ‘practice, impact, outcomes and how policies and protocols support good safeguarding practice’ (ADASS, 2011).
The Law Commission review of adult social care (2011) (PDF) recommends that adult safeguarding boards are placed on a statutory footing and outlines the functions in part 9, Recommendation 44 (p136 137).
The Government have since announced that Safeguarding Boards will be made compulsory for councils and put on a statutory footing.
Health and wellbeing boardsOpen
The core purpose of the new health and wellbeing boards is to join up commissioning across the NHS, social care, public health and other services that the board agrees are directly related to health and wellbeing, in order to secure better health and wellbeing outcomes for their whole population, better quality of care for all their patients and care users, and better value for the taxpayer.DH 2010a
The Health and Social Care Bill (2010), proposes the establishment of health and wellbeing boards on a statutory basis. Some local authorities have already set up such boards to bring together local authority, NHS, voluntary sector and user representatives to work in partnership to improve the health and well-being of the local population and encourage active, healthy living.
Safeguarding concerns should be prioritised by health and wellbeing boards and communication with the local safeguarding board should be established to ensure joined-up commissioning decisions between the parties involved.
Overview and scrutinyOpen
Ward councillors play a central role in the life of a local authority, as a conduit for discussion between the council and its residents and as a champion for local concerns.IDEA and the Centre for Public Scrutiny, 2009
Local Government and Public Involvement in Health Act (2007) gives powers to Overview and Scrutiny Committees to review and scrutinise local public service providers including care homes.
Scrutiny serves a number of functions:
- ensuring that decision making processes are clear and accessible to the public
- holding executives and local authority cabinets to account for their decisions
- promoting evidence-based policy making
- improving quality in public services
- ensuring stakeholders are able to influence policy.
Overview and scrutiny committees are made up of elected local authority councillors and they are responsible for holding local NHS and social care services to account. Methods of scrutiny differ between localities: as well as gathering information from police, safeguarding leads and other sources, councillors may visit people in care homes and talk to their relatives and care home staff.
The function of scrutiny is getting wider. Community-led scrutiny will involve increasing numbers of stakeholders. With increasing responsibilities for local authorities to ensure public health and wellbeing, the scrutiny function is uniquely placed to examine the effectiveness of local partnership working to ensure good practice in safeguarding.
A new independent consumer championDH 2010
The Health and Social Care Bill (2010) sets out plans to establish HealthWatch within the Care Quality Commission. Local Involvement Networks are already established and will become the local branches of HealthWatch.
HealthWatch, at a local level, will provide feedback from people that is vital to the commissioning process across health and social care. Ensuring that people receive the support they need to make choices and to complain when things are not right should improve outcomes. HealthWatch England will have powers to propose CQC investigations of poor services. It is important that commissioners are working with HealthWatch and CQC to ensure local concerns about poor services and safeguarding are addressed and inform future commissioning decisions.
Quality assurance and monitoringOpen
Commissioners should ensure good quality care. Service users and carers should not have to battle constantly for it!service user
Local authority and NHS commissioners are responsible for monitoring the standard of care in the services they commission. Commissioners, along with other regulatory functions, will need to move away from assessments of quality based on inputs and expenditure to develop outcomes-focused judgements about the value and quality of service provision. Commissioners should seek to develop good communication and share information with other authorities purchasing residential or nursing care in their area, the people placed in their area by other authorities and self-funders.
People who use services, their carers and representatives should be involved in monitoring. Commissioners should ensure people using services and carers have access to advocacy and support services to enable this to happen, in addition to the statutory requirement for local authorities to provide Independent Mental Capacity Advocate services.
Carers have a key role to play in the care and safeguarding of their loved ones who live in residential care. It is important that providers work in partnership with carers, relatives and close friends and that their expertise is recognised: they may be the first to notice when something is wrong. The perspective of people coming into the home from outside will be different and may be invaluable in the improvement of care standards.
Whilst keeping records on the number of safeguarding alerts and complaints may provide useful data, it is essential that monitoring activity focuses on outcomes - what people using the service want and value - and that the data is analysed rather than simply counted. Measuring outcomes remains a significant challenge and, as Bowman (2010) points out, compared with NHS outcomes measurement, ‘care typically addresses long term multiple and diverse user profiles with widely varying outcome expectations and complex interdependencies that present a higher order of complexity.’
It is important that within local authorities there are clear lines of communication between those commissioning services at macro- and micro-levels and that intelligence from the CQC is used to inform decisions locally. Equally, local professionals should provide service quality information to CQC. Good communication between all parties with a responsibility for adult safeguarding should ensure that concerns about service quality and potential safeguarding issues are identified and addressed at the earliest opportunity. Commissioners should develop a strategy and links with different social work and health professionals, councillors, complaints officers, the Local Authority Deputy and CQC to coordinate monitoring activity. The aim should be to:
- align activities as far as possible
- minimise the burden on providers
- eliminate repetition in terms of contact with residents and relatives
- ensure intelligence data is shared and utilised efficiently.
What others are doing - ideas you could use
Identify key people or teams to monitor care home quality
In Northamptonshire, quality monitoring nurses have been appointed to monitor and develop care homes. Each nurse has 20 registered nursing homes they link with. The role is performance monitoring and service improvement. The nurses do a full monitoring visit at least once a year where, amongst other things, they meet residents and families and review care plans. They provide guidance and training and advise on best practice. The nurses are also supported by some specialist services e.g. care homes infection control advisor; pharmacy advisors; tissue viability nurses and dieticians. They liaise with a range of services including the local GP to identify any emerging concerns. They use a quality monitoring tool to identify where areas of improvement are needed in a particular care home or where there is a need across a number of providers.
Where there are higher levels of concern, they work intensively with the care home, local authority safeguarding and CQC to specify improvements. They work with residents and their families to ensure they are able to make informed choices. The PCT work very closely with the local authority and the Care Quality Commission to share concerns about poor quality homes.
This escalation plan identifies the roles of the various parties according to the level of concern.
AP D care home escalation structure
Social Return on InvestmentOpen
Social Return on Investment (SROI) is a method of assessing value to include aspects that are valued by stakeholders. SROI provides a means to:
- map the full range of outcomes of a service and consider other relevant outcomes
- value these outcomes in order to make a comprehensive and informed assessment about value for money
- frame the discussion on where these outcomes are relevant and how they may be included in commissioning.
Commissioners can use the principles of SROI to:
- improve services and their outcomes
- unlock potential in their supply base
- reconfigure services or change commissioning practice to better meet people’s needs
- support or evidence links to policy objectives and avoid unintended consequences
- save money.
(Cabinet Office, 2009)
What others are doing - ideas you could use
Develop a local quality assurance framework to align monitoring activity and reduce the burden on providers
The London Borough of Sutton is implementing a Quality Assurance Framework for all commissioned services, based on that developed for Supporting People. It is based on a menu of eight core standards, three of which are applicable to care homes. The idea is not to duplicate CQC standards, but to complement them. CQC standards are considered to be a minimum requirement. The QAF is based on three levels (A-C), with providers self-assessing and providing supporting evidence, followed up by a validation visit from contracts officers. The QAF was successfully piloted with domiciliary care providers and further work aims to reduce the burden for both providers and commissioners.
Establishing a stakeholder group to review services as part of multi-agency quality auditing.
Social work reviewsOpen
Some social workers and health professionals are responsible for supporting individuals to choose a residential placement. Their responsibility includes assessing the suitability of the placement and its ability to meet the needs of the individual and reviewing this at least once a year. The consideration of safeguarding issues should be central to the process.
A feedback loop on service quality, including any safeguarding concerns, should be established between social workers and commissioners. This should form part of the wider communication networks to share such information.
Complaints and feedbackOpen
Service providers are required by CQC to have an effective complaints system in place ‘for identifying, receiving, handling and responding appropriately to complaints and comments made by service users, or persons acting on their behalf, in relation to the carrying on of the regulated activity.CQC 2009
Complaints should be viewed as a positive mechanism for service improvement and part of the safeguarding process. Commissioners can use complaints information and outcomes to inform commissioning decisions.
Commissioners should be aware that residents and relatives, for a number of reasons, may be fearful of complaining or providing negative feedback and that they may have very low expectations of the service.
What others are doing - ideas you could use
Use advocacy and volunteers to promote safeguarding and service quality, and reduce social isolation in care homes
Advocacy in Barnet ‘ADVANCE’ project is a local scheme where volunteers visit people in care homes who have no family to talk to them and listen to their concerns. They aim to place a volunteer advocate in each of the 120 care homes and day centres used by older people in Barnet.
Resources on prevention
- SCIE: Adult Safeguarding - Prevention
- Department of Health JSNA Guidance
- The Centre for Public Scrutiny promotes the value of scrutiny and accountability in modern and effective government and supports non-executives in their scrutiny role.
- IDeA: Councillors briefing on safeguarding adults
- IDeA: Adult safeguarding scrutiny guide
- IDeA: The role of district councils in safeguarding adults
- SCIE: Defining excellence in adult social care services