Older people badly let down by CQC
The Relatives & Residents Association has expressed continued disappointment with the role the Care Quality Commission has taken during the pandemic. In a letter to the regulator, R&RA’s chair outlines how older people needing care have been badly let down by the CQC. As a human rights crisis unfolded in care – with isolation infringing people’s rights to liberty, family life and wellbeing – the CQC retreated to the side-lines. Their lack of action has left people in care at risk. Their lack of voice and leadership has left the sector vulnerable. Their failure to adapt to the changing world has left care users and their families bereft. The letter calls on the CQC to take urgent action to remedy these failings and earn the trust and respect of those they exists to represent.
The letter is accompanied by a summary of insights and evidence from the R&RA Helpline of the barriers older people and their families continue to face around contact and the impact of isolation.
A copy of the letter is below.
The Relatives & Residents Association
By email only
11 May 2021
Ian Trenholm
Chief Executive
Care Quality Commission
Dear Ian,
I wrote to you last May to express our disappointment with the role CQC had taken during the Covid-19 pandemic. It is with regret that I write to you again, a year later, to express our continued disappointment.
As you know, the Relatives & Residents Association champions the rights of older people needing care in England. The R&RA Helpline has been supporting people at the sharp end of coronavirus and the measures taken to manage it.
We are living through the most difficult period in generations. At a time of unprecedented challenges and sustained infringements on rights, CQC retreated to the side-lines. This is when older people using care services needed their regulator the most. Over the past fourteen months we have all borne witness to a human rights crisis unfolding in care. Isolation and other restrictions have infringed people’s rights to liberty, family life and wellbeing.
CQC’s lack of action has continued to leave older people in care at risk. They have been neglected by the very system designed to protect their rights. CQC’s lack of voice and leadership have left the sector even more vulnerable and resulted in a further lack of trust in your authority. CQC’s failure to adapt to this changing world has left care users and their families feeling bereft of the protection and scrutiny specifically designed by Parliament to protect them. It is, therefore, of enormous concern and distress to our beneficiaries for the regulator to have reported to Parliament that you see no problem with the implementation of guidance on visiting whilst admitting that you do not collect data to justify this bizarre assertion. This is particularly troubling in the light of evidence from R&RA (and other organisations) specifically reported to CQC to the contrary.
Older people needing care have been badly let down by the CQC during the pandemic. It is imperative that you now take urgent action to remedy these failings and earn the trust and respect of those you exist to represent. R&RA has repeatedly called for CQC to take a proactive role in monitoring compliance with the Government guidance on visiting (see annex). Please explain to us why you are still not taking this proactive role.
A very real and new fear coming through the R&RA Helpline is the persistence of closed cultures in care settings at the expense of the needs and rights of care users. The current situation is in great danger of becoming the ‘new normal’ in care settings. CQC has a key leadership role to play in guaranteeing open, inclusive cultures across all care settings. This is not only about ensuring access to family and friends inside and outside the home, it is about face-to-face contact with health practitioners and other professionals who help ensure rights are protected. It is about the necessary access to other types of visitors and the outside world, to help create an engaging, stimulating environment, particularly important for those without family or friends to visit. It is about crucially ensuring that care users (and the relatives and friends they want to support them) are encouraged to participate in discussions and decisions about their care. In this connection, please let us know how many inspections during the pandemic have been triggered by concerns raised about closed cultures, as defined above, and by whom.
The care providers that have continued to operate with an open, transparent culture and have welcomed back family and friends have reported increases in care users’ wellbeing as well as improvements in staff morale. How are you sharing examples of good practice with all care providers?
Given your purpose to safeguard adults in receipt of care and to promote the improvement of services, CQC should be:
Restarting routine inspections of care services: prioritising settings with a history of serious breaches of the Regulations, those without a manager, with a high staff turnover, and those not inspected for three or more years.
Proactively monitoring compliance with Government guidance on visiting (in and out of care settings): insisting that care homes make their visiting policy explicit and report current practice to you as the regulator. The information should be publically available and assessed in CQC’s inspections and reports.
Representing the rights of all individuals using care services: particularly for access to healthcare – CQC should be calling for and encouraging reestablishment of face-to-face contact with health practitioners, social workers and other professionals.
Using its leadership voice in speaking up and raising awareness of the care sector’s needs: particularly for adequate sick pay for care workers.
We look forward to your response to these points and the questions outlined above. Please see the annex for a summary of what we are hearing on the R&RA Helpline about visiting and the impact of isolation. We would be pleased to provide further information on any of the issues highlighted.
Yours sincerely,
Judy Downey
Chair
The Relatives & Residents Association
Copy:
Rt Hon Matt Hancock MP, Secretary of State for Health and Social Care
Rt Hon Harriet Harman MP, Chair, Joint Human Rights Committee
Rt Hon Jeremy Hunt MP, Chair, Health and Social Care Select Committee
Annex: Summary of insights and evidence from the R&RA Helpline on visiting and isolation
R&RA has called for CQC to take a proactive role in monitoring compliance with the Government guidance on visiting.* Throughout the pandemic we have informed CQC of insights we gain from the R&RA Helpline about the impact of visiting restrictions, problems with compliance and the fear of our helpline clients of speaking out or raising this with CQC.** A summary of what we are currently hearing is included below along with a note about why families are afraid to speak up. We hope this will encourage CQC to take a proactive role in monitoring compliance to ensure care users receive quality care.
Fear of speaking out
When people face barriers or problems with gaining access to loved ones, too many are afraid to speak out to challenge this with the care home, use their legal rights or report it to CQC due to fear of reprisals (including, ultimately, eviction). The power imbalance is so vast and people using services are placed in such a vulnerable position, they are afraid to rock the boat. Despite CQC’s reassurances that issues can be raised anonymously and people’s identities protected, many remain afraid that the home will be able to identify them. This might be because the family have raised issues with the home previously, or they are the only family in a particular situation or due to the size of the home. CQC’s model of relying on problems being reported to you simply doesn’t work when so many people are afraid to speak up and have so much to lose. A new, proactive approach is needed to protect people’s rights.
EXAMPLE: A wife who has been trying to get better access to her husband has been warned by the social worker to stop rocking the boat with the care home for fear that they will lose the placement.
Blanket approaches
Some providers are still preventing visits
Providers only offering timed visits, often 15-30 minutes, strictly implemented even if the resident is distressed by this
Only offering visits in designated visiting rooms which are bare/unwelcoming (distressing for people with dementia) instead of familiar environments like people’s own rooms – this also restricts the number of visits a provider can facilitate
Time limits apply even on visits out of the home
EXAMPLE: One helpline client has had only two visits throughout the pandemic.
EXAMPLE: A husband who used to visit daily is limited to one 30 minute visit per week in a bare visiting room, which is so distressing for his wife they only spend 10 minutes together.
Lack of individual assessments
Widespread lack of individual assessments, even where requested
Residents and their chosen representatives not being involved in risk assessments or provided with a copy of the outcome or care plan
Lack of individualised approaches leads to visiting arrangements which cause distress and discomfort for case users (distressing settings, no protection from cold etc.)
EXAMPLE: A care home refused to carry out a risk assessment for a resident with a hearing impairment to review use of PPE and how this would hinder their ability to understand.
Essential caregiver role not being implemented
Lack of individual assessments (above) is a barrier to getting the essential caregiver role
Lack of understanding of the role and of essential caregivers providing emotional support, not just practical support
Failure to recognise changed care needs as a result of a year of isolation
Failure to recognise relatives as part of care team, instead seen as an optional extra
Blanket approaches with only one essential caregiver permitted in the home at once, strict time limited slots etc.
EXAMPLE: A husband who helps to feed his wife is only permitted access twice a week for two hours as her essential caregiver, with no justification offered for these restrictions.
Nominated visitors
Rigid approaches and lack of flexibility to meet resident/family’s needs
Additional restrictions/barriers put in place by care homes, such as nominated visitors needing to be from the same household/bubble
EXAMPLE: Sisters are prevented from using each other’s weekly visitor slot when one is unable to attend due to work commitments and the long drive.
Supervised visits
Staff sitting in on visits in care homes, to support the resident or for ‘health and safety’, meaning families can’t have private conversations, or discuss issues/concerns about care
Staff escorting residents on visits out of the home with their family
EXAMPLE: A daughter is told she isn’t allowed to take her mother on a visit out of the home alone and they must be accompanied by staff, which also limits the duration and location of the trip.
End of life visits only offered at very end
End of life visits only being offered in the final days when death is imminent, not in the final months/year of life as outlined in the guidance
Results in residents not having quality time with family (may already be unconscious when visits take place), and in end of life visits being granted and then withdrawn if the resident recuperates as a result of the contact
Strict time limits on end of life visits leading to further distress
Care homes disagreeing with end of life status and refusing this type of visit
EXAMPLE: A son was given 15 minute end of life visits with his dad but they were cancelled when he was reassessed as not in the final stages of life. They had only one visit, where the dad had to sit in a visiting room, before he was hospitalised and died.
Lack of access to healthcare
Many healthcare professionals are still not doing face-to-face visits in care homes
The two week quarantine after visits out has meant residents choosing not to attend medical appointments to avoid the isolation and the resulting detrimental impact on their mental health
Residents who need frequent access to healthcare or have regular check-ups have faced perpetual isolation after each appointment
People moving from hospital into care on a temporary basis for recovery/recuperation decline further as a result of having to isolate on arrival
EXAMPLE: A son fought to get his father back into rehabilitation, but now he will face rolling quarantine periods in isolation after each appointment.
EXAMPLE: The impact of isolation was so severe for one resident she decided to move out of her care home to live temporarily with her daughter. She is now attending health appointments she would have missed had she still been in care and facing quarantine.
Outbreaks
Closures of 28 days for outbreaks (more than twice as long as isolation periods outside of care settings) have led to increases in depression and confusion
The restrictive definition of an outbreak, and interpretation of it, have led to closures even when confirmed cases took place outside the home
The combination of above can lead to perpetual closures, leading to very long periods of isolation for residents
EXAMPLE: A resident who became withdrawn when isolating in her room during an outbreak, took to her bed, seeing no reason to get up. She described it as being like a prison and said she longed for some wallpaper to look at, rather than the blank white walls.
EXAMPLE: A home closed for a month after one member of staff tested positive, even though they were on leave at the time and there were no other cases in the home.
Additional barriers
Some families are facing other, additional restrictions, beyond those outlined in the guidance, including:
Insisting visitors travel to visits in private vehicles, unfairly excluding those without their own car
Banning residents from travelling in private vehicles on visits out (despite this being advised in the guidance) restricting the location and quality of the visit
Insisting visitors and/or residents have two doses of the vaccine before visits
Insisting visitors sign a disclaimer waiving liability before visits
EXAMPLE: A care home’s ban on residents using family transport for visits out in practice meant these visits couldn’t happen as there were no local amenities within walking distance.
Identifying characteristics have been changed in the examples, to protect anonymity.
* We did this in private meetings (on 23 February, 16 March and 14 April), in writing (on 24 and 25 February and 16 April, publishing an article on our website on 25 February), and in a stakeholder meeting (on 26 April). Following a letter from CQC’s chair to the Joint Committee on Human Rights on this issue we requested a further meeting (on 25 March) but CQC has yet to organise this.
** In the meetings above, in other stakeholder meetings and in our quarterly reports to CQC as part of the Tell Us About Your Care project.