The introduction of minimum staffing levels for care homes was a key recommendation of a Comic Relief-funded study published last year, which looked at preventing the abuse and neglect of older people. But six months on there are still no plans for a review on social care staffing, despite guidance on safe nurse staffing levels in hospitals being published last month by the National Institute for Health and Care Excellence.
The Comic Relief study, the Prevention of Abuse and Neglect in the Institutional Care of Older Adults (Panicoa), was undertaken over a five-year period and published its findings in December 2013. The report called for the UK Government to ensure health and social care regulators set and monitor standards for minimum staffing levels in care homes.
Although all Care Quality Commission-registered providers must currently ensure there are “enough members of staff to keep people safe”, a minimum standard is not clearly defined. It has now been twelve years since staffing levels in care homes last went under extensive review, with a study commissioned by the Department of Health in 2002 still considered the most recent.
2002 staffing review not implemented
The 2002 study was undertaken by a working group of care home good practice body the Residential Forum and produced two sets of guidelines, one for older people’s care homes and one for younger adults’ homes. However, neither of these were implemented due to concerns about the financial impact they would have on the sector.
“The Department of Health did some work on assessing the impact of implementing the guidelines and discovered that a significant proportion of the sector would fall below the staffing requirements and therefore there would be a financial impact,” says Des Kelly, executive director at the National Care Forum and member of the Residential Forum working group.
Staffing is one of the principal costs for care providers and, according to research by the Joseph Rowntree Foundation, staffing costs account for 45 to 60% of care home fees. This includes care staff, catering, cleaning and laundry staff, management, and administration staff, as well as additional staffing costs such as holiday pay, sick pay and employers’ pension contributions.
“All of these things have to be taken into consideration and, following the recession and cuts to the public sector, I think if you were to put new staffing guidelines into the mix again now it could cause quite an explosion,” says Kelly.
A complex sector
One of the key concerns for providers in favour of a review on staffing is that all care settings are taken into consideration, in order to produce a set of guidelines that meet the needs of a complex sector, rather than taking a one-size-fits-all approach.
“We have a clear vision of what a hospital ward is and what it does but that is less accessible to us in a care home,” says Dawne Garrett, professional lead for the care of older people at the Royal College of Nursing.
“Our broad view is that it would be highly useful to have some work done on safe staffing levels, similar to that done in hospitals, but if any work is done it needs to make sure that it is analysing similar environments of care and similar services, rather than a very broad area,” she adds.”
This issue was addressed to some extent by the working group, in so far as it produced separate guidelines for staffing in older people and younger adults’ homes. The work assessed the staffing needs of a care setting based on the needs of the residents, the nature of the building and the training requirements of the staff.
The needs of service users have been changing over time and staffing requirements have just been allowed to evolve without having a clear, professional idea about what the right level of staffing ought to be.” Des Kelly, National Care Forum
“The work separated out care for older people and care for younger adults because they are completely different in the way that you approach them,” says Kelly. “However the way we provide services has changed and there are a lot more new homes now, so there is a justifiable case for this to be revisited.”
“What we have now is a situation where the needs of service users have been changing over time and staffing requirements have just been allowed to evolve without having a really clear, professional idea about what the right level of staffing ought to be,” he adds.
The Panicoa study recognised that there was a need for minimum staffing levels and said that although staff were “typically hardworking and committed to delivering respectful care”, this was often undermined by workload pressures. It also said that senior managers could do more to protect their staff and better recognise the pressures that they were facing.
‘Care homes are not hospitals’
“It is known that staffing affects care and it is important that we get the right people with the right skills in the right place,” says Jill Manthorpe, professor of social work at King’s College London and contributor to the study. “However, care homes are not hospitals and we should be careful not to fall into the trap of becoming mini-hospitals.”
The move to introduce guidelines on safe nurse numbers in acute hospital wards in England was prompted by the public inquiry into the Mid-Staffordshire hospital scandal, which flagged up staffing as an issue. The guidance does not give a minimum requirement, but it states that a ratio of more than eight patients to one member of staff should signal that care may be being compromised.
“What we have got now is good evidence for hospitals that staffing ratios can affect patient outcomes but it would be complex to do the same in care homes,” adds Manthorpe. “We should be focusing on poor care and if you think staffing is one way to do that then that’s great, but we should not jump on the bandwagon for guidelines without doing the research.”
We should be focusing on poor care and if you think staffing is one way to do that then that’s great, but we should not jump on the bandwagon for guidelines without doing the research.” Jill Manthorpe, King’s College London
CQC ‘must be more robust’ on staffing
“I think a review will come back exactly as it did before and we will have the same arguments again,” says Nadra Ahmed, chair of the National Care Association. “What we need is for managers to make decisions on staffing based on the needs of client groups and for the CQC to be a critical friend to the sector and to be more robust in the questioning of why staffing is at a particular level.”
Garrett adds: “Minimum numbers are minimum numbers and they do not reflect the acuity and dependence of the patients. The skills of the staff and the environment they are in make a huge difference to the number of staff you need.”
So the jury is still out on whether a social care staffing review will take place, or indeed if there will be a will in the sector to champion safe staffing guidelines in the future. But, as Kelly comments: “This is a piece of work that has been kicked into the long grass for quite a long time now, it is overdue and sooner or later it is going to have to be addressed.”