Poor training of care home staff leaving residents at risk, investigation finds

Community Care research finds residential care staff are missing out on vital training in dementia care, safeguarding and the Mental Capacity Act

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Published in partnership with Unison

Staff working in residential and nursing homes are not being provided with the training they need to support adults with complex needs, research by Community Care has found.

Dementia care is particularly falling short, with even specialist dementia homes failing to provide training on the topic to their staff. Safeguarding, the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (Dols) were the other most common gaps.

We found examples of where the lack of training had resulted in safeguarding concerns not being reported, residents being unlawfully deprived of their liberty, and people with dementia being treated with no empathy or understanding of their care needs.

Unison said the findings highlighted the “shocking lack of investment” in the residential care system.

The Care Quality Commission’s chief inspector for social care said it was worrying that gaps existed in areas that are fundamental to the protection of vulnerable people’s rights.

About the research

Community Care wanted to understand the training gaps among residential care workers. We analysed 300 inspection reports published by the Care Quality Commission (CQC) between 1 October 2014 and 31 August 2015. We looked at where training had been identified as an issue by inspectors and where the gaps were in terms of topic area.

The analysis of 125 ‘inadequate’ services, 125 ‘requires improvement’ and 50 ‘good’, showed:

  • Training gaps were identified in 71% of care homes told to improve by the CQC.
  • Dementia care, safeguarding and the Mental Capacity Act were the topic areas that fared worst.
  • Almost half (49%) of the homes told to improve by the CQC were breaching regulations that require them to ensure a suitably trained and supported workforce.

The 300 care homes we looked at were inspected under the CQC’s new approach, provided residential and/or nursing care and supported adults over the age of 65 years.

Training gaps by rating3

Of the 250 homes told to improve by the CQC, 178 had gaps in training provision.

As would be expected, training issues were much rarer in homes rated ‘good’ by inspectors. Gaps were identified in only five of the 50 homes looked at, however, these gaps were also in the three topics specified above, suggesting a widespread issue with training in these areas.

Dementia care

Dementia care has been a government priority for the last five years. In March 2012, Prime Minister David Cameron set a ‘national challenge’ to drive major improvements in care, research and awareness by 2015. More recently, the challenge has been extended to 2020.

But our findings suggest this drive has yet to make an impact on some of the worst-performing care homes, with more than a quarter of those rated ‘inadequate’ or ‘requires improvement’ found to be lacking when it comes to providing training on the condition.

Excerpt from an inspection report of an 'inadequate' care home in Blackpool

Excerpt from an inspection report of an ‘inadequate’ care home in Blackpool

This is particularly worrying given that estimates published by the Alzheimer’s Society show 80% of people living in care homes have either dementia or severe memory problems.

Even more concerning is that of these 69 homes, 66 listed dementia as one of their specialisms on the CQC website, or supported residents living with the condition. In the worst cases, ‘specialist dementia homes’ were operating without providing any dementia training to staff.

Excerpt from an inspection report of an 'inadequate' care home in Dorset

Excerpt from an inspection report of an ‘inadequate’ care home in Dorset

Andrea Sutcliffe, chief inspector for social care at the CQC, said the findings were worrying due to the impact poor practice can have on people living with dementia.

“We know if people who are living with dementia are not supported in the appropriate way it can cause them additional confusion and distress.

“It impacts on their wellbeing and it may impact on their behaviour, which actually makes the jobs of people working in the service even harder because they are potentially dealing with a manifestation of that distress and confusion,” she added.

George McNamara, head of policy at the Alzheimer’s Society, said there was a massive challenge ahead to ensure the health and social care workforces are equipped with the right skills to support people with dementia.

“Central government must provide adequate resources to local authorities to tackle the crisis in staffing levels in care homes and this must factor in time for dementia training to ensure a person-centred service is consistently provided,” he said.

Mandy’s story

Mandy*, a night worker, has worked at the same care home for the last ten years. The home supports older people, some of whom have dementia.

“I haven’t had dementia training for at least four or five years,” she told Community Care. “There are some staff who get to go on the training but the providers don’t send everybody.”

“It makes me feel frustrated because I liked to keep updated and extra training would help me to better support the people I’m caring for. I could find better solutions and understand more.”

Safeguarding

Our investigation also found gaps in safeguarding training, with a quarter of care homes told to improve by the CQC failing to provide adequate training in this area.

In some cases, care workers had not received any safeguarding training, despite being in post for more than 12 months. Other examples included staff not receiving regular refresher training, or not being able to demonstrate the learning from training in practice.

Of 23 members of care staff working at the home, 17 had not received training on the safeguarding of people. – an ‘inadequate’ care home in Hampshire

Safeguarding is a statutory responsibility for providers, but nearly a third (32%) of care homes rated ‘inadequate’ or ‘requires improvement’ were also found to be in breach of Regulation 13 of the Health and Social Care Act 2008 (Regulated Activities) 2014. This regulation requires providers to ensure service users are protected from abuse and improper treatment.

These findings correspond with concerns raised in the CQC’s latest State of Care report, which found one in 10 adult social care services falling short on standards of safety. The report cited safety as the greatest concern in the sector and identified a lack of adequately-skilled staff as one of the key factors driving ‘inadequate’ ratings in this area.

Mental Capacity Act

Gaps in training on the Mental Capacity Act were also particularly prevalent. Our research found 42% of care homes told to improve by the CQC had MCA training gaps. A further 29% had not delivered training on the associated Deprivation of Liberty Safeguards.

Under the MCA, care providers should ensure decisions about a person’s care are made with their consent. Where a person is assessed as lacking capacity to make a decision, the provider must make a decision in the person’s best interests in line with the MCA code of practice.

The Dols should be applied where a person assessed as lacking capacity to consent to their care arrangements is likely to be deprived of their liberty. Where care home staff suspect care arrangements could constitute a deprivation of liberty, they must refer the case to their local authority to have it authorised.

An 'inadequate' care home on the Isle of Wight

An ‘inadequate’ care home on the Isle of Wight

Unsurprisingly, homes with an ‘inadequate’ rating were performing less well – more than a third had not provided adequate training in both the MCA and Dols. In the worst cases, staff spoken to by inspectors had ‘no understanding’ of how to ensure people’s rights and wishes are respected, and this had led to people being unlawfully deprived of their liberty.

One in 10 ‘inadequate’ homes were found to be depriving residents of their liberty unlawfully.

Andrea Sutcliffe said the findings supported those recorded by the Care Quality Commission in its annual Dols report – there isn’t a consistent understanding of the Act and the safeguards and that is “undoubtedly related” to the fact people are not getting appropriate training.

“It’s worrying that these are the places where we have the gaps because the MCA, Dols, and safeguarding are absolutely fundamental to people’s human rights being respected,” she said.

“What I’m bothered about is making sure people do something about it. Providers need to think about what they can do to address that deficit and how they can ensure the training they provide meets the needs of residents, is thorough and robust, and is not a one-off event.”

Other key findings

training gaps by topic area

Our research also highlighted a need to better support care staff in managing the health needs of residents. Of the homes told to improve by the CQC, 15% had training gaps in health conditions such as diabetes and epilepsy. Providers were also failing to provide staff with training on pressure sores, catheter care and invasive procedures.

Sutcliffe said better integration between the NHS and care homes was key to ensuring care staff have the skills and confidence to manage complex health conditions. “We need to be absolutely clear that the NHS does not stop at the care home door,” she said.

Sector reaction

Des Kelly, chief executive of provider organisation, the National Care Forum, said: “While it is difficult to know if the sample is representative, 300 care homes is a large enough survey to be disturbed by the findings. It is the responsibility of providers to ensure that staff are appropriately trained and developed. I am alarmed that services described as ‘specialist’ fall short on such fundamental statutory responsibilities.”

Heather Wakefield, head of local government at Unison, added: “This research highlights the shocking lack of investment in our residential care system, leaving clients vulnerable to inadequate care as a result of insufficient funding to support required training, appropriate staffing levels and safeguarding mechanisms.

“UNISON members and other staff are being exposed to criticism as a consequence. The UK is one of the world’s richest countries and we can afford to treat our elderly citizens better than this. We can also afford to put money into staffing and proper training for the job. Unless the government shifts its priorities and recognises that care needs to be properly funded, our residential care system will be unable to cope.”

Why do training gaps exist?

The responsibility for ensuring staff are trained and supported rests primarily with care providers, but our findings suggest in many cases training is not being seen as a priority.

Sutcliffe said staffing issues and financial pressures were two factors driving the problem.

“If homes are operating at a level that means they cannot release people for training because there aren’t enough staff then that’s a problem,” she said.

“Providers also see training as the area where they can cut the corners [when in financial difficulty] but it is a false economy. If you don’t train people and give them the capability and the confidence, they won’t be able to cope with the job and will leave.”

The increasing financial pressures the sector is facing have made the headlines recently, with significant cuts to council budgets, the increasing complexity of people’s needs and high vacancy rates all playing a part in providers’ ability to deliver care.

As part of this research, we also asked local authorities to provide their annual training budgets for the financial years 2013-14 and 2014-15, for staff working in the residential care services they commission. Only 30 councils were able to provide this information following a Freedom of Information request.

Of these, 60% of the councils had cut their budgets in 2014-15. In 2013-14, councils were spending an average of £55,000 on training for residential care workers, this reduced to an average of £43,000 in 14-15.

Kelly added: “I do not believe that the erosion of monies for training from local authorities can be used as an excuse. However, it seems likely to have contributed to the worrying picture that emerges from this survey.”

Do you need to brush up on your knowledge of dementia but haven’t been given the opportunity?

Dementia webinar_Ad for Inform_200x200

Community Care’s free webinar will offer tools to help.

The webinar will provide an overview of the key practice elements – from recognising how the condition affects people to communicating with individuals more effectively.

Our expert panel of speakers from the Care Quality Commission, the Alzheimer’s Society and Unison will also share success stories from the frontline, examples of what good care looks like, and strategies for building more positive relationships with people living with dementia.

Register for this free webinar here.

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9 Responses to Poor training of care home staff leaving residents at risk, investigation finds

  1. Gerald October 28, 2015 at 1:38 pm #

    I wonder if this survey includes the Public Sector as Unison tends to be rather biased against the Private (for profit) Sector.
    I have rarely seen anything that Unison is involved with have any good comments etc. for the Private Sector.
    Training problems is by no means restricted to Care Homes the whole Country is suffering due to under investment in the past, one only needs to look at the staffing crisis in the NHS, they have a massive underprovision of qualified nurses (reported regularly by the CQC) and have even resorted to recruiting from abroad, something Unison was totally against at one time.
    Lets have a balanced picture, can we ?

    • Rachel Carter October 28, 2015 at 1:58 pm #

      Hi Gerald, thanks for your comment. I selected the 300 inspection reports at random from the Care Quality Commission’s website. All care homes had been inspected under the new approach (introduced 1 October 2014) and supported adults over the age of 65, but I didn’t work to any other criteria. The sample therefore includes a mixture of public sector and private sector homes. Completely agree there needs to be a balanced picture because training is a sector-wide issue, but we chose to focus specifically on residential care in this instance. Thanks, Rachel Carter, Journalist at Community Care.

      • Gerald October 29, 2015 at 11:42 am #

        Dear Rachel.

        When I see “Published in partnership with Unison” I am always weary bearing in mind that they have very few members in the Private Sector.
        Did you involve any Local Authorities in the Survey as they are very much involved in training as they seem to be able to get grants etc.?
        As Michelle points out, there are shortfalls in the system but there is also no National Organisation willing or able to take this on.
        I tried to get a scheme of the Ground for training up senior HCAs into Nurses (for Nursing Homes Only) to try and help with th Nursing shortage situation, I have had no success what so ever as the establishment cannot get its head around this idea. The private sector tried to warn the Government of the shortage of Nurses and the effect of retrictions imposed by Immigation no one took any notice until the NHS needed nurses. Unison then did a U turn.
        Yes, there is apperthy ,but there is also frustration , the Public Sector dominated Care Homes and Nursing homes for years and it is only recently with the CQC introducing an even approach to inspections for ALL sectors that we are getting an overall view point.
        The main problem still is that the Public Sector is still funding placements to the Private Sector with all the old Politics involved as they used to when they were the Inspectorate. Social Care is has always been a Political football as long as it stays like this simple things like value for money and quality will be ignored.

    • James October 29, 2015 at 4:55 pm #

      Unison will push for workers to have appropriate training in both the public and private sector. All employers should be accountable whether local authority, charity or private limited company. Although, in my experience, local authorities do provide a standard package of training for all employees as part of policy and legal requirements. I’m a rank-and-file member, and do not represent the union in any capacity, but I would say that it’s important that we – unions, social workers, health professionals, commissioners – ensure that companies, who have a rather difficult task of meeting care needs and producing profits for their shareholders, are providing a good service for their clients and workers. More than public sector? No, but certainly robust measures to evaluate the private sector, which is a reasonable expectation when they have this dual (and often conflicting) purpose of need and profit. That’s another matter and sorry to detract from article.

      Local authorities, of course, do share responsibility in that reduced funding to private providers impacts their budgets for training and development.

  2. Michelle October 28, 2015 at 3:10 pm #

    The standard of training across the care sector has been an area of contention for many years but recently it has become increasingly worrying at the standards of some training being given to care staff. Training is at times poorly managed with managers being told to ‘just find the cheapest provider’ The course outlines/summaries/lesson plans should always be looked at to ascertain the modules being covered and to what extent. What are the competencies of the trainers delivering the course? I find that as long as a trainer has a nursing pin and a training certificate this seems to instill a belief that the training meets certain standards, with all respect to clinical trainers a valid nursing registration does not give competency to all subjects across the care sector. How many trainers are working in the care environment but have never worked in care themselves so therefore have very little understanding of the needs of both the staff and residents being cared for. Excellent training will impact on the standard of care given as will poor training……both have very different outcomes!! While care staff continue to be beaten with a stick i truly believe that sometimes mistakes happen simply because the staff do not know any better and this leads us back to the quality of the training given. The findings of this report are nothing new and I am sure they will be discussed in great depth but will anything change? I fear not! Until CQC start looking at the standard of training staff are receiving there is nothing to encourage the care industry to invest in their staff. We must move away from the mentality that training is simply a ‘tick box’ exercise and actually an investment in the care of both their staff and residents we will continue to have the same discussions. We also have the wonderful invention called E learning….. I truly believe this has absolutely no place in the care sector. First Aid, Pressure Care, Safeguarding, MCA DoLS, Dementia…I could go on and on all being given to care staff. Having completed a lot of these e learning courses I am shocked and appalled that you get not 1, not 2 but endless chances to correct a wrong answer! How on earth can this be deemed acceptable training? So the question I would very much like to ask Andrea Sutcliffe and her colleagues is this… Your much loved relative has dementia, they are frail and nearing the end of their life, the care home they are residing in looks lovely and ticks all of the boxes…..except your loved one is being cared for by a well meaning carer who has received all of their training from a computer….. Do you still feel safe and secure in the knowledge that your loved one is being properly cared for? This is a situation being repeated 1000’s of times over and over across the country and who gets the blame when things go wrong….THE CARE WORKER…the same care worker who is carrying out their job role in exactly the way they have been trained to do so.

  3. Alex Knapp October 29, 2015 at 11:15 am #

    Michelle – Gerald, you are quite right…

    However…

    We need to change the broken record. This story has not changed for years and it is not the training.

    It is the learning, knowledge, understanding, competence and safety to practice that is missing!!!!!

    Think about the output of training = learning, that is the reason people go on training, so they can apply what they have learnt. Now clearly if they don’t go on the training then the learning needs to be delivered in another way, because the provider has a duty to ensure that staff are safe to practice.

    Look at regulation 18 and 19 in the Fundamental Standards – the key word = COMPETENCE (aka safety to practice)

  4. John Burton October 29, 2015 at 11:52 am #

    I would like to add to Michelle’s sensible comments as follows. One of the enduring problems with the development of good care in care homes is that we don’t take a whole system approach and the regulator/inspector is not equipped to understand how good care works. We split care up into its theoretical parts. Frequently one sees in inspection reports that a home rates good on “caring” but is downgraded in other categories. How can that be? It’s a CARE home. As to training – the majority of training programmes are designed to prove that people have, at the point of finishing the training, given the right answers – or, as Michelle points out with E-learning, have eventually found the right answers to give. When inspectors question staff about dementia or safeguarding or whatever, they too simply want to be given the right answers. You observe (and make a judgement about) the quality of training by observing the care and discussing the issues with staff. You want to know whether staff UNDERSTAND what they’ve learned and can apply it in practice and discussion.
    And how is that sort of training achieved? Through managers and other leaders in the home reading, going on courses, taking part in leaning networks and action learning sets, and bringing ideas and learning back to the home and sharing it in practice every day.
    The best training takes place on the job, in handover meetings and supervision, in team meetings and special internal training events – everyone is leaning and developing their knowledge and expertise every day.
    The real experts on dementia are those staff who work in brilliant care homes with expert leadership and lively, learning teams – people who learn from their residents and are keen to give better and better care through relationships.
    Unfortunately, you can work in the best learning environment possible and be a real expert, but if you don’t have your worthless little self-printed, self-examined, certificate from some tin-pot little – or big – certified training outfit, CQC won’t understand that you really do understand your subject.

  5. Amina October 30, 2015 at 12:15 pm #

    I have been around several care home and I have observe
    The issue it is in my big worry that places employ un qulified staff with no theoretical background

  6. Diana November 2, 2015 at 4:33 pm #

    This webinar is very welcome, I have promoted it to my network of care providers.
    Could you consider holding one in the afternoon, as mornings are very busy in most care settings.