Adult social care in crisis?
Adult social care is under intense focus. In May, BBC’s Panorama programme screened shocking abuse at a hospital for people with learning disabilities. And more than 30,000 elderly residents face an uncertain future with the UK’s biggest care home provider, Southern Cross, closing and transferring its homes to other operators.
Meanwhile, social care professionals have flagged serious concerns about personalisation, one of the key policy drivers in adult social care. And while research shows personal budgets are improving outcomes, big variations exist between councils.
The future of adult social care remains uncertain. The Law Commission has set out plans to simplify adult care law, and the Dilnot commission has issued proposals to cap the costs of care to reduce the risks facing individuals. While the government will respond to both commissions in a White Paper next spring, it is unclear how far it will adopt the Dilnot proposals in particular.
Some of the key issues facing adult social care are outlined below.
You can join the debate on CareSpace, the online discussion forum for social care professionals.
Page last updated: 6 September, 14:00
Panorama abuse scandal
The fallout from Panorma’s programme on 31 May, Undercover Care, is being felt across social care. The BBC screened undercover footage of people with learning disabilities being choked, pushed and taunted by members of staff at Winterbourne View hospital, run by Castlebeck.
Arrests made/hospital closed
Police have arrested and bailed 11 people in relation to the case, on suspicion of ill-treatment under the Mental Capacity Act 2005, while Castlebeck has suspended two managers and 11 frontline members of staff. The 24-bed hospital has now closed.
The provider has apologised unreservedly for the abuse and commissioned PricewaterhouseCoopers to carry out an investigation into its services. However, in a damning report on Winterbourne View, the Care Quality Commission accused Castlebeck of “misleading” it by failing in its duty to report serious incidents to the regulator.
This was followed by a damning report on Castlebeck as a whole by the CQC, which found that half of its services were not meeting essential standards. Since then, two other Castlebeck services for people with learning disabilities, Rose Villa and Arden Vale, have closed after the CQC threatened legal action.
Concerns at Winterbourne View came to light after a charge nurse raised the issue with the hospital in October 2010 and his allegations were passed on to the local authority, South Gloucestershire Council, in its capacity as lead safeguarding agency, and then relayed to the CQC in December.
However, Castlebeck admits that its own whistleblowing procedures were not followed, and a multi-disciplinary safeguarding meeting into the issue was not held until February 2011. The CQC also failed to contact the whistleblower, which it admitted prevented it from taking swift action. It has subsequently disciplined a member of staff over the case, while it has also emerged that the CQC did not conduct any inspections of learning disability hospitals between October 2010, when concerns were raised at Winterbourne, and January 2011
The CQC is also conducting an internal review into its role, while South Gloucestershire Safeguarding Adult Board has launched a serious case review, which will be chaired by adult protection expert Margaret Flynn.
Care services minister Paul Burstow is considering an independent review into the case, to examine failings by the CQC and safeguarding agencies, and will decide whether to call a probe on the basis of the SCR’s findings.
In addition, Burstow has called on the CQC to carry out a series of unannounced inspections of learning disability hospitals such as Winterbourne View. This comes with use of private hospitals on the increase and in the wake of two national audits of specialist health provision for learning disabled people in recent years, both of which identified poor standards.
Commissioners are also subjecting learning disability hospitals to extra scrutiny in the wake of the scandal, while the number of inspections by the CQC has rocketed.
Experts demand reform
However, 86 learning disability experts and organisations have written to government to say this is not enough, and that learning disability services need wholesale reform, including an end to placements in hospitals and investment in alternatives in the community.
Though these placements are designed for short-term assessment and treatment, a Community Care investigation found that patients had been resident in them for an average of almost two years, with one in five in hospitals for at least five years.
Community Care has published a number of good practice pieces responding to the case:
- Why institutional services such as Winterbourne are still being commissioned despite years of expert guidance calling for community-based alternatives to be used instead.
- How staff training and good recruitment practices can ensure good-quality residential care for people with learning disabilities.
- Training tips for providers working with adults with challenging behaviour, from the British Institute of Learning Disabilities.
Community Care has also published a number of opinion pieces responding to the case:
- Social worker Phil Collins says the profession must stand up and be counted in hospital and secure settings.
- The manager of a private mental health hospital examines the barriers to good safeguarding facing the sector.
- The British Institute of Learning Disabilities’ Sharon Paley sets out her blueprint for avoiding another Winterbourne View.
- A council contract monitoring officer argues that it is becoming harder to tackle poor quality care because of cuts.
- A therapist questions the claims of some learning disability services to offer ‘therapeutic environments’.
- Castlebeck was urged to put values at the heart of its services by Andy Lusk, director of autism services at the charity Ambitious about Autism.
Debate is raging online on what the case means for care services for vulnerable people. Have your say on Community Care’s CareSpace forum.
The country’s biggest care home provider, Southern Cross Healthcare, is to close after its landlords decided to leave the group.
In an announcement made on 11 July, it said that 250 of its homes will transfer back to their landlords where the latter are companies involved in delivering care themselves, such as Four Seasons Health Care or Bondcare.
The company’s biggest landlord, NHP, has announced plans to set up a new company to run its 249 homes, in partnership with Court Cavendish, a firm run by former Priory Group boss Dr Chai Patel, backed by £14m in initial capital.
An announcement is due on the rest of Southern Cross’s 752 homes, which involve landlords who are not involved in the care business. The company expects its current management to play a role in operating these homes in future.
In a statement on 19 July, care services minister Paul Burstow urged landlords to come up with plans as quickly as possible in order to reassure residents over continuity of care. He also vowed that the Care Quality Commission would not lower barriers for registration for the new operators of Southern Cross homes.
However, it has been claimed that landlords will have to make substantial investments in homes – including in carpets, curtains and general maintenance – to bring them up to scratch, though this has been denied by Southern Cross.
In an interview with Community Care, published on 29 July, Patel admitted that new operators faced a battle to earn the trust of residents and relatives and restore the reputation of the homes.
Calls for regulation
The crisis has sparked concern across government and the social care sector about the risks to service users of private companies delivering care going bust.
Ministers have pledged to do all they can to protect residents across the homes, while calls are growing for an economic regulator to be introduced to monitor the finances of large providers.
The company blamed “unsustainable” rent bills from the owners of its care homes and falling revenue from councils for its fate; however critics have blamed its lease-back business model, under which it sold its homes to landlords and signed long-term leases to run them.
While it was able to meet annual rises in rents when council spending on care home places was on the up, it is now unable to do so.
This situation contributed to losses of over £300m in the six months to 31 March 2011.
At the end of May, Southern Cross issued landlords with an ultimatum to accept 30% less on their rents from June to September to enable the company to get its finances in order, in what was described as a “declaration of war” on landlords that many were minded to reject.
There followed further discussions between the company, landlords and lendors to find a way forward, but these failed.
The crisis has also sparked concerns for the Southern Cross workforce, particularly after theprovider announced 3,000 job losses and changes to working conditions, which unions said would damage the quality of care.
However, experts have said that landlords will have to invest in jobs as part of moves to bring Southern Cross homes up to scratch.
More Southern Cross coverage
Personalisation, a key policy driver in adult social care, is supposed to give service users more choice and control.
But social care professionals’ support for personalisation has plummeted, with only a minority now believing that personal budgets will benefit users in the medium to long-term.
- Bureaucracy is damaging personalisation. Three-quarters of practitioners say there is now more bureaucracy in their roles as a result of personalisation.
- Service users are fighting restrictions on the use of personal budgets.
- Many councils have made direct payments the default option for personal budgets, sparking concerns that service users are being denied choice.
- A rise in non-qualified social care staff under personalisation.
- Vulnerable groups, including older people and those with mental health problems, continue to face barriers in gaining personal budgets.
The survey results have sparked debate about the future of personalisation, amid concerns of a growing gulf between the views and experiences of service users and professionals.
Big variations between councils
Separately, big variations in council performance on personalisation were revealed by two further surveys on the state of personalisation:
- The Association of Directors of Adult Social Services’ latest poll of councils on personal budget take-up.
- The National Personal Budget Survey survey of 2,000 users and carers’ experiences of personal budgets by charity In Control and Lancaster University, commissioned by sector coalition Think Local Act Personal.
The latter found personal budgets were, in general, making a big and positive impact on the lives of users and carers but there were big variations between councils in helping users achieve good outcomes. Meanwhile, Adass found large variations in personal budget take-up between areas.
And while the National Personal Budget Survey found that direct payments were associated with better outcomes for users than council-managed budgets, Adass’s research found direct payment levels had stalled from 2010-11.
Social care reform
The adult social care system in England will be overhauled next year through legislation to simplify the law and make the funding system fairer and more sustainable. This will draw on the Law Commission’s proposals to reform adult care law, issued in May, and the recommendations of the Dilnot commission on care funding.
The government has already accepted Law Commission proposals to put adult safeguarding boards on a statutory footing and is considering other recommendations, including extending direct payments to residential care.
The Dilnot commission’s central proposal is a £35,000 cap on individual contributions to care, with the state picking up the rest of the bill. In total, its proposals would cost £1.7bn a year to implement and the government has already warned that this may prove too costly.
The inspection and regulation of adult social care is also under intense scrutiny.
While the government has ordered a probe into the Care Quality Commission’s role in the Panorama abuse scandal, it has yet to act on wider concerns about how adult social care is regulated.
But at the beginning of May, Community Care revelaved that adult care providers have seen a “frightening and unacceptable” 70% drop in inspections by the CQC in the past year, prompting fears for the welfare of service users.
Questions over whether systems for social care professionals to blow the whistle on poor practice are robust enough have also been raised.