Monitoring duplication blights care home managers’ lives

Care home managers are finding their time increasingly taken up by multiple information requests as councils, primary care trusts and the Care Quality Commission each look to monitor standards. Jeremy Dunning reports

My 40 hours a week is divided between 38 hours of paperwork and two hours hands on. I am expected to write reports, care plans and assessments on these service users yet I am unable to spend any time with them.”

This comment from a care home manager came in response to a recent snapshot survey by the Association of Care Managers (ACM), which found three-quarters of care home managers’ time was spent carrying out administrative tasks rather than attending to residents’ needs.

A key issue respondents identified was the duplication created by local authority and primary care trust contract monitoring systems that sit alongside what the Care Quality Commission already requires for homes in England.

Such duplication was wasting public resources and distracting providers from delivering services, according to a report last November by the English Community Care Association (ECCA), which found that councils were setting up their own quality assessment frameworks.

ACM head John Burton says the problem illustrates a lack of trust in managers and lack of confidence in the CQC’s inspection regime, which has led councils to set up their own checking procedures.

CQC inspections of adult care services plummeted by 70% in October 2010 to March 2011 compared with the same six months in 2009-10, as inspectors were diverted into the regulator’s programme of re-registering all providers.

The CQC also scrapped its quality ratings scheme last year, removing a means for commissioners to compare homes. There is no planned date for an alternative as the proposed replacement has been ditched.

“No one trusts the assessment CQC makes about care homes,” says Burton, adding that, because of this, local authority contract monitoring officers “are checking like proper inspectors, but they don’t know what to check and haven’t looked to see what’s going on in the home”.

The number of CQC inspections is increasing and the body now plans to inspect all adult social care services at least once a year instead of at least every two years as now.

It is also seeking to reduce duplicate monitoring. It has signed a protocol with the Association of Directors of Adult Social Services to ensure information is shared about care quality to reduce burdens on providers and improve efficiency.

This includes testing a “real-time” portal within which the regulator and councils will be able to share information on homes.

Some local authorities are also trying to reduce burdens on providers while also fostering care quality.

The ECCA has praised an initiative in Essex, where the council has adopted a collaborative partnership approach to improving care quality in residential settings.

Its contract monitoring team has been reshaped as a quality improvement team. It has replaced assessment frameworks, inspections and recommendations for care homes with an approach in which care home managers identify areas where they need support.

The quality clauses in the councils’ contract are assessed through self-assessment by managers, with the council carrying out random checks to ensure reliability.

The council’s work is based on the ­principles of the My Home Life initiative, an Age UK, City University and Joseph Rowntree Foundation project to highlight and extend good practice that will be led by the care home sector itself.

Essex has set up its own My Home Life Essex website so that care home managers can share good practice and exchange ideas. Though sponsored by the council, the website is owned by care home managers, and is focused on how they can work to enable staff to deliver better outcomes.

How far this sort of approach will be adopted by councils nationally remains to be seen. Adass president Peter Hay says some councils have made explicit political choices to have significant contract monitoring systems, partly as a result of care home failures.

And he emphasises that it will always be important for a director to keep on top of the local market and ensure that good standards and governance remain top ­priorities for homes.

A care home manager’s view

Mandy Thorn runs an 81-bed care home in Shropshire providing dementia care and nursing services. She is also a vice-chair of the National Care Association.

She has a contract with the primary care trust and one with Shropshire Council. Just 12% of the home’s residents are self-funders.

“I have an administration team so we can provide support to the manager to make sure we are prepared as far as the Care Quality Commission [and the local authority] is concerned,” she says. “But if you are a smaller provider, as I used to be, you do everything. Smaller providers will find the bureaucracy [of contract monitoring] a burden.”

Many care home managers report large amounts of duplication of information requirements from the regulator and commissioners.

Thorn says the only duplication for her surrounds information related to workforce issues that are submitted for the National Minimum Data Set, the Skills for Care resource that gathers information on the social care workforce.

But she says that this still takes a member of staff one day a month to input this data.

Thorn has a good relationship with her contract monitoring officers who, she says, work in a supportive rather than an overly officious way. “As long as we deliver what we are supposed to deliver against our contract and we inform them what is going on it is a light touch,” she says.

But providers in neighbouring authorities have not been so fortunate.

“In some areas some [monitoring] officers weren’t as aware of the sector as they should have been,” Thorn says.

Some monitoring officers demand that providers change their system of medication which, she points out, is not their role, and others have demanded changes in care plans, which she says should be a matter for the CQC.

A contract monitoring manager’s view

The role of the contract monitoring officer is quite a relationship-building one. We see it as something akin to intelligence gathering about our local providers. It’s more than just going in and just measuring against CQC stuff,” says Wendy Norman, strategic manager for procurement and contract compliance at Bromley Council, south-east London.

“We’ve developed our own quarterly assurance framework, which we’ve implemented over the last year or so. [Providers say] this is quite helpful because it helps managers prepare for when the CQC comes around and [it] is based around the outcomes framework.”

Officers ask managers to score the homes against a self-assessment before visiting and where there are issues they will suggest actions. She emphasises the importance of visits, saying there is no substitute for having someone on the ground.

She is clear that the role of contract monitoring is in part to fill gaps left by the CQC.

Norman says Bromley is looking for the same things as the CQC but adds: “We are aware of the fact they don’t get around very often. All the homes depend on how managers are doing and managers do move around [hence the importance of regular checks].”

However, she is sympathetic to managers in smaller homes at the level of paperwork – particularly when they had to re-register with the CQC.

The number of visits Bromley conducts per home depends on the number of people in them and how many people it has placed. It will visit all homes at least once a year but homes where the council has a block contract will be visited quarterly.

Norman says relationships are put under pressure if there are safeguarding alerts but ultimately she points out: “We will have to keep working with people.”

“The way we are approaching monitoring is that we are looking for continuous improvement,” she adds.

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