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.
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 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.
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.
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*, 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.”
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.
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
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.
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?
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.