Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission.
It didn’t take long for the news of our first outstanding services in adult social to be overtaken by more bad news about care homes. A study by two doctors from The Royal Free NHS Foundation Trust explored the levels of dehydration of patients admitted to hospital from care homes compared to patients admitted from their own homes which led to headlines like:
“Scandal of dehydration in care homes” — The Times
The study itself is interesting reading and a very helpful analysis by NHS Choices explains simply what it all means (thank you to twitter pals Dr Dermot O’Riordan and Ermintrude2 for pointing me in that direction).
Important focus for inspection
I am very glad that this important topic is being aired and explored. Nutrition and hydration have long been a key element of the regulation and inspection of care homes because we recognise the risks and impact for people who are older or living with dementia or a disability who do not eat or drink enough.
Current regulation 14 stipulates:
“Where food and hydration are provided…the registered person must ensure that service users are protected from the risks of inadequate nutrition and dehydration”
The new regulations due to come into force in April 2015 retain this requirement in slightly different language (again Regulation 14):
“The nutritional and hydration needs of service users must be met”
This means adequate hydration to sustain life and good health, including providing support if necessary.
Breaches of this regulation will constitute a prosecutable offence which means that where people using the service are not given adequate hydration and there is a subsequent risk to their life or good health, CQC will be able to move directly to prosecution without first serving a warning notice.
Our inspectors always focus on this essential aspect of care and it is a mandatory key line of enquiry in all residential services. Within our overall question of “is the service effective?”, we will ask “how are people supported to eat and drink enough and maintain a balanced diet?”. We will look at how people’s needs are met, whether risks are identified, what support is given and how people’s wishes and preferences are taken into account.
A good service will protect people from the risk of dehydration but a service will require improvement if people at risk of dehydration are not always sufficiently monitored, managed or encouraged. A service will be judged inadequate if poor monitoring and management of people’s drinking puts them at risk.
First, we should not jump to conclusions that all care homes deliberately restrict fluid intake to manage incontinence — a completely unacceptable practice. The study explains that they did not explore the reasons for dehydration in the research. The suggestions are speculation but we do know that poor practice exists in some homes. For example, in a home we recently rated as inadequate St Nicholas Nursing Home we observed poor monitoring of fluid intake, lack of support and choice.
Second, we do indeed need more research. The authors of the study suggest some possible reasons but to understand how we can avoid this life-threatening situation we need to have a better understanding of the causes so care home providers can do something about it.
And third, how can care homes improve their practice? Learning from others always helps. One of my favourite films from the Social Care Institute for Excellence highlights the importance of good nutritional care and hydration for older people and provides some helpful tips (I particularly liked the lively discussion about tripe!). Or take a look at the report of our first outstanding care home, Prince of Wales, which was rated outstanding for effectiveness too.
Learning for CQC and providers
What does this mean for CQC? As I have highlighted above a focus on nutrition and hydration has been and will continue to be a central part of our regulation and inspection of care homes. I have heard some providers complain about the attitude of inspectors who have picked up on accurate recording of fluid intake. Well, a study that demonstrates the direct impact dehydration has on whether someone lives or dies in hospital means I’m not going to apologise for that.
I am also interested in exploring how the information that hospitals have about admissions from care homes can be better used to inform our inspection activity. This has got to form part of our intelligent monitoring of services so that we are alerted to potential problems and can take action if necessary.
As ever, the people who can make the day-to-day difference are not CQC inspectors but the staff providing care and support to residents and the people running care homes. At CQC we set expectations of good practice through regulations, the questions we ask and the characteristics of our good and outstanding ratings; we follow up on issues of concerns and encourage services to improve or take regulatory action to force change; and we will share examples of good practice for others to learn from. But we are not there every day and providers and staff need to make sure they are taking the issues of hydration seriously at all times.
This study has an important message for all of us involved in the care home sector. Hydration is important for older people; there are challenges in maintaining adequate fluid intake, particularly for people living with dementia; and the symptoms of dehydration may be difficult to detect. But if we get it wrong, people can die.
Care homes need to make sure that they have sufficient, appropriately trained staff who can support their residents to drink — not pour a cup of tea, leave it out of reach and throw it away untouched. Understanding the needs of each resident, what prompts or assistance they may require should be a key part of care planning and the service provided. It is the least we can do.
Originally published at www.cqc.org.uk.