Andrea Sutcliffe, Chief Inspector of Adult Social Care at the Care Quality Commission.
Closing much needed services is always a tough decision but even more so when that service is someone’s home.
Personally, I don’t like moving — my childhood was spent in the same house from the age of 2 to 18 and I moved into my current home over 21 years ago. It would take a lot for me to contemplate the disruption of upping sticks and moving somewhere new. That’s me at 50, fit and healthy — how much worse is moving when you are old, frail and possibly living with dementia?
That’s why when CQC is faced with a provider of a residential or nursing home failing their residents, our first instinct is to make sure the service improves. Sometimes we can see that the owner or manager is already getting to grips with the problem and has a good plan in place. Sometimes we will use our powers to force providers to make changes through the use of compliance actions or warning notices for example.
In either case, we will always monitor what is happening and check to see that improvements are being made in a timely way. It is so much better for people to be cared for and supported in familiar surroundings by staff who know and understand them. That has got to be our aim.
But there are times when we just have no confidence that the service will improve — maybe the problems are too far gone; there is no insight about the need for change; the management is weak and ineffective; or the promised improvements have not happened.
When this happens we have two options — put simply, urgent action that would effectively close a home immediately or our normal course of action which means that closure will happen but over a longer period. This allows more time to plan the move and properly support the residents and their families and carers.
Given how disruptive any move can be, our preference would be to allow sufficient time in our normal process to plan the move and ensure proper communication and choice for residents. But if we judge the immediate risk to residents is so high that their safety, health and wellbeing are endangered, then taking into account our worries about the impact of a sudden move, we will have to take decisive action.
Whichever course of action we take, working closely with other agencies involved is vital. Local authorities and clinical commissioning groups who are commissioning the service will need to make alternative arrangements and organise the transfer, while the local authority has a responsibility to safeguard all adults in vulnerable circumstances. Good teamwork, clarity of respective roles and responsibilities and clear communication is essential to provide support for residents, their families and carers.
All of these issues have recently been in the public eye as a result of the closure of Merok Park, in Surrey, and Grantley Court, in Sutton.
Merok Park was a service that had a history of concerns that would be addressed by the next inspection but then would deteriorate again.
We had inspected earlier in the year and the service was compliant but we had identified areas for improvement. Identifying the concerns is an important part of encouraging improvement; it gives the provider an agenda for action.
However, partner agencies raised concerns with us and we inspected the home on 28 November and 1 December 2014 when we identified a number of serious issues with the care. We saw that people living in the home were not being appropriately supported by staff, and witnessed some incidents of poor manual handling.
People were being washed in cold water; there was a high risk of people developing pressure sores due to inappropriate beds. People were not supported to eat, and the home was dirty. The smell of urine in the home on the first day of the inspection was overpowering.
Some staff working in the home had not had criminal records checks, and staff were working up to 60 hours a week. There were not enough staff on duty, and relevant training had not been provided. A broken lift had left some people unable to get downstairs in the home for several weeks.
One of my inspectors said they had never been so worried about the safety and well-being of residents.
This was an awful service, which had deteriorated dramatically between our two inspections. We had no confidence in the response of the provider who was not taking our concerns seriously. The environmental and staffing issues could not be quickly resolved. Residents were at risk.
In these circumstances, we decided, and other agencies agreed, that it was not safe to leave people in the home. This was agreed on Friday, 5 December and we advised Surrey County Council and Surrey Downs CCG of the action we would be taking so that they could make plans for the safe and timely transfer of the residents.
Staff from CQC, the council and clinical commissioning group visited the home every day until the day of the transfer on Tuesday 9 December. Alternative accommodation was found for all residents and arrangements were made. On the day of the transfer, the ambulances did not arrive on time which meant that residents were delayed in leaving the home into the evening. I am sure this made a distressing move even more difficult for the residents and their families.
Grantley Court is owned by the same provider as Merok Park and was inspected in January 2014. The report was shared with the provider in March clearly setting out where improvements were required and we advised him that he was breaching regulations governing the running of care services.
We went back in September, to check whether the improvements required had been made but also because concerns had been raised with us by the local council. We found that the provider had not taken action to improve quality as we had required, and that standards of care at Grantley Court had deteriorated rapidly between inspections. The serious concerns at Grantley Court in September meant that we initiated our normal closure process and worked with Sutton Council so that they could make arrangements for residents to move to new homes. This process was in hand, but on 9 December the provider informed local authorities on that he wanted everyone to be moved out by the end of the week (12 December), which meant that the transfers had to be brought forward at very short notice.
Questions to answer
Our actions in these two cases have been questioned and although we have issued press releases and responded to queries from journalists, I would like to address some of the main ones here.
Why did Merok Park have to close so quickly?
The situation that we found at Merok Park on our inspection was truly awful. We considered people’s safety and quality of life and judged that they were more at risk by staying than moving. This is a difficult judgment but we felt that it was not safe for residents to stay especially as the problems with the building itself could not be sorted out quickly enough and the lack of cooperation from the provider.
Why did people have to move from Merok Park in the cold evening?
Surrey County Council and South Downs Clinical Commissioning Group worked well with us to put arrangements in place for the transfer of residents and to keep people safe until that could happen. On the day the plans did not go as expected and the ambulances were late and this clearly added to the distress that residents and their families experienced.
Why did we not take into account the impact of a sudden move on the residents?
The safety, health and wellbeing of people using services is at the heart of what we do and our decisions about when and how to tackle poor services always balance the risks between staying and moving. These are very difficult judgements to make but at Merok Park we were so concerned about the risk to residents if they stayed there, that we felt urgent action was necessary. I know that very sadly two former residents of Grantley Court and Merok Park died shortly after they moved. I would like to extend my sympathy to their families whose grief must have been worsened by these events.
Why did we not publish the January inspection report on Grantley Court earlier?
I bitterly regret that this report was not published until September. This was not good enough — we know that our reports are an important source of information for the public and we let down the residents and families of Grantley Court by not sharing publicly what we knew.
This was not a deliberate attempt to cover up our findings; it was the result of an error that should not have happened. The provider did know of our concerns and should have spent the time putting things right. He did not.
Why did we take so long to close Grantley Court?
As I have explained above, we were following our normal process by advising the provider of our proposal to de-register the home and ensuring that the local council were aware that this would mean residents would have to move. This meant that arrangements could be developed and discussed with residents, their families and carers while at the same time making sure that the provider knew what he needed to do to keep residents safe. We decided that the immediate risks to the safety and well-being of the residents at Grantley Court were not so great that we needed to take urgent action. In the event, the decision by the provider to force the rapid closure of the home meant that these plans had to be rapidly brought forward.
Who is responsible?
The provider running Grantley Court and Merok Park was responsible for these failures of care. We have an important role to set expectations, inspect, report and, working with others, take action as required.
Our expectations are clear in our provider handbooks and our new approach means that our inspections are more rigorous. However, we should have issued the January inspection report into Grantley Court much earlier. We did take action which we felt was appropriate in relation to what we saw — different circumstances will affect our judgements and mean that our responses should be different.
The experiences of the people living at Grantley Court and Merok Park were dreadful — in having to endure poor care and a poor environment; the failure of the provider to address these problems; and the disruption of moving at short notice. I wish none of this had happened and I am determined that we at CQC improve and play our part in making sure that people using social care services receive care that is safe, effective, compassionate and high quality. I expect providers and staff to play their part too.
Originally published at www.cqc.org.uk.