Surely improvements in residential care require a focus on governance?

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Last week Claire Keatinge, the Commissioner for Older People in Northern Ireland stated that criminal charges should be brought against care homes where staff repeatedly fail to meet standards. Her call came at the launch of a review into the regulation of care homes following a number of highly critical reports into several homes. We believe that a focus on effective governance and leadership in care homes is the answer.

Health and Social Care Trusts have responsibility for ensuring that homes have in place appropriate plans to care for residents from their area. The quality of this care is regulated by the Regulation and Quality Improvement Authority (RQIA). However, the prime responsibility for delivering good quality care to individual residents lies with the homes themselves.  While the report lays the responsibility with the ‘registered provider’ and ‘registered manager’, we believe the directors of the companies have questions to answer.

If you have a concern regarding how a relative is being cared for, your natural response is to raise it directly with the care home itself. Similarly, if you are a member of staff who has concerns regarding patient care, you will let senior management know. An effective complaints procedure will record these complaints, investigate them, make recommendations regarding how the service might be improved, implement these changes and review progress on an ongoing basis.

In the case of Cherry Tree Nursing Home in Carrickfergus, residents, their relatives and staff all made complaints. However, these complaints were not acted on. This resulted in the complaints being escalated to the RQIA. At this stage, one would hope, authorities would step in to ensure that improvements were made. However it appears that complaints and issues were not always followed up from one inspection to the next. Complainants were frustrated and concerned by the lack of progress and therefore started complaining to other agencies. Whistleblowers contacted the following agencies:

  • Cherry Tree House;
  • RQIA;
  • NHSCT;
  • Northern Ireland Human Rights Commission; and
  • Northern Ireland Ombudsman for Complaints

This should have sent up a big red flag to all involved that there was a serious problem which was not being addressed. While the independent review of the actions taken in relation to concerns raised about the care delivered at Cherry Tree House concluded that with a few exceptions, procedures were followed and inter-agency co-operation was good, this did little to stem the tide of complaints about the treatment of residents.

This raises the question – what good are procedures if they do nothing to improve performance? Has this review missed the point in terms of getting to the nub of how we can all be assured that care home residents are receiving quality treatment? At one point, the report states “Families and others communicated their lack of understanding in escalating complaints about the care in Cherry Tree House to external bodies. They did not understand the roles and responsibilities of health and social care organisations in respect of handling complaints. They had limited knowledge of support available to complainants”. When a complaint is made, the complainant should see an improvement as a result of having raised the issue. The period dealt with in this report was the 8 years between 2005 and 2013. Substantial failings, ongoing complaints and concerns were noted throughout this period.

One of the recommendations in the report is that a Trust non-executive director be appointed as a ‘whistleblowing champion’. Again, what is the point of this if complaints are not dealt with promptly and efficiently? However, holding the directors of the Cherry Tree home to account might have an impact, both in this case, and as a lesson to others in a similar situation.

Ms Keatinge said: “The findings of the independent review into Cherry Tree House nursing and residential care home highlight fundamental failings in the regulation, inspection and delivery of care to vulnerable older people. The fact that this home continued to operate for years, in spite of persistently failing to meet the necessary standards, is shocking. The whole complex system of registered owners and managers, professional standards and regulation, inspections, protections for whistleblowers, improvement and compliance regulations still did not protect vulnerable older people from years of cruelty and poor care. Clearly, the current system does not adequately protect those who rely on it for their care.”

The authors of the report hope “that this report and recommendations will lead to improved nursing and residential home care provision for older people in Northern Ireland”. We believe that it is more likely that this will be achieved if proper governance systems are implemented in nursing homes, with a strong board of executive and non-executive directors properly challenging and supporting management to run an organisation which puts the care of its patients at the centre of everything it does. It is the culture which needs to change, because culture trumps rules every time.

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