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Achieving Outstanding in Safe: Realising the (im)possible

It’s a widely acknowledged fact that getting Outstanding in the Care Quality Commission’s (CQC’s) Safe key question is notoriously difficult. In fact, many providers find it is their lowest-rated area. Here, Ed Watkinson from Quality Compliance Systems (QCS) offers his insider knowledge on how to achieve the elusive top rating.

As any registered manager knows, achieving an Outstanding rating in each of CQC’s five key questions is far from straightforward. In fact, in the Safe category, CQC data suggests that it’s almost impossible.

CQC’s State of Adult Social Care Services study provides a summary of every inspection carried out between 2014 and 2017. Astonishingly, it revealed that under 0.5% of providers in the UK achieved an Outstanding rating for the Safe key question. With 23% of homes also rated Requires Improvement for Safe, it’s fair to say that the vast majority of care providers fare much worse in this category than they do in others.

The inspector’s perspective

But why’s it so difficult for providers to score highly in the Safe key question? Well, it’s likely because CQC draws a clear link between safety and the outcomes for those using the service. In CQC’s eyes, if a provider isn’t delivering a safe service, then the outcomes for clients will most likely be negative.

When a CQC inspector checks a practice against the Safe key line of enquiry (KLOE), the evidence they will assess is much more tangible than in other categories.

Inspectors don’t use a sliding scale to assess safety; a practice is judged to be either safe or not. Moreover, a provider’s infection control policy either passes muster or doesn’t. While it wouldn’t be correct to say that inspectors make a binary decision, there’s little room for manoeuvre, and nor should there be.

This begs several questions. Is it possible to achieve an Outstanding rating under the Safe question, and, if so, how is it done? As a former inspector and a current adviser to QCS, it’s a question I’m often asked by registered managers.

Being on top of policies and procedures, and using systems to support improvement, is often the difference between a provider achieving an Outstanding rating and not, and, while it’s far from easy to be graded as Outstanding, if managers and care workers are prepared to learn from the few stellar providers who have excelled in this category, it can be achieved.

Making connections

Take, for example, the first KLOE of the Safe question, which assesses whether the systems, processes and practices in place keep service users safe from abuse.

The first point to make is perhaps an obvious one: any registered manager striving for an Outstanding rating needs to have put in place the basic building blocks to be considered Good. That means implementing a set of watertight policies and procedures and ensuring that staff not only understand them, but actively embrace them. Often, providers using technology to support improvement will reap the benefits, gaining extra insight and fresh perspectives around best practice.

Safeguarding is a broad term and expert opinion can help with getting to the nub of what it really is. Most of all, it’s about getting the message across to front-line care workers that safe services provide person-centred support. This means involving clients in their own care as much as possible – those who are Outstanding in the Safe category do things ‘with’ clients, not ‘to’ them.

Once the foundation blocks are laid, what separates an Outstanding service from a Good one is a transparent and co-productive approach to safety – and I don’t just mean promoting openness within a service. Outstanding-rated providers have formed close relationships with their local authorities, too.

I would advise any registered manager who doesn’t have a close relationship with their local authority to get to know its safeguarding team and ask their advice on how to follow best practice.

Why? Well, before CQC carries out an inspection it’s common practice to contact the local authority to find out whether the service has been in touch or raised alerts appropriately. In the eyes of CQC, an endorsement from a third-party will show the service in a much better light than any evidence it puts forward itself. In contrast, CQC takes a dim view of providers that adopt an insular approach and try to manage problems themselves.

Embracing risks

Services that don’t see the value in co-productivity tend not to receive an Outstanding grade in the Safe classification. Inward-looking homes often fail to manage risk properly, striking the wrong balance between risks to clients and individual freedoms. Many favour a risk-averse approach where everything a client does is seen as a risk, either to them, to staff, or to the reputation of the service.

This approach may eliminate risk altogether, but in doing so, the provider is not meeting CQC expectations. CQC expects people who use services have a right to live full and active lives. In this respect, the best services look creatively at how they can empower people to do what they want. And if this carries an element of risk, an Outstanding provider will seek innovative ways to mitigate it, so it becomes an acceptable risk.

Recognising roles

Outstanding care practices – in the words of CQC – also employ the right number of ‘suitable staff’ who not only ‘support clients’ but also ‘meet their needs’. Again, this isn’t an easy balance.

So, what’s the solution? Take a step back and clearly assess the needs of the people using the service. Registered managers should focus on the challenges faced and then ask themselves how many staff they need to provide Outstanding care.

The best providers recognise too that staff levels and the number of people using the service constantly fluctuate, as do the needs of each client. In this ever-changing environment, great care providers demonstrate dynamism and responsiveness to provide world-class care. As a result, many use dependency tools to accurately gauge numbers, and carry out regular person-centred care reviews.

That said, I believe it would be a mistake to wholly rely on dependency tools. Registered managers must recognise the role of staff and clients – this is the only way they can holistically assess a client’s changing needs.

To achieve an Outstanding rating in the Safe domain, providers need to also involve family in a person’s care. If the client is isolated, or does not have any family, Outstanding practice is evidenced by providers who go the extra mile and seek out advocates to help.

Taking this one step further, CQC really appreciates it when care workers involve people in their own care plans. This is perhaps best illustrated in ‘the proper use of medicines’ KLOE, which assesses ‘how medicines are ordered, transported and disposed of’.

Homes that are considered Outstanding in the medication process are those that put the person receiving the medication in control. That means empowering them to manage their own medication – if they have capacity and wish to do so.

This doesn’t mean the care home divorces itself from the entire medication process. That would miss the point. Instead, Outstanding providers are always on hand to provide tools, resources and support to enable their client to effectively manage their medication. Best of all, this promotes independence and helps the client live as full a life as possible.

Accepting responsibility

Demonstrating a culture of collaboration within a service is also critical when it comes to preventing and controlling infection in a care home. Outstanding care organisations share responsibility and ensure that everyone is fully aware of the environment in which they work.

I’ve inspected many facilities where staff have walked past an area that’s not clean. When I asked them why they walked by, they told me that it wasn’t their job to keep the home clean. That’s entirely the wrong attitude. The CQC view is that it’s everyone’s responsibility to ensure cleanliness. On a wider note, it’s about engendering an atmosphere where everyone does everything in the service. This paves the way for Outstanding hygiene and cleanliness.

On the flipside, I’ve also inspected homes where infection prevention measures have gone too far. Often, this manifests itself in the over-use of personal protective equipment (PPE). I visited a service recently where staff were wearing aprons and vinyl gloves in assisting a client to eat. This only served to create a barrier between the person and the care worker. What’s more, if it becomes ingrained in the culture, the home can feel like an institution, and not the person-centred service that CQC advocates.

Finally, many people ask for advice around the last KLOE, which centres on lessons learned. I always tell people that it’s not making a mistake that matters, but whether a service is able to understand why it happened, and then put systems in place to ensure that it doesn’t recur.

When errors are made, it’s important to create an environment where staff feel able to raise an issue and don’t suffer negative consequences from doing so. It’s also essential that, if an incident occurs, providers realise their limitations and aren’t afraid to call in outside help.

Ultimately, Outstanding care operators instil a culture of shared responsibility – particularly around quality assurance, and always undertake proper root-cause analysis so problems which are identified do not re-surface.

The three ‘C’s

At the beginning of this article, I echoed CQC’s view that achieving an Outstanding rating in the Safe key question was virtually impossible. Trailblazing providers are showing, however, that the impossible is possible with the right mentality.

As a care professional, my primary driver has always been to improve the quality of social care for the people who use services. Over 25 years, I’ve worked on the front lines – starting as a care assistant – and I understand the everyday challenges that care workers face. I’ve also been a registered manager, a policy writer and an inspector. My greatest passion is sharing my vision of how care providers can achieve the best possible CQC rating, using compliance as a central driver.

My advice for anyone wishing to improve their rating is to concentrate on the ideas that make for outstanding care, rather than focus on achieving an Outstanding rating. It is not a tick-box exercise and those that have their ‘eyes on the prize’ often end up disappointed.

In my experience, those who embrace the ideas in this article, which I summarise as the three ‘C’s – Collaboration, Co-production and Compassionate, person-centred care – are more likely to be rated Outstanding. Not only were they living and breathing the values, but in doing so, they were naturally fulfilling CQC’s criteria. That’s the real secret to achieving an Outstanding rating.

Ed Watkinson is Residential Care and Inspection Specialist at Quality Compliance Systems. Email: Twitter: @UKQCS

What can you do to improve your Safe rating? Have you made changes that have resulted in improvements already? Let us know by commenting below.

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