Written Evidence Submitted by the Care Quality Commission
(CLL0070)
1. We are the independent regulator of health and adult social care in England. Our purpose is to make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage these services to improve.
2. All areas of the health and care system have met the challenges of the pandemic head on, with staff going to great lengths to respond to this unprecedented health emergency. To manage the demand and keep people safe, we have observed services rapidly adapting the way they work.
3. Alongside the recognition that COVID-19 has fundamentally changed so much, it is important to recognise what has not changed. The problems that existed before COVID-19 have not gone away. People are still more likely to receive poorer care from some types of service, and from some providers, for the same reasons that they would have been more likely to receive poorer care before. We will maintain scrutiny on these services and providers, supporting improvement and taking action to protect people where necessary.
4. Throughout the pandemic it has been important to have a learning culture and proactively respond to emerging best practice. Looking forward, it is important that the learning and innovation that has been seen during the pandemic, both in individual services and in local systems, are used to keep people safe; to make sure people have access to high-quality care that meets their individual needs, and to develop health and social care for the future. This applies to both the short term, in planning for winter, as well as longer-term strategic planning.
5. Care homes in particular are bearing the brunt of a disease that disproportionately affects older people and those with multiple conditions and care needs. Adult social care staff are working hard to keep people safe, but the sector, already fragile, faced significant challenges.
6. Very quickly, care homes stopped visits from family and friends to try and control the virus. Measures put in place continue to have a huge impact on people, with some residents confined to their rooms, social events cancelled, and shared areas in the home – such as dining rooms and lounges – closed due to physical distancing. The impact on people not being able to visit partners or spouses during lockdown has increased loneliness and stress.
7. A key challenge for providers is in maintaining a safe environment – managing the need to socially distance or isolate people. Effective infection prevention and control will remain essential to protect people from acquiring COVID-19.
8. Among the many challenges faced by providers in recent months, they have had to make sure they have enough employees with the right skills to cope with new and increased demands. Homecare services face a significant challenge in maintaining continuity of care for the people they looked after. On 19 May 2020 we published our first COVID-19 insight report highlighting that agencies that submitted data to our homecare tracking survey had on average 9% of their staff absent because of the impact of the coronavirus.[1]
9. The speed and scale of the pandemic has required health and care providers to respond in new ways. The crisis has accelerated innovation that had previously proved difficult to mainstream, such as GP practices moving rapidly to remote consultations.
10. Arrangements and planning for people who are vulnerable to digital exclusion must not be lost in the rush to prioritise innovative and resource-saving online options. The challenge now will be to keep and develop the best aspects of these new ways of delivering services, ensuring that they meet people’s diverse needs and circumstances, while making sure that no one is disadvantaged in the process.
11. Research has demonstrated that care homes have struggled to access GP services,[2] [3] which indicates that older people, those with dementia, those with a learning disability and autistic people living in residential adult social care settings may be at greater risk from general health problems being left untreated, as well as COVID-19.
12. From our statutory duty to monitor and report on how services apply the Mental Health Act 1983 (MHA) we have identified how the COVID-19 pandemic has impacted detained patients, and on the services that care for and treat them. We found that mental health services that focused the most on applying the principles of least restriction were more successful in empowering their patients and staff to cope with the extra restrictions imposed during the first wave of the pandemic.
13. In our Monitoring the Mental Health Act in 2019/20 report we also set out the actions needed to support people subject to detention under the MHA. More information on this report and its findings can be found on our website.[4]
14. During the first wave of the COVID-19 outbreak, we developed data collection and digital monitoring tools – the Emergency Support Framework (ESF) – to enable our inspectors to have structured and consistent discussions with providers on the impact of COVID-19 on staff and people using services. The ESF helped us to identify where we might need to inspect or escalate concerns to partners. A key part of the framework focused on infection prevention and control.
15. Through the height of the crisis, our inspectors contacted more than 80% of adult social care providers using our ESF tool – more than 20,000 care homes – to better understand the impact of COVID-19, and to offer support, advice and guidance.
16. Through these calls we heard that care staff had to suddenly cope with a whole range of new tasks and take on aspects of care that they had never had to do before. The lowest paid staff had an enormous burden put on them. They had to care for large numbers of people faced with a new and complicated illness, understand complex guidance, and often be the only one to be with the person using services as they died, sometimes relaying families’ messages of comfort to the dying person.
17. On 13 April 2020, we launched a domiciliary care survey tool for regular data collection on COVID-19 related pressures from services who provide care for people in their own homes. We have a unique oversight of these services and of the care they provide for people who are often made more vulnerable by their circumstances, and because of the nature of care they require.
18. The survey asked domiciliary care providers to share with us the issues they were facing so that local, regional and national support could be mobilised. By asking providers to share this information with us on a daily basis, local authorities, clinical commissioning groups (CCGs) and other local bodies received that data. This means they did not need to make the same request, saving time and resources and helping to identifying solutions faster.
19. From 30 November 2020, domiciliary care services, extra care housing schemes and supported living schemes will report their COVID-19 information through the NHS England capacity tracker. The capacity tracker collects information from the wider adult social care sector and its findings are shared with us, to help us assess risk on a daily basis.
20. During the first wave of the pandemic we also saw an increase in calls to our national contact centre from health and social care staff raising concerns about care. The biggest increase came from staff in the adult social care sector, with 2,612 calls from adult social care staff raising concerns in the period 02 March 2020 to 31 May 2020, compared with 1,685 for the same period in 2019 – a rise of 55%.[5]
21. There was also an increase in information shared with us through our online Give Feedback on Care service. Infection control and practice (IPC) was the most common theme from this feedback, appearing in 44% of enquiries.[6]
22. During August, we carried out a special programme of IPC inspections in 301 care homes selected as potential examples of where IPC was being done well. The findings indicate that more than 90% assurance across all the elements looked at, and identification of a number of good practice examples.[7]
23. In our analysis of IPC in 139 inspections that were carried out in high-risk services from 1 August until 4 September 2020, the main areas that needed to improve were around having out-of-date IPC policies and in not using PPE in the most effective way.[8]
24. Our analysis indicated that there is no clear correlation between care home ratings and the number of deaths due to COVID-19 in those homes.[9]
25. Between 10 April and 6 November 2020, for every 1,000 beds there were:
26. We publish the analysis of our findings from the IPC inspections on a regular basis.[10] By sharing our findings with DHSC and our partners across the health and social care system we are helping to support the care system through winter. Our findings from our IPC inspections can be found in our report, How care homes managed infection prevention and control during the coronavirus pandemic 2020.[11]
27. As the risks from the coronavirus pandemic changed, we adapted our methods for monitoring services, from the ESF, to strengthen our focus on safety; how effectively a service is led, and how easily people can access the service. We will continue to adapt our transitional regulatory approach and remain responsive as the situation changes. More information on our transitional regulatory approach can be found on our website.[12]
28. On 07 October 2020, the Department of Health and Social Care commissioned us, under section 48 of the Health and Social Care Act 2008, to review how Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were taken during the coronavirus pandemic.[13]
29. This work builds on concerns that we reported earlier in the year, that elderly and vulnerable people may be being subjected to DNACPR decisions without their consent or with little information to allow them to make an informed decision. On 03 April 2020, we published a joint statement,[14] with the British Medical Association (BMA) Care Provider Alliance (CPA) and Royal College of General Practitioners (RCGP), reminding all providers that it is unacceptable for advance care plans, with or without DNAR form completion, to be applied to groups of people of any description.
30. We made another statement, on 14 August 2020, to share concerns that some older and disabled people living in care homes were not getting access to urgent hospital treatment, and this may have been based on assumptions that some groups are less entitled to care and treatment than others rather than on clinical need.[15]
31. Where the right processes are not followed, this may indicate an attitude that older and disabled people’s lives are worth less than others’. This would be unacceptable and discriminatory, and would breach people’s human rights.
32. The section 48 commission requests that we look at all key sectors, including care homes, primary care and hospitals, exploring implementation of best practice DNACPR guidance.[16]
33. Since the announcement, we have been working with people who have experience of this issue to help shape our approach. Through the valuable insight shared by stakeholders, people who use services, and providers, we have been able to hear examples of good practice and where decisions or processes do not appear to have been person-centred.
34. The review is looking at people’s experiences in care homes, primary care and hospitals and includes fieldwork that we will carry out in seven local Clinical Commissioning Groups across the country.[17] The interim findings of our review are expected to be reported later this year with a final report in early 2021.
35. Since April 2015, we have had a statutory responsibility to monitor and assess the financial sustainability of those care organisations in England that local authorities would find difficult to replace should they fail and become unable to carry on delivering a service. In this we are required to inform local authorities when it is thought that service cessation, as a result of business failure, is likely to happen.[18]
36. Since the start of the COVID-19 pandemic, our Market Oversight Team have been engaging extensively with the larger adult social care provider groups to understand not only how providers are being impacted today, but also how they can be expected to be impacted in the medium term.
37. We then share this information with the Department of Health and Social Care (DHSC), to inform policy thinking, and the Treasury to assist them in better understanding the likely effectiveness of the assumptions that they are making on the additional support that the health and social care system may need.
38. On 04 June 2020, we published more than 300 examples from the front line of changes that providers had made across health and social care, so that they could quickly learn from each other and consider whether innovations brought about by the crisis could help shape services in the future.[19]
39. To understand and harness the learning from the first wave of the pandemic for emergency care, we brought together a team of senior emergency department clinicians to develop a support tool that offers practical solutions which all emergency departments could consider to improve patient care and safety. ‘Patient FIRST’ also includes guidance for senior leaders at the trust and system level. More information on Patient FIRST can be read on our website.[20]
40. The fact that the impact of COVID has been felt more severely by those who were already likely to have poorer health outcomes makes the need for services to be designed around people’s needs all the more critical. It is important that new pathways and practices are developed in ways that reduce health inequalities and improve people’s lives.
41. Social care’s longstanding need for reform, investment and workforce planning has been thrown into stark relief by the pandemic. There needs to be a new deal for the adult social care workforce that reaches across health and care – one that develops clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation. The legacy of COVID-19 must be the recognition that issues around funding, staffing and operational support need to be tackled now – not at some point in the future.
42. The speed and scale of the response required by the COVID-19 pandemic has highlighted how any fragmentation in our current health and care systems may significantly impair the ability to respond effectively.
43. In July and August 2020, we rapidly mobilised teams to carry out the first phase of our Provider Collaboration Reviews (PCRs) to find out how health, social care and other local services worked together in eleven areas of the country, focusing on the over 65 population.
44. These PCRs involved understanding the journey for people with and without coronavirus across health and social care providers, including the independent sector and council and NHS providers.
45. The PCRs focused on eleven Integrated Care Systems (ICS) or Sustainability and Transformation Partnership (STP) areas. It built on our programme of reviews of local authority areas, which looked at how services were working together to care for people aged 65 and older.[21]
46. Taken together, the PCRs are intended to help providers and leaders of local health and care systems plan and work more effectively together as a matter of course. They have brought into focus the themes and learning that can be used to inform planning for the coming winter and any subsequent spikes of COVID-19.
47. The initial findings were included in our COVID-19 insight report, issued on 16 September 2020[22], and detailed findings have been published in our State of Care 2019/20 report.[23]
48. We have confirmed we will to look at provider collaboration in all ICS and STP areas in England by the end of 2021/22. The reviews will consider the impact of collaboration across different pathways and population groups; looking at how providers are re-establishing services and pathways in local areas, alongside continued responses to the impact of COVID-19. The current PCR programme focuses on how providers are working together to deliver urgent and emergency care services.
49. The reviews bolster recommendations made in our 2018 report on the findings of the local system reviews (LSRs), Beyond Barriers[24], in which reform of planning and commissioning of services was called for, particularly to support older people in their own homes. Additionally, we outlined that a new approach was needed for system performance management and joint workforce planning, as well as better oversight of local system performance.
50. As we have been developing our next strategy,[25] providers and the public have been clear that they expect our future regulatory model to reflect the increasingly joined up and system-based provision of health and care, building on the positive outcomes which were driven by our LSR programme. To do this in the most effective and efficient way, which delivers the best outcomes for providers and people who use services, our primary legislation would need updating
51. We will work with other agencies, voluntary and community organisations, system partners and other regulators and will use information we hold about individual providers and local systems, building on the work as part of the PCRs, to understand where there are barriers to good care and to target its activity to help break these down.
52. Many of the challenges faced by vulnerable groups have not been created by the COVID-19 emergency – it has simply pulled them into sharp focus and highlighted the implications for the most vulnerable, both now and in the future.
53. It has become clear that COVID-19 has had a disproportionate effect on some people with protected characteristics: people from BAME backgrounds, older people, and people with some long-term health conditions and other disabilities have been hit harder by the pandemic and its knock-on effects. These unequal effects have affected health and social care workers as well as people in need of care.[26]
54. From analysis of our own data about death notifications in adult social care from 10 April to 30 September 2020, we have found that the proportion of deaths in all adult social care setting due to confirmed or suspected COVID-19 was higher for Black people (28%), Asian people (25%) and people from mixed or multiple ethnic groups (26%) compared with White people (23%).[27]
55. To ensure we can support providers to deliver a good standard of care during the pandemic, we launched the Emergency Support Framework.[28] The framework covers issues such as:
56. These topics will continue to be explored as we develop our new transitional regulatory approach, which came into effect in September.[29]
57. We have shared our Equality Impact Assessment on the impact of COVID-19 on our regulatory work, to demonstrate good practice in identifying and acting on equality and human rights issues by health and social care bodies.[30]
58. We have delivered two webinars about equality and human rights issues with NHS trusts and commissioners. These offered an opportunity to discuss issues and good practice, such as positive engagement with BAME communities and good practice in risk assessments for BAME staff.
59. Early on in the pandemic, we heard concerns regarding the lack or slow availability of information about COVID-19 in translated community languages from statutory bodies. Voluntary organisations such as Doctors of the World, have produced good information to fill this gap[31], which we have proactively shared with providers of care.
60. Despite this, the delay in translated information may have put certain ethnic groups at a higher risk. People already experiencing barriers in accessing health services (asylum seekers, refused asylum seekers and undocumented migrants) need targeted information about COVID-19 and their access to care.
61. Addressing risks to Black, Asian and Minority Ethnic individuals requires a robust analysis of the issues and action to track progress in this area. We outlined possible solutions to these risks in our written submission to the Women and Equalities inquiry into ‘Unequal impact? Coronavirus and BAME people’.[32]
62. The period of time, following the first wave and before the winter pressures build, should be used as an opportunity for the NHS to identify how, through collaboration, it can reduce longstanding inequalities, for example to address some of the underlying causes of poorer health and therefore higher COVID-19 mortality in BAME communities or to take population health approaches.
63. We have seen some examples of promotion of equality already happening, mostly by anticipating where inequality might arise. We have outlined this in our State of Care 2019/20 report.[33]
64. On 9 April 2020, we were asked by DHSC to provide an interim solution to the challenge of the booking of test for symptomatic care workers who were self-isolating and had access to a vehicle.
65. We provided a solution when no other testing option was available. This ran until 25 April when it transferred to the government portal.
66. From 20 April to 4 May, we were also asked, and agreed, to assist in the ordering of kits being sent to care homes for the testing of symptomatic residents. We did not have any involvement in clinical oversight, leadership or direction of the testing service in care homes.
67. From 04 May 2020, we stopped having any involvement in testing in care homes and therefore now have no involvement in any aspect of testing.
68. We remain committed to supporting the national effort where it can add value, even though in this instance delivery of testing services fell outside of our statutory functions as the independent regulator of health and social care.
69. Given the structure of the adult social care sector, we were best placed to support this work as a national organisation with access to the detailed contacts at a provider-by-provider level, and relationships with provider representative groups.
70. On 27 November 2020 DHSC announced that our inspectors will receive weekly COVID-19 testing, following its decision to offer testing to key workers. This will offer additional assurance to care providers as we to work together with them to meet the continued challenges of the pandemic and keep people safe.
71. All our staff engaging in inspection and registration visits must undertake a risk assessment prior to the visit. They must use the PPE identified, have gone through training on its use, and have completed the Infection Prevention and Control training. If an inspector is displaying symptoms of COVID-19, they will arrange a test via the government portal. Should they receive a positive result they will no longer be available to go on inspection and must self-isolate.
72. We recognise that we need to strike a balance between making sure people’s experiences of care are heard and that quality of care can be accurately assessed, while minimising the risk of spread of infection and not adding unnecessary pressure on the health and care system.
73. Where on-site inspections are carried out, the action of our inspectors is targeted and driven by the information held on a service, focusing on areas where information cannot be collected in other ways, or on services that require more visits, for example in secure settings. Where we have information that people are not getting good care, a visit is often the best way to gain an understanding of what is really going on.
74. We produce an annual NHS Patient Survey Programme to provide feedback on the experiences of patients using NHS services. The methodology provides statistically robust data that allows comparisons of patients’ experiences of care across the country for every NHS trust.
75. The survey focused on a sample of more 10,000 patients discharged during April and May, including those admitted with confirmed or suspected COVID-19, and those admitted for alternate, unrelated reasons.
76. The results of this survey[34] have been published in the Inpatient experience during the coronavirus (COVID-19) pandemic report.
77. We will use the results as part of its insight for monitoring purposes. As winter approaches and the pandemic continues it is crucial that we act on this insight at a local and national level to drive further improvements, tackle inequalities in experience and ensure that a high quality of care is delivered for all patients when they are in hospital, and when they are discharged and return home.
78. The findings will be made available to organisations across the healthcare system to facilitate and feed into their own local improvement work.
79. Additionally, the findings will be shared with NHS England and Improvement, the Department of Health and Social Care and other relevant key stakeholders to inform the national and local response to COVID-19 and influence strategies that ensure safety is not compromised.
80. We have outlined the work we have done and continue to do to improve maternity services during the COVID-19 pandemic in our submission to the Health and Social Care Committee’s inquiry into ‘Safety in maternity services in England.’[35]
81. Since 28 April, CQC has been supporting the Office for National Statistics (ONS) in publishing counts of deaths in care homes, based on data on statutory notifications by care home providers. This data can be accessed on the ONS website.[36]
82. Since 19 May 2020 we have been publishing a series of insight reports intended to highlight COVID-19 related pressures on the sectors that we regulate.[37] Analysis of our current data, including on deaths in adult social care services, can be found in these documents.[38]
Death notifications
83. We are making changes to our notification forms to make them easier to use and to improve the quality of information collected. The death of a service user notification form has now been updated, with other forms being updated soon.[39]
84. In March of this year, we shared a message from the Secretary of State for Health and Social Care, Rt Hon Matt Hancock MP, with all registered providers of adult social care about how the Government intended to support the adult social care sector in England throughout the coronavirus outbreak.
85. We continue to support with cascading messages to the sector, including dissemination of the regular DHSC coronavirus social care update. To date, we have shared 23 updates, reaching around 130,000 people working in adult social care.
86. We offered to help with this because we had some very specific capabilities which we could bring to bear quickly for communication of this important information. Given the structure of the adult social care sector, we were best placed to support this work as a national organisation with access to detailed contacts at a provider-level, and relationships with provider representative groups.
87. We remain committed to supporting the national effort where we can add value, even though in this instance the action fell outside of our statutory functions as the independent regulator of health and social care.
(November 2020)
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[1] https://www.cqc.org.uk/news/stories/sharing-insight-asking-questions-encouraging-collaboration-cqc-publishes-first-insight-document-on-covid-19-pressures
[2] https://www.alzheimers.org.uk/news/2020-06-05/thousands-people-dementia-dying-or-deteriorating-not-just-coronavirus-isolation
[3] https://www.qni.org.uk/news-and-events/news/major-new-survey-of-care-home-leaders-confirms-severe-impact-of-covid-19/
[4] https://www.cqc.org.uk/news/releases/cqc-finds-mental-health-inpatient-services-coped-well-coronavirus-covid-19-there-will
[5] https://www.cqc.org.uk/news/stories/regulating-during-covid-19-why-raising-concerns-about-care-more-important-ever
[6] https://www.cqc.org.uk/sites/default/files/20201016_stateofcare1920_fullreport.pdf p.46
[7] https://www.cqc.org.uk/publications/major-report/covid-19-insight-issue-4
[8] https://www.cqc.org.uk/publications/major-report/covid-19-insight-issue-4
[9] https://www.cqc.org.uk/publications/major-reports/covid-19-insight-5-our-data
[10] https://www.cqc.org.uk/publications/major-reports/covid-19-insight-5-our-data
[11] https://www.cqc.org.uk/publications/themed-work/how-care-homes-managed-infection-prevention-control-during-coronavirus
[12] https://www.cqc.org.uk/news/stories/joint-statement-cqc%E2%80%99s-chief-inspectors-deputy-chief-inspector-lead-mental-health
[13] https://www.cqc.org.uk/news/stories/cqc-review-use-dnacpr-during-pandemic
[14] https://www.cqc.org.uk/news/stories/joint-statement-advance-care-planning
[15] https://www.cqc.org.uk/guidance-providers/adult-social-care/access-hospital-care-treatment-older-disabled-people-living
[16] https://www.cqc.org.uk/news/stories/cqc-review-use-dnacpr-during-pandemic
[17] https://www.cqc.org.uk/news/stories/reviewing-use-do-not-resuscitate-decisions-during-covid-19
[18] https://www.cqc.org.uk/guidance-providers/market-oversight-corporate-providers/market-oversight-adult-social-care
[19] https://www.cqc.org.uk/news/stories/innovation-inspiration-how-providers-are-responding-coronavirus-covid-19
[20] https://www.cqc.org.uk/publications/themes-care/project-reset-emergency-medicine-patient-first
[21] https://www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-health-care-england
[22] https://www.cqc.org.uk/publications/major-report/covid-19-insight-issue-4
[23] https://www.cqc.org.uk/publications/major-report/state-care
[24] https://www.cqc.org.uk/publications/themed-work/beyond-barriers-how-older-people-move-between-health-care-england
[25] https://cqc.citizenlab.co/en-GB/projects/cqc-s-draft-strategy-for-discussion
[26] https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Workforce-aged-55-and-over.aspx
[27] https://www.cqc.org.uk/sites/default/files/20201118%20COVID%20IV%20Insight%20number%205%20slides.pdf
[28] https://www.cqc.org.uk/guidance-providers/how-we-inspect-regulate/emergency-support-framework-what-expect
[29] https://www.cqc.org.uk/about-us/our-strategy-plans/our-strategy-2016-2021
[30] https://www.cqc.org.uk/sites/default/files/Equality%20and%20Human%20Rights%20Impact%20Assessment%20%28EIA%29%20Regulatory%20Transition%20Programme.pdf
[31] https://www.doctorsoftheworld.org.uk/coronavirus-video-advice/
[32] https://committees.parliament.uk/work/318/unequal-impact-coronavirus-and-bame%20-people/
[33] https://www.cqc.org.uk/sites/default/files/20201016_stateofcare1920_fullreport.pdf p.83
[34] https://www.cqc.org.uk/publications/themed-work/inpatient-experience-during-coronavirus-covid-19-pandemic
[35] https://committees.parliament.uk/writtenevidence/11048/html/
[36] https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases
[37] https://www.cqc.org.uk/news/stories/sharing-insight-asking-questions-encouraging-collaboration-cqc-publishes-first-insight-document-on-covid-19-pressures
[38] https://www.cqc.org.uk/publications/major-reports/covid-19-insight-5-our-data
[39] https://www.cqc.org.uk/guidance-providers/notifications/death-person-using-service-notification-form