Care homes have a problem — they are focusing on the wrong customer

The UK Care Quality Commission’s decade-long review into “at home” care services concluded last month and contained a striking and somewhat alarming statistic. While 95 per cent of the friends and family of people receiving care thought their relative always felt safe around their care workers, just 86 per cent of those in question did.

That gap in perceptions is important. In many cases, the person paying for at-home care services is a relative, not the person in receipt of care. Convince someone’s family that you are providing a first-class service and you can get away with providing a second-class one for a lot of the time.

It is easier to look as if you are providing top-of-the-range services when you know the spotlight is on you. But excellent care lies in what you are giving all the time, not just when somebody is watching. As the CQC noted, not all organisations were effective at remedying this, with one organisation seeking feedback from service users while care workers were in the room.

How to drive excellence in the provision of care for ageing adults is a tricky but crucial challenge for states as our populations get older. And people in “at-home” care are at the easier end of the spectrum, as they tend to be better placed to make complaints and those around them are much more able to spot when things go wrong.

Once people are in care homes, however, identifying a problem before it becomes a disaster is much trickier. CQC reports can tell you if a care home is good at handling medicines safely or responding to end of life plans, or respecting religious practices. It is harder to find out whether or not the food is good and the entertainment facilities are up to scratch because while these form part of the inspection framework, it is not easy for a layperson to parse exactly what a care home is doing well within a category. This is in stark contrast to reports into England’s schools, which come with a detailed explanation in plain language as to why specific establishments receive a certain grade.

How big is the problem? In the UK, half of over-65s now have complex care needs, although a smaller number will self-identify as needing complex care. In some ways, this may be self-reinforcing: the fact that understanding whether the quality of either at-home or residential care is any good is so complicated may mean that people convince themselves that they don’t need it, because the risks and difficulties of accessing it are so large.

Unlike schools and hospitals, however, most people who go into care homes don’t come out again. The client, very frequently, is not the customer: that is one reason why the “testimonials” page of almost every one is long on statements from the relatives of those in care, and not those in care themselves.

This makes assessing the quality of care homes much more dependent on inspections. While the life or death considerations that preoccupy government inspections matter a great deal, the reports are, obviously, less clear on the small things that make life more enjoyable for residents.

Although it is not a cure-all, one way to drive up standards is for governments to increase the number of people who use care homes for a short period of time. On, a UK website where relatives, residents and people with lasting power of attorney can leave reviews and ratings of care homes, people outside the institutions tend to focus on “big picture” questions like their relatives’ long-term health and conditions.

These are important, but so too are the subjects that pop up when you look at residents’ reviews, such as the quality of food and entertainment activities. Many of these reviewers are not permanent residents but those who have since left their care homes and returned to the outside world. Their feedback is particularly valuable in improving care for those who remain.

Governments could do all sorts of things to encourage this, from greater integration of health and social care to redirecting funding to reward care homes for maintaining reserved places for short-term visitors. Making it more financially viable for the partners of elderly people with complex care needs to move into care settings with them while continuing to come and go freely would also help.

Increasing the number of people who use care homes intermittently would fix one big problem with adult social care: that unlike so many other services, very few of those who use it can easily give candid feedback about what has gone wrong after the fact.

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