– of paragons, unicorns, duck-billed
platypuses and groundhogs
Kennedy @johnnycosmos says we are searching for some ‘rare beasts’ to manage
care homes – the Paragon or ‘outstanding individual’. Even rarer is the Unicorn
organisation which creates a culture for outstanding homes on limited
resources. He says there are too many duck-billed platypuses having ‘Groundhog
Days’ out there. Talk about mixed metaphors but……read on
The Care Quality Commission
(CQC) “State of Adult Social Care” makes for enlightening reading. Every care
home for older people has now been inspected and rated, a significant task. So,
what do we now know about the baseline quality in the sector? The figures go up
and down but just over 1% of all care homes for older people are rated as
‘Outstanding’ whilst just under 30% are failing to meet the grade and are
‘Inadequate’ or ‘Require Improvement’. Residential Homes do a bit better and
Nursing homes worse. These are the figures for care homes for older people
which tend to have a worse profile than care homes for younger people and
Of course, we must be
cautious this isn’t a snapshot; a census, it’s rolling data. Whilst a
proportion of failing homes have improved, following targeted re-inspections,
many remain below the benchmark; but they do remain firmly on the radar. There
is less surety though in relation to the homes rated ‘Good’. Many haven’t seen
an inspector for over a year or more. CQC report that on re-inspection approx.
25% of previously ‘Good’ homes have slipped. If we assume therefore (and yes,
it is an assumption) that the figures on ‘Inadequate’ and ‘Requires
improvement’ are pretty reliable, as these homes are regularly revisited, but
also assume that 25% of ‘Good’ rated homes are actually not; then what story
does that tell? Well it suggests that at any one-time half the care homes for
older people in England are failing the regulatory test.
Is it really
surprising? Care home quality is a very fragile thing. An extreme though
sobering example is one of the first care homes to be rated ‘Outstanding’ only
maintained their accolade for six months before being rated ‘Inadequate’. So,
what happened? Well the manager left. Skills for Care estimate manager turnover running at over 20%. Up to one in
four care homes lose their manager every year, and it’s nearer one in three for
The manager is absolutely
key. Where you find an ‘Outstanding’ care home you find a great manager.
Adequate resources are
likewise a common attribute, to say it’s not about money is false. But we must
be clear what we mean. ‘Outstanding’ care homes have adequate resources on the
floor of the care home, invested in the staff and the home. A care home may
have excellent fees but if they are not invested in the care, if they are taken
as excess profit, quality will suffer. I’ve tried to find one, but I can’t find
a single ‘Outstanding’ care home for older people that is wholly funded on
local authority fees! If you know one tell me. Adequate resources, enough
money, is absolutely necessary but in itself is not sufficient.
The third attribute is
about culture, values, confidence and authenticity. This either comes from a
proprietor of a small group of homes or the corporate leadership of a bigger
The vast majority of
‘Outstanding’ care homes are small private concerns. A smaller proportion can
be found in the ‘corporate’ and ‘voluntary’ worlds i.e. care groups with a few or
even many care homes. Really intriguing is that the rarest beast, the Unicorn,
is the consistently good care home group. Those with ‘Outstanding’ care homes
and solidly ‘Good’ ones across their stock, or indeed just solidly ‘Good’ ones.
They are Unicorns in a forest full of duck billed platypuses. More common, when
you find an ‘Outstanding’ care home in a group, is that they also have
‘Inadequate’ and ‘Requires improvement’ homes too.
So how do the Unicorns
do it? I can only describe it as an attitude with the body language to go with
it. In most care organisations, an ‘Outstanding’ care home is almost wholly
down to the manager, they’ve recruited a Paragon, a super woman or man, an
outstanding individual. It’s a relentless 24/7 never ceasing job, constantly
balancing priorities and demands. Constantly under scrutiny and suspicion. They
demonstrate excellent management and people skills but also considerable
personal resilience and a solid moral compass. They achieve in spite of the
system, internal and external.
All care providers
(well the vast majority) strive to provide good care. They seek to be good and
to be the best they can. They say all the right things and espouse all the
right values yet somehow, they just can’t get that consistency commonly. Why?
Because their body language doesn’t match their intent. They lack the
confidence of the Unicorns, the exceptional providers. They audit, check and
performance manage their managers to distraction but it’s all rather joyless.
They say, “we trust you, we value you, we’ll support you” but the body language
says something else. The body language screams anxiety and doubt.
They don’t mean to but
they are reacting to the system they are in. The negative body language is
created and reinforced by the already negative and adversarial ‘system’ that
surrounds care homes, giving the manager nowhere to find sanctuary, confidence
and solace. Only the Paragon can succeed. No wonder over a
quarter of managers leave every year, either out of the sector or in a desperate
attempt to find more understanding and aware surroundings. The work of ‘My Home Life’ has
highlighted the human impact on care home managers.
The very rare Unicorns,
the very best providers have body language that matches their rhetoric. They
understand and accept that the care home managers job is about the hardest job
there is, and that they are the fundamental to ensuring quality. The best providers understand and recognise
this, they strive to make the job as doable as possible, critically they strive
to free their managers to maximise ‘people time’ they also encourage fun and
initiative to fly. They demonstrate confidence and trust. Yes, they audit and
check but they also work hard to minimise the impact of bureaucracy. They
recognise that too much paper and complication creates more risk; things get
missed, priorities get blurred. They listen to their managers and create
systems that are SMART and attitudes that support creativity and relationship
centred care. They focus on their people. They put their ‘skin in the game’
with their managers. They don’t focus on the ‘systems’ demands as being their
‘raison d’etre’. They certainly don’t rely on recruiting a Paragon, they create
the conditions that enable a good manager to be outstanding.
So how are we going to
ensure that the quality of care in our care homes really does improve consistently
across the sector. That ‘Good’ or ‘Outstanding’ care homes are common and
sustainable. Our current quality theory is about inspection. A one tool
toolbox. Lionise the Paragon and Unicorns in a vain hope that others can
replicate at scale. Well it’s a bit like going to the York City team (currently
alas in Conference North !!) and showing a video of Real Madrid then saying
‘right lads, that’s how it’s done. Go and play like that on Saturday!’. Not
going to work, is it?
Our quality theory is
based on Paragons and Unicorns. In my view, there simply aren’t enough Superwomen
(83% of all registered managers are women) or men so it’s futile to base a
quality theory on them. Similarly, there will never be enough Unicorns. However,
we can learn a lot from the Unicorns.
If the system around
care homes learned from and replicated the attributes of the Unicorns then
perhaps we could have a quality theory that actually enabled the sector, as a
whole, to improve commonly and sustainably. If we recognised that care home
managers are the key to quality and that enabling them to thrive would have a
significant positive effect. If we recognised that care homes cannot thrive with
an arm’s length system, perhaps we can step out of the current ‘Groundhog Day’.
If the ‘system’ around
care homes; regulators, commissioners, health services adopted a more
appreciative and enabling approach, replicating the success of the Unicorns. More
care home managers and ergo more care homes would be able to improve and
sustain quality which would be good for all of us and help to address the
current continuous crisis.
So, what could the
system do, I use the word system because there isn’t actually anyone in charge!
- Speak out more robustly to power about the critical
levers of quality, don’t continue to brush over it. Status, funding, workforce
strategy and the crucial role of care home managers. The sector is crying out
for positive leadership.
- Engage collaboratively and systematically; role out
effective initiatives like NHS England’s ‘Enhanced health in care homes’,
bringing care homes into the ‘system’.
- Design a bureaucracy that works. SMART, effective and
universal. This would give confidence, reduce risk and minimise paper-time to
maximise people time.
Of course, care homes
and organisations are accountable for the quality of their care but holding to
account, alone, as the only driver of quality isn’t working and will continue
not to work. It’s not effective. If 50%
of care homes are failing at any one time, and crucially we never really know
which ones they are, then our quality theory has been disproved.
For quality to improve
in bounds the toolbox needs more tools. The system needs to polish its diamonds
and nurture its rare beasts before they become extinct.
Skills for Care
My Home Life