Linda Nazarko, MSc, BSc (Hons), RN, FRCN.
Director of Nursing, Nightingale House, London
Nursing and residential homes were regulated by Parts one and two of the Registered Homes Act (1984) until the Care Standards Act (2000) was introduced in April 2002. The old Act had two sections. Nursing homes were regulated under Part one and residential homes under Part two. Homes offering nursing and residential care were inspected twice and some homes were exempt from inspection. The Care Standards Act is a massive piece of legislation that goes far beyond merely regulating homes. It has 123 sections. There are nine parts and one supplement. Box 1 shows the areas it regulates.
The Act regulates fostering, adoption, childminding and day care and establishes a children’s commissioner for Wales. It also:
- Establishes a General Social Care Council in England and a Care Council for Wales
- Makes provision for the registration, regulation and training of social-care workers
- Makes provision for the protection of children and vulnerable adults
- Affects how homes are regulated and inspected.
Regulation of homes
The new system ends the distinction between nursing and residential homes. All homes will now be referred to as care homes. Health authorities and social services departments are no longer responsible for inspecting homes. A new body, the National Care Standards Commission (NCSC), will be responsible for inspecting homes.
The NCSC is more than just a regulator. It is also responsible for improving the quality of services, providing information and investigating complaints and informing and advising government about the range and quality of care services.
Changes to the inspection process
The Care Standards Act introduces a new set of regulations - the national minimum standards - (DoH, 2001a) and all homes will be required to comply with them. The Secretary of State for Health will have the power to review and amend these standards at any time. The Government plans to raise standards over a period of time.
The Central Council for Education and Training in Social Work is setting up a post-qualification award in inspection and inspectors will, for the first time, have a relevant qualification.
The Care Standards Act increases the powers of the inspectors. Box 2 gives details of what inspectors may do.
The Act specifies offences and lays down penalties for failure to comply with the Act. Box 3 outlines the offences.
Inspectors will have the right to apply conditions to registration. They may specify that a particular door is kept locked. The Act lays down penalties for offences. If the manager (or presumably someone for whom the manager is responsible) breaches the act the manager may be fined up to £5000 or even imprisoned for six months.
National minimum standards
In the past, nursing home inspectors used guidance produced by the National Association of Health Authorities and Trusts (NAHAT) and social services inspectors used different guidance. Now all inspectors will use new standards detailed in Care Homes for Older People: National minimum standards (DoH, 2001a). These are the minimum standards that homes must meet in order to retain registration.
There are 38 standards; most will be introduced immediately but some will be phased in over the next few years. These standards cover seven areas; each standard has a number of elements (Box 4).
This paper will now examine these standards and how they will affect delivery of care.
Choice of home - Standards 1 to 6 concern the choice of home. The standards aim to enable older people and their families to make informed choices about the home they choose. The standards state that the home must justify claims to have the ability to care for a specific client group. If the home claims, for example, to provide care to Jewish people, the home’s literature must detail the specific features of the home (such as the availability of Kosher food) that meet the needs of the client group. If a home claims to provide dementia care, literature must give details of specific features of the home and details of specialist training or education staff have in dementia care.
Homes are required to produce a statement of purpose, stating the aims, objectives, philosophy of care services and facilities provided. The home must provide a service users’ guide written in plain English. The guide must describe accommodation and services and give details of the relevant qualifications and experience of the registered manager and staff. It should state the number of places provided and the type of care delivered. The service users’ guide must contain a copy of the most recent inspection report, a copy of a residents’ survey and information on how to contact social services and the National Care Standards Commission (NCSC).
Homes do not have to issue each resident with a service users’ guide. The guide can be kept at a central point in the home. The guides are to be updated every six months.
Residents must have a contract stating the room to be occupied and details of rights and obligations.
The home is legally required to maintain care plans and to demonstrate the ability to meet assessed needs. Staff must deliver care that is based on good practice and clinical guidance such as Good Practice in Continence Services (DoH, 2000a) and the National Service Framework for Older People (DoH, 2001b).
If the home is to offer intermediate care it must provide dedicated facilities, and have equipment for therapy and treatment. Staff must have appropriate education and training and specialist services are to be provided by competent and skilled professionals. People admitted to intermediate care cannot be admitted to long-term care unless they have appropriate assessment.
Intermediate care is a fairly new concept and most contracts are short term and small scale. This standard effectively restricts provision of intermediate care to providers who have the ability to provide dedicated units and specially trained staff. There is a lot of evidence to suggest intermediate care is best provided in dedicated units but introducing this standard now may well deter some homes from providing intermediate care. This might restrict choice and older people may have no option but to travel far from family and friends to access intermediate care (Nazarko, 2002).
Health and personal care - Standards 7 to 11 relate to health and personal care. The aim of these standards is to improve the level of record-keeping, assessment and care planning within the home. Inspectors will use care assessments and care plans to make judgements on the quality of care delivered.
Care plans must be drawn up in consultation with the resident and meet relevant clinical guidance. Care plans must be signed by the resident or a representative if the resident is not capable. The resident must have access to the care plan. Care plans must be reviewed monthly to reflect changing needs. A falls risk assessment must be carried out.
Managers, especially those working in residential care homes with a workforce of care assistants, will need to spend a lot of time training and supervising staff to meet these standards.
Homes are required to carry out assessments to prevent the development of pressure sores and malnutrition.
Homes are also required to ensure that the person’s rights to privacy and dignity are upheld. Standard 11 states that the person should be able to die in his or her own room unless there are strong medical reasons to prevent this. We do not yet know how this standard will be interpreted. It could present difficulties if a person in a residential care home requires skilled 24-hour nursing care in the final weeks or days of life.
These health and personal care standards lay the foundations for benchmarking. It will be possible for the NCSC to benchmark homes within a few years. If benchmarking is introduced in the future it must be sensitive and evidence based. Crude figures may affect the willingness of homes to care for the most disabled of older people.
Daily life and social activities - Standards 12 to 15 require the home to demonstrate that it complies with good practice in relation to dignity and choice. Homes must demonstrate that routines and activities of daily living are flexible and reflect the needs and aspirations of the people who live in them. This standard is easily met by stating the person’s wishes and needs on the care plan. The care plan should specifically state the person’s normal chosen time of rising, retiring and washing. It should give details of whether the person prefers to bathe or shower.
Homes are required to offer open visiting - this is standard practice in homes. Visitors and friends are to be given written information about the home’s policy on maintaining their involvement.
Homes must enable residents to manage their own affairs, have access to advocates and to bring personal possessions to the home. Residents are to have access to their personal records.
Homes must meet standards in relation to meals and nutrition; most of these reflect good practice.
Complaints and protection - Standards 16 and 17 relate to complaints and protection. Homes may have to make minor adjustments to their complaints procedures because they must now give details of how to refer a complaint to the NCSC.
Homes are required to have a policy on protecting residents from abuse. A whistle-blowing policy is required. The home must comply with No Secrets - guidance on prevention and protection of vulnerable adults from abuse (DoH, 2000b).
Environment - Standards 19 to 26 deal with the physical environment of the home, including maintenance, room size and facilities.
All newly built and adapted rooms must now be 12 square metres. Single rooms accommodating wheelchair users must have at least 12 square metres of usable floor space. Unfortunately, the standards do not define a wheelchair user. If a person who is unable to move from bed to chair unaided is classified as a wheelchair user then around three-quarters of nursing care home beds should be this size (Reardon, 1996; Nazarko, 1997). By April 2007, 80% of rooms must be single rooms and all single rooms must be at least 10 square metres. All newly built and adapted rooms must have en suite toilet and washing facilities.
Homes must ensure that facilities are assessed by suitably qualified persons, including an occupational therapist to ensure adaptations are made to enable residents to function to capacity. The standard specifically refers to adaptations required to meet the needs of people with dementia.
In practice few homes employ occupational therapists. There is a national shortage of occupational therapists and community resources are limited. People living in care homes are considered low priority for assessments and services because services are targeted at people living at home.
The care-home sector is in crisis and homes are closing in ever-increasing numbers because fee levels do not meet the costs of providing care. The situation is so critical that the Association of Directors of Social Services (ADSS) has taken the unprecedented step of calling for extra aid to prevent closures (ADSS, 2002). The physical standards will means that the capacity of many homes will fall and smaller homes may close.
Staffing - Standards 27 to 30 deal with staffing. The standards state that the home must have a formal recruitment process and carry out police checks before employing staff or recruiting volunteers. The home must have a formal six-month long induction programme for staff. All staff are to have three paid training days a year. By 2005 50% of care assistants employed in the home must have NVQ level 2 qualifications. If agency staff are used 50% of agency staff must also have NVQ qualifications. Some government assistance with the cost of NVQ training has been announced.
Many homes are working hard to educate staff and some homes are already paying NVQ-qualified staff a premium.
Management and administration - Standards 31-38 deal with the management and administration of the home. Standard 31 deals with the qualifications and competency of the registered manager. This standard states that the manager must have at least two years’ experience in senior management in a relevant care setting. The manager must have expertise in caring for older people and, if the home is registered for nursing, must be a first-level nurse. This will end the practice of some homes appointing inexperienced or inappropriately qualified managers. By 2005 the manager must have an NVQ level 4 qualification in management or an equivalent management qualification. This standard will ensure that home managers have relevant expertise and qualifications and will be more sought after.
The standard does not give guidance about what the home should do if the manager leaves and the home is unable to find a suitably qualified replacement.
Regulation of care workers
The Care Standards Act also sets up mechanisms to regulate care assistants. The legislation makes provision for setting up a register, defining who will be able to join the register and introducing a code of conduct. This will be explored in detail in a future article in Professional Nurse.
One of the aims of the Care Standards Act 2000 was to set up a robust regulatory framework to ensure that all care homes are inspected by an independent national body. The aim of the national minimum standards was to ensure that all homes were regulated to the same standards. The national minimum standards document makes a number of assumptions about care homes. It assumes that all homes are functioning to the same standard and that standard is generally a low one. This assumption has led to the introduction of many standards such as the one relating to open visiting that were not required because they merely describe normal practice.
In some ways the opportunity to introduce meaningful standards that made a real difference to people’s lives has been lost because the standards are not evidence based and many of them do not take care forward. Those of us who deliver care can only hope that the standards will evolve and that the current standards are only a shaky step towards ensuring that older people receive quality care. If homes are to deliver quality care they will need the resources that they have been starved off for many years. I hope that the NCSC will persuade the Secretary of State of that.
The Care Standards Act. (2000) London: The Stationery Office.
Association of Directors of Social Services. (2002)Directors and Independent Care Providers Create New Fee level Initiative (press release 4 March 2002). Available at: www.adss.org.uk
Department of Health. (2000a)Good Practice in Continence Services. London: The Stationery Office. Also available at: www.doh.gov. uk/continenceservices
Department of Health. (2000b)No Secrets: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse. London: The Stationery Office. Also available at: www.doh.gov. uk/scg/nosecrets
Department of Health. (2001a)Care Homes for Older People: National minimum standards. London: The Stationery Office. Also available at: www.doh. gov.uk/ncsc
Department of Health. (2001b)National Service Framework for Older People. London: The Stationery Office. Also available at: www.doh.gov.uk/nsf
Nazarko, L. (2002)Rehabilitation part 1: the evidence base. Nursing Management 8: 8, 14-18.
Nazarko, L. (1997)Getting Better? Quality of care in UK nursing homes (MSc dissertation). London: South Bank University.
Reardon, M. (1996)Transfers to nursing homes. Elderly Care 8: 5: 16-18.