OPINION: ‘Outstanding’ – Holy Grail of poisoned chalice?

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Avnish Goyal, Chair of Hallmark Care Homes and Chair of Care England, assesses whether gaining CQC ‘outstanding’ is a double-edged sword.

Whilst achieving an outstanding rating from the Care Quality Commission is aspirational and something that all care providers should be aiming for, there are unfortunately potentially some pitfalls that can happen when you get there.

There is a national shortage of general managers, as well as an incredibly low number of outstanding care homes in the UK.  As of April 1st  this year, there were 497 care homes rated outstanding from the Care Quality Commission which equates to just 3.3% of the overall total.  Whilst this has increased in recent years and this is extremely positive, it has skewed the market for these general managers who are now a sitting target for every recruiter and operator as their CV is now their inspection report available to all. Hefty salaries, as high as six figures, are now being offered to lure them away. It is hard to see managers not being tempted by opportunities of career progression and high salaries. What then remains of the home they leave behind?

We have seen scenarios where the home manager has been poached and gone to a competitor, they have then rehired their key team members who were a part of that success and the outstanding home suddenly becomes a rudderless ship. The home can fall rapidly downhill to ‘requires improvement’ or even worse, special measures, if it is unable to recruit into these roles in a timely manner.

There have also been cases where general managers have moved to new homes lured by lucrative terms and conditions and have failed to deliver as they were not the sole reason for the success of their previous home but received all the recognition as the registered manager.

Care England have facilitated some research with the Outstanding Society, a forum where outstanding managers meet and share best practice. The Outstanding Society was formed by Nazareth Lodge owner Camilla Trimble three years ago. One of their current projects is looking at how services that were rated as outstanding deal with a lower rating on reinspection. The project is also helping to identify what elements of care secure an outstanding rating, as well as mentor and support services for those who are rated as ‘good’ and want to make the leap to outstanding. Suffice to say that at this initial stage, the research has shown some anomalies and Camilla will be seeking a meeting with Kate Terroni at CQC in the near future to discuss the results.

One of the main challenges that care providers are facing is that the outstanding characteristics are not as clearly defined as the other ratings, so for some providers it becomes difficult to interpret what CQC are looking for and there can be disappointment if the operator truly believes they deserved the outstanding rating but the inspector’s interpretation is different. Moreover, the risk is that (similar to some schools who become obsessed with their Ofsted inspection rather than giving the children a great education), care providers can become obsessed with their CQC inspection to the point that it becomes all about the inspection rather than creating sustainable and structural improvements, the intensity of which cannot be sustained post inspection.

Another challenge is, once you have received outstanding, where do you go from there? How do you maintain outstanding? Some inspectors want to see further improvement and innovation to award another outstanding and that can be hard to achieve as often sustaining the status quo is a challenge in itself. Due to the amount of work it takes to achieve the outstanding, knowing that the inspectors are not going to be rolling in for at least a couple of years and coupled with management changes, the home can quickly spiral downwards as the home can take its foot off the gas.

The other consideration that needs to be looked at is how does an outstanding rating benefit your business as well as those in your care? It should give you an advantage over fee levels and improve your occupancy, but the response seems mixed as there are homes that have requires improvement who still manage to be full with high fees. More work needs to be done on what the real benefits of outstanding are to fee level and occupancy, especially with all the factors above and especially if there is a risk of losing your key team members. I have heard some operators say that they are only aiming for a good rating because they know they will be under pressure if they achieve the outstanding rating and this is concerning.

When more care homes gain outstanding that is when the landscape will change and for me the 3.3% does not really reflect the quality of care this country is delivering. It is a CQC criteria, they have set the bar and they have set it very high and based it on their agenda. Two additional ratings between requires improvement and good and possibly one between good and outstanding would be helpful, as the gulf between these ratings is very high, however, this is not on the CQC agenda for now.

That is their prerogative, but I think there needs to be a rethink about what outstanding really looks like, how you get outstanding and how you keep it so that care providers will continue to work towards delivering outstanding care in their homes and view this in a positive light. Finally, it leaves the question whether getting outstanding is a Holy Grail or a poisoned chalice and I’ll leave it to the reader to decide.

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