Action on Elder Abuse Conference A Bitter Pill To Swallow National Care Standards Commission A Perspective

1
Action on Elder Abuse ConferenceA Bitter Pill
To SwallowNational Care Standards CommissionA
Perspective

• Presentation by
• Heather M. Wing OBE
• Director of Adult Services NCSC

2
Structure of Presentation

• Why this conference is so important - two case
  scenarios
• General issues arising out of this
• The role and function of the NCSC how we can
  make a difference
• The legislation
• The national minimum standards
• The methodology

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Scenarios

• Case 1 - pre 1/4/02
• Care home for 32 older people
• Registered with a local authority
• Established for many years
• Well respected within community
• Run by an ex - nurse, managed by a nurse
• Previous Inspection reports - no major issues,
  although inspector had a gut feeling all not
  well, but no evidence untilgt

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Case 1 continued

• Incidents of falls - numbers reported to I R
• Incidents of deaths - identified by inspector
  from looking at records
• Residents seemed sleepy and described as demented
  - attributed to old age
• Medication records - not well completed
• Discussion staff - identified problem one staff
  member, administration of medication
• Complaint from relative - change in his relatives
  demeanour
• Inspectors investigate

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Case 1 continued

• Identifies - care staff not trained in use of
  medication, effects on older people
• All aspects of medication practice unacceptable -
  including use as restraint - resulted in falls
• Over prescribing from GP - repeat prescription
  and no periodic review of service users needs -
  two large black bags of medication found in
  cupboard
• Possible deaths of older people - one member of
  care staff inappropriate use of medication -
  evidence collected by exhumation of several
  bodies
• Death certificates - death through old age -
  but not so
• OUTCOME - one member of care staff prosecuted and
  imprisoned, home owners registration
• cancelled.

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Case 2

• Pre 1/4/02
• care home for 18, owner an ex nurse also owned
  another home for 26 - all older people
• registered for many years with local authority
• some inspection reports identifying problems with
  hygiene, levels of dementia within home, lack of
  staff skills in dealing
• During one inspection, discussion with a relative
  reveals concerns about father change in his
  personality
• Owner attributes to onset of
• dementia

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Case 2 continued

• Inspector talks to elderly man, identifies
  possible use of restraint, physical chemical
  (tied to chairs and also use of medication)
• Detailed investigation during which matters
  deteriorate - evidence that service users being
  sedated to restrain to minimise demands on
  staff, staffing levels below required level
• Urgent cancellation - opposition from
  GP/Psychiatrist and family members
• Police Investigation
• Prosecution - 3 years later - manager convicted,
  owner deemed not fit to stand trial
• due to ill health

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Issues

• Never assume that all is okay because of peoples
  stated professions
• Not to be intimidated by cloak of
  professionalism or by asserted authority
• Tease out instincts
• Look for indicators e.g. falls, deaths, people
  described as suffering from dementia - evidence
  for this ( demented or over sedated?)
• Act when evidence appears - do not be frightened
  of challenging or of risking being challenged
• Be inquisitive
• Call in the experts if in doubt or need
• technical input

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Issues

• Relating to use and abuse of medication
• training/ education of care staff - especially
  attitude
• use of power/ control in respect of vulnerable
  people
• practice of professionals
• working with other professionals - education/
  roles
• preparedness all professionals to take
  appropriate action
• management of staff - internal QA
  processes/culture
• value of procedures and processes
• value of good records
• dealing with supporters of services, irrespective
  of evidence of poor care
• costs to the NHS and the country
• generally and on a human scale

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Issues - so what !

• Sets the context in which the NCSC has to operate
• That was then this is now
• Goes to the heart of our overriding role which is
  to protect and safeguard vulnerable children and
  adults
• Makes what we do and how we do it of critical
  importance - touches on so many factors which go
  to the heart of good or poor care

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NCSC - what it is, what it does

• Non departmental public body
• Independent - local, regional, national -
  Executive Management team
• Commission Board comprising 15 lay people
  chairman
• Regulatory - enforcement agency
• Powers drawn from Legislation
• Care Standards Act 2000
• Associated Regulations
• AND
• National Minimum Standards

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NCSC - what it is , what it does

• Commenced operation 1/4/02
• Responsible for the regulation of a range of
  services
• 42, 000
• Care Homes providing personal care/nursing
• Care Homes providing adult placements
• Domiciliary Care Agencies
• Nurses Agencies
• Independent Health Care
• Range of childrens services

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NCSC Role - Regulation

• Registration -
• Inspection -
• Complaints Investigations -
• Enforcement -

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NCSC - Role

• Ensure legal requirements are met
• Monitor national minimum standards
• Encourage improvement of standards over time
• Report on quality and availability of services
• Challenge poor practice
• Protect vulnerable people from abuse
• Take action to root out those providers not
  providing good care

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Law National Minimum Standards

• NCSC - statutory duty to carry out law to apply
  the NMS
• Applied wisely fairly - a force for good
• Law and NMS applied through National Methodology
• Person centred
• Evidence based information

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Principles of Regulation

• Fair
• Reasonable
• Proportionate
• Targeted
• Transparent
• Accessible
• Realistic

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Use of Medication in Care HomesThe Legislation

• Care Home Regulations 2001 - Regulation 12
  states-
• The registered person shall ensure that the
  care home is conducted so as to promote and make
  proper provision for the health welfare of
  service users to make proper provision for the
  care where appropriate , treatment, education
  supervision of service users.
• The registered person shall so far as is
  practicable enable service users to make
  decisions with respect to the care they are to
  receive their health and
• welfare

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Legislation cont.

• Care Homes Regulations 2002 - Regulation 13
  states-
• The registered person shall make arrangements
  for the recording, handling, safekeeping, safe
  administration disposal of medicines receive
  into the care home.
• The registered person shall ensure that
  unnecessary risks to the health and safety of
  service users are identified and so far as
  possible eliminated
• The registered person shall make arrangements
  by training staff or by other measures to prevent
  service users being harmed or suffering abuse or
  being placed at risk of harm and abuse

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Legislation cont

• Care Homes Regulations 2001 - Regulation 18
  states -
• The registered person shall ensure that
  at all times suitably qualified, competent
  experienced persons are working in the care home
  in such numbers as are appropriate for the health
  welfare of service users.ensure that the
  persons employed by the registered persons
  receive training appropriate to the work they are
  to perform

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Legislation Cont-

• Care Home Regulations 2001 - Regulation 21 Staff
  Views as to the Conduct of the home states-
• This regulations applies to any matter relating
  to the conduct of the care home so far as it may
  affect the health or welfare of service users
• Regulation 24 - Review of Quality of Care
• Requires registered person to set up a system to
  periodically review the quality of care look to
  ways of improving this
• Regulation 26 - Visits by Registered Provider
• Requires the provider or his representative to
  carry out monthly visits, to speak to service
  users/their representatives, staff, look at
  records
• events, complaints records, prepare a
• written report send copy to NCSC

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Legislation

• Care Home Regulations 2001 - Schedule 3 states
  the registered person must keep the following
  records
• A record of all medicines kept in the care home
  for the service user and the date on which they
  were administered to the service user
• details of any plan relating to the service user
  in respect of medication, nursing, specialist
  health care or nutrition

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National Minimum StandardsCare Homes for Older
People

• These standards approved in March 2001 have been
  designed to specifically link into the care home
  regulations 2001.
• They MUST be taken into account when making any
  regulatory decision(CSA 2000)
• They are focused on service users their quality
  of life
• Standards are grouped under 7 key topics choice
  of home, health personal care, daily life
  social activities, complaints protection,
  environment, staffing, management administration

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National Minimum Standards Older People

• References directly indirectly to the use and
  abuse of medication throughout the NMS
• Linked to the ongoing fitness of the registered
  provider and manager - onus on registered persons
  to demonstrate maintain their fitness to care
  for vulnerable people
• Throws up many issues which are interrelated
• Generally NMS are statements of good practice
  thus should not be seen as barriers but bridges

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NMS - Care Homes for Older People

• NMS 3 (3.3) - Needs Assessment -
• where individuals are self funding without care
  management funding, the registered person carries
  out an assessment which must include medication
  usage.
• NMS 9 (9.1 - 9.11) Medication
• The registered person has to ensure that there is
  a policy in place staff adhere to this in
  respect of medication which includes
• receipt of medication
• recording of medication
• storage
• handling
• administration disposal
• arrangements for service users to take
• responsibility for their own medication within a
  
• risk management framework

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NMS - Care Homes for Older People

• NMS 18 (18.1 - 6) Protection
• This standard primarily talks about the processes
  procedures which need to be established to
  protect vulnerable people from abuse in all its
  forms including chemical abuse
• It references adult protection policies and
  protocols No Secrets, whistle blowing - in
  accordance with the Public Interest Disclosure
  Act 1998, the POVA(protection of vulnerable
  adults)register, DoH guidance on restraint

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NMS - Care Homes for Older People

• Other NMS standards -relevant
• NMS standard 31 - Day to day operations
  competence, qualification skill of staff
• NMS standard 33 - Quality Assurance - home must
  establish an effective QA and monitoring system
• NMS standard 36 - Staff are appropriately
  supervised
• NMS standard 37 -Service users rights best
  interests are safeguarded by the homes record
  keeping policies
• NMS standard 38 - The health, safety welfare of
  service users staff are promoted protected

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Regulatory Methodology

• The regulatory methodology is the way the
  legislation and the Standards are applied - BUT
  all are interlinked.
• Whereas before 230 approaches - now only one
• Methodology follows 4 functional routes -
  registration process, inspection, complaints
  investigation, enforcement

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Regulatory Methodology

• Registration for example acts as a gatekeeper
  by vetting all applicants for registration and
  ensuring that they are suitable to be registered
  and are aware of and understand their regulatory
  accountabilities
• Through the process of periodic monitoring and
  evaluation of service being provided ensuring
  that registered persons continue to meet those
  requirements stated and laid down at registration
• Through prompt and effective investigation of
  complaints using information gathered wisely and
  fairly
• By taking appropriate and timely enforcement
• action where evidence to do so

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The Inspection Process

• Consistent approach
• Service user focused
• Evidence based
• Transparent
• using range of methodological tools e.g.
• Pre-inspection questionnaires
• case tracking, direct/indirect observation, one
  to one discussions/interviews, sampling, testing,
  checking, individual questionnaires, quality
  feedback from service users, staff, care
  managers,GPs, relatives, auditing
• against NMS

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NCSC focus

• Service user focused
• Robust use of all regulatory processes to root
  out poor practice, challenge abusive practices
• Report on good quality and where NMS are met and
  exceeded
• Ensure that during the regulatory processes there
  is a focus on the use of medication in respect of
  older people using the legislative imperatives
  and the NMS.
• Challenge attitudes which infer that it is
  acceptable to use medication to
• control and sedate older people

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Conclusions

• Registered Homes Act gave some powers - new
  legislation and NMS now much more focused on
  issues such as use of medication
• NCSC has access to expert advice - pharmacists
  and nurse inspectors
• NCSC staff - national training programme -
  regulators of care award
• Issues however relating to training and attitude
  of care staff, providers and managers
• Issue also of attitudes amongst some of the key
  professionals who have a major role to play in
  this area especially in respect of older people,
  their value of their rights to be protected
  wherever
• they may receive services