The importance of Good Governance for Care Home providers.

The team at Swift Management Services Limited often find that the term ‘Good Governance’ is misused and misunderstood. There is further confusion caused as local authorities and NHS professionals use the term: ‘Clinical Governance’ and bankers and auditors use terms such as ‘good financial governance’. These terms leave some providers in a quandary and we often hear comments such as “What is good governance, what do I have to do?”

We hope that we can help demystify the terminology for providers. In the simplest of terms, Good Governance is: putting processes in place and ensuring that your team do what you say they do. The processes in place should reflect best practice guidelines where they exist.

The management team, or provider needs to be able to demonstrate they monitor processes and take action to ensure that what is happening, is what they believe should be happening. The process of governance includes policies, procedures, forms and documentation, reports, and inspections from providers.

One of the most seen business governance failures is fraud taking place, and business owners not just in the care industry looking back in wonder as to how it happened. The banking policy and good business practice would dictate that all financial transactions are signed by two authorised people, or where transactions are electronic two people authorise them.

In many instances and based on a level of trust, one of the two signatories may sign an entire cheque book of cheques. The second person is then able to complete the cheque and add their signature or in the case of electronic banking one person gives their security information to the second to allow one person to undertake both parts of the authorisation process. For much of the time the process appears to work, and everyone is happy until something goes wrong and fraud is committed. One of the first questions asked is what governance checking was in place. In short, the management of the organisation did not recognise the practice before an issue arose and significant loss occurred.

Above is only one example of poor governance, but throughout the care industry there are multiple areas of the business where good governance is essential. These relate to the business, residents, and their care.

Any provider should be asking themselves if they are able to say that they know with certainty that what is supposed to be happening is happening. One governance tool used in large businesses is the auditor’s report, which should be a tool that is used to advise stakeholders about practice. Some care home providers view the regulatory report as a governance tool. That view is not appropriate, and a regulatory report should never be a governance tool. Governance should be an ongoingmethod of internal review, long before an inspection takes place.

The governance process can include, but is not limited to, provider visit reports, and a review against recognised clinical tools, to ensure that care trends are being maintained and action is being taken to ensure standards of care.

Good Governance and service improvement plans go hand in hand, and can make the difference between grades in effective, caring, responsive, safe, and well led. The Swift Management team can provide good governance audit tools, service improvement plans and provide governance audit reports. Providers who are regularly in a service, may see things so often that despite not being best practice, become the norm, and are no longer seen. Therefore, an external audit report can really help in the governance journey.

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Time for CQC to recommence the inspection process

At the beginning of the Covid-19 Crisis the Care Quality Commission, the English health and social care regulator ceased undertaking all but essential inspections, to maintain the safety of both the public and their own staff.

They instead established a system known as “The Emergency Support Framework”. This was a way in which they could keep in contact with health care providers across England. The focus remained on the five standards used to monitor health care in England: Caring, Safe, Effective, Responsive, and Well Lead.

Despite the emergency support framework telephone calls being documented and a summary being circulated, the evidence gained was not used to re-evaluate grades or allow action to be taken. As well as gathering information from outside sources and from statutory reporting alongside the emergency support framework calls, it seems the inspection process has stopped.

Only where serious concerns were identified was an inspection considered. We believe the inspection process now needs to start again in earnest. As time goes on and no inspections take place the issues care providers face exacerbate day by day. We fully understand that every provider whether they be rated Outstanding or Inadequate, have gone through a period of enormous pressure managing all the various issues surrounding the Covid-19 Crisis, but there is now a need to focus on inspection.

This may be a strange concept for some to grasp, but it is important to understand the picture faced by some care providers. There are several care providers who have suffered high numbers of deaths during the recent crisis. They have come under criticism from the media when the situation was in some instances out of their control. They will need to demonstrate that all standards are being met. A regulatory review of services will give the public reassurance.

The homes however that really do need urgent inspection are those that before lockdown were rated inadequate. The team at Swift Management Services Limited undertake support of care homes who need to improve following an inadequate rating and where enforcement action has been taken or is likely to be taken. Looking at one of our client’s stories may illustrate the situation:

We started working with one of our clients in late October 2019 when they had received their second inadequate inspection report. Since our engagement we have worked with the provider and supported them through a change process. We have provided regular updates for both the local authority and CQC. The improvements are clear to see. Under CQC guidelines a home rated inadequate should be inspected within six months. We contacted CQC to ask that the inspection be brought forward. The inspector advised that they had planned an imminent review, and would be within the six- month timeframe. This meant that our client only had a few weeks to wait. Then lockdown happened and the inspection process did not take place.

The home has been left for an additional three months without an inspection. Given the last inspection was the second inadequate inspection, should they be allowed to operate for a further nine plus months if the care was not safe without enforcement action being taken? Fortunately, this is not the case for our client. We are pleased to say our client has move on substantially, the care they provide is of a high standard and this can be evidenced. The difficulty they have is their published rating shows as inadequate. This is preventing them from admitting to the home, as the CQC ratings are very much taken into consideration by both local authorities and private clients alike.

If they are to continue to improve, they need the support of the regulator to review their grades which will allow them to admit new clients.

Any home that is rated as inadequate faces extreme financial hardship, as admission levels fall and costs of improvements increase, with no way of servicing the expenditure over an extended period. This uncertainty influences both the provider and the staff. There is uncertainty all around. Thankfully in our client’s case, the Swift Management Team, have been there to support them, and both the management and the staff appreciate our support, advice, and encouragement. They say that our team are part of the family, but that they are not receiving the recognition they need to take their business forward. They need a regulatory visit to review their grades.

Once the inspection happens, we will await with interest the grade they are given. In many cases a home will move from inadequate to requires improvement as the provider needs to demonstrate a sustained improvement. Given the delay in inspection we will be watching with interest as the sustained improvements can be evidenced to the regulator, through our regular submission of audits, feedback and record keeping.

Whilst we have only mentioned one specific client in this article, they are not the only client we have in the same position. We therefore welcome the inspection process starting again in earnest.

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