Giving the client a voice in their care

Nikki Hopkins, Operations Manager and Case Manager at CCMS, and Nikki Watts, Registered Manager for CQC and CIW, discuss the CQC single assessment framework

With the new single assessment framework now being rapidly rolled out by the CQC, it is important that all case managers are familiar with how that impacts the already complex work and practice.

The new framework will bring together all health, care and social care providers under the same criteria on which they are assessed. This will make it easier for the CQC to gauge and compare how well services are being delivered.

This includes case managers, care and nursing homes, health and care agencies, NHS and other health providers and will include local authorities for the first time.

All those who have a responsibility for delivering regulated activity will now be scored and graded against the same measures, with the vision to bring uniformity across a wide range of varied sectors. 

The single assessment framework will still cover the same five key areas we’re all familiar with - safe, effective, caring, responsible and well led. However, the CQC inspectors will now provide more clarification with a scoring system to determine how well the provider is performing to determine how they reach the awards of the existing outcomes of outstanding, good, requires improvement or inadequate. 

One key change is the use of new quality statements, known as ‘we statements’ and ‘I statements’ that replace the Key Lines of Enquiry (KLOEs), to evidence the levels of service and client satisfaction with the service the organisation delivers. 

The ‘we statements’ are designed to be from a provider’s perspective, so they can detail how they are delivering the standards the CQC expect - but now there is a much greater focus on the experience of clients and their perception of how a service is delivered, which will be captured through the ‘I statements’. Evidence of both will be continually gathered and monitored.

Nikki explains: “At CCMS, we welcome the single assessment framework and the changes it introduces. It will give use the opportunity to champion how the experience of our clients and ensuring their voice is heard is central to the way we work – we cannot be truly client-centric unless we work that way. We hope the fact this is now required and assessed by CQC will improve standards of care more widely. 

“Ensuring our clients are heard and involved in their care as much as possible is fundamental to their rehabilitation and that is important to us as a team. In our experience, engaging with our clients in the way we do can have truly transformational effects, particularly among more complex and challenging clients, for whom some of the frustrations they experience can be alleviated through feeling heard and involved.” 

The introduction of the ‘I statements’ in particular could well be a very significant step forward for clients and indeed for providers - and the story of “Kate“ can help articulate why.

Involving Kate in her own care - a life-changing impact

Kate is a young woman with Cerebral Palsy and borderline personality disorder. She is a very complex character and has a divisive communication style. This had led to a high turnover of care staff, with agencies funded by the local authority and carers who have refused to go back and work with her. This led to disrupted care that at times could be volatile due to Kate being confrontational and destabilising her support programmes, and those delivering them. 

Although Kate is reliant on a wheelchair and needs time to communicate, she is a vulnerable individual and absolutely knows what she wants. She has the capacity to decide what medication she wants to take and when. She decides what she wants to eat. She understands the risks and consequences of her actions, which was the source of a lot of conflict previously.

At CCMS we have a lot of experience in successfully working with very complex individuals, and Kate was someone we could apply this knowledge and expertise to, to help her transform her outlook and potential. 

What we saw when we met her was frustration. She didn’t want to be dependent and reliant on care, she wanted to be more independent. We realised that involving her and giving her more say in her care and care planning could be a way forward, to give some stability to her, those delivering her care, and to the package itself. These were things that previously would often change, as they were not really given the time to succeed or fail. 

It was important to Kate that she was made to feel heard, especially when someone was telling her what to do, what is best for her. Kate has strong opinions and was capable of communicating these. We wanted the situation for Kate to be different, for her to feel more empowered and at the helm of her own care.

Kate led the writing of her own care plans, her support programme and risk assessments. We supported her in doing this throughout the process, which built a strong therapeutic relationship that she perhaps had not with those previously involved in her care. We actually found her input was very valuable for us as professionals too. 

Kate was able to say how she liked her pets to be cared for and spoken to. She told us how she liked her kitchen to be kept and where she preferred items to go. She might not want her morning routine to start so early as she had been used to with a carer’s visit, so we could arrange for her medications to be set up by her bed. 

These were such an important layer of getting to grips with how she wanted her care to be delivered by her support workers. Her name became used in her daily care records. Rather than a support worker saying ‘I did this’, that changed to ‘Kate requested this’. The whole process of delivery, recording and reporting was adjusted to make it in line with Kate’s wishes and ability to vocalise those via her care planning. 

The shift in her feeling of control was hugely positive. Kate felt, at long last, as if she was in the driving seat. Rather than seeing us as professionals who were trying to control her, we became her team, to protect her and provided the scaffolding and infrastructure, while making sure financial and legislative matters were dealt with. 

Working with Kate she was able to define her care and personal requirements. She felt listened to, and it worked. As she is 100 per cent health funded, with no funds for case management, most of what we did was pro-bono work.

Through establishing a therapeutic relationship and ensuring she would engage, we managed to evidence that she needed 24/7 live-in support. The very small pot of money that existed from the remainder of her settlement was used to top up on other services, such as specific continence management hours each week.

The outcome was that this whole package worked effectively and efficiently, and Kate was happy to be supported in this way. There were less people involved in it, she had directly employed personal assistants that worked one week on, one week off. She got to know the people around her and there was less potential for destabilisation and crisis management. 

The ‘I statements’, which are now contained within the single assessment framework, were very prevalent to Kate and her care. This is an approach we routinely take, to ensure all of our clients can be involved in their care as far as their individual circumstances will allow. 

To ensure we continue to be as person-centric as we can be, we are holding ongoing workshops with our management team and our case managers to explore the single assessment framework. While we are confident we are delivering our service very well, we can always do more - and changes like this give the opportunity to reflect, discuss and learn, so we can do an even better job for our clients going forward.