Agenda item

Care Homes- Setting the scene and further investigation

Louise Grabham, Head of Strategic Commissioning & Procurement will be in attendance to provide a setting the scene with regards to the panels review of Care homes.


The Panel is also asked to Scrutiny review workplan which contains draft terms of reference for the review.



The Chair welcomed Louise Grabham, Head of Strategic Commissioning to the meeting, who was accompanied by George Wells, Commissioning Officer.


At the last meeting of the Panel, they had agreed to consider Care homes and consider their accessibility.


As way of background, the Head of Strategic Commissioning advised that the Strategic Commissioning and Procurement Team were responsible for commissioning a range of Adult Social Care Services, including Home Care, Residential Care, Independent Supported Living Services, Temporary Accommodation, Domestic Abuse Refuge Services and Complex Care and Support Services. This ensures value for money through thorough fee negotiations and partnership working with neighbouring local authorities, benefitting from economies of scale and intelligence sharing.


The panel learnt that Middlesbrough Council commission 28 older persons residential homes in Middlesbrough, 10 of which also able to deliver nursing care. The Council also commission several other, more specialist, residential placements, including for those with a learning disability, mental health condition, or those who require a forensic service.


Middlesbrough have one ‘in house’ residential service – Levick Court, which is registered for up to 16 service users, with 8 current residents.


Our Contract Monitoring Officers inspect our services to ensure they are delivering safe, effective care in line with their statutory responsibilities and our contracts. They work in conjunction with the Care Quality Commission (CQC) and safeguarding team to quality assure.  The Council has no jurisdiction to close a care home if it feels it does not meet criteria set out by the CQC, however shares intelligence if the Council has any concerns.


In terms of accessibility of care homes, the Panel were advised that:


In each phase of the creation of a new care home, or the conversion or development of an existing building, inclusive design principles must be considered from the outset. Every effort should be made to ensure that a care home is accessible to all residents and visitors, and their accessibility requirements will vary:


        Accessibility, in practice, means different things to different groups of people. Those who are physically disabled or frail will have different accessibility requirements to those with sensory, neurological or cognitive conditions.

        Guidance can be contradictory, for example, on mirrors in elevators. The placement of a mirror helps a wheelchair user to back in or out of the lift safely without having to turn, helping to prevent accidents. However, NHS guidance advises removing or covering mirrors, as for some living with dementia, seeing a reflection they fail to recognise can cause anxiety, anger, or terror.


In designing a new care home, there are a number of factors to take into consideration:

·        Legislative context

·        Reasonable adjustments

·        Building regulations

·        British standards

·        Inclusive design

·        Individual need

·        CQC Fundamental Standards Compliance

·        CQC Key Questions

The Panel were provided with the below information:


Legislative Context


Adequate access to buildings and services is a requirement of the following legislation:

        Equality Act 2010

        Building Regulations


The Equality Act 2010 consolidated all previous discrimination law relating to buildings access, including the Disability Discrimination Act 1995. Under the Act, all providers of goods and services must take reasonable measures to make their settings as inclusive as possible, including removing or altering any physical, attitudinal or operational barriers which stand in the way of people being able to access and use their services or facilities.

For people with disabilities, the Act requires service providers to be proactive in anticipating barriers and removing them:


        A person is classed as being disabled under the law if they have a physical or mental impairment that has a substantial and long-term adverse effect on their ability to do normal daily activities.



Reasonable Adjustments


Reasonable adjustments’ are defined by the Equality and Human Rights Commission (EHRC) as including steps to avoid “substantial disadvantage” for disabled persons caused by physical features — this includes removing the physical feature in question, altering it or providing a reasonable means of avoiding it.


The EHRC defines a ‘substantial disadvantage’ as any disadvantage that is more than minor or trivial. Service providers must be proactive and take action to make ‘reasonable adjustments’ whether or not they have any current disabled users. They are not expected to anticipate the needs of every prospective person who may access services, but they are required to think about and take reasonable and proportionate steps to overcome barriers that may impede people with different kinds of disabilities.

The duty to make reasonable adjustments most commonly applies to physical features and barriers. The physical features of a building or premises that are covered by the duty to make reasonable adjustments include:


        any feature arising from the design or construction of a building

        any feature on the premises, including any approach to, exit from, or access to a building

        any fixtures, fittings, furnishings, furniture, equipment or other moveable property in or on premises

        any other physical element or quality


Factors to be considered when justifying ‘reasonableness’ include the:

        practicality of the works

        financial cost





Proportionality is crucial in considering the necessity in adjustment works, and whether the work is deemed ‘reasonable’.


Building Regulations

Each building project, maintenance job, refurbishment or change contemplated to the care home premises should be mindful of the requirements of applicable buildings regulations.

In England, the Building Regulations 2010 Approved Document M: Access to and Use of Buildings (2015 Edition) apply.


The regulations set out minimum requirements in respect of door widths, accessible toilet provision, lifts, etc.


Approved Document M was updated in 2015 and 2016. They apply to newly erected premises or premises undergoing refurbishment only. Volume 1 deals with dwellings while Volume 2 covers buildings other than dwellings. In 2017 the Government published a set of Frequently Asked Questions to support the regulations.


British Standards

The Buildings Regulations cite British Standard BS 8300:2009 Code of Practice: Design of Buildings and Their Approaches to Meet the Needs of Disabled People. However, BS 8300:2009 has now been withdrawn and replaced by a new standard in two parts.

        BS 8300-1:2018 Design of an Accessible and Inclusive Built Environment. External Environment — Code of Practice.

        BS 8300-2:2018 Design of an Accessible and Inclusive Built Environment. Buildings — Code of Practice.


Part 1 promotes good practice design principles to ensure that the external built environment, such as the approach to a building and its grounds, meets the needs of all who use it, not only disabled people. The standard covers:

        developing an inclusive strategic design strategy for sites and external environments

        arrival at a destination and parking provision

        horizontal movement — access routes, hazards, signage, surfaces, gates and barriers, etc

        vertical movement — external steps, stairs, ramps, handrails, lifts, subways and bridges, etc.


Part 2 provides recommendations on the inclusive and accessible design of the interior of buildings. It covers a wide range of features relevant to care homes, including:

        developing an inclusive design strategy for buildings and building layouts

        access routes to and within buildings

        entering a building — doors, access control systems, entrance and reception areas

        horizontal movement — corridors and passageways

        vertical movement — internal steps, stairs, ramps, slopes, handrails, lifts, etc

        surface finishes, lighting, the provision of signs and audible communication systems

        facilities in buildings — such as seating, storage, windows, building services, etc

        counters and reception desks

        sanitary accommodation — showers, toilets, etc

        individual rooms — kitchens, bedrooms, quiet spaces.


The recommendations in the standards apply largely to new developments. However, they can also be used for assessing the accessibility and usability of an existing built environment and, where practicable, as a basis for improvement.



Inclusive design

Inclusive Design is the design of an environment so that it can be accessed and used by as many people as possible, regardless of age, gender and disability. To do this, built environment professionals should involve potential users at all stages of the design process; from the design brief and detailed design through to construction and completion. Where possible, it is important to involve disabled people in the design process.


The Commission for Architecture and the Built Environment (CABE) published and promoted the principles of inclusive design as it relates to the built environment:


        Inclusive – so everyone can use it safely, easily and with dignity

        Responsive – taking account of what people say they need and want

        Flexible – so different people can use it in different ways

        Convenient – so everyone can use it without too much effort or separation

        Accommodating for all people, regardless of their age, gender, mobility, ethnicity or circumstances

        Welcoming – with no disabling barriers that might exclude some people

        Realistic – offering more than one solution to help balance everyone’s needs and recognising that one solution may not work for all


Individual need

Each care provider completes a care plan for residents coming into their care, including the provision of adaptations or special equipment designed to ensure that the resident has access to all parts of their communal and private space.

Specialist advice from an occupational therapist should be obtained wherever necessary either to perform the assessment or to assess the home itself. In order to provide access to all parts of the premises for service users with physical disabilities, care managers may have to provide such adaptations and equipment, enabled by the Tees Community Equipment Service.


Service users with a visual or hearing impairment should have their needs assessed and a care should be developed which includes the provision of sensory adaptations or special equipment. Staff should work closely with such residents to monitor their progress and identify any tasks or actions where they have difficulty. This should include areas of personal care, such as bathing, washing, going to the toilet and dressing, problems with mobility, problems with money and social difficulties, such as having conversations or talking on the phone.


CQC Fundamental Standards Compliance


Care home providers in England must comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 to maintain registration with the Care Quality Commission (CQC). These include Fundamental Standards below which care must not be allowed to fall. With regard to disabled access and mobility, Regulation 15: Premises and Equipment, includes a requirement for premises and equipment to be suitable for the purpose for which they are being used.


Guidance for Providers on Meeting the Regulations provides a range of notes and prompts which describe how the regulations apply. For example, Prompts 15(1)(c)/(f) state that:

        people’s needs should be taken into account when premises are designed, built, renovated or adapted

        the size, layout and design of premises must meet current legislation and guidance and must be safe for the care and treatment being delivered

        service users should be able to easily access premises, and where this is not the case, reasonable adjustments should be made in accordance with the Equality Act 2010 and other relevant legislation and guidance.

        providers should take the anticipated needs of service users into account when locating services and should ensure easy access to other relevant facilities and the local community

        equipment, for example, chairs, beds, clinical equipment, and moving and handling equipment, should be accessible (for example, available when needed, or obtained within a reasonable time without posing a risk) at all times to ensure service users’ needs can be met.


CQC Key questions


CQC inspections in England are based on a ‘five key-question test’ to determine published ratings for each provider. Key question judgments are made with reference to guidance published by the CQC for its inspectors.


From November 2017, the revised guidance in Key Lines of Enquiry, Prompts and Ratings Characteristics for Adult Social Care Services applies. This contains:

        Key Lines of Enquiry (KLOE) which prompt inspectors to ask certain questions

        Ratings Characteristics which indicate what outstanding, good, requiring improvement and inadequate services look like.


With reference to disabled access to premises, inspectors are prompted to ask a range of KLOE questions, including:


        E6: How are people’s individual needs met by the adaptation, design and decoration of premises?

        E6.1: How are people involved in decisions about the environment?

        E6.2: How do the premises meet people’s diverse care, cultural and support needs?

        E6.3: What arrangements are there to ensure people have access to appropriate space:

o   in gardens and other outdoor spaces; to see and look after their visitors; for meaningful activities; to spend time together; to be alone?

        E6.4: How does the signage, the decoration and other adaptations to the premises help to meet people’s needs and promote their independence? How are any changes to the environment managed to avoid causing distress to people who live there?


To answer these questions, inspectors are encouraged to ask service users and their relatives their views and experiences about the care they receive. They are also prompted to gather feedback from other sources and stakeholders.


In addition to the KLOE prompts, the CQC guidance describes what inspectors should look for in services with different ratings. For example, with reference to disabled access, in a service rated as “good” inspectors are encouraged to look for evidence that:


        staff are clear about their responsibilities regarding premises and equipment

        staff share information about environmental and equipment-related risks with relevant external professionals

        people are involved in decisions about the premises and environment, regardless of their ability to communicate

        individual preferences and cultural and support needs are reflected in how premises are adapted or decorated

        people have access to outside space that has been assessed for risks, a quiet area to see their visitors, an area suitable for activities and private areas when people wish to be alone

        decorations and adaptations to the premises are laid out in a way that is accessible and helps to promote independence.


In a service rated as “outstanding” inspectors are prompted to look for evidence that:


        the service proactively engages with people and other organisations to assess and minimise risks to the environment, premises and equipment, and it anticipates issues

        the service works innovatively and mitigates risk creatively to maximise people’s autonomy and independence

        the service uses innovative methods to engage people in discussions and decisions about the environment they live in or use

        people’s environment reflects their individual preferences and culture, and supports their needs in the way they choose

        the service is designed around people’s needs and wishes, and uses innovative ways to help people to be as independent as possible

        where possible or appropriate, people are encouraged to help with decorating or furnishing the premises

        there are different areas for people to use for their preferred activities and private space to spend time with their families or visitors, or to have time alone

        all areas are maintained and decorated to a high standard, in a way that people have asked for, and take into account people’s cultural needs for how the space is used

        space is maximised and used creatively to promote independence.


The Head of Strategic Commissioning advised that out of the 28 Care homes commissioned by Middlesbrough Council, 2 were rated outstanding, 1 requires improvement and all others are rated good.


In summary it was explained to the panel that it was vitally important for care homes to consider all aspects of accessibility in their built design, developing their service around the resident and the needs of those employed by the provider.


Care home providers in England must comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in order to maintain registration with the Care Quality Commission (CQC). These include Fundamental Standards below which care must not be allowed to fall.


Care homes can seek further advice and support from their CQC Inspector, or by contacting a Middlesbrough Council Access Officer for tips on improving accessibility. The Panel were also advised that Middlesbrough social care visit care homes once a year and do an internal inspection/ audit of care plans.  The inspection will consider quality of care, individual needs (including diet) and speak to care home staff.


Social care staff, within 2 hours of receiving a referral will consider the most appropriate care home and work with their families.


Following the presentation, a Panel member queried whether care homes has scope to provide activities for individiauls. In response, the Panel were advised that most care homes have activity co-ordinators and if there is a specific activity which would assist with the service users mental health/ rehabilitation, occupational therapy would access and work with the service user/ families and care home. There is also a wishes and wants section within the care plan to identify hobbies and needs.


A panel member further queried what support was in place for individuals living in supported accommodation, especially for activities. The Director of Adult social care and health integration outlined that a lot of the Panel’s questions fell within the prevention agenda.


After a discussion with the Panel, it was felt that there was no merit or value in examining accessibilities of care homes, due to the regulations already in place. This topic would therefore not be investigated as part of the work programme.


It was clear that Panel members were more concerned about Prevention and support provided to individuals to help them stay in their own homes.  It was therefore agreed by the Panel, that at the next meeting, a setting the scene presentation would be provided on Prevention.


The Chair thanked the officers for their time and presentation.



        the information provided at the meeting be noted;

        That if required, the officers provide further updates on CQC inspections/ outcomes;

        That the Panel receive a setting the scene presentation in relation to Prevention at the next meeting.






Supporting documents: