Are care home ratings the full picture?

Choosing a care home is daunting at the best of times. During the pandemic, it has been even more challenging for people to arrange care for themselves or a family member.

Covid-19 has taken a dreadful toll on the care sector. In England, more than 39,000 care home residents died of coronavirus between 10 April 2020 and 31 March 2021. Strict restrictions on visiting have been in place since the start of the crisis. So since March 2020, it's been tricky to look around a care home in person.

Prospective residents have had to make their minds up about the best care home for their needs using other information, such as virtual tours and the care provider's website or brochure.

Inspection reports from the care regulator - in England, this is the Care Quality Commission (CQC) - are also available online. These reports can tell you useful information about how a potential care home shapes up.

However, Which? research shows that this data may not be particularly recent. We found that nearly half of the 14,705 residential care homes in England haven't been inspected in over two years.*

How are care homes regulated in England?

The CQC sets out the minimum standards for care homes. Inspectors scrutinise a home to determine the answer to five key questions:

• are they safe?
• are they effective?
• are they caring?
• are they responsive?
• are they well led?

After an inspection, the watchdog gives a care home one of four ratings: inadequate; requires improvement; good; or outstanding.

A long wait between inspections isn't necessarily something to be alarmed about. How frequently a care home is inspected depends on its current rating, says the CQC.

Homes rated as good or outstanding are normally inspected within 30 months of the last inspection report.

Providers with a lower rating are supposedly inspected more frequently. Services rated as 'requires improvement' should be inspected within a year, says the regulator. While 'inadequate' care homes should be inspected within six months.

• Learn more about quality and regulation of care providers

Long waits between care home inspections

But when we looked at the data, we found:

• 50% of care homes haven't been inspected for more than two years
• 22% of care homes rated good/outstanding haven't been inspected for more than three years
• 60% of cares homes rated 'requires improvement' or 'inadequate' haven't been inspected for more than a year
• The average time between inspections for care homes in England was 24 months

Of course, nothing has been normal since the coronavirus crisis started over a year ago. In England, routine CQC inspections were suspended at the start of the pandemic. The regulator did send inspectors to care homes if it suspected a significant risk - such as concerns around infection control - but otherwise it monitored care providers remotely.

'We continued to inspect where we saw risk of harm, abuse, systematic neglect or a breakdown in leadership,' said the CQC. 'We regulated services in a variety of ways to identify where support is needed. The information we collected was used to monitor and respond to risk, ensure providers are able to keep people safe and drive action ... where we see emerging issues that need further action.'

It's therefore not surprising that many care providers haven't been inspected recently. But it does mean you might want to take the inspector's conclusions - good or bad - with a grain of salt if it has been a while since the regulator last visited the home.

What do care home ratings tell you?

That's not to say that you should ignore a bad care home rating. Providers that are rated 'inadequate' in England means that the home has failed to reach expected standards. There may have been concerns about safety or the way the home is run at the time of the last inspection. If this happens, the regulator usually asks the failing home for an action plan to improve their services.

'The inspection reports do play a very important part of the selection process, but not in isolation,' says Claire Edwards, an elderly care consultant.

Seeing a care provider has a 'good' or 'outstanding' rating can offer a false sense of security, Edwards says. A glowing report does not necessarily mean it'll be the right home for you or your loved one. Likewise, a poor rating doesn't necessarily mean you shouldn't consider it.

How to read a care home inspection report

You can find care home inspection reports for care homes in England through our Care Services Directory or on the CQC website.

Zoom in on the most important parts and quickly determine the most relevant information for you or your loved one, suggests Edwards. You can also use the report to uncover questions you should ask the provider.

Use your judgement and ask questions

'If the inspection report has identified some concerns, then look at the particular point the CQC has picked up on and make a judgment about how important that is to you or your relative', says Edwards.

Don't be afraid to ask about what steps the care home has taken to address the concern, she says. If the care provider is defensive, that could be a red flag.

Note the date

Take note of the date of the inspection - if the care home has been rated 'good' or 'outstanding', it may well not have been inspected for a while. Conversely, if inspections occur very frequently, it might be a sign of problems.

It is a good idea to go back to the previous inspection report to see if points raised by inspectors have been addressed or whether they reappear in subsequent reports, says Edwards.

Spot red flags

High staff turnover is another warning sign. If this is mentioned in the report, it could indicate unsettled, unhappy staff.

How to choose a care home

When you're choosing a care home, there are going to be other factors that are just as (if not more) important than a provider's inspection report. You can often get a good idea of a care home's quality simply by word of mouth - and how other families in the local community feel about the care their loved ones have received there. A recommendation from a happy resident is worth its weight in gold.

What are your priorities?

The location might be a dealbreaker, for instance. You may prefer a home where you or your loved one already know other residents, or a home that is at the heart of your local community. Or you may prioritise specific facilities, such as an accessible garden or a home where pets are welcome.

You may have specific health needs, such as dementia, which some care homes will be better geared up for than others.

If you're not able to look around in person at the moment, it's still a good idea to speak directly with the care home's manager about how the home can meet your needs.

Enquire about the availability of places. And talk about fees and funding at the earliest opportunity. You'll want to eliminate homes that aren't suitable because they don't have space or they're out of your price range.

• Our free checklist of Questions to ask when choosing a care home has lots more you might want to ask when speaking with a care provider

Coronavirus questions

The CQC has now published data on how many confirmed Covid-19 deaths took place in individual care homes during the first and second waves of the pandemic. However, it's worth remembering that this is not necessarily an indicator of poor quality care. The care homes worst affected are generally in areas where there were many Covid-19 cases in the community. England's care regulator says it hasn't seen a link between a home's standard of care and the number of coronavirus deaths.

Still, it's worth asking the care home manager what health and hygiene measures they're practising to stop the spread of viruses such as Covid-19 and flu.

To reduce the risk of coronavirus being transmitted, it is likely new residents will need to self-isolate when they first move into the home. Find out what extra support will be offered during this time to help them settle in.

You could also ask how the home helps residents mix and enjoy life together at the moment, given the constraints of the pandemic.

Find out about the current visiting processes - and whether there are outdoor spaces available should indoor visits be restricted in future. Get the lowdown on testing,and how regularly residents, staff and visitors must have Covid-19 tests.

• Learn how to uncover key information when choosing a care home

Care home inspections are changing

Even though coronavirus restrictions are easing, care home inspections are not going back to the way they were. The CQC says it is moving away from relying on a set schedule of inspections to a more flexible, targeted approach.

It says it will visit a care provider in-person when there is a 'clear need to do so' , such as when there are concerns about risk, limited data, or it needs to speak to residents and their families face to face.

The CQC says care home ratings will become more 'dynamic' - they won't always need to carry out an inspection to update them. Only time will tell if this new approach makes care home ratings more relevant.

Some families are concerned that care homes will receive fewer physical inspections in future. The Relatives and Residents Association, which campaigns on behalf of older people needing care in England, has called for routine inspections to be restarted. Its director, Helen Wilbore said: 'There is no substitute for crossing the threshold to inspect a service to ensure it's delivering safe, quality care. Especially services for older people, who may not be able to communicate remotely or have relatives and friends to advocate for them.'

For more information about care homes, the different services they provide and how to choose the best one for your needs, visit our guide to care homes

*CQC inspection reports data accessed June 2021 for all residential social care homes in England