The Role of the Care Certificate in Patient Safety and Satisfaction

Patient safety and satisfaction is becoming an essential and frequently used indicator of the quality of healthcare in the UK. Good experience of care, treatment and support, together with effective, safe healthcare practice, is an essential part of an excellent health and social care service. However, at present the National Health Service (NHS) and the social care sector are facing the greatest workforce crisis in their history, with approximately four in five current NHS vacancies being covered by temporary, bank or agency staff. Many of these temporary staff, through no fault of their own, lack the skills or qualifications to cover more than the basic care duties, leaving many shifts uncovered according to a House of Commons Committee report. Staff shortages and lack of training have a direct impact on patient safety and satisfaction, as can be seen from the key findings of the following reports.

The Nuffield Trust and The King’s Fund have published the gold-standard measure of public attitudes and opinions towards the NHS and social care, as surveyed by NatCen during 2022. Unfortunately, the survey has found that public satisfaction with the health service has slumped to its lowest level ever recorded in the 40-year history of the British Social Attitudes survey.

The key findings of the survey included data such as:

• Overall satisfaction with the NHS fell to 29%, a 7-percentage point decrease from 2021. This is the lowest level of satisfaction recorded since the survey began in 1983.
• Over half (51%) of respondents were dissatisfied with the NHS, the highest proportion since the survey began.
• The fall in satisfaction was seen across all ages, income groups, sexes and supporters of different political parties.
• The main reason people gave for being dissatisfied with the NHS was waiting times for GP and hospital appointments (69%), followed by staff shortages (55%) and a view that the government does not spend enough money on the NHS (50%).
• Of those who were satisfied with the NHS, the top reason was because NHS care is free at the point of use (74%), followed by the quality of NHS care (55%) and that it has a good range of services and treatments available (49%).
• Satisfaction with GP services fell to 35% in 2022, down from 38% in 2021. This is the lowest level of satisfaction recorded since the survey began. The fall was much less sharp than between 2019 and 2021, when satisfaction fell by 30 percentage points.
• Satisfaction with Inpatient and Outpatient services fell to 35% and 45% respectively. Despite falling by 4 percentage points, Outpatients remains the highest-rated service.
• Satisfaction with A and E services dropped 8 percentage points to 30%, also a record low. 40% of respondents said they were dissatisfied with A and E services, an 11-percentage point increase and a new record level of dissatisfaction. This is the largest change in dissatisfaction in a single year since the question on A and E services was first asked in 1999.
• Just 14% of respondents said they were satisfied with social care. Dissatisfaction with social care rose significantly in 2022, with 57% of people saying they were dissatisfied, up from 50% in 2021.
• Dissatisfaction with social care was high across all ages, income groups, sexes, and supporters of different political parties. People over the age of 65, those on higher incomes and people of white ethnicity were most dissatisfied.
• The top reason for dissatisfaction with social care was that people don’t get all the social care they need (64%) followed by the pay, working conditions and training for social care workers not being adequate (57%) and there not being enough support for unpaid carers (49%).

The survey concludes that despite grim results, the founding principles of the NHS strongly hold up. The survey shows that contact with an NHS service softens people’s views, leading them to report higher satisfaction; however, the overall picture is one of sustained dissatisfaction across the board. The top reason for dissatisfaction of health and social care services, chosen by 64% of respondents, is that people don’t get all the social care they need, followed by 57% of people citing that pay, working conditions and training for social care staff are bad.

Imperial College London’s Institute of Global Health Innovation defines patient safety as: “patient safety refers to the absence of preventable harm in healthcare”. They have compiled a report on the National State of Patient Safety 2022, and the statistics reported are as follows:

• In 2020, it was estimated that 237 million medication errors occur in England each year, contributing to more than 1,700 deaths.
• In 2019, there were more than 130,000 avoidable deaths in Great Britain – more than 22% of all deaths. Of these, 64% were classed as preventable and 36% were classed as treatable.
• In 2020, there were estimated to be between 19,800 and 32,200 cases of “probably avoidable” significant harm to patients in primary care in England each year.
• As of July 2021, 41% of maternity services in England were rated as “inadequate” or “requires improvement” for safety by the Care Quality Commission (CQC).
• In 2020/21, the cost of clinical negligence claims incurred as a result of incidents was £7.9 billion.
• For the period April–June 2022, there was a shortage of more than 132,000 full-time equivalent healthcare staff, a vacancy rate of 9.7%.
• In 2019, 40% of staff reported feeling unwell as a result of work-related stress. This rose to nearly 47% in 2021.

The report concluded that the majority of patient safety data collected in the NHS in England relates to past episodes of harm. Far less data is available to provide insight into the safety of care in real time, or on the conditions that can make harm more likely to occur in the future.

Several insights can be drawn from the key findings of both of these reports, not least that there are growing concerns about quality care delivery in healthcare settings. Whilst staff shortages, an ageing population, evolving healthcare needs and a lack of funding are all issues that contribute to the ability to deliver quality care, staff training is also an important contributing factor. However, currently 54% of direct care workers do not have a Level 2 or above care qualification.

Understanding the Care Certificate

The Care Certificate is an agreed set of standards that define the knowledge, skills and behaviours expected of specific job roles in the health and social care sectors. In 2013, a public inquiry was set up to investigate alarming abuse and neglect cases at Mid Staffordshire NHS Trust. The inquiry and the resulting report is known as the Cavendish Review. The Cavendish Review found that the training and development of healthcare assistants and adult social care workers was often not consistent or good enough.

The Care Certificate was a recommendation from the Cavendish Review, which made suggestions on how to improve the quality of care provided by health and social care support workers. The review stated that “all healthcare assistants and social care support workers should undergo the same basic training, based on the best practice that already exists in the system, and must get a standard ‘certificate of fundamental care’ before they can care for people unsupervised”. The Care Certificate is now a recognised standard within the health and social care sector which the Care Quality Commission (CQC) considers to be the benchmark of induction into the sector. It builds on and replaces the earlier induction programmes, that is social care’s Common Induction Standards (CIS) and health’s National Minimum Training Standards (NMTS).

By standardising skills and knowledge and prioritising compassionate person-centred care, the Care Certificate provides employers, regulatory bodies, patients and their families with assurance that those who have successfully completed the Care Certificate possess the requisite requirements to provide competent, quality care and supports their ongoing professional development.

The Care Certificate was developed jointly by Skills for Health, Health Education England and Skills for Care. It was introduced in 2015 by the UK Department of Health and is based on 15 standards that care practitioners must adhere to:

• Understand your role
• Your personal development
• Duty of care
• Equality and diversity
• Work in a person-centred way
• Communication
• Privacy and dignity
• Fluids and nutrition
• Awareness of mental health, dementia and learning disability
• Safeguarding adults
• Safeguarding children
• Basic life support
• Health and safety
• Handling information
• Infection prevention and control

All new staff who are new to care will be expected to undertake the Care Certificate, usually as part of their induction, if they are employed as:

• Healthcare assistants
• Assistant practitioners
• Care support workers
• Support to clinical roles where there is direct contact with patients
• Adult social care workers, providing direct care in residential and nursing homes or a hospice
• Home care workers
• Domiciliary care staff

Other social care roles that can benefit from undertaking the Care Certificate include:

• Caring volunteers
• Porters
• Cooks
• Drivers with direct contact with patients / service users.

The Care Certificate applies across the health and social care sectors, is portable between sectors and organisations and is an assessment of both knowledge and competence. Each standard has associated learning outcomes and assessment criteria.

The certification process involves a combination of training and assessment components. Caregivers undergo comprehensive training to understand the core standards and then undergo assessments to demonstrate their practical application. Assessments are conducted by occupationally competent assessors who evaluate the caregiver’s competency in applying the core standards in various care scenarios. Individuals need to complete all of these in full, and need to demonstrate their competence before they can be awarded their certificate and be deemed capable to work unsupervised in their role.

By setting clear standards, the Care Certificate plays a fundamental role in standardising the skills and knowledge and in ensuring the consistency in performance that is essential for safe, compassionate, high-quality care and support. Standardisation reduces the risk of variation in the quality of patient care thereby improving patient outcomes and safety. The Care Certificate contributes to the ongoing professional development and quality of care provided by healthcare and social care workers.

Whilst there is no legal requirement for individuals to complete the Care Certificate, it is often a regulatory requirement, ensuring that caregivers meet the established standards set by regulatory bodies in the healthcare sector. It is also an expectation of the CQC that all health and social care employers provide their employees with suitable training for the Care Certificate, or an equivalent, that will provide individuals with the requisite skills and knowledge to meet the standards.

Training is important in health and social care, to ensure safety for everyone involved in delivering care and for those receiving it and to maintain the highest levels of care quality. The Care Certificate is designed to give everyone taking it, and their employers, the confidence that health and care professionals have the same introductory skills, knowledge and behaviours to provide compassionate, safe and high-quality care and support in their own particular workplace setting. This boost in confidence can contribute to higher job satisfaction for those working in the care sector, ultimately benefiting both healthcare professionals and the patients that they care for.

The Connection Between Competent Caregivers and Patient Safety

Patient safety is the avoidance of unintended or unexpected harm to people during the provision of healthcare. Safety in healthcare is everyone’s responsibility and has been a mantra in the sector for many years. Education and training of healthcare caregivers can not only embed the right approach to preventing and learning from errors, but can also keep the mind receptive to new ideas that could improve safety.

Human error and poor process and system design are widely recognised as contributory factors in patient harm incidents, so when healthcare staff are well-trained and competent, they are equipped with the necessary knowledge, skills and competencies to perform their duties effectively and to reduce the risk of errors that could compromise patient safety.

Standardised training, such as that of the Care Certificate, ensures that healthcare workers are aware of, and adhere to, established and regulated clinical protocols and guidelines. Following these protocols reduces variability in care delivery, and helps to minimise the likelihood of harmful events happening. Healthcare workers are also better equipped to recognise potential risks and hazards, to understand infection control measures, and to identify medication errors before they can lead to harm. A well-trained workforce plays a crucial role in safeguarding patient safety and enhances the quality of care that patients receive.

The Care Certificate, as we have seen above, involves a combination of training and assessment components, and in order to be awarded the Care Certificate the healthcare worker must meet all of the outcomes and assessment requirements. Learners are assessed on what they know and what they do in order to show that they understand and can carry out the standards in their role. As they complete the certificate, they will cover the same areas of learning as all the workers in the UK who undertake the Care Certificate, ensuring competence consistency across the sector, and each standard must be completed and assessed before they can work without direct supervision in any setting.

Ideally, someone would aim to achieve the Care Certificate when they first start work as a healthcare worker, and whilst there is no fixed time for when someone should achieve the certificate, on average, it takes a full-time member of staff 12 weeks to achieve it. This gives a healthcare worker the opportunity to study and practise all the fundamental aspects and practical skills relevant to quality care delivery.

The following case study provides an overview of a project implemented to improve patient outcomes through the development of competent caregivers.

In October 2015, Sutton Homes of Care launched a Nursing Home Pilot Scheme under the NHS England Vanguard programme. Sutton Homes of Care Vanguard covers a registered GP population of 180,000 and 27 GP practices; over 6% of the 75+ population live in care homes.

Sutton CCG currently commissions 74 care homes, which encompasses nursing homes, residential care of the elderly homes, and mental health and learning disability homes. The Vanguard application was made in partnership with London Borough of Sutton, Age UK Sutton, the Alzheimer’s Society, Epsom & St. Helier Hospitals NHS Trust, South West London & St. George’s Mental Health Trust and Sutton and Merton Community Services, the Community division of the Royal Marsden.

The programme aimed to:

• Improve the quality of care
• Support staff and improve confidence
• Improve recruitment and engagement

A joint intelligence group meets monthly consisting of commissioners, the council, the CCG, CQC and the Ambulance Trust. The group focuses on reviewing data such as monthly admissions and trends to identify local issues. The focus has included admissions due to catheters and other continence issues. In response to this, the programme has organised bespoke continence training delivered by the community continence nurses free of charge for nursing staff. This has been provided for two nurses per home with the expectation that they disseminate the learning to the other staff. A range of strategies have been identified to address workforce challenges, education and development:

• An e-learning tool with three modules including dementia and continence. The tools are available on the local authority platform to ensure all relevant staff are able to access them.
• Link nurses providing short bespoke training for staff during lunchtimes.
• Development of a podcast by the Challenging Behaviours Team describing topics like end-of-life care.
• Resource cards in the style of credit cards have been designed to educate staff on subjects like urine analysis, falls, sepsis and signposting on alternative options to calling an ambulance.
• Bi-monthly forums for link nurses, managers and staff to meet to network and access educational sessions.

Patient Satisfaction and Its Link to Quality Care

As we have seen from the statistics highlighted at the start of this article, patient experience is deteriorating across the NHS and social care settings, and research suggests that patient experience lacks the emphasis that was placed on it as recently as a decade ago. The research goes on to state that services designed without the input of people and communities and delivered with limited focus on people’s experiences are less likely to produce good outcomes and are more likely to waste stretched resources.

In other words, patient satisfaction reflects the extent to which healthcare services are patient-centred, a fundamental principle of healthcare in the UK. The NHS states that “Being person-centred is about focusing care on the needs of the individual. Ensuring that people’s preferences, needs and values guide clinical decisions, and providing care that is respectful of and responsive to them.”

A person-centred approach is a core skills education and training framework that articulates what it means to be person-centred, and how to develop and support the workforce to work in this way. It is a key standard within the Care Certificate aimed at developing a workforce with behaviours, skills and competencies that support and drive person-centred approaches to wellbeing, prevention, care and support. Healthcare workers who have completed the Care Certificate are more likely to involve patients in discussions about their care, listen to their preferences and concerns, and empower them to actively participate in their treatment and recovery process.

The Care Certificate also includes training on effective communication, which is crucial for building rapport, understanding patient needs, and addressing their concerns, again extremely important for providing quality care and accomplishing patient satisfaction.

The Care Certificate can play a crucial role in improving the patient experience and satisfaction in healthcare by equipping healthcare workers with the skills, knowledge and behaviours needed to provide compassionate, person-centred care that meets the needs and preferences of patients.

The Oxford Academic International Journal for Quality in Healthcare has suggested that there is a positive and powerful relationship between staff engagement and the safety and quality of the care they provide; employees engaged with their work will provide superior care to their patients.

A selection of patient comments captured by the North Tees and Hartlepool NHS Foundation Trust in their Patient Experience and Involvement Report 2022–2023 highlighted a correlation between well-trained staff and higher patient satisfaction. Comments included:

“I was very impressed with the care I received whilst in hospital, I was especially impressed with the lengths taken by staff to respect my privacy and dignity in a difficult hospital situation. All the staff were very knowledgeable and professional.”

“I am very grateful that the care and treatment was administered as quickly as possible after diagnosis – no delays. The staff were all professional, caring and efficient.”

“I was very impressed with this unit, team work was of the highest standard along with high standards by any individual member of staff. I felt comfortable, relaxed and cared for.”

Benefits of Implementing the Care Certificate

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. They monitor, inspect and regulate services and publish what they find. Where they find poor care, they will use their powers to take action. Failure to comply with any CQC regulations about healthcare quality and safety could result in a financial penalty or prosecution and an unlimited fine, not only for the care provider but also, in some circumstances, for the registered manager.

As part of their inspection process, the CQC expects healthcare providers to comply with its regulations, including those that relate to staff and training, i.e. regulations 18 and 19. The CQC continues to expect providers to induct, support and train their staff appropriately. They state that “Those who employ health care support workers and adult social care workers should be able to demonstrate that staff have, or are working towards, the skills set out in the Care Certificate. This is the benchmark for staff induction.”

The CQC have a wide set of powers that allow them to protect the public and hold registered providers and managers to account for failure to comply with the regulations. The Care Certificate is a significant factor in meeting the staff training requirements outlined in their regulations. This is one reason why it is beneficial for healthcare providers to ensure that they include the Care Certificate as part of their induction programme for new healthcare staff.

Healthcare providers can also use the Care Certificate as a benchmark qualification when recruiting experienced staff. The Care Certificate means that every healthcare worker, irrespective of where they are working, should have received a common standard of initial training. This should ensure that any new employees have the required knowledge, skills and competencies for the role, thereby mitigating the risk of poor recruitment, which can be a costly issue when having to replace staff who have not been able to successfully complete their probation due to capability concerns.

While the Care Certificate is not a mandatory requirement for working in the healthcare or social care sectors, many healthcare providers see it as a way to ensure that staff have the knowledge, skills and behaviours needed to provide safe, effective and consistent care. Having a Care Certificate or being willing to study for the Care Certificate is often seen as a positive attribute by recruiting employers. Once obtained, the Care Certificate is a transportable qualification recognised throughout the healthcare sector, thereby enhancing a person’s employability.

The Care Certificate doesn’t have an expiry date as such, meaning that once an individual has completed and been awarded the certificate, they do not need to retake it when changing employer. However, it is important that they maintain and update their knowledge and skills through ongoing training and development to ensure that they continue to provide safe and effective care.

Many employers may require staff to undergo regular refresher courses or continuing professional development (CPD) to maintain their competence and skills. For anyone considering developing their career in the healthcare sector, the Care Certificate provides a foundation that can lead to higher qualifications such as the Level 2 Diploma in Care, Level 3 Diploma in Health and Social Care, Level 5 Diploma in Leadership for Health and Social Care, Foundation degree in Health and Social Care and Bachelor’s degree in Health and Social Care.

Many employers may cover the cost of the Care Certificate training and assessment as part of their commitment to training and development. Other employers may require staff to pay for the training themselves or may offer to cover some or all of the costs. In some cases, individuals can get government funding for the Care Certificate.

Below are testimonials from healthcare providers who endorse the implementation of the Care Certificate:

Justin Hackney, Assistant Director – Specialist Adult Services and Safeguarding at Lincolnshire County Council gave the following testimonial about the Care Certificate:

“As an Assistant Director within the Lincolnshire Health and Care System, and with responsibilities for safeguarding Adults and commissioning care and support, I am delighted to see that Health Education England (HEE) have made the 5th of December a Celebration of the Care Certificate Day.

“The quality of the services we commission and provide to our local population are vitally important. We must therefore ensure the people that are employed across our services are properly inducted and have the values and skills necessary to underpin the quality of care needed.

“The Care Act 2014 encourages commissioners of care and support to promote the Care Certificate as a vehicle to underpin good quality services. The CQC are also explicit in their expectation that those who employ health care support workers and adult social care workers should be able to demonstrate that staff have, or are working towards, the skills set out in the Care Certificate, as the benchmark for staff induction.

“It is recognised that supporting care workers with the completion of the Care Certificate demonstrates that they are valued and will help to ensure standards of care are maintained and improved. For these reasons we would like you to join us in celebrating the success of those people who have already completed the Care Certificate and to help us with our mission to increase the uptake of the Care Certificate across our local health and care system.”

Mark Turton, Non-Executive Director of LinCA and Head of Workforce Development Care in Lincs Workforce Development stated:

“As a care provider you no doubt want to promote quality care and will need to ensure all your team can promote and deliver the basic requirements of care. By undertaking and completing the Care Certificate, you will be given peace of mind to allow this to happen.

“Many providers who reach CQC Outstanding, have supported their own in-house induction process with the addition of the Care Certificate. There is evidence that supports high retention and vacancy rates being influenced by a lack of quality introduction into the adult social care sector. Undertaking and ensuring that the Care Certificate is part of your formal offer during the induction process will support and reduce the pressures that fall on the workforce to cope with demands of care.

“So, join us in celebrating the successes, and if you are new to the idea of undertaking the Care Certificate, I would advise you to be brave and add it to your workforce offer to your existing, new and future staff.”

Borough Care holds a celebration event each quarter to celebrate colleagues completing the certificate. Commenting, Nicola Chatterton, Learning and Development Manager, said:

“I am so proud to celebrate the achievements of my colleagues. Colleagues work so hard to complete their Care Certificate and it is such an important foundation for work within the adult social care sector. I am so pleased that Borough Care recognises this achievement and celebrates such milestones. The event also supports and encourages colleagues with future development opportunities which again makes me feel so proud to work for an organisation that champions learning and development.”

Challenges and Future Considerations

The main challenges to implementing the Care Certificate cited in various studies were lack of interest from care workers, lack of resources – more specifically, funding, time needed and staff for backfill – and the need for relatively high levels of literacy to complete the certificate.

The government has recognised the issue for many healthcare providers of funding for training and development, and announced on 8 April 2024 that they are launching the new Adult Social Care Training and Development Fund. Eligible adult social care (ASC) employers can claim varying levels of reimbursement from this fund, for spend on upskilling the adult social care workforce in England.

Skills for Care is operating a Workforce Development Fund. It supports the provision of high-quality care and the continuing professional development (CPD) of staff across the adult social care sector by providing a contribution towards the costs of vocational learning. The fund allows employers to claim back money towards the costs of paid staff completing a broad range of adult social care qualifications, learning programmes and digital learning modules.

By including the Care Certificate in the induction programme for all new starters, and making completion an integral part of successfully fulfilling the probation period, healthcare employers can ensure that staff take up the qualification. This strategy can help to overcome staff lack of interest in the Care Certificate.

Time needed for study and backfilling for staff who are training can easily be overcome by providing staff with online training for the knowledge elements of the certificate. Staff can arrange to study at convenient times when the healthcare setting is less busy, or when there are sufficient staff available to cover. The practical elements require no backfilling as they and most of the assessments take place in the workplace during normal working hours.

As there is a rising demand for health services due to an ageing population with increasingly complex healthcare needs, there is an ever-growing need for suitably trained and competent healthcare staff to meet the demands of the sector. Continued technological and scientific innovation is likely to change the nature of care and how it is delivered, making the need for standardised, regulated training more essential across the sector.

Skills for Care has calculated that if the adult social care workforce grows proportionally to the projected number of people aged 65 and over in the population, the number of adult social care jobs will need to increase by 29% (i.e. around 480,000 new jobs) to around 2.16 million jobs by 2035. To provide safe, quality care to this increasing service user population, and to other healthcare service users in the UK, the sector must invest in training and developing staff, particularly those beginning their careers in the sector, with the Care Certificate.

Conclusion:

In this article we have recognised the issues that the healthcare sector faces in terms of patient safety and satisfaction that impact directly on the quality of the care that they receive. However, evidence presented has shown that improvements to healthcare can be made through a continuous and agile approach to development and training.

The Department of Health and Social Care’s adult social care workforce reform package which aims to support recruiting, retaining and empowering the care workforce, will be essential in supporting learning and development opportunities for people who work in adult social care, which in turn will contribute to improvements in care quality. The continued uptake of the Care Certificate will be an important cornerstone of this.