When Poor Practice Becomes “Just How We Do Things Here”

"We've always done it like that."

I think most of us who have worked in care for any length of time have heard that phrase. I've probably said it myself at some point, although hopefully not too often!

This phrase doesn't necessarily mean that what someone is doing is wrong. Sometimes, there is a perfectly good reason for doing something a particular way. However, when nobody can explain that reason, we need to take notice.

Understanding Poor Practice in Care Services

I've been reflecting on how poor practice develops in care services. We often discuss it after an adverse inspection outcome. But how did that practice become acceptable in the first place? How did it lead to a "requires improvement" or "inadequate" rating?

A new employee can complete all the induction and training we ask of them. Yet, they will learn a great deal from their colleagues. That's certainly how I learned in my first care role.

They observe experienced care workers who seem to know what they're doing. They see what happens when things get busy. They notice what tasks are prioritised and, more importantly, what tasks are overlooked. If everyone takes the same shortcut, why wouldn't they assume that's the right way to do it? If the manager knows it happens and doesn't challenge it, that reinforces the behaviour even more.

We can have a beautifully written policy stating one thing while everyday practice teaches people something completely different. We probably don't need to think too hard about which one will have the biggest influence.

The Reality of Shortcuts

Most shortcuts don't start with someone deciding to provide poor care. Often, people are just trying to cope. You're short-staffed. Someone has phoned in sick. A resident isn't well, and another resident has fallen. The phone is ringing, and the manager is helping on the floor. The task you planned for two o'clock isn't going to happen.

So, you move it to tomorrow. That's normal. Anyone who has managed a care service knows there are days like that. But what happens when tomorrow is just as busy? The supervision gets moved again. The competency assessment can wait until next week, and we'll catch up with the records later.

Nothing disastrous happens. Everyone gets through the day, so it happens again. Over time, a temporary workaround can become the normal way of working without anyone deciding that it should. Then, a new staff member joins and learns that version of the job.

Caring Staff and Poor Care

I've been involved in investigations where people have said, "But they're really caring." Sometimes they absolutely are. This isn't just something we see internally when things go wrong. I reviewed some recent CQC findings while writing this. In one service rated "Inadequate" this year, CQC reported that people and relatives generally felt safe. Inspectors observed staff being kind and caring. Yet, they also found significant problems with training and management oversight. Only 12 of 47 staff had received falls prevention training, despite many residents being at high risk of falls. Patterns and trends in residents' risks weren't being identified or acted upon.

Caring staff and poor care aren't necessarily opposites. People can genuinely care about the residents they support while working in a service where the systems, skills, oversight, or leadership around them aren't adequate.

That doesn't mean we ignore individual accountability. If someone knew what they were supposed to do, had been trained, was competent, and simply chose not to do it, that needs addressing. However, if I discover that five people are doing exactly the same thing, I will ask more than who did it. At that point, I don't think I have just a problem with five individual staff members; I potentially have a problem with what the service has come to accept.

What Are We Overlooking?

Leaders set standards in various ways, not just through policies, meetings, and supervision. What we walk past really does matter. You don't have to formally tell someone that something is acceptable. Sometimes, seeing it repeatedly and saying nothing does the same job.

This also applies when someone tells us they're struggling. If staff repeatedly receive the message that everyone is busy and they just need to get on with it, they may eventually stop communicating their struggles. I would much rather have someone say, "I don't know," or "I'm not confident doing this," than copy what everyone else seems to be doing.

Connecting the Dots

Another recent CQC report provides a sobering example. One resident experienced 30 falls in 12 months. The falls occurred, and information about them existed. However, CQC found that provider-level leaders and the registered manager failed to identify and effectively monitor the pattern to ensure improvements were made.

Thirty falls.

It would be easy to look at each fall individually. Was the person injured? Was the falls risk assessment reviewed? Was the family informed? Was the incident form completed? All perfectly reasonable questions. However, someone also needs to ask why this person has fallen 30 times and whether there is anything else we should be doing.

The same principle applies more broadly. A manager covering a couple of shifts might not worry me. An increase in agency use might have a reasonable explanation. A few overdue competencies need addressing, but they don't necessarily mean a service is unsafe. Neither does an increase in incidents on its own.

However, if the manager is regularly covering shifts, agency use is creeping up, staff are leaving, competencies are overdue, and incidents are increasing simultaneously, I want someone to connect those dots.

That's what good governance should do.

It should not provide us with six separate reports telling us six separate things are happening. Instead, it should help us understand whether those issues might be connected. By the time poor care is obvious, whatever contributed to it has likely been building for quite a while.

The Bigger Picture

When something goes wrong, we need to establish who was responsible. Individual accountability matters. However, we also need to ask what allowed it to happen and whether we could have seen it coming. If we only deal with the person at the end of the chain, we might solve the immediate problem while leaving everything around them unchanged. We shouldn't be surprised if we find ourselves dealing with a similar issue again.

I'm discussing this in the next episode of Beyond the Audit, which I'm recording for September. The episode will explore how good people can sometimes end up delivering poor care. The answer isn't always as simple as finding the person who made a mistake.

Sometimes, it is about the individual. Sometimes it's about competence, leadership, or pressure. Sometimes several fairly small issues have been allowed to become normal over time.

So, rather than another checklist this week, I encourage you to observe what happens when things get busy. What are people doing because "that's how we do it here"?

And would you be comfortable explaining why?