Fortune Favours The Brave
A regular podcast for business leaders exploring how businesses can harness risks and use them to their advantage. In each episode Howden Insurance Brokers will discuss a topical challenge or issue and what business leaders can do to overcome it.
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Fortune Favours The Brave
How care homes build claims defensibility and trust
Insurance claims can be stressful, but they don’t have to be chaotic. In this episode we dig into claims defensibility to show how strong culture, clear documentation, and open communication can turn difficult moments into credible, manageable cases.
Hosted by Richard Lawson, Senior Account Executive at Howden Health & Care, our latest care sector podcast provides practical steps to help care providers to reduce risk and protect their residents.
With the expertise of Rishi Jawaheer, Director of the Jawa Group and Sabrina Meetaroo, Divisional Director, Head of Legal, Risk & Claims Advocacy, Howden Health & Care. We discuss what you need to do from the first hour after an incident, how to manage CQC scrutiny and the importance of staff training. The conversation then moves to outline the insurance considerations you need to make.
Finally, we provide a summary on the role of digital tools can have to improve care management and discuss the importance of collaboration across providers, insurers and regulators.
Welcome to Howden's Podcast. Fortune Favours the Brave. We all take risks in our everyday life, and business is no different. In this podcast, we're speaking to the experts about a topical challenge or issue and what business leaders can do to overcome it.
SPEAKER_00:Hello and welcome to this episode of Fortune Favours the Brave. My name is Richard Lawson and I'm one of the senior XEX here at Howden Health and Care. In this episode, we're going to be discussing claims defensibility. I'm joined today by my guests, Sabrina Metterou. Hello, Sabrina.
SPEAKER_03:Hello, Richard.
SPEAKER_00:And Rishi Jawa here. Hi Rishi, how are you doing? I'm well, thanks, Rich. Thank you for having me. Rishi, as is tradition here on Fortune favors the brave, we like to ask our guests when the last time they did something brave, and that can be in a work or personal life, and how it paid off.
SPEAKER_01:Well, I think when it comes to bravery, I think the most brave thing I do on a regular basis is not listen to my wife. One example of this is when we were expecting our third child, and Clara was already telling me in the morning that the baby is coming, and I was not as worried about it. We got in the car and we were on the way to the hospital, and we went down a country lane called Shire Lane, and believe it or not, there was a massive cue, and we got stuck. The next thing I know, Clara had started removing her clothes, and I said, What's going on? I look over and then I see a little head pop out. I look at my phone, there's no reception on Shire Lane. So I think to myself, okay, it's all up to you now, Rishi. So the bravest thing I've ever done is I told Clara, you better push. And push she did, and then before I knew it, I had a little baby in my hands. We were sitting on this country lane in the car in this massive queue of traffic. I didn't have anything in preparation, but I did an amazing job because Tiago is has come out absolutely wonderfully. And uh now, if anyone listening to this podcast needs any emergency uh midwifery services, I'm available on request uh and an expert by experience.
SPEAKER_00:Let's see, you heard it here first, and uh I'll be honest with you, it's probably one of the bravest things we've had on the podcast series. So thank you ever so much for sharing. I mean, that's brilliant. I think what we'll do is we'll start by getting to know you a little bit more, Rishi. Yes. I mean, could you just give us a flavour of you know your background and your journey in the care sector?
SPEAKER_01:So my story starts with my parents. My dad's originally from Mauritius, my mum's from Sri Lanka. They both came to the UK in 1970 to work for the NHS, and they were involved in a program opening up smaller homes in the community when it was recognised by NHS and authorities that hospitals and institutions weren't the best places for long-term care. So whilst they were doing this for other organizations, they thought, why don't we do this for ourselves? They bought a small house, and my mum, my dad, my sister, and myself, we lived in one room at the top of the house and started one of the first care homes in our borough. And it was multi-generational living at its best, uh, and we lived as a family with the people we supported. We ate together, uh, we played together, and uh it was an amazing upbringing. And I know Sabrina has a very similar story, so this is where we connected. And I think going on from that, I then was telling everyone I was gonna have nothing to do with the family business, and I was gonna go off and do other things. And uh, about 19 years ago, I went to help my parents at the head office of our care group, which had grown over the last few decades, and um I haven't looked back since. So I've been with my parents leading the care group, and I'm so grateful and appreciative to all the hard work that they put in. And I could only realize and fully appreciate that once I'd actually entered the space of working at the care group. And more recently, after looking at digital transformation and trying a number of systems on the market, we couldn't get on with any of them because they'd been made by geeks trying to enter the care sector. And from my our experience of running homes, um, operating homes, understanding the skill level, we decided to develop a digital care management system, CareVision AI, which is an ecosystem for care operators, covering almost every element of what they need. And it ties in really well with the culture of collecting evidence and defensibility. Um, and this is really where my focus has been from a technology side, um, but also understanding things as a care provider.
SPEAKER_03:Such a nice story, Rishi. Always sort of takes me back listening to you talk about your story because it's so similar to mine in terms of my upbringing and my parents coming, also both from Mauritius, um, coming to the UK and um working for the NHS for a good number of years, and um purchasing a failing care home, which um, you know, within sort of three years or so they'd managed to completely turn around. So yeah, it it always resonates me um with me hearing your story.
SPEAKER_01:And that's why Sabrina and our team at the Care Group we connect so well because the kind of relationship and the dynamic that we enjoy, it goes beyond insurance, it goes beyond defensibility because she understands things from our perspective, and and this to us is invaluable.
SPEAKER_00:Amazing. So, I mean, today we are here to discuss claims defensibility. How best to be prepared for a claim, what policies and procedures to have in place and the impact of an unexpected claim can have on a care business. I think, Sabrina, it's probably best to start. You know, we we often hear the term claims defensibility, but for those who aren't familiar, what does it really mean in practice?
SPEAKER_03:Okay, well, thanks, Richard. So when we talk about claims defensibility, we're really talking about the organisation's ability to evidence good decision making and safe practice in a way that stands up to legal, regulatory, and insurance scrutiny. So, from an insurance perspective, defensibility isn't just about sort of winning a case, it's about demonstrating that care was delivered in line with established standards, that risks were identified and managed proportionately, and that the provider responded with transparency the moment something occurred. So, in practice, strong defensibility comes from everyday behaviours. So accurate, contemporaneous notes, adherence to protocol, culture where staff report issues early rather than retrospectively. So insurance isn't there to shield poor practice, it's there to support organisations who can show that they acted responsibly, reasonably, and with their residents' welfare at the core of that. Good defensibility isn't created on the day of an incident, it's created in the months and years beforehand through training, documentation, communication, and really importantly, leadership. It's ultimately a people-led concept. How your team responds in the first five minutes often determines the next five months, really.
SPEAKER_00:I mean, it sounds like it's a really important conversation piece for the care sector right now.
SPEAKER_03:I think it is. It's really important right now because the spotlight on the sector is very much brighter than it's ever been, in my view. Care costs are rising, the regulatory environment is more complex, and families understandably want more transparency. So, again, from an insurance angle, the claims environment has hardened. We're also seeing more scrutiny, not necessarily in a hostile way, but in a sort of a help us understand your decision making type of way. Insurers are analysing trends more closely, things like frequency of incidents, quality of documentation, response times, and leadership behaviours. Insurers want to see real patterns, so good documentation, timely reporting, consistent processes, and when providers can demonstrate that, they often see better outcomes and faster resolution, lower exposure, and ultimately more constructive engagement from their insurers. And claims generally resolve quicker with a lot less stress. So I think providers are sort of feeling tired to be on the on the back foot, really. Um, and this is why conversations like this are really important. It helps shift providers from feeling defensive to feeling more prepared, and this safeguards your residents, your staff, and your organization's long-term resilience, and that is really empowering as well across organisations.
SPEAKER_00:Thank you, Sabrina. I mean, Rishi, tell us from a provider's point of view. When something does go wrong in a care home, that might be a serious incident, a complaint, for example. What is that moment like, not just for the provider, but how does it affect your team? How does it affect your residents? How does it affect the families?
SPEAKER_01:I think uh Sabrina did a great job there of setting out the challenges that we face, the context of the care sector at the moment, and and there are enormous uh challenges that are there, and we're also dealing with the people's quality of life and so many elements that are important to families, and therefore the scrutiny is understandable. I think the foundation of how we work across the care sector has always been evidence-based, and defensibility is just a natural extension of that. If we are going to satisfy CQC, the Care Quality Commission, we need to ensure that we um are compliant and we have evidence to substantiate that. And I I I think in how we operate from a care planning perspective, from a health and safety perspective, how we support the people who are providing service and working on the front line, these all tie in to that defensibility and and having good evidence will only highlight the strengths of your organization.
SPEAKER_00:And I mean, Sabrina, from your experience supporting providers through moments that are challenging, what's the most important first step to take after an incident?
SPEAKER_03:I always encourage providers to think about the first hour principles. So, because that first hour does tend to set the tone for everything that follows next. So operationally, legally, from a regulation perspective, and in terms of the support that you can be afforded from lawyers and your insurance company. So, from my view, step one is always rest and safety, of course. Insurers and regulators will always look closely at how promptly and proportionately a provider acted. Step two would be getting those facts down. So ideally, while they're still fresh in everyone's minds, so try to avoid speculation. Just set down what you what has been seen, heard, or done. If you can, you should include time, location, the staff members involved, and the immediate actions taken. So from a claims perspective, contemporaneous notes really are gold. Step three is all about early escalation. So if something feels significant, loop in your internal team and your insurance, um, and if you have an in-house legal, etc., try and loop them in as well. There's a common misconception that you only call your insurance broker when something becomes contentious or when litigation starts. When in reality, the earlier you notify, the more support that you can more support you can be offered. So late notification is actually one of the most common ways of weakening your defensibility. Step four is keep that communication open, especially with family members. A simple, honest, and early conversation often diffuses a lot of the tension before it can become sort of adversarial. Families generally, in my experience, always respond well when there's transparency and that open, early communication. When these steps are followed, generally what what I see is that claims tend to be clearer, more manageable, and often they tend to be have more favourable results.
SPEAKER_00:Rishi, how do you approach building defensibility into your everyday operations, whether that's things like training, record keeping, uh, I mean communication, just for an example?
SPEAKER_01:I think it's human nature to always look on the positive and to think of the positive outcomes. And I think um uh care providers and and directors and CEOs often have the blinkers on when it comes to the negative side. And I think more often than not, you're not prepared for a situation that can arise. And when you try to take action at that stage, it's almost too late. And I think in order to optimize your chances of being in the best position from a defensibility perspective, I think it it's essential that you uh plan ahead for the rainy days, uh for those challenging days, and and and you sort of operate as part of your culture within the organization that you're in preparation for when it goes wrong as opposed to when it goes right. Um so I think more often than not, there's a number of steps and and and sort of ways in which providers can approach things to be more prepared rather than waiting for that situation to come and then play and catch up. So for example, when it comes to CQC, Care Quality Commission and and and their approach, often there's many avenues in which information will come to them, whether it's whistleblowing, through family complaints, through the local authority. So as a provider, uh you could be approached from any angle when it comes to these negative elements. So I I I think um this is where, as Sabrina set out, that idea of communication, uh transparency, being well organized, these will set you in a strong position for when these situations do arise.
SPEAKER_00:Brilliant. And I mean back to you, Sabrina. What are some of the common mistakes you've seen organizations make when responding, you know, under these pressure situations? And and are there any patterns that you see when providers are unprepared?
SPEAKER_03:So I think the most common thing I see, and it's such a human response, is to try tidying up that narrative a little bit too quickly. I think it's a very natural thing, but people want to explain, to make sense of things. Um but in those early hours that can cause inconsistencies. And once those inconsistencies appear in documents or statements, it becomes quite difficult to try and unwind from a claims perspective. So another big one I would say is any gaps between policy and practice. Policies that look great on paper, but if staff aren't sort of living those policies and procedures in their day-to-day work, that tends to come to light with lawyers and insurers and regulators pretty quickly. Insurers actually will look at this closely as it tends to signal risk. It's not that the care wasn't delivered, it's that it wasn't recorded. Um in a claims environment, if something isn't written down, then it's really difficult to ever evidence that it happened. Um, and especially you're in a then in a situation where you can't rely upon it. And then there's delayed reporting. So providers sometimes wait because they think, you know, let's just see where this goes. Hopefully, nothing will come of it. But late notification is one of the biggest factors, again, that can weaken defensibility. So early communication is always the best option there. And um finally, I think unprepared organisations um often lack a learning audit trial. So they manage their incidents but they don't record what changed afterwards. A strong defensibility position includes not just what happened, but ultimately what you learnt from it. How did you improve thereafter? So none of these mistakes come with bad intent. Um, they usually come from, unfortunately, a bit of fear. Um, and that's why culture, as Rishi mentioned, is so important. I also see the impact of closed cultures across the work that I do, where staff fear repercussions, and you know, that's when issues are reported late, they're inconsistent or they're incomplete. And from a claims perspective, it's difficult to defend. So providers treat risk as something to discuss openly and ultimately not something to hide from.
SPEAKER_00:Rishi, back to you. How how do you create a culture where people feel comfortable and confident to raise issues and learn from them and you know get away from that fear factor that Sabrina's kind of touched on there?
SPEAKER_01:Yeah, I think there's a number of things, and um like like all things in in my approach, um, I've learnt very well from my parents. And for example, it starts even with something as fundamental as the design of your space that you're working within. Our offices, as directors and leaders of our organization, are always near the reception so that families, staff members, they feel that they can come and approach the leaders of the organization. We have an open door policy where we're happy to discuss and having surgeries and uh other sort of forums for people to come and bring their views to us. We carry out staff surveys, uh professional surveys. We're constantly gathering feedback so that we can be responsive to those elements. And that not only ticks off a box with the CQC, the Care Quality Commission, and their inspection process, but also from a learning process, from a culture process and and and and bringing those things in. So I think this standpoint of open communication is essential. The other thing is Selecting the right partners to work with. And that could be from a banking perspective, from an insurance perspective. And across my care group, the kind of dynamic of relationship that we enjoy with Howden is not only talking about those times when things have gone wrong, but lots of the advice and guidance that Sabrina's just touched on. This is what we can enjoy and benefit from, so that we're in a strong position, so that when things don't go as planned, we know what we're doing and we've got a plan to come out of it. So these kinds of these kinds of pointers really help us along our way. And I think as providers, we can be proactive. For example, something like media training would often be overlooked. But we can get that in place now. CEOs, leaders of organizations can experience this media training so that in the event that something goes wrong, you want to put your best foot forward. Why not, as the head of the organization, be out there talking to the press and being able to do this in a measured, transparent way that not only protects the business but puts you in the best light? And these are some of the steps that we would take in in preparation for these challenges that do come up.
SPEAKER_00:Sabrina, I mean, obviously we've discussed a lot about when things go wrong and and what how to prepare. So when you see a claim handled well, what are the common threads for that? So you've you've sort of touched on good communication, clear leadership. What else is there?
SPEAKER_03:Quite honestly, although I've touched on it already, um, it really is, in my view, leadership and culture. Um, when a provider handles a claim well, you can almost feel the clarity in the room. People know their roles, documentation is consistent, and the team communicates openly. You know, senior managers taking ownership and giving their teams that reassurance. Obviously, good evidence, you know, that that's always a positive. It doesn't even need to be perfect, but it just needs to be reliable, logical, and timely. Notes that make sense, you know, clear care plans that actually reflect what's happening day to day. Insurers, um, regulators, lawyers really appreciate that level of credibility. The real standout, in my opinion, is communication. I think, you know, providers that talk openly with families, even when the news is sometimes uncomfortable, they tend to have far smoother journeys from what I can see. And some of those examples that Rishi gave there are brilliant. And the cherry on the top is learning, um, being able to say, here's what we've learnt, here's what we've changed. It really does carry a lot of weight in claims, but also, you know, it shows the culture of that particular care provider and that service. Providers who generally, you know, genuinely um analyse the incident, share those outcomes openly, and implement the change do tend to see fewer repeat issues, and as I say, they they have a smoother claims process. So, from my view, it's not about perfection, it really is about credibility, clarity, and most importantly, compassion.
SPEAKER_00:And Rishi, Sabrina there touched on uh learning from incidents. So, what's the one piece of advice you'd share with other care leaders about managing risk and learning from the incidents that can happen?
SPEAKER_01:Well, during this discussion, we've already touched on the importance of evidence and communication, having logs and a clear plan of what's taken place. So I think technology has a massive role to play in this for providers because with AI, with digital care management, there's so much available to us now to enhance our ability to record at the point of care when things go wrong. We can analyse trends through looking at the data that's being gathered and learn lessons and identify where we can make improvements. Um I I think how we record technology, ensuring that that is an enabler for the for the workforce, ensuring that that from a user perspective is easy to use. And that the key stakeholders have input into that technology, whether that's the family members, the professionals visiting, the residents, the people receiving support, and the people providing the support, all of those stakeholders need to be able to feed into that system. Um, and it does need to be overarching to be able to encompass all the areas of the operation and not just a singular focus on care planning. So that would be uh, you know, a real uh top tip from me in terms of technology and using that um to to to your best advantage. Another thing, as well, just to touch on to set the scene here, and I think it's really important for providers to understand the role that the regulator plays in this. And I know from personal experience, friends of mine that operate within the sector, um, that more often than not things can go wrong and go wrong very quickly. And one issue can snowball into another, which can impact in a greater way than anticipated. So, for example, something goes wrong in a care service and uh this is then highlighted to CQC. Maybe they come in as a follow-up from a complaint, maybe they carry out an inspection, and then they record what has happened and what they found. Now, I've heard instances that before even an inspection report has been released, CQC have actually carried out a press release. They have named and shamed the provider, they have talked about issues that have gone on without giving the provider an opportunity to even come back, uh, to have a comment. And this is where, again, things can go so wrong. You might actually be in the right, you might have sufficient evidence that CQC did not see at that stage. Um, but again, they might jump the gun, and that will only impact on you. And then once that happens, local authorities will stop placing with you, families will stop placing with you, your reputation is damaged, and all of the good work that you've invested over the years can fall down before your eyes. So I think being aware of what can go wrong and how bad it can get is so important in order to be prepared and to be in in that strong position.
SPEAKER_00:Wow, I mean, strong words there from Rishi Sabrina. I mean, from your point of view, do you have one change that you would like to see across the sector in how we all think about risk learning and accountability?
SPEAKER_03:Yeah, I would love to see a shift from fear-based risk management to confidence-based risk management. Care is inherently complex and we we can't get away from the fact that incidents will happen. But if we empower our teams with knowledge, tools, and give them the opportunity for open and honest communication, the sector ultimately becomes safer, more resilient, and just more open to that, to good change. In insurance terms, mature risk cultures see fewer in high severity claims because issues are caught early, they're recorded properly and they're communicated transparently. But the real benefit, again, I know we keep touching on it, but it's culture. When people feel that it's safe to report, um, you know, have that open communication, organisations do become much safer for the residents. So if we could normalize open dialogue about incidents, not as failures, but as opportunities for that systemic learning, I think that we'd create a more resilient, trustworthy sector overall.
SPEAKER_00:And Rishi, we've all heard the saying it won't happen to us. But for those care leaders who think that, what would you say about the importance of planning ahead?
SPEAKER_01:I think um just to go back to the example that I was just discussing of CQC jumping the gun and uh putting out press releases before providers have had the opportunity, I think we can turn that round as providers. And in the same way, if there is a situation, CQC have come in to investigate, why not, as a provider, with the media training that we've we've already experienced, go out there and be the first one to put a statement. Talk about what's happened openly, bring this into the public forum so that you can make that first mark and you can set the tone of the discussion rather than that coming from CQC or a press release that you can't manage and control. And I can talk about a number of examples from providers that I know where they have gone ahead of the curve, they have stayed ahead of the curve, and they have gone out there and put their best foot forward and openly talked about something that's gone wrong, but what they're going to do to put it right, and that will immediately put you in a strong position to maintain that reputation, to maintain your integrity, to protect all of the hard work that you've invested to build up that trust in the community. So I think as well, when we talk about these challenges and the things that go wrong, if providers are brave, if they do put their best foot forward, you can not only protect uh your organization, but you can show who you really are as people, and uh it can only have a positive impact further down the line.
SPEAKER_00:So, where do you see the future of risk management, Rishi, and claims culture heading in care?
SPEAKER_01:Well, it's a very interesting topic for me, Rich, because I've always had a passion for care, I've had a passion for technology, uh, and how we can how we can evidence things in the best way. And I would love to see more collaboration between insurance, between policy setters and the people creating technology, the providers themselves, to collaborate together so that we can almost build a culture within the technology space so that as we're recording, we're preparing for those rainy days. And I feel that we've done really well in care planning, in medication, but maybe the next step of care recording from a digital perspective can be to really focus on defence ability to put providers in the strongest position.
SPEAKER_00:And how about you, Sabrina? Where where do you see the future of the risk management and claims culture headed in care?
SPEAKER_03:I have to say I agree with what Rishi's saying. I I really do think we're moving towards a much more data-enhanced and collaborative claims environment. You know, using those AI and digital tools will really help providers identify patterns before they escalate. Patterns such as staffing pressures linked to incident spikes or deterioration patterns in residents with complex needs. Similar to what Rishi said earlier about AI and digital tools being overarching, uh, you know, technology doesn't replace that human element. So we need to ensure that they work in conjunction and very much in hand in hand. So what insurers and regulators want to see is still that authentic leadership, that consistent documentation and that transparent communication. I think we'll see a move towards shared learning networks, real-time risk dashboards, and as Rishi said again, um, partnership between providers, insurers, you know, the regulators. Um that's really important. Ultimately, the future is one where hopefully claims and incidences, then they're not feared, but they're managed with confidence because the foundations are strong and that providers understand that learning from these incidents and claims is is really what helps us put our best foot forward on the next occasion.
SPEAKER_00:Amazing. Look, I think we've covered claims defensibility and and the risk management around it in great detail, and I'm sure we could continue to talk about it for many hours. Unfortunately, that's all we have time for on this episode. I'd like to thank my guests. First of all, Rishi, thank you ever so much for joining us. Where can people find you? Do you have LinkedIn or is there anywhere else people can get for information on this subject matter?
SPEAKER_01:For anyone that wants to connect with me, I am on LinkedIn. And for more information about the technology that we use in our care group and many others across the country, you can go to carevisioncms.co.uk.
SPEAKER_00:Wonderful. And thank you again, Sabrina, for joining us. Where can people find you?
SPEAKER_03:You can also connect with me on LinkedIn or via our website, howdengroup.com.
SPEAKER_00:Wonderful. Once again, thank you ever so much for listening, and until next time, goodbye.
SPEAKER_02:Thank you for listening to this episode of Fortune Favours the Brave from Howden. To hear more episodes and subscribe to our channel, search Fortune Favours the Brave on your favourite podcast app.