John Burton explains why the regulation of social care must change its culture and why we need something more human and more local.
Author: John Burton
The Centre for Welfare Reform has published its Manifesto for Social Care Regulation. Here one of its Fellows, John Burton, an expert in Social Care, explains why the current system is doomed to fail and why we need a different approach.
Most care is given by family, friends, and neighbours, people who have a relationship with the person who needs their care. When more is needed, there may be local volunteers who step in to help. And when even more is needed formal Social Care organisations get involved and paid carers may be used. It is at this point that Social Care needs regulation and inspection because these organisations have the potential to exploit, neglect and harm as well as to support and care for people. Social Care regulation in the UK was brought about by a series of scandals of neglect and abuse in care homes in the 1980s and 1990s.
After nearly 20 years of failing national regulation and inspection of Social Care under separate but similar regimes in England, Scotland, Wales and Northern Ireland, it is urgent to reform the system. Regulation and inspection have repeatedly failed to protect the people for whom the system was designed. It is a highly centralised, bureaucratic and procedural system that favours large corporate providers of Social Care and fails to detect the nuances, both positive and negative, of the human relationships that are the essence of care. Social Care itself has now been structured to comply with regulation as its central purpose. There appears to be no understanding that this top-down, standardised system itself is incompatible with human-scale, relationship-based, person-centred care.
Social Care inspection was set up, first at a local government level in the 1990s, and then at a national level in the early 2000s. The first two English regulators were The National Care Standards Commission (NCSC) soon followed by The Commission for Social Care Inspection (CSCI), and then Social Care inspection was merged with Health inspection under The Care Quality Commission (CQC). The organisation got bigger, more bureaucratic and further detached from its core purpose and from the people it is meant to protect from abuse, neglect and exploitation. For most of this time, the regulator has insisted that they will not deal with complaints about care but simply want to be informed of them.
In a recent example of the CQC’s many failures of purpose and design, an inspection team reported that they were extremely worried by what they saw in an establishment for people with learning disabilities run by a large provider. The provider objected to the report and CQC senior managers altered the report and gave a “Good” rating, in spite of continuing complaints and whistleblowing which were ignored. Not for the first time, it was left to a “Panorama” TV crew to provide the evidence of shocking abuse and torture. The CQC have now commissioned two “independent” reviews to discover what went wrong.
It is obvious what is wrong. One only has to observe the practice of inspection, the convoluted process of reporting and “rating”, the misuse of measurement and what is being measured, to know that what goes wrong is the result of persisting with a flawed design. When the CQC is compelled to respond to criticism (usually only after MPs take up the most dramatic media stories of failure) the response is to redouble their efforts in the mistaken belief that “doing the wrong thing righter” will fix the problem.
So, what would be the right thing?
What system of inspection would be effective for people who need Social Care and for the public in general?
Any reform and reorganisation of the CQC should make it more effective and responsive, and should enable inspectors to understand how Social Care works. Inspectors need to be closer and more in touch with the services they are inspecting, so that they can pick up problems before they become serious, and so they can respond quickly to complaints and information from users, staff and public. The CQC should serve the public and therefore should engage directly with the public, without bureaucratic barriers. The costs of inspection should be realistic and understandable to the public who will be the judges of whether the regulator is giving value for money. The CQC should step down from regarding itself as the leading authority in Social Care practice and management. This can be achieved by dispersing and devolving the CQC and setting up local inspection teams to which users, staff and the rest of the public can have direct access and input.
The legislation for the regulation of Social Care does not force the CQC to function as it does. There is nothing to prevent the CQC operating on a local basis while retaining an overall but “hands off” and much reduced central management and administration. The CQC regulates all health and Social Care provision, and the services vary hugely in size and purpose, for example a large hospital and a small care home. However, shortly after the CQC’s first chief executive and senior management team left - following a series of spectacular failures - an important change was made from having generic inspectors, to having specialist inspectors for each sector (e.g. hospitals, GPs, dentists, care homes). It is perfectly practical to reorganise the CQC within existing legislation. So, to begin with, it would be possible to set up local inspection units to regulate local Social Care - care homes and domiciliary care (the focus of this manifesto).
The purpose of inspection is to check on behalf of the public that Social Care is good enough, and if it isn’t the regulator will require the provider to improve until it is good enough, or to cease providing care. A care service will be required to produce only those records that are needed for the best care of the users. Therefore to check that care is good enough, inspectors will sometimes need to check records and documentation, but nothing additional should be required solely for the purpose of inspection. Inspection itself should never create additional work for a care provider.
The method is to inspect care in action, to observe and listen to the experience of users, relatives, staff, managers, and anyone who has a professional or personal connection with the service. The purpose of checking records and documents is to follow up observations of care in action. The inspector must become familiar with the home and all aspects of life and care in the home. The inspector must be accessible to all those involved in the service - so - as long as they are the inspector for the service, their name and contact details will be readily available.
The inspector must make an unannounced full inspection of the home at least once a year and must produce a comprehensive and plainly written report which gives all those concerned with the home (residents, relatives, staff and so on) a detailed evaluation of the care provided. Depending on the type of service, the inspection visit should cover most of a whole day in the life and work of the home; so, arriving before breakfast would be usual. The report will be a public document and will be sent to local papers and other media as well as being readily available on line. The focus of the inspection will be the care in action, and this will be backed up by selective examination of records.
The existing standards are valid, and enforcement powers can be used when they are needed.
While being concerned with detail, the inspector must link details and understand underlying processes thereby evaluating the service as a whole.
If the inspector has concerns about the service and if concerns are brought to their attention, they must check them without delay. This will usually mean visiting the home unannounced, and this is likely to be “out of hours”.
The inspection unit or team should be known to the public and seen as a local resource. There should be an annual report presented to a public meeting. Someone looking for a home should be able to talk with an inspector and seek their advice. (Care homes are very different. For example, after talking with the enquirer, an inspector may recommend that they should visit three small “family” type of homes; whereas, after establishing that someone would prefer a home that is more like a hotel with care, the inspector may recommend visits to some larger homes with more elaborate facilities.) If the inspector knows the homes well, and knows the strengths and weaknesses of them, they are in a position to advise and discuss at a time when people need this sort of support. This gives the local inspection unit a positive role in the community (to which they are answerable), and it gives them the right sort of authority with the homes they inspect. (Of course, it would not be appropriate for an inspector - as a public servant - to favour or promote particular services. They must act as an impartial advisor solely for the benefit of the enquirer and the public at large.)
Inspectors could be employed on a freelance or employed basis, full or part-time. It would be good to have a mixture of experience and background. Ex-inspectors and ex-Social Care workers/nurses and managers have a lot to offer, but so do people with other backgrounds. While some freelance inspectors may work from home, it is essential to work as a team, with a shared ethos and clear remit, to meet regularly as a team for professional development and learning, and for all inspectors to have professional supervision. Ineffective, incompetent, or corrupt inspectors must not be retained.
A full-time inspector could have a “caseload” of up to 25 care homes, but of course this has to be adjusted according to the size and complexity of the homes. If reports are to be written immediately after each inspection, no more than two inspections can be completed in a week. This form of inspection requires flexibility and responsiveness, and some “out of hours” work.
The direct costs of inspection should be met by the providers and will ultimately be met from users’ fees, however such fees are paid. A service that requires additional inspection should pay additional costs. However, the costs attributable to the national CQC elements of the local service, such as statistical returns and analysis for Department of Health and Social Care purposes should be met by central government, as should all the costs of the central organisation. (Currently Healthwatch is organised and financed in this way.) Local inspection units and the costs for each home will be considerably less than those set out in the current fee structure. It would be fair to base fees (as now) on the number of residents in the home. All homes would have to pay their inspection fees at the beginning of the year to remain registered, and homes that required substantial additional visits and work would incur proportionate additional costs.
Local inspection units do not all have to be run in the same way. Normally units would have a local chief inspector to lead and manage the team, plus administrative staff in proportion to the number of homes (and therefore the number of inspectors) covered by the unit. But there should be room for units to innovate. For example, an inspection unit can be run by a chief inspector engaging only freelance (self-employed) inspectors who are paid per home or per completed inspection (including report). Another unit might be all full-time employees. Different units should be able to use different formats for their reports, and to experiment and innovate in inspection methods.
The publisher is the Centre for Welfare Reform.
The Reform of Social Care Regulation © John Burton 2019.
All Rights Reserved. No part of this paper may be reproduced in any form without permission from the publisher except for the quotation of brief passages in reviews.
