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Do we want an Outstanding rating from CQC?
Questioning subjectivity in inspection reports

Having read Care Quality Commission inspection reports for Outstanding learning disability care providers, Ian Pope asks whether there’s a place for subjectivity in the inspection process.

All social care providers want and aim for an Outstanding rating from the Care Quality Commission (CQC), don’t they? It gives services a chance to celebrate their achievements with individuals, inspires confidence in the service from users, their families and other stakeholders and can act as a positive marketing tool for the service.

As Nominated Individual for a learning disability provider, I like to keep on top of changes and developments with CQC. As part of my role, I work with managers of registered services to ensure they meet the regulations and provide a good quality service. It is no secret that the Registered Managers I support would love an Outstanding rating following a CQC inspection.

With this in mind, I have been reading inspection reports of ‘Outstanding’ learning disability services to see if there is anything we can learn from the success of others.

It is too often the case in our sector that we all have to collectively learn from the poor practice and mistakes of others. The charity I work for and I believe in celebrating success and building on that to positively impact the people we support.

I have been somewhat surprised by the descriptions in inspection reports of what makes the service Outstanding and it has made me question the value of the inspection report and if we really want that label if it means following some of this practice.

It has been a long-standing criticism of the inspection process that the report is a snapshot of one or two days in the service – how can the inspector fully assess if the people we support are receiving a Good or Outstanding service? This is a question that is hard to answer, although I appreciate CQC has published the Key Lines of Enquiry (KLOE) framework to help us understand what inspectors are looking for.

Should we ‘love’ our service users?

However, should we as social care professionals tell service users’ families or inspectors that we ‘love’ the people we support? I found this to be a theme in some reports – ‘family said that the staff love the residents’; ‘relatives said you can tell they love them’.

In my opinion, and that of the organisation I work for, we are social care professionals and not here to ‘love’ the service users, but to provide consistent, good quality support to the people who use our services.

We pride ourselves on being a forward-thinking organisation, which looks to enable service users to empower themselves and not to rely on their support unnecessarily. However, love implies a familial relationship and not one based on professional boundaries and a firm focus on the service user.

Furthermore, familial and loving relationships between service users and those paid to support them raises questions of appropriate relationships and the potential for safeguarding issues. Could a relationship become too familiar and is this positive for the people we support? Could service users have less autonomy and control over their decisions? What is the impact on a service user when a member of staff leaves? In my opinion, a relationship described as ‘loving’ could have a negative impact on the people we support, it could impact on others in the service, the relationships people have with others and could go as far as presenting with significant safeguarding concerns such as grooming, mate crime or other types of abuse.

These comments in themselves are not uncommon from families and friends of service users, but I question why the CQC has felt this appropriate or relevant to its description of an Outstanding service?

Availability of management

Another theme I found troubling was around the availability of the manager and staff in the services. I found several descriptions in Outstanding reports of managers being available 24-hours a day and always available out of hours.

There was one report where the manager told the inspector that they ask their staff team not to engage with the organisation’s on-call system, but to always call them if they needed any guidance or support out of hours.

There were also comments about staff coming into the service on their days off to support an activity.
Although both of these examples are commendable to the individuals involved, where is the CQC’s consideration of the wellbeing of those individuals?

Employers have a responsibility to the health and safety of their staff and management of stress. A situation as described has the potential to lead to burnout for the individuals involved and could have a significant impact on the wellbeing of those staff and managers.

It made me wonder that, if CQC had found these services to be Inadequate or Requires Improvement, would they have recorded this as a positive? I would hedge my bets that they would not. There would be comments about staff and management not having enough downtime or time away from the service to ensure they are adequately rested and refreshed when they are on duty.

I would expect CQC to, therefore, criticise a perceived lack of adequate support in the service and from the provider, to ensure the effective running of the service when the manager is not present.

Another potential issue with this arrangement is what are staff and service users learning by the manager taking all the responsibility and decisions? Could people become too over-reliant on one person? Again, a closer think about this can lead the mind to thoughts about safeguarding and whistleblowing, and how these procedures would be followed without any external view on the service.

Pets at home

I also read one report which talked about the registered manager bringing their dog to the service, so the service users could take it for a walk. Again, a positive outcome for the service users, but could this be achieved in a different and more creative way?

One of the services in my organisation has made links with the local dogs’ home; staff have been trained in basic dog handling by the dogs’ home and the service users are supported to take dogs from the home for a walk as a weekly activity.

I am really proud of the forward-thinking of the staff involved in this activity, in giving time to another local charity and encouraging service users to give their time to dogs who don’t have a family.

This makes me question how forward-thinking the CQC is in assessing the quality of outcomes achieved by service users. In both cases, a similar outcome has been achieved, but in the first one it is solely reliant on staff bringing the activity to the service and facilitating it, rather than using the community; building links with other organisations and people, and the opportunity to develop independence in the community as with the second example. The second meets more outcomes for service users without necessarily gaining any further recognition from CQC.

Impact on providers

So, what does this mean for providers? As an organisation, we are working with services to meet regulations and carry on with the great work being undertaken in supporting people to achieve their goals.
What it does mean for us, however, is that we are looking at inspections as a marketing exercise; services are focusing on gathering their good news stories to share with inspectors.

This has been a difficult shift for some managers as their relationships with inspectors have always been based on transparency and honesty. Our managers have sought guidance and reassurance from CQC.
Inspectors no longer appear to work in this way and this shift has been challenging for managers whose main focus is the delivery of a quality service rather than the promotion of their service.

It is apparent that the reports I read were written by inspectors who had enjoyed their time in the service and had been told lots of excellent things by the managers, staff teams and service users.

Although there are some comments which don’t sit comfortably with me, we can all still learn from those inspections to get the better outcome for the service.

KLOEs

It is important to note that I recognise that not all inspectors are alike; many reports are comprehensive and clearly relate to KLOEs. Many inspectors will value the downtime for managers and staff, the outcomes service users are supported to achieve, the professionalism of the staff employed in the service, and the resilience of the service users and those who support them.

What this does mean though, is that there is a question of consistency in the inspection reports, ratings and their characteristics. My view is that this subjectivity could undermine CQC in terms of what it is trying to achieve.

I believe CQC needs to reconsider its guidelines for both providers and inspectors to ensure there is consistency in ratings and reports, and goes some of the way to removing any subjectivity and personal opinion from inspection reports.

As our largest and most public critic, CQC inspections are an important performance indicator for us, they set us apart from our competitors and are a measuring tool used by many of our stakeholders so, of course, we want the Outstanding ratings.

We will continue to learn and develop the way we manage inspections, but we won’t bend from our ethos and will challenge any inspector, or other critic for that matter, if the comments made about our services don’t fit with our identity as a provider of choice.

Ian Pope is Senior Manager at Freeways. Email: IanPope@freeways.org.uk Twitter: @FreewaysCharity

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