After three disastrous years of the previous regime, the new guard at the Care Quality Commission (CQC) spent its first year trying to clean up the mess that was left behind. This time last year, CQC was front-page news – cock-ups and cover-ups. Unfortunately there are still skeletons in the cupboards and dirt lingering under the carpets. Why can’t people who are so experienced in organisational cultures and change, understand that it takes years to achieve deep change in any organisation, whether it’s a national regulator or a care home?
That question and its answer point to what is wrong. CQC is still reliant on concepts that are alien to social care which is based on relationships. CQC’s culture is one of compliance, quality assurance, performance and delivery. It’s how they run the organisation and how they make their judgements about social care services. They appear to have little idea of whole system change and of what lies beneath the surface of organisations. They believe it’s possible for a care home to change from inadequate to good in six months: just appoint a new manager and follow an improvement plan. (And you may need to engage a consultant to ‘ensure’ that everything appears to be in compliant order.)
So, in their annual report for 2013/14, CQC measures itself by ‘key numbers’. The Commission costs nearly £200 million a year. Adult social care had 22,066 inspections, nearly 200 less than in the previous year, yet the headline figure in the report is the 6 per cent overall increase due to introducing the inspection of GP practices. 238,621 calls were received by the National Customer Services Centre (NCSC) and there were 9,473 ‘whistleblowing contacts’.
When making any observation about any service, CQC inspectors are trained to ask themselves the question, ‘So what?’ So, what are we to make of the 9,473 whistleblowing contacts? And why were there fewer social care inspections? And what were the 238,621 calls to the NCSC about?
The annual report does attempt to explain but fails to make a systemic analysis. For example, why aren’t most of these phone calls and whistleblowing ‘contacts’ going directly to inspectors? Surely, if you need information, or help, or there is something worrying you about a social care service, you should contact the person who knows the service and is responsible for checking that it’s caring and safe.
And this points to the fundamental error in the design of a national care regulator. Social care services are local and they should have local inspectors, accountable to the people who rely on them, to check whether to a service is good enough. Instead, CQC maintains costly central systems that distance the relationships between public, providers and inspectors.
‘Special measures’ and ratings
Linked with the reintroduction of ratings in October is the announcement that from April 2015, care services that are rated as ‘inadequate’ will be put into ‘special measures’ if they don’t improve sufficiently within a specified time-scale (usually six months), and if they fail again they will be closed.
I don’t support the ratings scheme because no one, not even CQC inspectors, can draw precise, fair, and consistent lines between the levels, nor can anyone say for sure whether a service is 100 per cent safe. (No service is or should be.) CQC is setting itself up for embarrassment and failure as soon as the first service with a ‘good’ or even an ‘outstanding’ rating is exposed publicly and tragically as neglectful or abusive. This happened with the old Commission for Social Care Inspection (CSCI) ratings and continued when CQC maintained the same scheme. We can be 100 per cent sure that it will happen again with the new ratings.
However, CQC’s five broad and imprecise questions – Safe? Effective? Caring? Responsive? Well-led? – are a sensible basis on which to inspect. Add Andrea Sutcliffe’s ‘Is it good enough for my mum?’ and we have the essence of what inspection should be about.
If a service is not good enough, it needs improving and, depending on how far it falls short of being good enough, the local inspector must keep a very close eye on whether it is getting better, with residents and clients, relatives and staff communicating any concerns they have directly to the inspector. If the home shows no sign of improvement in a reasonable time, CQC should remove registration and the service should close.
The use of the term ‘special measures’ is merely a political ploy to signify that the Government is ‘cracking down’ on poor care. I don’t think it really changes anything. If inspectors were individually accountable for the services on their patch, they would be more likely to step in well before ‘special measures’ were needed. Make inspection simple, direct and local; adding to the superstructure is in danger of capsizing the ship.
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