Monday 18 December 2017
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Challenge not defensiveness

Des Kelly OBE reflects on how care providers should best respond to inspection reports on their services

I was surprised not to see more reaction (from providers or other commentators) in response to the blog, 'A night in Berlin', posted by Andrea Sutcliffe, Chief Inspector of Adult Social Care at CQC, earlier this week. Her main theme in the blog which was, as always, carefully constructed, chatty and accessible, covered provider reactions to the judgments of inspectors. She acknowledged that the results of the ratings so far are “probably a bit skewed” given they show 33% 'requiring improvement' and 8% 'inadequate' based on the small proportion of inspections undertaken to date. Andrea is disarmingly honest in stating explicitly that CQC is not above challenge and that there have been unacceptable delays in the publication of inspection reports.

However the comments that most interested me, and the crucial test of the effectiveness of the new inspection methodology, relate to the matter of consistency. It is of course vital that all stakeholders - those receiving care and support, their families, care staff, commissioners, providers, inspectors, other professionals - are confident that inspector's “judgements are rigorous and reliable from Newcastle to Newquay and everywhere in between”. There has to be complete confidence about the standards being assessed, the key lines of enquiry that inform the assessment and the process of forming a professional judgment in order to determine the rating that is awarded.

At this stage I need to make it absolutely clear that the NCF has consistently supported the use of quality ratings for all registered care services. We believe it is good for all those with an interest in improving care and support, wherever it is delivered. This is a critical part of securing continuous improvement for care services – in that sense, commissioners, providers and the regulators are in it together. We have also consistently argued that quality is the responsibility of the provider and cannot be inspected into care and support services.

In her blog Andrea comments that “the reaction from providers is proving to be very instructive. Some are as worried as us by what we have found and are committed to turning the service around. Others have recognised that the problems maybe run too deep and they cannot make the necessary changes - this may lead to closures or sales. I am sorry for the disruption this can cause people using services, but if it leads to improvements in their care then I welcome that. Even more worrying though are those providers who refuse to accept the judgment we have made and instead of concentrating on dealing with the problems, spend their time arguing with us.” There are a huge number of issues in this tough statement and I believe that all good providers would want to see services turned around or removed from the sector. But it is back to there being complete confidence in the inspection methodology, where the bar is set and the process used to form a judgment.

I have been contacted by two members in the last week. The first wrote that CQC had received a report of staffing issues at a home but found no problems when they visited - they gave the service a ‘requires improvement’ anyway – the manager and the provider cannot see the justification for this. In another inspection for the same provider the inspection report clearly states that the required standards are being met but they will not revise the rating until a full re-inspection is undertaken to check for consistency. This is what it says in the report: “… to improve the rating to ‘good’ would require a longer term track record of consistent practice.” Clearly the step between ‘good’ and ‘requires improvement’ is seen to be a significant one. There are however major commercial implications to this decision as the local authority has decided not to make placements to the home.

The second senior manager wrote to me earlier this week saying: “We have recently been subject to several inspections, sometimes on one site. It could be that a care home now gets inspected by”:

2 x CQC inspectors
2 x LA – contract monitoring (despite only having 5 residents on LA contract out of 72)
1 x CCG – NHS contract monitoring
2 x Healthwatch enter and view
1 x Infection control nurse
1 x expert by experience

That’s a lot of public money and time. And from a resident’s perspective it’s a lot of intrusion into their private lives. Each ‘inspector’ will require staff and management time that won’t have been planned for and could have an impact on the safety of the service. Has anyone considered the impact they are having on people’s lives? Imagine watching your favourite TV programme or listening to your radio show in your front room and having strangers trailing through asking you questions and watching what you’re up to. The idea of our design model is that we reduce people walking through lounges and dining rooms to create private and peaceful places. Add to that the stress on the management team who are providing the same information four times over.

Surely we need to keep proportionality in mind?

Sally Warren, Deputy Chief Inspector, addressed our Annual Conference last week and what she said was well received. Providers accept that there needs to be a timeframe for unacceptable quality and responded positively to an indication that the regulator is engaging with stakeholders, including providers, listening and acting on feedback. Her input stimulated a lot of discussion. Some of which touches on the issue that Andrea's blog highlights - celebrating the best of care services whilst also taking action to tackle poor care wherever it is found. For me the two go hand-in-hand. The issue of provider defensiveness in the blog is interesting. In my experience good providers will always be committed to turning around services that fall short of the standards. However it does go back to the matter of confidence in the judgment made which gives rise to the need for appropriate challenge. “Rigorous and reliable” says Andrea in relation to judgments … to which I’d like to add ‘robust’.

Des Kelly OBE
Executive Director
National Care Forum