Sunday 23 September 2018
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When being special is a bad thing-NCF blog by Des Kelly OBE

CQC are now only days away from the start of a major reform of every aspect of social care inspection which will introduce a new quality rating system and, once the Care Act is enacted in April 2015, new fundamental standards and enhanced powers. In fact just yesterday CQC published the Key Lines of Enquiry (KLOE) documentation with sources of evidence to demonstrate consistency of practice and the approach to service delivery and improvement.

The quality ratings system that has been piloted in two waves over the summer has been testing the operation of an assessment system that will award four different levels: outstanding; good; requires improvement and inadequate. The rating will result from an assessment based on the 5 questions: is a service safe? effective? caring? responsive? and well-led? The pilot has enabled CQC to develop and refine their methodology and they will shortly issue guidance to providers. This is a huge undertaking and it will be a challenge to complete inspections to assess and rate every registered care service by the end of March 2016.

The TLAP Quality Forum hosted a workshop with DH and CQC earlier this week at The King’s Fund to explore further the proposal of a ‘special measures’ regime offering improvement support to failing care services, due to be introduced from April 2015. I have written about special measures before (NCF Blog 16 July) when Jeremy Hunt made his announcement about tackling failing care homes and thereby reinforcing negative public perceptions that poor practice is common and merits a severe action.

In the short time since then there has been a lot of thinking and the workshop was an opportunity to reflect on what such a regime might involve and how it might work. It seems to be another indication of the way in which inspection and regulation is changing as the emphasis shifts significantly from monitoring compliance to acknowledging the role of regulators in driving quality improvement. In broad terms there appears to have been a high level of support for the fresh start approach at CQC but rushing ahead with proposals for a system called special measures remains problematic. The well-being of the individuals receiving care and support must always be the primary focus and this is at the heart of the dilemma in classifying a care service as in need of special measures.

The workshop included presentation by two providers (one of the largest and a medium-sized operator) who both told stories based on their experience of dealing with a failing care home. They were powerful reminders of how quickly services can fall into enforcement action and how difficult it can be to turn around a failing care service. And costly – in both cases the cost was estimated to be at least £500,000! Of course that is measuring only one aspect of cost and says nothing of the reputational damage, the anxiety created for people living in the home or their families or the staff. I know from experience that the journey from failing to meeting all the necessary standards is a difficult and challenging one and one that often takes a lot longer than is initially expected.

I was struck by the fact that these examples were from organisations sufficiently well-resourced to be able to manage the turn around. I wonder how typical they are of failing services. There were some interesting common characteristics. The most striking was the importance of the Registered Manager, and their leadership – a message about investing in good management. There were also issues about company recognition of the service failings, self-awareness and the degree of confidence in their commitment to improvement.

There can be no place for inadequate services and I support CQC using enforcement powers in a robust manner to remove poor providers from the care sector. But I don’t believe that quality can be inspected into a service.

The components that make up quality – user involvement, community engagement, continuous improvement, investment in the workforce, training and development, information, sound governance, openness, accountability, reflecting on practice – form part of the NCF Quality First framework. It is our view that all of these components are necessary; they are not optional elements and they cannot be grafted on to a failing service. And here is the difficulty: although paying attention to all of these aspects will not guarantee quality outcomes, the way in which they overlap/interact means that if anything slips below standard, the service should know about it quickly. Acting on that knowledge in a timely way is vital and demands effective leadership.

The workshop shared experience of improvement interventions and existing practices in order to develop support for this new system of ‘special measures’. It is encouraging that DH and CQC recognise that implementing a harsh special measures regime has the potential to seriously undermine the stability of care services, especially care homes, and risk vulnerable people needing to move as a home closes.

Being classified as in special measures would attract serious difficulties for local authorities in placing and funding people. Embargos on placements would inevitably follow swiftly. Smaller providers would be most at risk from such action. The role of local commissioners is crucial. Deciding on the entry and exit for special measures would of course be critical. How much time should be allowed to demonstrate improvement? There are still many questions to be considered. It is also essential that providers and their representative bodies are fully involved in working with the key improvement bodies to shape an improvement system and avoid the unintended consequences of special measures.

Given the new responsibilities and significant demands on CQC, the timing of this new regime could risk seriously undermining the progress that the regulator has made over the last couple of years. With a guide to regulation and inspection now available and handbooks promised by 9 October the NCF will support members through these changes. NCF was formed to improve quality care and support but I remain doubtful that social care services can be made to fit such a ‘special measures’ regime.