Tuesday 11 December 2018
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The snakes and ladders of regulation and inspection

Jo Williams admits defeat on “excellence”. Good.
Care Homes will be inspected at least once a year. Good.
PCAs (provider compliance assessments) are going. Good.
What next?

More than five years ago, in an article in Caring Times (“Quality Tosh” Caring Times July/August 2006) I argued that the regulator should first learn to inspect care homes properly before embarking on its doomed and pointless star-rating exercise. And if it did learn to inspect properly, it would understand that this pursuit of “excellence” was a diversion aimed at the care home “industry” (with whom it still has supporters) rather than having anything to do with providing good enough care for residents.

In fact, the introduction of star-ratings was designed to reduce the regulator’s workload. 3-star homes would be inspected every three years and 2-star every two. The more homes that were highly rated the less the inspectors had to do. Then the one-star and no-star homes would be put out of business, and again there would be less for the inspectors to do. That was the theory, anyway.

Failure demand
This short-term reduction in demand for inspection has now come back to bite CQC which is now plagued by “failure demand”; in other words the failure to inspect well enough or frequently enough has resulted in a long-term failure in care in hundreds of two- and three-star homes. CQC are now struggling to keep pace with an explosion of slow-burning care failures.

For five years, I have consistently written and spoken out against the star rating system and the reduction in inspection frequency. Just as I have opposed the use of self-assessment through AQAAs and PCAs.

How much time, money and effort has this scheme consumed in setting it up only to knock it down again? How many genuinely good but low-rated homes - and the residents who lived in them - have been sacrificed on the alter of “excellence”? How many homes that are even now rated as “good” and even “excellent” have turned out to be neglectful and abusive? If you don’t believe me, read the reports. When CQC triumphantly “expose” a home (but only after repeated complaints that have been initially ignored e.g. Winterbourne View and many others), look up the previous inspection reports and see how the same home has been rated as “good” or “excellent”, left for two or three years without inspection and oops! what a surprise! it’s suddenly no damned good at all.

How much time, money and effort has been consumed as providers attempted to increase their ratings? How much attention to care has been diverted into the paperwork and the bureaucratic contortions required to be “compliant”? How many care plans have been redesigned and rewritten, over and over again, to please the regulator . . . and then never used? How many “quality managers” have been appointed to go round a provider’s homes re-writing policies and procedures, checking that everything is in order for CQC, and diverting the resources of the home away from care and into “compliance”? How many consultants have been brought into homes and paid to complete AQAAs and PCAs? Compliance is not care. However, if managers prioritise care over compliance, they risk their own survival as a manager and the survival of the home as a business; and if they prioritise compliance over care they threaten the survival of the very purpose of the home itself: the welfare and care of residents.

CQC got rid of AQAAs only to replace them with PCAs. Now they are ditching PCAs. More wasted time, more wasted money, more wasted effort.

Cynthia Bower says people want homes to be inspected more frequently. The public have ALWAYS wanted homes to be inspected more frequently. Of course they have. When CQC “consulted” over keeping quality ratings, they told us that “people” told them they wanted them. It turned out that they had responses from all of FIVE members of the public (the rest were providers, professionals, or organisations) and we were not told how many of those five wanted to keep quality ratings.

The fantasy world of CQC
Last week’s evidence at the Mid Staff’s enquiry revealed some more of the truth about CQC. The farcical facade cannot be made to stand up much longer.

The picture that the senior managers gave to the enquiry in the summer was “aspirational”. It portrayed an organisation with sophisticated “double loop” or “double dial” warning systems detecting with pin-point accuracy when things are going wrong in the services that CQC regulates. There are “engagement forms” and “service level agreements”, and all sorts of other wheezes designed to pick up failures in care. To those that don’t have to suffer CQC’s abject failure in inspection, this might have sounded convincing until they saw Panorama and how all these sophisticated systems had failed the residents of Winterbourne View.

To some conscientious members of CQC’s workforce, the evidence given to the enquiry by Jo Williams, Cynthia Bower, and Amanda Sherlock was dangerously complacent and misleading about the capacity of CQC to identify neglect and abuse. An analytical report was commissioned by the head of intelligence to compare the aspirations with the reality. They didn’t match. What Williams, Bower and Sherlock told the enquiry was not what was happening. The member of staff who drew the short straw and was asked to compile the report was subsequently threatened with suspension. Fortunately for the public - who are asked to trust and pay for CQC - the report found its way to the enquiry and thereby exposed to public scrutiny.

The costs of this enquiry are likely to exceed £10m, but that does not include the costs borne by individual organisations giving evidence. I attempted to find out how much CQC had spent on preparing for and giving evidence - including legal costs - to the enquiry. They say they have no idea! Proudly, they disclosed the travelling expenses (2nd class!, but they don’t know how much they spend on independent solicitors coaching the likes of Jo Williams, Cynthia Bower, and Amanda Sherlock to present their fanciful pictures of CQC to a public enquiry that is attempting to find out how things went so disastrously wrong at Mid Staffs. They have no idea how much time has been spent preparing their “evidence”. Does CQC know how much time and money is expended by care homes in supplying CQC with evidence of compliance?

CQC claim that their effectiveness is reduced by being underfunded. My guess is that the Mid Staffs enquiry has cost CQC well over £1m in time, legal fees, and expenses. CQC costs some residents of care homes £182 a year each.

Let’s dismantle this absurd edifice and get back to square one: a clear, plain process of inspection in which inspectors check that care homes are providing good enough care.

The Association of Care Managers calls for a new approach to regulation and inspection of adult social care:
Prioritise the quality of care and the rights and safety of the people who use the services – this is the primary purpose of inspection
Inspect services as often as necessary but at least once a year
Inspectors should aim to prevent bad practice rather than to condemn it after it has occurred and after residents have suffered
Inspectors should be locally based and known – and accessible - to the public and users of the services
Inspection reports should be written for the public
Inspectors should work directly with residents and relatives, staff and managers of individual homes, NOT with the provider groups and organisations
Inspectors should respond to and investigate complaints, and be willing and available to visit the service without notice and at any time
Inspectors should understand how the services work and be willing and able (when appropriate) to help services to improve
People who use services should have a formal and influential voice in the assessment of care.

We believe all of this can be achieved with lower inspection fees. However, it will mean a total reorganisation of the CQC, dismantling the centralised bureaucracy and grandiose management structure, and setting up local Healthwatch inspection teams employing independent inspectors who will be judged by - and paid by - results.

ACM supports the effective inspection of care services, concentrating on the rights, safety and wellbeing of those who use the services.

John Burton, Head of the Association of Care Managers
October 2011