Jef Smith looks into social care complaints, reported on recently by Citizens’ Advice.
Few issues produce more varied reactions than complaints. I vividly remember a head of a local authority inspection unit — this was 30 years ago — pleading with a group of managers of services, “Please no complaints, they take up so much time”. At the other end of that spectrum of attitudes are the agencies which rightly boast of the improvements they have made to their services by taking on board insightful feedback from clients and their relatives. Complaints can indeed be destructive of morale and a time-consuming diversion from the main task, but if considered carefully they can also be positively creative. There is nothing like real experience for learning how to do better.
Pressures from regulators have certainly complicated the situation. Inspectors themselves have never been quite clear as to whether a high level of complaints is a sign of poor service or an indication of a provider’s openness to consumers’ comments. Many customers shy away from the formality and seeming negativity of “making a complaint”, eager to praise what they experience as good in a service but reluctant to voice anything which might sound critical.
A first step perhaps is to start to view complaints and compliments as two ends of a single continuum, with comments from the most bitterly critical to the most embarrassingly flattering equally capable of yielding useful insights. Such an attitude requires an atmosphere of openness in which clients — and staff for that matter — feel able to give feedback knowing that they will be listened to sympathetically and without recrimination.
Though our customers are often peculiarly vulnerable and therefore reluctant to be seen to be rocking the boat, social care is not alone in facing these issues. Insight into what we share with others in this respect came from a recent report, Learning from Mistakes, produced by Citizens Advice, the principle consumer body for the public sector. Most social care is of course now provided by voluntary and commercial bodies, but as many of our customers are publicly funded we occupy a private-public hybrid area and can learn from both sides.
Increase in requests for help
The starting point for this research was the fact that over the last four years there has been a 63% increase in requests for help in complaining. Note that this is not a two-thirds increase in actual complaints; the fact that people needed help from an independent organisation indicates that complaints procedures within the providing bodies themselves were deficient. Nearly half of the people consulted had indeed recently experienced poor service, but barely a fifth of these made a formal complaint, most of them because they felt that nothing would change. Nearly three quarters, however, had shared their frustrations privately, with younger people particularly — and predictably — turning to social media.
The report does not go into much detail as to how these moans can be captured, but there is here an important channel for feedback which should not be ignored. Younger people with disabilities are often in advance of the pack in the use of technology — they need to be. If someone expresses themselves as dissatisfied with a service on Facebook or Twitter, take note.
Some of the Citizens Advice report’s proposals are directly applicable to social care. The culture of complaints, it says, needs to be modernised and frontline staff need to be empowered. When my wife complained recently about a mobile phone for which she was being double-charged, we got caught up in a dispute between two companies which took us three months of calls, emails and headaches to sort out. I often make suggestions for improvements at my local supermarket, but shelf-filling workers tend merely to shrug helplessly and even the store manager usually simply refers me to “head office”. When I complained recently to my local hospital about the inefficiency of the appointments system, I was told it was the fault of a national computer and pursuing the matter took me into a procedural jungle.
Do you recognise any similarities between my experience and what it must feel like for a client to complain in your organisation? Would a care assistant pass on a client’s comment to a manager or feel too intimidated? Would the client have opportunity to by-pass a poorly performing worker and go straight to a manager? Does a local manager have authority to initiate appropriate action in response to a justified complaint or does the matter have to be referred up the hierarchy? Is your organisation seriously interested in responding to what your customers tell you?
An impartial and independent body
Two of the Citizens Advice report’s recommendation appear at first sight to be contradictory — that people should be able to complain to a single point of contact and that they should also have access to an impartial and independent organisation. It is indeed useful for any care provider to have a clearly identified route for complaints within the organisation, one which can be easily understood by clients, though this does not, of course, rule out their making their criticisms known in the first instance to whoever is to hand and feels to them to be sympathetic. Complaints procedures should also make it clear that if dissatisfied with the organisation’s response, clients have the chance to take a complaint to someone outside the organisation.
That body is not, however, the Care Quality Commission (CQC). There is a long history to the relationship between complaints and inspection, which ended with CQC’s predecessor ruling emphatically that complaints investigation was incompatible with the role of service regulation. It was disputed at the time whether the decision had been taken simply on grounds of resources since looking into complaints can indeed be very time-consuming, but for good or ill that remains the official position.
Though CQC continues to emphasise that the major responsibility for listening to customers and acting on that intelligence remains firmly with providers, the organisation is of course, still interested in an agency’s level of complaints and how they have been handled. It boasts indeed that it receives about 50 concerns about services every day and that this number is rising. CQC has set out its position in a clear statement entitled Complaints Matter, where it defines two objectives for its interest — “to improve how we use the intelligence from concerns and complaints to better understand the quality of care” and “to consider how well providers handle complaints and concerns to encourage improvement”. Information relating to complaints and concerns is therefore assembled before each inspection visit and during site visits a sample of complaints files are reviewed. This information can be expected to play a role in the grading eventually awarded to the service; “Is the service responsive?” is one of five key questions.
If CQC does not itself investigate individual complaints, however, to whom then can a seriously dissatisfied client turn? For a while, there was no clear answer to this question since the Local Government Ombudsman service appeared to be limited to people whose support was provided directly by a local authority and that was a swiftly diminishing group as successive governments enforced increasing use of the independent sector. This was clearly a very unsatisfactory situation.
One anomaly was that many clients whose provision came from a private or not-for-profit source were still funded by a council; did that make the service public or private? Then again, if these clients were to be afforded the protection of an Ombudsman, was it fair to exclude those who were themselves paying for exactly the same service? It was eventually resolved that the Ombudsman’s writ would effectively run to all social care customers, a fair outcome and one which has greatly benefitted the sector’s capacity to deal with complaints.
From time to time, the Ombudsman’s office publishes a report drawing together experience on a selected issue. In September 2015, it produced such a document, Counting the Cost of Care, which covered the lessons to be learned from complaints made by social care users. Although it dealt principally with the costs of residential homes, the recommendations relating to complaints relate equally comfortable to domiciliary care. It has a good deal to say, for example, about councils’ responsibilities, notably the often neglected function of informing potential clients of how care costs are calculated and particularly the role of top-ups to fees paid by or on behalf of consumers.
In a section with the title Getting things right first time — questions for providers, it poses four challenging questions. Are proper contracts in place with a council before service is offered to potential clients? Are communications about changes to contracts made directly with the council and not merely through residents and their families? Are proper considerations given to an individual’s circumstances before changes are made to care arrangements? And finally, are clients, and their families where appropriate, made fully aware of how to complain about fees and charging? If your agency can confidently answer each of those questions positively, you are likely to be doing very well — on other fronts too.
Despite its very specialised and limited role in relation to complaints, perhaps the last word should go to CQC. Writing in 2014, Professor Sir Mike Richards, Chief Inspector of Hospitals, remarked, “It’s time for all of us — regulators, providers, professionals and commissioners — to make the shift to a listening and learning culture that encourages and embraces complaints and concerns as opportunities to improve the quality of care.” It is essential to listen and learn, and what better source of data on our performance than our own consumers?