Last reviewed 5 August 2016

The fifth of the questions posed by the Care Quality Commission (CQC) when assessing the quality of a service is — “is it well-led?” This is the last question but it is far from the least important. In fact, CQC’s general attitude is that the management of any provision, from large general hospitals to the smallest of care homes, is critical to its effectiveness, Jef Smith explains.

“By well-led”, says CQC’s provider handbook for community adult social care services, “we mean that the leadership, management and governance of the organisation assures the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture”. Three key elements then — delivering good care, supporting learning and innovation, and promoting a sound culture; of each of these more in a moment. Before that, however, it is worth considering what are the differences between “leadership”, “management” and “governance”, each of which is identified as needing to contribute to an organisation being well-led. The distinction between the three functions is not immediately apparent.

Governance has to do with the manner of conducting the policy and affairs of an organisation at the highest level. Leadership is the sum of the activities involved in being in charge of, directing and organising a group of people. Management is the co-ordination of the efforts of people to achieve various objectives by using the available resources. In the context of a care home, governance falls to the board or governing body, management in the first instance is the responsibility of the head of the home’s staff, while leadership can involve a whole range of people from committee members to first line supervisors.

The need for a registered manager

Looking specifically at a home’s management then, we return to CQC’s three vital elements, the first of which is “delivering good care”, which sounds at first glance pretty straight forward. CQC, however, has a specific requirement that all services, as a condition of registration, have a “registered manager”. This role is defined in the Regulated Activities Regulations 2014 as the person who manages the carrying on of the organisation’s activities, that is, is in day-to-day charge of what goes on.

A great deal of attention has been given to setting out what sort of person is acceptable — or not acceptable — for this key role. Employers must “follow robust procedures to ensure that they gather all available information” about the people they consider for the job. Candidates must be “of good character”, by which is meant having high standards of “honesty, trustworthiness, reliability and respectfulness”. They must be appropriately skilled, experienced and qualified, command knowledge of applicable legislation and able to demonstrate “physical and mental health in line with requirements for the role”.

It is odd therefore that the obligation to have a registered manager in post has, to CQC’s considerable consternation, been evaded by many services, in some instances for long periods. The situation became so serious back in 2013, when nearly 10% of homes lacked a registered manager and 25% of those had been in that situation for two years or more, that the Commission set up a special project to improve the situation. As a result, a report by Andrea Sutcliffe, Chief Inspector of Adult Social Care Services, was able to claim a 57% increase in the number of new registered managers in the group of services targeted over a six-month period. It was subsequently decided that no service which had, without reasonable justification, lacked a registered manager for more than six months would be awarded a rating higher than “requires improvement”, and this threatened sanction seems to have worked. The presence of a registered manager does not, however, in itself guarantee the delivery of good care.

Supporting learning and innovation

The second element in CQC’s requirement for managers is to be able to support learning and innovation. These are actually separate objectives, both equally vital. Making learning available to staff requires not only the formal obligation of organising or facilitating relevant training, but also the more complex process of creating an environment where the desire for improvement in practice is endemic to the organisation. This is sometimes referred to as “a learning culture”, a useful term as it conveys the fact that advancing learning is not just a question of individual endeavour but a constituent of the whole staff group. People need to be able to admit to mistakes without constant censure, to look to colleagues as well as to their supervisors for support in aiming higher, to strive both personally and collective for the best that can be achieved.

Creating a climate for innovation involves similar elements — positive allowance of responsible risk-taking, encouragement of peer support structures and the fostering of mechanisms by which staff can try out new methods of caring without fearing censure if they fail. What, for example, helps people with dementia to live full lives? Recent experiments have suggested that activities as diverse as listening to music, physical exercise, reading poetry, participating in book clubs and playing table tennis may all work. None of these could have happened had not someone experimented, with of course the encouragement of their manager. That is innovation in practice.

A sound culture or ethos

CQC’s third element requires that a manager promotes a sound culture, a role which again overlaps with what has gone before. One of the old National Minimum Standards, now effectively replaced by CQC’s five tests, spelled out this quality rather well, using the term “ethos”. This specifically required the manager to promote “an open, positive and inclusive atmosphere”, to communicate “a clear sense of direction and leadership” and to encourage “innovation, creativity and development”. Not for the first time, I am left feeling that the scrapping of National Minimal Standards deprived managers of some very useful guidance.

Who are the registered managers?

Given the attention CQC has paid to the importance of every service having a registered manager, it is surprising how little is known about the actual composition of this important group. One of the few publications specifically focused on the issue came out in January, from a team of researchers at the Social Care Workforce Research Unit at King’s College London. The aim of the project, carried out in early 2014, was “to identify the characteristics of care home managers, descriptions of their leadership and managerial roles, their experience, skills and support, and the managers’ perceptions of their work and status and to identify knowledge gaps”.

The project revealed the breadth of the tasks undertaken, with evidence of many managers’ carrying legal and commercial responsibilities which go well beyond the social care duties identified in most official documents. Managers themselves describe their role as broad and stressful, much of the pressure arising from being held accountable not only by the owners of homes but also by commissioners, regulators, and residents and their families.

The manager’s role is always a lonely one, but this may be particularly true of social care, where managers as a group have many differences from their staff. They are a relatively elderly group, two-thirds being over 45, over a quarter over 54, and even 5% over 65. Eighty per cent are white, which is a much higher figure than for the workforce as a whole.

The lack of status is a recurring theme among managers and, despite high levels of both qualification and participation in non-mandatory courses, there are frequent complaints about the role not being regarded as professional even by related groups in the health services and elsewhere. There is no national professional body, and the social care workers accreditation scheme does not cover managers and in any case is voluntary. Many managers have also reported a lack of support and supervision from their owners.

Perhaps, for this reason, Skills for Care has made self-awareness and self-management central to the first plank in its Leadership Qualities Framework, which it calls demonstrating personal qualities. Other sections of the framework, published in 2015, address several familiar themes:

  • working with others

  • managing resources, people and performance

  • achieving improvement

  • setting the organisation’s direction

  • creating the vision

  • framing and delivering the strategy.

The document, officially endorsed by the Department of Health, is the closest thing yet to a comprehensive guide to the task social care manager’s face.

Top-down approaches to achieving change are frequently derided as excessively hierarchical. It is ironic therefore that in the social care world, where many generally accepted managerial assumptions are regularly questioned, the key authorities seem pretty universally to accept the critical role of leadership. It is certainly true that no other convincing model of running services exists, so for all practical purposes, the importance of the manager in care settings remains unchallenged. It is all the more paradoxical that so many agencies have operated for long periods without a senior manager. Perhaps the next research project should tackle the issue of how, somehow or other, they coped with the top job unfilled. How in short can an organisation manage without a manager?