Last reviewed 18 March 2015
In April, a new set of national standards for care services — community support, extra care housing, residential homes, and of course domiciliary care providers — will become operative. Jef Smith reports.
The new national standards for care services will carry the adjective “fundamental”, but whether they will prove any more durable or enforceable than the “minimum” standards (2003-2009) or the “essential” standards (2009-2014), which preceded them, remains to be seen. The idea of a basic level of quality below which no provider should fall was noble and sensible, but the imperative implied by the words minimum and essential has never been a reality, since widespread non-compliance with at least some of the standards has been routinely permitted.
To be fair, as successive reports from the Care Standards Commission (CQC) have demonstrated, domiciliary care agencies have regularly outperformed the rest of the sector, but even here there are serious shortcomings. In 2013/14, for example, more than 10% of agencies failed to comply with the standards for safeguarding, a figure which actually increased over the preceding year. Even more failed on suitability of staffing, and although the trend here is (very slowly) in the right direction, it is surely unacceptable that standards described as “essential” are regularly not achieved. Will “fundamental standards” herald a new era of firmness and consistency? There is already room for doubt.
The CQC will soon be using a new system for ensuring that care providers must, at the most basic level, perform in order to obtain , and retain, the registration without which they cannot legally carry on the business. The regulator’s view of performance, always important for reputational purposes, will in 2015 become absolutely vital, since it will be the basis for a public rating. It is hoped that increasingly savvy consumers will welcome arrangements that grade services as outstanding, good, requiring improvement or inadequate, and that, whether they are self-funders buying their own care or local authorities commissioning provision on behalf of those assessed as being in need, they will support high quality and shun agencies that fall short.
There are, however, several different statutory or quasi-statutory guides to quality that providers will have to keep in mind, both generally in their daily operations and specifically when preparing for inspections, and it is not entirely easy to relate these to each other. For a start, the Department of Health has published, and annually updates, what it calls its Adult Social Care Outcomes Framework. This document, produced in association with local government representatives, works on four “domains”, respectively ensuring quality of life, delaying and reducing the need for care, ensuring a positive experience of care, and safeguarding vulnerable adults, each of which is broken down into a set of outcome measures. It is true that this is aimed principally at commissioners, but the domains can surely be said to relate also to front line operators, those who actually deliver the services on which the outcomes depend.
Using the Framework and the Standards
At first glance the Framework looks quite sensible, even comprehensive, but when it is placed beside the eleven Fundamental standards, it becomes clear that there has been no attempt at aligning the two. Unlike the Essential standards, which were published by the CQC as the regulatory authority, the Fundamental standards are a Department of Health product, so why this lack of coherence? It is not that the documents actively conflict but, as they express objectives slightly differently and in a different order, the effect for a reader is at very least confusing.
The new standards, for example, divide the issue of consumers’ safety into “Safe care and treatment” and “Safeguarding service users from abuse and improper treatment”, a distinction not made in the Framework. The Framework’s section on quality of life might be said to be spelled out in more detail in the Standards’ “Person-centred care”, “Dignity and respect”, “Meeting nutritional and hydration needs” and “Duty of candour”, but could not these also be seen as ensuring “a positive experience” while being cared for? In fact, when you think about it, is there really much of a difference between “quality of life” and “a positive experience of care”? The impression becomes inescapable that these lists, multiple-authored — in fact generally drawn up by committee — are prepared with little reference to each other and with equally little consideration for providers who have to make operational sense of them.
Broadly speaking, the Fundamental standards cover pretty much the same territory as do the Essential standards, with the important addition of the Duty of Candour, but again it is a complex task to relate them to each other in detail. This might be thought a rather academic quibble, but from the point of view of a busy manager having to brief staff on their duties and ensure that local policies match national guidance, it represents one more headache.
Using the Standards and the KLOEs
Even more relevant from a practitioner standpoint is understanding how the new standards fit in with what CQC says its staff will be looking for when they carry out inspections. Here, the starting point is a set of five key components encapsulated in the questions “Is it safe? Is it effective? It is caring? Is it responsive? and Is it well-led?”. Andrea Sutcliffe, the CQC’s chief inspector of social care calls these her “Mum’s Test”, attempting, in a way that some find telling but others feel to be trivialising, to make us ask whether the service under scrutiny is one that we would be happy to use for our own mother or — for some of us, even those who are dads or not even parents at all — employ ourselves.
To unpack the five components, the CQC has published what it calls its Key Lines of Enquiry or KLOEs, addressed to inspectors but freely available to providers and others. The KLOEs give for each component a definition, a breakdown into three, four or five areas of application, a series of questions or prompts illustrating how each area might be explored, and a list of the sources of evidence to be considered. Thus, for example, a well-led service will be expected to demonstrate a positive culture, good management, effective methods of delivering high-quality care, and evidence of partnership with other agencies. So far, so persuasive.
Doubts start to arise when one asks how these particular five components were selected as critical. The response, that they were widely consulted on and attracted a generally warm reaction, is unconvincing; the consultation offered no alternatives and those who were asked were as unlikely to dismiss any of these apparently positive elements as to find motherhood or apple pie reprehensible. Elsewhere, the CQC has defined its own purpose as ensuring that care is “safe”, “effective”, “compassionate” and “high quality”. Safe and effective match the other list, and compassionate might be regarded as more or less synonymous with caring, but what has happened to responsiveness, and do the rather vague terms “high-quality” and “well-led” equate?
The choice of KLOE terms
The truth is that one could have set out any number of OK words without their proving particularly controversial in themselves, but what about the omissions? Where, for example, is one supposed to judge whether a home gives residents dignity, a key political objective over recent years, or to be sure that its workings are transparent, in line with the currently strongly pressed duty of candour?
Obviously one could shoe-horn these and similar desirable qualities into practically any list of components. Indeed the prompts show just how much overlap there is and indeed is acknowledged to be. To test the validity of the CQC’s structure for inspection, I asked Andrea Sutcliffe when I met her at a recent conference to identify which of the components embraces the politically all-important requirement for care to be personalised. She immediately replied Responsive, which does indeed include the — somewhat tautological — question, “How do people receive personalised care that is responsive to their needs?” and another that refers to “co-ordinated, person-centred care”. There is a separate reference, however, this time under Well-led, to “a positive culture that is person-centred” and many mentions elsewhere to obvious aspects of personalization, such as respecting people’s preferences, treating them as individuals, and supporting their personal choices. Personalisation, you might say, features nowhere and everywhere.
To test the validity of the CQC’s structure for inspection, I asked Andrea Sutcliffe when I met her at a recent conference to identify which of the components embraces the politically all-important requirement for care to be personalised. She immediately replied Responsive, which does indeed include the — somewhat tautological — question, “How do people receive personalised care that is responsive to their needs?” and another that refers to “co-ordinated, person-centred care”. There is a separate reference, however, this time under Well-led, to “a positive culture that is person-centred” and many mentions elsewhere to obvious aspects of personalization, such as respecting people’s preferences, treating them as individuals, and supporting their personal choices. Personalisation, you might say, features nowhere and everywhere.
Take another example. A home’s policies, procedures and practice in relation to safeguarding its residents would surely be tested during the part of an inspector’s investigations under the component Safe, but could a home be judged well-led or caring if it was unsafe? Surely not. In fact if a home fails on the questions designed for its being safe, responsive, caring or effective, could it conceivably be considered well-led?
Testing the system
Does this sort of double-counting and overlapping matter? The answer is that it will indeed matter very much when the scores derived from positive answers to the prompt questions are accumulated into an agency’s rating. The fact that the grading system will not of course operate by simple and transparent arithmetic actually adds to the problem, as an agency that an inspector claims failed to meets one of the components under one set of prompts will plausibly be able to point to a different set on which it did rather better.
Andrea Sutcliffe admits that the CQC is preparing for legal challenges, but the system will grind to a halt or at least seriously lose credibility if these multiply significantly. Ratings, don’t forget, will be crucial to business, so there will be every incentive for an agency to appeal against a grade that its management considers unjustly low.
It is difficult to see precisely how disputes of this sort will be handled. Andrea Sutcliffe told me that the five components and the KLOEs provide for a holistic view of a home’s functioning, which is better, she argues, than considering simply compliance with the regulations. Indeed, a home may be compliant with all of the regulations but still not be rated as outstanding.
The five components and the KLOEs, however, lack the statutory authority that Parliament has given to the regulations, a point that any decent lawyer will surely exploit and any court or tribunal be obliged to take into account. The rating system is going to be controversial whatever criteria are used for making decisions; that the CQC has chosen to erect a judgment structure that is virtually independent of the legislation is surely asking for trouble.