News

If the National Care Standards Commission were a balloon it would be sturdy, huge - and equipped for stormy weather. Ruth Winchester plots the likely course of the newest and most influential social care body and asks what it will mean for service users, while Alison Williams looks at the new regulations in respect of children's homes.

People are strange. You'd think that if you offered someone a very high profile post, a £100,000 salary, a seven-figure budget and reasonably free rein, most recipients would bite your arm off at the elbow.

But, alas, the National Care Standards Commission is still searching for a chief executive. And a convincing captain is essential if this new and immensely powerful body is to be guided through the storm it is sailing into.

Not that the commission's chairperson, Anne Parker, is to be underestimated - she has an impeccable background, and considerable experience. But by necessity, she remains a figurehead. Sceptics have suggested that potential chief executives have been put off by the commission's Newcastle location. In any case, worried service providers will only find out how much of a furore to expect when the chief executive finally takes the helm.

There is probably going to be a sizeable storm anyway, whoever gets the job. For the uninitiated, the National Care Standards Commission is the new, non-departmental public body currently being built to take over responsibility for the regulation of social care. It has accurately been described as "the most important new social care institution created for many years."

From April 2002 the commission will take responsibility for inspecting and regulating almost all forms of residential and domiciliary care, as well as adoption and fostering agencies, schools, nursing agencies and day centres. Inspection and support staff currently working for local and health authorities are in the process of being transferred to the employ of the new body, and from April all inspections of these services will be carried out by the commission.

Significantly, it will also be tasked with inspecting some services that have not previously been subject to inspection, such as domiciliary care services and smaller residential homes. But the real hot potato promises to be the introduction of several sets of new, nationally agreed minimum standards. Services that fail to meet these standards will be ultimately deregistered and closed down.

For the time being, the commission is gathering momentum in preparation for its launch next year, and is frantically recruiting staff, setting up regional offices, and consulting on several sets of national minimum standards. Many key standards are yet to be finalised. Those for younger adults and adult placements, and for care homes for children, are out for consultation. Standards for domiciliary care will be published in September for a three-month consultation - leaving perilously little breathing space between the final drafting and the onset of regulation in April next year. The standards for care homes for older people, however, have been the subject of months of wrangling and are now set in concrete.

Which raises the question, how set is set? There has been a well-documented national outcry from residential and nursing home owners about the introduction of new standards which, while undoubtedly well-intentioned, will swiftly put many of them out of business. Faced with the prospect of a long series of regulatory tests which many existing care homes will be unable to pass, owners are doing one of two things. A lucky minority are choosing to take the money and run, selling up their large homes in prime locations for huge amounts of cash, and hot-footing it to the Bahamas. The less fortunate majority are hanging on in there, hoping against hope that there is some element of discretion built into the standards, and that exemplary care and service in other areas will overcome the fact that some rooms are 12 inches too small.

As for being set in concrete, the answer, according to Anne Parker at least, is that the standards are non-negotiable. She told delegates at the National Care Homes Association conference in June that any element of "local discretion" would be minimal and that flexibility would be rigorously overseen by regional officers.

But more recently she has made far more conciliatory noises, adding that the NCSC could only succeed through a "partnership" approach and that the commission was aiming to "earn the respect and even the grudging admiration of the people whose services we will be inspecting". She also admitted that her former boss, health minister John Hutton, had expressed concern about the health of the sector and "wants me to be balanced... sensible, pragmatic and even-handed".

This will be music to the ears of many care home owners. In fact it seems likely that the decision on how rigidly the standards will be enforced has not yet been taken, which at least gives service providers a stay of execution. The situation is further confused by the publication of new care homes regulations - hidden at the back of the consultation document on standards for care homes for younger adults and adult placements.¹

These regulations are mandatory. Standards, on the other hand, are not. And while many service providers are in a furore about the detail contained within the standards, the regulations merely say that inspectors must "take account" of them and add that the commission "may also take into account any other factors it considers reasonable or relevant to do so". Which seems to leave considerable margin for the flexibility which so many service providers are keen to see.

But even if the commission manages to get service providers on board, they could still face a rebellion on an unexpected front. While most service users will undoubtedly welcome the long-term impact of the new national standards and the creation of an independent inspection body, they are less likely to welcome some of the shorter term implications, such as the closure of homes and services that do not come up to standard. A plethora of recent news stories will testify that residents and relatives are increasingly willing to challenge decisions that affect them or their loved ones, often using the Human Rights Act 1998.

This raises the ugly spectre of inspectors demanding the closure of homes that have consistently failed to meet minimum standards - and what's the point of having minimum standards if some services are allowed to sidestep them? - while the residents of the homes go to court in an attempt to keep them open. This scenario raises questions about whether the National Care Standards Commission is ultimately going to be in the uncomfortable position of enforcing standards which damage and disrupt the lives of vulnerable people, rather than improving them.

Of course, no one is opposed to the idea of minimum standards per se. In fact, service providers and users are universally delighted at the introduction of a national body to regulate and inspect a broad range of services to vulnerable people. They argue that it will improve services, create consistency, provide a forum for service development, and level the playing field between voluntary, private and public sector providers. But some have expressed concern that the commission is in danger of over-egging the pudding, unintentionally creating a crisis where before there was some kind of order.

The need for trained staff, for instance, could be one major sticking point. Care workers, dedicated though they may be, are notoriously badly paid, badly trained and transient - and training is expensive. How will service providers manage to meet the training standard which demands that half of staff are qualified to NVQ level 2 by 2005? What will happen if two care staff leave in the same week, suddenly leaving managers with a service provided by 30 per cent trained staff as opposed to 50 per cent? A more pressing question may be how these businesses, many of which are complaining that their profit margins are being cut to the bone, can afford to send a succession of staff on training courses, and replace them while they are gone.

But it is the physical standards that are causing most of the concern. Room sizes are one area where many homes are unlikely to meet the standards when they begin operating, and require substantial capital investment if they are ever to make the grade. Other standards, such as the provision of passenger lifts rather than chair or stair lifts, are also causing concern.

Sheila Scott is chief executive of the National Care Homes Association. She says: "We expect that the standards relating to quality of care will already be being met by our members - that the most they will have to do is tweak their procedures. But in the meantime we are advising our members to do nothing until they are inspected for the first time, and an action plan is agreed. A lot of homes are panicking and shutting now, because of the introduction of the minimum wage, because of the national standards and because of the high property prices. We are telling them that the standards aren't in place yet, and that when they are introduced it'll be done with good sense. No one can afford a massive collapse in the sector."

Ultimately, most service providers are likely to wait and see what happens, what stance the National Care Standards Commission takes in its first few months of operation, and how much margin there is for negotiation and compromise. Fundamental change will take years, and the commission is likely to be embroiled in regular court cases and appeals against home closures until the ground has settled. Ironically for a system set up to protect the interests of vulnerable people, service users and their relatives look set to be among the first in court.

¹ National Care Standards Commission, Care Homes for Younger Adults and Adult Placements: National Minimum Standards, consultation document, 2001. Available on the NCSC website at www.doh.gov.uk/ncsc

Home front

Alison Williams from the National Children's Bureau explains what the new standards will mean for children's homes.

Children's homes will be required to meet new national standards and regulations when they come into force next April under the new National Care Standards Commission. A change to the law will ensure proprietors and managers of children's homes are registered, instead of the homes themselves. It will be their responsibility to run the home according to the minimum standards.

The National Children's Bureau (NCB) was invited to work on the draft standards, which are out for consultation. The intention was always to set minimum standards which, if they were all met, would ensure a fully adequate but not "gold-plated" or unnecessarily costly service to children. We talked to managers and carers working in homes and their views have been fed into the newly published government document. The standards do contain some new requirements, but only where the people we consulted convinced us that they were necessary to protect children and give a fully satisfactory service. The standards are not intended to - and should not in practice - increase red tape, cause unnecessary work, or impose unjustified extra costs for homes.

NCB welcomes the fact that the new standards apply to more types of home than in the past. Private homes, small homes, voluntary children's homes, local authority homes, and special and other schools accommodating children over 295 days a year are all included and will all be subject to the same standards of child care practice.

Although it has been challenging to draft standards for such a range, it is reassuring that the Department of Health is now piloting the standards in different homes. The DoH needs to know from consultations and the pilots whether the objective of writing standards that work for such a wide range of homes has been achieved. So the jury is now out on how well the standards will work in practice with, at one extreme, very small homes (perhaps in domestic premises), and at the other extreme, large therapeutic communities or special schools.

The standards do contain some items that are likely to be new to most homes. Recommendations of the Utting and Waterhouse reports are included to improve the protection of children in residential settings. Homes will, for example, be required to increase monitoring of absconding and possible involvement in prostitution.

A "placement plan" is required for each child, stating how the home will provide day-to-day care, meeting the child's care plan with the services described in the home's statement of purpose. There are requirements about adequacy of funding, and for the home's manager to check specified key issues monthly, taking action where indicated.

There are new requirements for staff training and support, and for consultation and support to individual children - all strongly advocated by those we consulted.

Home managers might be concerned about possible requirements for extra staffing or upgraded building requirements (like larger rooms). These standards do not set staff numbers but they do require a sensible staffing policy with sufficient staff to meet children's needs. Homes have always been expected to do this, and the new standards do not therefore set higher standards, they simply require a satisfactory minimum, and openly set out the criteria by which this should be judged, by both homes managers and by inspectors.

The standards do set some minimum building requirements such as at least one toilet per five children, but not arbitrary room sizes. Instead, they list the sort of facilities that must be provided (furniture requirements for bedrooms for example), and require assessment of more important issues for children such as privacy and risks of harm, abuse and bullying.

Small private children's homes are in a unique position given they have just started to be regulated by social services departments to their various local standards (small voluntary homes have always had to register with the DoH). They will need to change to the new standards after a very short period of regulation under the old system.

The emphasis on inspectors assessing complex issues such as privacy and risk, rather than spaces, does of course raise worries that inspectors may vary in their assessments. Indeed, words such as "reasonable", "adequate" and "sufficient" are used in various standards, requiring broad judgements.

The counter to variable judgements lies with the National Care Standards Commission. The commission will be using the same standards and inspection methods throughout the country and will provide inspectors with the same qualifying training to a new national curriculum. Those concerned about variable findings might take comfort from the fact that for the first time, there will be a national qualification for inspectors.

Although the standards are still consultative, homes would be wise to start thinking about their implementation. In collaboration with children, they should start writing a young person's guide to the home's statement of purpose and they should be considering the best way to meet the new requirements for consulting children. NCB will be publishing guides for parents, children and young people and staff on what the standards will mean for them at the beginning of next year.

Alison Williams is the NCB's principal officer for projects focused on children in public care.