News

Care providers' criticisms

Inspections still inconsistent

Inspections too bureaucratic

Inspectors not distinguishing between standards and regulations

Some standards unfair

Delays in receiving inspection reports

Inspection scoring system not reflecting quality

While good service is taken for granted, bad service is seldom forgotten. Not surprisingly then, those who offer services are usually falling over themselves to tell the world just how good they really are, writes Katie Leason.

In this respect, the National Care Standards Commission is a modest organisation. When asked what was its most notable success in its first year as England's independent inspection body it came up with something most organisations would take for granted: being ready for work on the first day of operation.

"The most important thing was that we moved across into the commission and were all there sitting at our desks on the first of April," says Colin Hough, director of operations.

"We got all our staff into their new offices with their equipment, with their standards, with training and ready to get on with the job. That was an important milestone event."

Given that just two weeks before the commission was due to go live only 55 of its 1,700 permanent staff were at their desks, this achievement is perhaps more remarkable than it sounds.

And, while transferring staff over from more than 230 local authorities and health authorities was always going to be a challenge, it was not the only human resources issue to be tackled.

At the end of March, just days before the official opening, the commission was forced to transfer calls to its helpdesk to a centre in Selkirk in the Scottish Borders in what many saw as an early example of the commission's underestimation of the scale of the task in hand. The original four call handlers, restricted in number by the size of the room available, were never going to be able to cope with the 900 calls the centre received on its first day.

The commission went live on April fools' day, but it was no joke when, just 18 days into operation, it was sentenced to death. Health secretary Alan Milburn announced it was to merge with the Social Services Inspectorate and form the Commission for Social Care Inspection. The days of the National Care Standards Commission - the promised "tough independent watchdog to ensure that services are up to scratch" - were numbered before it had barely got off the ground. Its £12,290 logo began to look like even more of an unnecessary extravagance.

But in spite of the credibility that the commission lost in the aftermath of the government's announcement, it still had work to do registering and inspecting the 40,000 care services in England. And as its first - and possibly only - anniversary approaches, the big question is how well this has been done.

By the end of January, the commission had carried out 84 per cent of necessary inspections. Despite most staff not starting inspections until June, Hough says the commission expects to have completed its first round of inspections by the end of March - a brave prediction given that the commission's business plan for 2002-3 was not even published until the end of January.

Based on this prediction, some offices will have had a heavier workload than others over the past few weeks. While the North East office had inspected 97 per cent of services by the end of January, the South East had only managed 69 per cent. This undoubtedly raises questions about the performance of different offices and whether any corners are being cut to ensure targets are met.

However, Hough insists that the variation is due to recruitment issues. "When we came over in April we didn't have a full staff complement and that varied between regions and areas and largely reflects where areas found themselves in terms of performance," he says. Even today, the commission still has 44 inspector vacancies across England.

In the early days, the commission's mantra was that it would be able to provide consistent inspection and regulation of services. The 230 organisations previously charged with inspecting had resulted "in a piecemeal approach to inspection with unacceptable differences in quality standards across the country and confusion for service users and their relatives", the commission had claimed.

But, nearly a year on, it seems that the care sector is still hankering after this consistency. While Sheila Scott, chief executive of the National Care Homes Association, is generally positive about the commission's first year, she believes that work is still needed to eradicate inspectors' personal foibles. "We are not interested in the views of independent inspectors. We have got standards and regulations to meet. Just because someone doesn't like pink wallpaper is irrelevant," she says.

The commission accepts that consistency is not being achieved, and says training is under way "to bring everyone up to a common baseline".

"I think we'd accept that in our first year there would have been variation about people's approaches to inspection," Hough says. "We intend, through a national training programme for next year, to ensure that inspectors' skills in such areas as case tracking and interview will be brought up to speed and to a level that will encourage them to act in a nationally consistent way."

But lack of consistency is not the only aspect of the inspection process that has irritated care providers. Some consider the process to be more about inspecting paperwork than the care service users receive.

"The owner of a small care home's life should be revolving around the people in the home, not paperwork," Scott argues.

Inspectors award homes grades from one to four, against each standard, depending on how well it has been met. But there is concern in the sector that too few homes are receiving the highest score, and doubts have surfaced as to whether the scores are a fair reflection of quality.

Frank Ursell, chief executive officer of the Registered Nursing Home Association, believes the scoring system has been applied too rigidly. "The conspiracy theory is that they are scoring down this year so that they can score higher next year and show how good they are," Ursell says.

But Hough is adamant that this is not the case. "Inspectors are scoring them based on their professional judgement. They are observing, collecting evidence and making judgements. They have got clear criteria on how to make a score," he insists. However, the commission is unable to provide details of how the services inspected have been graded.


If the carrying out of inspections has caused ripples of dissatisfaction then the difficulties in accessing reports has created waves.

As of January, only a third (35 per cent) of reports had been completed, with as few as 22 per cent in the East Midlands. The delays in producing them have more than tested the patience of providers, with one care home in the south of England waiting more than seven months to receive its report.

Again, the feeling is that this is the result of the commission failing to fully understand the extent of its role. Hough himself makes no secret of the difficulties the commission faced in producing the inspection reports. Getting them out was "not as straightforward as thought" and there were problems with the IT system, he says.

"We admit we had some difficulties. Those are now behind us. Our progress in more recent times has been much better and we are getting reports out in a much more timely way and we aim to improve on that."

The aim is, he says, for reports to be completed and in the hands of the provider about two months after the inspection has been carried out.

Eventually, the reports will be available online, which will be welcome news for anyone who has tried to access information about a service via the commission's website. The new Inspection Report Finder is very much the "work in progress" that the commission describes it as. A search under "Bupa", one of the country's leading providers, comes up with just two homes and, even if by some coincidence one of these is the home being searched for, it is still necessary to make a phone call to get hold of the actual report.

Not being able to easily access inspection reports has been frustrating for service users and their families as well as for the providers, who can use them as a marketing tool.

But it's not just care providers who have issues with how the commission's first year has panned out. The inspectors who have been carrying out the commission's work have also identified key areas that need to be addressed.

"The biggest single moan is bureaucracy," says an inspector who did not want to be named. "There are aspects to the system which are contributing more to business inefficiency. The bureaucracy is more demanding than it was before, which was inevitable because the legislation and standards are more sophisticated than before."

The National Association of Inspection and Registration Officers held its annual conference in December and found that morale was low among inspectors, who felt professionally deskilled. Staffing shortages were found to have made targets unreasonable.

The conference report states: "It was suggested that if working practices did not improve by this time next year there would be an exodus of workers from registration and inspection work."

Concern was also raised about the size of inspectors' caseloads, with one inspector visiting 39 establishments. Hough puts this down to recruitment issues. He says: "The office had got a number of inspections to do and hadn't got a full complement of staff and so it was asking staff to take on more inspections." He cites between 25 and 30 establishments as a normal caseload.

Inspectors also feel upset by their working arrangements, where the system of "hotdesking" has left them without a permanent desk.

"We are hoping that the Commission for Social Care Inspection will take notice of the brave experiment with hotdesking and conclude that it would be more effective if inspectors had their own desk," says Nairo chief executive Sue Wilkinson. "Inspectors would feel more valued and treated more professionally if they had their own desk and phone number."

But there have also been positives for inspectors and Nairo is keen to emphasise that there are significant advantages to having a national framework of standards and regulations. Wilkinson says that the NVQ level 5 training qualification for inspectors will improve their status. She adds that consistency is starting to be achieved and that the solutions for dealing with bad practice are now more effective.

As its first birthday approaches, the National Care Standards Commission will be looking back and reflecting on how the year has turned out. The early years of any organisation are often the most challenging and in that the commission is no exception. It will come as no surprise that providers and inspectors have criticised facets of its operation and it is up to the commission now to respond accordingly.

But, however many miles it has covered on the road to improving regulation, the commission will no longer be in one piece by the time it reaches its destination.

(FOR A REPORT ON THE SITUATION IN SCOTLAND AND WALES click here)

Inspections and reports completed

Total number of inspections completed at the end of January: 22,203 (84 per cent)

Total number of inspection reports completed : 9,296 (35 per cent)

Number of inspector vacancies as of March: 44

Regional performance:

Inspections and reports completed

East Mids: 1,792 (79%) 503 (22%)

Eastern: 1,967 (87%) 873 (39%)

London: 2,335 (88%) 1,346 (51%)

North East: 1,293 (97%) 604 (45%)

West Mids: 2,355 (84%) 723 (26%)

South West: 3,303 (90%) 1,548 (42%)

South East: 3,569 (69%) 1,846 (36%)

North West: 3,122 (87%) 1,199 (34%)

Yorks & Humber: 2,467 (95%) 654 (25%)