Inspection and regulation

Social care inspection and regulation in England has been revolutionised since 2000 with significant reforms to inspection standards, inspectorates and the government's approach to targets.

Social care is assessed in two distinct ways. Local authorities are judged on their success in implementing government policy, managing public resources and responding to the needs of their communities. And social care providers, from public, private and voluntary sectors, must register with inspectorates and then face regular assessment and inspection. As with social care policy more generally, adults and children's services are assessed separately.

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Inspectorates:

Since 1 April 2009, the Care Quality Commission has been responsible for the regulation and inspection of adult social care and health, and monitoring the welfare of detained mental health patients. Previously these responsibilities were held by the Commission for Social Care Inspection, Healthcare Commission and Mental Health Act Commission respectively.

In April 2007, Ofsted took responsibility for inspecting and regulating children's social services from CSCI.

The Care Quality Commission

The Care Quality Commission's responsibilities start in April 2009, however it became a legal entity in October 2008, under chief executive Cynthia Bower - who has a background in both health and social care - and chair Barbara Young.

During the passage of the Health and Social Care Act 2008, the government conceded a number of amendments pushed by campaigners over the way the CQC should operate:

• In appointments to the CQC board, the health secretary will have to ensure that appointees, between them, have experience of all of its areas of responsibility. This was designed to counter concerns that the CQC will be dominated by health.
• It also responded to concerns from groups including Carers UK that users and carers would have insufficient clout in the CQC with an amendment requiring the regulator to publish a statement on how it would engage with users and carers and take account of their views.
• Another amendment stated that the CQC would have as its main objective the protection and promotion of the health, safety and welfare of people who use health and social care. This followed accusations from peers, including former health minister Lord Warner, that the bill as originally drafted lacked a clear statement of purpose for the regulator.

However, on the eve of the creation of the CQC, outgoing CSCI chair Denise Platt raised concerns about its potential to be an effective social care regulator, due to a lack of management expertise and the high political profile of the NHS. However, Bower pledged that social care was "embedded" in her organisation.

Ofsted

Ofsted's role in inspecting children's social services gained a much-increased profile following the Baby P scandal, which broke in November 2008.

On children's secretary Ed Balls' orders, it led a joint area review of safeguarding in Haringey, which issued a damning verdict in December 2008, precipitating significant government intervention in the council, including the removal of then director of children's services Sharon Shoesmith.

But the inspectorate was criticised for the good rating it gave Haringey Council in 2007, just months after Baby P's death, though it claimed it had been "mislead" by Haringey.

A key plank of the government's response to the Baby P case was its backing for Ofsted proposals to introduce annual safeguarding checks for councils.

Assessments of local authorities

The comprehensive area assessment

The CAA is a single inspection and assessment system for local authorities for all the services they commission or deliver, singly or in partnership. It was introduced in April 2009, replacing all the existing performance frameworks for councils: the comprehensive performance assessment, star ratings for adult social care and annual performance assessments and joint area reviews for children's services.

Its main elements are:-

• An annual area assessment of how local public bodies are collectively meeting local needs and their potential to improve. There is no rating for the area assessment, with areas receiving a narrative judgement. Poor performance will be highlighted by "red flags" and excellent performance by "green flats".
• Councils receive an annual scored assessment focusing on management of resources and performance.

It will be informed by the much-reduced set of 198 national indicators for local government, published in October 2007 as part of the 2008-11 comprehensive spending review.

It will also be informed by Ofsted and the Care Quality Commission's assessment of council performance in children's and adult social care services.

Children's services

Ofsted's annual assessment of children's services is scored on a four-point scale and based on a performance profile of local authorities, updated every quarter, which itself is informed by performance against the national indicators and inspections.

Inspections are triggered by service concerns, however Ofsted is also carrying out three-yearly inspections of the performance of council and their partners in relation to child protection and looked-after children's services. The only other periodic inspections of any service are of youth offending teams, which are carried out every three years by the probation inspectorate.

The looked-after children and safeguarding inspections take place at the same time, though there are separate scores for each on Ofsted's four-point scale:- outstanding; good; satisfactory and inadequate.

Ofsted is also carrying out unannounced site visits of councils' contact, assessment and referral centres for children's social care to evaluate their impact on minimising child abuse and neglect. These do not take place in years where councils receive their three-yearly inspections.

Though the annual checks were highlighted by Ed Balls as a key plank in improving safeguarding, the Association of Directors of Children's Services has warned that the annual checks would be disproportionate and place extra burdens on councils.

2008 was the last year for annual performance assessments and joint area reviews of children's services, which were introduced under the Children Act 2004.

In the 2008 APA, councils went backwards in performance. The proportion of councils rated good or outstanding fell from 78% to 73%, while the number of inadequate councils rose from zero to four. Children's secretary Ed Balls announced he was sending in "intervention experts" to turn round all those councils rated inadequate overall or in safeguarding specifically.

Adults' services

The Care Quality Commission's annual assessment of council adult social care services measures performance against the seven outcomes in the Our health, our care, our say care services white paper, published in January 2006: improved health and well-being, improved quality of life, making a positive contribution, choice and control, freedom from discrimination, economic well-being and personal dignity.

Councils are also assessed on commissioning, leadership and use of resources, but their annual score - on a four-point scale - is based on performance against the seven outcomes, unlike the adult star ratings system, which also measured performance on commissioning and use of resources.

There is no rolling programme of inspection for any adult client group, with inspections triggered by service concerns.

The assessment is in line with a performance framework drawn up by CSCI before its abolition.

Star ratings were introduced in 2002 and from 2006-8 only applied to adult social care. They were published each November, but are based on performance in the 12 months up to the preceding March. In the 2007-8 ratings, which referred to performance from April 2007-March 2008, councils improved notably, with 37% scoring the maximum three stars, up from 32% in 2006-7.

Amid councils' improvements, the validity of the star ratings system was questioned on two grounds:-

• Charities pointed out that it merely reflected councils' performance in relation to people whose care they arranged or funded, not the mass of people excluded by tight eligibility criteria or means-testing from care.
• The Association of Directors of Adult Social Services warned there was a mismatch between what councils were judged on through star ratings and what was expected of them by the government under the personalisation agenda.

Local area agreements

In its judgement of local performance, the CAA will use  local area agreements as a starting point. Under reforms introduced through the Local Government and Public Involvement in Health Act 2007, public bodies in an area must select 35 from the 198 national indicators as priorities, according to local needs. Provided these are accepted by their regional government office, the partners and government sign a three-year LAA, under which they will be set targets on their performance against these indicators. The LAA is backed by a grant, which rolls together a number of previously separate government funding streams and is designed to provide councils and their partners with financial freedom.

As part of the CAA, inspectorates will judge whether LAAs reflect the priorities of local communities and how well local strategic partnerships are performing against their objectives.

In June 2008, the Department for Communities and Local Government announced details of each area's LAA, illustrating the top priorities across England.

Overall, reducing the numbers of 16- to 18-year-olds not in education, employment or training was the most popular indicator, chosen by 115 out of the 150 LSPs.

Other top targets included the number of social care service users receiving self-directed support per 100,000 of population and the number of carers receiving needs assessments or reviews, specific carers services or advice and information, both chosen by 80 areas each.

The various social care targets performed variably in terms of popularity.

The reforms mark a shift in the government's approach to assessing public services - from one with many targets, heavily prescribed specific grants and regular inspection to one of fewer targets and more freedom for local public bodies. Under this model, inspection and intervention are reserved for those organisations and areas which are unable to improve themselves.

However, concerns have been raised about the number and quality of the adult social care indicators in the set of 198, which has prompted the Department of Health to review them. There are only eight indicators that directly relate to adult social care and it is felt that they do not fit well with the government's personalisation agenda.

Provider regulation:

Adults:

A new system for registering and regulating adult care providers will come into force in April 2010. Under draft regulations published by the Department of Health in March 2009, services would be regulated according to activities they provided - such as personal care - not according to organisation or service setting, as is currently the case.

There would also be a single overarching framework for health and adult social care. Some existing adult placement schemes will cease to be registered under the new framework because they do not provide personal care. As is currently the case, personal assistants hired by direct payment or personal budget users and day care providers that provide personal care will not be regulated.  

Currently, all providers of care and nursing homes, domiciliary care, adult placement schemes and nurses agencies in England must apply to register with CQC, showing that they meet relevant regulations under the Care Standards Act 2000 and the National Care Standards (Registration) Regulations 2001. Each organisation must appoint a "responsible individual" - a senior person in a managerial role - who must show they also meet regulatory requirements, including by undergoing an enhanced Criminal Records Bureau check.

Registration is then granted, refused or granted with conditions. Applicants can appeal to the relevant CSCI regional director and then to the independent first-tier tribunal (care standards) if they are not satisfied with the decision.

All registered providers are inspected. Until 2005, frequency of service was generally the same for each service (though poor performers were visited more frequently), for instance twice a year for care homes. However, under reforms introduced that year, CSCI ruled that services would face comprehensive key inspections a minimum of once every three years, with more frequent inspections for poorer providers.

This was then redefined in line with the quality ratings system for care providers, which fully came into force in 2008: three-star providers face an inspection once every three years; two-star services one every two years; one-star providers face an annual visit and zero-star services a twice-yearly inspection.

Higher performing providers can still be inspected through a random inspection, where a particular issue arises in a service, or a thematic inspection, which is designed to identify national trends.

Each service that has not received a full inspection receives an annual service review, summarising all the information CQC has received on that service this year. This includes the annual quality assurance assessment - which all providers must fill in, assessing their performance.

However, the regime of proportionate and risk-based regulation has proved unpopular with certain groups, including adult protection campaigners and even some  inspection staff amid fears that less frequent inspections will remove valuable safeguards.

When CQC took responsibility for adult social care, chief executive Cynthia Bower promised to review the system though said that the commission would retain a proportionate approach.

Children

A similar system of registration applies to children's services, which has been within Ofsted's since April 2007. Under this system, independent fostering, adoption and adoption support agencies, children's homes, both open and secure, residential special schools and residential family centres must register with the inspectorate, and then face regular inspection.

The government did propose to change the  frequencies of inspection for some children's services along similar lines to the reforms in adult services, with inspection frequency in inverse proportion to performance.  

However, while plans to change the minimum frequency of inspection for fostering agencies and residential family centres from once a year to once every three years, proposals for the best children's homes to be inspected once a year with the worst receiving at least three visits were dropped. All children's homes, as before, will continue to be inspected twice a year.

Workforce

Unison represents staff at Ofsted and the CQC, whilc regulatory staff have professional representation through the Social Care Association, which in January 2007 absorbed the former Care Regulators Association.

Scotland

In Scotland, social work functions provided by or on behalf of local authorities are inspected by the Social Work Inspection Agency, set up in April 2005.

The Scottish Commission for the Regulation of Care, better known as the Care Commission, handles the registration and regulation of care services for both children and adults.

In 2008, the Scottish government announced it would create a single inspectorate for social care by 2011.

Wales

As of April 2007, Wales has had a joint regulator and inspectorate for social services for children's and adults. The Care and Social Services Inspectorate Wales replaced the Social Services Inspectorate for Wales, which previously assessed councils, and the Care Standards Inspectorate for Wales, which previously regulated care services.