Inspectors 1, Residents 0

The resident is the most important person in the care home. So
why, asks Graham Hopkins, do inspectors spend more time filling in
forms than asking them what they think?

The National Care Standards Commission goes live on 1 April 2002
when it will assume sole responsibility for social care regulation
in England. “It will be a champion of quality care,” announced
Minister of State, John Hutton. The NCSC sees itself as “a champion
for safe, high quality services.” In a league of one I guess it’s
easy to be the champion, but what about the quality of the
performance?

The NCSC’s initial vision includes, a “suite” of “not just, but
also” statements. Thus, the NCSC is “not just an inspector of
standards but also a catalyst for improvement in care
standardsÉNot just a standards enforcer but also a standards
promoterÉNot just an inspectorate but also a proactive
body…” and so on.

This is apparently subject to the approval of accountants and
further thought, either of which may lead to a revision of the
vision. But, that aside, how can the NCSC be sure the goalposts
won’t be moved or that something will muddy the playing fields and
we will all end up with nothing?

The potential strength of the NCSC lies, so to speak, not only
in its independence but also in the opportunity to ensure
consistency of approach. For it must have been a perceived (but
probably very real) inconsistency in standard setting, inspection
process and enforcement that has caused the breakaway to the new
squeaky-clean care champions’ league from the old divisive,
politically-driven local authority one.

Reassuringly, the NCSC seems to want to keep the political
football at its feet with policies that show a thoughtful and
skilful belief in developing the quality of care through regulation
and in partnership with providers, rather than by launching itself
down the enforcement and legal minimum channels.

The introduction of national standards is a positive and crucial
move for the NCSC. But to keep its supporters happy, it needs to
ensure that its approach towards the vast bulk of its work –
inspection – is tactically sound.

At the moment, it seems that the process of inspection is too
reliant on fixed interviews with senior managers, and the
examination of records and buildings. Somehow the people who live
in or use registered care services all too often fail to have their
voices heard. Many inspectors admit that they haven’t enough time
to do everything during an inspection and often it is time with
residents that is cut from the schedule. Some delegate that aspect
to an accompanying lay assessor (a member of the public recruited
to help with inspections), but they are there to supplement
inspector time with residents not supplant it. The message we’re
left with at – intended or otherwise – is that residents are the
least important part of the job.

And yet ask any inspector and they will say the most important
person in a care home is the resident. So why does the practice
relegate the principle? Perhaps inspectors believe they can gain
more useful information talking to people who are on a similar
hierarchical level, or as has been suggested they just feel more
comfortable communicating with other professionals.

Also, inspectors believe that home owners and managers can give
the inspector the information they believe they need. And it is the
quality and quantity of that required information that needs to be
reviewed. In one inspection report format you can, by page eight,
discover how many residents have colostomy bags but you have to
wait until page 40 (of 41) to find a few meagre sentences on what
residents think of the home and what it must be like to live there.
But at least it’s there. More often than not it isn’t.

Inspectors have argued that it’s all well and good talking to
residents but you may “not pick up on all the issues that need
addressing” – which is inspector-speak for “residents might not
tell you about any problems”. This is because residents may be
grateful to the home (developing a “misplaced loyalty”), may have a
fear of retribution if they speak their mind, and, in any case,
have low expectations of care.

Perhaps it’s not just residents who suffer low expectations but
also the people charged with their protection. None the less, all
of these arguments are very real concerns. But I’m equally
concerned that an inspector might willingly adopt such a “not only
time-consuming but also possibly flawed” attitude to what residents
have to say – and not bother finding out. Or, worse still, make
some tokenistic: “So, do you like living here?” effort.

Many residents, of course, have great difficulty in
communicating lucidly, verbally or at all. In short, communicating
meaningfully with residents demands time, patience and effort –
three things sometimes in short supply for an already
over-pressurised target-driven inspector.

Another reason inspectors might feel uncomfortable talking to
residents is they may worry about making judgments. Checking for
chipped paintwork and checking records for fire drills is
relatively straightforward – either the paintwork is chipped or it
isn’t; either the fire drill happened or it hasn’t. It’s objective.
It’s provable. However, proving whether something less tangible
such as the “quality of care” (which we all talk about in feel-good
terms but rarely define) is any good is much less certain.

In making these judgments, normally confident inspectors look
about anxiously as they see themselves treading on the egg-shells
of subjectivity. They crave the solid marching ground of
indisputable objectivity. And retreat from commenting on the
“atmosphere” in a home in order to go over that risk management
policy again.

But isn’t judgment precisely the point of inspection? Isn’t that
what we pay inspectors for? If inspection truly was just a game of
football, judgment would be the ball. And an inspector unwilling to
make judgments would be a player unwilling to touch the ball. They
shouldn’t be on the pitch.

Inspectors should say whether a home is any good or not (by
assessing the quality of experience of living in a home) because
that is generally what residents, potential residents and all their
families (and staff, I’d wager) want to know first. Naturally,
inspectors should also detail the evidence that each judgment is
based upon, so that the judgment itself can be judged. And, I
suggest that although checking paperwork, the building and
interviewing managers and owners in offices are clearly part of the
overall game plan, the most time, energy and creativity during an
inspection must be spent with people.

This means involving all staff, relatives, visitors, friends,
social workers, carers and so on. And of that time spent with
people, most must be spent with the people who matter most of all –
the people who live in the homes.

All of this means, of course, the humanising of inspection,
making it accessible, friendly and people-centred. Interestingly,
research for my book showed that the quality most sought by
providers in “the ideal inspector” was not qualification,
experience or knowledge, but rather approachability.

Now that’s a tempting cross to get your head on if ever I saw
one. Which is also why it’s a shame the NCSC prefers – to date at
least – to be a monolithic “it” organisation (and undoubtedly a
“robust” one at that) rather than a people-centred, friendly and
diverse “they”. How much better to be able to substitute “NCSC” or
“the commission” for a friendlier pronoun: “it is our initial
vision” and “we welcome your views” and “please contact us”. Humans
live in care homes. Humans staff them. Humans inspect them. We
should be confident in our approach being human also.

If the NCSC, in formulating their goals, can pick an inspection
process that puts people, not things, at its heart then it might
rightly be challenging to be the true champions of care. And they
can start by developing different tactics to influence how an
inspector reads the game. Inspectors often say that they observe
care practices in a home while they are checking the building. I’ve
always wondered why they don’t check the building while observing
care practices. A small shift in words but a huge leap in culture.
And I’d pay good money at the turnstiles to see that.

Graham Hopkins is author of An Inspector Calls – A
Practical Look at Social Care Inspection, published by Russell
House (01297) 442 722.