Ready for take-off

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.