Beauty or beast?

The long-awaited National Care Standards
Commission is hatching. Ruth Winchester talks to chairperson Anne
Parker about how it intends to start work and gauges what sort of
reception the new body is likely to receive.

Next month, something will hatch in the social
care sector that will change it for ever. The egg has been visible
for a while, but no one was sure what would emerge from it. Now,
however, the shell is cracking. The National Care Standards
Commission is almost upon us.

This powerful new body has been set up under
the Care Standards Act 2000 to take responsibility for ensuring
quality in a very wide range of public, private and independent
care settings in England. These include residential and nursing
homes, day centres, children’s homes, domiciliary care services,
adoption and fostering agencies, nursing agencies and boarding
schools. In terms of regulation, many of these services represent
virgin territory.

Nor is this any harmless, voluntary “do it if
you feel like it” affair. The commission has very significant
powers – from warnings and fines through to closure of services and
exclusion of individuals from social care – and it is certain to
use them.

The overwhelming response from those about to
be regulated has been “we’re delighted that it will put the
emphasis on quality” followed by a lot of “buts” and “ifs” and
“what abouts”. And to be fair, the commission has hardly put
people’s minds at rest. Over the past 12 months it has given a lot
of conflicting messages about exactly what line it was going to
take over the standards and regulations. One starting point was
that the standards were “non-negotiable”, which caused a certain
amount of hysteria among care home owners whose rooms were six
inches too small.

There does, now, seem to be a reasonable
understanding on all sides about the distinction between the
standards and the regulations, and what line the commission is
going to take (at least in principle). Regulations are mandatory;
standards are not. The regulations say “jump”, the standards tell
you how high. The crucial point now is how the commission
interprets its responsibility to “enforce” the regulations, and
“take the standards into account”.

Unfortunately, anyone expecting a quick,
straightforward answer is going to be sorely disappointed. This
body is so large and so new that it is going to take time, probably
several years, before any real answers emerge.

At the time of writing – two weeks before the
Commission is due to go live – only 55 of its 1,700 permanent staff
are actually at their desks. This rather alarming statistic gives
some idea of the truly awe-inspiring scale of the operation and the
massive upheaval that is going on in local authorities and health
authorities across the country.

Inspection staff are being drafted in from 200
different employers. The commission has had to negotiate with
hundreds of different workers over hundreds of different sets of
terms and conditions, and they are all going to start work at the
beginning of April. Many are on day-release training courses in
preparation, but there is realistically no way that the whole
edifice will spring into co-ordinated action when it goes live next
month. Even if it did, the size of its regulatory task means it
will be some time before every corner of the country has had the
spotlight turned on it.

And, with so many people arriving at the
commission with different skills and experience, there are going to
be questions about the consistency of inspection and regulation
decisions. CCETSW and the General Social Care Council have created
a new training course for regulators, the Regulation of Care
Services Award. But it will take an estimated three to five years
before all inspectors are trained to that standard. In the interim,
how can one organisation be sure it is getting the same treatment
as another? The answer, according to commission chairperson Anne
Parker, is that they can’t. Not yet, anyway.

“Ensuring consistency is going to be
difficult,” she says. “It may feel unsatisfactory both from the
point of view of the field, and of our staff, for some time.
Inspectors are going to think we are horribly bureaucratic. Some of
the freedom of movement they’ve had in the past is going to be
constrained in the short term, while we say ‘hang on, can we look
at this,’ and a locality manager checks with her area manager. We
are going to be building case law, essentially.

“And it may feel unsatisfactory from the point
of view of the field, because they are not going to get a quick
response. I’m sure we will be criticised, because we are taking
time over some things that might have been given a snap decision in
the past.

“The timescale I’ve got in my head is that we
really ought to be demonstrating some consistency toward the end of
this year, and be making good progress toward achieving that at
about 18 months. And then stable by year three.”

This is probably not what people want to hear.
Regulation is going to be difficult for some, and hitting a moving
regulatory target is going to be harder. But for those who are
daunted by the task, Parker has some consolation. The first is that
any “regulatory absurdities” that have arisen during the drafting
of the standards and regulations – and providers argue that there
are many – will be drawn to the government’s attention. According
to Parker: “If we identify absurdities, or if there are things that
we cannot operationalise, then the government needs to know.”

The second is that the standards are not set
in stone and while the commission was not involved in the initial
round of drafting, it will draw on its substantial experience
within the sector in drawing up the next round.

“We’ve kept ourselves out of the consultation
loop on the standards this time – we have been given the
standards,” Parker says. “We see our role now as to comment on how
they can be used effectively as instruments for regulating – do any
of them not work very well, and what ideas are we picking up – to
inform the next round.

“The government intends to review these
standards periodically. What periodically means I don’t know – I
don’t imagine they’ll be digging them up every six months – but the
notion is that these are living things.”

Feeding into the evolution of the standards is
going to be a central part of the commission’s remit, and that
depends on intelligence gathering. There is a staggering
information black hole around some services – with no centrally
co-ordinated information about numbers of beds, numbers of staff,
client groups, dependency levels, outcomes or costs. Part of the
commission’s remit is to put some flesh on the bones. The idea is
that it will be a “virtual” organisation, existing wherever there’s
a laptop and a telephone, and regulation will be a largely
web-based process.

The new IT system is, of course, late in
arriving and, as Parker admits, “no one’s actually pressed the
button yet, so we don’t know whether it’ll sink into a heap with a
sigh when that happens”. But the idea is that inspectors will file
their reports online, and providers will have access to a web-based
resource centre where they’ll be able to find all they need in
relation to the NCSC.

The database will also provide the commission
with a lot of valuable information. “The objective is to be able to
gather information in computerised form, and be able to add it up,
subtract it and analyse it,” Parker explains. “At the end of the
year we should have a lot of data which tells us which standards
are being met, which aren’t, which are being exceeded and what good
ideas there might be out there.

“I am very much hoping that there will be good
ideas from providers who say to us, well, we might not be meeting
that particular standard, but we are meeting the outcome that sits
on top of that standard, and this is how. And that might be built
into future standards.”

Another key aspect of the work is what Parker
describes as “the unfolding of enforcement”. She suggests that year
one will be a relatively “softly softly” year for the commission
while it gauges the lie of the land and inspectors learn the ropes.
Year two will see the beginning of a gradual “ratcheting up” of
standards. But that does not mean a policy of non-enforcement –
laggards will not be tolerated. “We may well be moving into
enforcement earlier in some sectors where there is a very poor
history of compliance – where people are not arriving with a clean
sheet.”

With all this emphasis on provider
organisations and the inspections, the real raison d’ˆtre of
the commission is easily forgotten – protecting and ensuring
quality for service users. And therein lies the rub. Service users
are not a uniform bunch, and they don’t always want what the
government thinks they ought to want. A spate of recent battles
have been fought by residents over the unwanted closure of care
homes – and it is probable that sooner or later the commission will
find itself in the unenviable position of taking action which goes
directly against the wishes of the people it is there to
protect.

Parker hopes this uncomfortable scenario will
be avoided by listening to what service users tell them is
important. “It might be the case that there is pressure to focus on
room sizes, while all the residents tell us it is food we should be
focusing on. That would moderate our priorities. But we undoubtedly
will be in the position where we are making decisions that are not
entirely in accordance with the wishes of some service users, and
we will have to be very, very sure that we can explain what we are
doing, and why we are doing it. Hopefully we won’t get to that
stage as a matter of surprise to everybody – if things were really
that bad hopefully you would have spotted something coming. But you
don’t always, of course.”

While deciding whether a service is good
quality may be relatively straightforward, the commission is
heading into tricky territory when it comes to commissioning
arrangements. How, for example, will it handle a situation where a
provider cannot give quality services for the rates a commissioner
will pay?

One condition of any registration with the
commission is that of financial viability. Parker says: “It’s a
very complicated thing to make a judgement on. Is it financially
viable so that I’ll lend you some money? Is it financially viable
so I’ll buy shares in you? Is it financially viable so that you can
feed the residents and pay the staff and mend the roof? We are
talking with the market about that.

“But at some point, once you’ve got all the
other noise out of the system, you are going to come down to fee
structures and occupancy rates. At that point, it could be that we
have to say to a provider, on the basis of your assumptions on fee
structure and occupancy rates, you don’t look financially viable.
That’s a judgement we have to make.”

She is unwilling to be drawn further but
insists that money, while important, is not the whole equation. She
cites personal experience of similar organisations producing very
different outcomes with identical financial resources.

Perhaps this is the most difficult
characteristic of the commission to accept – that it doesn’t have
all the answers. There are questions to be asked about whether it
is fair to treat service users, staff and organisations as
unwitting guinea pigs in an unprecedented national experiment. In
any event, it is clearly going to be difficult for those on the
receiving end to have confidence in a process, and an organisation,
in its infancy.

Parker fully acknowledges the lack of
certainty, saying: “There are a lot of don’t knows.” But she adds:
“People are going to have to learn to live with some don’t knows,
while we work out what the right answer is.”