news analysis of first year for inspection bodies in England, Scotland and Wales

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

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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%)