Do the work or risk a fall

Regulation of the care sector is vital for the health and safety
of people receiving care. But a misconception persists among some
of those on the receiving end that regulation and inspection are to
the detriment of care providers.

My experience, however, suggests that the red tape associated with
regulation provides an invaluable protection for service providers
where they have been affected by events beyond their control.

Some years ago the inspection unit which I headed received
notification from a care home that an 80-year-old resident had gone
missing. Three days later the resident was found dead in a local
wooded area. He had died, it was thought, from hypothermia.
Naturally the home, its staff and service users were all very

Relatives and other professionals felt the home may have been
negligent. A team of inspectors was dispatched, not only to
investigate the situation but also to offer comfort and support to
the home – which up until the incident had enjoyed a good local

The inspectors sought to establish:

l The circumstances of the resident’s disappearance: the time,
date, resident’s state of mind, staff on duty at the time.

l The service user’s care plan and care needs.

l A risk assessment relating to the service user and generally
in the home.

l The records and reporting processes of the home.

The inspection was vigorous and concluded that the registered
person and the staff had done everything in an exemplary manner.
Record-keeping was of a high order, risk assessment processes for
the general day-to-day running of the home were in place and this
was replicated for all individual service users. Care plans were
detailed and there were regular reviews and reassessments of
service users’ needs. All procedures required under the legislation
had been followed.

There were sufficient staff on duty at the time the service user
“went missing” and in fact the service user, who was reasonably
mobile and in full command of his faculties, had arranged to go and
see a friend in a neighbouring village. The home was aware of this
and had undertaken, with the resident, a full risk assessment of
this arrangement in a discrete and measured way. This was fully
recorded and signed by both the resident and the manager.

At the inquest it transpired that the resident had a heart
condition of which neither he nor the home were aware. On returning
from his visit he had decided to go for a walk in the local wood,
where sadly his heart gave out.

The records, systems and processes operated by the home were
presented at the inquest when the provider was called to account,
and the inspectors gave evidence to verify that all regulatory
requirements had been followed.

The efficiency of the registered person, the staff and the home’s
overall commitment to good record-keeping, proper procedures and
risk assessment was validated. No blame was attributed to the home,
its management or any individual member of staff. In short,
adherence to the so-called “red tape” protected the provider.

“Just a minute!” I hear people say: “it didn’t protect the service
user”. Well, yes it did; it protected his rights. The service user
did not die because of negligence. By involving the service user in
assessing the risk involved in exercising his choice to go and
visit a friend, and by enabling him to exercise his choice, he was
free to see someone he cared about and to walk quietly on his own
in a peaceful part of the countryside. It was inevitable that his
heart was going to fail at some time and if this had happened in
the care home it would not have caused such a concern.

This story raises all sorts of issues relating to our view of old
age, service user empowerment, assessment and management of risk.
Most of all it shows that the regulatory requirements and the
relevant national minimum standards relating to records,
record-keeping, procedures, assessment and review of care needs are
important. They are not bureaucratic processes designed to impose
unnecessary burdens on staff and managers. They are designed to
provide evidence to support the decisions taken and to back up the
approach a home takes to any situation.

If this care home’s records and record-keeping had not been of a
high order, the ending to this story could have been very
different. Not least because the emphasis on service user
empowerment and freedom to exercise choice would have been lost in
the rush to pillory the care home provider and staff.

So the message is clear, “red tape” is important; it can bind the
functions of a care home together and provides a framework in which
difficult risk decisions can be taken with confidence.

The real challenge for both provider and regulator is to ensure
that the administrative and management processes which can flow
from “red tape” are applied in a measured and thoughtful manner.
These should be kept to a minimum but not watered down to the
extent that they become meaningless and, as a consequence, fail to

Future of the NCSC   

The National Care Standards Commission is the independent public
body responsible for the inspection and regulation of social care
services, nurses’ agencies and private and voluntary health care
services, totalling approximately 40,000 care establishments in
England. The NCSC places the interests of people who use services
at the heart of its operations and ensures that these services are
run in accordance with national minimum standards and legal

At present there are several organisations within government and
independent of it that have responsibility for regulating different
aspects of social care and health care in both the public and
private sectors. The need for a more unified approach has been
recognised and changes are set to take place.  The NCSC will soon
be evolving to form part of the Commission for Healthcare Audit and
Inspection (CHAI) and part of the Commission for Social Care
Inspection (CSCI). These commissions will take charge of
regulating, inspecting and auditing the social and health care

The NCSC will carry forward to the new commissions its duties in
protecting service users and its work with providers in raising
levels of care, ensuring everyone receives care that meets legal
requirements and national minimum standards.  

Until the time when the new commissions are established, the
NCSC will continue registering and inspecting care services;
investigating the complaints and concerns of service users and the
general public; taking enforcement action where necessary and
reporting back to government on the issues affecting the care
sector in England.    

Heather Wing is director of adult services, National
Care Standards Commission.


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