When will the inspector call?

Last month, the Commission for Social Care Inspection announced that the best providers of adult care services will be fully inspected once every three years. Currently, all providers are scrutinised once or twice a year. The CSCI’s David Behan explains the reasons for the change while Action on Elder Abuse’s Gary FitzGerald examines the pitfalls

David Behan, chief inspector, Commission for Social Care Inspection

The people who own and run care services are today more aware of the need to stamp out abuse and poor practice.

The proper regulation of providers, new qualifications for social workers and care workers and proper Criminal Records Bureau and reference checks are designed to professionalise a once unregulated sector. All care providers are now legally required to have proper complaints handling procedures. If found guilty of abuse or neglect – or even of knowing abuse or neglect was taking place – people can be subject to a criminal prosecution.

The CSCI’s remit is to regulate and inspect all social care providers, including councils, in England. Our main aim is to put social care service users first in everything we do. We want to see a care services industry that is professionally run and properly controlled by those who own and manage care services.

In our 2004 consultation on proposals for modernising our inspection process, people told us they wanted us to concentrate on improving the poorest services. They supported more unannounced inspections, simpler and clearer inspection reports, tougher enforcement to stamp out bad practice, and a greater involvement by service users in the process.

We are now in the process of delivering this. Central to our new approach is our move from the “one size fits all” process to a more targeted approach.

A key phrase in our inspection philosophy is “proportionate to risk.” Regulation needs to be proportionate to the risks to which people are exposed, and to the likelihood of failure occurring. The government has announced changes to the statutory regulations that allow us to vary the frequency of inspections.

Poor performers will face repeated inspections, spot checks and visits until they improve. In contrast, the best providers will not face as many inspections as long as they continue to reassure us they are delivering high quality care and have the performance assurance systems to do that. The frequency of inspection for each provider will be based on a rigorous, continuing risk
assessment.

The new system is designed to:

Encourage improvement and be tough on bad practice.

In the next 15 months every service will receive a full inspection to establish a baseline against which it can be judged. From 2007, there will be an annual review of each service informed by factors including information from the service provider, the views of service users, and evidence from any complaints received about the service. We will be tougher on poor performers, who will have to show they are complying with our requirements to improve.

We will also closely scrutinise the way councils commission services. From now on we will share inspection information with councils to ensure they are aware of our judgements on the quality of the services they commission. We will challenge councils that regularly commission poor quality services and ask why they continue to purchase poor quality care.

We put people at the centre of our work. Our job is to reconcile safeguarding, risk and people’s independence, while challenging poor quality care that does not meet the aspirations of people who use services.

Gary FitzGerald, chief executive, Action on Elder Abuse

The planned changes within the CSCI have their origins not in social care inspection itself, but in a document produced three years ago by the Prime Minister’s Office for Public Services Reform. Inspecting for Improvement: Developing a Customer Focused Approach, outlined the new direction for inspection bodies in general, and proposed the majority of the ideas later found in Inspecting for Better Lives. Consequently, there is a wider strategic context to these changes that extends beyond CSCI and covers a regulatory regime costing in excess of 500m in any one year.

Inspection has a key role in raising and maintaining standards, providing assurances to the public, and providing independent data on the reliability and quality of care provision. It has a historic role wherever there are risks to the health, rights or well-being of people and can provide protection to both service users and providers. But it cannot be the sole means by which such issues are assessed. It should not become so cumbersome or self-righteous that it gets in the way of good care provision or usurps the rights of people to control their lives. And it has been in danger of doing both.

Many of the new changes will be welcomed by users, providers and organisations that seek to ensure vulnerable adults have control over their lives. Targeting providers who consistently fail to deliver on minimum standards, while treating others as equals in the drive to improve care quality, is laudable. Finally discarding the pretence of announced inspections is long overdue.

Reducing unnecessary paperwork, while making reports understandable and consistent, is sensible. These changes are about processes and increasing the potential for inspection to be a useful tool in challenging abuse. There is a high probability they will have the desired effect and they should be supported.

It is the issue of “proportionate inspection” that causes alarm bells to ring. This is a risk-based approach that proposes increased inspection of poor performers while undertaking fewer inspections of others. It is modelled on the Audit Commission’s approach to the comprehensive performance assessment of local authorities and assumes the status quo can be used to predict future activity. The advantages are that it rewards excellent performers by offering less scrutiny while eliminating the need for increased investment to inspect poorer performers.

But even the prime minister’s own report recognised there may be some areas of service provision where the risk of not inspecting may be too high, and it is noted the CSCI have chosen not to introduce these reforms into children’s services.

The reality is that service provision for adults is highly variable. There are many excellent providers, with robust quality assurance systems and a commitment to care quality that is exemplary.

There are also a myriad of small providers who are struggling to survive, and there is a domiciliary care sector that is often close to crisis. If anything, this sector needs more – not less – help, support and regulation if it is to succeed and the regulators need to stay close enough to do this.

Apart from the potential impact on service users, proportionate inspection will not encourage public confidence. It is unlikely care provider quality assessments will do so either. They lack the independent verification people need, particularly if the last CSCI inspection was three years ago. Proportionality also fails to deliver the intelligence that is so often picked up by good inspectors.

In the final analysis, time will tell as to whether this is a strategy to re-engage positively with good care providers and challenge poor practice, or a budget cutting exercise. Perhaps some effective enforcement action may demonstrate which is which.