Star ratings for care homes: what are the drawbacks?

Two years ago, unable to cope and at breaking point herself, Molly Pullman* accepted painfully that her 86-year-old mother needed residential care. But the anguish didn’t stop there.

Emotionally and physically drained, she had to make another life-affecting decision, with no knowledge or experience on which to draw, about which home to choose. She read some inspection reports but found them overlong, heavy-going and full of jargon: she realised she was more than halfway through one report yet had no idea what the inspector thought of the home in question.

Grading system welcomed
In Molly’s case, a quality or star rating for care homes, as will happen from April next year under the direction of the Commission for Social Care Inspection (CSCI), would undoubtedly have helped her, as she says, “sort the wheat from the chaff ”.

Les Bright, professional adviser to the Relatives and Residents Association, agrees: “People need straightforward information to help them make judgements about services of which they may have had little or no previous experience. So adopting a familiar grading system ought to be welcomed.”

Indeed, a short, indicative survey of 93 care home providers by Community Care shows that two-thirds welcome the idea. However, there are also deepfelt concerns about the credibility of such a system, particularly on consistency.

Given that CSCI and its predecessor the National Care Standards Commission, were set up as national bodies in part to iron out local regulatory inconsistencies, it may be surprising to hear that, four years on, the old problems remain.

“The star-rating system is based on a moment in time and is at the discretion of the inspector,” says one home owner. “There is a lack of consistency between inspectors even in the same areas.”

Another says: “All inspectors have different views on what they would like to see and how it is documented. One inspector was happy to accept a paper format which was rejected a different inspector!”

Inconsistency is a charge that CSCI’s inspecting for better life programme director, Anni Hartley-Walder, accepts. “This is a big move for the commission as well as providers,” she says. “We started preparing for quality ratings two years ago and started implementing it last year with the new reports. Consistency is not a new issue for us – we have been tackling it incrementally as part of a three-year plan.

“A quality audit trail, a new information, communication technology system, and the key lines of regulatory assessment (Klora) – the criteria to be used for making judgements – will make sure our inspectors go out with a common understanding of the criteria we apply to judgements. However, it’s important to understand that consistency is not sameness.”

One provider group, though, is yet to be convinced. A spokesperson says: “We are worried that they will not be awarded fairly and consistently as we are experiencing considerable variation between inspectors.”

Others feel similarly. “CSCI has a long way to go before it achieves basic competence in inspection,” says John Burton, an independent social care consultant and author of Managing Residential Care. “There are many examples of inspectors failing to identify neglect and abuse and, conversely, of failing to discern the true quality of care in homes that are ‘good’ or ‘excellent’ but in unconventional and innovative ways that are unfamiliar to them.”

Indeed, inspectors have been reluctant to praise the “true quality” of homes, perhaps through a negative, fault-finding mentality or a fear that any such praised home might later be subject to scandal or enforcement action which may call into question their competence.

“The new reports say positive things about homes for the first time,” agrees Hartley-Walder. “Previously it felt like an inspector was coming in to find out what was wrong. By saying what you’re good at and what you’re improving as well as what you need to improve upon, we’re building up a balanced scorecard approach.”

If star ratings are to sparkle with meaning rather than glimmer with gloss, qualitative judgements about care and life experience need to be made – but with skill, understanding and care. You can be objective about whether there is a care plan: less so about whether it is any good (which is surely the more important judgement). You can be objective about whether a requisite number of bathrooms exists. But what about whether bath-time is a pleasurable as well as functional experience?

Training will be critical
Faced with such complexity, training will be critical, says Des Kelly, executive director of the not-for-profit sector’s National Care Forum. “Better information and a better understanding of the quality of services have the potential to improve care services radically,” he says. “The implementation and operation of the proposals will be a crucial aspect to introducing the change successfully, and guidance and training for inspectors would be essential.”

Hartley-Walder says CSCI has already made a huge investment in training. “I went around the country and personally trained every manager,” she says. “In January and February 2007, all commission staff will have a further five days’ training before the introduction of the quality-rating system. Over 18 months, every inspector will also go on plain English training.

” In the first year, however, no home will receive the top rating of four stars as a record of excellent care is needed to obtain the maximum accolade. Not so for the onestar homes. Hartley-Walder estimates that 5-8 per cent of the sector (which could be more than 2,000 homes) will be judged as providing an “overall poor quality service”.

But how poor is poor? Bright asks: “Should homes where ‘insufficient priority is given to people’s privacy, dignity and independence’ or where ‘there may be evidence of potential risks to health and well being’ still be in business?”

He adds: “Fifteen years ago, planners and policymakers believed that the move to a market in care would drive out poor quality services. If one-star homes exist it is an indictment of market economics, and strengthens the case for enforcement.”

Despite its desire to end bad practice, CSCI is yet to convince when it comes to enforcement. “We want to give providers time to improve,” says Hartley-Walder, who adds that CSCI is telling (but not publishing) all providers what their star rating would have been this year based on their “key” inspection. “One-star providers know who they are and what they need to do to improve,” she says.

It also seems likely, as our survey suggests, that providers will chase ratings, by shifting their focus on to the key areas to the detriment of others. “In the scramble to gain maximum stars, many important aspects of care will go by the board,” one owner warns.

“We hope that doesn’t happen,” says Hartley-Walder, “but we do want to encourage and incentivise providers to improve outcomes. If that’s the way it happens then I can live with that.”

Nonetheless, the National Care Association, which represents more than 4,000 independent care home owners, fears inaccurate or unfair star ratings could force some homes to close. “Our key concern is the potentially devastating impact it could have on small care providers should mistakes be made during an inspection,” says NCA chief executive Sheila Scott.

While CSCI acknowledges the anxieties of the sector, the tension remains that star ratings for care homes are a simple indicator for something that is complex.

Question of choice
Care homes are not hotels or restaurants; some five-star establishments disappoint and some of those with few or no stars pleasantly surprise. We tend to like what we’re comfortable with. Molly Pullman, like many others, didn’t have a real choice because the home she wanted for her mother had to be nearby. She decided to bin the CSCI reports and visit homes herself.

She plumped for the home in which she felt her mother would feel most at ease (and with some success: mother is thriving and Molly is happier).

But here’s the thing: the home she chose would never be a four-star home and, had it been rated two stars (a real possibility), Molly admits it unlikely that she would have even checked it out.

In the field of care, CSCI’s chaff might be Molly’s wheat. Now that’s four-star food for thought.

*Not here real name

Further information
Relatives and Residents Association

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