Rebuilding trust: How the CQC plans to transform adult social care inspections

Adult social care is once again in the media spotlight for all the wrong reasons.

BBC Panorama’s undercover filming at the Old Deanery Care Home in Braintree captured shocking footage of its elderly residents being mistreated. One elderly woman with dementia was slapped by an employee, a bed-ridden man was left lying in his own excrement and residents were repeatedly mocked by care workers.

With the mistreatment at the Old Deanery reviving memories of the abuse at Winterbourne View and the “clean bill of health” given to the home by the Care Quality Commission (CQC) in November, there’s a lot riding on the regulator’s forthcoming changes to adult social care inspections.

And the task of implementing those changes falls to Andrea Sutcliffe, the chief inspector of adult social care at the CQC.

The shocking footage captured by Panorama, she says, makes her feel sad and angry.

“I feel a huge disappointment on behalf of the people who are affected,” she says. “It also makes me feel very angry because it shouldn’t be happening. I feel very angry on behalf of the people who were affected but also angry on behalf of the people who do do a good job because everybody then gets tarred with that same brush.”

The uncovering of such failings is not just limited to TV documentaries, she adds: “Sometimes these things are not exposed through these sorts of programmes. We are picking up examples of poor practice on our inspections and people write to me about things all the time.

“It makes me feel even even more determined for the CQC to play its part, alongside other bits of the system that need to play their part, in actually making it better.”

The new regime

For the CQC, the new inspection regime that is currently being consulted on and tested out is what will make it better.

Sutcliffe says that the new approach, which will also introduce a grading system for the quality of care provided by services, will be more effective and probing, and should help raise the quality bar.

“There is some fantastic care, there is some care that needs to improve and there’s some very poor care,” she says.

“It is that variability that I am struck by and one of the things we are trying to do is to move away from saying a service is compliant or it is not compliant with basic minimum standards to actually be able to say whether they are inadequate, requiring improvement, good or outstanding.”

Under the revised inspections, which are due to start October, adult social care services will be judged on five broad questions: Is the service safe? Is it caring? Is it effective? Is it responsive to people’s needs? and is it well led?

“At the moment we know what those top-level questions are but the challenge is how do we make sure we ask questions of providers, of the people who use services and the intelligence and information we get from other people so that we can make a robust and credible judgment,” she says.

“We’ve got the consultation out at the moment which sets out how we plan to do that. We’re also coming to the end of our first wave of testing that with 250 providers and we’re learning a lot of lessons from that.”

Those lessons include avoiding duplication in what is examined under the five questions, knowing what information to request from providers in advance of inspections and making sure the resulting reports are clear enough for both people inside and outside the social care sector.

But the feedback, she says, is that the new approach is succeeding in digging deeper into what providers are doing.

“What we’ve also been getting back from the inspectors and our experts by experience, who are increasingly part of the inspection team now, is that they do feel we are getting underneath the skin of the service with the way that we are doing these inspections,” she says.

“So people are feeling much more confident about the judgments that they are making because they are taking that much more rounded view of what’s happening.”

Biennial inspections

Another change is that the best providers will be inspected at least once every two years rather than once a year.

It’s a change that might raise eyebrows given that the CQC introduced annual inspections in 2012 because some providers were going unchecked for up to two years.

But, says Sutcliffe, there are more checks and balances in the arrangement now.

First the assessment of whether a service is good enough to be inspected biennially will be made on a “very robust and rigorous basis” and the CQC is going to reserve the right and ensure it has the capacity to do a random inspection of the service at any point “that people don’t rest on their laurels”.

“We will also be improving our intelligent monitoring of services and making sure that we are picking up on any of the warning signs that may happen that would suggest to us that we should be going back in sooner,” she adds.

These warning signs include an increase in safeguarding notifications or unexpected admissions to hospital or the departure of the registered manager.

Examining the quality of management will be central in deciding what grades care services will get.

“I’m not sure where this comes from but there’s a saying that ‘the fish rots from the head’ and I think that’s right,” she says. “I’m a firm believer that the way that an organisation is run and led absolutely sets the tone for the service that is provided.

“What their vision is of what the service should be, how person-centred it is, what training they are putting in place to support staff to deliver the care in an appropriate way, managing the rotas, responses to the changing needs of the people who are staying there, all of those kind of things rest firmly and squarely with the people who are running the service and managing it on a day-to-day basis.”

Registered managers

In line with this view the CQC began a “crackdown” on services that lacked a registered manager back in September after finding that one in eight did not have one.

The CQC homed in on 2,439 services that lacked a registered manager. Now more than half (57%) of them have one in place and another 590 have been given a fixed-penalty notice, according to board papers released this week.

“We have issued a number of fixed-penalty notices to providers where they didn’t have a registered manager and there wasn’t an application in process and there wasn’t a good reason for that gap,” says Sutcliffe.

“The most important thing though is not for us to issue fixed-penalty notices, but to get people to recruit registered managers – that’s what we want to happen.”

Fixed-penalty notices are, of course, only one tool the CQC has for dealing with wayward providers. The Care Act has given it the ability to prosecute providers without having to give them a warning notice first.

“The Care Act as it now is will be incredibly helpful in strengthening the range of options that we’ve got to deal with poor practice and problem providers, so I think that it will give us options that we may, when the grounds are there to do that, we may need to take and we won’t shy away from doing that,” she says.

“But I think that one of the really important things that we’ve got to concentrate on is making sure we are encouraging services to improve.

“Of course there are circumstances where we will go in and see that it is just awful and we just have to act within 24 hours, but when you’re talking about adult social care this is people’s whole lives. Either they are getting services provided to them in their homes or they are in a residential setting that is now their home.

“They have every right to expect that services will do the right thing by them and certainly that we shouldn’t be closing things down overnight and moving them and putting them at risk from that point of view when actually we should be making sure that providers are doing the right things to improve the service.”

Hidden cameras

Another, more controversial, power that the CQC is now looking at how to employ is its ability to use mystery shoppers and covert surveillance to monitor providers suspect of delivering poor care.

The CQC has had the power for some time. It was granted under the Regulation of Investigatory Powers Act 2000, but the CQC is now consulting on if and how it should use this power.

It is, she admits, a power where finding consensus isn’t easy.

“We’ve asked some very specific questions around mystery shoppers and CCTV because as I’m sure you can imagine this is an idea has flushed out a lot of opinions,” she says.

“There is a huge range from some people who said ‘Why weren’t you doing it yesterday?’ to some people who think I’m the devil incarnate for even mentioning it and a huge majority within that who say ‘we can see there might be some circumstances but how do you make sure people’s dignity and privacy are respected?’.

“It’s a tricky one. Through what families and undercover reporters have done we’ve seen very poor care being exposed in that way and poor care that you would not expect to be on display in front of an inspector.

“So you could see that if you had very specific concerns and wanted to follow those up that could be one way of doing it.”

“What I’m really very keen for is that we actually do have an honest debate about it. I understand that people who are working in the service, many of whom do a cracking job and are dedicated, committed individuals who get let down by those people who do an awful job might not want a camera tracking them all day.

“But, equally, you just have to watch that poor daughter on the Panorama programme who was beating herself up that she had organised for her mum to go into that service and there she was watching her mum get slapped. The anguish that that causes for people is awful.”

Improving commissioning

But there are other less confrontational techniques that the CQC hopes will encourage providers to raise their game.

For a start there is the incentive of a good or outstanding CQC rating to boast about.

In addition Sutcliffe believes that the new inspection approach will also help to indirectly hold local authority and NHS commissioners to account.

“The information that we provide as a consequence of looking at providers is actually really helpful in giving some insight into what commissioners are doing,” she says.

“We’ve got to remember that this isn’t a unidimensional situation and about half of residential care and some domiciliary care is self-funded, but I think what we need to be doing is pulling together the information, and our ratings will really help us with this, in a way that enables us to demonstrate what the quality of those services local authorities are purchasing are.

“So once we’ve got to a position where we’ve done a lot of the inspections and ratings, we will be able to produce local authority profiles of services and provide that to, for example, health and wellbeing boards or clinical commissioning groups so that they can use that information to hold commissioners to account.”

But will these changes be enough to overcome the damage caused by high-profile incidents like those at the Old Deanery and restore public trust?

“I really hope so,” says Sutcliffe.

“It goes back to the point that we play a part in doing this so I think that we can really help in terms of winning back the confidence of the public in terms of adult social care by celebrating the successes of the good services, providing clear information that is credible and robust and demonstrates what good looks like but also that we are seen to be taking the firm action that we need to take when we uncover poor care.

“I do think we have a really important role, but we need to be doing that with providers, commissioners and other leaders across the social care sector.”#