Part of the blame for the mediocrity of many of our care homes and home care providers is the weakness of their regulators, the Adult Social Care Directorate of the Care Quality Commission.
The Commission rates providers for Safety, Effectiveness, Caring, Responsiveness (to users’ needs) and Good Leadership.
For each of these domains a provider will get a rating which can be Outstanding, Good, Requires Improvement or Inadequate.
Safety, responsiveness and good leadership are obviously important whatever is being inspected. Effectiveness is particularly crucial for hospital, GP and dentist inspections where there is a definite outcome to the service – some kind of bodily improvement. The Commission is often good at this sort of inspection. My excellent dentist had overlooked he need to have a decontamination room. Now, thanks to the CQC, he has one and all his patients are that little bit safer. The Adult Social Care Directorate is also good on safety issues, though sometimes what they criticise is rather trivial.
However, the domain which is arguably the most important in Adult Social Care is Caring and it is here that the weakness of this directorate is evident.
Over the last year there have been a growing number of cases where a worried relative has put a camera or an audio device in a vulnerable person’s room and discovered really disgraceful (or, as the CQC would have it, inadequate) care. The relative then takes the footage to the media (typically Panorama or the Daily Mail). On September 21st the Mail reported on the Ridings in Castle Vale near Birmingham where a carer was shown ripping the sheets off an elderly dementia sufferer while she slept and then ordering her to make her bed.
The Daily Mail’s articles are powerful and usually have a salutary effect on the provider. What their journalists often neglect to do is to include anything about what the Care Quality Commission’s rating for the home they are exposing.
The appalling care at The Ridings happened last January. In the very same month the CQC had rated the home as Good for Caring.
The reason why the CQC consistently fails to discover the really bad care is the inadequacy of the inspection methods that they confine themselves to.
They talk to a few users of the service. Necessarily these are the ones who can understand the CQC’s questions and leave out those with dementia who are usually the most at risk. Almost all the respondents describe their care in glowing terms – which is perhaps not surprising since they have to go on living in the homes and the homes know who they are.
The Commission also talks to some staff and some relatives but the staff are hardly likely to reveal abuse and the relatives are not around when it happens.
They use a technique called SOFI (Short Observational Technique for Inspection). This involves watching staff interacting with residents, especially at meal times. As the staff are well aware of the presence of the inspectors, this too is unlikely to reveal abuse.
Finally they look at care records; but perfect care records do not necessarily indicate perfect care.
After Panorama had shown a resident being slapped in the Old Deanery, Braintree, which had just had a clean bill of health from the CQC, the Chief Inspector, Andrea Sutcliffe, excused the Commission on the grounds that it was impossible for inspectors to see everything.
That may be true but if the CQC did not consistently set its face against the use of camera or audio surveillance, they would see a great deal more than they now do – and if they still missed anything, they could honestly say they had done their best. Not only will they not use it themselves but the guidance they have published for friends and relatives who might be considering it is quite discouraging. They go out of their way to emphasise all the pitfalls and play down the enormous benefits. Nor are they any more encouraging to concerned providers who want to put in camera systems. When they inspect such homes , their concern is to ensure that the footage is securely stored – there is little sign that they themselves want to look at it.
In conversation, Ms Sutcliffe claims that her reluctance to encourage homes to use cameras is the expense involved. She would rather see money being used on recruitment or training. It is true that the excellent camera system being offered by the new company, Care-Protect, would cost £10 per resident per day in a 70 bed home. However that is largely because they provide experts to monitor the footage for the provider. A small home care provider local to me offers relatives a video link to monitor their care for a flat £100.
Ms Sutcliffe’s other reason for holding back is that a substantial number of people object to cameras on grounds of residents’ privacy. This ignores the fact that most care home residents and home care users sacrificed their privacy at the moment when they started receiving personal care. It also ignores the strong likelihood that they would willing allow surveillance into their private space if that meant more kindness and compassion. In any case the Adult Social Care Directorate should be firmly in favour of cameras. They simply cannot do their job properly without them.
When Ms Sutcliffe became Chief Inspector, she proudly proclaimed that from now on the Commission would be applying the Mum Test (if care is not good enough for our own mother, it is not good enough at all). Two years on care in many settings is patently not good enough for anybody’s Mum but the CQC complacently accepts it.