How Collaboration can make the new Care Service Inspection Regime Benefit Everyone

A new system

At-a-glance report cards are to be introduced for every nursery, childminder and care home for elderly people from the start of April 2008 in a new move to make these services more transparent and accessible.

The Care Commission, Scotland’s national care regulator, which is bringing in the new regime, believes it will be easier for people who are likely to use the services to check a provider’s quality and performance and decide whether or not to use it on that basis.

Under the old system, providers faced two inspections a year, one announced and the other unannounced. The resulting reports were published on the Care Commission’s website with recommendations if standards were not met and requirements if regulations were not met.

The new system will aim to be easier to understand by introducing a simple ratings guide focusing on between three and five separate areas, including care and support or information; environment; staffing; and management/leadership.

Unlike in England, which is bringing in hotel-style star ratings, Scotland’s facilities will be marked from one to six, with six being excellent and three to four being adequate. The scores will be backed up with more detailed background and explanation.

In response to Care Commission findings that users want more input into how care services are run, providers will have to demonstrate that they have consulted with users and relatives if they are to have any hope of achieving top marks.

Is excellence possible?

The Commission argues, reasonably, that responsible care providers will welcome the new inspection regime since they are making best efforts to comply with National Care Standards as things stand.

However, with 15,000 inspections of care services being carried out in Scotland every year and the consequent demands on providers’ resources, it is also reasonable to expect that the standard of the inspections themselves is consistent, objective and of high quality.

Already there have been indications that the inspection regime bar is being set unrealistically high and providers have been given to understand that the “excellent” marking will rarely, if ever, be awarded. The rationale for this is that providers will always have something to strive for.

But this is just as likely to act as a strong disincentive. Managers and staff in care services do not take inspections lightly. They are eager to provide the best possible care and environment, not just on the day of the inspection but all year round. How dispiriting, then, to be warned that no matter how hard they try, it will not be good enough.

There is also a justified concern that a temporary failing in just one of the five areas could drag down the marking for an otherwise excellent establishment – and that the reduced marking would feature on the Care Commission’s website for long after the failing had been addressed.

The risk of inconsistency and subjectivity

The Commission must take steps to deal with subjectivity of opinion among its inspectors. There is ample anecdotal evidence of identical practices which are highly praised by an inspector in one establishment and roundly condemned by a different inspector in another establishment.

Providers will meet and willingly exceed the standards that are required of them but there must be consistency of application of these standards. There is no point in a perfect aim if you are aiming at the wrong target.

The Commission is keen on consultation and dialogue and it is important that this dialogue is not one way. Much more thought needs to be given to the appeals process whereby providers can dispute inspection findings.

There is very little evidence that appeals have ever altered inspection findings and a suspicion among providers that any appeal will result in more and more stringent inspections. This must be addressed.

Quality is paramount.

Everybody is in agreement that the quality of care is of paramount importance but, as the new inspection regime looms, providers might be forgiven for feeling that it is more likely to guarantee the quality of inspection performance targets.

If providers and inspectors work in partnership, there is no doubt that standards can be maintained and improved. However, that partnership should be based on mutual respect, collaboration and understanding. That way everyone will truly benefit.

Deepak Poddar is Managing Director of Little Einstein’s nurseries.

1 thought on “How Collaboration can make the new Care Service Inspection Regime Benefit Everyone”

  1. I am Project manager for the Regulating for Improvement Project with the Scottish Care Commission and have been centrally involved in the development and introduction of the new inspection approach which includes grading of services.

    This article raises some interesting points and I thought it would be helpful to respond briefly to some of them and to clarify some points about the inspection approach which are not entirely accurately reflected in the article.

    First, to be pedantic, the grading system we are using does use a six point scale but “three to four being adequate” is not a correct description. The details are on our website but , in brief, the six points of the scale are Excellent, Very Good, Good, Adequate, Weak and Unsatisfactory. It is important to note that the bottom two points in the scale reflect a judgment that the level of quality is below a tolerable level.

    The article comments that “providers have been given to understand that the Excellent marking will rarely if ever be awarded.” My concern is that this will be seen as implying that we have somehow instructed our officers not to award this grade. This is certainly not the case.

    If a service merits this grade on any of the aspects we inspect then this grade will be awarded.

    However no system which lightly awards top grades is likely to have much standing. I am sure all scientists would like to be awarded the Nobel prize but only a few get this because if it was too lightly awarded it would no longer be a real mark of the best achievement.

    In grading care services there is a balance to be struck between the needs of providers to feel acknowledged for the good work they do and the need to inform users and others about the real quality of services. All providers want to be seen as excellent but to award such a grade too lightly risks destroying the very meaning of the grade. Excellent providers should be seen as leading lights and so by definition this grade is likely to be awarded infrequently. This seems to me to be hardly an earth shattering conclusion.

    The Care Commission system works in such a way that it is possible, but difficult, to earn an Excellent grade on individual aspects of performance within each of the main areas or Quality Themes. Grades for each of four Quality Themes are calculated from the more detailed gradings. At the Quality Theme level an Excellent grade becomes still harder to achieve but not impossible and I refute the assertion that good providers will not strive for this. There are some providers who are very unrealistic about the quality of the services that they are providing and some will feel they merit an Excellent when they are clearly far short of this.

    The article refers to concern that “a temporary failing in just one of the four or five areas could drag down the marking for an otherwise excellent establishment and that the reduced marking would feature on the care Commissions website for long after the failing had been addressed”.

    There are a number of aspects of this that I wish to address. First it is true that any finding of Weak or Unsatisfactory performance within one of the Quality theme areas does indeeed result in the whole Quality Theme being graded at that level. But if you refer back to my explanation of what Weak or Unsatisfactoory means you will see that this is as it should be.

    These are findings that the performance is less than tolerable. We cannot hide such fndings from the public or users and carers as we produce the overall set of grades. One thing our system does do however is allow providers to be quickly regraded if they address the problems which have been found. This provides a great incentive for improvement.

    I also dont agree that this could drag down an”otherwise excellent establishment” – in our view Excellent services dont have inspections which find below tolerable performance – thats why we are prepared to grade them Excellent !

    The issue of objectivity and subjectivity is a complex one. Judgments which are about QUALITY as opposed to QUANTITY almost always involve some level of subjective judgment. Its not whether there is subjective judgment involved that is the real issue though. Its whether that judgment is guided and “constrained” in ways which ensure that it is applied as consistently as possible across different raters. We can all measure things like bed occupancy in Care homes, staffing ratios and so on and pat ourselves on the back that we are doing this very objectively. the problem is that looking at these things alone often misses the point because they often dont really measure QUALITY.

    The Care Commisison has taken extensive measures including significant training inputs for its staff to ensure that the grading system is applied as consistently as possible and we will continue too monitor this closely as the new approach is implemented.

    Finally in regard to appeals. The gradings represent a systematic way for the Commission to express its judgment about the Quality of services. As a regulator we have a statutory duty to advise on the quality of services and this is one of the ways we are fulfilling this duty. It is our judgment and therefore not something that is in that sense appealable.

    Having said that our approach also is built on providers self assessing themselves and self grading and we encourage real dialogue between the provider and the Inspecting Officer at the conclusion of the inspection about the findings. We will listen to what providers have to say but at the end of the day the Commission has the responsibility to assess the quality of the service and it will do so and express this in the form of the grades that it awards.


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