We are told today that the Equality and Human Rights Commission (EHRC) have discovered that some older people are not cared for in a dignified and respectful way and that as a result their human rights are not being met. To those close to the industry, this is no surprise at all. In fact the Care Quality Commission (CQC) in their last report 2010/11 stated that “One of the outcomes we look at covers ‘effective, safe and appropriate care’. For both NHS and adult social care providers, failure to meet the regulations on this outcome was one of the three most common reasons why we served compliance actions”.
Why does it happen? Because important people in the process are not fulfilling their responsibilities and, because they are failing to do that, a watch dog is expected to oversee an operation serving 500,000 people. The watch dog has no buying power – just the power to sanction and, in extremis, to close a non-compliant operation.
Let’s start at the beginning. By all means let’s take the Minister’s lead today and look at the front line and yes, there will always be rogue care workers who have, in the Minister’s words, switched off their basic compassion. With such a large number involved this is an inevitability which has to be carefully managed by the service provider. What many good people on the front line will tell you is that they are poorly trained and supported, poorly treated and asked to work with conflicting priorities – who are they serving the customer or their manager? This is also inevitable and also needs careful management.
Beginning to spot a theme here? Now ask a Local Authority commissioner about how carefully their provider is managed and you will probably be passed on to the contract manager – this is someone who takes over the management of the provider from the commissioner once the service starts to be implemented. Now when you talk to the contract manager they will tell you that they have too many contracts to manage and so they are behind, but they probably have a conversation several times each year on any specific complaints and some discussions about trying to get day-rate prices down. Does this sound like a good basis for checking on this careful management the provider needs to have in place? – No.
Maybe we need to look elsewhere? The Local Authority’s operations department deals with people approaching social services and, where necessary, assesses these people and decides upon a package of care to be delivered by one of the contracted providers. Each case will get logged on to the LA’s case management system and a purchase order sent to a service provider. In most instances the LA will get the care kicked off okay and then leave it to the service provider to look after. Anything up to a year later the case will be formally reviewed, but unless there is a complaint of some sort there will be no further checking. Have we now found a good basis for checking on the careful management the provider needs to have in place? – still no, but there is nowhere else to go, or is there?
Yes, there is a third party monitoring organisation, the CQC with a stretched team of inspectors who go round checking on the performance of registered social care providers. The only data I could find for my local care home was a self-assessment done by the provider when they first opened two years before. Does this sound like a good basis for checking on the careful management the provider needs to have in place? Regrettably no, and I think this the end of the story.
So to recap: the vast army of care workers out there needs careful management to ensure that sadists are rooted out and the good members of staff are properly trained, motivated and organised to excel at the job each commissioner has asked them to do. The council’s contract manager has to carefully manage the service provider (the contractor) but is not close enough to the provider to do that. The council’s operations manager has too many cases to look after so relies upon the provider and CQC. But in practice the provider is not carefully managed and the CQC, by their own admission is presiding over ineffective, unsafe and inappropriate care’.
What is the answer? Surely it is not to spend more money overlaying more third party checking and quality control. This seems to be the Department of Health’s first response. Any process engineer will tell you that quality control is wasted effort – it might be necessary but its need has to be routinely challenged.
I therefore strongly challenge the need for the CQC to be given more resources to check the front line services being provided by Local Authorities and their providers. The correct place to maintain quality is within the setting up and running of the contractual arrangement between commissioner and service provider. Notice I talk about two things: setting up as well as managing. As the EHRC correctly point out the commissioner must write a specification for the service which explicitly requires the provider to work in a way that protects human rights and they may well define particular measures the providers must adopt. Once the contract is signed, binding in the provider to deliver according to the specification, then the commissioning authority must guarantee that their chosen providers deliver what they have signed up to do. They pay for the service – they have a duty of care, no less, to ensure they get what they pay for from their nominated providers. This is what CQC should check first.
There are just over 150 local authorities with responsibility for adult social care and many hundreds of thousands of front line workers – where would you start? Is this what the Department of Health is suggesting?
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