The Care Quality Commission have recently completed the inspections of some 24,000 different locations providing adult social care. It published its State of Adult Social Care report covering 2014 to 2017 and clearly feels empowered and emboldened to draw conclusions from the inspections it has conducted.
Nursing Homes are singled out for particular mention in the report with one in three failing to be rated at least good overall. Across all adult social care providers one in four providers failed to be rated as at least good for the question ‘is the service safe?’ These conclusions are based within the confines of CQC’s inspections of providers, which by their very nature, are subjective opinions on service provision.
Given the continual stream of CQC negative reports about the performance of Adult Social Care and the subjective opinions of inspectors; is it not time that we started to look for a more balanced approach to the results of inspections that takes an objective account of the provider’s position. Is there not a need for a balanced, rounder, picture of care to come into the public domain. This should include fair due process which acknowledges that providers have rights, too.
In practice, we see the rating system being reduced to a binary judgement in the public discourse on care: so, we have ‘good and outstanding’ or ‘failing’ homes. This is simplistic and adds to the negative portrayal of the sector that is making it so hard to recruit the care managers and other care staff that are needed. The sector cannot survive on a diet of blame and criticism while the longstanding structural issues remain unresolved.
Providers who lack confidence to challenge inspectors
There is among some providers of adult social care a natural deference to the CQC inspector. This is in part due to the threat to their business of a damming report. As such findings made within reports, which may be factually inaccurate or misleading, go unchallenged. If a provider demonstrates a reluctance to challenge the findings of an inspector, then the ‘true’ picture of care at a location is inaccurate. This is not a criticism of CQC but a presentation of the other side of the argument which may go unheard. Of course, it is difficult to objectively draw out this information should a provider remain silent on challenging the findings of an inspector’s report, but this should be considered by managers when reading their report.
If a provider chooses to challenge the findings of an inspector, that same inspector will review the comments provided before dismissing or adopting the information provided. CQC may say that the matter is resolved by a report being reviewed by the inspectors’ manager. That is not independent, the manager should and will support those they manage; but of more importance that review occurs before the provider has put its case. It is a flawed process.
Should the inspector refuse to take into account issues raised by the provider there is little in the way of further challenge that can be made. There is the process of reviewing the ratings of a service but these will only be challenged on the narrowly defined grounds that the incorrect process was followed by the inspector. A provider may challenge by way of judicial review but this is time consuming, high risk and expensive. According to Ridouts Solicitors, the most effective way to challenge CQC is to provide commentary on the report and append relevant evidence which supports the providers’ objections.
Subjectivity of reports
Inspection reports are by their very nature highly focused on the inspection visit, although some underlying background information is used to inform findings. They remain a snapshot of the service in question at the specific point in time when the visit occurs. They are limited by the competence or otherwise of the inspector and by the provider’s presentation during the visit and the provider’s resolve following it. As such, the relevance of ratings and findings drawn from inspection reports can be questioned, especially when those findings are used as the basis for a change in strategy.
There is no evidence of robust challenge by CQC to its inspectors’ findings. Inspectors are, in effect, encouraged to believe that they are always right.
If we have two providers: one confident in its resolve and effective in its communication who successfully challenges CQC’s findings; set alongside the same provider who accepts CQC’s findings without challenge: Both of whom, provide exactly the same level of care, the only difference is the approach of the provider. The pertinent point is that the quality of care between provider one and two is at the same level; but CQC would ultimately rate each provider differently depending on their respective responses to its draft inspection report.
The latest report on the state of adult social care up to 2017 published by the CQC provides more negative evidence of the performance of the sector to the public. It can be argued that the report is based on the subjective opinions of inspectors, and does not give a balanced independent view of the sector. There is evidence that mangers are reluctant to challenge inspection reports for fear of poor ratings and damage to their business.
This blog article is not meant to be critical of the CQC but a call for a more objective approach to inspection where providers can feel confident that in challenging inspection reports their views will be heard independently. We may then get a more balanced approach to inspections and ratings.
Acknowledgement: Ridouts Solicitors
Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy