Examination of Witnesses (Question Numbers
320-339)
BARONESS YOUNG
OF OLD
SCONE, MR
RONALD MORTON
AND MR
SAMPSON LOW
12 NOVEMBER 2009
Q320 Dr Taylor: Because the commissioners
are responsible for the quality of care that is provided.
Baroness Young of Old Scone: Absolutely,
and also for making sure that there is enough service, even if
it is not a publicly funded service, for making sure that people
can get access to services and that they are signposted towards
them and that they get a proper assessment process.
Q321 Dr Taylor: I welcome very much
your new registration system, coming from April 2010. "It
marks a change from regulation based primarily on policy systems
and processes to regulation based primarily on outcomes."
To me, one of the weaknesses of the present system (and I am talking
rather about on the health side) is that trusts have only got
to answer the question that they have got a policy in place for
producing a certain result rather than the actual result. You
are going on to outcomes, and I want to know exactly how you are
going to assess outcomes: because in health you either get better
or you do not—that is easy. How are you going to assess
outcomes in social care?
Baroness Young of Old Scone: In
fact, it is not going to be that easy in health either, because
there is a single regulatory system across health and social care
and there is a range of 16 areas of outcome that we will want
to look at, and we will be publishing in the next two or three
weeks our guidance on each of these 16 areas which will subdivide
them into a whole variety of outcomes.
Q322 Dr Taylor: When does that come
out?
Baroness Young of Old Scone: It
is coming out in about three weeks' time. So there will be about
300 pages worth of guidance on what the outcomes are and how we
are going to judge them, and beneath that there will also be subsidiary
guidance, which will not have a statutory basis but will be there
to help people who are providing services and commissioning services
and, also, people who use services to understand what the best
available good practice around it is. For example, in social care
we will be looking at a whole variety of issues that range across
safety and safeguarding, protection of rights and dignity, staffing
issues, issues of nutrition, hydration—a whole variety of
different areas of care—and underneath that there will be
this more detailed signposting towards good practice.
Q323 Dr Taylor: Specifically, to
pick on dignity and respect, how will you assess that?
Baroness Young of Old Scone: Let
me give you an example. If we are looking at a service in a care
home, we will want to talk to individuals living there; we will
want to talk to their relatives; we will want to talk to the staff
about their approach to dignity and respect. If we are looking
at a home with people with dementia, who may not be able to tell
us how they feel about it, we have a specific assessment tool,
which is an observational tool, that allows us to sit with a group
of staff and service users and assess whether, in fact, there
is a real relationship between the staff and the individual and
their views, even if they are not able to be verbalised, are being
respected, and that has proven to be a very successful tool. It
is called SOFI (Short Observational Framework for Inspection).
So there is a whole variety of tools we will use to assess whether
dignity is being respected, including the very important one,
which is what are the views of the users and what are the views
of their families.
Q324 Dr Taylor: When you talk to
the residents and their families, will your inspectors be alone
or will they be with staff?
Baroness Young of Old Scone: Absolutely,
and quite often we take with us an expert by experience, someone
who has either been in receipt of services, and therefore can
understand from the perspective of a user, or else, for example,
I did an inspection last week in a home for a mixed group of elderly
people, some of whom have dementia, and we had a carer with us
who had looked after her elderly father and had had long experience
of working with someone with dementia, and she spent time with
the people, talking to them as individuals, while we did the boring
stuff of working out whether the staff had been properly trained
and whether the kitchen looked as if it was clean and stuff.
Q325 Dr Taylor: To me that is very
encouraging, because I had a huge argument with CSCI when they
got rid of their lay inspectors years ago, and there seems to
me to be a great importance of somebody who is lay, in that sense,
who might get more out of very shy residents.
Baroness Young of Old Scone: It
is also hugely important in the area of people with learning disabilities
or mental health problems, because unless you have experienced
the real frustration of not being dealt with as an individual,
you cannot really understand how that feels, and we get a lot
of value from our experts by experience.
Q326 Dr Taylor: When we get this
paper in three weeks' time, will this tell us how much of the
current national minimum standards are being carried over into
the new system?
Baroness Young of Old Scone: We
have got a process for mapping the national minimum standards
against the new system, but I do not think we will be publishing
that with the guidance. We could certainly show the Committee
that, if they wanted it.
Dr Taylor: Thank you.
Chairman: I would appreciate it if you
could do that.
Q327 Sandra Gidley: Baroness Young,
what enforcement powers do you actually have to take action against
services that fall short of expectations?
Baroness Young of Old Scone: We
have a wide range of enforcement powers, but I think we should
put that in context by saying we want to be an organisation that
is seen to be about improvement. So our first step is to work
with a service and its commissioners to try and get improvement,
but if that is not working, or if the circumstances are sufficiently
serious that we are worried that enforcement is the only way to
get real action, we have got a range of powers, which range from
a stern ticking off through to improvement notices. We have the
capacity with the new registration system that we can exact fines,
we can prosecute, we can apply conditions to their registration
which mean that they have to achieve an action plan or they will
lose their registration, we can suspend registration if it is
sufficiently serious or, at the end of the day, if a service is
simply not meeting standards that are acceptable, we can shut
it down and remove their registration. So we have got a pretty
flexible and wide range of enforcement powers under the new registration
system, which, of course, does not come in until 1 April for the
NHS and 1 October next year for health and social care.
Q328 Sandra Gidley: All of this is
in the public domain, so if somebody has had a stern ticking off,
is this a matter of public record?
Baroness Young of Old Scone: If
we formalise a warning, it will be a matter of public record,
but if we just take them behind the bike sheds and say, "Look,
if you carry on like this we are going to have to start getting
a bit more heavy", I think that is part of the improvement
process rather than part of the enforcement process.
Q329 Sandra Gidley: Would that be
recorded in any way?
Baroness Young of Old Scone: After
each full formal inspection we publish a report, and there will
be a history of enforcement action on our website for each provider,
but we want to expand the information we provide about services,
both health and social care. Each provider will have what is going
to be called a quality and risk profile, and that will bring together,
in one place, hopefully in an accessible form, everything we know
about the quality of that service, wherever that is gleaned from,
from service users and their families, from the information that
services provide us as part of the inspection process, from our
own inspections, from other sources of information about the quality
of care, other regulators, other quality bodies, and we want to
bring that together into a quality and risk profile which will
be available publicly so that both the users of services and those
who want to choose services can have access to it, but, also,
commissioners can use it for commissioning purposes and I hope
providers will use it to benchmark their services against each
other.
Q330 Sandra Gidley: So why, if somebody
has had a talking to behind the bike sheds, should that not be
a matter of public concern, if there are concerns? Should not
the public have as much information as possible?
Baroness Young of Old Scone: I
think it is matter of degree. If there is some minor issue that
they have just not understood the fact that it needs to be resolved.
Mostly, when we are going in, we are going in to be helpful and
to help services that are struggling to tackle a particular issue,
signposting them towards good practice, giving them a bit of support,
and I think that when you cross over the line and start taking
formal enforcement action, that is when it should be published.
If we were to publish every time we have a conversation with a
home about something that needs to be improved that is just part
of the everyday fabric of regulatory life, we would be writing
novels.
Q331 Sandra Gidley: You could say
the situation is a lot worse than you actually describe there?
Baroness Young of Old Scone: No,
I do not think so. Obviously, the importance for us is making
sure our inspectors are well trained and consistent so that everybody
is getting the same sort of judgment, because regulation is not
a science, it is an art. There is a lot of judgment about what
is a serious and notable problem that ought to be publicised and
what is actually just, "If I were you, I would do this differently",
and, "Joe Bloggs up the road does it pretty well, you might
want to go and look at it." It is all part of the ongoing
process of working with services to improve them, and it may not
just be poor services, it may actually be good services could
become even better.
Q332 Sandra Gidley: Do you follow
the same practice as CSCI used to, in as much as if somebody complains
about a care provider and the complaint is against the manager
of those services you actually ask the manager to look into the
matter and produce the report?
Baroness Young of Old Scone: As
of the establishment of the Care Quality Commission, we do not
have a complaints function. We are not responsible for the investigation
of complaints. If somebody complains about a service, we will
direct them to where they can take that complaint. The complaint,
in the first instance, ought to be provided to the service to
see if they can get satisfaction. If they cannot get satisfaction,
depending on the funding mechanism they have, they can either
go to the local authority, if the local authority has contracted
for that service, but what we would do with the complaint information
would be to assess it against what we know about that service.
Q333 Sandra Gidley: Do you receive
all the complaints information from different sources?
Baroness Young of Old Scone: No.
Q334 Sandra Gidley: Is that not a
flaw with your process? How can you adequately inspect something
if you do not know what is going on, if you do not know what the
issues are when you get there? Are you not working in the dark?
Baroness Young of Old Scone: Ronald
will be able to help me. Certainly when we inspect a service we
expect them to tell us what complaints they have received.
Q335 Sandra Gidley: You expect them?
Mr Morton: When we go into a service,
I think you mean, but we have a range of evidence sources about
services and we take those all into account.
Q336 Sandra Gidley: Baroness Young,
you just said that you did not have any information.
Baroness Young of Old Scone: Not
that we do not have any information, we do not have a responsibility
for the investigation of complaints. We expect the provider to
have a proper complaints process and to be able to tell us what
complaints they have received, but we do not have a responsibility
for investigating them and making sure that the person who complains
gets satisfaction.
Q337 Sandra Gidley: So the inspector
would see all of those complaints and any from any other sources?
Mr Morton: Indeed, and they would
take them into account in deciding how the quality of the service
was performing. So it is part of the range of evidence we would
take into account in assessing whether the service is good, bad,
or what the risk is to people using that service.
Q338 Sandra Gidley: If there is a
problem and everybody is complaining to the home and there are
these other processes, how is it fast-tracked so that you go in
there and help sort the problem? There seems to be a significant
gap in the system here.
Baroness Young of Old Scone: I
think there would be a number of ways in which that would be picked
up. Hopefully, if there were a service that was not doing well,
we would have already been able to assess that from the work that
we do in other ways.
Q339 Sandra Gidley: The word "hopefully"
does not give great reassurance, I am afraid.
Baroness Young of Old Scone: But,
also, the local authority has a responsibility, if they are commissioning
from that service, because under their contracting arrangements
they have a responsibility for making sure that the service is
of a good standard.
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