Social Care - Health Committee Contents


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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