Why Care Regulation Needs to Change

27/01/2017 11:33


The Care Quality Commission or CQC has probably one of the most important jobs in the country: to make sure that people who need care are safe from abuse. Unfortunately the evidence is that they are failing in this task and they are bound to fail because of how they are organised and how they think.

In the Centre for Welfare Reform's recent discussion paper, What's Wrong With CQC? John Burton, argues:

"The Care Quality Commission is not effective or responsive; it doesn't understand how social care works; it rarely uncovers neglect and abuse, and it responds too slowly when they are brought to its attention; its judgements are flawed and its ratings inaccurate and unhelpful; its inspection reports are poorly written and constructed; it costs much more than it should and imposes vast unnecessary costs on social care providers; it dominates and distorts the whole social care sector, and the organisation is blinkered, risk averse, top heavy and hopelessly bureaucratic."

Now this may seem extreme, but once you examine how CQC works in practice then this judgement seems quite balanced. For instance, what does CQC do in practice? Primarily it asks inspectors to make visits to places where people live and then determines how good those places are based on an examination of the documents that describe the policies, procedures and processes in place. For instance CQC is currently proposing that the first test for measuring the quality of social care services is:

"Are the systems, policies, processes and practices that are essential to keep people safe identified, implemented and communicated to staff?"

Now, on the face of it, this may seem reasonable. But how helpful is it to study documented policies and procedures if you want to find out what's really going on?

Ask yourself what would happen if the government sent an inspector round to your home to find out whether you were doing a good job as a parent or as a carer. Now imagine that the inspector evaluated your performance by reading your plans and procedures. Would this increase the level of love and care in the family or would it lead to a culture of fear and meaningless form-filling?

However, if you don't want to compare a care service to a family then compare it to a business, say a restaurant. Now restaurants are inspected, by local government as part of an agreed national scheme, and these inspections focus on hygiene and on objective factors that determine the level of hygiene. Inspectors are not ranking the restaurant's quality, that's for us to judge; the inspectors are helping us all avoid food poisoning. Government is not good at quality. We want it to focus on safety and we want it to look at issues of real safety, not at meaningless paperwork.

Alternatively, let's think about another business, say Information Technology. Information Technology improves because its pioneers are free to innovate. If the government were to set standards for how technology was to be developed then it would kill its development. But, as a previous report from the Centre for Welfare Reform demonstrated, the CQC does undermine best practice by dictating how organisations should work. What is more the norms that it is dictating are rarely based on more than a dubious plausibility. There is no strong empirical evidence to support these CQC standards and they often seem to imply that increased professionalisation of care is the answer to every problem.

The fact that CQC is ineffective is not a matter of theory. There is no empirical evidence to suggest that it is actually reducing abuse; and there is a lot of evidence that they are consistently missing it. For instance, David Hogarth has been tracking published cases of abuse by care homes. In none of the 47 cases he's identified since 2010 did CQC play an active role in uncovering abuse. In fact most of these care services passed their inspections and very many were deemed to be good care providers.

The Winterbourne scandal, which has led to an official policy to get 3,000 people with learning disabilities out of institutional care homes was not inspired by CQC findings, but by whistleblowing and an undercover Panorama documentary. And some families whose children were in that dreadful place say that it was one of the least bad places their children have been. Abuse is rife in institutional care settings and CQC is not the solution.

CQC's failure to achieve its central purpose is not merely about doing the wrong thing. It is also a matter of not doing any of the right things:

  1. Most people have little control over their own support; it is purchased for them and they are not given any meaningful control over who supports them or how. Despite an official policy of 'personalisation' the reality is it is very difficult for people and families to change what they get.
  2. When people do complain to CQC these complaints are not investigated, they are put in a database for future reference. In other words, immediate feedback, the most important information possible for improving quality, is effectively ignored. Even worse, families or staff who do blow the whistle on poor practice are often punished, rather than supported.
  3. The best people to inspect places are people with disabilities and families, these are the real experts in quality. Yet this approach, pioneered by community organisations around the country, remains under utilised.
  4. Local citizens are not involved in inspecting local services. While social care services, consumer protection and the police are all organised locally the system to protect people from abuse is managed regionally (London, North, Central and South). The system is based on irregular inspection by people who (working from home) may have to travel many miles to visit a home once every few years. Inspectors will have no ongoing relationship with a home, its residents, the community or with families. CQC's judgements are therefore inherently unreliable.

The things that would seem to help us keep people safe are the very things that it is impossible for CQC to do.

The CQC is not to blame for the collapse of social care, the loss of services for 700,000 people, the worsening funding crisis and the on-going abuse scandals. But it does give a false credibility to this failed system. It neither challenges the system nor influences the critical factors that really shape quality. It is time for a radical review of its purpose and organisation.