Regulation of care - managing the risk for service users

The abuse uncovered in a private care home by a  recent BBC Panorma program highlights once more the potential risks if care regulators adopt a light touch approach to the regulation of care services. The program uncovered very serious abuse at Winterbourne View, a 24 bed hospital run by the private provider Castlebeck.

Services such as these are regulated by the CQC ( Care Quality Commission) in England and by SCSWIS ( Social Care and Social Work Improvement Scotland ) in Scotland. The care services minister John Birstow said that there had been " "failures of inspection and adult protection which have exposed people to appalling abuse" at the care establishment and he has ordered investigations into the failure of regulatory and safeguarding processes to protect people in the establishment.

This case raises disturbing questions though about the nature of care regulation not only in England but also in other parts of the UK.There has been an increasing tendancy to take the view that regulation of care can be conducted by using providers own self assessments and somehow " validating" these. Seldom is any real explanation forthcoming as to what such validation will mean if it doesnt amount to inspector boots on the ground though.. There has also been talk of providers being subject to overall inspections at an "organisational level" and so de-emphasising the importance of the inspection of individual services. This is the new "management speak" in regulation, it's the latest buzz idea.

Those with any real experience of regulating care services know that the performance of individual services can vary widely even where they are provided by one provider. The claims that providers make about their own performance need to be treated with the utmost caution - even when those providers are public bodies such as local authorities. Equally, while demanding that providers involve users and carers can be very effective in driving improvement when coupled with good grading systems ( as evidenced by the former Scottish Care Commisison system for example in their report Improving the Quality of Care in Scotland ) this can only work when it is delivered through a system built on regular and sufficiently deep on site inspection of individual services.

The problem with the direction that regulators seem to now be taking is that they are turning regulation and inspection into a fire-fighting exercise rather than  a pro-active system which goes out looking for service failures.

Building systems based on risk is a sensible developement and the Scottish system referred to earlier is an example of how risk factors and quality measures can be used within an overall risk based system.

The problem is not with the principle of these systems, it is with decision makers who seem to think that risk judgments can be informed by largely self -reported data or by waiting for infromation to reach them that something has gone wrong with a service.

This approach to a risk based system becomes very passive but of course it can be delivered much more cheaply that a pro-active system based on frequent inspections. These new approaches which are built on greatly reduced inspection programs of course suite the politicians because they can be delivered with much smaller budgets. It also fits in with the demands of providers who always complain about being over-regulated. To some extent it also suits the senior management of the regulators who must please their political masters by claiming that regulation will continue to be effective even while budgets for on-site inspection are slashed.

It is time to stop kidding ourselves. Risk based approaches to regulation are needed but they can only work if delivered through an approach to regulation which is properly funded and can deliver regular on-site inspections.

It is time that the heads of regulatory bodies stood up and were counted and told the politicians clearly that unless regulation is properly funded to deliver regular boots on the ground inspections then there is a grave risk that other services like Winterbourne View will go undiscovered for long periods of time.

Food and Nutrition best practice in Care Homes for Older People

An individualised approach to food and nutrition for residents in Care Homes for Older People is a major element of delivering effective individual care plans. The food and nutrition needs of older people who are resident in care homes can not be met by a one size fits all approach to meal and food planning. The old approach of "cook" planning a seven day series of meals with limited choices certainly will not do as part of an individualised care planning approach.

When considering the individual food and nutrition needs of a residents a number of factors will need to be considered. The individual resident may have clear likes and dislikes that will need to be taken into account while at the same the care planner will want to ensure that the resident will receive a sufficient range if interesting and palatable foods so that their nutritional needs are met.

We have linked here to some useful resources that provide information about best practice in the field of food and nutrition for elderly residents of care homes.

BAPEN Bapen is The British Association for Parenteral and Enteral Nutrition. It is a multi-professional association and registered charity. Established in 1992, BAPEN is committed to improving nutritional care and treatment in hospital, care and the community. Their website has a wide rage of useful and educational material on a raneg of nutrition issues. They have a good tool for Nutritional risk screening called MUST(Malnutrition Universal Nutrition Screening Tool).
The address for BAPEN Office , Secure Hold Business Centre , Studley Road, Redditch, Worcs, B98 7LG Tel 01527 457 850 Fax 01527 458 718

Also available is the document "Food, Fluid and Nutriitional Care in Hospitals 2003". This was written for hospitals but most of it is relevant for caring for older people in care homes.  It should be available from Health Imrpovement Scotland.

Another Scottish publication is "Food in Hospitals national catering and nutrition specification for food and fluid provision in hospitals in Scotland 2008." This should be available from the scottish government website.

The Royal Institute of Public Health have a document called "Eating for Health in Care Homes - a practical nutrition handbook 2006"  This should be available via the RIPH website.

Another useful document is published by The Caroline Walker Trust. "Eating well for older people: practical and nutritional guidelines for food in residential and nursing homes and community meals. Second Edition 2004"

The following are some other useful publications;

A Practical Guide to Eating and Nutrition Care (Home Caregiver Series)  and Effective Menu Planning for the Elderly Nutrition Program

Sarah Baker case and the funding of care regulation

The case of Sarah Baker, the former drug addicted manager of Parkfield Care Home in Somerset, who has been convicted of the manslaughter of an elderly resident and theft of residents drugs should sound a serious warning bell for all political parties as they contemplate levels of funding for care services regulation after the election.

There has been a trend in the last few years, and a highly naive one in the view of this blog and in the light of the failure of regulation of the financial sector, to take the view that regulation of all forms can be drastically scaled back and the risk "transferred" back to the providers of care services by relying increasingly on a self assessment and self regulation model - with the regulator scaling back direct inspection drastically and "verifying" these activities.

While some movement in this direction is a healthy thing, there is, as is often the case in social care, a terrible tendancy to throw the baby out with the bathwater. The Sarah Barker case illustrates in the starkest terms the perils that lie ahead if a future government, under the excuse of "better regulation" , seeks to drastically reduce the funding for care regulators and leaves a mere rump which will "validate self assessment" and deal with complaints investigation after things have gone wrong.

The case illustrates why effective and in depth regulation directly at the service unit level is so vital and why models which relies too much on how the "organisation" is performing are deficient.  The only real way of testing if good quality care is being delivered is by actually going out and looking at it in detail.

Even in the best regulation system there will be severe cases like the Sarah Barker case. Nothing is more certain though than that we will see more and more of these cases if governments look to make "easy" savings by cutting back on regulation in this area.  Regulation can and must be made efficient and good risk predictor models developed so that intervention can be targeted. Self assessment can and should be encouraged and providers and services with a good consistent record can and should get a lighter touch.

But we should be acutely aware that as we tread this path the risks of more serious incidents in the care sector will rise significantly. The process of modernising regulation needs to be handled incrementally and with caution. Government needs to think very carefully before it abandons effective regulation and makes swinging budget cuts that will limit the ability of the Care Quality Commission (and the Care Commission in Scotland) to carry out effective regulation.

Doncaster Chidrens services enquiry ordered

Children's Minister Beverley Hughes is reported to have written to Doncaster Council to express concern linked to serious case reviews were ordered into the deaths of seven children in the area. Ofsted recently rated Children's Services in Doncaster as among the worst in the country and criticising their arrangements for protecting children as inadequate.
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Seven deaths are subject to serious case reviews with two children murdered by their fathers. Four of the children were less than one year old when they died.

16 month old Amy Howson died had her spine was snapped in two by her father, James Howson, 25. He was found guilty of murdering his daughter and told he must spend a minimum of 22 years in prison. The mother, Tina Hunt admitted cruelty and was given a 12-month suspended sentence.

The findings of three reviews on the deaths of children who were abused or neglected have already found that social workers missed chances to intervene. one review described the Children's Services department as chaotic.

Child & Youth Care Network Learning Zone Launch

The International Child and Youth Care Network provides a free online portal for Child and Youth Care practitioners ( including foster parents) to share discussions and issues and learn from colleagues. They recently launched a new free learning resource – The Learning Zone Network which offers free online learning modules.

Chairman of the Board of Governors of the Network Leon Fulcher, MSW, Phd, recently launched the new “The Learning Zone Network”.

The Learning Zone Network provides “an in-service education initiative for Child and Youth Care workers and Foster Parents seeking quality professional e-learning opportunities. Offered over the internet these courses provide the opportunity for self-paced learning in a flexible format using the latest technologies (video, audio podcasts, etc.).”

Access to the material on the Learning Zone Network is free.

Those working in Child and Youth Care may wish to sign up for the International Child and Youth care Network and Learning Zone. The Learning Zone offers a unique modular online environment for learning and development in Youth and Child care work.

The short learning modules on the Learning Zone are very interesting. They are video based ( you will need to use a computer which is Flash enabled) and allow you to test your observational skills – but be warned they are not easy!

Access at www.cyc-net.org/

The death of light touch regulation?

The current global financial crisis unavoidably raises questions about the general rush towards "Light touch" regulation that has been a feature not only in financial regulation in the UK but also in the general UK approach to regulation.

The move towards light touch regulation may not have started in the Blair years but Tony Blair made clear during his premiership that his concern was to ensure that regulation did not get in the way of business. Indeed regulation was seen almost as an obstacle to the efficient functioning of business.

This agenda was, of course, driven in part by the self interests of the business lobby, many of whom saw regulation not as the legitimate exercise of control by society on their conduct but as an impediment in their pursuit of "efficiency".

We have now seen the consequences when regulation becomes so light touch that it fails to adequately grapple with the risks arising in a regulated sector. The consequences for us all following the clear failure of financial regulation will be serious and long lasting.

This pressure for light touch regulation has been all too apparent in the care sector with care provider representatives often pressing for a significant reduction in regulation and painting it solely as a burden.

In the care sector a significant failure of regulation might not have national economic consequences but it may have profound consequences for the lives of people who are being supported by care services. In the worst case scenario people may die because of inadeqaute checks of safety critical systems. They may suffer abuse through inadequate management control, training or recruitment of staff. They may suffer long term blight on their lives through the drip drip corrosive effect of care which is sub-standard.

While we should no more accept inadequate regulation of care services than we should of financial markets this is not a call for highly bearaucratic regulation. That is the opposite extreme and would be as equally destructive of good quality care as a lack of regulation.

What is need is risk based and proportionate regualtion. This is not the same as light touch regulation. Light touch regulation implies that the regulation system aims to touch lightly on all providers alike. This may not always be what is desired but this is too often where talk of light touch regulation takes us.

In contrast to this, a risk based and proportionate regulation system will be focussed on assessing the risks in the regulated sector and distinguishing and intervening in those areas where the risk is highest. It means reducing the regulatory "footprint" on services which are demonstrably of good quality - but increasing it in where risk oor poor performance is apparent.

A move away from "cyclical" inspection has been apparent recently, for example as recommended by the crerar review in Scotland. There is little doubt that standard cyclical inspection can often safely be reduced but great care must be taken in moving in this direction.

If regulation is to be calculated on the basis of risk and be proportionate this can only be on the basis of intelligence. It is vital that some of this intelligence is collected first hand so that the regulator does not have to rely excusively for extended periods on information provided by those who are regulated. This has serious implications for the extent to which frequency of inspection can be reduced in the care sector and regulators must ensure that frequency does not reduce to the extent that they may no longer have reliable information on which to make risk assessments.

Rose Park Care Home Fire tests Scots Law

The Crown Office has announced that it is to launch a third attempt at a prosecution of the owners of Rosepark Nursing Home (Care Home) were 14 residents died in a fire in 2004.

Two previous attempts at a prosecution have floundered because of technicalities with Scots law which have so far resulted in the failure to hold anyone properly to account for the Rosepark care Home fire tragedy.

A first attempt at a prosecution foundered when the trial judge Lord Hardie ruled that it was only possible for the alleged offences to be carried out by employers, and he ruled that the three owners of the home who had been named in the indictment were not in fact employers in law.

Later in July 2008 a second attempted prosecution failed, this time because the indictment named the partnership as the legal entity in the indictment. The partnership had however at that time been dissolved and the prosecution could not proceed because having been dissolved the partnership no longer had any legal identity.

A third prosecution is now being attempted against Thomas Balmer, Anne Balmer and Alan Balmer in their capacity as the surviving partners of the dissolved firm of Rosepark Care Home.

The Crown Office said that "The whole surviving partners are indicted in their representative capacity only and not as individuals."

Also named on the indictment are Croftbank House Limited, formerly Balmer Care Homes Limited.

The Crown Office stated that "In Scots Law, a firm is a separate legal person distinct from the partners of whom it is composed. The Appeal Court held that on dissolution of the firm there was a complete cessation of the persona of the partnership (that is the separate legal person) and that a dissolved firm did not retain a limited persona for the purposes of criminal prosecution which could be prosecuted in its own name."

A Preliminary Hearing on the new indictment is to be held at the High Court of Justiciary in Glasgow on the 30th October 2008.

The relatives of those who died will be impatient to see a proper court examination of the occurrences around this fire. It is vital that the court proceeds with examining whether those charged with the duty of looking after their relatives safely fulfilled their responsibilities. It would be a sad day for justice in Scotland if this third prosecution also fell on a technicality and prevented the bereaved seeing those involved in the ownership and provision of this care home called to account.

This case must also proceed because otherwise it will become clear that other owners of care homes can by means of dissolving their partnerships or companies avoid being held to account for their actions.