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.

23 Social Workers had inappropriate relationships

The General Social Care Council has recognised that "inappropriate relationships" are one of the main areas of concern in the regulation of Social Work and Social care professionals in England. A report published today by the General Social care Council the body that regulates Social Workers and Social care professionals in England reveals that around 800 people have been refused professional registration and 23 people have been barred from practice by the social work regulator in the last five years.

The report ‘Raising standards: social work conduct in England 2003-2008’ which is published today is the first to address conduct activity since the General Social Care Council began registering social workers in 2003.

The report reveals that up to 31 March 2008:

214 people were refused registration by an independent committee, following issues relating to criminal convictions, health conditions, disciplinary matters etc.

582 people were refused registration on the basis of qualifications.

40 complaints about registered social workers or students are received on average per month.

There have been 49 independent conduct committee hearings resulting in 23 removals from the register, five suspensions and 19 people receiving an admonishment. In only two cases was no misconduct found.

Of concern is that over a third of all cases heard have concerned inappropriate relationships between social workers and people who use services or their family members. The Code of Practice for Social Care Workers is clear that social workers must not form inappropriate personal relationships with service users.

Sir Rodney Brooke Chair of the GSCC, said:
“Misconduct is very rare, and the majority of the 97,000 social workers and students carry out their work with true professionalism. Our report shows that where misconduct does exist, we have been able to take appropriate action to preserve public trust and confidence in social care services.

“Our first hearing took place just two years ago yet in that space of time we have been able to embed the standards expected of social workers through the Code of Practice and identify key issues such as those relating to inappropriate relationships.

“Perhaps more than any other profession, social workers should be acutely aware of the boundaries that should be in place in terms of their relationships with people who use services, their families and carers. Social workers must recognise and use responsibly the power that comes from their work, and ensure that nothing impairs their objectivity and ability to make sound judgements. Inappropriate relationships can potentially put people who use services at risk and we intend to work on a project to develop additional guidance.”

New Autism research Challenges traditional views

The traditional view of high end Autism has been that it arises in large part because of problems that the Autistic person has with responding to others - that the Autistic have an impaired ability to comprehend "the other".

Recent research findings published in the journal Neuron by Baylor College of Medicine researchers now turn this traditional view upside down.

The research appears to show that individuals with high end of the autism spectrum disorder actually have an inability to model "self" which causes a disability in understanding the world as a whole.

Dr. P. Read Montague Jr., professor of neuroscience, and director of the Human Neuroimaging Lab and the Computational Psychiatry Unit at BCM used a functional magnetic resonance imaging (fMRI) scanner to scan the brains of "high functioning" autistic individuals. The research found a "signature" in the brain that identified those with autism. This level of activity correlated with the severity of the autistic symptoms. The less activity - the more serious the symptoms. This could result in a test which would speed diagnosis.

The team used a technique called hyperscanning, developed in Montague's laboratory, which allowed them to scan two brains simultaneously while the research subjects played a trust game.
One player received an amount of money and then had to send whatever amount he or she wanted to the other player via a computer message. This amount is then tripled the second player then decides how much of this tripled amount to send back. The game is played over several rounds.

Previous work had shown that an area called the cingulate cortex was where most of the activity occured during the trust game.

The researchers compared the brain responses of normal subjects with "high functioning" autistic subjects and found that the autistic subjects did not play the game differently from their partners, who were taken from a population of similar teens without autism. Both groups of subjects made similar amounts of money overall and round by round.

However, the scans revealed that the the autistic youngsters' "self" responses were dim compared to normal subjects and the more severe the autistic symptoms the dimmer the response.

It was clear that the Autistic subjects cognitively understood the game but had a very low level of 'self' response which correlated with the severity of their autism.

"To have a good self concept, you have to be able to decide if the shared outcome is due to the other person or due to you," said Montague. "If people can't see themselves as a distinct entities at deeper levels, there is a disconnect."

Chris and Uta Frith (University College London) writing in the journal Neuron said, "This is an exciting result because it suggests that some mechanisms of social interaction are intact in these high-functioning cases. What is the critical difference between the self phase and the other phase? We believe that the simple distinction of self versus other is not adequate. "It involves higher-order mentalizing: you care what another person thinks of you, and even further, you care that the other person trusts you. You would not do this when playing against a computer. In autism there is no difference".

Further research to test the "model of self" aspects of Autism are anticipated which may throw light on the contribution of this deficit with people who are less high functioning. This research may also suggest intriguing possibilities for other ways in which to help people with autistic spectrum disorder.

Research published February 7, 2008, journal Neuron, (Cell Press. )

Autism Publications

Bristol Care Home Abuse Closure

Care regulator,The Commission for Social Care Inspection (CSCI) has applied for an emergency court order and closed Overnhill House, Downend, near Bristol. The care home for elderly people was shut because of concerns about the safety of residents following a period of monitoring.

Questions remain however about why there has so far been no police involvement given the nature of the concerns raised about what went on at the Overnhill home.

CSCI reported there had been complaints that one resident had been dragged across a room, that another had heavy bruising, concerns about issues about medication being administered and concerns about staffing levels .

All 10 people living at the Care Home were moved. The Owners, Danny Purgaus and Patricia Purgaus have not made any comment.

The home which has 14 beds was registered in 1992 and offered residential care for elderly people with dementia or Alzheimer's disease.

A CSCI spokesperson said, "The decision to close a care home is never taken lightly and is usually the last resort after every effort has been made to get the owners to improve standards and comply with legal requirements. We know all too well the impact that closure can have on the people who live there, their families and their carers, as well as members of the staff."

Bristol City Council said the authority had responded to concerns about the welfare of the residents and had found new residential placements for them.

An Avon and Somerset Police spokesperson confirmed that there has so far been no police involvement in the case.

The lack of police involvementy raises serious issues given the reports from CSCI that the complaints inluded the suggestion of at least one resident being dragged across the floor and the suggestion of heavy bruising on another.

Care Home residents are entitled not only to the protection afforded to them by a regulator such as CSCI - which appears to have acted firmly in this case. Care Home residents are also entitled to the protection afforded by the criminal law and it is clear that the police must investigate the possible abuse that may have taken place in this home.

Abuse of residents in care homes must be seen not only as a regulatory matter but also as a matter for possible criminal prosecution. Only when the State acts both to close such homes and to prosecute abusers will people in Care Homes feel truly protected.

Improving care for older people: Regulation and Inspection'

Driving Improvement in care services for older people explored at national conference.
Findings from Inspection and Regulation highlighted to help improve practice.

Shona Robison MSP, Minister for Public Health, addressed delegates at a national conference in Edinburgh today (29 January 2008). The National conference, ‘Improving care for older people: messages from regulation and inspection' explored how the findings of Inspection and regulation activity can help to improve practice in the care and support for older people in Scotland.

The event at the Edinburgh International Conference Centre (EICC) was jointly organised by the Scottish Social Services Council (SSSC), the Care Commission and the Social Work Inspection Agency (SWIA).

Over 150 delegates, including care service managers, heads of community care planning, people who use services and carers, shared experiences and discussed how the quality of life for people living in care homes can be improved.

Leaders from the SSSC, the Care Commission and SWIA spoke about how they work together to drive improvement through regulation and inspection. Delegates also participated in seminars and workshops on achieving quality through partnership, promoting nutrition in care homes and grading for improvement.

Shona Robison MSP, Minister for Public Health, said: "I am delighted to speak at this joint event organised by the three inspection and regulatory bodies with key responsibilities for the quality of care and the care workforce. Older people in Scotland with care needs deserve the best possible standards of care and support. The Scottish Government has demonstrated its commitment to older people, for example by making dementia a national priority and increasing Free Personal and Nursing Care payments. The work of the inspection and regulatory bodies plays a vital role in identifying and promoting good practice and in improving standards of care. This joint event is an important opportunity for care professionals to share knowledge and expertise."

Speakers at the conference included Professor Mary Marshall, who lectures and writes about dementia and is a member of the Independent Funding Review of Free Personal Care, Alexis Jay, Chief Social Work Inspector, Carole Wilkinson, Chief Executive, SSSC and Jacquie Roberts, Chief Executive, Care Commission.

MRSA in Care Homes and Nursing Homes

Methicillin-resistant Staphylococcus aureus (MRSA) is not only a dangerous, sometimes fatal and difficult to treat disease for hospital patients but also a significant concern in care home settings where residents often have nursing needs. Despite this surprisingly few studies have examined how to prevent MRSA spread among elderly residents in Care Homes according to Carmel Hughes, lead author of a recent review of the subject.

( Check here for other MRSA related publications)

MRSA Risk Factors
The usual antibiotics, like penicillin do not work with the organism MRSA and the problems it causes are compounded by the fact that it spreads very easily, often on the hands of health care workers. Elderly Care Home (Nursing Home) residents can be particularly vulnerable not only because the risk of infection increases with advancing age but also because a proportion of residents will have periods in an out of hospital where they may either pick up or pass on the bug.

In addition to these factors residents in nursing homes also live in close proximity to each other, are often on multiple medications, are susceptible to pressure sores and often have catheters. All of these are factors which facilitate MRSA infection.

The reviewers searched for randomized and controlled clinical trials that focused on infection control interventions in nursing homes. "We found no studies that looked at ways of preventing the spread of MRSA in nursing homes for older people," they report.

Hospitals have isolation facilities and greater access to infection control expertise compared to Care Homes and infection control training is not routinely available in nursing homes.

MRSA control measures in Care Homes
Care Homes (nursing homes) can and must still learn lessons from the existing research; which has been mostly hospital focussed.

MRSA intervention in Care Homes / Nursing Homes should include screening of recently admitted residents to the nursing homes possibly with the assistance of attending GP's. A thorough approach might also need to take account of residents who have periods of hospital admission and the possibility that they may aquire MRSA during these periods.

Staff training in the importance of hand washing and high standards of cleaning and decontamination is very important as are mechanisms to ensure the staff follow such routines. Identifying specific members of staff to take responsibility for promoting and monitoring infection control measures may also help.

Carmel Hughes is a professor of primary care pharmacy at Queen's University Belfast in Northern Ireland. The Cochrane Library is an international organization that evaluates medical research.
Reference: Hughes CM, Smith MBH, Tunney MM. Infection control strategies for preventing the transmission of methicillin-resistant Staphylococcus aureus (MRSA) in nursing homes for older people (Review). The Cochrane Database of Systematic Reviews 2008, Issue 1.

Scotland National Rape Crisis Helpline launched

Scotland will pioneer the first national rape helpine to offer support and information to anyone affected by sexual violence. The Scottish national rape helpline which is being launched today will provide support to victims and help for friends and relatives. The Rape Crisis Scotland helpline will be open seven days a week from 6pm until midnight. The freephone number is 08088 01 03 02.

Neither Scotland or the rest of the UK currently have a national helpline. Current funding levels only allow volunteers to handle phone lines for a few hours two or three days a week. This poor provision was despite the fact that reported rapes north of the Border had risen 8-per cent.

Women who were desperately in need of advice and support often had to leave messages on the answerphones because the helplines were not open. It was feared that this could be deterring women from reporting crimes such as domestic abuse cases.

Scotland's conviction rate for rape is among of the worst in Europe at approx 4-per cent. Reported rapes rose from 596 in 1997-98 to 900 in 2004-05 an 8-per cent increase.

Crerar Review: Public Scrutiny in Scotland

The Report by Professor Lorne Crerar of the “Independent review of regulation, audit, inspection and complaints handling of public services in Scotland” was published on Tuesday 25th September 2007 on http://www.scrutinyreview.org/

The Crerar review concludes there is widespread agreement that Scotland’s scrutiny system is too complex, costly and burdensome on public bodies. From the evidence gathered, Crerar finds that the scrutiny system doesn’t necessarily scrutinise the right things, has grown in a piecemeal fashion and requires strategic co-ordination.

The Crerar report short to medium term recommendations

• a radical increase in the sharing of information and co-ordination
between bodies.
• a renewed focus on users of services
• involving service users in standards setting
• an increased role for parliament
• fewer scrutiny organisations
• accessible reports by scrutiny bodies
• proportionality - focusing on poorer performing service providers and higher risk situations

Crerar Report - One scrutiny body for all?

In the longer term the report proposes moving to one national scrutiny body, one audit body, and one complaints handling body for the whole public sector.

Crerar report - other recommendations

The Crerar report also recommends that –
• Core risk criteria should be agreed by Ministers and agreed by Parliament to assess the need for current and future scrutiny
• Ministers should redistribute resources and functions from within NHS QIS,
the Scottish Government’s Health Directorates and the Care Commission in relation to private hospitals and related treatment – to an independent external scrutiny organisation
• All external scrutiny organisations should have one “status” with clearly defined lines of accountability to Parliament and to Ministers.
• Where scrutiny is needed, if there is more than one existing organisation, only one should be asked to do the work and be fully responsible and accountable. Creating a new scrutiny organisation should not be an option.

Crerar Report: Principles of scrutiny

The focus should shift to self assessment, supported by risk based, proportionate
external scrutiny. As service provider performance management improves in quality
and ability to reassure users, public and elected members, scrutiny can become
more proportionate to the risks, which in turn frees up delivery organisations to focus
further on improving their front line services. The scrutiny framework should –
􀂃 focus on the needs of the people who use services being scrutinised,
􀂃 drive improvement,
􀂃 ensure that public money is used as efficiently and effectively as possible.
The principles behind the system are for a simplified scrutiny landscape, with a
proportionate and co-ordinated approach.

Crerar Report: The future for Scrutiny bodies

The report does not make specific recommendations in relation to the future of particular scrutiny bodies as this was not the remit of the review. However the report does recommend that in the longer term there should be the development of one scrutiny body and this will have implications for a number of existing bodies.

Crerar Report: A Risk based and Outcome focussed approach to Scrutiny?

The report argues strongly for scrutiny which is risk based and which moves away from scrutinising inputs and processes and towards measuring outcomes.

The full report can be downloaded at http://www.scotland.gov.uk/Resource/Doc/82980/0053065.pdf

Healthcare associated infections study

National Healthcare Associated Infections (HAI) Point Prevalence Survey

This survey, carried out by Health Protection Scotland, is the most
comprehensive study ever undertaken into the extent of infections in Scotland
and leads the way in HAI research in Europe.

The survey recorded the presence of all types of infections in one day for every patient in every acute hospital. The survey found that the prevalence of HAI was 9.5 per cent in acute hospitals
and 7.3 per cent in community hospitals and the cost of these infections was approx. £183m per
year.
The study found that the highest numbers of HAI in acute hospitals were present in care of the elderly, medical and surgical wards.
The HAI task force will take these findings forward and is focusing on the following areas:
• examining the case for introducing an MRSA screening programme - targeting skin and soft tissue infections
• reducing blood stream infections
• ensuring additional surveillance data are put to use in the areas of general medicine and care of the elderly.

Vulnerable Young People transitions research

Scottish Executive: Review of Research on Vulnerable Young People and Their Transitions to Independent Living

The Scottish Executive has published a Review of research on vulnerable young people which was conducted by the Centre For Research on Families and Relationships, The University of Edinburgh ( Authors; Susan Elsley, Kathryn Backett-Milburn, Lynn Jamieson) The Full report is available from www.scotland.gov.uk/research

The report examines available research and data on the issues around vulnerable young people and their transitions from care to indepenedent living.

Recovered memories of abuse:new research

New research suggest that memories of abuse recovered through therapy may be less reliable than memories which are recovered spontaneously.

Some years ago an intense debate began about the reliability of recovered memories of abuse when a number of very high profile cases hit the headlines in a number of coutnries. In some of these cases memories of abuse had been recovered through intensive therapy and there was much debate whether such memories could be relied upon as accurate recollections of past events.

The whole issue of the reliability of recovered memory became a very hot topic in the fields of psychology and psychiatry with fierce advocates on both sides.

Elke Geraerts, a psychology post doctoral researcher at Harvard University and Maastricht University, the Netherlands, aimed to try to throw light on this problem using a large-scale research study designed to test the validity of such memories.


Of course people who recover memories in this way will tend to be convinced they are real authentic memories and this makes validating the recovered memories difficult.

Geraerts and her colleagues avoided this problem by using outside sources to corroborate the memories.

The researchers recruited people who reported being sexually abused as children.

They divided them into three groups.
1) Those whose memories were categorized as either "spontaneously recovered" (the participant had forgotten and then spontaneously recalled the abuse outside of therapy, without any prompting),
2) those whose memories had been "recovered in therapy" prompted by suggestion

3) those whose memories ofthe abuse was "continuous" in that they had always been able to recall the abuse.

Interviewers, who had no knowledge of which group the subject fell into, then interviewed other people who could confirm or refute the abuse events. these included others who heard about the abuse soon after it occurred, others who reported also having been abused by the same perpetrator, and those who admitted having committed the abuse.


The results to be published in the July issue of Psychological Science, journal of the Association for Psychological Science, showed that,

1) overall, spontaneously recovered memories were corroborated almost as often (37% of the time) as continuous memories (45%) but were less reliable.

2) memories that were recovered in therapy could not be corroborated at all.

Of course not being able to of confirm that the abuse had happened does not prove that the memory is false. It does however suggest that memories recovered in therapy need to be treated with a great dela of caution, as the therapy context raises the opportunity for suggestion.
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Source: news release issued by Association for Psychological Science.

Care Home Standards:When big is not better

The Care Home market in the UK has seen a significant move over recent years towards the consolidation of ownership into the hands of fewer and larger ownership organisations. While in financial terms this may make sense there has been concern among commissioners and regulators whether these larger corporate organisations are always delivering a better quality of care in their homes in comparison to the smaller or single single home providers that are becoming a less significant part of the market.

Much of the concern about the standards in the Care Homes provided by the "big players" has admittedly been anecdotal and we are not aware that there has been any systematic study of this in the UK. Nevertheless the anecdotal evidence seems quite strong and it has been interesting to speculate why these larger organisations sometimes do not match the quality of care in smaller scale provider organisations.

Now a study by the University of Michigan School of Public Health suggests that the very strengths of the larger nursing home chain- its ability to standardize and perfect administrative practices throughout the chain-may also be the very thing that hurts patient care. While the study was confined to the more Nursing Home oriented facility in the US, it may have important lessons for the delivery of care across the Care Home sector.

"Consumers need ways to identify what is a good or bad nursing home when making choices about where to place a loved one," said Jane Banaszak-Holl, corresponding author on the study. "Right now, we have an easier time distinguishing the quality in McDonalds versus Boston Market than we have distinguishing how, for example, a Sun-owned nursing home differs from a Beverly Enterprises nursing home."

As in the UK these larger chain-owned nursing homes are the predominant type of institutional care in the United States. Studies in the US have shown that care in chain-owned nursing homes is generally not as good as care in nonprofit and singly-owned nursing homes.

"If they (chain-owned nursing homes) are really not as good, we need to think about how to improve them," said Akiko Kamimura, a U-M doctoral student in Health Management and Policy at the School of Public Health, and first author of the study.

The study suggests that corporate standardization of clinical and facility processes improved resident care, but that corporate standardization of administrative processes hurt patient care. The study concluded that chains need to balance administrative efficiency with the local needs of the individual chain-owned facilities to optimize the quality of their patient care.

The researchers surveyed 203 nursing homes in Michigan and North Carolina and looked at the effects of corporate standards and training in three areas: administrative processes, clinical processes, and facility design. The study examined the impact on the total number of health deficiencies given to facilities on state inspections, and the percentage of residents with bedsores. An example of a health deficiency would be inserting a catheter unnecessarily because it makes care easier.

An example of standardizing administrative processes would be to share common marketing materials. An example of facility standardization would be to use the same facility layout, and an example of standardizing clinical processes might be to implement guidelines for the treatment of resident bedsores throughout the chain.

"Standardization is a way to think about changing service delivery across many areas, including administrative and clinical processes and even within facility layout," said Banaszak-Holl. Chains that over-emphasize administrative processes don't take advantage of how much their staff can learn---and ultimately improve patient care---from the shared knowledge of developing protocols for handling resident needs.

"What we have stressed in the larger project is that chain ownership is not necessarily bad for the quality of health care, Banaszak-Holl said. "What is problematic is a shift away from community values and local needs, and an overly strong emphasis on administrative rather than clinical outcomes. A good corporate chain can implement a set of practices that still attends to local needs and resident outcomes while introducing greater economies of scale and better business practices."

The study, "Do corporate chains affect quality of care in nursing homes" The role of corporate standardization" appears in Health Care Management Review.

Dementia: Research supports person centered care

An intensive comparative study of two nursing home units using contrasting approaches to dementia care for elders with severely disturbed behaviors has shown that "humanizing" approaches to dementia care may not only extend quality of life for patients, but also their length of life.

Central Michigan University professor of anthropology Athena McLean in her recently published book, "The Person in Dementia: A Study of Nursing Home Care in the U.S.," demonstrates the very different outcomes of two approaches to dementia care: a rigid task-oriented maintenance approach which placed emphasis on disease progression and a flexible person-centered approach which focussed on the older persons communication and individual needs.

There were dramatic differences in patient quality of life at the two nursing units.

Patients at the person-centered unit, where staff looked beyond physical and reasoning abilities to the person's will and relationship with others, were happier, had improved quality of life and lived longer.

Those at the unit which focussed on disability and pathology tended to have personal needs ignored, were heavily medicated and often failed to thrive.

"These findings address issues that medicine can't answer," said McLean. "They are valuable not only for improving the general quality of life for these elders, but also for the long-term outcome based on how they are treated and cared for. These elders require attention, time and a lot of caring interaction."

The study also showed that relations among professional and administrative staff within a service can significantly affect the quality of the dementia care elders receive.

According to McLean; "Good caregivers are leaving the profession because they are underpaid and unappreciated. It needs to be understood by policy makers, family members and clinicians alike that money needs to be put into retaining quality caregiving staff, instead of only fancy facilities, which is currently the trend."

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Translate documents to Braille free

A Danish company has launched a free service which will automatically translate documents into either Braille or speech. The service is free for non-commercial use and may be of great assistance for organisations seeking to ensure equality of access for the sight impaired.

The service can be obtained through the RoboBraille website .

RoboBraille allows the user to;

• Translate documents into contracted Braille
• Translate documents into speech
• Translate text into visual Braille
• Convert text documents between different character sets
• Convert Braille documents to specific Braille character sets
• Partition documents into smaller parts