For the social care sector to thrive, regulation and governance will need careful attention.
Social care in England is a jigsaw puzzle - a patchwork of providers, funding, and regulation. This leads to major variations in the standard and quality of care.
“We have an NHS that is publicly funded and a care sector where you pay your own way. That makes for a disjointed, or in many cases, two-tier system,” says Julie Rayner, the director of care quality, governance and compliance at Hallmark Care Homes. “Every care home should deliver great care - whether it’s local authority or privately funded - and there shouldn’t be such a differential in the standard of facilities for people after a life of contribution.”
David Williams, chief executive of the St Monica Trust which provides at-home care, dementia care, and homes in retirement villages for over 1,100 people, shares these concerns. He wants more co-production in terms of development of services and regulatory standards. He feels that at present, care providers are stifled by standards imposed by different regulators, commissioners and other stakeholders and so are unable, or unwilling, to innovate to address the issues around quality of care.
“The lack of acknowledgement by CQC that service innovation may challenge aspects of the current regulatory framework and the inability of inspectors to go off piste, in terms of the inspection, means it’s often easier for providers to stand still,” Williams says.
He adds the key to solving this is the development of “great communication and trusted relationships”, such as those offered by the Trusted Assessor scheme - a national initiative designed to reduce delays when people are ready to be discharged from hospital. The scheme is based on providers adopting assessments carried out by suitably qualified “Trusted Assessors” working under a formal, written agreement.
“The assessor works with local authorities and community NHS teams and that has worked very well,” he says. “But it depends on the local authority and community health groups listening to feedback and altering the process as appropriate. That three-way communication process is very important.”
Reduced funding, rising standards
Irene Sobowale is the chief executive of the Disabilities Trust, which offers community and residential support for people with acquired brain injury, complex physical or learning disabilities and autism. She observes that cash-starved local authorities are cutting funding, while quality, regulation and governance standards are rising.
“Providers are required to absorb the impacts of these tighter controls and regulations, requiring significant investment. Without additional funding, sustainable service provision is an ongoing challenge,” she says.
Chris Jackson, the chair of the National Association of Safety and Health in Care Services (NASHICS), canvassed his national executive committee (NEC) for this report, asking what would be needed to improve the situation for providers. They want to see “sharing between all parties, well before there is a need to act,” adding: “We need to try and build bridges at a local level, and promote inter-agency works.”
The committee gave examples of some providers having to deal with three regulators, across England, Scotland and Wales. They feel there is a need for a form of ‘Best Practice Support Agency’ to help providers hit all the necessary requirements.
“In multiple organisations, making the journey to best or excellent practice is a difficult one to navigate, given the plethora of guidelines from the Social Care Institute for Excellence (SCIE) and the National Institute for Health and Care Excellence (NICE),” they said.
Regulator and enforcer
The Care Quality Commission (CQC) acts as both regulator, responsible for registration and inspection, and enforcer. It has a wide range of sanctions available to it including criminal proceedings, powers to cancel provider registration, and the power to impose conditions on how services can be delivered.
Opinion was divided among our interviewees as to whether this combined role should continue. For some, the threat of sanction creates too much potential to sour relations with providers and has a negative impact on how providers, regulators and other stakeholders collaborate for the benefit of service users.
Williams agrees that work is needed to ensure the CQC’s focus of attention is on delivery of effective, safe, responsive and well-managed care. “Sometimes that is missed because inspectors are looking at some small particular detail and failing to triangulate the importance of that on the person’s experience of the service,” he adds.
While the CQC earned praise from interviewees for establishing standards for the sector, Williams says the unintended consequence has been the potential to stifle innovation.
Carrie Pilgrim, however, does not think inspectors stifle innovation: she says the pandemic has proved the resilience, forward-thinking and professionalism of the social care sector. “Social care is often referred to as the poor relation of NHS yet the pandemic has highlighted how responsive the sector has been,” she says.
“From my perspective, we have 20 operators in our homes and they were not sitting around waiting to be told what to do. We witnessed excellent leadership, timely decision making, and continual responsiveness to many policy changes directed from government. All of Octopus’ operators have been committed to adhering to changing regulation and most importantly keeping residents and staff safe.”
Interviewees want the CQC to have a stronger role in regulating health and social care commissioners. “Outcomes in care homes and social care are intrinsically linked to commissioning behaviour. It’s unfair to judge the service provider in terms of results when the commissioning behaviour has been wrong,” says Williams.
The CQC’s move to look at governance going up to board level was welcomed. Carrie Pilgrim is the clinical assurance manager at Octopus Real Estate, a specialist investor which works with providers, developers, and planners to create and fund purpose-built care homes and retirement villages. As part of its due diligence process as a landlord, Pilgrim says Octopus “looks for strong clinical representation on boards to ensure that there is a balanced approach in decision making”.
“This has been favourable during the pandemic, as senior clinicians and care experts have been able to be responsive to multiple changes in regulation in a very short space of time. These changes are also mapped, documented and have remained up to date and compliant throughout,” she says.
Sally Ireland is a barrister and head of regulation at the Associated Retirement Community Operators (ARCO) which represents around 100 organisations in the UK. The sector provides ‘housing with care’, allowing residents to own or rent and maintain privacy and independence with the reassurance of 24-hour on-site staff and communal facilities.
“Operators in our sector have a long-term relationship with residents – possibly 20 to 30 years, unlike two or three years in a care home,” Ireland says. “That means we require a variety of skills and expertise from board level down, as housing with care is about hospitality, wellbeing and wellness as well as domiciliary or personal care.”
Large numbers of long-term investors are entering this market, including major insurance providers and pension funds; Ireland says this is a positive, because they bring strong governance. “They make sure that everything is absolutely right in terms of due diligence. As long-term investors they are quite risk averse, and that shows this is a good sector to be investing in,” Ireland says.