News and Comment

Safeguarding adults from neglect and abuse in care homes

Wednesday 25 June 2014


Statistics published recently by the Health and Social Care Information Centre showed a 4% rise in the number of alleged abuse referred for investigation in 2012-2013. 45% of the alleged abuse took place in care homes. High profile media coverage of care home abuse, such as the Panorama programmes on the Winterbourne View and the Old Deanery scandals, drew attention to the neglect and abuse of disabled people and older people, respectively.

Much of the policy and media response have been in relation to addressing care failing through reviews and inspections, while drawing attention to the need for better training and supervision. Many have been quick to argue that, while regrettable, these scandals are one-off incidents and should not be taken as a reflection of the wider care homes sector. While it is clear that there are numerous examples of high quality care in care home settings, to continue thinking about care home failings as random occurrences to be addressed through better regulation and inspection is to settle on a partial solution.

Regulation and inspection serve important purposes. For example, 158 care homes have closed since 2011 following action taken by the Care Quality Commission (CQC). However, there are real limits to what they can achieve on their own. Andrea Sutcliffe, chief inspector of adult social care at the CQC, admitted that: “We cannot always know what goes on behind closed doors”. There are real questions about what goes into any consideration of ‘risk’ that underpins risk-based inspection approaches. In an insightful study published in 2001, Christopher Hood and colleagues argued that professional risk management strategies can often reflect public opinion and market forces, rather than stem from any objective analysis of risk.

Any inspection regime ultimately still relies on information provided to inspectors. The CQC for example accused Castlebeck, the company who ran Winterbourne View, of “misleading” it. It is noteworthy that both the Winterbourne View and Old Deanery scandals came to light as a result of whistleblowing, and even so only after numerous whistleblowers have come forward (11 in the case of Old Deanery).

Over and above doubts about the reliability of information underpinning regulation and inspection, there are additional questions about the effectiveness of the model of inspection. It is notable that a CQC inspection that took place at a time when the Panorama’s undercover investigation was being conducted gave the Old Deanery a clean bill of health. This raises serious questions about whether the model of inspection is fit for purpose.

The clarion call of ‘nothing about us without us’ should be embraced by regulation and inspection. The predecessors of the CQC: the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission, tested a model of reviewing and inspection in 2008 that involved people with learning disabilities as ‘experts by experience’ in looking at learning disability services. The evaluation conducted by OPM found that the involvement of ‘experts by experience’ added real depth and understanding amongst all members of the review/inspection teams about what a ‘good service’ looked like from the perspective of those may be using the service.

While regulation and inspection is important, they are only ever going to work within the context defined by how services have been commissioned, designed and delivered. The same principle of ‘nothing about us without us’ should similarly be applied to service commissioning and design to ensure that structures and processs that reproduce ‘vulnerability’ and ‘risk’ should be designed out of the system. For example, the evidence base points to the fact that inflexible services may actually lead to people being moved into residential care unnecessarily. Truly person-centred care should mean that patient and service user perspectives feed into commissioning and service design. It should not simply be a case of what commissioners or professionals think is ‘good for’ or ‘good enough’.

I will be talking about these issues at the Public Policy Exchange Symposium – Putting Compassionate Care First: Safeguarding Adults from Neglect and Abuse in Hospitals and Care Homes, on Wednesday, 25th June 2014.