QA is here to stay, but …

Quality assurance is a relatively new phenomenon in the field of social care. There have been inspectors for a hundred and fifty years, but it is only in the last two decades that standards have been defined tightly, targets and expectations made explicit, and services monitored and inspected against the standards.

Quality assurance is here to stay, and it is a matter of importance to everyone. Consider the main stakeholders. The general public wants to be reassured that services provided on its behalf are satisfactory. Purchasers of services want to know that they are getting value for money. Service providers want to know that they are delivering the quality of services they claim to offer. Staff like to know that they are doing a worthwhile job and that they have achieved what is expected of them. Service users and their families have the most to lose if quality services are not provided and want reassurance that they or their relatives are receiving good social care. Trainers are trying to improve practice standards. And of course, quality is the meat of the work of inspectors.

In short, everyone with an interest in social care has - or should have - an interest in quality.

Questions

This article is not arguing that we should do away with quality assurance therefore. It is, however, based on the premise that every valid development carries the seed of its own decay, and that we all need to be alert to failings in order to make the necessary adjustments and corrections. Quality assurance itself needs to be quality assured. Is it performing well? Is it providing value for money? What are the standards against which we should assess quality assurance? How do we know what impact it is having? Is it improving standards of social care as far as the key stakeholders are concerned?

As quality assurance systems become established, expand and make increased demands, so they use up more time and resources, both of which are precious commodities. How much should we spend on quality assurance?

There is also the danger that the processes and side-effects of quality assurance systems themselves affect the quality of care they are assessing. At what point might quality assurance actually cause harm?

It is important to ask these questions if we are to develop the highest standards of service and if quality assurance is to serve the service in achieving the best.

Basics

Let us start by looking at the basics of quality assurance. One can monitor and assess four different elements – inputs, process, outputs and outcomes.

To use a simple analogy, one can monitor a bakery making cakes. To check on the inputs – the things in existence before they start baking, - one can look at the ovens, the materials, the recipes, the staffing, the Health and Safety policies and so on. To monitor the process, one calls to check how things are going, for example, how well the ovens are working, whether the staff wash their hands, and what records are kept of temperatures. Output measures take account of the number of cakes produced, their types, the proportion rejected and the profits of the bakery. The outcome is assessed by what the people eating the cakes think of them: do they actually buy them, enjoy them, come back for more and tell their friends?

In a simple process such as cake production, it is relatively easy to identify and check these elements. Social care is concerned with a wide range of aspects of people’s personal lives, and it is much harder to monitor.

Inputs

The easiest element to check is the inputs. Are the premises all right? Is there the right equipment? Are there enough staff? Have they been properly trained? Are all the policies in place which the checking agencies require? Will the service be financially viable according to its business plan? Are the right fire precautions in place?

The list of input questions can be very long. All these things could and probably should be in place before the first service user turns up. Most of them are easy to assess. The premises can be inspected, the policies read, and the staffing records checked, for example. Indeed, it should be possible to check one hundred per cent of the factors identified as requirements at input level.

Because they are so easily identified, quality assurance systems have often focused on them. This is the area most often subject to lengthy checklists, but once these requirements have been met, many of them should not need to be rechecked, and monitoring agencies may be wasting their own time as well as the service providers’ if they keep going over them.

It is of course important to check that the ingredients are right – the premises, staffing and so on – but on their own, input criteria are quite inadequate as a test of quality of service. A pile of ingredients has to be baked before it is a cake, and in social care it is the way that services are provided that is critical to their quality.

The danger is that because of their checkability, there can be an over-emphasis on input standards, and not enough on process, outcomes and output.

Process

Process is also relatively easy to check in social care at a superficial level, but it is difficult at depth. Anyone who visits a service – a residential home or day centre, for example – will get a feel for the atmosphere by interacting with the staff and service users. Sometimes things will impress as friendly, relaxed, busy or purposeful; sometimes they can be cold, disorganised or give mixed messages.

Inevitably, since inspection visits tend to be limited to a few hours every so often, they tend to offer snapshot impressions, and the atmosphere and quality of practice can change, for better or worse, after the inspectors have left.

It is often argued, therefore, that visits of inspection should be unannounced, so that proprietors and managers cannot clean the premises, augment the staff and give a better impression than typical standards of practice. Certainly there is an argument for unannounced visits, as, in principle, services should always be demonstrating a high quality of practice, and they should expect to be able to satisfy inspectors whenever they call.

However, it has to be acknowledged that the number of times that really bad practice is identified on inspectorial visits is very small, whether the visits are announced or not. Records show that even in the places where serious abuse was being practised, visiting inspectors, councillors, board members and social workers were often unaware. Even within staff teams an abusive worker may conceal his/her malpractice or coerce others into silence It is no criticism of outsiders, then, if they fail to identify abuse or other failings.

The real value of the visits is that they can be used to set and reinforce standards, ensuring that service providers are clear about the expectations they have to meet and that they will not be able to plead ignorance as a defence if poor work later comes to light.

Unless someone speaks up - a service user, one of their friends or family members or a member of staff – it is very difficult for inspectors to identify bad practice, even if it seriously abusive. Sometimes people are frightened of retribution after the inspectors have left and will not speak out. Staff may be afraid that they will lose their jobs if the service is closed down. Inspectors cannot personally check the physical condition of service users, and many inspection methods risk becoming intrusive, infringing service users’ privacy.

While checking on process is important, therefore, it cannot be undertaken comprehensively, and current methods are most unlikely to identify bad practice. The best that can be hoped for is that through regular contact inspectors will come to be seen as reliable by potential complainants and whistle-blowers, and that over time they will feel able to raise issues of concern.

Outputs

In social care, outputs are important for people commissioning services, as they are indicators that they have achieved value for money. They are also useful to service providers for economic reasons, for example in consideration of occupancy levels and budgetary results.

They are rarely useful, however, in assessing the quality of a service in terms of the service users’ experience. If the social care on offer consists of a programme of treatment, it can be presumed that the higher the percentage of service users who complete the programme, the better for everybody. In most cases, though, outputs are essentially measures for managers.

Outcomes

Outcomes are the most important measures as far as service users and their families are concerned. As with the cakes, the question is whether the social care on offer is enjoyable, fulfilling or meets their needs. This can, however, be very difficult to assess.

In terms of the Maslow hierarchy of needs, it is relatively easy to see whether basic physical needs are being met through the provision of shelter, food, clothing and health care. It is harder to assess whether the quality of services such as counselling or education is good. It is almost impossible to tell whether a person’s potential has been fulfilled or whether they are fundamentally content as a result of the services provided.

These are often long-term questions. Has a person with disabilities had the opportunities to fulfil their potential, or have the services provided limited them? Has a child in care come to terms with the problems s/he was facing and developed a way of life to their satisfaction, as a student, worker, partner or parent? What impact the services have had may not be known for many years.

The Greek historian Herodotus concluded the story of Cyrus and Croesus by stating, “Call no man happy until he is dead”. Without taking him literally, it remains true that the success of much social care may only become apparent many years later, and certainly not to an inspector who calls briefly. People providing services actually have to work in the faith that what they are offering will lead to satisfactory outcomes. They have to apply theories and knowledge, such as research into effective practice, but in the end, they cannot be certain that what they are doing will be effective.

In cooking cakes, the cycle of operations is short and repetitive, and it is possible to learn from mistakes and improve over a relatively short time. In providing social care, the cycle is life-long, and by the time a worker has seen the outcomes of his/her early work, they may be in mid-career. While outcomes are the most important thing to assess, they are also the most difficult, but they must not be ignored.

Drawbacks

It can already be seen from this thumbnail sketch of the four aspects of inspection that there are serious weaknesses in any existing system if we wish to ascertain the real value of social care services. It is the most superficial things that we can check most easily, and the most fundamental, which matter most, that are hardest to get at. At best we only have a snapshot or set standards, and there are layers of defences which hide reality from external quality assurance inspectors.

In this paper, five main problems with the system of regulation of social care services will be considered.

Playing the Game

Quality assurance, like many aspects of life, is a sort of serious game. It has its rules. Those who play by them and fulfil expectations are the winners. Those who break the rules can be in never-ending trouble. The first group pass Go, collect the money and buy Mayfair; the second group go to Jail and do not pass Go on the way.

Playing the game entails having all the right paperwork up to date, all medication accounted for, all policies ready for inspection, the right staff on duty during inspections, and explanations ready to hand for any exceptions.

This does not mean that the quality of service as experienced by the service users is necessarily good. Certainly, agencies do need to have policies and medication does need to be administered properly, but even if all these aspects are spot on, the atmosphere in the service may be poisonously unhappy, and even if it is happy, it is pointless if the wrong service users have been admitted to the service.

The real danger is that service providers come to think that the checkable aspects which they are required to report on actually represent the best care, and that if they fulfil them, the quality of care will be good. Inspectors may like to think that this is so, and may feel that their interventions actually are improving care. Inspection is more likely to be cutting out bad practice than ensuring good practice.

Inspection may well be having an impact, but for many people receiving social care services, their real needs are concealed and much more fundamental. Some may be deeply unhappy, or be struggling with mental health problems, or have suffered abuse so that they cannot relate intimately to others, or may have addictions and personality disorders to grapple with. These problems may not be apparent and may be concealed by passivity or other reactive behaviour.

The inspectable social care setting within which these problems are addressed is no more than a medium for the social care workers to try to help service users resolve their problems. The medium is not unimportant as it is the vehicle for the message, but it is not the message. In the same way, spelling and grammar are important if a message is to be accurately conveyed, but they are not the message. Bad grammar and spelling may prevent the message getting across, and they need to be checked, but it is the message which is of greatest importance.

Inspection focuses more on the medium than the message. The danger is that the emphasis on what can be inspected may divert service providers and workers from meeting more fundamental needs. The medium, although serious, is less important than its meaning, but it may take over.

Conflicts in Values

Life often entails compromises between different aims and values, and quality assurance is no exception. People aiming to achieve quality in one aspect of social care may run into conflict with those advocating another cause.

For example, Health and Safety officers or trade union officials might state that staff should never lift service users but always use a hoist. Others might argue that this is not always practical, and that it is in processes such as lifting that there is bodily contact which is denied service users if they are always dealt with at arm’s length. We do not want staff to get bad backs, but we do not want service users to be dealt with uncaringly or institutionally.

Again, residents in a home might be encouraged to work in the kitchen, whether as a household occupation or as preparation for independence, but kitchen hygiene rules may declare that only trained staff with their NVQ certificates should be allowed in. Of course, residents can be trained, but such an approach to care cannot be considered as homely or informal.

Or again, fire protection officers may determine that a small group home, being in multiple occupation, needs self-closing doors, internal lobbies and fire exit signs, creating an institutional ambience and difficulties for free movement within the home.

All the people arguing for safety precautions are doing so with quality in mind - greater protection of staff health, better kitchen hygiene and greater fire safety. Yet in every case there are strong social care arguments to the contrary. In so far as social care is trying to provide a relaxed home-like setting, these quality requirements are counter-productive.

A major conundrum is that most of the problems which the safety measures are trying to address can be measured specifically, while social care needs cannot. Fire officers know about the rate of fire travel and the time which a resident will have to escape if a fire door is shut. Social care managers cannot be specific about the impact of the fire doors on the social life of the home - whether they result in less social interaction between residents, for example. Nor is it easy in the face of pressure from insurers, the public and safety-conscious agencies to argue that risks should be taken which might enhance the lives of service users.

In consequence, the quality of social care in a service may be unintentionally damaged by measures intended to enhance quality. Getting the balance right is difficult.

Value for Money

Then there is the serious question about the returns on the money invested in quality assurance. If nothing were spent on quality assurance, bad practices would go uncorrected. If a very large slice of the available resources went on quality assurance systems, money would obviously be wasted. But what is the right balance in between these extremes? How do we know where the balancing point is?

The cost of quality assurance is probably masked. Obviously, there are the inspectors’ salaries to pay, but the time spent by managers in preparing for inspections, acting as host and answering questions, responding to points raised and reporting back to their seniors is not costed. These activities are simply assumed to be part of their duties, and with the growth of quality assurance, a larger proportion of their time is presumably spent in this way.

Inspectors may also be unaware of their hidden impact on agency budgets. For example, if an inspector says that a policy is required on a new subject, the matter has to be researched and consulted about; drafts have to be drawn up, modified and approved; the policy will have to be applied throughout the agency; staff will need to be trained; and the implementation will need to be monitored. The final cost in staff time in a typical agency may amount to the equivalent of a number of full-time staff. All of this is likely to be concealed, and it may be questionable whether it is value for money.

Multiple Quality Assurance Systems

There is insufficient space in this article to describe all the systems in existence to assess quality, and there is a strong argument for an audit to be undertaken nationally. Services, particularly those which straddle a number of disciplines, may find themselves being checked and inspected by a number of organisations.

What is more, these organisations often require information which is similar to that required by other bodies, but in different formats and sometimes with slightly different definitions, timescales and so on. To say the least, standardisation and rationalisation could simplify the task for those preparing the material, and in the process save on resources.

Humans are not Machines

The analogy with cake-making breaks down in considering the human factor. Bakeries could presumably be designed with no staff, and with robot machines receiving the materials at one end and wrapped cakes ready to sell coming out of the other. Not so with social care.

Throughout all the processes, whether they involve practical tasks such as eating, dressing or bathing or whether they are more complex such as assessment of needs or counselling, the key is the human interaction between service users and staff. It may be in groups or it may be one-to-one, but it always entails relationships, and the quality of the experience for service users is directly affected by the staff, their attitudes, values, beliefs and commitment.

To some extent staff attitudes may be observable and recorded by inspectors, but the processes of observing and recording during brief visits are too blunt to assess the subtleties of human interactions at depth.

Social care workers are human and fallible. Setting up good social care is not like the design of an automated bakery, which will run and run once it is properly established. In social care, one day can go well and the next go badly; inspectors may see one picture and not the other. Group dynamics change as people come and go. Staff can have off days or go stale.

In the end, the key factor in achieving high standards of social care is the motivation of the staff. Their technical skills and knowledge are, of course, important, but it is their commitment that makes a difference to the quality of their work. If they become lazy or uncaring, for whatever reason, they may still find ways of meeting official quality assurance criteria, but as far as the service users are concerned, they are likely to experience unsatisfactory care. If staff are well motivated, they will be wanting to achieve high standards and their inner drive will ensure that they are sensitive to service users’ needs and respond creatively, as well as keeping to the required standards.

The danger is that if quality assurance standards are inappropriately specified or applied, they might undermine the motivation of staff, encouraging them to fulfil requirements and develop a checking mentality, focusing on detail rather than the primary aims of social care.

It was Saint Augustine who said, “Love and do what you will. (Dilige et quod vis fac.)” We might wish to be rather more specific than Saint Augustine, but the point about the key importance of fundamental values is well made. The people who require social care services have varying individual needs, some simple, some complex, and if these needs are to be met, the key will be the system’s ability to support staff to respond as human beings towards those they are there to serve.