Castlebeck and CQC – Brief Thoughts

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I don’t have time for a long post today, just a few brief thoughts that came to me as I considered the unsurprisingly critical report on Castlebeck by the CQC.

Of course it’s easy to be wise after the event but it leaves a bitter taste in the mouth when the CQC comes down hard on Castlebeck after it required a TV undercover programme to uncover the widespread abuse at Winterbourne View. Where is our faith in the CQC? Well, personally, I didn’t have any to begin with but this report is not a solution, it smacks of a desperation to gain any kind of public recognition of the CQC itself rather than a real attempt to improve any system of regulation.

Regulation costs. Good regulation costs. In the week that the Ofsted is planning two week, unannounced inspections of childrens’ services, I ask why services for adults have been allowed to be neglected?

Yesterday I heard Paul Burstow on the radio on my way home. Two things struck me, firstly that he didn’t seem to have any understanding of the difference between a hospital such as Winterbourne View and a care home. He  seemed to be happy to blame local commissioners for the quality of the placements that they commissioned in hospitals without an understanding of what had led to this situation – namely chasing the lowest prices.  He still is banging on about his so-called Excellence scheme which, if anything, will make things worse as I wrote here. The Excellence scheme is opt-in and it is for companies to pay to be a part of. That is not about excellence, that is about money-making.

The CQC should be demanding excellence from every single service it inspects. Every day. It doesn’t. It demands sufficient paperwork every couple of years, at most. That is how it inspects. Actually, the CQC doesn’t inspect any more. It does not have enough people to inspect, control and check.

We have allowed companies like Castlebeck to rake in millions of pounds of profits on the back of providing poor care to vulnerable residents and patients. We have allowed this because noone is calling the CQC and the government to account for destroying adult care services.

The CQC criticising Castlebeck – of course it will but remember this is on the back of one television programme with hidden cameras. What about the thousands of homes without hidden cameras? Where are the checks? Where is the scrutiny? Where is the excellence?

Light Touch Inspections, Winterbourne View and the CQC

There was a report on the Community Care website on Friday that the CQC were ‘calling time’ on their so-called light touch inspection ‘regime’ thereby rolling out potentially to annual inspections for adult services and care homes.

As the article emphasises

Bower said that the CQC had favoured a “proportionate, risk-based, light-touch” approach to regulation – in which services were left uninspected for up to two years in the absence of issues coming to light – but service users, providers and staff favoured more inspections.

“What people want, particularly people who use services, is for us to put our boots on the ground,” she said. “Inspections are a really positive quality assurance for providers.”

It’s hard to believe Bower would have been saying this if she had not been forced into the position by the Winterbourne View scandal where substantial abuse was uncovered.

A shame that she did not show more backbone and spirit in protecting the organisation that was handed to her to lead when all the cuts were coming hard and fast. It did not take a genius to work out that the only reason the so-called ‘light touch’ system was implemented in the first place was to save money. The problem is, that it has stripped the CQC of any credibility it might have had as a regulator.

And yesterday, this same CQC criticised Winterbourne View and it’s owners, Castlebeck had misled that self-same regulator about issues that where taking place and abuse that was taking place while they were inspecting the service.

Interesting to see the Independent highlight the issues which the CQC raised as criticisms of Castlebeck

Inspectors said they found people who had no background in care services had been working at the centre, references were not always checked and staff were not trained or supervised properly.

They added Castlebeck failed to meet essential standards, required by law, including:

:: The managers did not ensure that major incidents were reported to the Care Quality Commission as required;

:: Planning and delivery of care did not meet people’s individual needs;

:: They did not have robust systems to assess and monitor the quality of services;

:: They did not identify, and manage, risks relating to the health, welfare and safety of patients;

:: They had not responded to or considered complaints and views of people about the service;

:: Investigations into the conduct of staff were not robust and had not safeguarded people;

:: They did not take reasonable steps to identify the possibility of abuse and prevent it before it occurred;

:: They did not respond appropriately to allegations of abuse;

:: They did not have arrangements in place to protect the people against unlawful or excessive use of restraint;

:: They did not operate effective recruitment procedures or take appropriate steps in relation to persons who were not fit to work in care settings;

:: They failed in their responsibilities to provide appropriate training and supervision to staff.

While there is no excuse for such considerable failures, you’d think that a good regulator worth it’s proverbial salt should have picked up some of these issues through a thorough and robust regulation system.

Remember this is the same Bower who has promoted extensively the use of whistleblowing and family members as a ‘resource’ to augment their inspection processes. And then the organisation feigns upset when things are concealed to it.

How did we come to this? How did we, as a society, allow the organisation that regulates Health and Social Care to be stripped bare due to a resource-led decision and blunt its teeth so incredibly that people who depend on these services can have no confidence in its position to protect?

Money, cost, closed eyes and an ability to discharge responsibility for the care of those in our society who need particular protection has led for this situation to emerge.

Unfortunately I can’t go into details about some of the things I  have seen over the past week that makes me feel  much more strongly about these issues but suffice to say this – which, in itself – could even be too much.

I visited a care home which had an ‘excellent’ star rating. Yes, the stars are outdated but it is an easy way to check and remains so. There had been no inspections over the past year, at least, anyway. Excellent. And it looked it on the outside. My involvement was due to a large scale safeguarding investigation. Let’s just say it was very far from excellent and had been for a number of years, including when the last ‘excellent’ inspection rating had been given.

The inspections depend too heavily on self-reported data and too little on ‘feet on the ground’ and investigations skills. I sometimes wish I could try doing a really thorough, wholesale inspection of any given inspection service. I’ve worked in residential care. I know what I would look for. It angers and upsets me that self-reporting and the ‘light-touch’ were ever permitted for purely cost-related reasons.

But the CQC says it is increasing inspections – still it will not be close to previous levels. To see them criticise Castlebeck – all well and good – but it doesn’t take the responsibility for inspection and regulation away from them. It bears some resemblence to the social workers who are told they are more easily led by parents who conceal information from them. If the social workers are chastised for ‘believing’ why not the regulator.

It makes me angry. Maybe time to invest in regulation and inspection and demand better services that actually protect against, rather than mask poor care. It is ever more important.

Eligibility, Birmingham and Cuts

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While awaiting the details of the court judgement, there was an important ruling yesterday that Birmingham Council’s attempt to limit eligibility to social care services to those who have ‘critical’ care needs is unlawful.

Drawing out some of the definitions to what this actually means and could mean requires a look at the details of those who brought the case to court.

There were four defendents which the BBC explains include

a 65-year-old woman with severe learning difficulties who receives 24-hour care in a home paid for by the council

25-year-old man with a rare genetic disorder and severe learning disabilities who receives overnight respite care, also funded by the council

30-year-old deaf, autistic man with severe learning disabilities who is prone to self-harm. His specialist day care would also have gone under the plans


a 36-year-old woman with severe learning difficulties whose day care centre will close and who is also set to lose respite care

It’s useful to go back to the definitions of what ‘critical’ and ‘substantial’ needs are to understand fully the implications of councils moving the eligibility criteria from one stage to the next.

Critical needs exist where –

• life is, or will be, threatened; and/or
• significant health problems have developed or will develop; and/or
• there is, or will be, little or no choice and control over vital aspects of the immediate environment; and/or
• serious abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out vital personal care or domestic routines; and/or
• vital involvement in work, education or learning cannot or will not be sustained; and/or
• vital social support systems and relationships cannot or will not be sustained; and/or
• vital family and other social roles and responsibilities cannot or will not be undertaken

Whereas Substantial needs (those that Birmingham are stating they are no longer able to meet) exist where –

• there is, or will be, only partial choice and control over the immediate environment; and/or
• abuse or neglect has occurred or will occur; and/or
• there is, or will be, an inability to carry out the majority of personal care or domestic routines;
• involvement in many aspects of work, education or learning cannot or will not be sustained;
• the majority of social support systems and relationships cannot or will not be sustained; and/or
• the majority of family and other social roles and responsibilities cannot or will not be undertaken

A couple of things to be noted here. A differentiation is made between ‘abuse’ and ‘serious abuse’ so that one will be covered and the other won’t. What kind of ‘legal’ test would there be to determine when abuse counts as ‘serious’ or not? Can we see children in similar cirumstances being subject to a differentiation of level of care available depending on whether abuse is ‘serious’ or ‘not serious’? And who is doing the judging? Well, I can answer that last question. It is the social worker involved as I am asked as a matter of course to ‘band’ people according to these criteria.

The obvious glaring point is the lack of thought of any kind of preventative work that sticking so closely to the criteria will create. Where is the hope of creating those very creative personal budgets when only the very bare minimum of essential needs are being met.

I can’t claim anything other than relief that Birmingham case was challenged in court. These criteria and these levels of need look at people as lists of what they cannot do. That goes against everything that we know and the ways in which we practice by looking at strengths and looking at people as individuals. However, the reason the criteria were brought in in the first place was to end some of the ‘postcode lottery’ of care provisions and to bring consistency to who was offered what nationally. Of course, the problem remained that interpretations of these criteria vary so the consistency which is objected by ticking boxes (the only way the officials seem to know to apply it) depends, as mentioned previously on the social worker who is doing the ‘judging’.

Back to this case though, it was brought under the Disability Discrimination Act and hopefully the judgement will be available soon. Hopefully too, local authorities around the country will be leafing through it and realising that the wholesale and slapdash cuts that they are imposing are not legal.

As for the government of millionaires, none of them will be reliant on social care support from the council. They can buy in any support that they might potentially need and cannot understand the distress of those who are totally reliant on the availability of services.  They cannot understand the implication of their gung-ho ideological cuts and the thought of Cameron, Clegg and Osborne claiming ‘We’re all in this together’ sticks painfully in the throat.

Although I fully expect Birmingham to challenge this ruling, I hope that the case is held and that some of the trigger happy cutting is stopped and the very real effect of the cuts agenda is shouted out more loudly and more clearly – not just for those of us who are personally losing services but to raise our voices with those who cannot always shout so loudly.

That is what social justice is about and that is what social working is about.

Inspections and the CQC

Orchardville Care Home. Loving care is given t...

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I was interested to see that Mark Easton in his BBC blog, touched on the issue of residential care and the confusion in the regulatory system.

He talks about a man, Dave, who needed to place his mother in a care home and looked to the CQC ratings and saw two stars (good) and his mother found herself in an awful care home.

She moved to a better place but the post goes on to say how

Ministers are pushing ahead with plans to replace regular national inspection with a “localism” model, relying on residents and their families alerting the authorities to problems.

Whoah. So now care home regulation is going the way of volunteers and ‘big society’. This is frightening stuff. I know the CQC has been being wound down, in effect, for years. There are fewer inspectors and they inspect less frequently.

Local authorities ‘quality assurance’ teams who may have picked up the slack are being disbanded in the face of enormous cuts in local authority funding from the central government. Our teams are being decimated (or if you want to take the term literally – more than decimated).

Easton has a telling – and chilling quote from the CQC

As the CQC explains: “We rely on people who use services and those who care for and treat them to tell us about the quality and safety of services. This feedback is a vital part of our dynamic system of regulation which places the views, experiences, health and wellbeing of people who use services at its centre.

Again. A little stunned and frankly horrified silence on my part when I read this. It felt as if I was being punched in the stomach and that the people who rely on a decent and human system of care homes are being kicked in the stomach by the government and the death of the regulatory system as well.

Feedback is very far from ‘dynamic’. I’ve tried to raise issues myself with the CQC about concerns in residential homes that I’ve visited and when you finally track down the officer responsible, you might get a sympathetic mumble but little has actually been done – oh, except in one instance where I managed to trigger a massive safeguarding alert which encompassed ALL the residents of said home.  Maybe a regular inspection could have highlighted these issues before a social worker who only happened to be visiting by chance raised the alert (when I spoke to the inspector, she admitted she had never actually physically visited that home).  Is this really the best way to proactively improve the quality of care homes? Is this what the ‘Excellence’ scheme is about? To encourage the CQC to be let off the hook as larger care homes tick more boxes.

This is a scandal. This is NOT as expectation that should be on residents and families who often feel incredibly vulnerable leaving their loved ones in a care home to pick up.

It isn’t easy to find the correct CQC number to make a complaint. Their website was actually redesigned to be far worse and far more user-unfriendly that I expect it was done by a work-experience student or the child of one of the higher tier managers who said ‘I know about computers.. I can do it’.

I really hope they didn’t spend public funds on that redesign.. information is much more difficult to find now – or perhaps that was the purpose (I’m saying that tongue-in-cheek – I’m don’t really believe in conspiracy theories – incompetence is usually the more obvious answer!).

Easton goes on to explain that

English councils are expected to improve their monitoring of care home standards just as they make cuts to adult social services, squeezing commissioning budgets and looking to find efficiencies in backroom quality assurance operations. The head of CQC, Dame Jo Williams, recently made the point herself: “The providers will be asking themselves: what can I do to cut corners?”

It is not just central government inspection of care homes which is being cut back. Ministers have also scrapped official assessments of how well local authorities commission care services. In future, councils’ responsibility to ensure good standards will be monitored by a new local consumer champion HealthWatch, which itself relies on local authority funding. The NHS Confederation has warned of “inherent conflicts of interest” with a council funded body scrutinising its paymasters.

So just when you thought things couldn’t get any worse.

This demonstrates that the ‘so-called’ Excellence scheme is a sham by a body that is not fit for purpose (namely the CQC).

We need to protect and provide support to vulnerable adults but no tools are being provided to support this and gradually the tools we had are being stripped away.

This is more difficult to stomach as Ofsted have a new inspection regime that demands that childrens’ homes are inspected twice a year and all inspections will be unannounced.

Why is the same system not introduced for vulnerable adults?

That is the question we should all be asking. Why does our society allow adults who are dependent on us to suffer so much in comparison and to be subject to second-rate, third-rate services and regulation of care homes?

We should be clamouring and demanding the same inspection mechanisms as given to children.

But people need to know about the changes in order to protest against them. Too many of these changes have happened stealthily and without much debate.

So slowly we are seeing the ‘big society’ that Cameron envisaged. It isn’t about community networking and organisation. It isn’t about volunteering and ‘making the community a better place’. It is about absolving the government of responsibilities.

Would we allow ‘friends and families’ to provide the base of inspections in childrens’ services or in hospitals? No. Why could and should we allow it in adult social care?

Changes in the NHS – initial thoughts

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I’ll write more about the government proposals to reform the NHS after the Health and SOCIAL CARE Bill is published tomorrow. Oh yes, did anyone pick up that slight subtlety there that it is supposedly covering social care as well as health.. sneakily hidden in.. er.. the title of the bill. You wouldn’t have thought it.

But I shouldn’t be too cynical. That’s just the way that social care has and will roll.

The BBC have a great ‘simple guide’ to the reforms and what they may mean.

Most of my reservations are about the introduction of GP-led commissioning – so I’ll focus on that today.

I know it’s presented as being about more choice and more efficient services – but, as I’ve said before, when the Tories introduced the so-called needs-led agenda of the NHS and Community Care Act in 1990, the talk was about improving efficiency, cutting costs and providing more choice – hmm, those words seem familiar.

What were we left with?

Centrally commissioned services that led to ‘bidding wars’ and reverse auctions so that the company that could provide the service at the lowest cost would ‘win’ the contract. No choice – perhaps less choice as the cheapest options had to be sought regardless of quality.

Why does no-one look to the lessons that should have been learnt from the care sector? I know, there are some wonderful services out there and I don’t want to be dismissive but I feel strongly about the introduction of ‘the market’ to the care sector and I feel equally strongly about the potential failure of ‘the market’ in the health sector.

The US is hardly a glowing example of an efficient and cost-effective health care system after all.

I am not sure I buy into this ‘choice above all’ agenda. Choice is always going to be limited by cost. On a personal level, I live in one of the most deprived areas of the country. I don’t ‘know my GP by his name’. I don’t even necessarily trust the practice.  My current GP practice was ‘taken over’ by the PCT (Primary Care Trust)  for a while because of poor management and a few… financial shenanigans that led to all the doctors in the practice being dismissed. That’s a pretty big deal.

I wonder how a similar scenario would ‘play out’ in the ‘new world’ – where there is no PCT to ‘take over’. But Lansley and Cameron probably haven’t considered those kinds of scenarios. I just hope they remember that we don’t all have local village practices that we’ve been with for years and where everyone knows us and smiles at us in the street.

There are some of us living in very poor areas where some of the chronic health problems that are linked to poverty will very obviously and quite rightly take priority.

So would I get the same treatment for a more minor ailment and a lower priority ‘condition’ as someone in Knightsbridge? I’m not convinced.

Even less convinced because it won’t be my GP who is commissioning – it will be a private company that is hired by my GP. It will likely be the same people who worked in the PCT re-employed by companies like Care UK (a coincidence that they bankrolled Lansley’s private office?).  So it’s likely to be the same people, doing the same job (probably for less money) but for the benefit of shareholders rather than the public purse.

I don’t want to be a grumpy naysayer. I want the NHS to work and to work better.

I am worried though.

I await the publication of the Health and Social Care Bill with trepidation.

I  have reconfiguration fatigue already. The amount of  money my Trust must have spent on change, and more change and even more change and then some more adjustments to that change would probably fund another ward. Or have retained one of the few that have closed.

I want ideas that work. I want a system that works. I am just very sceptical. Perhaps it is up to the government to prove me wrong. I hope I am wrong.

Attitudes to Disability

Yesterday, the BBC published a survey commissioned from ComRes to mark the 40th anniversary of the ‘Chronically Sick and Disabled Persons Act 1970’ which was the first piece of legislation that recognised ‘disability’

It is hard to imagine that it was only forty years ago. Even harder when you realise (as I hadn’t actually known before yesterday – possibly I shouldn’t admit to that considering how much time I have spent studying social care legislation) that it was actually a Private Member’s Bill introduced by Alf Morris (now Lord Morris). It was the first legislation in the world to give rights to people with disabilities and Morris became the first designated Minister for Disabled People in the world. And it was pushed through as a Private Members’ Bill.
Lord Morris of Manchester, who was responsible for the passage of the legislation in Parliament

Reading his words, from an article he wrote in the Yorkshire Post last year, gain an added poignancy in the light of both the survey and the general current political climate. He says

“If we could bequeath one precious gift to posterity, I would choose a society in which there is genuine compassion for long-term sick and disabled people; where understanding is unostentatious and sincere; where needs come before means; where if years cannot be added to their lives, at least life can be added to their years; where the mobility of disabled people is restricted only by the bounds of technical progress and discovery; where they have the fundamental right to participate in industry and society according to ability; where socially preventable distress is unknown; and where no one has cause to be ill at ease because of his or her disability.”

It is important to remember that the equality legislation and general societal attitudes today were achieved by those with vision and passion on whose shoulders the government now stands.

Anyway, back to the survey –

The headline figure is that 90% of people polled believe that people with disabilities should be provided with ‘necessary funds’ to make workplaces accessible.  That’s a nice, comfortable figure. I have to say I do wonder about what the other 10% think though..

More concerning, to me at least, is that 40% polled believe that people with disabilities turn down jobs that they may be physically capable of doing. The question asked being

‘People with disabilities often seem reluctant to work even if they are capable of doing a job’.

That is a very high ‘agree’ figure in my mind. This is what the government want us to believe and have constantly pumped this rhetoric out to the grateful right-wing press.

Another interesting statistic is that 27% of people polled believe that

‘Government legislation to give disabled people access to work and independent living has gone too far’.

That surprised me. There is no such thing as complacency and patting ourselves collectively on the back for shifting social perceptions of disability.

Disability is and can be all of us. Our parents, our children, our friends and our colleagues. It is not ‘the other’ and can never be assumed to be. We all have a responsibility to providing that society that Morris spoke about where there is a genuine compassion where needs come before means. I fear we may be losing sight of that in the cuts rhetoric and the rolling back of services that encourage us to think about personal needs and gains rather than those of society as a whole.

I am mindful that some of the negative assumptions about disability exist because there are ‘invisible’ disabilities, particularly in mental health areas.

I used to work in a residential care home for adults with learning disabilities. We had a disabled badge on the car for the residents. The amount of times that staff were challenged by people who thought they weren’t ‘really disabled’ and didn’t ‘need the disabled parking space’ was almost comical. It was as if members of the general public needed to ‘see’ disability in order for the badge to be ‘justified’. That’s a very small, very silly example but without acknowledging and accepting that disability is broad and most often not visible, we can’t create the kind of society that Morris described so well.

As for ‘Big Society’ – we can’t create a better way of working inclusively without tackling prejudice, assumption and ignorance about what is and is not achievable and what can and should be done to help others living in our society with us. For me, the collective will seems a lot further away than it did before the election.

On Failing Care Homes

Today, the BBC report on a statement by Unison, who represent the inspectors who work for the CQC (Care Quality Commission), explaining how failing care homes will be able to thrive under the ‘cost-saving’ exercises which are the utterly despicable ‘desk based inspections’ that I’ve been railing against for over a year.

This is one of many areas that I don’t want to be right. I don’t want to be a ‘Cassandra’ type figure but I do want people to care and know that elderly and vulnerable people are not being protected by the current regime of inspection and that things are going to get worse unless there is a massive change in the way the CQC is run – remember the Chief Executive is Cynthia Bower, the same woman who was responsible for the West Midlands Strategic Health Board – which covered the Stafford Hospital whose problems we have become all too aware of. Hardly a glowing CV for someone appointed to a regulatory body.

The BBC article explains

Unison says the new system of written self-assessments will mean thousands of homes will avoid inspections altogether if they look good on paper.

But the Care Quality Commission, which introduced the system, said it would let inspectors focus on failing homes.

Which would be fine if they DID focus on failing homes. I  am, for the record, currently in the middle of a really unpleasant safeguarding investigation at a so-called ‘Good’ residential home. It only takes one day or one person for a ‘good’ home to turn into a really bad home. This is the point that is utterly and comprehensively missed by the ‘new’ system.

The BBC go on to explain

The new system replaces yearly automatic inspections for all homes.

It came into force in October and now means that homes which provide a good written self-assessment may not be inspected again, unless there is a serious complaint made about them to the commission (CQC).

For me, this is a horrific institutional abuse and dereliction of the duty of care that the state has towards adults who rely on us to provide high quality care for them. Firstly, I know for a fact this has been the system for way before October, as I have spoken to an inspector directly about care homes that I am worried about and have been told that they haven’t been ‘visited’. This is NOT a system that ‘came into force’ in October’.

And sorry, but when it takes a ‘serious complaint’ to trigger an inspection, we are setting such a low baseline for the standards of care that we expect. If they MUST move down this route and, if it wasn’t very obvious, I think it is a cruel and horrendous path to tread – then surely only those homes which provide faultless and outstanding care would be able to produce self-assessments, not ‘only those that don’t have serious complaints made about them’.

The CQC is not able to manage the work that is being generated for it – that’s the problem. It is purely and simply about cost-cutting.

According to the BBC article

Unison, which now represents about 700 inspectors, claims that the workforce numbers have halved since 2004.

And there we have it. The key to why the systems have had to change. It is not about providing a better service, it is not about more tailored inspection regimes – it is purely and simply about cost and cutting back the number of inspectors. They can’t spend two days inspecting every residential and nursing home because they don’t have the time to.

Paper-based self-assessment is as valueless as the paper it is written on. It is a completely inadequate system that produced poor quality care.

Can we rely on whistle-blowers? Perhaps but remember the people who often work in residential homes who we might rely on are often very poorly paid and this is a sector that relies very heavily on transient staff on minimum wages. Particularly the worst homes.

What about council’s own Quality Assurance teams? This is what I was told, informally, in conversation with an inspector. On the other hand, someone I know who works in our own council’s monitoring team tells me of potential job cuts they are being subject to. This is leaving a monumental gap in the checks and balances of the care home system.

Care is a big money business in this country.

Just last year, Andrew Lansley, the Secretary of State for Health under whose auspices the care sector lies, was given a donation to his private office of £21,000 by Care UK – one of the largest care ‘industry’ operators whose poor quality of care has been highlighted in the past in Panorama.

However this is not a party political issue. The previous government showed little care or interest in the proper regulation of residential and nursing care services but the further erosion of local authority budgets will lead to a worse system of regulation than we have ever had in this country.

This is scandalous in the extreme. Anyone from this government (and the last, to be honest) who claims they are protecting the vulnerable need only look to both the decimation of proper and thorough regulation of the care sector which has left the way open to abusive practices and the crushing of local authority budgets without ring-fencing which will lead to any back up checks and balances being slowly (or not so slowly) eroded.

No-one seems to care enough about these changes and what it means for quality and the CQC management seem to be able to get away with reassurances that ‘paper based’ inspections will be ok.

They won’t and they aren’t. I know. I worked in residential homes for years before I qualified. There is no such thing as over-regulation in this sector because the power imbalances are enormous and in some of the care homes, the residents, due to issues of capacity or through fear of consequences are not able to speak up about what is going on. We cannot rely on family members to be whistleblowers, it isn’t fair and it should be accepted that we can provide a good standard of care.

And, you know, not everyone has family.

And we can’t necessarily rely on social workers, like me, who go and review. Yes, I can and do pick up some aspects of care but we don’t have the powers to look at records about people we are not primarily involved with (quite rightly). We can raise concerns about individuals when we notice them but that is no replacement for a proper and stringent regulation regime.

We need inspectors, we need inspections and we need more of them. But they cost and it isn’t a price the government is willing to pay. But it should be.