Scottish Government

• There has been considerable inconsistency in inspection across Scotland. Whilst some areas have been subject to multiple inspections, other services, particularly those providing home care have not been inspected at all.
• A range of inspection agencies exist and there has been wide variation in criteria and standards used across the sectors of care provision.
• Variation has also existed locally with different standards, methods and reporting practices employed by different inspection agencies.
• Her Majesty's Inspectorate of Education (HMIE) have routinely used lay members and associate assessors over the last few years. These practices have been adopted only recently by some other inspection agencies.
• With the exception of HMIE, inspection reports have not routinely been available in alternative formats and community languages.
• Inspection reports tended to represent the views of service providers rather than service users. Inspectors appeared to spend a considerable amount of time checking policies and procedures and interviewing providers before speaking to users.
• Not all inspection practices were successful in capturing user voices. The way in which questions are asked and the reporting of information is therefore very important and must be subject to critical scrutiny.
• The new Care Commission standards are to be enforced in a way which is consistent but flexible. Consistency is necessary to compare services and to develop a national picture of service development. However, inspections must also reflect the local circumstances and histories of particular services. Combining these two elements is likely to be challenging for inspectors.

Introduction

In April 2002, a new non-departmental body, the Scottish Commission for the Regulation of Care (the Care Commission) assumed the responsibility for regulating care services which was previously held by NHS boards, local authorities, Social Work Service Inspectorate and HMIE.

The purpose of this report is to collate information on how current care services are being regulated, focusing in particular on the nature of the evidence gathered and the standards applied. The research provides a baseline, so that information generated by the new regulation system may be compared with the type of information produced under the former regime.

Research aims

The objectives of the research were to:

• provide a summary of approaches to regulating care services in the areas of pre-school education, residential care and care at home, and to provide an overview of the way in which the inspection of care services was reported in inspection reports;
• provide a summary of standards applied in the inspection of care services;
• identify the ways in which good practice, from the service user's point of view, were identified and defined in inspection documents;
• identify gaps in information which should be addressed in future approaches to the regulation of care services;
• provide a summary of the extent of current provision of care services.

About the study

Information was drawn from regulation literature produced during the years 1999-2000 and 2000-2001. A sample of inspection reports from a range of regulatory bodies including local authorities, Health Boards and Her Majesty's Inspectorate of Education (HMIE) was gathered and analysed with a view to addressing a number of questions around how the information was gathered, how it was analysed and presented for public scrutiny, the type of standards used and techniques for accessing user views.

In addition to analysing the reports of regulatory bodies, the quality and helpfulness of published statistics, Scottish Executive commissioned research and Accounts Commission publications were also reviewed. Having considered the nature of inspections in the areas of pre-school education and care, residential care and care at home services, some general points about the nature of inspection prior to the establishment of the Care Commission are presented in the report together with some general points about future directions for inspection in light of the new National Standards of Care.

Key issues identified

Range of inspection agencies and variation in criteria and standards

It is evident that complications have arisen as a result of some services being inspected by different agencies, reflecting different funding streams. For example, residential care homes have been inspected by health boards in relation to nursing care and by local authorities in relation to residential care. Similarly, some play groups, nurseries and childminders have been inspected by both HMIE in relation to their provision of funded pre-school education, and by local authorities with regard to their care services. The reports examined produced by different agencies also clearly reflect their principal mission. The experience of being inspected by different agencies is likely to have been difficult for service providers, although the present research did not include consultation about the process of inspection.

Lack of inspection in some areas

Whilst some areas have been subject to multiple inspections, other services particularly those providing home care, have not been inspected at all.

As direct payments become more widely available in Scotland more people will be employing individuals who will not be subject to inspection.

In child care, those minding a number of children in their own homes or other premises are obliged to register with the local authority, whilst some nannies may not be registered. Clearly, there are a number of unresolved issues about the extent to which the state should intervene in the context of people's private lives.

Variation in local standards

Examination of inspection reports suggested that varying standards were applied across the country. The location and nature of the inspection unit (local authority, health board, joint inspection unit) also influenced the standards employed. Since a range of standards are used, it is impossible to compare the quality of services in different parts of the country. This may be important for a service user moving to a new area, or for the Scottish Executive or Scottish Ministers, who need to develop a national picture of service performance across the country.

Variations in inspection methods and reporting practices

Just as standards used have varied, so too did inspection methods. Health boards and local authorities varied with regard to the precision of their performance indicators and the extent to which performance was scaled or recorded qualitatively.

Use of lay and associate inspectors

It is acknowledged that inspectors who are drawn from the same professional background as those involved in service delivery are likely to view the world through a similar lens. They may not be aware of the values and judgements which might be brought to bear by a member of the public from a different professional and social location. To ensure that inspections do not simply reflect professional concerns, but those of wider society, there is a growing emphasis on lay inspection. Peer review is also now being recognised and is being used in some areas.

Identification of inspection audiences

In order for an inspection report to be meaningful, its principal audience must be clearly defined. Many of the reports examined did not appear to have a clearly defined notion of their intended audience and many were not routinely available in alternative formats and community languages.

Capturing the user experience

The voice of the service provider was more prominent than that of the service user. Reports accorded relatively little weight to service users' views and generally did not convey a clear impression of what it felt like to be a person using a particular service within a particular institution. This part of the inspection process is clearly difficult to undertake.

Children, people with learning disabilities or mental health problems and frail older people are unlikely to respond readily to questionnaires. Moreover, interviews to access views may distort or present partial evidence. Another complicating factor is that different people, for example with learning disabilities, are likely to have different perceptions, like any other social group. Innovative methods are likely to be required to ensure that diversity of experience is recognised.

In the case of some groups such as young children, parents or carers are likely to be an important source of information. At the same time, it must be acknowledged that parents are not always sensitive to the views of their children and parents are very unlikely to voice concerns about the quality of childcare or pre-school education they have chosen for their children.

Future challenges for the Care Commission

The key challenges arising for the Care Commission that emerge from the analysis of inspection reports focus on the following issues:

• Implementation of integrated inspection arrangements: The Care Commission wishes to focus on the user experience rather than a service's administrative category or funding stream. This will require those undertaking inspections to consider the way in which the service enhances the individual's quality of life. This shift is likely to be challenging and will call for a considerable amount of co-operation and re-thinking by inspectors.
• Ensuring consistent and flexible services: Consistency is necessary to compare services and develop a national picture of service development, but at the same time inspections must reflect the local circumstances and histories of particular services.
• Enforcing regulations whilst using human and professional awareness: Whilst it is anticipated that inspections will have both internal and external validity and be robust in their methodology, application of standards and regulations may lead to important points being missed. In order for service users and providers to have confidence in the inspection process, inspectors must ensure that any inconsistencies are rapidly identified.
• Capturing the voice of the service user: Given past difficulties in incorporating the views of service users, innovative methods are likely to be required to ensure that a range of views are included. Likewise, whilst the voice of service users is essential in producing responsive services, it is possible that accounts of user views may present partial evidence or distort data in order to promote a particular policy agenda. Therefore, the way in which questions are asked and the reporting of information is very important and must be subject to critical scrutiny.