Modern Concepts of Quality and Risk
| Published date | 01 July 2010 |
| DOI | 10.1177/0952076709356869 |
| Date | 01 July 2010 |
| Subject Matter | Articles |
ßThe Author(s), 2010.
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0952-0767
201007 25(3) 305–326 Modern Concepts of Quality
and Risk
Challenges for the Regulation of Care for Older
People in Scotland
William Stein, Darinka Asenova and
Claire McCann
Glasgow Caledonian University, UK
Alasdair Marshall
University of Southampton, UK
Abstract This article is about the complex interplay between quality and risk in the
context of care for older people in Scotland. We review relevant theoretical
literature underpinning the concept of ‘quality’ and its relationship with ‘risk’ to
discover a wide range of regulatory challenges related to issues such as an
increasing number of older people; intense press scrutiny; private care home
provision; and, healthcare professionals increasingly shifting focus from generic
care needs towards a personalized approach focusing on the care needs of the
‘individual’. In this environment, risk control must be ‘negotiated’ against
resultant impact on the quality of life for individuals. We relate the existing
literature to the approach devised by the Care Commission for Scotland to
enforce published government standards: the adoption of a modern risk-based
approach to regulation involving the use of a risk assessment scoring tool to
determine and justify the level of regulatory intervention; and the development
of a quality assessment framework that articulates the existing government
standards. We conclude that if regulation and quality assurance are to concern
themselves more with risk, then this will best occur within the context of
integration and simplification rather than increased complexity –; perhaps with a
unified set of care principles and quality themes that make direct provision for
the management of risk. While this is of specific relevance to the regulator in
Scotland, the principles we discuss have application to other parts of the UK and
to other countries that face similar challenges.
DOI: 10.1177/0952076709356869
William Stein, Division of Accounting Finance and Risk, Glasgow Caledonian University, Cowcaddens
Road, Glasgow G4 0BA, UK. [email: w.stein@gcal.ac.uk] 305
Keywords Care Commission, inspection regime, national care standards, older people,
quality of life, regulation, risk, risk management
Introduction
Government has a responsibility to ensure that all care services are delivered to
meet current expectations of quality at minimum risk of harm to the public.
Within the last decade, Government policy in Scotland has brought about regu-
latory consolidation in the care sector by the creation, in 2002, of an independent
regulatory organization, the Scottish Commission for the Regulation of Care,
known as the Care Commission (Scottish Executive, 2001). By reference to a
set of National Care Standards imposed by the Scottish Government (Scottish
Executive, 2004a), the Care Commission has responsibility to inspect and regu-
late the provision of a wide range of care services, and to ensure continuous
improvement in service quality within the existing financial constraints.
The approach to regulation adopted by the Care Commission reflects general
advances in what is considered to be best practice concerning how risk is reflected
in the approach adopted by regulators. Beck (1992) famously argued that risk
‘may be defined as a systematic way of dealing with hazards and insecurities’.
The Hampton Report’s (2005) advocacy of a leaner, more effective and more risk-
based approach to regulation is just one of many modern guidance documents
which find value in the systematic treatment of risk. Hampton linked regulatory
intervention and enforcement to the use of risk assessment, arguing that where
service providers are risk assessed, resources can be targeted towards higher risk
service providers. Savings can then be invested to increase support for those
higher risk services. Thus, risk-based regulation can be cheaper yet better.
Heeding Beck and Hampton, the focus of this article is on the more systematic
and risk-based approach to the regulatory and quality assessment process as
developed by the Care Commission. The Commission’s approach is of interest
because the process involved an innovative combination: first, a risk assessment
scoring tool called the Regulation Support Assessment (RSA) which aims to
determine and justify the level of regulatory intervention (e.g., more frequent
inspections, specific requirements, or even closure of a service); and, second,
the development of a Quality Assessment Framework (QAF) that produces qual-
ity grades for publication. The result is two statistical indices running in parallel,
one related to risk, the other related to quality. We return to the RSA and the QAF
later in this article.
The scale of the regulation of care is considerable. There are many dimensions
to health and social care covering all ages and forms of vulnerability and disabil-
ity. The Care Commission regulate over 15,000 individual care service providers.
Over 329,000 people in Scotland use these services, which include: care at home;
care homes for children and young people; care homes for people with health
problems or learning disabilities; criminal justice supported accommodation
Public Policy and Administration 25(3)
306
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