Through a glass darkly: exploring commissioning and contract monitoring and its role in detecting abuse in care and nursing homes for older people

Pages110-127
Published date09 April 2018
DOIhttps://doi.org/10.1108/JAP-10-2017-0034
Date09 April 2018
AuthorSteve Moore
Subject MatterHealth & social care,Vulnerable groups,Adult protection,Safeguarding,Sociology,Sociology of the family,Abuse
Through a glass darkly: exploring
commissioning and contract monitoring
and its role in detecting abuse in care and
nursing homes for older people
Steve Moore
Abstract
Purpose The purpose of this paper is to present findings from face-to-face interviews undertaken with 16
care and nursing home managers employed in homes situated in two English local authorities. The research
sought to explore managersperceptions of the role of contract monitoring in the prevention of abuse.
Design/methodology/approach Semi-structured interviews were undertaken with 16 care and nursing
home managers.
Findings Though personnel employed by the local authority who conducted contract monitoring were
generally thought of positively by care home managers on a personal level, their effectiveness was perceived
to be limited as a result of their lack of experience and knowledge of providing care, and the methods that
they were required to use.
Research limitations/implications Thoughthe research draws upon the experiences of only 16 care and
nursing home managers in two local authorities, data suggest that current contract monitoring activity is of
limited utility in determining the true nature of care and the presence of abuse.
Originality/value Unusually, the paper explores care and nursing home managersperceptions of
contract monitoring processes in terms of how they perceive their effectiveness in preventing abuse.
Keywords Older people, Abuse, Empirical research, Adults at risk, Commissioning and safeguarding,
Contract monitoring and safeguarding, Safeguarding policy and practice
Paper type Research paper
Introduction
With the continuedshrinkage of public sectorowned and operated residentialcare home provision
for older people, and the long-standing provision of long-term care to older people requiring
nursingcare in privately owned nursinghomes, both of which are purchasedin the majority by local
authorities by means of their commissioning[1] functions, the importance of effective contract
monitoring is ever more salient to ensuring high-quality care that is free from abuse.
This is particularly true given the limited effectiveness of statutory regulation in preventing abuse
in care and nursing homes for older people, likely to be compounded by proposed changes to
regulatory processes over the next four years or so that amount to a further dilution of current
regulatory activity (Moore, 2017a).
As figures collated by The NHS Information Centre (2012), The Health and Social Care
Information Centre (2014a, b, 2015) and NHS Digital (2016) have clearly demonstrated,
36 per cent of all safeguarding concerns emanated from within care and nursing homes, of which
in excess of 40 per cent were substantiated or partially substantiated in each of the five periods.
Similarly, the research of Moore (2016a, b, 2017b) has revealed the significant extent and nature
of abuse that still occurs in private sector care homes for older people, and that a proportion of it
Received 3 October 2017
Revised 22 November 2017
22 December 2017
15 January 2018
Accepted 23 January 2018
Steve Moore is an Independent
Researcher and a Consultant
based in Dudley, UK.
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VOL. 20 NO. 2 2018, pp. 110-127, © Emerald Publishing Limited, ISSN 1466-8203 DOI 10.1108/JAP-10-2017-0034
remains unreported and is sometimes actively concealed. Further, it is apparent that abuse
continues to be perpetrated in care and nursing homes rated as goodby the Care Quality
Commission (CQC), the statutory regulator (Moore, 2017b), yet local authorities and their
partners in Clinical Commissioning Groups continue to spend many hundreds of thousands of
pounds of public money each year not only to monitor the contracts they have with care and
nursing home providers, but also to actively help them to overcome their inability (or reluctance) to
comply with contractual requirements. That this is the case is particularly paradoxical given that
care and nursing homes are managed by care managers registered with the CQC following a
fit personsprocess that should, theoretically, ensure that they are suitable and capable of
running a care or nursing home to the required standards. Similarly, contracts let to care and
nursing home providers by local authorities invariably include, either implicitly or explicitly, many of
the same standards required by the statutory regulator, and will, or should, in any case include a
boilerplateclause that requires those to who the contract is let to comply with all statutory
primary and secondary legislation from time to time in force. This naturally includes the Health and
Social Care Act 2008 that, along with its attendant regulations, renders the current fundamental
standards of careprescribed by statute to be legally enforceable.
The research described in this paper explores perceptions held by care managers of the nature
and efficacy of current contract monitoring functions in preventing and detecting abuse of older
adults who may be at risk, that, if detected, will almost invariably also confirm that not all of the
required contractual standards are being met.
Reviewing the literature
Inveterate failures of care homes to meet prescribed minimum/essential standards
Long awaited National Minimum Standards (NMS) for all care homes in England were introduced
by the Care Standards Act 2000. The Act also created the national regulator responsible for the
enforcement of these standards, the National Care Standards Commission that became shortly
thereafter the Commission for Social Care Inspection (CSCI). However, at the end of the first year
of the full implementation of the new inspection regime, only 26 per cent of care homes were
assessed as meeting the NMS, and at the end of the second year, 2004, 48 per cent
were assessed as doing so (Her Majestys Government, 2005, p. 61). In 2005, after three years of
revised regulation, 20 per cent of care home providers still failed to meet the NMS (Commission
for Social Care Inspection, 2005, paragraph 8.24), and in 2006 21 per cent continued to do so
(Commission for Social Care Inspection, 2006, p. 140). In the 2009 annual report produced by
the Care Quality Commission, the current regulatory organisation that succeeded the CSCI,
17 per cent of care homes still failed to meet all of the minimum standards (p. 62). In 2012, the
CQC reported that between 12 per cent and 16 per cent of homes were still not meeting
requirements of what had by that time become the essentialstandards of quality and safety
(Care Quality Commission, 2012, pp. 12-3), and in the report for 2016, 26 per cent of residential
care homes and 41 per cent of nursing homes were rated by them as either inadequateor as
requires improvement, that is, they continued to fail to meet all of what were by that time termed
fundamentalstandards (Care Quality Commission, 2016a, pp. 58-9).
In such prevailing circumstances, where many care homes continually fail to meet basic required
standards, it is difficult to see how current regulation can be expected to reliably identify the
subtler, often concealed institutional failures and practices that give rise to abuse. That abusive
practices and regimes may remain undetected is also a particular concern given that
the frequency with which care homes are inspected has fallen since the advent of the national
regulator from a minimum of two each year to a variable frequency of up to only one inspection
every three years, based upon assessment of risk using a range of indicators, including provider-
generated self-assessments. As Kingston et al. (2003, p. 27) have argued, a key element of
preventing the abuse of people who might be at risk in the care sector is stringent regulation and
inspection, yet the Care Quality Commission (2011, p. 12) determined in its first overview of the
care market that Outcome 4, effective, safe and appropriate carewas one of three outcomes
generating the most enforcement actions. Further, Killett et al. (2013, p. 131) concluded from
their study of organisational cultures in ten care homes that an inspection report indicating
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