The impact and consequences of inspection on residential care for older people: A critical analysis of four case studies of Commission for Social Care Inspection (CSCI) inspection

Abstract

This research examines the impact and consequences of inspection by the Commission for Social Care Inspection (CSCI). The study begins with a Systematic Review (SR) of existing literature that is divided into effectiveness and process questions. The results of this review show there is no international literature on the effectiveness of inspection at improving residential care for older people. There is also very little process literature. The second part of the research uses a multi-site case study approach with a longitudinal element, to qualitatively examine the impact of inspection in relation to the quality of care provided by residential care homes for older people. Four CSCI inspectors from four different inspection offices across England took part in the study. The case studies show inspection struggled to induce quality improvements in services and had little direct impact on residents. A ‘culture of ageism’ existed within the services and this influenced both provision and residents expectations of care. Provision in all four case studies was still dominated by institutional routine and a lack of service user empowerment. In this context despite clear evidence regarding the value of outcomes focused care this had, by enlarge, not filtered through to the services in this study and there was still a tendency to focus on outputs without relating these to service user outcomes. I argue that the complexity of residential care, which depends upon an interaction between environment, care home management, staff, residents, their relatives, and the government inspectorate means that the most successful method of quality improvement comes through partnership and negotiation between the these groups. My findings have shown that it is very rarely one group who is decisive in determining an improvement in quality and that change must come about through negotiation. Although inspection must incorporate a notion of ‘assessment’ that is standardised and measurable, it should also encompass professional judgement and actively seek to include elements of user-expertise. I argue that despite rhetoric that advocates this approach the inspection regime is hamstrung by a particular form of management values and practice. Constant ‘modernisation’ of the inspectorate has further emphasised a model of inspection that sees care as a series of discrete events, where each issue is clearly defined and decisions are taken by inspectors who choose between a prescribed set of judgement criteria. To this extent inspection is increasingly focused on audit. I raise the question whether in the changing landscape of inspection the CSCI has marginalised inspectors and risks losing a very valuable method of effecting change