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Quality in social care: we need an ear for stories as well as an eye for data


Care quality is improving. That statement may surprise many people, including the sizeable proportion of the general public who have serious concerns about the quality of care homes and home care services.

Yet the data tells a different, apparently more positive, story. In 2019, the Care Quality Commission (CQC) rated 84 per cent of care services good or outstanding, up two per cent on the previous year. Similarly, around two-thirds of those who used publicly funded care services say they were extremely or very satisfied with their care, virtually unchanged from 2017/18. According to the data, quality is apparently fine.

Inevitably, it is not quite that simple. As we have noted previously, carers report less satisfaction with the services received by themselves and the person they care for (38.6 per cent were extremely or very satisfied in 2018/19) and in 2019, the Local Government Ombudsman said that, while the number of complaints about social care was level, the type of complaints were ‘ever more serious’. Meanwhile, the media serve up a steady string of stories about poor-quality care or even abuse, leading to some to campaign for compulsory CCTV cameras in care homes. This does not suggest uniform quietude about quality.

Part of the issue is differing aspects of quality. Previously, we have noted that quality – one of eight major issues around social care – covered a range of concerns from abuse to undertraining of the workforce, from 15-minute care visits to lack of choice and control.

This range of concern was reflected recently when The King’s Fund convened a meeting of 20 social care experts – service users, providers, regulators, commissioners and commentators – to discuss quality with The King’s Fund international visiting fellow, Don Berwick. The conversation ranged across training, regulation, the role of carers, culture, management, motivation, and resources. The King’s Fund has written extensively on these issues, albeit often from the perspective of the NHS.

Yet the conversation kept returning to one key theme: quality of experience. The focus was less on rules and processes, and more on behaviour and the impact this has on people receiving care. The words that ran through the discussion were not so much process and inspection as warmth, kindness, empathy, respect, genuineness, love. These strongly reflect the NHS principle of ‘compassion’ – care given through relationships based on empathy, respect and dignity or ‘intelligent kindness’ – which is one of six ‘C’s originally developed in nursing but which have much wider application.

The existence of these qualities can be hard to evidence. One way, though, is through the power of people’s stories. The discussion hinged on two experiences of care, one good and one bad, reported by a participant. In the first, a social worker showed persistence and dedication, returning time after time over months to offer essential support even when at first it was refused. In the second, a nurse invoked rules on visiting hours to prevent a family member offering much-needed support to a relative. How – Don Berwick asked – do we explain these two very different behaviours?

‘Time’ was one explanation. The worker in the first example had it, in the second perhaps did not. Yet even if staff had more time, this would not necessarily lead to improvement. Don Berwick suggested that, at its most basic, quality improvement needs a clear organisational ambition to improve and an equally clear plan to deliver that improvement. It also, he went on to say, needs good, reliable information about what is happening. Some of the strongest information in health and care comes from narrative – those stories about what has gone well and what has gone wrong. We need to listen more.

But harder data has value too, so we also need to keep an eye on those CQC reports and user satisfaction surveys, for individual service evaluation and for the wider, regional and national trends. We may query and challenge the data, sometimes disbelieve it, but it tells us something useful about quality, even if it is not necessarily the whole story.