It Ain’t Necessarily So – 13: Is a ‘compliant’ home necessarily a good home?
with JOHN BURTON
We have become used to the idea that care homes are judged by their “compliance”, and that the regulator will determine whether the home is “compliant” or not. There are numerous consultants, many of them ex-regulators, offering to help you to make your home compliant . . . for a fee. To survive, a care home that is not compliant must become compliant, but is a compliant home necessarily a good home for residents?
In everyday language compliance has far from positive connotations. To me it means willing to conform, to do as you’re told, sometimes against your own better judgement. It means that someone else decides what’s best and, as long as you go along with it, you won’t get into trouble. There is a troubling standardisation and loss of identity about the idea of compliance. It is passive, not active; negative, not positive.
Is this a good basis for running a care home? Is it what your idiosyncratic group of residents would like?
The child psychiatrist Donald Winnicott wrote “Compliance carries with it a sense of futility for the individual and is associated with the idea that nothing matters and that life is not worth living.” Compliance is incompatible with freedom of thought, action and expression; it stifles creativity, individuality and self direction. Compliance may have a place in a prison but not in a home. A regime of compliance is likely to institutionalise.
Of course there are many excellent homes that are compliant, but they do not give good homely care by making compliance their priority. In the case of these homes, their good practice and ethos have been recognised by the regulator and found to be fully compliant with the “essential standards”. There are also fully compliant homes which are not good places in which to live and be cared for, and equally there are non-compliant homes that are great places to live in.
Think of your staff team. I know that sometimes you wish people would just do as they are told, but if they are reluctantly compliant with your orders, and neither understand nor care why they should do as you say, they will withhold their commitment and be reluctant to take responsibility. Surely, you would prefer to have a care team who delight in the individuality and non-compliance of residents; who can adapt, respond, and engage with residents, person to person; who are forever seeking out new ways to do the work and who will question established (compliant?) practice.
Social care as a whole has been complicit in allowing compliance to become a prime objective of provider organisations, and there is a sense of guilt associated with this, making it difficult not to be defensive when challenged.
We won’t run really good homes by trying to comply with external standards that are sometimes inconsistently interpreted and enforced. Good care homes are created and led by managers who have their own high standards and are clear that residents – with all their non-conformity and individuality – come first in all things.
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Anon: I doubt if you’ll get any managers who are willing to put their names to admitting that they hate the idea of compliance, because if you want to keep your job you’ve got to make compliance a priority. We have a so-called quality assurance system which means we have to verify every month that we’ve completed every scrap of paperwork, cleaning records, fridge and freezer tests, care plans, reviews, MAR charts . . . there are scores of them. So I spend hours every month filling in a form about filling in forms so it’s my fault if CQC finds we’re not compliant on an inspection.
It has a knock-on effect because I then chase team leaders, and they chase staff about filling in forms and so it goes on. It has a bad effect on residents because towards the end of each month everyone’s desperately trying to complete their paperwork instead of giving care. It’s ridiculous and it all comes from this idea that if something isn’t recorded it didn’t happen. Hasn’t anyone up there understood that the fact that something’s recorded does not necessarily mean it happened? When something hasn’t been done, no one in their right mind is going to fill in the quality monitoring return to say it hasn’t. You just lie.
If we are found to be non-compliant in any way at an inspection, another procedure and form is invented! No one wants to take responsibility for the fact that in care work things go wrong. People can’t be made to be compliant. You do have to make choices sometimes between time for real care and trying to prove that you’ve given it.
Compliance isn’t a long way off a totalitarian society where lying, corruption, fear and bureaucracy dominate. I just can’t see why intelligent people, government and regulators can’t see the connection.
Compliant manager, Midlands: My home is compliant but that doesn’t make it good. We have to be compliant with the essential standards and that’s fair enough, but we’re good because everyone – and I mean residents and staff – is treated with respect and affection.
I don’t want my staff to be “compliant” because it’s a dangerous state of mind. If they just did as they were told they wouldn’t be any good at the job.
They are all different and most of them will question anything they feel is wrong. I want them to respond to residents, not to obey my orders or anyone else’s. I want them to feel direct responsibility to residents and stick up for them if needed.
It would be nice if CQC recognised individuality and complimented us on it. We’re not trying to be the same as everyone else.