Ensuring standards: registration, inspection and quality assurance

The procedures for ensuring standards in continuing care are both mandatory (registration and inspection) and voluntary (quality assurance). The way in which these procedures have a bearing on this code are described in the following sections.

Local authorities and health authorities are responsible for registering residential care homes and nursing homes respectively. The registration authorities must ensure that the purposes and aims of establishments are clearly set out and that the standards of care they offer match these aims and objectives. They have a duty to ensure that the best quality of life for residents is achieved.

11.2.1 Registration process

Registration authorities should set out the registration requirements in general terms. This is best done in the form of a guide, listing key documents relating to the registration process. Throughout this process, registration staff will need to be available to monitor progress and preparations for the opening of the home. Advice may need to be given to proprietors about the initial selection of residents, selection of staff, preparation of a home brochure, and to ensure that the registration requirements agreed initially are being implemented.

Prospective owners/managers should be reminded that there are penalties for operating an unregistered home and residents must not be admitted until a certificate of registration is issued. Certificates of registration should be issued as soon as possible but the process of checking fitness has to be done thoroughly and may take time.

11.2.2 The suitability of applicants for registration

Registration authorities must ensure that all prospective owners/managers of homes possess some relevant qualifications or have some proven experience of employment within residential care. They should also be able to demonstrate competence in and understanding of financial projections and budgeting. They should show that they possess a business-like approach which will ensure that any new home will be managed on a secure financial basis which will not put the future welfare of residents at risk. Where the registration authority receives applications for registration from voluntary organisations, the local, regional or national chairman, secretary or like person of the management committee of the home is registered, together with the home's manager or administrator. The registration authority should ascertain the actual and legal divisions of responsibility within the organisation. Notification of any changes of those personnel should be made to the authority once the home is registered. The registration authority should ensure that a check is made on the Department of Health national list of people who have been reregistered.

11.2.3 Dual registration

When an owner wishes or is required to apply for dual registration as a residential care home and nursing home, the applicant must be able to satisfy the registration authority that the requirements of the regulations will be met within the home, and should satisfy both authorities that the recommendations of this code will be followed.

11.2.4 Change of owner or manager of a home

Once the initial certificate of registration has been issued, owners should notify the registration authority of any intended change of ownership. Registrations are not automatically transferred to new owners or managers. New applications must be lodged and references taken up. Residents and, where they wish it, their relatives should be fully informed of any changes. This is particularly crucial where there has been a close relationship formed between the owner/manager and the residents in his or her care.

11.2.5 Change of facilities or objectives

Conditions of registration relating to the age, gender, number and category of residents must be adhered to. If the registered person fails to abide by these conditions he or she may be prosecuted or have his or her registration cancelled. The registration authority must be informed of any proposed changes so that the validity of registration can be considered in the new circumstances. Once changes have been approved, the home's brochure should be altered so that it describes the new situation accurately.

11.2.6 Cancellation of registration

In circumstances where a registration authority is considering cancelling the registration of a home, the registration authority is required to serve notice of intention to cancel registration on the registered person and must spell out the grounds for doing so. The registered person has fourteen days to indicate a wish to make representation in writing or orally to an appeals sub-committee of the local authority (residential care homes) or to a committee of the health authority (nursing homes).

If cancellation is confirmed, the registered person has a right of appeal. The Registered Homes Act 1984 provides for appeals against decisions of registration authorities to be made to registered homes tribunals. Such appeals must be made within twenty-eight days of the decision to cancel registration being notified. Registration authorities should make owners aware of their right to appeal and the procedure to be followed.

The cancellation of registration cannot take effect until either twenty-eight days have elapsed with no appeal, or the tribunal has reached its decision. The decision of the tribunal is final.

At an appropriate stage, residents, next of kin, or key supporters should be notified that cancellation of registration may come into effect. It is also essential to notify any sponsoring agencies that it may be necessary for them to make alternative accommodation arrangements for residents.

Under the Residential Care Homes (Amendment) Regulations 1988 and the Nursing Homes Regulations 1984, homes must be inspected by the local authority (residential homes) and district health authority (nursing homes). Since 1991 all local authorities have been required to have in place 'arms length' inspection units with the statutory duty to register and inspect services within the independent sector and to inspect local authority residential care homes. Under the Registered Homes (Amendment) Act 1991, registration authorities must also register small care homes providing personal care to fewer than four people. Nursing homes have always been required to register if they provide care to one or more persons.

All registered homes and (since 1991) local authority homes must be inspected twice a year although registration authorities may choose to visit more often. At least one visit should be unannounced. This is essential following an anonymous or specific complaint made to an authority about poor standards of care in a home. Where an owner or company owns several homes, the registration authority may need to make such a visit to satisfy itself that the homes' managers are receiving adequate supervision and support. Inspections should be carried out by persons authorised to do so by the relevant registration authority. Inspections will vary in content, focus and length of time depending on any outstanding issues identified on previous inspections. Following initial registration, a visit of inspection should be made within the first three months of the home becoming established, or when a new manager of a home has been appointed. In the case of dual registration, it is advisable for joint inspections to take place. For this reason, the growth in the numbers of joint inspection units in recent years is to be welcomed.

Inspectors should focus on quality of care and quality of life issues as much as on the fabric of the building. Time should be devoted to asking residents and staff about standards of care provided. Care should be taken to ensure that courtesy, diplomacy and tact are used in inspecting individual residents' private rooms. The owner or manager of the home must make it possible for the inspection officer to spend some time in private with individual residents. Normally it should be possible for inspections to be conducted in a way which is seen to be constructive by managers and staff of the home. Recognition should be given to innovative and good care practice. Time should be given to discussing and reviewing, with the owner or manager, the objectives of the home and how the care of the residents can be enhanced.

At the inspection any change of circumstances affecting the registration will need to be identified. The authority should ensure that a report of the inspection is sent to the owner and the manager, drawing attention to any specific points of consultation and specifying any variation in the registration requirements. The inspection reports of residential care homes must be available to the public.

Inspectors appointed by registration authorities to undertake inspection of residential and nursing homes, to give advice to staff and be responsible to the respective registration authorities for recommendations concerning registration should be knowledgeable and skilled in communicating with owners and managers from a wide range of backgrounds. They should have sufficient experience and status to merit the respect of both colleagues and staff of homes. Many authorities now require inspectors to have had some direct experience of running or managing residential and nursing homes themselves.

Residential care homes are required under the 1984 regulations to have a complaints procedure in place. While there is no statutory requirement for nursing homes to do this, it is good practice to do so. The complaints procedure should be outlined in the home's brochure.

The majority of complaints regarding the management of a home will normally be satisfactorily resolved by the owner or manager and there will be no need for the registration authority to be involved.

When complaints cannot be resolved internally the registration authority should be informed of the complaint. All complaints regarding a specific home should initially be made in writing to the registration authority, giving details of any action already taken and with whom the matter has been discussed. The registration authority will then take the necessary steps to investigate the complaint and arrange to interview the owner/manager, resident and all other people relevant to the specific complaint. Following the investigation/interview, a letter should be sent to the owner and manager, resident and the complainant stating the outcome and specifying any action.

The registration authority must make available for consultation a list of all private and voluntary homes currently registered in its area. Many authorities have also found it helpful to publish a more detailed list of registered homes describing their individual characteristics and specific services provided, such as levels of staffing and medical cover provided within the home. General information can also be given on how to obtain advice about financial assistance towards the cost of accommodation, and on the difference between a private and voluntary home and between a residential care home and a nursing home. Enquirers and prospective residents should also be reminded to request a copy of the home's brochure when seeking initial information from an owner or manager.

Quality assurance is the process whereby service providers and those receiving care can assess the services to check that acceptable standards are being met. This can be done through self-assessment or by bringing in an outside body to conduct the assessment. In order for this process to work, agreed standards have to be set before any assessment can take place. Performance against those standards can then be measured through the quality assurance process. This code can provide the basis for setting the standards.

11.6.1 The benefits of QA

There are many benefits for homes which establish quality assurance procedures. QA requires managers and staff to agree what constitutes acceptable standards of care and assists them in setting up processes for monitoring their progress towards achieving them. Drawing up and agreeing standards should involve all those concerned, including residents. The day-to-day experience of those who live and work in the home should provide the starting point for the process. Essential to the process of quality assurance is the idea of self-audit or self-assessment whereby managers and staff systematically examine the service they provide, assess their performance against standards which they have already agreed in conjunction with residents, and then make adjustments and improve meets where performance is shown to be deficient. Establishing a group, involving staff and residents within the home, to be responsible for quality assurance is an important first step. The QA process can be undertaken even where an outside assessor is not called in to do a formal assessment. Quality assurance should involve all members of staff at every level. Through this, standards are raised and team-working is developed.

11.6.2 QA systems

There are a range of QA systems which can be used in continuing care settings. The following are examples: