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CHAPTER 3 KNOWLEDGE AND AWARENESS OF CURRENT SCRUTINY ARRANGEMENTS
Summary
Participants in the study were more familiar with and more knowledgeable about inspection and complaints handling than about regulation and audit. This was as a result of their experience and involvement in the processes, with many having been consulted as part of an inspection or having utilised complaints procedures. Audit was the aspect of scrutiny with which participants were least familiar. Levels of knowledge and awareness of scrutiny methods varied greatly, generally due to experience of a particular service. Relatives of people in care homes and parents of secondary school pupils were among the most knowledgeable and users of council services and citizens (talking about the coastguard service) among the least knowledgeable. Many participants were aware of relevant scrutiny bodies, in particular, the Care Commission, Her Majesty's Inspectorate of Education ( HMIE), Health and Safety Executive and the Scottish Public Services Ombudsman ( SPSO). Knowledge of scrutiny methods and scrutiny bodies varied a great deal.
3.1 This chapter considers what participants know about current scrutiny arrangements. It covers all four types of scrutiny but is structured around the different groups of public service users who were involved in the study. The main reason for doing so is that knowledge varied greatly between groups (and also within groups) and where a group was knowledgeable about one aspect of scrutiny it generally tended to be knowledgeable about other aspects of scrutiny and vice versa. Analysis in the subsequent chapters, however, is not presented in this same way.
3.2 Overall, participants were more knowledgeable about inspection and complaints handling than about regulation and audit. Audit is not mentioned in this chapter as knowledge of it was minimal: many participants knew about some forms of audit, generally the financial as opposed to non-financial types of audit, some were aware of the legal requirement of organisations to be audited, and some had heard of 'Audit Scotland'. 3
3.3 It should also be noted that we are reporting on what the participants think they 'know' and we cannot guarantee that what they say is accurate.
Relatives of older people in care homes
3.4 Participants with relatives in care homes were among the most knowledgeable participants about all aspects of scrutiny. There was widespread awareness of the Care Commission and the fact that it is responsible for scrutinising care homes.
3.5 More specifically, there was a general awareness that the Care Commission was responsible for conducting inspections of care homes. It was generally understood that the Care Commission checks many factors, ranging from fire regulations to nutrition. It was thought that it would tend to check only some aspects on each visit to the home, unless there had been a major change, for example new management, in which case it would conduct a full inspection.
3.6 Experience was more varied in terms of whether or not relatives were actually aware of inspections taking place and whether or not they had been involved in them. While some were completely unaware that they had occurred, others had either seen posters asking for relatives to get involved or been told by members of staff that the inspection was happening. The following quote is an example of a relative who had not been informed of the inspection.
I know nothing about that. I have no experience of the Care Commission. They certainly have not notified me that they were visiting the nursing home at all. As far as I am concerned, they don't exist. I have seen their certificates so I have no doubt they do visit the home in question.
3.7 In another case, the participant felt well informed:
The nursing home my dad is in, he had an inspection I think it was November, and everybody was told about it. I was told and my sister and my brother and my dad was told.
3.8 Awareness of Care Commission inspection reports varied. Some relatives had been provided with copies when they first visited the care home, some had used the internet to access them, while others were not aware that they could obtain these reports. Having been made aware of the reports in the course of the research, the latter said they wished that they had been able to see reports when they were selecting a home for their relative. It was suggested that care homes should be required to provide copies to relatives visiting the home for the first time.
3.9 While those who had read reports found them useful, the issue of value for money was not covered but was of great importance to relatives: it's very difficult to know whether you are getting value for money or not. Relatives did not know how their money was being spent but were aware that care home fees could vary greatly for no apparent reason:
… the cost of providing the service varies from around … £500 … up to £1500 a week, which is a huge difference. One just wonders how the money is spent and it is very difficult to establish that.
3.10 Relatives of care home residents were very knowledgeable about complaints procedures. It was widely known that care homes have their own complaints procedures which usually involve going to the manager in the first instance, but that relatives could go to the Care Commission if the complaint was not resolved internally or if their complaint concerned the management.
3.11 The fact that residents or relatives themselves ultimately contribute to the costs of scrutiny was recognised. It was understood that care homes pay a registration fee to the Care Commission which covers the cost of scrutiny and that they cannot operate without being registered with the Care Commission. Residents/relatives' fees will have been used to pay for the cost of scrutiny.
3.12 Finally, relatives of care home residents were aware that the Care Commission has the power to close care homes.
Parents with a child in a nursery
3.13 Knowledge of scrutiny methods varied greatly within the group of parents with a child in a nursery. While most participants were largely unaware of the Care Commission and the way in which nurseries are inspected and regulated, one individual was particularly knowledgeable due to the fact she had recently been looking into opening a nursery herself. Others who had heard of the Care Commission had done so because their child's nursery had been inspected. It was not, however, until their child was actually at nursery that the parents gained any awareness of the fact that nurseries are scrutinised and the way in which this is done.
3.14 Only one individual reported knowing that it is the Care Commission which sets standards, and requires that nurseries must produce a manual detailing their policies and procedures. However, while other parents were familiar with this manual and had seen it in their child's nursery, they were not aware that it was a requirement of the Care Commission.
3.15 In terms of inspections, there was generally limited awareness of their existence and there had been little involvement in them. While the Care Commission and HMIE were mentioned by some as bodies who conduct inspections, few parents had been involved in the inspection process or knew what it involved. Only one individual had a more in-depth knowledge of the way in which inspections were conducted and the factors scrutineers would check, for example, play, equipment and cleanliness.
3.16 Inspection reports were not widely utilised by the parents. The one individual who had read a report had only done so when she looked at opening her own nursery:
I think the report is out on display in some places. I think we have one in ours, in the bit before you go in, in the foyer there is like information that tells you what they've had for snack and all that and I think it's hanging up in there.
3.17 While it was known in some cases that the reports can be accessed on the internet and that some nurseries do have them available, there was a suggestion that it should be the role of the nursery to make people more aware of them.
3.18 Participants understood that they could either raise complaints with the nursery directly or with the Care Commission. However, they did not feel that all parents would know such information as it is only referred to in small print in the nursery's manual. It was also recognised that the Care Commission is responsible for investigating complaints but that these ' would have to be major'.
3.19 Some parents were aware of the Care Commission's powers and sanctions. It was, however, acknowledged that the Care Commission would often be reluctant to close a nursery as there might not be another available for the children to go to. They named one nursery that several of the parents considered had problems, but had not been closed for that very reason: ' if they closed…[it] they would have nowhere to put the children'.
Parents of secondary school pupils
3.20 Parents with a child currently at secondary school had gained much of their knowledge of scrutiny through being involved in inspections. Once more, there was a wide range of experiences, with some parents having a great deal of knowledge about scrutiny and others knowing very little about it.
3.21 Parents assumed that secondary schools must work to a set of standards covering such areas as class sizes, curriculum, teachers' hours and hygiene in the canteen. It was suggested that the Scottish Executive and the Health and Safety Executive would have been responsible for setting these standards (though in fact it is the local authority). While the responsibilities of HMIE were generally understood, one individual thought that the Care Commission conducted annual inspections of the curriculum, standard of teaching and health and safety.
3.22 Knowledge of secondary school inspections had been gained largely through experience. Parents had contributed to the inspections either by talking to inspectors or by completing questionnaires:
Parents were invited in to meet one of the lay inspectors and visitors to the school were polled…
3.23 Not all parents received an invitation to be involved: while some parents had contributed to an inspection, others with children at the same school had been unaware of any inspection taking place. Where they had been involved it was when HMIE inspected. These inspections were seen as being the most important, since they were in-depth and detailed. It was known that HMIE inspectors tended to be ex-teachers:
So they actually do try to get information from the whole school environment … it is a big issue for the school … [because] they do delve relatively deeply. It is not just … superficial.
3.24 Following inspections it was thought that a set of actions points would be given to the school to help it improve and that a report would be written. Such a report would be readily available to parents either from the school, presented at school parents meetings or downloaded from the internet.
3.25 It was asserted that all parents know that they can go to the school directly if they have a complaint. This was seen as the standard complaints practice. It was thought that most parents felt comfortable complaining to head teachers as they are regarded as approachable:
I don't think anybody is wary now of going down to school. When I was younger my parents would have been quite wary of doing that because … everybody in schools … was held in quite high esteem. I don't think you are quite so afraid to do that… now [because] … they are more approachable.
3.26 It was thought that parents would only take a complaint further if it could not be resolved internally. On these occasions, participants believed that there would probably be somewhere else they could take a complaint, either within the council or to someone independent like an ombudsman, but they were not clear about what this process would be.
3.27 There was a perception that although both HMIE and the Health and Safety Executive have many powers over secondary schools, such as the ability to close down a school or put in a new head teacher, they do not actually use them. Instead they focus on securing improvements by giving a badly performing school a poor report and encouraging it to improve. However, it was recognised that this does not always work and that some schools continue to receive poor reports.
6 th year secondary pupils
3.28 Although the 6th year pupils attended a school that had recently had an HMIE inspection, they tended to be largely unsure of the way in which secondary schools are scrutinised. They were aware, however, that an inspection had recently taken place in their school and some had been interviewed by the inspectors. Pupils thought that the inspectors were checking grades, safety and school facilities. They did not think that teachers' qualifications and teaching ability were checked during the inspection. Instead, they thought that qualifications would be checked only when teachers initially applied for the job and teachers' performance was checked by other teachers.
3.29 The pupils were aware that a report would be written as a result of the inspection and were interested in seeing it. However, they felt that if it was a bad report then the head teacher would try to prevent them from seeing it: if they said anything wrong he wouldn't want us to hear about it.
3.30 Once more, participants were particularly familiar with the complaints procedures, knowing that either parents or pupils could go to the head teacher to make a complaint. They were also aware that there used to be a complaints box and a pupil council, which had recently been removed for reasons unknown to them.
3.31 In terms of the powers of scrutiny bodies, pupils thought that the only thing that could happen as a result of poor performance is that teachers could lose their jobs. 4 The school pupils did not mention that scrutiny bodies could play a role in helping poorer performing schools to improve.
Young people who have been through the care system
3.32 Young people who had been through the care system tended to be familiar with the Care Commission. While they were knowledgeable about the procedures that should be followed by the Care Commission when scrutinising children's homes and foster carers, there were mixed views as to whether the Care Commission actually sticks to these procedures.
3.33 Again, there was a high level of knowledge of the inspection process. Experience ranged from one individual having himself been a lay assessor to others having had little or no involvement in the process. Some young people were very complimentary about Care Commission inspections:
We were always encouraged to talk to inspector … they would sit round the table and they would explain what they were there for. … [T] hen … they would go into the living room and if anybody wanted to … talk to them on a one to one [they could]. We were very lucky with the people we got in the Care Commission because they all did that. I always seemed to feel they tried their best to do something for us.
3.34 Most, however, felt that the Care Commissioners were not interested in them:
… they are not mainly interested in the young people, they are interested in what the … staff are doing to the house and … the appearance of the place.
… they treat you like a number.
3.35 There was also a perception that Care Commission inspectors do not check things as thoroughly as they should for fear of discovering something that they did not want to deal with:
I don't think they check their staff as much as they should because if they … [did] something might come up and … [they would] … need … new staff and then that takes up time and money - so what's the point?
3.36 Some of the young people knew that a report was produced at the end of an inspection but had never seen one. They thought it could be accessed either from their unit manager or the internet, but only the lay assessor had actually seen one. There were differing views on whether or not the information in a report could be trusted. The former lay assessor was adamant that the report was an accurate representation of everything that had been said during the inspection. However, there was scepticism as to the accuracy and reliability of the report when the inspectors were in the building for such a short time.
3.37 While young people were well aware of complaints procedures, they were concerned that complaints forms are never investigated:
You have complaint forms in the Home and anywhere you're staying and if you've got something to say you can put it in. And I guarantee by the time the service manager comes to make enquiries about it, it's gone. I'm telling you, they rip it up.
Recent NHS hospital patients
3.38 As a group, recent NHS hospital patients knew very little about the scrutiny of hospitals. There was much uncertainty as to whom, if anyone, inspected hospitals and what they would check if they did. It was suggested that if hospitals were inspected then patients would hear about it in the media:
I would say they're not being checked - if they are being checked they are very lax.
3.39 There were guesses as to what might constitute an inspection, if such a thing existed. For example, they thought it might be triggered by an outbreak of MRSA, or, if more regular it might check parity of services between departments and/or hospitals, cleanliness and patient care. Participants guessed that Quality Improvement Scotland might be the body which would be responsible for inspecting hospitals, while the Clinical Standards Board might set rules and regulations for hospitals to follow. Little was known about the outcomes of any hospital inspections, although some participants thought they had seen hospital league tables.
3.40 Recent NHS hospital patients were not aware of having seen information in hospital wards informing them of how to make a complaint. However, most felt they could approach a member of staff at the hospital with any concerns they had. They also seemed to know that they could raise a complaint with their local MP, the SPSO or the Health Council, if it had not been resolved internally.
3.41 In terms of the powers that scrutiny bodies have, the group mentioned that doctors could lose their jobs if they did not adhere to rules and regulations. There was a feeling that such procedures had been tightened as a result of the Harold Shipman case. The issue of scrutiny was linked to professional regulation in the minds of participants. 5
Citizens
3.42 The group of citizens discussed a service that they had never used before, the coastguard service. 6 There was a predominant 'I'm sure there must be' attitude when they considered whether the coastguard service was scrutinised. As might be expected, they had given this no prior thought and had very limited knowledge of how this service was scrutinised.
3.43 The citizens were fairly sure that there would be standards that the coastguard must adhere to - in the same way that all work places have standards to follow. The standards were thought to cover various elements relating to the role of the coastguard and health and safety issues. There was a feeling that someone in the profession would have produced a set of regulations and that an external body would investigate if rules were broken. The group had no concerns that they were ignorant of the exact nature of the regulation followed by the coastguard service as they were comfortable in the knowledge that someone in the profession had set appropriate standards.
I think it's the backdrop that is essential to a civilised living. You expect if you go to sea you expect that somewhere in the background there is an emergency service if you got into trouble it will deal with it. That's all we need to know, we are not knowledgeable enough to assess whether it's an efficient service.
3.44 The citizens were also unclear about which bodies would conduct such scrutiny. There was an assumption that there would be internal checks and a suggestion that an external body might also conduct checks. While the group did not know who this body would be, they assumed that it was either a maritime body, the Audit Commission or a department of the Scottish Executive. They were unsure what the outputs of any inspections would be, but thought that it would be possible for members of the public to obtain such information, if necessary, by using the Freedom of Information Act.
3.45 There were further guesses as to whom a user of the coastguard service would complain if they were unhappy with the service provided. Suggestions included the head of the service, a local MP or the SPSO.
Users of council services
3.46 The group of council services users had similar views and attitudes towards the scrutiny of council services as citizens had towards the scrutiny of the coastguard service. It was a subject to which they had not previously given much thought and they simply assumed that council services must be regulated and checked by someone.
3.47 Health and safety was again mentioned as an area where there would be regulation that councils, like other organisations, would have to follow. When asked specifically about the regulation of refuse collection, it was suggested that there would be regulations specifically related to refuse collection that had possibly been set by the Scottish Executive and/or ex-professionals.
3.48 There was little knowledge about inspections of council services, although it was thought that councils are accountable to the Scottish Executive and to the Health and Safety Executive.
3.49 Whilst most other groups were fairly knowledgeable about complaints procedures, users of council services were not so familiar with the way in which they would make a complaint about council services. It was suggested that a council service user could first make the complaint direct to the Council. However, this was not seen as always being particularly easy as people often did not know which department of the Council they should go to. It was suggested this might be made easier if council services users were, firstly, more familiar with the way in which the Council worked: you don't know how the hierarchy of the council works, who you go to if you are not happy with the first person and, secondly, if it was known who was responsible for inspecting the Council.
3.50 It was suggested that the Council may not actually investigate individual complaints and would instead wait to see if they received any more similar complaints. If a council service user did not feel that their complaint had been resolved by the Council, the group suggested various other places that a service user could take their complaint: the SPSO, environmental health, Citizens' Advice Bureau or a local MP.
Comparisons between participants and groups
3.51 As mentioned above, knowledge of scrutiny methods varied a great deal. However, even among those who were least knowledgeable, there was a general assumption that things were being checked, that they 'must be', even when participants did not know how or by whom. People only really found out more detailed information when they or their relative began to use a particular service. Therefore it seemed that people gain their knowledge through experience or from to talking to others in the same position as themselves.
3.52 While some service users wished they had known a bit more about scrutiny, particularly about scrutiny outcomes, when they were choosing a service provider, in general participants seemed content to get the information they needed ( e.g. to make a complaint) when they needed it. This is supported by the feelings of the users of council services and the citizens who were talking about services which they did not use or with which they had not encountered problems. These groups were quite happy in the knowledge that these services would be scrutinised and they had given little thought to the way in which this was done, prior to their involvement in the study.
3.53 Knowledge of the institutions responsible for scrutiny also varied a great deal. There were numerous references to some institutions ( e.g. the Care Commission, HMIE, the Health and Safety Executive, and to 'the ombudsman') and some of the activities of these bodies are quite well understood. On the other hand, there was little knowledge or awareness of the activities of institutions responsible for the scrutiny of hospitals or general local authority services. It is significant that knowledge and awareness of the arrangements for scrutiny appear to be greatest for those services where users have a continuing involvement with the service in question.
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