Compliance, the principal tool of measurement used by the Care Quality Commission, has no place or validity in the life and work of a care home. It is a negative and submissive concept. Nothing ever grew and developed, no initiative, no advance was ever made by compliance. Compliance is static and change is dynamic. The notion of compliance could only be of use to check important but secondary technical services to the home, and such checks should be made by suitably qualified and experienced technicians. For example, the lift must be properly maintained, medication managed well and accounted for, and food stored and prepared safely, but such compliance is not the primary purpose of a care home.
Those of us who were trained and qualified as residential workers or residential social workers - trained to practise, manage and lead - received a thorough grounding in such areas as human growth and development, loss and change, social psychology, group processes, community and institutionalisation, leadership, ethics, ageing and society, social work methods, social policy, counselling, dependency and power relationships, family and individual therapy, etc. etc. We were encouraged to enquire, to challenge, explore, and debate ideas. We thought, read, and argued. We were not taught “compliance”. Courses differed and, of course some were better than others, but I very much doubt if any residential social work course ever mentioned “compliance”.
No, I’m wrong. In the early 70s, when I did my qualifying training, the word compliance described a worrying aspect of, for example, a child whose infancy and early years had compelled them to keep their heads down and to find a way of surviving the hostile and persecutory world around them. These days, we might take compliance in an eighty-year-old resident of a care home to indicate that they may be being abused, bullied or medicated, and they had attempted to avoid further pain and humiliation by withdrawing into themselves and being “quiet”, compliant and unnoticed. “No trouble.”
“The creativity that we are studying belongs to the approach of the individual to external reality . . . Contrasted with this is a relationship with external reality which is one of compliance, the world and its details being recognised but only as something to be fitted in with or demanding adaptation. . . in a tantalising way many individuals have experienced just enough of creative living to recognise that for most of the their time they are living uncreatively, as if caught up in the creativity of someone else, or of a machine.” D.W.Winnicott, Playing and Reality.
Care homes are caught up in what the machine of CQC has created - compliance. We will break free of the constraints of compliance only if we start acting like professionals and leaders of our care communities. We must stop acting like quiet, frightened, compliant children, anxious to please by fitting in with the rules and restrictions imposed on us. We must grow up, join forces in taking responsibility for our own profession, and lead the development of care homes as highly valued local centres of care and support.
Over ten years, the national regulators have turned social care upside-down. Instead of the needs of users instigating the form and operation of care services, and those services, led by the registered managers, being designed and managed at a local level to meet those needs, the regulators have imposed their misinformed and blinkered design for care. This top-down approach has in turn spawned a new layer of quality-assurance, management and consultancy which is now seen as essential to prove to the regulators that providers are compliant. And this self-perpetuating arrangement flourishes alongside the cosy pretence of personalisation. Compliance-centred is the very opposite of “person-centred” care.
It seems extraordinary that while those at the head of this appallingly wasteful and dysfunctional system have had the advantages of sophisticated management training and mentoring, they seem incapable of understanding their part in it.
According to Paul Hoggett (University of the West of England), social work/social care professionals need the capacity . . .
- to tolerate and contain uncertainty, ambiguity and complexity without resorting to simplistic splitting into good/bad, black/white, us/them, etc.
- for self-authorisation, that is, the capacity to find the courage to act in situations where there is no obvious right thing to do
- for reflexivity, that is, to take oneself as an object of inquiry and curiosity and hence to be able to suspend belief about oneself; all this as a way of sustaining a critical approach to oneself, one’s values and beliefs, one’s strengths and weaknesses, the nature of one’s power and authority, and so on
- to contain emotions such as anger, resentment, hope and cynicism without suppressing them and hence to be both passionate and thoughtful.
What do we think Tom Kitwood would have made of this compliance culture? Would it not fit perfectly with his description of a “malignant social psychology”? Is it not understood at any high level in Government, Department of Health or CQC that the malignant effect of compliance does not merely “filter” softly down to the way residents in care homes are treated, it is - albeit unwittingly - aimed directly at them and blights their lives.
When senior members of CQC are cornered, and when they cannot bully their way out of the corner, they resort to the excuse that they have no choice and are merely following the orders given them by government but are short of resources, and “give us time - we’re a young organisation”. Such excuses are a betrayal of professional ethics.
As social care professionals and leaders, registered managers must take their cue from their own professional standards. We must support each other, learn from each other, and always put our clients first.
John Burton, ACM