1. Trust and the National Care Homes Contract Conversations in Health and Social Care June 12, 2013 Catherine-Rose Stocks-Rankin, University of Edinburgh PhD student, Social Policy - CR.Stocks-Rankin@ed.ac.uk

2. Commissioning in Scotland Scottish Government (2010) Procurement of Care and Support Guidance, p. 19

3. Strategic Commissioning “All the activities involved in assessing and forecasting needs, agreeing desired outcomes, considering options, planning the nature, range and quality of future services and working in partnership to put these in place” “Strategic commissioning is not just about purchasing services from external providers, although this is an important element of the commissioning process” Social Work Inspection Agency (2009) Guide to Strategic Commissioning, p. 5

4. Procurement “The process by which public bodies purchase goods, services and works from third parties. It is not the only method of securing services; other options include the provision of services in-house, shared services arrangements or grant funding. Procurement is one element of a wider commissioning process” Scottish Government (2010) Procurement of Care and Support Guidance, p. 5

5. National Care Homes Contract “Governs the relationship between local authorities and older people’s care homes across Scotland. The rationale for developing the NCHC was to raise the quality of care provided in care homes and to standardise the funding of placements local authorities purchase from external service providers for publicly funded clients” Scottish Government (2010) Procurement of Care and Support Guidance, p. 24

6. PhD Research Based on a 30 interviews across the care sector, including care home managers, commissioners, contract managers, social workers and policy makers Caring Work – Jean Tronto’s ‘Ethic of Care’ Trust – Sevenhuijsen’s idea of trust and care

7. Perceptions Commissioner A: I suppose I see it from both ways because if these businesses fail then you have no care homes and you're in an even worse position - so I know - yes they make profits - but I also know how the dependency rates have gone up and their staffing needs to pay attention to that because that's one of the things they check apart from anything else but also they want to provide good care … somehow they do have to keep the balance and they're not going to do if they're not making money

8. Perceptions Contract Manager A: We've had a few care homes that have had a few problems in terms in quality. They are now back again – there [are good] scores which have yet to be released from [the Care Inspectorate]. But you know in times like that, we will normally apply the punitive measures to try to bring them up to scratch in terms of quality Researcher: What would a punitive measure in your case include? Contract Manager A: Like withdrawing quality payments for instance, and that will also be based on judgment. If we withdraw it, does it do the care home good? If the care home is already suffering, it could be financial that's causing the problem and if you withdraw financial support that they need to improve, what do you gain?

9. Responsibility Contract Manager B: But if they get a low grade like a one or a two, often what happens is that we'd go out and visit the home and find out why it was a one or a two and what actions they're going to put in place to increase their grades. Then we would make a decision about whether to reduce their fee rates.

10. Activities Commissioner A: It may that the Care Inspectorate will say 'we will be going in more often to inspect’. We've got a residential review team in the Council which the social workers can go in and review individual people. We may do a sample of reviews. We would kind of look at the whole. Part of it is about monitoring where they're at but part of it is about trying to support them with their improvement - and mostly the care homes that we work with actually recognise that - they feel supported as well.

11. Activities Contract Manager A: We look for a minimum of sixty-five percent of staff should have [SVQ 2]. Sometimes, considering a lot of realistic factors, we will normally allow that to go below, unless it’s far below, way below, maybe below 60% then probably we will sit down to see how we can help them develop y’know, staff, to the level that we were looking for. So, it’s not always, just do it. We find ways to help them do it, especially when certain care homes have some problems recruiting staff.

12. Care Homes - Reaction Care Home Manager A: It’s as if they want to control the contract and have a means of controlling budgets so that on the one hand they’ll say, well we can afford a two point seven five percent increase this year and the guideline rate, well great, it was closer than last year so thanks for small mercies but we’ll take it back because we can find in clause fifty-seven B, Paragraph C, Section D you haven’t actually managed to fulfill every single item, so, you’re in material breach and therefore for a period of three months we’re taking twenty pounds off of your weekly fees for residents.

13. Care Homes - Reaction Care Home Manager A: The fundamental problem with care inspections, and that’s not a criticism of individuals involved, it’s the regime - it’s the system. There’s probably no other better way of doing it, but it’s a paper exercise, it’s a box ticking exercise. There are questions to ask but ultimately it’s what you pick out of the atmosphere: are residents happy, contented, alert, to the extent they can be, do you feel that there in a part of the family where they’re accepted even if they’re making noises? Are the care staff seemingly, enjoying what they’re doing? That’s the kind of thing you can’t quantify, you can’t actually describe it very easily. I don’t envy care inspectors trying to get that out in a score, you can’t score it.

14. Caring The Contract Manager cares about the implications of their work; the application of a penalty might have adverse effects on an already weak or instable entity. Contract Managers take care in their efforts to meet with the care home manager and discuss the context of the poor grade Contract managers, and Councils, will care give through their efforts to provide staffing support Tronto, J. (1993) Moral Boundaries: A Political Argument for an Ethic of Car

15. Trust Despite their efforts to support care homes, the Council’s activities are viewed with suspicion Tronto’s four phases of caring: caring about, taking care, care giving, care receiving These only work when support is well- received Trust is a necessary element of this process

16. Trust Care Home Manager A: You want to be able to trust providers that they willingly do the right thing. Rather than being some sort of, police trying to push them to do things or making them feel victimized. I don’t know how to put it but, we try to build trust and once the trust is there, they are even more willing to tell you when there is a problem.

17. Trust Care Home Manager B: The home down the road, Sunset Pine, was affected by false allegations, and some true allegations, about a year and a half ago, and that’s still recovering from that time, now local community still will have it in their mind about the staff that worked there at the time, so it’s a long time to fix a broken service - you can gain reputation very quickly but you can lose it very quickly as well, it takes a longer time to gain it, but to lose it is very quick.

18. THANK YOU! Contact Details: CR.Stocks-Rankin@ed.ac.uk