This is a summary of independent research funded by the National Institute for HealthResearch (NIHR) Doctoral Research Fellowship Programme. The views expressed are those ofthe author and not necessarily those of the NIHR or the Department of Health and Social Care.

Improving the quality of residential carefor older people:

A study of government approaches inEngland and Australia

Lisa Trigg

PSSRUPersonal Social Services Research Unit

Contents

1 About the study 1

What did I do? 1

2 Key findings 2

3 Introduction 5

How I did the study 5

Background to residential care 5

Background to residential care in England and Australia 6

History of inspection and accreditation 7

What do governments do now to encourage good care? 9

Conclusion 9

4 Understanding quality 11

How each country defines quality in its standards 13

5 How does each government use information to improve quality? 15

What are the differences between England and Australia? 15

6 What difference do the governments make to the quality of residential care? 18

What difference do the governments make? 20

How do the ratings help? 22

What can governments do to encourage relationship-centred quality? 22

Conclusion 24

7 Why are the systems in England and Australia different? 25

References 29

Acknowledgements

I would like to thank everyone who gave up their time to be interviewed for this study and especiallyto the managers and staff of the providers I visited. I was struck by how generous people were withtheir time and by how prepared they were to share their thoughts and opinions.

I would also like to thank my PhD supervisors, Dr José-Luis Fernández and Dr Isabel Shutes at theLondon School of Economics and Political Science, Dr Anna Howe for her support in Australia, and forall my friends, colleagues and family for supporting me through this research.

The information in this summary is from the author’s PhD thesis. More information on the researchmethods and interview participants, as well as more detailed results, can be found athttp://etheses.lse.ac.uk/3772

February 2019

1 About the study

The purpose of this study was to find out what governments can do to encourage careproviders to improve their quality. To do this, I compared the approaches of England andAustralia to improving quality in residential care for older people.

The main activity by each government toimprove quality is through the inspection of carehomes. The government in England has createdthe Care Quality Commission (CQC) to inspectcare homes, and in Australia, the AustralianAged Care Quality Agency (AACQA)* has beenset up to review and accredit homes. In bothcountries, the governments also say that carehomes will improve if people can choose whichone to move to, and a lot of importance isattached to making it easier for people tochoose the homes they prefer.

What did I do?

I conducted interviews in England and Australiato look at the differences in how things work. Iinterviewed politicians and people ingovernment, charities representing residents and carers, bodies representing care homeorganisations, and senior managers from theCQC in England and AACQA in Australia. I alsoconducted interviews at five different care home organisations in each country – tenorganisations in total.

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*AACQA was merged with the Aged Care Complaints Commissioner on 1 January 2019 to form the Aged Care Quality andSafety Commission.

2 Key findings

The main differences between the twocountries’ approaches to quality in residentialcare are summarised in Table 1 at the end of thissection

Comparing England and Australia showed thatthere were lessons which could be applied inother countries.

1. Governments and people making policyshould think about provider quality in threedifferent ways

It is very difficult to define ‘quality’ in residentialcare, and this makes it difficult for governmentsto put things in place to address quality. Forpeople living in residential care, quality will bemade up of many different parts, from thestandard or size of the accommodation to howsafe and secure they feel.

For my study I came up with a new way ofexplaining the different types of quality for carehome organisations. These categories draw fromboth existing studies (1–4) and from what Iheard in my interviews. The three types ofquality are:

n Organisation-focused quality is whereproviders are most interested in making surethat their residents are safe and that they allreceive the same standard of clinical care. Thistype of quality is important for all residents,but for some providers, it is as far as they go.

n Consumer-directed quality is where providers treat residents and their families like customers or ‘consumers’ and focus onthings that help them to attract new residentsand their families, like the design ofaccommodation or the type of activities onoffer. One author has referred to this as‘cruise ship living’(5)

n Relationship-centred quality is the best type of quality and is where every resident istreated as an individual with her or his ownpersonality, regardless of how unwell she orhe is. The most important priority for thesecare homes is to help all their staff andresidents and families form good relationshipsso that everyone feels that they matter.

2. Different policies will influence what type ofquality providers will focus on.

• Inspection and accreditation tend to focusproviders on organisation-focused quality inthe form of basic standards of safety andgood processes. Some ways of funding care,for example, the Aged Care FinancingInstrument in Australia, can also result inproviders focusing on this type of quality.

• Promoting consumer choice as a way ofimproving quality can result in providersfocusing on the visible aspects of care, orconsumer-directed quality.

• Providers who deliver relationship-centredquality tend to do it because they aremotivated to do so, regardless of what thegovernment might do. But something thatseems to be useful is to provide a rating ofquality, as in England, so that providers knowwho to copy.

3. The best strategy for improving quality is tohave a mix of policy approaches and providechecks and balances.

• Having different groups involved with quality,for example, the CQC in England and localsafeguarding teams, means that there mightbe less chance of poor quality slippingthrough the net. However, this only works ifthese groups communicate effectively.

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• Having different programmes runningalongside inspection and accreditation canalso help to provide checks and balances.Examples include the Community VisitorsScheme and National Aged Care AdvocacyProgram in Australia, although recently theyhave not been used effectively to supportquality as they were originally intended.

• Being aware of the imbalances betweendifferent policies and strategies is important.For example, the way providers are paid mightmotivate them to concentrate on one type ofquality regardless of what is required byactivities like inspection.

4. Governments need to communicate whatgood quality looks like. Without a vision forgood quality, it is impossible to know how toencourage care homes to deliver it.

• Governments should play a role in makingsure that information is available about thequality of each provider.

• The government in England has put a lot ofeffort into making sure people can tell thedifference between good and poor providers.The information includes ratings whereproviders are scored outstanding, good,requires improvement or inadequate. Theinspection reports produced by the CQC alsotry to describe what it’s really like to live in thecare home. The CQC also publishes reports onthe state of care in England and talks freelyabout where it sees poor care.

• In Australia, there is much less informationavailable, although this is changing, startingwith the introduction of Consumer Experiencereports in 2017.

• Governments need to make sure that not allthe attention is on ‘input’ standards like howbig the rooms are, or on ‘process’ standardslike how medication is managed, as these candistract care homes from delivering highquality, relationship-centred quality and causethem to focus on the wrong priorities.

5. The reasons why governments approachquality differently can be due to biggerhistorical reasons.

• In England, even though there is a lot ofemphasis on consumer choice, there is still a ‘welfarist’ flavour to how the governmenttreats quality. This is because localgovernment in England was, for nearly twocenturies, very involved in the delivery of care.Social workers and local authorities play acentral part in organising care and quality isinformed by a human rights-based approach(6).

• In Australia, there is a more ‘consumerist’approach which in part stems from the factthat care has always been delivered by otherorganisations, such as faith-basedorganisations. The federal government takesthe lead in contracting with providers, andquality is linked to consumer protection andchoice.

• In the past in England, there has been agreater tendency for the government to reactto scandals and crises in both health andsocial care – often called ‘never again’ eventsbecause of the way politicians often say thingslike ‘we will make sure this never happensagain’. Until recently in Australia this wouldhave been unusual and there was much more‘bipartisan’ support where the parties agreedwith each other. This changed recently withthe impact of the Oakden scandal* inAustralia.

• A number of individuals have been veryinfluential in driving certain approaches inboth countries. In England, there have beenindividuals behind the human rights approachin quality over nearly 20 years. In Australiacertain individuals have pushed hard to givechoice to consumers with the aim ofimproving quality.

• Provider organisations in Australia have alsobeen better at working together than inEngland. This is one reason why providers inAustralia seem to have had more influenceover how regulation has been designed andcarried out.

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*The Oakden scandal refers to the uncovering of mistreatment and neglect at a unit for people with dementia in SouthAustralia in 2016 (7).’

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Table 1: Quality in residential care in England and Australia

ENGLAND AUSTRALIA

QUALITY AND INSPECTION/ ACCREDITATION

What do the standardslook at?

Try to consider the experience of theperson

Look at how good the processes are for runningthe home

What is mostimportant?

The right of the individual to live a goodlife

The need for consumer protection and goodinternal processes

How is quality scored? Using ratings (Outstanding/Good/Requires Improvement/Inadequate)

The ‘Mum Test’

Pass or fail

INFORMATION ABOUT QUALITY

What information doesthe regulator publish?

Inspection reports which try to describewhat it’s like to live in the home

Ratings for every home

Reports on the quality of care is across allproviders

Accreditation reports based on the provider’sprocesses

Information on what the resident’s experience islike (since April 2017)

What do care homespublish?

CQC ratings at the home and on theirwebsite – this is compulsory

Prices on MyAgedCare website (compulsory)

How are residentratings and reviewsused?

Some ratings and reviews are available onNHS Choices and the CQC website butthere are very low numbers of reviews

Under development

What part doesinformation on qualityplay?

CQC aims to use ratings to encourageproviders to improve quality to protecttheir reputations, as well as helpingpeople choose homes

Emphasis is on publishing information to helppeople choose homes

WHAT AFFECTS QUALITY AND HOW?

Organisation-focusedquality

CQC inspections include making sure theresidents are safe

Accreditation reviews make sure the providershave safe, standard processes

The way the government pays providers (throughthe ACFI) can mean that providers focus too muchon organisation-focused quality

Consumer-directedquality

Half of residents pay for their own careand companies improve consumer-directed quality to attract them

Many residents pay deposits and accommodationpayments and companies improve consumer-directed quality to attract them

Relationship-centredquality

The best providers improve relationship-centred quality independently, but it helpsthat the CQC highlights examples ofoutstanding care for providers to copy

The best providers improve relationship-centredquality on their own, without governmentinvolvement

3 Introduction

Many countries around the world are trying tofind ways of making sure that older peoplereceive good care and support when they needit. However, for many years, there has beencoverage in the news about neglect and abusein residential care (8). England and Australia areno exception. Both countries have had severalscandals in residential care. The latest of theseare the problems at the Oakden mental healthfacility in South Australia in 2016, where anumber of older people living with dementiahad been neglected and badly treated.

Even though there are many problems inresidential care, there are also many goodproviders. But it is not clear why some care homeproviders are motivated to provide very goodcare while others continue to provide poor care.The aim of this study was to try to understandwhat governments can do to encourage moreproviders to go the extra mile and deliver goodor excellent care for their residents.

How I did the study

To find out about what happens in residentialcare for older people, I compared what happensin England and Australia. I chose these twocountries because they are very similar in howand when residential care is used and they bothuse external inspections to review the quality of care. I interviewed two different groups ofpeople in each country, and asked each groupslightly different questions:

Group 1: In these interviews I tried to find outabout how each country’s care system haddeveloped and how it works now. I intervieweddifferent types of experts in residential care,including politicians and people working in thegovernment, people from groups representingproviders and older people, staff from AACQAand the CQC, and consultants and academics.

I interviewed 32 people in England and 47people in Australia.

Group 2: I then interviewed staff from 10different care homes to find out what reallyhappens on the ground. In total I interviewed 9 people from 5 care home organisations inEngland and 15 people from 5 organisations inAustralia. I visited at least one care home fromeach of these organisations.

The term ‘care home’ from England is usedthroughout the report as a catch-all to refer toall residential homes in both countries, includinghomes that offer both personal or nursing careor both.

Background to residential care

People only go into residential care when theyneed a lot of support and help

Most countries try to help people to stay in theirown homes as long as possible. What thismeans is that, when older people finally needresidential care, they are often very unwell andneed a lot of support. In England and Australia,at least half of the older people in residentialcare are also living with dementia (9, 10).

People in residential care need different types ofsupport

Many residents need help with ‘personal’ care,for example, getting dressed or going to thetoilet. Many residents will also need clinical carewhich can range from the simple administrationof regular medication to more complicated care.The high number of people living with dementiameans that many older people in residential careneed specialist dementia support. Also, many ofthe older people will spend the rest of their livesin residential care, so end-of-life care is also veryimportant.

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People can spend long periods of time inresidential care

Once they move into residential care, olderpeople will often live there permanently. Thismeans that everyday things like accommodationand food are also important, in the same waythey would be in the person’s own home.

Background to residential care inEngland and Australia

Comparing countries is often helpful as it allowsus to see how governments have tried to solvesimilar problems in different ways. This is not as straightforward as it sounds. Sometimesgovernments do things differently because ofcomplicated and longstanding reasons to dowith the history and culture of the country.

Previous researchers have written about thedifferences between residential care in Englandand Australia (11–14), and also between theway inspections are carried out in each country(15). These differences are important becausethey help to explain some of the findings of thiscurrent study.

One important difference between England and Australia is the way the country is governed.In England, there is a central government inLondon, which collects most of the taxes andpasses all of the laws. In Australia, theseresponsibilities are split between the central(called ‘federal’) government and the six stategovernments.

Some of the main differences in how the caresystems work are outlined in Table 2:

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ENGLAND AUSTRALIA

Who pays for care? About half of people in care homes pay forthemselves.

The other half are paid for by their localcouncil or by the National Health Service (if they are very unwell).

The government pays something towardsthe care of everyone in residential care.

For the less well-off, called ‘low means’residents, the government also helps to payfor accommodation.

Who organises the carepaid for by thegovernment?

There are 152 councils (called localauthorities) who liaise with the care homecompanies to organise care for people whoare paid for by the government.

All of the care is organised through thefederal government, rather than throughthe governments of each state andterritory, as is the case for health care.

Who delivers care? Most of the companies that deliver care areprivate companies that make profits fortheir owners and shareholders.

More of the companies that deliver careare voluntary and religious organisationsthat put their profits back into theirorganisations.

How is care inspected ineach country?

The CQC inspects care providers and giveseach home a rating of outstanding, good,requires improvement or inadequate.

The CQC has the ability to close down aprovider or even bring criminal charges if itfinds a provider has provided very poorcare.

AACQA reviews each home and simplypasses or fails the home.

The Agency hardly ever fails homes, butwhere it does, it must send the report andrecommendations to the Department ofHealth for them to take action. AACQAcannot take further action without thepermission of the Government, through the Department of Health.

Table 2: Differences in how care is organised in England and Australia

There are roughly the same number of carehome residents in England as in Australia, whencompared to the population of older people. In England, about 410,000 people were usingresidential care as at December 2016 (16), whichworks out at about 4.1% of people aged 65 and over (17). In Australia, the total number ofpeople in residential care was about 184,000 inJune 2017 (18), or about 4.8% of people aged65 and over (19). One difference is that homesin Australia tend to be bigger – care homes inAustralia have an average of 70 places,compared to around 40 in England (16,18).

History of inspection andaccreditation

In England, inspection in residential care hasbeen increasing since the 1990s. Following theNHS and Community Care Act 1990, councilsstarted to use external companies for deliveringmost residential care, instead of providing itthemselves. This meant that the governmentand councils needed a system where they couldkeep an eye on what was happening in carehomes that they were not involved in running.Across the board, and not just in social care, theamount of regulation increased from the 1980sand a report in 2005 (20) observed that there

was too much regulation and ‘red tape’ forbusinesses. Because of this, in 2006, thegovernment announced that the inspectionbodies which were in place at the time for alldifferent types of care (including health care,and residential and home care) would bemerged into a new body, the CQC.

In Australia, the reasons why inspectionsincreased were initially different to England. TheAustralian government has always used privatecompanies to deliver most of its residential care.Most of the private companies who deliver carein Australia are ‘not-for-profit’ voluntaryorganisations, usually run by religiousorganisations. This is different from Englandwhere most companies are in the business ofresidential care to make money. The splitbetween for-profit and not-for-profit care ineach country is shown in Figure 1.

The Australian government introducedinspection in the 1980s after an inquiry knownas the Giles Report discovered horrible cases ofabuse and neglect in nursing homes (21). Theintroduction of regulation was in line with thepriorities of the Australian Labor Partygovernment of the time, which wanted to makesure there was a fairer and better system ofresidential care. When the Liberal governmentcame to power in 1997, the rules were relaxed,

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* The Liberal Party in Australia is most similar to the Conservative Party in England

Figure 1: Ownership of residential care places [16, 18]

ENGLAND

Not-for-profit

Local authority/NHS

For-profit

AUSTRALIA

Not-for-profit

Stategovernment

For-profit

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Figure 2: Legislative and organisational milestones in quality regulation

and a system of accreditation was introduced.The government set up a body called theAustralian Aged Care Accreditation StandardsAgency to look after residential care. ThisAgency was in place until 2014, when it was

relaunched as the Australian Aged Care QualityAgency (AACQA) and given the responsibility forcare delivered in people’s homes and in thecommunity. The history of regulation in eachcountry can be seen in Figure 2.

ENGLAND AUSTRALIA

Registered Homes Act 1984 sets upvoluntary standards for residential care. 1984

NHS and Community Care Act 1990specifies that local authorities set uparms-length inspection units from 1993

1993

Care Standards Act 2000 legislates forfirst national inspection body. NationalCare Standards Commission (NCSC)goes live using National MinimumStandards in 2002

2002

Commission for Social Care Inspection(CSCI) replaces NCSC and implementsstar ratings

2004

CQC undergoes transformationprogramme. Launches newFundamental Standards and Mum Testand re-introduces ratings

2015

Health and Social Act 2008 establishesCare Quality Commission (CQC). CQCgoes live in 2009 with generic EssentialStandards of Quality and Safety forboth health and social care. Star ratingsdiscontinued

2009

2001

Aged Care Act 1997 establishesindependent Australian Aged Standardsand Accreditation Agency (ACSAA) forresidential care only. In 2001 first roundof accreditation completed against 44Accreditation Outcome Standards

1987Outcomes Standard Monitoring teamsset up in State branches of Departmentof Health to monitor nursing homes

1991 Outcomes Standards Monitoringextended to hostels

2014

Living Longer, Living Better Act 2013creates Australian Aged Care QualityAgency (AACQA) to monitor residentialand community care from 2014.Department of Health embarks ondevelopment of new quality framework

2018AACQA launches new Aged CareQuality Standards across residential andcommunity care, to come into forcefrom 2019

2019AACQA and the Aged Care ComplaintsCommissioner merged to form AgedCare Quality and Safety Commission

What do governments do now toencourage good care?

It can be difficult for governments to encouragegood care because now they usually rely onprivate care companies to deliver care. Thesecompanies can be set up to make a profit fortheir owners or shareholders, or can be not-for-profit, where they spend any extra money theymake on improving their homes and services.

Governments have tried three main ways toencourage these care companies to improvetheir care:

1. Inspection

A common way of encouraging providers toimprove their care is to do regular inspections.Governments often set up separateorganisations to carry these out. Theseorganisations decide how well providers aremeeting specific standards. These standardscome in three different types (22):

Structural standards about things like thenumber of staff in the home, or how big therooms are.

Process standards about things like how the carecompany goes about keeping track of people’smedication, or whether they have processes forhandling complaints from families.

Outcome standards about things like whetherthe care company is good at helping residents to enjoy life or to feel safe and secure.

2. Markets and competition

Many governments have tried to encourageproviders to improve quality by having ‘markets’in residential care. This means that people get tochoose which care provider they use. What issupposed to happen is that providers will go outof their way to show they are better so that theyget chosen (23). The problem with this is thatchoosing a residential care place is not as simpleas other decisions in life, like buying a fridge orchoosing a hotel, because:

• The older person may not be well enough tobe able to find out about different care homesand make good choices.

• The person living in the care home has oftennot decided they need residential care orthought much about which care home to use.These decisions are frequently made by theindividual’s family or by a person such as adoctor or a social worker.

• It can be difficult to work out which are thebest care homes by just visiting them andwithout actually going to live in them.

• People often go into residential care when acrisis happens, for example, the death of theirpartner or because of a health problem, suchas a broken hip. This means there is often notmuch time to look around at different carehomes. Sometimes people just have to choosethe first home which has a place available.

• Once the person is in the care home, theymay be too ill to move or even to tell peoplethat the care they are receiving is poor.

• When things are not going well in residentialcare, their families and friends of residentsmaybe worried about complaining in case itaffects the way the resident is treated.

3. Quality information

When governments try to use markets toimprove quality, they often make informationavailable on how good the provider is. This cancome in many forms, for example, ratings fromresidents (like the ones for hotels on websiteslike TripAdvisor), or scores from inspectors forhow well they do certain things. However, thereis lots of research to say that people do notmake use of this information because they areunwell or the decision has to be made veryquickly (24–26). But this does not mean thathaving ratings is pointless – for example, inhealth care ratings work because providers canbe worried about their reputation or aboutlosing business if they get a bad rating (27, 28).

Conclusion

Researchers have already found that inspectionsand reviews have helped to raise the most basicstandards of care, even though there are stillexamples of very poor care. But inspections arenot so helpful for encouraging care companiesto deliver really good quality care. Giving people

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choice of care home is another way ofencouraging care homes to improve, but thisalso has its problems, because people are oftentoo unwell or stressed to make good decisions,or because there are not many options available.

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4 Understanding quality

There are many challenges to understandingquality in residential care. Some of the reasonsfor this include:

• Quality means different things to differentpeople. An example is that one person mightlike to have privacy and their own space,while another may prefer to have thecompany of other people. To complicatethings, people can have different preferencesat different times.

• Quality is made up of many different things.Quality in a care home can include things asvaried as how good the nursing care is,whether the home is clean and tidy, how safesomeone feels, how good the food is, andwhether people feel there is enough to dothat they enjoy.

• Quality in care can vary depending on who isdelivering it and when. The quality of care canbe different from each care worker, from thesame person from day to day, or even fromhour to hour. The quality of care can also beaffected by how well the resident and the careworker get on together.

Because of these challenges, an important partof this study was to find a new way of talkingabout provider quality. I developed threedifferent ways of talking about quality:organisation-focused quality, consumer-directedquality and relationship-centred quality. I did thispartly by looking at what had already beenwritten about quality in general (29–31), andspecifically about quality in care homes (1–4),and also by thinking about what people told mein their interviews. The three types of quality are:

Organisation-focused quality is where providersare most interested in making sure that theirresidents are safe and that they all receive thesame standard of clinical care.

There is less emphasis on making sure peoplefeel part of a community. People living in thesehomes are treated as if they are patients, andthe accommodation often has the look and feelof a hospital.

Consumer-directed quality is where providerstreat residents and their families like customersor ‘consumers’ and focus on things that help to attract new residents and their families.

The sorts of things these providers mightconcentrate on might be the appearance of thehome or making sure there is a formal scheduleof activities laid on. These care homes may lookand feel like hotels, with entertainment andactivities organised like they might be in a hotel– something which has been called ‘cruise shipliving’ (5).

Something often said is that families can feelguilty about placing their relative in a home, butthey often feel better when they can see a highstandard of accommodation or lots of activitiesfor their relative to do.

Relationship-centred quality is the best type ofquality and is where every resident is treated asan individual with her or his own personality,regardless of how unwell she or he is.

The most important priority for relationship-centred care homes is to help all their staff andresidents and families form good relationships so that everyone feels that they are important.These care homes are as focused on the qualityof life of their residents as they are on thequality of the care they provide. These carehomes try to be as homelike as possible, whichcan mean they are often not the tidiest or bestpresented of care homes.

The term ‘person-centred’ is often used to referto this type of care but this term means manydifferent things to different people, ranging

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from giving people control of their care budgetor writing down information about the personsuch as what time they would like to get up inthe morning, right through to care being aboutrelationships and connections (32, 33). For this

reason, I use the term ‘relationship-centred’ todescribe the best quality care, a term originallycoined by health care researchers in the US (34)and adapted for use in residential care by Daviesand Nolan in the UK (35).

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Table 3: Different quality orientations

PROVIDER QUALITY ORIENTATION

Organisation-focused Consumer-directed Relationship-centred

What does the providerfocus on?

Internal processes Consumer preferences andchoice

Quality of life of residents,families and staff

What is important to theprovider?

Patient safety and quality ofcare

Consumer rights and choice Human rights and quality oflife

What does ‘care’ mean? Care is a process Care is a service Care is a relationship

How is work organised? Task-centred and routine Customer-centred andindividual

Person-centred andrelational

What does ‘resident’ mean? Passive patient Empowered consumer Individual with‘personhood’

Who has the power? Resident is dependent onthe care worker

Resident is superior to thecare worker

Resident and care worker inequal, two-way, meaningfulrelationship

What is the accommodationlike?

Hospital-like Hotel-like Home-like

How each country defines quality inits standards

The CQC and AACQA have different powers,responsibilities and reporting lines. In England,the CQC can bring criminal charges againstindividuals and providers, including formanslaughter, where the AACQA has to referdecisions and issues to the Department ofHealth in Australia.

The standards each country uses are alsodifferent. In England, the standards look at whatthe experience is like for the person living in thehome. Called the Fundamental Standards andlaunched in 2015, the standards are based onfive questions as shown in Table 4.

The CQC gives each home a rating or score foreach of these questions, either ‘Outstanding’,‘Good’, ‘Requires Improvement’ or ‘Inadequate’.The CQC then uses a set of ‘key lines of enquiry’(KLOEs) to direct the focus of the inspection(37).

When the CQC launched the standards, theChief Inspector of Social Care, Andrea Sutcliffe,also introduced the idea of the ‘Mum Test’,which she explains here:

“On their visits, I will ask our inspection teams toconsider whether these are services that theywould be happy for someone they love and carefor to use. If they are, then we will celebrate thisthrough our ratings. If they are not, we will taketough action so that improvements are made.Above all else, my priority is to make sure peoplereceive care that is safe, effective, high-qualityand compassionate.” (38)

In Australia, a set of 44 Accreditation Standardssplit into four themes (see Table 5) wereintroduced in 1997. The Standards focus mainlyon whether care homes have good processes,for example, whether they record medicationproperly for each individual.

In Australia, there are only two outcomes toaccreditation reviews. Providers can either passor fail. If they fail, the Agency refers the providerto the Department of Health so that they candeal with the provider. There are several thingsthe Department of Health can do, includingsending in a team to sort things out (something

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Table 4: The five questions in the CQC’s FundamentalStandards (41)

KEY QUESTION

Is it safe?

Is it effective? (Does it give good results?)

Is it caring?

Is it responsive? (Does it meet people’s changingneeds?)

Is it well-led? (Is it managed well?)

Table 5: Accreditation Standards in Australia (39)

STANDARD PRINCIPLE

1. Management systems, staffingand organisationaldevelopment

Does the way the home is run help to meet the needs of the people who livethere, their families and friends, and all the people involved in running thehome? Does the way it is run help it to adapt to change?

2. Health and personal care The physical and mental health of the resident will be looked after in partnershipwith the person themselves, their families and friends and the health care team.

3. Care recipient lifestyle The resident keeps all their rights and is helped to take control of their own lives,both in the home and outside in the community.

4. Physical environment and safesystems

The home is safe and comfortable to help the residents, visitors and the peoplewho work there to have good quality lives and wellbeing.

which the provider has to pay for), or they canalso close the provider down if they need to.However, very few providers are flagged up ashaving problems by the Quality Agency (40, 41)and 98% of providers pass accreditation overall(42). Because of this, at first sight it looks likeeverything is much better in Australian aged carethan in England, but this did not turn out to bethe case. People I interviewed told me that carehomes had become very good at knowing whatto do to pass accreditation, even though theymight not really be providing good care for theirresidents. This is made easier because theaccreditation standards have been the samesince 1997 and so providers are very familiarwith them.

Australia’s Accreditation Standards are differentfrom the CQC’s Fundamental Standards in twomain ways:

1. Even though they are called outcomesstandards, the Accreditation Standards aremainly concerned with making sure thatproviders have good processes in place forinternal quality improvement. AACQA doesnot specify what these processes should looklike. Reviewers in Australia could be moreinterested in whether a care home had a goodway of making sure that they gave the correctmedication out to residents as their doctorshad prescribed, rather than whether residentshad been prescribed the right amount ofmedication in the first place. In England, while

some of the KLOEs explore the quality ofprovider processes, the overall approach toinspection is to make sure the provider isdelivering care which is person-centred andpasses the ‘Mum Test’.

2. Providers can only pass or fail the Standardsand there is no way of knowing whether theyjust scraped through. This means that all thesystem can tell is whether providers achievedthe minimum standards of quality (43, 44). In England, the CQC replaced its pass/failcompliance approach with the ratings systemin 2015. It is not good enough that theprovider simply passes the inspection – theCQC uses the ‘Mum Test’ to make sure thatinspectors would be happy for a loved one oftheirs to live in the home.

While I was conducting this study, the AustralianGovernment was in the process of developingnew Consumer Outcome Standards to replacethe Accreditation Standards, to cover residentialcare and home care. These standards wereintroduced in 2018 and will be rolled out in2019 (45). These new standards are moreinterested in what life is like for the people wholive in the home, but they are still based on asystem of pass or fail and stop short of statingwhat good quality looks like. However, theAustralian Government is planning the roll-outof ratings, as recommended by the Carnell-Paterson review into the events at Oakden (46).

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5 How does each government use informationto improve quality?

One of the ideas for improving care homes is tomake information available about how good orbad they are. By making information available,governments hope that one of two things willhappen to make providers improve their quality.Either people will use information to choose thebest providers and other providers will get betterto attract and keep new residents, or providerswill run their businesses well simply becausethey want to make sure they keep up a goodpublic reputation.

Publishing quality information sounds simple,but there are lots of issues tied up with it. Asexplained earlier, quality is not easy to define or explain, so it is very difficult to findstraightforward ways of saying how good aprovider is. One answer is to give numbers forunwanted types of incidents in the home, forexample, did a lot of residents have falls? Butthis is much less straightforward than it sounds.It may be that there were a lot of falls becausethe home had the most unwell residents, orbecause the home believes that it is better forpeople to get up and move around and riskfalling, rather than use things like bed rails ormedication to restrain them or keep them safefrom falls. Researchers have also found thatproviders might do unwanted things to keeplooking good. So, for example, to keep thenumber of falls low, care homes might refuse to take very frail residents, or they might giveresidents drugs to make them less likely to movearound and fall over.

There is also the issue of how information onquality is collected. Residents and their familiesmay not be able to comment on care andanyway, it is not like in a hotel where you havelots of people coming and going so a lot morepeople can leave reviews (47). Residents can also

be worried that staff may treat their relativesbadly if they know they have publishedinformation that is critical. Governments can askproviders to collect and publish qualityinformation, but researchers have found that it isdifficult to make sure that all providers publishthe same amount of information (48).

What are the differences betweenEngland and Australia?

The way governments in England and Australiawrite and talk about quality is different. It iseasier to get an idea of which care homes arebetter in England than in Australia. I found thisout in the interviews, and also because of theproblems I had in finding good care homes totalk to for my research. In Australia, even asenior participant from an industry organisationadmitted it was ‘breathlessly impossible’ to workout which were the better care homes.

There were three features about informationthat are different in each country:

1. Each country has different types ofinformation available to the public

One of the biggest differences between the twocountries is how easy it is to tell the differencebetween good homes and bad homes. InEngland, the CQC uses ratings to show howgood a provider is, and then the provider mustdisplay this rating at their location and also ontheir website. The ratings are Outstanding,Good, Requires Improvement or Inadequate.This means that it is possible to see what theCQC inspectors thought of a provider’s quality.

At the same time, there are some problems withratings. One is that the inspector is making up

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her or his mind based on spending only one ortwo days at the home, and the management ofthe care home might go out of their way tomake sure there are more staff working on thatday and that things are running much moresmoothly than normal. Another problem is that,when care homes receive a poor rating thingscan quickly deteriorate. Staff begin to leave,which makes things worse, and the care home is then even less likely to attract new residents.With less money coming in, the care home canstruggle to address the problems the inspectorspotted in the first place.

There are currently no ratings in Australia,although it is now planned to introduce them inthe future because of the problems at Oakden.During the study, people told me about twoAustralian government activities to help withshowing how good or bad providers were. Oneproject was to ask providers to voluntarily reporthow well they were doing in four specificareas*. The four areas were the number ofrestraints, the number of pressure sores, andwhether residents were losing weightunexpectedly. These are all important measures,but previous research shows that focusing onspecific, clinical measures can mean that otherthings get neglected – particularly around thequality of life of residents (49).

The other plan in Australia was to ask residentsand their families to leave reviews on websitesand, at the time of the study, the governmentwas looking at different systems for doing this.In Australia, many people spoke about how the‘baby boomers’ born after the second world warwould be much more demanding than thepeople in care homes now, and so they wouldbe more likely to leave reviews. Some peopletold me that this would be so successful that it

would mean that the government could stopinspecting care homes at all.

Previous research says that relying on reviewsfrom residents and their families might not be agood strategy (47). In England, the governmentintroduced these types of reviews in 2011, butthis has not been successful, mainly because sofew people have written reviews. One person inthe government in England told me this is partlybecause there are too few people going in andout of care homes to post enough reviews onthe internet, when compared to how manypeople visit GPs and hospitals.

2. Finding out what is it like to live in the home

The goal of the CQC in England is to helppeople understand what it’s like to live in thehome. It uses three ways to do this:

• The inspectors talk to residents and theirfamilies. Where residents are unable tocommunicate, the inspectors spend timewatching what is going on to see how theresidents are involved in the home.

• The inspectors take people with them whoeither have personal experiences of living in a care home or, more commonly, have beenclose to someone who has lived in a carehome, for example, their husband or mother.These people are referred to as ‘experts byexperience’.

• When the inspectors write their reports, theytry to include examples of things they saw inthe home to help bring it to life. To help seethe difference between the inspection reportsin England and the accreditation reports inAustralia, Table 6 shows examples fromreports in each country:

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* This project was known as the National Aged Care Quality Indicator Program, launched in 2016. More information isavailable at https://agedcare.health.gov.au/ensuring-quality/quality-indicators/about-the-national-aged-care-quality-indicator-programme

3. Talking about bad provision

One of the biggest differences between the twocountries is whether it is legal to shareinformation about bad providers.

In Australia, the law which applies to residentialcare (the Aged Care Act 1997) says that thegovernment cannot draw attention to specificproblems in care homes. It is not possible forAACQA to publish reports with informationwhich might make it easy for people to workout which providers they are talking about.

It is different in England. Not only can inspectorsput negative information in specific inspectionreports about providers, but the CQC alsopublishes information about problems in bothhealth and social care. These reports include areport every year on the state of care and alsospecial reports about specific problems such ashow difficult it is when older people movebetween hospitals and residential care (52).

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Table 6: Selections from inspection and accreditation reports (54, 55)

ENGLAND: a focus on ‘the lived experience’ AUSTRALIA: a focus on processes

There was a lively and energetic atmosphere in theservice. We saw people being involved in the running oftheir home laying tables, folding laundry, and dusting.

Lifestyle staff plan daily activity programs in bothgroups and individual settings and offer a range ofactivities including the celebration of special occasions.Lifestyle staff evaluate and redesign programs asnecessary based on resident feedback andparticipation. Information from resident meetings andsurveys also assists lifestyle staff in planning programs.Residents and representatives said they are satisfiedwith leisure interests and activities offered forresidents

The service had a stable staff team, the majority of whomhad worked at the service for a long time and knew theneeds of the people well. The continuity of staff had ledto people developing meaningful relationships with staff.We observed a person peeling potatoes with the cook.They informed us that they enjoyed doing this eachmorning and would have a good chat with the cook.

6 What difference do the governments maketo the quality of residential care?

So far, this report has focused on what I learnedin the interviews about the regulatory systems ineach country. Another important part of thestudy involved visiting residential care providersin each country to see what happens in practice.

I interviewed people from five residential careproviders in England and five in Australia. Thedetails of these organisations are given in thetable below. Each person agreed to participateanonymously, so I have changed their job titlesand the names of each organisation to makesure they cannot be identified. The providerswere a mix of for-profit and not-for-profit inboth countries.

At the start of the study, I only planned to dointerviews with care providers who were goingthe extra mile and delivering really good care.However, this was difficult in Australia becauseof the lack of information to help identify thegood providers. While the CQC’s system ofratings is not perfect, the ratings system gave agood sense of which providers in England aregood. In Australia, nearly all providers passaccreditation, but there is no information otherthan whether they pass or fail, so it is hard toseparate the ones who are going the extra milefrom the ones who are just scraping through. Inthe end, I asked people at AACQA and theDepartment of Health to help me identify goodorganisations. There was only limitedinformation they could share with me and thismeant that the group of five providers I

interviewed in Australia was much more mixedin terms of quality than the group in England.

In both countries there were different standardsof accommodation depending on whether theresident was paid for by public money or not.

Four of the providers in England have stoppedaccepting residents who are paid for by theirlocal authorities. This has been happeningfrequently recently because the rates paid bycouncils have been falling or have stayed thesame for some time, and providers say they canno longer afford to take new residents at therates paid by the local authorities.

In Australia, the situation is slightly different. All providers approved by the government takepublicly-funded residents, otherwise thegovernment pays them lower rates for care.

At the providers I visited this meant that therewere two standards of accommodation: one forwealthier residents, and a different standard forresidents whose accommodation is paid for bythe government – referred to as ‘low means’residents. The differences in accommodationwere striking. At three of the providerorganisations (two for-profit and one not-for-profit), RAD/DAP-paying* residents generallylived in single rooms while many low meansresidents shared rooms of up to four people.These shared rooms were more like smallhospital wards than homelike bedrooms. InEngland, there are now very few shared rooms,

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*A RAD (Refundable Accommodation Deposit) is where the accommodation part of care home fees is paid for upfront as alump sum. Residents can opt instead for a DAP (Daily Accommodation Payment) which is like a regular rental payment. Thelevel of payments is determined by the quality, location and features of the accommodation and is capped by thegovernment. More information on how people pay for residential care in Australia is available atwww.myagedcare.gov.au/costs/aged-care-homes-costs-explained/paying-accommodation-aged-care-home

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Table 7: Characteristics of the Provider Organisations

ENGLAND Silver Birches Chestnut Hawthorn Poplar Maple

Ownership Not-for-profit For-profit For-profit Not-for-profit For-profit

No. of homes 11–20 50+ 6–10 20–49 20–49

Home(s) visitedin study

Residential Residential/nursing

Residential/nursing

Residential Residential/nursing

Local context Village/rural Suburban Rural Suburban Suburban

Environmentand feel

ConvertedVictorian home

Purpose-built,modern

Purpose-built,homely

Converted Victorianhome, slightlydilapidated

Purpose-built,modern

Interviews OperationsDirector

Care HomeManager

Care HomeManager

Chief Executive

OperationsDirector

Senior Manager(shared services)

Care HomeManager

OperationsDirector

Quality Manager

AUSTRALIA Acacia Waratah Eucalyptus Banksia Hibiscus

Ownership Not-for-profit For-profit Not-for-profit For-profit Not-for-profit

No. of homes 1–5 6–10 11–20 50+ 6–10

Home(s) visitedin study

Residential Residential/nursing

Residential/nursing

Nursing Residential

Local context Rural Suburban Suburban Suburban Suburban

Environmentand feel

Large estate witha number ofservices

Purpose-built,modern

Large estatewith a numberof services

Large estate with anumber of services

Large estatewith a numberof services

Interviews Chief Executive

OperationsDirector

Quality Manager& Senior Manager(shared services)

Chief Executive

Senior Manager(shared services)

Care HomeManager

Senior Manager(shared services)

Quality Manager

Care HomeManager

Chief Executive

Care HomeManager

Operations Director

OperationsDirector

and usually only for couples. The guidelines inAustralia are that providers can have an averageof 1.5 low means residents per room (53).

One provider in Australia thought that lowmeans residents probably do not expect the bestaccommodation and it was like being able toafford different classes on an airline:

“Some people are lucky, get on a jumbo jet andturn left, most of us turn right and sit down theback. […] So yeah, some people will choose andhave the means to sit up in first. But if it’s thegovernment paying for your seat that you’re not surprised if you’re down the back.” (Senior Manager, Waratah, Australia)

At the same time, two providers in Australia,both not-for-profit, said that they tried to deliverthe same overall experience to all residents,regardless of funding, although it was notpossible to verify this.

In both countries, some of the providers wererunning homes which looked and felt like hotels.They had smart reception desks, expensivedecoration and furnishings, waiter service andmenus in the dining rooms and fresh flowers.

What difference do thegovernments make?

The following section looks at how and if qualityimprovement is linked to what the governmentsin each country do. It finds that somegovernment actions can influence qualityimprovement, but this is mainly the type ofquality linked to organisation-focused orconsumer-directed quality. There are not suchstrong links between government actions andrelationship-centred quality, because this type ofquality depends on the ‘intrinsic’ motivation ofproviders, motivation which comes from doingthings because they are personally rewarding(54). Even so, there are ways governments caninfluence relationship-centred quality, forexample, by identifying outstanding providers as role models for other providers to copy.

Regulation and quality improvement

All the people I interviewed said that inspectionand accreditation in each country have generallyimproved the basic level of quality. Otherwise,

they did not think that inspection andaccreditation had made much difference tohigher levels of quality. In both countries, thestandards can unfortunately lead to anunnecessary focus on paperwork andbureaucracy.

One of the problems in Australia is that theAccreditation Standards have been much moreconcerned with how things are done, ratherthan what difference they make, as mentionedabove.

In the case of an Accreditation Standard called‘continuous improvement’, one problem I foundin two of the providers was that they were moreconcerned with making sure they had writtendown what improvements they were doing,than whether they actually made any difference.

Some Australian researchers have looked atnursing homes in the past and called what theseproviders were doing ‘continuous improvementritualism’ (15). What they mean is that careproviders are more concerned about the ‘ritual’of improving quality, rather than really making adifference to the lives of their residents.

For these two providers, the improvements weremostly simple things like changing the type oftrays they used at mealtimes or for organisingfor homes to be redecorated. Otherimprovements were to help to run the homesmore smoothly. So, for example, one hometalked about improving handovers betweenshifts. This definitely is helpful for residents andfor better quality care (55), but the provider wasmuch more focused on how much moreefficient it made their home.

“And then these are care ones that we’ve recentlydone, so we’ve redone our handover sheets tobe more comprehensive. So there was a needthat when we have agency staff or casual RNs[Registered Nurses] that are coming that don’tknow the residents very well, we needed a lotmore information on those handovers about theresidents.” (Care Home Manager, Waratah, Australia)

One Australian provider explained how thepriority is often on recording things rather thanwhat is needed for a feeling of ‘normal’ life. Shegave the example of how people need to writedown whether people prefer tea of coffee:

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“ … they wanted to see the list that we had ofwhat tea and coffee people have. I said ‘oh, wedon’t have a list.’ And they said ‘oh, but youneed to be able to demonstrate whether peoplelike tea or coffee.’ And I said, ‘no, we actuallydon’t have to demonstrate that. What I have todo is demonstrate that that person has receivedwhat they’ve chosen. And they may choosecoffee today but they may choose tea tomorrow.Once I have a list, I’m actually removing that dailychoice.’ ‘Oh, but what if you have a casual staffmember?’ I said, ‘yeah, same rule applies, ‘wouldyou like a tea or a coffee?’’. It’s not hard.”(Operations Director, Hibiscus, Australia)

So, while ‘continuous improvement’ is animportant standard in Australia, there wasnothing to suggest that this really had an impacton the best, relationship-centred, quality.

There were care providers in both countries wholooked like they were delivering relationship-centred care. The attitude of these providers wasthat they had to pass inspection or accreditation,but this was just business as usual and not thebe-all and end-all. Instead, ‘real’ qualityimprovements were happening day-in, day-out.A participant in Australia (Hibiscus, OperationsDirector) explained that the key to passingaccreditation was ‘to know the regulationsbetter than the regulator’ but making sure theirresidents were happy with their lives was muchmore important.

Money and quality improvement

A special feature of the care system in Australiais the use of the Aged Care Funding Instrument(ACFI)*. The government uses the ACFI todecide how much it pays providers for eachresident’s care. One of the problems with theACFI is that it means providers can be veryfocused on making sure that the residentreceives specific types of care, like certain typesof pain treatment, rather than thinking abouthow to help the resident to get back on theirfeet or become more independent. This issomething that was talked about by many of thepeople I interviewed in Group 1. The providers Italked to did not say directly that the ACFIaffected the way they worked, but at the same

time said other things which suggested thatmaking sure providers got as much money fromthe government as possible could take a higherpriority than whether their residents had ahigher quality of life.

Choice and quality improvement

One of the goals for letting people choose theircare home is to encourage homes to improvetheir quality to attract more residents. Talking to providers confirmed something the otherparticipants told me, that having a ‘market’ incare led to a focus on consumer-directed quality.The ‘consumer’ was not necessarily the resident,but often their families or friends who werechoosing the home. The large amounts ofmoney involved meant that appealing to new,wealthy, residents could outweigh what theinspector or accreditation reviewer were lookingfor. Quality improvement was often focused onthe visible features of the home, rather thanrelationship-centred quality, for example:

• Appearance of the home

Homes focused on consumer-directed qualityoften looked and felt like upmarket hotels.Often the design of the building was to appealto the family of residents, rather than theresidents themselves. This provider in Englandwas about to start renovating their home, eventhough the residents liked the ‘shabby chic’ lookof the home:

LT: So, you were telling me about [your]refurbishment…why did that become a priorityhere?

“… It’s one of our older homes. […] And whilstour residents love, perhaps, potentially a shabbychic look, their sons and daughters don’t, theywant something that’s a bit more ‘in themoment’ for mum or dad. So, we’re trying tocreate that homely environment that’s a little bit lighter and brighter.”(Operations Director, Maple, England)

In fact, some of the homes were decorated inunsuitable ways for people living with dementiafor example, isolated rooms, bright whitebathrooms and softly-lit dining rooms. The high-

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* More information on how the ACFI works can be found at https://agedcare.health.gov.au/funding/aged-care-subsidies-and-supplements/residential-care-subsidy/basic-subsidy-amount-aged-care-funding-instrument/aged-care-funding-instrument-acfi-user-guide

end homes had features such as printed menusand silver service in their dining rooms.Participants said that the quality of the homeand the quality of life of the residents did not go hand in hand:

“And that’s [good quality] just not whetheryou’ve got five-star accommodation or three-staraccommodation because ultimately what we’vefound is that you can have a beautiful facilitybut very inadequate care and it’s not a nice placeto be.” (Operations Director, Banksia, Australia)

• Cruise ship living

One of the ways homes try to attract consumersis by showing that they have plenty of activitiesfor residents. All the providers in the studiesoffered activities and therapies for residents, for example, music therapy and pet therapy.

But for the providers who treated residents asconsumers, the emphasis was on having formaltimetables of activities rather than just lettingthings happen when residents wanted them to –like living on a cruise ship. Other providers gaveexamples of how things like ‘Snoezelen rooms’*and the ‘Namaste Care’** programme wereused to stimulate or comfort people living withdementia. For the best providers, stimulating andcomforting residents was just part of day-to-dayliving, and did not rely on formal programmes.

• Sales and marketing

All the homes were interested in knowing whatresidents and families thought about the homeand the way it delivered care. However, thereason for being interested in what they thoughtvaried from provider to provider. For homesfocused on consumer-directed quality, askingresidents and relatives was much more aboutmaking sure the homes knew how to attractresidents in the future. For relationship-centredproviders, understanding the feelings ofresidents and their families was part of day-to-day living. These providers talked about the bestideas for quality improvement coming from theirown residents on a day-to-day basis.

How do the ratings help?

The CQC introduced the ratings in England sothat providers would want to improve theirquality to get a ‘good’ or ‘outstanding’ rating.From my conversations with providers, it lookslike the ratings might be having an effect. Forone provider in England, even the possibility ofrelatives looking at the CQC ratings meant thatthe ratings were important. But for anotherprovider, being outstanding was something they would do even if ratings did not exist andbeing outstanding was all about wanting theirresidents to have the best quality of life possible.

The CQC ratings might be helpful for providersto know who they can look to for inspiration,but this requires further research. One persontold me that it can be hard for providers who are not ‘Outstanding’ to understand quite whatis involved with being ‘Outstanding’ – anotherperson told me this even applied to someinspectors.

What can governments do toencourage relationship-centredquality?

The use inspections and reviews in England and Australia have had some success in raisingthe basic levels of quality in each country. Butpast research also shows that there is lessgovernments can do to encourage providers todeliver relationship-centred quality and in fact,things like inspection can hinder this type ofquality improvement.

Sometimes, the rules and regulations involvedwith inspections can be a problem forrelationship-centred quality (58–60). This isbecause it is difficult to make rules for the typesof things managers do to deliver relationship-centred quality, for example, around leadershipand how they support staff to developmeaningful relationships with residents and theirfamilies. An example is how the managers at therelationship-centred providers in the study wererelaxed about what happens in the home and

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* ‘Snoezelen’ rooms are specially designed for people living with dementia to stimulate them with things like lighting andtactile surfaces (56).

** Namaste Care’ is for people living with the advanced stages of dementia who might otherwise be left out of otheractivities (57).

were not worried about strict timetables andrules. They were creative about managing risksto the health and safety of their residents (forexample, having kettles available or keeping pets and animals) and accepted messiness anduntidiness where it helped to create a cosy andhomelike environment.

Providers in both countries agreed that therewere things about inspection and regulationwhich could make providing relationship-centredquality more difficult. However, providers inEngland thought that the new CQC standardswere better than the old standards because they were more focused on outcomes than the previous regulations.

In both countries, providers commented howthey sometimes ‘went into battle’ withinspectors and reviewers where they felt thatwhat the inspector wanted was not best for theresident. The best providers felt that their staffshould be able to make decisions even thoughthey might do things which the inspector mightnot like. One provider gave the example of astaff member who realised why a resident wasfinding it difficult to sleep and took actionswhich in other providers might have triggeredconcerns about the level of physical contact:

“They’re great in that we had a gentleman comein here and he’d lived with his wife forty years,no, forty-five years they’d been married andhe’d be very distressed in the evenings, wecouldn’t get him to want to settle, he didn’twanna go to sleep and one of our guys justthought, you know what, I need to lie in the bedand hold him, because that’s what happens withhis wife. Got on the bed, held him, five minutes,sleeping soundly, all night long. Other peoplewould medicate.” (Group Interview, Hawthorn, England)

Respect for the resident’s wishes came up moreoften in the interviews in England than inAustralia. One provider said the Mental CapacityAct in England was a big influence as it meant ashift from ‘the nurse knows best’ to giving morecontrol to residents.

On my visits, it was clear that there were carehomes in both countries that were trying todeliver relationship-centred quality. This suggeststhat relationship-centred care is not connected

to regulation but is something which providersdecide to do by choice. Unfortunately it is not possible to say whether there is morerelationship-centred quality in one country than the other as I only spoke to five providers.

So, if providers decide to deliver relationship-centred quality independently of regulation, the question is what can governments do toencourage relationship-centred quality. Theinterviews with the providers came up with fivethings to assist managers in improving quality.This help seemed to be more important to smalland medium organisations, which had fewerpeople available within their organisations towork on quality.

1. Learning and development

The managers in the study who were mostpositive about quality also looked out forinformation and inspiring ideas. They did theirown research for new ideas, including reading,attending conferences and training programmesand visiting other provider organisations. Whilelearning and information was helpful forimproving their knowledge, they were not thesource of motivation for improving quality.

2. Getting to know other managers

Managers in England talked about the benefitsof getting together with other care homemanagers, either within the same company, or inexternal groups. One manager described a localnetwork of about 25 managers where guestspresented different aspects of running carehomes. This network was seen as highly valuableby the participants, in part for the moral supportit provided:

“If you ask the managers, they say it’s been themost valuable thing they’ve ever had. And Ican’t tell you why except that they value the factthat you’ve got the opportunity to talk openly,without fear of being criticised. It’s time out, you know, ‘cos we all need that.” (Care Home Manager, Poplar, England)

In England, managers had particular praise forthe My Home Life programme (for moreinformation see http://myhomelife.org.uk),which promotes relationship-centred quality bybringing managers together for training events

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and support (61). This was also mentioned inother interviews and some people thought theprogramme should be funded by government.

There is lots of debate in previous researchabout whether not-for-profit providers deliverbetter quality than for-profit providers. My studydid not have enough providers in it to be able tosettle this question but one thing that came upis that not-for-profit providers seemed morelikely to collaborate with and support each otherthan the for-profit providers in the study.

3. Models of care

Providers in England thought that thegovernment could play a bigger part in advisingwhat models of care to adopt, for example, thebest way to look after people living withdementia. A participant from one of the industryassociations which represented smaller providerstalked about a bigger role for government totest specific models, rather than just issuegeneral guidance about quality. The participantcommented on how the sector needed a bodylike the NHS Improvement Agency to testapproaches and come up with practical help to implement them.

4. Practical interventions

In both countries, provider organisationsmentioned hands-on projects as being veryhelpful. In England, an example was regulardistrict nurse and pharmacist visits set up by a local authority and the local ClinicalCommissioning Group (CCG). In Australia,managers and staff talked about the DementiaBehaviour Management Advisory Service(DBMAS). DBMAS is a service funded by theAustralian government and is staffed by teamsof professionals who provide support bytelephone. In Australia, all the providers in thestudy had accessed the DBMAS for advice onhow to deal with difficult situations withresidents living with dementia. Hands-oninterventions like the CCG project and DBMASwere viewed by providers as more helpful thantraditional training.

5. Prizes and awards

Some providers thought that prizes and awardswere good for motivating staff. Awards were allabout rewarding individuals:

“I think it’s important that we give them thatrespect and give them the opportunity toactually recognise what they do, because carersare not good at blowing their own trumpet. […]So, it’s the staff that win the award, not theentry.”(Care Home Manager, Poplar, England)

These prize and award ceremonies and eventsare run mainly by private organisations andconnected with industry magazines andconsulting services. In Australia, AACQA itselforganises better practice conferences, training,education and state-based awards to recogniseexamples of innovative and leading qualitypractices. It was unclear whether these awardshelped to improve poorer providers or whetherawards simply served as a showcase for high-quality providers.

Conclusion

Providers cannot be focused on only one type ofquality or on one type of quality improvement.All providers must make sure they deliverorganisation-focused quality because the safetyof residents and the quality of clinical processesis so important. Providers can also focus onrelationship-centred quality and consumer-directed quality at the same time. Wealthierresidents might expect luxury accommodation if this is what they have been used to, but it isimportant that homes do not just focus onconsumer-directed quality while neglectingrelationship-centred quality.

At the end of all the interviews, I asked whatgovernments could do to help improve quality.More money was frequently mentioned,especially in England.Several people in Englandcommented on the different between howmuch money is spent on training in the NHScompared to social care.

In both countries, many saw the mainresponsibility of government was to make surethere were enough skilled workers, throughmaking sure immigration policies were effectiveand providing training and education. Bothcountries are facing chronic shortages of skilledworkers, particularly of qualified nurses (62–65).There is a need for further research on whatgovernments can do to support making surethere are enough workers.

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7 Why are the systems in England andAustralia different?

This report has identified several differencesbetween the systems in England and Australia.This final section looks at possible explanationsfor why the two systems are different.

One of the biggest differences is whetherresponsibilities are mainly held in centralgovernment (as in Australia), or whether there is a mixture in who holds responsibility fordifferent parts of the system (as in England). In England, many different bodies are involveddirectly or indirectly in quality, for example, the CQC, local authorities, HealthWatch andsafeguarding boards. This means that there ismore ‘noise’ and checks and balances in thesystem than there seem to be in Australia.

There has also been more change in the systemin England, with three different regulators since2000 and different approaches to standards and ratings. In Australia, there was virtually nochange in the system between 1997 and 2014.

One benefit of the amount of change in Englandis that it can avoid the issue of ‘regulatorycapture’, where providers work out how theycan game the system. In Australia there isevidence of this ‘regulatory capture’ and also of‘corrosive capture’ (66), where providers arguethat the regulator is not making any difference.My interviews suggested that both forms ofcapture have also been easier because providerscan lobby the government in Australia aboutmany different aspects of the system, whereproviders in England have to work with both thecentral government and local authorities – andthe local authorities pay the bills.

There have been some previous studies into whygovernments do regulation differently (67–69). I looked at these studies to see whether they

could help me explain why the systems inEngland and Australia are different.

I found three main explanations for whyregulation looks different in each country.

1. Politics and ‘never again’ events

There are lots of examples of wheregovernments have put regulation in place afterproblems have been covered in the news. Theseexamples are not just in residential care, but insectors including nuclear power, the airlines andother forms of transport. One of the mostfamous international examples is where securityregulations for flying were stepped up after the 9/11 attacks in New York in 2001 (68).Sometimes these regulations are more aboutmaking the public feel safe than about whetherthey really make any difference.

In England, there have been many changes tothe inspection system for residential care since it was first introduced in 2000. My study foundthat these changes have often been because of‘scandals’. Problems in health and care for olderpeople tend to get called ‘scandals’ once theyare covered in the news (70). Otherwiseproblems which are just as bad can happenwithout attracting much attention.

In England (but not in Australia), the changeshave been caused by scandals which have noteven been in residential care for older people.The first scandal which was mentioned in theinterviews in England was at Longcare in the1990s, where adults with learning disabilitiesexperienced awful abuse, including sexualabuse. More recently, the biggest influence onhow inspection works in England was a scandalat Mid Staffordshire hospital, often referred to

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as the ‘Mid Staffs’ scandal. An enquiry intoproblems at the hospital found many examplesof poor care and people dying unnecessarily(71). Because the CQC is responsible forinspecting all types of care, including generalpractice doctors, hospitals, dentists, residentialcare and care provided in people’s homes, thisenquiry had a major effect on what the CQCdoes in other areas, including residential care for older people.

People I interviewed said that these scandalswere a big influence on regulation in Englandand that this led to ‘fads’ in how inspectionworked. One participant told me that politicianstended to get too involved:

“We’ve had an unfortunate history in Englandand the UK, of playing with regulation – it’sbeen a bit of a political football I think – so well-intentioned, but the politicians can’t seem toleave it alone.”(England, industry association, P5)

The situation was very different in Australia, at least until very recently. There has been anabsence of major scandals in the news inAustralia since the Giles Report. An exceptionwas the ‘Kerosene Baths’ incident, where ahome in Victoria was closed down in 2000 afterolder people in the home had been given bathsof diluted kerosene to treat scabies, and one ofthese people had died (72, 73). But even thisscandal did not lead to any major changes in theaccreditation system in Australia. This situationchanged dramatically recently (after I finishedthe interviews for this study) when problemswere uncovered at the Oakden Older PersonsMental Health Service in South Australia (7). Thistriggered the Carnell-Paterson Review of theregulation of quality in aged care in Australia(46). This was followed by an exposé into agedcare by the Four Corners TV programme (similarto Panorama in the UK) and in response thegovernment announced a Royal Commissioninto aged care (74).

When compared to England, there has also beenmore cooperation (or ‘bipartisan support’)between the political parties in Australia aboutmaking changes to residential care. This isbecause both the parties are afraid of what cango wrong in residential care, something which isseen as a continuous risk:

LT: But all through all of [the Aged Care ReformStrategy], there seems to have been bipartisansupport. It seems to be one policy area that isn’tvery contested. […] Why is that?

“Well, I think people understood, one: it was a –because aged care is a headline waiting tohappen.”(Australia, government, P7)

2. The power of organisations

Researchers who have studied regulation beforesay that the biggest influence on how regulationworks is the power that businesses have overgovernment (75, 76). Some researchers havedescribed how this has also happened inresidential care (15, 77–79).

In England and Australia, the businesses whorun care homes have different levels of influenceover the government, with businesses inAustralia seeming to hold more sway thanbusinesses in England.

One of the reasons for this is that in Australia,the federal government in Canberra looks aftereverything to do with residential care, fromdeciding who can open care homes, to payingfor residents’ care, to inspecting the care homes.This means that it is easier for businesses to‘lobby’, or try to influence, politicians and theDepartment of Health because everythinghappens in one place. And because theDepartment of Health is the part of governmentwhich pays for the care of residents, carecompanies have very strong reasons to try toinfluence it.

In England, it is much more complicated toinfluence the government about what happensin residential care because responsibilities are sospread out. The central Department of Healthlooks after policy and the CQC looks afterregulation but everything else is looked after by152 local councils. This makes it very difficult forbusinesses to have influence over every part ofwhat the government does in residential care.

There is also a difference in how well companieswork together to influence the governments ineach country. Residential care businesses inAustralia are much better organised as a groupthan in England and more companies appear tobelong to industry associations. There are three

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main associations which represent carecompanies in Australia, as well as associationsthat look specifically after the interests ofreligious organisations. It was not possible tofind out how many care providers were part ofthese groups, but it seemed to be much morecommon than in England. In England there arefour national associations that represent careproviders, but membership is thought to bemuch lower than in Australia. There are manylocal associations in England because manybusinesses have either one or a very smallnumber of homes often based in just one or two council areas.

In Australia, another important group is theNational Age Care Alliance, referred to as‘NACA’. NACA was set up following theKerosene Baths incident to have more influenceover government policy. In 2018 it has 50members*. All the members are nationalorganisations which in turn look after othergroups, for example, providers, residents anddifferent types of care professionals. Thegovernment gives money to NACA and asks forhelp from its members on developing policiesabout residential care.

In England, the closest thing to NACA is theCare Provider Alliance (CPA). This was set up in 2009 to represent residential care providers. It has eleven members, all of which look afterthe interests of different groups of providers**.However, it does not have much money or anypermanent staff and this means the CPA cannotinfluence the government in England in the wayNACA can in Australia.

Another difference between the two countries is the type of organisation speaking up for olderpeople. In England there are many organisationswhich say they represent older people and whichoffer practical advice. There are also severalorganisations in Australia, but the mostinfluential one is the Council for the Ageing or ‘COTA’, an organisation which tends torepresent wealthier individuals, rather than thewhole cross-section of older people, andparticularly ‘low means’ residents.

The lack of representation of the voices of allresidents might be partially due to reforms put in place under the Howard Government, forexample, through the defunding of theCombined Pensioners and SuperannuantsAssociation (CPSA), an organisation whichrepresents less wealthy pensioners. Also, runningup to the 2011 Inquiry by the ProductivityCommission, the concept of the consumer waspromoted by key influencers, most notably, IanYates of COTA and Glenn Rees, formerly of theDepartment of Health and Alzheimer’s Australia,and also, for example, by Mark Butler, formerMinister of Aged Care. The frustration of one ofthe smaller user and carer organisations aboutthe lack of representation of less powerfulconsumers was clear.

3. The influence of individuals

So far, this chapter has looked at the role of‘never again events’ and the influence of interestgroups in how regulation is designed. However,these factors do not explain the main differencesbetween the two systems, namely the role ofhuman rights-based approaches in England, andthe importance of the consumer and markets inAustralia.

England has taken a human rights-basedapproach to quality with a high level of stateinvolvement, while Australia sees quality assomething which can be tackled by creating‘consumers’, by giving people choice andcreating a market for care.

Human rights have not always received a lack ofattention in aged care in Australia. In the 1980s,a human rights lawyer, Chris Ronalds, was askedto look at resident rights in the sector (80). Herreport led to the drawing up of a Charter ofResidents’ Rights and Responsibilities and theset-up of three support programmes forresidents and relatives: the Aged Care AdvocacyProgram, the Community Visitors Scheme andthe Aged Care Complaints Scheme. However,my interviews and visits suggested that theCharter, along with the Aged Care AdvocacyProgram and Community Visitors Scheme,appear to have lost influence.

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* www.naca.asn.au/about.html

** www.careprovideralliance.org.uk/list-of-members.html

Another explanation for this difference is that there are individual people or ‘policyentrepreneurs’ who have had a strong influence.Previous studies have looked at the importanceof specific people in influencing how regulationworks, referring to them as ‘policyentrepreneurs’ (81, 82). In England, intervieweesspoke frequently of the influence of twoindividuals, Denise Platt (the Chairman of CSCI)and David Behan (the Chief Executive of CSCIand eventually the CQC), in making the rights ofthe individual the most important part of quality.

One possible explanation for how the system isdesigned in Australia could be the turnover in

public servants in Canberra (83). One formerpolicymaker commented on how Australiandepartments tend to look to consultants foradvice and problem-solving. Current staff in thegovernment commented on how little time theyhad to conduct research and prepare policypositions. Stepping into the gap are the CEOs of provider organisations in Australia who havetaken on leadership roles in many of the groupslooking after policy for the government. InAustralia, virtually all the participants in thestudy highlighted the influence of Ian Yates, theChief Executive of COTA, in all areas of agedcare policy and particularly in the 2012 reformsin aged care.

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