Regulations should enable hospital and community settings to work together on care appraisals, says Hilary Thomas

In my attempt to familiarise myself with the various nooks and crannies of my new organisation I recently visited two residential care homes.

One was run by a hugely enthusiastic manager who in his early 20s stacked shelves for a large supermarket. In his own words, he 'couldn't get excited' about whether he sold own-brand baked beans or a named variety and decided to pursue a national vocational qualification in health and social care.

His tutor suggested he might want to become a care worker in a care home. Within weeks of appointment, he was elevated to team leader. After a period in a regional support team, where he was inspired and encouraged by several key staff, he has now returned to manage the home, all in less than five years.

I was struck by his passion, motivation and drive to make a difference. He apologised for the state of his office – though every document he showed me, be it a quarterly report or an employment record, was neatly filed on a shelf. He confessed he would rather spend time in the communal areas with the 50 elderly people in the home than sorting out his administrative tasks.

When he inherited the home it had a poor rating from the Commission for Social Care Inspection and in weeks he has raised this to average. But he is frustrated that moving to the next stage – good – seems to elude him.

I visited a second home very close by and both managers had a very low opinion of the nearby district general hospital. They each gave examples of residents who had been admitted to hospital with their skin in good condition and within days had returned with severe pressure sores.

They could cite examples where service users had returned with Clostridium difficile, MRSA, or both. Swabs performed before transfer demonstrate that the MRSA was acquired in hospital. The hospital has been invited to apply for foundation status.

In the same week, I was involved in the investigation of another home after an incident. With more than 3,000 people in our care such events are bound to happen but what was revealing - and worrying - was that the Commission for Social Care Inspection rating in this home was at odds with our own internal assessments. It was deemed good - a fact that undermined our internal credibility as we were trying to address issues.

Looking from within

My point is not that external assessments by regulators should not take place, nor that the bodies overseeing them are not competent. They have an impossible task - damned if they rate somewhere too low or too high. How can an assessment which is often based on paperwork and a few hours or days really probe beneath the surface of the culture of an organisation? The chief medical officer wants to see 360-degree appraisal, including feedback from patients, as part of the assessment of doctors for revalidation. Similarly, those who interact with hospitals and social care are given an opportunity to contribute to its assessment through surveys.

I believe that the value of our own internal evaluation, which was honest, transparent and owned by those concerned, should be used to enrich the external inspection. And that is not by taking it at face value – the way assessments are conducted, irrespective of outcome, should illuminate the ethos of an organisation.

Surely any regulator should be working with us in the process to achieve a degree of consistency and a better understanding.

Similarly, is it not valid for a hospital to comment on the condition of residents who arrive in hospital from a home, or for a home to comment on the care received by its residents? A hospital that discharges elderly patients - the most vulnerable members of society - with bedsores and newly acquired infections seems an odd choice for foundation status.

There is a richness in this internal knowledge that should not be ignored. Regulators and the regulated need to work together – the whole is inevitably greater than the sum of the parts.