National Care Standards Review: Consultation Analysis

4 A New Structure For The National Care Standards

Background

4.1 The Scottish Government proposes a new structure for the National Care Standards which makes it easier for those receiving care to understand what to expect, and helps service providers deliver high quality care more easily. Under this model, overarching quality standards, based on human rights law and standards, would set out the essential requirements that should be core to any service such as dignity, equality, fairness, respect, the best interest of the child and children's evolving capacities. They would describe elements of a quality care experience rather than requirements that are specific to a particular service type.

4.2 A general set of standards would sit below the overarching quality standards and cover areas relevant to all health and care services, for example, participation, quality assurance and improvement, personalisation and health and wellbeing. These general standards would set out both the essential requirements which anyone using a service can expect and the aspirational elements which promote improvement.

4.3 A suite of specific standards would sit underneath the general standards and would apply to particular groups of people or particular types of service.

4.4 It is proposed that there would be clear links between the three tiers to show how the overarching quality standards guide the way services are delivered. The Scottish Government's aim is to simplify, align and reduce overlap whilst ensuring the standards drive improvement.

Question 2a): Do you agree that overarching quality standards should be developed for all health and social care in Scotland (Yes/No/DK)

4.5 439 respondents (92% of all respondents) provided a response to this question. Of these, 390 (89%) agreed that overarching quality standards should be developed for all health and social care in Scotland. 23 respondents (5%) disagreed, 2 respondents had mixed views, and 25 respondents (6%) did not know. Significant amongst those opposing the proposal were six day care providers (over one-third of all day care providers) and ten individual respondents. Four private sector bodies, two voluntary sector respondents and one housing association also disagreed with the proposal.

Views in favour of overarching quality standards being developed for all health and social care in Scotland

4.6 In addition to most respondents providing general, broad support for the proposal, three specific reasons to support it dominated responses:

• Overarching quality standards will promote greater consistency between agencies in how they deliver services.
  35 respondents from a wide range of sectors highlighted this specifically. One individual respondent remarked:
  "It means that everyone who knows me should want the same thing for me".
• Everyone can expect the same level of care no matter who they are.
  33 respondents, largely voluntary organisations and individuals provided this argument, commenting that users will know what to expect irrespective of the service they are accessing or their specific needs.
• Will result in greater integration of care.

4.7 33 respondents across seven different sectors commented that the proposal was sensible in view of the current overlaps in health and social care services, with both having to work together in many cases, for example, where people have complex needs. Some individual respondents suggested that it would be artificial to maintain a separation of health and social care. One respondent (Vol) remarked that staff competencies are shared across these different services. Another (Ind) considered that the proposal would lead to more effective use of limited resources.

4.8 Three other key reasons to support the development of overarching quality standards for health and social care were put forward by fewer respondents. 17 respondents envisaged this as helping to promote a shared value base across the different domains. One respondent expressed their view thus:

"....this is essential in the light of health and social care integration legislation. Overarching quality standards will support the development of shared understanding and cultures across health and social care" (Social Work Scotland).

4.9 14 respondents referred specifically to the Public Bodies (Joint Working) (Scotland) Act 2014 and the agenda to integrate health and social care services, commenting that overarching quality standards are essential in this context.

4.10 14 respondents described how they found the previous 23 standards confusing and welcomed the proposed approach as a means of streamlining and consolidating the standards. One respondent stated:

"When I first started in my current position and looked for the National Care Standards for a Care at Home service, I found the range of different versions quite bewildering, especially when a lot of the core principles are shared by all care providers.Unifying these shared principles into overarching quality standards is a positive step that should make it easier for people seeking care and care providers alike to see the guiding principles for all care" (Assistance in Care Services).

4.11 Two further respondents (LA, Vol) were in agreement that developing overarching standards would help those inspecting services, by producing a more coherent picture nationally and reflecting the increasing integration between regulatory bodies.

4.12 A prevailing view amongst supporters was that any new overarching standards should dovetail with those which professionals already work to including those associated with GIRFEC, the Healthcare Quality Strategy, national health and care wellbeing outcomes and Standards of Care for Dementia.

Concerns over the proposal

4.13 The most commonly raised concern over the proposal (highlighted specifically by 12 respondents) was that what they perceived to be the current imbalance between health and social care with different models and approaches to outcome and risk associated with each, may work against an effective, integrated approach to standards. Several considered that it would be challenging to produce overarching, relevant standards across both areas of service without the medical model dominating. One individual respondent remarked:

"I am concerned that if there were overarching health and social care standards they would be health focused and therefore based on achieving performance standards and targets, waiting lists etc. Person- centred outcome focused quality standards may be reduced in stature and therefore may not be the main driver of service improvements or focus."

4.14 One individual respondent held an opposing view, however, envisaging that the proposal would contribute to addressing this imbalance:

"Right now there is a difference in the quality of the care between the social care and the health services, with social care being seen as the poor relation but with the health service causing the most damage. Being judged against the same standards, which the population would be aware of, would give an even playing field and allow the prioritising of funding and support for failing services."

4.15 Another dominant concern over developing overarching quality standards was that these would need to be relatively general and broad brush and that this may result in their being "dumbed down" to a level of generality which loses meaning and effectiveness. One respondent commented:

"We have concerns that a political initiative about overarching standards may result in a set of standards that are so high level and abstract that they could become impossible to meet because they will have to address so many diverse professional workstreams and care environments" (United Kingdom Homecare Association).

4.16 Four further respondents agreed that overarching standards may not be detailed enough to be enforceable or measureable. They argued that the standards would require to be written in a manner which would ensure genuine regulatory impact.

4.17 Other arguments and cautions against the proposal were expressed each by only a few respondents:

• One size does not fit all and standards should be tailored for each sector (children and adults were identified as different sectors in this respect).
• The previous standards were not overly complicated and the proposal may well confuse rather than simplify.
• Current standards work well and there is no need to change.
• Even with overarching standards, there will be little sign of joined-up thinking between different care services.
• The more tiers of standards which are produced the greater the more likelihood that they will be ignored.

Other comments

4.18 Ten respondents commented on terminology with several recommending that the word "standards" be replaced with words such as "principles", "duties" or "framework", to reflect their view that these are not actually standards per se but more an ethos and approach.

4.19 Three respondents requested a definition of what is meant by "service". One (Reg) asked for clarity on the meaning of "social care" which they argued could mean different things across different local authorities.

4.20 One individual respondent perceived the proposal as positive in contributing to common terminologies across health and social care services.

4.21 One respondent (Rep) sought more information on the precise relationship between the proposed three tiers of standards.

Question 2b): Do you agree that overarching quality standards should set out essential requirements based on human rights? (Yes/No/DK)

4.22 434 respondents (91% of all respondents) provided a response to this question. Of these, 398 (92%) agreed that overarching quality standards should set out essential requirements based on human rights. Six respondents (1%) disagreed, 2 respondents had mixed views, and 28 respondents (6%) did not know.

Views in favour of the proposal

4.23 Many respondents referred to arguments in favour of human rights-based standards which they had documented in response to question 1. Amongst those respondents who provided clear reasons in support of the proposal in question 2b), the most common view was that human rights are generally applicable across different services and different sectors of users. Basing the overarching quality standards on human rights was seen as a way of making expectations clear for both service user and provider, and providing re-assurance of this to the user. A few respondents commented that a human rights-based approach is wholly compatible with the current person-centred approach. One respondent (Ind) remarked that as Scotland becomes more diverse in culture, it is important to re-emphasise underlying principles of Scotland's public services.

4.24 A recurring theme was that overarching standards based on human rights will lay the foundation and baseline against which other standards can be benchmarked.

4.25 Two voluntary organisations agreed that the proposal will be important in leading change. One commented:

"A focus on human rights at this overarching level could positively impact on the purpose and mission of each discrete and individual organisation and service, whatever the speciality" (Who Cares? Scotland).

4.26 Two respondents (Rep, Vol) argued that the proposal does not go far enough, and standards for each proposed tier (not just the top tier) should be grounded in human rights. They argued that this would help to translate abstract human rights into meaningful ways of working on the ground.

Views on development and implementation of overarching standards based on human rights

4.27 Some respondents expressed views on how best to develop and implement the overarching standards. There was a call for use of consistent terminology between the standards and human rights information in order to avoid confusion. One voluntary organisation recommended that the quality standards be co-produced with service users to ensure these are meaningful and enable users to exercise their rights proactively.

4.28 A common theme, emerging from six different sectors, was that the service delivers should have assistance and training to help them to understand how human rights-based quality standards should be manifest in their daily working practices. One idea was for good practice to be promoted and publicised:

"We would like examples of good practice 'sector leaders' to be highlighted and that this can give inspiration to other less well performing services to aspire to improve" (Healthcare Improvement Scotland's Public Partners).

4.29 Some respondents felt that the standards would need to be more specific in identifying more precisely the implications of their human rights grounding. For example, supporting those with incapacity to make decisions affecting their care; providing BSL interpreters, access to advocates, transport and other active support for people with disabilities. A few respondents called for the quality standards to be presented to users in a manner which they could readily understand and access.

4.30 Another dominant theme was that of ensuring new standards are measurable and can be used as a yardstick against which to assess level of and improvements in service provision. Various respondents emphasised what they perceived to be the importance of regulators being able to assess service delivery objectively and consistently. It was envisaged that regulators would require guidance on how to use the standards as part of their inspection regime. One individual respondent remarked:

"....we still have to make meeting those rights affordable and deliverable - and enforceable. Rights alone are pie in the sky if the related regulatory support is inadequately constructed."

4.31 One respondent (Vol) re-iterated a point previously made that some people subject to criminal justice measures have restricted rights, and that their particular position will need to be considered when developing and implementing the new standards.

4.32 One local authority recommended that the standards should make clear that human rights should be exercised only to the extent that one person's rights should not impinge on the rights of others.

Concerns about the proposal

4.33 A variety of concerns were raised about the proposal, with each tending to be highlighted by only a few respondents. Some questioned what individual service users would do if they felt that their human rights had been breached, with suggestions that guidance is made available on how to assess this, and steps to take if human rights are not upheld.

4.34 Another concern was that human rights-based standards would replace commonsense with regard to delivering quality services, which might lead to curtailed initiative, individual decision-making, risk-taking and good leadership.

4.35 Other queries and concerns were:

• Why would the standards be based on human rights and not equality rights? Both already feature in legislation governing service provision, yet only human rights feature in the proposals on new care standards (Vol).
• The human rights focus may reflect minimum standards which is at odds with aspirational levels of provision (Rep).
• What are the implications for costs? What will be the situation if there are insufficient resources to implement human rights-based quality standards? (HA).
• Not all services deal with all people, for example, some focus on specific age groups to the exclusion of others. How would this reconcile with standards based on non-discriminatory practice? (Priv).

Views of those opposed to the proposal

4.36 Amongst the very small minority of respondents who disagreed with the proposal the following reasons were provided:

• Not necessary as Scotland is already signed up to the convention of Human Rights.
• There should be responsibilities to accompany the rights.
• The human rights-base makes the standards too vague.
• Contributes to unnecessary bureaucracy.
• Overarching standards should be clinically and operationally justifiable, deliverable and sustainable within the resources available. Human rights should provide only an adjunct rather than a dominant part of this.

Question 2c): Do you agree that the current National Care Standards should be streamlined and a set of general standards developed that would sit below the overarching standards and apply to all services? (Yes/No/DK)

4.37 423 respondents (89% of all respondents) provided a response to this question. Of these, 349 (82%) agreed that the current National Care Standards should be streamlined and a set of general standards developed that would sit below the overarching standards and apply to all services. 28 respondents (7%) disagreed, nine respondents (2%) had mixed views, and 37 respondents (9%) did not know. Amongst the 28 respondents who disagreed, were nine individuals, with the remaining opponents spread across six different sectors.

Views in support of the proposal

4.38 The prevailing view amongst supporters of the proposal was that streamlining the standards would help to create a simplified structure of standards, which will be easier for service user and service deliverer to understand and access. A typical remark was:

"Alzheimer Scotland supports the proposed structure of the National Care Standards and believes that the tiered approach of standards is a useful way of distinguishing between the different intended outcomes of each, as well as making it clear which standards apply to each service."

4.39 A recurring view was that streamlining would reduce what some perceived to be the current duplication in standards, by amalgamating common themes which cross-cut health and social care services. Some described the proposed structure of standards as logical, providing a natural flow from the overarching vision to more specific issues. One respondent described this progression as a "golden thread" (CHCP).

4.40 The joined-up potential of the proposed structure was viewed as particularly helpful in a range of scenarios:

• where users are transferring from one service to another, for example, a young person transferring between children's and adults' services;
• for first-time service users who are unfamiliar with the system and do not yet know about their rights and entitlements;
• where someone uses more than one type of service or a person delivers care across more than one type of service.

4.41 Despite offering general support to what was proposed, many respondents argued that in addition to common standards, there was a clear need for more specific, tailored standards dedicated to particular sectors. Most commonly identified in this respect were children's services, although others mentioned older people's services and mental health services.

Concerns over the proposal

4.42 The most common concern (amongst supporters and opponents of the proposal alike) was that streamlining may result in standards that are so vague and general as to be rendered meaningless and unaccountable. Concerns were raised that important technical and specific safeguards particular to certain groups could be lost in the rationalisation of standards. The needs and rights of minority ethnic service users was one example provided. Some considered that common areas between services may be fewer than suggested in the consultation.

4.43 Many respondents emphasised that they supported the notion of streamlining, but were concerned that what was suggested may result in a framework of equal complexity to the status quo, thus inadvertently running contrary to the intention of simplifying. A typical remark was:

"There is a real danger that, in the pursuit of streamlining the system, too many tiers are created which could be confusing for those who use services" (Barnardo's Scotland & Children1ST).

4.44 Some organisations queried whether it was necessary to have three tiers in the new framework, or whether the proposed top two tiers could be amalgamated. If kept separate, some called for greater clarity and distinction between them. One respondent commented:

"....work would need to be undertaken to ensure that the 'second tier' general standards are sufficiently different from the over-arching standards based on human rights. For example, themes such as participation and personalisation are not wholly different from the type of over-arching standards that are grounded on human rights principles. It may therefore be an unnecessary complication and as such a single structure of national care standards with specific standards sitting below these may be more appropriate" (COSLA).

4.45 A small minority of respondents were more strongly opposed, providing their view that what was proposed appeared to be a replacement of one complex framework with another. Typical remarks included:

"PAMIS is unsure about the benefits of a three tier approach and we are concerned that it will cause confusion. On a practical level care and health providers are going to look at the set of standards that pertains to the aspect of care that is relevant to what they deliver."

4.46 Other concerns were expressed by only a few respondents:

• The more general the standards the more open to individual interpretation they will be.
• In striving to find commonalities between services the standards should not lose sight of the central focus on the care of the person.
• General standards should not result in losing the flexibility to accommodate the wide range of circumstances across different services.
• The new standards need to align with existing legal requirements and targets or this will result in confusion and duplication.
• The case has not been made strongly enough for revising the current standards and perhaps these should simply be reviewed and streamlined, rather than creating new ones.
• When standards are too generic this can result in producing misplaced expectations on some services.

Requests for more information

4.47 Ten respondents requested more detail and subsequent debate on the content of the proposal before giving judgement on it. In particular, some wished to see the balance of commonality of issues against specifics relating to particular areas and issues.

4.48 Five respondents requested illustrative examples and guidance to illuminate how the standards would apply in a range of circumstances.

Question 2d): Do you agree that the current National Care Standards should set out essential requirements and aspirational elements? (Yes/No/DK)

4.49 419 respondents (88% of all respondents) provided a response to this question (although several others provided related commentary but did not indicate clearly whether they agreed or disagreed with the proposal). Of these, 315 (75%) agreed that the current National Care Standards should set out essential requirements and aspirational elements. 51 respondents (12%) disagreed, 11 respondents (3%) had mixed views, and 42 respondents (10%) did not know. Almost half of those opposing the proposal were individuals; 12 were voluntary organisations and the remaining opponents were spread across five different sectors.

Views in support of the proposal

4.50 The most common view in support of the proposal was that setting out clearly the essential requirements in additional to aspirational elements of standards would help to drive improvement and increase overall quality of care. Those expressing this view explicitly were largely voluntary organisations and individual respondents along with six professional representative bodies and five representatives of the NHS. A recurring view was that detailing essential and aspirational aspects would provide services with helpful signposting for their "journey" to improved standards of care and prevent them stagnating at the lowest acceptable level. Typical comments included:

"There has to be essential minimum standards and these need to be clear to ensure that they are understood and adhered to. Aspirational standards give people the opportunity to think about how they can improve and do this in a creative way" (Individual respondent).

"The Society welcomes the suggestion of introducing essential elements which should be the hall mark of any care or support service. Introducing aspirational elements if done in a constructive and assets based way could help to raise standards, support continuous improvement and could help to transform organisational cultures" (British Psychological Society).

"This will give a clear indication of the difference between satisfactory and excellent performance. Including both will provide a clear pathway for health and social care services to develop and incorporate the principles of performance and continuous improvement to service delivery" (NHS Health Scotland).

4.51 One respondent (Ind) commented that this approach already works well in the education sector. Others (Vol, LA) predicted that introducing essential and aspirational elements of standards would encourage services to self-evaluate.

4.52 Four respondents recommended that within a framework of both essential and aspirational elements, it will be important to focus on achieving the essential aspects first and foremost. One individual respondent presented their view thus:

"....what is essential should not be held back by what would be desirable. Once the essential goals are achieved, more efficient focus can be given to the desirable but non essential elements".

4.53 A further four respondents including three local authorities, argued that essential and aspirational elements should form part of the overarching tier of standards rather than the second tier.

4.54 It was commonly felt across several sectors that in order to be meaningful, the aspirational elements should be realistic and achievable over time, and not just a "wish list". For some, this meant that additional resources would need to be put in place to support the drive towards attaining the aspirational level of standards. Two respondents (Vol, Ind) suggested that attaching a timeframe to the aspirational elements might focus services on the need to achieve these, and make them more meaningful.

Concerns over the proposal

4.55 Many respondents (both supporters and opponents) raised concerns over aspects of the proposal. The most common concern was that introducing essential and aspirational elements to this tier of standards could be overly complex and may detract from the key message and expectation that general standards should reflect high quality in themselves. Some felt that whilst it was helpful to express aspirational levels as something to aim for, this could be done more effectively by separate illustrations of good practice, or recognition of excellence, outwith the care standards framework. Comments included:

"ENABLE Scotland believes that all of the essential requirements for a good quality health and social care support service should be aspirational for the achievement of the individual's person centred outcomes.

In our experience, there is an issue already with a lack of consistency of approach to grading, and we would fear that adding another layer of complexity to this would be unwelcome, and more worryingly, create an opportunity for service providers to seek to deliver only the 'essential' and not the 'aspirational' elements of a good quality service in order to pass the Inspection process (ENABLE Scotland).

"We have some concerns that if we are looking to improve standards of care by aspiring to "best practice" that we do not divorce best practice from what are considered essential requirements. Often the essential elements focus on process and factors that can be counted and may not be linked with achieving good outcomes which best practice aspires to achieve" (North Lanarkshire Council).

4.56 Amongst those recommending simplification and restriction to essential requirements only were several who referred to what they considered to be effective sliding scales and grades used in inspection and regulatory frameworks which they felt recognised and encouraged improvement and best practice, without the need for setting aspirational targets.

4.57 Another common concern was that including both essential and aspirational elements within the general standards could result in an ambiguous inspection regime in which increased emphasis will be placed on individual inspectors' value judgements. Clarity was called for over the status of aspirational elements and whether these would fall within the scope of inspection. Some respondents argued that they had no place in a compliance framework and would not be enforceable. Comments included:

"We strongly believe the standards should set out essential requirements as they will be 'policed', and it will cause confusion if 'aspirational elements' cloud what is vital" (Treasure Island Nursery Ltd.).

"If aspirational elements are included in Standards, what would be the mechanism for monitoring these, so that the aspiration showed some measurable progress towards being achieved? In the absence of this, having aspirations included in Standards which are then marketed to people using services as something they can use as a yardstick to measure their experience against, becomes confusing" (Befriending Networks).

4.58 One further prevailing concern was over terminology, with a recurring view that to designate elements of service as "aspirational" could give out a message that these were optional extras, not part of the general scheme of things, add-ons rather than mainstream priorities. Coupled with what many saw as a lack of regulatory requirement and incentive to achieve these, the aspirational elements were predicted to be de-prioritised by services. One respondent commented:

"we have concerns surrounding the language used in this section of the consultation. Describing requirements or components as essential and aspirational, implies that there is a minimum standard that services need to achieve and anything over and above is optional. This should not be the case; there should be considerable focus on continuous improvement, and scrutiny programmes to inspect quality standards should reflect this" (Voluntary Health Scotland).

4.59 17 respondents remarked that if aspirational elements are introduced, these will require regular review, updating and stretching as services begin to achieve them. Flexibility was called for so that innovative practices of different providers can be incorporated into the framework, but also so that differences in approach across services can be accommodated.

4.60 A view expressed explicitly by 13 respondents was that only essential elements should be set out in the standards, with individual service providers left to establish their own aspirational targets, individualised and tailored for their particular circumstances.

4.61 12 respondents cautioned that services users may be confused by aspirational elements, with expectations falsely raised that these are statutory requirements to be met by service providers. One respondent remarked:

"....there would have to be a very clear understanding of how these aspirational elements were communicated to people who use services, as they may lead to unrealistic expectations on service providers which funding and commission arrangements may not allow for" (CrossReach).

4.62 Other substantive concerns expressed by only a few respondents were:

• Difficult for services to evidence that they have achieved aspirational elements.
• Would the aspirational element of service provision be eligible for funding?
• Could create complexities over procurement of services - at what level of expectation would procurement take place and be assessed, essential or aspirational?

Question 2e): Do you agree a suite of specific standards are developed for particular aspects of care, circumstances or need? (Yes/No/DK)

4.63 412 respondents (87% of all respondents) provided a response to this question (although several others provided related commentary but did not indicate clearly whether they agreed or disagreed with the proposal). Of these, 327 (79%) agreed that a suite of specific standards should be developed for particular aspects of care, circumstances or need. 23 respondents (6%) disagreed, five respondents (1%) had mixed views, and 57 respondents (14%) did not know. Those opposing the proposal were largely individual respondents and voluntary organisations and groups.

4.64 Overall the responses to this question revealed some confusion about the topic and the examples provided in the consultation document, which resulted in a plethora of responses from individuals listing aspects of care they appreciated, and other areas they wished to see improved and prioritised (e.g. seeing the same professional consistently over time; being listened to; being given meaningful things to do; prompt access to services when needed).

4.65 Amongst the few substantive reasons for supporting the proposal, the following emerged most frequently:

• Specific standards are more reflective of specific needs and are more tailored to particular circumstances.
• Specific standards are helpful for service provider and user alike. One respondent commented:
• "Clarity and specificity are necessary if the new standards are to be more manageable and accessible for practitioners than has been the case to date" (Educational Institute of Scotland).
• Specific standards help the inspectoral regime by being more measurable and focused than general standards.
• Standards based on aspects of care, circumstance or need encourage cross-cutting support and liaison between providers and serve to limit gaps in provision.

4.66 Other reasons provided by one or a few respondents for supporting the proposal were:

• The specific standards could potentially apply to unregulated providers too.
• A need to ensure safety and wellbeing.
• Able to signpost to relevant legislation and guidance such as the Dementia Standards and GIRFEC.

4.67 The seven examples provided in the consultation document generated much debate. Whilst some respondents welcomed a specific standard relating to children and young people, others called for a separation of infants from children, or young people as a distinct standard. Other recommendations were for standards relating to:

• looked after children
• children in foster or adoptive care
• children in need
• children and young people at points of transition, e.g. between children's and adults' services

4.68 Several respondents advocated specific standards for adults; vulnerable adults; or older adults. Two remarked that older people as the largest group of care recipients and should therefore merit a standard dedicated to them.

4.69 Whilst one respondent (Vol) specifically welcomed the proposed standard on nutrition for older people, four others requested that this be broadened to nutrition for all.

4.70 The proposed standard on people in the criminal justice system received very little comment, the few respondents referring to this, in favour.

4.71 Six respondents welcomed the proposed standard on supporting people who use medication, although one dissenting view was that most people who are cared for are on medication and this topic would be better placed within a general standard.

4.72 There was support for including infection control in communal settings within the specific standards, largely from individual respondents. Likewise, a few respondents expressed their support for including people with learning disabilities, although one (Reg) recommended threading this topic through other standards rather than focusing on it in isolation.

4.73 Five respondents referred specifically to the proposed specific standard on palliative care, with all in support.

4.74 Many respondents recommended additional standards which they wished to see included in the final suite (listed below from most to fewest mentioned):

• dementia
• mental health
• general support services such as housing
• sensory impairment/loss
• communication issues
• addiction services
• complex needs
• non-medical interventions (such as psychological therapies)
• minority ethnic communities
• restraint for children/young people in distress
• people in the community
• safety
• control of diabetes
• homelessness
• carers

4.75 A small number of respondents urged that specific standards focus on health and social care settings such as hospital; day services; residential/care homes; and own home.

4.76 Some felt that particular themes should run through whichever standards are finally adopted: adult and child protection; human rights; safety, hygiene and respect.

Concerns about the proposal

4.77 Although there was much support and enthusiasm for the proposal, there were also many concerns raised by supporters and opponents alike. The most commonly raised concern (46 respondents) was that this approach could result in a myriad of standards to cover the diverse range of care, circumstances and need existing, thereby negating the overall aim to streamline the current standards. Comments included:

"A common sense approach would be needed to make these simple as there may be a tendency to create complex systems which are difficult to implement. It is unclear whether the specific standards will be based around place, client type, circumstances or a combination of all which may not result in the streamlining of the present standards and publications and ultimately non achievement" (Perth and Kinross Council).

"....there is risk of the end product being no less, or even more complex, than existing standards" (Social Work Scotland).

4.78 Another prevailing theme was that specific standards such as these which focus on particular characteristics of a person and specific services, do not align with person-centred or human rights approaches, which focus on the whole person and their overall needs. Many respondents provided examples such as that of a disabled child with learning disabilities and physical impairments, who is in need of a range of support and will not fit neatly into one or two of the specific standard categories.

4.79 A recurring view was that the examples provided are confusing in that they reflect a mix of aspects of care, groups and services, with approaches from the general to the specific. Some respondents called for greater consistency in the nature of the specific standards. One respondent remarked:

"The topics included for illustration are not like-for-like, some refer to groups of people others to specific issues such as nutrition. We feel that a subject such as nutrition is directly related to the overarching human rights aspiration and should therefore come under a general quality standard. Many of the people with learning disabilities that we support would come under several of the proposed headings. We are concerned that a suite of many different issues will cause confusion; running the risk that groups of people may not be included in important standards" (Real Life Options).

4.80 Whilst five respondents expressed their view that the proposed standards may not be specific enough to be useful, others called for broad, flexibility in the standards so as to avoid prescription which some perceived to be incongruous with self-directed support and personalisation. One respondent remarked:

"We do not want to create an inflexible regime that risks limiting innovation" (CCPS).

4.81 A small number of respondents highlighted what they saw as the importance of developing the specific standards in collaboration with users, carers, service providers and the third sector.

4.82 16 respondents did not see the need for the third tier of standards, with most considering that only overarching and general standards would be needed within the new framework. Some envisaged the specific standards would be better packaged as guidelines or protocol which could be referred to in the overarching and general standards. Two voluntary sector respondents cautioned that the specifics of the third tier could detract from the important, broad standards presented in the overarching tier.

4.83 Three respondents expressed concern that the more specific the standards, the more likely they will need regular updating.

4.84 Two voluntary sector respondents perceived the word "suite" to be meaningless for most readers, and preferred instead "guidelines" or "indicators".

Summary of main findings

• There was much support for the proposal for overarching quality standards under the new National Care Standards structure.
• Most respondents wished to see the current National Care Standards streamlined and a set of general standards developed that would sit below the overarching standards and which would apply to all services.
• A common concern, however, was that streamlining may result in standards that are too vague to be of use.
• The majority view was in favour of the National Care Standards setting out both essential requirements and aspirational elements, although some respondents were concerned that this may be too complex.
• Much support was expressed for the development of a suite of specific standards for aspects of care, circumstances or need.