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The Prerequisites and Practices of Auditing Residential Care: On the Licensing and Inspection of Residential Homes for Children in Sweden
Stockholm University, Faculty of Social Sciences, Department of Social Work.
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this dissertation is to describe and analyse the prerequisites and practices of auditing Swedish residential care for children. Residential care is a complex intervention provided to children in vulnerable life situations. The care is extensively delivered by private providers and shows difficulties in demonstrating clearly positive treatment effects. Licensing and inspections are policy instruments to address alleged quality problems in decentralised and marketised welfare services. However, in research there are mixed opinions on the ability of audits to generate improved service quality.

The dissertation consists of four papers exploring central facets of the audit system. The empirical material is based on interviews (n=50) with inspectors and residential staff, documentation (n=286) in terms of guidelines and license/inspection decisions and observations (n=12) at inspection-related events. Each paper includes a unique set of data.

Paper I analyses the controls that private residential homes undergo prior to their entry into the market. The results show that a majority of applicants are granted a license and that the controls do not reduce the need for ex post control. There is limited guidance on care content and research evidence is weakly incorporated in the controls. Overall, the state exerts limited influence over the composition and professional development of the care market.

Paper II explores the operationalisation process of care quality in inspections. The results show that the standards display a marked variation and there is no differentiation between different residential homes. In general, the standards focus on reducing malpractice and not maximising care quality. In practice, the inspections are often discussion-based and standards relating to work with children are often indistinct.

Paper III analyses how inspections are perceived by representatives from residential homes. The results show that inspections induce reflection and to some extent shape the administrative parts of care, but also that it is difficult to discern the actual impact of the inspections on the work. The inspections appear to bring a degree of stability and legitimacy to the work, but there are sometimes tensions between standards and professional judgment.

Paper IV studies the influence the inspection process grants children in care. The results suggest that different inspectorial rationales (regulative, supportive and protective) may influence the agency children exert and that it is difficult to allow children’s views to have a substantial impact on the process. Overall, there tends to be a gap between what the children find important and what the audits can address in concrete terms.

The theoretical ideas used to analyse the results are derived from institutional organisational theory and the thesis on the audit society. The overall analysis shows that 1) making certain core care aspects auditable and ensuring their impact is difficult (e.g., children-staff relationships, children’s views and use of research knowledge), 2) the system has a restrained character and is in many senses associated with inconclusive formative effects, 3) the use of uniform goals does not necessarily equal a more suitable care provision and 4) the audits signify strong symbolic values. Despite the limitations, the audits may help to discipline care providers, secure a minimum level relative to the audited care aspects and induce reflection among auditees.

Place, publisher, year, edition, pages
Stockholm: Department of Social Work, Stockholm University , 2018. , p. 90
Series
Stockholm studies in social work, ISSN 0281-2851 ; 38
Keywords [en]
Child welfare, Out-of-home care, Residential care for children and adolescents, Audit, Licensing, Inspection, Quality Indicators
National Category
Social Work
Research subject
Social Work
Identifiers
URN: urn:nbn:se:su:diva-151624ISBN: 978-91-7797-135-1 (print)ISBN: 978-91-7797-136-8 (electronic)OAI: oai:DiVA.org:su-151624DiVA, id: diva2:1177723
Public defence
2018-03-09, Aula Svea, Socialhögskolan, Sveavägen 160, Stockholm, 10:00 (Swedish)
Opponent
Supervisors
Note

At the time of the doctoral defense, the following paper was unpublished and had a status as follows: Paper 2: Manuscript.

Available from: 2018-02-14 Created: 2018-01-25 Last updated: 2018-02-22Bibliographically approved
List of papers
1. Entering the Market: On the Licensing of Residential Homes for Children and Youth in Sweden
Open this publication in new window or tab >>Entering the Market: On the Licensing of Residential Homes for Children and Youth in Sweden
2018 (English)In: British Journal of Social Work, ISSN 0045-3102, E-ISSN 1468-263X, Vol. 48, no 3, p. 843-859Article in journal (Refereed) Published
Abstract [en]

In Sweden, residential care for children to a great extent takes place in a care market, and a precondition for private care providers to enter the market is a licence issued by the state. The aim of the study is to describe and analyse the regulatory conditions for and output of licensing in the market of residential care for children in Sweden. Analytically, licensing is considered a formative mechanism, which means that it shapes the development of the supply side of residential care. The empirical material consists of an analysis of formal licence decisions and interviews with inspectors managing licences. The results show that the majority of the applicants were granted a licence during the year of the study and that the licensing process consists of a few stringent standards. Further, the stringent standards are influenced only to a limited extent by knowledge generated from research on residential care and the applicants are granted a fair degree of leeway as regards how to organise the care content. The findings are discussed based on whether the licensing system takes advantage of its potential and what it may entail for the residential care market at a broader level.

Keywords
Residential care for children, licensing, quality standards, qualitative methods
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-145656 (URN)10.1093/bjsw/bcx063 (DOI)000432002200017 ()
Funder
Swedish Research Council
Available from: 2017-08-16 Created: 2017-08-16 Last updated: 2018-05-28Bibliographically approved
2. Securing the Floor but Not Raising the Ceiling? Operationalizing Care Quality in the Inspection of Residential Care for Children in Sweden
Open this publication in new window or tab >>Securing the Floor but Not Raising the Ceiling? Operationalizing Care Quality in the Inspection of Residential Care for Children in Sweden
2018 (English)In: European Journal of Social Work, ISSN 1369-1457, E-ISSN 1468-2664Article in journal (Refereed) Epub ahead of print
Abstract [en]

In many countries, inspections are employed as a central instrument to the promotion of good social work practice, but how inspections operationally should achieve this is not evident. By utilizing data from guidelines, inter-views and observations, the aim of the article is to analyze how the Swedish Inspectorate operationalizes care quality within the service residential care for children. Analytically, the Inspectorate is regarded as an open system that is receptive to different ideas of how to operationalize care quality. The results show that: a) the standards display a marked variation, change annually and are similar across all homes, b) there is a limited link to good quality care as it is defined in empirical research, c) there are several driving forces for care aspects to inspect and, in general, the distinct standards pertain to formal re-quirements, while how the care is provided is associated with more indistinct standards and d) if there is no obvious malpractice in care provided, the in-spections appear to have rather unclear formative effects. The results are inter alia discussed regarding whether inspections foster the idea that the ‘floor’ of the care is raised (i.e. securing a basic level of care) but not the ‘ceiling’ (i.e. maximizing care).

Abstract [sv]

Säkra golvet men inte höja taket? Hur vårdkvalitet operationaliseras inom tillsyn av institutionsvård för barn i Sverige

I många länder utgör statlig tillsyn ett centralt styrmedel för att förbättra det sociala arbetets praktik. Syftet med föreliggande artikel är att beskriva och analysera hur vårdkvalitet operationaliseras inom svensk institutionsvård för barn och unga. Det empiriska materialet består av tillsynsmyndighetens interna riktlinjer, intervjuer med inspektörer och observationer vid tillsynsbesök. Med utgångspunkt i institutionell organisationsteori betraktas tillsynsmyndigheten som ett öppet system som är mottagligt för olika idéer beträffande hur vårdkvalitet ska definieras. Resultaten visar att (a) de standarder som används uppvisar en stor variation, ändras årligen och är desamma för samtliga typer av institutioner, (b) standarderna har begränsad koppling till god vårdkvalitet så som det definieras inom empirisk forskning, (c) det finns flertalet motiv till val av granskningsområde och standarder för vårdens faktiska utförande är ofta oskarpa samt (d) om en institution inte avviker påtagligt från de standarder som används förefaller tillsynen ha tämligen oklara formativa effekter. Resultatet diskuteras bland annat utifrån om tillsynen bidrar till att säkra vårdens “golv” (dvs. säkerställa en miniminivå i relation till standarderna), men inte vårdens “tak” (dvs. optimera vårdens kvalitet).

Keywords
Residential care for children and youth, Audit, Inspection, Quality standards, Institutionsvård för barn och unga, Granskning, Tillsyn, Kvalitetskriterier
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-152141 (URN)10.1080/13691457.2018.1476331 (DOI)
Available from: 2018-01-25 Created: 2018-01-25 Last updated: 2019-10-14
3. Adjusting to standards: reflections from 'auditees' at residential homes for children in Sweden
Open this publication in new window or tab >>Adjusting to standards: reflections from 'auditees' at residential homes for children in Sweden
2016 (English)In: Nordic Social Work Research, ISSN 2156-857X, E-ISSN 2156-8588, Vol. 6, no 3, p. 222-233Article in journal (Refereed) Published
Abstract [en]

In recent years, state inspection of Swedish residential care for children has been reinforced. This study explores how inspections are perceived from the point of view of residential staff. The empirical material is based on interviews (n = 23) with residential staff and managers (n = 55) of residential homes subject to requirements from the Swedish Inspectorate. The material has been analysed using concepts shedding light on the different aspects of how audit affects ‘auditees’. The results suggest that inspections have mainly shaped the administrative part of care; that compliance with regulatory standards bring about stability in the work performed; that the standard-setting sometimes creates tensions between professional judgment and formal authority; and that inspections play an accreditation role for the residential homes. The implications of this are discussed, e.g. that the regulatory standards seem to target aspects of care that are alternatives to those of evidence-based practice, that general standards to some extent challenge the possibilities of organising the care according to the individual needs of the children and that the receptiveness of professionals to inspection ideas entails both possibilities and obstacles for the development of a professional field.

Keywords
residential care for children, audit, inspection, out-of-home care
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-131104 (URN)10.1080/2156857X.2016.1192054 (DOI)
Available from: 2016-06-13 Created: 2016-06-13 Last updated: 2018-01-29Bibliographically approved
4. Conditioned agency? The role of children in the audit of Swedish residential care
Open this publication in new window or tab >>Conditioned agency? The role of children in the audit of Swedish residential care
2017 (English)In: Child & Family Social Work, ISSN 1356-7500, E-ISSN 1365-2206, Vol. 22, no S2, p. 33-42Article in journal (Refereed) Published
Abstract [en]

At a policy level, governments increasingly stress the importance of children's rights and their ability to participate in decision-making in child welfare services. An example of this is that the Swedish inspectorate targeting children in residential care is required to consult children and to take account of their opinions. This paper details a study exploring the influence that the inspectorate grants children and particularly how children's views influence the inspection process. The study draws on interviews and observations of inspectors as well as an analysis of a representative sample (n = 147) of documentation from inspections performed during 2012. The result indicates different inspectorial rationales, which in turn influence the importance children's opinions are assigned in the inspection process. Moreover, the findings demonstrate difficulties in giving children's views substantial impact on the inspection process. This can be attributed to the fact that most of the regulatory quality criteria used by the authority diverge from the aspects of care that children attach most importance to. The study adds empirical findings to how the participation of children is realized during inspection.

Keywords
audit society, children’s participation, inspection, residential care, sociology of childhood
National Category
Social Work
Research subject
Social Work
Identifiers
urn:nbn:se:su:diva-124389 (URN)10.1111/cfs.12234 (DOI)000394907100004 ()
Funder
Swedish Research Council
Available from: 2015-12-21 Created: 2015-12-21 Last updated: 2018-01-29Bibliographically approved

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