When the Care Quality Commission (CQC) introduced changes and additions to the Key Lines of Enquiry (KLOEs) and prompts last November, there was a sharp intake of breath across the sector. How would these quite bold changes to the way care quality is measured ripple throughout the sector?
The CQC changes
The new KLOEs and prompts involved greater emphasis on:
• Sharing of information.
• Use of best practice.
• Security of records.
• The Equality Act.
• End of life care.
• Use of technology.
• Learning from mistakes and improvements.
• How services evidence improvement.
We’ve had twelve months now for the changes to be implemented and over that period, we’ve noticed some distinct patterns emerging. Our recent CQC inspection support reviews have revealed changing patterns in a number of areas. Overall, higher numbers of ‘Requires Improvement’ and ‘Inadequate’ ratings have been recorded. This is unsurprising, as the number of prompts has increased whilst the assessment threshold has remained the same.
From our observations and audit findings, we see the main areas of difficulty being:
|Our observations in practice||Suggested remediation|
|Insufficient robustness within recruitment procedures – inconsistent and incomplete background and DBS checks. This may signify increased pressures on care providers to maintain staffing levels in the face of high staff turnover.||Create a checklist detailing all the pre-employment checks required and a strict ‘fire-break’ system that ensures you cannot confirm an appointment until all checks are complete. This could be as simple as a ‘prospective candidate’ and a separate ‘successful candidate’ spreadsheet. The pre-employment checklist must be complete before anyone is moved from prospective to successful, and job offers can only be made to people on the successful spreadsheet.|
|Gaps in staff management – we see lack of regularity, depth and effectiveness of appraisals and supervisions. In addition, training is often out of date and/or not recorded accurately. Both of these areas could result in a ‘Requires Improvement’ rating under the new KLOEs of ‘safe’ and ‘effective’.||An effective audit system is key to maintaining compliance in these areas. Audits highlight where practices are falling short of intended quality standards. Importantly, the audit should result in a summary report and action plan being developed – often we see audits being seen as an end-point in themselves.|
|Lack of documentary evidence – we see situations where the quality of care delivery is very high, but the CQC rating is threatened by a lack of record-keeping and evidence. CQC inspectors are largely evaluating the care records rather than the actual care itself, so this is a real threat.||Staff training and routine feedback at supervisions and staff meetings is important in reinforcing the importance of diligent record keeping. At the risk of sounding old-fashioned and matronly, strong and effective quality leadership from the Registered Manager is central to maintaining standards.|
To take away
It is important to point out that these are not observations about the sector as a whole, but about why some providers face problems with their CQC inspections. These issues relate to the governance of care. This may reflect demand challenges or under-resourcing within the system. However, an important ‘take away point’ for all providers is that, as far as CQC compliance is concerned, effective care management systems and practices are equally as important as high-quality, hands-on care delivery.