In the first of two articles, Quality Compliance Systems (QCS), a leading provider of content, guidance and standards for the social care sector, spoke to Ed Watkinson, a former CQC inspector, to explore, examine and demystify the four key themes that make up the new CQC strategy. Ed Watkinson begins with the theme, ‘People and communities’.
In a bold new vision, the Care Quality Commission (CQC) has set out a strategy, which it says combines ‘learning and experience’ with ‘valuable contributions from the public, service providers’ and its partners.
The CQC says its strategy, which covers four key themes (‘People and communities’, ‘Smarter regulation’, ‘Safety through learning’ and ‘Accelerating improvement’), will be more ‘relevant’, ‘flexible’ and more ‘responsive’ to cope with the ever-increasing challenges that the social care sector faces.
The CQC also says that the new directive will ensure that it achieves its core aims – to not only ensure that social care providers deliver ‘safe, effective, compassionate high-quality care’ but that the CQC also gives them the tools to change.
Why people and communities are central to the new CQC strategy
Working with and for the local community is central to the new CQC vision. It is also vital that care services embrace three additional sub-themes that the CQC is also keen to champion. The CQC is heavily committed to banishing inequality in services and wants to see a culture of equality, diversity and human rights deeply embedded in every service in the land. Care services, if they haven’t already, need to create policies that not only ensure that their services are promoting these key values, but that they can present evidence of the fact that they are central to the culture of the service. That means being aware of the Equality Act and of people’s protected characteristics. Services also need to demonstrate, through their assessment and care planning processes, that a culture of diversity and inclusion is present. If you’re reading this as a Registered Manager, ask yourself – are you aware of people’s individual needs and do you and your staff value and respect them?
Outstanding providers, who have worked hard to instil a person-centred culture of care in their service, will create plans that reflect the personal history and beliefs of each service user.
The care plans that social care providers create with service users, should be a reflection of the policies, procedures and safe culture that form the foundation blocks of the service. As soon as policies change, which has happened a lot during the pandemic, Registered Managers using the QCS system will receive instant updates, which aim to ensure that they are never behind the regulatory curve.
Having created a COVID-19 Resource Centre during the pandemic, QCS has become one of the leaders in providing best practice content, which is designed to help front line mangers and their staff build person-centred cultures within their services.
Secondly, the CQC has pledged to pay much greater scrutiny to local areas, systems and also local ancillary services. On one level, this is an attempt by the CQC to promote greater cost efficiency models, while on the other hand, the regulator is striving to nurture a rich culture of collaboration, co-production and co-design within services.
In doing so, the CQC will be much more focused on local areas than it will be on individual providers. What do I mean? Well, take a care home operating in a particular location for instance. Let’s imagine that it’s a residential home in Bedford. The CQC is not going to look at the home as single entity, but it will see it as a part of a wider, more holistic and integrated service that in the CQC’s words ‘builds care around the person’. The CQC will therefore look for evidence of collaboration on many different levels. It will closely observe how care staff interact with residents. It will want to see that there is fruitful partnership between care staff and management and a good understanding between managers. But at a much deeper level, it wants to know that between the care home, local authority, primary and secondary care services, and other local voluntary or community services in Bedford, there is a shared understanding of what the local community wants and needs.
The CQC also wants to gain an accurate understanding as to how a particular home supports the bigger picture. It wants to see whether the care home truly understands the issues and pressures experienced in that particular area, how it is coping with them and suggest ways in which it can improve outcomes for providers.
I think one of the key differences between the new strategy and the old one, is that the CQC is now being much more objective about what ‘quality care’ should mean to people. In this sense, the CQC is looking to alter its regulatory role and become more of a ‘co-ordinator of resources’ and guide services towards tools which they can use to aid and accelerate improvement. I believe this represents a profound sea-change compared to previous strategies, where many providers felt – rightly or wrongly – that the CQC was playing the role of a pure regulator focused on enforcement and not working with individual services to drive and guide improvement.
Listening and acting
In order to act in the best interests of the people using services – it is vitally important to listen. In this respect, the CQC will devote significant resources so that service users, their families, or people regarded as important to them, can provide feedback. With increased collaboration, the CQC has promised ‘to make the most of existing sources of feedback’ so those providing information ‘don’t have to repeat themselves’.
I think the main point to stress on feedback, however, is just how far the CQC has pledged to cast its net when gathering it. It wants to seek the views of the under-represented – people who traditionally don’t have a voice or who may be experiencing ‘closed cultures’. When you consider the systemic abuse that was uncovered at the Winterbourne View care home by Panorama over a decade ago, it can only be a good thing that the CQC plans to shine a greater spotlight on these services.
Overall, the wider and more comprehensive the feedback it receives from people will prove a great benefit to the CQC. Why? Well, the more opinions that the CQC collects, the more real-time intelligence it will have. This rich seam of information will enable the CQC to develop a more reasoned and rational response to how it can efficiently and effectively improve regulatory frameworks, ensuring that services pay even closer attention to promoting equality, diversity and human rights than they did before.
The challenge for the CQC, however, will be to develop high-tech systems that can process the increased amount of information gathered – which will come from multiple sources. The hope is that with access to more information, the CQC will be able to take a more proactive approach. This will allow them to be much more responsive in targeting services where poor practice has been identified by a number of different sources.
Smarter regulation – what it means for providers
The CQC has promised that it ‘will be smarter’ and regulate ‘in a more dynamic and flexible way’. But what does this really mean?
Firstly, one major tangible change is that there are likely to be fewer site inspections in the future, and when they occur, the CQC inspections teams will be much less scheduled in their approach. The CQC may turn up with little warning, but it will come prepared with lots of data and intelligence that it has gathered from a range of different sources including agencies, local authorities, commissioners and the NHS. If inspection teams do deem it necessary to inspect, it will be because they want to see practice in action, or because the only way that they feel that they can properly assess the service, is by talking to front line staff, managers, service users and their relatives.
This marks a departure from the CQC’s previous commitment, which was much more linear and binary. The CQC said simply if services were rated as inadequate, they would be re-inspected three months later and if services were outstanding, inspectors would return three years later. In my view, there were some flaws to this approach, which the CQC have recognised. For example, it fails to take into account the fact that services can go from outstanding to inadequate very quickly. It only takes a highly experienced front-line manager to leave, or a service to receive a number of complaints, for the quality of the outcomes received by service users to slip away.
Hopefully, this more data-driven approach to inspection will enable the CQC to be much more responsive and agile when it comes to inspections. I think that the CQC’s desire to develop much more of a relationship with providers than before will also be appreciated by providers. In understanding how providers function and the challenges they face at a local level, the CQC will be in a stronger position to work with services to suggest preventative measures before smaller issues develop into bigger problems.
As the CQC moves towards a culture of continuous monitoring, it is unclear whether the CQC will insist on providers filling out the Provider Information Return (PIR) once a year, or whether it will be slowly phased out. Until this point is clarified, however, services should continue to complete the form.
With the CQC choosing to embrace continuous monitoring, this is where content platforms like QCS, come into their own. With access to a myriad of policies, procedures, auditing and risk assessment tools, front-line providers have all the tools they need – whatever setting they find themselves in – to deliver high-quality care.
In the new strategy, the CQC states that it is will ‘co-ordinate data collections’. The CQC is keen to use data more effectively to avoid ‘duplication’ and ‘workload for services’. It plans to share the information it gathers through ‘data-sharing agreements’. How exactly this will work and what technology the CQC will use to manage the process is unclear. But, if enhanced data sharing enables the CQC, and the services that it regulates, to carry out more dynamically managed inspections, then it could allow for the CQC to change the rating of a service without undertaking a site visit. Or, if an inspection is required, the inspection and rating process is likely to be a lot more fluid. The written reports will change too, in that they won’t be long and convoluted texts. Instead, they will be much more accessible and targeted for a particular audience. They will also be more widely promoted and service users, those regarded as important to them, and a range of different services will be more clearly informed about the work of CQC and the services of interest to them.
Real improvement or a raft of unanswered questions?
Will smarter regulations work? Perhaps it is cliché, but they say, ‘the proof of the pudding is always in the eating’. Therefore, I think it very much depends on the quality of information and sources that the CQC receives when considering whether or not to change a rating. Two key questions which the CQC is yet to answer are ‘how much evidence will inspectors need to consider a rating change’ and ‘will the CQC change rating for each of the five key questions, but not actually change the overall ratings?’ We simply don’t know, but I believe that there is no substitute for face-to-face inspections.
In part two of this series, Care Quality Systems (CQS) asked Ed Watkinson, a former CQC inspector, to explore, examine and demystify the remaining two themes that make up the CQC strategy. In the second of two articles, Ed Watkinson reviews ‘Safety through Learning’ and ‘Accelerating improvement’. Read the second article here.
Care Quality Commission – A new strategy for the changing world of health and social care – CQC’s strategy from 2021
Ed Watkinson, Residential Care and Inspection Specialist
Ed has wide experience across a variety of roles in the care sector. He has been a care assistant, registered manager, area manager, care manager and senior commissioner. He has also served as a Planning and Commissioning Manager for Buckinghamshire County Council and as Methodology Developer and Regulatory Inspector for the Commission for Social Care Inspection. Most recently, he has worked as a Regulation Manager for Barchester Healthcare.
In addition, Ed was on secondment with the Care Quality Commission during 2014 and was central to the development, piloting and roll out of the Care Quality Commission’s new inspection methodology as part of their Policy Team.