The key components of regulation by the Care Quality Commission (CQC) are registration, inspection, compliance and enforcement. While the emphasis given to inspections has waxed and waned over the years, it is clear that they will remain an essential feature of CQC regulation. For one thing, CQC is obliged to set out the minimum frequency of inspections linked to its performance assessment of services. Currently, this is six months for Inadequate services, twelve months for Requires Improvement services and two and a half years for those rated Good or Outstanding, calculated from the publication date of the inspection report.
All CQC inspections in adult social care comprise two main elements: compliance with legislation and ratings. The two are distinct; in terms of public perception, ratings have become the dominant partner. However, if CQC wishes to take enforcement action against a service, it must identify a breach of compliance with statutory requirements, so the compliance aspect will be particularly important to those care services that are at risk of enforcement action.
A Good rating is seen by CQC as the minimum standard nowadays and those services that fail to attain this rating are becoming the subject of increasing regulatory scrutiny and intervention. Commissioners and lenders will also be concerned by an Inadequate or Requires Improvement rating. Providers need to be ready for inspection day in order to demonstrate the strengths within their services and how they are addressing any shortfalls.
Filling in the paperwork
In planning an inspection, CQC will review the Provider Information Return (PIR) submitted by the provider. This form is the provider’s opportunity to set the scene, presenting positive information about the service, so far as is possible. In time, CQC intends to replace the PIR with Provider Information Collection (PIC). CQC sets out the importance of this provider submission in its internal guidance document, Planning Inspections:
‘The PIC…collects essentially the same information [as the PIR] but will be accessible to providers as a live online portal rather than an annual submission. The provider is prompted to complete the PIC every three months as a minimum, but [it] is available as a live record they can update at any time.
‘The PIC gathers key information from providers about their service. As well as providing important information about the quality of a service it also gives indicators about how well a service is led and managed. A detailed accurate PIC can indicate a well led and well managed service [my emphasis]. Well led services should have the information requested in the PIC readily available under their own quality management arrangements (as required by regulation 17). Poor quality information or failure to submit a PIC can indicate that a service is not well led.’
The starting point must therefore be to spend time pulling together a comprehensive and accurate PIR/PIC. You may also wish to consider carrying out a review of your service as part of the PIR/PIC preparation using CQC’s Key Lines of Enquiry, prompts and sources of evidence, perhaps employing external consultants. Some people call these ‘mock inspections’.
Any actions resulting from the review or mock inspection can be put into an action plan and implemented in advance of the inspection. This is evidence of effective governance, employing the same assessment framework as CQC: the single, shared view of quality.
Previous inspection reports
CQC will use your last inspection report as an integral part of their inspection planning. As CQC’s Planning Inspections guidance states:
‘The previous inspection report is a vital source of information for inspection planning. Previous reports:
- Highlight areas that need to be followed up on inspection, including breaches, poor ratings, or recommendations we have made.
- Show the service’s history, and whether it is responsive when concerns are noted.
- Show whether the service sustains good quality care or only resolves problems when CQC has identified them.’
You will need to ensure that any compliance issues and any other criticisms of your service emanating from the last inspection have been addressed, as these will be reviewed when CQC returns. If the manager of a service changes, it is crucial that the new incumbent is aware of CQC’s concerns and is confident that they have been and/or are being addressed.
The start of the inspection
First impressions in life count for a great deal and it is no different with inspections. The lead inspector will introduce themselves to the manager or other senior person on duty and will explain the type of inspection to be undertaken, whether it is comprehensive or focused. The lead inspector may well ask some open questions at this point. CQC’s internal Evidence Gathering guidance sets out the type of questions that may be asked and it’s useful to be familiar with and prepared for these:
‘Make it clear at the start of your site visit or other contact with the provider or manager that you are looking for evidence of a ‘good’ service. It may be useful to ask them the following questions:
- Tell me how you are providing a good service? Do you have evidence to show this?
- What achievements are you most proud of?
- What have you done recently that has made a major difference to the people who use your service?
- How have you made sure your service is inclusive and respects the equality, diversity and human rights of people who use the service and the staff who work there?
- How do you gather information and feedback from people who use your service, their carers and families, and care staff?
- What is your biggest challenge?
- What plans do you have to improve the service?
‘These sorts of questions start inspection contact in a way that shows we are ‘looking for good’ and focused on encouraging improvement. You can look into their answers during site visit and other inspection activity, and use them to develop your evidence gathering plans responsively.’
A rights-based approach
You will have noted that one of the questions the lead inspector may well raise is in relation to equality, diversity and human rights. CQC’s whole regulatory framework is human rights focused. It has adopted what it calls the FREDA principles: Fairness, Respect, Equality, Dignity and Autonomy. In addition, there is the Right to Life principle and an additional principle around staff rights and staff empowerment.
In February 2019, CQC published Our human rights approach for how we regulate health and social care services. Providers and managers should familiarise themselves with this document, as well as other publications such as Equally Outstanding, Quality Matters and Developing People, Improving Care.
You will also want to be able to demonstrate to inspectors that you are meeting the requirements of the Equality Act and Human Rights Act, be it in terms of lesbian, gay, bisexual and transgender rights or ensuring that staff are free from the risk of violence, harassment, discrimination and abuse.
Linked to this, CQC inspectors will look at compliance with the Accessible Information Standard, which dictates that everyone should be able to access information in a way that is suitable for them. Inspectors will review documentation and speak to staff to ensure this standard is both understood and implemented. As CQC advises its inspectors in its guidance document, Gathering Evidence:
‘It should be possible to see whether providers are meeting the requirements to “identify, record and flag” people’s accessible information requirements through looking at assessments and care plans. When selecting care plans for tracking, you should ask that the plans include a sample of people who require information or communication in a different format due to disability, impairment or sensory loss.
‘In order to see whether needs are being “shared and met”, it might be necessary to talk to staff and people using the service, or through observation.’
This is a key area that services often fall down on. Without fail, CQC will look at compliance with the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) requirements as it has a statutory duty to monitor them.
Concerns are frequently identified in inspection reports about an absence of decision-specific mental capacity assessments and a failure to record best interest decisions fully. Issues that often arise around DoLS include a failure to notify CQC of an authorisation or a withdrawal of a DoLS application, so it’s essential that providers are up-to-date with this. CQC will also be expecting providers to chase local authorities for authorisations, notwithstanding the current backlog of around 125,000 applications.
Making the most of it
Providers and managers should ensure they get the most out of the feedback session at the end of the inspection. The lead inspector should allow you time to respond to their feedback and ask questions. They should also record your responses in their notes. This is your opportunity to try to head off issues and/or identify matters to take up with CQC after the inspection.
After the inspection, hold a debrief session with staff and establish if there are any issues you need to respond to CQC about before the draft inspection report is received.
Finally, you should supply any additional information to CQC before your report is issued, as a matter of priority. In doing this, you can have an impact before the report is drafted. Don’t wait for it to arrive several weeks down the line, by which time memories will have faded.
Always do yourself justice by ensuring you are an active participant in the inspection, not a passenger or spectator.
Neil Grant is Solicitor and Partner at Gordons Partnership LLP. Email: firstname.lastname@example.org
How do you prepare for a CQC inspection? Has CQC commented on anything you’ve done particularly well? Share your experiences and feed-back on Neil’s article in the comments section below.