Q. I understand that the Care Quality Commission’s (CQC’s) new assessment framework comes into force in November. What do I need to know and how can I prepare for the new inspections?
A. Laura Hannah, Solicitor and CQC Regulatory Expert, Stephensons Solicitors LLP
The CQC’s strategy for 2016 to 2021 sets out its aim to achieve a more ‘targeted, responsive and collaborative approach’ with the aim that more people receive high-quality care in the future. This is only the most recent part of a changing regulatory landscape in which the CQC has radically changed its approach to health and social care services in recent years.
In December 2016, the CQC issued its first consultation, Our Next Phase of Regulation, which proposed a standardised approach across the health and social care sector for the first time. A response to this consultation was published in June 2017 and this confirmed the changes to be made to the current assessment frameworks. A second consultation was published in June 2017 and a third is expected later this year.
The CQC has already confirmed that it will be moving from its current 11 separate assessment frameworks to just two: one for healthcare, and one for adult social care. The purpose of this is for the CQC to try to ensure that its end-to-end approach, from registration, monitoring and inspection to rating and reporting, provides a single, high-level process that can be tailored to individual providers. It is hoped that by reducing the number of assessment frameworks, this will improve the clarity and transparency of inspections and ratings, help providers to understand how they are being assessed, allow the public to compare services and ensure that inspectors make assessments in a consistent way. The CQC believes that this will reduce complexity and confusion, particularly for providers that deliver more than one type of service.
However, in the response to the initial consultation, there was some concern from providers that having only two assessment frameworks may take the process of simplification too far and be unsuitable across the whole of the two sectors. In light of this, the CQC has set out its plans to continue to develop and publish additional sector and service-specific materials that link to the assessment frameworks and provide more detailed information about how they will apply in the context of a particular service.
The ‘Five Key Questions’ will remain in place as the basis of the assessment frameworks. As such, the CQC will continue to assess care homes by asking whether they are safe; effective; caring; responsive; and well-led. However, the Key Lines of Enquiry (KLOEs) will be merged to provide one set of questions and prompts for the healthcare sector and one for adult social care. A number of changes have also been made to the KLOEs and these are intended to simplify the process by more closely aligning the five questions and the characteristics that reflect a rating.
New, strengthened themes throughout the framework
The wording of some KLOEs and prompts have been revised to provide clarity. Additional prompts have been added and some have been moved between the key questions. The new KLOEs also include six new, strengthened themes that the CQC has deemed necessary to improve on.
- System leadership, integration and information-sharing.
- Information governance and data security.
- End of life care: Delivering good quality care at the end of life.
- Personalisation, social action and the use of volunteers.
Whilst this has resulted in more KLOEs overall, and some duplication across themes, the majority of the content remains the same or similar to the current frameworks. The CQC has also acknowledged that, for some KLOEs, prompts and characteristics will not necessarily need to be applied in all settings and will only be applied where they are relevant and proportionate to the type of provider being inspected. In fact, the new KLOEs helpfully make clear the types of services within the sector that each KLOE or prompt applies to, so this may at least streamline this large document. It is, however, apparent that the new KLOEs will need to be monitored and reviewed regularly by the CQC, in order to measure their success and, if necessary, adapt them further to ensure that they continue to reflect the most current methods.
In strengthening its assessment of well-led, the CQC has also made it clear that there is a demonstrable link between leadership, culture and the delivery of safe, high-quality care, and its focus on well-led is intended to support and reinforce this link. The new well-led framework includes a clearer emphasis on ensuring sustainability of services, which we have already seen to be an increasing focus of inspections and a consideration for the CQC in deciding whether to pursue or continue with enforcement action in recent years.
It is envisaged by the CQC that these changes to the KLOEs will make them more relevant by bringing them in line with changes and innovations in care and national policy. It is also hoped that the changes will encourage providers to focus on the needs of people using the services as a whole and encourage greater accountability from providers overall.
When do the changes come into force?
The CQC has confirmed that the new assessment framework for community and residential adult social care services will be introduced in November 2017. The CQC has also indicated that no changes will be made to the assessment framework for a further two years whilst it assesses the success of the changes. This is likely to reflect the approach it has taken in recent years. The last assessment framework was introduced in early 2015 and the first consultation was issued in December 2016, during which time the CQC assessed the suitability of the framework and identified suggested improvements through its inspections and monitoring of care providers under that framework.
What should providers do now?
Overall, many of the criteria from the new assessment framework remain the same and it should not be too much of a shock for providers facing an inspection after November 2017. In fact, it will undoubtedly benefit those registered providers that deliver more than one type of service across the adult social care sector, as the one framework for all of these types of services will hopefully reduce complexity and confusion and provide a more consistent approach to regulation.
In recent years, there has arguably been a lot of contradictory findings across different services in the same sector, which has possibly resulted in varying ratings. Having just one framework for adult social care services may help providers understand more easily what is expected of them.
The success and effect of such changes will not be clear until the new framework is introduced and, therefore, providers need to spend this time between now and the implementation date in November 2017, ensuring that they are familiar with their respective new assessment framework.
The new KLOEs for the adult social care sector have already been published by the CQC and it is strongly advisable for registered providers to spend time reviewing these to ensure that they are prepared for their next inspection and know what will be expected of them. For those providers who have based their current internal policies, procedures or quality monitoring systems on the current framework, these will also need to be reviewed and updated as soon as possible to ensure that they are compliant and in line with the new framework.
In any event, registered providers should be mindful of the new KLOEs for inspections being undertaken now. Whilst they do not apply to inspections until after November 2017, a good understanding of the future framework and, in particular, the strengthened themes throughout, will provide any inspectors reviewing a service with confidence in a provider’s ability to lead a well-led service in the future. There is also nothing stopping providers from using the new KLOEs immediately as a basis for any factual accuracy challenges against draft inspection reports, where they support a challenge against the CQC’s approach, or lack thereof, to a particular key line of enquiry.
Providers may also wish to consider the additional sector support which is available to them during this period of change. Specialist care consultants can assist in providing care homes with practical advice on compliance, and they can also carry out audits or mock inspections of the care home prior to any CQC inspection. This would enable providers to address any areas of non-compliance in advance of their inspection.
Specialist legal advice may also be sought where a registered provider or manager wishes to challenge a finding or decision of the CQC, including factual accuracy challenges to draft inspection reports. This process will remain the same after November 2017.
For registered providers and managers of care homes facing an inspection under this new assessment framework, it is important that they are fully prepared for their next inspection. This includes having a good working knowledge of the new framework. As with any change, there are likely to be some stumbling blocks along the way and a need for further modification to the assessment framework as the CQC learns from its future inspections. It is therefore extremely important that providers and managers seek specialist assistance where required and make detailed and supported challenges to any findings or decisions that are not accurate or consistent with the CQC’s strategy and framework.
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