A Shift In Culture – The key to avoiding Risk-Based Inspections

Over 50% of CQC inspections in Adult Social Care are currently triggered by “information of concern” and providers should take note that over 55% of these “risk based” inspections have resulted in a rating of Requires Improvement or Inadequate. Providers should therefore be very wary of any “Information of concern”, which is not limited to formal whistleblowing reports, making it to the CQC.

There is not a huge amount providers can to do to influence when the CQC deem there is a risk high enough to prompt an inspection and they cannot (nor should they try to) control what people choose to tell the CQC (or not), but what they can do is make every effort to foster a culture which is positive, and which will stop people having “concerns” or “information” which they feel need to be taken to the CQC in the first place, or at all. Providers can often do this by taking some steps to improve culture in their service.

Plus, with these same steps, even if they can’t stop the CQC receiving “information of concern”, or crossing the threshold in the first place, providers can at least put themselves in a better position to defend any criticism or alleged regulatory breaches which arise from such later on if they find they do need to.

Open culture is key

100% of people will not be happy 100% of the time. Complaints, concerns, issues and differences of opinion will arise, but in a genuinely open and transparent culture these rarely need to become more than a good learning point. In our experience, by far the best approach is to take steps to encourage an environment where issues, complaints and concerns simply do not arise in the first place, or, where they do, they are brought directly to the provider.

In a truly open culture:

Concerns are much more likely to be brought to someone’s attention early and allow them to be dealt with promptly, appropriately and at a low level;

People who feel respected and listened to are more likely to speak up in the first place and cooperate in trying to deal with any concerns raised proactively and constructively; and

People feel positively engaged and good about the service when they feel they have a say. Concerns are less likely to arise in the first place, and views and opinions which can be shared freely are less likely to escalate into concerns or complaints.

To help achieve an open and transparent culture, services should promote a culture of regular and constructive communication, where people feel that they can raise concerns, and that those concerns are listened to, and are properly resolved. This includes low level “niggles” that might not (yet) be serious enough to be a “concern” or grounds for formal complaint.  Complaints and information of concern can be raised by any individual who has any involvement in a service, including, for example, visiting health professionals, commissioners and local community members and so providers should try and encourage this culture of open communication as broadly as possible.

Culture is not something that can be changed overnight. It will take time and energy from all parties and it will depend on the service, the service users and all manner of other factors as to what may work best in any one case. However, we tend to see the best results in services which take significant efforts to encourage and support people to communicate openly, and where those efforts are further supported by good governance policies, processes and systems, and both are well documented by way of evidence.

Promoting better communication

Providers should try and take every opportunity to encourage open and frank communication. The more people talk, the more opportunity providers will have to know what is going on, and deal with any issues as soon as they arise.

To promote better communication providers will want to actively encourage and support:

  • Open and frank discussions amongst staff about their own concerns and any raised by residents / families / visiting staff/professionals/the community;
  • Regular and proactive communications and interactions between the service and service users, staff, families, visiting professionals, community groups and other organisations; and
  • A genuine respect for peoples differences of opinion and views.

Using innovative, or creative ways to encourage, obtain, share and act on feedback and make it a multi-way dialogue is generally encouraged and can help reassure the CQC that there is a positive culture in place. Again, it will depend on the service as to what might work best, but we have seen a number of practices achieve success with some or all of the following:

  1. Ensuring information about how to give feedback and raise concerns, both formally and informally, is very easily accessible to people with a range of accessibility needs, in a number of different ways
  2. Having staff, service user and family forums, workshops or engagement sessions in a number of different formats, which are well attended
  3. Organising and participating in community engagement sessions and projects
  4. Having communication or engagement champions
  5. Engaging in cross service/authority engagement or information sharing opportunities (at provider or regional level, or with Local Authorities)
  6. Clear information being displayed throughout a service of how to complain or give feedback and to inform people how feedback has been acted on
  7. Having management / provider drop in sessions or surgeries
  8. Having a truly open door policies and/or drop-in sessions
  9. Actively using social media, review sites and electronic surveys to engage with people
  10. Involving people in formal consultations such as surveys and polls
  11. Being involved with external verification, accreditation, quality standards, or auditing schemes

Allowing opportunities for anonymous feedback is also a good idea. Obviously the provider cannot engage with those involved in the same way to resolve issues, but this can help encourage people to raise concerns internally in the first place. Whistleblowing policies may be relevant here where reports are from staff or other professionals, but anonymous concerns could be raised by anyone; and they should still be taken seriously by whatever means they come to light.

Listening to and respecting people’s wishes is not just about the bad. The more open the culture, the more positive feedback providers should get as well.  People will have a wealth of information, views and wishes, and good ideas which can help develop, improve and innovate a service and constructive and positive engagement is likely to help improve a service for all concerned.

Evidence of positive feedback through these communication channels might also help a provider build an evidence base to defend any unfair criticism from the CQC or other authority, or push for better ratings, should they find themselves needing to do so.

The role of governance

Whilst the success of any change in culture will hugely depend on the individuals involved, much will also come down to governance systems and processes in place, and how those encourage and foster better communication and transparency and lead to positive changes in culture.

Policies                                                                                                 

Robust and suitable policies for whistleblowing and complaints should already be in place and be easily accessible to all they relate to. These should be monitored for compliance, and reviewed and updated at regular intervals with the involvement of those who they apply to. Staff should be encouraged to be aware of and familiar with these, and supported to understand why they are in place, and to follow them. Those policies should make it clear that people should be given appropriate levels of support, and information, throughout the relevant process(es).

However, providers might want to think a little wider. Open communication can also be built into other policies or activities to help encourage an open and transparent culture – and demonstrate the efforts taken to do so; such as being factored into auditing and quality monitoring documents, staff training, development and competency management, and when engaging with third parties or service users.

Services may wish to consider also having in place additional communications policies, or expectations set out in employee handbooks, service user handbooks, professional agreements or contracts or training materials which can help set standards for promoting good flows of communication, particularly where any one party may feel a concern or issue has arisen.

Active management of Complaints/Alerts/Information/Feedback

Providers are required to handle complaints appropriately but it might not be as simple as following policies or meeting minimum requirements. They may well want to go over and beyond what is required of them and should be proactive in addressing and dealing with concerns and communicating outcomes to those involved. Initiatives such as those above might not be necessary, but might make all the difference.

What is often important is that people can SEE and FEEL that their feedback, concerns or complaints are being listened to and addressed appropriately and promptly. People want to understand how their concerns are being dealt with and see what action has been taken so proactive feedback can really help. Concerns and complaints can even be turned into the positive if they are carefully handled and if providers are able to ensure that people can see this it may further encourage them to bring concerns to the provider, rather than elsewhere, in the first place.

Good Record keeping

To some degree, good culture will speak for itself and should hopefully mean, over time, that less “information of concern” would be directed to the CQC in the first place. Providers should not assume, however, that they will not need evidence to demonstrate what they have done.  It is all very well doing great things or avoiding the CQC’s scrutiny, but providers need to ensure that they can demonstrate the position at any time, with clear evidence. They might need documentary evidence, for example, to counter any “information of concern”, or show on an inspection that any “concern” is misplaced or unnecessary and is not indicative of an ongoing, systematic or wider problem. This could be relevant in CQC activity but also in engagement wither others, such as Local Authorities.

It is impossible to list all the ways a provider might want to evidence good culture but providers will at the very least want to keep clear records of communications and interactions, and all feedback – both positive and negative. They will want to be able to demonstrate that they actively encourage and act on formal and informal feedback, and that people know their views are valued and listened to. Records should be able to demonstrate that feedback is dealt with according to suitable policies and processes, in a timely way, and that those involved are kept updated at appropriate intervals. They should show that concerns and complaints having been acted upon quickly, and any risks arising from them have been identified and mitigated to the fullest extent possible in the period of resolution, and any trends or themes arising identified quickly and taken into account. Any lessons learned or constructive feedback should clearly feed into any programme of improvements, or future development strategy.

Summary

Working towards a more transparent and culture, where people communicate openly and constructively on all matters, is likely to benefit everyone concerned.

With a bit of effort, a service can, over time, improve its culture and this article should give providers some tips on how they might work to achieve this. There is every chance that if it can be achieved, there will be less risk of “information of concern” arising in the first place, or escalating, or going the CQC’s way, which might help to avoid risk-based inspection activity.

Plus, even if this cannot be avoided and the CQC do inspect, this same work should, in theory, enable providers to demonstrate there is nothing to be “concerned” with at all, or at least not anymore and might even give them evidence in support of favourable conclusions in inspection reports and Good or Outstanding ratings.    

If providers would like help with or advice on how to deal with the CQC’s risk-based approach, or to make changes in their service’s culture, or on CQC inspection activity more generally Ridouts can help. Please contact our specialist team of solicitors on 0207 317 0340 or ask for a call back via the website.

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