“If it’s not written down – it didn’t happen.” This is the reality facing providers when it comes to inspections and providing evidence to CQC on what has or has not happened in their service. If something is not recorded in an establishment’s paperwork then, according to CQC, this means it did not happen and in turn the provider is failing in some manner.
We would therefore expect that the evidence CQC collect at an inspection is comprehensive and adequately reflects what is observed. At Ridouts we have made a number of requests for CQC inspection notes as part of our case work. These have been provided, albeit with some redactions, due to “confidentiality” issues. However, in almost all cases, we have received inspection notes that are of very poor quality.
The Inspector’s Guidance states that an inspector is to “accurately record” all the evidence gathered in the site visit record. The inspection site visit record is designed so that observations can be recorded by inspectors chronologically. Inspectors are required to record dates, times, people spoken with and their role.
The Inspection Notes that we have seen rarely contain times. Noting what time something is said to have been observed is of course hugely important in order to contextualise allegations. For example, if there is an allegation that the premises were unclean then it is very important that an inspector records when this is observed. If this is observed in the morning around the time that service users are getting out of bed, there may well be dirty laundry, soiled bedding and used incontinence pads being collected and disposed of. There is likely to be an odour as a result too. What is important though is what the inspector observes next. Were the items cleaned up or were they left there all day? Merely stating that there was an odour at some point during the inspection does not demonstrate unclean or unsafe premises or a risk of infection as is often the assumption jumped to by an inspector. It is our experience that the inspection notes do not always permit an inspector to join those dots to reach the conclusion they draw.
The inspection site visit record allows inspectors to record their evidence and alongside that evidence record which KLOE they think is the most relevant. Whilst CQC guidance to inspectors states that this does not have to be done at the time of writing down the evidence it suggests that it might be useful to do this before the end of the inspection so that the inspector is assured that they have gathered enough evidence to make a judgement and have covered all the questions and KLOES that they planned to look at. Before the end of a site visit an inspector is required to refer to the KLOEs and prompts to make sure they have robustly corroborated the evidence. Some Inspection Notes that we have seen fail to do this and therefore this raises the question of how the inspector has assured themselves that they have collected enough evidence to make a robust judgement. The Inspection Notes contain such a lack of evidence it calls into question whether a comprehensive review has taken place.
The inspection site visit record also allows an inspector to record whether they think the evidence gathered is positive or negative – thereby encouraging CQC to be balanced in its views and not merely find fault.
However, if all of the above is not done have inspectors followed CQC’s procedures correctly? – A key to challenging a service’s rating through the Rating Review Process.
Not only have we found that Inspection Notes tend to be of poor quality we have also, in turn, found that they do not reflect what has then been put into the Draft Inspection Report or a Warning Notice that is issued.
We find that evidence is lost in translation between the inspection notes and the draft inspection report. A singular window that is observed to be dirty in the Inspection Notes all of a sudden becomes “windows were observed to be dirty”. A very different situation is being presented to the reader of the report.
Some notes are written in the form of abbreviations that contains such limited detail as to be non-comprehensible. As a result it would appear that memory has been largely relied upon as details appearing in the Draft Inspection Report and Warning Notice do not appear in the Notes. This may not be such a problem if the Reports are drafted within a day or two of the inspection and sent to the provider for comment. However, sometimes inspection reports arrive weeks, if not months, after the site visit. How much is drafted from hazy memories and will inspectors who have a large workload and a number of homes to inspect, remember if their memory serves them correct – does the Inspection Report reflect your service or is the inspector confusing it with the home they inspected two weeks ago or the one inspected a month ago?
Is the integrity of the inspectors called into question, firstly by poor evidencing but also, secondly by issuing the Draft Inspection Reports and Enforcement Action on the basis of that evidence? This does call into question whether CQC can seek to rely upon these Notes as its evidence to demonstrate non-compliance. Would this evidence stand up to scrutiny in a Tribunal or before a Magistrates court if CQC relied upon them to take enforcement action?
I mentioned above that the majority of inspection notes that Ridouts has viewed have been of poor quality. The exception to that was one set of notes from an inspector on an inspection team that positively supported our client’s position. The Lead inspector had conveniently ignored those notes.
The above demonstrates that whatever the circumstances the inspection notes are vital to understand just what it is that CQC has collated or not collated. Providers should be requesting notes where they wish to challenge CQC findings. These may help to strengthen a provider’s response, they may not but they will certainly help a provider to understand the case against it.