There appears to be a buzz phrase going round CQC at the moment. At the May 2020 CQC Board meeting “crossing the threshold” was said a number of times by different Board members – “…nothing beats crossing the threshold…”, “…people going out, crossing thresholds to one level or another…”, “…as this infection risk does reduce that we are becoming ever more active in crossing the threshold…”. It was bugging me. I knew I’d heard this phrase before and then it dawned on me – The Hero with a Thousand Faces, by Joseph Campbell. The Hero’s Journey – the story of the initially reluctant Hero, pulled from their ordinary world and encouraged by a mentor to “cross the threshold” into adventure. Tests and challenges present. Struggling on, the Hero reaches the innermost cave, the most dangerous place, from which point the Hero overcomes their ordeal, seizes the treasure they sought and returns, transformed, to their ordinary world with the benefits of the treasure. Campbell determined that all stories follow the same basic narrative.
Now rather than CQC thinking of itself as a Hero it may just mean that they’re getting ready to start physical inspections again, following the decision to stop all standard inspections from 16 March 2020, in response to the COVID-19 outbreak.
However, despite the cessation of inspections CQC have slowly been building up to physical inspections again. The Emergency Support Framework (“ESF”) (the pitfalls of which I have previously commented on here) has been rolled out in adult social care (“ASC”) and soon to be instigated within the hospital and primary medical services directorates. Between its launch on 1 May 2020 and the CQC Board meeting on 20 May 2020, CQC had initiated 1466 conversations with providers, but only completed 864. With over 25,000 social care organisations on the books, at this completion rate, this means that CQC would complete all ASC conversations by Christmas 2021. No wonder they’re keen to get going again.
But if the inspector’s current ordinary world is making telephone calls to providers and the challenge of physical inspection is COVID-19 and the difficulties that this presents, there may be some reluctance to “cross the threshold”, after all, all our lives have taken on a new self-contained ordinary. But Ian Trenholm has said the ESF will lead to more on-site activity, whether partial or full inspection and this encouragement from the top of the organisation will enable inspectors to take that step across the threshold, armed with data that they didn’t previously have (the ESF system has locations’ regulatory history in one place, something that inspectors have previously highlighted as an issue). There are going to be trials and tribulations – maintaining social distancing whilst thoroughly inspecting and accessing what is needed to make informed judgements. Inspections are likely to take longer, require more co-ordination but may give the provider more control over the conduct of the inspection.
Many providers feel unable or unwilling to be the Devil’s advocate to the formed or forming opinions of the inspector during the inspection. After all, inspectors have wide powers of inspection and this can lead to inspectors being provided with a free-run of the service. Whilst providers cannot obstruct an inspection, there are opportunities to present a service in the best light possible so that opinions are influenced before they are committed to paper.
Inspectors are unlikely to be able to move freely around the service particularly in the initial stages of physical inspections returning. Providers will have risk assessments around social distancing, moving through the service, and numbers of people in any one room at a time. Inspectors will have to comply or face placing themselves or others at risk.
So what can providers do? Provide the inspectors with a room. One in which you place evidence of good practice. Have your supporting documentation in files (including those supporting any Provider Information Return you’ve submitted). Break it down by topic, in line with the KLOEs characteristics. We know that CQC is very formulaic and moving more and more to standardisation so best make the inspector’s job finding relevant information easier and in the order the draft report will be written.
When the inspector arrives at the service take them to that room and talk them though the documentation. Leave them to review the evidence of your good practices whilst you get the service ready, staff gathered, make them a cup of tea etc. CQC are supposed to go into an inspection looking for ‘Good’, so why not start the inspection on a positive footing?
Whilst inspections will be more contained than usual CQC will have to be more open about their thought process to enable you to facilitate access to certain areas of the service. This enables a dialogue to ensue and for a provider to be alert to potential areas of concern. This will provide you with an opportunity to present documentation that addresses any arising concerns so these can be nipped in the bud and before they’ve taken root and make their way into feedback.
In order to facilitate the inspector’s movement around the service, it may warrant a staff member accompanying them. This allows you to see what they see. Make notes of what is observed in real time, and keep a note of your conversations with the inspector.
These are tips that I’ve been providing to providers for years but it can be difficult to implement in practice. However, COVID-19 may give providers the opportunity to redress the balance and practice some of these techniques to facilitate and demonstrate their good work. This can become habitual even when COVID-19 is long gone.
Perhaps COVID-19 provides that opportunity for a subtle shift in power towards providers and with it this story bucks the trend – that despite “crossing the threshold” it isn’t the inspector that’s the Hero in this story, but rather the provider and carers. But then we knew that already.