Quality & Compliance Magazine: Inspection, but not as we know it

What does the CQC’s new compliance framework mean for you? Jenny Wilde explains.

The old regime

Inspection used to mean a visit, either announced or unannounced, to a registered care service with the minimum frequency of inspection defined in statute. Until only a few years ago, care home providers could expect two inspections a year, with a focus by inspectors on inputs, systems and paperwork. The system was highly prescriptive and the criticism was that it was largely a tick-box exercise. Inspection reports were published but often the information was already out-of-date by the time the public got to view them.

The new regime

The form of regulation experienced by providers now is dramatically different. There is no longer a minimum frequency of inspection. Services can, and do, go years without being inspected. When inspections do take place they are now almost always unannounced and their stated focus is on outcomes, a suitably vague term which attempts to convey aspects of how people experience care, treatment and support and whether they are safe and effective. The standards are far less detailed and as a consequence providers have more discretion about how they operate their services. Reports are still published but the intention is for inspectors to use all the information available to the CQC about the service to judge compliance, not just what is observed or recorded during the visit.

Compliance monitoring

Inspection is no longer the preferred term of the CQC, as the process of compliance monitoring is far broader than simply an inspection (now called a site visit) and may not even involve one if it is felt unnecessary. Instead, the CQC refers to its assessments of compliance against Essential Standards as ‘Reviews of Compliance’ which can either be ‘planned’ or ‘responsive’ to particular circumstances. The CQC has indicated that each service should have a planned review within 3 months and two years of the last. This is a policy decision and may well change over time, linked to capacity and resources.

The new regulatory system focuses on information capture and analysis on a continuous basis, of which a site visit is only one potential source of information. Other sources include:

  • people who use services
  • partner agencies such as Councils and the Health and Safety Executive
  • providers themselves.

In due course, the public will see a profile for each service which will provide a more live judgement around compliance than the old system based on the publication solely of an inspection report which has been criticised as being reactive and a snapshot in time only.

Meeting outcomes

The approach the CQC has adopted to check compliance with the Essential Standards is also radically different. The clear focus of the Guidance on Essential Standards is on outcomes. To promote consistency in making judgements about compliance, the CQC has published a document called the Judgement Framework for its compliance inspectors and assessors. This provides a systematic approach to making decisions about compliance through a four-stage process. Stage 1 requires the CQC inspector to decide whether the evidence is sufficiently robust. If it is, then they can proceed to Stage 2 which requires a judgement about compliance. If the decision is that the service is non-compliant with an Essential Standard, then the inspector proceeds to Stage 3. During this stage the inspector will determine the impact on service users of the concern and the likelihood of the impact occurring. The outcome of that decision will be used in an internal matrix that can be found in the Judgement Framework and the inspector will decide whether the overall concern is minor, moderate or major. The final stage will see the inspector validating the judgement and producing the report.

Provider Compliance Assessments

The new regime has already revealed itself to be a self regulatory system and providers will be tasked with confirming their own compliance via regular Provider Compliance Assessments (PCA). Most will have done this already through the re-registration application. My colleague Neil Grant discusses these provider compliance assessments in a further article in this issue (pages 5-6).

It is important to emphasise that, whilst ticking a box to declare compliance is easy, proving it to the CQC is another matter.

Providing evidence of compliance

The system is outcome-based and this indicates that the CQC will want evidence to show that the outcomes are being achieved. This will mean paperwork proving that the standard of the service meets those set out in law.

Those who have reviewed the Guidance about Compliance will see that providers are expected to show, for example, how a service user’s human rights and dignity have been respected and how they have been provided with choice. This may seem difficult to convey through paperwork, however, there are ways that this can be done, i.e. through questionnaires and feedback forms.

The need for accurate and thorough recording has never been more important and providers should be thinking about the best ways to evidence their compliance. As a matter of good housekeeping, a provider should have such documents in an easy-to-reach location so that the CQC inspector can be satisfied as soon as they request the document.

Quality and risk profiles

Inspections will become less frequent and the CQC will be more ‘responsive’ than they have before. The Quality and Risk Profile (QRP) has been devised as a way of capturing and displaying the standards of providers. The CQC will be alerted when a concern is raised against a provider, for example, by a complaint from a member of the public or by the commissioning authority.

The CQC will then see this as a ‘green light’ to conduct a targeted, unannounced site visit to investigate the concern.

The format of the QRP is currently under construction; however, providers can go to the CQC website and see those of NHS providers. Whilst there will be some key differences, it may be helpful to see what kind of information will be available for the public to see.

Conclusion

The key to inspections is to be prepared. Inspectors are under an obligation to check that outcomes are being met, so ensure that you have the evidence to back up your compliance.

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