If you are looking for a legal perspective on the new Provider Compliance Assessment tool, then read on.
Compliance monitoring
The Care Quality Commission (CQC) has introduced a system of compliance monitoring based on the continuous checking of all available information about each registered provider. All the information about a provider will be used to assess risk and prompt regulatory activity. Registered providers will be required to provide information to the CQC whenever the regulator is gathering additional information during a ‘review of compliance’, the new name for the assessment of services and facilities against the Essential Standards. The request for such information is not optional. The CQC has broad ranging powers to require providers to submit information that it considers it needs for the purposes of its regulatory functions.
Provider Compliance Assessment tool
The CQC has developed a Provider Compliance Assessment (PCA) tool in relation to each of the 16 Essential Standards most directly related to the quality and safety of care. This is described by the CQC as being a ‘…self-assessment tool for you to monitor your compliance with the Essential Standards of Quality and Safety’ Provider Compliance Assessment: Guidance for providers, CQC, 2010.
It can be used by providers to demonstrate compliance to the CQC as part of the compliance review process. The guidance adds, ‘You can use it as a routine internal assurance tool, or as an ad hoc assessment in response to specific concerns. It is not mandatory for you to use or complete this document’. This must be correct as providers may have their own audit tools which capture evidence in a different format from the CQC version. So, whilst providers must provide information requested by CQC, they can choose to submit information in their preferred format rather than the PCA format if they so choose.
Routinely, the CQC is asking providers to submit PCA information within 5 working days, often in relation to all 16 Essential Standards, although short extensions of time are being granted. This short timeframe reflects the expectation of the CQC that providers should have evidence readily available ofthe extent of their compliance with the Essential Standards on a location-by-location basis through the operation of an ongoing system of quality assurance. This is backed up by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, which require the effective operation of systems to regularly assess and monitor the quality of services. The term ‘regularly’ is not defined in the regulations, but the safest and most effective course would be for providers to have a continuous monitoring system in place, so far as practicable.
What happens if insufficient information is supplied? If a provider is not able to provide the CQC with the requested information in the stipulated timeframe (or does so, but it is incomplete) then the CQC may well assume that the provider does not have an effective quality assurance system in place. Almost certainly the provider will then be subject to a site visit. If theprovider anticipates that they cannot realistically make the deadline, it would be sensible to give advance notice with full reasons and seek agreement for a revised timeframe. Wherever possible, however, providers should do their very best to comply with the original deadline set by the CQC.
Is the PCA tool essential?
The first issue for providers is whether to use the PCA tool. Obviously, the CQC prefer it to be used as it is designed to fit in with their systems. The principal advantage in completing it is that the provider will cover all the matters that the CQC considers relevant in judging compliance with the Essential Standards. It ensures that all the relevant outcomes (listed under what are called ‘prompts’ in the CQC Guidance about compliance) are addressed in the summaries of evidence that the provider is obliged to complete in each PCA. Furthermore, as the PCA is CQC’s preferred tool, using it avoids unnecessary conflict and potentially awkward correspondence with the CQC.
What sort of evidence should be provided?
The CQC stresses the importance of the use of outcome evidence in the PCA, which should then be used to judge the level of compliance in relation to each prompt, employing a classic traffic light system: green, yellow, amber and red. The CQC has issued guidance for providers on ‘using evidence of outcomes to demonstrate compliance; it lists types of evidence that providers may wish to source for outcome evidence. These include surveys, complaints and feedback from people who use services, and surveys of their carers and families. The CQC advises providers in the same guidance document to focus on evidence that ‘comes directly from people who use services and those acting on their behalf, and relates to the experiences of individual people who use the service’. Therefore, providers will get more credit for including outcome evidence linked to the quality of life of people who use services rather than information about systems and processes.
Our experience suggests that a large percentage of PCAs still focus on inputs and processes rather than outcomes. The CQC acknowledges that many providers are in the
process of adapting to a new way of capturing information which will become more sophisticated over time. The same challenge, of course, confronts the CQC compliance inspectors.
The judgement framework
Providers who use the PCA tool ought to have regard to the methodology set out in the CQC document called Guidance about Compliance: Judgement Framework, CQC, March 2010, which is written to help CQC staff to check a provider’s compliance. The reason for this is that the traffic light system in the PCA tool corresponds to that in the Judgement Framework. Therefore, providers ought to consider the impact of any non-compliance on people using the service (low, medium, high) and the likelihood of it recurring (unlikely, possible, almost certain). There is a matrix in the Judgement Framework that then identifies the level of concern: minor (yellow), moderate (amber) and major (red). Careful thought will be required to ensure that the scoring in the PCA tool is accurate in reflecting what is happening in the service. The bottom line, as always, is to know what is happening in your services and to know how they will be judged by the regulator.
We have seen completed PCAs with ambers and reds where the evidence suggests there were no more than minor concerns. On the other hand, if there are problems in a service then the provider will need to reflect this accurately in deciding what colour code to apply to each outcome area set out in the particular PCA document. The CQC says that it will give credit to providers who are aware of their shortfalls, include them in the PCA and have appropriate plans in place to manage them. Confidence in a provider is one of the criteria that the CQC will consider in deciding whether enforcement action is necessary. The greater the confidence in the provider, the less likely it is that enforcement action will follow.
