On 9 April 2014, CQC issued for consultation its Provider handbooks for residential and community adult social care. The consultation is open until 4 June 2014. The major change being consulted on is the new rating system for providers which is due to be introduced from October this year.
The new ratings system is to be based on the 5 key questions against which inspectors will judge a location, namely is the service (1) safe, (2) effective, (3) caring, (4) responsive, and (5) well-led. There will be ratings for each of the five questions with an overall rating for each location.
The proposed ratings are “outstanding”, “good”, “requires improvement” and “inadequate”. There will be no rating of adequate, given the view that all providers should be striving for more than the minimum in terms of service delivery. The problem, however, is that an element of ambiguity arises given that the handbooks state that “requires improvement”can encapsulate scenarios of compliance and non-compliance.
To promote consistency, CQC has developed what are called “key lines of enquiry” or “KLOE” linked to the 5 key questions. The KLOE are essentially high-level questions, some of which inspectors must answer during an inspection, with others being discretionary. The handbooks state that inspectors will have to choose four discretionary KLOE, although depending on circumstances they may look at more. CQC will build ratings from all the recorded evidence. CQC has developed “prompts” for inspectors in relation to each KLOE which identify the particular quality issues that inspection teams will focus on.
CQC has developed “characteristics” to describe what good, outstanding, requires improvement and inadequate care looks like in relation to each of the five key questions. These are described in appendix B to the handbooks. CQC says these represent a non-exhaustive “checklist” and that “not every characteristic has to be present for the corresponding rating to be given.” There will no doubt be disputes about the application of these “characteristics” to individual services, particularly where the professional judgement of the inspection team departs from the CQC guidance.
The ratings principles
The proposal is that each key question or domain will have equal weighting and will contribute equally to the overall location rating.
CQC is proposing some essential principles that will apply to the award of the overall location rating, namely:
1. If 2 or more key questions are rated “inadequate”, then the overall aggregated rating will normally be “inadequate”;
2. If 1 of the key questions is rated “inadequate”, then the overall rating will normally be “requires improvement”;
3. If 2 or more of the key questions are rated “requires improvement”, then the overall rating will normally be “requires improvement”;
4. At least 2 of the 5 key questions would normally need to be rated “outstanding” before an aggregated rating of“outstanding” can be awarded.
Significantly, it is proposed that if a location does not have a registered manager where one is required as a condition of registration and satisfactory steps have not been taken to recruit one within a reasonable time, the rating can never be better than “requires improvement”. Similarly, if statutory notifications have not been submitted to CQC in relation to relevant events at a location without good reason then it is proposed that will limit the well-led rating to no better than“requires improvement.”
Reviews of ratings
At Ridouts we have very real concerns about the adequacy of the proposed review system. First, the rating review process will only be available to a provider after publication of the inspection report. Secondly, a review can only consider cases where the inspection team has failed to follow published policies and procedures. Therefore, a review will only cover the process of awarding ratings not their merits.
If the review system is introduced in its proposed form, its evident limitations will make it all the more important for providers to scrutinise draft inspection reports with the greatest care with a view to challenging facts, findings, judgements/ratings, as necessary, as part of the factual accuracy comments process as the means of trying to get relevant ratings amended. What providers should not do is place their faith in a review system that merely looks at process issues.
Providers should read the full consultation documentation given that it covers a range of topics such as covert surveillance, Provider Information Returns (the proposed successor to the old AQAAs and Provider Compliance Assessments) and important changes to the regulations.