UKHCA Briefing Paper CQC’s consultation on the way CQC regulates,

UKHCA Briefing Paper
CQC’s consultation on the way CQC regulates,
inspects and monitors care
In June 2013, CQC published A New Start: Consultation on the way it regulates,
inspects and monitors care. This follows Raising standards, putting people first,
published the previous April which set out a new purpose for CQC: to make sure
health and social care provide people with safe, effective, compassionate, highquality care and to encourage care services to improve. To deliver its purpose,
CQC is planning to make significant changes to how it works. It is also acting on
the recommendations of the report by Robert Francis into the failings at Mid
Staffordshire NHS Foundation Trust and the government’s response in Patients
First and Foremost.
The consultation is CQC’s next step towards making the changes to deliver its
purpose. It sets out the principles underlying how it will inspect all services and
some more detailed proposals for how it will inspect NHS trusts and foundation
trusts and independent acute hospitals. It also includes some joint proposals
between CQC and the Department of Health (DH) on changes to regulations that
underpin its work, including some important new responsibilities for CQC set out
in the Care Bill.
The consultation is the first of a series of consultations on detailed changes to
how different types of services will be inspected, with changes being
implemented at different times during the next three years. CQC intends to run
the first of its consultations for adult social care in autumn 2013 which will set
out its initial thinking on how it will changes its regulatory approach for this
The focus of this Briefing Paper is CQC’s thinking on the way it inspects adult
social care services, including introducing ratings. It does not look at how it will
inspect and regulate NHS and independent acute hospitals.
General principles
To get to the heart of people’s experience of care, CQC says it needs to ask the
right questions about the quality of services. It will ask the following five
questions of every service:
Is it safe?
Is it effective?
Is it caring?
Is it responsive to people’s needs?
Is it well-led?
 By safe, CQC mean that people are protected from physical, psychological or
emotional harm.
 By effective, CQC mean that people’s needs are met, and their care is in line
with nationally-recognised guidelines and relevant NICE quality standards or
that effective new techniques are used which give them the best chance of
getting better or living independently.
 By caring, CQC mean that people are treated with compassion, respect and
dignity and that care is tailored to their needs.
 By responsive, CQC mean that people get the treatment and care at the right
time, without excessive delay, and that they are listened to in a way that
responds to their needs and concerns.
 By well-led, CQC mean that there is effective leadership, governance (clinical
and corporate) and clinical involvement at all levels of the organisation, and
an open, fair and transparent culture that listens and learns from people’s
views and experiences to make improvements. The focus of this in on
A better system for organisations applying to provide care
CQC says that the system and checks it uses when providers apply to register
with it need to be stronger, to make sure that those who intend to provide care
are focused on-high quality care and understand the commitment they are
making to people about the care they will receive.
 CQC will introduce a better system for providers applying to register with it to
provide care. CQC will do this by making sure that:
The process of registering with it is effective and efficient, partly
through building efficient digital services.
Providers who already deliver good quality care can offer new services
There is a more robust test for providers whose ability to deliver
quality care is less clear.
Those who register make a commitment to deliver safe, effective,
compassionate, high quality care.
Named directors or leaders of organisations are personally held to
account for that commitment. This is in addition to making sure
providers and registered managers are held to account for the care
they provide.
Those CQC register show it that they have good plans for how they will
provide care, including an effective system for spotting and dealing
with problems. They must also show that they focus on the right things
when they employ staff, and that they are committed to listening and
acting on the views and experiences of people who use their service.
 From July 2013, CQC will start to apply this different system to those offering
services for people with learning disabilities. CQC will learn from this when it
adapts and extends it to other types of services in the future.
 CQC will work towards making sure that when those who provide services
register a change of name or a new owner, they cannot do this in a way that
hides any previous or current concerns about the quality and safety of the
service from CQC or from the public.
 DH is proposing to make changes to regulations that support these
improvements and which would make it easier for CQC to take tough action,
including prosecution.
Intelligent monitoring of information and evidence about the
quality and safety of care
CQC says it does not always make the use of all the information available to it in
terms of it directing its regulatory activity. CQC will rethink and redesign the
way it uses information. In future, it will be clearer about the indicators that are
most important in monitoring the quality of care and focus on the information
that matters for each type of care.
 CQC will make better decisions about when, where and what to inspect by
using information and evidence in a more focused and open way.
 CQC will continue to gather information from national and local data and
intelligence sources, past inspections, and from local authority overview and
scrutiny committees. Also, working closely with local Healthwatch and local
voluntary groups as well as information from people who use care services
about their quality and safety of their care, including concerns and
complaints. It will take full account of information from care staff, including
Simple clear standards to judge the quality and safety of services
In future, CQC will go beyond statements of legal compliance with standards of
quality and safety, and tell people what it thinks about the quality and safety of
the care given by that provider.
 CQC will make sure the public are clear about the safety and quality of
care they can expect from their health and social care services. This will
reflect the five questions CQC will ask about the quality and safety of
 These standards will help CQC judge whether or not services are safe,
effective, caring, responsive to people’s needs and well-led when it is
registering, inspecting and rating services. CQC will use them to support
its professional judgements about these five areas rather than to record
‘compliance’ or ‘non-compliance’ with standards.
 CQC has reflected on the findings and suggestions made by Robert Francis
in his report. It proposes that it builds on his proposals to look at:
Fundamentals of care
Expected standards
High-quality care
 CQC will be actively engaging with clinical professionals and representative
bodies to ensure the standards are meaningful to those delivering front-line
care, alongside our engagement with people who use services.
Fundamentals of care
 All care services will be required by law to meet the fundamentals of care and
the expected standards. CQC will make sure that the bar for each of these
levels is very clear
 The fundamentals of care represent the basic requirements that should be
the core of any service. The fundamentals of care will set a clear bar below
which standards of care should not fall.
It is CQC’s intention that the new regulations will allow it to prosecute breaches
of care without the need to issue a warning notice first.
Expected standards
Expected standards set out what anyone using a service can expect as a matter
of course. They set a higher bar than the fundamentals of care and will relate
directly to whether a service is:
CQC will look at whether any of its existing ‘essential standards’ could be
reflected in the new expected standards.
Following this consultation, DH will issue a draft of the new regulations for
further discussion in the autumn, and CQC will issue draft guidance on the
expected standards in parallel.
The guidance will replace the existing, detailed Guidance about compliance and
will recognise the different care experiences possible, ranging from treatment in
a hospital to visiting a GP or living in residential care. It will make clear that a
person’s wellbeing must be considered, particularly where people are generally
cared for longer term, at home, in hospital or in residential care.
High-quality care
The definition of high-quality care will be led by organisations such as NICE, for
example NICE quality standards. CQC’s inspectors will use good practice
guidance developed by these other organisations to identify and describe
whether a service is providing high-quality care. CQC will also look for where
providers are using new ways of providing good, innovative care.
Expert inspection teams, led by Chief Inspectors of Hospitals,
Social Care and General Practice
 CQC is appointing Chief Inspectors of Hospitals, Social Care and General
Practice to lead national teams of inspectors who specialise in particular
types of care (CQC inspectors will no longer be generalists who inspect all
types of care). The Chief Inspectors will ‘shine a powerful light’ on the
quality and safety of care. Their teams will include independent clinical
and other experts, such as people with in-depth experience of using care
 CQC inspectors will speak to more people who use services and frontline
staff to hear about the reality of the care they receive, to senior members
and to board members. They will also inspect at nights and at weekends
services that provide 24-hour care.
 The inspectors will use professional judgement, supported by objective
measures, to assess the quality and safety of care. They will also issue a
rating which will highlight good and outstanding care, expose mediocre
and inadequate care and encourage services to improve.
 CQC will inspect services less often if it is confident that they are offering
safe, high-quality care and can continue to do so. CQC will focus less on
the number of inspections it carries out and more on the number of days
it spends inspecting services.
Action being taken by CQC
 CQC will expect and encourage those who provide care to be open and
honest about issues and problems that are affecting the quality and safety
of people’s care. CQC expect providers of care to respond positively to
feedback and to take action to put things right where necessary. CQC is
clear that “it is the responsibility of those who run and work in the service
to improve it.”
 CQC will follow up on all of our inspections and judgements to make sure
that a service has improved or remains high-quality care. It has a range
of existing powers it can use to make sure the service takes action.
From April 2014, CQC will have powers to:
Hold Board members to account for failing to honour their
commitments to provide safe, high-quality care. CQC says this could
result in them being removed from their posts.
Prosecute a provider for failing to provide fundamental levels of care,
without having to issue a formal warning first (this is reliant on
legislation being passed by Parliament).
Make sure the service is open and honest with the people who use the
service and their families about things that have gone wrong and why
this has happened – this will be covered by the new ‘duty of candour’
planned for inclusion in revised CQC regulations (see box below).
 DH will shortly consult on the accountabilities of board members in parallel to
this consultation.
Duty of candour
 The government intends to introduce a statutory duty of candour as a CQC
registration requirement on all health and social care providers. Under this
duty, providers will be required to make sure staff and clinicians are open
with people who use services and their families where there are failings in
care and to provide an explanation for it.
 The registration requirement should be sufficiently clear that CQC could
prosecute an organisation without having to issue a warning notice. The new
registration requirement should mean CQC can take action against a provider
that was not open with people who use services about failings in care.
Better information for the public
 CQC’s inspection reports will explain the reasons for the inspection and
describe its findings, assessment and judgement on the expected
 Safe
 Effective
 Caring
 Responsive to people’s needs
 Well-led
 The inspection reports will include a simple summary of the main points
for each of the five questions so that people can quickly understand the
quality and safety of the service, together with more detail. They will set
out clear areas of excellence and areas where improvement is required
and explain what will happen next and include a rating to help people
compare services.
 CQC will develop over the next three years a rating system for most
providers of health and social care. Its ratings will develop to become the
single, authoritative assessment of the quality and safety provided by an
organisation. They will be primarily based on the judgements of CQC’s
inspectors about whether services are safe, effective, caring, responsive
to people’s needs and well-led, and will take into account all the
information it holds about a service and the findings of others. CQC will
develop them in partnership with the public, partner organisations,
providers of services, clinical and other experts.
 CQC will also be keen to draw on the insight and day-to-day
understanding of partners such as local authorities, health and well-being
boards, overview and scrutiny committees, and of commissioners such as
clinical commissioning groups and GPs in their interaction with the
services they commission.
 Ratings will be updated as a result of inspection by CQC. How often
inspections take place will depend on the last rating and CQC’s continuous
monitoring of services.
 CQC will publish the information on which the rating is based.
 CQC will make clear on its website when a service is being inspected so
that the public understands that CQC’s judgement and rating might
change. It plans to publish any new rating as quickly as possible
following its inspection.
 CQC will begin by rating providers of acute services from December 2013,
and will start to introduce ratings for adult social care services from 201415.
CQC’s consultation questions on adult social care1
What do you think about the overall changes we are making to how we
regulate? What do you like about them? Do you have any concerns?
Do you agree with our definitions of the five questions we will ask about
quality and safety (is the service safe, effective, caring, responsive and
Fundamentals of care
Do you think any of the areas in the draft fundamentals of care above
should not be included?
Do you think there are any additional areas that should be fundamentals
of care?
Are the fundamentals of care expressed in a way that makes it clear
whether they have been broken?
Do the draft fundamentals of care feel relevant to all groups of people and
Should the rating system seek to be the ‘single, authoritative assessment
of quality and safety’? Although the sources of information to decide a
rating will include indicators and the findings of others, should the
inspection judgement be the most important factor?
Would rating the five key questions (safe, effective, caring, responsive
and well-led) at the level of an individual service, a hospital and a whole
trust provide the right level of information and be clear to the public,
providers and commissioners?
CQC’s has also asked a number of questions about the inspection and regulation of NHS and independent
acute hospitals, ratings for acute hospitals, the draft Regulatory Impact Assessment accompanying the
consultation, and the separate Annex on the Proposed model for intelligent monitoring and expert judgement
in acute NHS trusts.
Duty of candour
Do you agree that a duty of candour should be introduced as a
registration requirement, requiring providers to ensure their staff and
clinicians are open with people and their families where there are failings
in care?
Do you agree that we should aim to draft a duty of candour sufficiently
clearly that prosecution can be brought against a health or care provider
that breaches this duty?
Do you have any other comments about the introduction of a statutory
duty of candour on providers of services via CQC registration
CQC’s consultation on the way it regulates, inspects and monitors care is open
until Monday 12 August 2013.
The consultation document can be downloaded from:
UKHCA’s position
UKHCA issued the following press release:
United Kingdom Homecare Association, the professional association for
homecare providers, welcomed the Care Quality Commission’s consultation
“A new start”, which opens up debate on quality standards in health and
social care.
The CQC is proposing to set “Fundamental Standards” - the most basic
minimum standards that the health and social care providers must meet or
face enforcement action. The fundamental standards will not replace CQC’s
current Essential Standards of Quality and Safety, although these will be rewritten in the future.
Colin Angel, UKHCA Policy and Campaigns Director, said:
“CQC has indicated greater willingness to produce the new standards by
talking to providers and their representatives in much greater detail than has
happened in the past - a move which we thoroughly endorse.”
The proposals also include plans for a quality rating system to be introduced
for NHS hospitals from late 2013 and adult social care providers from 2014.
Colin continued:
“Adult social care providers have been extremely keen for CQC to introduce a
quality ratings system. While many will be disappointed to learn that these
ratings are unlikely to be introduced until 2014, UKHCA would rather see
workable ratings produced rather than an unsuitable system developed in
UKHCA has already been in discussion with CQC about their proposals to
raise the bar for registration of new providers of care services by applying
greater scrutiny to organisations applying for registration.
Colin concluded:
“It is in the interests of people who use services and the social care sector
that providers entering the market are totally committed to safe, effective
and well-managed services.”
UKHCA also welcomed the CQC’s plans for inspectors to be more specialised
than currently, and the Commission’s intention to use external experts to
assist the inspection process.
Francis McGlone
UKHCA Senior Policy Officer
© June 2013
This briefing is provided as a service to UKHCA member organisations. It does
not attempt to be an exhaustive statement of law. United Kingdom Homecare
Association Ltd accepts no liability for organisations acting or refraining from
acting solely on the information contained in this briefing.