Provider Compliance Assessments
Helen Pettengell
Judi Burwood
Ongoing monitoring
compliance
System entry
Application
made
Information
Capture
Judgement
On risk
Application
assessed
Judgement
made
Judgement
published
Information
analysis
Regulatory
judgement
Regulatory
response
Happy Days Retirement Home, Nowhere in Hertfordshire AL1 1CR
Summary of our latest checks on the standards you have the right
to expect
Standards of treating people with respect and involving
them in their care
Standards of providing care, treatment & support, which
meets people’s needs
Standards of caring for people safely and protecting
them from harm
Improvements required
Improvements required
Standards of staffing
Standards of management
Improvements required
What are you expected to comply
with ?
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Two pieces of legislation.
Health & Social Care Act 2008 (Regulated
Activities) Regulations 2010.
CQC (Registration) Regulations 2009.
28 Regulations.
Essential Standards translate the regulations
into expected outcomes and are legally
required.
A different Approach from CQC
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Compliance inspectors are now generic across
ALL services.
Focus on outcomes rather than inputs.
All visits to a service includes observation.
Policies & Procedures not examined as a
matter of routine.
A service should be compliant with the
regulations at ALL times.
Monitoring Compliance
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Focus of compliance will be on the 16 essential
standards. Level of compliance determines
level of review and regulatory action within
CQC.
Planned reviews & responsive reviews.
Review of compliance report.
Provider compliance assessment.
Current Focus
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CQC are now currently ensuring ALL social
care providers have a compliance visit.
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More likely to be focused
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Will not routinely request PCAs
Encouraging responsibility
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A service should be compliant with the
regulations at ALL times.
Provider is responsible for identifying &
managing non compliance.
Making improvements.
Quality of the care provided.
Provider Compliance Assessment
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The PCAs relate to 16 out of 28 regulations
that relate directly to the quality and safety of
care.
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Providers must have evidence that they meet
the outcomes.
Essential Outcome Areas
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Outcome 1 – Respecting & involving people who use
services.
Outcome 2 – Consent to care & treatment.
Outcome 4 – Care & welfare of people who use
services.
Outcome 5 – Meeting nutritional needs.
Outcome 6 – cooperating with other providers.
Outcome 7 – safeguarding people who use services
from abuse.
Outcome 8 – Cleanliness & infection control.
Outcome 9 – Management of medicines.
continued
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Outcome 10 – Safety & suitability of premises.
Outcome 11 – Safety, availability & suitability of
equipment.
Outcome 12 – Requirements relating to workers.
Outcome 13 – Staffing.
Outcome 14 – Supporting workers.
Outcome 16 – Assessing & monitoring the quality of
service provision.
Outcome 17 – Complaints.
Outcome 21 – Records.
Essential Standards of Quality &
Safety
The judgement Framework
The Purpose of the PCA
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Self Assessment tool
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Use it routinely or Ad Hoc
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Not mandatory
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Detail compliance/non compliance
Provider Compliance Assessments
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Will not routinely request prior to a review
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Can request some or part of a PCA
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Request should not exceed 5 PCAs
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Must submit within the specified timescale
Provider Compliance Assessment
continued
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Do not have to use CQC tool
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Each PCA should ONE location only
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You do NOT need to complete a PCA for each
regulated activity.
How to complete the PCA
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Focuses on outcomes.
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Peoples experiences & views.
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Involved & listen to.
What is outcome evidence?
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Evidence that centres on what it is like for the
person receiving services
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The impact of policies, procedures & systems
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Evidence relating directly or indirectly from the
people who use the services
Summary
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Download PCAs - do not need to use CQCs
format
Work on them in word
Tell the truth
Repetitive
Keep them updated
Future Consultation
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Current consultation on the judgement &
enforcement policy
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Simplifying the regulatory model
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More targeted - swift action if non compliant
Consultation continued:
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CQC will continue to make scheduled,
responsive & themed inspections of services
Unannounced & at least an annual inspection
Targeted
QRP
Setting the Bar incorporated into judgement
framework
Continued:
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Compliant or non compliant
Focus on identifying areas of non compliance
Where non compliance found judgement on impact
on people will be made after
Confidence in provider
Escalating scale of enforcement
Level of impact on people for each regulation
deemed non compliant.
Will publish a summary of warning notices
Other reviews of methodology
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The government was consulting on the scope
of registration
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Proposal for new form of notice
Future themed inspections
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On top of the planned & responsive reviews:
More inspections on dignity and nutrition in
2012
Themed inspection programme of home care
services.
Outcome 1:
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Respecting and involving people who use
services (Regulation 17).
Outcome 4:
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Care & welfare of people who use services
(Regulation 9)
Outcome 6
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Cooperating with other providers. People
receive safe and coordinated care when they
move between providers or receive care from
more than one provider (Regulation 24).
Outcome 7:
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Safeguarding people who use services from
abuse (Regulation 11).
Outcome 9:
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Management of Medicines (Regulation 13)
Outcome 16: Quality &
Management
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Assessing & monitoring the quality of service
(Regulation 10)
How to contact us
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JHHCA@gmx.com
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07960 602059 – Helen Pettengell
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07960 602069 – Judi Burwood