CQC – New Fundamental Standards: Part 1, an
Introduction (included because of the QCS background information it gives)
With the help of QCS, the new standards don’t have to be scary
Background
In recent years adult care scandals appear to have been never-ending. The Mid Staffordshire NHS Foundation
Trust problems, reported to have caused 1,200 unnecessary deaths, leading to the Francis Report on NHS
patient safety and quality, are the most infamous. However, the independent sector has not been immune. In
addition to the drip, drip, drip of information from the CQC regarding individual service failings, the Winterbourne
View failures and subsequent scandal highlighted that no-one was immune from investigation and the potential
to be found wanting.
The CQC acknowledged that the existing framework for inspection and judgement left Providers confused. The
current CQC requirements are listed in a way that does not clearly differentiate between those requirements
which are essential and those which are desirable. This lack of clarity has led to confusing inspections and
judgments’, unnecessary conflict between Providers and the CQC, and the enforcement of good standards of
care to be impaired.
The Consultation sets out to focus the CQC on its core purpose: “We make sure health and social care services
provide people with safe, effective, compassionate, high quality care and we encourage care services to
improve.” (Provider Handbook (Adult Social Care) Consultation, Page 2)
In order to achieve this purpose, they say that their role is now to “monitor, inspect and regulate services to
make sure they meet fundamental standards and safety and we publish what we find, including performance
ratings to help people choose care”. (Provider Handbook (Adult Social Care) Consultation, Page 2)
The reaction from Government has been predictable. Something had to be done to reassure the public. The
CQC has been shaken around, a new care Act passed, new Parliamentary Regulations proposed, new
standards of registration and inspection developed, together with the return of the much derided but much loved
quality rating scheme.
At the time of writing, late July 2014, the state of play is that in January 2014 the Department of Health published
‘Introducing Fundamental Standards – Consultation on proposals to change CQC registration regulations’, a
document setting out the reasons for reforms, the broad outlines of the proposed reforms to CQC registration
and inspection processes. The document also included, as Appendix A, the proposed new regulations for adult
social care in the form of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The
Regulation was stated as coming into force in October 2014. However, the CQC website currently indicates that
the implementation date is April 2015, subject to Parliamentary process.
The CQC have published, over an extended period, documents describing their detailed proposals for delivery of
the new registration and inspection system based on the Fundamental Standards. The proposals were published
as consultations, and the deadline for responses is currently listed on the CQC web site as October 17th 2014.
To confuse matters, a recent statement by a CQC Inspection Team Manager was to the effect that they were
expecting to begin implementation in October 2014, had been informed that the Regulations would not be
through Parliament by then, but were “going to start implementation anyway”. Given that public statements by
CQC staff are scripted and officially sanctioned, the clear implication is that Providers would be best advised to
begin implementation of any changes required to meet the Fundamental Standards from, or very soon after,
October 2014.
The new regulatory processes
The CQC has published a schematic of their regulatory process under the new arrangements.
(Provider Handbook (Adult Social Care) Consultation, Page 6)
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent monitoring

Expert inspections

Judgement and publication

Followed by action, if indicated by the inspection outcome
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 7)
Flowing out of the eleven Fundamental Standards in the Regulations, the CQC have developed five Key
Questions to be asked of the Service, each of which is expanded by the Key Lines of Enquiry, or KLOEs, which
will, for as long as they last, be referred to by the female name (K)Cloe(s). The KLOEs will structure the
inspection process, and each KLOE is expanded by a series of prompts, or more detailed requirements.
Thus far, the Fundamental Standards look like the usual rearranging of the same requirements into a different
structure. However, beneath the bland exterior lie some changes of focus and emphasis which will have
significant consequences on how adult social care providers register and manage their organisations and people
in future.
Quality Compliance Systems Ltd (QCS) provides legal and quality compliance management systems for adult
social care providers in England, Scotland and Wales. Although the changes being outlined only affect England
in legal terms, the changes in emphasis brought about by their implementation will ripple out into Scotland and
Wales.
QCS is preparing its management systems for the expected implementation of the Fundamental Standards
approach in October. In a series of articles each aspect of the new regime will be discussed and the revised
QCS approach outlined.
CQC – New Fundamental Standards: Part 2,
Registration
QCS can help you along the path to achieving your registration requirements
This article will expand on the registration element of the process.
Registration
If one word were to describe the proposed new approach to registration of new providers, it would be “robust”.
Judging from historical precedent presumably this rigorous approach will also apply to variations in registration.
Applications for variation, being a time when a provider is at a negotiating weak point, has long been seen by
regulators as a time when pressure can be brought to bear on issues which were difficult to enforce under
normal circumstances.
Several elements of the process of registration, which while they are present in the current system have been
refocused and reinforced.
Fit person
The CQC have stated that they will take a more rigorous approach to judging if a person having strategic or
managerial control of a care organisation is a fit person to do so. A quote from CQC documents point to the foci
of the examination (our emphasis):
“Our 2013-16 strategy document ‘Raising Standards, Putting People First’ states that we would introduce a more
thorough test for organisations applying to provide care services. This would include making sure that named
directors, managers and leaders of a service commit to meeting our standards and are tested on their ability to
do so.” (Provider Handbook (Adult Social Care) Consultation, Page 11)
The old test of Fit Person, which sometimes appeared to rely solely on the absence of any adverse content of
the disclosure process, now looks to become a more proactive and rigorous process, with an added focus on the
ability of the proposed provider to understand and lead an effective adult social care organisation.
Skills
In the past, fairly bland and untested assurances as to skill levels and approaches have sometimes appeared to
be sufficient for a provider to gain registration. Demonstration of skills which indicate an understanding of adult
social care processes and how they affect the safety and well-being of the user of the service have not always
been required, and certainly not tested. Often, it appeared that the management of the organisation to meet care
standards was assumed to be delegated to the Registered Manager, with the provider only having to
demonstrate or assert general business skills. This approach was seriously let down by there being no obvious
mechanism to police the reliance on a safety net with two anchor points – the provider and the manager. A high
risk situation could occur when a competent manager left employment and thus left the provider with no, or poor,
skills in adult social care, leaving the service rudderless. It also had to be questioned whether such a provider
had the skills to competently recruit a manager. If the CQC deliver on their promise of rigorous enforcement of
standards of adult social care competence of providers as well as managers, there will be a welcome
improvement in the depth and health of management in some organisations where it is currently lacking.
To quote CQC again:
“Registration will assess whether new providers have the capability, capacity, resources and leadership skills to
meet relevant legal requirements, and are therefore likely to provide people with safe, effective, caring,
responsive and high quality care. The assessment framework will allow registration assessors to gather and
consider comprehensive information about proposed services, and make judgments about whether applicants
are likely to meet these legal requirements.”
(Provider Handbook (Adult Social Care) Consultation, Page 11)
Management of the business and financial skills
The Southern Cross collapse and general panic focused minds on judging the financial capability of providers to
maintain a safe and effective care service. While mechanisms are being brought in to specifically address the
issue of financial stability for larger providers, it should be assumed that a change of approach will be evident to
some extent at least throughout the registration process for all sizes of provider. Start-up business plans may
come under more detailed scrutiny in future, with a reasoned assessment of the provider to provide a financial
and resource safety net for the inevitable challenges to the smooth progress which most business plans lay out.
Care skills
The implication of the CQC quotation under “Skills” above is that there will be improved focus on the specific
adult social care skills of providers, and the individuals that make up the entity, even if they are several, such as
a board of directors or multiple partners. Those individuals who cannot demonstrate preceding care skills may
well have to exhibit robust mechanisms for ensuring that their functioning is care-aware, and sensitive to the
specific requirements of the adult social care sector.
Focus on culture as a means to an effective service
The management model, within which the staff oriented elements of the Quality Compliance Systems (QCS)
compliance system were developed, held to the view that staff could not be expected to respect those for whom
they cared if their employer did not, through every process affecting those staff, show respect for the staff
themselves. For many years this principle was hidden or unacknowledged within many care services, but the
Francis Report has highlighted the importance of a respectful and therefore open culture on the quality of care.
The QCS system will continue to be developed within these principles, reinforcing the cultural effect of the whole
system, which is to promote caring and responsive processes because staff are themselves treated with the
respect due to them.
The QCS system is not a disparate compilation of disconnected policies and procedures; the pack of policies
has an underlying cultural identity, which staff reading it may not be consciously aware of, but through it will be
encouraged to follow best practice. The promotion of a respectful and positive culture extends from recruitment,
through induction, day to day management, informing and involvement of staff, discipline – which is conducted
fairly and transparently, finally to termination.
Whatever the contents of the QCS system, it affects staff; the effect will be negated unless there is effective
leadership and management. The system seeks to inform staff at all levels that they are an indispensable part of
the whole. Responsive management of quality and culture is embedded, encouraging leaders and managers to
prioritise on these functions.
Generally
Some of the above could be dismissed as a possibly unlikely interpretation of the consultation documents seen
to date, summarised by the quotations. However, the appearance of the top-level Fundamental Standard of
“Well-led” points clearly to a sharpened focus on the leadership skills contained in an applicant organisation, in
addition to the preceding requirement for management skills. Experienced operators of adult social care know
well that the execution of even highly detailed and robust management process is no assurance of safe and
effective care. No manager, or supervisor, can be omnipotent. The more astute of those in control of
organisations, of any kind but especially those delivering care, know that effective and empowering leadership
leads to a positive, open and performing culture, which, when then combined with a rigorous management
process, leads to consistently improved organisational performance. The Stafford debacle followed by the
reports on it, firmly make this point.
It is likely that much or even all of these requirements will feature in the new registration process. Clear signs of
a movement towards this goal have already been seen in the feedback from Quality Compliance Systems (QCS)
customers who have been assisted and advised by us as they go through the registration process. Providers
also need to be aware that although the CQC currently uses the caveat “new” in respect of the proposed
registration process, the standards developed will inevitably roll out across existing providers in time.
The QCS Care Quality Management System has always been based on the human rights principles on which
the new Standards are founded. In addition, good leadership principles are embedded throughout the system,
and the creators and maintainers of the system are assiduous in their adherence to a common “voice”, which in
turn helps create a culture which is strongly standards-based, which seeks to drive out poor performance and
reward safe and effective care practice throughout the organisation, not just the direct care departments. As
such, the QCS system is very well-placed indeed to meet the new Standards, and existing users of the system
will find that their task of compliance will be significantly eased by their prior use of the system, as long as they
implement it in its entirety.
During the development of the QCS response to the Fundamental Standards, due to be implemented in October
2014 and available from QCS from September, a new Leadership Policy and Procedure will be introduced to
highlight the elements of the QCS system which support good leadership and develop culture. One effect of the
new Policy will be to highlight the importance of links between policies which promote good leadership, and also
point out those policies which may under the existing registration regime have appeared to be optional, but
which now become mandatory. The Policy will enable QCS customers to check their leadership effectiveness,
make adjustments where necessary, and set out confidently on a path to achieving robust compliance with
registration requirements.
Background
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October
2014 a new regime of registration and inspection. This is in response to failures of the current regime to spot and
deal with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime,
demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent monitoring

Expert inspections

Judgement and publication

Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 6)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 7)
CQC – New Fundamental Standards: Part 3, The
Standards
The QCS team is here to help you easily and confidently transition to the new
inspection regime
This article will expand on the Fundamental Standards themselves.
The Standards
The CQC now proposes that eleven Fundamental Standards be introduced, below which no provider will be
expected to fail, backed by swift and effective enforcement action.
The eleven proposed Standards give rise to the five Key Questions the CQC will ask of each Service:

Is it Safe, protecting people from abuse and avoidable harm?

Is it Effective, with care, treatment and support achieving good outcomes, promoting good quality of life,
and being evidence-based wherever possible?

Is it Caring, with staff involving people and treating them with compassion, kindness, dignity and
respect?

Is it Responsive, with services organised in such a way as to meet people’s individual needs?

Is it Well-led, with leadership, management and governance asserting the delivery of high quality
person-centred care, supporting learning and innovation, and promoting an open and fair culture?
In order to focus inspections and judgments on the Fundamental Standards, inspectors will use a set of question
formats termed Key Lines of Enquiry (KLOEs). Each KLOE set will include a mandatory set of enquiries which
will be checked on every inspection, plus four other enquiries as indicated by the inspector’s knowledge of the
Service, intelligence gathered, or concerns raised. The KLOEs will be expanded by “prompts”, which will define
the particular evidence which the inspector will look for. An advantage of this approach will be improved levels of
consistency between inspections of the same Service over time, and between Services.
Attention is drawn in the Consultation to the CQC’s principle of promotion of Equality and Human Rights. The
new approach is said to be firmly based on this principle. In consequence, the underlying approach of inspection
will be to look at what rights people hold, as opposed to what the Service should do for people.
The human rights approach will underpin the examination of the eleven Fundamental Standards, each of which
will be scrutinised through the filters of fairness, respect, equality, dignity, autonomy, rights to life, and rights for
staff. In addition to underpinning the KLOEs, the human rights approach will similarly reinforce the proposed
ratings system, Intelligent Monitoring, inspection methods, learning and development of the CQC staff, and the
CQC’s own policies and procedures.
Key Lines of Enquiry
Each of the five Key Questions is expanded by Key Lines of Enquiry. As the name suggests, these are the more
detailed requirements which the CQC will expect to see during inspections, supporting each of the Key
Questions.
Each service sub-type has its own set ok KLOEs, for instance, community services, residential services, mental
health services.
Taking the community KLOEs as an example, each Key Questions has a number of KLOEs to expand it.

Safe – 5 KLOEs

Effective – 4 KLOEs

Caring – 4 KLOEs

Responsive – 3 KLOEs

Well-led – 4 KLOEs
Each of the KLOEs has a varying number of prompts to further elucidate the requirement.
As an example, the following is S1, the first KLOE in the community care set.
(Provider Handbook (Adult Social Care) Consultation, Page 34)
Note that this KLOE is highlighted. The implication of this will be discussed in the article about the proposed new
Inspection process.
This example demonstrates one factor in the new standards; the language of the detailed requirements is
familiar, and is clear. Those who know the Essential Standards and the detailed prompts will feel a sense of
comfort from seeing the familiar. However, there are some changes.
There are changes of emphasis, partly as a result of sharpened language and partly because of the focus on
safety in particular. Do not lose sight of the fact that the original furore around Stafford, Winterbourne View and
Southern Cross centered on the safety of users of the services. It is not surprising therefore that added
emphasis has been given to the area of Safety.
The other notable emphasis change, which also arises from the same furor, is the highlighting of Leadership and
sound governance of care provider organisations. It has been noted, not before time, that requiring certain
processes does not deliver quality services. Good governance, leadership support good management and an
achieving, open, effective and safe culture, and the new Fundamental Standard of Well-led focuses’ on exactly
that area.
Overall the KLOEs and prompts are more outcomes orientated than process orientated. This is presumably in
recognition that processes do not of themselves deliver safe and effective services. The true measure of how a
service performs is how the user of the service feels about that performance. The days of ‘Matron knows best’
have long gone, but their replacement, the ‘Professional knows best’ is still with us, and the intention of the
Fundamental Standards is to drive professional input to the place it should be, which is advisory and not
mandatory on the service user.
The QCS system has already been fully reviewed to judge its compliance with the Standards, KLOEs and
prompts in order to meet the September 2014 revised system launch date. Because of the history of the
development of the system, the regular, rigorous review and updating by a large team of expert contributors, and
the speed with which changes are made to the system and delivered direct to your desktop, the review found
that only small changes were required to existing policies.
However, the reinforced emphasis on measuring outcomes as defined by service user views means that a very
significant proportion of the evidence which will be required to be placed before CQC inspectors to demonstrate
compliance will stem from direct questioning of the service users themselves wherever possible, or their
advocates and family where not possible. QCS is developing a suite of customer, staff and professional
questionnaires in order to provide this information. The questionnaires will be completely focused on providing
exactly the information required by the prompts in order to make delivery of the information by the provider, and
interpretation of the data by the CQC.
Safety in the QCS system is embedded throughout; QCS does not regard the Health and Safety Policy as the
only source of safety information. Every policy is vetted to confirm its contribution to safety and safe practice
before publication, on the principle that the policy manuals are the primary staff training resource. While in the
ideal world all staff know and understand all policies, including Health and Safety, a robust management system
ensures that a staff member who only reads the policy related to their current activity is working to safe principles
in that activity.
Personalisation has always been a fundamental principle within the QCS system. All policies promote the
individual application of process rather than blanket application, but most importantly of all care planning is made
the central pivot of all processes in the Service. The QCS system encompasses the strategy that all activity in
the Service happens because one or more care plans call for it. The corollary is that if an activity is not called for
in a care plan, the question must be asked “why is it happening?” The answer could be “because we have
always done it”, which is wasteful and potentially depersonalising and therefore should cease, or because of
some underlying legal requirement, in which case the requirement should be double checked for validity and
only imposed if there are no alternatives. Everything in the care planning system, including the policy and
procedure and care plan format is designed to make it easier to take the personalised approach as opposed to
others.
By definition, the effective use of the care planning cycle embedded in the QCS format makes responsiveness
easier – the service user is constantly reminded that they are expected to be represented in the process and in
control of it, and the staff user is pulled along a path which encourages them to constantly review the
effectiveness of the care strategy agreed with the service user.
Historically, the QCS system has been heavily dependent on a human rights approach, arising originally from
Homes are For Living In, and being broadened with the enactment of the Human Rights Act in 1998. Every
policy has been created and reviewed through the prism of human rights, and the full set promotes respect for
human rights throughout all activities.
The availability of a system already closely compliant with, but further updated to the new Fundamental
Standards, backed up by the QCS Customer Care team to answer questions and concerns, means that QCS
management system users will be able to confidently transition from the old to the new inspection regime.
Background
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October
2014 a new regime of registration and inspection in response to failures of the current regime to spot and deal
with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime,
demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent Monitoring

Expert inspections

Judgement and publication

Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 2)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 2)
CQC – New Fundamental Standards: Part 4, Evidence
gathering
QCS is here to help you gather all the evidence you need for the new CQC
inspections
This article will expand on the approaches to evidence gathering which the CQC will use.
Evidence gathering
The CQC says that their intelligence gathering system is called Intelligent Monitoring, and it is used to identify
when where and what to inspect. This approach is key to their policy of targeting scarce inspection resource
where it is most needed.
A previous article explained that the 11 Fundamental Standards are monitored by asking 5 Key Questions, each
of which are themselves expanded into several Key Lines of Enquiry (KLOEs). Similarly to the previous
Outcomes, each KLOE is further expanded into a set of Prompts, which are in effect the key performance
indicators for the KLOE. Some, but not all of the KLOEs are listed as “Mandatory”, which means that they will be
assessed at every inspection. The other KLOEs are to be inspected on a different schedule, and it is this
schedule which will be informed at least in part by the Intelligent Monitoring process. KLOEs which have been
indicated through Intelligent Monitoring as a potential risk area will be added to the next inspection schedule for
that Service, or trigger an out of schedule on-site inspection.
Some of the sources of intelligence are explained in the CQC publication Provider Handbook – Consultation,
section 4, page 20.
Healthwatch
CQC explain, in Provider Handbook – Consultation, section 3, page 15 that:
Local Healthwatch staff and volunteers work to make sure the voices and experiences of people who use
services, carers, families and the public are heard. They also influence the planning, provision and improvement
of health and social care services and represent people’s views on the health and wellbeing boards set up by
local authorities. We will have a regular and two way relationships with local Healthwatch in every area, giving
them the opportunity to share their evidence about social care services including their ‘enter and view’ reports
when they have visited services themselves. We will coordinate our inspection plans with their own enter and
view programme to ensure we are not both visiting services at the same time.

Statutory notifications

Safeguarding alerts

Reports from users of services

Reports from staff

Reports from the public
Notifications of all these data will be viewed by the CQC individually, and also examined for negative trends. The
QCS system encourages and facilitates a simple administrative system to record all notifications to simplify
regular trend review for Quality Assurance purposes.
To illustrate the approach, the CQC have published a draft example of sources of intelligence in their publication
Provider Handbook – Consultation, section 4, page 21.
This process has been in use by the CQC for some years, ever since they moved from regular inspections to
targeted inspections. However, Providers should not be complacent about the process simply because it has
been around for some time. The CQC clearly state that while Intelligent Monitoring will inform risk assessment
and may trigger further information gathering or an on-site visit, it will not be used on its own (our italics) to
decide final judgments. The language indicates that Intelligent Monitoring may influence final judgments,
together with other information; therefore all Providers need to be aware of and manage the flow of information
arising out of their day to day operations. The days of the on-site inspection being the only factor in the final
judgement have long gone, and lack of attention to information supervision could have negative consequences.
The QCS system is explicit about what information needs to be reported to the CQC, and how to do it. The
intention is that through the exposure of all employees to the Policy and Procedure system, they are all aware of
their reporting responsibilities to management, assisting the Registered Manager in maintaining the legally
required level of notification.
Within the Quality Assurance model in the QCS system, data is managed in such a way that identifying trends,
be they negative or positive, is enhanced and surrounded by action oriented mechanisms to make sure that
responsive action takes place as a result.
The QCS care compliance system is being edited and updated to match the new standards, including the need
for good information management and analysis. For instance, the matter of feedback to CQC from Service
Users, families, professionals and employees should not be left to chance. The responsible Provider regularly
surveys each of these groups. The objective is to identify dissatisfactions at an early stage and feed them into
the service improvement management system before they reach crisis proportions, leading to reports to external
agencies such as CQC. In other words, using surveys intelligently to drive the quality assurance process, rather
than simply as a mechanism for a pat on the back. The design of the new QCS surveys has moved away from
the traditional question-based format to a format which enhances the flow of information about their rights given
to the Service User. This in turn meets one or more of the new KLOEs, a compliance not achieved by
conventional survey methods.
QCS is providing a full suite of surveys to each group mentioned above, each survey focused on one of the Key
Questions. In addition, a totally revise Mock Inspection Toolkit is in preparation which will be split into two useful
elements – first of all a statement of the processes, usually based on QCS Policies and Procedures, which need
to be in place to produce the results expected by the Standards. This section will form a major part of the
Provider’s compliance implementation plan. Secondly, we are providing a checklist of evidence which should be
provided by the processes, enabling the Service to periodically audit that it is actually carrying out the required
processes identified in part 1, and producing the required evidence. Planning and regular use of the Toolkit will
give Providers the information they need to steer their Service along the path to full compliance with the
Fundamental Standards.
Finally, on the subject of information, the CQC have introduced the Provider Information Return (PIR). This
document is a modification of the familiar Provider Compliance Assessment, edited and expanded to match the
Fundamental Standards. The CQC state that they have not yet decided if this will be regularly issued, or whether
it will be a pre-cursor to inspection. It will primarily be available online.
Much of the updates which QCS is introducing into its compliance management system to meet the
Fundamental Standards is aimed at assisting the Provider to gather the information required by the PIR over
time, with the effect that the information should be more accurate, not compiled as a result of a last minute rush,
and, critically, open for analysis throughout the data gathering period so that trends can be identified and
managed. These may be negative trends which require correction, or positive trends which require building on.
Background
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October
2014 a new regime of registration and inspection in response to failures of the current regime to spot and deal
with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime,
demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent Monitoring

Expert inspections

Judgement and publication

Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 2)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 2)
CQC – New Fundamental Standards: Part 5,
Inspections
This is what your new inspections will look like
This article will expand on the approaches to inspections which the CQC will use.
In their draft Provider Handbook, published in April 2014 for consultation, the CQC sets out its proposals for how
inspections will work after 1st October 2014.
Some key overall points are:
Community services inspections will usually be pre-announced 48 hours before they will take place. This is not
done in order to negotiate a suitable day, but to inform the service that the inspection is to take place on the
appointed day, and to make sure that the manager, or a senior person in charge, is there on the day. “A senior
person in charge” implies a working deputy to the manager if the manager is unavoidably absent. This is not the
Provider if they are not in day-to-day management control, and therefore not able to provide detailed operational
information. The inspector is interested in what is actually happening in the service, not what the Provider hopes
or assumes is happening.
For residential services, site visits will normally be unannounced.
According to the handbook, the inspection team will consist of either one person, or a small team.
The expanded team may involve Experts by Experience, who will be people with personal experience of services
either directly themselves, or by being a carer for someone else who has received care. They will be responsible
for contacting service users for their opinions. The Expert will feed back to the Inspector, and may accompany
them on their site visit.
Inspection frequencies will depend on the rating of the service:

Inadequate – within 6 months of the last inspection

Requires Improvement – within 12 months of the last inspection

Good – within 18 months of the last inspection

Outstanding – within 24 months of the last inspection
In addition to these inspections there will be inspections that:

Respond to risk

Are carried out to follow up on any action the CQC has told the Provider to take
The CQC will also each year inspect 10 per cent of randomly selected ‘good’ and ‘outstanding’ rated services
that are not due an inspection in accordance with the timescales above.
Planning Inspections
The CQC inspection planning will take into account:

Intelligent monitoring, as explained in our previous article

Registration information

Previous inspection reports and follow-ups

Comments and feedback from people who use the service, and the public

Healthwatch feedback

Local voluntary and community groups, including equality groups

Feedback from questionnaires sent by the CQC

Feedback from telephone interviews

Information from other agencies. Fire and environmental agencies are mentioned for residential
services, but none are specified for community services.

The Provider Information Return (see a later article)

Statutory notifications

Applications for variation of registration

Information from staff, in the form of feedback from questionnaires
The site visit
The visit will begin with a meeting with the senior person on duty, and the inspector expects to see the manager,
registered person, nominated individual, or senior person in charge.
The inspector will inform you which Key Lines of Enquiry they will be inspecting, and:

Whether they are following up on any previous issues

The proposed length of the inspection

The roles of the inspection team members

Who they plan to speak with

Documents they want to review

How they will feedback about what was found during the inspection
During the visit the inspector and/or the Expert by Experience will gather views about the service from people
who use it, individually or in groups depending on the service type, speaking to them either in person, by
telephone or by visiting them at home, and speaking to families and visitors, again depending on the service
type. Where there are communication barriers they will use interpreters, other specialists and care staff
expertise. The inspector will also speak to friends and relatives of people who use the service, either on the
telephone or in the person’s home, before, during or after the day they visit the service office.
Information will also be gathered from staff, by which they mean the Registered Manager, senior person on duty,
or care and support staff, cleaning staff, catering staff, maintenance staff, (depending on the service type) or all
of these.
Other information will be gathered by:

Observing care (but not intimate personal care)

Using the SOFI 2 (Short Observational Framework for Inspection) tool when there are people using the
service who are unable to tell them about the care they receive (in residential services)

Tracking individual care pathways (care plans)

Talking to volunteers, community professionals and other people involved in the service

Looking at the environment, including individual and communal rooms (in residential services)

Reviewing records
In some situations where they have concerns they may seize some forms of evidence, use photographs and
take copies of documents. They may also need to gather evidence under the provisions of the Police and
Criminal Evidence Act 1984 (PACE). If they do this, they will explain to the senior person on duty what they are
doing and why.
Throughout the inspection the inspector will continuously evaluate the evidence they have seen, and make
adjustments to their assumed schedule to take account of findings, obviously in particular any concerns they
may have.
If the inspector finds any concerns around safeguarding, they will invoke the CQC safeguarding protocol and
bring the matter to the attention of the manager or person in charge. If the person subject to the abuse is
deemed to be at risk, the Inspector will take immediate appropriate action.
Closing the visit
At the end of the inspection visit to the service, the inspector will hold a feedback meeting with the person in
charge on the day of the inspection. At this point in the inspection the inspector will only be able to give high
level feedback which will not include what the rating for the service might be.
At this meeting the inspector will:

Explain what has been found during the visit

Highlight any issues that have emerged

Explain that this is preliminary feedback and that they cannot make a judgement until they have
considered all the evidence together. For example, there may be evidence from Experts by Experience to
analyse, or feedback from people they could not speak with on the day

Say when the report can be expected, how any factual inaccuracies can be challenged and what the
publishing arrangements are

Answer any questions from the person in charge and receive their feedback on the inspection process
so far

Say what the next steps will be
Background
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October
2014 a new regime of registration and inspection in response to failures of the current regime to spot and deal
with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime,
demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent Monitoring

Expert inspections

Judgement and publication

Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 2)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 2)
CQC – New Fundamental Standards – Part 6,
Judgement
What’s changed in how the CQC will reach a judgement about your service?
This article will expand on the approaches to inspections which the CQC will use.
In their draft Provider Handbook published in April 2014 for consultation, the CQC sets out how it will handle
Inspection Judgments from 1st October 2014.
The method of reaching a judgement does not appear to have changed. That is hardly surprising as there are
not many variations possible on “using professional judgement”.
As we have seen in previous articles, the criteria on which the judgments will be reached have not changed
dramatically. Much has been moved around, and expressed in different words, but in the end the major change
is not in the fundamentals, but in the emphasis. This statement is, of course, true only of the upper reaches of
quality care services. While poor services have always been characterised by formulaic approaches to care, with
little or no understanding of personalisation, the best services have long understood the importance of
individually tailored care. Similarly, safety has long been a priority for good services, hopefully leaving the
scandals over abuse and premises risk to those at the bottom of the quality stack. How do the good services
differentiate themselves in these two critical areas, amongst others? By attending the third change of emphasis,
which is the discovery by the CQC standard writers that not much good happens in any service unless there is
vision, leadership, good values and the management skills to bring these consistently to bear on the whole
service.
Therefore, following the long period which it will take many providers and managers to gain an operational
understanding of the Fundamental Standards, the best services will come to understand that they do not have to
revolutionise their service, but think about it differently. The publication, in the Provider Handbook, of quite
detailed information about the evidence which the CQC will look for has given an insight into this previously
opaque area, allowing the interested service to create measurement tools to find out before inspection how they
think they may be performing. It is a characteristic of a good and well-managed service that it normally has a
fairly accurate idea of its own performance levels, and does not receive too many surprises – everyone is proud
of that they do and want to do it well.
Below par services will, however, have a hard time. It is possible that poor services work in relative ignorance of
their legislative responsibilities anyway, and the shuffling around of the requirements can only exacerbate that
problem.
Ratings are back
One major change will, however, focus minds on improving performance, and that is the return of Ratings. No
longer is it sufficient for a service to simply claw its way over the legislative threshold by a tiny margin – in the old
inspection regime, no differentiation was made between “only just made it” and “exemplary”, so for some the
attitude was, “why bother?”
Ratings change all that. All CQC registered services between October 2014 and April 2016, will be awarded a
rating ranging from ‘Outstanding’, to ‘Good’, down to ‘Requires improvement’, and finally ‘Inadequate’. With the
possibility of poor services being publicly labeled ‘Requires Improvement’ or even ‘Inadequate’, there will be
plenty of incentive to improve. Even the top range of services will be striving to reach or retain ‘Outstanding’ – it
is in their nature to want to be the best.
What does this mean on a day-to-day basis? As outlined in the previous article on Evidence, the gathering of
evidence of how well you are working is no longer an option. It is an essential part of daily management, in order
to clearly demonstrate how your service is performing, and how you are managing it towards improvement,
wherever it is now.
How can QCS help?
For those using the QCS Compliance System, the process will be a little easier. QCS has published within their
management system – soon available to all existing and new clients – a set of tools intended to help services
cope with the new inspection regime with relative ease. The tools are:

A complete suite of Surveys, focused on the Key Questions – for Service Users and their advocates;
their families; professional advisors, and staff. Many of the KLOE prompts cannot realistically be supported
by direct documentary evidence; the criteria are based on the Service User’s feelings and understandings,
which can only be evidenced by formal surveys.

A Mock Inspection Toolkit, with checklists of evidence required for each KLOE.

A new Policy for each KLOE, listing those QCS Policies and Procedures which contribute to the
achievement of that KLOE. Also included in each Policy is a narrative explaining the processes, based
mainly but not exclusively on the QCS Policy pack, that are required to be in place and successfully running
in order to generate the evidence to be found when carrying out the Mock Inspection.

A renewed emphasis on the management and quality assurance processes which have always been a
key element of the QCS system, but which in the past were advisable but not so critical for simply reaching
the regulatory threshold. In the new regime they are critical, and we point this out at numerous points in the
new tools.
In addition to these innovations, QCS has developed a new approach to Mock Inspections, Surveys, Supervision
and Training which will, in our opinion, significantly enhance performance and therefore legislative compliance.
Next week, the final article in our series of New Care Standards guides will outline how the new Ratings system
works from the CQC point of view, and try to tease out what the strategies of providers and managers should be
in order to achieve their best outcome from the rating process.
Background
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October
2014 a new regime of registration and inspection in response to failures of the current regime to spot and deal
with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime,
demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these
being:

Registration

Intelligent Monitoring

Expert inspections

Judgement and publication

Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 2)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 2)
CQC – New Fundamental Standards: Part 7, CQC
Ratings
From 1st October 2014, the Care Quality Commission (CQC) began inspecting adult social care providers using
the new model inspection regime, which we have covered in preceding articles. The CQC say that all services
will be rated by April 2016. The new approach, as proven by the published Fundamental Standards themselves,
the Key Lines of Enquiry (KLOEs) and the prompts (the expansion of the KLOEs into more detailed evidence), is
not a radical change. However, as we have noted, there are some significant changes in emphasis, with wellpublicised focus on the safety and effectiveness of the service. Less well-signposted has been the ramping up of
examination of leadership and management matters, presumably as a result of the corporate scandals of recent
years. How much of the leadership and management spotlight will be beamed on smaller and medium sized
services remains to be seen, but this article will demonstrate that no provider, whatever their size, can produce
good results in the other four Fundamental Standards without excellent leadership and management processes.
The one new concept, or to be more precise, the concept which has been returned to, is the awarding of ratings.
The ratings will be:

Outstanding

Good

Requires improvement

Inadequate
How will CQC ratings be awarded?
The CQC state that: “Inspection teams will base their judgments on all the available evidence, using their
professional judgement. They will particularly use the key lines of enquiry, the prompts and our guidance on the
ratings levels” (Source – The CQC Provider’s Handbook, all versions). Therefore, the inspection will be the key
driver, but as we have seen, Intelligent Monitoring (IM), a continuous process, will have an effect on the
outcomes of inspection. Should IM indicate concerns, or concerns are raised during the inspection, further
investigation over and above the initial inspection may take place.
First of all the CQC will use their ratings methodology and professional judgement to arrive at a rating for each of
the five Key Questions – is it Safe, Effective, Caring, Responsive, Well-led? For each of the five Key Questions
the inspector will ask themselves:

Does the evidence demonstrate that we can rate the service as good?

If yes – does it exceed the standard of good and could it be outstanding?

If no – does it reflect the characteristics of requires improvement or inadequate?
This flow chart illustrates the process:
Services will be rated ‘Inadequate’ usually where one or more regulations are breached. Some ‘Requires
improvement’ services may also be in breach.
The process of arriving at the rating is further illustrated by this diagram from the CQC’s Provider Handbook.
The ratings characteristics are freely published by the CQC. Because they are too detailed to include in this
article, the reader is advised to download them from:
The aggregation rules, leading from the five individual Key Questions rating to the overall rating are as follows:
Services are rated at two levels.
Level 1: Using rating methodology and professional judgement to produce separate ratings for each of the five
Key Questions.
Level 2: Aggregate these separate ratings up to an overall location rating using ‘ratings principles’.
An illustration, from The CQC Provider’s Handbook, all versions
The rating aggregation principles are set out in the Appendix to the Provider’s Handbook, which can be found at
the links given above.
The principles can be modified by using professional judgement, having regard to all of the evidence. The CQC
quote the following in the Provider’s Handbook as examples:

Where the concerns identified have a very low impact on people who use services.

Where we have confidence in the service to address concerns or where action has already been taken.

Where a single concern has been identified in a small part of a very large and wide ranging service.
The CQC emphasise that the starting point of their deliberation is the description of a good service. They say
that the characteristics are not a tick list; it is a guide to professional judgement. Not every characteristic has to
be present, particularly at the extremes. For instance, they make the point that in an otherwise good service, one
instance of an inadequate characteristic that affected service users could lead to an overall rating of ‘Inadequate’
whatever else the results were.
It is plain, therefore, that any provider, whether or not they are aiming for an ‘Outstanding’ rating, had best be
absolutely certain that no standards are dropped across the board, lest they be banished to the outer reaches of
‘Inadequate’, and be totally out of the running for consideration of any outstanding characteristics. Conversely,
the CQC say that: “Even those rated as outstanding are likely to have areas where they could improve.” (Source
The CQC Provider’s Handbook, all versions).
The CQC give passing mention to quality control and quality assurance in the statement “with consistency
assured through the quality control and assurance process” (Source – The CQC Provider’s Handbook, all
versions).
Quality Compliance Systems (QCS) would argue that this statement, and the preceding one “Even those rated
as outstanding are likely to have areas where they could improve” fail to develop the concepts sufficiently to be
of significant help to providers’ management strategy. This is no surprise, and not a criticism, because the CQC
are not tasked with examining how good things happen, just whether or not they do. It is in filling in this gap that
QCS comes into play.
The QCS approach to compliance management is that providers do not run their organisations to provide
compliance. Compliance is not their customer. Their service users are their customer, and most providers have a
passionate vision of what they want to achieve for their customers. That vision is usually expressed in such
terms as “excellent”, “personal”, “wow factor” and similar entirely positive language. Therefore, providers develop
leadership and management techniques to achieve their personal goals, which, based on the above language
will be very close to the requirements of registration bodies. However, that leaves providers open to the risk of
missing some vital element of registration (and other legal) compliance, even as they satisfy their own vision and
their customers’ expectations. Also, in some cases, techniques of leadership and management are poorly
understood by care managers who have risen through the vocational skills ranks without exposure to
contemporary leadership concepts, and they feel that they do not have the skills, or the time, to square the circle
of personal vision versus legal compliance.
It is precisely to fill this confidence gap that the QCS compliance system comes into play. The QCS system
brings to its users a multi-dimensioned approach to care service management which is well suited to the new
regulatory environment:

A recognition that while excellent service does not flow from individual policies and procedures, however
many of them there are, it does flow from the consistency which comprehensive, best practice, practical
and well-applied policies and procedures can provide.

QCS is the resource to seamlessly square the circle between the excellent care approach which
providers want to provide and their legal compliance responsibilities. Our policies and procedures are
based on best practice and when diligently applied through thorough staff training result in excellent safe
and personalised services, while always meeting or exceeding legal standards.

The QCS approach recognises that an excellent management system is not a collection of discrete
policies – it is a comprehensive and consistent model which supports the user to achieve not just excellent
results occasionally, but to achieve them consistently, and even continuously improve on them. The
consistency is a result of the QCS quality assurance approach, which underpins every policy in the system.