- The CQC’s proposed changes to inspection aim to ‘reduce complexity’ and create more consistency.
- Proposals include changes to the registration of services for people with learning disabilities.
- The five key question test will remain unaltered and still forms the basis for the rating system.
- Some of the changes to the five key questions have come about because of areas of weakness discovered by CQC inspectors.
The Care Quality Commission (CQC) has put forward proposals for changes to the way it regulates health and adult social care services in England.
The proposals are set out in a new consultation document published in December 2016. Our next phase of regulation: a more targeted, responsive and collaborative approach sets out proposals to implement the ideas for change originally put forward in last summer’s CQC strategy for 2016 to 2021.
The consultation seeks views on:
- changes to CQC assessment frameworks across all sectors to ‘reduce complexity’ and create more consistency
- how CQC will regulate ‘new models of care’ and larger or ‘complex’ providers in future
- how inspectors will change the registration of services for people with learning disabilities
- how inspectors will regulate NHS trusts and foundation trusts from April 2017, including how they might change their approach to rating them.
The CQC says it wants to achieve a regulatory system that enables inspectors to be more flexible and responsive to innovative practice and changes in care provision.
Changes to the assessment framework
The current system of regulation consists of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, the fundamental standards and an assessment framework based on the five key question test: asking if services are safe, effective, caring, responsive and well-led. Key lines of enquiry and ratings characteristics are set out in CQC’s guidance handbooks for each sector. These help providers know what is expected of them and guide inspectors in applying ratings judgements.
In Our next phase of regulation, CQC proposes moving away from the 11 separate assessment frameworks currently published for each type of provider. Instead, there will be just two ‘overarching’ frameworks: one for health care and one for adult social care. Draft copies of the proposed replacement handbooks have been published on CQC’s website along with the main consultation document. These are: Annex A1: Key lines of enquiry, prompts and ratings characteristics – healthcare services; and Annex A2: Key lines of enquiry, prompts and ratings characteristics – adult social care services.
The CQC has retained two separate frameworks to reflect that, while the types of care provided in health and social care are not mutually exclusive, the purposes, settings and nature of care are sufficiently different to require a different focus in assessments. Common themes have been reviewed across the health and adult social care sectors to ensure that both sectors are assessed under the same key questions. Where possible, similar wording has been used. The result for adult social care is a single handbook to replace the existing residential and community guidance.
Annex A2 not only sets out the combined guidance for all adult social care providers, it also includes a useful colour-coding system to show where new lines of enquiry have been added and where others have been altered.
For example, under key question 1 (‘Is the service safe?’), the first key line of enquiry remains: ‘How are people, including children and families, protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?’
However, two new key lines of enquiry have been added to this section, prompting inspectors to ask:
- Are the systems, policies, processes and practices that are essential to keep people safe identified, implemented and communicated to staff?
- Are people’s individual care records accurate, complete, legible, up to date and securely stored to keep people safe?
Care providers will want to have a careful look through the proposed new handbook annex and take note of the changes that will affect their self-audit and quality assurance processes.
Our next phase of regulation states that the changes are intended to reduce complexity and confusion and to simplify the regulation process by more closely aligning the questions asked of different sectors. The CQC hopes that the result will be a fairer system, with more clarity about what ‘good care’ looks like.
The revised assessment frameworks will be introduced in phases. The new framework for community and residential adult social care services will apply from July 2017 after a further consultation in the spring.
CQC stresses that its intention has not been to ‘shift the bar’ and make it harder to achieve a good rating.
The five key question test
Under the proposed changes, the five key question test remains essentially unaltered and still forms the basis for the rating system. However, CQC has proposed changes to alter the emphasis in some of the questions.
Is the service safe?
CQC says that the safety question will remain a key focus in the future targeted approach and that it will continue to look at whether people are protected from abuse and avoidable harm. However, inspections have highlighted the greatest concerns to date in this area, and so CQC says it has strengthened several elements of safety. These include recruitment practices, safeguarding, discrimination, medicines management, information-sharing and management, and responding to external alerts and reviews.
Is the service effective?
CQC is not proposing to change the focus of the ‘effective’ key question. Some elements have been strengthened, however. For example, there is a new key line of enquiry prompting inspectors to ask how well staff, teams and services work together to deliver care and treatment.
Is the service caring?
Under the proposed changes, the key question on caring still focuses on compassion, kindness, involvement and emotional support, but CQC has strengthened assessments in this area to look at how the service supports a caring culture.
One new key line of enquiry is a prompt for inspectors to ask if a service gives staff the time, training and support they need to provide care in a compassionate and personal way. They are also prompted to ask if rotas, schedules and practical arrangements are organised so that staff have time to listen to people, answer their questions, provide information and involve people in decisions.
Is the service responsive?
The ‘responsive’ question has been refocused. The consultation document states that, following feedback from providers, aspects such as service-planning for population needs have been moved from the ‘responsive’ question to the ‘well-led’ question. Key lines of enquiry relating to end-of-life care have been moved from ‘caring’ to ‘responsive’.
Is the service well-led?
The well-led question for healthcare providers puts more emphasis on providing a demonstrable link between leadership, culture and the delivery of safe, high-quality care. To support this change, additional key lines of enquiry and prompts have been added to guide inspectors. CQC has updated the social care framework so it aligns with these changes.
The concept of ‘themes’ is strengthened in the updated framework, reflecting changes in the way care is delivered and the increase in integrated systems where providers work closely together.
Key themes for the future are identified as:
- leadership, integration and information-sharing
- information governance and data security
- new technologies and innovations
- end-of-life care
- personalisation, social action and the use of volunteers.
CQC's next phase of regulation makes no proposals for changes to the current ratings system, apart from the rating of healthcare trusts. It does, however, hint that CQC is rethinking how it approaches providers who have improved their performance after a ‘requires improvement’ rating but have not yet done enough for a ‘good’ rating. CQC will include further details on this in another consultation in the spring.
Complex providers and new models of care
The updated framework for inspection proposes changes to the way larger and more complex organisations are rated and registered. Again, CQC will make firm proposals in the spring about how larger providers are registered at the level of what it calls the organisation’s ‘guiding mind’.
CQC admits that inspectors need to be more flexible in future to better support those providers employing ‘new or innovative approaches’ to care.
Registering services for people with learning disabilities
As part of the consultation, CQC is seeking views on draft updated guidance for providers that are registering to care for people with learning disabilities.
The proposals are contained in Annex B: Registering the right support. CQC’s policy on registration and variations to registration for providers supporting people with learning disabilities, also published on the CQC website.
Several modifications are proposed to the regulation of NHS trusts, including acute, mental health, community and ambulance trusts. A more responsive, collaborative, targeted approach is set out, with more importance given to effective leadership.
- The main consultation document and supporting materials can be found on the CQC website at:www.cqc.org.uk/content/our-next-phase-regulation.
- A second consultation will be held in the spring of 2017 to decide on final changes.
About the author
Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.