- Have a well-briefed team to support inspectors.
- Keep careful notes of the inspection.
- Always insist on full feedback.
- Raise concerns on the day.
- Always tell inspectors that you will require copies of their notes of inspection.
- Prepare your own CQC style of report.
In my article in the first half of the magazine, I talked about how to prepare for a CQC inspection. In this part, I look at the inspection day, the inspection report, and what to do after the inspection.
The inspection itself
If you have had notice of a CQC inspection, make sure that all your team are briefed well in advance. If possible, have extra staff available so that staff who know the service well can be available to support and assist the inspectors.
If the inspection is unannounced, deploy informed staff as soon as possible and bring in extra staff as soon as possible to meet any shortfalls.
Remember, while it is a criminal offence to obstruct an inspection, it is absolutely not wrong to accompany and support the inspectors. You need to know what they have observed and who they have spoken to. Inspectors should always be asked if they need anything further and given information if they have missed something. Far too often inspectors criticise the service in the inspection report, and the manager replies that the answers were there all the time. Always ask for feedback as the inspection progresses (‘Is there anything further that we can help you with?’)
Keep notes or digitally record information as the inspection progresses. You should reconstruct the inspection afterwards and produce your own report of the process. This will be invaluable if there are disagreements with the CQC that lead to judgments that the service perceives to be unfair. If you do not have a note of what happens then there is little answer to the inspector who says ‘that is what I saw on the day’. Take photographs. This is easy now with modern mobiles. CQC is seeking evidence and you need to be able to verify that evidence.
At the end of the inspection, always insist on feedback. Inspectors will be tired and may wish to cut this short, but you are entitled to feedback. CQC policy is that there should be no surprises in the draft report. If you have not insisted on feedback, you are in a poor position to challenge an inspection report when you haven’t challenged the inspector’s findings on the day.
If there are matters that can be addressed on the day or shortly after, or if there is information that could not be supplied on the day, or if there is something said in the report that is demonstrably wrong, supply that information as quickly as you can (within a few days will be appropriate).
Inspectors must review that extra information, BUT it must be full, frank and clear. It must be factual, not argumentative. Argument is for the factual accuracy review, when you can challenge facts, proportionality and the conclusions that the CQC has drawn.
Make sure any additional information is in written form and that you have brought adequate copies to demonstrate what you had done.
Whatever you think, remain cool, professional and respectful to inspectors. If you feel the inspectors’ behaviour is inappropriate, tell them at the time – perhaps in a natural break or at feedback – while maintaining professional courtesy. It is much better to raise your concerns on the day than after you have received a less than flattering report, as it may seem as if you are raising the issues because you are unhappy with the result. This is about improving the credibility of your position, as it develops.
Always note who is on the inspection team, when they arrive and when they leave. Do not hesitate to ask inspectors details of their actual experience. There is nothing wrong with being an expert in inspection but clinical social care experience may sometimes be lacking in those who simply are good at process. By questioning inspectors you will be able to put into context criticisms or praise to see if their viewpoint is either personal/subjective, or if it is based on real professional experience. Always tell the inspectors that you will need to see their notes of inspection and confirm that in writing.
After the inspection
Reaction following the inspection must be swift and focused.
- Immediately organise a debrief from senior staff and care workers on the floor.
- Address any issues reported either at feedback by CQC or reported by your staff.
- Report immediately to CQC any relevant material to clarify operational issues and fill gaps in evidence. This is to inform CQC directly, as its role is to report accurately so that a fair picture is presented to the public.
- If there are concerns about the conduct of individual inspectors, consider carefully whether and when to raise issues. Inspection is a brutal process, uncomfortable at the best of times and sometimes soul-destroying, and can affect the confidence of care staff. CQC has a job to do. Just because it is uncomfortable to be on the receiving end does not mean that inspectors have stepped beyond their remit.
- Complaints have a poor record of success. CQC is supportive of its own staff in a way that it would not tolerate for a care provider facing a complaint.
- It is better to let the challenge on facts and judgments stand on its own, rather than to muddle it with complaints about inspection conduct. Genuine criticism of inspectors’ conduct will emerge better from analysis of the facts than from a complaint.
- A complaint will not be addressed until after the report has been finalised. That finalisation will be significantly influenced by the inspectors about whom the complaint is made.
- Prepare your own CQC-style report of the inspection. Challenge will be much more persuasive if the issues have been articulated before CQC’s judgment is known. Better still, report to CQC before it produces the report. However, if there has been inadequate feedback from the visiting inspector you may not know what is to be said in the report.
- Get ready! When the draft inspection report arrives you will have a very short time to respond and that will be your last real chance to make your case.
The draft report
It may take a long time for the draft report to arrive. It will probably be at least four weeks and may be much longer. This explains the need for you, like CQC, to have contemporary records of your view of the events at the inspection. Without that, challenges articulated some four to six weeks later will lack credibility. All those who seek to make a case must produce credible evidence.
It is often said (based on advice advanced by CQC) that there is little point in challenging an inspection report. That is absolutely bad advice. The response to the draft report is vital as matters move forward. If what is said in the report is not challenged then it will be taken as established truth by the CQC. Subsequent challenges will not be easy and may be impossible, as the response is likely to be ‘Why did you not say this at the time?’
There is no effective external adjudication on challenges, but even if the inspectors refuse to accept the challenge (and it is effectively the inspector who will be the judge in their own case) the substance of the challenge will be on record and available as a counter if there are subsequent issues.
CQC itself advises that the factual accuracy response to the draft report is the provider’s one and only chance to challenge facts and judgements. Judgements can be challenged, particularly when based on facts, which are themselves under challenge.
No benefit is achieved by accepting fake allegations in the hope that humouring the regulator is a sensible outcome – it is not and will not help your relationship with them.
However, only challenge the findings where there are good grounds. Misconceived challenges create an illusion of operational ‘denial’. Challenge where you are right and can demonstrate this. If CQC is right, get on with addressing the issues.
The draft report should be addressed line by line. You may need the advice of external consultants or even lawyers. The more measured and rationally argued the challenge is, the more likely CQC is to take it seriously.
You cannot challenge on the basis that you plan to do better next time. This may work in enforcement action but not on a simple factual accuracy check to an inspection report. The fact that you have covered simple things in your challenge does not change the validity of the report, but it may affect judgments. If this is well-argued, with evidence, it may encourage CQC to note the improvement in the factual report.
There is every reason to share your responses/challenges with other stakeholders, such as commissioners or service users’ families.
- Time is short. You will have 10 working days to respond. After that CQC will close the file and publish the report.
- CQC is legally obliged to publish the report, unlike a warning notice, where it has the discretion to publish.
Speak with your directors or owners. Critically review the report. Act and act quickly. This is your only chance.
The option of a rating review is illusory. Such a review will only be accepted if there is a challenge that involves the inspectors having failed to use their accepted methodology. You may not get a rating review on the basis that facts or judgments are simply wrong. The process of the rating review will not delay publication of the report.
It is well worth getting your advisers to submit a contrast between the criteria for a rating with the draft of the report. This can demonstrate fault on the part of the inspector and will open the door more easily to a rating review.
Inspection is the cornerstone of regulation. The impression given on external review is critical.
Published inspection reports are absolutely central to the sustained survival and enhanced success of the care service in question.
Changes in the process, the increased power and influence of CQC and the hardening attitude of vital stakeholders make understanding and managing the inspection process a central part of the role of any care service manager.
The best care service business will have empowered service managers who are able to demonstrate understanding and ability to deliver successful performance reflected in positive external reporting.
About the author
Paul Ridout is Managing Director of Ridouts Professional Services PLC, and has worked with providers of health and social care services for more than 45 years. He heads a team of expert and experienced lawyers in health and social care regulation and operation. The team of 10 has over 100 years’ combined experience. Ridouts delivers advice and support for care service providers on registration, inspection, CQC enforcement, safeguarding and related contract, employment and operational issues. These include challenging inspection reports and arranging mock inspections for care providers, working with Ridouts consultancy team. www.ridout-law.com