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2015019 900401 ASC inspection handbook October 2014 v 3.10 Page 1
Inspection handbook Adult social care
October 2014
2015019 900401 ASC inspection handbook October 2014 v 3.10 Page 2
The Care Quality Commission is the independent regulator of health and adult
social care in England
Our 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.
Our role
We monitor, inspect and regulate services to make sure they meet fundamental
standards of quality and safety and we publish what we find, including performance
ratings to help people choose care.
Our principles
We put people who use services at the centre of our work.
We are independent, rigorous, fair and consistent.
We have an open and accessible culture.
We work in partnership across the health and social care system.
We are committed to being a high performing organisation and apply the same
standards of continuous improvement to ourselves that we expect of others.
We promote equality, diversity and human rights.
2015019 900401 ASC inspection handbook October 2014 v 3.10 Page 3
Contents
Foreword from the Chief Inspector of Adult Social Care ................................................. 4
1. Introduction ................................................................................................................... 5
2. Experts by Experience (ExE) ......................................................................................15
3. Inspection .....................................................................................................................20
4. Judgments and ratings ...............................................................................................41
5. Actions and recommendations .....................................................................................46
6. Reporting ........................................................................................................................48
7. Quality control and assurance ......................................................................................49
8. Publication ......................................................................................................................50
9. Request for rating review ..............................................................................................52
10. Enforcement .................................................................................................................53
11. Focused inspection ......................................................................................................54
12. Evaluation .....................................................................................................................57
13. Support .........................................................................................................................58
Appendix A: High Level inspection flowchart .................................................................59
Appendix B: High level post inspection flowchart ..........................................................60
Appendix C: Expert by Experience inspection flowchart ...............................................61
Appendix D: Expert by Experience post inspection flowchart ......................................62
Appendix E: Ratings request for a review – at a glance process: .................................63
2015019 900401 ASC inspection handbook October 2014 v 3.10 Page 4
Foreword from the Chief Inspector of Adult Social Care
Dear colleague Welcome and thank you for taking the time to read this Inspection Handbook, which sets out our approach to inspecting adult social care services.
More than a year’s work of careful preparation and discussion informed the development of this approach. We started with the framework that the Care Quality Commission applies to all health and care services:
The five key questions – is a service safe? effective? caring? responsive to people’s needs? And is it well-led?
The ratings – to judge whether a service is inadequate, requires improvement, is good or outstanding.
But the detail of our methodology (including the key lines of enquiry, the evidence we will consider and the ratings characteristics) was developed in collaboration with people who use services, carers, providers, commissioners, national partners and our staff. The external and internal co-production groups as well as the roundtable discussions and workshops, the outcome of consultation and two phases of testing all helped to shape the final design of the approach set out in this Inspection Handbook.
We have considered what processes and tools we need to support inspectors so we can be confident that the judgements we make are robust, fair and consistent. The Inspection Handbook brings this all together – it sets out how we will carry out our inspections, the questions we will ask, how we will arrive at a rating judgement and what enforcement action might look like.
I know from the feedback we have had, that inspectors feel this approach really helps us to get under the skin of services, and delivers a much more holistic view of how well they are performing. By doing better inspections we can make better judgements, which can only help to improve adult social care services across the country.
We have produced this updated version of the Handbook to reflect the introduction of the new regulations and fundamental standards, which come in to effect from 1 April 2015. The regulations introduce new duties to CQC, and also mean significant changes for how we take enforcement action against providers.
At the heart of our approach are the people using services, their families and carers – asking the questions that matter to them, listening to their views, taking action to protect them when that is necessary and providing them with clear, reliable information. We must never forget that, which is why I always talk about the Mum Test – is this a service that you would be happy for someone you love and care for to use? If it is, that’s great and let’s celebrate it. But if it is not, we have to do something about it.
I hope you find the Inspection Handbook a useful tool to do just that and thank you for all your hard work and commitment to make a difference. Best wishes
Andrea
Andrea Sutcliffe, Chief Inspector of Adult Social Care April 2015
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1. Introduction
This handbook describes our approach to our new style inspections of adult social care from October 2014.It applies to all adult social care inspections – residential, community services and hospice services.
Service types Containing
Ad
ult s
ocia
l care
S1. Residential social care Care home services with nursing; Care home services without nursing; Specialist colleges
S2. Community based adult social care services
Domiciliary care services; Extra Care housing services; Shared Lives schemes; Supported living services
S3. Hospice services Hospice services; Hospice services at home including children’s hospice services
Types of inspection
We have comprehensive and focused inspections.
Comprehensive inspections take a good look at a service and award a rating. They are at least every two years subject to available resources. The following frequencies will apply:
Services that are rated as ‘outstanding’ will normally have a comprehensive
inspection within two years of the last comprehensive inspection
Services that are rated as ‘good’ will normally have a comprehensive
inspection within 18 months of the last comprehensive inspection
Services that are rated as ‘requires improvement’ will normally have a
comprehensive inspection within 12 months of the last inspection
Services that are rated as ‘inadequate’ will normally have a comprehensive
inspection within 6 months of the last inspection
We also undertake a number of random inspections of good and outstanding services each year that are not due an inspection in accordance with the timescales above.
And we carry out inspections in response to risk. These may be comprehensive or focused inspections.
Focused inspections do not look at all five questions and may address specific breaches of the regulations or respond to specific concerns.
Our inspections will usually be unannounced. In a few instances, where there are
very good reasons, we may let the provider know we are coming. For example, we
may contact small homes to check that people are home before setting off to inspect.
We also normally give domiciliary care services and shared lives schemes 48 hours
notice before our site visit. Please see section 3.1.4 below for further detail.
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Introduction of the fundamental standards regulations From April 2015 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 come into force. These regulations introduce the fundamental standards that providers must meet. The regulations also introduce the following new statutory duties: The duty of candour (regulation 20) Regulation 20 requires registered persons to be open and honest with the people who use their service when something goes wrong with their care or treatment. When a specified safety incident has occurred in respect of care provided, the regulation sets out clear legal duties on registered providers about how and when to notify people using their service (or their relevant representatives) about those safety incidents. This includes informing people about the incident, providing reasonable support, and providing truthful information and an apology. This statutory duty on organisations supplements the existing professional duty of candour on individuals. You can find detailed guidance on the duty of candour here [Insert Link]. The fit and proper person requirement for directors (regulation 5) Regulation 5 requires that directors, who have overall responsibility for the quality and safety of care, and for meeting the fundamental standards, are fit and proper for this role. It applies to all providers that are not individuals or partnerships. We may take enforcement action where we have evidence that a provider has not met the requirement to appoint and have in place fit and proper directors. You can find detailed guidance on fit and proper person requirement for directors here[Insert Link]. We have published guidance for providers on meeting the regulations to help providers understand how they can meet the fundamental standards and other legal requirements. We have also updated our enforcement policy. You can find further information at section 10 below. We will provide training to support the enforcement guidance. Guidance on how to report on breaches of the legislation is in the report writing guidance on the intranet. Guidance is also available on the arrangements supporting any enforcement action we take during the transition to the new regulations. Requirement to display ratings From April 2015 providers must display their CQC ratings. Further information has been included at section 4.5
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Market Oversight of ‘difficult to replace’ adult social care providers From April 2015, we will have a new function to oversee the financial stability of the
most difficult to replace providers of adult social care. This will make sure we can
give local authorities early warning of likely business failure, so they can put plans in
place to ensure people continue to receive care if a service has to close. Local
authorities have a duty under the Care Act to ensure people continue to receive care
when care services close.
Providers will enter the scheme automatically if they are considered to be difficult to
replace. It is not a sign that they are at risk of failure. Providers are considered
‘difficult to replace’ on the basis of their size, concentration within local markets
and/or if they provide specialist services. This includes both residential and non-
residential services.
The Market Oversight & Corporate Provider Team will monitor providers in the
scheme. You will not need to change how you inspect services in the scheme. But
you must make the team aware of any significant issues or concerns that arise from
your inspection of a provider in the scheme, and also for corporate providers that are
not part of the scheme. For example, if you note staffing or maintenance issues due
to budget cuts or where you are giving ‘Inadequate’ or ‘Outstanding’ ratings. You
should try to do this before you finalise your report so we can respond appropriately
and swiftly in relation to corporate providers, where we need to.
You can find more detailed guidance on the intranet here. We have also published guidance on our website.
Our new methods We have refined and improved our new methods and tools using feedback from our external consultation, internal and external co-production meetings, and inspections that tested the new approach. Our approach means that we focus on people’s experience of care and support, using five key questions. Our focus is to look for what is good and to encourage improvement rather than looking for compliance with regulations. However, our approach also makes sure that we can take any necessary action where services are inadequate or need to improve. We have developed more tools to help us to understand the experience of people using services, such as the greater involvement of Experts by Experience and the use of questionnaires.
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1.1 The five key questions
To get to the heart of people’s experiences of care and support, the focus of our
inspections is on the quality and safety of services, based on the things that matter
to people. We ask five key questions about the care service we are inspecting:
Is it safe?
Is it effective?
Is it caring?
Is it responsive to people’s needs?
Is it well-led?
For the regulation and inspection of health and social care services, we have defined these five key questions as follows:
Safe By safe, we mean that people are protected from abuse and avoidable harm. In adult social care, this means that people are supported to make choices and take risks and are protected from physical, psychological and emotional harm; abuse, discrimination and neglect.
Effective By effective, we mean that people’s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. In adult social care, this means that people are supported to live their lives in the way that they choose, and experience the best possible health and quality of life outcomes.
Caring By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. In adult social care, this means that people, their families and carers experience care that is empowering, and provided by staff who treat people with dignity, respect and compassion.
Responsive By responsive, we mean that services are organised so that they meet people’s needs. In adult social care this means that people get the care they need, are listened to and have their rights and diverse circumstances respected.
Well-led By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality, person-centred care, supports learning and innovation, and promotes an open and fair culture. In adult social care, this means that management and leadership encourage and deliver an open, fair, transparent, supporting and challenging culture at all levels.
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1.2 Key lines of enquiry
Beneath each of the five key questions there are a series of ‘key lines of enquiry’
(KLOEs). KLOEs are posed as questions to help you focus your inspection and
consider what evidence you may want to gather to help you form a judgement about
the quality of the service for each of the five key questions.
There are three sets of KLOEs one each for residential services, community services
and for hospice services. KLOEs ensure consistency of what we look at under each
of the five questions and make sure we focus on those areas that matter most. This
is vital to reach a credible, comparable and consistent rating across all the services
we regulate.
There are 21 KLOES in total: 16 of these are mandatory KLOEs that must be
covered at every comprehensive inspection. There is one extra mandatory KLOE
(responsive 3) for specialist colleges.
As part of your planning for a comprehensive inspection you should consider
whether you need to assess any of the five non-mandatory KLOEs. Your decision
should be based on intelligence you have about the service taking into account
areas of identified risk or areas of good practice. During an inspection you may also
want to look at one or any of the non-mandatory KLOEs if you come across
information that raises concern.
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KLOEs for residential services and community services
Mandatory KLOEs are highlighted in yellow.
PLEASE NOTE: E5 is a residential KLOE only. It does not apply to community
services
Safe
S1 How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?
S2 How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected?
S3 How does the service make sure that there are sufficient numbers of suitable
staff to keep people safe and meet their needs?
S4 How are people’s medicines managed so that they receive them safely?
S5 How well are people protected by the prevention and control of infection?
Effective
E1 How do people receive effective care, which is based on best practice, from staff who have the knowledge and skills they need to carry out their roles and responsibilities?
E2 Is consent to care and treatment always sought in line with legislation and
guidance?
E3 How are people supported to have sufficient to eat, drink and maintain a
balanced diet?
E4 How are people supported to maintain good health, have access to healthcare services and receive ongoing healthcare support?
E5 How are people’s individual needs met by the adaptation, design and decoration of the service?
Caring
C1 How are positive caring relationships developed with people using the service?
C2 How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support?
C3 How is people’s privacy and dignity respected and promoted?
C4 How people are supported at the end of their life to have a comfortable, dignified and pain free death?
Responsive
R1 How do people receive personalised care that is responsive to their needs?
R2 How does the service routinely listen and learn from people’s experiences, concerns and complaints?
Mandatory for specialist colleges only
R3 How are people assured they will receive consistent co-ordinated, person-centred care when they use, or move between, different services?
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Well-led
W1 How does the service promote a positive culture that is person-centred, open, inclusive and empowering?
W2 How does the service demonstrate good management and leadership?
W3 How does the service deliver high quality care?
W4 How does the service work in partnership with other agencies?
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KLOEs for hospice services
Mandatory KLOEs are highlighted in yellow.
PLEASE NOTE: C4 is not included as a separate KLOE. This is because end of life
care and dignity in death is a theme throughout all of the hospice services KLOEs.
Safe
S1 How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?
S2 How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected?
S3 How does the service make sure that there are sufficient numbers of suitable
staff to keep people safe and meet their needs?
S4 How are people’s medicines managed so that they receive them safely?
S5 How well are people protected by the prevention and control of infection?
Effective
E1 How do people receive effective care, which is based on best practice, from staff who have the knowledge and skills they need to carry out their roles and responsibilities?
E2 Is consent to care and treatment always sought in line with legislation and
guidance?
E3 How are people supported to eat and drink enough and maintain a balanced
diet?
E4 How are people supported to maintain health, have access to healthcare services and receive ongoing healthcare support?
E5 How are people’s individual needs met by the adaptation, design and decoration of the in-patient hospice or day hospice?
Caring
C1 How are positive caring relationships developed with people using the service?
C2 How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support?
C3 How is people’s privacy and dignity respected and promoted?
Responsive
R1 How do people receive personalised care that is responsive to their needs?
R2 How does the service routinely listen and learn from people’s experiences, concerns and complaints?
R3 How are people assured they will receive consistent co-ordinated, person-centred care when they use, or move between, different services?
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Well led
W1 How does the service promote a positive culture that is person-centred, open, inclusive and empowering?
W2 How does the service demonstrate good management and leadership?
W3 How does the service deliver high quality care?
W4 How does the service work in partnership with other agencies?
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Prompts and sources of evidence To help you answer the five key questions, each KLOE has a set of prompts and potential sources of evidence. Prompts are questions that sit beneath each KLOE. Exploring the prompts as part of your inspection will help you to gather the evidence to judge the quality of the practice in the service. When considering the prompts and sources of evidence you must remember that the questions you ask and the sources you use must lead you to sufficient evidence to be able to answer each KLOE and make a robust judgement. The prompts and the sources of evidence are not an exhaustive list, or a ‘checklist’ that you have to use. However, you must make sure you gather sufficient evidence to be able to reach a robust judgement. Consider the amount and depth of evidence required to answer the KLOE and the overall question. You may not need to cover every prompt for each KLOE to do this, or you may think of some additional prompts that would help you gather the evidence needed. The potential sources of evidence column describes ways in which you may be able to find the evidence for each KLOE. It suggests evidence that may help you plan your inspection, the questions you might want to ask people, what you may want to observe and the types of records you might want to review. More information about selecting KLOEs can be found in the planning section below.
The KLOEs, prompts, sources of evidence and characteristics of rating levels
have not been included in this handbook, but are available on the intranet
here.
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2. Experts by Experience (ExE)
This section outlines the key role that Experts by Experience (ExE) play in our inspections. It takes you through their involvement from planning to reporting but must be read alongside the detailed processes later in the handbook. ExE bring a richness and diversity to our inspection activities, along with a personal experience of using or caring for someone using services. By working with them, we are able to focus on the experience of people who use services and demonstrate how much we value this perspective in our inspections. ExE are part of the inspection team and must be proactively involved in the whole process. Initially ExE will be available for approximately 50% of adult social care inspections. Each region will be told the number available and you will have to identify the inspections where you need an ExE. As new arrangements come into place for ExE we expect this to increase. In the interim. you should use the following criteria when making your decision:
Large services – 50 people or more.
Phone calls for medium and large domiciliary care agencies.
Services where planning shows contradictions in evidence.
Services where there are concerns that people’s voices aren’t heard in services.
Services where people have communication difficulties which the ExE can better overcome or understand, or where the inspector judges that an ExE with similar experiences will give people more confidence to share their views of the service.
Services where someone with experience and skills in communicating with people with complex needs is needed. For example, someone who uses Makaton.
Services where there are outstanding compliance actions and we want to find out about improvements from the experiences of people using the service.
Services where we want additional evidence from an ExE to help support the judgement.
There are two flowcharts showing how you should work with an ExE in Appendices C and D below.
2.1 Planning The ExE will have a maximum of 10 hours for the inspection. This time will include all their activity: pre-inspection work, site visit or telephone calls, feedback and writing their report. To book an ExE you must complete a webform, which is available on the intranet here. It is important that you give all the information asked for so the support organisation can best meet your needs when allocating an ExE. You should complete the webform six weeks before the inspection. If you need to cancel or reschedule an inspection or make any changes to your request, you will need to do this via the webform. You should try to do this as soon as you are aware of the change. If you need to make a change or cancel your request with less than 72 hours’ notice, you will need to contact the support
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organisation and ExE directly as well as completing the webform. CQC is still charged when changes are made with very little or no notice. The support organisation will contact you before they allocate an ExE to check that the details are correct and there are no last-minute changes. They will select an ExE based on your requirements and send you a profile of the ExE which will include details of their experience. If the allocated ExE does not have the relevant experience you should ring the support organisation to discuss. If you cannot resolve the matter with them then you should email the involvement team at [email protected] The support organisation trains their ExE so they know and understand their role and our inspection process. They make sure they are aware of our new approach. You must involve the ExE at the planning stage of your inspection. You should use your judgement to decide how much of the planning tool you share with the ExE, you can share it all if you wish. As the planning tool will include relevant information from the pre-inspection information pack there is no need to share the information pack with them. Agree as much as possible which areas you want them to look at. Make sure the ExE knows what questions to ask and what you want them to look for during the visit and discuss how they should record their responses. They will be given a report template to complete. You can see a copy of the residential and community versions on the intranet here. Remind them that they need to include in their report the number of people they have spoken with, along with their role and that they should record direct quotes from people where they can. You will need these to make the evidence come alive in your report. If the ExE is going to have a support worker with them on the day, they must also be involved in your pre-inspection discussions. This is so they can help the ExE to understand the questions and what is expected of them during the inspection. We are currently piloting Inspection planning tools in Easy Read format with ExE. If you are inspecting a supported living service or extra care housing where people live at one address, it is better to take an ExE with you on the visit instead of asking them to phone people. Remember that unless the supported living or extra care housing address is the actual location registered with us, you can only enter the premises on the invitation of the people living there. And you can only enter a Shared Lives carer’s house with the agreement of both the carer and the person they are supporting. This is because we have no powers of entry and inspection where a service is provided in premises used wholly or mainly as a private dwelling.
2.1.1 Before the inspection ExE – community services (including shared lives and hospice services at home) An ExE will usually support you by ringing people who use services to ask for their views. You should consider how many people you want to get feedback from and ask the ExE to support you to contact a representative sample. You may choose to call some of your selected sample yourself too. The ExE can make the calls to up to a maximum of 20 people over two days. You should select slightly more than your chosen sample to take account of those people who don’t want to speak to an ExE.
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You should arrange to call the ExE before the inspection to brief them about the service. It helps them to have some background information. For domiciliary care services inspections it is useful to discuss ways of helping the people they are ringing to understand why they are ringing. For example, explaining the colour of the uniform the agency worker may wear, or referring to ‘the morning person’. This is because some people are cared for by more than one agency. If they are ringing people who use a Shared Lives scheme or Shared Live carers make sure they are familiar with the correct terminology and have read the Shared Lives supporting information which their support organisation has a copy of. You should tell the ExE the days you want the calls to be made. If you think it will add value to your inspection, you could ask an ExE, who lives near to the service, to go with you to the domiciliary care agency or shared lives scheme office. This would give the ExE the opportunity to talk to staff and any other relevant people who may visit the office. They could also ring people who use the service or their relatives from the office. If they do, they should find a private room to make the calls from and should not use the service’s telephone.
2.1.2 Before the inspection – residential services Before the inspection, you must discuss the practical arrangements for the visit. Consider transport arrangements, access to buildings, where and when you will meet on the day, the time the ExE has available, whether they need to bring their lunch and so on. When planning the day, you must make sure that the ExE has a break at least every four hours and that they are clear about their role and what they will be looking at on the day. Find out whether or not they will be available to take part in the feedback session at the end of the inspection. Some ExE have personal circumstances that mean they may not be able to, but wherever possible, you should include them in the feedback. If they stay for the feedback, they may not be able to be with you at the beginning of the site visit. You must negotiate this before the visit.
2.2 Site visits to residential services An ExE is a full member of the team and should be encouraged to be involved as much as they would like. While it is important for the ExE to talk to people who use the service it is not a role that is totally delegated to them. You will also need to speak with people who use the service, visitors and staff. ExE can be involved in a wide range of inspection activity, such as:
Talking with people using the service.
Observing care practice, mealtimes and activities.
Reviewing the environment.
Talking to staff, visitors or any other person that will help in understanding the quality of the service.
Note: ExE are normally only permitted on-site with you (and their ID badge). ExE are advised that if they arrive without their ID badge they should not take
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part in the inspection. They must not arrive before you do and must leave at the same time or before you. The exception to this is in a supported living or extra care housing setting where you may want an ExE to chair a group of people using services without you being there. The decision to do this will be at your discretion as the lead inspector. You must also remember that we have no powers of entry and inspection where a service is provided in premises used wholly or mainly as a private dwelling. So you could only hold a group there for inspection purposes with the agreement of the people who live there. The ExE should be part of the initial meeting with the registered person or most senior staff member on duty. Introduce them and explain the specific inspection activities they will be involved in. Through the day, the ExE should introduce themselves and explain their role as they meet people using the service, staff, and visitors. You and the ExE, along with other inspection team members, must make arrangements to meet at points throughout the day to share your findings and, if necessary, re-plan the activities that need to be undertaken for the rest of the day. This will also help you avoid duplicate activity. If at any point the ExE finds out information that really concerns them, they should report this to you immediately. Make sure you explore the issue thoroughly and sensitively with them. You should then collect your own first-hand evidence, especially if there is potential for enforcement or safeguarding action. A small number of ExE are currently piloting the use of the site visit record book. At the end of the inspection you and the ExE must share your findings before preparing to give feedback to the registered manager or senior person on duty. If the ExE cannot be involved in the feedback session make sure you have all the information you need from them.
Phone calls to people using community services There is an introductory script that support organisations provide to each ExE to use at the beginning of their phone calls. They should initially find out whether the person using the service wants to take part in the phone call. If they do not, the ExE must respect their wishes and apologise for disturbing them. They should also give them an option to ask us to ring a friend or relative. Phone calls can be made to people from the day of the 48-hour notice to the agency. This option allows the ExE time to share information with you that you may wish to follow up on your office visit. When they are making their calls, you should be available so they can contact you if there are any issues that arise from the telephone calls. If any real concerns are raised the ExE should report them to you or the support organisation immediately. When they have finished their calls you should ask the ExE for interim feedback before they send you their report. Ideally this should be before your visit to the office. Please also see section 3.1.4 below, which gives more detail about the process for inspection of community services.
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2.3 After the inspection ExEs should send you their report as soon as possible after an inspection. Their reports should always be with you no more than five working days after the visit but you can ask them whether it would be possible for the report to be sent earlier than this. You should use their comments and quotes to in your report under relevant key question headings. Refer to the ExE in the report as a full part of the inspection team – not that they accompanied you. See section 3.2.7 (After the inspection – involving the team) for more details
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3. Inspection
There is a full end-to-end process chart for inspection available on the intranet.
3.1 Planning and pre-site-visit activities You should record all the time you spend on each inspection on the Activity Recording Tool (ART) available on CRM. The guidance is available on the intranet. It is important we have information about inspection time to help us plan for the future and to be able to explain to providers about the fee structure. If you need any help using ART, please contact your Regional Operations Systems Support Officer regional (ROSSO). Planning our inspections is essential if we are to ensure that we are targeted. It will help you make sure you have used all the relevant information to identify what you need to look at and how you will do this.
3.1.1 Setting up the inspection in CRM For each inspection, you should initially set up an inspection record (prefix INS) process in CRM, and select the inspection type “new approach”. This is where you record key stages in your inspection process, store documents, send out correspondence, and record when previous non-compliance is met or if new breaches have been identified. The guidance on how to complete this is here.
3.1.2 Using the planning tool Planning your inspection activity is essential and you must keep a record of this in the planning tool. The planning tool allows you to consider the information and intelligence we have about a service and:
order it under the five key questions
consider what the information tells you and what activities will undertake to answer the five key questions
consider who else you might want to take with you and what you want them to do.
The planning tool template includes information about how to complete it. Once the CRM inspection process has been set up, you can begin to review the information we have received since the last inspection and start to complete an inspection planning tool for the type of service you are inspecting: Planning tool for inspectors – Community Services Planning tool for inspectors – Hospice services Planning tool for inspectors – Residential
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3.1.2.1 Reviewing information we have received In the first stage of planning, you will review and use information from, and received since, the last inspection. This includes: information from the last inspection
CRM
the pre-inspection information pack
the Provider Information Return (PIR)
the information sharing tool
questionnaires.
This enables you to complete the first section of the inspection planning tool. This section is for high-level summary only and is your audit trail of the information you have considered as part of the inspection. The Pre-inspection information pack To make sure you have robust and detailed information before your inspection the Intelligence Directorate has developed a Pre-inspection information pack. This pack includes detail from CRM, the Provider Information Return (PIR), and questionnaires (community services only). PIR and questionnaire data will only be populated if the provider has completed the information within the deadlines we provided. Anything that is returned late is unlikely to feed into the information pack as there is a cut off period when the data needs to be locked down to process and upload into the information pack. To help you plan and identify areas to focus on in the inspection, the pre-inspection information pack document provides you with data, analysed information and the provider’s own assessment of how they meet the five key questions and how they plan to improve their service. The information is presented under the five key question headings. Instructions on how to access the dashboard and use the inspection information pack can be found in this guidance document and online presentation. Information from PIRs and questionnaires have to be received within prescribed deadlines to make sure the data makes its way into the information packs. More information about the process and timelines for gathering this information can be found here. You will receive the information pack at least two weeks before the inspection date so that you can use it for your planning. Save the pack to the inspection process in CRM as an audit trail. There is a section in the inspection planning tool for you to provide a high-level summary of the information in the PIR. You can see blank PIRs on the ASC intranet page.
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The PIR
The PIR is a form that asks the provider to give some key information about their service, how it is meeting the five questions, and what improvements they plan to make. We are moving towards making the PIR an ‘online’ document and sending out reminders to get it up to date. Currently NCSC send a link to an online PIR form for each location to complete in advance of your inspection, in batches. Providers must give us the information we require for example in the PIR. Generally we will only ask the provider to complete and submit one PIR before an inspection. In some circumstances we will ask providers to complete more than one PIR for a location. This will usually be where a provider is carrying on a community service, such as a domiciliary care service, from the same location as a care home. You should not take the information contained in the PIR as evidence in its own right, as it is a data set and self-declaration completed by the provider. However, it will give you important information to help you decide what needs to be tested during an inspection and whether you need to inspect any of the remaining KLOEs. When a PIR or spreadsheet is not submitted
PIR forms include sections for statistics and quality information a good provider should have readily available under the good governance arrangements required by regulation 17. We also use regulation 17(3) to require that the provider sends us the information requested in the PIR. We cannot insist that they use the PIR form but we do need to know that they are gathering the information they need to understand the quality and safety of their service. Where a PIR has been requested but has not been submitted, you should contact the provider as soon as possible before the planned site visit. Tell them that:
We have not received a PIR from them.
That providers were sent an email (or letter) telling them about the PIR, and how to find their PIR report template on line and how to contact us for support if they were having difficulty with the form.
That providers were told that filling in and submitting a report was required under 17(3), and that they could use our PIR form to do so.
That the plans set out by CQC in A Fresh Start to use information to plan a proportionate approach to regulation and to target our resources in the best way possible received widespread, cross sector support.
The purpose of the PIR is to help CQC inspectors plan their inspections of ASC locations and will also assist the service by making sure information is provided in advance and will reduce demands on managers during the day.
They are in breach of regulation 17(3), which is an important regulation and a key contributor to our evaluation of their performance in the Well Led key question
It will therefore be very difficult to award any better than a rating of ‘Requires Improvement’ for ‘Well Led’, which may affect their overall location rating. When we have requested this information but the provider has not sent a PIR or spreadsheet or provided the information in another format, we will not normally award better than ‘Requires Improvement’ when we are making our judgements for the well-led question. This is because we would expect a ‘good’ provider to have the information we ask for to hand, as they would be using it for planning and delivering a good, safe service. However, you can use your judgement when you think there are exceptional circumstances that suggest a better rating is appropriate – for
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example, if the provider gives a clear and firm commitment to send us a PIR and or spreadsheet in future, or where the provider has not received a PIR request. If we have requested a PIR or spreadsheet and we have not received one, you need to report this in the inspection report.
We will not follow enforcement processes in these circumstances, but rely on the levers provided by the ratings process to encourage providers to submit PIRs and requested information for questionnaires in the future. The information sharing tool When you are inspecting a service you have not visited before, you should send the tool to the previous inspector/s or manager because they may have some information about the service that is not recorded on CRM and which will inform the inspection. This tool is available on the ASC intranet page. Save copies of completed information sharing tools as an attachment to the inspection process on CRM. Questionnaires For community services, NCSC send a letter to providers with a spreadsheet (quarter 3 [Q3]) or link to an online form (quarter 4 [Q4]) asking them to give us contact details of:
People who use their service.
o For community based hospice services we ask providers to include the
details of all people who may have used their service over the last 12
months
o Some people who have used community based hospice services in the
last 12 months may have passed away, so we ask for the contact details
of a close relative/friend to send the questionnaire to. We are aware of the
sensitivities and do not want to cause upset or distress for people, so we
ask providers to only include the details for friends/relatives who would like
to share their views about the service with us.
Care staff, medical and nursing staff who work for community based hospice
services, shared lives workers and shared lives carers.
Community health and social care professionals.
For Q3 the letter asks the provider to complete the spreadsheet and submit it within a specified timeframe. For Q4 they are asked to complete an online form rather than the spreadsheet. Not everyone who uses a service will have the skills to fill in a questionnaire, speak on the telephone or talk to us when we are in the service so we ask managers to identify people who are able to:
Fill in a questionnaire.
Respond to a telephone interview.
Receive a home visit.
In services that are caring for people who may be at the end of their life, for example domiciliary care agencies and community based hospice services, we must be mindful that some people may not be in a position to share their views with us. We ask providers to only include the contact details of people who it is appropriate to send questionnaires to, or who have given their consent. Where we know that
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questionnaires are being sent to children or young people they will be marked for the attention of a parent/guardian. Once the contact list spreadsheet (q3) or contact details form (q4) has been used to send out questionnaires, NCSC will save it in a restricted activity on CRM. They will notify you by email and tell you where it is stored. The contacts spreadsheet (q3) or contact details form (q4) will highlight who the questionnaires have been sent to. We will hold the data for six months and then destroy it. This approach ensures we provide a secure process for receiving information and that we treat people’s data appropriately. People who use community services are sent paper questionnaires to fill in, and a letter for them to give to a relative or friend inviting them to fill in an online questionnaire. People can ask for a questionnaire in an alternative format. Information from questionnaires is uploaded into the inspection pack. Late questionnaires are scanned and emailed to you by NCSC. You should save these questionnaires in the inspection record on CRM. If the questionnaire is received before the date of the site visit this can be included as part of the inspection. If the questionnaire is received after the site visit then the information is used for ongoing monitoring purposes. Any information of concern is treated in line with CQC policy. The questionnaire end to end process is available on the intranet. For residential services, NCSC asks the provider to complete a spreadsheet (q3) or an online form (q4) with the details of community professionals involved with the service. When the form is submitted by the provider it will be emailed directly to you. On receipt, you will save the spreadsheet (q3) or form (q4) in the inspection tab for the service on CRM. You can then use this information to contact professionals for their views. 3.1.2.2 Planning which KLOEs to look at To help you with your planning we have pre-populated the planning tool with the KLOEs. The mandatory KLOEs are highlighted in yellow. Your review of the pre-inspection information and intelligence will inform you of areas of increased risk and/or where good practice has been identified and you want to explore further. This will help you identify any of the remaining KLOEs that should be drawn into your inspection. During the inspection, your findings may indicate that you need to change or add to the KLOEs you have selected. You must keep a clear audit trail of these changes and record the reasons why you made the change on the planning tool. In the planning tool there is a free text box under each of the KLOEs and things to consider. You can use it to provide as much or as little detail as you think you need, but bear in mind that the final document needs to be in sufficient detail to provide an audit trail of the information you have considered and your plan to test it out. For example, it would help your audit trail if you inserted existing evidence, information from the PIR and any concerns received from questionnaires that need to be
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followed up or corroborated. Your plan should say what evidence you need to gather, who you need to speak with and the methods you plan to use. 3.1.2.3 Other planning considerations Record in the planning tool the people that you or another member of the team plan to speak with, the specific areas you want to get their views on, and the records you will want to see during the site visit. Choose a representative sample of people to speak to. The planning tool should say what you want members of the team to do, for example, what to observe, who you want them to talk to and the type of questions you want them to ask. Remind team members that they are looking for positives and not focusing only on breaches of regulations. Wherever possible, the information in the planning tool should be given to each team member and discussed with them before the visit. In addition, each member of the team (including the ExE) should be given a copy of the sections of the planning tool relevant to them. There is also a section at the end of the tool that allows you to set out an overall briefing for the members of the team. You can cut and paste specific areas of responsibility for each team member from the tables under the KLOE. Remind team members that they are looking for positives and not focusing on breaches of regulations. For both residential and community services inspections plan to speak directly to people who use services yourself as well as the ExE and/or specialist advisor speaking to them. For community services this could be through phone calls or home visits.
3.1.3 Other pre-inspection activity 3.1.3.1 For both residential and community services you should contact relevant stakeholders for feedback and record this on the planning tool. For example, local groups including Healthwatch, local authorities and health care professionals. For shared lives schemes, if the shared lives panel chairs’ details are available then you should contact them for views about the scheme and any recommendations the panel has made. You do not need to record this as an activity or enquiry in CRM but you should summarise the feedback received in the feedback section of the inspection planning tool. Overview and scrutiny committees Inspection teams work with overview and scrutiny committees to share information about local care services. For Adult Social Care, an inspection manager or designated inspector will have responsibility for maintaining relationships and working with local overview and scrutiny committees. There is detailed guidance available on the intranet, here
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3.1.3.2 Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Where appropriate, plan how you will assess the provider’s compliance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA sets out what must be done to make sure that the human rights of people who may lack mental capacity to make decisions are protected, including when balancing autonomy and protection in relation to consent or refusal of care or treatment. This includes decisions about depriving people of their liberty so that they get the care and treatment they need where there is no less restrictive way of achieving this. If the location is a care home, CQC is required by law to monitor the operation of the DoLS, and to report on what we find. The definition of a ‘care home’ can be read in our DoLS guidance, which you can read at this link. Providers of care homes are required to submit applications to a ‘Supervisory Body’ for authority to do so. For any other provider, applications must be made to the Court of Protection. During your inspection, you must consider whether people’s liberty is being restricted. If you find evidence that it is, you need to identify and report on whether related assessments and decisions had been properly taken and reviewed using the assessment and best interests decision-making approaches described in the Code of practice to the Mental Capacity Act. You should also consider whether any accumulations of restrictions being experienced by anyone amount to unauthorised deprivation of their liberty. A recent Supreme Court judgement has widened the scope of restrictions that may amount to deprivation of liberty. You can read more about this here. You should check to see if the provider is complying with conditions applied to the authorisation or Court Order. You must assess and report on whether the provider has properly trained and prepared their staff in understanding the requirements of the Mental Capacity Act in general, and (where relevant) the specific requirements of the DoLS. You can read more about these requirements in the separate guidance documents on the Act and the DoLS here. 3.1.3.3 Complaints We have committed to strengthening our approach to assessing complaints and concerns during our inspections. How the service routinely listens and learns from people’s experiences, concerns and complaints is a mandatory KLOE. You need to make sure you gather sufficient evidence to be able to answer this. The inspection information pack will provide you with information about complaints received from or about the service. When you are in the service, your discussions with people should cover their understanding of the complaints process, their experiences of raising concerns or complaint and their satisfaction with the outcome of any complaint made.
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You should explore whether complaints are encouraged, taken seriously, investigated thoroughly and if the outcome is shared with the person who made the complaint. There is further information in the KLOE (responsive 3) to help you assess how complaints are managed. When you inspect community services make sure you look at any complaints raised by people not included in the spreadsheet address list returned by the provider.
3.1.4 Community services – talking to people who use the service 48-hour notice You should telephone the registered manager 48 hours before the day of your site visit to domiciliary care agencies and shared lives schemes to notify them of your visit. This is to ensure that the manager will be in the office and, if they are usually on the rota to work with clients, that they can arrange alternative cover for their visits. For supported living schemes and extra care housing you should use your judgement about whether or not you should give this notice. This is because extra care housing schemes vary in their arrangements. Your decision should be based on:
The location of the scheme manager
The location of the housing (one site or more widely spread)
The amount of care and support provided.
So, for example, if the housing is all on one site and there is a manager available there as well you would not need to give 48-hour notice. Before you phone the service, review the address spreadsheet stored in CRM to decide which people to contact for a call or visit. When we send out questionnaires, we include a sentence that tells people that an inspector or ExE may ring them in the next few weeks or months. We also tell them that if they do not want to speak to us they can contact us to say that they do not want to take part in the process. We also give them an option to ask us to ring a friend or relative. In addition to the 50 people who have been identified to receive questionnaires, you need to identify a maximum of 25 people to telephone. You then need to inform NSCS who you have selected by:
Highlighting on the spreadsheet in green the 25 people you want to inform about the telephone call
Emailing the spreadsheet to NCSC at [email protected]
In the subject line type: LOCATION ID; LOCATION NAME; CONTACT REQUEST; DATE OF INSPECTION
Please email NCSC no later than 5 days before you wish the letters to be sent.
NCSC will send a standard letter to these people approximately seven days before we give the service 48-hour notice, to introduce the role of our Experts by Experience and to tell them we will be inspecting the service they use. When we call them, if the person using the service does not want to take part
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in the process we respect their wishes and apologise for disturbing them. We also give them an option to ask us to ring a friend or relative.
If you wish an ExE to make some telephone calls for you, you should send the spreadsheet to the support organisation, using the contact details they have sent by email to you. You must password-protect the spreadsheet as it contains people’s contact details. The instructions on password-protecting the spreadsheet are included below:
Go to file at the top left hand side of the spreadsheet
Click on info
Click on permissions
Click on encrypt with password Please use a unique password that will not be easy for someone else to work out. Do not send the password by email. You should then phone the support agency to give them the password. This is to protect the confidential information that you are transferring. The agency and the Expert by Experience are acting on our behalf and have their own confidentiality procedures. They will destroy personal details once they have completed their work. Late or non-returned spreadsheets: where services are not identified on the master spreadsheet, providers either have not returned their completed spreadsheet (containing the personal information details of people who use service, staff and community professionals) or have returned their spreadsheet after the cut-off date for sending out questionnaires. Late returned spreadsheets will be been sent to you by NCSC for information via CRM. You must save the spread sheet in a restricted activity in the inspection record on CRM. Where you have received a completed spreadsheet for a late returned service, please contact the service directly to ask for the password to unlock the spreadsheet. You can then follow the process bullet pointed above to get the letters sent advising people that they may be contacted via telephone. Where responses are received to questionnaires, this data will be uploaded into information packs and will be available for you to review. If you are unsure how to access the information pack, please read the following guidance for Access to Data Packs Dashboard. This approach allows the ExE to make phone calls from the day of the 48-hour notice. If people are unavailable on the first two days of calls or phone calls are made after the site visit, issues may be raised that you need to follow up on. This may mean that you need to carry out a further visit to the service. There may be exceptional circumstances where we will be unable to send out introductory letters and questionnaires in advance of contacting people. For example, where an urgent focused or comprehensive inspection needs to be carried out in response to concerns raised about a service. In these circumstances, the lead inspector should ask the registered manager or provider to make initial contact with people to make them aware that they may receive a call from a member of the inspection team. The expert by experience can then contact people without cold calling.
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For services other than Shared Lives schemes, we expect that inspectors will carry out home visits to help gather sufficient and robust evidence about the care and support provided. You do not need to be accompanied by the registered manager of the service being inspected but ensure you read the lone working policy and the home visits guidance before your visits. For shared lives schemes, home visits are not always the best place to speak to some people who use the schemes. This is because they may associate a visit from an ‘official’ as being related to a move. Instead, you could visit people who use shared lives schemes at the day service they attend, by joining shared lives carers and workers meetings or through inviting people into the Shared Lives office for a discussion. You can ask about details of these, or other opportunities to meet people that use services, from the manager of the Shared Lives scheme when you make your 48-hour notification call. If you do visit people at home, you should only do so with their permission and that of the Shared Lives carer. You may begin to arrange to meet with people who use the scheme and Shared Lives carers during the 48-hour notice call or during the site visit. You should involve the manager or Shared Lives workers in making these arrangements in consultation with people who use the scheme and the Shared Lives carers. Offer the person who uses the shared lives scheme the opportunity to have their shared lives carer present when you speak with them. You should not routinely ask to see records in people’s homes. If a person using a scheme offers to show you their service user plan during a visit then you should look at it. Otherwise, you should look at records in the Shared lives scheme office.
3.1.5 Additional resources Usually, a single inspector and an ExE will be sufficient for most of our inspections in adult social care. However, to ensure we gather sufficient and robust evidence to support a judgement on whether a service is safe, responsive, caring, effective and well-led, there will be certain circumstances or situations where a planned inspection would be strengthened by any or all of the following:
A larger inspection team.
Having members with specific skills
More time being spent in the service.
Criteria that may indicate the need for any of the above include the size or complexity of a service, increased levels of risk, or services where we are already taking enforcement action or where this is possible. As you plan your inspections, the Guidance on how to use resources for inspection will help you work out whether you need more time or specific skills. For hospice services, you should always include in the inspection team a pharmacist inspector and a specialist advisor with appropriate skills, or someone from within CQC who knows about hospice care.
If, after using this guidance, your planning indicates that you need additional resources, you must record your evidence and rationale for this in your planning tool and share it with your inspection manager. They will need to agree and sign off these additional resources.
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Bank inspectors are available as second inspectors and have been trained in our new approach. If, after reading the resource guidance, you have identified in your planning that you need a second inspector you should, with your manager’s agreement, email your regional resource officer and make your request. Specialist advisors If, after reading the resource guidance, you have identified in your planning that you need a specialist adviser for the inspection, you should, with your manager’s agreement, use the webform on the intranet to make your request. NCSC will book the advisor and let you know who it is. You will also need to use the webform to advise about cancellations or rescheduled inspections. Specialist advisors have been briefed about our new approach. You can read their briefing document here. There is a report template for specialist advisors to use the report their findings. It is very similar to the template that the ExE use. You can see a copy here. You should brief the specialist advisor before the inspection, making clear the areas that you want them to use their expertise in and what you specifically want them to do. Provide them with relevant pre-inspection information and sections of the planning tool. Make sure you also address practical issues, such as accessibility to the service and whether or not they need to take their lunch. If you do not need a specialist advisor for a full day, be clear with them about this and discuss with them how they should best use the time they have. You must also ask your manager to complete the warrant statement for the specialist advisor so that you give it to them when they arrive at the service. Remember to ask them to give it back to you before they leave. Introduce the specialist advisor when they arrive at the inspection and explain to the manager their focus during the inspection. Make sure that you check their progress with them at regular intervals through the day, and that they know to raise concerns or safeguarding issues with you immediately. They will record their findings in the site visit record which will be sent directly to them. When they have completed their given tasks they can stay on site to write their report if this is appropriate, or leave the inspection. If they leave, they must feedback to you before they go and must make time to write their report afterwards. Remind them that ideally you want the report in two working days, and that it should be with you no more than five working days after the inspection visit. If the specialist advisor is still on site at the end of the visit, you can either give them the opportunity to provide feedback about their findings or present it on their behalf. Make clear to the specialist advisor that we give headline information at the feedback and do not indicate a rating.
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Pharmacist inspectors
If, after reading the resource guidance, your planning identifies that you need a pharmacist inspector for the inspection, you should use the webform to arrange this. You should use this same form to make any changes or to cancel your request.
You should work with the pharmacist in the same way that you work with the specialist advisor with regard to:
Pre-inspection information and setting of clear tasks
Introduction when they arrive on site
Site record sheets
Regular checkpoint meetings during the day
Headline feedback before they leave
The pharmacist inspectors will record their findings in the site visit record book. There may be occasions when it is not possible to provide a pharmacist inspector to support the site visit. If so, a pharmacist inspector may offer support before the site visit to help the lead inspector with the inspection planning, or provide remote support for the inspection team on the day of the visit to help interpret evidence or offer guidance if concerns are identified.
There may also be occasions where the medicines management team identify that they have additional pharmacist capacity. In these circumstances a pharmacist inspector may contact the lead inspector for a service and ask to be included in the inspection team. This will give pharmacist inspectors the opportunity to be involved in inspections of services other than those where concerns around the safe management of medicines have already been identified. Experts by Experience
See section 2 above for information about involving an ExE in an inspection Interpreters
In some circumstances, you might need an interpreter, although this may not become apparent until you receive the inspection information pack or speak to other stakeholders. Make sure as part of your planning that you consider the need for an interpreter. It is fundamental to our new approach that you talk to people who use services and sometimes the only way to do this is through an interpreter. If you need an interpreter contact, the Accessible Communications team for help and advice. To make sure you get the support you need for the inspection, you should ask for these resources as soon as possible, as the booking process will often take some time.
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3.2 Site visit
3.2.1 The start and the focus of the visit
Introductory session When you arrive at the service, you should speak to the registered person or senior staff member on duty. If an ExE or specialist advisor accompanies you, you must introduce them as part of the inspection team. If this is the first time that we have inspected the service using our new methodology you should explain to the registered person, or most senior staff member, that our approach to inspections has changed and that you will not be looking for ‘compliance’ as you did in the previous methodology. Tell them you will be ‘looking for good’ as the starting point of the inspection. When you first introduce yourself and the team on the day of the site visit, you could consider asking the following questions as a way of starting the inspection:
What evidence can you show me that you are providing a good service?
What has been your greatest achievement at the service?
What is the biggest challenge you have at the moment?
What are your plans for developing the service?
How do you gather, and use, the views of people that use your service? These questions can stimulate and direct the first conversation, and start the inspection in a way that shows we are ‘looking for good’ and interested in encouraging improvement. During the inspection, you can investigate the responses they have given, and use them to inform areas that you look at or questions that you may ask people who use the service. However, you should ensure that you do not normally spend more than 15 minutes in the office at the start of the inspection. It is important to get out and see what is happening in the service. This is a fundamental change in the way inspections are undertaken, and is a tangible way in which we have changed from a ‘compliance’ model of regulation to a framework that encourages improvement. The language used, and attitude adopted are vital in ensuring that providers understand our change in approach. The ‘decision tree’ diagram in section 4.1 below gives a more graphical explanation of what this change means in practical terms. You should also tell the senior person on duty that the emphasis of the inspection is on understanding the experience of people who use the service, and so you will focus on speaking with them and those people important to them.
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In addition, you will observe care practice and how staff interact with people who use the service. You could refer them to the Provider Handbook for their sector, which is available on our website, and tell them that this explains the changes. You should explain what the five questions are and how we use key lines of enquiry to inform our inspections. Tell them about mandatory KLOEs and, if you are going to inspect any of the non-mandatory KLOEs, which ones you are going to include. It may help to give the manager or senior person a copy of the key lines of enquiry you will be inspecting and a list of any records that you want to see. This will give them an opportunity to get the records for you and to think about any other evidence that would show how they provide good or outstanding care. Also, explain that you will be inspecting against the current regulations and how you will report on all of the findings of your inspection. If you are following up on any previous areas of non-compliance, you will need to explain how you will address these in your final report [see report writing guidance]. It may be helpful to share the outline of your visit plan with the senior person on duty as it includes details about the proposed length of the inspection, who you plan to speak with and documents you plan to review as part of the inspection. You should also tell them that you will give headline feedback about what was found during the inspection. Site visit record book The site visit record book is a new tool to record your evidence on when you are on site. It will provide a consistent way to record evidence. You must use this tool to record your evidence during a visit. Our intelligence directorate are currently exploring how we might develop a way of doing this electronically in the future. There are two parts to the site visit record. The larger first part is used to record your notes on and the smaller second part to record the feedback that you will give the provider at the end of the site visit. The pages are perforated so that you can tear them out at the end of the site visit and use the book again at your next inspection. The record has been developed to be simple, easy to use and to complement the new inspection methodology. The record allows you to write the evidence chronologically, and you do not have to move between sections to write your evidence. On the record there are columns for you to write next to the evidence which key question and KLOE you think is most relevant to the evidence you are recording. You can also record whether you think the evidence is positive or negative. You do not have to do this at the time of writing the evidence but it might be helpful for you to do it before the end of the visit. This will give you:
some assurance that you have enough evidence, and have covered all the
questions and KLOEs that you planned to look
a way of deciding what you want to draw into your feedback to the provider
a head start on your report writing as you will have begun to order your evidence.
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At the end of your notes you must record that you are satisfied you have collected enough evidence to reach a robust judgement about each of the KLOEs you have inspected.
The feedback part of the record has separate sections for the five key questions so that you can review the evidence you have gathered and organise the key points you want to feedback to the manager or senior person. During the visit Use your plan and the KLOEs to direct and inform what you look at. This will help you gather your evidence and link it to the five key questions. As you review and reflect on the evidence you have gathered, you should also consider whether the requirements of the law are being met. It is important that you are visible and available to people who use the service, staff and visitors. You should not base yourself in an office. Reviewing records is an important part of the inspection but, whenever possible, it is best to do this in a communal area so you can observe practice at the same time. However, you must maintain confidentiality when you are looking at personal information. As lead inspector, it is important to check your plan during the day to make sure you are covering each of the relevant areas. If there is an inspection team then it is important to have brief, regular meetings during the visit to take stock, review and reallocate tasks as necessary. If the inspection team is large and it is difficult to co-ordinate people’s time so that they can all meet, then you should make sure you co-ordinate by checking out progress individually with people. This is important to make sure that you are in a strong position to oversee and direct inspection activity to get the best out of the team and to ensure that information is being shared appropriately. You will need to plan time in for this activity. We will be testing the use of posters as a means of informing people who use services and people who matter to them, staff and visiting professionals that the location is being inspected; and to invite them to provide feedback. Testing will be done by three teams during April at a variety of service settings. If successful we will roll out inspection posters for general use later in the year.
3.2.2 Gathering evidence
Gathering evidence about how the service promotes equality, diversity and human rights (EDHR) is a vital area of the inspection activity. EDHR has been threaded through the KLOE and characteristics of ratings so you should record your evidence under the most relevant question. There is more information about EDHR, our thinking and the principles underpinning our work at the following link.
There are various methods for gathering evidence during the inspection. These include observation, the Short Observational Framework for Inspection (SOFI2), interviews, informal group discussion, inspecting records and so on. You may find it helpful to gather and record your evidence under each key question, as this will help with consistency when you come to write your report. Remember to gather evidence of good practice, as well as making sure that you corroborate evidence sufficiently
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where you identify potential breaches of the regulations. Where you find good practice, consider whether there is evidence of outstanding practice. Recording evidence You must accurately record all the evidence you gather in the site visit record. This includes information that people tell you about the care provided as well as relevant evidence from any records or policies and procedures you consider it is necessary to read. Make sure you record dates, times, people you spoke with and their role if they are not the person receiving care.
When talking to people who use the service you should tell them who you are, what you are doing and how you may use the information they are giving to you. You should also ask if they mind if you make a note of their name and what they say. (ExE and SPAs can add that this is so they can share the information with the inspector). If you need to record a person’s full name (and if they have not objected to you making notes) then do so. If you do not need to record a person’s full name, then just collect a first name and surname initial or just initials as this provides a limited protection to people’s privacy. You should ensure that whatever you record is good enough for the purposes of the inspection. It is a question of judgment whether you need to record a person’s full name. Some examples of cases where a full name is likely to be needed are;
where a person shares information of significant concern with you;
where the person gives you information that you are likely to want to cross-
reference or check later;
where you anticipate that the information may be challenged or disputed;
where the information is clear evidence of a breach of regulations.
In less clear cut cases, initials will usually be adequate. For routine and uncontentious information, for example, general comments about the service, such as ‘the food is always nice’ you won’t need to make any note of the person’s name or initials.
During your visit, if you have concerns about the safety of people using the service you must follow CQC’s safeguarding procedure. Before you close the visit, you should refer to the KLOEs and prompts. You must make sure that you have enough evidence to answer the five questions and make a rating. You should also make sure that you have robustly corroborated the evidence. This is particularly important if there are breaches of the regulations that you intend to tell the provider to take action about or if you are going to take enforcement action. In this case, you should make sure that you have enough evidence for each regulation that you intend to require action under.
3.2.3 Gathering the views of people who use services and others We put people who use services at the centre of our inspection process to ensure we focus on what matters to them. You must gather the views and experiences of people who use services in all inspection activity, record it and use it in your judgements. Likewise, the views of their relatives, friends and advocates are important. In a residential setting, talk to as many visitors as you can. Volunteers at
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the service are another good source of evidence and, if present, you should speak with them about the care provided and their involvement in the service (see 3.2.4 below). There is an introduction to the tools you can use, and links to them, in the involvement section of the intranet. Talking to children and young people It is important that we establish the views of children and young people using the services we inspect and ensure that we act in accordance with their wishes and decisions. This is more clear cut for those over 18, but we should assume that 16-18 year olds are able to make their own decisions unless there is reason not to. Those under 16 may also be able to make decisions about their care and treatment. If a child of 16 or 17 is not competent to make a particular decision, then a person with parental responsibility can make that decision for them, although the child should still be involved as much as possible. For further information about consent to talk to a child, see the Consent, recording and retention of evidence guidance and the CPI Code of Practice. Remember that it is equally important that we also listen to and capture the views of parents/family/carers or those with parental responsibility. The Mental Capacity Act and children The Mental Capacity Act does not generally apply to people under the age of 16. For further details, see chapter 12 of the Mental Capacity Act Code of Practice. The Deprivation of Liberty Safeguards only relate to people aged 18 or over. If the issue of depriving a person under 18 of their liberty arises, other safeguards must be considered, such as the existing powers of the court, particularly those under section 25 of the Children Act 1989, or use of the Mental Health Act 1983. When inspecting services, such as services for people with a learning disability, which are used by young people under 18 as well as those over 18, you must take the above into account.
3.2.4 Gathering the views of staff and others
During your visit talk to relevant professionals, managers or staff and volunteers,
either in person or by phone. To help with this, see the guidance on semi-structured
interviews. When talking to staff, do not take them away from their work for too long.
Approximately 15 minutes should be sufficient to gather the information you need.
However, there may be occasions when it will take longer because of the nature of
the discussion – for example, if a staff member is being reticent about telling you
something about the service which could be important.
You may find it helpful to structure your questioning around the KLOEs and sources of evidence for each key question area.
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Remember to follow up on issues identified against each key question. Consider checking on:
Staff knowledge.
Training provided.
Documented guidance.
Supervision.
Feedback from people using the service and/or their carers.
Incidents.
Manager awareness.
If the service involves volunteers in their work, you should also consider checking:
their awareness of what to do in terms of safeguarding, whistleblowing and
feeding back any concerns
that the managers, staff and the volunteers themselves are clear about their role
in care, and that this is distinct from paid staff
how they are recruited and supported
feedback from people who use the service and/or their carers.
There are further examples in the ‘potential sources of evidence ‘column in the KLOEs.
3.2.5 Other inspection methods/information gathering
Make sure you use a range of inspection methods as part of the inspection. These include review of records, pathway tracking, direct observation, and may include the use of the Short Observational Framework for Inspection (SOFI 2). SOFI 2 SOFI 2 is a tool to help you assess the care of people who are unable to tell you verbally about the care they receive. Unless there is a good reason not to, you are expected to use SOFI 2 whenever you inspect services used by people who are unable to verbally communicate with you because they have dementia, learning disabilities or other cognitive impairments. SOFI 2 is a useful tool for corroborating, or not, what people have told us. You should also consider using SOFI 2 in all your inspections, especially if there are people using the service who you judge may not be able to speak out for reasons other than those identified in the paragraph above. SOFI 2 helps you collect structured, defensible information through observation of one to five people for a flexible period, and it offers a means to analyse the collected information. Using SOFI 2 fully and recording all coding frames provides strong evidence to base judgements on and to feed back to providers. SOFI 2 documents are available here. You must have completed SOFI 2 training before you use it.
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Inspecting at mealtimes Engagement at meal times is a positive thing for Inspection teams. It is a good opportunity to get insight into the interactions between residents and between staff and residents. There are different ways to get this insight, and it will be for each inspection team to make a judgement about the most appropriate option for the specific home they are inspecting, taking into account the likely impact on the home and service. You can get the insight by either: - you, the ExE or SPA eating the meal, and sitting with residents to experience the meal with them, or - by observing the meal time through SOFI There are advantages and disadvantages to each, and inspection teams will need to decide which is best on the day. Eating a meal with residents gives very good direct experience and an opportunity for a relaxed discussion with residents, but the experience is limited to that particular table and not all the residents. Carrying out a SOFI allows for an opportunity to observe a whole mealtime and not restrict the observations to a single table. If the inspection team judge that it is appropriate to share a meal with residents, the person who eats the meal should offer payment for it. If payment is refused by the home, a small charitable donation should be made in its place. Payment for such meals will not be reimbursed through the expenses system. Individuals should eat what has been prepared and not be too particular about their meal choice (aside from any special dietary requirements). How much evidence is enough? You and your inspection team should aim to collect good quality, corroborated evidence. The evidence you collect will depend on the circumstances of the inspection and you must use your judgement as an inspector to decide when you and your team have collected enough evidence. You should aim to have strong relevant evidence that supports your judgement and any breaches of the regulations you find, rather than lots of weak evidence. If you do find a breach of the regulations, you should try to collect evidence that shows whether the breach is a one off or sustained. This includes collecting evidence about harm, or the risk of harm, to people using services (where appropriate). You will find it helpful to refer to your inspection plan and the KLOEs you are looking at during your site visit to decide when you have collected enough good quality evidence.
3.2.6 Closing the visit Record the key areas to be included in the feedback session on the site visit record. You should give your feedback to the senior person or people at the location. You will only be able to give feedback about the day and your findings so far. If possible, the ExE should be part of the feedback, but you should lead it. Neither you, nor the other members of the inspection team, should give any indication about what the rating might be or about any enforcement action that may
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be taken in relation to breaches. This is because you need time to take a considered view on the evidence that has been gathered during the inspection before coming to a decision, taking into account the management review process where that is relevant. Explain that:
You are unable to tell them what their ratings are at this point as you need to consider all of the available evidence and, where relevant, await reports from specialist advisors and Experts by Experience.
You will be rating the service at both key question and overall location levels, and that the ratings will be included in their draft report
That ratings will be based on our evidence about the service, and should they have concerns about the ratings we award them, they will have the opportunity to question this during the factual accuracy process.
The email accompanying their final report will explain under what the circumstances and how they can request a review of their ratings. The process is also described in the Provider Handbook that is available on the CQC website.
If you have concerns about the service, briefly outline the possible outcomes. If you consider that these concerns need to be addressed immediately then make this clear. Allow the senior person time to respond and ask questions – make a note of their responses in your notes. The feedback session should be a two-way discussion. You should give the manager or senior person the opportunity to feedback to you their experience of the inspection.
We are piloting the use of a written inspection feedback summary form in April 2015 which will be used by inspectors at the end of an inspection visit to provide a written headline summary of their verbal feedback for the provider. It will show provisional findings only and not pre-empt any regulatory or enforcement action which may be taken. We will advise you if and when this will be rolled out for use in all inspections.
3.2.7 After the inspection – involving the team
If an ExE or specialist adviser is involved in the inspection they should ideally send you their report within two working days of the inspection and if not, no later than five working days. Use the evidence they provide as you draft your report and speak to them before you send them the draft, so that they can feed into the judgement-making process. You should share your thoughts about the rating, referring to the evidence and, if possible, together reach agreement. If agreement cannot be reached, then it is your judgement as the lead inspector that is final. Email them an editable version of the draft report so that they can check the factual accuracy of how you used their findings. You should do this before you submit your report for peer review. The ExE and specialist adviser are encouraged to respond in two working days but have a maximum of five to review the factual accuracy of their contribution and make changes to the text.
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When the report is finalised you must tell each of the inspection team members so they can securely destroy their notes. The exception to this is if you need the ExE and/or SPA notes because there is a request for a rating review or we are taking enforcement action and the first hand evidence in their notes is vital. In these instances you must ask the ExE and/or SPA to send the notes by secure email to you for safe storage.
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4. Judgments and ratings
4.1 Making a judgement You must use the ‘Characteristics of each rating level’ to help you decide the appropriate rating for each of the five key questions. It is important that you use them to ensure that our ratings are consistent and reliable. There is a different set of characteristics for residential, community and hospice services, and they are available at this link. The five key questions ask whether services are: safe, effective, caring, responsive and well-led. Ratings are reported on a four-point scale: The sections describing the characteristic of ‘good’ for each key question have the most detail. This should help you to inspect for good. The remaining three sections (outstanding, requires improvement and inadequate) build on this description and describe how the characteristics differ from the description of good. If you find that a service is good under a question, for example safe, you should then go on to check whether you have sufficient evidence to show that it is outstanding. If a service is not good, you will need to review your evidence to judge whether it requires improvement or is inadequate. The characteristics are not a checklist and are not exhaustive. While they link to the prompts in the key lines of enquiry, they are not meant to map across exactly. They are written to give you a picture of a service in respect of the five key questions. You will need to make a professional judgement, based on the history of the service and the evidence you have gathered. A service does not have to meet every area covered in the characteristics to fit in that rating section. You may also find that some of the characteristics may not always be appropriate for different types of services. You will need to take a proportionate approach when a service sits somewhere between two rating levels. You should consider the size and type of the service, whether you have enough evidence, the outcomes for people and the severity of any breaches of regulations. You may need to speak to your line manager to get a second opinion or carry out a management review.
Rating
Outstanding
Good
Requires improvement
Inadequate
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We need to be as consistent as we possibly can so that our ratings are reliable and provide accurate information. This will also help reduce the numbers of requests for review. As you consider your evidence following an inspection you may develop a sense of what the rating for a particular question could be. However, you must make sure your rating decisions for each of the five key questions are determined by assessing your evidence against the characteristics. When you make your judgement for each of the five key questions, you must use the information you have gathered during the visit – what you saw, felt and heard on the day. Assessment of pre-inspection information must be undertaken appropriately, consistently and be balanced against the findings of the visit. As you did with the inspection process, you make your judgements by first looking at the level of ‘good’. The decision process has been set out in a ‘decision tree’ below.
Is it good? (using the KLOEs and characteristics
of good)
Yes
Can the provider demonstrate that the service is outstanding?
(using the characteristics of outstanding)
Yes
Outstanding
No
Good
No
Is the impact on quality significant or are concerns widespread?
(looking at the concerns and using the characteristics of inadequate)
No
Requires improvement
Yes
Inadequate
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4.2 Giving a rating Any judgements at the key question level of ‘inadequate’ will usually reflect a service that is in breach of some regulations. Services that have a judgement of ‘requires improvement’ may be in breach of one or more regulations. Or the service may not be in breach of regulations but does not meet the characteristics of good or the Mum test. There is a process for providers to request a review of their rating. However, we expect most issues to be resolved at the factual accuracy stage of the reporting process. The process for providers to challenge their rating is in section 8 below.
4.3 Calculating the overall rating We have created a ratings aggregation tool from which you will be able to calculate overall location ratings. The tool works by applying principles in relation to the combinations and numbers of ratings for the key questions. The broad principles are as follows: Two ‘outstanding’ and three ‘good’ ratings at key question level = outstanding Two ‘requires improvement’ ratings at key question level = requires improvement Two ‘inadequate’ ratings at key question level = inadequate The tool produces an initial overall location rating for the combination of key question ratings that you entered. When the rating tool calculates the initial overall location rating, you must then check whether any of the factors that can limit the rating for ‘well-led’ apply. The ratings aggregation tool will be incorporated into a new CRM inspection report form that will take over from the digital publishing tool later in 2015. Factors that can limit the rating for ‘Well-led’ For the well-led question, there are principles that you must take into account when you make judgements about the rating. The table below shows events and circumstances that mean that the well-led key question can never be rated better than ‘requires improvement’.
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Limiting factors
The location has a condition of registration that it must have a registered manager, but it does not have one, and satisfactory steps have not been taken to recruit one within a reasonable timescale.
The location has another condition of registration that is not being met without good reason.
Statutory notifications were not submitted in relation to relevant events at a location without good reason.
When we have requested a PIR and the provider has not returned it or the contacts spreadsheet, or supplied the requested information in another reasonable format. Providers should have this information readily available to them through the internal systems they are required to have to monitor and improve the quality of their service.
In addition, the overall rating for a service would not normally be better than ‘requires improvement’ if enforcement action is being taken. Final overall location ratings must be consistent with the relevant summary rating definition for the band chosen in the characteristics of ratings levels (see below). If, as the inspector, you feel that the overall rating does not accurately reflect the service, you must review your key question evidence and consider whether you have fairly and accurately made judgements about all the relevant evidence. Do this with other members of the inspection team. This may make a change to a key question rating which may then affect the overall location rating. If, after reviewing the evidence, the overall rating still doesn’t reflect your team’s judgement and feel about the service, then you can make a judgement to vary it as long as the varied judgement is consistent with the characteristics for the rating you have chosen. You should record your final overall rating in the relevant box in the rating tool along with your reasons for doing so. Inspection managers and the quality assurance and control process panels will need to agree with the change. Summary rating definitions
Outstanding: innovative, creative, constantly striving to improve, distinctive, exceptional
Good: consistent level of service that people have a right to receive, robust arrangements when things go wrong, open and transparent.
Requires improvement: may have elements of good practice but inconsistent, potential or actual risk, inconsistent response when things go wrong.
Inadequate: significant harm has or is likely to occur, shortfalls in practice, ineffective or no action taken to put things right or improve.
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4.4 When a rating is not given Sometimes, we won’t be able to award a rating. This could be because:
The service is new or not fully operational, or
We do not have enough evidence (for example, it is a 40-bedded care home that has recently opened but only 8 people are living there at the time of the inspection).
In these cases we will use the term ‘Inspected but not rated’.
4.5 Displaying Ratings From April 2015, providers must clearly display their CQC ratings at any premises from which they provide a regulated activity, at their head office, and on their website(s) if they have one. They must do this no later than 21 calendar days after it has been published on our website. This is to make sure the public see the ratings, and they are accessible to all of the people who use their services. Ratings do not need to be physically displayed where providers are delivering care to someone in their own home. Display of ratings must be conspicuous and legible. Providers are ultimately responsible for deciding how to display them and will need to demonstrate that what they do use is at least as conspicuous and legible as the suggested CQC poster. If you assess that a provider’s rating is not displayed legibly and conspicuously, or is inaccurate, you should discuss this with the provider. You should tell them why it is not meeting the regulation and ask them to take appropriate action. We should encourage providers to raise awareness of their most recent rating when they are communicating with people who use their services by letter, email or other means.
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5. Actions and recommendations Actions and enforcement actions When you have considered all the evidence you have gathered on the inspection, you will know whether there have been any breaches of the legislation. You must report on these both in the body of the report and in a table at the end of it. You must quote the relevant piece of legislation breached when you list the actions that the provider must address. There is more detail in the reporting section below. Recommendations Our purpose is to encourage services to improve. One way of doing this is to make recommendations in reports at key question level when there aren’t any breaches of regulations. Our focus is on ‘good’ and we want to concentrate on encouraging providers rated as ‘requires improvement’ at key question level to reach a ‘good’ rating. For this reason, recommendations should normally be used when a rating of ‘requires improvement’ has been given. Although there will be occasions, especially under the well led question, where a rating of inadequate might be given and a breach of regulations may not have occurred and it might still be appropriate to make a recommendation. At other rating levels it isn’t normal practice to suggest a recommendation for how the provider could improve. This is because if the rating is ‘inadequate’ there would usually be a breach of regulations. And therefore the action to be taken will be clear in the enforcement action we have specified. We think that ‘good’ providers will have the necessary knowledge, right approach and desire to improve their own rating to be outstanding without us making recommendations. You do not need to make a recommendation whenever there is a rating of ‘requires improvement’. You should only make a recommendation when you see a clear reason and it would be of benefit for the provider and the people using the service to do so. Recommendations should always be high level and guide the provider towards other guidance and information that they might want to refer to in order to improve their service. Recommendations should not be precise, narrow or specific about one element of the service provided. We need to remember that we are not managing the service, but we want to encourage improvement. For example, we would not recommend that the provider changes the colour of the décor in the communal lounge or that people who use services should sign their care plans. But, we might recommend that a provider of a care home for people with dementia seek relevant guidance about dementia friendly environments or in a home for people with learning disabilities, they follow national guidance about the use of Health Action Plans. For example: We recommend that the service explores the relevant guidance on how to make environments used by people with dementia more ‘dementia friendly’
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We recommend that the service considers the Department of Health guidance on the use of ‘Health Action Plans’ You should follow up on recommendations at the next visit to the service to see if progress has been made. The provider could have demonstrated that they have addressed the issue, but in a different way than was indicated in the original recommendation. This is acceptable. If a provider has ‘met’ the recommendation when you revisit this does not necessarily mean that their rating will improve, because other issues might become apparent that affect the rating. At your next visit you will need to review all your evidence for the key question area and look at the characteristics of rating to come to a decision about their rating. For further information and examples, please see Writing recommendations - guidance for inspectors. Action Planning If a provider has not met the regulations (but people are not at immediate risk of harm) we will ask them to provide a report, telling us what action they will take to meet the regulations. We will do this by issuing a ‘requirement notice’ in the final inspection report. Providers should inform us in writing when they have completed the action plan.
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6. Reporting Before starting to write your report you must read the report writing guidance , which is available on the intranet. The guidance addresses:
Writing comprehensive inspection reports
Writing focused inspection reports
Writing focused follow up reports for Wave 1 inspections.
To make sure your report is in a readable style we suggest you refer to the Think Local Act Personal (TLAP) Social Care Jargon Buster which is available on the intranet.
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7. Quality control and assurance Your inspection reports are public documents and will be available on our website. It is important that we quality control and assure them because we need to be sure that we are providing reliable information and doing the right thing for people who use services. As the author you are primarily responsible for the quality of your reports, so you should make sure that they are accurate, readable, well-constructed and follow our house style. Always check your work thoroughly. All draft reports must go through quality review checks before they are sent to the provider for factual accuracy checks. These quality checks:
Assess consistency in reporting, making judgements and taking regulatory action.
Assess the rating for each question and the overall rating.
Check that reports are written to house style.
The process includes a peer review of your report by an inspector. Peer review is an essential element of the quality control process. You should not see it as personal criticism but rather an opportunity for informed and constructive feedback that aims to improve the quality and consistency of report writing. It also recognises that, having spent a considerable amount of time and effort writing a report, many people find it difficult to objectively review their own work. There are a range of approaches to peer review. These include: cross-team buddying, rotation in teams, using team meetings to do some peer reviewing (developmental), wave inspectors reviewing newcomers. Initially, peer reviews should involve an inspector with experience of the Wave 1 and/or 2 until inspectors who didn’t work on the waves feel confident with the approach. Peer reviews can be conducted by Lync to review and encourage discussion and learning. Whichever approach is used, the peer reviewer must always complete the QA\QC tool for each section of the report they review. Issues about a report that cannot be addressed by peer review should escalated by the inspector who wrote the report to their inspection manager for further guidance. Once the report has been peer reviewed, you must submit it, through your line manager for review. Your line manager will review your first 10 reports against the QA\QC tool. After this, they will review all reports of inspections with an outstanding or inadequate rating and others as they think necessary taking into account the inspector’s performance. A selection will go forward to the regional and national panels. You should aim to issue the draft report as soon as you can, but it is important that the reports are of good quality and are consistent in what they include and in the judgements made. The factual accuracy process for providers remains unchanged. Letters to accompany draft reports for factual accuracy comments are available in CRM.
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8. Publication All reports must be completed using the publishing tool. If you do not have a publishing tool account you will receive an email form the Digital Development team advising you of your account details. When your report has been approved for publication, you must follow the steps in the Digital publishing guidance to publish your report on the website. If your report is likely to attract the attention of the local media, you should contact your Regional Engagement Manager before you press the publication button – and ideally well in advance of publication. We won’t always issue a press release, but as a general rule – they need to know of all reports where our overall judgement is Outstanding or Inadequate, or where we are taking enforcement action. If you do not know the name of your Regional Engagement Managers – you should send a quick email to
8.1 How to create a separate PDF version of the report summary
We want providers to make the report summary easily available, so it must be made into a PDF document and saved as a file on CRM. It can then be sent out with the complete final report.
When the final report has been agreed, and has been through the quality control process, navigate to the report summary template and save a copy to your desktop.
From here, go to ‘The overall summary’, copy the text from this section of the report,
and paste it into the template. You will need to include the ratings table.
You should then convert the summary template into a PDF document.
To do this: 1. Go to File>Save As 2. Save File name as ‘yyyymmdd Location name Inspection Report
Summary’ 3. Below this, in Save file type, select PDF 4. Press Save
Then save it to attachments in CRM using file type final report. This is then sent out to the provider with the final report as an attachment. How to create a PDF Quick Start Guide
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8.2 Final report covering letter When a breach of regulation has been identified, we send an ‘actions report’ form
with the final letter for the provider to record how and by when the regulations will be
met.
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9. Request for rating review Requests for review of ratings
The Ratings Review Secretariat has been established to deal with any requests from providers for a review of their rating. The final letter/cover letter that goes to providers on the publication of their report includes guidance for requesting a review. Once a submission is received, the Secretariat will manage the investigation (with input from CQC colleagues as required) and lead on any correspondence with the provider. Any queries (from colleagues or providers) about the requests for review process should be directed to [email protected]
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10. Enforcement Enforcement is a core component of the operating model that we use to improve
health and adult social care services and to protect the health, safety and welfare of
people who use them.
We can take enforcement action against anyone who provides regulated activities
without registration, or registered persons or managers who breach conditions of
registration or relevant sections of the Health and Social care Act 2008, the Care
Quality Commission (Registration) Regulations 2009 and the Health and Social Care
Act 2008 (Regulated Activities) Regulations 2014.
Our new approach to inspecting adult social care services has already uncovered
issues that have led to increased enforcement action. When you consider that
enforcement action is required, you should follow the enforcement handbook. This is
used in conjunction with the enforcement policy and the decision tree to guide you
through the decision-making and enforcement process.
10.1 Special Measures
We want to ensure that services found to be providing inadequate care do not
continue to do so. Therefore we have introduced special measures.
The purpose of special measures is to:
• Ensure that providers found to be providing inadequate care significantly improve.
• Provide a framework within which we use our enforcement powers in response to
inadequate care and work with, or signpost to, other organisations in the system to
ensure improvements are made.
• Provide a clear timeframe within which providers must improve the quality of care
they provide or we will seek to cancel their registration.
Services rated as inadequate overall will be placed straight into special measures.
Services awarded an inadequate rating for any key question will be re-inspected
within six months. If there remains an inadequate rating after six months, in any key
question the service will be placed into special measures.
Once a service is placed in special measures we will re-inspect within six months to
check that sufficient progress has been made. If, following inspection, we feel
sufficient progress has been made we will remove the service from special
measures.
If sufficient progress has not been made when we re-inspect and there are
inadequate ratings for any key questions, further action will be taken to prevent the
service from operating, either by proposing to cancel their registration or to vary the
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terms of their registration. We will then closely monitor the service until it either
closes or substantial and rapid improvements are made.
Special measures does not replace CQC’s existing enforcement powers: it is likely
that we will take enforcement action at the same time as placing a service into
special measures. And in some cases we may need to take urgent action to protect
people who use the service or to bring about improvement, in accordance with our
enforcement policy.
11. Focused inspection 11.1 Scheduling a focused inspection
When you receive an action plan after an inspection, you need to schedule a focused inspection in CRM. This should be within three months of the date by when the provider has said they will have made the improvements needed to meet the regulations. You should use your judgement about whether this should be sooner. To do this, follow the guidance for setting up an inspection in CRM and select the type ‘New Approach’.
The inspector who carries out the follow up inspection will usually be the portfolio holder. If you are not the portfolio holder then you must liaise with your manager and assign the inspection on CRM to the relevant inspector.
From 1 April 2015 we will carry out all focused inspections using the fresh start methodology. Carrying out a focused inspection without visiting the premises
We are exploring whether there are times when it is appropriate to follow up on
requirements made during inspections without actually visiting a service. This would
only be where any risks were very low. We will be testing this, and if it is found to be
effective, will introduce it for general use later in 2015.
11.2 Planning
When planning your follow up inspection you should complete the front section of the planning tool with any information received since the last inspection. Where relevant, contact stakeholders for feedback before the site visit. You must also include details of the action plan under the relevant KLOE and the methods you will use to check what the provider has told us. Where relevant you should follow the guidance in this handbook for requesting additional resources.
11.3 Site visit
When you carry out a focused inspection you should follow your plan and focus on the relevant key question(s). This does not mean that if you find other areas of concern you should ignore them. If you find significant risks or actual harm you must include this in your inspection and contact a manager to discuss what you have found. If you find potential hazards that are not exposing people to risks of
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immediate harm you should complete your follow up inspection and arrange an MRM to discuss the next steps.
11.4 Ratings and focused inspections
The evidence you gather at a follow up focused inspection visit could, in theory, lead to changes in key question ratings and even overall location ratings. You should reassess the key questions inspected in a focused inspection by setting your evidence against the characteristics of ratings. It is possible for key question ratings to be changed after a focused inspection, but you must pay careful regard to the criteria in the characteristics of ratings. The ratings characteristics are written in terms of there being a track record and consistency of practice, which would be unlikely to be achieved in the time between the comprehensive inspection and the follow up inspection. For example, it is doubtful that a service would be able to achieve the consistency characteristics required to be ‘Good’ within a few weeks or months of being judged ‘Requires improvement’. Where you have been able to improve the rating awarded, or where you have ‘reduced’ a rating because things have got worse, you should change the relevant rating in the publishing tool.
Where the last comprehensive inspection took place less than six months ago, you should use a fresh aggregation tool to see whether the overall location rating should be changed. If so, the overall rating should also be changed in the publishing tool. We will not change an overall rating if we carry out a focused inspection more than six months after a site visit for a comprehensive inspection. This is because we will not be able to make judgements about all aspects of the service at a reasonably similar time, which we must be able to do in order to award an overall rating. If you have reviewed your evidence and you judge that the rating for a key question/s should be changed, you will need to review the inspection timescales as follows:
If the new rating is ‘better’ than or the same as the existing one, the planned date
of the next comprehensive inspection does not change.
If the new rating is ‘worse’ than the existing one, the date of the next inspection is
brought forward in line with the appropriate timescale from the date of the last
inspection.
11.5 Concerns
When we are responding to concerns we may not have time to ask for a PIR or to invite people to fill in questionnaires. Inspectors will enquire about quality assurance arrangements and findings during their visit.
Where the location is a community service, inspectors will choose people to call during the visit. Calls will be made by inspectors and experts by experience as soon as possible afterwards. Inspectors will call other stakeholders, for example community professionals, before or after the inspection as needed.
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11.6 Focused inspections to follow up after ‘compliance’ inspections
From 1 April 2015 all inspections must be carried out using the Fresh Start methodology. Please refer to the report writing guidance if you are following up after compliance inspections.
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12. Evaluation We will continue to evaluate our approach in the following ways:
Quarterly surveys of inspectors, experts by experience and specialist advisors.
Monitoring of time through ART for inspectors and ‘checkbox’ forms for Experts
by Experience and specialist advisors. The completion of ART is a vital part of
our evaluation and will affect future development so please ensure you record all
the time you spend on each inspection
Inspectors’ success stories. Inspectors are invited to share their stories about how we have helped providers, the public or other stakeholders to take action to improve the quality of care. These stories are used to better understand and celebrate our successes. Some will developed into more detailed case studies to be included in our public score card.
o Please share your stories in the form on the following link: o https://webdataforms.cqc.org.uk/Checkbox/inspectorstories.aspx.
Post inspection provider survey. The survey is sent to every provider once their inspection report is published.
These approaches will be supported by thematic evaluation projects on cross cutting themes, with evaluation activities to include:
Measuring CQC’s impact in terms of Costs and Benefits
Expert by Experience Evaluation
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13. Support There are various ways that ongoing support will be provided for our new approach.
12.1 OSU Changes to guidance or new processes will be publicised in the weekly OSU which will have a dedicated ASC section. The OSU will highlight what has changed or what is new and provide direct links the documents on the ASC intranet page.
12.2 FAQs Frequently asked questions will be consolidated into one list and will be available on the ASC intranet page. Any questions that are no longer relevant will be removed. New questions and answers will be added each week.
12.3 Guidance documents When guidance documents are updated, so that you will be able to see if things have changed since you last read them, we will add a ‘date of last update’ to the document and the link on the intranet. A table at the front of each document will show what has been updated since the previous version.
12.4 Lync training We will provide Lync sessions to update and give you more detail – for example, about the publishing tool.
12.5 Mailbox There will be one ASC mailbox address: [email protected] Queries will be triaged and sent to the best person to respond.
12.6 CRM Support: ROSSOs are able to offer guidance and advice on any issues relating to the ‘new approach’ inspection record process in CRM. All CRM queries should be sent to your regional ROSSO Support mailbox.
12.7 Publishing Tool The digital development team are able to provide support with any issues relating to the Publishing Tool. There are both online and email helpline links to the team available within the Tool itself. There is additional written guidance on the use of the Publishing Tool available on the CRM guidance page of the intranet.
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Appendix A: High Level inspection flowchart
Inspection scheduled
Review service information available
Complete inspection planning tool and identify any other KLOEs as necessary
Are additional resources needed? (Specialist advisor, inspector)
Introductions to staff at the location – including roles of the inspection team, plan, purpose and process
Main inspection process – gather evidence against the key questions, discussions with people that use services, SOFI2, review of documentation and other inspection
methods
During inspection regularly meet with the inspection team to discuss
emerging issues and adapt plans
Inspection team share inspection findings and prepare feedback
Close inspection
Seek line manager approval
Obtain resources and define roles on
inspection
Begin site visit
No
Yes
Feedback to provider including all inspection team members if possible
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Appendix B: High level post inspection flowchart
Review evidence. Write draft report using the template in publishing tool and incorporate the views of the inspection team.
Use characteristics of ratings to come to a draft rating judgement on the five questions, and the aggregation tool to come to a draft rating
for the service
Send draft report to provider
Respond to any factual inaccuracies identified by the provider
Share draft report with inspection team to ensure they are satisfied with the content and the judgements (return from them in max 5
days)
When content agreed use the Quality Assurance process (including peer review) to ensure the draft is agreed for publishing
Publish report on CQC website
Send report and separate ‘overall summary’ to provider
Manage any compliance or enforcement actions using current processes
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Appendix C: Expert by Experience inspection flowchart
6 weeks prior to inspection Inspector completes webform to request Expert by Experience
2 weeks prior to inspection Review service information with ExE (CRM, inspection information pack, questionnaires)
Agree ExE roles and responsibilities, topic
areas/questions for inspection, when phone calls are to be made
for community services
Community services – From time of 48 hour notice ExE undertakes telephone interviews
with people that use services
Discuss practical arrangements for the visit (timings, transport, access, length of visit)
Begin site visit
Introductions – Explain ExE role and responsibilities to staff, and others, at the service
Arrange regular meetings with the ExE to share findings and update inspection plan
During inspection/phone calls ExE reports high level concerns to
inspector. Inspector manages and shares information as appropriate
ExE undertakes inspection activity – gathering views of
service users, staff and others
Ex by Ex and inspector share inspection findings and prepare
feedback, with ExE involved where possible
Close inspection
ExE allocated by support organisation
ExE share findings with inspector to advise their site visit
Site visit
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Appendix D: Expert by Experience post inspection flowchart
Expert by Experience (ExE) send their report to inspector to use in draft report as soon as possible & no later than 5 working days after the
inspection
Involve ExE in judgement decision and agree a rating
Send draft report to ExE for their return no later than 5 working days
Correct any factual inaccuracies identified by ExE
Return to publishing procedure
Go to quality control /assurance process
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Appendix E: Ratings request for a review – at a glance process: NB A Ratings Review Team and an Independent Reviewer are in the process of
being appointed. Some details in the process below will change when detailed
workflows for the new team and reviewer have been agreed. Look out for an
announcement and revised guidance in due course.
1. Applicant providers must tell us within 5 working days of the publication of a final
report that they want to submit an application. They do so by emailing (or writing to) NCSC.
2. NCSC will reply to the provider within 2 working days with instructions about how to submit an application.
3. Applications can only be submitted online and within 15 days of the publication of the report, using a hyperlink provided in the instructions.
http://webdataforms.cqc.org.uk/Checkbox/ASCAppeals.aspx
4. The checkbox form automatically forwards the Request email to the [email protected] mailbox and sends a copy to the applicant.
5. NCSC validates request for review. Validation is a simple check that the location and inspection ID are accurate, and that text has been entered into appropriate fields
6. NCSC saves the request email into CRM and sends a template email to Digital Communications requesting that a standard ‘Under Review’ flag is added to the location’s content on our website.
7. NCSC sends request to a reviewer in another region. Reviewers are HOIs. HOIs can ask IMs in their region to undertake specific tasks on their behalf, but accountability remains with the HOI.
8. The HOI reviews the evidence and rating awarded in the location inspection report against the relevant KLOEs, characteristics of ratings, records relating to inspection team consultations, the aggregation tool, and the completed QA/QC tool for the report. Where needed they contact the provider or members of the inspection team for more information.
9. The HOI makes a judgement about whether the relevant rating(s) were correctly awarded, and makes a recommendation about whether the ratings should be changed using the Request for Rating Review Form.
NB – the HOI can recommend that ratings go ‘down’, stay the same, or go ‘up’. They are not restricted by the provider’s wishes.
10. The Chief Inspector or a Deputy Chief Inspector reviews the Request for Rating Review Form and any source material they want to read (e.g. the report). They record their decision in the Review Form. If they do not accept the HOI’s recommendation, he or she will explain their rationale for not doing so in the Form.
11. Where the decision is not to make any changes the Inspector will send an email to the provider using a template letter (available on the intranet) that explains the outcome, and setting out the rationale (as described in the Request for Review
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form). They will then contact the Digital Communications Team to ask that the website flag is removed. NCSC log the decision as an activity in the inspection record.
12. Where it is confirmed that a change in ratings will be made, the HOI / IM will discuss the changes needed with the inspector and inspection manager.
13. The Inspector will contact the Digital Communications Team to ask that they create a clone of the relevant original report, and give them editing rights.
14. The inspector edits the report as needed and discusses the amended report and ratings with the inspection team, for their information.
15. The inspection manager signs off the amended report, which will be published and replace the existing report. The revised report and separate overall summary will be sent to the provider by email, together with a template letter confirming that the ratings have been changed, and a summary of why (available on the intranet). NCSC log the decision as an activity in the inspection record.
