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The CQC changes inspection arrangements
The CQC, established in 2009, has this week made changes into the way in which it regulates and inspects. This article outlines the main changes and who it will effect.
The Care Quality Commission was established in 2009 as a non-departmental public body, responsible to the Government for regulation and inspection of health and social care services in England. At establishment, the CQC was responsible for regulation and inspection of NHS hospitals, care homes, and functions of the Mental Health Act 1983 previously the remit of the Mental Health Act Commission.
Since establishment the CQC has widened its regulation and inspection remit to cover domiciliary care , dentists, and GPs (due in 2013). Towards the end of 2011 the CQC held a consultation on proposals to the way in which they regulated and inspect, and as a result made changes which come into effect on 1st April 2012.
Frequency of inspections.
Having gradually reduced the frequency of onsite inspections since their establishment, arguably as a means of coping with resource restrictions – reduced staff levels in plain English, the CQC is now reversing the decline. They say that they will inspect “most” hospitals, care homes and domiciliary care providers at least once a year, and dentists once every 2 years. In order to do so, the decline in the number of inspectors will be reversed and more will be recruited. The workload of each inspector will be reduced, allowing them more time to become familiar with each service being inspected.
If this statement turns out to be true, services should therefore expect to find themselves under increased scrutiny, even though the press release puts the change on more uplifting terms. The changes are to a significant extent a result of criticisms of the effectiveness of the CQC in spotting and dealing with abuses of service users. Therefore, expect more and closer examination, more often.
Services will of course be re-inspected when they are found not to comply with any of the standards, or are judged to be at risk of failing to meet a standard in the future.
Each on-site inspection will focus on one standard from each of the five main chapter headings within the standards. There will be no advance notice of the standards which will be inspected. The standards chosen for examination will be depend on the profile of the service being inspected, and any intelligence gathered which might indicate concerns. Between inspections, all 16 standards will be checked by the current method of intelligence gathering, and action taken where there is any indication of a risk of poor care.
Provider Compliance Assessment
Because inspections will be unannounced, the current system of requesting portions of the Provider Compliance Assessment (PCA) to be delivered to the CQC prior to an inspection cannot happen in future. They may ask for information either during or following an inspection. They state that this will only happen “if we need to corroborate evidence”. In this context, the PCA has, according to the CQC, become an optional method of providing information, rather than the mandatory method. They note that some Providers have become used to using the PCA as a method of internal quality management, and they expect them to continue their use. The implication is that the expect others to drop the PCA. However, services need to bear in mind that they are still required to provide information as required, and that it is the responsibility of the Provider to prove that they meet the standards, not the responsibility not the inspector to find that information. The inspector is focussed on finding out what is wrong; not proving what is right. Therefore unless the service has a system which replaces the function of the PCA, which is to demonstrate that the service critically examines its service and plans and delivers improvements, then they should drop the PCA at their peril.
Consistency of judgements
Providers, and assessors from other quality awards, have long had concerns about the consistency of CQC inspection judgements. Complaints about inconsistencies in inspections have always been a feature of provider/inspector relations, but the increasingly apparent professionalism of CQC has given rise to higher expectations, but disappointment. As the CQC raised the bar by publishing more and more apparently systematised guidance, the evidence of a corresponding lifting of their own game by improved consistency has been hard to find. The new system makes reassuring statements in this area, but no evidence is offered of new systems to be used by inspectors, or improved training, which might result in improvements to consistency.
The purpose of inspections is clearly stated to be to identify if a service is compliant with the standards, or non-compliant. However, they also state that “a balanced approach” will be taken, and the report will contain observations on what the inspector has seen, heard and felt. They do not say that these will be positive, but imply that they are, and that the resulting report will be useful as a balanced view for service users and commissioners of services.
CQC state “Following an inspection, we will judge providers to be either compliant or non-compliant with the regulations. This is simpler and easier to understand, and it will help us target noncompliance more effectively.” One wonders what we thought they were doing before. They will no longer impose improvement actions on services where they consider that a service currently meet the standards, but may not do so in the future.
Where a service is judged not to meet any regulation, CQC will decide on the possible effect that the non-compliance has on service users, and take appropriate and proportionate action. The level could be adjudged to be minor, moderate or major, as illustrated by existing CQC publications. On this basis CQC will decide if the action to be taken is compliance action or enforcement action. They say that this will be a more fair, proportionate and consistent approach.
The follow up on identification of non-compliance will be on a fixed timescale. There will no longer be extensions to the timescales given to become compliant, and the action will be escalated on the expiry of the initial time allowed if satisfactory action is not taken.
Warning notices will be published, unless the Provider produces a good reason why they should not be published, and the appeal is upheld.
Time will tell what the changes actually mean for Providers. Some of the statements made in the CQC information release are woolly and do not give any real indication what will occur. As with all aspects of care services, the outcomes depend on the skills and training of the staff, and the tools which they have at their disposal. There has been ample evidence for some time that the CQC has not fulfilled its potential in these areas, sometimes producing inconsistent results. The only tangible promise is that Providers will see more inspectors, more often, and they should be prepared. The use of a systematised quality assurance and quality improvement programme, such as the QCS Care Compliance System is essential to first of all keep complaint, and of a lapse happens, it is quickly found and a tried and tested method of returning the service to full compliance is applied. If a robust management system such as the QCS system is energetically applied, the service will exceed the minimum standards set by CQC, and will be in the business of delighting its customers.