CQC – New Fundamental Standards: Part 2, Registration
This article will expand on the registration element of the process.
If one word were to describe the proposed new approach to registration of new providers, it would be “robust”. Judging from historical precedent presumably this rigorous approach will also apply to variations in registration. Applications for variation, being a time when a provider is at a negotiating weak point, has long been seen by regulators as a time when pressure can be brought to bear on issues which were difficult to enforce under normal circumstances.
Several elements of the process of registration, which, while they are present in the current system have been refocused and reinforced.
The CQC have stated that they will take a more rigorous approach to judging if a person having strategic or managerial control of a care organisation is a fit person to do so. A quote from CQC documents point to the foci of the examination (our emphasis):
“Our 2013-16 strategy document ‘Raising Standards, Putting People First’states that we would introduce a more thorough test for organisations applying to provide care services. This would include making sure that named directors, managers and leaders of a service commit to meeting our standards and are tested on their ability to do so.” (Provider Handbook (Adult Social Care) Consultation, Page 11)
The old test of Fit Person, which sometimes appeared to rely solely on the absence of any adverse content of the disclosure process, now looks to become a more proactive and rigorous process, with an added focus on the ability of the proposed provider to understand and lead an effective adult social care organisation.
In the past, fairly bland and untested assurances as to skill levels and approaches have sometimes appeared to be sufficient for a provider to gain registration. Demonstration of skills which indicate an understanding of adult social care processes and how they affect the safety and well-being of the user of the service have not always been required, and certainly not tested. Often, it appeared that the management of the organisation to meet care standards was assumed to be delegated to the Registered Manager, with the provider only having to demonstrate or assert general business skills. This approach was seriously let down by there being no obvious mechanism to police the reliance on a safety net with two anchor points – the provider and the manager. A high risk situation could occur when a competent manager left employment and thus left the provider with no, or poor, skills in adult social care, leaving the service rudderless. It also had to be questioned whether such a provider had the skills to competently recruit a manager. If the CQC deliver on their promise of rigorous enforcement of standards of adult social care competence of providers as well as managers, there will be a welcome improvement in the depth and health of management in some organisations where it is currently lacking.
To quote CQC again:
“Registration will assess whether new providers have the capability, capacity, resources and leadership skills to meet relevant legal requirements, and are therefore likely to provide people with safe, effective, caring, responsive and high quality care. The assessment framework will allow registration assessors to gather and consider comprehensive information about proposed services, and make judgments about whether applicants are likely to meet these legal requirements.”
(Provider Handbook (Adult Social Care) Consultation, Page 11)
Management of the business and financial skills
The Southern Cross collapse and general panic focused minds on judging the financial capability of providers to maintain a safe and effective care service. While mechanisms are being brought in to specifically address the issue of financial stability for larger providers, it should be assumed that a change of approach will be evident to some extent at least throughout the registration process for all sizes of provider. Start-up business plans may come under more detailed scrutiny in future, with a reasoned assessment of the provider to provide a financial and resource safety net for the inevitable challenges to the smooth progress which most business plans lay out.
The implication of the CQC quotation under “Skills” above is that there will be improved focus on the specific adult social care skills of providers, and the individuals that make up the entity, even if they are several, such as a board of directors or multiple partners. Those individuals who cannot demonstrate preceding care skills may well have to exhibit robust mechanisms for ensuring that their functioning is care-aware, and sensitive to the specific requirements of the adult social care sector.
Focus on culture as a means to an effective service
The management model, within which the staff oriented elements of the Quality Compliance Systems (QCS) compliance system were developed, held to the view that staff could not be expected to respect those for whom they cared if their employer did not, through every process affecting those staff, show respect for the staff themselves. For many years this principle was hidden or unacknowledged within many care services, but the Francis Report has highlighted the importance of a respectful and therefore open culture on the quality of care. The QCS system will continue to be developed within these principles, reinforcing the cultural effect of the whole system, which is to promote caring and responsive processes because staff are themselves treated with the respect due to them.
The QCS system is not a disparate compilation of disconnected policies and procedures; the pack of policies has an underlying cultural identity, which staff reading it may not be consciously aware of, but through it will be encouraged to follow best practice. The promotion of a respectful and positive culture extends from recruitment, through induction, day to day management, informing and involvement of staff, discipline - which is conducted fairly and transparently, finally to termination.
Whatever the contents of the QCS system as it affects staff, the effect will be negated unless there is effective leadership, and management. The system seeks to inform staff at all levels that they are an indispensable part of the whole. Responsive management of quality and culture is embedded, encouraging leaders and managers to prioritise on these functions.
Some of the above could be dismissed as a possibly unlikely interpretation of the consultation documents seen to date, summarised by the quotations. However, the appearance of the top-level Fundamental Standard of “Well-led” points clearly to a sharpened focus on the leadership skills contained in an applicant organisation, in addition to the preceding requirement for management skills. Experienced operators of adult social care know well that the execution of even highly detailed and robust management process is no assurance of safe and effective care. No manager, or supervisor, can be omnipotent. The more astute of those in control of organisations, of any kind but especially those delivering care, know that effective and empowering leadership leads to a positive, open and performing culture, which, when then combined with a rigorous management process, leads to consistently improved organisational performance. The Stafford debacle, followed by the reports on it, firmly make this point.
It is likely that much or even all of these requirements will feature in the new registration process. Clear signs of a movement towards this goal have already been seen in the feedback from Quality Compliance Systems (QCS) customers who have been assisted and advised by us as they go through the registration process. Providers also need to be aware that although the CQC currently uses the caveat “new” in respect of the proposed registration process, the standards developed will inevitably roll out across existing providers in time.
The QCS Care Quality Management System has always been based on the human rights principles on which the new Standards are founded. In addition, good leadership principles are embedded throughout the system, and the creators and maintainers of the system are assiduous in their adherence to a common “voice”, which in turn helps create a culture which is strongly standards-based, which seeks to drive out poor performance and reward safe and effective care practice throughout the organisation, not just the direct care departments. As such, the QCS system is very well-placed indeed to meet the new Standards, and existing users of the system will find that their task of compliance will be significantly eased by their prior use of the system, as long as they implement it in its entirety.
During the development of the QCS response to the Fundamental Standards, due to be implemented in October 2014 and available from QCS from September, a new Leadership Policy and Procedure will be introduced to highlight the elements of the QCS system which support good leadership and develop culture. One effect of the new Policy will be to highlight the importance of links between policies which promote good leadership, and also point out those policies which may under the existing registration regime have appeared to be optional, but which now become mandatory. The Policy will enable QCS customers to check their leadership effectiveness, make adjustments where necessary, and set out confidently on a path to achieving robust compliance with registration requirements.
In Part 1 of the series we have seen how the Care Quality Commission has proposed to implement from October 2014 a new regime of registration and inspection. This is in response to failures of the current regime to spot and deal with poor quality care before too many people were harmed.
We saw that the CQC proposes a new, clarified and re-focused registration and inspection regime, demonstrated by the following schematic.
The schematic demonstrates that the CQC regard their overall registration process as having five steps, these being:
- Intelligent monitoring
- Expert inspections
- Judgement and publication
- Action, if indicated by the inspection outcome
(Provider Handbook (Adult Social Care) Consultation, Page 6)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 7)
Michael Dempsey - QCS Compliance Director