CQC – New Fundamental Standards: Part 3,The Standards
This article will expand on the Fundamental Standards themselves.
The CQC now proposes that eleven Fundamental Standards be introduced, below which no provider will be expected to fail, backed by swift and effective enforcement action.
The eleven proposed Standards give rise to the five Key Questions the CQC will ask of each Service:
- Is it Safe, protecting people from abuse and avoidable harm?
- Is it Effective, with care, treatment and support achieving good outcomes, promoting good quality of life, and being evidence-based wherever possible?
- Is it Caring, with staff involving people and treating them with compassion, kindness, dignity and respect?
- Is it Responsive, with services organised in such a way as to meet people’s individual needs?
- Is it Well-led, with leadership, management and governance asserting the delivery of high quality person-centred care, supporting learning and innovation, and promoting an open and fair culture?
In order to focus inspections and judgements on the Fundamental Standards, inspectors will use a set of question formats termed Key Lines of Enquiry (KLOEs). Each KLOE set will include a mandatory set of enquiries which will be checked on every inspection, plus four other enquiries as indicated by the inspector’s knowledge of the Service, intelligence gathered, or concerns raised. The KLOEs will be expanded by “prompts”, which will define the particular evidence which the inspector will look for. An advantage of this approach will be improved levels of consistency between inspections of the same Service over time, and between Services.
Attention is drawn in the Consultation to the CQC’s principle of promotion of Equality and Human Rights. The new approach is said to be firmly based on this principle. In consequence, the underlying approach of inspection will be to look at what rights people hold, as opposed to what the Service should do for people.
The human rights approach will underpin the examination of the eleven Fundamental Standards, each of which will be scrutinised through the filters of fairness, respect, equality, dignity, autonomy, rights to life, and rights for staff. In addition to underpinning the KLOEs, the human rights approach will similarly reinforce the proposed ratings system, Intelligent Monitoring, inspection methods, learning and development of the CQC staff, and the CQC’s own policies and procedures.
Key Lines of Enquiry
Each of the five Key Questions is expanded by Key Lines of Enquiry. As the name suggests, these are the more detailed requirements which the CQC will expect to see during inspections, supporting each of the Key Questions.
Each service sub-type has its own set ok KLOEs, for instance, community services, residential services, mental health services.
Taking the community KLOEs as an example, each Key Questions has a number of KLOEs to expand it.
- Safe - 5 KLOEs
- Effective - 4 KLOEs
- Caring - 4 KLOEs
- Responsive - 3 KLOEs
- Well-led - 4 KLOEs
Each of the KLOEs has a varying number of prompts to further elucidate the requirement.
As an example, the following is S1, the first KLOE in the community care set.
(Provider Handbook (Adult Social Care) Consultation, Page 34)
Note that this KLOE is highlighted. The implication of this will be discussed in the article about the proposed new Inspection process.
This example demonstrates one factor in the new standards; the language of the detailed requirements is familiar, and is clear. Those who know the Essential Standards and the detailed prompts will feel a sense of comfort from seeing the familiar. However, there are some changes.
There are changes of emphasis, partly as a result of sharpened language and partly because of the focus on safety in particular. Do not lose sight of the fact that the original furore around Stafford, Winterbourne View and Southern Cross centered around the safety of users of the services. It is not surprising therefore that added emphasis has been given to the area of Safety.
The other notable emphasis change, which also arises from the same furore, is the highlighting of Leadership and sound governance of care provider organisations. It has been noted, not before time, that requiring certain processes does not deliver quality services. Good governance, leadership support good management and an achieving, open, effective and safe culture, and the new Fundamental Standard of Well-led focusses on exactly that area.
Overall the KLOEs and prompts are more outcome orientated than process orientated. This is presumably in recognition that processes do not of themselves deliver safe and effective services. The true measure of how a service performs is how the user of the service feels about that performance. The days of ‘Matron knows best’ have long gone, but their replacement, the ‘Professional knows best’ is still with us, and the intention of the Fundamental Standards is to drive professional input to the place it should be, which is advisory and not mandatory on the service user.
The QCS system has already been fully reviewed to judge its compliance with the Standards, KLOEs and prompts in order to meet the September 2014 revised system launch date. Because of the history of the development of the system, the regular, rigorous review and updating by a large team of expert contributors, and the speed with which changes are made to the system and delivered direct to your desktop, the review found that only small changes were required to existing policies.
However, the reinforced emphasis on measuring outcomes as defined by service user views means that a very significant proportion of the evidence which will be required to be placed before CQC inspectors to demonstrate compliance will stem from direct questioning of the service users themselves wherever possible, or their advocates and family where not possible. QCS is developing a suite of customer, staff and professional questionnaires in order to provide this information. The questionnaires will be completely focused on providing exactly the information required by the prompts in order to make delivery of the information by the provider, and interpretation of the data by the CQC.
Safety in the QCS system is embedded throughout; QCS does not regard the Health and Safety Policy as the only source of safety information. Every policy is vetted to confirm its contribution to safety and safe practice before publication, on the principle that the policy manuals are the primary staff training resource. While in the ideal world all staff know and understand all policies, including Health and Safety, a robust management system ensures that a staff member who only reads the policy related to their current activity is working to safe principles in that activity.
Personalisation has always been a fundamental principle within the QCS system. All policies promote the individual application of process rather than blanket application, but most importantly of all care planning is made the central pivot of all processes in the Service. The QCS system encompasses the strategy that all activity in the Service happens because one or more care plans call for it. The corollary is that if an activity is not called for in a care plan, the question must be asked “why is it happening?” The answer could be “because we have always done it”, which is wasteful and potentially depersonalising and therefore should cease, or because of some underlying legal requirement, in which case the requirement should be double checked for validity and only imposed if there are no alternatives. Everything in the care planning system, including the policy and procedure and care plan format is designed to make it easier to take the personalised approach as opposed to others.
By definition, the effective use of the care planning cycle embedded in the QCS format makes responsiveness easier – the service user is constantly reminded that they are expected to be represented in the process and in control of it, and the staff user is pulled along a path which encourages them to constantly review the effectiveness of the care strategy agreed with the service user.
Historically, the QCS system has been heavily dependent on a human rights approach, arising originally from Homes are For Living In, and being broadened with the enactment of the Human Rights Act in 1998. Every policy has been created and reviewed through the prism of human rights, and the full set promotes respect for human rights throughout all activities.
The availability of a system already closely compliant with, but further updated to the new Fundamental Standards, backed up by the QCS Customer Care team to answer questions and concerns, means that QCS management system users will be able to confidently transition from the old to the new inspection regime.
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 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-focussed 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 2)
The scope of each of these processes is based on the new definitions of quality, these being:
(Provider Handbook (Adult Social Care) Consultation, Page 2)
Michael Dempsey - QCS Compliance Director