By Kieran Seale and Peter Kinsey
As a provider of health and social care services, you will have heard of the Care Quality Commission (CQC), an independent regulator of such organisations. However, having a full understanding of the guidelines as well as demonstrating CQC compliance is no easy task.
Established in 2009, CQC’s primary role is to ensure that health and social care providers deliver safe, effective, compassionate, and high-quality care.
Verita works collaboratively with organisations to develop policies and procedures, systems and infrastructure in order to address compliance concerns. In this article we discuss what CQC compliance is, the basis on which organisations are rated, how to prepare for an inspection, and how to move forward afterwards.
What is CQC Compliance?
CQC compliance refers to meeting the standards and regulations set by the Care Quality Commission. It is a term used to describe the ability of a healthcare organisation or service provider to adhere to the guidelines and requirements set by the commission to ensure the safety, quality, and effectiveness of care provided to patients or service users.
Whether starting a new care organisation or changing your existing service offering you will need to demonstrate compliance with CQC requirements. Compliance with CQC regulations is important for organisations to maintain their registration and demonstrate their commitment to providing high-quality care.
Which organisations do the CQC inspect?
The CQC monitors, inspects, and regulates a wide range of healthcare providers and services including:
- Independent healthcare providers and clinics
- Hospitals (both NHS and private)
- General practices (doctors’ surgeries)
- Dentists and dental practices
- Mental health services
- Social care services (such as nursing homes, residential care homes, domiciliary care agencies)
- Ambulance services
- Adult social care services (such as day-care centers and support services for people with learning disabilities)
They also encourage care providers to make improvements and take action to protect the people who use these services.
How do CQC rate a provider? What are the 5 key CQC questions?
The rating process typically involves the following steps:
Inspection: CQC inspectors visit healthcare or social care providers on-site to assess various aspects of their service. Inspectors may be clinicians, social care experts, or other individuals with relevant experience.
Key Lines of Enquiry (KLOE): Inspectors evaluate providers against five key questions known as KLOEs, which are:
- Is the service safe? Assessing whether patients/clients are protected from avoidable harm, abuse, and infection.
- Is the service effective? Assessing the quality, effectiveness, and appropriateness of care, treatment, and support.
- Is the service caring? Evaluating whether staff treat people with compassion, respect, and involve them in their own care.
- Is the service responsive? Assessing how well the provider meets the needs and preferences of individuals and responds to complaints.
- Is the service well-led? Evaluating the leadership, management, and governance of the provider.
Evidence collection: Inspectors gather evidence during the inspection through direct observation, speaking with staff and patients/clients, reviewing documentation, and analysing data.
Rating: Based on the evaluation of the KLOEs and the collected evidence, CQC assigns a rating to the provider. The ratings are as follows:
- Outstanding: The provider is performing exceptionally well.
- Good: The provider is meeting expectations and providing a quality service.
- Requires Improvement: The provider is not consistently meeting expectations and improvements are needed.
- Inadequate: The provider is performing poorly and requires significant improvements.
Report publication: After the inspection, CQC publishes a detailed inspection report on its website, which includes the rating, findings, recommendations, and any required actions for improvement.
How can you prepare for a CQC inspection?
CQC have previously talked about the characteristics they see in the organisations that are improving. They are that the organisation is outward looking, it responds well to feedback and where the leaders have an ‘open door’ culture. It is striking that these features of improving organisations are the same as those of good leaders – outward looking, responsive and open. Leadership that is open to new ideas, to learning and to doing things better is strong leadership. And leadership of this kind is critical in ensuring that health and social care organisations provide good outcomes for patients and service users.
At Verita we have been working with a number of organisations in recent months who are facing CQC inspection, particularly relating to their leadership and governance – whether they are “well led”. Although the words ‘CQC inspection’ run a chill through most managers, CQC are really only looking for evidence that organisations have strong, high quality leadership in place. Leadership of this kind is something that all organisations need – whether the CQC asks them for it or not.
We have developed a comprehensive approach to responding to “well led” reviews which helps organisations assess the effectiveness of their leadership and any areas for improvement in response to the questions that organisations are being asked. The framework also helps organisations prepare for CQC inspections, particularly looking at the key lines of enquiry that relate to “well led”. Our experience is that the approach we have developed works equally well in both health and social care provider organisations.
There are two publicly available frameworks which define the key elements of a well led organisation: the NHS Improvement well led framework and the CQC key lines of enquiry. There is a lot of overlap between the two; the NHS Improvement framework is more comprehensive with eight main components, whilst the CQC framework has four. Four of the components are virtually identical in both frameworks, with the CQC one having an additional component, “working in partnership with other agencies”, which is not included in the NHS Improvement document. We have combined the two to produce nine components of well led:
- Leadership capacity and capability
- Clear vision and credible strategy
- Culture of high quality and sustainable care
- Clear responsibilities, roles and systems of accountability
- Clear and effective processes for managing risks, issues and performance
- Appropriate and accurate information which is effectively processed, challenged and acted on
- People who use services, staff and families are actively engaged and their voices are heard
- There are robust systems for learning, continuous improvement and innovation
- Working in partnership with other agencies for the benefit of patients or service users
Verita’s approach involves triangulating data from a range of sources to produce the most comprehensive picture possible of an organisation and how it works. This includes interviews with staff throughout the organisation from Board level to the front-line, with patients or service users, their families and external stakeholders, including commissioners. We also review a range of documentation, including, for example, the terms of reference of governance committees and the minutes of Board meetings.
In our experience, there are a number of aspects of the way that an organisation works that are particularly important:
Are the right people with the right skills leading the organisation?
Does it have a culture that is focused on both effective management and the patient or service user experience? For example, is more attention paid to financial performance, the patient or service user experience or a balance of the two?
Are governance processes adequate – is there an appropriate committee structure and audit process involving the right people that scrutinises the right information to assess how well the organisation is performing? Is it straightforward or too complicated?
Are senior managers visible, known to staff and in touch with what is really going on in the organisation?
Is there a culture of evidence? In a heavily regulated sector we know that, is something isn’t recorded, it hasn’t happened. Is there a clear flow of information that is evidenced, for example in meeting minutes, that tracks through to the Board?
Is there a clear “golden thread” from the ward to the Board? This involves both the scrutiny and transmission of data and the presence of senior managers on the front-line checking that the data they are receiving mirrors the experience of front-line staff and patients or service users and that key messages are being effectively communicated.
Is there a strong voice for patients or service users and their families and is there evidence that it is acted on?
What to do if your organisation receives a poor rating
There are lots of ways in which people would like to respond to an unfavourable report on CQC compliance – not all of them printable in a polite blog. But what actually is the right way to respond?
We have been thinking about this question as we work with a client which received a CQC inspection a few months ago.
We were particularly focused on the question of whether the organisation was ‘well led’, and what it means to be a well led organisation.
There are, of course, lots of things to think about in the guidance – vision, leadership, people, systems, etc. Before thinking about those, however, you need to ask yourself if you know how well led you really are. By definition, those that are worst led have the least awareness of this. But it is often very difficult for any organisation to see itself objectively.
Without objectivity, challenging the CQC is fairly pointless. But even with a degree of awareness, simply challenging the words that the CQC have used in their compliance report can also be fruitless – for two other reasons.
Firstly, it is quite difficult to change people’s minds about what they have already written. They will have thought about it and (hopefully!) had it checked before it is sent out. You will need something compelling to get them to think again.
Secondly, how does arguing about words help anyone? It certainly doesn’t improve the service patients receive. More fundamentally, it doesn’t demonstrate compliance to the CQC in terms of being a well led organisation.
How can you demonstrate CQC compliance following an inspection?
Clearly you need evidence, and you can prove some things with board minutes and committee structures. But it is hard to prove many of the more subjective elements in this way.
Maybe it is helpful to think about the problem like this: if you were giving feedback to someone about how their organisation was run, what would you want them to say in response? We think that it would be something along these lines:
- Thank you for your feedback. We have considered carefully what it means for our organisation.
- We think that you missed (or got wrong) the following things about our organisation.
- While we might not agree with the particular points you make about how we are run, we have been reflecting on these issues ourselves. We know that we can always learn and improve things and this is what we have underway to improve in these areas.
Many organisations bring in advisors at the last moment to help them to “respond” to the CQC. How useful is a last-minute response, really? What effect will it have on compliance? For the organisation we have been working with we have spent some weeks talking to them about how they are governed and how they can improve. Some of the things we identified were the same points as the CQC ones, while some were completely different! But this process meant we could give them information for a focused response to their inspection report.
More importantly it meant that we could give them useful feedback for the longer term – to help the organisation move forward in light of CQC compliance and genuinely improve how they are run.
Real improvement, of course, is the only thing that will genuinely make a difference to ratings in the long term. And improving the way organisations are actually run is, of course, the real point of the whole process!
Verita work collaboratively with organisations to develop policies and procedures, systems and infrastructure in order to address compliance concerns. If you’d like to find out more about the CQC compliance support we can offer, please book a free consultation or contact Ed Marsden on 020 7494 5670 or [email protected].
Kieran Seale is a director at Verita.
Peter Kinsey has worked in health and social care for 35 years. Most recently he was Chief Executive of ‘Achieve together’, one of the largest learning disability provider organisations in the UK. Peter led the successful merger of CMG and the Regard Partnership to form Achieve together.
This article was originally written in May 2020 and updated with additional content in August 2023.