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Changes to how CQC inspects and rates care homes

Care Quality Commission inspections

As a care home owner, it’s your legal obligation to meet the Care Quality Commission (CQC) standards ensuring residents’ health, safety and welfare.

CQC conducts regular inspections based on your home’s rating. CQC has now implemented their new assessment framework for care home providers in England, which differs in some aspects from the previous process.

About the CQC’S new assessment framework

What remains the same?

The CQC’s new approach to assessment continues to ask the five key questions, which apply to all health and social care services. The CQC asks if the services are:

  • safe
  • effective
  • caring
  • responsive to people’s needs
  • well-led

The CQC will also continue to provide an overall location rating as part of its assessment. For each key question and the overall location rating the CQC will continue to apply its four-point ratings scale, awarding a rating of outstanding, good, requires improvement or inadequate.

Rating aggregation

CQC has provided additional clarity on how scores will be aggregated when they determine the overall service rating of a care home. The five key questions are all stated to be equally important and are weighted equally when determining the overall service rating.

For an overall rating of outstanding, a service will normally need to have both:

  • At least two key questions rated as outstanding.
  • The other key questions rated as good.

The overall rating will normally be good if there are both:

  • no key questions rated as inadequate.
  • no more than one key question rated as requires improvement.

The overall rating will normally require improvement if two or more key questions are rated as “requires improvement” and will normally be inadequate if two or more key questions are rated as inadequate.

How does the new framework differ from the previous approach?

There are several key differences in how CQC will assess the quality of services:

  • Evidence gathering: CQC will expand information gathering beyond inspections to include various methods at different times, prioritising people’s experiences and shifting away from inspections as the main evidence collection method.
  • Frequency of assessments: Evidence CQC collects or information it receives can trigger an assessment at any time. As a result, the rating of a service will no longer be the main driver when deciding when CQC next assesses a service.
  • Assessing quality: CQC aims to assess quality more frequently by using evidence from various sources and reviewing multiple quality statements, rather than solely relying on inspections as currently done.

Quality statements replace CQC’s previous key lines of enquiry (KLOEs), prompts and rating characteristics. The quality statements are described by CQC as a set of commitments that providers are expected to live up to, highlighting what is needed to deliver ‘high-quality, person-centred care’.

Evidence categories

As part of its new approach to evidence gathering, and in order to make the results of assessments more transparent and consistent, CQC has grouped the different types of evidence they will consider during their assessments into six distinct categories. These are:

People's experience of health and care services

CQC defines people’s experiences as:

“a person’s needs, expectations, lived experience and satisfaction with their care, support and treatment. This includes access to and transfers between services”.

This is not limited to just people using the service, but also their families, friends, and advocates. Evidence collated can include phone calls with individuals, emails and completed feedback forms submitted to CQC, as well as feedback received by community groups, health and care providers themselves and local authorities.

Evidence may also be taken from groups representing people who are more likely to have a poorer experience of care, people with protected equality characteristics and unpaid carers

Feedback from staff and leaders

This is feedback from people working in a service, for a local authority or in an integrated care system, as well as groups of staff involved in providing care to people. It may also include evidence from people in leadership or management positions.

Examples of evidence CQC may consider include results from staff surveys, direct feedback from staff, interviews with staff or leaders, and whistleblowing.

Feedback from partners

This is evidence obtained from people who represent organisations that interact with the service provider in question, such as commissioners, other local providers, accreditation bodies and professional regulators.

Observation

Evidence obtained through observation on-site by CQC inspectors will remain an important cornerstone of any assessment. CQC may also rely on external bodies undertaking observations, such as Local Healthwatch.

Processes

CQC’s assessment in this regard will focus on how effective processes are to the relevant quality statement. CQC will consider data and information that measures how well such processes actually work. Examples include results from audits, findings and learning from safety incidents, access times for treatment and care, and case note reviews of people’s care and/or clinical records.

Outcomes

Assessment of outcomes considers how the service has affected people’s ‘physical, functional or psychological status’, with CQC considering aspects such mortality rates, emergency admissions and re-admissions, infection control rates, and vaccination and prescribing data.

Such evidence will not just be obtained at local service level, but from other wider sources such as national clinical audits.

I statements

So-called ‘I statements’ now form part of the assessment framework applied to services by CQC. They more specifically tie into people’s experiences and reflect what people have said matters to them in respect of the services they receive. For example:

“I have care and support that is co-ordinated, and everyone works well together and with me.”

“I am in control of planning my care and support. If I need help with this, people who know and care about me are involved.”

Providers are expected to make it easy for people to share feedback and ideas or raise complaints about their care, treatment and support, as well as involve them in decisions about their care and tell them what’s changed as a result. CQC may request information and documentation in this regard when collating evidence as part of their assessment.

Why are ratings important?

Your care home’s rating must be publicly displayed on-site and on your website. Failure to do so may lead to fines unless all reasonable steps have been taken. A low rating could lead to resident departures, difficulty attracting new residents, and staff motivation loss or turnover, potentially causing revenue decline.

Ultimately, a bad rating may lead to the forced closure of your business if you fail to improve your service.

Starting an assessment

CQC will continue to apply existing rules when giving notice of assessments. This includes where an unannounced on-site visit is conducted.

As is currently the case, CQC will email you to tell you when an assessment is scheduled to be undertaken. At this stage, CQC may also request specific documentation or evidence for their review.

In some cases, CQC may not need to carry out a site visit if the scope of their assessment does not require this. Where on-site assessment is undertaken, CQC has stated that – where possible – it will aim to provide feedback immediately after completing such on-site attendance.

Challenging your draft report

Before your final rating is published, you’ll get a draft report. If you’re dissatisfied, you can dispute the accuracy and completeness within ten working days. Any need for extra time must be promptly communicated to CQC. This process remains the same as the old framework, and must be done within ten working days. Any exceptional circumstances that mean you need more time must be explained to CQC immediately.

If facing unfavourable ratings, seeking legal advice upon receiving the draft report is advised for optimal success. We’ll collaborate with you and other professionals to refute inaccuracies in the information relied upon by CQC.

Our aim is to demonstrate how accurate and complete information can lead to better ratings. We’ll assess whether preparing your submission or making it on your behalf or is the best approach.

Challenging your final report

All is not lost if you fail to successfully challenge your draft report. CQC also allows care providers to request a review of their ratings after publication of their final inspection report.

You can only request a ratings review by asserting CQC failed to follow its process for deciding on ratings. This process cannot be used to ask for a rating to be reviewed on the basis that a provider disagrees with CQC’s judgements.

A request must be submitted within 15 working days. When a review is taking place, CQC will display a message on their website, but the report will remain published and available.

Challenging your ratings after your report has been published can be a stressful and overwhelming process. We can help you prepare your request and respond to any communication from CQC in a swift, balanced and effective manner.

Judicial review

We can also help you challenge your ratings through the courts. This is the appropriate route to take if you would like to challenge the substance of the final report, as opposed to challenging that CQC failed to follow its process. Our solicitors can advise you on whether a ratings review or a judicial review is most suitable.

Speak to an expert

We have a focus on the healthcare sector, including care homes. Our solicitors can work with large care home groups and owners of single homes. For more information, request a consultation.

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