CQC Inspections and the new Single Assessment Framework

In the past the Care Quality Commission (CQC) visited providers on-site every three years to conduct inspections. Providers were required to submit a Provider Information Return (PIR), which CQC used as their main source of information about the provider's services.

Inspectors now review information about a provider's services remotely. They have access to your previous inspection reports and ratings. They use "monitoring information" collected through CQC's data sources. To facilitate this new approach, the Provider Portal will be a crucial component.

Covid-19 and CQC inspections 

During the COVID-19 pandemic, CQC halted its usual on-site inspection program and instead implemented an Emergency Support Framework, which involved communicating with providers through phone calls and tele-conferencing.

As pandemic-related restrictions started to ease, CQC introduced a Transitional Monitoring Approach (TMA). Virtual methods for gathering information were still in use, but inspection activity was limited to specific areas of concern that had been brought to the Commission's attention.

The primary focus of inspections during this time was on the Safe and Well-Led Key Lines of Enquiry (KLOE).

CQC: Transitional Monitoring Approach

The main objective of the Transitional Monitoring Approach (TMA) was to keep an eye on potential risks. The information collected through this process was then used to determine whether regulatory action, such as an on-site inspection, was necessary and what the priority of that action should be.

CQC has started to resume on-site inspections focusing on specific areas of concern and prioritising services that have registered in the past three years but have not yet been inspected. Inspections can fall into one of three categories: 

• Comprehensive
• Targeted
• Focused

The New Single Assessment Framework 

In July 2022, CQC announced that it will adopt a more flexible and responsive approach to regulation, which will be supported by a new Single Assessment Framework. This new framework will gradually replace the current Key Lines of Enquiry (KLOE) system.

The implementation of the new Single Assessment Framework is expected to continue throughout 2023. In the meantime, CQC will continue to monitor, assess, and rate providers using its current methods. The Commission has been collaborating with providers to ensure a smooth transition to the new framework.

CQC is improving its monitoring approach by applying lessons learned from the Transitional Monitoring Approach (TMA). Each month, the Commission reviews information on most of the services it regulates. Based on this review, CQC will prioritise any necessary activity.

For lower risk services, CQC will publish a statement on its website to inform providers and the public that there is no evidence suggesting the need to reassess the current rating or quality of care at that service at that time.

CQC will maintain its focus on safety and effective leadership across all regulated services. It will engage in structured conversations with providers, prioritising safety and leadership.

CQC will continue to use existing Key Lines of Enquiry (KLOE) to monitor services and will employ digital methods and local relationships to facilitate direct communication with service users, their families, and staff.

If monitoring activity leads to an inspection, CQC will employ its existing inspection methodologies and Key Lines of Enquiry to ensure the provision of safe and high-quality care. However, inspections will be more targeted, with a focus on areas of risk.

As a result, inspectors may not assess all KLOEs, and inspections may not always result in a change in rating.

Types of Inspection

CQC conducts various types of inspections based on factors such as the time since the last inspection, information received about the service, and any concerns that need to be followed up. There are three types of inspections: Comprehensive, Focused, and Targeted.

Comprehensive Inspections

Comprehensive inspections cover all 5 Key Questions, safe, effective, caring, well-led, responsive. 

Comprehensive inspections provide an overview of the entire service, examining all five Key Questions to evaluate its performance. CQC usually conducts Comprehensive inspections in the following situations:

• When a service has been registered but has not yet been rated.
• When there is a perceived risk to the safety and well-being of service users or if there has been a significant decline in the quality of the service.
• When there is a considerable improvement in quality that could enhance the overall rating of the service.

Notice of Inspection

Comprehensive inspections are usually conducted without prior notice, although there are some instances where providers may be informed beforehand. The notice period can range from 48 hours to one week. During the pandemic, inspections were more focused on areas of concern, which may not always result in a change in rating.

With the new inspection framework, CQC will place more emphasis on remote intelligence gathering and the use of Targeted and Focused inspections. The re-rating process will also become more flexible and responsive. CQC is exploring ways to accelerate the re-rating of services that have made significant improvements in quality, especially those currently rated as Requires Improvement. 

Focused Inspections

A Focused inspection is typically carried out in response to specific information received by CQC, or as a follow-up to previous inspection findings. Unlike Comprehensive inspections, not all Key Questions are looked at during a Focused inspection. However, depending on the findings, the scope of the inspection can be expanded into a Comprehensive inspection.

The aim of a Focused inspection is determined by the specific concerns or information that prompted it, which will affect the timing, evidence requirements, and necessary resources, such as involving Experts by Experience or Specialist Advisors.

Some key features of Focused inspections include:

• They always assess the Well-Led Question and any other relevant Key Questions based on the information that prompted the inspection.
• They are smaller in scale than Comprehensive inspections.
• They can result in a change of overall rating at any time, using both the Key Question ratings awarded during the Focused inspection and remaining Key Question ratings from the last Comprehensive inspection.
• They are often unannounced.

Targeted Inspections

Targeted inspections are conducted to evaluate specific risks or concerns, such as compliance with Warning Notices or potential safety hazards. Unlike Focused inspections, they don't cover all areas of the service, but rather focus on the inspector's identified concerns.

For example, if there are reports of issues with medication management, the inspector may examine medication administration record charts but won't investigate all aspects of medication management.

Targeted inspections don't assess the Well-Led Key Question, unless there are concerns about the service's leadership. They are usually unannounced and may occur before a Focused or Comprehensive inspection. They don't affect the service's rating or the timing of scheduled Comprehensive inspections.

However, if significant improvements are identified or further areas of concern are found, the inspection's scope can be expanded into a Focused or Comprehensive inspection.

CQC’s New Approach

After releasing its latest Strategy, CQC conducted a consultation regarding changes to its regulatory approach, including inspections. The Commission announced its new approach in October 2022. The development of this new approach will continue throughout 2023, with implementation expected towards the end of the year.

In the meantime, CQC will continue to utilise its current systems to monitor, evaluate, and rate providers. 

What changes should we expect?

Under the new approach, CQC will make changes in several areas, including how it collects information and rates services, while retaining the fundamentals of inspection.

Gathering evidence will involve making greater use of a wider range of sources, including people's experiences of care services, gathered through various channels and at different times, such as the Provider Portal. The Commission's focus will shift from on-site inspections as the primary source of evidence collection to a more risk-based and focused approach. Providers should emphasise evidence of a systematic approach to risk assessment and management, which should be up to date and relevant for accurate information about their services.

If there are any doubts about the inspector's lines of inquiry, it is appropriate to ask for clarification during the inspection. It's essential to challenge inaccuracies during the Factual Accuracy process.

How often will assessments be conducted?

CQC is moving away from a scheduled three-year cycle of inspections, and monitoring activity will increasingly be triggered by evidence collected or received by the Commission. For example, concerns over staffing levels, missed or late calls, or staff recruitment, training, and supervision may trigger inspection activity. This shift in emphasis will allow CQC to focus its activity where it's most needed, whether at the sector or provider level, and gather evidence in both planned and responsive ways.

Assessing Quality

CQC's more dynamic approach to assessment will result in more flexible and regular judgments about service quality, rather than from a fixed point in time. The wider range of evidence collected will allow the Commission to be more selective about how it weighs evidence. Assessments will be more structured and transparent, using evidence categories as part of the assessment framework, including people's experiences of health and care services, feedback from staff and leaders, feedback from partners, observations, and processes.

Individual scoring of the evidence categories should allow for easier ranking and benchmarking of services.

Planned Activity

CQC has established an initial schedule for ongoing assessment of each evidence category in the assessment framework. This will determine how often CQC needs to gather evidence for each category, based on the service type. The Commission aims to update information for all evidence categories relevant to a service within two years, but there won't be a fixed point for this like the Provider Information Return (PIR).

It's important to note that the collection of evidence does not necessarily indicate imminent inspection activity. The frequency of planned evidence collection may vary depending on additional national priorities or changes in the Commission's view of risk in an individual service or area.

Responsive Activity

CQC has become more responsive to immediate risks or changes in service quality since the start of the COVID-19 pandemic. The Commission takes action in response to concerns raised by whistleblowers, safeguarding reports, statutory notifications, and feedback from people using services or their families through CQC’s ‘Give feedback on care’ site. 

CQC will also collaborate with local Healthwatch groups and Experts by Experience to better engage with people, families, carers, and communities whose voices are not always heard. If CQC has concerns about the transparency of the evidence received, site inspections will still be an option. 

Ratings under the new framework

Under the new framework, CQC will still use the same 4 ratings to describe the quality of care: Outstanding, Good, Requires Improvement, and Inadequate. However, there will be a new scoring system for the Key Questions of Safe, Effective, Caring, Responsive, and Well-Led, which will determine the rating. These scores will also form the basis for the overall view of quality at the service level.

CQC's Quality Statements, which outline the standards of care that people should expect in each regulated sector, will still be in place.

Assessing the quality of care

To assess the quality of care, CQC will focus on specific types of evidence for each Evidence Category within a sector. This evidence can come from various sources, such as on-site inspections and statutory notifications. Scores will be given for each Evidence Category based on the evidence collected, including people's experiences, feedback, observations, and processes.

CQC will use a three-step process to produce ratings for the Key Questions and Overall quality. Firstly, scores for the Evidence Categories will be combined to give a score for the relevant Quality Statement. Secondly, scores for the Evidence Categories will be combined to give a score for the relevant Key Question. Finally, Key Question ratings will be aggregated to give an overall rating for each Key Question.

CQC's scoring system will have four levels: 4 = exceptional standard of care, 3 = good standard of care, 2 = shortfalls in the standard of care, and 1 = significant shortfalls in the standard of care. The new system will align with the current system.

The specific types of evidence that will be focused on under each Evidence Category for each sector will be outlined by CQC as the new system develops. The table below shows an example of how the scoring system might work in practice.

Score Description

4 Evidence shows an exceptional standard of care

3 Evidence shows a good standard of care

2 Evidence shows shortfalls in the standard of care

1 Evidence shows significant shortfalls in the standard of care

Example: 

The aim is for the percentage score to allow for more detailed information sharing and enable benchmarking for providers in the future. To make the scores easier to understand, suggested thresholds have been proposed that can convert the percentage to a score. These thresholds are as follows:

25-39% = 1

39-62% = 2

63-87% = 3

Over 87% = 4

These proposed scores map to the current quality ratings of Outstanding (4), Good (3), Requires Improvement (2), and Inadequate (1).

In terms of governance, CQC's operational teams will continue to use their professional judgement when making decisions about quality. The inspectors' judgements will undergo the Commission's quality assurance processes as usual. The use of scoring in the assessment process will allow the Commission to be more transparent about how they reached their judgement on quality, show if a service is nearing another rating, and determine if quality is improving or declining within a rating.

More Information about CQC and Inspections

If you have any questions about CQC inspections visit Care Begins at Home Facebook Group and ask me a quesiton. I will also be providing further updates in the group about the new framework and what to expect.