October 2013 A fresh start for the regulation and inspection of adult social care

Our purpose and role Our purpose Our role We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve Our role We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care Published in April 2013 Thousands of people - members of the public, our staff, providers, professionals and others – have given their views during CQC’s consultation on its strategy for the next three years We will be strong, independent, expert inspectorate that is always on the side of people who use services 2

Asking the right questions about quality and safety Is the care: Safe? Effective? Caring? Responsive to people’s needs? Well-led? These underpin the entire model. Safe - People are protected from physical, psychological or emotional harm. Effective - people’s needs are met, and their care is in line with nationally-recognised guidelines and relevant NICE quality standards , or effective new techniques are being used which give people the best chance of getting better or living independently. Caring - People are treated with compassion, respect and dignity and that care is tailored to their needs. Responsive to people’s needs - treatment and care at the right time, without excessive delay, and people are listened to in a way that responds to their needs and concerns. Well-led - effective leadership, governance and clinical involvement at all levels. Open, fair and transparent culture. Using people’s views to make improvements. 3

Our new approach Model shows the different stages: Registration Surveillance Model shows the different stages: Registration Surveillance Standards Expert inspection Judgement and publication – ratings Action where needed

Named leaders held accountable Registration A more rigorous test to deliver safe, effective, compassionate, high- quality care Legally binding Named leaders held accountable Registration Making sure those we register make a commitment to deliver safe, effective, compassionate, high-quality care Making sure that named directors or leaders of organisations are personally held to account for that commitment, and that they are suitable for the job Making sure those we register show us that they have good plans for how they will provide care, including an effective system for spotting and dealing with problems Building efficient digital services that will transform the way providers get involved and communicate with us 5

Surveillance Continuous monitoring to identify failures and risk of failure “Smoke alarms” Use local and national information sources Use qualitative information from people Surveillance Surveillance We will monitor information and evidence continuously to predict, identify and respond more quickly to services that are failing, or are likely to fail We will continue to gather information from national and local data and intelligence sources, past inspections, Quality Surveillance Groups, Clinical Commissioning Groups, and from groups such as local Healthwatch, local overview and scrutiny committees and local voluntary groups Information from people who use care services and from whistleblowers will be two of our most important sources of information to make sure we understand the reality of people’s care Smaller number of more focused indicators that will trigger action by us when a certain level of concern is reached. These ‘triggers’ will be different for different types of services 6

Expert inspections Chief Inspectors of Hospitals, Social Care, and General Practice Expert inspection teams Longer inspections, more time talking to people Intelligence used to decide when, where and what to inspect Inspectors using professional judgement Expert inspections Expert inspection teams led by the Chief Inspectors and including independent clinical experts How often we inspect, how long we spend on an inspection, and the size and membership of the inspection team will be based on the ‘risk’ of the service - the type of care being offered, the vulnerability of people who use it, the information we have about a service, and its current rating 7

Expected standards of care High-quality care. Clear standards Three levels: Fundamentals of care Expected standards of care High-quality care. By law services must meet fundamentals of care and expected standards Clear standards to judge quality and safety These standards will help us to judge whether or not services are safe, effective, caring, well-led and responsive to people’s needs. These standards will have three levels: Fundamentals of care Expected standards of care High quality care. All services will be required by law to meet the fundamentals of care and the expected standards. Less guidance, some examples to avoid box ticking Senior inspectors will use data and evidence, including information from the public and care staff, and from our partners such as NHS England, Monitor and the NHS Trust Development Authority, to help them decide where, when and what to inspect 8

Characteristics of adult social care services and the people who use them Adult social care often affects every part of people’s lives for long periods; people often have complex and varied needs What good looks like differs according to people’s different aspirations and choices. Personalisation hugely important People are often not patients, so effectiveness looks different too. People are often in very vulnerable circumstances or lacking in mental capacity Care is generally provided in people’s own homes – poor quality care has a devastating effect on them and family carers Role that unpaid carers play is critical

Characteristics of adult social care services and the people who use them Varied sector - large numbers of providers of different sizes and types, strong private and voluntary sector - and a lack of consistent, high quality data Services commissioned by a range of people and organisations. Significant number of people fund their own care Less nationally recognised guidance and fewer standards Integration of health and social care services is key

Adult social care regulation - strengths and weaknesses Focus on people’s views and experiences Limited focus on leadership, governance and culture (including corporates) Gathering people’s views more difficult in domiciliary care Range of methods including speaking to people, observing care, questionnaires, and using our Short Observational Framework for Inspection (SOFI) Lack of data and information to inform our activity Lack of sophisticated approach to surveillance Regular inspections Inconsistency in our judgements and less room for professional judgement Experts by experience on inspections Limited use of specialist advisors Many in CQC have an ASC background Enforcement not used as effectively as possible Internal tools that support our staff such as the Inspection Record web form Lack of ratings

Top 5 priorities for the Chief Inspector Develop changes to how we monitor, inspect and regulate adult social care services Develop a ratings system for adult social care services Develop an approach to monitoring the finances of some adult social care providers Support our staff to deliver Build confidence in CQC 1 2 3 4 5

What we will do better – our top ten proposed changes 1 More systematic use of people’s views and experiences, including complaints Inspections by expert inspectors, with more experts by experience and specialist advisors Tougher action in response to breaches of regulation, particularly services without a registered manager for too long Checking providers who apply to be registered have the right values and motives, as well as ability and experience Ratings to support people’s choice of service and drive improvement 2 3 Minimising duplication of activity between CQC and Local Authorities – including work on the information sharing portal Focus on leadership, governance and culture – different approach for corporates and singletons Corporates – how well does the Board deliver its corporate responsibilities, how can we assess well led at a corporate level Accountability for recent failures – how to hold providers to account for failures identified during the inspection that have already been addressed Systematic use of user voice – better analysis of complaints and whistleblowing evidence to inform our approach Asking the right questions at registration – checking people have the right values and motives as well as ability and experience Ratings – vital in adult social care to support consumer choice, and decision making often about a home for life Move away from annual inspections to a frequency informed by ratings – frequency to be decided but Approach to surveillance – better data and indicators – helps us target and direct our activity – e.g. in domiciliary care timeliness of visits and number of zero hours contracts local teams will improve their surveillance, supported by Intelligence 4 5

What we will do better – our top ten proposed changes 6 Better data and indicators to help us target our efforts New standards and guidance to underpin the five key questions Avoid duplication of activity with local authorities Focus on leadership, culture and governance with a different approach for larger and smaller providers Frequency of inspection to be informed by ratings 7 8 9 Minimising duplication of activity between CQC and Local Authorities – including work on the information sharing portal Focus on leadership, governance and culture – different approach for corporates and singletons Corporates – how well does the Board deliver its corporate responsibilities, how can we assess well led at a corporate level Accountability for recent failures – how to hold providers to account for failures identified during the inspection that have already been addressed Systematic use of user voice – better analysis of complaints and whistleblowing evidence to inform our approach Asking the right questions at registration – checking people have the right values and motives as well as ability and experience Ratings – vital in adult social care to support consumer choice, and decision making often about a home for life Move away from annual inspections to a frequency informed by ratings – frequency to be decided but Approach to surveillance – better data and indicators – helps us target and direct our activity – e.g. in domiciliary care timeliness of visits and number of zero hours contracts local teams will improve their surveillance, supported by Intelligence 10

Other ideas we want to discuss Better use of technology to capture people’s views and experiences Specific guidance on our expectations for the induction and training of staff who work in adult social care services How we might encourage services to be more open and better integrated with local communities, creating an open culture Allowing providers to pay for additional inspections if they believe the quality of their service has improved Finding a better way of regulating supported living schemes Potential use of mystery shoppers and hidden cameras to monitor care Can we make better use of technology – particularly in domiciliary care – simple technology to capture user views

Ratings for providers, and for separate services as well? Ratings to help people choose between services and to encourage improvement Ratings for providers, and for separate services as well? Ratings for each question? Safe Effective Caring Responsive to people’s needs Well-led Ratings Ratings will be a dynamic process. We will make clear on our website when a service is being inspected so that the public understands that our judgement and rating might change. We will publish the information on which the rating is based. Should we provide ratings for individual services (e.g., emergency services, maternity) as well as at hospital level and for the overall trust? What are the pros and cons? Should we provide ratings for each of our key questions: is the service safe, effective, caring, well-led and responsive to people’s needs? Our reports of our inspections will explain the reason for the inspection and describe our findings, assessment and judgments on whether a service is safe, effective, caring, well-led, and responsive to people’s needs. 16

Developing a ratings system One overall rating for a service, always based on inspector’s professional judgement with rules to make this fair, transparent and consistent Four point ratings scale – outstanding; good; requires improvement; inadequate – but more work needed on the descriptions To be outstanding, it must feel outstanding to people who use the service, their families and carers. Other characteristics of an outstanding rating might include: involvement in the local community; good integration with local health partners; person- centred care; open and transparent sharing of information about the quality and safety of a service; supporting people in their choice of where to die Allowing providers to pay for an additional inspection could Enable providers to have improvement publically recognised sooner Incentivise providers to strive to improve their services Allow us to be more responsive when providers believe their service has made improvements Limits on ratings, e.g. can’t be outstanding unless: users, families and carers think so data is shared transparently the service can demonstrate it acts on user views effective approach to safeguarding Services that under report – denying CQC a source of information – fixed penalty notice No registered manager for long period without good reason – fixed penalty notice

Developing a ratings system We are considering whether to offer providers the opportunity to pay for an additional inspection if they believe the quality of their service has improved The things we look for will develop over time as people’s needs and aspirations change Allowing providers to pay for an additional inspection could Enable providers to have improvement publically recognised sooner Incentivise providers to strive to improve their services Allow us to be more responsive when providers believe their service has made improvements Limits on ratings, e.g. can’t be outstanding unless: users, families and carers think so data is shared transparently the service can demonstrate it acts on user views effective approach to safeguarding Services that under report – denying CQC a source of information – fixed penalty notice No registered manager for long period without good reason – fixed penalty notice

Monitoring the finances of some providers Care Bill is expected to establish CQC as the financial regulator for the sector, overseeing the finances of an estimated 50 – 60 care providers that would be difficult to replace were they to go out of business CQC is expected to: Require regular financial and relevant performance info from some providers Provide early warning of a provider’s failure Seek to ensure a managed and orderly closure of a provider’s business if it cannot continue to provide services In carrying out this role we will Carry out financial checks on a small number of providers Monitor risks to financial sustanability and ensure providers have effective sustainability plans in place Require information from providers in order to facilitate an orderly closure of a provider’s business should it become necessary Oversee and coordinate th eprocess when a provider fails across all involved local authorities

Next steps Period of open and inclusive engagement with our stakeholders to develop our thinking and co produce the content for a formal consultation next year Engage widely with people from October 2013 to Spring 2014 so they shape and improve the new approach: Meetings with external advisory groups and other working groups on particular aspects of work Round table events and workshops on specific topics and issues On line forums and discussions, surveys and social media Events and workshops on regulatory approach, standards, ratings Public focus groups and engagement through our network of local groups, including Local Healthwatch

Timelines Oct 2013 – March 2014 Co-production and development to shape consultation proposals March 2014 Consultation on regulatory approach, ratings and guidance March – May 2014 Wave 1 pilot inspections June 2014 Evaluation; guidance and standards refined July – Sept 2014 Wave 2 pilot inspections and initial ratings of some services Oct 2014 New approach fully implemented and indicative ratings confirmed March 2016 Every adult social care service rated