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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. What we will do better – our top ten proposed changes1
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

14. What we will do better – our top ten proposed changes6
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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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