The Care Quality Commission (CQC) is now well into the second year of its new approach to monitoring, inspecting and rating care homes, with the methodology of “intelligent monitoring” central to its operation. In the following article, Vicky Powell examines exactly how intelligent monitoring is being used to support the new approach.
Intelligent monitoring as an aid to inspection
In October 2014, following a consultation process which started in April of that year, the CQC began using its new approach to monitoring, inspecting and rating care services, replacing annual inspections with a new system of intelligent monitoring to decide where and when to carry out checks.
Intelligent monitoring has been described as the gathering and analysis of information about care services and the process of examining all that available material, in support of the CQC’s new approach.
The CQC relies on its Adult Social Care Intelligent Monitoring (ASCIM) tool for each care service it needs to evaluate. This tool comprises a set of indicators with each indicator designed to be used as a prompt for the inspection teams, to raise questions and provide supporting evidence for judgments.
However, the indicators are not used in a standalone manner to make judgments about a care service but rather are applied as part of a whole range of information including the experiences of people who use services, staff experiences and performance.
All of this helps inspectors identify particular areas to investigate further on inspection.
The indicators relate to the following five key questions (which are asked also of other services, such as hospitals and GP practices, not just care services).
Is the care service safe? In other words, are people protected from abuse and avoidable harm?
Are the services effective? Here, inspectors ask if the care, treatment and support achieve good outcomes, help people to maintain their quality of life and are based on the best available evidence.
Is the care service caring? In answering this question, inspectors will ask if staff involve and treat service users with compassion, kindness, dignity and respect.
Is the care service responsive to people’s needs? Are the services organised in such a way that they meet the needs of service users?
Is the care service well-led? This question relates to the leadership, management and governance of the organisation, asking if it is providing high-quality care that is based around individual needs, that encourages learning and innovation, and that promotes an open and fair culture.
In practical terms, each of the five key questions is broken down into a further set of questions known as the CQC’s key lines of enquiry (KLOEs). This helps the CQC decide exactly what to focus on in the inspection. The KLOEs can vary — for example, the inspection team might look at how risks are identified and managed to help them understand whether a service is safe.
Intelligent monitoring and care service ratings
The CQC points out that care services are not given an aggregate score based on the ASCIM indictors.
Whether a care service is finally rated as outstanding (green star), good (green dot), requiring improvement (orange dot) or inadequate (red dot) will be based on a combination of the intelligent monitoring results, as well as what is noted during the inspection process and other information.
The monitoring information which the CQC looks at is wide and includes:
people’s own experiences of care
information from the public, including service users’ families and friends and also other community professionals or groups
what carers and the staff of care services tell the CQC
information that care providers have to send the CQC by law (for example, notifications of serious incidents)
previous regulatory decisions, such as warning notices issued by inspectors.
Confidentiality and transparency
Unlike in the other regulated sectors, the CQC does not publish intelligent monitoring information it collects on care services because:
there is less data available than in other sectors (for example, in hospitals)
the type of data the CQC collects on care services is less consistent than in other sectors
there is a risk that staff or people who use services could be identified
some of the information the CQC collects is confidential.
Furthermore, intelligent monitoring information is not published at a provider group or brand level, with its regulatory work looking at a service location level only.
Although care providers are unable to view their own ASCIM information on the CQC website, the CQC points out that in fact providers will already have access to most of the data on which intelligent monitoring is based. This is because most of the information is submitted to the CQC by providers either directly or indirectly, for example, in the form of provider information returns (PIRs) or statutory notifications.
The exception will be in the case of information from whistleblowers, complaints or questionnaires which the CQC has undertaken to keep confidential to protect both staff and people who use the service.
Intelligent monitoring in practical terms
The CQC has published in its provider handbooks for care services initial sample indicators for care services in which it highlights a number of “safety events” in the context of intelligent monitoring as:
death, serious injury and abuse
incidence of pressure sores, medication errors or falls
admissions to hospital for preventable conditions
previous inspection judgments and enforcement actions
safeguarding alerts and concerns.
While sources of information could range from people using the services to the public, including for example, local groups such as Healthwatch, the national consumer champion in health and care, similarly, indications of intelligence from and about staff could come from:
an absence of, or frequent changes in, the care service’s registered manager
examination of staff to client ratios as well as staff qualifications, training, turnover or vacancies.
The CQC acknowledges that the indicators do focus on negative performance and says this is because the primary purpose of intelligent monitoring is to highlight potential issues that may lead to poor care which can then be followed up through inspection. However, the CQC says future versions of the intelligent monitoring tool may include indicators that highlight good care.
The final rating for a care service may be outstanding or inadequate, but the aim of intelligent monitoring is, in all cases, in the words of the CQC, to allow inspectors “to really get under the skin of the care service”.