In this two-part article, Chris Payne explains how to successfully improve your Care Quality Commission (CQC) quality rating by using the inspection report to draw up an improvement plan and change your care service for the better.
The CQC publishes its latest quality ratings monthly on its website. At the time of writing, the latest figures (June 2017) show as follows: Outstanding: 24, Good: 902, Requires Improvement: 406, Inadequate: 71.
These ratings are for all regulated health and care services, including hospitals and GP practices, not just care homes and domiciliary care, so it is difficult to extract the ratings that apply specifically to adult social care. However, the figures suggest roughly that for every two services that have had a satisfactory inspection, there is another one that currently requires some level of improvement to meet fully the fundamental standards which all services must achieve to meet their registration commitments.
Of course, not too much should be read into a single month, and the figures are anyway not directly comparable. However, they are not that far away (if anything slightly worse) from the numbers for adult care services produced for the last CQC State of Care report for 2015–2016, which, at end of July 2016, had rated 1% as Outstanding, 71% as Good, 26% as Requires Improvement and 2% as Inadequate. CQC found that there had been a drop of 5% in inadequately rated homes from the previous year, which it attributed in part to its methods to drive up standards.
What do you do with an adverse inspection report?
Any caring, committed care provider, manager and staff, who receive an adverse inspection report with a lower than expected quality rating will, inevitably, be very disappointed, even if they have had some warning from the verbal feedback that inspectors gave at the end of their inspection. They might even suffer from something like a grief reaction: shock, followed by disbelief or denial, giving way to anger and a sense of unfairness before having to accept it and do something about it. With the draft report, CQC provides 10 days for the report to be checked for any factual inaccuracy, and, as explained in the provider handbook, there are limited means to challenge the fairness or validity of the assessments.
It is, obviously, important to use the opportunity to correct any factually incorrect statements, but it is equally, if not more important, not to waste too much negative energy on reacting negatively to the report’s contents. It is far better to use the same energy and time in thinking how to make the required changes. However, dissatisfied with the assessment, it must be remembered that CQC has the law on its side and the powers that go with it, and to challenge its authority successfully requires a strong evidence backed case. There is no point in tilting at windmills from a sense of grievance alone.
Therefore, the first step to be taken in making the necessary changes is to develop a positive attitude, and to develop positive attitudes in all those who need to be involved in the change effort, particularly the care service’s staff, and, not least, service users and their family members and friends. What must not happen is ignoring or putting off the issues to be addressed. It is no good filing away the inspection report and forgetting about it. The report should be used as a key tool with which to shape the improvement plan.
A service in special measures can expect a further comprehensive inspection within six months, and focused unannounced inspections at any time, particularly if CQC is notified of any further concerns during this time. The CQC does not expect a service to remain in special measures for longer than 12 months, and is prepared to increase its enforcement actions if there is insufficient evidence of improvement, which could mean the service being deregistered and going out of business.
Planning the changes
As a first step, it is important to study the inspection report carefully and critically, and discuss its contents and findings with everyone affected by the assessments. It will also be useful to refresh one’s knowledge of the regulations, where there is non-compliance, and the Key Lines of Enquiry (KLOE) used by the inspectors to gather evidence. Time should be put aside to do this, because inspection reports can be a hard read, and it is sometimes difficult to extract the juice from them to fuel the practical actions that are needed. This is partly because inspection reports are formulated to reflect a standard approach in the gathering of evidence and the making of judgments.
CQC’s State of Care Report for 2015–2016 comments that services perform best at being caring with most involving people in their care, and treating them with compassion, kindness, dignity and respect. They receive lower ratings for safety and leadership. This general finding is supported by a reading of 20 consecutive reports of services that have been placed, and are currently in, special measures with an inadequate rating overall. All were rated as inadequate on safety and leadership, but the ratings varied on the other three domains between “requires improvement” and inadequate.
It is actually unsurprising that ratings are generally lower for safety coupled with well-led than for other aspects, simply because it is the largest of the five domains and includes the widest range of issues to be addressed: safe personal care, particularly in respect of the many risks to personal safety that can be identified; safe use of medicines — a common issue; safe use of equipment and facilities, safe environments that meet all health and safety standards, including infection control, safeguarding from abuse, safe staff recruitment, etc. Because all safety issues have corresponding management responsibilities, particularly regarding auditing, which is a key requirement of “good governance” (Regulation 17), the ratings of “well-led” will be likewise affected.
To use an inspection report as a working tool requires joined up thinking to make the connections between the specific inspection findings, the reasons for the inspectors’ judgments, and the provider’s own assessments. Some improvements can be made in a relatively self-contained way. For example, a finding that: “the provider did not have a safe system of recruiting staff and checks were not always undertaken to make sure staff were of good character before they supported people who lived at the home”, requires delegating an appropriate person to check and make good any gaps in the staff files. It should be remembered that inspectors rely a great deal on documentary evidence, and, chore though it can be, keeping up with the “paper work” is essential. If one has not already been made, the appointment of an administrator with a remit like that of a practice manager in a GP surgery to oversee the record-keeping systems and documentation with a view to making and keeping them fit for purpose, should be considered; not least to free up the registered manager to concentrate on the improvements to the care that are needed.
Other parts of the inspection report have wide action planning implications. Take this example: “Risks of harm and injury to people were not always identified and when they were, actions to minimise those risks were not always in place or followed by staff. Staff did not have the knowledge to deal with emergencies.”
The sentence requires some working out, but the body of the report from which this example was taken, in fact, identified a range of risks, which were heightened because of the service users’ support needs from dementia and other conditions. So, the inspectors found risks to service users of:
burning and scalding from hot surfaces or equipment
accidents from being left unattended in communal areas
injury and possibly fire risks from smoking in non-smoking areas, and being unattended
trips and falls from trailing wires and equipment that had not been put away
skin damage and pressure sores from incorrect use of pressure relieving equipment
insufficient measures to reduce risks of falls to people who were assessed as high risk of falling
inconsistent recording of accidents from falls and lack of risk reducing and preventive measures
lack of emergency action plans, including evacuation plans in case of fire
insufficient numbers of trained first aiders.
This is a formidable list, which requires careful assessment to formulate effective action plans. One method would be to plan immediate or short-term actions (eg 1–3 days for some, one week maximum for others), medium term (eg by end of 12 weeks) and longer term (24 weeks). (The CQC, however, will impose its own timescales if the required actions are included in a Warning Notice.) Time frames should represent the total time needed, so tasks requiring longer to effect should still start straight away.
Immediate/short term. Designated person(s):
to identify and report on all uncovered radiators, provide covers if needed
to check all thermostat settings and report
to provide temporary insulation for “boiling tea urn” (as identified in this report)/to allocate named staff member to supervise use of tea urn
to check whole premises for safety hazards as described above and report
to check and set correctly all pressure relieving equipment being used and report any conflicts.
Medium term. Designated person(s):
to review and modify, as necessary, the care plans, risk assessments and risk management plans for service users identified as being at risk from smoking, falls and accidents, and users of pressure relieving equipment as identified in the inspection report
to complete health and safety audits on all equipment and hazards in the premises that could result in trips, slips and falls, burns, scalding and fires from illicit smoking
to bring all personal evacuation plans up to date
to review and revise as necessary procedures for recording and learning from accidents
to replace completely the hot water urns used for making tea, etc with more suitable and safer facilities (which could also require less staff supervision).
Longer term. Designated person(s):
to review and revise all service users’ care plans and risk assessments
to have a schedule for auditing care plans so that the process can be sustained
to have comprehensive procedures and systems in place to make the service completely safe for service users
to review and revise as necessary staffing levels required to keep service user’s completely safe
to have a full complement of trained staff first aiders.
The action plans, of course, will need expanding to include details of who will be responsible for doing what and how, for checking progress, and for assessing the results.
Unfortunately, the report from which this example has been taken requires improvements in several other areas, each of which needs addressing systematically so that a final comprehensive action plan emerges. These other issues are also typically found in services requiring improvements, including: mental capacity and deprivation of liberty, training provision and effectiveness, and staff support generally, person-centred care, including issues of choice, respect and dignity, nutrition and hydration, lack of activity and stimulation, and complaints.
Part two of this article will appear next week, explaining the improvement process and how to actually make the necessary changes.