Last reviewed 3 July 2014

Last year the Care Quality Commission (CQC) published a new strategy, Raising Standards, Putting People First — Our Strategy for 2013 to 2016. The document looked forward to a range of improvements in the way that the CQC goes about inspecting and ensuring the quality of registered health and social care providers in England, including domiciliary care. What are the proposed changes and what will inspections look like in the future, asks Martin Hodgson.

The strategy was written in response to a number of high-profile care failures, including the Winterbourne View and Stafford Hospital cases. In it, the CQC stated that it would change its inspection process and introduce a new test for services, centred around five key questions.

  • Are services safe?

  • Are they effective?

  • Are they caring?

  • Are they responsive?

  • Are they well led?

The changes relating to adult community social care services were originally published in A Fresh Start for the Regulation and Inspection of Adult Social Care. This was followed in April, by the CQC publishing new inspection handbooks for each sector and announcing that it was consulting on the contents pending implementation in October.

Applying the five key questions to adult social care

A Fresh Start and its follow-up handbooks provide guidance on the application of the five key questions to domiciliary care. The CQC states that these are based on the principle of looking at the things that matter to the people who use the services.

For example, asking if services are safe will include checking whether:

  • medicines are managed properly

  • people are supported by staff, particularly those who are in need of safeguarding

  • providers learn from safety incidents.

Asking if services are effective will include checking that:

  • people’s care, treatment and support achieve good outcomes, promote a good quality of life and are based on the best available evidence

  • the care of those with long-term conditions is managed well

  • people are supported to be involved in the assessment of their needs and have choice about who provides their personal care.

Asking if services are caring will include checking that users are treated with:

  • compassion

  • dignity

  • respect.

Asking if services are responsive will include checking whether:

  • services are organised so they meet people’s needs

  • service users get the care they need, are listened to and have their rights and diverse circumstances respected.

Asking if services are well led will include checking whether:

  • the leadership, management and governance of the organisation assure the delivery of high-quality, person-centred care

  • management and leadership encourage and deliver an open, fair, transparent, supporting and challenging culture at all levels

  • staff are supported and provided with training and supervision.

For adult social care services a key focus will be on people who lack capacity and on specific issues such as advocacy, the use of restraint, and the implementation of the Mental Capacity Act.


Inspectors will agree a rating for each provider. Judgments will be made on whether the care provided is:

  • “Outstanding”

  • “Good”

  • “Requires Improvement”

  • “Inadequate”.

The overall rating will be built up from ratings for each population group of service users looked at and within this for each of the five key questions.

For a service to be Good or Outstanding, it will have to demonstrate that it:

  • is compassionate

  • is caring

  • is open

  • is transparent

  • learns from its mistakes

  • seeks to make sure there are no barriers to accessing care

  • has a person-centred approach to care.

Key lines of enquiry

The five-key-question test will be supported by “Key Lines of Enquiry” (KLOE). These consist of a series of mandatory and discretionary questions, which will be used by inspectors to inform their judgments.

The KLOE are set out in appendix B of the consultation handbook. They help to describe what a good service looks like in the context of each of the five questions.

KLOE will inform the making of consistent ratings judgments by inspectors, which will be based on a mixture of local information gathered about a provider, onsite inspection and what the CQC calls “intelligent monitoring”.

New Fundamental Standards

New legal standards are being introduced to underpin the system.

The Francis Inquiry report recommended the introduction of new fundamental standards of safety and quality below which care should never fall. A proposed set of standards were included in draft regulations which were subject to a consultation, finishing in April.

  1. Care and treatment must reflect service users’ needs and preferences.

  2. Service users must be treated with dignity and respect.

  3. Care and treatment must only be provided with consent.

  4. All care and treatment provided must be appropriate and safe.

  5. Service users must not be subject to abuse.

  6. Service users’ nutritional needs must be met.

  7. All premises and equipment used must be safe, clean, secure, suitable for the purpose for which they are being used, and properly used and maintained.

  8. Complaints must be appropriately investigated and appropriate action taken in response.

  9. Systems and processes must be established to ensure compliance with the fundamental standards.

  10. Sufficient numbers of suitably qualified, skilled and experienced staff must be deployed.

  11. Persons employed must be of good character, have the necessary qualifications, skills and experience, and be capable of performing the work for which they are employed.

The draft Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 are intended for enactment in October, when they will replace the Essential Standards of Quality and Safety.

Intelligent monitoring

Intelligent monitoring involves the CQC using various methods to collect information about a service and give inspectors a clear picture of how care is being delivered and what may need to be followed up.

People’s views will be gathered from a range of sources, including:

  • individual comments received from the public

  • local voluntary and community organisations

  • local Healthwatch teams as they develop their approach to adult social care

  • carer groups and local advocacy services.

The CQC says it will make more systematic use of people’s views and experiences, including their complaints, and have proposed the use of “mystery shopper” techniques and hidden cameras.

Another proposal is to allow providers to pay for additional inspections if they believe the quality of their service has improved.

Expert-led inspections

From 1 April 2014 CQC inspectors were reorganised and moved into new Inspection Directorates. Supported by an academy for training, inspectors responsible for adult social care are now led by a Chief Inspector of Adult Social Care, Andrea Sutcliffe.

Inspectors will be experts in adult social care and inspections will also involve an expert by experience. The CQC states that it will utilise specialist advisors where needed, eg where specialist input on dementia or palliative care is required.

The frequency of inspections will be based on ratings, with poorer services inspected more frequently than good and outstanding services. Inadequate services will be inspected again within six months, while outstanding services might have two years before their next inspection.

Of the first wave, 250 inspections have already taken place across the country to test the new framework. The results of these will be considered along with the results of the earlier CQC public consultation. The KLOEs have been updated and progress has been included in the handbooks published for each sector.

The evidence and input from both the consultation and wave-one inspections will inform a second wave which will start in July.

The CQC hopes for full implementation of the new systems from 1 October 2014.

Responding to poor care

The CQC states that it will use the full range of enforcement powers available to it in response to care services that provide poor care to make sure they improve. These will be used in conjunction with the new fundamental standards.