Last reviewed 20 June 2017

The Care Quality Commission (CQC) has published new “key-question” guidance for its inspectors which will have a direct impact on how care homes, domiciliary care services and primary care providers are inspected and rated. Martin Hodgson examines the changes.

The updated guidance

The new guidance from the CQC applies to adult social care and healthcare services in England. It has been produced in response to a consultation held at the end of 2016, which made a number of proposals designed to strengthen the regulatory system and help inspectors to arrive at more consistent judgments.

The principal changes take the form of completely refreshed guidance to replace the existing appendices to the service handbooks, originally published by CQC in 2015.

While there are many different versions of the current handbook appendices — one for each type of service — these have been merged into two publications.

  • Key Lines of Enquiry, Prompts and Ratings Characteristics for Adult Social Care Services.

  • Key Lines of Enquiry, Prompts and Ratings Characteristics for Health Care Services.

The first of these applies to a wide range of social care services, including both care homes and domiciliary care services. The latter includes GP practices, out-of-hours services, dental practices and hospitals.

To help providers and stakeholders update any aligned systems or processes, the CQC has published two PDF versions of each assessment framework: one final version, and one that makes clear where it has introduced changes. All new content has also been integrated in the CQC’s provider web pages.

The versions are available on the CQC website alongside the current appendices which will cease to apply from November 2017 for adult social care and for primary healthcare. From that date, the new framework will be used in both adult social care and primary care inspections.

KLOE, prompts and ratings characteristics

Like the existing appendices, the new guidance contains key lines of enquiry (KLOE), prompts and ratings characteristics. These represent the framework and guidance which inspection teams use when making their rating judgments about service providers.

  • KLOEs and prompts take the form of a series of questions that inspectors are prompted to ask in order to help them answer the five key questions.

    1. Is the service safe?

    2. Is it effective?

    3. Is it caring?

    4. Is it responsive?

    5. Is it well-led?

  • Ratings characteristics attempt to describe what a service looks like in the context of each of the five questions and at the four ratings levels.

    1. Outstanding.

    2. Good.

    3. Requires Improvement.

    4. Inadequate.

The guidance can provide huge assistance to inspection teams, helping them to know what to ask and what to look for in different types of service. Ultimately, it helps them in making their ratings judgments which are then included in their report and published on the CQC website.

In this context, the guidance also provides key resource for service providers, helping them to understand how grading judgments are made and what inspectors might be looking for.

The “next phase of regulation” consultation

The KLOE and ratings characteristics have been updated in accordance with a consultation that was launched by the CQC as a way of strengthening its regulatory systems following the publication of its strategy for 2016–2021, Shaping the Future.

The consultation paper was published in December 2016. Our Next Phase of Regulation — a More Targeted, Responsive and Collaborative Approach, sought views on a range of issues, including:

  • how the CQC will regulate new models of care and complex providers

  • changes to CQC assessment frameworks across all sectors to reduce complexity and create more consistency

  • new proposals on the registration of services for people with learning disabilities

  • how inspectors will regulate NHS Trusts and Foundation Trusts.

The results, Response to the Consultation on CQC’s Next Phase of Regulation, has been published on the CQC website along with the updated five key-question guidance. It states that, overall, respondents to the consultation were supportive of the CQC proposals to make inspections clearer, more consistent and more transparent. Suggestions for revised and updated assessment frameworks were supported. The majority of respondents (71%) agreed or strongly agreed with the CQC proposal to move to the two assessment frameworks, one for adult social care and one for healthcare, rather than to maintain the old arrangement of having different frameworks for each service type.

The consultation response is available at

The changes to the KLOE and ratings characteristics

The five key questions under which inspectors make rating decisions have not changed, and neither have the Fundamental Standards that they link to. However, some of the KLOE and ratings characteristics that relate to the questions have been altered. New items have been added and others have been moved from one key question to another. Others have been reworded. Much of the rationale behind these changes is to bring the frameworks closer together, thus bringing more consistency across different sectors, and to make the guidance clearer.

The CQC says that during the consultation, it received detailed suggestions for improving or clarifying specific KLOEs and prompts, in particular around person-centred language, medicines, end-of-life care, equality, diversity and human rights, autonomy, authority and consent.

Specific changes in the healthcare guidance include the merging of the previous KLOE guidance across healthcare providers and greater alignment with the adult social care guidance. This has involved adding a number of new KLOE questions and prompts, including the following.

  • In the “safe” key question: (S4) How does the provider ensure the proper and safe use of medicines, where the service is responsible?

  • In the “effective” key question: (E4.3) How are people assured that they will receive consistent, co-ordinated, person-centred care and support when they use, or move between different services?

  • In the “caring” key question: (C3) How are people's privacy and dignity respected and promoted?

Questions relating to “responsive” services have been considerably strengthened with a greater emphasis on services taking account of the particular needs and choices of different people, including people at the end of their life.

Second consultation

The publication of the response to the December 2016 consultation, together with the new updated five key-question guidance, has been accompanied by the publication of another CQC consultation.

Consultation 2: Our Next Phase of Regulation, a More Targeted, Responsive and Collaborative Approach to Regulating in a Changing Landscape of Health and Social Care is available on the CQC website.

This follow-up consultation makes a number of proposals, including:

  • further aligning the way CQC monitors, inspects and rates primary medical services and adult social care services

  • developing a new way of collecting data to ensure a better view of quality

  • allowing longer intervals between inspections for services rated as good and outstanding

  • the abolition of the current limit that prevents CQC from amending ratings following inspection if the last rating was awarded less than six months previously

  • improvements to the structure of registration and the CQC definition of “registered providers”

  • further information on how the CQC intends to monitor, inspect and rate new models of care and large or complex providers.

The new consultation closes in August 2017. The results will be implemented in November alongside the new KLOE and ratings guidance, thus completing the “next phase of regulation” overhaul to the inspection regime.