Last reviewed 26 November 2019
In this article, which is divided into two parts, Chris Payne looks at the new arrangements for completing the CQC’s Provider Information Return, providing discussion on the new forms and guidance on how to address some of the more challenging sections and questions.
Part 1. The changes being made
As described in Croner i’s Inspection Procedures topic, “CQC Insight” is a keystone of the current approach to the monitoring and inspection of health and social care services. “Insight” refers to the gathering together and updating of information on a registered service, obtained from different sources such as: commissioning and safeguarding authorities, other regulators involved in the service, complaints and concerns about the service, notifications made by providers in line with their legal requirements, previous inspection reports and the service itself, by it completing on request, a Provider Information Return or PIR.
Inspectors are expected to check the whole information regularly to see if there is any matter that they should follow up and to help them with the planning and timing of inspections. The objectives for asking care providers to complete a PIR can be found in the CQC’s original “Fresh Start” (2013) document in which it was proposed to collect more information directly from providers to:
provide CQC with information and assurance between inspections
encourage providers to be open and transparent about their services
share with CQC the information, which they should be collecting anyway for quality assurance purposes.
The aim has been to provide a snapshot of a service, though given the length and complexity of the PIR, “profile” would probably be more appropriate.
The PIRs for the “fresh start” in 2014 were designed as pre-inspection questionnaires around the 5 key questions - Is it: safe, effective, caring, responsive and well-led? Few care managers would dispute that completing their PIR has not been other than onerous and time-consuming. As indicated by the queries made to the Croner-i helpline, many have had to ponder deeply over the meaning of questions, wonder how they might provide meaningful answers – though there are many factual questions – and have become stressed and tired by the sheer length.
In May 2018, CQC announced it was changing its PIR format, which would become known as the “Provider Information Collection” (PIC). The PIC would work by a provider setting up an online account and it would then complete a return within three months based on a similar format to the PIR, which it could then update at its discretion, but at least annually. Without at least annual updating, as with a PIR, CQC would not award a rating of better than “requires improvement” in the well-led category at their next inspection.
For presumably practical and technological reasons, the PIC idea did not get beyond piloting stage, and has been shelved for the foreseeable future. CQC has instead reverted to asking for a PIR, with a revised form, which was probably developed for the PIC. Rather than it being used just as a pre-inspection information gathering tool, it will now be completed online annually to coincide with the service’s first inspection date. This retains the PIC idea without the technology that went with it.
CQC has revised both the form structure and questions, which, on balance are improvements of the previous. It is more compact and logical though still not easy to follow in places. The biggest change is the absence of the leading general questions asking how a provider will address each of the five key questions (how will you assure that your service is safe, etc?), which are included, nevertheless, in registration application forms.
The five key questions still form the basis of the questions but are more focused on specific issues such as medication. As with the previous PIR, the form consists of questions requiring a factual answer, such as “How many people are currently receiving support with regulated activities as defined by the Health and Social Care Act from your service?” (i.e. current occupancy or numbers of service users being provided with home care). There are then more open-ended questions to be completed in text of no more than 500 words, though respondents are encouraged to be concise.
How the new PIR Works
CQC sends to the service registered manager a request for completion and a link to the online form to be completed within the stated time period – four weeks from receipt. There are now separate forms for care homes and for adult community services (as well as for Shared Lives schemes and Specialist Colleges).
CQC has helpfully published text versions of the new forms, which includes cross references to the corresponding KLOEs, on its website so that they can be studied beforehand with detailed guidance available from its website (dated September 2019). The letter of request will also indicate sources of help and support and a link to an updated FAQ sheet.
The form is divided into sections and sub-sections with the first six common to residential and community services, though there are variations in the questions according to type of service. After the contact information, which is mostly pre-populated the structure is.
Changes (2 leading questions on changes made and planned as discussed in Part 2 of this article).
People who use your service, including current numbers, “dependencies” of service users linked to registration categories and a series of questions about how the provider meets equality laws (discussed in Part 2 of this article). There are questions on numbers of service users whose affairs are looked after by others with powers of attorney or as Court of Protection appointed deputies (see Mental Capacity topic for more information) and with residential care numbers of people with deprivation of liberty authorisations (as discussed in the Human Rights and Deprivation of Liberty topic). There are related questions on numbers of service users with restrictions and restraints built into care plans (as discussed in Restraints and Restrictive Practices topic). A section asks about funding arrangements.
CQC shows interest in finding out how services are meeting the Accessible Information Standard (see the model Accessible Information policy for guidance). The residential PIR also asks about numbers of people effectively bed bound (which would also be a legitimate question for domiciliary care services but is not asked there) and about visiting arrangements. Respondents to this last question should be aware of updated October 2019 CQC guidance on visiting rights, which draws attention to the part played by consumer law in a care home’s visiting policy. (See Visiting and Visitors model policy).
Services you provide. This is a relatively short section focusing on the use of assistive technology in service delivery, and an additional question on the residential PIR on oral health, which reflects NICE guidance and the CQC’s own report “Smiling Matters” (June 2019). (See Oral Care topic for detailed practice guidance). Additional questions can be found in the sections for different service types.
Staff. The three sub-sections here ask for information about (i) staffing numbers, vacancies, (ii) training and qualifications and (iii) the registered manager. The residential PIR includes questions on registered nurses (as required in nursing homes) and any appointments of nursing associates, which is a new NMC registered role applying to England.
Commissioners and Partnerships. This section asks for information about commissioning arrangements e.g. from local authorities and CCGs, and what kind of involvement the service has with them (as discussed in the Commissioning, Tendering and Contracting topic).
Quality Assurance and Risk Management. The questions are slightly different from one form to another. The residential PIR asks about safety concerns for premises and medication, and deaths. The community PIR asks about safety of medication only in this section. Both forms want information about the service’s involvement in any external accreditation schemes such as Investors in People initiatives or awards that could reflect positively on the service, their exercise of their Duty of Candour in the event of any serious mishaps to service users for which the service can be held responsible and about complaints and compliments. These should all be relatively straightforward. If the service has nil involvement in any of the accreditation and award schemes mentioned, simply say so with a N/A.
Service Type sections
The Community Services form has separate sections (7- 9) for domiciliary care agencies, supported living schemes and extra care, respectively. In completing the online form it is important to know exactly what service type is being represented. “No” to “are you a “domiciliary care agency” takes you into “are you a supported living service?” and “no” to that leads to extra care. “Yes” to domiciliary care leads to questions specifically for that type of service. The aim of these sections would appear to avoid some of the confusion in the previous forms from lumping together questions that clearly applied to specific service types. For example, the domiciliary care section asks a series of questions about visiting and staffing arrangements that reflect the concerns commonly expressed about domiciliary care services. Care providers should have systems to collect and collate the information requested ongoingly rather than leave it to a once a year scramble to put it altogether.
The final section on both forms Anything Else provides the space to inform CQC about aspects of the service that are not covered elsewhere. There is a 500 word limit.
Part 2. How to complete the new PIR
As with all questionnaires the key is to study the question and break it down before trying to answer, with as much supporting evidence as can be compressed into a few words. This is particularly important with some of the more elaborate PIR questions. For example:
Section 1. Changes (to be completed by all providers)
1.1. asks (both forms) “Describe the impact of changes you have made in the past 12 months on people using your service. Consider the characteristics of good and outstanding ratings to identify relevant changes”. Basically the request asks you to describe the cart and what it might be carrying before the horse pulling it. But to answer it you need to think through in reverse:
what changes have we made?
how have we made them?
how have they made service users safer and improved their health, wellbeing and quality of life?
are the changes sufficiently effective for the service to comply with the relevant regulations? (and being a good or outstanding service in quality ratings terms).
The nub of the answer lies in (iii) above with (iv) acting as a benchmark. Responses might refer to any improvement plans and how effective they have been in improving service quality. You might use the last inspection report too and how you have met requirements e.g.
through improving medication administration procedures by weekly checks of records and monthly auditing, which is independent of the weekly checks, we are confident that we are providing safe care (the latter bit being the “impact” in line with the regulations); as also evidenced by a pharmacist whom the service employs to make quarterly checks of the whole system.
we have added some innovative signage which has helped service users with dementia to find their way around their home, and have had fewer incidents of their getting lost or confused, and fewer accidents from bumps and falls.
all staff have now received dementia care training which helps them to be more responsive to residents’ needs, which was commented on by relatives and visiting professionals in the most recent quality assurance survey.
1.2 is a linked question because it is about the future, puts the horse back in front of the cart in line with the thinking process described in (i) – (iv) above. “Describe the changes you have planned for the next 12 months and the impact you expect these to have on people using your service. Consider the characteristics of good and outstanding ratings to identify relevant changes”. Some answers will reflect a continuation of current improvement plans e.g.
a new lift is being installed which should be easier and safer for residents to use, and which should promote their independence and mobility
we are appointing a full-time activities coordinator to improve residents social lives, which the most recent inspection report stated requires improvement
we are planning to reduce the use of agency staff by a vigorous recruitment campaign with consultancy help, which should provide more reliable care for service users and more effective staff communication and teamwork.
Section 2. Equality, Diversity and Human Rights (Questions 2.16 – 2.22 Community Services; 2.19 – 2.25 Residential PIR)
The questions under Equality, Diversity and Human Rights (section 2) are challenging but can be addressed using a similar way of thinking to that for section 1:
what have we put into place?
how has it worked?
has it made a difference, if so what?
how does it help us to achieve the required standards?
Accessible Information Standard
The first question, “how do you make sure you meet the Accessible Information Standard?” would seem to be linked to a previous question “do people who use your service have any specific communication needs or preferences?”. An answer might include one or more of the following in line with an Accessible Information policy.
The service has an accessible information policy based on the Accessible Information Standard.
We have used this to identify x number of people with specific communication needs e.g. because of brain injury, strokes, hearing and / or sight impairments, learning disabilities, etc.
For each person (or set of persons with similar needs) we have provided information in easy-to-read, audio, pictures, signs, etc. (with specific examples against the different types of need identified).
In line with the Accessible Information Standard, individuals’ communications needs are displayed prominently in their files for all staff to see and be aware of them.
Staff involved with any person with specific communication needs are always trained and supported to communicate with the person in line with their needs.
Equality and protected characteristics
The next two questions in this section overlap but the second, as the CQC guidance points out, could also apply to care service staff who are also covered by the Equality Act 2010. With both questions it is important to consider their relevance to the care service in the last 12 months. The first asks you to tick the relevant boxes to show what you have done “to ensure or improve care quality for people in relation to the following equality characteristics:
Age e.g. by ensuring that an elderly resident receives the health care that he or she needs and is not discriminated against because of age
Disability e.g. by ensuring a person’s social life is not restricted because of their learning or physical disability
Gender e.g. by ensuring gender appropriate facilities and privacy
Gender reassignment e.g. by constructively supporting a user experiencing gender transition
Race e.g. by enabling the person’s cultural life and dealing with any form of racism within the service situation
Religion and belief e.g. by supporting a service user to observe their usual religious and cultural practices
Sexual orientation e.g. by supporting any people in a same sex relationship and having a zero – tolerance approach to any expression of homophobia
None of the above – simply tick this if you have not had any cause to address any of the above.
The second related question requires a free text response, “what specific work have you undertaken in the past 12 months to ensure your service meets the needs of the people with protected characteristics? Protected Characteristics are Age, Disability, Gender Reassignment, Marriage and civil partnership, Pregnancy and Maternity, Race, Religion or Belief, Sex, and Sexual Orientation”. This has a 500 word limit.
Under the Equality Act, a care provider must make “reasonable adjustments” for anyone with a “protected characteristic”. You might, for example, include how you have celebrated any same sex marriage of service users (see for example model policy Promoting Social Contacts and Relationships) policy and what policies you have adopted to support pregnant staff, which would involve making reasonable adjustments, based on a risk assessment (see, for example, New and Expectant Mothers at Work policy in the Maternity and Family Rights topic).
The approach is to identify the protected characteristics that you can identify – if any – and describe what you have done in response. (Guidance on the Equality Act can be found in the Equality and Discrimination topic and its application to care service users is reflected in the Equality, Inclusion and Diversity policy. For example.
The main protected characteristics which this service addresses under the Equality Act are:
Religion or Belief
All our residents are eligible in term of their age (if a home for older people) and we have ensured that they are always treated with dignity and respect and promote their independence by ensuring that they can vote in elections, have access to the internet etc. as they would in their own homes.
We have a zero anti-racism policy and e.g. have acted promptly on occasions to address racist and homophobic behaviour, which have been followed up by inviting specialist speakers to discuss these issues at residents’ meetings, which have been well attended and appreciated by those attending.
We have one resident who is a member of a church with a particular set of beliefs, for whom we have made special arrangements to be visited by members of that congregation (or to attend that church).
The next question asks about impact of the actions taken to promote equality, which would then be satisfactory for compliance purposes. For example.
Feedback suggests that users with protected characteristics are satisfied that the service makes every effort to challenge and deal with any discrimination because of their age, sexual orientation, race or religious beliefs and any complaints they might need to make on this account will be promptly and fairly dealt with.
Staffing arrangements and human rights
Of the three remaining questions in this section two are on staffing arrangements a) to show how you meet individual needs including anyone with a protected characteristic, which might have needed additional input and b) how you have developed your staff over the previous 12 months to respect users’ human rights and to apply values of dignity, independence etc in practice.
Your reply to the second part might include any new training introduced to develop staff awareness and responsiveness to human rights, for example, to develop least restrictive practices for people with mental incapacity, which as a result, enhances people’s human rights.
How as a service you have implemented policies on human rights is asked in a separate question in this section. Answers will inevitably shade into the previous equality responses, but you could find some alternative examples such as
We show our commitment to human rights by, always respecting residents wishes to change their daily routines and activities, and to be very flexible in respect of anyone’s visiting arrangements, which can be at any time.
Service users’ choices in respect of such as holidays, outings and social activities use of facilities, hair care, staff to support them when keeping appointments are all respected (provide specific examples of significant exercises of choice in the past 12 months).
Sections 1 and 2 probably contain the most challenging questions. With some of the others, as discussed in part 1 of this article, it is useful to think of the context in which the questions are being asked, which often reflect CQC’s current concerns and interests, for example, in the light of its “Smiling Matters” report on the importance of care providers focusing on the oral health of its service users, and the continuing importance of protecting the human rights of people without mental capacity to decide on their care and support arrangements. It must be remembered that completing a PIR will now be an annual event so it will be useful to accumulate information over the period by, for example, keeping a log of significant changes and their impacts as they are made, which will then be available when the next time for “completing the PIR” comes along.