CQC chief unapologetic over dropping annual inspections to focus on poorest providers

Next month, the Care Quality Commission will go back to the future by ending annual inspections of all adult care services and reintroducing a “risk-based approach” that will see the best-rated services inspected half as frequently.

But whereas annual inspections were introduced two years ago to address concerns that the previous risk-based approach was leading to poor care being missed, CQC chief inspector of adult social care Andrea Sutcliffe makes “no apologies” for reintroducing this approach.

“We need to be focusing our effort on encouraging those services that are rated ‘inadequate’ and ‘requiring improvement’ [under the new four-tier rating system] to improve and absolutely making sure that that is happening.”

Speaking ahead of the changes, which she was tasked with coordinating on joining the organisation 12 months ago, the chief inspector says that eradicating poor care must continue to be a top priority for her inspectors and the sector as a whole. As such, inadequate-rated services will be reinspected within six months and those rated as requiring improvement will be seen within a year.

Sutcliffe defends the CQC’s decision to reduce the frequency of inspections for services rated outstanding – who will be reinspected within two years – and those assessed as good, who will be seen within 18 months.

This resembles the system used prior to 2012, when services underwent an inspection at least once every two years with poorer performers being inspected more frequently.

But Sutcliffe says there will be “no apologies” for focusing inspectors’ effort on the services where people are at the greatest risk, because, she says, the CQC will be better placed to pick up on signs of deterioration in good or outstanding services.

“I’m confident about this decision because we will be using the information that comes in about services in a much more intelligent way,” she says. “If we start getting information about unexpected notifications of death, concerns about safeguarding or whistleblowing reports, we will be going back and we have retained the capacity to do that.”

Services rated outstanding and good will also be subject to unannounced inspections before the time period is up, to ensure that providers do not “get complacent”. If a highly-rated service subsequently declines into a poor standard of care, it will receive a new inspection and a new rating immediately. “We will be very clear about what we want the service to do,” says Sutcliffe.

Tried and tested

Sutcliffe says two periods of testing of the new model – with approximately 250 providers inspected between April and June, and a further 700 in July – has shown that “it is a much better way to inspect services”.

She links this to the five questions the CQC will be asking of every service – whether it is safe, effective, caring, well-led and responsive to people’s needs.

“Asking those five key questions gives us a much broader and a more holistic view of the services that we are inspecting,” says Sutcliffe.

Inspectors will be looking at, for example, whether or not people are being treated with dignity and respect, the arrangements in place for safeguarding and risk assessments, whether or not care plans are reflecting a conversation with an individual and what the culture and values of a service are like.

“We are now able to really get under the skin of a service and looking at those five specific areas has meant that services that may previously have been compliant have now been identified as having issues that they need to deal with,” she says. “I think that is a real benefit to the service and to the people who are using the services.”

The CQC has also asked providers to fill out ‘information returns’ about their services, which are being used to help inform the regulator’s work, but Sutcliffe says this has also highlighted a lack of information held by the regulator about adult social care services. “This is a very important step forward but it also exposes that we don’t have as much information in adult social care and as consistently as we do in some of the other areas that the CQC regulates,” she says.

“That is a lesson learned for the sector more widely, not just the CQC, that we do need to do a lot more on this.”

A specialist service

Appointing a series of specialist inspectors was also top of Sutcliffe’s to-do-list and this is well on the way to becoming a reality. An adult social care directorate was established on 1 April and the senior leadership team across inspection and regulation is now in post, which includes four deputy chief inspectors and 15 heads of service.

“We have enough inspectors on board to start implementing the new arrangements and that is what we will be doing, but we are still recruiting for a full establishment,” she says.

Inspectors will now also ask questions in inspections to ensure care staff are properly trained and have a good understanding of the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (Dols).

“Dols and the MCA are not as well understood as I would like in services,” says Sutcliffe. “We can see some good practice but we also see some practice where we do not think people truly understand what a [deprivation of liberty] is and how people need to implement safeguards.”

She is concerned that providers understand the impact of the Supreme Court’s landmark ruling in March in the cases of P v Cheshire West and Chester Council and P&Q v Surrey County Council, which effectively lowered the threshold for a deprivation of liberty.

“I want to promote that further through what we do in our regulation and inspection of adult social care by making sure that, at the very least, services are demonstrating that they are thinking through the implications of the Cheshire West ruling and are putting in hand measures to manage that.”

Getting tougher

The organisation is now in the process of developing a system of special measures for failing services, which was announced earlier this year. “As with all of the changes, I didn’t want this to be a case of ‘this is what’s happening’ so we are talking with people about what it could look like and the issues that would trigger special measures,” says Sutcliffe.

“The way that we make change happen in adult social care is for everybody to own the problem and own the solution,” she adds. “The critical thing for me will be when do we call time on the amount of time that people have to improve – special measures will help us to determine that.”

Sutcliffe has also explored the option of using covert surveillance to help prevent the neglect and abuse of service users. “Every time we have the conversation we have people who think we should have been doing it yesterday and everywhere to people who think we are the devil incarnate for even suggesting it,” she laughs.

But while the CQC does have the powers to use such techniques, Sutcliffe insists it will remain a last resort for now. Instead, the CQC will publish guidance for both providers and the public in terms of what issues they should take into consideration if they are considering using surveillance techniques, which should be available by the end of October.

The next steps

The CQC’s new regulatory duty to monitor the ‘financial health’ of large providers, which aims to protect vulnerable people in the event of a provider’s collapse, will be a key change in 2015 and Sutcliffe will be charged with ensuring that everything is in place for this to go ahead. “We will need to ensure that we’re tackling this effectively,” she says.

“We are doing work now on the detail of the operating model, for example what exactly does it mean in terms of the information we will require from companies, “ she adds. “We also need to do some more work about what the skills and expertise we need internally so that we can review that information  appropriately, but it will be a mixture of new and existing staff taking on the role.”

Thoroughly “embedding and developing” the new approach will also be top of the agenda and Sutcliffe’s priority will be to ensure inspectors are supported through training and development to “really understand what good looks like” in individual services and for particular groups of people who use those services.

She adds: “We’ve got the framework, we’ve got the assessment but how do we absolutely make sure that providers are capable and confident of considering the different needs of people in those services?”

So, now more confident in an approach that makes better use of information and puts the voice of the service user at the heart of its work, Sutcliffe says she’s “ready to roll”. But when asked if she’s any more confident one-year-on that problems of poor care are being addressed, the chief inspector takes a long pause. “I think I would have to say yes,” she says. “But I would say it with a cautionary note.”

“There has been a greater focus on poor care and a greater willingness to tackle some of those problems. But we haven’t cracked it yet, there is still a lot more to do.”

Join the discussion on quality of care at Community Care’s conference ‘Safeguarding adults in care homes and hospitals: Growing standards of care quality to protect adults’ on 2 December.