For many providers, reaching an ‘outstanding’ rating with the Care Quality Commission (CQC) can seem like a difficult task. For others, it’s an ambition that is at the centre of their mission.
Of course, achieving ‘outstanding’ is meant to be difficult. Only 2% of inspected social care services achieved the rating in 2018, a statistic that has remained largely static since 2014. More domiciliary care services rank outstanding compared to residential services, and similarly nearly five times as many residential settings are rating as ‘inadequate’ as domiciliary services. This speaks to the different challenges between the two types of service provision.
Below are some tips that may help you if your ambition is to be outstanding. It may not surprise you that planning is key.
Planning and Preparation
As with anything, the key to a great CQC inspection is plenty of planning and preparation. There should be no surprises when the inspector calls: all the standards they measure you against are available for free online.
Firstly, you should be aware of what type of inspection you are due to receive. There are three types:
- Comprehensive inspection – A holistic inspection usually carried out where there is a risk of a deterioration in quality or an upturn in quality that may affect your rating.
- Focused inspection – More structured, narrow inspections carried out in response to a complaint or to follow up on specific findings from a previous inspection. These are usually unannounced.
- Combined inspection – Where the organisation provides services that span different areas of health and social care, for example, “mental health, community health, and care homes”. Different inspections are carried out by specialists for each service area.
If you know what type of inspection you are likely to receive, you will be able to plan more effectively. Focused inspections are the simplest to plan for, since you will likely already be aware of the issue to which they are responding. Comprehensive inspections require much more planning and work. All inspections will emphasise your equality and diversity credentials – such as providing reasonable adjustments – and your compliance with the Mental Capacity Act and Deprivation of Liberties Safeguards.
Fortunately, the CQC’s criteria is public and open for all. Here’s two of the key documents you should be aware of:
The CQC document ‘How we regulate health and social care’ should be your first port of call when planning for an inspection. The document summarises how the CQC inspects. It also includes the appeals and complaints procedures should the inspection not go the way you hoped. The document signposts you to other documents that will be of help.
Assessment Framework – the Key Lines of Enquiry (KLOEs)
The KLOEs are the primary questions any CQC inspector will ask as part of their visit. There are five key areas of focus:
- Are service users safe from abuse and harm?
- Is the care delivered effective? Does it lead to good outcomes?
- Are staff caring and compassionate towards those in their care?
- Are services responsive to the needs of service users?
- Is the organisation well-led? Are there effective governance arrangements in place?
Beneath these areas of focus are a series of questions that the inspector will ask. They will, of course, need evidence to support any answers you provide. The CQC KLOEs documentation also gives an explanation as to what providers must do to get an outstanding rating for each question. It is important to compare your service against these criteria. This will give you an indication as to where you are likely to fall in your inspection.
The KLOEs underwent some changes in November 2017. Advantage have a guide to the updates available to download for free.
CQC reports online
As since the CQC is a public regulator, all its reports are available online. Reading the reports of ‘outstanding’ services will give you a good indication of what inspectors are looking for when they visit. Conversely, reading reports of ‘good’ services will give you an idea of the gap between these ratings and ‘outstanding’ and what you need to correct. All inspection reports can be found on the CQC website alongside the details of the different providers.
You will notice in some reports that there are specific mentions of instances where the inspector believes the organisation is exceptional or innovative. If you have developed a particular procedure or use a piece of technology that you believe will differentiate yourself from other providers, make sure you highlight it on your inspection.
Aim for two questions to be outstanding
Not many know that, of the five key questions asked by the CQC, only two need to be outstanding for you to get an overall outstanding rating. Although you need to need to deliver as best as you possibly can in all five areas, you will likely already be relatively strong in at least two areas compared to others.
If that is the case, you should build on your strengths. You should understand why you are so strong in these areas and focus on them. It is easier to concentrate your efforts and to make a real impact with staff on a limited number of areas, rather than spread your resources too thinly.
Use an evidence file
It is not enough for you to answer questions well. Inspectors need evidence. Nor should you rely on the inspectors being able to find good or outstanding practice. You need to be proactive. You should maintain an evidence file that you are constantly updating, preferably something that the inspector will be able to take away with them. This may include documents such as:
- Your policies and procedures
- Organisation chart
- Minutes of senior management meetings and meetings with outside agencies
- Records of any incident investigations, including the outcomes, or any meetings where safeguarding issues are discussed
- DBS records for staff
- Health and safety and fire risk assessments
- Training needs analyses and evidence of staff training
- Legionella test records
- Equipment maintenance records, including PAT tests
- Compliance with data protection requests
If you are consistently updating this file – best categorised as per the KLOEs – then will be fully prepared when an inspection occurs.
This file is not just about ticking boxes, though. You should record examples of where you feel your organisation has developed practices or delivered care that are innovative or particularly exceptional. You should also record examples of good team work, where your staff have gone above and beyond, or great feedback from service users and/or their families. If you have had any requests for information from the CQC, such as online provider information collection (PIC) or provider information return (PIR) requests, keep records of what the request was and your response.
Surveys and feedback
The best evidence that you are delivering excellent care is feedback from the people in your care and their families. Of course, you can obtain this through individual requests, and it may be a good idea for you as a manager to get out and talk to the people in your care or their families.
If time is a factor, though, a survey – paper or digital – can help. Any survey must strike a balance between hitting some of the key criteria required by the CQC, and ensuring it is not too long and foreboding for someone to complete. Do not be tempted, however, to throw out any survey results that criticise your services. Negative feedback collected in these surveys is, in fact, hugely beneficial for two main reasons:
- It validates the survey and all the other responses by showing that the results are genuine and unfiltered
- It provides an opportunity for you to demonstrate to the inspector that you have acted on people’s concerns
It is best, if you can, to collect feedback consistently over a long period of time. This will help give you a more accurate picture of how your organisation is functioning and take account of changes in staff and service users.
For those seeking to use digital surveys, there are a range of online providers. SurveyMonkey is one of the most popular and has a free option.
Carry out mock inspections
CQC inspectors will not just interview you. They will also interview your staff to ensure they are aware of your organisation’s policies and procedures and of their responsibilities as carers. Carrying out mock inspections will get them used to questioning and help you identify where there are gaps in staff knowledge. It will build confidence, meaning that you and your staff will be able to talk about how great your services are with more authenticity.
You should not, though, prepare a ‘script’ for your staff. CQC inspectors will be able to see through it. It will also have long-term negative consequences, creating a culture of mistrust in your organisation. If your organisation is well-led and has a mission to deliver excellent care, you should largely be able to trust your staff to show off how good you are.
Again, staff surveys will help you an insight into carers’ awareness of their responsibilities and how they feel about your organisation. A people-oriented organisation will regularly solicit staff feedback to help improve its services.
You can carry out the inspections yourself, have a senior member of staff do it, or procure outside help. There are now a number of organisations that can carry out mock audits and inspections. Get in touch with us to find out who we recommend.
Ensure all staff training is up to date
Staff training is one of the easiest things to fall short on. All your care staff should be up to date on their mandatory training, including health and safety training, fire training, and all the mandatory care subjects. You must ensure that records are kept of all the training, including copies of the certificates.
Innovative care organisations will look beyond the bare minimum, of course. Outstanding providers will have development plans for members of staff. This will not just help the CQC inspection but also improve staff retention and morale. They will also be able to demonstrate an ongoing system of staff training that highlights when a training need is likely to emerge. Advantage centres use our accreditation portal to help keep track of training needs and records.
Getting your training or training systems accredited demonstrates a commitment to quality, consistent training. Click here to find out how Advantage Accreditation may be able to help you with this.
Be aware of limiters
Even if you perform well against the ‘well-led’ KLOE, you may be unable to reach an outstanding rating under certain circumstances. These ‘limiters’ are:
- If the setting has no registered manager when it should have, or if there have been insufficient attempts to hire one
- There is another condition of registration that has not been met
- You did not alert the statutory authorities about a relevant event
- The provider has not completed a PIC request
You should also be aware that, in some cases, the CQC will not be able to give a rating. This is only likely if it is a brand new organisation, if there has been a significant change in operations or ownership, or if there isn’t enough evidence.
Now for the inspection …
Provided you have done your preparation and planning, the inspection itself will go a lot smoother. Here’s some tips though that may help you:
- Shout about your successes – act as if the inspector is a potential client
- Smile, and get your staff to smile too
- Highlight anything you do that is innovative to stand out from other settings
- Don’t lie and don’t be afraid to say if you don’t know the answer – trying to cover your tracks will only come back to bite you later
If you are a truly outstanding organisation, then you won’t need any tricks or shine. Hopefully this guide will help you put a plan in place to ensure that your greatness really shines through!
If you need any more advice, get in touch with the Advantage Accreditation team.