Care Quality Commission (CQC) revisions to its Transitional Monitoring Approach - what should providers be thinking about?

With the Care Quality Commission now considering consultation responses in respect of its long-term regulatory approach, life goes on under their Transitional Monitoring Approach.

09 April 2021

With the Care Quality Commission now considering consultation responses in respect of its long-term regulatory approach, life goes on under their Transitional Monitoring Approach. That approach is already a significant step away from the pandemic support-centred Emergency Support Framework and back towards greater scrutiny, higher expectations and increased enforcement. Now the CQC have announced some developments in the current approach that providers should all be aware of.

Inspections

Routine inspections have been suspended since March 2020, replaced with monitoring call, infection prevention and control (IPC) inspections and reactive inspections where concerns are raised. Routine, comprehensive inspection will never return as the mainstay of CQC regulation and rating, that much is clear from the CQC’s plans for the future. However, the latest announcement does open up the possibility of inspections in a broader range of circumstances even under the transitional approach.

Transitional Inspections – to be Welcomed or Avoided?

We are often told by providers that they know how a CQC inspection will go early on in the process. First impressions are key to a positive outcome. By their very nature, most inspections under the transitional approach will be a reaction to some concern and that may mean that the first impression is set before inspectors even arrive. For services with positive ratings, therefore, our perception and the feedback we have received is that they are something to be avoided. Dealing promptly and effectively with staff concerns or complaints from any source and ensuring compliance with CQC notifications as well as good preparation for Transitional Monitoring Calls and IPC inspections will be key to achieving this.

Provider Information Returns

Annual Provider Information Returns to adult social care will also be tested before becoming compulsory after the impact on provider businesses has been assessed. Such a consideration would appear necessary. The forms vary for different types of service but, when broken down, contain well over 100 questions. Many of those are narrative, some with 500 word limits. There is a real risk that this will be to the detriment of smaller providers, without the additional senior manager time required for such an exercise. Care will have to be taken to make sure that the CQC’s plans for assessing care quality by data collection over inspection does not simply become a rating of how good providers are at completing forms. Registered Managers will be required to complete the returns upon request from the CQC.

Adult Social Care

For adult social care, IPC inspections will continue in care homes and are to be adapted and extended to community setting such as supported living and extra care. Whilst the intent behind these inspections is laudable, the process has caused concern for a lot of providers. IPC ratings are published by CQC without any available process for challenge. Poor ratings can cause reputation and financial harm to businesses. Providers should also ensure that their service is ready to give a good impression to CQC in areas other than IPC. We are aware of IPC inspections being converted into responsive inspections, leading to urgent enforcement action unrelated to IPC.

A more welcome change will be the re-emphasis on inspections for re-rating purposes. Many providers who have made improvements following Requires Improvement or Inadequate ratings have complained that they have been unable to secure a re-rating under the CQC’s pandemic approach. It seems that these inspections will prioritise those services that might add to system capacity, perhaps where a negative rating or lack of rating for a new service is inhibiting commissioning. As such, providers hoping for a re-rating would be well-advised to coordinate their request with local commissioners.

Hospitals

As well as responding to identified risks, inspection and rating of services currently rated Inadequate or Requires Improvement will recommence. Although providing the opportunity for a re-rating it is far from certain how much that will be welcomed by NHS Trusts, in particular, who have been under much pressure over the last year. The CQC will commence IPC inspections in response to concerns, rather than as a routine measure as with care homes.

There is also a plan to review the rating of all hospital providers, although the announcement is silent on whether that will be through inspections or otherwise, as the CQC looks to move towards data collection as a means to keep ratings more up-to-date. Data on emergency departments and maternity services, an area that has generated much concern in recent months, will be considered alongside ‘local intelligence’ and may prompt focussed inspections. For maternity, in particular, teamworking and culture will be a focus. For this reason and others, we would encourage Trusts to renew their efforts to obtain feedback from staff and to act quickly on that feedback.

Mental Health, Learning Disability and Autism

The CQC continues to emphasise the inspection and regulation of what they consider ‘high risk’ services, including those where closed cultures may exist and where service users are particularly vulnerable. In effect, this means that providers of mental health, learning disability and autism services can inspect more inspections and greater scrutiny than other providers. That scrutiny will be even greater for in-patient and secure settings. Health and care in prisons and other secure settings is an area where more routine inspections are to recommence.
A feature of the CQC’s recent approach to services of this kind is its focus on the Well-Led domain. Well-Led inspections of larger providers have continued through the pandemic and are to be increased under these new, interim plans. This is also a feature of the CQC long-term plans, including the potential for parent companies in larger care groups to be required to register and subject to Well-Led inspections. The next phases of Provider Collaboration Reviews, where local systems are considered by CQC as a whole, will focus on learning disability and mental health systems as well as cancer care. There is also increased scrutiny at provider level on how providers cooperate with and learn from other providers and stakeholders.

Primary Care

Inspections will resume of children’s services (jointly with OFSTED), independent primary care providers (especially those without a current rating and newly-registered providers. Other services will be inspected where there has been previous cause for concern, such as a negative rating or a Good rating but where a breach of regulations has been identified. Such breaches can include matters as missed CQC notifications or duty of candour failings and so providers should take this opportunity to ensure their systems and processes in these areas are robust. Dental providers are to see a programme of inspections focusing on the use of technology.

Registration

Perhaps unsurprisingly, the CQC will continue to prioritise registration applications related to the pandemic response. We are beginning to see that definition applied more broadly, perhaps to services designed to reduce bottlenecks in the flows of patient discharge after COVID. The knock-on effect is that we are seeing concerning delays in processing standard registration applications, which has the potential to prejudice acquisitions that might bring much-needed investment to services including those in financial difficulties. The CQC’s commitment to streaming this process is to be welcomed but currently lacks any specifics.