Navigating change: What does the CQC’s new single assessment framework mean for providers?

This article first appeared in the December issue of Care Management Matters. Since drafting, further detail has been released by CQC around timescales, information gathering and format.

The CQC is changing the way it inspects and reports on services, but what are the evidence requirements for providers and what areas of the current system will remain the same? Philippa Doyle, partner and head of social care,  shares her analysis of the new process.

CQC’s long-awaited Single Assessment Framework (SAF) is slowly being shared. Its implementation has been somewhat delayed, due to IT technicalities and resourcing, but we seem to have a clear(ish) timetable for providers to have access to the new portal in Autumn/Winter 2023, with social care providers in the South ‘going live’ first on 21st November and the rest of the country expected to go live in the new year.

Keep watching CQC’s website and sign up for updates to ensure you have the most up-to-date information.

Business as usual?

Whilst the SAF is badged as a full-scale change in the inspection process, that change sits with CQC, not with providers.

It is CQC that is changing the way it inspects, the questions it asks, how it rates, and how it reports.

For providers, it is business as usual.

The regulatory framework that underpins the delivery of care has not changed and is not changing. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Fundamental Standards of Care, enshrined in Part Two of those Regulations, are here to stay.

All of the good work that you and your teams have done so far and continue to do, and all the excellent policies and procedures you have in place can stay.

Keep ensuring your care planning is person-centred.

Keep ensuring your staff are up to date with training.

Keep ensuring your medicines management is carefully delivered, monitored, and audited.

Inspection insights

The SAF is CQC’s new inspection regime. The CQC says it will regulate in a smarter way, adapting and responding to risk, uncertainty, and demand. We have seen clear signs of that already. During and post-COVID-19, CQC inspections were led by risk. This meant that there were direct complaints to its helpdesk, whistleblowing allegations, and concerns raised by commissioners, which led to poorly performing services, or those perceived as being poorly performing, being at the front of the queue when it came to re-inspections. Long gone is the inspection programme where a good service would not expect to see CQC again for two years.

The four ratings of: Inadequate, Requires Improvement, Good, and Outstanding, remain.

The five key questions or domains of safe, effective, caring, responsive and well-led will also remain.

Understanding requirements

What will change is the introduction of quality statements, which replace the previous 300 or so key lines of enquiry.

These quality statements are phrased as questions and providers will be judged against the available evidence to show how those questions are met. Each statement is scored from 1 – 4 based on the quality of the evidence submitted to CQC.

At the end of the process, providers will be able to see very clearly exactly where their service is doing well, and where there are gaps that require extra attention. Those providers looking to increase their rating up to the next level will also be able to see how far away from achieving that rating they are and where they need to focus their efforts.

CQC has very helpfully shared the different types of evidence that might be required to answer each of the quality statements and this is where the SAF differs for different sector groups.

There are eight different sector groups:

• Ambulance services
• Care homes and supported living services
• Community health services and hospices
• Homecare and shared lives services
• Independent doctors
• Mental health services
• NHS acute hospital services
• Primary health services

Each sector group will have slightly different evidence requirements, but all the details are available on CQC’s website for a service to map across each quality statement and what evidence they need to put forward.

The evidence categories are all very familiar too and are all based on the work CQC currently carries out when it inspects a service.

There are six evidence categories:

• People’s experience of health and care services
• Feedback from staff and leaders
• Feedback from partners
• Observation
• Processes
• Outcomes

Processes is one of the more notable ones for providers to be aware of – this is any series of steps, arrangements or activities which are carried out to enable a provider or organisation to deliver its objectives. CQC assessments will focus on how effective policies and procedures are. To do this, CQC will look at information and data sources that measure the outcome from processes. For example, CQC may consider processes that measure and respond to information from audits, look at learning from incidents and/or notifications and will review people’s care and clinical records.

Outcomes is a more NHS-based rather than social care-based evidence category. This will look at outcomes measured in the context of the service and the specifics of the measure. For example, mortality rates, emergency admissions and re-admission rates to hospital, infection control data, and vaccination and prescribing data. This information will be sourced from patient-level data sets, national clinical audits and initiatives such as the patient-reported outcome measures (PROMs) programme.

Uncertainty remains

What we regrettably can’t say at the current time is how much time CQC will give providers to upload evidence to the portal, how often information will be requested, or the format of the information you will have to upload. None of the requests should involve the need to create any new documents though – anything asked for should already be freely available, in just the same way as it might have been requested during previous inspections.

It might be most helpful for providers to look at the quality statements in context.

They are expressed as “I” and “we” statements.

The “we” statements show what is needed to deliver high-quality and person-centred care and the “I” statements reflect what people have said matters to them.

Using learning culture as an example:

The “we” statement reads:

We have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly and lessons are learned to continually identify and embed good practices.

And the “I” statements are:

I feel safe and am supported to understand and manage any risks. I can get information and advice about my health, care and support and how I can be as well as possible – physically, mentally and emotionally.

The evidence categories CQC will use to judge and score your responses to those statements are as follows:

Feedback from partners –

Commissioners and other system partners – how well do you report safeguarding referrals and make notifications to CQC?

Health and care professionals working with the service.

Processes –

• Duty of Candour records.
• Evidence of learning and improvement.
• Incident, near misses and events records.

The evidence submitted is then scored out of 1 – 4

4 = Exceptional standard.
3 = Good standard.
2 = Shows shortfalls.
1 = Significant shortfalls.

For example, if the service scored a 2 in learning culture, this would then feed into the overall scoring in the safe domain. Please see the table below for what an example service might look like:

This particular service has scored some twos and some threes and when that is converted into a percentage, it has scored 65.6% which puts it squarely into the good rating.

The service can see where it needs to do better, for example, infection control. This enables providers to know where to concentrate their efforts to improve. The theory is that the service will be able to submit evidence to CQC of its improvements and if CQC is satisfied with it, the scoring would be adjusted, which for some services might see an uplift from Requires Improvement to Good.

The percentage scores are clearly laid out:

• 25 to 38% = Inadequate
• 39 to 62% = Requires Improvement
• 63 to 87% = Good
• Over 87% = Outstanding

So as a service, you can see whether you are “just” missing out on a rating, or if you’ve “just” made it into the next category.

Do be mindful that there are some rating limiters:

• If the key question score is within good range but with a score of 1 for one or more statements, the rating is limited to Requires Improvement.
• If the key question score is within outstanding range but with a score of 1 or 2 for one or more quality statement, the rating is limited to Good.

Transparency is key

I am very hopeful that this new way of inspecting, evidence gathering and reporting will provide a far more consistent and transparent approach to regulation. Evidence is key though, even more than it ever has been. Providers will be uploading A LOT of information onto the provider portal before a visit and CQC’s analysis of a service will only be as good as the evidence submitted. It is worth engaging with the different questions, and what evidence CQC is looking for, to ensure that what you provide is specific and relevant. It is no good telling CQC everything you know about a subject – you have to actually answer the exam question.

Hempsons has worked with providers for many years supporting them through the CQC process. Our Fundamental Standards of Care training packages for registered managers and front-line staff can help you navigate the regulations, improve the lives of the people you support and tick CQC boxes too. Do get in touch for more information on how we can support you.

Watch our recent CQC webinar