What does a Care Home Manager need to know about CQC inspections?

In this article Liam leads the reader through the various topics and issues surrounding CQC Ratings, Safeguarding in Care Homes and the general, good practice expectations required of Care Home Managers.

What does a Care Home Manager need to know about CQC inspections and be aware of to run a safe, compliant care home?

Topics covered in this article

Introduction

What are the CQC ratings and what do they mean?

What are KLOEs (or Key Lines of Enquiry) and what do they mean?

What does the CQC Rating mean for a Care Home and its Manager?

Are CQC Ratings fair and representative?

What are the notifications that a Registered Manager needs to send to the CQC?

What are the CQCs safeguarding requirements of Care Home Managers?

For Care Home Managers, what is deemed good practice when managing safeguarding alerts?

Disclaimer

Introduction

To manage a Care Home you have to be registered with the CQC as “the registered manager” and go through that process.

The provider and the particular Care Home needs to be registered with the CQC prior to that.

The CQC inspection checks there is quality care in the Care Home, with sound governance and a well managed staff team and that all relevant controls are in place.

What follows is not exhaustive as certain elements below vary by Care Home provider, type of and size of Care Home service and is based on my work at mid to large homes for older people over the last 7 years (2013 – 2019).

Your local CQC Inspector and your Local Authority Social Work / care team may have unique positions on some of these points.

What are the CQC ratings and what do they mean?

Here’s a definition of each CQC rating:

Inadequate – serious breaches, it could lead to the home being closed if the provider doesn’t take urgent action.

Requires Improvement – some breaches, which warrant closer scrutiny. In the inspectors view, the service is below the minimum standard which is “good.”

Good – meets CQC standards. Following inspection, the service is considered to meet the needs of the residents when considering the 5 KLOE’s framework.

Outstanding – 3% of services get this, and the rating includes an element of continuous improvement. This is the ultimate rating. All progressive services will aim for this though there are more “outstanding” ratings in smaller homes. Often these services are more person centred than larger homes.

What are KLOEs (or Key Lines of Enquiry) and what do they mean?

You will need to have a good working knowledge of the KLOE’s – key lines of enquiry. The Key Lines of Enquiry or KLOEs indicate whether a service is considered to be “safe", "caring", "effective", "well-led" and “responsive".

These are known as the CQC standards used to assess a Care Home.

From these inspections comes the ratings - Inadequate, Requires Improvement, Good, Outstanding.

There is a rating given to each of the 5 KLOE’s at the point of rating – an inspection will conclude with a rating for each question and an overall rating given to the Care Home.

If there are two or more KLOE ratings of ‘Requires Improvement’ the service is rated as ‘Requires Improvement’ overall, if there are two or more KLOE ratings of ‘Inadequate’ then the service is rated as ‘Inadequate’ overall.

To be rated as ‘Outstanding’ overall the service must achieve at least two KLOE ratings of ‘Outstanding’ with no KLOE being rated as ‘Requires Improvement’.

The overall rating is the measure that determines how the home is regarded in terms of compliance which in turn reflects reputation / public image.

If the overall rating is ‘Good’ or above it is compliant.

Residents have a right to care that meets the CQC standards.

What does the CQC Rating mean for a Care Home and its Manager?

The overall CQC rating is a measure of how well the care home is doing for the public.

The overall CQC rating is a measure of how well the home is doing for the public.

If it is ‘Good’ or ‘Outstanding’ it is a positive message to families and therefore for admissions.

If the rating is ‘Requires Improvement’ it can negatively affect both.

Of course, a poor CQC rating can be difficult if the CQC doesn’t come back to check progress for one year as the negative rating will stand for that time.

With the pressures from above (from a regional director in the larger organisations or the owner in the smaller organisations) it is usual for Care Home Managers to overly focus on the inspection rating.

In my view, the primary focus for Care Home Managers should be that the residents experience high-quality care EVERY day so that when the inspectors come, there should be nothing to fear from an inspection.

The audit schedule and previous whole home audits and accompanying action plans should help protect Care Home Manager from many surprises!

Are CQC Ratings fair and representative?

Yes, most of the time the ratings are fair and representative of the experience of the residents and a fair reflection of the inspectors on the day.

Sometimes they may be unconsciously biased. This could be based on previous experiences with the home.

Sometimes inspections come as expected after the receipt of a PIR (PIR stands for Provider Information Return).

In August 2019 the CQC announced that care providers would be required to complete an annual PIR on the anniversary of their first inspection visit. This means that a service rated as ‘Good’ or ‘Outstanding’ may complete more than one PIR before an inspection visit from the CQC. It also means that the service will no longer get “notice that an unannounced inspection is due”.

At other times, unannounced inspections come in response to a whistleblower making allegations.

In some cases, staff can deliberately misuse these processes to try and harm the reputation of the home by giving a false report to the CQC. Most of the time, by investigating these allegations, they are shown to be unproven and malicious. This is common.

If there is an unannounced inspection to check where a concern is raised and it leads to an overall downgrading of the rating to ‘Requires Improvement’, this is a serious matter.

There is a mechanism to challenge an unfair rating as well as unfair comments, but most of the time this isn’t necessary.

The CQC collects data from other sources, often meeting monthly to review homes that are struggling. That way it can prioritise care homes where there are mounting concerns.

What are the notifications that a Registered Manager needs to send to the CQC?

Registered Care Home Managers have an obligation to report in various things to the CQC.

Two of the most common CQC notifications used by a Care Home Manager are:

• Reg 16 - reporting a death - “the death of a person using the service”

• Reg 18 – reporting of “Alleged or actual abuse, DOL’s applied for, serious injuries and incidents reported to the police”.

Failing to do this is considered a serious breach of the regulations.

The registered manager doesn’t need to do the notifications themselves but they must ensure that if delegated that they are completed to the required standard AND completed and sent off promptly.

A failure to submit a notification to the CQC will result in a rating for the ‘Well-Led’ KLOE of ‘Requires Improvement’ (at best).

What are the CQCs safeguarding requirements of Care Home Managers?

Registered Care Home Managers have a legal obligation to notify the safeguarding team within their local authority when there has been abuse, suspected abuse or when a person has been at risk of harm of abuse.

The Care Act 2014 changed the definition of a vulnerable adult to a person at risk.

A person is at risk if they are being harmed or abused or at risk of harm of abuse and they cannot protect themselves from that.

The abuse can take a myriad of forms – financial, emotional, physical, psychological, etc.

The safeguarding team will decide if it meets their threshold for abuse for a safeguarding alert to be raised formally, for further investigation.

Each local authority will have different thresholds – some with a low threshold will want everything reported.

Others will have a higher threshold and use it only for exceptional or serious ongoing concerns.

Suspected abuse also needs to be reported into the CQC using the relevant notifications (No 18).

The registered manager (or their representative in the home) needs to speak to the safeguarding team, ask for advice and then follow this advice. This is an actual obligation.

For Care Home Managers, what is deemed good practice when managing safeguarding alerts?

Good practice with managing safeguarding alerts will usually entail taking immediate action to reduce / eliminate the risk to a resident.

After checking with safeguarding, the manager will likely be required to investigate with interviews / statements as needed.

If the Care Home is requested to undertake an investigation it is vital that the person doing this is trained and competent to do so.

By not following the correct procedures (asking “why” questions rather than “what” questions or interviewing people in the wrong order - e.g. alleged victim first, witnesses next, other people next, alleged perpetrator last) the investigation can be jeopardised.

The Registered Manager will be required to summarise and discuss. That is, to take action and use it as learning so it doesn’t happen again.

Throughout the process, they are there to listen and understand the experience of the resident and communicate what is being done at different points of the investigative process.

In this way, the Registered Manager is letting them feel they’ve been taken seriously and that serious concerns are addressed appropriately, with due confidentiality.

This is a complex area, but these general principles hold.

The key tip is that the Registered Manager needs to demonstrate a responsible and proactive attitude to deal with these matters but ask for advice from safeguarding first.

If they fail to do so, the safeguarding team may get more closely involved to ensure things are dealt with robustly and effectively.

Disclaimer

This is dated 20.9.19 and is a qualified introduction to these matters – it should not be used as an authoritative guide to run a home or be considered actual advice.

Please ensure you follow the advice on the CQC website, together with the company policies and guidelines from your employer.

The views expressed are those of the author.

Read more articles like this

• The Complete Care Home Manager Career Guide

• Other articles by Liam and his Podcast series 'Care Home Quality'

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