Guidance

1.  Introduction

The following has been taken from CQC’s website:

We’re the independent regulator of health and social care in England.

Our purpose: We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

Our role

  • We register care providers.
  • We monitor, inspect and rate services.
  • We take action to protect people who use services.
  • We speak with our independent voice, publishing our views on major quality issues in health and social care.
1.1  CQCs New Strategy – Single Assessment Framework

The CQC released their new strategy in 2021, with an emphasis on collaborative working, patient engagement, safety through sharing learning from experiences of users of the service and professionals, quality improvements and adopting a flexible smarter approach to inspections and regulation.

“We set out our ambitions under four themes

  • People and communities: Regulation that’s driven by people’s needs and experiences, focusing on what’s important to people and communities when they access, use and move between services
  • Smarter regulation: Smarter, more dynamic and flexible regulation that provides up-to-date and high-quality information and ratings, easier ways of working with us and a more proportionate response
  • Safety through learning: Regulating for stronger safety cultures across health and care, prioritising learning and improvement and collaborating to value everyone’s perspectives
  • Accelerating improvement: Enabling health and care services and local systems to access support to help improve the quality of care where it’s needed most

Their aim is “to ensure health and care services provide people with safe, effective, compassionate, high-quality care and to encourage those services to improve. “

To deliver this new strategy, they are working towards a new Single Assessment Framework

1.2  CQC New Framework  – https://www.cqc.org.uk/assessment
  • Ratings and the five key questions remain
    • four-point ratings scale (outstanding, good, requires improvement and inadequate).
    • five key questions (safe, effective, caring, responsive and well-led)
  • Quality statements focus on specific topic areas under key question. They set clear expectations of providers, based on people’s experiences and the standards of care they expect. They replace our key lines of enquiry (KLOEs), prompts and ratings characteristics.
  • We’re introducing six new evidence categories to organise information under the statements
  • Registration is also based on this framework. It is the first assessment activity for providers in an integrated process.

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1.3  CQC – How We Will Use It

We will:

  • use a range of information to assess providers flexibly and frequently. Assessment is not tied to set dates or driven by a previous rating
  • collect evidence on an ongoing basis and can update ratings at any time. This helps us respond more flexibly to changes in risk
  • tailor our assessment to different types of providers and services
  • score evidence to make our judgements more structured and consistent
  • use inspections (site visits) as a vital tool to gather evidence to assess quality
  • use data and insight to decide which services to visit. When on site, we will observe care and talk to staff and people who use services
  • produce shorter and simpler reports, showing the most up-to-date assessment
1.4 CQC – Assessing Quality & Performance – Ratings

See https://www.cqc.org.uk/assessment/quality-performance/reach-rating

CQC say that to support the transparency and consistency of their judgements, they will introduce a scoring framework into their assessments. Where appropriate, they’ll continue to describe the quality of care using our 4 ratings:

  • outstanding,
  • good,
  • requires improvement, or
  • inadequate.

When they assess evidence, they assign scores to the key evidence categories for each quality statement that they’re assessing. Ratings will be based on building up scores from quality statements to an overall rating.

This approach makes clear the type of evidence that they have used to reach decisions.

They will use scoring as part of their assessments and you will find more detail about scoring on their webpage, however in brief it says:-

As we are moving away from assessing at a single point in time, in future we will likely assess different areas of the framework on an ongoing basis. This means we can update scores for different evidence categories at different times.

Any changes in evidence category scores can then update the existing quality statement score.

We will follow these initial 3 stages for all assessments:

  1. Review evidence within the evidence categories we’re assessing for each quality statement.
  2. Apply a score to each of these evidence categories.
  3. Combine these evidence category scores to give a score for the related quality statement.

After these stages, we build up scores from quality statements to an overall rating. This depends on the type of assessment.

For service providers

  • The quality statement scores are combined to give a total score for the relevant key question. This score generates a rating for each key question (safe, effective, caring, responsive, and well-led).
  • We then aggregate the scores for key questions to give a rating for our view of quality at an overall service level.

We will initially only publish the ratings for providers, but we intend to publish the scores in future.

CQC have also published a detailed example of how they reach a rating for a GP Practice. We would recommend taking a look at this in full to understand the complexity. In summary, each category score is calculated as a percentage and then all the percentages are converted back to an overall score.

At key question level they translate this percentage into a rating rather than a score, using these thresholds:

  • 25 to 38% = inadequate
  • 39 to 62% = requires improvement
  • 63 to 87% = good
  • over 87% = outstanding

Their aim is to introduce this during 2023. CQC published an update in April 2023 that tells us that:-

  • In summer we’ll start to roll out our new provider portal, notifying providers individually when they’re able to sign up. We’ll do this in stages and provide support and guidance.

They will be starting to roll this out in the summer with further developments later in 2023.

  • Later in 2023 we’ll gradually start to carry out assessments of providers in the new way.
  • These changes will take time and will continue into 2024. But we we’ll continue to keep everyone informed as we know that providers, local authorities, integrated care systems and others need time to prepare for the changes.

Over the coming months we’ll provide much more detail about how we’ll use our new assessment approach when we start to roll it out later in the year. We’ll give an update on what good looks like under our new assessment framework, the evidence we’ll prioritise and how providers will interact with our new operational teams.

We’ll also start to share case studies from the engagement work we’ve been doing on our provider portal.

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2  CQC and CAS Alerts

From 1 October 2019, MHRA will send Central Alerting System (CAS) alerts directly to GP practices, replacing any local arrangements previously in place. All GP practices in England are contractually required (From 1st October 2019 GMS/PMS Regulation 74G/67G) to register to receive CAS alerts directly from the MHRA.

CQC, will on inspection be checking on the mechanisms around CAS alerts.
We have an excellent example below of a logging sheet for this purpose. We give thanks and credit to our colleagues at Testvale Surgery for sharing with us a copy of this log they have created. Click here – CAS Alerts Log from Testvale – if you wish to download and use for your practice.

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3.  CQC: Challenging the CQC

It is well known that practices are nervous of challenging CQC inspectors during the inspection visit and usually leave complaining until after the visit or even later, when the draft report is received.

The CQC often then see the complaint as a reaction to something in the report rather than a genuine complaint either about the process or the way the inspection team interpreted regulations or responses to questions.

We are aware that it is daunting to challenge on the day but it is far better to raise something at the time or as soon after the inspection has taken place once the issue has been reflected upon than to wait until the report has been seen.

So, your first route is to discuss the issue with the lead inspector on the day, providing any evidence you have which contradicts what has been said by one of the inspectors. Again, you could make contact in the following day or so for the same purpose.

If you miss that opportunity your next one is your response to the factual accuracy of the report and full details around this can be found at the following link: https://www.cqc.org.uk/guidance-providers/how-we-inspect-regulate/factual-accuracy-check

If your complaint is about the manner and attitude of one of the inspectors, then this needs to be made to the lead inspector on the day/day after (unless it’s the lead inspector who is the issue.) In this case you would direct your complaint to the CQC national complaints team at this link : https://www.cqc.org.uk/contact-us/how-complain/complain-about-cqc

The LMC can also raise your complaint via the Regional Inspection Leads, if you supply all the relevant information.

Where we see a pattern of issues arising the LMC will raise this with the GPC for their regular meetings with CQC.

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4.  CQC: Pre-Inspection – Supportive Information

Notification of a CQC inspection call or visit can raise high levels of stress in all staff!  It is an opportunity for the practice to show how well they are working as a team and the quality of care they are providing for their practice population.

4.1 Top Tips

With our grateful thanks to Cleveland LMC who have kindly given permission for us to link to their resources on this topic.

There are documents for the following headings

They have been collated by a member of their team who was previously a CQC Inspector. We would point out that Cleveland LMC advise that these are due to be updated in due course in line with CQC’s Single Assessment Framework.

4.2  Clinical Searches – July 2022 Update for Practices in Preparation for Potential Future CQC Inspections.

There has been an updated CQC YouTube presentation on the remote searches carried out by the CQC GP SPA during a practice inspection.

The CQC slide set that details the clinical searches can be downloaded here. Slides 20-26 have the clinical detail around the searches.

These clinical searches are now routinely used when carrying out inspections of GP practices. They were designed to focus on areas of clinical importance, reflecting the profession’s agreed shared view of quality and to contribute to a consistent regulatory approach.

CQC also say that their National Professional Advisor has also provided the following information which you may find helpful.

The Specialist Pharmacy Service (SPS) who recommend monitoring intervals for all drugs, returned to normal intervals from Feb 22: Since February 2022 SPS now recommend that monitoring can proceed as normal using their medicines monitoring guidance. This is based on the usual shorter BNF and NICE CKS monitoring intervals.

The content and focus of the remote clinical searches have been agreed by the RCGP and the BMA. It represents a reasonable approach to assessing some important features of safe and effective health care delivery. The searches will be regularly reviewed and updated. This will reflect changes to guidance, new alerts or areas that are considered important for additional review.

The attached list was the requested information for CQC prior to an inspection in a practice in HIOW recently. This list is an example and practices shouldn’t assume that they will automatically be asked to provide exactly the same information.

You can find more information on how these searches have been constructed, how to download, along with FAQ on the Ardens website available from June 2022.

There are specific videos on using these searches in the various GP computer systems.

CQC also have a slide set from their webinar on their regulatory model.

Clinical system search detail can also be seen within CQC GP mythbuster 12

Long term condition management and monitoring

We have asked CQC about their expectation regarding long-term conditions management and monitoring of patients prescribed high risk medicines.

They have given the following update: –

In relation to high risk medicines, we look at this under our KLOE S4. How does the provider ensure the proper and safe use of medicines, where the service is responsible?

In accordance with General Medical Council (GMC) guidance ‘Good practice in prescribing and managing medicines and devices (updated April 2021)’, our expectation is that before issuing a prescription (including a repeat one) we expect to see prescribers review the monitoring or know that it has been completed, and can access information showing it remains safe for the patient to receive the medicines.

4.3  Practice Access Data

As patient access is a topic raised on a number of occasions, we thought is might be useful to have some data to hand to offer to CQC in preparation for a visit/inspection. We have put together a short checklist. It is by no means exhaustive or compulsory in any way, so please don’t feel you have to use this. It is simply a checklist you might find useful. Click HERE to download a copy.

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5.  CQC: Provider Companies

Given that CQC are inviting practices to spend around 30 minutes at the beginning of the inspection visit describing the practice, its ethos, what it does well etc, the LMC has produced a generic presentation template which you may wish to use for this purpose. Please feel free to adapt in any way you wish and if you think we’ve missed anything important, please do let us know.

CQC and Provider Companies

The LMC has been contacted on a number of occasions by local GP provider companies who are confused about the need to register with CQC.

The LMC has met with CQC to discuss this specific question and the following is a summary of those discussions:

  • If the Provider Company actually PROVIDES the regulated activity then it will need to register with CQC eg the Provider Company employs the staff directly and is a completely separate legal entity*.
  • If the Provider Company holds the contract for that regulated activity but sub-contracts all of the work to practices, then they do not have to register
  • If a practice holds a sub-contract from the Provider Company to undertake regulated activity on its behalf then the practice statement of purpose would need to list this, particularly if the practice is providing the regulated activity from another ‘location’ rather than their own practice premises
  • If a practice is providing the service to patients of another practice within its own premises and is already registered to provide that service for its own patients then there is no need to seek any further registration but the statement of purpose should show this
  • If a Provider Company is planning to provide a service it cannot register with CQC until the contract has actually been awarded (the CQC regulations state the provider must be providing the service). CQC confirmed it cannot accept organisations onto its register who have made unsuccessful bids.

* It is also important to be clear if the place where the service is being provided is classed as a location and the rule set for this can be found at:  What is a location? – Care Quality Commission (cqc.org.uk)

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6.  CQC: Provider Group Registration

The LMC has been contacted on a number of occasions by local GP provider companies who are confused about the need to register with CQC.

The LMC has met with CQC to discuss this specific question and the following is a summary of those discussions:

If the Provider Company actually PROVIDES the regulated activity then it will need to register with CQC eg the Provider Company employs the staff directly and is a completely separate legal entity*.

If the Provider Company holds the contract for that regulated activity but sub-contracts all of the work to practices, then they do not have to register.

If a practice holds a sub-contract from the Provider Company to undertake regulated activity on its behalf then the practice statement of purpose would need to list this, particularly if the practice is providing the regulated activity from another ‘location’ rather than their own practice premises.

If a practice is providing the service to patients of another practice within its own premises and is already registered to provide that service for its own patients then there is no need to seek any further registration but the statement of purpose should show this.

If a Provider Company is planning to provide a service it cannot register with CQC until the contract has actually been awarded (the CQC regulations state the provider must be providing the service). CQC confirmed it cannot accept organisations onto its register who have made unsuccessful bids.

* It is also important to be clear if the place where the service is being provided is classed as a location and the rule set for this can be found at: What is a location? – Care Quality Commission (cqc.org.uk)

The LMC has asked the CQC to comment on our article and the following is their response in respect of actual registration when submitting a bid but before being awarded a contract:

” The Health and Social Care Act 2008 only requires registration where regulated activity is provided. Companies bidding for contracts will often need to apply for registration before they know whether they have been successful. CQC may ask for confirmation from applicants that they WILL provide regulated activity (e.g. that they have been awarded a contract to do so) before they grant registration. CQC cannot register Companies that will not provide regulated activity (i.e. those that are unsuccessful). Companies can, in these circumstances, withdraw their applications. “

In summary, they have softened their stance and applications can be submitted and either followed through or withdrawn once the outcome of the bid is known.

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7.  CQC: Schedule for Partnership Agreements

BMA lawyers have produced the following schedule for inclusion in new/revised partnership agreements.  However it is expected that it may be revisited and further discussions with the CQC have taken place and the wording may be expanded somewhat.

The Partners acknowledge that the Care Quality Commission (CQC) has issued directions stating that all primary healthcare service providers shall be required to register online and pay a fee in respect thereof. Accordingly the Partners agree that:

  1. There is a duty upon them to register with the CQC as and when required.
  2. That they have appointed or shall appoint a manager (who need not be a GP) for the purposes of the registration and ongoing responsibilities in respect thereof.
  3. There shall be a fee for such registration payable per annum and that such fee shall be borne by the Practice.
  4. DBS checks shall be required to be made for those Managers referred to in 2. above, as appropriate.

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8.  CQC: Statement of Purpose

Please see the following link to the CQC website for guidance on writing a statement of purpose:

Statement of purpose – Care Quality Commission (cqc.org.uk)

Your may also like to include the following in your Statement of Purpose:

  • Prevent Ill health, improve well being and provide services that improve local health outcomes
  • Deliver services that are responsive to the needs of our local communities and our commissioners
  • Deliver financial duties and ensure the efficient use of resources
  • Be the employer of choice
  • Provide services that are equitable, accessible and of high quality
  • Invest in the wider community interest
  1. To deliver high quality, integrated care that is closer to home and which meets individual needs
  2. To deliver innovative and flexible solutions that support and improve health and wellbeing
  3. To deliver value for money and be financially sustainable

 

 

CQC: Statements of purpose. Guidance for providers

 

 

 

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CQC
Last Reviewed Date
07/12/2023