Inspection handbook. Adult social care. October ASC inspection handbook October 2014 v 2 00 Page 1

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1 Inspection handbook Adult social care October ASC inspection handbook October 2014 v 2 00 Page 1

2 The Care Quality Commission is the independent regulator of health and adult 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 monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care. Our principles We put people who use services at the centre of our work. We are independent, rigorous, fair and consistent. We have an open and accessible culture. We work in partnership across the health and social care system. We are committed to being a high performing organisation and apply the same standards of continuous improvement to ourselves that we expect of others. We promote equality, diversity and human rights ASC inspection handbook October 2014 v 2 00 Page 2

3 Contents Foreword from the Chief Inspector of Adult Social Care Introduction Experts by Experience (ExE) Inspection Judgments and ratings Actions and recommendations Reporting Quality control and assurance Publication Request for rating review Enforcement and actions Focused inspection Evaluation Support...56 Appendix A: High Level inspection flowchart...57 Appendix B: High level post inspection flowchart...58 Appendix C: Expert by Experience inspection flowchart...59 Appendix D: Expert by Experience post inspection flowchart...60 Appendix E: Ratings request for a review at a glance process: ASC inspection handbook October 2014 v 2 00 Page 3

4 Foreword from the Chief Inspector of Adult Social Care Dear colleague Well here we are rolling out our new approach to inspecting adult social care services! More than a year s work of careful preparation and discussion has informed the development of our new approach. We started with the framework that the Care Quality Commission applies to all health and care services: The five key questions is a service safe? effective? caring? responsive to people s needs? And is it well-led? The ratings to judge whether a service is inadequate, requires improvement, is good or outstanding. But the detail of our methodology (including the key lines of enquiry, the evidence we will consider and the ratings characteristics) has been developed in collaboration with people who use services, carers, providers, commissioners, national partners and our staff. The external and internal co-production groups as well as the roundtable discussions and workshops, the outcome of consultation and two phases of testing have all helped to shape the final design of the approach set out in this Inspection Handbook. We have also considered what processes and tools we need to support inspectors so we can be confident that the judgements we make are robust, fair and consistent. The Inspection Handbook brings this all together it sets out how we will carry out our inspections, the questions we will ask, how we will arrive at a rating judgement and what enforcement action might look like. I know from the feedback we have had, that inspectors feel the new approach really helps us to get under the skin of the service and delivers a much more holistic view of how well the service is performing. This can be challenging as it can take longer to do, but if we are doing better inspections, we will be making better judgements, which can only help to improve adult social care services across the country. At the heart of this are the people using services, their families and carers asking the questions that matter to them, listening to their views, taking action to protect them when that is necessary and providing them with clear, reliable information. We must never forget that, which is why I always talk about the Mum Test is this a service that you would be happy for someone you love and care for to use? If it is, that s great and let s celebrate it. But if it is not, we have to do something about it. I hope you find the Inspection Handbook a useful tool to do just that and thank you for all your hard work and commitment to make a difference. Best wishes Andrea Andrea Sutcliffe, Chief Inspector of Adult Social Care October ASC inspection handbook October 2014 v 2 00 Page 4

5 Adult social care 1. Introduction This handbook describes our approach to our new style inspections of adult social care from October 2014.It applies to all adult social care inspections residential, community services and hospice services. Service types Containing S1. Residential social care Care home services with nursing; Care home services without nursing; Specialist colleges S2. Community based adult social care services Domiciliary care services; Extra Care housing services; Shared Lives schemes; Supported living services S3. Hospice services Hospice services; Hospice services at home including children s hospice services Types of inspection We have comprehensive and focused inspections. Comprehensive inspections take a good look at a service and award a rating. They are at least every two years subject to available resources. The following frequencies will apply: Services that are rated as outstanding will normally have a comprehensive inspection within two years of the last comprehensive inspection Services that are rated as good will normally have a comprehensive inspection within 18 months of the last comprehensive inspection Services that are rated as requires improvement will normally have a comprehensive inspection within 12 months of the last inspection Services that are rated as inadequate will normally have a comprehensive inspection within 6 months of the last inspection We also undertake a number of random inspections of good and outstanding services each year that are not due an inspection in accordance with the timescales above. And we carry out inspections in response to risk. These may be comprehensive or focused inspections. Focused inspections do not look at all five questions and may address specific breaches of the regulations or respond to specific concerns. Our inspections will usually be unannounced. In a few instances, where there are very good reasons, we may let the provider know we are coming. For example, we may contact small homes to check that people are home before setting off to inspect ASC inspection handbook October 2014 v 2 00 Page 5

6 Legislative background New regulations will come into force in April Until then we continue to use the existing regulations and our current enforcement policy. In the future, there will be new regulations. When we have these we will produce and publish provider guidance to help providers understand how they can meet them. As well as the provider guidance, we will also update our enforcement policy, which will help you understand how breaches are identified, reported and followed up. And we will provide training to support the guidance. Guidance on how to report on breaches of the legislation is in the report writing guidance on the intranet. Our new methods We have refined and improved our new methods and tools using feedback from our external consultation, internal and external co-production meetings, and inspections that tested the new approach. Our approach means that we focus on people s experience of care and support, using five key questions. Our focus is to look for what is good and to encourage improvement rather than looking for compliance with regulations. However, our approach also makes sure that we can take any necessary action where services are inadequate or need to improve. We have developed more tools to help us to understand the experience of people using services, such as the greater involvement of Experts by Experience and the use of questionnaires. However, the skills of inspection that you need and many of the processes you follow are similar to those we have used before October The five key questions To get to the heart of people s experiences of care and support, the focus of our inspections is on the quality and safety of services, based on the things that matter to people. We ask five key questions about the care service we are inspecting: Is it safe? Is it effective? Is it caring? Is it responsive to people s needs? Is it well-led? ASC inspection handbook October 2014 v 2 00 Page 6

7 For the regulation and inspection of health and social care services, we have defined these five key questions as follows: Safe Effective By safe, we mean that people are protected from abuse and avoidable harm. In adult social care, this means that people are supported to make choices and take risks and are protected from physical, psychological and emotional harm; abuse, discrimination and neglect. By effective, we mean that people s care, treatment and support achieves good outcomes, promotes a good quality of life and is based on the best available evidence. In adult social care, this means that people are supported to live their lives in the way that they choose, and experience the best possible health and quality of life outcomes. Caring By caring, we mean that staff involve and treat people with compassion, kindness, dignity and respect. In adult social care, this means that people, their families and carers experience care that is empowering, and provided by staff who treat people with dignity, respect and compassion. Responsive By responsive, we mean that services are organised so that they meet people s needs. In adult social care this means that people get the care they need, are listened to and have their rights and diverse circumstances respected. Well-led By well-led, we mean that the leadership, management and governance of the organisation assure the delivery of high-quality, person-centred care, supports learning and innovation, and promotes an open and fair culture. In adult social care, this means that management and leadership encourage and deliver an open, fair, transparent, supporting and challenging culture at all levels. 1.2 Key lines of enquiry Beneath each of the five key questions there are a series of key lines of enquiry (KLOEs). KLOEs are posed as questions to help you focus your inspection and consider what evidence you may want to gather to help you form a judgement about the quality of the service for each of the five key questions. There are three sets of KLOEs one each for residential services, community services and for hospice services. KLOEs ensure consistency of what we look at under each of the five questions and make sure we focus on those areas that matter most. This is vital to reach a credible, comparable and consistent rating across all the services we regulate ASC inspection handbook October 2014 v 2 00 Page 7

8 There are 21 KLOES in total: 16 of these are mandatory KLOEs that must be covered at every comprehensive inspection. There is one extra mandatory KLOE (responsive 3) for specialist colleges. As part of your planning for a comprehensive inspection you should consider whether you need to assess any of the 5 non-mandatory KLOEs. Your decision should be based on intelligence you have about the service taking into account areas of identified risk or areas of good practice. During an inspection you may also want to look at one or any of the non-mandatory KLOEs if you come across information that raises concern ASC inspection handbook October 2014 v 2 00 Page 8

9 KLOEs for residential services and community services Mandatory KLOEs are highlighted in yellow. PLEASE NOTE: E5 is a residential KLOE only. It does not apply to community services Safe S1 How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights? S2 How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected? S3 How does the service make sure that there are sufficient numbers of suitable staff to keep people safe and meet their needs? S4 How are people s medicines managed so that they receive them safely? S5 How well are people protected by the prevention and control of infection? Effective E1 How do people receive effective care, which is based on best practice, from staff who have the knowledge and skills they need to carry out their roles and responsibilities? E2 Is consent to care and treatment always sought in line with legislation and guidance? E3 How are people supported to have sufficient to eat, drink and maintain a balanced diet? E4 How are people supported to maintain good health, have access to healthcare services and receive ongoing healthcare support? E5 How are people s individual needs met by the adaptation, design and decoration of the service? Caring C1 How are positive caring relationships developed with people using the service? C2 How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support? C3 How is people s privacy and dignity respected and promoted? C4 How people are supported at the end of their life to have a comfortable, dignified and pain free death? Responsive R1 How do people receive personalised care that is responsive to their needs? R2 How does the service routinely listen and learn from people s experiences, concerns and complaints? Mandatory for specialist colleges only R3 How are people assured they will receive consistent co-ordinated, personcentred care when they use, or move between, different services? ASC inspection handbook October 2014 v 2 00 Page 9

10 Well-led W1 How does the service promote a positive culture that is person-centred, open, inclusive and empowering? W2 How does the service demonstrate good management and leadership? W3 How does the service deliver high quality care? W4 How does the service work in partnership with other agencies? ASC inspection handbook October 2014 v 2 00 Page 10

11 KLOEs for hospice services To be added in early October following sector consultation. If there are a different number of number of mandatory KLOEs for hospice services this will be made clear here ASC inspection handbook October 2014 v 2 00 Page 11

12 Prompts and sources of evidence To help you answer the five key questions, each KLOE has a set of prompts and potential sources of evidence. Prompts are questions that sit beneath each KLOE. Exploring the prompts as part of your inspection will help you to gather the evidence to judge the quality of the practice in the service. When considering the prompts and sources of evidence you must remember that the questions you ask and the sources you use must lead you to sufficient evidence to be able to answer each KLOE and make a robust judgement. The prompts and the sources of evidence are not an exhaustive list, or a checklist that you have to use. However, you must make sure you gather sufficient evidence to be able to reach a robust judgement. Consider the amount and depth of evidence required to answer the KLOE and the overall question. You may not need to cover every prompt for each KLOE to do this, or you may think of some additional prompts that would help you gather the evidence needed. The potential sources of evidence column describes ways in which you may be able to find the evidence for each KLOE. It suggests evidence that may help you plan your inspection, the questions you might want to ask people, what you may want to observe and the types of records you might want to review. More information about selecting KLOEs can be found in the planning section below. The KLOEs, prompts, sources of evidence and characteristics of rating levels have not been included in this handbook, but are available on the intranet here ASC inspection handbook October 2014 v 2 00 Page 12

13 2. Experts by Experience (ExE) This section outlines the key role that Experts by Experience (ExE) play in our inspections. It takes you through their involvement from planning to reporting but must be read alongside the detailed processes later in the handbook. ExE bring a richness and diversity to our inspection activities, along with a personal experience of using or caring for someone using services. By working with them, we are able to focus on the experience of people who use services and demonstrate how much we value this perspective in our inspections. ExE are part of the inspection team and must be proactively involved in the whole process. Initially ExE will be available for approximately 50% of adult social care inspections. Each region will be told the number available and you will have to identify the inspections where you need an ExE. As new arrangements come into place for ExE we expect this to increase. In the interim. you should use the following criteria when making your decision: Large services 50 people or more. Phone calls for medium and large domiciliary care agencies. Services where planning shows contradictions in evidence. Services where there are concerns that people s voices aren t heard in services. Services where people have communication difficulties which the ExE can better overcome or understand, or where the inspector judges that an ExE with similar experiences will give people more confidence to share their views of the service. Services where someone with experience and skills in communicating with people with complex needs is needed. For example, someone who uses Makaton. Services where there are outstanding compliance actions and we want to find out about improvements from the experiences of people using the service. Services where we want additional evidence from an ExE to help support the judgement. There are two flowcharts showing how you should work with an ExE in Appendices C and D below. 2.1 Planning The ExE will have a maximum of 10 hours for the inspection. This time will include all their activity: pre-inspection work, site visit or telephone calls, feedback and writing their report. To book an ExE you must complete the ExE request webform which is available on the intranet here. It is important that you give all the information asked for so the support organisation can best meet your needs when allocating an ExE. You should complete the webform six weeks before the inspection. If you need to cancel or reschedule an inspection you should contact the support organisation as soon as ASC inspection handbook October 2014 v 2 00 Page 13

14 you know you are making a change so that they can reallocate an ExE. Ideally you should ring them but if this is not possible please send an with RESCHEDULED INSPECTION or CANCELLED INSPECTION and the date in the subject line. The support organisation will contact you before they allocate an ExE to check that the details are correct and there are no last-minute changes. They will select an ExE based on your requirements and send you a profile of the ExE which will include details of their experience. If the allocated ExE does not have the relevant experience you should ring the support organisation to discuss. If you cannot resolve the matter with them then you should the involvement team at The support organisation trains their ExE so they know and understand their role and our inspection process. They make sure they are aware of our new approach. You must involve the ExE at the planning stage of your inspection. You should share with them the relevant pre-inspection information and planning tool and agree as much as possible which areas you want them to look at. Make sure they know what questions to ask and what you want them to look for during the visit and discuss how they should record their responses. They will be given a report template to complete. You can see a copy of the residential and community versions on the intranet here. Remind them that they need to include in their report the number of people they have spoken with, along with their role and that they should record direct quotes from people where they can. You will need these to make the evidence come alive in your report. If the ExE is going to have a support worker with them on the day, they must also be involved in your pre-inspection discussions. This is so they can help the ExE to understand the questions and what is expected of them during the inspection. If you are inspecting a supported living service or extra care housing where people live at one address, it is better to take an ExE with you on the visit instead of asking them to phone people. Remember that unless the supported living or extra care housing address is the actual location registered with us, you can only enter the premises on the invitation of the people living there. And you can only enter a Shared Lives carer s house with the agreement of both the carer and the person they are supporting. This is because we have no powers of entry and inspection where a service is provided in premises used wholly or mainly as a private dwelling Before the inspection ExE community services (including shared lives and hospice services at home) An ExE will usually support you by ringing people who use services to ask for their views. You should consider how many people you want to get feedback from and ask the ExE to support you to contact a representative sample. You may choose to call some of your selected sample yourself too. The ExE can make the calls to up to a maximum of 20 people over two days. You should select slightly more than your chosen sample to take account of those people who don t want to speak to an ExE ASC inspection handbook October 2014 v 2 00 Page 14

15 You should arrange to call the ExE before the inspection to brief them about the service. It helps them to have some background information. For domiciliary care services inspections it is useful to discuss ways of helping the people they are ringing to understand why they are ringing. For example, explaining the colour of the uniform the agency worker may wear, or referring to the morning person. This is because some people are cared for by more than one agency. If they are ringing people who use a Shared Lives scheme or Shared Live carers make sure they are familiar with the correct terminology and have read the Shared Lives supporting information which their support organisation has a copy of. You should tell the ExE the days you want the calls to be made. If you think it will add value to your inspection, you could ask an ExE, who lives near to the service, to go with you to the domiciliary care agency or shared lives scheme office. This would give the ExE the opportunity to talk to staff and any other relevant people who may visit the office. They could also ring people who use the service or their relatives from the office. If they do, they should find a private room to make the calls from and should not use the service s telephone Before the inspection residential services Before the inspection, you must discuss the practical arrangements for the visit. Consider transport arrangements, access to buildings, where and when you will meet on the day, the time the ExE has available, whether they need to bring their lunch and so on. When planning the day, you must make sure that the ExE has a break at least every four hours and that they are clear about their role and what they will be looking at on the day. Find out whether or not they will be available to take part in the feedback session at the end of the inspection. Some ExE have personal circumstances that mean they may not be able to, but wherever possible, you should include them in the feedback. If they stay for the feedback, they may not be able to be with you at the beginning of the site visit. You must negotiate this before the visit. 2.2 Site visits to residential services An ExE is a full member of the team and should be encouraged to be involved as much as they would like. While it is important for the ExE to talk to people who use the service it is not a role that is totally delegated to them. You will also need to speak with people who use the service, visitors and staff. ExE can be involved in a wide range of inspection activity, such as: Talking with people using the service. Observing care practice, mealtimes and activities. Reviewing the environment. Talking to staff, visitors or any other person that will help in understanding the quality of the service. Note: ExE are normally only permitted on-site with you (and their ID badge). ExE are advised that if they arrive without their ID badge they should not take ASC inspection handbook October 2014 v 2 00 Page 15

16 part in the inspection. They must not arrive before you do and must leave at the same time or before you. The exception to this is in a supported living or extra care housing setting where you may want an ExE to chair a group of people using services without you being there. The decision to do this will be at your discretion as the lead inspector. You must also remember that we have no powers of entry and inspection where a service is provided in premises used wholly or mainly as a private dwelling. So you could only hold a group there for inspection purposes with the agreement of the people who live there. The ExE should be part of the initial meeting with the registered person or most senior staff member on duty. Introduce them and explain the specific inspection activities they will be involved in. Through the day, the ExE should introduce themselves and explain their role as they meet people using the service, staff, and visitors. You and the ExE, along with other inspection team members, must make arrangements to meet at points throughout the day to share your findings and, if necessary, re-plan the activities that need to be undertaken for the rest of the day. This will also help you avoid duplicate activity. If at any point the ExE finds out information that really concerns them, they should report this to you immediately. Make sure you explore the issue thoroughly and sensitively with them. You should then collect your own first-hand evidence, especially if there is potential for enforcement or safeguarding action. ExE will record their findings in the site visit record which will be sent directly to them. At the end of the inspection you and the ExE must share your findings before preparing to give feedback to the registered manager or senior person on duty. If the ExE cannot be involved in the feedback session make sure you have all the information you need from them. Phone calls to people using community services There is an introductory script that support organisations provide to each ExE to use at the beginning of their phone calls. They should initially find out whether the person using the service wants to take part in the phone call. If they do not, the ExE must respect their wishes and apologise for disturbing them. They should also give them an option to ask us to ring a friend or relative. Phone calls can be made to people from the day of the 48-hour notice to the agency. This option allows the ExE time to share information with you that you may wish to follow up on your office visit. When they are making their calls, you should be available so they can contact you if there are any issues that arise from the telephone calls. If any real concerns are raised the ExE should report them to you or the support organisation immediately. When they have finished their calls you should ask the ExE for interim feedback before they send you their report. Ideally this should be before your visit to the office. Please also see section below, which gives more detail about the process for inspection of community services ASC inspection handbook October 2014 v 2 00 Page 16

17 2.3 After the inspection ExEs should send you their report as soon as possible after an inspection. Their reports should always be with you no more than five working days after the visit but you can ask them whether it would be possible for the report to be sent earlier than this. You should use their comments and quotes to in your report under relevant key question headings. Refer to the ExE in the report as a full part of the inspection team not that they accompanied you. See section (After the inspection involving the team) for more details ASC inspection handbook October 2014 v 2 00 Page 17

18 3. Inspection There is a full end-to-end process chart for inspection available on the intranet. 3.1 Planning and pre-site-visit activities You should record all the time you spend on each inspection on the Activity Recording Tool (ART) available on CRM. The guidance is available on the intranet. It is important we have information about inspection time to help us plan for the future and to be able to explain to providers about the fee structure. If you need any help using ART, please contact your Regional Operations Systems Support Officer regional (ROSSO). Planning our inspections is essential if we are to ensure that we are targeted. It will help you make sure you have used all the relevant information to identify what you need to look at and how you will do this Setting up the inspection in CRM For each inspection, you should initially set up an inspection record (prefix INS) process in CRM, and select the inspection type new approach. This is where you record key stages in your inspection process, store documents, send out correspondence, and record when previous non-compliance is met or if new breaches have been identified. The guidance on how to complete this is here Using the planning tool Planning your inspection activity is essential and you must keep a record of this in the planning tool. The planning tool allows you to consider the information and intelligence we have about a service and: order it under the five key questions consider what the information tells you and what activities will undertake to answer the five key questions consider who else you might want to take with you and what you want them to do. The planning tool template includes information about how to complete it. Once the CRM inspection process has been set up, you can begin to review the information we have received since the last inspection and start to complete an inspection planning tool for the type of service you are inspecting: Planning tool for inspectors Community Services Planning tool for inspectors Hospice services Planning tool for inspectors Residential Comment [GD1]: Link to be added when available ASC inspection handbook October 2014 v 2 00 Page 18

19 Reviewing information we have received In the first stage of planning, you will review and use information from, and received since, the last inspection. This includes: information from the last inspection CRM the pre-inspection information pack the Provider Information Return (PIR) the information sharing tool questionnaires. This enables you to complete the first section of the inspection planning tool. This section is for high-level summary only and is your audit trail of the information you have considered as part of the inspection. The Pre-inspection information pack To make sure you have robust and detailed information before your inspection the Intelligence Directorate has developed a Pre-inspection information pack. This pack includes detail from CRM, the Provider Information Return (PIR), and questionnaires (community services only). PIR and questionnaire data will only be populated if the provider has completed the information within the deadlines we provided. Anything that is returned late is unlikely to feed into the information pack as there is a cut off period when the data needs to be locked down to process and upload into the information pack. To help you plan and identify areas to focus on in the inspection, the pre-inspection information pack document provides you with data, analysed information and the provider s own assessment of how they meet the five key questions and how they plan to improve their service. The information is presented under the five key question headings. Instructions on how to access the dashboard and use the inspection information pack can be found in this guidance document and online presentation. Information from PIRs and questionnaires have to be received within prescribed deadlines to make sure the data makes its way into the information packs. More information about the process and timelines for gathering this information can be found here. You will receive the information pack at least two weeks before the inspection date so that you can use it for your planning. Save the pack to the inspection process in CRM as an audit trail. There is a section in the inspection planning tool for you to provide a high-level summary of the information in the PIR. You can see blank PIRs on the ASC intranet page. The PIR The PIR is a form that asks the provider to give some key information about their service, how it is meeting the five questions, and what improvements they plan to ASC inspection handbook October 2014 v 2 00 Page 19

20 make. We are moving towards sending out the PIR annually. Currently NCSC send a link to a PIR for each location to complete in advance of your inspection. For quarters 3 and 4 (Q3 and Q4) in 2014/2015 we will send the PIR out in batches. The regulations state that providers must give us the information we are asking for in the PIR. You should not take the information contained in the PIR as evidence in its own right, as it is a data set and self-declaration completed by the provider. However, it will give you important information to help you decide what needs to be tested during an inspection and whether you need to inspect any of the remaining KLOEs. When a PIR or spreadsheet is not submitted PIR forms include sections for statistics and quality information a good provider should have readily available under the internal monitoring and quality assurance arrangements required by regulation 10. We also use regulation 10 to require that the provider sends us the information requested in the PIR (as a report under Regulation 10(3)). We cannot insist that they use the PIR form but we do need to know that they are gathering the information they need to understand the quality and safety of their service. Where a PIR has not been submitted you should contact the provider as soon as possible before the planned site visit. Tell them that: We have not received a PIR from them. That providers were sent an (or letter) telling them about the PIR, and how to find their PIR report template on line and how to contact us for support if they were having difficulty with the form. That providers were told that filling in and submitting a report was required under 10(3), and that they could use our PIR form to do so. That the plans set out by CQC in A Fresh Start to use information to plan a proportionate approach to regulation and to target our resources in the best way possible received widespread, cross sector support. The purpose of the PIR is to help CQC inspectors plan their inspections of ASC locations and will also assist the service by making sure information is provided in advance and will reduce demands on managers during the day. They are in breach of regulation 10(3), which is an important regulation and a key contributor to our evaluation of their performance in the Well Led key question It will therefore be very difficult to award any better than a rating of Requires Improvement for Well Led, which may affect their overall location rating. When we have not received a PIR or spreadsheet, and the provider has not supplied the requested information in another format we will not normally award better than Requires Improvement when we are making our judgements for the well-led question. This is because we would expect a good provider to have the information we ask for to hand as they would be using it for planning and delivering a good, safe service. However, you can use your judgement when you think there are exceptional circumstances that suggest a better rating is appropriate for example, if the provider gives a clear and firm commitment to send us a PIR and or spreadsheet in future ASC inspection handbook October 2014 v 2 00 Page 20

21 If you do not receive a PIR or spreadsheet you need to report this in the inspection report. We will not follow enforcement processes in these circumstances, but rely on the levers provided by the ratings process to encourage providers to submit PIRs and requested information for questionnaires in the future. The information sharing tool When you are inspecting a service you have not visited before, you should send the tool to the previous inspector/s or manager because they may have some information about the service that is not recorded on CRM and which will inform the inspection. This tool is available on the ASC intranet page. Save copies of completed information sharing tools as an attachment to the inspection process on CRM. Questionnaires NCSC send a spreadsheet to providers of community services asking them to give us contact details of: People who use their service. Care staff, their equivalent in hospice services, shared lives workers and shared lives carers. Community health and social care professionals. The letter asks the provider to complete the spreadsheet and return it within a specified timeframe. Not everyone will have the skills to fill in a questionnaire, speak on the telephone or talk to us when we are in the service so we ask managers to identify people who are able to: Fill in a questionnaire. Respond to a telephone interview. Receive a home visit. In services that are caring for people who may be at the end of their life, for example domiciliary care agencies and hospice services at home, we must be mindful that some people may not be in a position to share their views with us. We ask providers to only include the contact details of people who it is appropriate to send questionnaires to, or who have given their consent. Where we know that questionnaires are being sent to children or young people they will be marked for the attention of a parent/guardian. The spreadsheet is password protected. NCSC will remove the password for community services before saving the spreadsheet in a restricted access area of CRM. Once the contact list spreadsheet has been used to send out questionnaires, NCSC notify you by and tell you where it is stored. The spreadsheet will highlight who the questionnaires have been sent to. We will hold the data for six months and then destroy it. This approach ensures we provide a secure process for receiving information and that we treat people s data appropriately. People who use community services are sent paper questionnaires to fill in, and a letter for them to give to a relative or friend inviting them to fill in an online ASC inspection handbook October 2014 v 2 00 Page 21

22 questionnaire. People can ask NCSC to send them questionnaires in an alternative format. Information from questionnaires is uploaded into the inspection pack. Late questionnaires are scanned and ed to you by NCSC. You should save these questionnaires in the inspection record on CRM. If the questionnaire is received before the date of the site visit this can be included as part of the inspection. If the questionnaire is received after the site visit then the information is used for ongoing monitoring purposes. Any information of concern is treated in line with CQC policy. The questionnaire end to end process is available on the intranet. For residential services, NCSC asks the provider to complete a spreadsheet with the details of community professionals involved with the service. The spreadsheets are password protected when returned by the provider. On receipt, NCSC will save the spreadsheet in a restricted access area of CRM. They will send you an to tell you where it is stored. You should then ring the provider to ask for the password so you can access the information and contact professionals for their views Planning which KLOEs to look at To help you with your planning we have pre-populated the planning tool with the KLOEs. The mandatory KLOEs are highlighted in yellow. Your review of the pre-inspection information and intelligence will inform you of areas of increased risk and/or where good practice has been identified and you want to explore further. This will help you identify any of the remaining KLOEs that should be drawn into your inspection. During the inspection, your findings may indicate that you need to change or add to the KLOEs you have selected. You must keep a clear audit trail of these changes and record the reasons why you made the change on the planning tool. In the planning tool there is a free text box under each of the KLOEs and things to consider. You can use it to provide as much or as little detail as you think you need, but bear in mind that the final document needs to be in sufficient detail to provide an audit trail of the information you have considered and your plan to test it out. For example, it would help your audit trail if you inserted existing evidence, information from the PIR and any concerns received from questionnaires that need to be followed up or corroborated. Your plan should say what evidence you need to gather, who you need to speak with and the methods you plan to use Other planning considerations Record in the planning tool the people that you or another member of the team plan to speak with, the specific areas you want to get their views on, and the records you will want to see during the site visit. Choose a representative sample of people to speak to. The planning tool should say what you want members of the team to do, for example, what to observe, who you want them to talk to and the type of questions you want them to ask. Remind team members that they are looking for positives and not focusing only on breaches of regulations. Wherever possible, the information in ASC inspection handbook October 2014 v 2 00 Page 22

23 the planning tool should be given to each team member and discussed with them before the visit. In addition, each member of the team (including the ExE) should be given a copy of the sections of the planning tool relevant to them. There is also a section at the end of the tool that allows you to set out an overall briefing for the members of the team. You can cut and paste specific areas of responsibility for each team member from the tables under the KLOE. Remind team members that they are looking for positives and not focusing on breaches of regulations. For both residential and community services inspections plan to speak directly to people who use services yourself as well as the ExE and/or specialist advisor speaking to them. For community services this could be through phone calls or home visits Other pre-inspection activity For both residential and community services you should contact relevant stakeholders for feedback and record this on the planning tool. For example, local groups including Healthwatch, local authorities and health care professionals. For shared lives schemes, if the shared lives panel chairs details are available then you should contact them for views about the scheme and any recommendations the panel has made. You do not need to record this as an activity or enquiry in CRM but you should summarise the feedback received in the feedback section of the inspection planning tool Mental Capacity Act 2005 and Deprivation of Liberty Safeguards Where appropriate, plan how you will assess the provider s compliance with the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The MCA sets out what must be done to make sure that the human rights of people who may lack mental capacity to make decisions are protected, including when balancing autonomy and protection in relation to consent or refusal of care or treatment. This includes decisions about depriving people of their liberty so that they get the care and treatment they need where there is no less restrictive way of achieving this. If the location is a care home, CQC is required by law to monitor the operation of the DoLS, and to report on what we find. The definition of a care home can be read in our DoLS guidance, which you can read at this link. Providers of care homes are required to submit applications to a Supervisory Body for authority to do so. For any other provider, applications must be made to the Court of Protection. During your inspection you must consider whether people s liberty is being restricted. If you find evidence that it is, you need to identify and report on whether related assessments and decisions had been properly taken and reviewed using the assessment and best interests decision-making approaches described in the Code of practice to the Mental Capacity Act. You should also consider whether any accumulations of restrictions being experienced by anyone amount to unauthorised deprivation of their liberty. A recent ASC inspection handbook October 2014 v 2 00 Page 23

24 Supreme Court judgement has widened the scope of restrictions that may amount to deprivation of liberty. You can read more about this here. You should check to see if the provider is complying with conditions applied to the authorisation or Court Order. You must assess and report on whether the provider has properly trained and prepared their staff in understanding the requirements of the Mental Capacity Act in general, and (where relevant) the specific requirements of the DoLS. You can read more about these requirements in the separate guidance documents on the Act and the DoLS here Complaints We have committed to strengthening our approach to assessing complaints and concerns during our inspections. How the service routinely listens and learns from people s experiences, concerns and complaints is a mandatory KLOE. You need to make sure you gather sufficient evidence to be able to answer this. The inspection information pack will provide you with information about complaints received from or about the service. When you are in the service, your discussions with people should cover their understanding of the complaints process, their experiences of raising concerns or complaint and their satisfaction with the outcome of any complaint made. You should explore whether complaints are encouraged, taken seriously, investigated thoroughly and if the outcome is shared with the person who made the complaint. There is further information in the KLOE (responsive 3) to help you assess how complaints are managed. When you inspect community services make sure you look at any complaints raised by people not included in the spreadsheet address list returned by the provider Community services talking to people who use the service 48-hour notice You should telephone the registered manager 48 hours before the day of your site visit to domiciliary care agencies and shared lives schemes to notify them of your visit. This is to ensure that the manager will be in the office and, if they are usually on the rota to work with clients, that they can arrange alternative cover for their visits. For supported living schemes and extra care housing you should use your judgement about whether or not you should give this notice. This is because extra care housing schemes vary in their arrangements. Your decision should be based on: The location of the scheme manager The location of the housing (one site or more widely spread) The amount of care and support provided. So, for example, if the housing is all on one site and there is a manager available there as well you would not need to give 48-hour notice. Before you phone the service review the address spreadsheet stored in CRM to decide which people to contact for a call or visit ASC inspection handbook October 2014 v 2 00 Page 24

25 When we send out questionnaires we include a sentence that tells people that an inspector or ExE may ring them in the next few weeks or months. We also tell them that if they do not want to speak to us they can contact us to say that they do not want to take part in the process. We also give them an option to ask us to ring a friend or relative. For those who have not had questionnaires, you should identify a maximum of 25 people to telephone and then inform NCSC who you have selected. You can do this by highlighting on the spreadsheet the 25 people you want to inform about the telephone call and then ing the spreadsheet to NCSC at In the subject line type LOCATION ID; LOCATION NAME; CONTACT REQUEST; DATE OF INSPECTION. NCSC will write to these people approximately seven days before we give the service 48-hour notice, to tell them we will be inspecting the service they use. When we call them, if the person using the service does not want to take part in the process, we respect their wishes and apologise for disturbing them. We also give them an option to ask us to ring a friend or relative. This approach allows the ExE to make phone calls from the day of the 48-hour notice. If people are unavailable on the first two days of calls or phone calls are made after the site visit, issues may be raised that you need to follow up on. This may mean that you need to carry out a further visit to the service. For services other than Shared Lives schemes, we expect that inspectors will carry out home visits to help gather sufficient and robust evidence about the care and support provided. You do not need to be accompanied by the registered manager of the service being inspected but ensure you read the lone working policy and the home visits guidance before your visits. For shared lives schemes, home visits are not always the best place to speak to some people who use the schemes. This is because they may associate a visit from an official as being related to a move. Instead, you could visit people who use shared lives schemes at the day service they attend, by joining shared lives carers and workers meetings or through inviting people into the Shared Lives office for a discussion. You can ask about details of these, or other opportunities to meet people that use services, from the manager of the Shared Lives scheme when you make your 48-hour notification call. If you do visit people at home, you should only do so with their permission and that of the Shared Lives carer. You may begin to arrange to meet with people who use the scheme and Shared Lives carers during the 48-hour notice call or during the site visit. You should involve the manager or Shared Lives workers in making these arrangements in consultation with people who use the scheme and the Shared Lives carers. Offer the person who uses the shared lives scheme the opportunity to have their shared lives carer present when you speak with them. You should not routinely ask to see records in people s homes. If a person using a scheme offers to show you their service user plan during a visit then you should look at it. Otherwise, you should look at records in the Shared lives scheme office Additional resources ASC inspection handbook October 2014 v 2 00 Page 25

26 Usually, a single inspector and an ExE will be sufficient for most of our inspections in adult social care. However, to ensure we gather sufficient and robust evidence to support a judgement on whether a service is safe, responsive, caring, effective and well-led, there will be certain circumstances or situations where a planned inspection would be strengthened by any or all of the following: A larger inspection team. Having members with specific skills More time being spent in the service. Criteria that may indicate the need for any of the above include the size or complexity of a service, increased levels of risk, or services where we are already taking enforcement action or where this is possible. As you plan your inspections, the Guidance on how to use resources for inspection will help you work out whether you need more time or specific skills. For hospice services, you should always include in the inspection team a pharmacist inspector and a specialist advisor with appropriate skills, or someone from within CQC who knows about hospice care. If, after using this guidance, your planning indicates that you need additional resources, you must record your evidence and rationale for this in your planning tool and share it with your inspection manager. They will need to agree and sign off these additional resources. Bank inspectors are available as second inspectors and have been trained in our new approach. If, after reading the resource guidance, you have identified in your planning that you need a second inspector you should, with your manager s agreement, your regional resource officer and make your request. Specialist advisors If, after reading the resource guidance, you have identified in your planning that you need a specialist adviser for the inspection, you should, with your manager s agreement, use the webform on the intranet to make your request. NCSC will book the advisor and let you know who it is. Also use the webform to advise about cancellations or rescheduled inspections. Specialist advisors have been briefed about our new approach. You can read their briefing document here. They also have a report template to use to draft their report. It is very similar to the template that the ExE use. You can see a copy here. You should brief the specialist advisor before the inspection, making clear the areas that you want them to use their expertise in and what you specifically want them to do. Provide them with relevant pre-inspection information and sections of the planning tool. Make sure you also address practical issues, such as accessibility to the service and whether or not they need to take their lunch. If you do not need a specialist advisor for a full day, be clear with them about this and discuss with them how they should best use the time they have ASC inspection handbook October 2014 v 2 00 Page 26

27 You must also ask your manager to complete the warrant statement for the specialist advisor so that you give it to them when they arrive at the service. Remember to ask them to give it back to you before they leave. Introduce them when they arrive at the inspection and explain to the manager their focus during the inspection. Make sure that you checkout their progress at regular intervals through the day. They will record their findings in the site visit record which will be sent directly to them. When they have completed their given tasks they can stay on site to write their report if this is appropriate, or leave the inspection. If they leave, they must feedback to you before they go and must make time to write their report afterwards. Remind them that ideally you want the report in two working days of the inspection. If the specialist advisor is still on site at the end of the visit, you can either give them the opportunity to provide feedback about their findings or present it on their behalf. Make clear to the specialist advisor that we give headline information at the feedback and do not indicate a rating. Pharmacist inspectors If, after reading the resource guidance, your planning identifies that you need a pharmacist inspector for the inspection, you should use the pharmacist request form available on the medicines resources page of the intranet. You should work with the pharmacist in the same way that you work with the specialist advisor with regard to: Pre-inspection information and setting of clear tasks Introduction when they arrive on site Site record sheets Regular checkpoint meetings during the day Headline feedback before they leave There may be occasions when it is not possible to provide a pharmacist inspector to support the site visit. If so, a pharmacist inspector may offer support before the site visit to help the lead inspector with the inspection planning, or provide remote support for the inspection team on the day of the visit to help interpret evidence or offer guidance if concerns are identified. There may also be occasions where the medicines management team identify that they have additional pharmacist capacity. In these circumstances a pharmacist inspector may contact the lead inspector for a service and ask to be included in the inspection team. This will give pharmacist inspectors the opportunity to be involved in inspections of services other than those where concerns around the safe management of medicines have already been identified. Experts by Experience See section 2 above for information about involving an ExE in an inspection Interpreters In some circumstances, you might need an interpreter, although this may not become apparent until you receive the inspection information pack or speak to other ASC inspection handbook October 2014 v 2 00 Page 27

28 stakeholders. Make sure as part of your planning that you consider the need for an interpreter. It is fundamental to our new approach that you talk to people who use services and sometimes the only way to do this is through an interpreter. If you need an interpreter contact, the Accessible Communications team for help and advice. To make sure you get the support you need for the inspection, you should ask for these resources as soon as possible, as the booking process will often take some time ASC inspection handbook October 2014 v 2 00 Page 28

29 3.2 Site visit The start and the focus of the visit Introductory session When you arrive at the service, you should speak to the registered person or senior staff member on duty. If an ExE or specialist advisor accompanies you, you must introduce them as part of the inspection team. If this is the first time that we have inspected the service using our new methodology you should explain to the registered person, or most senior staff member, that our approach to inspections has changed and that you will not be looking for compliance as you did in the previous methodology. Tell them you will be looking for good as the starting point of the inspection. When you first introduce yourself and the team on the day of the site visit, you could consider asking the following questions as a way of starting the inspection: What evidence can you show me that you are providing a good service? What has been your greatest achievement at the service? What is the biggest challenge you have at the moment? What are your plans for developing the service? How do you gather, and use, the views of people that use your service? These questions can stimulate and direct the first conversation, and start the inspection in a way that shows we are looking for good and interested in encouraging improvement. During the inspection, you can investigate the responses they have given, and use them to inform areas that you look at or questions that you may ask people who use the service. However, you should ensure that you do not normally spend more than 15 minutes in the office at the start of the inspection. It is important to get out and see what is happening in the service. This is a fundamental change in the way inspections are undertaken, and is a tangible way in which we have changed from a compliance model of regulation to a framework that encourages improvement. The language used, and attitude adopted are vital in ensuring that providers understand our change in approach. The decision tree diagram in section 4.1 below gives a more graphical explanation of what this change means in practical terms. You should also tell the senior person on duty that the emphasis of the inspection is on understanding the experience of people who use the service, and so you will focus on speaking with them and those people important to them. In addition, you will observe care practice and how staff interact with people who use the service. You could refer them to the Provider Handbook for their sector, which is available on our website, and tell them that this explains the changes. Comment [CA2]: Link to be added. Not available yet. You should explain what the five questions are and how we use key lines of enquiry to inform our inspections. Tell them about mandatory KLOEs and, if you are going to inspect any of the non-mandatory KLOEs, which ones you are going to include ASC inspection handbook October 2014 v 2 00 Page 29

30 It may help to give the manager or senior person a copy of the key lines of enquiry you will be inspecting and a list of any records that you want to see. This will give them an opportunity to get the records for you and to think about any other evidence that would show how they provide good or outstanding care. Also, explain that you will be inspecting against the current regulations and how you will report on all of the findings of your inspection. If you are following up on any previous areas of non-compliance, you will need to explain how you will address these in your final report [see report writing guidance]. It may be helpful to share the outline of your visit plan with the senior person on duty as it includes details about the proposed length of the inspection, who you plan to speak with and documents you plan to review as part of the inspection. You should also tell them that you will give headline feedback about what was found during the inspection. Site visit record The site visit record is a new tool to record your evidence on when you are on site. It will provide a consistent way to record evidence. You must use this tool to record your evidence during a visit. Our intelligence directorate are currently exploring how we might develop a way of doing this electronically in the future. There are two parts to the site visit record. The first part to record your notes on and the other to record the feedback that you will give the provider at the end of the site visit. The record has been developed to be simple, easy to use and to complement the new inspection methodology. The record allows you to write the evidence chronologically, and you do not have to move between sections to write your evidence. The record is a one page word document so you will need to print off enough pages for the inspection you are planning. You should also print pages for the ExE and specialist advisor and share them with them at the beginning of the inspection. Alternatively, you could double side the record when you are printing and bind the pages together to form notebooks for each person. On the record there are columns for you to write next to the evidence which key question and KLOE you think is most relevant to the evidence you are recording. You can also record whether you think the evidence is positive or negative. You do not have to do this at the time of writing the evidence but it might be helpful for you to do it before the end of the visit. This will give you: some assurance that you have enough evidence, and have covered all the questions and KLOEs that you planned to look a way of deciding what you want to draw into your feedback to the provider a head start on your report writing as you will have begun to order your evidence. At the end of your notes you must record that you are satisfied you have collected enough evidence to reach a robust judgement about each of the KLOEs you have inspected ASC inspection handbook October 2014 v 2 00 Page 30

31 The feedback part of the record has separate sections for the five key questions so that you can review the evidence you have gathered and organise the key points you want to feedback to the manager or senior person. During the visit Use your plan and the KLOEs to direct and inform what you look at. This will help you gather your evidence and link it to the five key questions. As you review and reflect on the evidence you have gathered, you should also consider whether the requirements of the law are being met. It is important that you are visible and available to people who use the service, staff and visitors. You should not base yourself in an office. Reviewing records is an important part of the inspection but, whenever possible, it is best to do this in a communal area so you can observe practice at the same time. However, you must maintain confidentiality when you are looking at personal information. As lead inspector, it is important to check your plan during the day to make sure you are covering each of the relevant areas. If there is an inspection team then it is important to have brief, regular meetings during the visit to take stock, review and reallocate tasks as necessary. If the inspection team is large and it is difficult to coordinate people s time so that they can all meet, then you should make sure you coordinate by checking out progress individually with people. This is important to make sure that you are in a strong position to oversee and direct inspection activity to get the best out of the team and to ensure that information is being shared appropriately. You will need to plan time in for this activity Gathering evidence Gathering evidence about how the service promotes equality, diversity and human rights (EDHR) is a vital area of the inspection activity. EDHR has been threaded through the KLOE and characteristics of ratings so you should record your evidence under the most relevant question. There is more information about EDHR, our thinking and the principles underpinning our work at the following link. There are various methods for gathering evidence during the inspection. These include observation, the Short Observational Framework for Inspection (SOFI2), interviews, informal group discussion, inspecting records and so on. You may find it helpful to gather and record your evidence under each key question, as this will help with consistency when you come to write your report. Remember to gather evidence of good practice, as well as making sure that you corroborate evidence sufficiently where you identify potential breaches of the regulations. Where you find good practice, consider whether there is evidence of outstanding practice. Recording evidence You must accurately record all the evidence you gather in the site visit record. This includes information that people tell you about the care provided as well as relevant evidence from any records or policies and procedures you consider it is necessary to read. Make sure you record dates, times, people you spoke with and their role if they are not the person receiving care ASC inspection handbook October 2014 v 2 00 Page 31

32 When talking to people who use the service you should tell them who you are, what you are doing and how you may use the information they are giving to you. You should also ask if they mind if you make a note of their name and what they say. (ExE and SPAs can add that this is so they can share the information with the inspector). If you need to record a person s full name (and if they have not objected to you making notes) then do so. If you do not need to record a person s full name, then just collect a first name and surname initial or just initials as this provides a limited protection to people s privacy. You should ensure that whatever you record is good enough for the purposes of the inspection. It is a question of judgment whether you need to record a person s full name. Some examples of cases where a full name is likely to be needed are; where a person shares information of significant concern with you; where the person gives you information that you are likely to want to crossreference or check later; where you anticipate that the information may be challenged or disputed; where the information is clear evidence of a breach of regulations. In less clear cut cases, initials will usually be adequate. For routine and uncontentious information, for example, general comments about the service, such as the food is always nice you won t need to make any note of the person s name or initials. During your visit, if you have concerns about the safety of people using the service you must follow CQC s safeguarding procedure. Before you close the visit, you should refer to the KLOEs and prompts. You must make sure that you have enough evidence to answer the five questions and make a rating. You should also make sure that you have robustly corroborated the evidence. This is particularly important if there are breaches of the regulations that you intend to tell the provider to take action about or if you are going to take enforcement action. In this case, you should make sure that you have enough evidence for each regulation that you intend to require action under Gathering the views of people who use services and others We put people who use services at the centre of our inspection process to ensure we focus on what matters to them. You must gather the views and experiences of people who use services in all inspection activity, record it and use it in your judgements. Likewise, the views of their relatives, friends and advocates are important. In a residential setting, talk to as many visitors as you can. Volunteers at the service are another good source of evidence and, if present, you should speak with them about the care provided and their involvement in the service (see below). There is an introduction to the tools you can use, and links to them, in the involvement section of the intranet. Talking to children and young people It is important that we establish the views of children and young people using the services we inspect and ensure that we act in accordance with their wishes and ASC inspection handbook October 2014 v 2 00 Page 32

33 decisions. This is more clear cut for those over 18, but we should assume that year olds are able to make their own decisions unless there is reason not to. Those under 16 may also be able to make decisions about their care and treatment. If a child of 16 or 17 is not competent to make a particular decision, then a person with parental responsibility can make that decision for them, although the child should still be involved as much as possible. For further information about consent to talk to a child, see the Consent, recording and retention of evidence guidance and the CPI Code of Practice. Remember that it is equally important that we also listen to and capture the views of parents/family/carers or those with parental responsibility. The Mental Capacity Act and children The Mental Capacity Act does not generally apply to people under the age of 16. For further details, see chapter 12 of the Mental Capacity Act Code of Practice. The Deprivation of Liberty Safeguards only relate to people aged 18 or over. If the issue of depriving a person under 18 of their liberty arises, other safeguards must be considered, such as the existing powers of the court, particularly those under section 25 of the Children Act 1989, or use of the Mental Health Act When inspecting services, such as services for people with a learning disability, which are used by young people under 18 as well as those over 18, you must take the above into account Gathering the views of staff and others During your visit talk to relevant professionals, managers or staff and volunteers, either in person or by phone. To help with this, see the guidance on semi-structured interviews. When talking to staff, do not take them away from their work for too long. Approximately 15 minutes should be sufficient to gather the information you need. However, there may be occasions when it will take longer because of the nature of the discussion for example, if a staff member is being reticent about telling you something about the service which could be important. You may find it helpful to structure your questioning around the KLOEs and sources of evidence for each key question area. Remember to follow up on issues identified against each key question. Consider checking on: Staff knowledge. Training provided. Documented guidance. Supervision. Feedback from people using the service and/or their carers. Incidents. Manager awareness ASC inspection handbook October 2014 v 2 00 Page 33

34 If the service involves volunteers in their work, you should also consider checking: their awareness of what to do in terms of safeguarding, whistleblowing and feeding back any concerns that the managers, staff and the volunteers themselves are clear about their role in care, and that this is distinct from paid staff how they are recruited and supported feedback from people who use the service and/or their carers. There are further examples in the potential sources of evidence column in the KLOEs Other inspection methods/information gathering Make sure you use a range of inspection methods as part of the inspection. These include review of records, pathway tracking, direct observation, and may include the use of the Short Observational Framework for Inspection (SOFI 2). SOFI 2 SOFI 2 is a tool to help you assess the care of people who are unable to tell you verbally about the care they receive. Unless there is a good reason not to, you are expected to use SOFI 2 whenever you inspect services used by people who are unable to verbally communicate with you because they have dementia, learning disabilities or other cognitive impairments. SOFI 2 is a useful tool for corroborating, or not, what people have told us. You should also consider using SOFI 2 in all your inspections, especially if there are people using the service who you judge may not be able to speak out for reasons other than those identified in the paragraph above. SOFI 2 helps you collect structured, defensible information through observation of one to five people for a flexible period, and it offers a means to analyse the collected information. Using SOFI 2 fully and recording all coding frames provides strong evidence to base judgements on and to feed back to providers. SOFI 2 documents are available here. You must have completed SOFI 2 training before you use it. Inspecting at mealtimes Engagement at meal times is a positive thing for Inspection teams. It is a good opportunity to get insight into the interactions between residents and between staff and residents. There are different ways to get this insight, and it will be for each inspection team to make a judgement about the most appropriate option for the specific home they are inspecting, taking into account the likely impact on the home and service. You can get the insight by either: - you, the ExE or SPA eating the meal, and sitting with residents to experience the meal with them, or - by observing the meal time through SOFI ASC inspection handbook October 2014 v 2 00 Page 34

35 There are advantages and disadvantages to each, and inspection teams will need to decide which is best on the day. Eating a meal with residents gives very good direct experience and an opportunity for a relaxed discussion with residents, but the experience is limited to that particular table and not all the residents. Carrying out a SOFI allows for an opportunity to observe a whole mealtime and not restrict the observations to a single table. If the inspection team judge that it is appropriate to share a meal with residents, the person who eats the meal should offer payment for it. If payment is refused by the home, a small charitable donation should be made in its place. Payment for such meals will not be reimbursed through the expenses system. Individuals should eat what has been prepared and not be too particular about their meal choice (aside from any special dietary requirements) Closing the visit Record the key areas to be included in the feedback session on the site visit record. You should give your feedback to the senior person or people at the location. You will only be able to give feedback about the day and your findings so far. If possible, the ExE should be part of the feedback, but you should lead it. Neither you, nor the other members of the inspection team, should give any indication about what the rating might be or about any enforcement action that may be taken in relation to breaches. This is because you need time to take a considered view on the evidence that has been gathered during the inspection before coming to a decision, taking into account the management review process where that is relevant. Explain that: You are unable to tell them what their ratings are at this point as you need to consider all of the available evidence and, where relevant, await reports from specialist advisors and Experts by Experience. You will be rating the service at both key question and overall location levels, and that the ratings will be included in their draft report That ratings will be based on our evidence about the service, and should they have concerns about the ratings we award them, they will have the opportunity to question this during the factual accuracy process. The accompanying their final report will explain under what the circumstances and how they can request a review of their ratings. The process is also described in the Provider Handbook that is available on the CQC website. If you have concerns about the service, briefly outline the possible outcomes. If you consider that these concerns need to be addressed immediately then make this clear. Allow the senior person time to respond and ask questions make a note of their responses in your notes. The feedback session should be a two-way discussion. You should give the manager or senior person the opportunity to feedback to you their experience of the inspection ASC inspection handbook October 2014 v 2 00 Page 35

36 3.2.7 After the inspection involving the team If an ExE or specialist adviser is involved in the inspection they should ideally send you their report within two working days of the inspection and if not, no later than five working days. Use the evidence they provide as you draft your report and speak to them before you send them the draft, so that they can feed into the judgementmaking process. You should share your thoughts about the rating, referring to the evidence and, if possible, together reach agreement. If agreement cannot be reached, then it is your judgement as the lead inspector that is final. them an editable version of the draft report so that they can check the factual accuracy of how you used their findings. You should do this before you submit your report for peer review. The ExE and specialist adviser are encouraged to respond in two working days but have a maximum of five to review the factual accuracy of their contribution and make changes to the text. When the report is finalised you must tell each of the inspection team members so they can securely destroy their notes. The exception to this is if you need the ExE and/or SPA notes because there is a request for a rating review or we are taking enforcement action and the first hand evidence in their notes is vital. In these instances you must ask the ExE and/or SPA to send the notes by secure to you for safe storage ASC inspection handbook October 2014 v 2 00 Page 36

37 4. Judgments and ratings 4.1 Making a judgement You must use the Characteristics of each rating level to help you decide the appropriate rating for each of the five key questions. It is important that you use them to ensure that our ratings are consistent and reliable. There is a different set of characteristics for residential, community and hospice services, and they are available at this link. The five key questions ask whether services are: safe, effective, caring, responsive and well-led. Ratings are reported on a four-point scale: Rating Outstanding Good Requires improvement Inadequate The sections describing the characteristic of good for each key question have the most detail. This should help you to inspect for good. The remaining three sections (outstanding, requires improvement and inadequate) build on this description and describe how the characteristics differ from the description of good. If you find that a service is good under a question, for example safe, you should then go on to check whether you have sufficient evidence to show that it is outstanding. If a service is not good, you will need to review your evidence to judge whether it requires improvement or is inadequate. The characteristics are not a checklist and are not exhaustive. While they link to the prompts in the key lines of enquiry, they are not meant to map across exactly. They are written to give you a picture of a service in respect of the five key questions. You will need to make a professional judgement, based on the history of the service and the evidence you have gathered. A service does not have to meet every area covered in the characteristics to fit in that rating section. You may also find that some of the characteristics may not always be appropriate for different types of services. You will need to take a proportionate approach when a service sits somewhere between two rating levels. You should consider the size and type of the service, whether you have enough evidence, the outcomes for people and the severity of any breaches of regulations. You may need to speak to your line manager to get a second opinion or carry out a management review ASC inspection handbook October 2014 v 2 00 Page 37

38 We need to be as consistent as we possibly can so that our ratings are reliable and provide accurate information. This will also help reduce the numbers of requests for review. As you consider your evidence following an inspection you may develop a sense of what the rating for a particular question could be. However, you must make sure your rating decisions for each of the five key questions are determined by assessing your evidence against the characteristics. When you make your judgement for each of the five key questions, you must use the information you have gathered during the visit what you saw, felt and heard on the day. Assessment of pre-inspection information must be undertaken appropriately, consistently and be balanced against the findings of the visit. As you did with the inspection process, you make your judgements by first looking at the level of good. The decision process has been set out in a decision tree below. Is it good? (using the KLOEs and characteristics of good) Yes No Can the provider demonstrate that the service is outstanding? (using the characteristics of outstanding) Is the impact on quality significant or are concerns widespread? (looking at the concerns and using the characteristics of inadequate) Yes No No Yes Outstanding Good Requires improvement Inadequate 4.2 Giving a rating Any judgements at the key question level of inadequate will usually reflect a service that is in breach of some regulations. Until April 2015, you will therefore need to refer to the Guidance about Compliance, Essential Standards of Quality and Safety and follow existing processes in relation to compliance actions, warning notices, and other enforcement options ASC inspection handbook October 2014 v 2 00 Page 38

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