The return of the regulator: What adult social care needs to know

The Care Quality Commission’s new assessment regime for adult social care is getting under way. It will mark a return of assessments for council social care departments after a gap of more than a decade.

We commissioned some rapid learning from the CQC pilots through interviews with five directors of adult social care about their experiences and what advice they have for other councils. Our existing Top tips document still remains a useful reference.

The pilots were run during the summer and autumn at five councils – Birmingham, Lincolnshire, North Lincolnshire, Nottingham and Suffolk. There were three parts to the assessment – the evidence gathering, the on-site visit by CQC staff and follow up/clarification stage after the fieldwork.

The pilots were asked to submit documents under 48 categories. This included a self-assessment along with a variety of other requests including a market position statement, complaints documentation, safeguarding and approaches to communication.

They were given three weeks to provide this although some asked for extensions. The councils found that for many categories multiple documents and pieces of evidence had to be submitted. One council ended up submitting more than 200 pieces on evidence.

On top of that the CQC undertook case tracking, involving retrospectively following the pathway of a small number of cases to gather evidence for the assessment.

The pilots had to submit 50 cases with the CQC then asking for detail, including reflective logs for 10. Six were followed up by the CQC for interviews.

The fieldwork took place around two months after the evidence gathering. CQC assessors carried out interviews through a combination group and one-to-one sessions.

A wide range of people were interviewed from directors of social care and senior managers to councillors, chairs of the health and wellbeing boards, directors of public health, people, carers, provider staff and, of course, frontline staff. For some, this meant more than 100 people were involved in the interviews.

The CQC has said councils will start receiving notification of their assessment from December. As part of its learning from the pilot process, it has identified three areas it will be seeking to change. They are:

• simplifying the information return
• reviewing the case tracking process to make it more efficient when looking at how individual people access and receive care through a local authority
• further developing engagement with the public through community and voluntary groups.

Embracing the process positively and openly

Embrace the assessment process as a positive experience and as part of your improvement and transformation journey.

You want no surprises. Advice from the pilots is to be open about your weaknesses and areas for improvement and set out how you are addressing them. Ask yourself: do you want to tell the CQC about your weaknesses or do you want them to tell you? This process will uncover weaknesses and it is better to be transparent and set out what you are doing to tackle them.

The CQC will be interested in the direction of travel and hopefully councils will be given credit for being aware of the challenges they face and having actions to address them and this will encourage openness and a vehicle to support improvement and get help. Even outstanding services will have challenges that they are working on.

Resourcing the assessment process

Do not under-resource your work on the assessment process is a key message from the pilots. The workload is immense and adult social care departments will not have experienced anything like this for a decade. A dedicated core team with a lead officer are needed to prepare and coordinate the work on a full-time basis. Select the team with the right skills.

During the fieldwork do not underestimate the logistics of the visit and have the team ready to meet CQC and help them navigate their way to meetings and focus groups.

Directors need oversight of the preparation process and to take ownership of it. Weekly meetings are suggested to demonstrate leadership of the process and ensure awareness of any issues where you need to intervene.

And have resource still available after the fieldwork to deal with any follow-up questions or requests. CQC may need more information about things they have seen or discussed. One example from the pilots was where they had to conduct interviews with specific people they did not see on the site visit.

Corporate and political awareness

Secure corporate buy-in from senior leadership as well as political leaders. Provide regular briefings to cabinet on CQC expectations and how the council’s performance will be measured in key areas and the significant risks arising from any adverse judgements.

Explain the need for some dedicated workforce and system resource to prepare thoroughly and effectively for the assessment.

Take the opportunity to discuss with key elected members, especially any relatively new to the adult social care portfolio, the central themes of the Care Act 2014 that the CQC assessment process is designed to test out, including the overall spirit of the Act and its specific statutory requirements.

Maximise your business intelligence in advance

Use available activity and performance data to inform your preparation, including service user and carer surveys and statutory data returns. However, primarily focus on what your data tells you about care quality, impact, user and carer experiences and outcomes – not processes.

Use your data and engagement insight to support your evolving local narrative. Check how well you currently gather activity and performance data and service user and carer feedback and consider the quality and accuracy of your information.

Are you confident your own data and intelligence is accurate and considered together does it portray a picture that is recognisable and explicable?

Think beyond service data – there are also likely to be service user and carer satisfaction, financial, workforce and complaints reporting requirements. Can you access and collate this information easily?

Self-assessment and evidence

Ensure your self-assessment, evidence and data aligns to support your key assertions. Everything flows from the self-assessment questionnaire – it should establish your story.

You have to evidence what you say in that and then show with the case tracking that you are doing that. If you get that right then that flows into the fieldwork. You have a clear narrative. Ask yourself: what do we know and how do we know it?

Staff need supporting

Frontline staff were sometimes anxious and apprehensive about being interviewed by CQC during the onsite visits.

We offer staff support workshops to help prepare frontline staff for CQC interviews through mock inspection questioning and helping them develop their own narrative and be able to confidently draw on evidence to back it up.

Principal social workers have had a central role, with a solo, often hour and half interview early on in the fieldwork. They have collectively expressed a need for support in their role in the assessment process and we are providing webinars, tools and workshop support specifically for principal social workers going forward.

Consulting with staff from children’s service who are used to inspection processes has also been of benefit.

You need to create the right environment with staff for constructive and positive engagement. The experiences staff had, were positive in the end especially for frontline staff. It is a chance to tell their story, what they do and the difference they make and something they don’t often get to do.

Communications

Think about how to communicate the results of the assessment once it is published to both internal and external audiences.

We can provide support for developing a proactive approach to developing your communication strategy as part of your preparations pre- and post-assessment.

Some of the pilots are planning roadshows to take it out to staff and partners. You will also need to use it to refresh action plans. But before the process starts it will need communicating to get everyone ready in staff meetings and through the normal communication channels.

Gather insights from partners and providers

The CQC assessment is likely to look for evidence of collaborative and co-operative working relationships with partners, operationally and strategically, and will comment on your organisational culture as observed or experienced by your partners.

Feedback from partners is one of six evidence categories that CQC will use to form their judgement. A range of statutory partners, providers and local strategic partners will be approached for their views on the council’s performance. The voluntary sector, community organisations, Healthwatch and independent adult social care providers are all likely to be involved.

You can draw upon their insight as part of the preparation for assurance, particularly in areas they think the council should improve, or equally, where they recognise existing performance is of a high standard.

Be clear on co-production and responding to diverse needs

Two areas that are important across the assessment as a whole are co-production and showing an understanding of people’s lived experiences, and equity of access, experience and outcomes – for both service users and carers. Effective co-production can also support a better understanding of barriers to care, equity and outcomes.

Part of this is about knowing your place and community, informed by demographic and performance data, but also understanding which groups or communities are more likely to experience poor care and support.

This is not just about people with protected characteristics, it requires much broader thinking around people who are socially and economically marginalised and ‘inclusion’ health and care.