CQC Quick Guide to Compliance Monitoring Final for Web

8/3/2019 CQC Quick Guide to Compliance Monitoring Final for Web

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How we monitorcompliance

Once you are registered under the Health

and Social Care Act, we will monitor

whether you continue to meet the

essential standards o quality and saety


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Care Quality Commission: How we monitor compliance2

Gathering information

We will keep a constant check on all the inormation aboutyou that is available to us. We hold this in a Quality and RiskProle (QRP) or each provider.

We will involve and gather inormation rom people who useyour services, public representative groups and other agenciesand regulators.

We will also use the inormation you supply directly to us inthe statutory notications that you must make in writingabout events and changes to your service. (Please note thatthere are new notication orms on our website and you mustuse these rather than any old Care Standards Act orms youmay have.)

The inormation we gather during a review o your service willalso eed back into the QRP.

We will use all this inormation to make judgements aboutthe level o risk o you not meeting the essential standards,the requency o planned reviews, and whether we need toollow up on concerns.

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Care Quality Commission: How we monitor compliance 3

Frequency of reviews

The requency o our reviews has changed and we will nolonger carry out reviews at set intervals. Instead, we will havea programme o planned reviews in which every location isreviewed at least once every two years.

We will carry out planned reviews more requently the shortest timespan is every three months where we are

concerned about the quality o care at a location or where aprovider is carrying out high risk activities.

Our rst priority is to monitor those providers that wereregistered on condition that they made key improvements.

We also carry out responsive reviews where we have concernsabout the quality and saety o care (see page 5).

We do not normally give providers advance notice o a reviewo compliance. However, as soon as a review is underway,we will indicate this on our website. We will also say whetherit is a routine review, or whether it is in response to concerns.

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What happens in a planned review

A planned review is a ull check o the 16 essential standardsthat most directly relate to the quality and saety o care.

We start by reviewing the inormation we hold in theQuality and Risk Prole. I, having analysed this inormation,we cannot conrm that you are meeting the essentialstandards, we will gather more inormation.

We may:

Contact people who use your services and theirrelatives or carers.

Contact your Local Involvement Network or Overview andScrutiny Committee.

Ask or inormation rom our partner bodies.

Ask you to send us the relevant sections o the ProviderCompliance Assessment (PCA), or other inormation.

Carry out a visit.

The PCA is a helpul tool you can use as part o your internalquality assurance process to assess and record how you aremeeting the essential standard outcomes and, i you identiyareas o concern, how you intend to make the necessaryimprovements. You can download it rom our website. You donot have to use the PCA tool i you already have your ownway o recording your quality assurance, you can send this tous instead when we ask or the inormation.

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Care Quality Commission: How we monitor compliance 5

Responsive reviews and whattriggers them

I, at any time, we have concerns that you are not meeting

the essential standards, we can carry out a responsive review.This would be triggered by specic inormation we receivethat highlights concerns. Your local inspector will considerthis using their local knowledge and determine whether itidenties a risk that needs urther investigation in aresponsive review.

We will also carry out a responsive review when we areollowing up on enorcement action we have taken.

A responsive review is not a ull check o compliance with the16 essential standards. Instead it targets the areas o concernand the standards to which they relate. It may include a visit.

We may look wider i urther concerns arise during the review.

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I we visit you, we will ocus on the outcomes we expectpeople who use services to experience. We will directlyobserve the care being provided, and talk to the people whoare using your services and your sta. We may also review therecords o people who use your services to assess theoutcomes they experienced.

We will try to complete a visit in a day and we aim to disruptyour services as little as possible. I we have signicantconcerns or the scope o the visit is wide, we will try to usea larger team during the visit.


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What we will do in responseto concerns

Once we have gathered and analysed all the inormation,we will make a judgement about whether you are meeting theessential standards.

I you are not meeting the standards, we will look at theimpact o our concerns on people using your service and thelikelihood that these will happen again. We will also consider

actors such as whether vulnerable people use your service.

Where issues can be resolved quickly and easily, we maysimply discuss them with you.

I you are meeting essential standards, but we have concernsthat you may not continue to do so, we may set animprovement action and ask you to send us a report stating

how you will make improvements.

I you are not meeting essential standards, which meansyou are not complying with the regulations, we may set acompliance action. This also requires you to send us a reportstating how you will make the necessary improvements.I you do not make the improvements, we may decide to takeenorcement action

We will always ollow up improvement and compliance actionsto check that the necessary improvements have been made.

I services are not meeting the essential standards and areailing to provide sae care to people using them, we have awide range o enorcement powers that allow us to take swiaction. This includes sending out warning notices, imposing

conditions, charging nes, suspending registration andprosecution. As a last resort we can cancel a providersregistration.

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Contact us

I you have any questions about how we monitor compliance, you can:

Look at our website: www.cqc.org.uk

Speak to your local compliance inspector or manager

Call our National Contact Centre on 03000 616161

Email us at [email protected]

Sign up or our monthly e-bulletins at www.cqc.org.uk/

newsandevents/newsletter.cfm

Write to us at:

Care Quality Commission, Citygate, Gallowgate,

Newcastle upon Tyne NE1 4PA

Please contact us i you would like this leaet in another ormat

or language.

Registered ofce:

Care Quality Commission, Finsbury Tower, 103105 Bunhill Row,

London EC1Y 8TG

CQC-162-17000-STE-122010

CQC Quick Guide to Compliance Monitoring Final for Web

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