Free article: CQC inspection - a summary of the changes

Published: Monday, 10 July 2017

Martin Hodgson provides an analysis of the CQC inspection changes.


  • The CQC has published new 5 key-question and KLOEs guidance for inspectors, coming into force November 2017.
  • The new guidance contains a number of new and amended Key Lines of Enquiry (KLOEs).
  • The 5 key-questions and fundamental standards regulations remain unchanged.
  • The third CQC consultation on changes will be published in the Autumn 2017.

The Care Quality Commission has published the updated guidance for inspectors that it consulted on at the end of 2016. The new guidance is intended to help inspectors to make their inspection judgements more accurate and consistent, including the published quality ratings that they apply to services.

The guidance was due to be implemented for care home and domiciliary care inspections from July 2017. However, the publication of the guidance was delayed due to the general election and the implementation has been put back to November 2017.

The new guidelines replace the Appendices to the Service Handbooks which were published by the CQC in 2015. The contents have been extensively revised and updated and have been published in two new documents:

  • Key lines of enquiry, prompts and ratings characteristics for adult social care services
  • Key lines of enquiry, prompts and ratings characteristics for health care services.

The various appendices that were originally produced for each service type have been merged into these two documents in a move that has been designed to make the system simpler and clearer. In addition, the CQC wanted to make rating decisions more consistent across adult social care and healthcare, thus a good deal of work has gone into bringing the advice together where relevant.

The key message for care homes and domiciliary care services is that, from November 2017, their separate handbook appendices will no longer apply. Instead they will both use the new merged social care document.

The new guidance provides service owners and managers with information about the types of questions inspectors might ask and the things they will be looking for when they visit. Service managers should read the new guidance and note the changes that have been made which might affect them. They will need to amend any audit tools they have set up using the old 2015 appendices.

The changes made are extensive.

Both the old appendices and the refreshed guidance contain information that helps inspectors when applying the 5 key-question test: key lines of enquiry (KLOE), prompts and ratings characteristics.

KLOEs and prompts are questions that inspectors are encouraged to ask in order to help them answer the key-questions:

  • is the service safe
  • is it effective
  • is it caring
  • is it responsive and
  • is it well-led?

Ratings characteristics are a series of descriptive statements which are intended to suggest what a service might look like in the context of each of the five questions and at the four ratings levels: Outstanding, Good, Requires Improvement or Inadequate.

The KLOE and ratings characteristics in the new guidance remain based on the 5 key-question test and the Fundamental Standards, however, they have been changed in order to bring more clarity and transparency and to make inspections easier and more straightforward. Several new KLOE have been added and many prompts have been added or re-worded to make them clearer. Questions about end of life care have been moved from the ‘caring’ key-question to the ‘responsive’ question. In addition, the ‘caring’ and ‘well-led’ questions have been substantially strengthened.

Service providers will find two versions of the new adult social care guidance when they visit the CQC website (see further information for links).

The first is the final version of the newly merged document as it will apply from November 2017. The second is a version which highlights the changes the CQC have made. This has been produced to help providers apply the same changes to any audit systems they might have.

Also on the website, until November, are the current appendices.

Alongside the new guidance the CQC have also published their full response to the consultation they ran at the start of the year, of which the replacement of the handbook appendices was a key part.
The original consultation paper, Our next phase of regulation - a more targeted, responsive and collaborative approach, was published in December 2016. It sought views on a range of issues, including:

  • how inspectors will regulate new models of care and complex providers (where providers offer different types of services)
  • changes to CQC assessment frameworks across all sectors to reduce complexity and create more consistency
  • new proposals on the registration of services for people with learning disabilities
  • how inspectors will regulate NHS trusts and foundation trusts, including how they might change their approach to rating them.

The consultation was launched by the CQC as part of its efforts to strengthen its regulatory systems and achieve the objectives of its latest strategy, Shaping the Future 2016 to 2021.

The response to the consultation states that:

  • respondents were generally positive about the changes to the handbook appendices, and especially about the proposals to make inspections clearer, more consistent and more transparent
  • 71% of respondents agreed or strongly agreed with the CQC proposal to move to two assessment frameworks, one for adult social care and one for healthcare, rather than to maintain the old arrangement of having different frameworks for each service type
  • many suggestions were made about KLOE questions that should be reworded – many of these suggestions were used in the updated guidance
  • many respondents highlighted the complexity and variety of health and adult social care providers and warned against a “one-size-fits-all” approach to inspection processes and methods
  • others recognised that alignment between settings and sectors – for example between care homes and domiciliary care and between health and social care - was important for a shared view of quality.
  • The Care Quality Commission has also published the second part of its “next phase of regulation” consultation into changes in the regulatory system for health and social care. The second consultation paper appears as it also publishes its full response to the first part. 

The first consultation paper, Our next phase of regulation - a more targeted, responsive and collaborative approach, sought views on a range of issues, including changes to the criteria on which inspectors make their rating judgements and the replacement of the service handbook appendices with updated documents. The response to this was published on the 12th June, along with the refreshed guidance.

The second part of the “next phase of regulation” consultation carries on the conversation from the first paper and includes proposals developed to help the CQC meet the aims of its 2016 to 2021 five-year strategy, Shaping the Future. It includes proposals for all sectors covered by the CQC but includes a particular focus on changes to how the CQC regulates primary medical care services and adult social care services.

Key areas covered are how the CQC will in future:

  • register, monitor, inspect and rate new models of care and large or complex providers
  • use its unique knowledge and capability to encourage improvements in the quality of care in local areas
  • regulate primary medical care services and adult social care services
  • carry out its role in relation to the “fit and proper persons” requirement.

The consultation states that the CQC intends to pursue its “more targeted” and collaborative approach to regulation by placing a greater emphasis on integration and leadership. In some respects the updated inspection guidance published alongside the second consultation already supports this by considerably strengthening the leadership and governance questions that an inspector is prompted to ask when visiting an adult social care provider.

Specific proposals for all types of providers include:

  • re-structuring the approach to registration so the CQC can hold more information about different types of services
  • clarifying who is required to register with the CQC so they can hold to account all of those who are responsible for the quality of services
  • improving inspectors understanding of large and complex organisations so they can take a more targeted and responsive approach to their regulation
  • identifying a single CQC relationship-holder for each complex provider who will work alongside named leads
  • developing a new provider-level assessment for corporate providers of health and social care services and other complex providers
  • undertaking a small number of targeted reviews to look at how health and social care work together and to identify improvements that can be made.

Specific proposals for adult social care include:

  • strengthening the use of “information and relationship management” with providers
  • developing a new “CQC Insight model” that brings together information about all the locations of a provider to help inspectors see the broader context for performance
  • increasing the period between comprehensive inspections for services rated as “good” from two to two and a half years and from two to three years for services rated as “outstanding”
  • removing the “six month limit” which only allows inspectors to change an overall rating if a focused inspection is carried out within six months of the previous comprehensive inspection
  • extending the time in which inspectors can gather views from service users about the quality of domiciliary home-care services
  • developing a more flexible approach for inspecting care delivered to people in their own homes, including a “toolkit” of methods to support evidence gathering.

The timescales set for the implementation of the various proposals vary from this year through to 2021 in some cases. However, the CQC hopes that by November 2017 the second part of the consultation will have concluded and everyone will be able to move forward using a clearer and simpler system that fits in with their 5-year strategy.

The second consultation closed on the 8th August.

The CQC says that it will hold a third consultation, focusing on how it will regulate and rate independent healthcare services, in the Autumn.

Further information

About the author

Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.

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