Pleased with your CQC inspection or bruised by the experience? David Finney gives you the key issues.
The first phase of inspections of substance misuse services by the CQC Hospital Directorate is now complete and all reports published. The experience of providers under this new regime has been varied: some received accolades, while others with previously excellent ratings have been severely criticised. Some services have even closed as a result of the new approach.
Sometimes CQC have ‘requested’ that providers temporarily suspend admissions while changes are made. This has been serious where there is a quick turnover of residents (in detox, for example) and numbers in treatment quickly reduce. Problems have also arisen when commissioners have been informed of negative comments in an inspection report, which has led to admissions being suspended or reduced.
CQC have already published the ‘key lines of enquiry’, used by inspectors, but many inspection judgements seem to be have been made according to additional criteria, such as NICE guidelines, extra guidance issued by CQC or simply the interpretation of regulations by the inspector.
Therefore, providers often ask me: are inspectors looking for services that replicate the NHS, or do they appreciate the distinctiveness of residential rehabilitation services, or the informality and reach of community-based services?
So, let us consider some of the issues attracting inspectors’ attention:
1. The Mental Capacity Act. CQC expect that all staff have some awareness of what this act means for their service. Staff training is important, but staff also need to know what to do if someone lacks capacity while in the service, and how to assess for capacity in the first place.
2. Governance. CQC seem to increasingly expect an NHS-like system of accountability, where matters such as incident management, safeguarding, service user outcomes, key performance indicators etc are formally monitored; improvements made and risk registers produced. It is reasonable to expect corporate bodies to have such formal systems, but smaller services often have less formal ways of overseeing their work, which can be just as effective, but harder to evidence to the inspector.
3. Ligature risks. A focus on this topic springs from the mental health background of the CQC directorate inspecting substance misuse services. To my knowledge, there have been very few incidents of suicide risk in residential services, but now services are being expected to thoroughly examine their environment for ligature risks. CQC provide separate guidance about this issue on their website.
4. Clinical issues. These have been many and varied, but inspectors have often focused on assessment tools such as SADQ and CIWa for alcohol dependence and withdrawal, and other tests for drug dependence such as SDS. They often comment on the use of emergency medication such naloxone and rescue medication for seizures. NICE guidelines figure highly in CQC inspection reports, whereas they are only mentioned in passing in the ‘key lines of enquiry’. There is also an expectation that providers have a multi-disciplinary team (MDT) in place; smaller services who are not equipped with an array of professionals on their staff team may have some difficulty explaining how they provide this.
5. Care Issues. These have included a wide range of subjects, from a lack of thoroughness in initial comprehensive assessments and seemingly low involvement of clients in their care planning, to the lack of privacy in shared rooms and the new topic of a requirement for same-sex accommodation (which seems to reflect concerns about mixed wards in the NHS).
6. Statutory notifications. There has been controversy over which deaths to report, especially in community services where service users may have infrequent contact with drug and alcohol workers. Exactly what qualifies as a death ‘while receiving a service’ is clearly up for debate with CQC. Other events, such as when police are involved or when a serious injury occurs, are also classed as ‘notifiable incidents’ by CQC, which providers can easily overlook. As it is a statutory requirement to make these notifications, CQC will deem any omission to do so as a ‘breach of regulation’, which has serious implications in terms of enforcement action.
These are just some of the issues causing concern and setbacks for substance misuse services – as if the funding crisis suffered by many services were not enough to dampen spirits. The CQC Hospital Directorate has certainly been making its presence felt during this round of inspections; so what of the future?
There is no public indication of when CQC will introduce ratings for the substance misuse sector, and the most recent consultation about CQC methodology amalgamated all the criteria into a generalised document that said very little about substance misuse services at all. Should providers just wait and hope for the best until we find out what CQC will do next – or is it better to actively prepare for the next round of inspections in the light of what we know already?
David Finney is an independent social care consultant who has been involved in the inspection of substance misuse services for 21 years, most of the time working for government inspection bodies. He is planning a training event to address these issues on 10 July.