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How we monitor compliance

Once you are registered under the Health and Social Care Act, we will monitor whether you continue to meet the essential standards of quality and safety

Gathering information
We will keep a constant check on all the information about you that is available to us. We hold this in a Quality and Risk Profile (QRP) for each provider. We will involve and gather information from people who use your services, public representative groups and other agencies and regulators. We will also use the information you supply directly to us in the statutory notifications that you must make in writing about events and changes to your service. (Please note that there are new notification forms on our website and you must use these rather than any old Care Standards Act forms you may have.) The information we gather during a review of your service will also feed back into the QRP. We will use all this information to make judgements about the level of risk of you not meeting the essential standards, the frequency of planned reviews, and whether we need to follow up on concerns.

Care Quality Commission: How we monitor compliance

Frequency of reviews
The frequency of our reviews has changed and we will no longer carry out reviews at set intervals. Instead, we will have a programme of planned reviews in which every location is reviewed at least once every two years. We will carry out planned reviews more frequently the shortest timespan is every three months where we are concerned about the quality of care at a location or where a provider is carrying out high risk activities. Our first priority is to monitor those providers that were registered on condition that they made key improvements. We also carry out responsive reviews where we have concerns about the quality and safety of care (see page 5). We do not normally give providers advance notice of a review of compliance. However, as soon as a review is underway, we will indicate this on our website. We will also say whether it is a routine review, or whether it is in response to concerns.

Care Quality Commission: How we monitor compliance

What happens in a planned review

A planned review is a full check of the 16 essential standards that most directly relate to the quality and safety of care. We start by reviewing the information we hold in the Quality and Risk Profile. If, having analysed this information, we cannot confirm that you are meeting the essential standards, we will gather more information. We may:

Contact people who use your services and their relatives or carers. Contact your Local Involvement Network or Overview and Scrutiny Committee. Ask for information from our partner bodies. sections of the Provider Ask you to send us the relevantor other information. Compliance Assessment (PCA), Carry out a visit.
The PCA is a helpful tool you can use as part of your internal quality assurance process to assess and record how you are meeting the essential standard outcomes and, if you identify areas of concern, how you intend to make the necessary improvements. You can download it from our website. You do not have to use the PCA tool if you already have your own way of recording your quality assurance, you can send this to us instead when we ask for the information.

Care Quality Commission: How we monitor compliance

If we visit you, we will focus on the outcomes we expect people who use services to experience. We will directly observe the care being provided, and talk to the people who are using your services and your staff. We may also review the records of people who use your services to assess the outcomes they experienced. We will try to complete a visit in a day and we aim to disrupt your services as little as possible. If we have significant concerns or the scope of the visit is wide, we will try to use a larger team during the visit.

Responsive reviews and what triggers them

If, 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 specific information we receive that highlights concerns. Your local inspector will consider this using their local knowledge and determine whether it identifies a risk that needs further investigation in a responsive review. We will also carry out a responsive review when we are following up on enforcement action we have taken. A responsive review is not a full check of compliance with the 16 essential standards. Instead it targets the areas of concern and the standards to which they relate. It may include a visit. We may look wider if further concerns arise during the review.

Care Quality Commission: How we monitor compliance

What we will do in response to concerns

Once we have gathered and analysed all the information, we will make a judgement about whether you are meeting the essential standards. If you are not meeting the standards, we will look at the impact of our concerns on people using your service and the likelihood that these will happen again. We will also consider factors such as whether vulnerable people use your service. Where issues can be resolved quickly and easily, we may simply discuss them with you. If you are meeting essential standards, but we have concerns that you may not continue to do so, we may set an improvement action and ask you to send us a report stating how you will make improvements. If you are not meeting essential standards, which means you are not complying with the regulations, we may set a compliance action. This also requires you to send us a report stating how you will make the necessary improvements. If you do not make the improvements, we may decide to take enforcement action We will always follow up improvement and compliance actions to check that the necessary improvements have been made. If services are not meeting the essential standards and are failing to provide safe care to people using them, we have a wide range of enforcement powers that allow us to take swift action. This includes sending out warning notices, imposing conditions, charging fines, suspending registration and prosecution. As a last resort we can cancel a providers registration.

Care Quality Commission: How we monitor compliance

Publishing the outcome of a review

When we have completed a review of compliance, we will send you a report as soon as possible setting out our findings, our judgements about compliance, and whether we have asked you to send us a report to tell us how you will make improvements. You will have 14 days to check our report for factual accuracy. We will then finalise the report and publish it on our website. If we are proposing to take enforcement action against a provider, we will publish our report when the representations and appeals processes have concluded. However, if we take urgent enforcement action for example, suspending a provider or registered manager, or varying the conditions of a providers registration due to major concerns we will state this on our website immediately, making it clear that this action may be appealed. If we cancel a registration, we will remove information about the provider or manager from our website. We will normally brief the local, national and trade media: compliance report When we publish a review ofactions, or where wethat setsup compliance or enforcement follow compliance conditions set during initial registration.

When we take urgent enforcement action. or When we have followed up improvement, compliancemade enforcement action and found that the provider has
improvements which makes them compliant.
Care Quality Commission: How we monitor compliance

Contact us
If 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 enquiries@cqc.org.uk Sign up for 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 if you would like this leaflet in another format or language. Registered office: Care Quality Commission, Finsbury Tower, 103105 Bunhill Row, London EC1Y 8TG CQC-162-17000-STE-122010