LINks and CQC briefing: 2 enter and view - Care Quality Commission

LINks and
CQC
working
together
Introduction
2
LINks ‘enter and view’ visits and
CQC inspections
September 2012
This is one of a series of new briefings for local involvement networks (LINks) about
how to work with the Care Quality Commission (CQC). It builds on the Guide for
LINks: How LINks can work with the Care Quality Commission (June 2011) which is
available free at www.cqc.org.uk/public/sharing-your-experience/involving-peoplewho-use-services.
The briefings have drawn together learning and examples from CQC’s work with
LINks over the last three years and, in particular, from work with 26 LINks who took
part in a national CQC development project during 2011/12. CQC would like to thank
all the LINks for their contributions. The briefings also include learning for
Healthwatch which we hope will be of interest to local authority Healthwatch
commissioners and shadow Healthwatch organisations.
CQC is the independent regulator for health and social care services in England. We
value any information from people who use services and their representatives to help
us check on the quality and safety of care, and we have a statutory duty to ‘have
regard’ to the views of LINks.
CQC’s local relationships with LINks will remain in place until 31 March 2013 and
transfer to local Healthwatch from 1 April 2013. The learning from our work with
LINks will be used to develop a guide for local Healthwatch about working together
with CQC from April 2013. CQC will work closely with Healthwatch England from
October 2012 to best coordinate its work with emerging Healthwatch.
LINKs and CQC working together – 2: LINks ‘enter and view’ visits and CQC inspections 1

LINks and CQC – principles of working
together
CQC works with all LINks across the country to exchange information that can help
us both to tackle poor care. We respect the independent status of LINks, and the
different roles we play in holding services to account for the care they provide. We
recognise the need to maintain public confidence in both our organisations, and to
be open and transparent about how we cooperate and when we need to work
separately. We strive to use our resources effectively, avoiding duplication of effort.
About this briefing
This briefing explores how LINk enter and view visits and CQC inspections can
complement each other, with illustrative local examples. It sets out:
• What are LINk ‘enter and view’ visits
• What is a CQC inspection
• ‘Enter and view’ visits and CQC inspections – a comparison
• Exchanging information about visits and inspections
• How to make LINk visit reports useful to CQC
• Examples of LINks and CQC working together
• Learning for Healthwatch
Key messages
• LINks can, under certain circumstances, visit publicly-funded health and care
services to help monitor the services and to gather people’s views about care –
as part of a wider engagement strategy.
• The Department of Health’s Code of conduct (2008) provides good practice
guidance and is supported by CQC.
• High quality LINk evidence and reports from their visits can provide invaluable
information to CQC to support the regulation of health and social care services.
• LINks can make use of CQC national reports and local inspection reports about
services to inform its priorities, and its enter and view activity.
• Coordinated LINk visits and CQC inspections can together, provide strong
evidence of the standards of care provided by a service, and the experiences of
that care from people who use it and their families and friends.
• Working together, CQC and LINks can make the most of this evidence to tackle
poor care, as well as minimise the burden of monitoring and inspection on
providers.
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What are LINk ‘enter and view’ visits
“LINks may, in certain circumstances, enter health and social care premises
to observe and assess the nature and quality of services and obtain the views
of the people using those services. In carrying out visits, LINks may be able to
validate the evidence that they have already collected from local service
users, patients, their carers and families, which can subsequently inform
recommendations and be fed back to relevant organisations. Properly
conducted and co-ordinated visits, carried out as part of a constructive
relationship between LINks and organisations commissioning and/or providing
health and social care services, may enable ongoing service improvement.
LINks’ role is not to seek out faults with local services, but to consider the
standard and provision of care services and how they may be improved.”
(Department of Health, 2008)
Regulations based on Section 225 of the 2007 Local Government and Public
Involvement in Health Act require certain health and care providers to allow
“authorised representatives to enter and view, and observe the carrying-on of
activities on, premises owned or controlled by the services-provider”. “The 2008
Entry Regulations cover the issue of ‘enter and view’ in two ways:
• Firstly, in terms of a duty upon services-providers to allow the LINk’s authorised
representative to enter and view and observe the carrying-on of activities on
premises they own or control.
• Secondly, there are particular requirements placed upon the individuals who
carry out the activity as authorised representatives.”
With certain exceptions, a LINk may visit any NHS trust, GPs, dentists, optometrists
and pharmacists; local authority social care premises and places that are contracted
with the NHS or local authority to provide health or social care services. It may carry
out announced or unannounced inspections.
A Code of Conduct relating to Local Involvement Networks’ visits to enter and view
services (2008) is available at:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_087285
The Code sets out good practice in ‘enter and view’, including preparing for a visit,
managing a visit and using the findings. It recognises that visiting services is only
one method a LINk can use to monitor the quality of care provided or to gather the
views of people using the service, and their families. CQC encourages all LINks to
make use of the Code of Conduct.
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What is a CQC inspection?
The Care Quality Commission inspects care in hospitals, care homes, dentists and
other services, including those provided in people’s own homes, and we publish our
findings on our website and in our inspection reports.
We inspect most health and social care providers every year or every other year. We
re-inspect services that aren’t meeting government standards, and we inspect at any
time when there are concerns about poor care. All of our inspections are
unannounced unless there is a good reason for us to let the service know we are
coming. During our inspections we:
• Ask people about their experiences of receiving care.
• Talk to care staff.
• Check that the right systems and processes are in place.
• Look for evidence that the service isn’t meeting government standards.
Sometimes our inspectors are accompanied by an Expert by Experience (a person
who has experience of receiving care) who also talks to patients.
Types of inspections
We carry out three types of inspections.
• Scheduled: these are unannounced inspections that focus on a minimum of five
of the government standards, and they’re also tailored to the type of care that is
provided at the service.
• Responsive: these are unannounced inspections that are carried out where there
are concerns about poor care.
• Themed: these inspections focus on specific standards of care or care services.
Information from LINks that tells us about people’s experiences of care or
observations about care environments may help to inform a scheduled inspection or
to trigger a responsive inspection. It may help us decide which standards to check
and what to look out for when we inspect a service.
Our findings
Our inspectors judge whether or not services are meeting the government standards.
If the service is not meeting the standards, the inspector will decide whether there is
a minor, moderate, or major impact on people who use it, and they may decide to
take Enforcement action.
You can see whether or not a care service is meeting the government standards by
visiting its profile page on our website at www.cqc.org.uk. The standards are
grouped under five headings, with a green tick or a grey cross beside it, which is
updated every time a new report is published.
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‘Enter and view’ visits and CQC inspections – a
comparison
LINk enter and view CQC inspection
Providers have a duty to allow a LINk to
enter and view publicly funded health and
care services and observe the care
provided. They can refuse to allow entry
under certain circumstances, such as if the
visit compromises either the effective
provision of a service or the
privacy or dignity of any person.
A LINk cannot access parts of a service –
such as where the premises are noncommunal
parts of care homes.
Only authorised representatives of the
LINk can undertake an ‘enter and view’
visit. The LINk must have agreed
procedures for making decisions about
who can be an authorised representative.
Representatives can be authorised only if:
• They have undergone a Criminal
Records Bureau check, in line with
section 113A of the Police Act 1997,
and have a certificate to verify this; and
• A ‘nominated person’ of the LINk has
considered the certificate and is
satisfied that the person is suitable to
carry out visits.
A LINk is expected to document the
findings from the visit. The Code of
Conduct states that reports should offer a
balanced assessment of the service and,
where appropriate, make
recommendations for improvement.
In all cases, a copy of the draft findings
and any recommendations should be sent
to the provider to check for
CQC has the power to enter all regulated
health and social care services to inspect
them against the standards of quality and
safety set by government.
It can inspect a service that provides
‘regulated activities’, wherever it deems it
necessary to do so, as set out in the
Health and Social Care Act 2008.
CQC can inspect any part of a service
where regulated activities are taking
place, or if it needs to gather information
to fulfil its regulatory role.
CQC inspectors can undertake an
inspection with a number of other people.
These may include specialist
professionals in a particular field, Mental
Health Act commissioners, and Experts
by Experience (see link above for details).
People who accompany an inspector are
working on behalf of CQC to help the
inspector make a judgement about the
quality and safety of care provided by that
service. Their evidence is used by the
inspector and informs their judgement
and the inspection report they write.
CQC produces an inspection report
following every inspection and publishes
this on its website. A draft is shared with
the provider for factual accuracy.
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factual accuracy and to allow for any
recommendations to be considered.
LINks are not able to enter and view
children’s social care services.
LINks can observe care and talk to people
using services, visitors and staff. They
require permission from the provider or an
individual if they wish to look at policies
and procedures, case notes and other
written evidence.
What LINks say
CQC inspects children’s health services.
However, it only inspects children’s social
care services as part of a joint inspection
programme with Ofsted. From 2013 this
will look at the multi-agency
arrangements for the protection of
children in local authority areas.
CQC inspections involve inspectors
spending time observing care, and talking
to people using services, visitors and
staff. They will also check policies and
procedures and track case notes.
As part of the national LINks and CQC project, a small number of LINks
accompanied CQC staff on their inspections to better understand what the regulator
does. They said:
“Our LINk can devote more time to listening to residents and finding out in
greater detail how they experience life in the home – such as their daily routine,
how they get on with staff and how they perceive their treatment by them; specific
activities they enjoy, and things they would like to do but are not able, and why.”
“I can see the need for LINk visits not to try and replicate CQC inspections. There
needs to be a specific purpose for a LINk visit, either prompted by information
received from members of the public or in response to a request from another
organisation.”
“Our LINk can understand how a service connects with other services and how
different services work together – from the point of view of people using all the
services”
“CQC has to focus on the essential standards but LINks can have a wider focus.”
“CQC inspections can last a whole day while LINk visits tend to be shorter. CQC
can gather more information in their inspections.”
“In conversation with our local CQC staff team, we have found our reports add
extra details and a wider perspective to the existing inspection reports for care
homes.”
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“CQC inspectors are able to corroborate evidence in a way that LINk authorised
representatives can’t; for example, by being able to check records and care
plans, by being able to go anywhere within the home and examine any aspect of
it, and talk to any member of staff, resident or visitor.”
Contact: Brighton and Hove LINk, Herefordshire LINk, Hampshire LINk and Devon
LINk for more information about learning from a CQC inspection.
Exchanging information about visits and
inspections
Sharing LINk enter and view information with CQC
The Code of Conduct on enter and view visits encourages LINks to establish
whether any other visits are being planned around the same time as the LINk’s visit
by CQC or other local organisations. It also recommends that LINks share their
findings from visits with the regulator, to highlight both positive and negative
evidence about the quality and safety of care. CQC would like all LINks to:
1. Talk to your local CQC contact if you plan to enter and view a service.
2. Find out what we know about that service and whether we plan to inspect it soon.
3. Agree with your local CQC contact how to coordinate an enter and view visit with
a CQC inspection if they are going to happen close together.
4. Keep in touch – tell your local CQC contact what you find from the visit as soon
as you can – especially if you identify any concerns about the quality or safety of
the care.
5. Send us the evidence you gather, whether positive or negative, and share your
report by sending it using the webform at: www.cqc.org.uk/localvoices
How to make LINk enter and view reports useful to CQC
� Include the name and address of the service so we can identify it easily
� Explain what you did, who you observed and who you talked to – tell the story of
your visit
� Set out what you saw and what people told you without interpreting it or making
assumptions
� It helps us if you can group your evidence into themes that relate to the standards
we check ( see some examples below)
� Try to set out sentences which state your findings clearly
� Avoid scanning your documents as this makes it difficult for us to use
� Keep it simple and to the point
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� Send your reports to us at www.cqc.org.uk/localvoices and attach them to the
webform.
How LINks can use information from CQC inspections
LINks can expect local contact with CQC at least every three months, and more
often where there are common issues and information to share. These meetings,
and the contact in between, will give your LINk the chance to find out which services
we intend to inspect over the coming six months, as well as any concerns or general
findings from recent local inspections.
CQC sends all LINks email updates on inspection activity and national press
releases of interest. We also send LINks local press releases at the time local press
offices receive them, to give you notice of reports that may make local news. The
CQC website allows your LINk to search recent inspection reports and analyse
information from our market reports. These set out the main trends and issues our
inspectors are picking up across several thousand inspections every three months.
This information can help inform LINks priority setting, and decisions about enter and
view activity.
Examples of LINks and CQC working together
Hampshire LINk
Hampshire LINk has developed a feedback mechanism for residents, family, friends
and staff at care homes in Hampshire to share their perceptions of the standards of
care provided. They share information gathered with CQC. Work has included
developing a toolkit of templates designed to enable visits, including:
• An introductory letter to care home managers, residents or their families and
friends.
• Individual member feedback forms and membership organisation feedback
forms.
• Questions to ask while visiting and completing a feedback template.
A LINk subgroup worked on the project with advice from the local CQC manager,
and LINk representatives shadowed CQC inspections as a learning experience.
Several referrals of particular concern have been passed to CQC following the
setting up of an electronic communication protocol designed to ensure that all
concerns referred to Hampshire LINk are passed onto CQC.
A Care Homes Feedback Online Survey was also undertaken as an alternative to
visits. This was circulated to 5,000 LINk members and stakeholders to identify
examples of good practice and areas for improvement in care homes across the
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county. The full report Hampshire LINk Care Home Survey 2012: A snapshot of care
standards in residential and nursing homes in Hampshire is available from the LINk.
Contact: Janet Parsons, Hampshire LINk Management Board Member Adult Social
Care, parsonsjan@btinternet.com
Derby LINk
Derby LINk has run a programme of visits to care and residential homes in the city
looking at the quality and experience of care from the perspective of the residents,
their relatives and the staff of the homes. Information from the visits has been shared
with CQC and has informed CQC inspections.
The LINk is undertaking visits to some services for people with learning disabilities
and some mental health services. They are working with local groups of people who
use these services to develop accessible and relevant surveys, and developing
training for members to be able to visit these services.
Further work continues with the local CQC manager to develop a more formal
communication strategy and information sharing protocol.
An Enter and view report template has been developed which links across to CQC
standards. The template covers:
Theme/related to
CQC outcomes
Involvement and
information
Personalised care,
treatment and support
Safeguarding and
safety
How this is gathered by the LINk
The LINk’s residents survey is specifically related to
choice as are the questions asked of staff and visitors.
The survey questions relate to the perception of quality of
care for residents, visitors and staff.
All the LINk members and staff team have undertaken
safeguarding awareness training and any identified issues
are discussed with staff at the time of the visit and
included in their reports. They request incident reporting
data from the local safeguarding board to identify any
trends or previous occurrences.
Suitability of staffing The LINk asks about current staffing levels and the
number of qualified staff on duty at any one time. Visitors
and residents are also asked about their experiences and
perceptions of staff and staffing levels.
Quality of management Staff are asked about the level of support they receive and
whether they feel they have time to carry out their duties.
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Suitability of
management
This is covered in the LINk’s staff and visitor surveys.
The LINk has a complete toolkit for carrying out visits, including survey templates,
report templates, leaflets and posters and a flowchart of activity.
Contact: Jim Moore: james.moore@communityactionderby.org.uk
Kent LINk
In 2011, the LINk undertook 36 enter and view visits to residential homes in East
Kent, working with the local authority and the local older people's forum. Following
the success of this project a further 57 visits to residential homes across the county
were undertaken in 2012. All homes visited have contracts with the Kent County
Council's (KCC) Adult Social Services.
The 2012 visits included observations of the homes and the care, and talking to
residents and staff. Information gathered will be shared with CQC and KCC. With
advice from CQC local staff, the LINk developed an observation sheet that it used
across all the visits and tied in with CQC’s outcomes.
Each project has produced a report that will be submitted to CQC and KCC and will
hopefully influence future care and help share practice. A spreadsheet and online
survey was used to collate data from each of the visits.
Information was shared with the local CQC team from each of the visits and
uploaded onto CQC's website. The information covered a range of quality and safety
issues in each home, including:
• Name, address and type of home.
• Observations about residents’ involvement in care planning, in planning their day
and the service provided, including the menu; in routine daily activities such as
helping in the kitchen and whether there are regular residents meetings; dialogue
between residents and staff and between residents; menus and choice of meals;
access to snacks and food/drink at night; and whether residents appreciate and
enjoy meals.
• Observations about whether residents are moving about the home, in the garden,
evidence of activities and residents taking part in activities, whether trips take
place and evidence of activities and trips.
• Observations about the environment, cleanliness, accessibility and adjustments
for people with a disability; whether residents can bring their own
belongings/valuables/furniture; accessibility of information about safety and
safeguarding, complaints, and menus; access to and use of bathing facilities;
overall respect and care for people using the service and whether dignity
champions are available and active.
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• Residents’ responses to questions about all of the above and their own views
about their care.
The local CQC inspection teams have been able to use this information to inform
whether any services need a responsive review and in ongoing monitoring of the
services.
Contact: Louise Murrell, louise@kentlink.org
Devon LINk
Devon LINk have reviewed their enter and view training materials with authorised
representatives. This included a one-day session with advice from the local CQC
compliance manager and inspector about a CQC inspection. As part of the national
project, LINk representatives also attended a small number of CQC inspections. This
has helped develop their materials which include:
1. What is involved in a CQC Inspection – A Briefing Session to LINk Authorised
Representatives.
2. A simple guide outlining the difference between CQC inspections and LINk Enter
and View visits.
3. A flowchart to illustrate how the LINk and CQC share intelligence about local
services.
4. A presentation to show how the LINk collects, logs and filters data and how this
can be used by CQC.
5. Examples of questions that can be used to engage with people experiencing a
service.
The LINk has agreed with Devon County Council how they will use enter and view
visits to monitor the quality of services as part of the Quality and Improvement
Monitoring Sub Group. This has also included agreeing the process for reporting a
safeguarding concern and a safeguarding training session for authorised
representatives.
Information from the visits already undertaken have already been shared with CQC
and used to inform CQC inspections.
Contact: Lorna Davis, lorna.davis@edvsa.org.uk
Sutton LINk
The LINk has over 20 authorised volunteers who carry out monthly visits to hospital
wards and care homes. It has developed a range of tools and templates to support
its enter and view activity. This includes:
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• A protocol for LINk care home monitoring between Sutton Adult Social Services
and Housing and Sutton Pathfinder LINk/Healthwatch and care home monitoring
form.
The protocol sets out how the LINk will use monitoring visits and enter and view
visits as part of its work. It sets out how LINk volunteers receive CQC information
about a care home to inform their visit, and how final reports are shared with CQC.
The LINk’s health and wellbeing working group may also take further action following
publication, and write a letter to CQC.
The monitoring form includes issues of access, the entrance, the building, the
communal areas, meals (choice and flexibility), residents’ rooms, staffing levels,
security, personal care, health, policies and procedures, social activities, end of life
care, residents’ appearance, involvement, general issues and family and friends.
There is a section for safeguarding concerns and further information from family and
friends.
• A protocol for LINk hospital monitoring visits between the local hospital trust and
Sutton Pathfinder LINk/Healthwatch and hospital monitoring form.
This also sets out how the LINk will share any findings from hospital monitoring visits
with CQC, and highlights the areas volunteers will cover in their visits. These include:
• Physical factors
• Cleanliness
• Maintenance
• Meeting diversity
• Discharge information
• Privacy and dignity.
The hospital monitoring form records details under each of these areas, with
questions as prompts. There is also a specific monitoring form for visits focused on
the provision of food and drink for older people and a specific enter and view form for
a mental health service visit.
The LINk has also developed a recruitment and induction programme, including:
providing references, induction interview, CRB check, safeguarding training and a
course on enter and view that includes practical case studies and is designed and
delivered by the LINk. All protocols and policies have been shared with CQC. The
LINk liaises with local CQC staff and shares information on a regular basis.
Contact: Janice McCullock, janice@suttoncvs.org.uk
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East Sussex LINk
East Sussex LINk has developed a LINk legacy enter and view package as part of
their transition year work programme as a Healthwatch pathfinder, and to strengthen
their existing function for enter and view. They have also worked with CQC as part of
the LINk’s enter and view activities, sharing information from visits already
undertaken and establishing systems and processes for relating to CQC. The overall
enter and view package includes:
• Application/recruitment process.
• Training programme with core and optional modules.
• Policies, procedures and processes.
• Resource pack with templates.
The application/recruitment process includes how the LINk manages the expression
of interest from an individual; the role description; the application form; skills audit
form and the invitation to take part in a training programme.
The core training module includes an understanding of the role of the authorised
representative; safeguarding adults at risk; mental capacity act; deprivation of liberty
safeguards; equality and diversity and child protection and safeguarding procedures;
as well as an understanding of the regulatory framework for children’s services.
Optional modules include ‘sit and see’ which is a locally devised programmes to
improve observation skills; producing reports; working with the regulators (CQC);
and other learning identified by individuals and basic Makaton.
There is a training programme for authorised representatives to maintain and update
their skills.
Policies, processes and procedures include a range of resources for enter and view,
including developing relationships with CQC and the local safeguarding board.
The LINk is also exploring the option of providing specialist independent evaluation
services to providers such as for services for people with a learning disability or
services for people with dementia.
Contact: Elizabeth Mackie, Elizabeth.mackie@thecountylink.net
Learning for Healthwatch
The Department of Health will publish regulations setting out the duty on providers to
allow Healthwatch organisations to enter and view services. This will provide the
legislative basis for Healthwatch visits. In addition, Healthwatch England will be
developing advice and support to Healthwatch about the use of visits in engaging
with local people and monitoring services.
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CQC and LINks’ work together has identified the following learning for Healthwatch
on making effective use of visits:
A strategic approach
• Understand the new regulations for enter and view – which services you can visit,
for what purpose, and with what effect.
• Understand what CQC, local authorities and other commissioners are doing on
their inspections and visits, and the standards they check.
• Agree criteria for how visits will be used as part of the work of Healthwatch –
what can trigger them, where will information come from to inform them and who
you need to work with in making the decision to visit a service.
• Agree how visits will be shared and used alongside the work of overview and
scrutiny committees, GP practice participation groups, Foundation Trust
governors, NHS patient-led inspections and any other local visits by the public
and their representatives.
• Agree the approach to announced versus unannounced visits.
Developing an enter and view programme
• Plan recruitment, training and support for volunteers and develop materials
needed – and discuss this with your local authority. In particular, consider how
training related to safeguarding, deprivation of liberty safeguards, and equalities
and diversity is incorporated into enter and view training. In addition, support
systems will be needed for representatives following visits.
• Training about CQC and regulation should form part of the training programme
for volunteers and Healthwatch staff.
• Develop information and communications for providers and commissioners to
explain your approach to visiting services and use of ‘enter and view’ – and why
Healthwatch may wish to visit services. This includes explaining how you relate to
CQC and share information with the regulator from visits.
• Where a provider refuses entry, it is important to have a clear process for
handling this locally. A process for handling provider concerns about visit reports
or complaints following a visit is also needed. There may be particular issues for
Healthwatch relationships with small care providers to manage.
Gathering and reporting information
• Use information from partners and other stakeholders, including CQC to inform
your decision to visit a service.
• Discuss your enter and view plans at an early stage with CQC – to ensure they
complement any inspections or enforcement activity (as well as any discussions
needed with other local stakeholders).
• Plan what you will view during the visit and who you will talk to and/or observe.
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• Agree a consistent format for recording observations and interviews.
• Agree a consistent format for reporting on visits and identify relevant themes to
group information (where relevant, it may help to use the government standards
for quality and safety used by CQC when compiling the report).
Making the best use of the findings from visits
• Enter and view reports can be effective without making specific
recommendations. They can focus on reporting the details of what they have
seen and providing a summary, with some sort of thematic analysis.
• Enter and view visits need to be agreed with clarity about who will share the
findings with whom and for what use. Where visits are undertaken in partnership
with other bodies, this agreement is needed with them as well as within
Healthwatch from the start of the work.
• Share all interim and final findings with CQC as a matter of course, as part of
ongoing information sharing with local CQC contacts.
• There can be pressures from the press to publicise findings from visits – a media
plan can help to manage this.
• Healthwatch needs a clear protocol for the action it will take if it identifies
safeguarding concerns, and on deprivation of liberty safeguarding concerns
during visits.
Further information
• CQC website www.cqc.org.uk
• Healthwatch England website www.healthwatch.co.uk
• Guide for LINks: How LINks can work with the Care Quality Commission June
2011 available free at www.cqc.org.uk
• A Code of Conduct relating to Local Involvement Networks’ visits to enter and
view services (2008) is available at www.dh.gov.uk
• Patient led inspections of the care environment (PLACE)
(These new patient led inspections will replace the current Patient Environment
Action Team (PEAT) inspections, in hospitals offering NHS-funded care. LINks,
local Healthwatch and Healthwatch England are playing a role in developing
these inspections. Further information can be found at www.dh.gov.uk)
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