What those KLOEs really tell us

As I’m sure readers of this blog are well aware, in adult social care services the CQC currently has twenty five key lines of enquiries (KLOEs) covering their five service domains (Safe, Effective, Caring, Responsive and Well-led).  These are all then broken down into ‘sub-KLOEs’, or ‘prompts’ as the CQC like to call them.  But what are these KLOEs actually for and who uses them?

The most straightforward answer to the first question, which effectively answers the second as well, is that the KLOEs are used by CQC inspectors to help them ‘navigate’ their way through the quality of a service.  Both the domains and the KLOEs ‘break down’ a service into more manageable ‘segments’ of quality.  For example, take the ‘Safe’ domain; this has six KLOEs, which together help guide the inspection team in what to look for when making an assessment and evaluation of how safe a particular service is.  These are not ‘measures’ or ‘metrics’ of quality; rather they indicate what an inspection team should be looking for when assessing and evaluating the ‘Safe’ domain.

And this brings us to the question of evidence.  As I’m sure you are also aware, the inspection team are essentially looking for evidence of quality across the service, and the domains and KLOEs are designed to help them collect such evidence.  But what does such evidence look like?  The first point to note is that there are no ‘right’ or ‘wrong’ answers, no ‘right’ or ‘wrong’ evidence.  Having said that, some evidence is better or ‘stronger’ than others.  Furthermore, the CQC likes each piece of evidence to be corroborated by other evidence.

For example, take KLOE S1 (the first KLOE in the ‘Safe’ domain), which asks the question: “How do systems, processes and practices safeguard people from abuse?”  There are many possible sources of evidence for this KLOE; in fact, the CQC has a list of suggested sources for all the KLOEs, broken down by domain and KLOE, which for ease of access I have reproduced here.   However, this list is by no means exhaustive, and CQC inspectors are quite at liberty to choose their own sources.  What is more important is whether the evidence for S1 (and all the other KLOEs) can be corroborated; in other words, are there several different pieces of evidence, from several different sources, which strengthen the case for how this particular KLOE is assessed and evaluated?

So in terms of concrete evidence for SI, the fact that a service has a comprehensive safeguarding policy and set of procedures is clearly one piece of evidence.  But this doesn’t really tell the inspection team much.  For example, has anyone actually read the policy?  Do staff know what to do if they come across a safeguarding issue?  Have staff ever attended training for safeguarding?  Simply having a policy in place, even if it is very comprehensive, is no guarantee that the service is actually protecting its service users from abuse.  However, if, when interviewed by the inspection team, care staff are able to explain how they would deal with a particular safeguarding scenario, then this is likely to make the inspection team feel far more confident that service users are protected from abuse, rather than simply relying on the existence of a safeguarding policy.  And if the training records of the service show that all staff have completed safeguarding training within the last year, this even further strengthens the case for being confident that service users are protected.

Ideally, each inspection should involve a systematic collection of evidence for each KLOE by the inspection team.  However, it important to note that inspectors are not obliged to stick to this ‘script’, so to speak.  They may well have some questions of their own, which are not necessarily covered by the KLOEs, but which may be very relevant with regards to the service they are inspecting.  This is particularly the case if the inspection team has been alerted in advance that there are specific problems within a service.

Having said that, the twenty five KLOEs do, in my view, comprise a pretty comprehensive framework for ‘mapping-out’ quality across a service.  And this brings me back to my original question: what are these KLOEs for and who uses them?  There is another answer to both questions, which is that the KLOEs are a useful tool for helping managers assess and evaluate quality across their own particular services.  In other words, the KLOEs are not there just to help CQC inspectors.  Rather, they can be used by service managers on a continuous basis to ‘map-out’ quality across their services.

A number of services have already adopted this approach, and often integrate it into their existing monthly or quarterly quality assurance reviews.  In other words, these reviews will use the five domains and twenty five KLOEs to help the manager or quality assurance lead gather evidence for quality across the whole service.  And this is something the CQC themselves would certainly encourage, because it makes their job a lot easier.  If an inspection team arrives at a service that has already comprehensively ‘mapped-out’ quality across all five domains, and has a comprehensive list of evidence for each KLOE, then this immediately demonstrates to the inspection team that the manager is already ‘speaking their language’ and understands the importance of collecting evidence for quality.

Furthermore, although the inspection team will want to verify for themselves the evidence collected by the service, the very fact it is systematically documented means they (and the service manager) should be able to get their hands on it very quickly.  So, going back to the example of KLOE S1, the service will (hopefully) have already documented that there is a comprehensive safeguarding policy and set of procedures in place, and that their training matrix shows that all staff have recently completed safeguarding training.  Furthermore, such documentation should include the location of such evidence, for example, in a particular filing cabinet, or in a particular folder on the system.  This means that the inspection team can very quickly locate the policy, procedures and training records, and check they are indeed up to standard.

But even more importantly, the manager themselves will know that the evidence exists, and is robust enough to prove to them that their service is fit for purpose.  And this is the key point about managers and providers using the KLOEs themselves: it is a way to enable them to be confident at all times that their service is up to scratch with regards to quality, because they can be continually collecting evidence for each KLOE.  Furthermore, this process of continuous monitoring will help identify any potential issues with the service at an early stage, and give the manager a chance to address them before they get out of control.   And, finally, introducing such a system of continuous monitoring or audit will help the service ensure it is compliant with Regulation 17 (Good governance), which I discussed in my previous post.

But of course this then raises the question of how, in a practical sense, you can use the KLOEs to assess and evaluate quality across the whole service.  In other words, what practical steps do you need to take to conduct this kind of ‘mapping’ exercise on a continuous basis?   Luckily, the answer is quite straightforward: you use a KLOE audit tool!  This allows you to collect evidence for each KLOE, and to record any actions you might need to take if the evidence shows the service is not up to scratch with regards to a particular KLOE.

Such a tool is (relatively) simple to create in Excel or a similar spreadsheet program.  Alternatively, you could look at purchasing an off-the-shelf version, such as the one provided by Therapeia.  Either way, it is important, in my view, to ensure that the tool is in a digital format (there are still paper-based versions on the market, apparently), and, ideally, is in a standard spreadsheet format.  The reason for this is quite simple: most managers and admin people (the two groups most likely to be using such a tool) are familiar with spreadsheets and therefore will not be too daunted by using an audit tool which uses the same layout.  Furthermore, having the data in such a format makes it much easier to share it with other agencies, including the CQC itself.

And this last remark brings me to another important point: the CQC appears to be moving towards a system of continuous online monitoring called called Provider Information Collection (PIC), which  based on an updated version of the Provider Information Return (PIR).  Although my understanding is that this is still in the development phase, it seems reasonable to assume that this will become fully rolled-out in the adult social care sector in the not too distant future.  The requested information is based on the five key domains (Safe, Effective, Caring, Responsive, Well-led), and therefore it would seem sensible to have already got into the habit of collecting evidence for each of the domains and their respective KLOEs.