A lack of oversight?

A common criticism of many services that the CQC has rated ‘Requires Improvement’ or ‘Inadequate’ is that the manager was not aware of the problems that the inspection team found during their visit.  I’ve found this to be the case with a number of my own clients, who were often visibly shocked when the draft report came in.  To put it bluntly,  they just didn’t see it coming.

Usually this lack of oversight, as the CQC tends to describe it, is highlighted in the ‘Well-led’ section of the report.  Furthermore, it is often linked to a breach of Regulation 17 (Good Governance) of the Health and Social Care Act.   What this usually means is that the service provider did not have adequate systems and processes for monitoring quality of care across the five domains (Safe, Effective, Caring, Responsive, Well-led). If they had had such systems and processes in place the chances are that they would have been aware of the issues highlighted in the CQC report and addressed them well before the inspection team arrived.

In a previous post I argued that it is essential for managers to see ‘the big picture’ regarding their service because without it they are essentially flying blind.  Furthermore, this will simply exacerbate the level of crisis management and ‘fire-fighting’ that already tends to be the day-to-day norm for most managers.  But this then begs the question: how does a busy manager, already locked into crisis management mode, find the time and energy to see the ‘bigger picture’ and gain oversight of the whole service?

As readers of this blog will probably know already I have consistently advocated using some version of the CQC’s own inspection methodology in order to provide an overarching framework for quality assurance and good governance.  The reason for this is simple: when the CQC carries out its inspections all they are doing is ‘mapping-out’ quality across the whole service.  The domains and key lines of enquiry (KLOEs) are simply a way to ‘break-down’ quality into manageable ‘slices’.  The KLOEs are the nearest thing the CQC has to a ‘measure’ or ‘metric’ of quality, and the inspection process is essentially a matter of gathering evidence for each KLOE, even if this is not explicitly stated during the inspection process or in the report.  And it is this body of evidence which provides the material for the overall ‘quality map’  and is the basis for the inspection report and ratings.

It would seem to be sensible, therefore, if managers were able to do their own ‘quality mapping’, rather than simply waiting for the CQC’s next inspection.  Furthermore, it would seem to make even more sense to carry out this process on a continuous basis so that the manager always has an up-to-date ‘map’ or ‘picture’ of the service.  In other words, they have continuous oversight of the service.

Of course, the CQC’s framework, based on the domains and KLOEs, is not the only way to ‘map-out’ a service; managers are quite at liberty to devise their own set of ‘quality metrics’ and to collect evidence for these.  However, it seems a bit pointless to reinvent the wheel, so to speak, when there is a perfectly workable system already in existence.  It is also worth pointing out that if the service is using an oversight framework that is essentially harmonised with the CQC’s then it becomes much easier to share information with them.  It also means the service provider is ‘speaking the same language’ as the CQC, which can only make communication between the service and the Commission much easier.

In terms of the practicalities of setting up such an overarching framework for quality monitoring, there are a number of different ways to do this, and some providers like to build their own system.  However, for those that don’t have the time, expertise or inclination to do this then one option is to use Therapeia’s own KLOE Audit Toolkit which contains all the necessary resources to identify, collect, analyse and report KLOE evidence on a continuous basis.  Whichever system you use, however,  it is essential that it gives you a comprehensive overview of the whole service and is kept continually up to date.

But to return to my original question: how does a busy manager, already locked into crisis management mode, find the time and energy to see the ‘bigger picture’ and gain oversight of the whole service?  There is no easy answer to this question, but it is worth remembering the following points.  Firstly, having continuous oversight of the service will in itself help alleviate the need for crisis management in the first place.  Often crisis situations arise because the manager is not seeing the wider picture, and is being perpetually reactive rather than proactive.  Secondly, although it might seem like a lot of time and effort to gather evidence for all the KLOEs, once the first ‘cycle’ of the evidence collection process has been completed then it does not take much time and effort to keep the evidence up to date.  This is because much of it remains the same over relatively long periods, for example, policies and procedures.  This means that only evidence that dates quickly, for example staffing rotas and care notes, needs to be reviewed and updated on a regular basis.  And thirdly, if the KLOE auditing process is made part of a manager’s daily routine then it soon becomes second nature and takes up very little time each day.