Staying one step ahead of the CQC

In my experience, many providers and service managers regard Care Quality Commission (CQC) inspections as something to be endured rather than welcomed.   However, it is always worth remembering that the whole purpose of these inspections is to ensure that each service is safe, effective, caring, responsive and well-led.  And the key point here is that there is nothing to stop providers and managers doing this themselves. In fact, according to the CQC, continuous service monitoring is the cornerstone of good leadership and governance.  In CQC parlance, this is all part of developing a 'Well-led' service. 

Therapeia can help you ensure that your service is well-led by:

  1. Conducting a review and assessment of the leadership and governance of your service.  This is based around using the CQC's Key Lines of Enquiry (KLOEs) for the 'Well-led' domain. Once the process is completed it is hoped that managers and providers will continue to conduct their own reviews and assessments on an ongoing basis.
  2. Providing access to an online Self-Assessment Tool, which allows you to conduct your own, continuous service monitoring.  This is based on collecting evidence for all of the service's KLOEs using the CQC's own methodology.
  3. Conducting an analysis and diagnosis of your own evidence, in order to help you ascertain whether such information is helpful both for your own management needs, and to satisfy the CQC that you are providing a quality service that is based on strong leadership and robust governance.

Please click on the relevant tab above to find out more about each option.

It is clear from the CQC's own ratings data that in adult social care services there is a strong correlation between the ratings figures for ‘Well-led’ and the overall rating figures.  In other words, services that have positive ratings for ‘Well-led’ tend to have positive ratings for the other four domains (‘Safe’, ‘Effective’, ‘Caring’ and ‘Responsive’).  And, needless to say, the reverse is also true: those services with a negative rating for ‘Well-led’ tend to do badly across the other domains as well. Furthermore, the CQC's latest State of Care report highlights the fact that strong and effective leadership, coupled with robust systems of governance, are key to the overall performance and quality of any service.

With this is mind, Therapeia can provide a through review and assessment of the leadership and governance within your service, and how this impacts on issues such as team working, service culture, and quality assurance systems.  The review process is based on an initial gathering evidence for the five CQC 'Well-led' key lines of enquiry (KLOEs), but can extend beyond this if the evidence suggests there might be more underlying issues that need exploring.  The aim is to give you a comprehensive assessment of the quality of leadership and governance within your service.  This is in turn will provide you with a better understanding of the overall quality of your service, and the opportunity to address any outstanding issues before the next CQC inspection.

However, unlike CQC inspections, the aim of the assessment process is primarily to provide a learning experience for the service and its management.  Therefore, rather than trying to replicate exactly the same conditions as a 'live' CQC inspection, the focus here is to work closely with the service manager in order to help them gain a better understanding of how well-led their service actually is, and what this might mean in terms of how safe, effective, caring and responsive it is. This means that when an actual CQC inspection does occur they will be much better prepared, and, hopefully, will have already identified and addresses any outstanding problems.  Furthermore, following the initial review and assessment, the process can be conducted on an ongoing basis by the provider or manager themselves, rather than simply being used to help them prepare for CQC inspections.

Each service review and assessment follows broadly the same pattern:

  1. An initial, pre-visit evaluation of the service, collecting relevant background information regarding the service. This is similar to the pre-inspection work carried out by the CQC.
  2. An onsite visit to the service for at least one full day, depending on the size and complexity of the service. This is in order to meet and talk with key stakeholders, including service users, relatives, staff, management and visiting professionals to get their perspectives on the leadership and governance of the service.  It also provides an opportunity to gain a better understanding of the overall culture and ethos of the service.
  3. A review of all key documentation relating to leadership and governance, for example, quality assurance reports, management strategies, stakeholder feedback information, supervision records, etc.  As far as possible, this will be conducted off-site using document uploads, emailing, etc.
  4. A thorough analysis and assessment of the gathered evidence, which is then used to write a detailed report with recommendations for the provider.

Therapeia’s online Self Assessment Tool aims to encourage providers and service managers to use the CQC's own inspection methodology in order to conduct their own quality assurance (QA) reviews on an ongoing basis.  It can either be used an an alternative to having Therapeia conduct its own full assessment of your service, or as a follow-up to such an assessment, in order that you can continue the QA process at your own pace.

You can use the tool to collect evidence of quality across different aspects (‘domains’ in CQC jargon) of the service using the CQC’s key lines of enquiry (KLOEs). This allows you to build up a picture (or ‘map’) of quality based on up-to-date information. One of the great advantages of the tool is that you can add and update evidence with a few clicks of the mouse and keyboard. It also means you can essentially conduct an ‘inspection’ or self-assessment of your service on an ongoing basis, and be continually gathering and updating evidence.

By spending only 30 minutes a day using the Self-Assessment Tool, it is possible to build up a complete picture of quality, based on the 25 KLOEs, in less than a month. This is based on the good practice of collecting a minimum of three pieces of evidence per KLOE.

Please take a look at this demo table which shows you the type of information the Self-Assessment Tool can track and record.

The underlying philosophy behind Self-Assessment Tool is quite simple: quality and quality assurance should be at the heart of any service, not just an afterthought or add-on. And remember: CQC inspections are just QA conducted by an external agency, nothing more and nothing less.

Please click here to register an account so you can use the Self-Assessment Tool. And please click here to begin entering your own data.

Please note: you will need to pay a one-off registration fee £249.99 to access and use the CQC Self-Assessment Tool. This price includes any updates to the Tool, as long as these do not reflect any major changes to CQC's inspection methodology. It is also considerably cheaper than hiring someone to come out and conduct an onsite ‘mock inspection’ (though Therapeia can offer this as well!). Please also note: payments are made through the Stripe payment gateway, which is a very tried, tested and secure online payment system.


In addition to providing service reviews and assessments, and the online Self-Assessment Tool, Therapeia can also provide an analysis of the evidence that providers and managers may being collecting, either with the Self-Assessment Tool or their using their own system.  Sometimes it is not easy to be able to interpret the value or relevance of such information, or what it means in terms of a potential rating for the service.  Because of my background in CQC inspections and change management over the last 20 years or so, I feel I am well-placed to give an honest assessment of the evidence, and to suggest any remedial work that may be required to improve service quality.

If you would like to find out more about how Therapeia  help you stay one step ahead, please call me on 07712 176180 or email me.  Alternatively, you can contact Therapeia using the form below.

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