Way back in the June 2013 publication, A new start: Consultation on changes to the way CQC regulates, inspects and monitors care, the CQC explained that it was committed to ensuring people within the system receive safe, effective, high-quality care, and implemented numerous changes to encourage care services to improve. One major change was the introduction of the CQC's Key Lines of Enquiry (KLOE).
The Key Lines of Enquiry all sit under five central questions, that inspectors use to help establish whether a service is providing the high standard of care expected of them. Here are those questions:
Is your service...
Safe? Service users, staff and visitors are protected from abuse and avoidable harm.
Effective? People’s care, treatment and support achieve good outcomes, promote a good quality of life and are evidence-based where possible.
Caring? Staff involve and treat people with compassion, kindness, dignity and respect.
Responsive? Services are organised so that they meet people’s needs.
Well-led? Leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, supports learning and innovation, and promotes an open and fair culture.
The Key Lines of Enquiry (KLOE)
Inspectors then use a set of standard KLOEs that are directly linked to the five key questions listed above. These include a set of 16 mandatory KLOEs which address the key priorities of every service, such as, “How are people protected from bullying, harassment, avoidable harm, abuse and breaches of their human rights?”. The mandatory KLOEs are included at the end of this article.
Inspectors may also select additional KLOEs which will support their effort to determine the quality and identify risks. An example of an additional question an inspector may choose to ask is, “How are people supported at the end of their life to have a private, comfortable, dignified and pain-free death?”. A list of all current KLOEs is available to providers and is listed in the consultation handbook, Appendices to provider handbook: Community adult social care services.
When deciding what additional KLOEs to use when inspecting your care service, the inspector will consider what they know and have been told about your service already. In addition, if they happen to encounter other areas of concern or good practice during the inspection itself, they can bring new KLOEs into the equation.
There has been a level of confusion from some care providers around how the inspectors measure the answers to KLOEs. Within their report, A fresh start for the regulation and inspection of adult social care: Working together to change how we inspect and regulate adult social care services, the CQC outlined that they will, “…use these questions when making decisions about registering providers; as a framework for our use of data, evidence and information in our surveillance of services; and in our guidance, inspections, ratings and published inspection reports”.
It is important to remember that the KLOEs selected frame for each inspection and because they can alternate from one inspection to the next, you really need to understand and be prepared for all of them to have the best chance of securing a Good or Outstanding rating. The diagram illustrates this and emphasises the influence of the selected KLOEs over the rest of the inspection process:
Source: Care Quality Commission Provider Handbook: Adult social care services
The KLOE prompts
Under each Key Line of Enquiry there are a further set of what the CQC calls 'prompts'. For example here is Key Line of Enquiry S3 (under the key question 'is the service safe?') with its associated prompts:
It has to be said that these prompts are a guide, not an exhaustive list or checklist that has to be followed. However, the guidance still plays a significant role in the inspection and the inspector's decision making, being the foundation which the inspector's own judgement and factors that become apparent during an inspection are built upon. Familiarising yourself with the prompts can also give you a window into how inspectors work and the ways in which they are supposed to approach inspecting a service.
You can find more CQC prompts along with their Key Lines of Enquiry here
During the inspection
As we already discussed, before a site visit inspectors will select which KLOEs they intend to use based on an ‘information pack’ the CQC provides to its inspectors. This pack is collated from information provided by people who use the service, stakeholders and from the provider itself. Once at a site visit, inspectors will then indicate which KLOEs they will be inspected to the responsible persons and will gather evidence by talking to service users, visitors and staff, observing care, as well as reviewing records and tracking individual care pathways.
Having accurate, up-to-date, complete and easily accessible records used was, and for some care providers, still is a massive headache and a source of anxiety when it comes to inspections. The use of digital care records has made this aspect of inspections more of a strength than a weakness for those providers that have embraced the technology. It's not just that digital records have a level of reliability way beyond that of paper, it's also the additional, often forgotten elements such as inbuilt time and date stamping and audit logs that make providing evidence or proof so much easier.
Regardless of the records you use and their reliability, speaking to people that use your service, visitors and staff remain a core component of evidence gathering. Bear in mind this can extend to catering and cleaning staff, not just care workers and managers. If inspectors are not able to speak to the people they wanted to during the inspection, then they may arrange to do so outside of that timeframe.
Finally, when deciding what questions to ask people it is our old friend the Key Lines of Enquiry that guide the inspector. Although the answers given and information provided may cause the inspector to add in additional KLOEs, they will still be looking for evidence that relates to answering those originally selected Key Lines of Enquiry too.
Mastering the KLOEs and being best prepared for your next inspection
Preparing for a CQC inspection can be difficult even when you have all the knowledge and best practice to hand. Many care providers are more confident and prepared for care inspections with the help of Access Care Compliance. It's unique, and uses the CQC's frameworks to guide you through mock inspections and makes your auditing processes less time-consuming, more targeted and effective.
Available for providers of all sizes and from across social care, whether domiciliary, residential, supported living and so on, take a look at these case studies from Aspire Care Group, Minster Care Group and New Directions Flexible Social Care. For a fully guided demonstration of Access Care Compliance complete this form or find out more here.
The Mandatory Key Lines of Enquiry
Below are the mandatory Key Lines of Enquiry for residential and community care services. Please note that E5 is a residential KLOE only. It does not apply to community services.
Safe:
- S1: How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?
- S2: How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected?
- S3: How does the service make sure that there are sufficient numbers of suitable staff to keep people safe and meet their needs?
- S4: How are people’s medicines managed so that they receive them safely?
Effective:
- E1: How do people receive effective care, which is based on best practice, from staff who have the knowledge and skills they need to carry out their roles and responsibilities?
- E2: Is consent to care and treatment always sought in line with legislation and guidance?
- E3: How are people supported to have sufficient to eat, drink and maintain a balanced diet?
- E4: How are people supported to maintain good health, have access to healthcare services and receive ongoing healthcare support?
- E5: How are people’s individual needs met by the adaptation, design and decoration of the service?
Caring:
- C1: How are positive caring relationships developed with people using the service?
- C2: How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support?
- C3: How is people’s privacy and dignity respected and promoted?
Responsive:
- R1: How do people receive personalised care that is responsive to their needs?
- R2: How does the service routinely listen and learn from people’s experiences, concerns and complaints?
Well-led:
- W1: How does the service promote a positive culture that is person-centred, open, inclusive and empowering?
- W2: How does the service demonstrate good management and leadership?
- W3: How does the service deliver high quality care?
Taken from CQC's ASC inspection handbook October 2014 v 2 00
While we do our utmost to assure the information contained in this article and our other articles is accurate and up to date we are not responsible for any provider's inspection preparedness or any negative consequences that result from incorrect information. Please make use of all resources provided by the CQC to ensure you are as informed as possible.
