What are the CQC Key Lines of Enquiry?

September 12, 2020

CQC will carry out inspections on your service based on the five Key Lines of Enquiry.

Usually an inspection will focus on certain areas such as SAFE or WELL LED, please use the list below to see exactly how each of these areas can be broken down and what questions your inspector will need answers for.

Our Mock-Inspection Toolkits are available to customers and these enable Managers to measure current practices against the ‘Outstanding’, ‘Good’, ‘Requires Improvement’ and ‘Inadequate’ ratings.

Following these guides, Managers will be able to get a good idea of what rating they may receive following current practices and ways the service could improve, including the types of evidence that would demonstrate how the service follows each KLOE in line with the different ratings. They also include action plans so Managers can highlight points for improvement and start implementing them as soon as possible, helping them to feel prepared for their inspection wether it has been scheduled or not. Forward planning in this way also shows the service is striving for improvements and working towards the highest standard of care delivery.

SAFE

How do systems, processes and practices safeguard people from abuse?

S1.1	How are safeguarding systems, processes and practices developed, implemented and communicated to staff?
S1.2	How do systems, processes and practices protect people from abuse, neglect, harassment and breaches of their dignity and respect? How are these monitored and improved?
S1.3	How are people protected from discrimination, which might amount to abuse or cause psychological harm? This includes harassment and discrimination in relation to protected characteristics under the Equality Act.
S1.4	How are people supported to understand what keeping safe means, and how are they encouraged and empowered to raise any concerns they may have about this? If people are subject to safeguarding enquiries or an investigation, are they offered an advocate if appropriate or required?

How are risks to people assessed and their safety monitored and managed so they are supported to stay safe and their freedom is respected?

S2.1	What arrangements are there to manage risks appropriately, and to make sure that people are involved in decisions about any risks they may take?
S2.2	How do risk management policies and procedures minimise restrictions on people’s freedom, choice and control, in particular for people who lack mental capacity?
S2.3	Are people’s records accurate, complete, legible, up-to-date, securely stored and available to relevant staff so that they support people to stay safe?
S2.4	Are formal and informal methods used to share information with appropriate parties on risks to people’s care, treatment and support?
S2.5	Are there thorough, questioning and objective investigations into whistleblowing or staff concerns, safeguarding, and accidents or incidents? Are action plans developed, and are they monitored to make sure they are delivered?
S2.6	How is equipment, which is owned or used by the provider, managed to support people to stay safe? How are the premises and safety of communal and personal spaces (such as bedrooms) and the living environment checked and managed to support people to stay safe? How does the provider manage risks where they provide support in premises they are not responsible for?
S2.7	How do staff seek to understand, prevent and manage behaviour that the service finds challenging? How are individuals supported when their behaviour challenges? How well does this align with best practice?

How does the service make sure that there are sufficient numbers of suitable staff to support people to stay safe and meet their needs?

S3.1	What arrangements are there, including within the rotas, for making sure that staff have the right mix of skills, competencies, qualifications, experience and knowledge, to meet people’s individual needs?
S3.2	How is safety promoted in recruitment practices, arrangements to support staff, training arrangements, disciplinary procedures, and ongoing checks?
S3.3	Do staff receive effective training in safety systems, processes and practices?

How does the provider ensure the proper and safe use of medicines?

S4.1	Is the service’s role in relation to medicines clearly defined and described in relevant policies, procedures and training? Is current and relevant professional guidance about the management of medicines followed?
S4.2	How does the service make sure that people receive their medicines (both prescribed and non- prescribed) as intended (including controlled drugs and ‘as required’ medicines), and that this is recorded appropriately?
S4.3	How are medicines ordered, transported, stored, and disposed of safely and securely in ways that meet current and relevant legislation and guidance?
S4.4	Are there clear procedures for giving medicines covertly, in line with the Mental Capacity Act 2005?
S4.5	How does the service make sure that people’s behaviour is not controlled by excessive or inappropriate use of medicines?
S4.6	How do staff assess the level of support a person needs to take their medicines safely, particularly where there are difficulties in communicating, when medicines are being administered covertly, and when undertaking risk enablement assessments designed to promote self-administration?
S4.7	How does the service engage with healthcare professionals in relation to reviews of medicines at appropriate intervals?
S4.8	How do staff make sure that accurate, up-to-date information about people’s medicines is available when people move between care settings? How do medicines remain available to people when they do so?

How well are people protected by the prevention and control of infection?

S5.1	What are the arrangements for making sure that premises are kept clean and hygienic so that people are protected from infections that could affect both staff and people using services?
S5.2	Do staff understand their roles and responsibilities in relation to infection control and hygiene?
S5.3	Are policies and procedures maintained and followed in line with current relevant national guidance?
S5.4	Where it is part of the service’s role to respond to and help to manage infections, how does the service make sure that it alerts the right external agencies to concerns that affect people’s health and wellbeing?
S5.5	Have all relevant staff completed food hygiene training and are correct procedures in place and followed wherever food is prepared and stored?

Are lessons learned and improvements made when things go wrong?

S6.1	Do staff understand their responsibilities to raise concerns, to record safety incidents, concerns and near misses, and to report them internally and externally, where appropriate?
S6.2	What are the arrangements for reviewing and investigating safety and safeguarding incidents and events when things go wrong? Are all relevant staff, services, partner organisations and people who use services involved in reviews and investigations?
S6.3	How are lessons learned and themes identified, and is action taken as a result of reviews and investigations when things go wrong?
S6.4	How well is the learning from lessons shared to make sure that action is taken to improve safety across relevant parts of the service? Do staff learn from reviews and investigations by other services and organisations?
S6.5	How effective are the arrangements to respond to relevant external safety alerts, recalls, inquiries, investigations or reviews?

CARING

How does the service ensure that people are treated with kindness, respect and compassion, and that they are given emotional support when needed?

C1.1	Are people treated with kindness and compassion in their day-to-day care and support?
C1.2	How does the service make sure that people, and those close to them, feel they matter, and that staff listen to them and talk to them appropriately and in a way they can understand?
C1.3	Do staff seek accessible ways to communicate with people when their protected and other characteristics under the Equality Act make this necessary to reduce or remove barriers?
C1.4	Do staff know and respect the people they are caring for and supporting, including their preferences, personal histories, backgrounds and potential?
C1.5	Do staff show concern for people’s wellbeing in a caring and meaningful way, and do they respond to their needs quickly enough?
C1.6	Do staff understand and promote compassionate, respectful and empathetic behaviour within the staff team?

How does the service support people to express their views and be actively involved in making decisions about their care, support and treatment as far as possible?

C2.1	Do staff recognise when people need and want support from their carers, advocates or representatives to help them understand and be involved in their care, treatment and support? How do staff help people to get this support?
C2.2	Do staff make sure they give information to people, their families and other carers about external bodies, community organisations and advocacy services that can provide independent support and advice, answer questions about their care, treatment and support, and, where necessary, advocate for them? How does the service support people to contact and use these services?
C2.3	Does the service give staff the time, training and support they need to provide care and support in a compassionate and personal way? Are rotas, schedules and practical arrangements organised so that staff have time to listen to people, answer their questions, provide information, and involve people in decisions?

How are people’s privacy, dignity and independence respected and promoted?

C3.1	How does the service and staff make sure that people’s privacy and dignity needs are understood and always respected, including during physical or intimate care?
C3.2	Do staff respond in a compassionate, timely and appropriate way when people experience physical pain, discomfort or emotional distress?
C3.3	How are people assured that information about them is treated confidentially in a way that complies with the Data Protection Act, and that staff respect their privacy?
C3.4	How does the service take people’s preferences and needs and their protected and other characteristics under the Equality Act into account when scheduling staff?
C3.5	Can people be as independent as they want to be?
C3.6	Are people’s relatives and friends made to feel welcome and able to visit without being unnecessarily restricted?
C3.7	How does the service make sure that young adults have choice and flexibility about their privacy and the amount of parental involvement in managing their care and support after moving into adult services?

EFFECTIVE

Are people’s needs and choices assessed and care, treatment and support delivered in line with current legislation, standards and evidence-based guidance to achieve effective outcomes?

E1.1	Are people’s physical, mental health and social needs holistically assessed, and is their care, treatment and support delivered in line with legislation, standards and evidence-based guidance, including NICE and other expert professional bodies, to achieve effective outcomes?
E1.2	What processes are in place to ensure there is no discrimination, including in relation to protected characteristics under the Equality Act, when making care and support decisions?
E1.3	How is technology and equipment used to enhance the delivery of effective care and support, and to promote people’s independence?

How does the service make sure that staff have the skills, knowledge and experience to deliver effective care and support?

E2.1	Do people have their assessed needs, preferences and choices met by staff with the right qualifications, skills, knowledge and experience?
E2.2	Are staff supported to keep their professional practice and knowledge updated in line with best practice?
E2.3	Do staff and any volunteers have effective and regular mentorship, support, induction, supervision, appraisal and training?

How are people supported to eat and drink enough to maintain a balanced diet?

E3.1	How are people involved in decisions about what they eat and drink and how are their cultural and religious preferences met?
E3.2	How are people supported to have a balanced diet that promotes healthy eating and the correct nutrition?
E3.3	Are meals appropriately spaced and flexible to meet people’s needs, and do people enjoy mealtimes and not feel rushed?
E3.4	How are risks to people with complex needs identified and managed in relation to their eating and drinking?

How well do staff, teams and services within and across organisations work together to deliver effective care, support and treatment?

E4.1	How do staff work together to ensure that people receive consistent, timely, coordinated, person-centred care and support when they are referred to, use, leave, or move between, different services?

How are people supported to live healthier lives, have access to healthcare services and receive ongoing healthcare support?

E5.1	How are people’s day-to-day health and wellbeing needs met?
E5.2	How does the service make sure that people can understand the information and explanations about their healthcare and treatment options, including medicines, and their likely outcomes?
E5.3	How are people involved in regularly monitoring their health?
E5.4	Can people access care, support and treatment in a timely way and, where the service is responsible, are referrals made quickly to appropriate health services when people’s needs change?

How are people’s individual needs met by the adaptation, design and decoration of premises?

E6.1	How are people involved in decisions about the environment?
E6.2	How do the premises meet people’s diverse care, cultural and support needs?
E6.3	What arrangements are there to ensure people have access to appropriate space: • in gardens and other outdoor spaces • to see and look after their visitors • for meaningful activities • to spend time together • to be alone?
E6.4	How does the signage, the decoration and other adaptations to the premises help to meet people’s needs and promote their independence? How are any changes to the environment managed to avoid causing distress to people who live there?

Is consent to care and treatment always sought in line with legislation and guidance?

E7.1	Do staff understand the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004 and other relevant national guidance?
E7.2	How are people supported to make their own decisions in line with relevant legislation and guidance?
E7.3	How and when is possible lack of mental capacity to make a particular decision assessed and recorded?
E7.4	How is the process for seeking consent monitored and reviewed to ensure it meets legal requirements and follows relevant national guidance?
E7.5	When people lack the mental capacity to make a decision, how do staff ensure that best interests decisions are made in accordance with legislation?
E7.6	How does the service promote supportive practice that avoids the need for physical restraint? Where physical restraint may be necessary, how does the service ensure that it is used in a safe, proportionate, and monitored way as part of a wider person-centred support plan?
E7.7	Do staff recognise when people aged 16 and over, who lack mental capacity, are being deprived of their liberty, and do they seek authorisation to do so when they consider it necessary and proportionate?

RESPONSIVE

How do people receive personalised care that is responsive to their needs?

R1.1	How do people, or those with authority to act on their behalf, contribute to planning their care and support, and how are their strengths, levels of independence and quality of life taken into account?
R1.2	How does the service make sure that a person’s care plan fully reflects their physical, mental, emotional and social needs, including on the grounds of protected characteristics under the Equality Act? These should include their personal history, individual preferences, interests and aspirations, and should be understood by staff so people have as much choice and control as possible.
R1.3	Where the service is responsible, how are people supported to follow their interests and take part in activities that are socially and culturally relevant and appropriate to them, including in the wider community, and where appropriate, have access to education and work opportunities?
R1.4	Where the service is responsible, how are people encouraged and supported to develop and maintain relationships with people that matter to them, both within the service and the wider community, and to avoid social isolation?
R1.5	How does the service identify and meet the information and communication needs of people with a disability or sensory loss? How does it record, highlight and share this information with others when required, and gain people’s consent to do so?
R1.6	How is technology used to support people to receive timely care and support? Is the technology (including telephone systems, call systems and online/digital services) easy to use?

How are people’s concerns and complaints listened and responded to and used to improve the quality of care?

R2.1	How well do people who use the service know how to make a complaint or raise concerns and how comfortable do they feel doing so in their own way? How well are people encouraged to do so, and how confident are they to speak up?
R2.2	How easy and accessible is it for people to use the complaints process or raise a concern? To what extent are people treated compassionately and given the help and support they need to make a complaint?
R2.3	How effectively are complaints handled, including ensuring openness and transparency, confidentiality, regular updates for the complainant, a timely response and explanation of the outcome, and a formal record?
R2.4	How are people who raise concerns or complaints protected from discrimination, harassment or disadvantage?
R2.5	To what extent are concerns and complaints used as an opportunity to learn and drive continuous improvement?

How are people supported at the end of their life to have a comfortable, dignified and pain-free death?

R3.1	Are people’s preferences and choices for their end of life care and where they wish to die, including in relation to their protected equality characteristics, spiritual and cultural needs, clearly recorded, communicated, kept under review and acted on?
R3.2	How are people, and their family, friends and other carers, involved in planning, managing and making decisions about their end of life care?
R3.3	How are people reassured that their pain and other symptoms will be assessed and managed effectively as they approach the end of their life, including having access to support from specialist palliative care professionals, particularly if they are unable to speak or communicate?
R3.4	How does the service make sure that it quickly identifies people in the last days of life whose condition may be unpredictable and change rapidly and, where required, that people have rapid access to support, equipment and medicines?
R3.5	How does the service support people’s families, other people using the service and staff when someone dies?
R3.6	What arrangements are there for making sure that the body of a person who has died is cared for in a culturally sensitive and dignified way?

WELL LED

Is there a clear vision and credible strategy to deliver high-quality care and support, and promote a positive culture that is person-centred, open, inclusive and empowering, which achieves good outcomes for people?

W1.1	Are managers aware of, and do they keep under review, the day-to-day culture in the service, including the attitudes, values and behaviour of staff and whether they feel positive and proud to work in the organisation?
W1.2	How does the service promote and support fairness, transparency and an open culture for staff?
W1.3	How do managers make sure that staff are supported, respected and valued; have their rights and wellbeing protected; and are motivated, caring and open?
W1.4	Does the service show honesty and transparency from all levels of staff and leadership following an incident? How is this shared with people using the service and their families in line with the duty of candour, and how does the service support them?
W1.5	Do leaders have the skills, knowledge, experience and integrity they need to lead effectively – both when they are appointed and on an ongoing basis?
W1.6	Does the service have, and keep under review, a clear vision and a set of values that includes a person- centred culture, involvement, compassion, dignity, independence, respect, equality, wellbeing and safety? How do leaders make sure these are effectively embedded into practice? Do all staff understand and promote them?
W1.7	Is the leadership visible and capable at all levels and does it inspire staff to provide a quality service?
W1.8	Do managers and staff have a shared understanding of the key challenges, achievements, concerns and risks?
W1.9	How does the organisation promote equality and inclusion within its workforce?
W1.10	Are there cooperative, supportive and appreciative relationships among staff? Do staff and teams work collaboratively, share responsibility and resolve conflict quickly and constructively?

Does the governance framework ensure that responsibilities are clear and that quality performance, risks and regulatory requirements are understood and managed?

W2.1	Do staff receive feedback from managers in a constructive and motivating way, which enables them to know what action they need to take?
W2.2	Where required, is there a registered manager in post?
W2.3	Does the registered manager understand their responsibilities, and are they supported by the board/trustees, the provider and other managers to deliver what is required?
W2.4	Are all relevant legal requirements understood and met, including CQC registration requirements, safety and public health related obligations, and the submission of notifications and other required information? Do managers understand recommendations made by CQC, keep up-to-date with all relevant changes, and communicate them effectively to staff?
W2.5	How does the service make sure that responsibility and accountability is understood at all levels so that governance arrangements are properly supported? Do staff know and understand what is expected of them?
W2.6	Are there clear and transparent processes for staff to account for their decisions, actions, behaviours and performance?
W2.7	How does the service make sure that its approach to quality is integral and all staff are aware of potential risks that may compromise quality?
W2.8	How does the service assure itself that it has robust arrangements (including appropriate internal and external validation) to ensure the security, availability, sharing and integrity of confidential data, and records and data management systems, in line with data security standards? Are lessons learned when there are data security breaches?

How are the people who use the service, the public and staff engaged and involved?

W3.1	How are staff actively involved in developing the service? Are they encouraged to be involved in considering and proposing new ways of working, including ways of putting values into practice?
W3.2	Are there strong links with the local community? How has the service strengthened relationships beyond the key organisations?
W3.3	How are staff supported to question practice and how are people who raise concerns, including whistleblowers, supported and protected?
W3.4	How does the service enable and encourage accessible open communication with all people who use the service, their family, friends, other carers, staff and other stakeholders, taking account of their protected and other characteristics?
W3.5	How are people’s views and experiences gathered and acted on to shape and improve the services and culture?

How does the service continuously learn, improve, innovate and ensure sustainability?

W4.1	Are resources and support available to develop staff and teams, and drive improvement?
W4.2	How effective are quality assurance, information and clinical governance systems in supporting and evaluating learning from current performance? How are they used to drive continuous improvement and manage future performance?
W4.3	How is success and innovation recognised, encouraged and implemented?
W4.4	How is information from incidents, investigations and compliments learned from and used to drive quality?
W4.5	How does the service measure and review the delivery of care, treatment and support against current guidance?
W4.6	Are information technology systems used effectively to monitor and improve the quality of care?

How does the service work in partnership with other agencies?

W5.1	How does the service work in partnership with key organisations, including the local authority, safeguarding teams and clinical commissioning groups and multidisciplinary teams, to support care provision, service development and joined-up care? Does it do so in an open, honest and transparent way?
W5.2	Does the service share appropriate information and assessments with other relevant agencies for the benefit of people who use the service?

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What are the CQC Key Lines of Enquiry?