Registration with the Care Quality Commission (CQC) is a starting point of the official service delivery for any organisation providing regulated care in people’s homes in England. At the same time, the registration is a final point of the pre-delivery journey, as each organisation needs to show an understanding of and compliance with the CQC requirements, create organisational structures and systems and recruit relevant staff.
The aim of this toolkit chapter isto offer practical advice on how a community based care co-op would go about securing CQC registration. The text explores:
- care and what options those who need care have
- regulatory context - what is and what is not regulated care
- CQC’s role, and
- organisational requirements, staffing, the process of registration and what needs to be gathered, written up and submitted.
It is worth noting that the CQC does not distinguish between standard-for-profit businesses and co-operatives or social enterprises (whatever their specific legal status). Therefore any specific practice, policies or structures connected to the type of the organisation setting up to deliver domiciliary care work is not reflected here. The toolkit explores different organisation models, governance and ways of working in the Getting organised chapter.
Care - options and regulatory context
Most of us will need some care and support in some stages of our lives. We mainly tend to think about people who are older or those who live with physical, learning or other disabilities. Some people might need care or extra support after an injury or during/after an illness.
It may be that someone will not need extra help from professionals during this time and that family or community members will be able to offer required support. This might change over time - everyone’s needs and level of care might shift depending on the situation.
It is worth mentioning that when someone is looking after somebody informally, they might also need support for themselves. There are organisations and services which offer support with many aspects of a carer's life and needs, such as taking a break. Carers are also entitled to claim certain benefits and get other practical help from statutory bodies, e.g. local councils or social services.
When someone needs or decides to get professional support, there will be some options they have, again, depending on their situation. Some people might need or want to live somewhere where the care will be provided round the clock - this is called residential care. There are different types of residential care and there is help and support available when decisions are being made about the most suitable place to get support from.
On the other hand many people wish to and be able to stay in their own home. The house or flat might need adaptations (e.g. when mobility changes), people could move in and stay in housing with support (e.g. sheltered accommodation), and/or someone might just need extra support and care for a shorter or longer period of time in their current home. The care people receive at home is called domiciliary care. Since the aim of this toolkit is to support groups and organisations who want to run community based co-operative care services, we are concentrating on this way of providing care.
Regulated and non-regulated care and support
It is essential to mention that as part of the care and support someone might need, there are some activities which are regulated - that means that the organisation/company doing such work needs to be registered for this work with a relevant authority, in England that is the Care Quality Commission (CQC), see more on that below. In fact, when we talk about domiciliary or residential care we generally refer to regulated elements of this support because such care will very likely involve personal care, which is classed as a regulated activity.
Specifically, personal care involves supporting people with things like washing, bathing or cleaning themselves, getting dressed or going to the toilet. It also includes assisting to eat as well as advice, encouragement and emotional and psychological support. Other ways of supporting people are not bound by the regulatory framework, e.g. cleaning, household tasks or shopping. Currently, these two elements of support are often disconnected, delivered by different people or organisations and are not coordinated enough.
The model of care delivery CCCV is envisaging to deliver wants to re-connect these and engage the local community and both staff and volunteer members in supporting more holistic and person centred care provision. Our toolkit’s chapter Community Care Services explores the benefits and possibilities which coordination and mutual interconnection of the additional layers of care and support can have - from shopping to befriending, to spending time together on common hobbies and keeping those who need care more active and feeling better for longer.
It is worth noting that practically, from a perspective of a newly emerging service provider, it is important to consider both elements of care equally (regardless of whether these are regulated or not) in context of both quality of the services and processes which ensure health and safety, safeguarding and other key issues; i.e. internal policies and procedures need to cover both.
What is the Care Quality Commission (CQC)?
Now that we know registration with CQC is necessary if you want to care for and support people in their homes, let’s have a look at the body itself. CQC regulates all health and social care services in England. The commission ensures the quality and safety of care in hospitals, dentists, ambulances, care homes and the care given in people’s own homes.
CQC is funded by the Department of Health and Social Care and acts as an independent watchdog that inspects the registered care providers to make sure the services they provide come up to scratch. By law, all care providers in the UK must provide services to minimum standards of safety and quality.
What does CQC do?
CQC registers care providers; following the registration monitors, inspects and rates the services; it protects and takes action on behalf of people who use the services and as an independent body publishes views on major issues in health and social care. CQC also oversees health and safety (H&S) investigations in context of care provision.
What does CQC want to see?
There are key standards, principles and ways of working that CQC expects all the providers to comply with and fulfil - both at the point of registration and on an ongoing basis, which is checked during the inspections.
The fundamental standards are the standards below which your care must never fall.
Everybody has the right to expect the following standards:
1) Person-centred care - You must have care or treatment that is tailored to you and meets your needs and preferences.
2) Dignity and respect - You must be treated with dignity and respect at all times while you're receiving care and treatment. This includes making sure:
- You have privacy when you need and want it.
- Everybody is treated as equals.
- You're given any support you need to help you remain independent and involved in your local community.
3) Consent - You (or anybody legally acting on your behalf) must give your consent before any care or treatment is given to you.
4) Safety - You must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Providers must assess the risks to your health and safety during any care or treatment and make sure their staff have the qualifications, competence, skills and experience to keep you safe.
5) Safeguarding from abuse - You must not suffer any form of abuse or improper treatment while receiving care. This includes:
- Degrading treatment
- Unnecessary or disproportionate restraint
- Inappropriate limits on your freedom.
6) Food and drink - You must have enough to eat and drink to keep you in good health while you receive care and treatment.
7) Premises and equipment - The places where you receive care and treatment and the equipment used in it must be clean, suitable and looked after properly. The equipment used in your care and treatment must also be secure and used properly.
8) Complaints - You must be able to complain about your care and treatment. The provider of your care must have a system in place so they can handle and respond to your complaint. They must investigate it thoroughly and take action if problems are identified.
9) Good governance - The provider of your care must have plans that ensure they can meet these standards. They must have effective governance and systems to check on the quality and safety of care. These must help the service improve and reduce any risks to your health, safety and welfare.
10) Staffing - The provider of your care must have enough suitably qualified, competent and experienced staff to make sure they can meet these standards. Their staff must be given the support, training and supervision they need to help them do their job.
11) Fit and proper staff - The provider of your care must only employ people who can provide care and treatment appropriate to their role. They must have strong recruitment procedures in place and carry out relevant checks such as on applicants' criminal records and work history.
12) Duty of candour - The provider of your care must be open and transparent with you about your care and treatment. Should something go wrong, they must tell you what has happened, provide support and apologise.
13) Display of ratings - The provider of your care must display their CQC rating in a place where you can see it. They must also include this information on their website and make our latest report on their service available to you.
This is a summary of the framework - CQC also provides a comprehensive practical overview (including related legislation) with a breakdown of what they expect the care provider to demonstrate at the point of registration and during the inspections.
Key features of service providers
Building on the main principles above, when CQC comes to inspect the care provider, they are framing their inspection around these five main questions, these are called key lines of enquiry (KLOEs).
- Are they safe? The care receivers are protected from abuse and avoidable harm.
- Are they effective? The care, treatment and support achieves good outcomes, helps the person to maintain quality of life and is based on the best available evidence.
- Are they caring? Staff treat the care receiver with compassion, kindness, dignity and respect.
- Are they responsive to people’s needs? Services are organised so that they meet the person’s needs.
- Are they well led? The leadership, management and governance of the organisation make sure it’s providing high-quality care that’s based around individual needs. It encourages learning and innovation, and it promotes an open and fair culture.
More about how the inspection works practically is below.
Journey with CQC as domiciliary care provider
As mentioned above, CQC registration is an official start of service delivery journey, prior to this, though, any organisation will need to ensure understanding and compliance with the intense regulatory framework and submit the application to register. Following that, once trading, recruiting, delivering and growing, ongoing quality assurance, compliance and cooperation with CQC in terms of queries will be required and inspections, which evaluate and rate the service, will take place.
The website of the Care Quality Commission (CQC) is the ultimate source of up to date information and contains relevant guidance for each step of the registration. Here, an overview of the steps offers a summary of the framework which will need to be cross-checked with the most recent information on the CQC website (e.g. there could be a temporary hold on registrations; new legislation might arise overtime, some of the regulatory framework might shift).
Before the application goes in
The application for registration will need to show that the organisation comply with the fundamental standards and key features of the service - as mentioned above. The organisation needs to take part in interviews, the official premises need to fulfil certain criteria and the nominated individual and proposed registered manager will also need to be involved.
The current key pieces of legislation (Summer 2020) for domiciliary care services are Health and Social Care Act 2008 and its associated regulations and Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
Registered Manager and Nominated Individual
Registered Manager (RM) and Nominated Individual (NI) are two key personnel who need to be part of the organisation for the service to be able to register.
It can be that a person who is in the team/organisation already is a registered manager, alternatively the organisation will need to recruit someone who will be able to apply to become one.
The RM needs to have
- relevant qualifications
- current, up to date training in: safeguarding, complaints handling, medication, consent, mental capacity, health and safety and human resources
- written proof of all your qualifications and completed training
- evidence that shows your competence, skills and experience
One of the first things you will need to do is to get a CQC countersigned DBS (Disclosure and Barring Services) check for the RM. According to the official guidance this can take up to 8 weeks.
The nominated individual (NI) is responsible for supervision of the delivered regulated activity. The person appointed is ideally a director, manager or secretary and
- is of good character
- is able to properly perform tasks that are intrinsic to their role
- has the necessary qualifications, competence, skills and experience to supervise the management of the regulated activity
- has supplied the documents that confirm their suitability
The application must include information about how appropriate the organisational premises are for the activity they are registering to deliver. In the case of domiciliary care, where the plan is to deliver personal care within people’s homes, this information still needs to be included because the regulated activity will be legally carried on and managed from this space. There are relevant elements of the premises, for example people’s records are to be kept safely and securely.
Policies and other documents/evidence
Alongside having key people in the team and having appropriate premises to run the service from, there are a few more documents which are required for the registration and will be checked as part of the assessment. It is worth noting again, that this list might shift and change and all aspiring providers would be strongly encouraged to get the update information from the CQC website.
The list as of Summer/Autumn 2020 is following:
- Provider application form
- Registered Manager application form
- Governance document
- Business plan
- Financial forecast
- Statement of financial viability from an accredited financial specialist
- Quality assurance system
- Statement of purpose
- Organisational structure and staffing structure
- Sample care plan
- Confirmation of registering with the Information Commissioner’s Office (ICO)
- Health and safety risk assessment (List of risk assessments)
- Emergency plan
List of policies and procedures (required at the time of our registration)
- Safeguarding policy and procedure
- Medication policy
- Recruitment policy
- Complaints policy
- Safety and security of the building policy
- Mental Capacity Act and Deprivation of Liberty Safeguards policy
- Equality and diversity policy
Current overview of regulatory standards and assessment framework (Autumn 2020)
CQC offers relevant guidance on how compliance with the requirements
- how to meet 28 points of regulatory standards at the point of registration and when inspections are being made: https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-providers-managers
- assessment framework for new registration (KLOEs): https://www.cqc.org.uk/sites/default/files/20180630_asc-registration-assessment-framework-with-sources-of-evidence_v009.pdf
Once the aspiring service provider is ready, the application to the CQC can be submitted
- this is done online: https://www.cqc.org.uk/guidance-providers/registration/try-our-new-online-registration-service
- the potential provider is needs to set up an account
- once the documents are submitted, the assessment process starts, the interview with the Registered Manager will follow
- CQC offers guidance on how to fill in the online form: https://www.cqc.org.uk/sites/default/files/20171218_900027_new_provider_application_form_guidance_all_providers_v2%282%29.pdf
- basic case studies of registration application which were refused/approved offer rough idea about what the regular is looking for: https://www.cqc.org.uk/guidance-providers/registration-notifications/domiciliary-care-agencies-personal-care-application
What happens during the registration online
Here is the current link (December 2020) to details about what is needed for registration: https://www.cqc.org.uk/guidance-providers/registration/register-new-provider-adult-social-care-residential-services
You will need some more information readily available to fill in the online application - the document which summarises the content of the application: https://drive.google.com/file/d/1QlgqFIgzzzD0PIJz-nTRgoKQJoQ8SL7K/view?usp=sharing
What happens next after your registration is successful
When the service is registered, the compliance is checked on an ongoing basis through inspections. Domiciliary care services received 48 hours notice prior to the so called comprehensive inspections, which are general inspections. There are also focused inspections which are carried out when there is an issue/concern about service delivery or when the provider has been through major change of circumstances.
A report is produced after each inspection - this includes CQC ratings of the service. The most recent report with the ratings needs to be available to view (e.g. on the website) and displayed within the office setting.
Towards CQC registration: checklist
- Check up to date guidelines from CQC
- Make a ‘going backwards’ plan: if you have a date in mind which you need your registration to be completed by then apply the current recommended waiting times and make a timeframe for your actions which need to be taken
- Recruitment: RM and NI and relevant checks you need (DBS)
- Premises: securing relevant premises, you will need a signed lease
- Financial & business planning: getting an accountant to check and sign of business plan and financial projections
- Policies and procedures: get a current list of required policies and procedures and get them together
Additionally, going forward, new requirements have been introduced by the CQC in response to the Covid-19 outbreak and need to provide extra protection for both those who need and those who deliver care. Specifically, CQC now requires PPE contracts to be in place in advance of getting the registration.
This chapter is by no means exhaustive and provides an introduction into the framework of CQC expectations and what you need to follow. We are working on further practical, our experience based support materials - e.g. list of resources we have used for learning within the Board so that all members have up to date and relevant knowledge, interview/s with our Registered Manager/s who will summarise how they have experienced the process...and more!