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We are going to share ideas and articles here gathered from over a thousand managers and leaders completing "Lead to Succeed" with us, with contributions from our own team of experts, former inspectors and business leaders.
Resistance to change (part 2)
Thanks again for the feedback on last week's blog; there are a couple of points that I want to pick up just before we get stuck into the the blog proper for this week. Once again, please keep the feedback coming!
One of the tools outlined in Module Four of Lead to Succeed to support and facilitate change is “using the resistance”. This means giving people a chance to air their views and providing time for them to “come around” because change can be daunting initially. However, both of these rely on your openness to change in the first place and sometimes that can be tricky. If you look back at the blog a couple of weeks ago, “Requires Improvement to Outstanding”, the first conversation Pam had was with the manager, which is why awareness of our perspective is so important which is something we cover in the CPD Day “Self Management”.
Furthermore, when giving people a chance to air their views, we must be aware of the people who are perhaps less keen to air their views and not assume their silence is acceptance or commitment to the proposed changes. You will of course know who those people are because you know your team…
So, let’s move on to the last two strategies from Module Four, Problem-Solving Circles and Learning, both of which have proven extremely valuable in the sessions we have facilitated and I wanted to take a moment to share some of the examples. The Grey Matter Learning ethos is Know, Understand and Do - attending is the easy bit, it is the learning you take away and what you do with that learning which makes the difference to your service and the people you support.
Learning If attending is thus the easy bit (though we do appreciate the level of effort that goes into getting to the session in the first place - organising rotas, covering shifts and organising the funding etc), then why go to all that trouble and not do something with it? Of course, receiving the certificate at the end of Module Five is great, but the learning you take away is so much more important.
The most common feedback about Lead to Succeed is the sharing of experience with fellow managers and leaders from other settings; the opportunity to learn from what they have done and knowing “we are all in the same boat” is sometimes very reassuring. But this is one of the most powerful elements of learning; someone in a similar situation has overcome a challenge you are facing and has potentially done so successfully - this is exactly the kind of learning that needs sharing!
There is a slide in Module Four which contains many different forms of learning and “training” is only one of them. For example, one of the books I always recommend is Neil Eastwood’s “Saving Social Care” which contains a wealth of knowledge and useful stuff for £12 from Amazon and an investment of a few hours’ reading time. Look out for the “box interview”; it is so simple to do and very effective.
If you think back to the CQC Outstanding blog post from a couple of weeks ago, one of the things that stood out for me was the mindset of an outstanding provider [according to CQC] was “there is always room for improvement”. It means there is always an opportunity to learn and find something out, as long as we are open to the possibility. Therefore, the learning method is not the important part because there are so many different ways of learning; the learning and putting it into practice is the part that counts, the bit that impacts on our service and hopefully the lives of the people we support.
This is why the action plans in Lead to Succeed are so vital; they are an opportunity to capture the ideas that you have in the session and provide a framework for implementation and reflection. Some managers have shared how they have used their action plans to demonstrate to CQC evidence for the 5th key question...is the service Well Led?
Ultimately, learning comes in many forms but the critical element is that we apply it in practice and then measure its impact, not just to demonstrate to CQC, but also to evidence our progress and to make any appropriate tweaks as we go.
Problem-Solving Circles (sometimes known as Problem-Solving Groups) When I was first introduced to Problem-Solving Circles, I have to say I was slightly sceptical. However, having facilitated a number of them in Modules Two and Four, I have witnessed their power first-hand and grown to really appreciate them for the useful tool they really are. Ideas that other managers have shared, things that I have learnt along the way that are free, straightforward and impactful are always useful and Problem-Solving Circles tick all three boxes. Briefly, they work like this:
2 minutes of the problem - ideally, you need a facilitator so the problem-sharer does not get interrupted and sticks to time(ish) - everyone else just listens at this point
1 minute of clarification - questions from the people in the room to really understand the problem, which the problem sharer can respond to.
2 minutes of ideas and suggestions - the problem-sharer remains silent at this point and just notes down the ideas. I like to count up the ideas and generally ask for a bit of feedback afterwards along the lines of: “That’s new”, “I’ve tried this idea”, “This is different”, etc. My experience with Problem Solving Circles has shown me that five minutes can have a huge impact, even when the challenge at first can seem insurmountable. One of the great by-products of using a problem-solving circle is everyone getting involved in the solution, particularly when we are talking about change and doing things differently. If the whole team is part of the solution, everything moves that much smoother; I only wish I had found out about problem-solving circles sooner, I know I could have put them to good use on many occasions. You will have seen in earlier posts one of my sayings: “nobody has a monopoly on good ideas” and a problem-solving circle is a great way to uncover something you may not have thought of. Getting input from the whole team is a way to capture ideas from the frontline which may be obvious to frontline staff but not so obvious to leaders and managers; the key is being open to both the possibility and to any suggestions. CQC Outstanding providers have a culture that is open and willing to learn in order to contribute to continuous improvement, so look out for ideas from the team and encourage them to come up with ideas. You might not be able to do everything they think of, but you might just find a real nugget of awesomeness that facilitates transformational change.
Resistance to change...
Hello again and thank you for the feedback and engagement that has happened with the blog post over the past few weeks. If you've implemented any of the ideas or suggestions we have shared, please do let us know. Towards the end of last week's blog, we talked about Pam's example of how she supported a provider to move from Requires Improvement to Outstanding. We mentioned resistance to change because obviously to make that level of change requires effort; this week, I want to move on to Module 4 of Lead to Succeed - Managing the Process of Change. We will re-visit CQC inspections in the near future, mainly due to the blogs prompting so many suggestions!
One of the early slides in Module 4 states: “Change is assisting people to move from an arrangement that is familiar or comfortable to something new, that is potentially threatening or uncertain.” The Wikipedia definition: “Change management is a collective term for all approaches to prepare, support, and help individuals, teams, and organisations in making organisational change. The most common change drivers include: technological evolution, process reviews, crisis, consumer habit changes and organisational restructuring.”
One of the reasons I included the Wikipedia definition is to highlight some of the common drivers to change. It is interesting to note that the reasons included technological evolution; we’ve certainly all seen that in social care, in dramatic ways over the past few years. Crisis and organisational restructuring are also familiar concepts in our sector; we've all been through either one or both of those and know the uncertainty that they bring.
In an earlier draft of this blog, I had written “change, you can't escape it” i.e. there will be external scenarios that happen which necessitate change, as well as internal reasons; the things you want to do because you know it will positively impact the lives of the people you support.
Why is change important? A quote often attributed to Albert Einstein, but one which he apparently never said, was actually stated by Benjamin Franklin: “the definition of insanity is doing the same thing over and over and expecting different results”. If we therefore want to improve our inspection rating like Pam's example last week, the likelihood is that we will need to make changes, even if they are just tiny tweaks (see Outstanding Mindset blog from two weeks ago), they are still changes. Remember to ensure that any changes are recorded to evidence Continuous Improvement in your service.
If the needs of someone we support change, we can't carry on delivering the same service that we've delivered; up to that point, we have to review, and then possibly change, what we do in order to meet that person's needs. This means change remains a constant part of our lives and therefore the only thing we can control is how respond to it (I used respond, rather than react deliberately because I am working on a future post: the difference between responding and reacting).
One of the activities that I really enjoy at the start of Module 4 is “Story Time”, where the delegates are asked to think of a situation where they made a change which was successful and that they felt proud or passionate about making that change. The reason I love this activity is because it gets people's mindset switched into the positive reasons for making change. Quite often, people can be resistant to change whether it's because of their personal disposition, or fear of the unknown, fear of losing their job or even the scary one “but, we have always done it this way!”
We have established that change is going to happen and that change is important. We just can't carry on doing the same thing over and over again. Let's take some time now to look at some of the practical strategies that Skills for Care suggest in Module 4; for me, this is the best bit about Lead to Succeed....
Using Co-production “The term Co-production refers to a way of working whereby everybody works together on an equal basis to create a service or come to a decision which works for them all. It is built on the principle that those who use a service are best placed to help design it.”
The above is taken from this great resource: https://www.thinklocalactpersonal.org.uk/_assets/COPRODUCTION/1_page_profile_for_coproduction_2.pdf
Whilst this is well worth looking at as a whole, there are a couple of highlights for me regarding facilitating change. One of the co-production “top 10 tips” is: “Come with a blank agenda and then build your agenda (or plan) with the people who use services and their families or carers.” I do love this as it forces you to be open to possibilities, new ideas or suggestions. As mentioned in a previous blog, “nobody has a monopoly on good ideas”, and this is a simple way to uncover them.
Another top tip is to have “great facilitation and listening skills” and we will discuss this in more detail in the future too, because it is a subject close to my heart. But, by using your listening skills, you will hear and learn about all of the other perspectives that may differ from your own, which is a great way to develop understanding of the need to change, why it might be important and the positive impact it can have. Using the resistance - I love this too as, although it may not always be easy, it can be really effective. The top tips here are taken directly from Module 4: Give people time to come on board Give people who disagree chance to air their views Identify potential barriers and develop plans to address them Easy peasy, squeezy lemons! But let’s have a look at each one in turn: Give people time to come on board - this may not always be that straightforward because time is the most precious resource that we cannot get more of. If you think back to last week's blog and the psychologist Nathaniel Brandiel: “awareness is the first step”, by giving people time to get on board, what happens is it raises their awareness and facilitates the opportunity to appreciate different perspectives, which in turn supports making the change. Give people who disagree the opportunity to air their views - this method, on the surface, may not seem straightforward, but actually it shows that, not only have they been heard, they've been listened to as well. This also gives you the opportunity to understand different perspectives and to potentially address the challenges that are raised - if you don't know about it, you can't do anything about it. Identify potential barriers and action plans to address them - with any change, large or small, it is important to review as we go and find out how we are doing. It may be that we need to review our plan after six weeks and make additional tweaks or changes. I had not anticipated this blog becoming quite as long as it has, so the last two practical strategies will be saved for next week; using Problem Solving Circles and another of my favourite subjects….Learning!
Requires Improvement to Outstanding...
Thanks again for the feedback about last week’s blog; as always, if you have implemented any of the suggestions or ideas we have shared, we would love to hear from you!
As I said last week, I wanted to spend a little bit of time this week looking at Pam’s specific example of how she supported an organisation to go from Requires Improvement to Outstanding; ultimately to show that is possible and achievable, it just takes a whole team approach. For completeness, I have included Pam’s example below:
“For the service I supported to Outstanding, I began by having a very honest and difficult conversation with the manager which led to other challenging conversations with staff. It’s crucial that the staff are on board and understand their part in it all, rather than inspection being seen as something which goes on behind the closed door of the manager’s office.
Within a month everyone could see their part and actions to address these coming to fruition. This resulted in staff looking forward to me returning so that they could give their updates to be recorded on the action plan.”
Let’s take a closer look at what Pam did and what we can glean from her example…
“I began by having a very honest and difficult conversation with the manager” In the blog two weeks ago, I shared some figures from the recently released Skills for Care program “Well Led” which we have just started delivering:
99% of “good” or “outstanding” services had either “good” or “outstanding” in the fifth key question - “Is the service well led?”
This demonstrates that the manager’s role is vital, because those services that do not achieve good or outstanding in “Well Led” find it very difficult to achieve good or outstanding overall. So, Pam’s starting point is of course, spot on. But what did she talk about? The key component of the conversation was firstly that the manager understood there were challenges (see “awareness is the first step” later on), but (and in some respects the most important) was willing to embrace the changes, despite people’s usual reaction to change i.e. resistance and this is something we will talk about in a future post. Think back to last week’s post, “continuous improvement is a mindset”, and a key characteristic of good and outstanding services. (see below)
“which led to other challenging conversations with staff” According to the psychologist Nathaniel Branden, “Awareness is the first step” and is the precursor to impactful change. As soon as the conversation with the manager has happened, the natural next step is to talk to the staff in order to build a culture of openness and fairness that CQC are looking for evidence of.
“It’s crucial that the staff are on board and understand their part” It starts with communication…. if the experience of staff in previous inspections has been something that they should be worried about because the manager is worried, then this is the opportunity to shift the mindset of staff. Set the expectation that inspection is an opportunity to shine, it's an opportunity to show the inspectors what a fantastic job they do.
Staff should be clear about what they are responsible for, namely the duty of care that they have for their safety to practise and inspection is a reflection on the whole team, hence the need for them to be on board etc
“inspection being seen as something which goes on behind the closed door of the manager’s office” Perhaps in the past, inspection did take place behind closed doors in the manager’s office before CQC took over; those of you who have experienced a CSCI inspection will know what I mean. However, think back to the blog post “CQC Inspection Methodology” that we posted a few weeks’ back and you will know that inspection is very focused on what's actually happening in practice. CQC will spend time talking to both staff and the people you support plus, wherever possible, external stakeholders.
One of the things that we talked about in that CQC inspection methodology post was how to prepare your staff for what's going to happen when CQC are carrying out their inspection and one of the key pieces of that jigsaw is observation. https://www.linkedin.com/pulse/cqc-inspection-methodology-sarah-knapp/
Clearly observation is not something that can happen in the manager’s office; it is something that happens with the people you support and it is vital that CQC actually see what's happening in practice….
“Within a month everyone could see their part and action to address these coming to fruition” Thinking back to what the psychologist Nathaniel Branden said, awareness is the first step, but the second step is acceptance. One of my favourite modules in Lead to Succeed is module 2 which is Developing Positive Culture. When we, as leaders, set the expectations and the culture appropriately i.e. “we are all in this together”, change can actually take place very quickly.
As Pam described, within a month people could see their part and see it coming to fruition. This has a huge impact on motivation, morale and the confidence of our staff which in turn impacts on the quality of service delivered to the people we support.
“This resulted in staff looking forward to me returning so that they could give their updates to be recorded on the action plan.” Look what happens when “we are all in this together”; we share a common goal, staff are actually looking forward to inspectors returning so they can share their successes and achievements. This is exactly the kind of culture CQC are looking for...
Next week we are going to discuss, resistance to change and some of the practical strategies outlined in module 4 of Lead to Succeed.
CQC Outstanding and Well Led (part 2)
Thanks for the feedback about last week’s blog. If you have implemented the “outstanding plan” and found it successful, then please let us know.
So I said at the end of last week’s blog that CQC’s inspection model is built on what matters to people. it is the very essence of the five key questions and we wholeheartedly support linking inspection to the needs of people who access services, but what is the impact of achieving outstanding? Why is it important? What are the benefits of outstanding and how can you instill “outstanding” into the mindset of staff?
Some of the below text is taken directly from the CQC document I referenced last week: https://www.cqc.org.uk/sites/default/files/20170420_celebratinggoodcare2017.pdf and any comments directly taken from the CQC documents are shown in italics:
Some of the best care we have found is in services that acknowledge there is always room for improvement – they are proactive about seeking feedback and they learn from concerns and complaints. This feeds into the continuous improvement cycle and having a clear understanding of this is vital and is actually part of the mindset we talked about in a previous post. If we think we can, we are probably right and if we think we can’t, well you probably guessed it.
We [CQC] have found that good leadership is a central part of improvement – services that improve tend to have leaders who are visible and accountable to staff, promote an open and positive organisational culture, and engage effectively with partners. We facilitated a Lead to Succeed recently with a provider in the Midlands and as part of module 2 - Developing Positive Culture, one of the participants commented “we often see the Directors in the care home” which is fantastic, because it is a foundation of the open and positive culture CQC are looking for evidence of.
Improvements in the quality of care people are receiving are happening despite tight financial constraints and increased demand across the sectors. So given what I described above, it makes sense to have robust leadership, a strong vision and a set of values which govern and direct ways of working, forming part of the solution to this ever-growing challenge.
Some of the other things that Outstanding providers do are below: Leadership promotes a culture of high quality, person-centred care and its vision and values are driven by quality and safety Constantly learning and striving to improve Leadership that is continuously learning Staff share a common philosophy, vision and values Staff articulated the provider’s values in their own words Staff spoke very highly of the leadership – they felt well-supported by managers Managers were visible and approachable, staff training was encouraged for new learning and skills, and morale was excellent The manager worked alongside staff, as a role model, and observe their practice All staff understood the culture, vision and values Staff told CQC how they were involved in the development of the strategy to achieve its vision
One of the things that struck me as I developed the list above is how often vision and values kept appearing (the list was much longer in the earlier drafts of this post), but what also stood out was “staff share” or “staff articulated” or “all staff understood”. Clearly, staff are a vital part of the inspection process; think back to the post about CQC Inspection Methodology and what I said at the beginning of this post - it is what matters to people and that is why “staff” are so important. https://www.linkedin.com/pulse/cqc-inspection-methodology-sarah-knapp/
I think these are great examples of Values Based Leadership, something we will cover in a future blog...
Back to “what does outstanding look like”, the document above is something we use as part of our facilitation of module 5 for Lead to Succeed; it provides really useful pointers as to the evidence that CQC are looking for.
When everyone knows what an outstanding service looks like, they can begin to map themselves against it ensuring that they can identify where they’re doing well (with robust evidence) and any gaps; supported by a robust action plan, which everyone is aware of and is actively working towards achieving. Hopefully what we have talked about over the past couple of weeks has given you some pointers that will enable staff and leaders to know exactly what outstanding looks like and therefore what to do to build your action plan accordingly.
So to draw this post to close, I asked my colleague Pam Darroch (a former Care Quality Monitoring Officer) to share an example of how she supported an organisation to go from Requires Improvement to Outstanding. Her words are as follows:
"For the service I supported to Outstanding, I began by having a very honest and difficult conversation with the manager which led to other challenging conversations with staff. It’s crucial that the staff are on board and understand their part in it all, rather than inspection being seen as something which goes on behind the closed door of the manager’s office."
"Within a month everyone could see their part and actions to address these coming to fruition. This resulted in staff looking forward to me returning so that they could give their updates to be recorded on the action plan."
We are going to talk more about this example next week...
I hope that over the past few weeks you have been able to see some practical ways you can work towards achieving outstanding. I have included a link to the Skills for Care document that we mentioned a couple of times because it is useful and over the coming weeks we are going to look at more ideas from it.
In case you missed the earlier posts, please see links to earlier posts here: Inspection Methodology https://www.linkedin.com/pulse/cqc-inspection-methodology-sarah-knapp/ Outstanding Log https://www.linkedin.com/pulse/outstanding-log-sarah-knapp/ One Drawer Inspection Kit https://www.linkedin.com/pulse/one-drawer-inspection-kit-sarah-knapp/ Just Got Your PIR? https://www.linkedin.com/pulse/just-got-your-pir-pic-sarah-knapp
Finally, please send through any suggestions or ideas you might have.
CQC Outstanding and Well Led
Thanks to everyone who is subscribing to the blog. We will be moving on to topics other than CQC in the near future and we are always happy to hear ideas and suggestions for future posts. This one is designed to bring together many of the themes, ideas and tools that we have talked about over the past couple of months.
In order to effectively discuss a CQC “Outstanding” inspection and how to get ready for one, we need to spend a moment defining “Outstanding”: What does outstanding look like? There is a slide in module 5 of Lead to Succeed that describes the four CQC ratings and next to outstanding it says “the service is performing exceptionally well”. As we said a couple of blogs ago, we are well beyond meeting the standards and the regulations when we get to outstanding which is why only the top 3 or 4 percent of organisations actually achieve it.
What do CQC look for in order to give an outstanding rating? As part of my research, I found this document from Skills for Care https://www.skillsforcare.org.uk/Documents/Standards-legislation/CQC/Good-and-outstanding-care-guide.pdf (286 page document) which is full of useful stuff. It also describes the Provider Information Collection (PIC) that CQC were trialling, but in the end the best bits of the PIC were incorporated into the Provider Information Return (PIR). This is taken from page 42:
Outstanding providers: “Promote creative ways to mitigate risk” “Use evidence, analysis, learning and external expertise to make improvements” “Staff are exceptionally kind and compassionate and regularly exceed expectations” “Use creative, innovative and efficient approaches that go the extra mile” “Have a strong, visible person-centred culture”
These are just a few examples, and some of you may have noticed that there is one example from each key question. So if we know what outstanding providers do, and there are many more examples in the document linked above, can we build some sort of benchmarking process that facilitates a plan of action to move us towards outstanding - maybe we could think of it as our “outstanding plan”. Think back to the “outstanding log” from a couple of weeks back: if you have an “outstanding plan” alongside an “outstanding log”, the inspectors will see your intention and be able to guide you accordingly.
Why “Well Led” the fifth key question is so important When you look at the five key questions and the KLOEs (Key Lines of Enquiry) contained within them, it is understandable to think that first key question, “Safe”, is the most important because it has six KLOEs within it, compared to “Caring” for example which only has 3 KLOEs. (It is also worth noting that key questions are not KLOEs). However, allow me to share a couple of stats, from module one and the very beginning of Lead to Succeed:
94% of “good” or “outstanding” services had either “good” or “outstanding” in the fifth key question - “Is the service well led?”
84% of “inadequate” services had inadequate leadership.
However, since the publication of the figures above in the CQC State of Health and Social Care 2014/5 report, CQC has revised the first figure, and it is now:
99% of “good” or “outstanding” services had either “good” or “outstanding” in the fifth key question - “Is the service well led?”
I am not suggesting that any of the five key questions is any more important than any other, but if the service is not well led, it is extremely unlikely to be outstanding in the other key questions. Moreover, it is really interesting that CQC has been clear (link below) in its recent updated “How CQC regulates, monitors and inspects adult social care services” that the fifth key question “Is the service well led?” will always be included in both focussed and comprehensive inspections”
Additionally, if you do not submit your PIR in time, (see page 4 in above), the highest rating CQC can give you for the “well led” key question is requires improvement, which further reinforces the importance of Well Led.
I believe this is why Skills for Care has developed both Lead to Succeed and the Well Led program and supported them with Workforce Development Funding as well.
Funnily enough, I was tidying my office the other day and came across a notebook from 2007 and some notes I had taken at a Skills for Care conference where leadership had been identified as the critical factor in what made a service 3 stars or excellent, as it was back then. Not much has changed, except now we have brilliant programmes to develop the leaders of the future.
Find out more about the Skills for Care programmes here: https://greymatterlearning.co.uk/face-to-face-learning/
Remember the “Mum test” I always used to say, what about the “me test” - would I be happy here?
I did a bit of digging before writing this blog and found another really useful document: https://www.cqc.org.uk/sites/default/files/20170420_celebratinggoodcare2017.pdf
In the introduction it says: “Our Inspection model is built on what matters to people”, and this is the basis of the five key questions. However, reading it made me think that that is much more than either everyone’s training or current policies being up-to-date.
As this post has become much longer than I had anticipated, I am going to share the second half next week...
Business As Usual
We hope you find our blog useful and, if you have implemented any of the ideas we have shared, please do let us know - we would love to hear from you….
This week, I wanted to go back to the blog from three weeks ago where we talked about the CQC Inspection Methodology and something we mentioned i.e. “Business As Usual” https://www.linkedin.com/pulse/cqc-inspection-methodology-sarah-knapp
One of the key themes throughout the recent series of blogs about CQC and inspection, based on the Skills for Care Lead to Succeed programme and the feedback from the participants, is be prepared and don’t leave getting ready for inspection to preceding weeks just before inspection. There are numerous reasons for this, some of which we have already discussed. Ultimately, however, if you are prepared then the inspectors can come whenever, because they would not see anything different on any given day.
This is the essence of “business as usual”; when the inspectors are there, you want them to see exactly what happens on any “normal” day - due to your excellent preparation and on-going procedures and processes, you and your team are delivering exceptional care and support day in, day out. In our experience, staff can often be left out of the loop; they don’t understand how they are involved in the process and inspection is usually dealt with “behind closed doors”. This is something we hope will change because managers are not the only people with great ideas; in fact, involving staff can sometimes generate some of the best ones!
Think of it this way: “business as usual” is doing what you would normally do despite the inspectors being there; simply put, it is integrity, a measure of your leadership and values….
If you leave getting ready for inspection until “just beforehand”, then the impression of “exceptional” will wear thin pretty quickly. If staff are not prepared for what a “normal day” can include, then a visit from inspectors could well increase their anxiety and cause them, and possibly the people they support, some distress.
Another way of looking at it is, if the behaviour of staff appears contrived when the inspectors are there, instead of “business as usual”, it is much more difficult to “keep up appearances” than it is to do what you normally do. This will likely cause staff undue stress which can be avoided by simply preparing them for what will happen and encouraging them to focus on their regular routine and not do something special because CQC are carrying out an observation.
If staff are well prepared for what a “normal” day can entail, then a visit from the inspectors is unlikely to make any difference. Furthermore, if we can upgrade our collective mindset about inspection, the impact will be long-lasting. For example, if the senior team shows any anxiety, or is less than excited about having CQC visit, this will naturally cascade to staff and they will think that they have something to worry about.
Thinking back to my blog three weeks ago, you know CQC’s inspection methodology, so you can prepare accordingly and that is not just the team “in the office”, it’s everyone. As we have suggested previously as well, this is your opportunity to shine, so coach your staff to do exactly the same as they do on any “normal” day. Help them to appreciate that much of what they do is exceptional and CQC needs to know about the amazing job they do, all the time, often in challenging circumstances.
Welcome back and thanks for the feedback about last week’s post on the “One Drawer Inspection Kit”; please keep in touch and share your feedback if you have implemented the One Drawer Inspection Kit or any of the other suggestions we have shared. We would love to hear from you!
This week’s article will be a little shorter but, hopefully, just as valuable - the “Outstanding Log”.
We can’t take credit for this idea; one of the team leaders on a Lead to Succeed programme shared this a few months’ back. Essentially, the team leader described what she had done to implement this in her setting and the impact that it had on her team, but also the volume of evidence they collected using it. It goes something like this:
They added a simple question to their handover process: “what have we done that is outstanding today?” Now that will only take seconds to ask, but the impact of that question is huge, because it gets everyone thinking “what have I done today?”, “was that outstanding?” and, as such, it can create a shift in mindset for the staff.
Now let’s be clear, outstanding according to CQC means: “the service is performing exceptionally well”, so we are beyond meeting expectations - we are exceeding them.
So, another way of phrasing the same question might be “what have we done that is exceptional today?” By incorporating this simple question into the handover process or perhaps a team meeting if that works better for you in your setting, staff know that question will be asked and the mindset shift it creates is they will start looking for examples to share in that meeting, because that is just how our minds work - we can’t help it!
However, the critical piece of the jigsaw is how we record what gets shared…
If it is therefore part of the handover, create a space on the handover documentation which gets completed with a brief description of what happened and why it is exceptional. Similarly, if it is part of the team meeting, then find a way of capturing the “exceptional”.
Bear in mind that you won’t capture examples on every shift or every team meeting, but hopefully what will happen over time is that you capture examples that build into something extremely valuable, for what is essentially a small investment of time.
Think back to what I said last week: use the One Drawer Inspection Kit to give the inspectors a map to follow, then use the “outstanding log” to capture all the reasons why you are exceptional and make it is the first thing you give them when they arrive!
One Drawer Inspection Kit
Following on from last week’s blog about mandatory training, this week I wanted to talk about the “One Drawer Inspection Kit”... One of the best things about Lead to Succeed is the “practical strategies” - all of the modules include activities which always result in one of the managers or team leaders in the room sharing their experiences. This means everyone gets to learn from that strategy and potentially shapes it into something they can use in their own setting. One of those strategies is the “One Drawer Inspection Kit” and the following includes some of the suggestions from over 1,000 managers who have completed Lead to Succeed with Grey Matter Learning. One of the key themes in the latter half of module 5 is “be prepared”! One of our top facilitators is a former inspector and always suggests “don’t leave getting ready for inspection until just two weeks before inspection”. If you read our blog https://www.linkedin.com/pulse/cqc-asking-you-complete-pir-sarah-knapp/, you will now know that, just because you have completed the Provider Information Return (PIR), it does not mean CQC is coming next week! Try to avoid frantically gathering all your evidence together when you get your PIR, because you will miss something that happened months ago that is fantastic evidence as to why your organisation is outstanding. For example, if you change an agreed way of working, make sure you capture the “why”; what were the reasons for making the change and most importantly what was the impact - can you evidence “continuous improvement”... The One Drawer Inspection Kit is a method or a way to start collecting that evidence together on an on-going basis. Start by building a set of “sign-posts” in your Kit that guides the inspector to the location of all those bits of evidence we talked about last week. Think of it like a map for the inspector to follow that enables them to find exactly what they are looking for. You can make the map specific to your setting, the people you support, the regulations that you have to meet and most importantly - HOW you meet them. You know where all the evidence is, will your staff? Think of the One Drawer Inspection Kit as a way to remove the pressure from your staff. If everyone knows where the Kit is, you can brief, coach and guide your staff that they will most likely find what they need in there, should CQC ask. By regularly updating the Kit, you are regularly updating the “map” and you are demonstrating the continuous improvement that the inspectors are looking for. (One of the handy by-products is that this avoids the need to have copies of everything, everywhere; avoiding the need to remember where they are when they need to be updated). One manager shared with us that they have what they call the “outstanding log” as part of their Kit; another manager shared how they have an “evidence matrix” in theirs; and, one suggested that they were going to house their Kit in the same location as their “thank you” wall, where all of their compliments and thank you letters are! Be creative and find ways to showcase all of the fabulous work you and your team do every day. I will talk more about the outstanding log in next week’s blog, but in conclusion make it as easy as possible for the inspector to find the evidence they need. You only have a short time with the inspectors to shine, so coach your staff to think of inspection as an opportunity to showcase their work, rather than a cause of anxiety. You may then transform their perspective and possibly the result as well. I hope you found this post valuable: the One Drawer Inspection Kit and outstanding log are just some of the tools available to you that don’t require huge amounts of time or money to implement, but which can have a dramatic impact on your CQC rating. We will do our best to keep sharing the ideas we hear from managers just like you over the coming weeks. And, as we start to deliver the new “Well Led” programme, I am sure there will be even more great ideas and suggestions...
Thanks for all the feedback about last week’s post around handling complaints and potential ways you can overcome any possible challenges. This week, I wanted to give some consideration to another topic that often comes up in the Lead to Succeed (L2S) workshops we deliver - Mandatory Training…
Leading and Managing the Inspection Process (the fifth module of L2S) includes an activity called “Potential Sources of Information for the KLOEs”; this is great for getting people thinking about the many types of evidence available to show the inspector why you are outstanding (think of the sources of evidence document as a starting point which you can add examples and relevant evidence specific to your setting). It is always encouraging to see the long lists of sources of evidence, but the one that always seems to be top of the list is the training matrix. Here’s why…
If you have been in the Social Care sector for a while, you will remember as I do when the inspection body was CSCI, (the previous name for CQC - see below) for which some of our L2S facilitators were inspectors; I’m therefore drawing on their experience as part of this blog. A CSCI inspection was very focussed on whether or not people were trained and up-to-date, mainly because the training and its frequency were stipulated in the legislation.
When CSCI became CQC, both the inspection process and legislation changed via the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, to be precise, which changed the emphasis to “Competence”. Those of you who know the regulations will know that regulations 5 and 19 “fit and proper persons” include: providers only employ 'fit and proper' staff who are able to provide care and treatment appropriate to their role and to enable them to provide the regulated activity.
Going back to that activity in module 5, why is the training matrix still the first thing that appears in the sources of evidence activity? It was probably the first thing during the CSCI days to be asked for, yet CQC inspectors spend much more time observing what is actually happening in practice (you will recall we talked about SOFI in an earlier post.) Managers who complete L2S with us regularly share that inspectors have arrived at 6.30am and talked to the staff finishing the night shift; have arrived at lunchtime and had lunch with the residents; and, have been on visits with staff in domiciliary settings. This is very different from the previous paper-based, mostly office-based, version of inspection, although occasional stories of inspectors staying in the office and not carrying out observations still circulate.
To achieve outstanding in this area, we recommend that you evidence to CQC and possibly your commissioners and internal auditors, that not only have staff been trained, but also the learning journey you have taken them on and how they continuously improve and learn on an on-going basis. You all know the expression “you learn something new every day” or “every day is a school day”. The most important aspect of any kind of training is that they are putting what they have learned into practice, every day with the people they support. Otherwise, what is the point in investing time, money and effort into training?
Training is only a piece of the jigsaw as the learning that happens as part of that process is much more important and the competence that follows is even more important, which is why in the recent Skills for Care publication “Mandatory Training”, it clearly recommends that “knowledge and competence should be assessed at least annually”. You therefore need to consider what you have in place to capture this crucial piece of the puzzle.
One of the critical pieces of evidence CQC are looking for is that of continuous improvement; just ensuring your training matrix is up-to-date does not achieve this. Making sure every member of staff has had the necessary training to do their job safely sounds like the first step on the journey to meeting the regulations, but given that the regulations also include Regulation 18 which states: “To meet the regulation, providers must provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service”, there is much more to it than just being “up-to-date”.
There are many different pieces of evidence that can show why you are outstanding, often demonstrated by the long lists of evidence that managers come up with during the “sources of evidence” activity, proving that the training matrix is just scratching the surface. One great tip is to collect all of those sources of evidence together into a “One Drawer Inspection Kit” (also in module 5 - Lead to Succeed), which is the subject of next week’s blog.
Dealing with complaints during a CQC Inspection
Hi everyone and welcome to the blog for this week. We were going to cover a topic different to this, however there was a comment on last week’s blog (via LinkedIn) which I thought was important to pick up on before moving on. If you didn’t see it on LinkedIn, this is the comment below (from Eddie Stevens):
“A recurring conversation I have when I run workshops is with unhappy registered managers who are challenging a rating that was negatively impacted because an individual complained directly to the inspector during the feedback stage. The common theme here is that the service knew about the complaint and had evidence to prove they had responded and dealt with this appropriately and robustly, but the inspector somehow missed this.
As a provider it is vital to proactively share these complaints with CQC, in particular those which have been vexatious or not resolved to the satisfaction of the individual, along with details of any action plans or support which has been put in place to support the individual as a result of the complaint. By sharing them in this way, it puts the provider on the front foot and ensures the inspector can join-up the feedback they have received with the records available. It also demonstrates an Outstanding approach where the individual is at the heart of the service and is truly listened to and empowered.”
In brief, Eddie is part of the team at Grey Matter Learning and part of his role is delivering the workshops that he describes at the beginning of his post. So, he is regularly in front of rooms full of managers just like you, listening to their challenges and hopefully sharing solutions.
Okay, so let’s pick up the first point, “unhappy managers, challenging a rating”. This is also something we cover as part of our delivery of Lead to Succeed, Module 5 of the Skills for Care leadership and management programme (Leading and Managing the Inspection Process). As Eddie suggests, it is vital that, during the short time the inspectors are with you, you ensure that they can find, or you show them, the evidence about your service. This is because, once they leave, you can only challenge factual errors or omissions, which means if they don’t see the evidence ON THE DAY, it becomes harder to challenge a rating. Think of it as closing the gate after the horse has bolted which means you are then on the back foot.
In future posts, we will share ideas around the “outstanding log” a way to make sure you have a collection of evidence “ready to go” that makes what I have described above more straightforward.
Next, “someone you support complained directly to the inspector”. Be prepared for this - remember in last week’s post when we talked about the inspection methodology and how the inspectors will talk to the people you support and your staff? This can easily happen. By preparing both your staff and the people you support for what is going to happen during the inspection, you can potentially avoid this happening.
Eddie then describes a common theme regularly shared by managers that “the service knew about the complaint and had dealt with it and had the evidence, BUT the inspector somehow didn’t see that evidence”.
Thinking back to what I said earlier about what you can challenge after the inspection is limited (the appeals documentation even limits the number of characters you can add to it), it is imperative that you get the evidence in front of the inspector when they are there. For instance, if you know that someone you support is not happy with your resolution or the actions you have taken, perhaps you can ask you inspector for advice, this is the situation, this is what we have done, have we missed anything? Bear in mind, you may not want to wait until the actual day of inspection to do this; you can ask this kind of question anytime and really get on the front foot. Being open and honest is a foundation for trust not only between you and your inspector, but also with your team and the people you support.
Therefore, as Eddie mentioned, if you “share the particular complaints that have not been resolved to the satisfaction of the person and share your action plans”, you can seek an alternative perspective on the same set of circumstances.
In doing so, you set the tone for the inspection, so you can then support the inspector to join the dots with what they have seen, heard and been told, demonstrating that you are open and transparent. This then instantly moves you from the back foot to the front foot, ensuring that the inspector sees all of the fantastic work you and your team do every day, backed up by robust evidence of competence.
You can see the original post here: https://www.linkedin.com/pulse/cqc-inspection-methodology-sarah-knapp/
CQC Inspection Methodology
Following on from last week’s blog about the PIR, this week I want to look at what CQC will actually do whilst they are on site with you; in other words, what is the “Inspection Methodology”?
This is taken directly from module 5 of Lead to Succeed, the Skills for Care leadership program that Grey Matter Learning is accredited to deliver. So let’s take a look at the methodology, as follows:
Let’s look at each one in turn:
Planning. Firstly, CQC will plan their inspection before they arrive, using what you have put in the PIR. Using any feedback they have captured (notifications and alerts etc), they will also look at previous inspection reports and much more. This means that, by the time they arrive, they will already have formed opinions about your service and will have ideas about the kind of evidence they are expecting to see in order to form their judgement about your rating.
Therefore, it is vitally important to find ways of communicating with your inspector on a continuous basis so they have plenty of information available to them to support their planning process, but also so they have more than the “on paper” view of your service. For example, if you (or your team) came up with an idea that you felt would improve your service, why not share it with your inspector, who else has done this? Ask them if they think there are any obvious pitfalls or things you might have missed; alternatively, do they know anyone you could contact for advice?
Gathering feedback. This too will take place before the inspector arrives, in so much as they will talk to the people you support and sometimes your staff (using the information you put in the PIR) to collect objective feedback about your service and to contribute to the planning process. Bear in mind that they will not limit who they speak to, i.e. just to those people you include in the PIR; they are likely to include the Local Authority, commissioners, the safeguarding team, potentially the Fire Service or Environmental Health.
Talking to people. On the day, CQC will talk to the people you support (wherever possible) and so it would be prudent to discuss this with the people you support so that they know who the inspectors are, what might happen whilst they are there and what they are there to do. But rest assured, they will talk to as many people as possible to build a clear picture of your service, therefore this is going to include your staff. What can you do to prepare your staff? Have you seen the questions in the CQC document “Prompts and Characteristics”, because it contains lots of questions that might provide some clues:
If we start to look at the order of the inspection methodology, we are halfway through and the manager(s) has not had a great deal of involvement. So if CQC are going to plan what they do before they arrive and gather feedback, as well as talk to the people you support, is there a way you can do the same? CQC have shared their “process”, their methodology, so let’s use it to prepare and make the actual day of inspection less scary for everyone.
I am sure you will have seen “How CQC regulate Adult Social Care”, but it has recently (at the time of writing) been updated and contains lots of useful information to support you to prepare.
We will share ideas on some of the tools you can use to do this in future posts, but the key here is preparation; like I said in our previous blog, don’t wait until two weeks before inspection to “get ready”, because there will be huge volumes of evidence available. All you need are methods for capturing it.
Observation. I am sure you are all aware of SOFI (Short Observation Framework for Inspection) which is “how” the CQC will carry out the observations. Some managers during the Lead to Succeed sessions have shared how they have had two (or sometimes more) inspectors and one “just sat in the lounge and watched what was going on” whilst the other inspector was with the manager or the staff.
For those of you who are familiar with Dementia Care Mapping, SOFI works in a similar way: recording observations every two minutes for a period of approximately 20 minutes to capture a holistic view of the service delivered and, most importantly, the reactions and interactions with the people you support.
So if CQC are going to “talk to people” and use “observation” as described above, can you do the same to get your staff ready for what is going to happen when the inspectors arrive? Many of the managers who have completed Lead to Succeed already use things like “spot checks” and “quality audits” to check performance. However, if during a team meeting you outlined to staff what is going to happen and how you’re preparing for it, then there is no need to worry when CQC are here - “just do what you normally do” should be the message. We are going to talk about “business as usual” in a future blog.
Talking to staff. This is the bit that most people find challenging. You know “that” member of staff that will say they have never had supervision, because you call them “one to ones” and CQC call it supervision (more about that in a future post too). Many managers have shared that one of the questions CQC are likely to ask is “what do you think of your manager?” I suspect this question is asked to find about “well led” and the KLOEs that support it, rather than whether or not people “like” their manager. Therefore, as we know that CQC are asking this kind of question, why not include it in supervision and support your staff with the answer?
However, there are a wealth of resources available from CQC that outline the questions the inspectors will ask. The five “key questions” are by their very nature questions and the CQC doc “sources of evidence” and the “KLOEs” all contain questions. So if we know that CQC are going to ask questions and we know what those questions look like, maybe we can start “practising confidence”. Confidence is key when staff are answering the questions that CQC ask. We therefore recommend, either in team meetings or during the spot checks we talked about earlier, ask your staff questions! In doing so, you can support your staff to be confident in their answers and you can coach them where appropriate, which is a great way to take the “nerves” out of the situation on the day.
Reviewing records. I always find it interesting that reviewing records is last in the list, but I also believe that it is last for good reason! CQC will do all of the above and build a picture of your service and THEN check that the paperwork matches up with what they have seen, heard and been told. This means there is a good chance that by the time they get to the paperwork they will already have a rating in mind and the paperwork is just an opportunity to find more evidence to support the rating they have in mind.
Follow the blog for future posts about each of the individual stages outlined here.
Well, if you read their document from November 2017 on how they will monitor, inspect and regulate Adult Social Care services, it would suggest that by now we should all be using a PIC (Provider Information Collection). However, according to the most recent document released by the CQC (click here), it seems that this is no longer the case, which is what I want to talk about today...
It looks like the CQC are going to stick with the original name of PIR (Provider Information Return)...
Is this a good thing?
Well, from what I can see, it could be. Why? Because, going forward, it’s going to pick up on some of the elements which they had hoped to introduce with the PIC (outlined in Nov 17 version) which I liked the look of...
For example, completion will be on an annual basis – good, because it’s a lot easier to keep on top of things rather than waiting for 2 or 3 years before updating the information about your service. Who remembers when & why they changed an ‘agreed way of working’ 18 months ago because it now feels like it’s always been like that? This of course means we miss out on recording some crucial evidence of continuous improvement! It’s a real shame that it will only be available on an annual basis, as opposed to being constantly available to update (maybe even forming part of our monthly QA checklist). I liked the idea of it being available to update quarterly, if not more often – it supports the formation of good habits.
Another addition to the new PIR process is that if the return is not sent back to CQC by the advised deadline, the best rating you can receive for Well Led is “Requires Improvement”. I love the idea of this; why wouldn’t you want to make sure you reply in good time? Like it or not, in everything there are consequences; this is one of them.
There’s some good guidance around on how to complete the PIR e.g. this document hasn’t long been published and will keep us on track with not only the question coverage, but also gives some hints and tips on how to complete it and it also gives some rationale behind the guidance.
Page 15 reminds us all of the AIS. “The what?” I hear some of you ask…this relates to the Accessible Information Standard (which happens to have been around for a few years now – but I’m still hearing from people that they’ve never heard of it!!!). So now that you’ve heard of it – are you compliant? Do you have good robust evidence to show your regulator?
And whilst we’re at it, are we all up to speed with the Protected Characteristics? Can we even remember how many of them there are? We might be good at being able to evidence equality & diversity for the people we support – but what about towards our staff? I know a manager who was unable to answer this when asked by her inspector…what evidence do you have available to you?
Residential PIR click here
Community Services PIR click here
If you want to know more about Grey Matter Learning and why we care about Social Care, follow our facebook page for more updates. https://www.facebook.com/greymatterlearning.co.uk/
Ever driven down the High Street or around the local Business Park and seen a banner outside the local care provider with “We are inadequate” in huge writing? Probably not, given that no-one wants to publicise they have work to do, or that their service is not as it should be.
But let’s not underestimate how important a successful inspection is, not just because you don’t want to get that banner made for your setting, but because you want your inspection to be a success so staff are proud to come to work, families recognise you as the local provider of choice and your hard work is recognised externally.
If you have just received your PIR/PIC and think that CQC are “due”, think again. There is much more to the PIR (Provider Information Return) than meets the eye, because CQC will use it to risk assess which providers get inspected and when. This means that if you do a good job of your PIR/PIC (Provider Information Collection), you have the opportunity to show CQC that you are doing a great job and are therefore not a priority for inspection.
So, if you leave “getting ready for inspection” to when you first receive your PIR/PIC, you could well be missing out on a wealth of evidence that could tip your service into “Outstanding”. Over the coming weeks in this blog, we will be exploring feedback and ideas from real managers, just like you, who have shared their experiences as part of our delivery of “Lead to Succeed”, the Skills for Care leadership and development programme.
The starting point is: don’t wait for the PIR/PIC or until two weeks before inspection to “get ready” - be “inspection-ready” at all times by coaching staff for what will happen when the inspectors arrive so they are also ready. Even more critically, find ways to capture and record the reasons you are outstanding on a continual basis. Stick with us - we’ll be sharing ideas on this very issue over the coming weeks.
To set the ball rolling, the first idea is to create a “one drawer inspection kit” (more can be found in module 5 of Skills for Care - Lead to Succeed). During many sessions, managers have shared their experience of inspection (not just CQC, but internal quality audits and Local Authority contract monitoring visits, etc). These are along the lines of: “They came when I was on holiday!!!” Imagine the inspectors turn up whilst you are on holiday; do your staff know where all the evidence is? Could they support the inspectors whilst you aren’t there? Well, the “one drawer inspection kit” is a simple tool to empower staff and colleagues to do just that and to give you some peace of mind at the same time.
Choose a place that contains a set of signposts to all the evidence that the inspector might want or need (relevant to your setting/regulations/registration). That way, if the inspectors arrive whilst you are on holiday, your colleagues are already coached to say the following: “Our inspection kit is here. In it, you will find lots of reasons why we are outstanding and, if you need anything further, I will be available in x location”. Future posts will include “business as usual” when the inspectors arrive...
Think of it this way: the “one drawer inspection kit” is a way for you to evidence all of the amazing work you do, day in, day out, and why wouldn’t you want to make absolutely certain to get that evidence in front of the inspector on the day?
If you want to know more about Grey Matter Learning and why we care about Social Care, follow our LinkedIn page for more updates. https://www.linkedin.com/company/1298179/