CQC Transitional Monitoring Activity (TMA) Internal Guidance

CQC has sent me its internal guidance on its transitional inspection framework under the Freedom of Information Act. It is essential reading for those concerned with regulatory compliance of health and social care services. I attach them below.

There is a guidance document that applies to all services – ‘Inspection guidance for Transitional Monitoring Activity’ – supplemented by 6 service specific guidance documents, one each for, Independent Hospitals (Dialysis Services), Independent Services for those with Learning Disabilities and/or Autism, Independent Ambulance Services, Adult Social Care, Primary Medical Services and NHS Trust level (urgent and emergency care services). CQC says others will follow.

Of great practical use, the documents set out not only the questions that CQC will be asking on TMA calls, but also the sources of evidence inspectors may wish to look at to obtain supporting evidence. That will help managers to prepare for the calls.

The disclosed documents provide a far more detailed picture of the TMA (a term new to me). Details include:

Inspectors have a TMA app that includes all the services in their portfolio.
The services are prioritised automatically based on previous ratings and other (unspecified) data held by CQC. This is a new feature. Such automation of regulatory decisions raises questions about fairness as providers will not have access to the underlying data or the opportunity to comment on them.
Inspectors may obtain evidence from a variety of sources before the TMA call. That includes:
- Local Authority/other stakeholder feedback
- Last inspection/registration report
- Feedback from people using the service and/or people who support them
- Feedback from staff
- Evidence of how the provider gathers and acts upon the views and experiences of people using the service.
There is a particular emphasis on obtaining people’s experience of care. If that cannot be obtained reliably, CQC will consider an inspection even if no risk has been identified. Providers may, therefore, wish to consider what evidence about service users’ experience they can obtain and make available in the event of a call.
Inspectors are also guided to consider closed cultures.
The TMA call will be on Teams or by phone.
The guidance discourages recording of calls but does not prohibit providers from doing so. Indeed, paragraph 14.3 of the Inspection Guidance provides a range of options to inspectors should providers wish to record the calls.
As above, the questions the inspectors will ask are set out in the service specific documents.
CQC expects requested evidence to be available by screen sharing during the call or otherwise within 24 hours. Inspectors have discretion to accept documents beyond that but no guidance is provided on how to exercise that power.
The inspector will give a risk score between 1 and 5 for each KLOE. 1 is very high, and 5 is very low.
Risk is based on level of harm (major, moderate, minor, disproportionate restrictions of liberty) and probability of harm (harm has occurred, probably, possible).
Usually, further regulatory action will only be considered if a service is scored 1 or 2 in any KLOE.
There is an exception in respect of cases where 3 is awarded but moderate harm or disproportionate restrictions of liberty or loss of human rights is possible. In such cases, inspectors will use their judgement as to whether to the TMA outcome is changed and a management review meeting (MRM) will be held to discuss a proportionate response.
Adult Social Care and PMS services will receive a summary record if there is to be further regulatory action. Hospitals may do so in time.
TMA calls are not inspections and will not result in a change of rating.
This means that, as anticipated, services that were rated as requires improvement will not be inspected if CQC is content with the level of risk following the TMA call and so their ratings will not change.
Scores of 1 require a MRM within 24 hours and/or alerting other stakeholders such as the police and safeguarding.
Scores of 2 will require a MRM within 2 working days. Services where a 3 was awarded but CQC considers that regulatory action is needed will be subject to a MRM within 5 working days.
The MRM will decide what regulatory action is required.
TMA calls are by consent. Any refusal to engage will be considered at a MRM. I think ordinarily that will result in an inspection, though it could lead to a statutory request for information.