Key Lines of Enquiry (KLOE) explained
The CQC Key Lines of Enquiry are used by the Care Quality Commission (CQC), who regulate all health and social care providers in England. CQC inspectors use the Key Lines of Enquiry (KLOE) to guide and direct their inspections of care services. Established and new care providers alike will probably know something about the Key Lines of Enquiry, but few too many understand how the Key Lines of Enquiry fit within the CQC's approach and how they are used during inspections.
CQC Key Lines of Enquiry: Origins
The CQC introduced the Key Lines of Enquiry following consultations in 2013. The CQC explained that it was committed to ensuring people within the system receive safe, effective, high-quality care, and implemented numerous changes to encourage care services to improve. One major change was the introduction of the CQC's Key Lines of Enquiry (KLOE).
CQC KLOEs are replaced in 2022-2024
Beginning in 2022 and piloting with a small group of providers for CQC Inspections in 2022, the CQC will move away from the KLOEs, replacing them with the new 'CQC Topic Areas' and 'CQC Quality Statements'.
This change was originally set to take place in April 2023, but the CQC has since poured uncertainty on the exact timing, stating they may need more time to successfully implement the new methods, depending on responses of providers, inspectors and other stakeholders involved in pilots.
Given the uncertainty it's best to read this article, then learn more about the CQC New Inspection Framework. This will give you knowledge to help you successfully navigate both the current methods (the KLOEs) and begin preparing for the new methods (using CQC Quality Statements).
How do KLOEs and CQC 5 Standards fit together?
When CQC inspectors evaluate any care service they are guided by 5 areas. People refer to these areas collectively by different names, you might sometimes hear the CQC 5 Domains, the CQC 5 Standards or the 5 Key Questions. Different terminology, same application in practice.
Each CQC Key Lines of Enquiry (KLOE) sits within one of the CQC 5 Standards. The KLOEs are like the constituent parts, the building blocks that make up the 5 Standards.
When a CQC inspector wants to see if a service is ‘Safe’ (Safe is one of the CQC 5 Standards) for example, they will select one of the KLOE under ‘Safe’ and use this as the criteria to test the service against.
But before we get into all that, lets first cover what the 5 Standards are.
What are the CQC 5 Standards?
It's important not to confuse the CQC's 5 Standards with the CQC Fundamental Standards. It's confusing terminology I agree! Especially as the 5 Standards were drawn out of the CQC Fundamental Standards.
So lets clear things up. The Fundamental Standards are the minimum requirements a care provider needs to meet. The Fundamental Standards are enshrined in law as part of The Health and Social Care Act 2008. Read the CQC's summary of the Fundamental Standards.
Out of the Fundamental Standards the CQC created their 5 Standards/5 Domains:
(In no particular order)
Safe: Are service users, staff and visitors are protected from abuse and avoidable harm?
Effective: Is people’s care, treatment and support achieving good outcomes, promotes a good quality of life and is evidence-based where possible?
Caring: Do staff involve and treat people with compassion, kindness, dignity and respect? Is the culture of the organisation a caring one?
Responsive: Are services are organised so that they meet people’s needs? This is a little vague. Essentially ‘Responsive’ concerns whether care is shaped to fit the individual. Is it flexible to those preferences and needs? Does it adapt to fit if those needs or preferences change? It maps on very closely to the principles of Person Centred Care
Well-led: Does leadership, management and governance of the organisation assure the delivery of high-quality person-centred care, support learning and innovation, and promote an open and fair culture?
The Key Lines of Enquiry (KLOE)
Inspectors then use a set of standard KLOEs that are directly linked to the five key questions listed above. These include a set of 16 mandatory KLOEs which address the key priorities of every service, such as, “How are people protected from bullying, harassment, avoidable harm, abuse and breaches of their human rights?”. The mandatory KLOEs are included at the end of this article.
Inspectors may also select additional KLOEs which will support their effort to determine quality and identify risks. An example of an additional question an inspector may choose to ask is, “How are people supported at the end of their life to have a private, comfortable, dignified and pain free death?”. To get a more comprehensive reference point use the CQC's KLOEs and rating characteristics for adult social care services.
When deciding what additional KLOEs to use when inspecting your care service, the inspector will consider what they know and have been told about your service already. In addition, if they happen to encounter other areas of concern or good practice during the inspection itself, they can bring new KLOEs into the equation.
There has been a level of confusion from some care providers around how the inspectors measure the answers to KLOEs. Within their report, A fresh start for the regulation and inspection of adult social care, the CQC outlined that they will, “…use these questions when making decisions about registering providers; as a framework for our use of data, evidence and information in our surveillance of services; and in our guidance, inspections, ratings and published inspection reports”.
It is important to remember that the KLOEs selected frame each inspection, and because they can alternate from one inspection to the next, you really need to understand and be prepared for all of them to have the best chance of securing a Good or Outstanding rating. The diagram illustrates this and emphasises the influence of the selected KLOEs over the rest of the inspection process:
The KLOE prompts
Under each Key Line of Enquiry there are a further set of what the CQC calls 'prompts'. For example here is Key Line of Enquiry S3 (under the key question 'is the service safe?') with its associated prompts:
It has to be said that these prompts are a guide, not an exhaustive list or checklist that has to be followed. However, the guidance still plays a significant role in the inspection and the inspectors decision making, being the foundation which the inspector's own judgement and factors that become apparent during inspection are built upon. Familiarising yourself with the prompts can also give you a window into how inspectors work and the ways in which they are supposed to approach inspecting a service.
You can find more CQC prompts along with their Key Lines of Enquiry here
During the inspection
As we already discussed, before a site visit inspectors will select which KLOEs they intend to use based on an ‘information pack’ the CQC provides to its inspectors. This pack is collated from information provided from people who use the service, stakeholders and from the provider itself. Once at a site visit, inspectors will then indicate which KLOEs they will be inspecting to the responsible persons, and will gather evidence by talking to service users, visitors and staff, by observing care, as well as reviewing records and tracking individual care pathways.
Having accurate, up to date, complete and easily accessible records used was, and for some care providers, still is a massive headache and a source of anxiety when it cam to inspections. The use of digital care records has made this aspect of inspections more of a strength than a weakness for those providers that have embraced the technology. Its not just that digital records have a level of reliability way beyond that of paper, its also the additional, often forgotten elements such as inbuilt time and date stamping and audit logs that make providing evidence or proof so much easier.
Regardless of the records you use and their reliability, speaking to people that use your service, visitors and staff remains a core component of evidence gathering. Bear in mind this can extend to catering and cleaning staff, not just care workers and managers. If inspectors are not able to speak to the people they wanted to during the inspection, then they may arrange to do so outside of that timeframe.
Finally, when deciding what questions to ask people it is our old friend the Key Lines of Enquiry that guide the inspector. Although the answers given and information provided may cause the inspector to add in additional KLOEs, they will still be looking for evidence that relates to answering those originally selected Key Lines of Enquiry too.
Mastering the CQC KLOEs with software
Preparing for a CQC inspection can be difficult even when you have all the knowledge and best practice to hand. Many care providers are more confident and prepared for care inspections with the help of Access Care Compliance. Its unique, and uses the CQC's frameworks to guide you through mock inspections and makes your auditing processes less time consuming, more targeted and effective.
Available for providers of all sizes and from across social care, whether domiciliary, residential, supported living and so on, take a look at these case studies from Aspire Care Group, Minster Care Group and New Directions Flexible Social Care. Find out more about this Care Compliance Software.
Master the CQC KLOEs without software
Even if you are not using CQC software or other tools, there are concrete steps you can take to master the Key Lines of Enquiry, to help you help your simultaneously receive a better inspection rating and improve your care services.
The most important KLOEs, the Mandatory KLOEs, are listed in the section below. I recommend that for each KLOE you ask: “Can we (our service) fully evidence that we absolutely meet this KLOE?”
For example, for KLOE S4 (under Safe): “How are people’s medicines managed so that they receive them safely?” How would you evidence that medicines are managed safely?
- Are your MAR charts/eMAR well maintained, clear and legible?
- Are there gaps in these records? Are they messy?
Do you have records of medication related incidents? What action did you take? What was the outcome? - How does you make sure that people’s behaviour is not controlled by excessive or
inappropriate use of medicines? - Are there clear procedures for giving medicines covertly, in line with the Mental Capacity Act
2005?
In addition, especially for residential care:
- Are medicines stored safely and do you have a process in place to evidence this?
- How do you work with pharmacies to improve safety around medicines?
- How are medicines ordered, transported, stored, and disposed of safely and securely in ways that meet current and relevant legislation and guidance?
This is not an exhaustive list, but it will get you moving on the right track. The point is not just that you know that medicines are managed safely but you able to evidence it to someone who comes into your service out of the blue. What methods can you evidence it?
Going through this exercise will help identify short comings in your services you can fix and put better quality management processes in place. When an inspector comes to your service rather than being met with someone flailing around to find the evidence, you can show you have a confident, well run service that has the right processes in place.
You can find a full list of the Key Lines of Enquiry (KLOE) and underlying prompts in this document from the CQC here.
The Mandatory Key Lines of Enquiry
Mandatory KLOEs for residential and community care services
Note: E5 is a residential KLOE only. It does not apply to community services
Safe
S1How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?
S2 How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected?
S3 How does the service make sure that there are sufficient numbers of suitable staff to keep people safe and meet their needs?
S4 How are people’s medicines managed so that they receive them safely?
Effective
E1 How do people receive effective care, which is based on best practice, from staff who have the knowledge and skills they need to carry out their roles and responsibilities?
E2 Is consent to care and treatment always sought in line with legislation and guidance?
E3 How are people supported to have sufficient to eat, drink and maintain a balanced diet?
E4 How are people supported to maintain good health, have access to healthcare services and receive ongoing healthcare support?
E5 How are people’s individual needs met by the adaptation, design and decoration of the service?
Caring
C1 How are positive caring relationships developed with people using the service?
C2 How does the service support people to express their views and be actively involved in making decisions about their care, treatment and support?
C3 How is people’s privacy and dignity respected and promoted?
Responsive
R1 How do people receive personalised care that is responsive to their needs?
R2 How does the service routinely listen and learn from people’s experiences, concerns and complaints?
Well-led
W1 How does the service promote a positive culture that is person-centred, open, inclusive and empowering?
W2 How does the service demonstrate good management and leadership?
W3 How does the service deliver high quality care?
Taken from CQC's ASC inspection handbook October 2014 v 2 00
While we do our utmost to assure the information contained in this article and our other articles is accurate and up to date we are not responsible for any provider's inspection preparedness or any negative consequences that result from incorrect information. Please make use of all resources provided by the CQC to ensure you are as informed as possible.
