Care Quality Commission’s New Inspection and Regulation Regime – where are we now (Part 2)?

In June 2024, we wrote a blog on the Care Quality Commission’s (CQC) New Inspection and Regulation Regime, with a particular focus on key changes, its rationale, practical applications, and early signs of difficulties.

 

interim independent report

In July 2024, Dr Penelope Dash, an Independent Lead Reviewer, released an interim review of the CQC’s operational effectiveness. The interim report evaluates the CQC's current performance, focusing on the Single Assessment Framework (SAF), support for innovation, and the efficient delivery of health and care services. This review was based on management information from the CQC provided to the Department of Health and Social Care, as well as interviews and roundtable discussions with approximately 200 stakeholders. The full report is expected in autumn 2024.

 

summary of the findings

The review found significant concerns with the CQC’s operational effectiveness. The findings of the interim report are summarised below.

Recently, the CQC restructured its teams, shifting from specialists to generalists. This change meant that inspectors, who once had specific sector knowledge, now visit various types of facilities without relevant experience. For example, some inspectors visiting hospitals had never been in one before, and others in care homes were unfamiliar with dementia care.

This shift away from sector-specific expertise has led to a loss of trust from providers, who feel the assessments are less informed and less valuable. Additionally, the previous model fostered strong relationships between CQC and providers, enabling better understanding and sharing of best practices. This approach has been largely lost, leaving CQC less effective in improving healthcare and social care services.

4. Concerns around the SAF

We previously explored the changes brought to the CQC, in respect of the new framework, SAF. In short, the framework aims to evaluate the quality of healthcare and social care services based on 34 quality statements. These statements align with five core areas of care: safety, effectiveness, caring, responsiveness, and leadership. For each statement, the SAF collects evidence through six categories: people experience, staff experience, partner experience, observations, processes, and outcomes. However, this review has identified several key issues with the SAF:

• Lack of Clear Standards for 'Good' or 'Outstanding' Care: One major concern is the absence of clear definitions for what constitutes 'good' or 'outstanding' care. The framework does not provide detailed descriptions of these standards, leading to inconsistencies in assessments and missed opportunities for improvement. Providers have reported difficulties in understanding what inspectors are looking for, and inconsistencies in ratings across different sites of the same provider have been noted.
• Insufficient Focus on Outcomes: The SAF includes an evidence category for outcomes, but the review found that outcomes are not sufficiently emphasized. For example, in primary care, only a small fraction of quality statements and evidence categories address care outcomes. There is limited use of available data on patient outcomes, and the review highlighted a lack of focus on disparities in care outcomes among different population groups.
• Poor Communication and Layout of SAF Information: The SAF’s presentation on the CQC website has been criticized for being confusing and poorly organized. This issue extends to internal communication within the CQC, where staff have struggled to articulate the framework’s details and its application.
• Transparency Issues with Data on User Experience: The review also found that the data used to assess user experiences is not transparent. The methods for analysing this data and ensuring its representativeness are unclear. The reliance on national surveys and a small number of interviews may not provide a comprehensive view of service quality.
• Absence of Resource Use and Efficiency Assessment: Despite the Health and Social Care Act 2008 mandating the consideration of resource use, the SAF does not include a quality statement on efficient delivery of care. There is no objective assessment of how resources are utilized, which could impact the overall quality of care.
• Limited Consideration of Innovation in Care Models: The SAF has been criticized for its limited consideration of innovation in care delivery. While there is a quality statement on learning and improvement, there is no systematic approach to evaluating how organizations are adopting new technologies or innovative care models.

5. Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (often several years ago) to calculate a current rating

The review found that overall ratings for providers are often based on inspection outcomes accumulated over several years, raising credibility issues. Although this approach has been in place for a while, it became less transparent with the introduction of the SAF, which aimed to use more frequent assessments and emerging data. However, due to insufficient inspections, this problem has not reduced. To address this, the CQC plans to focus on individual quality statement scores and increase the number of quality statements assessed to enhance accuracy.

 

Recommendations of the report

The interim report made the following recommendations:

1. Quickly improve operational performance.
2. Fix the provider portal and regulatory platform.
3. Rebuild expertise within the organisation and relationships with providers to regain credibility.
4. Assess and update the SAF to ensure it meets its intended purpose.
5. Clarify the rating calculation process and increase transparency, especially for ratings based on multi-year inspections.

 

response to the interim report

Following the recent interim report, care provider leaders have strongly criticised the CQC. Health Secretary Wes Streeting expressed his concern over the findings, stating, "I was stunned by the findings, which showed the organisation was not fit for purpose."

Echoing these concerns, Jane Towson, Chief Executive of the Homecare Association, criticized the delays faced by social care providers. She remarked, “It is outrageous that social care providers are left waiting interminably for registrations and ratings, directly impacting local capacity, quality of care, and sustainability of providers.”

Professor Martin Green OBE, Chief Executive of Care England, supported the findings of Dr Dash's report, noting that it accurately reflects care providers' concerns and outlines a clear path for improvement stating: “The CQC must embark on a radical improvement program that should not only include tangible performance improvements but also shift away from a culture of blame.”

Together, these responses underscore a pressing need for comprehensive reforms within the CQC not only to restore its credibility but to enhance the effectiveness in safeguarding the quality of care across the health and social care sectors.

 

future steps

The path ahead for the CQC involves crucial reforms aimed at rebuilding trust in health and social care regulation. Kate Terroni, the CQC’s interim chief executive, has acknowledged the review’s findings and is already implementing key changes, including increasing inspections, upgrading IT systems, and enhancing interactions with service providers. Over the summer, the CQC’s progress will be closely monitored, with a full report expected in the autumn. Both the Government and the CQC are committed to these improvements to restore confidence in the quality of care provided to patients and their families.

To address the concerns raised in the report the Government and the CQC have outlined a series of immediate steps:

1. Appointment of Professor Sir Mike Richards: The CQC will appoint Professor Sir Mike Richards, a former Chief Inspector of Hospitals, to review and reform the CQC’s assessment frameworks.
2. Improving Transparency: The CQC has also committed to improving transparency in how it determines its ratings. This will help ensure that the public and providers have a clearer understanding of how these crucial assessments are made.
3. Increasing Government Oversight: The Government will increase its oversight of the CQC, requiring regular updates on the progress being made to implement the recommendations from the interim review. Finally, Dr Penelope Dash will also review the effectiveness of all patient safety to ensure that every aspect of care regulation is up to standard.

 

further information

If you have any questions regarding this blog, please contact Shannett Thompson or Manvir Grewal in our Regulatory team.

 

about the authors

Shan is a Partner in the Regulatory Team and is the firm’s Training Principal. She trained in the NHS and commenced her career exclusively defending doctors. She provides regulatory advice predominantly in the health and social care and education sectors.

Manvir is a trainee solicitor at Kingsley Napley. She is currently in her third seat with the Public Law team. Her first seat was in the Real Estate and her second seat was in the Regulatory team.