The health and care sector in England make up 20% of public expenditure and roughly 12% of the economy. It isn’t an exaggeration to say that our lives depend on it. That’s why there is a body set up to ensure its effective functioning – the Care Quality Commission. But that very body is itself at the heart of a new investigation.

In May 2020, Dr Penny Dash was asked by the government to review the CQC and its new Single Assessment (SAF) Framework, introduced in November 2023. She has published an interim report, in advance of the full report being published in Autumn 2024, and it makes for concerning reading. But what problems have been identified, and what changes might we see in the short term?

Some of the Key Questions for the CQC

The report addressed these main questions:

• Is CQC inspection actually a barrier to reform and change – if so, how is this being addressed?
• Do CQC’s investigations and ratings drive the correct responses among providers
• Do inspections and ratings take account of patients thoughts and feelings properly?
• How will the new scoring system affect ratings and the 5 key areas (safe, caring, responsive, effective and well-led)?
• Are CQC’s regulations and processes fit for an age of digital healthcare?

Key Interim Findings

Concerns around the SAF:

• There is no satisfactory description of what ‘good’ or ‘outstanding’ care looks like, resulting in a lack of consistency in how care is assessed and a lost opportunity for improvement.
• There is a lack of focus on outcomes (including inequalities in outcomes).
• The way in which the SAF is described is poorly laid out on the CQC website and not well communicated internally or externally.  
• The data used to understand the user voice and experience, how representative that data is, and how it is analysed for the purposes of informing inspections, is not sufficiently transparent.
• There is no reference to use of resources or efficient delivery of care in the assessment framework which is a significant gap despite this being stated in section 3 of the Health and Social Care Act 2008.
• The review has found limited reference to innovation in care models or ways of encouraging adoption of these.  

Poor operational performance:

• Just 7,000 inspections and assessments were carried out in 2023 to 2024, partly due to the roll out of the SAF. This compares to more than 16,000 inspections conducted in 2019 to 2020. The target for 2024 to 2025 is for 16,000 assessments.
• There is a backlog of new-provider registrations
• Re-inspections don’t happen quickly enough once a ‘requires improvement’ rating has been given, affecting the ability of hospitals to discharge to these organisations
• The average age of current ratings is 3.7 years
• 1 in 5 inspectable locations has never been rated
• Significant challenges with the provider portal and regulatory platform: These have been widely reported; document uploads and password rests don’t work properly or take too long. Poor IT systems are preventing effective roll out of the SAF, causing time loss for already-stretched providers

Considerable loss of credibility within the health and care sectors:

• When they restructured themselves, the CQC decided to rely much more on generalist inspectors. But this has led to cases of hospital inspectors who report never having been in an hospital before, and care home inspectors admitting they had never met a dementia patient before.
• Where there used to be three types of chief inspector (of social care, primary care and hospitals) there are now just two chief inspectors (of “adult social care and integrated care” and one for healthcare). The previous chief inspector of healthcare was unfortunately taken ill a year ago and has been unable to work.
• Lack of clarity regarding how ratings are calculated and concerning use of previous outcomes:
  The review states “it is not credible or right” that overall provider ratings can be calculated using inspections done over several years. In fact, this has been going on for years (not just since the SAF). Despite the CQC wanting to move away from this, they are not doing enough new inspections to allow this to happen.
• Providers don’t understand how the CQC calculate ratings – this creates the view that it is impossible for them to be able to change their rating. Ratings need to be credible and transparent. 

Recommendations

1. Improve operational performance rapidly: work has begun under the interim CEO, but more needs to be done, and consideration should be given to moving the nascent ICS assessment team to other sectors given the delays in starting ICS assessment work.
2. Fix the provider platform – this work is ongoing
3. Rebuild relationships with providers to restore credibility, and get the right expertise back into the CQC again: senior clinicians need to be appointed as chief inspectors urgently. There needs to be a sense of pride and incentive about being a CQC advisor. Top performing managers could even be allowed to become assessors for a few weeks a year, and this should be something to be proud of.
4. Review the SAF and ensure it is fit for purpose: clearer definitions of each evidence category needed; give greater emphasis and prominence to use of resources within the well-led domain - and build skills and capabilities to assess; improve the quality of documentation on the CQC website; significantly improve transparency and robustness of data used for user and staff experience.
5. Make it clear how ratings are calculated, especially around the use of past inspections and how they are used: all providers and users should understand how ratings are achieved, and the CQC must reconsider using old ratings and multi-year assessments. 

The CQC are still finding their feet when it comes to the new assessment regime. The important thing to remember as a practice is that you should have knowledge of all the areas they may inspect on; the areas they choose to inspect on are prompted by previous intelligence and data - for example, if there has been a whistleblowing concern.

The CQC has now also appointed Professor Sir Mike Richards to conduct a targeted review of how the single assessment framework is currently working for NHS trusts and where they can make improvements

The full terms of reference of the review can be found in Appendix 3 of the report here. You can also read who was spoken to as part of the review. In this period of change it’s more important than ever to get the basics right and know how to be CQC-ready. 

Thornfields offers a workshop called Preparing for a CQC Inspection which will help you. We also run a course on Managing Change in Healthcare to help our clients in this ever-changing healthcare landscape. And on our YouTube site you can see a video of our latest expert-led webinar on How the SAF Is Going So Far. We will update our materials as and when new information about the CQC and their inspection framework comes to light.