Back to the drawing board or back in time for the CQC? All key aims of the CQC’s transformation plan are found to have failed by internal and external reviews

The independent review into the operational effectiveness of the Care Quality Commission (CQC) by Dr Penny Dash, which started in May 2024, published its full report on 15 October 2024^[1], the same day that the CQC published its own internal review undertaken by Sir Mike Richards^[2].  The reports are strikingly similar and equally critical of the impact of the CQC’s transformation programme, which we spoke about in our January 2024 article.

The transformation programme promised a simpler, more transparent process which would enable more regular assessments through the introduction of a Single Assessment Framework (SAF), together with an organisational restructure and new IT system (the regulatory portal).  However, a lack of clarity about the operation of the SAF, and confusing guidance from the CQC on its new approach was concerning from the outset, as discussed in our May 2024 article. The resounding conclusion of both Dr Dash’s and Sir Richards’ reports is that the transformation programme has failed and there is “an urgent need for a rapid turnaround of the CQC.”^[3]

The extent of the failure, which has resulted in “widespread and severe loss of confidence in the CQC”^[4] such that, Sir Richards reported, some local authorities are choosing to undertake their own assessments before commissioning services, led both reports to question why such a shift in the operation and structure of the CQC was needed in the first place.

One size does not fit all

The consensus of both reports is that by trying to “make things simpler”^[5] the CQC arrived at an overly complicated SAF which has made it slower and more difficult to assure safe care.  Included in a summary of “unanimous” views of CQC staff about the SAF in Sir Richards’ report is the observation that, “it doesn’t take account of the major differences in size, complexity or function between services/organisations, or in the nature of the information necessary to assess a service.” Both reports observe that the SAF, and operational decisions to separate clinical and operational leadership, has had the effect of creating a generalist approach to inspections rather than the specialist approach that is needed.  Critically, the risks in each sector, and evidence needed to assure effective mitigation of the same, are very different.  For example, what good looks like in hospital services will be informed by very different evidence to the evidence needed to inform what good looks like in social care.  An equal weighting for each quality statement and evidence category regardless of sector, which is a fundamental principle of the SAF, does not provide sufficient emphasis on sector specific outcomes, leading to a loss of credibility with providers who are struggling to understand what ‘good’ or ‘outstanding’ looks like for their service.

The application and effect of the 34 quality statements under the SAF is heavily criticised in both reports.  The decision to take a selective approach and rely on previous ratings to inform scores against the quality statements not assessed during inspections was found by both reports to lead to unreliable ratings.  The number of quality statements and a complicated aggregate scoring system has added to the already under resourced inspection process, succinctly summarised in Sir Richards’ report as, “It takes longer to look at less”. It is no surprise then that backlogs have increased significantly causing a considerable adverse effect on the sector, and frustration among service providers who are waiting for approvals to operate of have their ratings updated, and frustration for the public having to rely outdated information when making choices about their care.  

Future considerations

Sir Richards left the CQC seven years ago after a four-year tenure as the CQC’s Chief Inspector of Hospitals where he was responsible for developing and overseeing the delivery of inspections and ratings; two further Chief Inspectors were in post with the same responsibilities for adult social care and primary care services.  Sir Richards explained as context to his findings that during his tenure as a Chief Inspector, “almost all” regulated services were inspected and rated “over a period of a little more than three years”.  Sir Richards also concluded with this theme suggesting that if it was possible then, it is possible now, but the CQC needs to revert to the former structure of specialist Chief Inspectors, “strongly” recommending that a fourth Chief Inspector for mental health services is also appointed.

Both reviews recommended that further consideration should be given to the use of overall gradings.  Dr Dash raised whether the use of a scorecard approach, with each of the five key questions rated (safe, effective, responsive, caring and well-led), and dispensing with an overall rating, a step recently taken by Ofsted (discussed in our article about Ofsted’s decision to remove headline gradings here) could be beneficial for providers and the public.

Both reports also raised that increasing specialist resource and a rising number of regulated services to inspect requires funding.  Sir Richards commented that provider fees have not increased since 2019/20, had they increased with inflation, an additional £25.3 million would have been received by the CQC in 2023/24. Dr Dash found that the Department for Health and Social Care could do more to ensure that the CQC is sponsored effectively.

CQC’s response to the reviews

The CQC has welcomed both reviews and accepted all “high-level” recommendations, recognising that “rapid” action is needed to address “serious organisational failings”.^[6] In a press release following the publication of the reviews, the CQC committed to:

• Appoint at least three chief inspectors to lead on regulation and improvement of hospitals, primary care and adult social care services. 
• Consider whether a fourth chief inspector is needed to lead on regulation and improvement of mental health services.
• Modify the current assessment framework to make it simpler and ensure that it is relevant to each sector, stating it will keep the five key questions (safe, effective, caring, responsive and well-led) but change the 34 quality statements.
• Stop scoring individual evidence categories.
• Start working to fix the regulatory platform and provider portal “in the immediate term”.

Since the start of this week (18 November 2024), work on the provider portal has started and providers will be unable to register as a provider or a manager using the provider portal whilst further development work is undertaken.^[7]  Application forms on the CQC’s website will need to be used instead.  Whilst further disruption for providers, hopefully a positive sign that under the leadership of a new Chief Executive, Sir Julian Hartley, work to improve and restore confidence in the CQC is underway.

The extent to which the CQC will resemble itself pre-transformation plan remains to be seen but a return to three Chief Inspectors is certainly a show of intent.  We will be monitoring developments closely and our team are on-hand to assist with your healthcare, social care and education regulatory queries.
 

^[1] Review into the operational effectiveness of the Care Quality Commission: full report - GOV.UK (www.gov.uk)

^[2] Review of CQC's single assessment framework and its implementation - Care Quality Commission

^[3] See 1 above

^[4] See 2 above

^[5] See 2 above

^[6] CQC responds to reviews by Dr Penny Dash and Professor Sir Mike Richards - Care Quality Commission

^[7] Changes to how you register with CQC - Care Quality Commission