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October 7, 2024

What to do about the CQC?

AlteaPlus Essential

By Will Marshall, Head of Legal and Risk Management

What to do about the CQC?

Implications of the interim Dash report

In May 2024, the Department of Health and Social Care (DHSC) commissioned an independent review, to be led by Dr Penny Dash, a leading public health doctor, into the operational effectiveness of the Care Quality Commission’s (CQC’s) new Single Assessment Framework. The CQC had recently completed the rollout of its new framework and publicly welcomed the review, clearly not anticipating the shockwaves that were to follow the publication of Dr Dash’s blistering interim report at the end of July.

The interim report identified multiple, fundamental problems that together raised an ‘urgent need for a rapid turnaround’ of the principal regulator of healthcare and adult social care in England Review into the operational effectiveness of the Care Quality Commission: interim report - GOV.UK (www.gov.uk).

The implications of the report reverberated across Westminster and beyond. The new health secretary, Wes Streeting, confessed he was ‘stunned by the extent of the failings in an institution that is supposed to identify and act on failings’, and described the CQC as ‘not fit for purpose’. Government acts after report highlights failings at regulator - GOV.UK (www.gov.uk).  For its part, the CQC quickly fell on its sword, with its interim Director, Kate Terroni (also newly in post), unreservedly accepting the review’s findings and recommendations. Response to the interim findings of the Dash review into CQC's operational effectiveness - Care Quality Commission

A raft of urgent interim remedial steps was hastily announced, including an independent review of the CQC’s flagship new assessment framework. The publication of this review and the Dash Inquiry’s final report are both expected later this autumn.

Issues with SAF

Much of the Dash review focused on the CQC’s controversial new single assessment framework (SAF). This had been launched to considerable fanfare in November 2023 to replace the previous system of inspections and assessments. The SAF was intended to make the assessment process simpler and more insight-driven, producing more frequent and sector-focused inspections.

The SAF was gradually rolled out to registered providers over the winter of 2023/24. However, the new IT-led framework – that placed an onus on healthcare and social care providers to self-assess via a new digital portal – suffered from significant teething problems from the start.  In particular, providers struggled to report patient safety incidents (as they are required to do), and new providers faced delays and difficulties when applying for registration online, placing greater strain on already stretched capacity.

Registered providers who were subject to the SAF were increasingly reporting concerns about a perceived lack of clarity regarding how the all-important inspection ratings were being calculated, especially the use by inspectors of previous inspection ratings (often from several years ago) to calculate a current rating.

It was against this background of provider concern that the Dash review was commissioned by the DHSC to examine the suitability of the SAF methodology for inspections and ratings.

Interim findings

The interim Dash report’s ‘emerging findings’ make for sobering reading for the CQC. The review consulted over 200 senior managers, care givers and clinicians working across the health and care sectors, and over 50 senior managers and advisors at the CQC. It found evidence of ‘significant failings’ which had led to a ‘substantial loss of credibility’ for the CQC within the health and social care sectors. Perhaps most damaging, the report found there to be a ‘deterioration in the ability of the CQC to identify poor performance and support a drive to improved quality’ – criticisms which go directly to the heart of the regulator’s core functions.

The report’s findings are summarised around 5 topics as follows:

  • 1. Operational inefficiencies: Issues included long delays in re-inspections, with some providers waiting years, and a backlog in registrations of new providers. Only 7,000 inspections and assessments were carried out in 2023-24, compared with more than 16,000 in 2019-2020. Some organisations had not been re-inspected for several years – in July 2024, the oldest rating for a social care organisation dated back to October 2015 and for an NHS hospital to June 2014. Many providers, particularly in social care, had never been rated, affecting service users' ability to make informed decisions.
  • 2. IT system failures: Problems with the provider portal and regulatory platform were found to have caused delays and frustrations. Providers had struggled with slow processes, such as uploading documents or resetting passwords, taking staff away from front-line care.
  • 3. Loss of expertise and credibility: The review identified a loss of sector-specific expertise within the CQC, particularly in healthcare. It found that inspectors often lacked the necessary experience, leading to mistrust in inspection outcomes and missed opportunities for improvement. The review heard of inspectors visiting care homes and commenting they had never seen anyone with dementia before.
  • 4. Concerns about SAF: The review identified 6 specific areas of concern with the SAF, including the following:
  • There was no description of what ‘good’ or ‘outstanding’ care looks like. This resulted in a lack of consistency in how care is assessed (particularly across multisite organisations such as larger care home groups). However, perhaps more fundamentally, it also meant there was a lost opportunity for improvement as providers struggled to know what the inspectors were looking for and, as a result, were unable to lean from the inspections.
  • The Dash report described the CQC’s website guidance on the SAF (to providers and the public) as poorly laid out and confusing. Worryingly, the review found this confusion extended to the CQC’s own executive team, with few able to describe how the quality statement/evidence category framework was intended to operate or how ratings were calculated.
  • There was no objective assessment of the use of resources to deliver efficient care. The review described this as ‘disappointing’ - as effective use of resources is a particularly impactful way of improving the quality of care for any provider.
  • The review found a similar lack of evidence of a systematic consideration of innovation in care delivery.  This was described as a ‘missed opportunity’ as innovation can be key to driving better quality and more efficient and responsive care.
  • 5. Unclear rating methodology: The review identified a lack of clarity regarding how ratings were calculated, reporting that providers found the CQC’s rating process opaque. This concern was exacerbated by the practice of aggregating inspection outcomes over multiple years to calculate a current rating, an approach that the review concluded simply could not be ‘credible or right’.

Recommendations

The report made five fundamental interim recommendations, including improving operational performance through targeted staffing, fixing the IT systems, rebuilding the CQC’s in-house sector expertise, reviewing the SAF to make it fit for purpose, and increasing transparency in how ratings are calculated. The full report is expected to be published in late 2024.

Reaction to the report

In the CQC’s immediate response to the report, Kate Terroni acknowledged that the findings ‘aligned’ with previously known issues about the SAF. She stated: ‘We accept in full the findings and recommendations in this interim review, which identifies clear areas where improvement is urgently needed.’ She assured the press and public that the CQC was ‘working at pace and in consultation with our stakeholders to rebuild that trust and become the strong, credible, and effective regulator of health and care services that the public and providers need and deserve.’

Wes Streeting announced 4 immediate steps that the Government and CQC would take to restore public confidence in the regulator and ensure patients received an accurate picture of the quality of care available. These included:  

  • the appointment by CQC of Professor Sir Mike Richards to review CQC assessment frameworks. Sir Mike was a hospital physician for more than 20 years and became the CQC’s first Chief Inspector of Hospitals in 2013, retiring from this role in 2017
  • improving transparency in terms of how the CQC determines its ratings for health and social care providers
  • increased government oversight of the CQC, with the CQC regularly updating the department on progress, to ensure that the recommendations in Dr Dash’s final review are implemented
  • asking Dr Dash to review the effectiveness of all patient safety organisations

The way forward - rebuilding trust

Rebuilding confidence and trust in a reformed CQC is clearly now an imperative for the government and the regulator. Professor Richards’ recommendations are awaited, but it is clear that there is no ‘quick fix’ solution to some of these issues and that any changes will take time – and money- to take effect.

However, urgent reform is also critically important for providers and the public. There is clearly little public comfort to be drawn from Dr Dash’s conclusion that the CQC’s poor operational performance is impacting its ability to ensure that health and social care services provide people with safe, effective, compassionate and high-quality care. This not only erodes public confidence, but potentially increases the risk of harm to patients and service users. It will not be easy to rebuild public confidence in a regulator who is currently deemed to be unable to consistently and effectively judge the quality of health and care services, including those in need of urgent improvement. 

As for providers, there’s an urgent need to clarify and effectively communicate what constitutes good" or "outstanding" care. The failure to do this under the SAF has made it very hard for providers to understand what is expected of them, potentially resulting in missed opportunities for quality improvement as organisations struggle to know the benchmarks they are aiming for.

Restoring consistency in assessments and clarity about ratings is also vital. The absence of this not only creates confusion and erodes trust in the regulator but risks being unfair to providers and, in some cases, causing them unjustified financial and reputational harm. The reported difficulties in accessing the provider portal have led to frustration, stretched resources and – in the case of the backlog in registrations – in some instances, caused business damaging levels of loss of revenue to small and financially vulnerable new providers.

Inconsistent care quality ratings are also a cause for concern for the providers’ insurers, who will be worried by the absence of clear definitions of what constitutes ‘good’ or ‘outstanding’ care. Without a consistent framework for evaluating care standards, insurers face challenges in determining the true quality of an organisation’s care, making it harder to accurately evaluate its liability risks. This can create difficulties in assessing risk accurately or pricing premiums based on the quality of care provided. Insurers will also be concerned if providers cannot learn from inspections – and the resulting missed opportunities for their insureds to identify and better manage their risks going forward.

A robust, effective and transparent CQC is clearly pivotal for the health and social care sectors. This is a pressing problem: in June 2024, there were almost 54,000 locations registered with the CQC Using CQC data - Care Quality Commission including almost 30,000 social care organisations. It is clearly imperative that steps are taken to fix the problems identified in the Dash review as soon as possible. Publication of the final Dash report, together with Professor Richards’ review of SAF, will be critical to setting the pathway for this process and we’ll be closely monitoring these developments at AlteaPlus.

“The information contained in this article does not represent a complete analysis of the topics presented and is provided for information purposes only. It is not intended as legal advice and no responsibility can be accepted by Altea Insurance for any reliance placed upon it. Legal advice should always be obtained before applying any information to particular circumstances.”

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