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A Care Quality Commission (CQC) rating for health and social care providers can have far-reaching impacts. The ratings are a public display (there is a legal obligation to display ratings) of how the CQC perceives a provider’s quality of service delivery – they are designed to empower service users and incentivise service providers.
It would be easy to assume that organisations looking to improve their ratings are those with the most significant challenges. However, it is not uncommon for organisations to slip down a rating or two. If the change in rating catches the organisation off guard, the consequences can be dramatic, such as senior leaders finding their positions untenable. This blog explores how maintaining a rating can be problematic for organisations unaware of the challenges.
What are the quality ratings?
CQC inspections and the resulting quality ratings are designed to provide users with information to fuel decision-making on choosing service providers. They are also intended to drive improvements.
The CQC will inspect all health and social care providers carrying out a regulated activity. The CQC will then rate each service (save a few exempt) against five key questions:
- Is the service safe?
- Is the service effective?
- Is the service caring?
- Is the service responsive?
- Is the service well-led?
34 Quality Statements, split across the key questions, detail what the CQC expects providers to be able to say about their service. The CQC will seek evidence on how providers satisfy the quality statement; this evidence is rated on quality, and the scores feed into the Key Question rating:
- Outstanding: The service is performing exceptionally well.
- Good: The service is performing well and meeting our expectations.
- Requires improvement: The service is not performing as well as it should, and we have told it how it must improve.
- Inadequate: The service is performing poorly, and we’ve taken action against the person or organisation that runs it.
What is the challenge?
1. Time between inspections
A delay between CQC inspections can pose several challenges for an organisation in the healthcare sector:
- Lack of external validation: Regular inspections validate an organisation’s efforts to maintain and improve quality. A delay can leave the organisation without valuable feedback and recognition. They also allow opportunities for minor adjustments, preventing an organisation from eventually heading in the wrong direction.
- Resource allocation: Organisations may need regular deadlines for data requests to consistently focus on quality improvement. Physical inspections also drive efforts and ensure adequate resource allocation for internal assurance processes.
- Preparation challenges: When information scrutiny and physical inspections are infrequent, staff can become less accustomed to the process, making it more challenging to prepare effectively when an inspection or information request does occur.
- Complacency risk: Extended periods without scrutiny may lead to complacency within the organisation, potentially resulting in a gradual decline in standards or less rigorous adherence to best practices
- Missed improvement opportunities: Without regular external assessments, the organisation might overlook areas that need improvement or fail to address emerging issues promptly.
- Benchmarking difficulties: Less frequent inspection reports can make it more difficult for an organisation to compare its performance against peers and industry standards. Equally, if the sector is experiencing inspection delays, it is more challenging to learn from other inspections.
2. Changes in Key Personnel
Changes in an organisation’s key personnel can significantly impact its preparation for a Care Quality Commission (CQC) inspection or information request. In particular, changes can affect:
- Knowledge transfer: New personnel may need to gain their predecessors’ institutional knowledge and experience, potentially leading to gaps in understanding of CQC requirements.
- Team dynamics: Leadership changes can affect staff morale and teamwork, potentially impacting the collective effort required for inspection readiness. In addition, leadership can significantly impact culture, an organisation’s culture may have changed entirely between inspections, especially if there is a protracted period between inspections.
3. Changes in CQC expectations
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 have remained largely unchanged since their introduction. The CQC inspection methodology has altered several times, with comprehensive inspections giving way to targeted inspections, and now the single assessment framework details the new methodology. However, expectations change more frequently.
The inspection process is designed to drive improvements. For example, innovative (aka Outstanding) practices ten years ago will become standard (aka Good) over time as more providers learn and implement similar processes. Similarly, accepted “good” practice will change, and a failure to adapt will result in outdated practices being used and rated as “Requiring Improvement” or “Inadequate”.
4. Accurate feedback
The CQC has designed a comprehensive approach to monitoring health and social care services post-registration. They aim to collect data from diverse sources to inform their inspection strategies, determining optimal timing, locations, and focus areas for inspections.
People’s opinions and experiences play a significant role in the CQC’s assessment framework. Unfortunately, this has also proven challenging for service providers. Vocal feedback can often skew the perception and requires time and effort to adjust it noted by the CQC. Many reports published reference “…a service user reported…” as evidence to support a finding. Service providers need to actively engage with patients to gain representative feedback from all their service users.
5. System-wide issues
Your CQC rating can be impacted by system-wide issues, even when you operate independently. These challenges often stem from your position within a broader healthcare landscape, particularly if you work under white label or commissioned arrangements.
Key challenges you should be aware of include:
- The Patient Journey: You are often just one step in a longer patient pathway. Even if your portion of the service is excellent, a negative experience at another touchpoint can unfairly reflect on you.
- Fragmented Governance and Responsibility: You may experience a disconnect between your clinical responsibilities and external factors that are beyond your control.
- In white-label arrangements, you are responsible for the clinical quality and safety of the service, while the commissioning company controls the branding and marketing. This can lead to mismatched patient expectations if the service is misrepresented.
- When providing commissioned services, you may be bound by contractual terms that do not keep pace with evolving CQC standards. In these cases, clear accountability and documented discussions are imperative to evidence the “root cause” of why your service is provided in a certain way.
- Obstructed Feedback Loops: Patient feedback is a critical part of the CQC assessment. In a white label model, feedback may be directed to the commissioning company rather than to you, the actual clinical provider. This makes it challenging for you to gather representative feedback, learn from it, and evidence improvements to the CQC.
Good governance arrangements are critically important when organisations combine to deliver a service.
How to turn a challenge into an opportunity.
Providers should be in frequent communication and not just about incidents. But when incidents do occur, there should be a low threshold for reporting them to the CQC. Quiet organisations cause more of a concern than vocal ones (you’ll still need to be able to evidence organisational learning from your incidents).
Organisations must be able to demonstrate they know and are discharging their legally mandated obligations. Importantly, these are a minimum, i.e they are the standards below which care must never fall. Understanding the obligations will ensure that service policies and procedures are written with obligations in mind, and improvement plans focus on the right actions.
Robust governance assures that mandated activities, including those delivered by a consortium or via third parties, are being done to the standard required through regular self-assessments. Setting out an effective governance structure ensures that risks to the organisation, its staff and its service users are addressed effectively. It allows service improvement decisions to be made whilst considering legal obligations and it ensures the sustainability of the organisation.
Engagement must be part of a continuous feedback loop where organisations dedicate time to analyse the information gathered, implement tangible actions based on the findings, and clearly communicate these outcomes. This transparent, action-oriented approach is crucial for building trust, encouraging ongoing participation, and ensuring governance decisions are based on a truly representative understanding of the organisation’s performance and challenges.
Conclusion
Maintaining a CQC rating is an ongoing challenge that requires vigilance, proactivity, and adaptability from health and social care providers. Infrequent inspections, personnel changes, changing CQC expectations, the challenges of gaining accurate feedback, and system-wide pressures all contribute to the difficulty of sustaining high-quality ratings.
However, these challenges also present opportunities for growth and improvement. By actively engaging with the CQC, thoroughly understanding regulations, implementing robust governance structures, and maintaining open communication with service users, staff, and stakeholders, organisations change these challenges to opportunities.
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