Background and definition of the assessment framework
CQC’s assessment frameworks are our statutory definition of quality and safety.
The frameworks are designed to:
- help the public, providers and others understand what good care should look like
- make sure our regulation is consistent, while still recognising differences between sectors
- help us spot when providers are breaching regulations and decide what action we need to take
- work well for the wide range of organisations we regulate
- make sure our judgements are clear, fair and easy to understand
- support a shared view of quality across the health and care system
- make sure our approach can adapt and stay relevant in the future.
The role of assessment frameworks in our regulatory model
Our assessment frameworks support each of our commitments, helping us set clear expectations, build trusted relationships, focus on what matters to people, provide transparent judgements, act to protect the public, use our independent voice, and convene partners to improve care.
Setting expectations
The assessment frameworks and supporting guidance set out what good care looks like. They create a shared understanding of quality, help providers reflect on their performance, reduce inequalities, and ensure transparency about how we assess services. People and providers expect more from us than ensuring that services meet minimum standards. This is why, to be rated as good, providers need to demonstrate that they are doing more than the minimum requirements set out in regulations.
Connecting and building relationships
Strong, trusted relationships are essential for effective regulation. Our frameworks give us a shared, consistent basis for conversations with providers and partners, helping align priorities and support improvement across the system.
Inspecting what matters to people
Inspections enable us to observe care, listen to people, and assess providers against our key questions. The frameworks ensure inspections focus on what matters most to people and support our National Preventative Mechanism duties to prevent ill-treatment.
Reporting and rating
Our ratings and reports give clear information and drive improvement. The frameworks underpin these judgements, ensuring we apply a consistent, transparent approach to reporting quality and performance.
Enforcing when necessary
When people may be at risk, our enforcement powers protect them and hold providers to account. Our assessment frameworks are based on and link to the fundamental standards of care that people have a right to expect. Where necessary, we take enforcement action against those regulatory standards, which are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Using our independent voice
We publish independent insights on the quality of care. The frameworks ensure these insights are grounded in consistent evidence, strengthening our credibility and influence.
Convening the system
Bringing together health and care providers, partners, the public and leaders creates shared purpose and momentum for change. The frameworks provide a common language and understanding of quality, making collaboration easier and more effective.
Structure and content of our assessment frameworks
We developed the draft assessment frameworks for each sector by taking account of the extensive feedback received during our internal and external engagement and consultation work over the last year, as well as the recommendations of the independent reviews carried out by Dr Penny Dash, Professor Sir Mike Richards and the Care Provider Alliance.
We have 4 draft sector-specific frameworks, covering:
- adult social care
- primary care and community services
- mental health care
- hospitals (secondary and specialist care)
Each of these frameworks has 4 components:
- The 5 key questions we ask of all providers: Is the service safe, effective, caring, responsive and well-led? This is the level at which we make ratings judgements, where we have the power to do so.
- Key lines of enquiry that indicate what we will assess within each key question. Each key question has between 3 and 7 of these supporting questions, which replace the current quality statements.
- Rating characteristics that describe what outstanding, good, requires improvement and inadequate look like in each sector.
- ‘I statements’ that describe the outcomes and experiences that people who use services tell us they expect from a good-quality service.
Taken together, these components form the ‘quality indicators’, which we are required to set out by section 46 of the Health and Social Care Act 2008.
When the frameworks refer to ‘people’, we mean everyone who uses services – including adults, children and young people – as well as their families, friends and carers. This includes people with protected equality characteristics (under the Equality Act 2010) and those most likely to experience poorer experiences and outcomes of care, barriers to care, or wider health and social inequalities.
Alongside these components in the assessment frameworks, we will publish detailed supporting guidance to help people understand and apply the assessment frameworks. This guidance will:
- explain the scope of each supporting question and the topics that we will consider under each key line of enquiry
- show how each topic maps to the fundamental standards of care, set out in the Health and Social Care Act (Regulated Activities) Regulations 2014, and the Care Quality Commission (Registration) Regulations 2009
- provide specific detail on what good care looks like in different types of services, including links to existing standards and best practice developed by our partners in health and adult social care.
We will publish this supporting guidance separately from the assessment frameworks so that we can update it more quickly in response to changes in policy, practice, and evidence. Significant changes to the assessment frameworks themselves will only be made following consultation.
Purpose of the ‘I statements’
‘I statements’ are a core part of our assessment frameworks. They reflect what people have told us matters most to them, and they are drawn from the Making It Real framework co-produced by Think Local Act Personal (TLAP) together with a wide range of partners and people with lived experience of health and care services. The Making it Real framework:
- supports personalised care for people who use services
- supports people working in health, care and housing
- provides a jargon-free set of personalised principles focused on what matters to people.
‘I statements’ help us stay focused on what is important to people who use services. They guide how we gather, listen to and act on what people tell us. People’s experiences of care will directly inform our decisions and prompt us to take appropriate action across all our work.
How research informed our guidance on outstanding care
We commissioned The King’s Fund to help us define what outstanding care looks like and how it differs from good care.
The research drew on a review of existing literature and a series of interviews with CQC staff, providers, CQC Experts by Experience, and other experts. These interviews explored people’s understanding of outstanding care and a set of principles that should cover to help describe it.
Across the evidence, there was broad agreement that outstanding care can be understood in 3 main ways:
- as something that goes beyond good care
- as something that people can feel and recognise
- as a way of delivering care that embeds consistency, learning, innovation and improvement.
You can read a summary of the research and read the full report on the King’s Fund website.
The evidence also showed that outstanding care in different settings shares some common features and drivers, such as a person-centred approach and a focus on innovation and learning.
These findings were used to develop a set of high-level, universal principles that apply across all sectors we regulate. The principles were tested and refined through workshops involving providers from a wide range of sectors, Experts by Experience and CQC operational staff, including inspectors.
These principles have informed our draft guidance on outstanding care to give providers, and our own inspectors, a clear, evidence-based sense of what outstanding care looks like, without creating a checklist. The guidance is intended to support more consistent judgements, reinforce our focus on people’s experiences, and help ensure that our description of outstanding care reflects what matters most to people who use services.
The 5 principles are:
- Delivering truly person-centred care
- Embedding a culture of compassionate and inclusive leadership
- Prioritising equity and inclusion
- Continuously integrating learning into practice to drive improvement and innovation
- Having a purposeful approach to making a positive difference for people who use services, staff and the wider system
How we apply our assessment frameworks
The rating characteristics are intended as a guide, rather than a comprehensive list of everything that might be relevant under each key question or key line of enquiry. They will sit alongside external best practice standards and sector-specific guidance, and we expect providers and inspectors to use these together.
Not every element of the rating characteristics will apply to every service, and so services do not need to demonstrate every characteristic to meet a particular rating. They are an indication – not a checklist.
We may not cover every part of the assessment framework every time we inspect a service, or comprehensively assess every area of every service. We ensure that we gather enough evidence to be assured of our judgements. We will also consider the impact on ratings of significant quality failings that result in enforcement action.
Aggregating ratings using the rating principles
Our approach to ratings aggregation has not changed and we set this out in our guidance.
Services we do not rate
Some types of service are exempt from CQC’s legal duty to give a rating. Our approach for these services has not changed and we will provide a judgement to reflect whether they are compliant with the regulations. Read our guidance on how we make judgements about providers that we do not have the power to rate.