We commissioned the Care Provider Alliance (CPA) last autumn to review our single assessment framework alongside the review by Professor Sir Mike Richards. We are grateful to the members of the CPA who took part in and supported this work.
The review examined the perspectives of adult social care providers of the assessment framework and what they want from regulation by CQC. It also raised provider concerns about assessment, registration, and backlogs.
Sir Julian Hartley, Chief Executive of CQC commented “We welcome this report which has been instrumental in ensuring we hear the voices of a wide range of adult social care providers, as the findings are a robust reflection of their views and experiences.”
Feedback represents over 1,200 respondents to an online survey and the views of more than 100 providers shared through 5 workshops.
James Bullion, Chief Inspector of Adult Social Care and Integrated Care, added:
“This report gives us a practical agenda for change which we will incorporate into our urgent improvement work underway in CQC. Professor Vic Rayner, as chair of the CPA, met with me and my Executive Team colleagues and with the CQC Board to discuss the findings of this report. She articulated a powerful message on behalf of providers, including in some cases the distressing impact of approaches to regulation and assessment on their organisations and mental wellbeing. We are grateful for their feedback and acknowledge their experience.
“We acknowledge too the strength of feeling from providers about the need to improve their experience of inspection. Underlying this report (but not looked at in detail) are the changes needed to improve our computer systems, portal arrangements and communications. CQC colleagues have themselves struggled with the challenges caused by the technology issues and rollout of the assessment framework, including the clarity of how the system worked, training, complexity of the approach, and the consistency of approaches in different care sectors. CQC inspectors are skilled and dedicated to good regulation and have struggled to be effective because of these factors”.
Recommendations and our responses
There are 11 recommendations in the report and key messages in the survey. We have now considered these in detail and our responses to each recommendation are listed below.
We are already taking urgent action on our priority improvement workplan to address concerns about our performance on backlogs, assessment frequency, registration delays, and publication of reports. Generally we see good alignment between the recommendations in this report and the work that we have already started to rebuild good regulation.
As we are currently delivering organisational change and improvement, it will be important to consider the CPA report’s recommendations effectively alongside existing work. We are determined to improve providers’ experience of regulation with the development of a handbook which describes what we expect from providers, what they can expect from CQC, as well as giving our staff the tools and time to do their job. We are strengthening sector leadership in CQC and want to continue to work with the CPA to oversee progress. This report provides a good agenda for shared work over the coming months.
Recommendation 1
Create a reduced set of quality statements (the specific numbers suggested by providers were all under 20) and assess all providers on a consistent set of statements for every routine inspection. This should reflect a meaningful reduction in the burden that the assessment framework imposes on providers, rather than condensing the same workload into a smaller set of quality statements.
Our response:
We accept in principle the focus of the recommendation on reducing burden on providers and supporting a more consistent, efficient use of the single assessment framework. We will address this through our wider work to review the assessment framework, in which we welcome the support of the CPA.
The question of the “right number” of quality statements and a “consistent set” will need to be explored as part of consultation on the assessment framework, and our suggested outputs following the review.
Recommendations 1a and 1b
- 1a: The ‘standard set’ of quality statements applied to each service type may flex to the elements of service delivery most relevant to them.
- 1b: Shared Lives providers were the only group to differ in this regard and would prefer flexible and more frequent assessment drawn from a reduced set of quality statements.
Our response:
We will review these points as part of our wider work to develop the assessment framework, and consultation on it.
Recommendation 2
Create guidance for each service type at the quality statement level. Each set of guidance should include specific examples of what good and outstanding looks like and highlight where an aspect of a quality statement is not applicable to the service type.
Our response:
We accept this recommendation and will prioritise work to develop this guidance on “what good looks like” with stakeholders including the CPA and your members.
Recommendation 3
Use the information in the Provider Information Return to plan a timeline, CQC staffing, and priorities for assessment.
Our response:
We welcome this recommendation. We will be looking at how we can improve the use of the existing PIR data in the short term, and then how we can develop this over time.
Recommendation 4
Share this assessment plan, including evidence requests, with providers and give them advance notice of inspection.
Our response:
We cannot accept this recommendation. It would require formal consultation to ensure a balanced view of research evidence, the views of people who draw on services, provider and wider stakeholder perceptions.
Learning from serious cases, including Professor Glynis Murphy's review and our work on closed cultures show us that unannounced inspections are a critical part of our work. They help us to understand the true and authentic culture of services and get under the skin of what they are really like for people. People and family members tell us how important it is to them that we carry out unannounced inspections.
We do, however, recognise the strength of feeling amongst providers that sits behind this recommendation and acknowledge the need to address its root. We will do this through our CQC Way and ongoing foundational improvements. Providers, the public and our own colleagues must expect a fair, respectful, and consistent inspection experience. This must be conducted by someone knowledgeable of their sector or service type, that looks for balanced evidence including the good – regardless of who crosses the threshold, when or whether it is announced or unannounced.
We must, through our work together, ensure that we approach inspections in a truly collaborative, transparent and supportive way. Together, we need to re-establish a mutually respectful place of wanting to find and highlight good practice and protecting people or making improvements to make a difference for people.
Recommendation 4a
Evidence requests, assessment timelines, and number of inspectors must be reasonable and proportional in their scale of demands on services.
Our response:
We accept this recommendation and recognise this also addresses the preparational element of recommendation 4. These expectations must be made clear in the handbook and supported by our CQC Way, as well as the strengthening of our induction and learning.
Recommendation 5
Ensure that evidence included in decision-making has been corroborated rather than taken at face value, to produce a balanced appraisal of the service and is not wholly focused on finding issues or risk.
Our response:
We accept this recommendation. It will be part of our wider foundational improvement work. See also comments under recommendation 4.
Recommendation 5a
Detail efforts made to triangulate information in the report.
Our response:
We accept that reports must be transparent and clear to providers and the public.
We will need to further explore with providers the real concerns here, and whether lengthier and more detailed public reports are the correct way to address them. We must ensure that reports give the public reader and people who draw on and choose from services the right information.
Recommendation 5b
Increasing the rate of inspections does not help providers or the public if the assessment process and report are not meaningful and reflective of the findings on the day of inspection.
Our response:
We agree with the sentiment of this recommendation, which we will address through our wider work to ensure quality of inspections, as well as our foundational improvements.
This must also go hand in hand with clear mutual expectation on how to get the best out of inspections, and a constructive collaborative approach.
Recommendation 6
Re-write the reports of providers who have been assessed in the period of time between the implementation of the SAF and the stabilisation of the regulatory approach to a consistent and meaningful process.
Our response:
We acknowledge the concerns that sit behind this recommendation for affected providers. We are addressing the underlying issues through our immediate actions and foundational improvements.
However, we cannot rewrite published reports. Our legislation requires us to assess provider performance and report on it. We have discharged this statutory duty through our reports, so rather than rewrite those reports we would consider whether there was a need to reassess and issue a new report.
Recommendation 7
Develop a shared, meaningful approach to co-production with providers for use in further work to be completed during CQC’s ongoing recovery programme.
Our response:
We accept this recommendation, and co-design is at the heart of CQC’s recovery and rebuild programme, as we have set out through our shared work to develop the CQC Way.
Recommendation 8
Re-introduce a single point of contact/named inspector for providers.
Our response:
We have previously acknowledged that we need to review the way in which we manage relationships with providers. We have piloted new approaches to this across the sectors and are currently evaluating these pilots. We want to be clear about the research evidence that supports our future relationship management approach, and we will be looking at models of implementation here.
We will also address this recommendation through our foundational improvements, to review how we organise ourselves and integrate operations and regulatory leadership.
Recommendation 9
Train inspectors, with the involvement of care providers, to understand and respect each type of care service and the people that they support.
Our response:
We accept the recommendation to ensure there is consistent knowledge and respect of different service types of care services, and the people drawing on their support. We are already addressing this through our foundational improvements, including our alignment to sector-based knowledge and expertise led by 4 chief inspectors, as well as strengthening our induction and learning offer.
We will explore opportunities to involve care providers to meet with our colleagues to share insights and experience and incorporate this in our teams’ ongoing learning.
Recommendations 10 and 10a
- 10: Establish an independent body to mediate all complaints and challenge processes.
- 10a: Ensure that this is fully accessible and able to support smaller providers who may not have the same level of resource to commit to these processes.
Our response:
We acknowledge this recommendation. However, it is not in the gift of CQC to establish such a body. Rather this is an action which requires decision and action by other bodies, and it would need to be applied to all sectors. Furthermore, in terms of challenges, our factual accuracy process was upheld by the Court of Appeal as a fair process, and the judicial review pre-action protocol requires consideration of alternative dispute resolution. We also have a national complaints team who are independent of the operations teams.
We recognise that behind this recommendation and strength of feeling will sit a loss of trust in CQC. This, as above, we will need to address through our collaborative cultural work, including the CQC Way, and co-design work to rebuild trust.
Recommendation 11
Ensure that all changes in regulatory approach thus far and in future are effectively communicated to all inspectors to reduce inconsistencies in implementation. Communications to providers about changes expected at CQC should be accompanied by achievable timescales for completion.
Our response:
We accept the recommendation that we must effectively communicate changes in our regulatory approaches. This includes internal and external engagement and communications as part of our immediate actions and foundational improvements. The CQC Way is an essential part of this. We are committed to driving its activation across the organisation, and with our external stakeholders, to promote mutual fairness, respect, and consistency throughout our regulatory work and collaborations.
We have committed to co-design and co-production with providers throughout our improvement journey and changes at CQC. We will also continue to work closely with the CPA to keep track of our progress against the recommendations agreed to from the report.