5: Reviewing the expectations and experiences of people who raise concerns with us
Key findings and recommendations
Expectations of people who use services and workers when they raise concerns about care with us
Our review found that:
- CQC is not generally meeting the expectations of the public or people who work in care services when they raise concerns with us. We do not meet expectations in terms of the follow-up service people receive and the action taken as a result. This demonstrably affects public confidence in CQC.
- CQC's role in handling concerns raised by members of the public is inherently confusing. CQC invites feedback from the public about their experiences of care, but is not able to resolve their concerns or investigate their complaints. This is because we do not have the powers to do so, except for complaints made under the Mental Health Act.
- The public understands our role once it is clarified with them. However, when someone shares a concern with CQC, they can be frustrated that we can't resolve it. This can undermine their trust and motivation for sharing feedback with us. People from ethnic minority groups and disabled people, who are more likely to have a poorer experience of care and face discrimination, highlighted the impact of this frustration and undermining of trust with us.
- Some people from ethnic minority groups and some disabled people who use services told us they felt they were unlikely to trust CQC with their concerns because they had no knowledge of CQC or our role. Health and care workers who had less knowledge about CQC said they were unsure about whether they could trust CQC with their concerns.
- When the public and health and care workers raise concerns with CQC, they see this as a serious matter. It can also often be a last resort following a lack of response with the provider or other parts of the health and care system. They are often distressed by their experiences, and may fear reprisals by the service, such as being evicted.
- Members of the public with disabilities were concerned about whether CQC would understand that people with protected characteristics are disproportionately affected by discrimination.
- Health and social care workers from ethnic minority groups had low expectations of CQC responding to concerns about discrimination. Our research did not provide evidence about what drives these low expectations, including whether or not they are specific to CQC, but research in Workforce Race Equality Standards reports states that more people from Black and minority ethnic backgrounds have personally experienced discrimination compared to their White colleagues.
People's experiences of raising concerns about care with us
- CQC's channels for providing feedback are easy to find and easy to use and generally meet the public's and health and care workers' expectations. Some improvements could be made for people who are fearful or traumatised, whose first language is not English, who face communication barriers due to disability or sensory impairment, who have low literacy skills or who are digitally excluded.
- Most people who contacted us by phone had a positive experience of the way the call was handled. They felt listened to, with only a small number not feeling heard. People generally described our call handlers as 'sympathetic' and 'concerned' about their experiences, especially since they were often distressed or angry. Overall satisfaction with the service provided by telephone is 4.6 out of 5 (from a total of 19,954 responses).
- However, overall people who took part in our research generally did not have a good experience of raising concerns about care with us. This was driven by people expecting that CQC would investigate and resolve their concern and that CQC would provide clear and frequent communication once people had raised their concern.
- While anyone raising a concern receives a generic response from CQC, further follow-up is at the discretion of the inspector and is therefore inconsistent. People who do have their concerns followed-up and are contacted have a better experience.
- The lack of follow-up provided to people who raise a concern with CQC means that they could not necessarily know whether or not they had been discriminated against. A small number of the public who had raised a concern with CQC felt the lack of follow-up from CQC was due to racial or other discrimination. However, most participants felt that there was no discrimination or unfairness in the way they were treated.
What does the information we collect tell us about how we listen and respond to concerns?
- CQC does not collect demographic or protected characteristic information from people who raise concerns. This means we can't use this information to show whether certain groups are experiencing poorer care or discrimination. It also means we cannot currently check whether people experience discrimination when we handle their concerns.
- We are unable to easily or confidently report on how many concerns we have received from members of the public and how we have acted on them, as we do not accurately or consistently collect this data. For example, where there is an option to record action taken in response to information received through our 'Give Feedback on Care' service, the most common option chosen is 'unspecified'.
- Most concerns raised with us by members of the public are categorised as Priority 3 meaning there may have been a breach of fundamental standards. Where data is available to indicate how CQC has responded to those concerns, the most common response is either 'unspecified' or 'no further action'. This means that we do not have assurance that some Priority 3 concerns about potential breaches of fundamental standards are being acted on appropriately.
- Our capacity and capability to analyse qualitative information from the public is not fully developed, although plans are in place to make this possible.
- CQC does not collect or monitor levels of satisfaction among the public and care workers about the process of raising a concern.
Aim 1: The public, workers of services registered with CQC, and other stakeholders trust CQC to listen to and act on their feedback and concerns in an inclusive manner
We recommend that CQC should:
- Make clear how our Contact Transformation programme will deliver on the commitments in the CQC and the Public Engagement Strategy relevant to this review. This includes improvements in how information of concern is captured, prioritised, stored and analysed, and the customer service we provide back to individuals who raise concerns with CQC.
- Develop and publish externally an agreed organisational approach to the customer service the public and organisations that represent them, and people working in care services can expect when they share concerns about care with us. This includes all direct channels (webform, telephone, email, letter, face-to-face), as well as how we will offer a feedback loop to keep them informed about how their concern is being assessed and acted on.
- Consider offering different levels of customer service response, depending on the severity of concerns being raised, the vulnerability of the person raising them, and the type of service involved.
- Develop a clear, transparent, easily reportable process for tracking how each concern raised by members of the public and organisations that represent them, and people working in care services has been triaged, assessed and acted on. This will enable a feedback loop to individuals, effective reporting, accountability and quality assurance.
- Introduce a process to understand the public's experiences of sharing concerns about care with us, so we can continually improve this key area of our work.
- Measure both the timeliness of how concerns raised by members of the public are responded to, and whether the action has mitigated the presenting risk, and implement a quality assurance system for this.
- Based on the above new processes and protocols, develop new, clear information for the public to enable them to understand what they can expect when they raise concerns with us, as well as our response.
- Consider further investment to increase public awareness and understanding of CQC's role in this area, particularly among people from ethnic minority groups and disabled people. This will help establish and maintain public trust and confidence and increase CQC's access to people's experiences of care.
Aim 3: CQC has a culture in place, supported by effective policies, processes and practices, to listen to, act on, and respond to information of concerns about care from workers of services and others. It does this in a way that is free from institutional or interpersonal discrimination.
We recommend that CQC should:
- Review and improve our information capture and prioritisation processes to help us better understand and report on the volumes and types of concerns about care received from members of the public and the action we have taken in response. This includes capture of demographic and protected characteristics. This work also includes introducing an audit process to make sure this information is accurately recorded.
- Urgently address the constraints on how we can analyse concerns raised by the public and workers in care services, including how the data is captured and stored. This will support the above recommendations and ensure all information of concern is appropriately assessed and acted on.
Aim 6: Relevant CQC colleagues feel confident, skilled and empowered to handle whistleblowing and information of concerns about care
We recommend that CQC should:
- Review available staff resources to make sure these are sufficient to enable both effective monitoring of services and responsive on-site inspections when there are early indications of deterioration in quality or of the emergence of a closed culture (shared recommendation with section 1).
- Review internal guidance, training and wider activity to create a stronger positive culture across the organisation that enables us to deliver outstanding customer service to members of the public raising concerns about care with us. This work should include specific focus on discrimination recognising different approaches that may be needed. This is in line with our strategic ambition for regulation that advances equality and protects people's human rights.
Why we looked at this area of our work
Information from members of the public and from health and social care workers about the quality of care is vital to our regulatory work. Unlike any other data, this feedback can offer near real time information about how the quality of care may be changing for the better or the worse. We know that if we don't listen well to the people who use services and people working in health and care we will not be able to regulate effectively.
Evidence about how we need to improve in this area has informed CQC's Strategy from 2021, our imminent Public Engagement Strategy from 2023 and our published People's Experiences Principles and Frameworks. Our expectation is that CQC's Transformation Programme will deliver on these improvements. We looked in more detail at this area for this review because we wanted to know more about how well we listen when people raise concerns with us to deepen our understanding of the improvements we need to make.
We wanted to develop our understanding of:
- the expectations of people who use services and workers when they raise concerns about care with us
- the experiences of people who use services when they raise concerns about care with us
- what the information we collect tells us about how well we listen and respond to concerns.
What we looked at
We reviewed existing insight we held in CQC that would help us to answer the questions defined by the review.
In understanding expectations of people who use services and the public we reviewed existing focus group research and surveys. This research was carried out as part of our ongoing work to deliver our strategic commitment to regulation driven by people's experiences of services and published principles in this area. The existing insight we reviewed included:
- focus group research with 23 members of the public and 3 organisations that represent people who use services into the expectations and experiences of sharing information with CQC about health and care; participants included people with a long-term health condition or disability, and people and carers with a range of digital confidence
- different methods of research into the barriers to digital inclusion and sharing experiences of care with 5 seldom heard groups who are more likely to be digitally excluded
- engagement with 212 people to explore their expectations of sharing feedback about care directly with CQC: 151 people with a learning disability, 18 people who care for an autistic person or someone who has a learning disability, 43 autistic people, and 3 people who are Deaf who have a learning disability or who are autistic
- insight from national organisations that represent people who use services
- annual public awareness and sentiment tracking survey results.
We carried out further work to fill the gaps in our insight as follows:
- An online survey to give us quantitative insight. The survey was sent to 2,000 people, with a particular focus on people from ethnic minority groups, disabled people and health and social care workers.
- 6 online focus groups comprising 39 participants and including a mix of health and social care workers and people who use services, including people from ethnic minority groups and disabled people.
- We commissioned 1-to-1 semi-structured telephone interviews with 40 members of the public who raised a concern about care directly with CQC through our Give Feedback on Care (GFoC) webform, via email or telephone in the period between April and September 2022. We had target numbers of interviews set by gender, age and ethnicity.
- We analysed CQC information to understand what it can tell us about how we respond to concerns about care raised with us by the public. We looked at information from 41,128 enquiries, categorised as Information of Concern from members of the public between April and September 2022.
What we found from our review
Expectations of the public, health and care staff and organisations that represent the public when they raise concerns about care with us
What the general public expect
Methods to contact CQC and raise concerns about care
Our review has found that, in general, people feel that CQC's channels for raising concerns about care (telephone, email and our Give Feedback on Care webform) meet their expectations and are sufficient to meet their needs. Some improvements could be made for people who are fearful or traumatised, whose first language is not English, who face communication barriers due to disability or sensory impairment, who have low literacy skills or who are digitally excluded.
Digital exclusion is complex and uneven and there is not a single solution to enabling people who are digitally excluded to share their experiences of care. Even within seldom heard groups, our review of existing insight showed there was variation in the type of communication people would feel comfortable using. Therefore, it is important that there is diversity in the channels for people to share their experiences of care.
Channels that involve a human element, such as a telephone call or face-to-face conversation with an inspector, were perceived to be more accessible, particularly for those who may struggle to share information in a written format. In addition, human interaction was felt to make it easier to convey feelings and emotions, as well as explain complex situation.
Expectations of CQC's role
There is a fundamental disconnect between the general public's expectation of CQC in relation to raising concerns about care and our statutory abilities in this area. The idea that CQC want to hear concerns about care but can't take up complaints on behalf of individuals was confusing to general public participants of our focus group research. This creates frustration. The frustration is that CQC is asking for feedback about care but doesn't offer an individual resolution of a complaint. But it is also frustrating that CQC is expecting people to tell their story twice – once to the provider for a response to their complaint, and then to CQC.
Our 1-to-1 interviews with people who raised a concern about care direct with CQC in the past 12 months found that many participants expected that we have the power to investigate or resolve a concern on their behalf, and the ability to personally intervene on behalf of a person who might be at risk of significant abuse or neglect. A small number of participants did not expect an immediate investigation. They instead just wanted their concern logged or fed into the next CQC scheduled inspection. This smaller group tended to have had previous interactions with CQC, either in a professional capacity or having raised a concern before. Crucially, however, almost all still expected to receive feedback from CQC about the outcomes of their concern.
Our review has found that there are some differences in public expectations of CQC depending on the type of service feedback is provided about and the seriousness of the concerns being shared. For example, when people are raising concerns about a service where people live, the need for CQC to create a sense of safety is paramount and the fear of reprisals by the service is strong.
A review of our existing insight showed that the fear of retribution by the service as a result of submitting feedback to CQC is a clear theme. This was especially true for groups already disproportionately discriminated against, such as Gypsy, Traveller and Roma communities, leading them to be reluctant to submit feedback to CQC. Reluctance to submit feedback for fear of backlash was not limited to these groups but was common, with some people who use services not submitting feedback until the point of desperation or not submitting any feedback at all despite experience of poor care.
For some people the need for anonymity from the beginning of any interaction with CQC was highlighted, with concerns raised over the requirement to provide identifying information such as room numbers at a care home. Eviction from care homes or restrictions on visitors as a result of supplying feedback were noted as particular concerns and issues.
In our online survey of the public, in response to the question 'how likely are you to raise a concern about care directly with CQC?':
- 47% gave a neutral response stating that they were neither likely or unlikely to do so
- 33% said they were either somewhat likely or very likely
- 20% said they were either somewhat unlikely or very unlikely to raise a concern about care.
People that identify as Black or Black British were the most likely (very/somewhat likely) to report a concern to CQC (60%). Twenty-eight per cent of people surveyed that identified as having a disability indicated that they did not know where to raise concerns. This was higher than other groups.
Figure 9: How likely or unlikely are you to raise a concern about care directly with CQC?
|How likely are people from an ethnic minority group to raise a concern with CQC||Total of all respondents||White||Asian or Asian British||Black or Black British||Mixed / Multiple||Other ethnicity||Prefer not to say|
|Neither likely nor unlikely||47%||46%||62%||33%||50%||67%||44%|
Expectations of initial response from CQC after concerns about care have been raised
Our focus group research found that most general public participants who understood CQC's role with complaints, once it had been explained, expected that an initial response from CQC would include:
- an acknowledgement/confirmation of receipt
- a timescale for any further response
- information about how to make a complaint.
Participants also wanted to receive a copy of what they had sent via the online feedback form, explaining that they were unlikely to save the text separately and would want a copy for future reference.
Disabled people who participated in the focus group research were particularly concerned that anybody sending feedback to CQC should be made aware of how to make a complaint. This was based on an assumption that the public would primarily be motivated to make a complaint and that any report to CQC would be a secondary concern. Participants from ethnic minority groups were particularly concerned that CQC should reassure people that their concerns would be reviewed, so that people feel that CQC valued their feedback.
For a small minority of focus group participants, there was a continued expectation of a response to their specific feedback and a named case handler, even after CQC's inability to investigate and resolve concerns had been explained. This illustrates that, even when our role has been explained, for some people this will never be acceptable as it does not meet their expectations.
Before raising their concern with CQC, most participants in our 1-to-1 interviews had already reported the issue to their health or social care provider, but had not been satisfied with the outcome. This is because CQC was often perceived as being a higher authority, or an escalation point. Many participants asserted that they had no desire to spend their time contacting CQC to raise concerns, and that they were not the 'type' to complain over nothing. There was, therefore, an expectation that we would take their concern extremely seriously and really listen to what they were saying.
Participants tended to be upset and distressed when they raised their concern to CQC. They often felt like their voice, or their complaint was not being heard by the provider and therefore they escalated their concern to us.
In our 1-to-1 interviews, people who had raised a concern about care with CQC had expected us to continue to provide clear and frequent communication with them. This expectation, and CQC's perceived failure to meet it, led to much of the feelings of frustration later in the process.
Expectations of prioritisation
Participants in our focus groups assumed that CQC would prioritise action based on the number of complaints about a particular service. Participants with disabilities suggested that we could look at concerns associated with particular groups, such as people who use health and social care services most frequently. This suggestion is likely to be influenced by this group's awareness that some people are more likely to have poor experiences of services than others.
Forty per cent of respondents to our online survey expected us to look at the nature of the concern reported in order to determine how serious that concern is. And 18% thought that the seriousness of the concern may be categorised based on who has reported it.
Expectations of the action CQC would take
In our focus groups, the general public struggled to answer the question about what action we'd take because of a lack of knowledge of CQC and our role. The smaller group of public participants who wished that CQC would pursue individual complaints wanted CQC to initiate an inspection of the service that was the subject of the feedback. These findings suggest that meeting public expectations for a small, but significant minority of people, will not be possible. This is because we do not have the statutory ability to resolve complaints.
The larger group of public participants who understood CQC's role once it had been explained, suggested that CQC would check that the service had addressed the issues raised, or that we would risk-assess incoming feedback and investigate the most serious concerns. When focus group participants were given information about the potential actions CQC may take in response, the larger group felt that the process for responding to a concern was better than they had expected. In particular, participants from ethnic minority backgrounds who wanted reassurance that CQC would review their concerns were satisfied by a description of the potential actions CQC may take in response.
Expectations of feedback about action taken by CQC
The smaller group of focus group participants who wished that CQC would pursue individual complaints, even after CQC's role had been explained, wanted to know if their feedback had led to any direct action and, if not, how it had contributed to CQC's work.
The larger group of general public participants who understood CQC's role once it had been explained, indicated that their expectations varied depending on the perceived seriousness of the feedback provided:
- If the information was perceived to be serious or urgent, there were higher expectations of more prompt, personalised feedback.
- If the feedback was not perceived to be serious or urgent, there was a more general expectation that CQC would offer reassurance that the information provided had been useful.
What workers in regulated health and social care services expect
Methods to contact CQC and raise concerns about care
Our focus group research with health and social care workers found that our existing channels for raising a concern about care reflected their expectations and were enough to meet their needs. Thirty-one per cent of health and social care professionals who completed an online survey suggested that CQC should gather concerns from Freedom to Speak Up Guardians.
Expectations of CQC's role
Our focus groups found that workers have high expectations of CQC's response to reported concerns. They felt that sharing concerns with CQC was a very serious matter and they would not do so unless all other internal options had been exhausted. This heightened their expectations of CQC's response. Health and social care workers reported that that they were much more likely to use internal complaints or whistleblowing processes rather than raise concerns to CQC. Not all health and social care staff understood CQC's role, although most had heard it.
Expectations of initial response from CQC after concerns about care have been raised
Workers believed that sharing concerns with CQC was a very serious thing to do and would be taken seriously. There was an expectation that CQC would respond to all concerns reported, regardless of how it was reported, with a non-automated email and reference number.
Health and care workers had clear expectations about the content and purpose of the acknowledgement email. This was expected to be tailored to workers by:
- including information about what those reporting concerns can expect to happen
- communicating that the feedback is being taken seriously
- providing an assurance of confidentiality.
Overall, health and care workers' expectations of CQC's initial response were higher than the general public (once CQC's role had been explained).
Expectations of prioritisation
Health and social care workers expected CQC to assess and prioritise incoming feedback based on seriousness and urgency, similar to medical 'triage'.
They also suggested we would analyse the evidence they receive, such as by identifying 'clusters' of complaints from patients in the same population group, or about specific services or specific locations.
Health and social care workers had high expectations that we would take their reports particularly seriously, because they have the knowledge, understanding and experience to be able to identify the most important concerns.
Expectations of the action CQC would take
Health and social care workers expected us to initiate investigatory activity, such as asking clarification questions, gathering evidence or carrying out unannounced inspections. Overall, they thought a lengthy process was likely to start because of their feedback to CQC.
Expectations of feedback about action taken by CQC
When asked how they would expect CQC to inform them about what has been done with their concern, health and social care workers in our focus group research indicated they expected to be kept up to date throughout our investigatory process, as well as at its conclusion. Participants expected CQC to be discreet with the details of the case, given their understanding of patient confidentiality and data protection. While they did not expect detail, they expected their contribution to be acknowledged by an email of reassurance that CQC had acted on the information provided.
Perceptions of how well CQC listens and acts on concerns about care
People's trust in CQC and confidence in how well we will listen to their concerns is directly related to how effective CQC is in raising public awareness, knowledge and understanding of the organisation. Some members of the public from ethnic minority groups and some members of the public with disabilities who took part in our research felt they were unlikely to trust CQC with their concerns because they had no knowledge of the organisation or its role. People from ethnic minority groups felt that CQC needed to build public confidence before expecting people to trust them with their feedback.
Disabled people in our focus groups were also concerned about whether CQC would understand that people with protected characteristics are disproportionately affected by discrimination. This was prompted by their perception that CQC's feedback about any concerns raised would be generic.
Our review of existing insight demonstrated that a lack of awareness of CQC and understanding of our role was a common theme in focus group research around giving feedback about care experiences. Participants in focus groups and interviewees highlighted that awareness of CQC's role and remit was particularly low among ethnically diverse communities, people with low digital confidence, and other marginalised groups that tend to have minimal involvement with governmental or regulatory bodies. There was a shared lack of clarity as to what falls within CQC's remit. Lack of awareness about CQC is a barrier to people raising a concern about care with us.
Workers in regulated health and social care services
CQC's independent status is key. Some workers have a perception that CQC is part of the NHS system and too 'close' to the providers it regulates. Where CQC has not raised awareness, knowledge and understanding of its role, including among some health and social care workers from ethnic minority groups, people are less likely to believe that CQC listens to concerns or reports them.
For health and social care workers in our focus groups, trust and confidence in CQC was directly related to how well CQC had built awareness and knowledge among them. It was suggested that increasing knowledge and understanding of CQC's work would be likely to encourage health and care workers to trust CQC to respond to their concerns.
Health and social care workers from ethnic minority communities had low expectations of CQC responding to concerns about discrimination. These low expectations were not specific to CQC: one participant described how they had not raised an issue about discrimination (internally) due to a perception that it would not be addressed. However, another described receiving a staff feedback form before an inspection, reporting evidence of discrimination, and not receiving any personal response from CQC.
To encourage workers from ethnic minority groups to share any concerns about discrimination with CQC, it was suggested that we should:
- Create more of an understanding about how workers' feedback informs CQC's regulatory work in order to build confidence and encourage them to trust us with their feedback.
- Appreciate that the act of reporting discriminatory issues to CQC reflects a hope that they will be addressed. To foster this sense of hope, the trust implicit in the act of reporting concerns needs to be recognised and acknowledged.
Organisations that represent people who use services
The perception of some organisations that represent people who use services is that there is an increasing lack of confidence in CQC due to previous mishandling or lack of feedback following people sharing experiences of care. In our annual survey of national organisations that represent people who use services, concern that CQC does not always follow up on concerns and complaints contributed to more negative impressions of CQC.
Organisations that represent people who use services have told us that the lack of response from CQC encourages representatives to bypass the established feedback channels and opt for using their professional network to directly contact CQC staff, as they believe this provides more assurance that their feedback will be acknowledged.
An internal report shared with us by the charity Relatives and Residents Association suggests that there is a perception that services will take negative action against people who raise concerns, and that CQC cannot protect people from these reprisals (including eviction from residential services).
"In services where people live many are afraid to speak out to challenge due to fear of reprisals (including, ultimately, eviction). The power imbalance is so vast and people using services are placed in such a vulnerable position, they are afraid to rock the boat. Despite CQC's assurances that issues can be raised anonymously, and people's identities protected wherever possible, many remain afraid that services will be able to identify them. This might be because the family have raised issues with the home previously, or they are the only family in a particular situation or due to the size of the home."
(Relatives and Residents Association)
People's experiences of raising a concern about care direct with CQC
Our research found the experience people have when they raise concerns about care with CQC is mixed. Where the experience was negative the main reported concern was a lack of response to submitted feedback. This was linked to feelings of dismissal and frustration. A lack of clarity about expected next steps, estimated deadlines and potential outcomes was a consistent issue for people.
Where the experience was positive, this was driven by receiving a quick and detailed response from CQC. Those who were pleased with how CQC handled their concerns reported that they knew their feedback had led to clear and actionable learnings.
Our findings suggest we do not offer a consistent experience when members of the public raise concerns about care with us. How we respond may depend on how an inspector chooses to handle the concern, as opposed to following an agreed organisational approach.
The absence of a consistent feedback loop, that tells people how we have acted after concerns about care have been shared with us, is a major barrier to people having a good experience when they share concerns with us.
Context in which people raise concerns with CQC
People were often frustrated, angry and upset due to the significant emotional distress caused by the concern they were raising, or because they had already tried other avenues of raising their concern and saw CQC as their last port of call. They tended to expect CQC to have power over the service provider in their own particular case.
In addition, several of the participants in the 1-to-1 interviews were experiencing mental health conditions or struggling with disabilities. This group felt the role of CQC was to help protect them.
Process of raising concerns with CQC
Generally, participants in the 1-to-1 interviews were satisfied with the process of contacting CQC with a concern. They liked that they had the choice of the email, webform, and telephone and saw the process as very straightforward and clearly signposted. Few participants struggled to raise a concern. Some suggested, however, that certain members of the public might be excluded from raising a concern because of factors including, but not limited to literacy, a basic understanding of English, or not having the time to contact CQC.
Most participants who used the telephone service had a positive experience of raising a concern and felt listened to. Feedback about the call handlers was generally very positive, with only a small number of participants not feeling heard.
Participants generally described the call handlers as "sympathetic" and "concerned" about their experiences. Since they were often distressed or angry, they appreciated the empathetic feedback from call handlers. This was particularly the case when call handlers fed back their experiences in an affirming way, for example by agreeing that the care described was inadequate and needed to be investigated.
Call handlers were generally perceived to appear interested and participants recalled that they demonstrated a sense of urgency. Participants also noted that CQC staff had excellent listening skills, for example call handlers appeared interested, allowed participants to finish their sentences, and reflected back to participants with relevant questions.
Participants felt that call handlers knew what process to follow and how to deal with their concerns in the right way. Participants were made to feel that they had "done the right thing" and that their concern was important to CQC.
A small number of participants reported a more negative experience of reporting a concern via the phone, and recalled the call handlers as being disengaged, or not actively listening. They felt that the call handler was recording things accurately but not engaging with the about their concerns.
Follow up contact from CQC
Members of the public often appeared to misunderstand the role of CQC regarding what the next steps of raising their concern would be. Many thought that CQC would investigate their case and most thought that there would be some form of dialogue and follow up with CQC, in addition to the confirmation of receipt emails. Many were therefore surprised or distressed when this didn't happen.
Almost all participants in our research felt that they would have liked to have heard back from CQC so that they could be assured that their concerns were acted upon. However, most reported that they had not heard anything further from CQC. Where this was the case, they felt the concern had gone unaddressed and felt let down by CQC as a result. Some participants were concerned that other people would continue to experience the poor care that they themselves had experienced. As a result, participants reported that they felt disappointed and let down, and some reported feeling angry. These feelings of distress were particularly strong in people who had raised more serious safeguarding concerns, or concerns about vulnerable people.
A small number of participants said they would be unlikely to report another concern in the future, as they had lost trust in CQC. A small number of participants did see positive action taken directly as a result of raising a concern with CQC, for which they were grateful, and they reported a good experience overall.
Follow up action
The majority of participants were not aware of, or informed of, any action that was taken as a consequence of them raising concerns. Participants who were aware that actions were taken were mainly those who were contacted by providers to resolve issues following their contact with CQC.
Many participants were unsure if any action had been taken as a result of them raising a concern. This was because they were not informed of whether this had happened. They described their feelings about this using words such as "helpless", "annoyed", "upset" and "worried". Participants felt that they had tried to 'do their bit' but wasted their time in raising concerns.
A few participants believed that action had been taken because they observed changes themselves; others were informed by a third party that changes had occurred.
A very small number of participants understood that the service they contacted CQC about had been inspected following their concerns being raised but noted this might simply have been coincidence as they had received no follow-up communication from CQC. These participants felt this was not good enough and they were also disappointed not to have been informed about the results of the inspection.
Some participants were informed by CQC that their information had been passed onto the provider, and the provider subsequently contacted these participants to resolve things directly with them. Generally, these participants were more positive about their overall experience than participants who did not know whether any action had been taken. However, some felt that the action was not sufficient, and a couple of participants felt that services should have been 'closed down'.
Discrimination by CQC
The lack of follow up provided to people who raise a concern with CQC means that they would not necessarily know whether or not they have experienced discrimination. A small number of members of the public who had raised a concern about care with CQC who took part in our research felt the lack of follow up was due to racial or other discrimination. However, most participants in the 1-to-1 interviews felt that there was no discrimination or unfairness in the way they were treated.
One participant felt that their concerns were not taken as seriously as they might have been because they were mentally unwell at the time. This participant felt listened to by CQC when they first contacted them to raise concerns, but did not hear anything back following this. They felt frustrated and annoyed as a consequence. They considered that they would have been reassured that they were being taken seriously if they had heard back and been informed that their concerns were being looked into.
A further participant was very dissatisfied with the way that their concern had been handled by CQC – both in the way they had been treated by CQC and the fact that we had not initially intervened to address the issue, as had been expected. In the absence of any explanation for this, the participant thought they may have experienced racial discrimination.
Discrimination by health and social care services
Some of the concerns raised with CQC were about issues relating to discrimination. Participants raised concerns that they (or the person that was receiving care) experienced disability, racial, sexuality and religious discrimination.
One common theme among participants who had raised issues of discrimination was that they were disappointed not to receive follow up from CQC. This was particularly marked in comparison with those raising concerns not linked to discrimination. Many felt that follow up would have been appropriate and reassure them that their concerns had been acted upon.
As almost all felt that they had been listened to in their original contact with CQC, this lack of follow-up was unexpected, as they felt they had been right to raise the issues but then felt unsure whether any investigation or action was taken as a result. This was particularly strongly felt by participants who had raised concerns that they felt were serious.
Participants who felt they experienced racial discrimination included someone who was advocating for a person who did not speak English, and had been left without services or information in their language.
Several people stated that they had been discriminated against by staff from mental health services, including participants who:
- felt they were not treated 'as a human'
- had homophobic comments made about them
- received negative comments about their faith
- were autistic and receiving treatment under the Mental Health Act
- felt the service was prioritising higher-risk patients
- felt they were not taken seriously as they were a young mum.
What does the information we collect tell us about how we listen and respond to concerns?
We receive concerns about the quality of care in regulated services through a variety of sources, but primarily through telephone calls or emails to our National Customer Contact Centre and through our online Give Feedback on Care service. All information of concern is recorded as an 'enquiry' in our systems.
Most enquiries are categorised and prioritised by our National Customer Contact Centre and allocated to an inspector. Everyone who shares information of concern with CQC who provides email contact details receives an automated email response thanking them and informing them that the information will be shared with appropriate CQC staff.
We looked at information from 41,128 enquiries, categorised as Information of Concern from members of the public between April and September 2022:
- 38.7% were received through our online Give Feedback on Care webform
- 36.3% by telephone
- 24.1% by email.
CQC does not routinely capture, in a reportable way, the action taken in response to all information of concern. This includes information of concern we receive from members of the public. The exceptions to this are action taken for:
- enquiry records that have safeguarding records created
- information of concern received through our online Give Feedback on Care service.
The actions captured against information of concern that have safeguarding records created are different to the actions captured against concerns received via our Give Feedback on Care service. There is no audit undertaken to quality assure that the 'action taken' captured in our contact management system accurately reflects what the inspector did or didn't do in response to the information received.
Of the 41,128 enquiry records, 19,705 reviewed as part of our sample have generated at least 1 safeguarding record. For those 19,705 records, the most common action was 'no further action':
- 45.7% prompted 'other actions' taken of which 54.3% were 'no further action'
- 25.8% prompted a safeguarding referral
- 14.6% prompted contact with the provider
- 11.5% prompted no action (note, there is no difference between 'no action' and 'no further action')
- 1.3% prompted an inspection to be brought forward
- 1.2% prompted a Management Review Meeting.
The most common action for concerns received via our Give Feedback on Care webform was 'unspecified' (29.9%) meaning the inspector did not select an option from the structured list to confirm what action, if any, they took. The second most common action (27.9%) was to use the information to inform inspection planning; the third most common was to contact the provider (15.9%). Only 0.2% prompted a responsive inspection.
Most concerns raised with us by members of the public are categorised as Priority 3 meaning there may have been a breach of fundamental standards (see Receiving information and triage for more information on how we prioritise information of concern). However, where data is available to indicate how CQC has responded to those concerns, the most common response is either 'unspecified' or 'no further action'. This means that we do not have assurance that some Priority 3 concerns about potential breaches of fundamental standards are being acted on appropriately.
Our review has found that our current information capture processes make it challenging to confidently report on both the volume of information received from members of the public about concerns about care and the action we have taken in response.
CQC does not collect demographic or protected characteristic information from people who raise concerns with us. This means that we are unable to identify from those concerns whether or not poorer care or discrimination is being experienced by people from different demographic groups or people with protected characteristics, and we cannot provide evidence of action or reporting in this area. Also, we cannot currently check whether people experience discrimination when we handle their concerns.
In addition, it is not possible to accurately report on:
- whether CQC had any further contact with the individual who shared concerns with us, including what that follow-up contact involved, as this data is not captured in a reportable way
- themes and trends on what members of the public are sharing with us when they raise a concern, as this data is not captured
- what action CQC has taken in response to concerns about care received from members of the public. Some information is captured for enquiries with a safeguarding record, and for enquiries made through our Give Feedback on Care webform, but this is not consistent across all concerns (for example, across all contact channels and across all prioritisation levels)
- whether individuals who shared concerns about care were satisfied with the process of sharing their concerns, including any response they received from CQC, satisfaction levels with the action taken by CQC, and what would have improved people's experience.
We do carry out some customer satisfaction tracking for contact by telephone and for ease of use of the Give Feedback on Care webform.
People who contact CQC by telephone report a high degree of satisfaction with the experience. In 2022, we received 19,954 responses to at least one of four questions. People were asked to select a number 1 to 5, with 5 being 'extremely satisfied':
- 4.60 out of 5: 'Overall how satisfied are you with the service you received today?'
- 4.78 out of 5: 'How satisfied are you with the way our advisor spoke to you today?'
- 4.53 out of 5: 'How satisfied are you that when you called us today we were able to answer and resolve your enquiry?'
- 4.44 out of 5: 'How easy it was it to contact us today?'
The survey findings are not reported by type of enquiry, such as whether the enquiry is from a member of the public raising a concern about care, a registered provider asking a question, or someone asking about registering to deliver regulated services.
People who share an experience of care with us through our Give Feedback on Care webform are invited to complete a short satisfaction survey on ease of use of the form. In January 2023, 517 people completed this short survey. The total satisfaction score for ease of completing the Give Feedback on Care webform was 95.55%. There is currently no equivalent survey for people who contact CQC via email or our general enquiries webform.
There should be a thorough evaluation of how well CQC listens and acts on concerns about care raised with us by people who use services, following the implementation of recommendations from this review. This should seek to understand whether CQC has improved its practices against the following aims in this review:
- The public, workers of services registered with CQC and other stakeholders trust CQC to listen to and act on their feedback and concerns in an inclusive manner. [Aim 1]
- CQC has a culture in place, supported by effective policies, processes and practices, to listen to, act on, or respond to information of concerns about care from workers of services and others. It does this in a way that is free from institutional or interpersonal discrimination. [Aim 3]
- Relevant CQC colleagues feel confident, skilled, empowered and supported to handle whistleblowing and information of concerns about care. [Aim 6]
Six months after this review is published, CQC should look at progress against the implementation of the recommendations. After 12 months there should be an evaluation report on the outcomes of CQC's response and this should mark the formal close of the review. The evaluation should then continue to understand the full impact of the recommendations in achieving the aims set out.
To evaluate how this review has impacted CQC's ability to listen and act on concerns about care raised with CQC by people who use services, possible methods include:
- recommendation tracking
- a survey of people who have provided feedback or raised a concern about care
- focus groups with those responsible for handling whistleblowing and information of concern about care
- interviews with organisations that represent people who use services about how well CQC listens to and acts on feedback and concerns in an inclusive manner
- analysis of whether CQC has acted on information of concern about care, and how this varies by protected characteristics
- analysis of the public awareness and sentiment tracking survey.