CQC suffering ‘substantial loss of credibility’, review finds

A government-commissioned review into the Care Quality Commission (CQC) has found ‘significant failings’ that have led to ‘a substantial loss of credibility’ within the health and social care sector.

The report into ‘operational effectiveness’ from Dr Penny Dash, chair of the North West London Integrated Care Board (ICB), has highlighted several key issues including delays in producing reports and poor quality of reports.

It also raised concerns around the CQC’s recently launched Single Assessment Framework (SAF) – used to assess GP practices, care homes and hospitals – including issues around inconsistencies and a lack of clarity.

The review, which was commissioned by the Department for Health and Social Care (DHSC), identified a ‘stark reduction in activity’ at the CQC in recent years, with a total of 6,700 inspections and assessments being conducted in 2023 to 2024 compared to 15,800 in 2019 to 2020.

Some organisations have not been inspected ‘for several years’, the report suggested.

The average age of current ratings across all locations is 3.9 years, with the oldest rating for a social care organisation dating back to February 2016.

Dr Dash found that the CQC’s current model of generalist inspectors and ‘a lack of expertise’ at senior levels was impacting the credibility of the watchdog.

The CQC went through a restructuring last year, which moved staff from three directorates with a focus on specific sectors into teams operating at local level, ‘resulting in a loss of expertise’ which meant providers did not trust the outcomes of reviews, Dr Dash concluded.

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She said: ‘This review has found significant failings in the internal workings of CQC, which have led to a substantial loss of credibility within the health and social care sectors, deterioration in the ability of CQC to identify poor performance and support a drive to improved quality, and a direct impact on the capacity and capability of both the social care and healthcare sectors to deliver much-needed improvements in care.’

Her review received more than 125 emails from CQC staff members and saw letters from trade unions to former health secretaries informing them of ‘significant issues’.

Last year, the CQC rolled out its new assessment framework, as reported by our sister title Pulse.

While it continues to use five key questions (safe, effective, caring, responsive and well-led) and a four-point ratings scale (outstanding, good, requires improvement and inadequate) to assess health and care settings, the changes saw the CQC introduce six new ‘evidence categories’ to organise information under the statements.

But among her recommendations, (see below) Dr Dash suggested a ‘wholescale review’ of the assessment framework was needed to address concerns raised.

For example, it said the SAF failed to recognise the ‘challenges in balancing risk and ensuring high-quality care across an organisation or wider health and care system’.

‘Providers have referred to a number of examples where one aspect of care is assessed in isolation of the consequences for other areas of care and, therefore, other patients and users,’ it said.

The review’s recommendations:

Today’s publication follows an interim report from July, which flagged issues including a ‘lack of clinical expertise’ and a ‘lack of consistency’ in GP inspections.

At the time, the CQC’s then interim chief executive, Kate Terroni, issued an apology for the ‘mistakes’ made by the regulator.

Today, health and social care secretary Wes Streeting said the government was ‘taking steps to reform the CQC, to root out poor performance and ensure patients can have confidence in its ratings once again’.

‘This government will never turn a blind eye to failure. An overly complex system of healthcare regulation and oversight is no good for patients or providers. We will overhaul the system to make it effective and efficient, to protect patient safety,’ he added.

Responding to the report, Professor Martin Green, chief executive officer of Care England, said the adult social care sector had been ‘raising the alarm for years, calling for urgent intervention’.

‘The time for action is now. The sector can no longer afford systematic delay from those accountable for the CQC’s failures,’ he added.

The DHSC has commissioned a second review considering the ‘wider landscape for quality of care’, with a focus on patient safety, to be published in early 2025.

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‘Fundamental reset of the organisation needed’

Separately, the CQC has today published its own internal review by Professor Sir Mike Richards, former chief inspector of hospitals at the watchdog, examining its assessment framework and its implementation. This was in response to the government’s interim report from July.

It argued that a ‘fundamental reset of the organisation is needed’ and that the CQC ‘will never be able to deliver on its objectives’ if the current structure is maintained.

And it recommended that the use of one-word ratings for GP practices, care homes and hospitals should be evaluated.

Recommendations from the CQC’s internal review in full:

Structure

1. The organisational re-structure has had a serious negative impact. CQC should revert to the previous structure. Separate sector-based inspection directorates led by Chief Inspectors should be re-established and the Regulatory Leadership directorate should be re-integrated with the inspection directorates.
2. Cross-directorate working can still be achieved either for thematic or strategic work by giving relevant people responsibility for this as part of their job plans. Similarly, integration between sector inspection teams can be maintained by giving dual responsibilities for integration at a local (perhaps ICS level) and specialism/sector responsibility for a wider geography (perhaps 2 or 3 ICSs depending on population size) to staff at Deputy Director or ‘head of’ level.
3. Simplify the single assessment framework and ensure it is fit for purpose in each sector, rather than slavishly expecting a single approach to work well across all sectors and for systems assessments. As a start, remove the evidence categories and scoring at evidence category level.
4. Model the resource needed to undertake inspections at reasonable intervals, both with comprehensive inspections and with a more limited approach (see below).
5. Re-establish relationship owner roles for all sectors.
6. Remove the separation between the roles of assessors and inspectors.

Assessment framework

1. Abandon the concept of a ‘single assessment framework’. The services that CQC regulates are diverse and it has not proved helpful in practice.
2. Retain the 5 key questions across all sectors. They have stood the test of time, though some simplification might be desirable.
3. Retain the I statements as these are liked by many people I have spoken with. They can act as useful prompts when asking about people’s experience of care.
4. Retain the quality statements but modify where necessary to avoid overlap and to make inspection simpler. Agree which quality statements are most needed for inspections in different sectors/services and then use consistently.
5. Routine use of all evidence categories for all quality statements should be abandoned. This is complicating the single assessment framework without benefit. The evidence categories should only be used as an aide memoire to ensure evidence is corroborated
6. Scoring at evidence category level should be abandoned.
7. Key lines of enquiry (KLOEs) relevant to the quality statements selected for inspection in a sector or service should be developed. For hospitals, these can largely be taken from the previous methodology.
8. Standards relating to the quality statements/KLOEs should be developed in conjunction with the National Quality Board, NHS England, Royal Colleges and representative bodies in adult social care. CQC’s National Professional Advisers should take a leading role in this for individual services.
9. The evidence that should be sought for each quality statement should be defined and a handbook of rating characteristics should be developed.
10. Peer review should be encouraged at least for hospital inspections. This should build on the current role of the executive reviewer. All trusts should be expected to contribute to a pool of reviewers.
11. Immediate feedback should be given at the end of inspections, though with caveats that this may change on review of further evidence. At the very least, serious adverse findings should be brought to the attention of the relevant person in the provider and confirmed in writing.
12. ‘Quick fixes’. If minor negative findings are noted on an inspection, these should be included in a report. However, if these can be rectified swiftly (say within 2 weeks) and adequate assurance can be given that this has occurred, they should not affect ratings.
13. Quality assurance processes for reports and ratings should be reviewed by CQC. This is vital to help ensure consistency and should be undertaken by staff with expertise in the relevant sector.
14. Reports must provide a narrative that can be understood both by the provider and by the public. Suggested word lengths for different sections may be helpful, but a degree of flexibility should be allowed.
15. Training in the use of the simplified assessment framework recommended above should be given very high priority.

Data and insight

1. Available data should be used more effectively. High priority should be given to working with NHS England, Healthcare Quality Improvement Partnership (national clinical audits) and the Get It Right First Time (GIRFT) programme and others to develop a shared view of data required for assessments and ratings.
2. Measures of patient experience collected by hospitals and GP practices should be standardised, so that evidence on this is comparable between providers and is available on much larger numbers of service users. This could potentially also be applied to the adult social care sector.
3. Retain the ‘clinical searches’ approach that has been developed for primary care. However, this should be able to be done centrally, reducing the time taken by SPAs on individual practice data. This would help to identify high or low risk practices before an inspection. It would also release SPAs to participate in inspections, adding to credibility.
4. The NHS staff survey has been demonstrated to be an effective measure of the culture of NHS trusts. Results from the survey should be incorporated into inspections of the well-led key question.

Staffing

1. An urgent review of staffing within the current operations and regulatory leadership directorates should be undertaken. This should assess the numbers of staff at different grades with expertise in the different sectors that CQC regulates.
2. The role of Deputy Chief Inspector should be reinstated, with additional posts being re-created. The current network director role is unsustainable.
3. An increase in the number of inspection team staff will almost certainly be needed at other levels, if CQC is to undertake appropriate numbers of inspections within reasonable timescales
4. Pay bands should also be compared with comparable roles in the NHS and adult social care.
5. Recruitment will almost certainly be needed in some areas.

Prioritisation of future inspections 

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In primary care: National Professional Advisers have recommended that the ‘safe’ and ‘effective’ key questions should be given priority, with ‘well-led’ being inspected if significant issues were discovered in the first 2 key questions. The inclusion of the ‘effective’ key question reflects the significant improvements to inspection methodology using ‘clinical searches’. If these could be done nationally, this would improve identification of high-risk practices and would reduce the burden on individual specialist professional advisers, who could then be available on site during inspections.

Source: CQC

Parts of this article were first published by our sister title, Pulse.