Review of CQC's single assessment framework and its implementation

Professor Sir Mike Richards
Former Chief inspector of Hospitals at CQC (2013 to 2017)

1. Summary

This review has been commissioned by the board of the Care Quality Commission (CQC) to complement the report by Dr Penny Dash, by looking at changes that CQC made following the publication of its new strategy in 2021 and their impact. Importantly, this review makes recommendations on solutions to CQC’s current problems.

The transformation programme that followed the 2021 strategy had 3 key elements:

• A major organisational restructure.
• The introduction of a single assessment framework across all the sectors that CQC regulates (hospitals, mental health services, ambulances, primary and community care services and adult social care).
• The development of a new IT system, named the regulatory platform.

These 3 initiatives are clearly interlinked, but this review has shown that all 3 have failed to deliver the benefits that were intended, despite being initially welcomed by providers. This has had the following major adverse consequences:

• CQC has been unable to fulfil its primary purpose “to ensure health and care services provide people with safe, effective, compassionate high-quality care and to encourage these services to improve”. Far fewer inspections have been carried out than in previous years; publication of inspection reports have been seriously delayed, and providers have expressed serious concerns about both the inspection process and the quality of the reports.
• Staff involved in inspections have become demoralised and angry that their concerns about the changes have not been listened to by senior leadership. This has led to considerable numbers of staff leaving the organisation, further compounding the problems relating to assessments, inspections and enforcement. However, I found that many of the remaining staff remain committed to the purpose of CQC and are desperate to see things improve.
• The structural re-organisation has resulted in separation of those responsible for developing policy and strategy related to regulation from those responsible for operational delivery. Operational reality has therefore not been reflected in policy and strategy.
• Clinical leadership and oversight of the inspection programmes has been lost as Chief Inspectors are no longer directly responsible for the inspections in their own sector and are less available and visible to support those at the front line. For the past 2 years, CQC has only had 2 Chief Inspectors (both of whom are currently interim), rather than the 3 as set out in legislation.
• The single assessment framework, while having some positive elements derived from the previous assessment approach, is far too complex and, as currently constituted, does not allow for the huge differences in the size, complexity and range of functions of the services that CQC regulates. One size does not fit all. Some elements of the quality statements are causing confusion both to CQC inspectors and to providers. In addition, the evidence categories and scores are causing major delays to report writing.
• The regulatory platform has had a serious adverse impact on the working lives both of CQC staff and of those working in provider organisations who are expected to upload information onto a ‘provider portal’. People who use the platform say that there are, as yet, no signs that these problems are being resolved.
• Staff morale is low, especially among inspection staff, as seen in the results of the most recent staff survey. Sickness levels have risen over recent years, especially among inspection staff.
• Staffing levels in the inspection teams are currently insufficient to undertake the duties of the regulator within reasonable timescales. Staff remain concerned that they are unable to respond to emerging risks in a timely way. Insufficient induction and training has been given to new staff.
• While recognising the independence of the regulator, providers across health and social care report that the previous sense of partnership with CQC to develop effective approaches to assessment of quality has been lost.
• Progress on the use of data to inform assessments of hospital services has been at best very modest over the past several years. In some respects, the intelligence available to inspection teams is less useful than it was pre-pandemic. This has a particularly negative impact on assessments of outcomes for people using services.
• Processes to ensure consistency of judgements and the adequacy of relevant evidence – which is vital to good regulation – have been adversely affected by the downgrading and dilution of quality assurance processes.
• Over the past 2 to 3 months, CQC has started to take steps to mitigate some of the problems identified in this report. However, the organisation needs to go much further.