Review of CQC's single assessment framework and its implementation

9.1. General comments across sectors

To gain insights into the views of providers concerning the single assessment framework and its implementation, I have spoken with leaders of several major representative organisations. These include:

• NHS Providers
• The NHS Confederation
• The Independent Health Providers Network (IHPN)
• Care England
• The National Care Forum
• The Homecare Association
• The Royal College of General Practitioners
• The British Medical Association
• The Shelford Group of NHS Trusts

Information they have provided has been supplemented by surveys of members of several of these organisations and from large group meetings with their members.

Provider organisations have clear views on the overall impact of CQC’s transformation programme, but they may not always be clear whether the problems lie with the single assessment framework itself, or with its implementation. They are all clear on the major problems related to the regulatory platform. It is also clear that problems relating to the single assessment framework and its implementation are common to hospitals and adult social care.

General comments relating to the transformation programme can be summarised as follows:

Support for the approach:

• There was widespread support from providers when the transformation programme was first announced. CQC received several thousand responses to its consultation, which were broadly supportive. However, it is important to note that these positive comments were in response to the concept of a single assessment framework and were made before the single assessment framework had been developed. From the outset, staff within CQC expressed concerns about the concept. No formal consultation was undertaken once the single assessment framework had been developed, and very little piloting was undertaken before rollout in December 2023.
• As recently as 2023, the NHS Providers annual survey of regulation reported that “Trusts continue to be supportive of the direction of travel indicated by the regulators”. Around 8 out of 10 supported the changes initiated by CQC to deliver more risk-informed and responsive regulation. However, the survey also showed that “support for these principles contrasts with trust leaders’ experience of regulation at the frontline.”
• The need for high-quality regulation is recognised across all sectors: “We want good regulation”. In other words, the principle of a unified approach to assessment was welcomed, but the practice has fallen far short of what was anticipated. The need for change in the first place has now been questioned.

Views on implementation:

• Several of the umbrella organisations in health and social care had warned CQC against tackling all 3 elements of the transformation programme at one time. Their concerns had not been acted on.
• There had been too little piloting and no evidence of learning or change as a result of the pilots that had been carried out.

Views on trust and confidence:

• There has been widespread and severe loss of confidence in CQC. This applies not only to providers, but also to local authority commissioners of social care. I heard that some local authorities are now conducting their own assessments before commissioning services because they have lost confidence in CQC.
• The sense of partnership between CQC and provider organisations has been lost.
• The loss of relationship owners is keenly felt. Providers need a point of contact.
• The current approach has a major emphasis on looking for what is wrong – not what is working well or is innovative. This is an impediment to innovation.
• The new approach is difficult for providers to understand and is not clearly set out by CQC. The National Care Forum had found it necessary to produce a ‘mega-briefing’ to help its members understand the new approach.
• The current approach lacks credibility. Both healthcare and adult social care organisations expressed extreme dissatisfaction with the current regime.

Impact on providers:

• Delays in registration are having an adverse impact especially on independent health and adult social care providers. In one instance, the provider was not informed for a month even though registration had been successfully completed.
• CQC is currently undertaking too few inspections and re-inspections. This has a serious adverse financial impact on independent sector providers (health and social care) who have a previous rating of requires improvement.
• Providers feel they are not getting value for money, considering the fees they pay to CQC.
• Delays in getting through to the CQC helpline are causing major frustration for providers.
• Final reports frequently bear little relationship to the feedback given immediately at the end of an inspection.

Headline findings from surveys conducted by umbrella organisations are shown in Appendix 3.

9.2  General views on the transformation programme from adult social care providers

Specific comments made by leaders of adult social care providers (care homes and/or homecare) included:

• “My organisation has had 6 inspections. All were different. They had no clue what they were looking for.”
• “Did CQC need to change? They were respected. Scrap what we’ve got now.”
• “The provider information request (PIR) takes hours, and then we get no feedback.”
• “We are not getting value for money”.
• “Total disaster. Huge damage.”
• “Some inspectors don’t have knowledge about things that matter in care homes – dementia, learning disabilities, rehabilitation.”
• “The evidence categories are a nonsense.”
• “We need sector handbooks.”
• “How do we get to outstanding?”
• “The number of people who are spoken to on site should be standardised. Otherwise, inspectors may not get a balanced view.”
• “The report structure is awful.”

Some individuals also felt that an independent body should be established to oversee CQC and to hear appeals.

9.3  General views on the transformation programme from NHS trusts

The views of NHS chief executives on the new approach can be summarised as follows:

• Inspection teams sometimes lack credibility, without adequate knowledge of the sector, and lack seniority especially for assessment of the well-led key question at trust level.
• The culture among inspection teams has changed for the worse. There is now no sense of partnership. Inspectors are only looking for what is wrong – not for evidence of what is good or innovative. Inspection teams can instil fear, warning that if findings are challenged, the outcome will be worse.
• CQC is on a downward spiral and should revert to what was working previously.
• Judgements are inconsistent.
• Some senior staff in trusts are no longer willing to take part in inspections due to a feeling that objectivity had been lost and that outcomes appeared pre-determined.
• Some trust CEOs noted the difficulty in approaching CQC’s senior team and felt that it had become detached from the sector.

9.4  Specific views on the single assessment framework

There were specific comments relating to the single assessment framework across all sectors:

• The selection of only a sample of quality statements for an inspection and then combining with old ratings is widely thought to be unhelpful and inappropriate.
• Combining old and new ratings gives an unreliable picture of current quality and safety and can be unfair to providers.
• The initial selection of 5 quality statements for adult social care inspections had been greeted with incredulity, though this has now been increased to 12 to 14.
• Process measures are over-emphasised. More emphasis should be given to outcomes or proxies for outcomes in all sectors. CQC should work with providers and academics to devise outcome measures, where these are not currently available.
• Delays in getting reports out are far too long.
• When a report does arrive, it is of very limited value and bears little relation to what was found on the day of inspection.
• Scoring has increased (not decreased) inconsistency.
• Quality assurance of reports appears to have been lost.
• Rating characteristics should be brought back. The loss of the provider handbook contributes to the loss of transparency.

9.5  Specific views on the organisational restructure

Specific issues relating to the organisational restructure include:

• The loss of relationship owners is seen as a severe retrograde step. Providers no longer know who they should contact when things go wrong.
• The loss of inspectors who have knowledge and experience of the relevant sector contributes to the loss of confidence and credibility in CQC’s current approach. This also contributes to the lack of consistency between inspections, which is observed by corporate providers in both independent health and adult social care.