CQC Update - Inactivity at the Regulator of Regulated Activity

Recent events at CQC have highlighted an organisation in turmoil.  Ian Trenholm, the former Chief Executive has resigned with almost immediate effect, and the HSJ has reported that the interim CEO, Kate Terroni, has produced an internal problem statement admitting that “the way we work is not working and we are not consistently keeping people who use services safe”.  Further evidence of this can be seen in CQC’s Corporate Performance Report to its May Board  showing that, at year end 2023/24, CQC was exceeding its risk tolerance on the following measures:

• We do not transition to our new ways of working safely and effectively
• We do not meet stakeholder expectations
• Our operational workforce is not as productive as it should be
• We do not make an accurate and timely assessment on the quality of care or risk for people using services

As Dr Penny Dash leads the Cabinet Office review of CQC’s effectiveness, it is worth taking stock of the current state of play, and how CQC is fairing in the performance of some of its key functions.  Effective regulation has a vital role to play in permitting market entry, taking action against poor quality care, driving improvement, informing service user choice and providing assurance to a range of stakeholders in the sector.  However, from the outside, it appears that CQC has largely ground to a halt:

Registering New Services

CQC’s guidance  states providers should submit their applications for registration “when everything is in place to start providing … services. This includes having the locations and staff ready to provide services”.  Historically, CQC has had a guideline (though not a guarantee) of processing applications in 10 weeks.  As timescales for determining applications lengthened, CQC introduced a KPI for 2023/24 to reduce the volume of applications taking more than 10 weeks to process.  Despite this, the position worsened considerably so that the proportion of applications taking more than 10 weeks to process has more than doubled from 22% (in April 2023) to 54% (in March 2024).

It is now not uncommon for registration applications to take six months to process, and we have been contacted by a number of clients experiencing significant delays in getting new services registered.  These delays not only deprive an over-stretched health and care system of much-needed additional capacity for the benefit of service users, but also impact commercially on operators (who are already incurring the costs of premises, equipment and staffing) and act as a disincentive for future investment into new services.

Inspection/ Assessment Activity 
 
As we have highlighted in a previous article, there are serious concerns regarding whether, due to their limited scope, and scoring methodology, CQC’s new assessments under the Single Assessment Framework (“SAF”) provide a true reflection of the quality and safety of services.  However, leaving aside the question of the quality of the SAF assessments, a further concern is the extent to which they are happening at all.  CQC carried out a total of only 6,970 inspections/ assessments across the whole sector in 2023/24, and its corporate performance report shows that these have tailed off significantly since the implementation of the SAF in December 2023:

Updating Ratings of Existing Services

One of the key drivers of CQC’s new Strategy and the implementation of the SAF was to move to a system of ‘more dynamic’ regulation, with more meaningful ratings giving an up-to-date and accurate picture of quality.  However, partly due to the tail off in inspection/ assessment activity, this is not happening.  Taking the adult social care sector as an illustration, CQC’s latest data (as at 3 June 2024) shows that, out of a total of 23,965 locations with published ratings, over 50% had their most recent report published in 2020 or before.  The age of most recent published inspection reports are:

Services stuck in 'Requires improvement' 

A particular concern in the sector is around services which are stuck with a ‘Requires improvement’ ratings awarded at inspections many years ago, when despite the service having long since addressed the issues, CQC has not reassessed to update the rating.  The current data for the 3,918 services rated ‘Requires improvement’ across all adult social care locations shows over 2,000 of them had those ratings awarded in 2022 or before:

The need to ensure that published ratings provide a truly up to date picture of services is fundamental and the failure to do so can have considerable impact in terms of:

• the choices made by prospective service users (and their families) in their decisions on care providers; 
• placement/ contracting decisions by public sector commissioning bodies and healthcare insurers;
• the morale of, and ability to retain and recruit, staff in health and care services; and 
• whether services are compliant with covenants in leases and/or agreements with their lenders.

Assessment of Newly Registered Services and the impact on Commissioning Decisions

It has long been one of CQC’s priorities to ensure new services are inspected quickly following their registration.  

CQC’s current guidance on the SAF still states that, for services that have not yet been inspected, CQC will “normally collect evidence for all the quality statements within the first year”.  

However, it appears this is a complete disconnect with reality and is far from being delivered.  Taking the adult social care sector as an example, there are currently 5,133 locations on CQC’s database which do not have a rating, over 2,000 of which were first registered in 2022 or earlier.  CQC’s Business Plan for 2024/27 presented to its Board in May 2024 indicates that currently only 6.4% of services receive an assessment within 12 months of registration.

CQC has a duty to publish the frequency with which it will carry out assessments and previously indicated that it would publish the frequency of its assessments under the SAF in July 2024.  However, it appears that this too has been delayed as only last week CQC launched a survey to gauge views on its proposed frequency of assessments.  Not only that, but within this survey, CQC stated that its proposed priorities for planned assessments for 2024/25 included only a “proportion of services where the rating is >5years” and only a “proportion of newly registered services”.

CQC’s failure to assess and rate some services may also impact providers’ ability to bid fairly in procurements for health and care services where commissioners may require a particular CQC rating as a prerequisite for delivering a contract.

Conclusion

As indicated the current levels of inactivity on CQC’s part risks a range of detrimental impacts on service users, staff, operators and investors across the health and social care sector.  The current state of play cannot be allowed to continue and we await the outcome of the Cabinet Office review, and any action CQC may take in the interim, with interest.

If you wish to discuss any of the issues arising in the article, please contact Carlton Sadler or Siwan Griffiths.