CQC ‘not fit for purpose’, says Streeting, in wake of damning report

Story updated 29 July 2024

The Care Quality Commission is “not fit for purpose”, health and social care secretary Wes Streeting has declared, after a damning report found significant failings within the regulator.

Dr Penny Dash found that inspection levels were still well below pre-Covid levels, a lack of expertise among inspectors, inconsistency in assessments and problems with the CQC’s IT system.

Also, social care providers were waiting too long to be registered and have their ratings updated, affecting capacity levels in local areas, said the interim report of Dash’s government-commissioned review of the regulator.

As a result of these problems, the CQC was unable to consistently and effectively judge the quality of services it regulates, including residential homes, nursing homes and domiciliary care agencies.

Probe focused on new assessment approach

The review, commissioned in May 2024 by the previous Conservative government, was designed to assess the suitability of the CQC’s single assessment framework (SAF) for assessing and rating health and social care providers.

This was introduced in November last year and was designed to reduce duplication in the previous four separate assessment frameworks and move away from inspections being the CQC’s primary source of evidence of a service’s quality and compliance with regulations.

Instead, it planned to collect data and insights on services on an ongoing basis, for example from feedback from people who used services or partner organisations or from information submitted by providers.

Dash, whose interim report was based on conversations with 170 health and social care leaders and staff and 40 CQC senior managers and professional advisers, identified significant problems with the regulator beyond the implementation of the SAF.

‘Poor operational performance’

She found that the organisation’s operational performance was “poor” and had deteriorated, including that:

• The CQC carried out just 7,000 inspections and assessments in 2023-24, compared with 16,000 in 2019-20.
• At the end of 2023-24, 54% of provider registration applications were more than 10 weeks old, up from 22% at the end of 2022-23.
• Of the services CQC had the power to inspect, an estimated one in five had never received a rating, some of which had registered more than five years ago.
• The average age of providers’ overall ratings was 3.7 years, while some organisations had not been reinspected for several years: the oldest rating for a social care provider dated back to 2015.
• Call centre performance was poor with the regulator taking 19 minutes on average to answer calls about registration from January to June 2024.
• The provider portal – launched last year to enable providers to submit information to the regulator – had resulted in significant problems for some users, who said they were unable to easily upload documents and waited hours for password resets.

Lack of inspection expertise identified

Dash also identified a lack of specialist expertise among inspectors, linked to a decision by the regulator to rely much more on generalists in inspection teams.

Her review was told of care home inspectors who had not met a person with dementia before.

She also found a significant reduction in ongoing relationships between CQC staff and providers, which had previously been useful for sharing good practice and building providers’ confidence in the regulator.

Dash concluded that these trends were “impacting the credibility of CQC, resulting in a lost opportunity to improve healthcare and social care services”.

No description of what constitutes good or outstanding care

In relation to the SAF itself, Dash found that it did not contain a description of what good or outstanding care looked like.

“The review heard time and again from providers that they struggle to know what inspectors are looking for, they are not learning from them and, as a result, they don’t know what they need to do to be better.”

Providers also reported a lack of consistency in ratings, with multi-site organisations saying that differences in ratings between services did not accord with what they knew about differences in performance.

No reference to use of resources in framework

There was also no quality statement within the SAF relating to use of resources or efficient delivery of care, despite it being a legislative requirement for the CQC to assess this.

Dash said this was disappointing as “effective use of resources is one of the most impactful ways of improving quality of care for any provider”.

And though the SAF was designed to increase the emphasis on gathering the voice of service users, the review found a lack of transparency in the data used to measure this, how representative this was and how it was analysed.

Most of the data was apparently harvested from surveys, “which may or may not be representative or statistically significant at a service level, and this is then supplemented by a number of interviews with service users”, Dash said. There could be as few as tens of such interviews carried out even where a service was looking after thousands of people a year, the report added.

Issues with how ratings are calculated

The interim report also identified a longstanding problem of providers’ ratings being based on outcomes from inspections over several years, which it said could not be “credible or right”.

While the SAF was designed to correct this by basing ratings on more frequent assessments of a service drawn from up-to-date information, the problem continued because the regulator was not undertaking sufficient such assessments.

Dash also heard that providers did not understand how ratings were calculated, resulting in a sense that it was “impossible” to change ratings.

She is due to publish her final report this autumn, but made five recommendations at this stage, urging the CQC to:

1. Rapidly improve operational performance.
2. Fix the provider portal and regulatory platform.
3. Rebuild expertise within the organisation and relationships with providers in order to resurrect credibility.
4. Review the SAF to make it fit for purpose.
5. Clarify how ratings are calculated and make the results more transparent, particularly where multi-year inspections and ratings have been used.

CQC ‘not fit for purpose’

“I have been stunned by the extent of the failings of the institution that is supposed to identify and act on failings,” said Streeting. “It’s clear to me the CQC is not fit for purpose.”

He added: “I know this will be a worrying development for patients and families who rely on CQC assessments when making choices about their care.

“I want to reassure them that I am determined to grip this crisis and give people the confidence that the care they’re receiving has been assessed. This government will never turn a blind eye to failure.”

The DHSC said that, on the back of the interim report:

• The CQC has appointed Professor Sir Mike Richards to review its assessment frameworks. A former hospital doctor, he was the regulator’s first chief inspector of hospitals from 2013 until his retirement in 2017.
• There would be improvements in the transparency of how the CQC determined its ratings for health and social care providers.
• The department would increase its oversight of the CQC, with the regulator regularly updating the DHSC on progress, to ensure that Dash’s final review recommendations were implemented.

Last month, Ian Trenholm resigned as CQC chief executive, to be replaced, on an interim basis, by his deputy, Kate Terroni.

Regulator ‘accepts findings in full’

In response to today’s interim report, Terroni said: “We accept in full the findings and recommendations in this interim review, which identifies clear areas where improvement is urgently needed. Many of these align with areas we have prioritised as part of our work to restore trust with the public and providers by listening better, working together more collaboratively and being honest about what we’ve got wrong.

“We are working at pace and in consultation with our stakeholders to rebuild that trust and become the strong, credible, and effective regulator of health and care services that the public and providers need and deserve.

‘Work is underway to improve how we’re using our new regulatory approach. We’ve committed to increasing the number of inspections we are doing so that the public have an up-to-date understanding of quality and providers are able to demonstrate improvement.

‘We’re increasing the number of people working in registration so we can improve waiting times. We’re working to fix and improve our provider portal, and this time we’ll be listening to providers and to our colleagues about the improvements that are needed and how we can design solutions together.

“We’ll be working with people who use services and providers to develop a shared definition of what good care looks like. And we’re also developing a new approach to relationship management that enables a closer and more consistent contact point for providers.”

Provider leaders demand improvements

Care provider leaders joined Sweeting in heavily criticising the regulator in the wake of Dash’s interim report.

“It is outrageous that social care providers are left waiting interminably for registrations and ratings, directly impacting local capacity, quality of care and sustainability of providers,” said Homecare Association chief executive Jane Towson.

The association cautiously welcomed the DHSC’s response to the report but urged further action, calling for:

• A complete overhaul of the CQC’s inspection and assessment system.
• Immediate action to clear the backlog of uninspected and unrated providers.
• A significant investment in recruiting experienced, sector-specific inspectors.
• Regular, mandated reporting on the CQC’s progress in addressing these failings.

“We want and need an effective regulator and are dismayed that CQC’s incompetence is actively harming the sector it’s meant to regulate and protect,” Towson added.

“This is going to be a long and difficult journey for the CQC, but one that is entirely necessary,” said Care England chief executive Martin Green.

“The CQC must embark on a radical improvement program that should not only include some tangible improvements in their performance, but also needs to move away from a culture of blame.

“We all want proportionate and effective regulation, and the challenge now is for CQC to take action and work with organisations across the sector to deliver it.”