Can the Care Quality Commission live up to expectations?

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This week marks one year since Robert Francis published his second report into failures of care at Mid-Staffordshire Foundation Trust.

Mid-Staffs Director of Quality and Patient Experience Julie Hendry gave a moving presentation at a conference at the Fund in November summarising the journey that the trust have been on since 2009 and the progress they have made and continue to make.

But what developments have there been more broadly across the system?

One year is barely long enough to achieve culture change. But locally, both in response to the first Francis report and more recently, there are countless examples of improvements in how boards monitor and manage quality, how care for frail older people is organised in hospitals, and how leaders listen to and involve patients. There are also organisations continuing to struggle to focus on quality – the picture is inevitably mixed. Nationally, the final full government response to Francis balanced commitments to strengthen how quality is monitored with initiatives to help teams and organisations improve safety and support staff wellbeing.

One of the most high-profile actions at a national level, though, has been the overhaul of the Care Quality Commission (CQC) and the introduction of its new inspection and surveillance processes.

Quality regulation has an important role to play in the system, and many of the developments under way at CQC, such as the move to specialist inspection teams and the balance of inspection and data surveillance, reflects the evidence about what works and builds on the experiences of CQC’s predecessors (which were neatly analysed in Prof Gwyn Bevan’s chapter on regulation in our 2011 book evaluating Labour’s reforms). But regulation is just one element in the whole architecture of roles and responsibilities for assuring and improving quality in the system.

Increasingly in recent months, I have heard worrying statements that hint at an underlying belief that CQC will assure quality in the NHS – that Mike’s army will prevent a catastrophe like Mid-Staffs ever happening again.

The recent Health select committee report into CQC warned that if it ‘cannot pre-empt high-profile failings’ it will not be ‘credible’ and that it ‘must identify problems and trigger inspections before they become widely publicised by the media’. Early identification of problems before they become serious is of course the goal we want to achieve, but no attempt at proportionate risk-based regulation will ever get this perfectly right every time.

Even the CQC’s own website, perhaps understandably for simplicity’s sake, claims: ‘We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care’.

But regulators cannot assure quality – it can only ever be the third line of defence against poor care, as we argued in our paper on quality assurance. The first line of defence is frontline staff. These are the people who deliver care, who, when properly empowered and supported, can act to improve quality and to address problems. The second line of defence is the leaders and boards of organisations. And third are the national bodies in the quality system, of which CQC is one. To require the CQC to guarantee high quality care at all times in all places risks undermining  local responsibility for the quality of care as well as establishing an unreal expectation over what it can achieve

This is not to argue that we should accept regulatory failure. CQC should be no less held to account than any other part of the system – it is essential that it continues to develop, test and refine the most effective possible mix of regulatory activities to fulfil its role. But let’s remember that it is not the panacea for the health and care system’s problems.

This blog is also featured on the British Medical Journal website.


Norman Ascough

Comment date
23 May 2019

It seems from the Whorlton Hall exposure that the CQC is actually not able to identify genuinely bad care homes. Does the CQC use techniques similar to the BBC's? If not then why not? Are those techniques considered "unfair", "underhand"? If they are then the CQC has no real chance of detecting bad management and practices.

Putting the above aside, did the CQC receive any information from whistleblowers about Whorlton Hall, and if it did then was any action taken - it seems not. Does the CQC actively encourage whistleblowers as part of its normal operation? If it doesn't then perhaps it ought to consider that approach (or would that be considered unfair or underhand?).

There are an awful lot of questions arising from the Whorlton Hall episode about the CQC's modus operandi. How will they be answered? We'd prefer not to see the usual cop-out statement about not enough funding - it's doubtful that working with whistleblowers would require much funding. Seeking out these abysmal practices by any means ought to be the CQC's standard working method. But.. we suppose it's easier to carry out a cursory visit and use a ticked checklist rather than do a real investigation; We know little about the CQC's methods but whatever they are they clearly do not work.

We'd be interested in a reply, but we imagine nothing of any importance will be forthcoming.

Christian Classen

Comment date
01 July 2014
It is good to see common sense still prevails. This is a great article that clearly articulates what should be a given, just like the HSE which cannot "ensure" safety across all it's domains. It is a real positive the King's Fund is supporting the CQC with such balanced perspectives.
It brings me back to what I was reliably informed some years ago would make the NHS great. I.E. leadership, leadership, leadership. Quality management goes hand in hand with good leadership. With leadership comes responsibility and accountability for what we do.
Leadership values if instilled will by default ensure compliance as the organisation is driven by the need and desire to preform and provide the best care / service it is capable of.
As a regulatory body of limited resource it cannot ultimately be held responsible for "all" NHS organisations which essentially are self governed. Enforcing, monitoring and supporting roles though yes. What the CQC cannot afford is missing out on critical management or operational components through submissions, inspections or alerts, which could likely result in failure to deliver safe and effective care. In the current climate "pre-empting" failures in any /all organisations cannot be categorically guaranteed as one can appreciate the complexity and scale involved and can only be determined with available information.

sandeep s lall

Project Manager,
Leeds Community Healthcare NHS Trust
Comment date
18 June 2014
Very good article, specially like the 3 lines of defence argument

Catherine Foot

Assistant Director,
The King's Fund
Comment date
11 February 2014
Peter, yes of course you can use our argument.

Peter Weeks

owner / partner,
Comment date
06 February 2014
I like your model of the 3 levels of care quality; first frontline staff, then managers and boards, finally regulatory checks as a backstop; hopefully never used.
We are a business Care2Improve providing independent care quality assessment and reporting to managers of care homes and home care providers. We find that sadly the majority of care providers we meet do not see the value in having someone come in and do a full audit and tell them the true facts as stated by service users, care staff, relatives and other professionals.
Our service costs £400 but most care homes and dom care agencies say it's too much. Can you really assess your own quality fairly and thoroughly?
We would like to use and refer to your 3-level if you agree as it fits with our marketing message of "don't rely on CQC it's too late when they find out".
Peter Weeks

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