Initiating improvement: the impact of the Care Quality Commission’s approach to inspection

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Part of CQC provider ratings and their impact on care quality

I wouldn’t go as far as to say the National Audit Office’s (NAO) report on the Care Quality Commission’s (CQC) performance was glowing. But I would say that it was considerably less negative than previous reviews. CQC has now inspected all NHS hospitals, general practices and adult social care providers in England. The inspections are reportedly more intelligence-driven than in the past. And although CQC continues to have difficulties recruiting inspectors and other staff, vacancy rates are nowhere near as high as they were in 2015.

Much of the negative feedback has been about the delays between an inspection and publication of the report and the rating – many months in some cases. The delays could be because of the time it takes to undertake the necessary quality assurance, appeals and challenges. However, they could also be attributed to CQC not having enough inspectors to consolidate the huge amount of intelligence required to confidently make an assessment. Now that CQC has completed all the baseline inspections of NHS hospitals, general practices and adult social care providers, there is the opportunity to consider how best to regulate these providers into the future with the finite (and decreasing) resources it has available to it.

As part of its most recent strategy, CQC has outlined a risk-based approach to inspection in the future – more frequent inspections for providers rated as ‘inadequate’ or ‘requires improvement’, and a more hands-off approach to providers rated ‘good’ or ‘outstanding’. As 82 per cent of providers have been rated good or outstanding (as at quarter one, 2017/18) this could significantly change the way that CCQ approaches inspection.

The NAO’s 2015 review described how challenging it was for CQC to assess and understand its impact. Since then, CQC has been able to report that between 2016/17 and quarter one 2017/18, most providers previously rated as requiring improvement or inadequate improved their rating on reinspection (particularly hospitals and general practices). However, neither NAO nor CQC have been able to articulate how the model of regulation or inspection has contributed towards that impact.

For the past two years, The King’s Fund has been researching the impact of CQC’s approach to inspection (funded by the Department of Health and done in partnership with Manchester Business School). Our report will be published early in 2018, but we have already found many ways in which CQC can make, and is making, an impact. For instance, providers can change their behaviour and try to improve their performance in anticipation of an inspection; providers respond to reviews and ratings of comparable organisations; staff act as expert advisers for inspections of other providers and take what they have learnt back to their own organisation. Directly responding to an enforcement action or ‘must do’ directive is only one way that providers change in response to a CQC inspection.

We know that the process of quality improvement is complex, and we would argue that articulating the role of regulation in that process is also extremely complex and multifaceted. We have recently suggested that responsibility for improving the quality of care across providers must be shared by organisations across the whole health and social care system. In our current research we are finding that system partners are often required to work collaboratively to take action on regulatory issues identified by CQC. While CQC has no statutory function in directly supporting quality improvement, it clearly plays a role in bringing stakeholders together to address performance issues and to hold providers to account.

There are both opportunities and challenges in inspecting and regulating care in a system in which providers and commissioners are increasingly working in partnership. Our research is showing that the causes of and solutions for regulatory issues can sometimes be found outside the organisation being inspected. Consequently, the emphasis on individual provider inspections and ratings must be considered in the context of the wider system. CQC’s own provider survey found that adult social care providers felt less supported than their NHS counterparts in responding to CQC’s directives. Interestingly, a lower proportion of these adult social care providers were able to improve their rating on reinspection, suggesting that such support is important for quality improvement.

CQC is piloting place-based inspections. However, using the existing overall ratings might not be particularly useful at a system level. CQC needs to recognise the complex relationships between providers and commissioners within a system. Struggling providers – particularly those rated inadequate or in special measures – need the support of other local providers, commissioners and national agencies to understand and respond to CQC interventions and improve care. As CQC has extended its remit to regulating adult social care providers, it is essential that these providers have access to the same level of support as NHS providers and can contribute to supporting others within the system. CQC must consider the range of ways its approach to regulation and inspection impacts on health and social care providers and must keep pace with the current policy environment that emphasises partnership working, distributed leadership and accountable care systems.

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