Summary of board meeting: CQC November 2024

For more detail on any of the items outlined in this summary, please find the full agenda and papers. 

Chief executive reflection

• The interim chief executive, James Bullion, began the board meeting by announcing that from Monday 2 December CQC will be rolling out a new hybrid assessment.
• CQC needs to radically improve its assessment performance. The organisation’s recovery will need to look at all aspects of its work, including how it addresses registrations and backlogs, and how teams are structured.
• The new assessment approach will include a reduced number of steps.
• To avoid a confusion, providers assessed using the current arrangements will continue in the normal way.
• In February 2025, CQC will report to the board on the impact of the change in assessment approach.
• More information on this will be published on CQC’s website. 

Local authority assessment

• James Bullion updated the board on the local authority assessment teams. CQC are now working in 72 councils, and 13 reports have now been published.
• Partnerships with stakeholders such as the Local Government Authority and Association of Directors of Adult Social Services have been vital to the roll out and boosted confidence in the scheme internally and externally. 

Maternity

• Following the publication of the national maternity programme report and improvement resource in autumn 2024, CQC has prioritised overseeing the quality and safety of maternity services.
• High-risk services will be monitored centrally to quickly identify concerns and ensure they are addressed immediately.

System pressure pathway

• As winter approaches, and pressures on urgent and emergency care services are expected to intensify, CQC is committed to inspecting a range of services contributing to this pathway.
• This will ensure that, as health services focus on people moving from hospitals to the community, quality of care and the delivery of key standards remain central.
• CQC will be looking at systems that are under pressure. 

Independent Care (education) and Treatment Reviews

• Independent Care (education) and Treatment Reviews (ICETR) are intended to improve treatment of people with learning difficulties or autistic people in long-term segregation. These reviews are on target to be fully handed over to CQC from NHS England by March 2025.
• Since the programme started in December 2023, CQC has given a high level of support to a cohort of 93 individuals. CQC has undertaken 21 panels reviews, with a further 36 scheduled to take place from now until February 2025.
• CQC has set up an external oversight panel to enable scrutiny of the quality and impact of ICETR’s.

Mental health

• The Mental Health Bill, which was introduced in parliament on 6 November, is likely to increase the second opinion appointed doctor (SOAD) work undertaken by CQC. SOADs can be requested to safeguard people who do not, or cannot, agree to their treatment under the Mental Health Act.
• CQC has written to ministers to highlight concerns around the delays to replacing deprivation of liberty safeguards with the liberty protection safeguards.
• In December, a report looking at the work CQC carries out with the national preventative mechanism, is being published. It looks at people who are detained in services, their experiences, and whether they are kept safe. The report focuses on the work CQC has conducted on section 40, the restrictive practice and patient and care quality framework.

Performance Q2 metrics

Performance

• 60% of services have a rating that is less than five years old, down from 68.5% last quarter. The target is 75%, and the average age rating is now 3.9 years.
• CQC’s annual provider survey asks whether providers feel like CQC have used the experience of people effectively within their judgement; 77% of respondents were positive that CQC does this, up from 75% in the previous survey.

Corporate balance scorecard

• At the end of September, CQC had completed 1,639 assessments.
• At the end of September, CQC also had 2,844 (37.9%) registration applications that were more than 10 weeks old. This is a key area of CQC’s recovery, and the organisation is working on several workstreams to improve this, including by increasing the number of staff available to carry out this work.
• In September, CQC received 249 Mental Health Act complaints, an increase from a 176 monthly average in 2024.
• In September, CQC also received 1,229 SOAD requests.
• In Q2, 78% of assessments included a site visit (against a target of 75%).

Risk

• There are four risks that are operating outside of the tolerance set by the board, including:
• S6. We may not have enough quality data to be an intelligence-based regulator that shares information with others so they can act. 
• C4. Regulatory data integrity, confidentiality and availability may be compromised due to ongoing operation of legacy systems and due to change and running both old and new systems together. 
• Three risks have now materialised, including:
• S9. Following transition to our new ways of working we are not effectively delivering our core business.
• O2. Ineffectiveness in internal workings of CQC has led to a deterioration in the ability to identify poor performance and support a drive to improve quality.
• The risks are directly linked to the transition to CQC’s new ways of working.
• In response, CQC is creating a new executive sub-committee on performance and risk, and three new risk categories (regulatory risk, governance risk and information risk). Risk categories have been allocated to the executive committee and its sub-committee to enable greater scrutiny. 

Context

• The final update of the Dash review was published on 17 October. It identified seven recommendations, which included:
  • Review the single assessment framework (SAF) and how it is implemented to ensure it is fit for purpose, with clear descriptors, and a greater focus on effectiveness, outcomes, innovative models of care delivery and use of resources.
  • Rebuild expertise within the organisation and relationships with providers in order to improve credibility.
  • Clarify how ratings are calculated and make the results more transparent.
  • Formally pause assessments of integrated care systems (ICSs).
• The review also identified next steps to take place over the next six and 12 months to enhance the SAF. These included: 
  • Rebuilding expertise within CQC (six months).
  • Fostering stronger relationships with providers and wider sectors in order to improve credibility (six months).
  • Greater emphasis on effectiveness, outcomes, innovation and use of resources (12 months).
• CQC accepted the findings and recommendations from the final Dash report. 
• The Richards review had 30 recommendations and five suggestions for the regulatory prioritisation of future inspections.
• CQC agreed on four main high-level recommendations from the report, these included:
  • Align the organisation around sector expertise by appointing at least three chief inspectors to lead on regulation and improvement of hospitals, primary care, and adult social care services.
  • Modify the current assessment framework to make it simpler and ensure it is relevant to each sector.
  • CQC is in broad agreement with all the recommendations in the review.

Key changes being made

Leadership

• CQC is in the process of appointing three inspectors: one for adult social care and ICSs; one for hospital health care; and on for community and primary care. There are ambitions to appoint a fourth inspector for mental health care.
• CQC is reviewing regulatory leadership and operational services to integrate into a combined regulatory delivery service. This will include teams led by sector specialists, with named relationship managers from health and social care providers.
• CQC is working to stabilise and fix its regulatory platform and provider portal to increase productivity and effectiveness.
• CQC will seek to improve pay and job attractiveness.

Assessment framework

• CQC will explain how their assessment framework operates through a handbook co-produced with providers. The framework will ensure the regulators priorities focus on sector and service needs.
• The approach used to produce ratings will be transparent and clearly explained on CQC’s website.
• CQC will continue to use the five key questions of safe, effective, caring, responsive and well led across all sectors. The ‘I’ and ‘we’ statements will continue to be used as well.
• Engagement has begun on the following changes:
• CQC will categorise evidence but not score evidence at that level.
• CQC will not use previous ratings or default scores as part of the calculation of new assessment scores and ratings.
• CQC will review scoring as a feature of assessments and scores at quality statement level until that review is complete.
• CQC will review 34 quality statements to ensure clarity and remove duplication.
• CQC will produce guidance and characteristics to explain what levels of ratings mean and set out clear definitions of what ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’ looks like.

CQC is also planning work to:

• Build greater knowledge and insights into innovation in healthcare and social care and include these in quality statements.
• Give greater emphasis to and expand the outcome measures used. To do this, CQC will build on work it has conducted with partners, including from the healthcare quality improvement partnership, getting it right first time programme, and national clinical audits.
• Improve transparency and robustness of the data used to understand the experiences of patients, service users and staff. 

In September 2024, Ofsted stopped issuing one- or two-word ratings for schools. Instead, Ofsted is developing a ‘report card’ system, which is expected to roll out in September 2025. It is carrying out engagement and research into the right approach. 

• A review into health and social care ratings highlighted that they have five main functions, to:
  • increase accountability to the public, users, commissioners of care, and (for publicly funded care) to Parliament,
  • aid choice, 
  • help improve the performance of providers,
  • identify and prevent failures in the quality of care, and
  • provide public reassurance as to the quality of care.
• The review did not provide the answer to how ratings should be compared, but it did recommend a quarterly review or refresh of ratings.
• It advised that for hospitals, a whole institution rating is more of a managerial concept than a clinical one, and aggregate ratings should include service-level information as that is what patients and service users need.

Current approach

• CQC’s current assessment report has one-word ratings, but can also provide a report card.
• Reports include scores at quality statement level, a rating at key question level, an overall rating and context for their judgement.
• For acute trusts, one-word ratings are no longer based on an aggregate of service ratings. Instead, it is a rating based on a separate assessment against the well led framework.
• CQC states that its ratings are used as a summary to help people understand how a provider has demonstrated good practice, if they have met fundamental standards, and to help drive improvement.

Implications for CQC

• Since the Ofsted announcement there has been scrutiny about how CQC use ratings, including in NHS Providers’ report which recommends that CQC review the effectiveness of one-word ratings.
• The Dash review stated that ‘changes to one-word ratings could be beneficial in allowing greater clarity to be brought to the different key questions of quality, allowing a ‘balanced scorecard’ approach across ‘safe’, ‘effective’, ‘responsive’/’caring’ and ‘well led’.
• The Richard’s review concluded: ‘during the course of this review, the issue of ‘one-word ratings’ was raised on numerous occasions by providers. Further consideration should therefore be given to this issue.”
• Generally, the public find ratings more useful when there is a greater perception of choice, such as in adult social care.
• For trusts, people perceive less choice and find ratings interesting but perhaps less useful.
• Some sectors use ratings for marketing and commissioners use ratings to manage contracts and ensure safety in the services they pay for. 
• CQC states that moving to a different approach would require a formal consultation. It would require CQC to make changes to systems and processes, and this would impact providers that are required to display ratings following an assessment.
• Options for CQC to explore with stakeholders include:
  • do nothing and keep their ratings approach the same, 
  • remove overall ratings and only provide scores and ratings at quality statement and key question level,
  • award different types of ratings, or
  • introduce a differentiation of approach between sectors, for example stop rating in some sectors and change the approach in other.
• Ofsted is a key partner for CQC’s joint targeted area inspections and special educational needs and disability. These do not have one- or two-word ratings but are an area where they need to be aligned.

Next steps

A review of one-or two- word ratings is not a current priority for CQC. CQC is keeping this under review alongside the Department of Health and Social Care. Any new approach will require extensive engagement and consultation and must be based on research evidence and learnings from Ofsted and others.