Research by the King's Fund and Manchester University (Smithson R. et al., 2018) found that CQC's regulation (in particular its inspections, reports and ratings) impacted providers in many different ways. The research concluded that the value and purpose of regulation is rarely contested by providers, but the way in which it is practiced and experienced makes all the difference.
It stated: "That does not mean that regulatory standards and procedures do not matter, but that the human interactions and social dimensions of inspection and rating are very important indeed." The report went on to say that providers particularly valued "consistency, fairness and objectivity, experience and credibility, and a strong orientation towards patients or service users. They also highlighted the importance of what might be termed soft or interpersonal skills – such as sensitivity, kindness, putting people at ease, showing empathy and facilitating discussion or enquiry. However, sometimes CQC staff were quite negatively perceived, for example as being aggressive, nitpicking, critical or confrontational." These findings strongly resonate with what we have heard in our various interactions with trust leaders.
Relationships
Trust leaders often describe the regulator's ideal role as being a 'critical friend', constructively challenging their weaknesses and acknowledging their strengths. However, they often report a significant power imbalance, and describe an 'adult/child' dynamic.
Trust leaders greatly value a positive, consistent relationship with their local CQC relationship manager and team. They appreciate being able to operate on a 'no surprises' basis – keeping their local team abreast of changes in their trust, sharing concerns as they arise and seeking advice on an ongoing basis, rather than waiting for the time of the next inspection. This allows trust leaders to work with CQC representatives who understand the operational reality of their trust and adequately reflect that in their regulatory outputs.
However, many report frequent changes in personnel and lack of continuity, which make it harder to build such relationships. We have also noted that, under its new approach, CQC will be scaling back its relationship management function at a local level (CQC, 2023) for many adult social care, primary and independent healthcare services. While these functions are being preserved for trusts and community interest companies in the short term, it will be important that CQC continues to recognise the value of stable stakeholder relationships on an ongoing basis. Such relationships enable some of the right-touch regulation principles, specifically the principles of consistency, transparency and accountability – to be fully enacted in practice. These relationships are vital in setting the tone for the national level relationship between providers and CQC, and determine the overall level of trust in the regulator.
Recommendation 3:
We recommend that: CQC appreciates the value of supportive, consistent and stable relationships between local CQC teams and providers and actively encourages these. This will enable open, honest and collaborative dialogue.
Inspections
Our regulation survey findings and subsequent member interviews revealed that the experience of being inspected by CQC and the quality of inspection reports depended on the skills and expertise of the team involved. While in some cases trusts said CQC had provided a fair and honest assessment of their service – even while being critical – in other cases their experience was very poor. Trust leaders shared that they often experienced inspections by teams with no sector-specific expertise, or by staff who were not senior enough for the interactions they were having with the trust’s executive team.
The anticipation of inspections was often described as 'stressful' and was compared to preparing for an exam. Trust leaders reported negative attitudes from CQC inspection teams, including some accounts of 'bullying'. They believed inspectors sometimes arrived with a preconceived idea, or not having reviewed the evidence the trust submitted in advance.
Recommendation 4:
We recommend that: CQC continues to invest in improving the training, as well as the conduct and behaviour of its inspection teams, to ensure greater credibility, consistency and objectivity, and to allow for transparent, well-informed and constructive provider and system assessments.
Trust leaders also shared an observation that CQC inspectors sometimes prioritised process over patient outcomes and were not receptive to examples of good practice. They described a predominantly transactional approach, focused on procedure, and a tendency to over-emphasise technical failings, such as in relation to fridge temperatures, the condition of facilities, or recommended staff training, even when patients were receiving good quality care. They felt the inspection and reporting regime did not acknowledge how trust staff often had to make pragmatic decisions in imperfect circumstances to keep services running as effectively as possible at times of extreme pressure.
We heard repeatedly that CQC inspection teams did not take the operating context into account, particularly since the Covid-19 pandemic. For example, some members experienced planned inspections during periods of industrial action. We also heard about a lack of recognition of events and circumstances outside of the trust's control, such as systemic workforce challenges or crumbling estates (caused by dated infrastructure and insufficient capital funding).
Trusts also shared experience of inspection reports containing multiple factual inaccuracies, which consumed time, effort and energy from trust staff to correct. Much of trust leaders' criticism of CQC's inspection reports was linked to their tone and narrative. They believed that reports should also aim to capture the positive stories and the good practice examples witnessed by the inspection team, and those shared by interviewees during the inspection and beyond.
These points demonstrate how CQC could modify its approach to become more agile and targeted in its interventions. A regulatory approach that is more responsive to context, evaluating how organisations and their staff deal with imperfect circumstances beyond their control, would be more constructive and useful to providers and the wider public. We have witnessed a positive shift in CQC's recognition of some providers' operational pressures in recent months, accounting for the impact of industrial action among other challenges. This recognition needs to become the norm.
Recommendation 5:
We recommend that: CQC better reflects operational circumstances in its inspections and reports, and highlights providers' positive achievements alongside their shortcomings. Trusts would like to see CQC build on improvements it has made in acknowledging the operating context they are working in, as witnessed over the most recent winter period.
Ratings
Ratings for health and social care services were suggested by the health secretary in 2012 (BBC, 2012) with a view to provide an 'easy-to-understand, independent and expert assessment of how well somewhere is doing relative to its peers'. They were introduced by CQC in 2013, following an independent review carried out by the Nuffield Trust (Nuffield Trust, 2013) and a public consultation (CQC, 2013).
The Nuffield Trust review identified five possible purposes of ratings: to increase public accountability; to aid choice; to help improve the performance of providers; to identify and prevent failures in the quality of care; and to provide public reassurance for the quality of care. It suggested that 'a system of provider ratings could act to improve accountability for the quality of care, provided ratings were simple and valid, and were reported publicly, widely and accurately'. The review recognised the potential of ratings in bringing transparency, aiding choice and providing a level of public reassurance, but also described their limitations in terms of preventing future failures and bringing improvements. It also referred to the ratings' timeliness as a prerequisite for their usefulness and added value. Importantly, the review highlighted the inherent tension between the need for simplicity (particularly in providing public accountability) and for sufficient complexity (for example, to capture the complex nature of different services within the same trust).
In line with this, trust leaders feel ratings are a complex issue. Many see them as an over-generalisation of care quality, while also recognising their value in providing transparency and being easy for patients and the public to understand.
Trusts' main concerns about ratings were linked to their objectivity and their timeliness. Trust leaders felt ratings were too subjective and dependent on the assessment of the individual inspector on the day. They also believed that CQC ratings provided a snapshot in time and that, given there is often a long gap between inspection and re-inspection, these could become more misleading over time. This was particularly true for services and providers rated as 'requires improvement'. This rating category applies to a very large number of providers, which are traditionally considered low risk by CQC and are therefore not a priority for re-inspection. Trust leaders shared experiences of being 'stuck' in this rating category and left unable to demonstrate the improvements they have made.
Objectivity and timeliness of ratings are key for delivering on the original intended purposes of ratings, as defined by the Nuffield trust. They also support the right-touch principles of transparency, accountability and agility.
Our interviewees described the impact that ratings can have on staff and service users. They reflected on how a negative rating had had a demoralising effect on their staff and how it had directly affected recruitment and retention. They were also concerned about the message such a rating gives out to the public and how it affects public perceptions and patient choice. The unintended consequences of ratings for staff and patients should draw CQC's attention to the principle of targeted regulation, one which is focused on the problem and aims to minimise side effects.
Recommendation 6:
We recommend that: While retaining its impartiality and objectivity, CQC could reflect on the tone and delivery of its inspection activities, including its inspections, reports and ratings, to make sure its outputs do not have an unintended adverse impact on providers.
The above comments and recommendations are even more pertinent in the context of the recently published findings of the inquiry into Ofsted’s Inspections by the House of Commons Education Committee (UK Parliament, 2024). The latter considered aspects of Ofsted’s approach in light of the tragic death of primary school headteacher Ruth Perry, and made a series of recommendations which could be applied to some of the areas of concern raised about CQC. These include inspectors' behaviour and expertise, the use of single word ratings, and the regulator's complaints procedure.
CQC's recent board paper on this topic is important, as it outlines its plans to develop a training programme for inspection teams (HSJ, 2024) to help them identify and manage signs of distress in providers.
While we recognise the differences between the two regulators' approaches, we believe that now is the right time to take stock of these findings and apply relevant learning and recommendations to CQC’s work. For example, CQC may need to consider the value of its single-word ratings, modelled upon Ofsted’s rating system. As suggested by the Nuffield Trust and by many trust leaders, a single-word rating will inevitably oversimplify what happens in a very complex organisation.
A narrative rating qualifier might provide additional nuance, to aid public understanding and capture the positive achievements of providers alongside the one-word rating. This could be consistent with CQC's new assessment approach, which aims to provide shorter, better-evidenced, and more consistent inspection reports. For example, this could be captured alongside, or as part of, the summary view of the service (CQC, 2023), which has been suggested for inclusion in future reports.
Recommendation 7:
We recommend that: CQC re-evaluates the success of its single-word ratings against their intended purpose, and considers the addition of a narrative rating qualifier as part of its new provider assessments reports, in the context of the Ofsted inquiry findings.