And so it has begun – the rollout of the long-awaited CQC’s new assessment regime is underway. Having commenced in the South of England and working region by region, registered providers in London and the East of England are next in line to be assessed under the new single framework followed by the North and Midlands expected to start from early February.
The CQC’s website contains a wealth of material about the assessment process which, understandably, is very detailed. It covers everything from evidence gathering to ratings for a variety of different organisations in a range of different scenarios. So, after wading through much of the information available to date, what are the headlines? What do you, as a healthcare or social care service provider, need to know in a nutshell?
What will stay the same?
The CQC will continue to ask the same five key questions of services (are they ‘safe’, ‘effective’, ‘caring’, ‘responsive’ and ‘well-led’?) and the existing 4-point ratings scale will remain (‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’). There will be some key differences, however, in how the quality of services are assessed and the final ratings are arrived at.
What has changed?
Inspections and evidence gathering
The CQC’s new approach embodies a shift away from reliance on inspections and towards utilising diverse evidence sources, including people's experiences. It is envisaged by the CQC that inspections, which will become more targeted to address specific needs or concerns, will serve to support the CQC’s evidence gathering activity rather than being the primary method by which evidence is obtained. The CQC will continue to request evidence directly from providers and undertake on-site activity more frequently where concerns about a service exist, however, there will be a greater emphasis on evidence gathering via both on-site and off-site methods. These methods will include engagement activities like feedback, focus groups, and surveys, in addition to directly speaking to people and observing activities.
Frequency of assessments and judgements
The timing of assessments will become more fluid, rather than following a frequency schedule according to previous ratings. As the CQC diversifies evidence sources and gathers information about providers and services on a more regular basis, such evidence can trigger an assessment at any point. In addition, judgements (i.e., new ratings) will no longer only be made after an inspection. The CQC expects that its new approach to evidence gathering will allow them to make judgements about quality more regularly, which will keep CQC ratings of services more up to date.
Assessments and ratings
The CQC’s key lines of enquiry (‘KLOEs’) of old have been replaced with new ‘quality statements’. The quality statements set out what standards of care are expected of service providers. The CQC will gather evidence to assess quality in line with the quality statements.
A new scoring system has been introduced which will feed into and inform CQC ratings. Further detail on the scoring system is set out below but, essentially, the evidence supporting each quality statement will be assessed and scored. Those scores will be collated to give a score for each quality statement, which will then be collated again to give a score for each overall key question. The scores will indicate which rating will be given for each key question and those ratings will be aggregated to give an overall rating of quality.
Remit
The CQC’s remit will now extend to assessing local authorities and integrated care systems in addition to registered healthcare providers. These new CQC responsibilities will not be covered in this article, however, if you require any further assistance or information in this regard, please contact us.
Publication
Initially, only service ratings will be published on the CQC’s website in the same way as prior to the new regime. Service providers should be aware, however, that the CQC does intend to move to publishing the scores in the future.
What is the CQC aiming for?
The CQC expects the changes to introduce greater flexibility. This should enable regular updates to service provider ratings based on changing circumstance. This should also allow the CQC to be more selective and focused in the areas which they inspect and the evidence that they gather.
In explanations of how the new assessment regime will work in practice, the CQC mention several times that providers will not be required to prepare specific documents or present information in certain ways. The CQC’s emphasis is on trying to keep processes simple, structured and consistent whilst avoiding adding to provider workload.
The CQC has also set out its aim that the new regime will promote greater structure and transparency. It is envisaged that the scores will not only promote consistency in the CQC’s quality assessments, but they will also show with greater transparency how close the service sits to either the next rating below or above its current rating according to the CQC’s latest assessment.
How will the new scoring system work?
This is where the new process can appear to be quite complex on first reading. There are many nuances to the scoring system depending on the type of service being assessed and whether or not it has an existing rating. In a very simplified explanation, the CQC has devised a number of quality statements which underpin each of the five key questions and describe the standards of care that are expected. An example of a quality statement, which in this instance underpins the ‘safe’ key question, is:
We assess and manage the risk of infection. We detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.
In assessing each quality statement, the CQC has identified which of six evidence categories will be relevant dependent upon the type of service. The six evidence categories are:
- People’s experience of health and care services
- Feedback from staff and leaders
- Feedback from partners
- Observation
- Processes
- Outcomes
The CQC has then set out the types of evidence it will focus on in respect of each evidence category in assessing the quality statement. For example, mortality rates are one type of evidence that the CQC will consider as part of the outcomes category and survey results are evidence that falls within the people’s experience category.
After assessing all of the evidence for each evidence category relevant to the quality statement in question, including both new evidence obtained and evidence already held, the CQC will give a score for the evidence category. The scores for each of the evidence categories are then combined to give a score for the related overarching quality statement.
Here is where the scoring system becomes somewhat complicated. The quality statement score is then converted into a percentage by dividing the total score by the maximum possible score. The percentage is then converted back to a score between 1 and 4 based on set thresholds. The effect is that each quality statement underpinning the specific key question has a score between 1 and 4. These quality statement scores are then added together and converted into a percentage by, again, dividing the total score by the maximum possible score. This percentage represents the percentage score of the specific overarching key question (e.g., safe) and is translated into a key question rating using the following thresholds:
- 25 to 38% = inadequate
- 39 to 62% = requires improvement
- 63 to 87% = good
- Over 87% = outstanding
The overall rating for each key question is known as an underlying rating. An aggregated rating for the quality of the service will then be given based on the underlying ratings for each key question. The CQC has set out in guidance, known as ratings principles, when an aggregated rating may be more likely to be outstanding or requires improvement based on the underlying ratings. Again, in very simplified terms, an aggregated outstanding rating will normally require a prescribed number of underlying outstanding ratings with remaining underlying ratings to be good, in the same way that an aggregated requires improvement rating will normally require a set number of underlying requires improvement ratings. Small numbers of underlying inadequate ratings can have the effect of capping the aggregated rating to no higher than requires improvement.
The CQC has stated that it may depart from their ratings principles in certain circumstances, such as where ratings for the five key questions range from ‘inadequate’ to ‘outstanding’ and these need to be aggregated to form an overall rating. In doing so, it will take into account certain factors such as the extent and impact of identified concerns and confidence in the provider to address the issues.
The above is a much condensed explanation. If you are looking for more specific and detailed guidance on how the new scoring system will apply to your individual service, please get in touch and we can assist you.
How will previous ratings impact new ratings?
If your service has a previous rating, the CQC will select which quality statements under each key question it wishes to consider at the first assessment under the new framework. The CQC will gather evidence for each of these quality statements and score them according to the new system. For the remaining quality statements under the key question, a score will be allocated between 1 and 4 (where 1 is inadequate and 4 is outstanding) based on the previous rating for that particular key question.
If you have recently taken over as the new provider of a service, whilst the previous CQC rating of the service will be displayed on the CQC website and used to plan your first CQC assessment, it will not be used to produce an aggregated rating. The new assessment will produce a new rating and judgements for your service.
When will the changes affect you as a provider?
The CQC will contact you in advance of assessing your service under the new regime and will provide you with information on how to prepare for the assessment.
Assessments of registered providers in the South and East of England and London are already underway. Assessments will commence for providers in the North of England and the Midlands from 23 January 2024. From 27 February 2024, the new assessment framework will be used for all registration activity, whether that is a new CQC registration application or a change to registration for existing providers.
How can we help you?
If you are a health or social care provider and require advice or assistance, please contact us. Our team are on-hand to help with your CQC and other regulatory enquiries.
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