Independent report. Review into the operational effectiveness of the Care Quality Commission: full report (15 October 2024)

Summary

In May 2024, Dr Penny Dash was asked by the Department of Health and Social Care (DHSC) to conduct a review into the operational effectiveness of the Care Quality Commission (CQC).

An interim report of her work, providing a high-level summary of her emerging findings, was published in July 2024.

This full report summarises the final findings of the review, outlining the necessary changes to start improving CQC. It makes seven recommendations and is aimed at:

• health and care professionals
• health and social care services
• academic and professional institutions
• the general public.

Alongside the review’s full report, DHSC wanted to independently determine if the review’s concerns were substantiated with objective data through the consideration of a number of research questions.

A second review considering the wider landscape for quality of care, with an initial focus on safety, will be published in early 2025.

Content

The conclusions of the review are summarised around 10 topics.

Conclusion 1: poor operational performance 

There has been a stark reduction in activity with just 6,700 inspections and assessments carried out in 2023, compared with almost 15,800 in 2019. This has resulted in:

• a backlog in new registrations of health and care providers
• delays in re-inspecting after a ‘requires improvement’ or ‘inadequate’ rating
• increasing age of ratings

The review has concluded that poor operational performance is impacting CQC’s ability to ensure that health and social care services provide people with safe, effective and compassionate care, negatively impacting the opportunity to improve health and social care services, and, in some cases, for providers to deliver services at all. 

Conclusion 2: significant challenges with the provider portal and regulatory platform

New IT systems were introduced at CQC from 2021 onwards. However, the deployment of new systems resulted in significant problems for users and staff.

The review has concluded that poorly performing IT systems are hampering CQC’s ability to roll out the SAF, and cause considerable frustration and time loss for providers and CQC staff.

Conclusion 3: delays in producing reports and poor-quality reports

All sectors told the review that they can wait for several months to receive reports and ratings following assessments. The review has heard multiple comments about poor-quality reports - these have come from providers and from members of the public. 

Poor-quality and delayed reports hamper users’ ability to access information, and limit the credibility and impact of assessments for providers.

Conclusion 4: loss of credibility within the health and care sectors due to the loss of sector expertise and wider restructuring, resulting in lost opportunities for improvement

CQC underwent an internal restructuring in 2023, alongside the introduction of the SAF and new IT systems. The restructuring moved operational staff from 3 directorates with a focus on specific sectors into integrated teams operating at a local level, resulting in a loss of expertise.

The review has found that the current model of generalist inspectors and a lack of expertise at senior levels of CQC, combined with a loss of relationships across CQC and providers, is impacting the credibility of CQC, resulting in a lost opportunity to improve health and social care services.

Conclusion 5: concerns around the single assessment framework (SAF) and its application

The SAF has set out 34 areas of care quality (called ‘quality statements’) that could be applied to any provider of health or social care with a subset applied to assessments of integrated care systems (ICSs) and local authorities. These align to the 5 domains of quality used for many years and referred to as ‘key questions’ within the SAF. For each of the 34 quality statements, there are 6 ‘evidence categories’. These are: people experience, staff experience, partner experience, observations, processes and outcomes.

The review has identified 7 concerns with the SAF as follows:

• the way in which the SAF is described is poorly laid out on the CQC website, not well communicated internally or externally, and uses vague language
• there is limited information available for providers and users or patients as to what care looks like under each of the ratings categories, resulting in a lack of consistency in how care is assessed and a lost opportunity for improvement
• there are questions about how data on user and patient experience is collected and used
• more could be done to support and encourage innovation in care delivery
• there is insufficient attention paid to the effectiveness of care and a lack of focus on outcomes (including inequalities in outcomes)
• there is no reference to use of resources or the efficient and economic delivery of care, which is a significant gap
• there is little reference to, or acknowledgement of, the challenges in balancing risk and ensuring high-quality care across an organisation or wider health and care system

Conclusion 6: lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous inspections (that often took place several years ago) to calculate a current rating

The review has learnt that overall ratings for a provider may be calculated by aggregating the outcomes from inspections over several years. This cannot be credible or right. Furthermore, providers do not understand how ratings are calculated and, as a result, believe it is a complicated algorithm, or a “magic box”.

Ratings matter - they are used by users and their friends and family, they are used by commissioning bodies (the NHS, private health insurers and local authorities), and they drive effective use of capacity in the sector. They are a significant factor in staff recruitment and retention.

Conclusion 7: there are opportunities to improve CQC’s assessment of local authority Care Act duties

The Health and Care Act 2022 gave powers to CQC to assess local authorities’ delivery of their adult social care duties after several reports and publications identified a gap in accountability and oversight of adult social care. The review found broad support for the overall assessment framework but also heard feedback that the assessment process and reporting could be improved. 

Conclusion 8: ICS assessments are in early stages of development with a number of concerns shared

The Health and Care Act 2022 introduced a new duty for CQC  to review and assess ICSs. Statute sets out 3 priority areas for CQC to look at: leadership, integration and quality of care; and the Secretary of State can set priorities on other themes. CQC developed a methodology for these assessments, which was tested in pilots in Dorset and Birmingham and Solihull, but wider rollout has been paused as a result of a number of concerns shared with the review.

Conclusion 9: CQC could do more to support improvements in quality across the health and care sector

The review heard a consistent comment that CQC should not be an improvement body per se, but, at the same time, could do more to support the health and care sectors to improve. It could do this, for example, through the description of best practice and greater sharing of new models of care delivery, leading international examples of high-quality care and more innovative approaches - particularly the use of technology. 

Governance structures within organisations are crucial to improvement. A greater focus on how organisations are approaching and delivering improvement, rather than looking at input metrics, could enable more significant improvements in quality of care.

Conclusion 10: there are opportunities to improve the sponsorship relationship between CQC and the Department of Health and Social Care (DHSC)

DHSC’s sponsorship of CQC should promote and maintain an effective working relationship between the department and CQC, which should, in turn, facilitate high-quality, accountable, efficient and effective services to the public.

The review has found that DHSC could do more to ensure that CQC is sponsored effectively, in line with the government’s Arm’s length body sponsorship code of good practice.

The review’s recommendations

The health and care sector is one of the most significant drivers of health, public satisfaction and economic growth. It needs - and deserves - a high-performing regulator.

In order to restore confidence and credibility and support improvements in health and social care, there is a need to:

• rapidly improve operational performance, fix the provider portal and regulatory platform, and improve the quality of reports
• rebuild expertise and relationships with providers
• review the SAF to make it fit for purpose with clear descriptors and a far greater focus on effectiveness, outcomes and use of resources
• clarify how ratings are calculated and make the results more transparent
• continue to evolve and improve local authority assessments
• formally pause ICS assessments
• strengthen sponsorship arrangements.