Introduction

CQC is in the process of rolling out a new way of inspecting, monitoring and rating registered services called the Single Assessment Framework. The Single Assessment Framework is underpinned by a consideration of Equality and Human Rights.

The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 remain essentially the same. Breaches of regulation and enforcement action will follow similar pathways to those already in place.

The five Key Questions will stay the same so that services will continue to be rated under Safe, Effective, Caring, Responsive and Well Led.

However, the numerous KLOEs, which were prompts under each of the five Key Questions have been replaced by 34 Quality Statements. These Quality Statements are the same for all registered services and have been co-produced with people using services.

Calculating ratings under the new Framework

Ratings will be calculated in a more detailed way than previously. Individual Quality Statements will be rated on the quality of evidence and aggregated to inform a rating for each Key Question and the service overall. CQC have said this will be a more transparent way of rating than previously. This all sounds like good news for care providers.

However previously, two very strong pieces of Outstanding evidence for a Key Question would be sufficient for a rating of Outstanding when all other evidence was Good. The way ratings will be calculated in future will make it more difficult to gain an Outstanding rating in any Key Question and therefore for the whole service. Which is not such good news for care providers.

Let’s look at an example related to a home care service under the Safe Key Question to illustrate this point.

Learning Culture and Involving People to Manage Risks are two of the eight Quality Statements under the Safe Key Question.

Let’s assume you have some fantastic evidence of your Learning Culture. For example, you have analysed your care visit data and recognised some clear patterns in late calls. You have worked with your scheduling team and significantly reduced the number of late calls with a greatly improved outcome for the people you provide care for.

CQC look at the evidence of your processes, your data and the feedback from people who say how reassured they now are about the reliability of your service. CQC are impressed with your improvements and award you the maximum score of 4 for this Quality Statement.

You also have some strong evidence of Involving People to Manage Risks. You have developed some accessible information to support people to make informed decisions about risk so they can take part in interesting activities. CQC look at the evidence of your processes, your data and testimonials from people about their improved quality of life as a result of this. Again, CQC award you the maximum score of 4.

This means you would gain a score of 4 for both Learning Culture and Involving People to Manage Risks which equates to Outstanding i.e. “an exceptional standard”.

If you then gain a score of 3, which equates to a Good rating for each of the other 6 Quality Statements, you will achieve a total score of 26 out of a possible 32. If we express this as a percentage, as CQC do, then 26 as a percentage of 32 = 81.25%.

This looks like a great score and you may be forgiven for thinking this would be enough to gain an Outstanding rating for the Safe Key Question. However, to gain an Outstanding rating, CQC say you need to score over 87 percent. This means your rating would be Good for the Safe Key Question, despite having some powerful evidence of Outstanding practice.

Indeed, to achieve Outstanding for Safe, a provider will need to score 4 for at least four of the eight Quality Statements. So the bar has well and truly been raised by CQC in terms of achieving Outstanding for Safe.

It would also make no difference how many pieces of Outstanding evidence you had of a Learning Culture or of Involving People to Manage Risks. The maximum score you could achieve would be 4 in each.

It is a similar calculation for all the other Key Questions: Effective, Caring, Responsive and Well Led, even though the number of Quality Statements varies in each. The strong pieces of evidence in two Quality Statement areas which could previously have resulted in an Outstanding rating will now not be sufficient to reach over 87% and will be rated Good.

CQC have said they want to show how close services are to either achieving a lower or higher rating and so will publish the percentages so that people who read the report can see this information. However, this will be small consolation for those services with a score of say 80 – 87% and therefore a rating of Good in a Key Question who may have previously achieved Outstanding. It will be impossible for this not to affect morale, reputation and business success.

CQC judgements when scoring the Evidence Categories

As we have seen, Evidence Categories (such as processes, observation and people’s feedback) are scored and inform Quality Statement ratings, then ultimately the overall rating of the service. However, scoring relies on CQC judgement about the quality of evidence deemed sufficient to award a maximum rating of 4. This is not an exact science and is vulnerable to inconsistencies of approach in the same way as the previous rating system.

Conclusion

Overall CQC have set out to make their new inspection process more transparent and fairer. They have consulted people who use services to come up with their new Quality Statements. These statements are what people have said are most important to them and this is an encouraging development in the CQC approach. However, services will need to work very hard to produce evidence of Outstanding care across a greater number of Quality Statements to be in with a chance of an Outstanding rating.

The percentage of services achieving this rating before the new Single Assessment Framework was regularly less than 5%. What smaller percentage will it be now?

About the Author

S Hunneyball

Neil Grant

Partner