How long do you have to be Good before you are rated as such?  The question arises from a common frustration in the sector.  A provider may temporarily drop the ball in relation to a service that results in an Inadequate rating.  The provider accepts the rating and does everything necessary to raise standards.  Often, that will include a change of manager and tightening of quality monitoring systems.  CQC returns within 6 months and recognises the improvement.  The content of the report couldn’t be more glowing.  However, CQC rates the service as Requires Improvement on the basis that not enough time has elapsed since the last inspection for the home to demonstrate ‘consistency’.  The provider argues that the content of the report plainly supports a ‘Good’ rating.  Who is right?

First, it is important to recall that there are two separate legal frameworks relevant to inspections: the regulations and the KLOES.  The reason for that was a political decision when ratings were re-introduced that the regulations should represent the minimum standards and providers should not be rated highly just for meeting minimum expectations.

Under the relevant legislation, the criteria for ratings are not the regulations but rather ‘whatever indicators of quality the Commission devises’.

Those indicators are set out in the KLOEs and rating characteristics.

Consistency is referenced repeatedly in the rating characteristics.  For example, the general descriptor of Requires Improvement for Safe, includes ‘The service has an inconsistent approach that sometimes puts people’s safety, health or wellbeing at risk’.

How should CQC assesses consistency?  CQC has helpful guidance on this point in its internal document Inspection Guidance – Judgments and Ratings.  The guidance is intended to help assess whether a location is achieving sustained and continuous improvement following a breach.  It sets out the following prompts to assist in that task:

• Does the provider understand what went wrong and why? What is the evidence for this and how is this corroborated?
• What has the provider learnt from the breach evidence?
• How has this learning been put into practice?
• Has the breach been resolved, and is the legal requirement now met? How has quality improved?
• What has the provider done to put things right? Have relevant systems and processes, equipment or training been introduced which reduce or eliminate the risk of the breach happening again?
• Is there ongoing support available for staff/managers to help prevent further issues?
• Can the provider demonstrate that the improvements they have made are sustainable? What is the evidence to support this? What plans, checks or audits are in place to check that the changes made will continue to be effective in the future?
• What do people using the service say about the improvements? What impact have the improvements had on them?

Those prompts are not objectionable, and indeed are sensible, providing they are used to judge relevant prompts rather than being used as a substitute.

Significantly, there is no reference in them to a minimum period of time before sustained and continuous improvement can be achieved.  That is appropriate.  Sometimes CQC will reinspect sooner than others following an inadequate inspection.  The key issue is what CQC finds when it inspects.  If the answer to the prompts are favourable to the provider, it should be rated accordingly.  The previous breaches will be covered in the previous reports that will, of course, remain available to anyone who wishes to research the compliance history of the service.

In its annual report following the re-introduction of ratings, CQC wrote that the ratings would give the public a better and more transparent understanding of the quality of different services, while also encouraging providers to improve.   Those objectives are not fully realised if ratings are based on poor quality which has since been remedied.    People encountering a ‘requires improvement’ rating will categorise the service exactly as such: that it requires improvement.  CQC would, unfairly and inaccurately, be placing it into a category with other services that truly do need to improve.

Providers facing this issue should draw it to CQC’s attention in the factual accuracy process.  If that does not resolve the matter, it can be raised through the rating review process as it is clearly an example of CQC not following its own process.

Please contact me if you need further information on this or any other regulatory issues or inquests:

Jonathan Landau, Barrister

5 Chancery Lane
London, WC2A 1LG
DX: 182

Telephone: 0207 406 7532

Mobile: 07980 897 429

Email: jlandau@healthcarecounsel.co.uk

https://www.healthcarecounsel.co.uk/