Dash review of the CQC: what you need to know

Overview

Penny Dash’s review of the operational effectiveness of the CQC

Between May and October 2024 Dr Penny Dash reviewed the CQC, based on extensive engagement with senior managers from primary and secondary care providers and integrated care boards, caregivers and clinicians, patient and user groups and CQC staff. The review highlighted ten areas of concerns:

1. Poor operational performance

• There has been a stark reduction in activity with just 6,700 inspections and assessments carried out in 2023 to 2024, partly due to the roll out of the single assessment framework (compared with 15,800 in 2019 to 2020).
• There is a backlog in registrations of new providers. In 2024, 54 per cent of applications pending completion were more than ten weeks old (compared with 22 per cent in 2023).
• Some organisations have not been re-inspected for several years. Between 2015 and 2024, the time taken to carry out a re-inspection after an ‘inadequate’ rating has increased from 87 days to 136 days. The oldest rating for a social care organisation is over eight years old and the oldest rating for an NHS hospital is ten years old.
• Of the locations the CQC has the power to inspect, 19 per cent have never been rated.

2. Significant challenges with the provider portal and regulatory platform

• New IT systems, including the provider portal and regulatory platform (for assessment, registration and enforcement) have had problems.
• Issues such as uploading documents and delays in password reset are hampering CQC’s ability to roll out the single assessment framework (SAF) and appropriately manage concerns raised with CQC. This causes considerable frustration and time loss for providers and CQC staff.

3. Delays in producing reports and poor-quality reports

• All sectors can wait for months to receive reports and ratings following assessments, increasing burdens and stress on staff and losing crucial quality improvement time.
• Providers and the public raised issues with poor-quality reports. For example, differing messages in summaries and the main report, and disparity between the tone and evidence used in a report and the subsequent rating awarded.
• There should be greater consistency in the quality of reports and learning from examples of better-quality outputs that have been published. 

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’s internal restructure in 2023 moved operational staff from three sector-based directorates into local integrated assessment and inspection teams (IAITs) including inspectors and assessors. Under the previous model, ‘inspection managers’ worked within the sector-based directorates. Now ‘operational managers’ oversee an integrated team of inspectors and assessors with different specialisms.
• The restructure reduced expertise and seniority of inspection teams, compounded by changes to the chief inspector roles. Where previously there were three experienced chief inspectors (of social care, primary care and hospitals), there are now two chief inspectors: for adult social care and integrated care, and for healthcare.
• Engagement between CQC staff and providers has reduced. Previous chief executives and chief inspectors would spend considerable time with health and care sector leaders, building relationships, hearing their perspectives on care delivery, and explaining and sharing the insights CQC was gathering.

5. Concerns around the single assessment framework (SAF) and its application

• The SAF aimed to collect data and insights in advance to have an ‘always on’ assessment model. This would enable a ‘risk-based’ approach, identifying emerging problems earlier and assessing organisations more frequently. While sensible, this approach depends on robust and timely data.
• The review has identified seven concerns with the SAF:

1. SAF’s description is poorly laid out on the CQC website, not well communicated internally or externally and uses vague language.
2. There is limited information describing what care looks like under each of the ratings categories, resulting in a lack of consistent assessments.
3. There are problems with data on user and patient experience collection.
4. Poor support and encouragement of innovation in care delivery.
5. There is insufficient attention paid to the effectiveness of care and a lack of focus on outcomes (including inequalities in outcomes).
6. SAF does not consider efficient use of resources and economic delivery of care, despite this requirement in section 3 of the Health and Social Care Act 2008.
7. There is little acknowledgement of the challenges in balancing risk and ensuring high-quality care across an organisation or wider health and care system. SAF does not consider innovation in care models or ways to encourage adoption of innovation.

6. Lack of clarity regarding how ratings are calculated and concerning use of the outcome of previous outdated inspections to calculate a current rating

• Concerningly, overall ratings for a provider may be calculated by aggregating the outcomes from inspections over several years.
• The SAF was intended to prevent the use of inspections (and associated ratings) from previous years as more frequent assessments would be undertaken based on emerging data and intelligence, but, because CQC is not doing the number of assessments required to update ratings, the problem continues.
• Provider and CQC staff are confused about how ratings are calculated.

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 adult social care after several reports identified a gap here.
• The nine local authorities that have been through the entire assessment process and sector representative bodies were broadly supportive of the assessment framework.
• Local authorities feel the assessment process and reporting could be improved through improved engagement between the CQC and local authority staff and better descriptors of what ‘good’ or ‘outstanding’ looks like.
• Local authorities’ question how well their commissioning functions are assessed.

8. ICS assessments are in early stages of development with concerns shared 

• Under the Health and Care Act 2022, CQC was given the duty to review and assess ICSs. CQC is legally required to consider: (1) leadership, (2) integration and (3) quality of care - presumably from all individual providers within an ICS. 
• CQC developed a methodology for these assessments, which was tested in pilots in Dorset and Birmingham and Solihull, but wider rollout has been paused.
• It is not clear if these reviews are accessing or outcomes. 
• Assessment do not focus on or measure progress against ICSs’ four core purposes.
• It is not clear what ‘good’ looks like (e.g. for structures) nor what specific data (metrics) should be used to assess leadership, integration and quality across an ICS.
• Assessments risk duplicating provider assessments - some data requests could or should have been considered in provider assessments rather than ICS assessments. 
• CQC should recognise the challenges of clinical risk management in working effectively across multiple providers.
• It is difficult to meaningfully hear residents’ views of care quality across a whole system. 
• Preparation of assessment is too slow and the associated costs (both CQC fees and staff staff) are too high, particularly in addition to provider inspection costs.
• Assessments overlap with the NHS England’s Oversight Framework.

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

• CQC should not be an improvement body but could do more to support the health and care sectors to improve. 
• Descriptions of what ‘good’ and ‘outstanding’ delivery of care looks like should guide inspections. This could include descriptions of new models of care delivery, international examples, more innovative approaches and the use of technology. CQC could be a substantive repository of high-quality and innovative models of care. 
• Reports need to be clearer, specifying opportunities to improve and encouraging development of clear action plans. These should be followed up on in a timely manner 
• Inspection teams should inspire as much as instruct, helping organisations to understand where there are opportunities for improvement and setting out what a better model of care could look like. This requires high-calibre, credible and knowledgeable teams to carry out inspections.
• Existing collection of user feedback should be used far more systematically and comprehensively. 
• Assessments should consider how organisations approach and deliver improvement (becoming self-improving organisations) rather than just looking at input metrics. 

10. There are opportunities to improve the sponsorship relationship between CQC and the Department of Health and Social Care (DHSC)

• DHSC should promote and maintain an effective working relationship with CQC, facilitating high-quality, accountable, efficient and effective services to the public. 
• DHSC should ensure CQC is meeting its KPIs for operational performance and regularly discuss timely management information linked to those KPIs. 
• DHSC should reduce the time taken to respond to requests from CQC (e.g. replacing senior roles).
• The National Quality Board (NQB) should consider its role in agreeing definitions of high-quality care and how to measure outcomes, consider innovation in assessments, consider best use of resources and where limited public funds could be spent most effectively, and assess trade-offs or balance risk considerations.

Other areas for further consideration 

The review raised four other areas for further consideration:

1. One-word ratings: The government recently announced that Ofsted would end the use of one-word ratings and so it would be reasonable to similarly consider their use in health and social care. Changes to one-word ratings could be beneficial in allowing greater clarity on the different areas of quality. The government should consider improving transparency of ratings across different services and sites in larger providers.
2. Finances within CQC - both how CQC is funded and the costs of running the organisation efficiently and effectively: Under the current funding model, it is difficult to ensure efficient and effective service delivery from CQC when providers are obligated to pay; decide on fee levels; and ensure that resources available match the requirements of CQC while remaining efficient and effective. As the sponsor organisation, DHSC should consider to how address this.
3. The need to ensure the NHS Federated Data Platform results in a single ‘data lake’ across the health and social care sectors: A single repository of data on quality of care (including use of resources) across the health and care sectors would benefit CQC and the wider health and care sector. This would streamline performance management and improvement across all services. The government should develop a common set of data about quality of care across all sectors.
4. The wider regulatory landscape: Over 100 organisations exert some regulatory influence on NHS providers. Within the NHS, integrated care boards (ICBs) ensure high-quality providers and NHS England oversees ICBs to ensure they are delivering against their four objectives. There is significant overlap between the role of NHS England, ICBs and CQC. The government should review how many regulatory bodies there are to ensure more effective and responsive regulation.

Sir Mike Richards’ review of CQC's single assessment framework and its implementation

Commissioned to complement the Dash review, Sir Mike’s report considers changes to the CQC’s inspection approach, resulting from CQC’s 2021 strategy, and makes recommendations on solutions to CQC’s current problems. The transformation programme that followed the 2021 strategy had three key elements:

1. A major organisational restructure.
2. The introduction of a single assessment framework across all the sectors that CQC regulates (hospitals, mental health services, ambulances, primary and community care services and adult social care).
3. The development of a new IT system, named the regulatory platform.

Sir Mike concludes that all three elements failed to deliver the benefits that were intended. This has resulted in:

• CQC being unable to fulfil its primary purpose ‘to ensure health and care services provide people with safe, effective, compassionate high-quality care and to encourage these services to improve’. Far fewer inspections have been carried out than in previous years, publication of inspection reports have been seriously delayed, and providers have expressed serious concerns about both the inspection process and the quality of the reports.
• Inspection staff have become demoralised and angry that their concerns about the changes have not been listened to by senior leadership, with many staff leaving the organisation, further compounding the problems. Staff morale is low and sickness levels have risen over recent years. However, many remaining staff remain committed to the purpose of CQC and are desperate to see things improve.
• Operational reality has not been reflected in policy and strategy after the structural re-organisation separated the staff responsible for each. 
• Clinical leadership and oversight of the inspection programmes has been lost as chief inspectors are no longer directly responsible for the inspections in their own sector and are less available and visible to support those at the front line. 
• The single assessment framework is far too complex and does not allow for the huge differences in the size, complexity and range of functions of the services that CQC regulates. Quality statements are confusing both inspectors and providers. Evidence categories and scores delaying report writing.
• The ‘provider portal’ is harming the working lives of staff in CQC staff and providers. 
• Inspection teams are insufficient to deliver the duties of the regulator within reasonable timescales. Staff are concerned that they cannot respond to emerging risks in a timely way. Insufficient induction and training has been given to new staff.
• Health and social care providers report have lost a previous sense of partnership with CQC to develop effective approaches to assessment of quality has been lost.
• Use of data to inform assessments of hospital services has not significantly improved. Intelligence available to inspection teams is sometimes less useful than it was pre-pandemic, hindering assessments of outcomes for people using services.
• Quality assurance processes have been downgraded and diluted, undermining consistency of judgements and the evidence quality, both vital to good regulation.

CQC’s response

In response, CQC has committed to:

• Reorganise around sector expertise, with at least three chief inspectors to lead on regulation and improvement of hospitals, primary care and adult social care services. Consideration will also be given to whether a fourth chief inspector is needed to lead on regulation and improvement of mental health services. 
• Modify the current assessment framework to make it simpler and ensure it is relevant to each sector. This will enable CQC to carry out and report on inspections more quickly. It will retain the five key questions (safe, effective, caring, responsive and well-led) across all sectors, but will amend the 34 quality statements to ensure clarity and remove duplication. CQC will stop scoring individual evidence categories.
• Ensure they have the right systems and tools in place to support its regulatory activity. CQC is working to stabilise and fix its regulatory platform and provider portal in the immediate term. While it does this, CQC is exploring options for delivering assessment activity away from the current systems, so that it can rapidly assess, rate, and publish reports for the public. 
• Improve the experience for providers registering with CQC. They are urgently reviewing what specific changes are needed to the provider portal to do this.
• Make scoring of evidence more transparent and strengthen its focus on nationally agreed priorities.
• Pause assessments of integrated care systems for six months. 
• Improve processes and strengthen arrangements for peer involvement of expert reviewers and advisors.

Analysis

Our members across the health and care system value the role of regulation in supporting patient safety and care improvement. But over the past few years they have repeatedly raised concerns around CQC’s operating model. They will recognise the issues raised by both Dr Penny Dash and Professor Sir Mike Richards in their reports. Indeed, the NHS Confederation and many of our members directly contributed to these reports. 

It is encouraging to see the robust response from CQC to these findings and the open approach they have taken throughout the process. We will continue to work closely with CQC colleagues to support them to change and become a more effective regulator. We support Penny Dash’s suggestion to reconsider the use of one-word ratings to improve transparency of ratings across different services and sites in larger providers.

If implemented in full, we believe the recommendations will improve the regulation of health and care professionals and allow the CQC to support improvement. Given the findings of the Dash review and feedback from ICS leaders, we believe the decision to pause ICS inspections is the right one. We will continue to work with our ICS members and CQC colleagues to ensure the approach adds value for systems and the public.