- CQC is now focusing on adult social care services rated as overall ‘requires improvement’, particularly those who are repeatedly rated as such.
- Services rated as requires improvement will be subject to ongoing monitoring.
- The CQC has set out three stages of action each time a service is rated as requires improvement.
It is a statutory requirement for CQC to carry out its functions in a targeted, risk-based manner. Until now it has focused much of its attention on services rated overall inadequate, placing them in special measures and, in the absence of sufficient improvement, taking enforcement action against them. In 2017-18, 141 locations were ‘enforcedly closed’, with 73% being in adult social care (ASC). However, overall inadequate services in ASC only make up a tiny minority of services, at around 1-2%. Consequently, CQC is now turning its attention on ASC services rated requires improvement overall, which comprise around 20% of services in ASC. In particular, CQC is intent on concentrating on those services that are rated requires improvement overall on a repeated basis.
The change of focus
CQC gave notice to the ASC sector about its approach to services repeatedly rated requires improvement by way of changes made in May 2018 to its guidance for providers and managers, How CQC monitors, inspects and regulates adult social care services. In emphatic terms, CQC states that:
‘Good care is the minimum that people receiving services should expect and deserve to receive. Providers should aim to achieve and sustain an overall rating of good or outstanding.’
CQC sets out the process it will follow in dealing with services rated requires improvement overall.
First rating of requires improvement
The guidance states that CQC ‘will write to inform the provider that subsequent ratings of requires improvement may constitute a breach of Regulation 17 (good governance) and suggest sources of help for the provider to seek improvement. The letter will be copied to the lead commissioner at the same time, where appropriate.’ It is not clear when it would be inappropriate to copy in the lead commissioner. Indeed, CQC’s internal guidance states that the letter will be copied to the lead commissioner.
If there is a breach of regulation, CQC must consider proportionate enforcement action in accordance with its published enforcement policy guidance.
CQC may also ask the provider for an improvement action plan under Regulation 17(3). CQC’s internal guidance states that the provider must return the improvement action plan within 28 days of the request. In practice, inspectors often ask for the plan within 14 days. Providers should check, therefore, that they have been given 28 days.
The service rated requires improvement will be subject to ongoing monitoring.
Second requires improvement rating
At stage 2, CQC must ask the provider for an improvement action plan with timescales, which must be agreed with the provider and the commissioner.
CQC may also seek a meeting with the provider and the manager to discuss their concerns and what support is needed. Commissioners may also be invited to the meeting.
In its internal guidance for inspectors, CQC states, ‘where we find breaches of regulations, we will conduct a Management Review Meeting involving the inspector, Inspection Manager and Legal to discuss what action is required. We will consider if breaches of key questions also impact on the well-led question.’ It has long been a concern of mine that any alleged breach of regulation under safe, effective, caring or responsive is carried over as a breach of Regulation 17 (good governance) in the well-led section of the inspection report. On the back of the management review meeting, CQC will decide if proportionate enforcement action is required.
The service rated requires improvement will continue to be subject to ongoing monitoring.
Third requires improvement rating
CQC must hold a further management review meeting to consider a breach of Regulation 17 and any other breaches. The internal guidance states that CQC must ‘consider taking enforcement action e.g. using positive conditions, Warning Notices or other appropriate enforcement action depending on risk and/or lack of improvement’.
If a meeting was not convened with the provider after the second inspection, CQC will instead consider holding one with the provider, manager and commissioners at this stage to discuss the concerns and support needed.
There has been speculation that, after the third requires improvement rating, CQC will automatically rate well-led as inadequate. The internal CQC guidance suggests this may be the likely conclusion, stating ‘if Well-led rated Inadequate [sic], the service may still be rated RI [“requires improvement”] overall. It should only be rated Inadequate if it meets the characteristics of Inadequate.’
We could be looking at a situation where more services end up being rated requires improvement given that, if there is any breach of regulations, a service cannot have a higher rating than requires improvement. It may also be difficult for services to move up to good if inspectors raise sustainability arguments, even though there are no breaches of regulations. This is because a service with a rating of requires improvement may be in breach of one or more regulations, or ‘not be in breach of regulations but does not meet the characteristics of good or the Mum test’. Quite how inspectors are supposed to rate a service against the Mum test is beyond me.
What is clear from the above is that, to prosper in the sector, services are going to have to be good or outstanding. It will be important to consider the reasonableness and proportionality of CQC’s judgements and ratings in inspection reports, given the significant impact that they will have if a service is rated requires improvement. In particular, if CQC alleges breaches of regulations, it will be essential to consider the facts and context carefully. This is an exercise best conducted with the assistance of lawyers trained in gathering and evaluating evidence.
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