CQC Focus On Decline, Not Improvement – Are You At Risk?

On 20 September 2021, CQC hosted a webinar for adult social care providers in relation to its current monitoring approach and set out how it is currently monitoring and prioritising inspections.

What did CQC say about its current monitoring approach?

During the webinar, CQC said that the COVID-19 pandemic has prevented normal inspection of services for the past 18 months and it is now trying to emerge and recover from the pandemic. In order to do this, its current monitoring approach is meant to have the purpose of helping CQC prioritise its inspection activity. Each month all data that is held about a service will be reviewed by CQC and this will enable inspectors to prioritise inspections where the risk is deemed to be greatest.

All services will be reviewed by CQC on a monthly basis. Inspectors will review information held on services using an app based monitoring system (which providers will not have access to). This will flag up any services where risk may be present. During the webinar, a delegate asked if CQC is able to share its specific data model with providers for them to see how the information about a service is being assessed by CQC. CQC said that it is not able to share its model with providers but said that the type of information about a service that CQC will focus on is information it has received about a service from people such as relatives and staff as well as partner agencies. CQC will then contrast this information against CQC registration information and against current CQC ratings to help inform what type of monitoring is carried out.

Once information on a service is reviewed, CQC will determine the level of risk and CQC’s monitoring approach will involve one of the following depending on whether the risk is low, medium or high:

  1. Low risk = published assurance statement on CQC’s website
  2. Medium risk = Direct Monitoring Activity (“DMA”)
  3. High risk = On-site inspection

Further information in relation to CQC’s monitoring areas are set out below.

  1. Low risk – published assurance statements

CQC will continue to publish public assurance statements on its website for low risk services. The statements are meant to inform providers and the public that CQC has not found any evidence that the service rating or quality of care needs to be re-assessed at that time. An example of a published assurance statement on CQC’s website contains the following information:

We carried out a review of the data available to us about [X service] on [X date]. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage. This could change at any time if we receive new information. We will continue to monitor data about this service. If you have concerns about [X Service], you can give feedback on this service.”

The sentence, “… If you have concerns… you can give feedback on this service” suggests that CQC is only interested in hearing about concerns that people have about providers and is not interested in hearing positive things about a service.

During the webinar, CQC said that at the current time, there were published assurance statements  for 60% of providers. Assurance statements will not change the rating of a service. Ratings will only change as a result of physical inspections and as stated above, inspections will only be carried out if a service is deemed to be high risk. If CQC inspectors are carrying out inspections with a focus on risk it is more likely that they will downgrade a service’s rating rather than uplift it.

  1. Medium risk – Direct Monitoring Activity

CQC’s DMA will involve direct communication between CQC and a provider. This is likely to be in the form of an inspector making a monitoring phone call to the provider

There are two possible outcomes from CQC’s DMA. Either ongoing monitoring of the service by CQC or an on-site inspection. Again, it will not change a service’s rating. CQC has said that it needs to assess the risk in a service and this will determine whether or not a service is inspected. Services where risk is deemed to be greatest will be prioritised for an inspection.

If CQC’s DMA does lead to an inspection, no information will be published on CQC’s website on an interim basis and an inspection report will be published. Providers will have the opportunity to submit factual accuracy comments to CQC in the usual way.

  1. High risk – Inspection

During the webinar, CQC stated that at the current time only 6% of providers had been physically  inspected but caveated this by saying that this figure could change at any time if CQC receives information of concern about a service.

Inspections are no longer based on frequency thresholds and there are no fixed timeframes for when an inspection will be triggered. CQC is targeting its inspection activity where it is needed most. This means that if a provider has been inspected recently, unless CQC has concerns, it is unlikely to be inspected for quite some time.

Provider Information Return’s and how they fit with CQC’s new monitoring approach

Previously when Provider Information Return’s (“PIR’s”) were sent to providers it indicated that an inspection was imminent. However, under CQC’s new monitoring approach, PIR’s are now being sent to providers in line with their registration anniversary and CQC has said that it cannot provide definitive timescales for inspections.

During the webinar, CQC said that PIR’s are still an important tool for monitoring a service as they help inspectors determine what Key Lines of Enquiries (“KLOE’s”) they follow up on. CQC also indicated that they were a good tool to use to demonstrate that a service is ‘Outstanding’. However, even if PIR’s are able to demonstrate that a service is outstanding, this does not mean much as it will not result in a change of rating. Only an on-site inspection can change a service’s rating.

Concerns about CQC’s monitoring approach

CQC has made it clear that it is continuing with its risk-based approach and is only carrying out targeted inspections where it has concerns about a service. This is of particular significance for providers who are rated as ‘Requires Improvement’ as a ‘Requires Improvement’ rating alone is not enough to trigger an inspection. Those providers’ ratings may continue to remain unchanged for a long period of time. As a result of risk based monitoring and a heavy reliance on intelligence and data, it is likely that CQC will focus on negative findings.

Services rated as ‘Requires Improvement’ are likely to suffer the most under CQC’s new monitoring approach. This is because a ‘Requires Improvement’ rating is likely to cause issues for providers who are tendering for new contracts with commissioners. Such ratings are viewed negatively by local authorities and can be used as an excuse to pay less in fees. There are also potential issues with banks, lenders and insurers. Providers may struggle to attract new business from potential residents and struggle to retain and recruit staff. In turn these factors can threaten the financial viability of a service.

The CQC has confirmed that it is not able to downgrade or upgrade ratings for services without crossing the threshold and carrying out an inspection. Many providers are likely to feel that it is unfair that they are required to continue displaying an out of date CQC rating on their website just because CQC cannot come back in and re-inspect.

There are also implications for services rated as ‘Good’ but striving for ‘Outstanding’. These services are not due to be inspected anytime soon, as the data will indicate that there is no apparent need to inspect and CQC has indicated that it does not have the resources to focus on inspecting good to outstanding services.

There is also an issue with new services which have not yet been inspected and rated by CQC. Previously they would have been inspected within 12 months of being registered but a number of services have now passed this deadline. CQC has said that it will prioritise inspecting new services that were registered over 12 months ago. Ridouts has heard anecdotally that some commissioners are refusing to commission with providers who have not yet been inspected or rated by CQC. This puts providers at a significant disadvantage in terms of fees they can secure and in relation to insurance premiums.

Another danger with the new monitoring approach is that standards in services which were previously rated as ‘Good’ before the pandemic might have slipped. There is a risk that this will lead to closed cultures and that poor care will go undetected. With a heavy reliance on data, it is possible that if providers make a number of notifications to CQC, this will increase their chance of an inspection. However, this should not be the case as notifications also indicate that a provider is being open and transparent with CQC.

The view from Ridouts

Our firm has seen an increase in enforcement activity across the sector since the introduction of CQC’s Transitional Monitoring Approach and now current monitoring approach. There appears to be a shift from looking for ‘Good’ and ‘Outstanding’ services to looking for non-compliance with the Regulations.

There is a heavy reliance on what people tell CQC. People rarely share positive information with CQC and there is little opportunity for providers to challenge or provide context to the information that CQC receives. Even when context is provided, it is not always listened to by CQC.

The danger with the app based monitoring system is that it only shows perceived declining standards of care and not improving standards of care. Concerns remain about how CQC inspectors assure themselves of the validity of the data they are relying on to assess risk. CQC needs to ensure that any information gathered is properly verified and used to inform proportionate decision making.

CQC’s position is that its approach to regulation continues to be constrained by the pandemic. However, CQC does not take into account that providers are still very much in the midst of the pandemic and dealing with various pressures as they approach the winter. CQC expects providers to operate business as usual but the same does not seem to apply to CQC!

Conclusion

Whilst CQC has said that it will get around to inspecting all services, there is no definitive timescale for when this might happen. Providers should be wary of CQC’s new approach to monitoring activity as it focuses on risk rather than improvements. This means that there is a shift away from looking at ‘Good’ to looking at risk. If CQC inspectors are limited to assessing risk when determining whether or not they will carry out an inspection, it is possible that other good care being provided by a service may be overlooked by CQC. This could lead to information being skewed and increased enforcement action by CQC as a result.

The providers that will be most negatively impacted by CQC’s current monitoring approach are those that are rated as ‘Requires Improvement’. A ‘Requires Improvement’ rating means that a service is not performing as well as it should and it has been told by CQC that it must improve. A member of the public will rely on the rating provided by CQC and misleading out of date ratings may paint a poorer picture of a service than what is actually the case.

If you require assistance or advice in relation to any issues with CQC, our specialist solicitors can help. Please contact Ridouts Professional Services Ltd using the email address info@ridout-law.com or by calling 0207 317 0340.

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