If one is to believe the inspections carried out by CQC, the care sector appears to be in crisis. The figures presented are stark with two out of five care homes in the adult social care sector and almost three quarters of NHS Trusts/Foundation Trusts failing to meet the required standards.
The conclusions drawn from inspection reports of providers in the health and social care sector seem to be based on a presumption of inadequacy rather than competency. It would appear that, contrary to guidance from CQC which requires inspectors to start with the presumption of a good service, the exact opposite is happening in practice. There is also the additional problem that there is no rating that covers the ‘compliant provider’. The ratings that can be awarded at each inspection are ‘outstanding’ ‘good’ ‘requires improvement’ and ‘inadequate’. This framework is an ambitious one with ‘good’ being the supposed baseline; but there appears to be a significant gap between ‘requires improvement’ and ‘good’ which isn’t captured in the current ratings awarded to providers. This could be seen to provide a misleading picture of the level of care provided to the public who inevitably will rely on the ratings rather than dissect the underlying detail.
This may seem at first glance as an exercise in semantics but this ratings void uncovers a fundamental issue at the heart of the inspection regime ushered in October of last year. Much deference is given to the professional judgment of inspectors and their, at times, highly subjective opinions of service provision. These opinions often do not reflect the actual quality and safety of service provision.
Turning to the most recent CQC minutes for the September 2015 board meeting, we find that only one request for a review of ratings has been granted. This is the process which was given to providers to ‘challenge’ the ratings decisions after publication of the report. This low number is presumably because providers can only challenge the process of awarding the ratings, not their merits. It reinforces the importance of challenging facts, findings and judgements at the factual accuracy stage. This should be the moment to try to get ratings changed. After publication it is too late: CQC will say that the provider will have had a chance to change the ratings by challenging the facts, findings and judgements before publication of the report. CQC will also no doubt point to the internal quality assurance process prior to publication of the report although the robustness of this is variable in our experience.
The task faced by CQC to meet its ambitious targets of inspecting all adult social care locations, some 25,500 locations, would require an additional 13,000 inspections (50.9%)) between now and September 2016. CQC does still believe it will be able to achieve this target although despite the influx of additional inspectors it appears that the CQC will once again be a victim of its overly ambitious aims. There is a large disparity between the goals of CQC and the practice of carrying out inspections. As a public body CQC has admitted cost considerations are to be taken into account when considering the length of inspections which could further call into question the value of the inspection process. There is undoubtedly massive pressure on inspectors to deliver as against their targets and this can have an adverse effect on the reliability and effectiveness of each inspection. At the same time there is recognition that CQC has to become more risk based and targeted in how it carries its functions.
Perhaps the main issue with inspections and the respective ratings is that they are far too subjective in assessing services: a ‘good’ in one place could be a ‘requires improvement’ in another. Inspection reports, despite their length still only provide a snapshot of the ‘state’ of a service during a visit with reliance often placed on anecdotal information rather than robust, corroborated evidence.
There is always room for improvement and every care home in the land would be mindful of that fact. However, the issue we are faced with is that the current system of ratings portrays a health and social care system as being increasingly substandard. This is not the case, far from it. What CQC should do is rate services as compliant or not on inspection in order to present a fair picture of the state of care in England rather than apply an aspirational rating system that is capable of giving a distorted impression of the quality and safety of the care home sector.