HSJ Insight and Influence: The Department of Health consultation to expand CQC’s rating powers

Topics covered: Ridouts professional advice

The Department of Health has recently opened a public consultation on whether to extend CQC’s powers to inspect and rate additional sectors that it regulates.

After the Mid Staffordshire Public Inquiry, CQC’s Ofsted-style ratings system was introduced for hospitals in England and Wales in April 2014, in the Government’s commitment to make “hospital performance more transparent and easier to understand through a clear system of ratings”.  CQC’s ratings system was extended to the social care sector and GP practices shortly afterwards in October 2014.

The Department of Health has said that there is now a case to apply performance ratings to other sectors regulated by CQC.  In identifying to which sectors to extend CQC’s rating and inspection powers, the Department of Health has considered whether the application of ratings to additional sectors would be of value to users and commissioners, whether there is a need or benefit to the sector and whether CQC would have the capacity to fulfil a ratings function in respect of the proposed sectors.

The additional sectors being proposed for inclusion in the ratings systems are:

  • Independent community health service providers
  • Cosmetic surgery providers
  • Independent ambulance services
  • Independent dialysis units
  • Refractive eye surgery providers
  • Substance misuse centres
  • Termination of pregnancy services

The general rationale for extending CQC’s ratings powers would be to ensure consistency in the availability of information about providers in those sectors, to provide fuller information on the safety and quality of service provided and assist in service user choice.  Despite being an obvious sector to be brought under CQC’s ratings remit, dentists have not been included in the present consultation.

Weaknesses in CQC’s current ratings system

Before CQC’s rating system is extended to further sectors, CQC should reflect upon and rectify deficiencies in its current rating system.

CQC’s ratings system replaced CQC’s former system of essential standards of quality and safety, in which CQC would assess whether providers were compliant with the 28 essential standards and assess the degree of risk, if any, that was posed to service users in respect of each essential standard.  CQC now awards the ratings of outstanding, good, requires improvement and inadequate ratings to health and social care providers across five key questions (whether the service is safe, effective, caring, responsive and well-led).  Providers are then awarded an overall rating which is aggregated from the five key questions.

CQC’s ratings system has revealed itself to be a blunt instrument and a crude form of categorisation which is not based on compliance.  One of its core deficiencies is the opaque gap between the ratings of ‘good’ and ‘requires improvement’, with no clear demarcation of where compliance falls between the two ratings.  Furthermore, providers who are found to have an overall rating of ‘inadequate’ face significant repercussions by being placed directly into special measures.  If a service that has been placed into special measures receives a ratings of inadequate in any key question at the inspection six months after being placed into special measures, CQC will begin the process of taking action to prevent the provider from operating the service.

A further weakness in the current ratings system is CQC’s ratings review process.  CQC has to date limited a provider’s ability to challenge its inspection findings by stipulating that it will only consider factual accuracy challenges to the draft inspection report through its narrow factual accuracy process, which must be completed within 10 days of the provider receiving the draft report.  Only once an inspection report has been published will CQC permit a provider to request a review of the ratings awarded.  Ratings reviews are extraordinarily difficult to secure on the basis that CQC will only permit a review of ratings if the provider can demonstrate that CQC did not follow its own procedure in rating and aggregating its findings in accordance with CQC’s own guidelines.

The rigid and narrow channels through which providers can challenge CQC’s inspection findings means that it is very important that providers challenge CQC’s inspection reports at the factual accuracy stage to secure changes to both the facts and ratings awarded.  The recent High Court case of The Queen (on the application of SSP Health Limited) v Care Quality Commission has redressed some of the power imbalance between CQC and providers in relation to the factual accuracy process.  Mrs Justice Andrews stated “The whole point of affording an inspected entity the opportunity to make factual corrections is to produce a final report that is based, so far as is possible, on accurate and balanced fact findings.  This was the only opportunity to put the record straight.”


Greater regulation of the sectors which are the subject of this public consultation, particularly in light of Sir Bruce Keogh’s 2013 report which highlighted the risks of an under-regulated cosmetic industry, should be a very positive development to assist service user choice and protect the public who use these services.  The failings in CQC’s rating process must however be rectified if CQC’s ratings are to be a fair and correct reflection of the services they rate.

The Department of Health’s consultation will close on 14 October 2016.

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