Following the roll-out of CQC’s rating system and the new Regulated Activities Regulations that came into force in April 2015, CQC is allocating new ratings for providers at an ever increasing speed. Whilst CQC is happy to publish information on the relatively high percentage of services that have been rated as ‘Good’, and indeed services should be commended for receiving a ‘Good’ rating, where does this leave those services rated as ‘Inadequate’ or ‘Requires Improvement’?
At Ridouts we have noticed a number of inherent weaknesses in the rating system.
Providers who have initially been rated as ‘Requires Improvement’ or ‘Inadequate’ are struggling to move above these ratings in subsequent inspections in spite of significant improvements. Why is this?
The consistency of practice argument
One of the reasons for CQC’s refusal to increase a rating to ‘Good’ is because it says it needs to see consistency of practice over time. However, there is nothing to state what is considered to be an appropriate amount of time for a provider to demonstrate consistency. This lack of clarity leaves the ‘consistency’ point open to wide interpretation by CQC inspectors.
In its internal guidance for inspectors, CQC states that if a focused inspection is carried out more than 6 months after a comprehensive inspection then a provider’s ratings cannot be improved upon. The reasoning for this is because CQC “will not be able to make judgements about all aspects of the service at a reasonably similar time, which we must be able to do in order to award an overall rating.” However, CQC states that ratings can be increased (at key question and overall location levels) if a focused inspection takes place within 6 months of a comprehensive inspection. This in turn implies that there should be a period starting somewhere between 0-6 months where providers can be considered to display consistency of practice to enable a rating or ratings to be improved. However, the same internal guidance states, “…it is doubtful that a service would be able to achieve the consistency characteristics required to be ‘Good’ within a few weeks or months of being judged ‘Requires Improvement’.”
The whole consistency of practice issue is most unsatisfactory and potentially highly unfair. What CQC should do is rate a service as the inspectors find it on the date of the inspection, noting how long it has been since the previous inspection. Instead what we have is a rating system that continues to rate services that clearly have improved to “Good” as “Inadequate” or “Requires Improvement”. This is misleading both to the wider public and to statutory commissioners of services.
Failing to look at all the key questions on re-inspection
CQC states that focused inspections do not look at all five key questions and may address specific breaches of the regulations or respond to specific concerns.
We are coming across examples where key question ratings set after a comprehensive inspection, persist because CQC has not looked at those key questions on reinspection. These old key question ratings can affect the overall rating, even where CQC changes other key question ratings after a focused inspection. The persistence of old key question ratings is particularly unfair given that in most cases providers will have addressed the issues identified by CQC in relation to those key questions.
If CQC attends a service to carry out a focused inspection, providers should enquire as to what exactly CQC will be looking at. If the inspection is following up from a previous comprehensive inspection that found ratings of ‘Inadequate’ or ’Requires Improvement’, providers should encourage CQC to look at all of the outstanding areas of concern, not just a limited number. Otherwise, providers may continue to be rated at a level that is not reflective of the actual service provided and this rating will continue to be applied until the next comprehensive inspection comes around. If inspectors refuse to look at all the concerns, this should be noted down in writing during the inspection, and followed up immediately with CQC. Every effort should be made to persuade CQC to re-inspect those additional areas as soon as possible to get the relevant ratings improved. Evidence to demonstrate improvement should also be supplied as it may be possible to persuade CQC to improve a rating or ratings if improvements can be clearly demonstrated.
Throughout all of this CQC does not appear to have due regard to the commercial implications of the rating system. In many circumstances providers rated as ‘Inadequate’ or ‘Requires Improvement’ are viewed more unfavourably, compared to those services with higher ratings, by both commissioners looking to place service users with providers and potential private service users. Indeed, many local authorities will cease placing service users with providers that are rated as ‘Inadequate’. Therefore the longer the ‘Inadequate’ or ‘Requires Improvement’ rating remains on the service the bigger impact this will have on the provider’s business. If CQC has acknowledged that the service has improved but insists on continuing to apply a judgement that is not reflective of the actual service provided, either due to consistency of practice or as a result of issues not being looked at during a focused inspection, then this is clearly unfair and raises the potential for judicial review of CQC’s decision.