I recently saw a post on LinkedIn that said “Who is actually holding the Care Quality Commission to account”. It’s a good question. Sadly it often falls to Providers to challenge and question CQC, both its actions and its judgments.
Challenge usually, but not always, accompanies a rating of Requires Improvement or Inadequate. As of May 2019, 17% of active care home locations in England were rated either Requires Improvement or Inadequate. The remaining 83% are rated Good or Outstanding. Which group would you rather fall into? The group that CQC says is providing acceptable care or the group that isn’t?
Requires Improvement doesn’t necessarily mean that poor care is being provided. It can cover a spectrum of care and the smallest of things can tip a rating into Requires Improvement; one example of a MAR chart entry being missed – a disproportionate response if there are no systematic governance concerns; or CQC disagrees with a response taken by a provider in respect of an incident, not that the provider failed to take any action at all; or veiled criticisms and it’s really not clear what CQC are referring to.
The latter is probably the most frustrating position for a provider to be in when it receives its draft inspection report. You just don’t really understand what CQC is referring to – an unidentified service user on a fluid chart, on an unidentified day, may not have received sufficient fluids but no details of what fluids they should have had or did have are noted – and it’s not clear if this is a one off, or it’s a recording issue and what the impact may or may not have been on the service user.
What is particularly galling is the fact that CQC is now refusing to provide providers with inspection notes. On one occasion I requested that CQC provide the notes that detailed a conversation that had allegedly taken place with the home manager, including the quote that now appeared in the inspection report – we were facing a he said, she said situation. CQC stated “This is not relevant for the submission of the factual accuracy submission.” Interesting. CQC’s position appeared to be that the very document used to record evidence and observations was not relevant, and we should just trust them.
In last month’s Ridout Report, my colleague Samantha Cox spoke about the new factual accuracy comments (“FAC”) form that CQC has introduced. She noted that when submitting a FAC table, for each point made, a provider “must specify exactly where [CQC] can find the information that supports [a provider’s] correction”. Any supporting documentation must specify the page and paragraph number and highlight the relevant part of the document that relates to the point the provider is making. It’s funny how CQC expects a provider to be so specific but they can be so vague. Of course, CQC fails to understand that a provider cannot be specific if it isn’t told the evidence upon which an allegation is made. CQC is trying to improve its efficacy as a regulator, yet it seems to expect a provider to review all service users fluid charts for every day since the previous inspection (as this is the timeframe which can be inspected) to try and determine who it might be that didn’t get full fluids. Hardly a good use of the provider’s time and one that could be easily dealt with, if CQC actually bothered to record the details. What is so difficult about flicking through their inspection notes and saying “Oh yes that was Ethel Percy on 2 June 2019”. The reality is that the inspector probably didn’t bother to write it down.
Of course, providers have tried to second guess and put forward information based on assumption, only for CQC to say, that isn’t the service user concerned. Thanks CQC. You could have saved us all a lot of time by simply telling us in the first place. However, we have had a situation where CQC have provided the initials of a service user who had been identified as part of a concern. This was responded to but CQC then said they’d got the initials wrong – it was a different service user. This raised questions about the reliability of the inspection notes and thus the reliability of the entire Report but still they refused to disclose the notes!
The upshot? CQC can make a half-baked attempt at justifying itself but a provider must spoon feed CQC and pinpoint the evidence to the exact paragraph. This seems a little unbalanced.
And it’s not just the evidence base where CQC’s standards fall far short of those expected of provider. It’s OK for CQC to take weeks to get a draft inspection report to you and a few further weeks to consider your FAC but if you miss that 10 working day deadline to submit your FAC, you’re toast! You had your chance! An extension? You’re delaying our ability to publish our reports in line with our KPIs! If CQC truly want to speed publication up then it should provide reports swiftly and without delay.
You receive your draft inspection report weeks after the inspection and read it eagerly only to discover that CQC apparently witnessed a drag-lift whilst at the inspection and this is a safeguarding risk which the provider must deal with. No mention of this was made on the day of the inspection, and it’s taken 6 weeks for CQC to notify you of this, in the body of the report. Of course, CQC are supposed to engage in dialogue on the day of the inspection; it’s supposed to feedback any concerns; which would allow the provider to take immediate action; and if it truly thought there was a safeguarding matter then it should raise an alert, there and then. It’s apparently OK for CQC to wait 6 weeks to raise a concern, but if a provider did not raise a safeguarding alert in good time, this would affect its rating. In such situations, our advice to clients is to report CQC to safeguarding for failure to act.
You know how CQC don’t like daily records that say “Good day. All personal care given”? CQC’s new inspection reports are full of stock phrases. They have drop down boxes to choose from or multiple options to delete, as required. The phrases don’t really accurately reflect the home – they seem to have been crowbarred in. They haven’t been personalised to the home. Ok, so reflective personalised care of a service user is not the same as an inspection report, but CQC expects a detailed, accurate record – why can’t providers expect the same?
And talking of standard phrases in inspection reports, you know the phrase that often reads something like this “There was no registered manager in post and there had been no registered manager for nine months. However, there was a manager who was in the process of applying to the Commission for registration.” CQC fail to add a sentence after this that says, “The manager applied to us the week after they started, but due to our incompetence/bureaucracy/no real reason* we haven’t registered them for about 9 months” *delete as appropriate.
CQC does have an important role to undertake. Sometimes it gets it right and the rating of Requires Improvement or Inadequate is justified. However, how can providers trust that CQC is truly switched on when it fails to meet the standards it sets for providers? We hear a lot about leadership and leading by example but it appears that CQC is party to the school of “Do as I say, and not as I do”. CQC would gain a lot more respect and perhaps less challenge from providers if they were operationally stronger and at the end of the day, justified, with reference to evidence, their position. Without this, it won’t just be the 17% camp that people start to question, but questions regarding whether the 83% camp can accurately be relied upon will also be asked. Even CQC’s own Board members are questioning this. At the May 2019 CQC Board meeting Lewis Appleton, NED, said that as ‘Good’ had been defined so widely, “everyone” is good and it seemed “implausible”. Providers should continue to hold CQC to account, ask questions, and challenge where necessary. It might make the difference between a ‘Requires Improvement’ rating and a ‘Good’ rating and drive up standards at CQC at the same time.