CQC has completed its first cycle of inspections under its new inspection regime. But, what now? How have inspections impacted the adult social care sector? The Kings Fund and Alliance Manchester Business School (“AMBS”) have produced a report evaluating the CQC’s approach to inspecting and rating health and social care providers. The findings of the report are no surprise; it highlights that despite findings of significant improvement in the CQC’s new approach to inspecting, there is still room for improvement. It is envisaged that the findings of the report will promote a wider and reflective account of how regulation may have an impact on organisational behaviour and performance. Through analysing findings from their research, the Kings Fund and AMBS have developed a new framework that outlines 8 ‘impact mechanisms’ which describes the ways in which regulation can affect provider performance, to help regulators understand the impact of regulation. I highlight 3 examples of ‘impact mechanisms’ outlined in the report, below.
Directive impact and Stakeholder impact
The report describes directive impact as a means in which “providers take actions which they have been directed or guided to take by the regulator.” This can include CQC taking enforcement action against a provider, where the severity of enforcement can range from issuing warning/compliance notices to prosecution or cancellation of a provider’s registration.
Not surprisingly, the report states that the greatest directive impact tended to apply to providers with ‘Requires improvement’ and ‘Inadequate’ ratings and those with other types of enforcement action.
Although changes in such providers described above, were often substantial, the report identifies that the adult social care sector, which has limited support from of external stakeholders in comparison to the acute and the mental health sector, who have support from national bodies such as NHS Improvement and NHS England. Therefore, in such circumstances, a hard-hitting directive impact of CQC enforcement powers may lead to services being closed down, as limited support is provided to make necessary improvements.
It is important to highlight that ‘special measures’ for providers was put in place to enable CQC to work with other agencies to ensure that providers take the necessary action to make improvements and support the provider during this process. However, this is unfortunately not the case in reality and we have often found this mechanism to be abused by the regulator. Rather than using this process as a means to support the provider to make improvements, it is a wasted opportunity, where much of the focus is on scrutiny, rather than support. It is widely known that adult social care is becoming one of the most daunting healthcare challenges of our day; therefore, the demand for such services will outweigh the supply if providers are not given the necessary support to make improvements.
The report describes relational impact as “results from the nature of relationships between regulatory staff and regulator providers.” The report acknowledges that whilst guidance is available for inspection teams, there is still a great variation in the way inspections are carried out. In particular, the report states that relationships between the CQC staff and healthcare professionals affected the way regulation worked and impacted services. Providers have given feedback stating that to foster better working relations, they would like to predominantly see consistency, fairness, and objectivity from CQC staff, especially within CQC inspection teams.
It is often the case that CQC inspectors have taken personal approaches when undertaking inspections and deliberately not looking for characteristics of “Good” because of predetermined prejudices against a provider. It is imperative for CQC to invest in training its staff to ensure that they have the necessary skills and credibility to enable them to improve relationships with providers, whilst maintaining consistency and objectivity. Likewise, to enable consistency of a positive working relationship, providers must encourage its staff to engage with the inspection team to breakdown barriers which may promote any hostility or miscommunication. However, on the other hand, one can argue that having one inspection team dedicated to a provider may result in the CQC staff losing objectivity to make accurate regulatory judgements. It is therefore a fine balancing act to ensure that a positive professional relationship is maintained.
If a constructive relationship of respect and trust is fostered between the regulator and provider, it is more probable that this will motivate for driving improvement and enabling both parties to working collaboratively to achieve objectives.
Another important point raised in the report is the recommendation that CQC should develop and use regulatory interactions further, rather than relying heavily on findings from comprehensive inspections. Alternative ways to develop regulatory interaction can be drawn from CQC’s intelligence data and insight to develop its model in various ways in each sector rather than a one size fits all approach.
Reflection is key here. The report highlights instances where both the regulator and providers of health and social care services can work towards making improvements. CQC must consider whether it is using its enforcement powers proportionately and where providers are failing, offer the appropriate support to ensure that improvements are made in a timely manner. Providers should reflect upon their relationship with the CQC and what it can do to ensure that the inspection process is not a negative experience by taking steps to foster a positive professional relationship with its inspection teams. For further information on the report, please refer to: https://www.kingsfund.org.uk/publications/impact-cqc-provider-performance