CQC have recently completed the inspections of some 24,000 different locations providing adult social care. It published its State of Adult Social Care report covering 2014 to 2017 and clearly feels empowered and emboldened to draw conclusions from the inspections it has conducted. Nursing Homes are singled out for particular mention in the report with one in three failing to be rated at least good overall. Across all adult social care providers one in four providers failed to be rated as at least good for the question is the service safe? These conclusions are based within the confines of CQC’s inspections of providers, which by their very nature, are subjective opinions on service provision.
Provider deference
Amongst some providers of adult social care there is a natural deference to the CQC inspector. As such findings made within reports, which may be factually inaccurate or misleading, go unchallenged. If a provider demonstrates a reluctance to challenge the findings of an inspector then the ‘true’ picture of care at a location is inaccurate. This is not a criticism of CQC but a presentation of the other side of the argument which may go unheard. Of course it is difficult to objectively draw out this information should a provider remain silent on challenging the findings of an inspectors report, but this should be considered when reading their report.
Challenging findings
If a provider chooses to challenge the findings of an inspector, that same inspector will review the comments provided before dismissing or adopting the information provided. CQC may say that the matter is resolved by a report being reviewed by the inspectors’ manager. That is not independent, the manager should and will support those they manage; but of more importance that review occurs before the provider has put its case. It is a flawed process.
Should the inspector refuse to take into account issues raised by the provider there is little in the way of further challenge that can be made. There is the process of reviewing the ratings of a service but these will only be challenged on the narrowly defined grounds that the incorrect process was followed by the inspector. A provider may challenge by way of judicial review but this is time consuming, high risk and expensive. The most effective way to challenge CQC in our experience at Ridouts, is to provide commentary on the report and append relevant evidence which supports the providers’ objections.
The importance of ‘safe’ and ‘well-led’ questions
There is a clear focus on the questions of safety and leadership within providers. CQC’s State of Adult Social Care report states that more often than not if a home is rated good or outstanding for the well led question it is more likely to receive the same rating overall. What appears to be clear is that although there are five key questions these two questions are of more significance than the others. For example, for the question is the service caring, 95 per cent of all services received good or outstanding. It appears that this question is of little impact in relation to a providers overall rating. It appears to be almost presumed that the vast majority of providers are ‘caring’.
Geographical interpretations
The report includes an image of England split into local authority areas with the level of quality shaded in different hues of purple; from the darkest being the lowest level of quality to the lightest possessing the best levels. Each provider will be subject to their own unique circumstances and drawing generalised conclusions based on location seems to be a redundant exercise. A simple aggregation of the quality of care provision may present itself as a useful colourful image but it is of limited use.
Subjectivity of report
Inspection reports are by their very nature highly focused on the inspection visit, although some underlying background information is used to inform findings. They remain a snapshot of the service in question at the specific point in time when the visit occurs. They are limited by the competence or otherwise of the inspector and by the provider’s presentation during the visit and the provider’s resolve following it. As such the relevance of ratings and findings drawn from inspection reports can be questioned, especially when those findings are used as the basis for a change in strategy.
There is no evidence of robust challenge by CQC to its inspectors’ findings. Inspectors are, in effect, encouraged to believe that they are always right.
If we have two providers: one confident in its resolve and effective in its communication who successfully challenges CQC’s findings; set alongside the same provider who accepts CQC’s findings without challenge: Both of whom, provide exactly the same level of care, the only difference is the approach of the provider. The pertinent point is that the quality of care between provider one and two is at the same level; but CQC would ultimately rate each provider differently depending on their respective responses to its draft inspection report.
“Unsafe” providers
CQC may well be seen to lack responsibility with its use of highly charged language. The headline from the report reads that 25 per cent of homes are unsafe. If the public were asked to review the actual criticisms (which may or may not be true) we believe that they would find that they did not justify such strong language. The use of such strong language will naturally cause concern in those with loved ones placed or waiting to be placed in care. Such language should not be used except in cases where it is justified. Speculation as to possible risk is not the same as a finding of “unsafe”.
CQC should review its policy and take robust steps to substantiate allegations and only label as unsafe those findings which truly justify such an allegation. This alarmist press release will do nothing to address any issues but may put the vulnerable at risk by frightening their families from placements in much needed care.
Redoubling efforts
CQC will now look to redouble its efforts in targeting those providers that it finds to be below ‘good’ in any given area. It is not CQC’s duty to ensure that providers properly seek to clarify and challenge its own findings. It is for providers to set out their stall and ensure that CQC has the correct information upon which to base its findings. The public should recognise the inherent limits of CQC’s inspection approach when reading CQC’s state of care report and any inspection reports to properly contextualise the issues at hand.
