This is the fourth in our series about the Care Act and in this case is about what the Act itself says about health and social care ratings. Going back as far as 2013, the Nuffield Trust were asked to research, consult and consider the need for ratings in health and social care. The key statement from all of this work was  that ‘there is a gap in the provision of clearly presented, comprehensive and trusted information on the quality of care of providers which might properly inform the public and users  about the quality of care as well as improve the accountability of providers to the public’. As a result, the Government asked the Care Quality Commission (CQC) to develop and publish a new independent system of ratings. At the same time Government enabled this in the Care Act 2014 by giving sole responsibility to CQC, thus excluding Ministers from involving themselves in deciding the methodology of the ratings; probably no bad thing since political involvement in such things can so easily end in tears.

Since 2103 CQC have picked up the baton, developed their proposals for a methodology, consulted extensively with the sector and the public about it and tested their proposals in two live waves of inspections around the country. All this work is now complete and the results have informed how inspections and their subsequent ratings will be determined. The new system commenced at the beginning of October.

Inspections will be built around the 5 key questions: Is the service safe, effective, caring, responsive and well led? Greater focus is then brought to bear in a series of Key Lines of Enquiry (KLOEs) which concentrate on mandatory questions to be explored in each of the key questions. Optional questions may be added where the inspector needs to dig deeper. There are a total of 25 potential KLOEs so it is wise for providers to be prepared to answer all of them.

The fundamental position that CQC take is to start from the position that the service is rated as GOOD and to vary that judgement based on the evidence they have collected prior to and during the inspection. Each of the 5 fundamental questions are rated separately and given equal weighting. They are then collected together to produce an overall rating for the service against the following principles:

  • If two or more of the key questions are rated ‘inadequate’, then the overall aggregated rating will normally be ‘inadequate’.
  • If one of the key questions is rated ‘inadequate’, then the overall rating will normally be ‘requires improvement’.
  • If two or more of the key questions are rated ‘requires improvement’, then the overall rating will normally be ‘requires improvement’.
  • At least two of the five key questions would normally need to be rated ‘outstanding’ before an aggregated rating of ‘outstanding’ can be awarded.

That seems to be quite straight forward but the plot thickens a little by the addition of 3 conditions (called ‘limiters’ by CQC) which would automatically apply if:

  • The location has a condition of registration that it must have a registered manager but it does not have one and satisfactory steps have not been
  • The location has any other condition of registration that is not being met without good reason, and/or
  • Statutory notifications were not submitted in relation to relevant events at a location without good reason.

In these circumstances, the rating can never be better than ‘requires improvement’ but could sink to ‘inadequate’ if in the judgement of the inspector the impact on people who use the service  in terms of the severity of harm would demand an ‘inadequate’ rating.
Once the rating has been established by CQC and challenged where necessary by the provider along with any attached enforcement actions it will be added to the CQC website  for public viewing.

Overall, the new system of rating services has been well received by both the public and the social care sector and seems to rectify the shortcoming identified by the Nuffield Trust. Of course we have yet to see it in full swing so we can judge whether it is itself rated as good or needs improvement.

Julie Hopkins

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