CQC Single Assessment Framework - the good, the bad and the ugly
We break down the positives and negatives of the Single Assessment Framework, the publication of the interim report of the independent review into the operational effectiveness of the CQC and what this all means for registered providers.
The Care Quality Commission (CQC) should play a crucial role in ensuring that health and social care services in England provide safe, effective, and high-quality care.
The Good
To enhance the consistency and clarity of inspections, the CQC has introduced a Single Assessment Framework (SAF), designed to provide streamlined and smarter regulation of health and social care services.
The single assessment framework replaced four assessment frameworks - providing a uniform approach to assess all types of health and social care services, including care homes, hospitals, GP practices, and mental health services. By applying a consistent set of criteria, the CQC aims to simplify the inspection process and hold every service to the same standard.
Whilst providers face the challenge of adapting to the new framework, it may be good news to most that:
- The legislation (the Health and Social Care Act 2008, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the Care Quality Commission (Registration) Regulations 2009) has not been amended.
- The five key questions remain the same; is the service 1) safe, 2) effective, 3) caring, 4) responsive, 5) well-led?
- The 24 Key Lines of Enquiry and 121 sub-Key Lines of Enquiry which underpinned the five key questions, have been replaced with just 34 quality statements, also known as 'I' and 'We' statements which describe what 'good' care looks like.
- Evidence categories have been introduced, which include scoring evidence of feedback from service users, staff interviews and observation.
The SAF is the CQC's attempt to fulfil the ambition set out in its strategy, to be a flexible and dynamic regulator that "provides up-to-date and high-quality information and ratings" in the form of continuous monitoring and ongoing engagement with service providers. Instead of relying solely on periodic scheduled inspections, the CQC gathers information regularly using various sources allowing for a more responsive evaluation of care quality.
The Bad
The strategic aim of providing the public with up-to-date high-quality information comes with its challenges. Providers need to be alert to the possibility of ratings being changed at any time, based on data and intelligence not just inspections, which means that potentially everything that takes place within your service could be picked up by the CQC and possibly impact your rating.
When developing the SAF, the CQC expressed that its inspection reports were too long and needed to be streamlined. Providers are now faced with trying to mount challenges against reports that lack detail and fail to evidence the ratings that have been applied.
According to the CQC, uniform assessment processes should avoid discrepancies in ratings and make it easier for the public to compare services. However, providers have often felt that discrepancies in ratings stem from the CQC failing to fully understand their service. A one-shoe-fits-all approach to regulation, which fails to appreciate the differences between and within sectors is hardly 'flexible' 'dynamic' and 'responsive'. Providers have also been concerned about the variability in attitude and quality of the inspection teams. A uniform inspection process does not directly tackle this problem.
The Ugly
Since May 2021, the CQC has been planning and developing its new regulatory approach, calling it a "complex transformation". However, in May 2024, things turned ugly. The commissioning of the independent review into the operational effectiveness of the CQC, was the first sign that the SAF was in trouble.
We witnessed a downward spiral involving Ian Trenholm, CQC CEO stepping down in June; in July, Kate Terroni, CQC interim CEO publicly apologising for the flawed implementation of the new regime, and then later that month, the publication of the interim report of the independent review, led by Dr Penny Dash which identified "significant failings in the effectiveness of the CQC".
Amongst other findings, the implementation of the SAF and the provider portal was heavily criticised, with findings that there is a lack of:
- Inspectors' experience and knowledge
- Consistency between assessments
- Clarity and structure on the CQC's website
- Description of what 'good' and 'outstanding' care looks like
- Rationale for prioritising particular quality statements
- Published description of the data and statistical analysis that will be used to understand the user voice and experience.
The interim report recommended a wholescale review of the SAF by sector experts, concluding that due to the failings identified, the regulator is unable to consistently and effectively judge the quality of health and care services.
What does this mean for Providers?
The CQC has accepted in full the findings and recommendations in the interim report and recognises the need for urgent improvement. It has said it is working at pace to improve the support and guidance for providers, to increase the number of assessments, to fix the provider portal and to improve its relationship with providers.
Over the next few months, providers should look out for an interim statement from the CQC regarding the frequency of assessment for each type of service which is due in September, and Dr Dash's final report due in the Autumn. In addition, the CQC has said it will be developing a new handbook for all providers "to explain what providers can expect from an inspection, what customer services standards you should expect from CQC, and how we can together reach a shared understanding of what 'good' looks like for different service types".
Note, the CQC is continuing to inspect services under the SAF and there have been no announcement of changes to the SAF itself. Providers should continue to remain alert to assessments under the SAF and their ratings being changed at any time. However, the findings from the recent review may mean that the CQC is more willing to listen to and engage with providers. The interim report provides useful independent commentary on the deficiencies within the CQC which may help providers to successfully challenge adverse findings.