The new CQC strategy
Time for change
As the CQC reveals its five-year strategy, Caring Times looks at what it means for people working in the care sector, and what care leaders have to say about the new approach
It’s “ambitious”, “bold”, and follows “extensive consultation” with the public, providers of health and social care services, and charities. And whether it’s warmly welcomed, or wearily accepted by care home management and staff, the launch of the Care Quality Commission’s (CQC) five-year strategy this May is set to change the way the care sector is regulated. As the regulator said when it announced its new strategy: “CQC’s purpose of ensuring high-quality, safe care won’t change, but how it works to achieve this will.”
A new strategy for the changing world of health and social care, was developed to “enable more effective regulation for the future and support services to keep people safe”, CQC says.
Commenting on the rationale behind the new approach, at the start of an eight-week strategy consultation this January, CQC said: “The pandemic has forced health and social care to think differently, and we are no exception. For CQC, it has accelerated the need for us to change.
“We need to make changes to the way we regulate so that it’s more relevant, working with health and care services to find solutions to problems and improve outcomes for everyone. We also want to be more flexible to help us manage risk and uncertainty.”
[subhead] Four themes
The new strategy focuses on four themes:
People and communities: regulation that is driven by people’s needs and experiences, focusing on what is important to them as they access, use and move between services.
CQC says it wants to be “an advocate for change, with our regulation driven by people’s needs and their experiences of heath and care services, rather than how providers want to deliver them”.
“This means focusing on what matters to the public, and to local communities, when they access, use and move between services. Working in partnership with people who use services, we have an opportunity to help build care around the person: we want to regulate to make that happen.”
Smarter regulation: a more dynamic and flexible approach that provides up-to-date and high-quality information and ratings, easier ways of working with CQC, and a more proportionate regulatory response.
“We will be smarter in how we regulate,” CQC states, adding that it will “ keep pace with changes in health and care, providing up-to-date, high-quality information and ratings for the public, providers and all our partners”.
It will also “regulate in a more dynamic and flexible way so that we can adapt to the future changes that we can anticipate – as well as those we can’t”. “Smarter use of data means we’ll target our resources where we can have the greatest impact, focusing on risk and where care is poor, to ensure we’re an effective, proportionate and efficient regulator,” CQC says.
Safety through learning: an unremitting focus on safety, requiring a culture across health and care that enables people to speak up and in this way share learning and improvement opportunities.
While recognising that “health and care staff work hard every day to make sure people’s care is safe”, CQC says safety is “still a key concern for us as it’s consistently the poorest area of performance in our assessments”.
The regulator says it’s “time to prioritise safety: creating stronger safety cultures, focusing on learning, improving expertise, listening and acting on people’s experiences, and taking clear and proactive action when safety doesn’t improve”.
Accelerating improvement: encouraging health and care services, and local systems, to access support to help improve the quality of care where it’s needed most.
CQC says it will “spotlight the priority areas that need to improve and enable access to support where it’s needed most”. The regulator will “empower services to help themselves”, while retaining its “strong regulatory role”. To do this, CQC says it will collaborate and strengthen its relationships with services, people who use them, and health and care partners.
Running through each of these themes are two core ambitions:
- Assessing local systems: giving the public independent assurance about the quality of care in their area;
- Tackling inequalities in health and care: pushing for equality of access, experiences and outcomes from services.
CQC says it will work to make “a positive impact on the experiences of everyone who receives care, while regulating in a targeted way, which supports services to improve and prioritise safety”.
[subhead] Fundamental change
One fundamental change is that CQC will assess how well local health and care systems are working and addressing local challenges. This is likely to be underpinned by legislation in the forthcoming Health and Social Care Bill. The strategy also recognises that effective regulation to improve the quality of care depends on people’s feedback and experiences.
CQC says it will develop more ways to gather views from a wider range of people, including those working in health and social care, and improve how this is recorded, analysed and used consistently.
“This will make it easier to quickly identify changes in the quality of care, both good and bad,” CQC says.
The regulator will aim to make it easier for people, their families and advocates to give feedback about their care and will provide a response on how this is used to inform regulation. And CQC says it will “increase scrutiny of how providers encourage and enable people to feedback and how they act on this to improve their service”.
The strategy also sets out how innovative analysis, artificial intelligence and data science techniques will be used by CQC to support proportionate decisions based on the best information available – “ensuring that it will be ready to act quickly and tailor regulation to individual circumstances” the regulator says.
CQC says it will “encourage and champion innovation and technology-enabled services, and also encourage services to “play an active part in research to improve care for all, foster innovation and enhance people’s experiences of care”.
[subhead] Focus on quality
Another major change is the way in which CQC will provide information on quality, including ratings, so that these are “more relevant, up to date, and meaningful”.
“This will support people to make informed decisions and be confident that the information provided fully reflects the quality of care available to them and their loved ones,” CQC says.
While on-site inspections will remain a vital part of regulation, CQC says it will move away from a set schedule of inspections to a more flexible, targeted approach using a range of regulatory methods, tools and techniques to assess quality and ensure an up-to-date picture.
Ian Trenholm, chief executive at the Care Quality Commission says: “Our purpose has never been clearer. In our assessments we will ensure that services actively take into account people’s rights and their unique perspectives on what matters to them. We will use our powers proportionately and act quickly where improvement is needed, whilst also ensuring we shine a positive light on the majority of providers who are setting high standards and delivering great care.
“This is not a static strategy – we will continue working with others to understand any further improvements required as we implement these changes, to make sure we are protecting people, and with others, driving change.”
The regulator says it will “review this strategy regularly so we can adapt to changes and be prepared for what the future holds”.
[BOX} New CQC strategy: what the sector says
Leaders in the care sector spoke to Caring Times about their reaction to the new CQC strategy, their overall impressions, what impressed them, and what was cause for concern.
As with any new strategy the ‘devil is in the detail’ – and overall, the reaction from the sector is that the detail is lacking.
Nadra Ahmed, executive chairman of the National Care Association, says the CQC has “put out a vision, but there is not enough substance in there to tell us how that vision will be realised”.
“Light on detail”
“The consultation is very light on detail, says Professor Martin Green OBE, CEO of Care England. “There is no evidence within the document about why this is the right approach, what are the drivers, what is the evidence behind the proposals within the strategy, nor is there any indication of how the CQC will enact all the changes or when.”.
Green adds that the strategy does not provide the necessary detail “in order for the adult social care sector to fully understand what the next steps are and what will be required going forward”.
“The sector is under a great deal of pressure at present so further clarity before any proposals due to be brought forward would be of immense benefit to the sector.”
Green says that because “ensuring that the individual in receipt of care is placed at the centre of the system is paramount to the delivery of good care, we therefore support the direction of this theme by empowering people to drive change”.
“However, it would be useful to understand how the CQC intends to involve people in a meaningful way,” he says.
Liz Jones, policy director, National Care Forum, says there “some good ambitions” in the strategy, “particularly with the focus on making sure that social care meets people’s evolving needs”.
“There’s also a solid commitment to accelerating improvements”, she says. “We would like our regulator to help us improve where we need to, and to be a stimulator for how we might share that learning, and how that might help us to help ourselves in terms of benchmarking and innovation,” she says.
Jones finds it helpful that the strategy acknowledges that “providers don’t work in isolation – they work within a local health and care system”. She “absolutely commends” the CQC “for their focus on people”. And she says the strategy’s commitment to encourage and champion innovation and technology for better care “is something we should really welcome”.
Also welcome, is “more flexibility and more communication with stakeholders”, says Karolina Gerlich, executive director, the Care Workers’ charity.
Ahmed says that while it may be a “shiny new strategy”, from a provider perspective “there isn’t enough there to give us confidence, based on current experiences”. She gives the example of the CQC wanting to be a more flexible regulator but does not say how this will be achieved.
Ahmed points out that the strategy states the regulator “wants to engage with the public and stakeholders – presumably families and relatives – in relation to good practice”. While acknowledging that is fair, she is concerned that if stakeholders have any issues with a care home, rather than engaging with the manager “as the first port of call” they will immediately go to the CQC to raise any issues. She says this could “take away the ability of the care home manager to deal with issues” prior to it becoming a CQC problem, and that an informal concern could become a formal complaint.
If the CQC is also the first point of contact for families with issues then this could lead to a negative picture of a care home’s performance as “people aren’t going to ring up the CQC to say they’ve had a wonderful experience”, says Ahmed.
Data and intelligence
For Jones, a concern is the strategy’s focus on “better, more dynamic use of what the CQC is calling data and intelligence”.
“What it seems to mean is that they are building an intelligence model to get a flow of data and intelligence from all sorts of places about services.”
However, currently she says there is not the “openness and transparency” as to what that data actually is, “though I’m assuming it’s things like complaints, whistleblowing, and feedback from commissioners”.
“What we really need is some insight into what that data model is going to include and what evidence there is behind some of it,” she says. Without this, providers could spend time and effort on compiling unnecessary information for their inspections.
Another concern for Jones is that if data highlights an issue at a care home, will the inspection concentrate on what is not working so well, rather than it being “a full, holistic look at that service in the round”? She says the focus would then be on safety and risk, rather than also looking at “interesting new developments and innovations”.
While the strategy is ambitious for the health and social care sector to use smart data and technology, Ahmed points out that for small to medium providers, particularly since the pandemic, “this sort of financial investment might be out of reach”, and that staff “may not have that level of data expertise”.
She suggests there could be an “over reliance on the data submitted”, and is also “not clear what legal redress there might be if data is incorrectly interpreted”.
Gerlich’s main concern is that “not enough attention and care consideration has been given to the workforce”.
“CQC’s new strategy is very much focussed on people who draw on care services. While this is great to see, unfortunately it isn’t in the right proportion with looking at people who deliver that care.
“There is a worry that potentially more is going to be expected of people, but without additional support. With a focus on appropriate levels of training and skill we need more detail on who is going to fund providers to deliver this.”
Leaders in the care sector would like to see more detail about how the strategy will be implemented. “There’s some great things in this strategy but now we need to get to the next level of detail”, says Jones.
“Managers and staff need to be acknowledged”
They have also highlighted what they feel is missing from the strategy – just how much care managers and their teams have been through since the pandemic hit.
“Members feel as though CQC did not always support them well during the pandemic. Care homes managers and staff need to be acknowledged as frontline staff and have access to the same resources as their colleagues in the NHS,” says Green. (Care England is behind #We Care for England https://www.careengland.org.uk/we-care-england a campaign demonstrating the worth of care and in particular, staff working in the care sector.)
“The people we support have been through a pretty torrid time and I don’t get a sense in the strategy that this is recognised,” says Jones.
While the new strategy has been launched during the pandemic, Ahmed says “there’s no recognition” of the challenges for providers. And not all providers will be in a position to embrace those challenges – with the pandemic taking its toll, managers and their teams are experiencing burnout and fatigue.
Ahmed believes that what the sector “desperately needs” at this moment in time is support to rebuild. “My question would be: is this a strategy that will rebuild, or move us towards rebuilding the sector?”
<box out> Advice for providers
Carl May-Smith, is partner and barrister at Browne Jacobson whose health law team provides legal services to the health and social care sector.
Here is some of the advice May-Smith gives clients in response to the CQC ‘s new strategy.
- “As the CQC looks to focus on user experience much more, we are recommending more regular and proactive collection of feedback from services users and their families. Not only will this give advance warning of any concerns that might be raised, but it has the potential to paint a more balanced picture than feedback provided directly to the CQC.
- “There will clearly be greater expectations on providers to provide regular data to CQC across a range of measures. It will be vital to ensure that this role is properly understood and resourced. Some of this data is to be made publicly available and failure to provide accurate data in a timely manner may lead to unwarranted concerns by the CQC.
- “Active engagement with local CQC inspectors will be more important than ever. In its most recent update, announcing a pilot and imminent roll-out of monthly remote reviews, the CQC continues to emphasise that inspectors’ judgment will remain at the heart of their decision making. This will be particularly important for providers who feel their current rating should be revised upwards, as it is not clear how this will be achieved as inspections are targeted at services of concern.
- “Equally, more specialist services are recommended to engage to familiarise their local inspector with how their service operates given the risk that the data they report may appear as an outlier against less high-acuity services.
- “A lot will change in the coming months and years under this strategy and it will be essential that providers stay up-to-date. Providers that are to thrive under the new system will respond quickly to these changes.”