In July 2024, Health Secretary Wes Streeting declared the Care Quality Commission (CQC) ‘not fit for purpose’. His statement followed the publication of a critical interim report into the CQCs operational effectiveness.
Led by Dr Penny Dash, the interim report highlighted major failings in the CQC's role as England's health and social care regulator and made various recommendations ahead of her final report.
The final report, released on 15 October 2024, confirms the failings of the CQC regarding its operational effectiveness, leading Streeting to call for an overhaul not just of the CQC, but other regulatory bodies, including the National Guardian’s Office, Healthwatch England, the Health Services Safety Investigations Body, the Patient Safety Commissioner and NHS Resolution.
This article summarises Dr. Dash's findings and recommendations, with a particular focus on the criticisms of the CQC’s single assessment framework and the need for reform.
The CQC is the independent statutory regulator for health and adult social care in England. Its mission is to ensure that services provide safe, effective, compassionate and high-quality care. To achieve this, the CQC monitors, inspects, and rates registered care providers. When services fall below required standards, the CQC can:
In May 2024, the Department of Health and Social Care commissioned a review of the operational effectiveness of the CQC’s new single assessment framework methodology. The review was conducted by Dr Penny Dash and her interim report, published on 26 July 2024, presented a critical overview, revealing a regulatory body losing credibility. Key findings included:
Dr Dash's initial recommendations for the CQC included:
Released on 15 October 2024, Dr. Dash’s final report re-affirms her earlier findings on the CQC’s operational failings and sets out recommendations in more detail. Her conclusions have prompted the health secretary to warn patients that CQC inspection ratings cannot be trusted and should be taken ‘with a pinch of salt’.
In light of the conclusions, the health secretary has called for an overhaul of not just the CQC, but all other bodies responsible for patient safety in England, including the National Guardian’s Office, Healthwatch England, the Health Services Safety Investigations Body, the Patient Safety Commissioner and NHS Resolution.
The health secretary has planned further reviews to take place into their operation, with an ultimate aim to streamline the six overlapping bodies and address systemic issues that have allowed serious problems to persist.
The CQC's single assessment framework, rolled out in November 2023, revolves around five key questions: whether a registered service is safe, effective, caring, responsive to needs, and well-led. Each question is supported by quality statements, commitments expressed as ‘we statements’, that set the standards for high-quality, person-centered care in line with regulations.
Quality is evaluated through several evidence categories, including service users' experiences, staff feedback, inspection observations, process reviews, and outcome analyses such as mortality and infection rates. Each category receives a score from one to four, with four indicating an exceptional standard and one indicating significant shortfalls.
An overall score is calculated by averaging the evidence category scores, and converting them into a percentage for each key question. An inspection rating is then awarded in light of the overall percentage score achieved. The rating thresholds are:
A detailed explanation of this process can be found here.
Dr Penny Dash’s recommendations regarding the CQC’s single assessment framework have sparked considerable debate in the health and social care sector. This is particularly in the wake of recent reforms by the Office for Standards in Education, Children's Services and Skills (Ofsted), who from 2 September 2024 abandoned the use of single and double-word ratings from their own inspection system of education, skills and learning facilities, in large part driven by the conclusions in the inquest into the death of a headteacher, Ruth Perry.
Regarding the CQCs own assessment system, Dr Penny Dash has urged the regulator to clearly define what ‘outstanding’, ‘good’, ‘requires improvement’ and ‘inadequate’ looks like in guidance, so that services know where they are going wrong and what needs to be done to improve.
Dr Penny Dash has also called for a more clear and transparent approach to the calculations that determine a rating. But is this enough? Some health and social care bodies and professional bodies, such as the Local Government Association and Sir Julian Hartley, chief executive of NHS Providers, think not. They urge that the CQC should, like Ofsted, abandon single and double word assessment ratings, or at least qualify them with a narrative.
The case of Ruth Perry underscores the pressures that single and double-word ratings can exert on leaders, regulated professionals and organisations. A single negative rating can overshadow years of hard work and the term ‘inadequate’ can have severe reputational consequences for organisations and detrimental effects on leadership welfare.
Moreover, rigid ratings can encourage a tick-box mentality, where organisations focus overly on compliance rather than genuine patient-centered care. Leaders may prioritise meeting arbitrary standards out of fear of negative ratings instead of striving for high-quality care.
Given the existing pressures in health and adult social care, there is a compelling argument for the CQC to reconsider its use of single and double-word ratings. Simplifying complex health and social care dynamics into labels can create unnecessary stress and pressure and paint an overly simplified picture of an organisation’s performance. A more comprehensive approach is necessary—inspections should aim to understand each practice's unique circumstances and challenges while recognising their efforts to improve.
Detailed narrative ratings could provide health and social care professionals and the public with a clearer picture of a service’s strengths and areas for development, moving beyond simplistic ratings.
Dr Dash’s reports have exposed deep flaws within the CQC, particularly regarding its new single assessment framework. While her recommendations aim to enhance transparency and operational effectiveness, the debate over whether the CQC should abandon single or double-word ratings altogether is gaining momentum. As Ofsted has demonstrated, adopting a more nuanced approach that recognises the complexities of each health and social care provider’s circumstances could lead to better outcomes for both providers and patients.
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