The CQC's rating regime for health and social care needs to be nuanced

After the Care Quality Commission abolished its star ratings system in 2010, just four years later the system has now been reintroduced but is already under fire over inconsistencies in the latest findings.

The rating system allows provider organisations, including GP practices, to be categorised as either “outstanding”, “good”, “requires improvement” or “inadequate”.

‘The feeling from many hospital trusts is that they get a particularly raw deal under the new system’

“Inadequate” providers have six months to improve patient care and change the way they operate, or face closure.

In October the CQC published its fifth annual report on the state of health and social care in England. It found that two in three hospitals are falling short of providing adequate care. Two in three social care providers are “good” and the regulator rated its first “outstanding” batch of providers.

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• CQC could become enforcer of ‘zero harm’ rules

Patchy picture

This is a big year of change for the CQC. The inconsistencies in ratings between service providers may well be ironed out over time, but the health watchdog must get this right sooner rather than later to avoid patient suffering.

What does the annual report actually tell us about the steps needed to improve failing health and social care providers? Does a blanket review system work for all health and social care providers?

There is already a lot of discussion about the criteria for placing providers under each rating category.

‘An “outstanding” rating could hide some areas of practice where standards are slipping’

The feeling from many hospital trusts is that they get a particularly raw deal under the new system. Large trusts have several departments, so one might be performing well while another is seen as failing, dragging down the trust’s overall rating.

This is something that would not apply to a small care home, for example. On the other hand, poor quality of care could be hidden by better performing departments.  

Of course, these changes are intended to help to raise standards overall. However, we all know that an overall “good” or “outstanding” rating could hide some areas of practice where standards are slipping or simply not good enough.

Special measures

The CQC appears to have a lot on its hands after placing another three GP surgeries into special measures using the new ratings system.

Some senior voices in the health and social care sector have argued that naming and shaming practices “only makes matters worse” by putting them under the spotlight.

Early signs also suggest that the first few inspections under the regime targeted more “higher risk” providers, which the CQC had pre-empted based on information already gathered.     

‘Some have argued that naming and shaming practices “only makes matters worse”’

Regardless of the CQC’s protestations that the new system of inspections and quality ratings system will succeed in rooting out poor standards of care, the organisation is in serious danger of spreading itself too thin.

These changes are just the beginning.

From April there will be another round of reforms to social care inspection, as well as the introduction of the “fit and proper persons” regulations and legislation surrounding the “duty of candour”, which aims to give service users and their relatives honest and accurate information about the standard of care provided.

Out of kilter

The annual report did rate a large proportion of care homes as “outstanding”, which was considerably disproportionate to the number of hospitals achieving that standard – just one: Frimley Health Foundation Trust in Surrey.

So far, 20 social care services have been labelled “inadequate” by the CQC and only nine (26 per cent) of the acute hospital trusts inspected under the new regime were “good”.

But for those service providers in England, the rating system falls short of identifying specific issues that need to be tackled, so we are left wondering how much action will actually be taken to improve the situation.

Over in Wales, a recent independent review by the Older People’s Commissioner for Wales actually revealed that too many people living in care homes have an “unacceptable” quality of life.

This was part of a proactive approach to highlight the delivery of care home services based on rigorous spot checks rather than a tick box exercise to categorise practices under a “green, amber, red” rating system.

The review found that staff shortages were a particular issue, and some patients were left for whole days without “social stimulation”, giving them a sense of uselessness.

‘The flaws and inconsistencies of the new ratings system are a problem’

Urgent action is needed to address this situation, but do we really think the problems witnessed in Wales are not happening across the border?

The Care Standards Act is soon to be passed by the Welsh government. It intends to strengthen the regulation and inspection of social services in Wales and will hopefully help to bring an end to some of the shocking practices revealed by the commissioner’s review.

Perhaps the CQC can learn a few lessons from the hands on approach in Wales by dealing with care providers in isolation rather than a blanket review that groups together hospitals, care homes and adult social providers.

Although it is still early days for the new ratings system in England, the flaws and inconsistencies that have already been uncovered are a problem. So independent reviews for individual practices that take into account the specific variables of each provider would be welcomed.  

Robert Rose is a partner at Lime solicitors and a medical negligence expert