The new CQC Single Assessment Framework (“SAF”) has a number of features which, in theory, providers should welcome as part of the move towards smarter regulation.  These include:

·         More up to date assessments of the state of a provider’s service – which would have the benefit, for instance, of providers not being stuck with ‘Requires improvement’ ratings based on shortfalls identified at an inspection a number of years ago which have long since been rectified;

·         The need for CQC to have evidence in each of the key evidence categories before it can score a service’s compliance with a Quality Statement – which should improve triangulation and guard against CQC being overly reliant on a single source of information; and

·         The fact that judgements will be made, and scores awarded, at the level of individual evidence categories – which means there should be increased clarity for providers on how their scores and ratings are reached, so that they know clearly what they need to improve, or what they need to challenge (if they disagree with the findings).

However, the roll out of CQC’s guidance on how it will assess, score and rate services under the SAF raises concerns that some of the potential benefits of the new system may be undermined by the practical application of the framework.  The ‘proof will be in the pudding’ and precisely how CQC operates the new system. 

Over a series of alerts we will set out a number of issues we see with the new system and today we focus on the issue of the lack of clarity around the frequency of assessments and initial scoring and initial assessments under the SAF. 

The Frequency of Assessment

Whilst more up to date assessments would be welcomed by providers and the public, the precise minimum frequencies with which CQC will assess services under the SAF is still not known.  CQC has indicated that it will publish its intended frequencies of assessment next July.

Initial Scoring and Initial Assessments under the SAF

To arrive at ratings for a service, CQC will need to have scores for each Quality Statement under each of the key  questions.  Gathering fresh evidence for each of the 34 Quality Statements for each service at this stage would be a mammoth exercise, akin to the previous comprehensive inspection programme CQC undertook when ratings were first introduced.  However, CQC does not intend to do that as it already has extensive information regarding the quality of those services which have already been inspected and rated. 

Consequently, CQC is intending to effectively pre-populate services’ initial scores for a number of Quality Statements under the SAF based on the most recent previous inspection findings CQC has regarding those issues under its former system.  Whilst this seems sensible on the face of it (as the vast majority of evidence CQC has gathered historically will be relevant to the new Quality Statements), it is the way CQC is proposing to do this which causes some concern.  CQC’s guidance states:

“When we carry out our first assessment of your service, we will select which quality statements to look at. The selection of quality statements will be determined by national priorities, set by type of service, as well as a consideration of the information we hold about your service.

For each of the quality statements we look at, we will collect evidence and score all the relevant evidence categories. This means the scores for those quality statements will be entirely based on our new assessment.

For the remaining quality statements, we will base the scores on our previous findings. We will do this using the current, published ratings for the relevant key question. These scores will be:

4 for each quality statement where the key question is rated as outstanding

3 for each quality statement where the key question is rated as good

2 for each quality statement where the key question is rated as requires improvement

1 for each quality statement where the key question is rated as inadequate”

For those Quality Statements which are to be scored (for the purposes of the initial assessments) with a score ‘translated’ from previous inspection findings, rather than being assessed afresh, there is a concern about how that ‘translation’ exercise will work. Subject to a few exceptions [1], Quality Statements which are not being assessed afresh will have their initial scores based on the most recent rating for the key question they sit under.  This would mean, for instance, that if a service was previously rated as ‘Requires improvement’ (which equates to a score of ‘2’ under the SAF) for ‘Safe’, all Quality Statements under ‘Safe’ which are not assessed afresh will be given an initial score of ‘2’.  This is potentially unsatisfactory for two reasons:

  • ‘Lost in Translation’ - firstly, even if the findings at the time of the previous inspection were still reflective of the current position, it is a blunt instrument (and probably not reflective of reality) to score all those issues with the same score.  It is not uncommon, under the previous inspection regime (and, indeed one of the consequences of the use of ‘ratings characteristics’ which CQC is trying to get away from) for a service to be rated ‘Requires improvement’ for, for example, ‘Safe’ because of shortfalls in just one area (eg medication management) when the findings in all the other areas under that domain were positive.  Due to the ‘translation’ approach, therefore, there is a risk that CQC will be issuing new assessments and ratings calculated in part on the basis of Quality Statement scores which not only relate to previous findings, but may be a misrepresentation of those previous findings.

  • ‘Tipping the Balance’ - Secondly, there is no indication of how many Quality Statements CQC will assess afresh, as opposed to relying on scores ‘translated’ from previous inspection findings, in its initial assessments under the SAF. This is significant as, even if the ‘translated’ score for a Quality Statement was truly reflective of CQC’s findings in relation to those issues at the time of its previous inspection (ie all aspects of the ‘Safe’ domain were genuinely ‘Requires improvement’), the provider may have made significant improvements in those areas in the interim.  However, with the arithmetical calculation method of arriving at ratings and all Quality Statements weighing equally, if CQC does not carry out new assessments of a sufficient number of Quality Statements to ‘tip the balance’, there is a danger that genuine improvements which have been made in the interim will not be recognised; in such a situation, the provider may remain stuck with a ‘RI’ rating which does not reflect the current state of its service.

It will therefore be really important to see CQC’s approach in terms of the extent of its reliance upon ‘translated’ scores in its initial assessments of previously rated services under the SAF.   

If you wish to discuss any issues relating to CQC’s new Single Assessment Framework, please contact:

Carlton Sadler or Siwan Griffiths.

[1] Where the issues covered by a Quality Statement have moved from the domain of one key question (eg ‘Safe’) under the old regime to a different key question under the SA, or were not covered at all under the old regime (eg Environmental sustainability).

Read more

CQC’s New Single Assessment Framework - Although ‘Updated’, Will Assessments Properly Reflect the Up to Date Position?

CQC’s New Single Assessment Framework - Reports: Clearer, Shorter

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