The CQC inspection process is getting better but it continues to struggle with consistency, determination to improve the process and unwillingness to join the siren calls for ‘heads to roll’. Sir Mike Richards has been honest about these things.

What did the NHS hope for as the Care Quality Commission began its new hospital inspections a year ago?

‘HSJ awards the watchdog a “requires improvement” rating’

Most of all it wished for a consistent approach, which recognised the challenges surrounding NHS care and made coherent judgements that could be acted on swiftly.

CQC ratings are divided into: outstanding, good, requires improvement and inadequate. “Requires improvement” is the most appropriate rating for the CQC’s new hospital inspection regime.

The challenge of consistency remains

It is important to recognise the CQC inspection process is getting better. The claim by its chief inspector of hospitals Sir Mike Richards that we now have a better view of NHS quality than ever before may be presumptuous but the aspiration is not unrealistic.

Sir Mike should be praised for his honesty about the CQC’s struggle with consistency, determination to improve the inspection process and unwillingness to join the siren calls for “heads to roll” every time a trust is found wanting.

‘It is important to recognise the CQC inspection process is getting better’

The CQC does not operate in a vacuum - which means blame must be shared. For example, Monitor and the NHS Trust Development Authority have failed to provide sufficient challenge to the CQC’s sometimes questionable judgements. Trusts too must acknowledge their part in the weakness of inspection teams.

As Sir Mike said in last week’s HSJ webinar, trusts should expect to release the same calibre of clinicians to CQC duty as they would hope to see when their turn for scrutiny arrives. This would stop inspection teams too often lacking up to date knowledge.

The government also handed the CQC a timetable that required it to produce judgements before it was fully ready. It compounded that crime by creating a fevered environment in which even poorly constructed conclusions were treated as gospel.

Trusts marked down by the CQC often say they were “aware” of the issues and had “already begun action to tackle them”.

Rating the CQC

So it is with the CQC itself, but it is worth recording where improvement is most needed.

Better information must be given to inspection teams - briefing papers are too often beset by inaccuracies and omissions. Likewise, the quality of final reports has to be dramatically improved.

One very senior clinician, a supporter of the new CQC leadership, wrote to HSJ recently complaining of inspectors “cutting and pasting in verbatim from other trusts’ reports; refusing to change reports that are factually incorrect; [and] an excessive focus on easy to measure things like notes and not on quality of care”. The resulting reports were “sloppy, ill focused and unbalanced”.

The CQC has acknowledged that a trust’s failure on the “well led” domain when combined with care quality problems is the most likely route to special measures. It is crucial, therefore, the regulator is successful in its efforts to refine its judgements in this area.

‘The legacy of the old “defensive” CQC lingers on. It has not always shown the appropriate humility and caution’

The aggregation process, which lies behind this judgement, is highly problematic. One trust chief executive leading an inspection described overseeing a tortuous exercise as various inspectors - none with senior leadership experience - all inputted their various scores to produce a result that had a kind of internal logic, but little relation to reality as the lead inspector saw it.

The CQC is also aware of the danger of marginal judgements skewing overall results and has tried to build a process to combat that. But the legacy of the old “defensive” CQC lingers on. It has not always shown the humility and caution appropriate to its place on the learning curve and the possible consequences of its findings on the organisations affected.

Sir Mike speaks of finding “unacceptable variation” in NHS care and that too would be the services’ verdict on the first year of CQC inspections. But the commission’s efforts to improve mean it can aspire to a better verdict in 2015.

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