The next wave of CQC inspections will be a challenging time for hospital trusts and the regulator alike, says Joanna Shar, as all parties will be in an experimental phase

Red pencil marking ticks in boxes

The second wave of the Care Quality Commission’s new style hospital inspections are due to take place between April and June. The results of the inspections will be scrutinised with great interest, as it is likely that if successful, the framework will be used as the CQC’s inspection model across the wider health and social care sector in future.

The regulator’s indication that its new inspection regime will be an evolving process emphasises the importance of trusts’ participation and input over the next few months, with full implementation from October this year.

Ridouts has obtained a copy of the CQC’s internal guidance document regarding its new framework for inspecting acute NHS trust and foundation trust hospitals under a freedom of information request: Framework for inspecting wave 1 and 2 (February 2014). While the new inspection regime is a welcome change to the old discredited framework, there are elements which are still unclear and of some concern. 

Key elements

The CQC’s inspections under its new framework will be more comprehensive and will have the following key components:

  • Eight core services at each location will be assessed (medical care, surgery, intensive/critical care, maternity and family planning, services for children and young people, end of life care and outpatients).
  • Each provider will be reviewed in relation to the five “domains”; namely whether the service is safe, effective, caring, responsive to people’s needs and well led. The inspectors will follow key lines of enquiry related to the five domains and these lines of enquiry, based on information CQC holds on each trust, will direct the focus of the inspection.
  • Ratings will be on a four point scale (outstanding, good, requires improvement or inadequate).
  • Inspection teams will only consider whether there has been a regulatory breach where a provider is judged to ‘require improvement’ or be ‘inadequate’. Should action be taken in respect of a regulatory breach, the current enforcement policy will be applied.

The CQC has said hospital trusts involved in second-wave inspections will be awarded shadow ratings at six levels:

  • location level for each domain for every core service provided;
  • location level for each core service;
  • location level for each domain;
  • overall location level;
  • trust level for each of the five domains; and
  • combined trust level rating.

Ratings and appeals

While the CQC’s new inspection framework is intended to be easier to understand than the old regime, the matrix of grades across each domain, core service, location and level could give rise to confusion. Details of how the commission will assimilate the numerous grades at the five levels into one combined trust level rating are still ambiguous.

The CQC has indicated that not every characteristic in its guidance will need to be present for the corresponding rating to be given. If the impact on quality is significant, for example, displaying just one “inadequate” characteristic could lead to a rating of inadequate. Equally, trusts that are rated outstanding may still have areas in which they may need to improve.

As there is no public guidance about how these decisions will be made, there are questions about how the CQC will ensure consistency across hospital trusts. It is hoped that the National Quality Assurance Group’s checking of grades should facilitate a degree of consistency between inspections. If the process is to be consistent, fair and transparent, however, such details need to be clear and unambiguous before the framework is implemented.

‘The CQC has said trusts’ ability to appeal their ratings will only occur in the five working days after ratings have been published’

Another surprising element of the new inspection framework is that it appears that trusts will not be informed of their ratings when they receive their draft report for factual accuracy comment. 

There are internal inconsistencies in the CQC’s guidance on this point. Indications suggest that trusts will only find out their ratings once the reports have been finalised. The CQC explains in its guidance for inspectors that the rating will be removed from the draft report on the basis that the rating at that stage has not been agreed by the NQAG. This element of the new system is likely to be unpopular with trusts and raises concerns about fairness, as it denies trusts the opportunity to comment and challenge ratings before reports are made public.

The concern about trusts’ ability to directly appeal draft ratings is all the more acute in light of the potential difficulties that might be faced in ensuring consistency in grading. The effect of this apparent rule is that it once again raises questions regarding the transparency and independence of the process. 

While the CQC has said it will be introducing an appeals process, it is still under development. What is apparent is that appeals will be conducted internally by the CQC and will be heard by a panel of senior inspection team members with no previous involvement in the inspection that is the subject of the appeal.  An appeal will be in writing only, with no opportunity for the trust to attend the panel hearing. Perhaps most significantly, the CQC has said trusts’ ability to appeal their ratings will only occur in the five working days after ratings have been published. This raises an issue about the fairness of the process and may lead to action having to be taken by some trusts through judicial review proceedings.   

Managing the inspection process

The absence of an opportunity to challenge ratings before publication of the inspection report makes a trust’s management of the inspection processes all the more important. The CQC will use data held about hospitals, dubbed “intelligent monitoring” to form hypotheses about each trust, which they will test on inspection. The information the CQC gathers about each hospital trust analyses 150 different indicators covering a range of information including patient and staff experience and statistical measures of performance.

‘Once the final report is issued it will be too late to avoid reputational damage and all the consequences that may flow from that’

This analysis, combined with surveillance material, will be reported in data packs and given to a trust one week before its inspection. Trusts should spend time scrutinising these data packs to ensure that they not only prepare for the inspection thoroughly, but that the information represents the trust fairly and accurately. Any factual inaccuracies should be dealt with before the inspection process begins.

The CQC has indicated that it will hold a feedback meeting with trusts at the end of each day of the inspection with a final feedback session at its conclusion. Once again, it will be imperative that trusts actively engage in this process and ensure that any factual errors or incorrect opinions that may arise are corrected at the time. Factual inaccuracies and unjustified findings that are not corrected may otherwise lead to misleading ratings.


The next wave of inspections will be a challenging time for trusts and the CQC alike, as all parties will be in the experimental phase before full implementation after October.

Once the final report is issued it will be too late to avoid reputational damage and all the consequences that may flow from that. Trusts will need to ensure they actively participate in the inspection process and challenge inaccuracies in relation to facts and findings to ensure their services are fairly represented to the public.

Joanna Sharr is a solicitor at Ridouts LLP