CQC’s single assessment framework

The Care Quality Commission (CQC) — the independent regulator of health and social care in England — has published a new assessment regime. Here, Senior Associate and regulatory specialist Matt Coles lays out the implications for providers.

What is the CQC’s single assessment framework?

The CQC’s single assessment framework is the new assessment regime that CQC will use across all services and providers it regulates. It is based on the existing five key questions and ratings system. The CQC says that the framework sets out how it will view quality of service and make judgements.

The CQC wants services and providers to create cultures that learn and improve. The framework sets expectations for how services and providers need to work together — and within systems — to plan and deliver safe, person-centred care.

The new framework is for providers, local authorities and integrated care systems. It is intended to provide the CQC with an up-to-date view of quality that covers all sectors and service types, from the point of registration onwards.

Reasons for change

The CQC says that the new framework is designed for simplicity, enabling it to focus on what really matters to people and better reflecting how care is actually delivered by different types of service and across a local area, as well as establishing one single framework that connects registration activity to its assessment of quality.

Implementation

Following the initial release of details back in July 2022, in December 2022 the CQC confirmed a further postponement into 2023 to allow for a phased rollout to occur.

From spring 2023, it will ensure that the required technology is in place and working. In the summer, a staged launch is planned for a new online provider portal. The CQC says that providers will be able to apply to register with the CQC and make ongoing changes to registration through this portal.

Towards the end of 2023, the CQC plans to gradually start carrying out assessments under the new framework. By this point, it intends that all online interactions with providers will take place via the portal.

The CQC states that it will provide regular updates and more detail throughout the remainder of 2023. In the future, it will base assessments of quality in all types of services (and at all levels) on this single assessment framework. In the meantime, its current methods of monitoring, assessing and rating providers will continue.

What’s different with the new framework?

The existing five key questions (safe, effective, caring, responsive and well-led) and four quality ratings (outstanding, good, requires improvement and inadequate) will continue to be used under the new framework.

The existing key lines of enquiry (KLOEs) and prompts will be replaced with new ‘quality statements’. Under each key question there will be specific topic areas linked to a list of relevant regulations for ease of reference.

Quality statements

The quality statements describe what the CQC believes high-quality and person-centred care looks like. For each, the CQC will state what evidence it will always need to collect and consider. This will vary depending on the type of service and the level at which the CQC is assessing. For example, the evidence required when a new service is registering will differ from a service that is already in operation.

The CQC has developed six categories for the evidence required to assist providers in organising information under the different quality statements. The key questions and quality statements are available to read in full, together with the list of relevant regulations.

Key question 1: Safe

Quality statements: Learning culture / Safe systems, pathways and transitions / Safeguarding / Involving people to manage risks / Safe environments / Safe and effective staffing / Infection prevention and control / Medicines optimisation.

Key question 2: Effective

Quality statements: Assessing needs / Delivering evidence-based care and treatment / How staff, teams and services work together / Supporting people to live healthier lives / Monitoring and improving outcomes / Consent to care and treatment.

Key question 3: Caring

Quality statements: Kindness, compassion and dignity / Treating people as individuals / Independence, choice and control / Responding to people’s immediate needs / Workforce wellbeing and enablement.

Key question 4: Responsive

Quality statements: Person-centred care / Care provision, integration, and continuity / Providing information / Listening to and involving people / Equity in access / Equity in experiences and outcomes / Planning for the future.

Key question 5: Well-led

Quality statements: Shared direction and culture / Capable, compassionate and inclusive leaders / Freedom to speak up / Workforce equality, diversity and inclusion / Governance, management and sustainability / Partnerships and communities / Learning, improvement and innovation / Environmental sustainability – sustainable development.

Evidence categories

The evidence categories detail the types of evidence that the CQC intends to use to understand the quality of care being delivered against a particular quality statement.

The number of evidence categories (and the sources of evidence that the CQC will consider) will vary according to the service type, the level of assessment and whether the assessment is at the point of registration or for an existing service. The CQC says that it will set out the types of evidence that it will focus on in each required evidence category when it assesses a quality statement.

Each evidence category has an initial schedule for ongoing assessment. This sets out the length of time before the CQC needs to collect evidence for that category in each service type. The CQC’s current ambition is to update the information it holds about a service across all required evidence categories within a two-year period. The six evidence categories are outlined below.

Evidence category 1: People's experience of health and care services

The CQC will encourage service users, their families and representatives to share their experiences at any time. These experiences will be at the heart of the CQC’s judgements and the CQC wants to ensure that gathering and responding to feedback is central to its expectations of providers and services.

Key points:

1. The CQC considers that service users, as well as their families, friends and advocates, are the best sources of evidence regarding care experiences. The CQC will consider the context and impact of people’s experiences in its analysis.
2. People’s experiences will be valued as highly as other sources of evidence and will carry equal weight with the other evidence categories.
3. The CQC will always treat any negative feedback received about a poor case as a concern. It will review further and gather more evidence, even if other evidence sources haven’t indicated any issues.

There will be increased scrutiny of (and support for) how providers and systems encourage, enable and act on feedback.

Evidence category 2: Feedback from staff and leaders

This is evidence from people who work in and lead a service. Sources may include results from staff surveys, interviews with individuals and staff focus groups, as well as evidence from providers’ self-assessments and any compliments and concerns raised.

Evidence category 3: Feedback from partners

This is evidence from organisations that interact with the service that is being assessed. The CQC may gather evidence through interviews and engagement events.

Evidence category 4: Observation

The CQC will observe the quality of care either off-site, on-site, or a combination of both. It will gather evidence from interviews with staff and professionals who work in the service and from calls with people using services, as well as their families and carers.

Evidence category 5: Processes

Assessment will focus on how effective policies and procedures are. The CQC will look at information from the provider and data sources that measure these processes (such as data from infection prevention control, reported incidents and notifications and reviews of care records).

Evidence category 6: Outcomes

‘Outcomes’ focuses on the impact of care processes on individuals. This covers how care has affected people’s physical, functional or psychological status. Outcomes will be considered in the context of the service being assessed.

Changes in the assessment process

Gathering evidence

Evidence will be gathered from a wider range of sources (such as people’s care experiences), rather than on-site inspections (previously the primary source).

According to the CQC, this will provide the flexibility to update the ratings for key questions and overall ratings when things change, based on more frequent assessment of evidence. It says that it may not always need to attend to gather evidence and update changes.

The CQC will also work with other people (such as families and carers) and organisations to help collect evidence.

Frequency of assessments

A service's rating will no longer be the main factor in deciding when the CQC next needs to assess. Under the new framework, the evidence it collects or the information it receives at any time could trigger an assessment.  

The frequency of visits will increase where:

• there is a greater risk of a poor or closed culture going undetected
• it is the only way to gather people’s experience of care
• it is the only way to ensure that the right people and activities will be available to assess quality
• it has concerns about transparency and availability of evidence.

Assessing quality

Judgements about quality will be made more regularly, instead of only after an inspection. Evidence from a variety of sources will be used and any number of quality statements will be looked at. Evidence categories will be used as part of the assessment framework and the CQC will give a score for the assessment.

How the CQC will reach a rating

Quality of care will continue to be rated as either ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. A new scoring framework will be used which will translate into one of the ratings for the five key questions. Scores will also be the basis for the CQC’s view of quality at an overall service level.

The CQC says that initially, only the ratings will be published. However, it also intends to publish the scores in future. The CQC believes that the system will provide better clarity about how it has reached a judgement on quality, to show if a service is close to another rating and to show whether quality is moving up or down within a rating.

To assess a particular quality statement, the CQC will take into account the evidence it has in each of the required evidence categories. Depending on what it finds, it will give a score for each evidence category (for example, a maximum score of 4 reflects an exceptional standard of care, whereas the lowest score of 1 reflects significant shortfalls in the standard of care).

As the CQC moves away from assessing at a single point in time, in future it is likely that it will assess different areas of the framework on an ongoing basis. Scores for different evidence categories could therefore be updated at different times.

The CQC points out that any changes in evidence category scores can then update the existing quality statement score. This in turn could impact the rating.

The CQC will follow these stages to produce a key question and overall rating for a service:

1. Review evidence types within the evidence categories for each quality statement.
2. Score each of these evidence categories.
3. Combine these scores to give a score for the related quality statement.
4. Combine the quality statement scores to give a total score for the relevant key question.
5. This score generates a rating for each key question.
6. Aggregate the key question ratings to give the overall rating.

Implications for providers — a summary

The system is changing. Here are the key points that services and providers need to be aware of and prepare for.

1. We can expect the portal to open in the summer of 2023, with the roll-out under the new framework commencing towards the end of the year.
2. Fundamentally, the new framework will bring a degree of flexibility to the CQC that services and providers will need to be prepared for. There will be real time, ongoing review and monitoring which will allow the amendment of scores (and even ratings) at short notice and at any time without a site visit.
3. Judgements about quality will be made more regularly, instead of only after an inspection. Assessment will not be tied to set dates or driven by a previous rating.
4. The CQC will use a wide range of information and sources to gather evidence (including from service users, their families and providers’ employees) to assess. It won’t be solely reliant on site inspections for the source of its evidence.  
5. Feedback from people’s experiences will be central to the CQC’s judgements and this will be valued as highly as other sources of evidence. It therefore follows that we will see increased scrutiny of how providers encourage, enable and act on feedback received.
6. The CQC says that it will always treat any negative feedback about a poor case as a concern. It will review further and gather more evidence, even if other available evidence sources haven’t previously indicated any issues.
7. In relation to frequency of assessments, a service's rating will no longer be the main factor when deciding when next to assess. Evidence collected or information received at any time can trigger an assessment.
8. The frequency of assessments will also increase where concerns exist (such as the risk of a poor or closed culture going undetected), where there are concerns about transparency and availability of evidence or a visit is more likely to be required (as it is the only way to gather people’s experience of care, or to ensure that the right people and activities will be available to assess quality).
9. Ultimately, any changes in evidence category scores can allow the CQC to then update the existing quality statement score. This could then impact upon the rating of the service or provider.

We are here to help care home operators navigate the challenges that may lie ahead and we will provide further updates as the year progresses. For all enquiries, please get in touch with me at matthew.coles@brabners.com or call 0161 836 8953 / 07342 998 107.