How the CQC calculates ratings
The CQC has recently launched a new inspection framework that introduces quality statements to replace the formerly used key lines of enquiry (KLOEs). The quality statements cover 34 topic areas which will be assessed using the CQC’s five key questions.
The new inspection and assessment framework works as follows:
- To assess a particular quality statement, the CQC will evaluate the evidence in five categories: people's experiences of health and care services, feedback from staff and leaders, feedback from partners, observation, and processes.
- CQC will assess the evidence collected about each quality statement and score it on a 4-point scale: 1 (evidence shows significant shortfalls), 2 (evidence shows some shortfalls), 3 (evidence shows a good standard) and 4 (evidence shows an exceptional standard).
- The quality statement scores are combined to give a total score for the relevant key question (safe, effective, caring, responsive, and well-led). Based on the total score, a provider is given an overall quality rating of ‘inadequate’, ‘requires improvement’, ‘inadequate’, and ‘outstanding’.
The CQC publishes inspection reports on its website for every inspection that it has carried out.
Each year the CQC publishes national data on overall ratings for adult social care showing the proportion of providers in each quality rating. The chart below shows the breakdown of the CQC’s ratings for 2023:
CQC Ratings for adult social care, 2022 and 2023
CQC Inadequate
A CQC ‘inadequate’ rating is given when two or more of the CQC’s five key questions have been rated as inadequate. When this happens, the service is usually placed into special measures. Until improvements are made, the service will be kept under review.
In extreme cases, the CQC can cancel the provider’s registration on the spot. Otherwise, the CQC will take appropriate enforcement actions and re-inspect the service within six months.
Providers need to make the required improvements to their service before the next inspection. If the specified improvements have not been achieved, the CQC has the power to shut down the provider. For adult care social services, the time limit for staying in special measures without making necessary improvements is 12 months.
In 2023 the CQC rated 1% of adult social care services as inadequate.
CQC inadequate practices
Here is a selection of comments from CQC inspection reports where providers received CQC inadequate ratings:
“People were at risk of harm due to a lack of staff supervision and mitigation of known risks associated with their needs. Staff lacked the knowledge, information and training to ensure the safety of people during distressed behaviours which placed them and others at risk of harm. Staff lacked the understanding and skills needed to effectively support people living with complex dementia.”
“People’s medicines were not managed safely. There were concerns about the way medicines were stored, used, and disposed of. This placed people at significant risk of harm. Areas of the home were not clean. This placed people at risk of the spread of infection. Some parts of the premises were not safe, equipment was left in people’s bedrooms and not stored safely. This placed people at risk of harm.”
“People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice. People’s care plans did not always reflect the outcomes of capacity assessments or authorised deprivation of liberty safeguards and conditions.”
How to improve a CQC inadequate rating
Here are three ways to improve an inadequate rating:
- Develop strong management: The quality of your management is the foundation of whether your service performs well or poorly. Weak managers are not able to support and implement improvement. In some cases, existing managers can be trained through learning and development. If this does not work, new managers may need to be recruited.
- Develop a positive workplace culture: Your workplace culture defines the character of your organisation. This culture informs the values, beliefs, attitudes and behaviours of every individual in the organisation. Services rated ‘good’ and ‘outstanding’ by the CQC have cultures which are open, transparent, supportive and committed to being a learning organisation that continuously drives improvements.
- Develop effective processes: Well-thought-out processes are required to achieve and sustain lasting improvements. Processes should be informed by evidence from practice and meet contractual and regulatory guidelines. Broken systems and processes are a common cause of poor inspection ratings.
CQC Requires improvement
A CQC ‘requires improvement’ rating is given when two or more of the CQC’s five key questions are rated as requires improvement. Requires improvement does not necessarily indicate incompetence. Even a well-led service with dedicated staff can be rated requires improvement if there is a breach of CQC regulations.
There are some CQC rules that can mean a provider cannot get better than an overall requires improvement rating. One example is where the key question score is within the good range, but there is a score of 1 for one or more quality statement scores.
In addition, there are some circumstances where the well-led key question will be limited to requires improvement including:
- The service should have a registered manager in place, but it does not have one and satisfactory steps have not been taken to recruit one within a reasonable timescale.
- Statutory notifications have not been submitted about relevant events at the location without good reason.
- The provider has not returned PIR information where requested by the CQC.
Lastly, the overall rating for a service cannot be better than requires improvement if there is a breach of the regulations.
Requires improvement rated providers may need to complete an action plan, setting out how they intend to improve and by what timescales. The CQC will scrutinise the action plan to check it will address the issues in a timely way.
The CQC will schedule a requires improvement follow-up in 12 months to see if the improvements have been implemented.
In 2023, the CQC rated 16% of adult social care services as requires improvement.
CQC requires improvement practices
Here is a selection of comments from CQC inspection reports where providers received CQC requires improvement ratings:
“Improvements were needed to record where people were at risk from poor skin integrity. The provider had not ensured effective contingency planning where work was in progress to improve and upgrade the environment, to ensure people were protected from the potential risk of harm.”
“The relevant risk assessments to promote safe care and minimize the risk of catching and spreading infections were not in place. This meant staff did not have information on how to safely provide support to people. The managers did not always have robust oversight to ensure all areas of safe care and infection prevention and control were monitored.”
“Improvements were needed to record keeping systems relating to accidents and incidents, restrictive practice interventions and debriefs to record in detail lessons learned. There were not always enough appropriately skilled staff to meet people’s needs and keep them safe. There was a dependency on the use of agency staff at the time of the inspection.”
How to improve a CQC requires improvement rating
Here are three ways to improve a requires improvement rating:
- Engage staff: A motivated and engaged workforce is essential to drive positive change throughout your organisation. This comes from having a common purpose that everyone believes in. Staff members should be empowered to make their own decisions and have the freedom to be innovative and creative.
- Invest in learning and development: High-quality learning and development, from onboarding to ongoing training helps your staff to improve their standard of care. This should include references to appropriate regulations and best practice standards. Setting learning goals and conducting post-training evaluations ensures accountability.
- Build strong networks: During inspections the CQC will want to see who your organisation has engaged with. Having strong networks encourages learning from others to drive improvement. Good networking opportunities include social media, your local community, national adult social care organisations, trade organisations, local or national charities, and health and social care specialists.
CQC Good
A CQC ‘good’ rating is given when none of the five key questions are rated as inadequate and no more than one key question is rated as requires improvement. The CQC uses the good rating to designate that the service is meeting their regulatory requirement.
A rating of good is what all adult social care providers should aspire to. In fact, the new CQC quality statements are written at the level of good.
Services the CQC rated as good can still be improved as the highest rating is outstanding. Achieving an outstanding rating is very difficult, as it is reserved for services which use creativity and innovation to provide services that consistently perform at an exceptional level.
In 2023, the CQC rated 79% of adult social care services as good.
CQC good practices
Here is a selection of comments from CQC inspection reports where providers received CQC good ratings:
“The registered manager led the service with kindness and compassion and knew all the people using the service well. A visiting healthcare professional said, “The management are very knowledgeable and person-centred. They are caring towards residents and families and they’re well organised.” Relatives said their family members had improved mentally and physically since coming to the service.”
“Opportunities were available for people to take part in group or individual activities. We saw people laughing and speaking with each other and joining in with the activities. Relatives spoke of the positive impact on their family member of spending time with others. People expressed confidence in raising concerns, and complaints were investigated as per the provider’s policy.”
“Staff knew the process to follow if they felt someone was at risk of abuse and knew their responsibilities to keep people safe from avoidable harm. Risks associated with people’s care had been appropriately assessed and regularly reviewed. Robust procedures were followed when new staff were recruited and there were, on the whole, enough staff on duty to meet people’s needs in a safe way.”
How to improve a CQC good rating
Start by learning about what outstanding means to the CQC. Study outstanding inspection reports and visit outstanding services. Identify what best practice looks like and understand what support and learning systems are required to get there.
Here are five steps to take to improve from CQC good to outstanding:
- Decide what to improve: Start by reviewing the performance of the different areas of your service and identifying which areas are performing well and which are not. Don’t just look at issues, look at the root causes. For example, low standards of care may be caused by a shortage of staff. Prioritise improvements, starting with the most pressing issues.
- Plan and implement the improvement: Research how other organisations have dealt with similar issues. Plan your solutions based on the perspective of your service users. Write an action plan with SMART (Specific, Measurable, Attainable, Relevant and Timely) objectives, clear steps, and defined milestones.
- Monitor performance: Monitoring your performance is the only way you can ensure that your improvements are making a difference. Draw up a quality assurance process that outlines the desired outcomes and each individual’s expected contributions. Then set up internal audit programmes to collect information and measure quality.
- Collect evidence for the CQC: It’s no good if you have an outstanding service but you have not properly documented it. Take care to capture the moments where your service has made a notable difference and have specific evidence prepared in relation to each quality statement.
- Publicise the improvement: When you’ve made improvements, letting people know about it can really boost your reputation with your clients and the wider community. Share a news story in the local press, talk about what you’ve been doing on social media, or hold an open day for the public.
CQC Outstanding
A CQC ‘outstanding’ rating is given if two or more of the five key questions are rated as outstanding. The outstanding CQC rating is a sign that the service is performing exceptionally well. Services with an outstanding rating are highly sought after.
In addition to increasing the demand for your service, a CQC outstanding rating will boost staff morale, reducing absenteeism and increasing staff retention. It will also give you a reputation for excellence making it easier to recruit top talent to work for you.
In 2023, the CQC rated 4% of adult social care services as outstanding.
CQC outstanding criteria
The CQC’s criteria for an outstanding rating are based on its five key questions:
- Safe: Are people protected from avoidable harm?
- Effective: Does care, treatment and support achieve good outcomes for maintaining quality of life?
- Caring: Do staff treat people with compassion, kindness, dignity and respect?
- Responsive: Are services organised to meet people's needs?
- Well-led: Does the management encourage care provision based on individual needs, support learning and innovation, and promote an open and fair culture?
CQC outstanding characteristics
The CQC considers outstanding services to have the following qualities:
- Safe: A comprehensive safety system with a focus on openness, transparency and learning from mistakes.
- Effective: Outcomes for people are consistently better than other services. People’s feedback describes the service as exceptional.
- Caring: People are respected and valued as individuals. They are practically and emotionally empowered as partners in their care.
- Responsive: Services are tailored to meet individual needs, offering flexibility, choice, and continuity of care.
- Well-led: The governance and culture of the service are focused on providing high-quality person-centred care.
CQC outstanding practices
Here is a selection of comments from CQC inspection reports where providers received CQC outstanding ratings:
“The service clearly demonstrated the characteristics of providing excellent care in how it was responsive to people’s needs and in the leadership of the service. People were at the heart of the service and staff were clearly committed and compassionate, striving to provide excellent care at all times. The registered manager had developed innovative ways of involving people in how the service developed and was a part of the local community.”
“Arrangements for social activities were innovative, met people’s individual needs, and followed best practice guidance so people could live as full a life as possible. People organised events at the home themselves. Photographs throughout the home showed people taking part in a wide range of activities, events and celebrations throughout the year. The home had a key role in the local community and links with other community organisations which provided information and support to people.”
“People and their relatives told us; they were exceptionally happy with the care provided and described staff as ‘Angels’. Staff sought information about each person's individuality, skills, cultures, and lifestyle choices which allowed staff to celebrate and focus on areas which were important to people. Staff encouraged, empowered, and supported people to share their views. People were always treated with the highest level of respect and with their dignity preserved.”
How to improve your CQC rating
The surest way to improve your CQC rating is by making your care services progressively more compliant through systematic audits and mock inspections.
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Our CQC care compliance software is designed to help you to ensure regulatory compliance and improve your CQC rating.
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- Work with the CQC’s standards to ensure compliance, enhance your quality, and improve your ratings.
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