Last reviewed 9 March 2012

These are seriously troubled times for the Care Quality Commission (CQC), but when, since its inception in 2010, has the CQC been out of the firing line? The attacks have regularly exceeded the sort of hostility any effective regulator generates, but most of them, sadly, have been fully justified, Jef Smith discusses.

For a start, the weakness deriving from the absence of anyone in the CQC’s higher management with recent social care experience was never thoroughly addressed. This has left it vulnerable to the allegation that its focus is permanently skewed towards the more publically and politically sensitive NHS, and has undermined its credibility with a large swathe of its clientele.

Additionally, redirecting resources in the early years into the time-consuming task of registering the diverse range of health facilities, alongside re-registering social care services, distracted both staff and management from vital inspection work.

A bad year for the CQC

A range of scandals, ranging from virus-infected hospitals wards and staff who failed to observe service users’ basic rights of dignity and adequate nutrition, to the serious abuse of residents in a variety of institutions, regularly posed the question: where were the inspectors?

In 2011, one such incident featured the mistreatment of people with learning disabilities in an establishment called Winterbourne View. The CQC, it emerged, had been guilty not only of a failure to inspect diligently, but also of ignoring the urgent evidence of a whistleblower. The concerned ex-staff-member subsequently went to the BBC, who filmed and broadcast irrefutable evidence of physical and psychological abuse, forcing the CQC into a series of humiliating public apologies. A major exercise to review facilities for people with learning disabilities has been drip-feeding reports at regular intervals over recent months; their revelations of inadequate care and incompetent commissioning serve not so much to boost the CQC’s credentials as to question how such failings escaped attention for so long.

A report from the National Audit Office in December 2011 alleged bad value for money and claimed that there was a risk of “unsafe or poor quality … care”. The last straw was a public attack on the CQC’s management style and methods from Kay Sheldon, one of its own commissioners. In response to these mounting pressures, the Secretary of State for Health appointed Gill Rider, a former Cabinet Office civil servant, to carry out an independent investigation of the CQC’s governance. Serious though the situation was, the need for this was questioned, since the already planned Performance and Capability Review had been brought forward and had started work in October, strengthened with a team of senior civil servants and external assessors and chaired by Una O’Brien, the Department of Health’s permanent secretary.

The resignation of the chief executive

That body reported at the end of February, its predominantly critical tone prompting the resignation of the CQC’s chief executive Cynthia Bower. Bower had looked vulnerable for almost the entirety of her tenure. Not only did she have to shoulder a lion’s share of the blame for the organisation’s failures, she was also personally handicapped by her record as a regional manager within the NHS during the period when major failings occurred in Mid-Staffordshire’s hospital care, the investigation of which has been ongoing.

In an official statement, Bower casually described her pending departure — she will remain in post until the autumn — as “time to move on” and spoke of her achievements as “progress already made”. For her part, Una O’Brien, whose report was the catalyst for Bower’s announcement, stated that “Cynthia has provided energetic leadership to the CQC from its very outset”. All this, it seems, is designed to emphasis that Bower’s departure is emphatically not a sacking.

Commentary from providers was less charitable. Keith Lewin, senior partner at Brunswicks, a firm of solicitors whose practice has been built up over the last six years around representing independent health and social care providers, mockingly headed his comments “Bow-ing out!” and drew attention to Bower’s salary of close to £200,000. “It is high time that Cynthia Bower fell on her sword,” said his statement, adding pointedly that “there are others in the CQC who ought to consider their positions”. Other commentators were less blunt, lamenting past mistakes but trying to look to the future. The UK Home Care Association spoke for many in referring to the CQC’s “particularly difficult start”, seeing “an opportunity to refocus its activities”, and expressing the view that it had now “begun to move in the right direction”.

This conciliatory and forward-looking tone was also present, to an extent, in the exchange of letters between the Department of Health and the CQC, the texts of which were released as an introduction to the Review’s report, but there is no mistaking the iron fist within the velvet glove. “Delays in registration and criticism from stakeholders on inspection have challenged public confidence,” wrote O’Brien, but even such frankness understates the crisis that the CQC has been through.

In the six months from October 2010 to March 2011, less than a third as many on-site inspections were carried out than in the similar period a year earlier. O’Brien admits that “the scale of the task facing the CQC was underestimated — both by the CQC and the Department of Health”. It is true that the budget for regulation fell by 6% between 2008/09 and 2010/11, but the Commission has actually underspent the available resources in the last two completed financial years, largely because it was operating with high levels of staff vacancies.

The recommendations of the review

The review’s 23 recommendations are grouped under six headings:

  • strategy

  • resources and prioritisation

  • accountability

  • engagement and communication

  • development

  • delivery of the regulatory model.

Candidates for the chief executive post, which will be advertised shortly, will need to study the review closely, but they would benefit from not reproducing its jargon. The CQC and Department of Health need to break out of this abstruse dialogue and address themselves in much more accessible terms to a range of stakeholders, notably the providers, commissioners and consumers of services.

Under the first heading, Strategy, the Department is demanding a revised statement of “the role and impact of regulatory action … over time”, improvements in “strategic planning and analytical capacity”, and “clearer measures of success and simple strategic performance metrics”. In response, the CQC has promised public consultation later this year on a revised five-year strategy, and the involvement of an expert independent partner in the process of devising better success measures.

The second group of recommendations, concerned with resources and priorities, start by calling for better understanding of how different methods of regulation — thematic reviews, more frequent inspections and a focus on selected standards — can reduce risk. To this the CQC responds that it will carry out “work on our capacity model and further development of our business performance framework based around the Corporate Scorecard”. Other proposals under this heading include greater transparency of management information and better planning for new responsibilities; the CQC does not demur from this threat of additional work, but it does take the opportunity to slip in the view that it may need more money, which it expresses as “assessing the resource implications of these actions”.

The review’s proposals on the CQC’s management structure are wide-ranging. The Board, which currently consists of four non-executive members, should be strengthened by the addition of a minority of senior executives so that they can be held to account at the highest level. A currently discontinued development programme for board members should be reinstated, and the CQC should strengthen the capacity of the executive team, ie its top level management, in areas such as “strategic capacity” and “sector-specific expertise”.

This represents a damning indictment of the CQC’s senior managers; in response, the CQC promises, somewhat guardedly, “to consider how to address” these points. Presumably it and the Department will get further advice from Gill Rider’s report when it is published.

On the issue of communication, the review tackles the CQC’s poor record on engagement with its stakeholders, other health and care sector regulators, and its own front line. This section certainly reflects points repeatedly made by providers, who have frequently criticised the duplication of work arising from diverse regulators’ demands, and the poor contact the CQC’s headquarters seems to have with its locally-based inspection teams.

It remains to be seen whether the CQC’s recent introduction of what it calls “a new stakeholder management structure”, with a central Stakeholder Committee, advisory groups and sector specific stakeholder forums, will be effective.

Regarding the “regulatory model”, the report calls for:

  • better evaluation of specific ways of working

  • systematic use of user feedback

  • a tailoring of compliance mechanisms to different sectors

  • improved access for inspectors to specific user and practitioner expertise

  • more consistency and transparency in the way regulation is carried out

  • guarantees that there will be sufficient skilled inspectors to meet future needs

  • effective work on adult safeguarding.

As much of this has been called for many times in the past, the need to repeat it is a clear judgment on the CQC’s competence.

Although Bower maintains that her resignation is not related to the review’s criticisms, the fact that it occurred on the day the report was published inevitably gave the impression that she was accepting some responsibility for the CQC’s manifest failings. Her forthcoming departure temporarily takes pressure off Dame Jo Williams, the Commission’s chair, whose sacking might have been an alternative means of signaling a new start. The review at several points calls for action from the Department of Health, thus accepting that there is room for improvement there too, but having been prepared by civil servants it refrains from any criticism of politicians.

Ministers, however, must certainly take some of the blame for the care regulator’s sad story so far. There has been more or less continuous reorganisation through the last decade, with demands for tough action on provider failures alternated with calls for lighter touch inspection. The very breadth of the CQC’s responsibilities which have made its early years so difficult were the result of conscious but controversial political decisions.

The only person to come out of the debacle with some credit is Lady Young, the CQC’s first chair, who surprisingly resigned only a few months into the organisation’s life. Perhaps she sensed the serious trouble ahead.