The Rating Game – Inside the mind of the CQC

Andrea Sutcliffe, CQC chief inspector of adult social services.

Andrea Sutcliffe, chief inspector of adult social care at the Care Quality Commission, is challenging the care home industry to deliver Outstanding service for all of its residents, but less than 1% of homes currently achieve this standard. Is the ratings system too tough, or do operators just not get it? Rob Corder spoke to the CQC chief to find out.

Andrea Sutcliffe is stuck between a rock and a hard place. In 2014 the CQC was told that it would have to recoup its entire £249 million annual budget from the operators it inspects rather than be funded by the taxpayer. Care home operators were aghast when she went to them with the news and consulted with them on how to make the change.

Trade association Care England argued that the industry could – under duress – come up with the money if its contribution built up slowly over four years. Ms Sutcliffe agreed, only to be told by the Treasury that it would have to accelerate the process and move to full cost recovery within two years.

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Oh and by the way, the Treasury added, your budget is also being cut from £249 million to £236 million.

“The overarching financial envelope changed and we got to the position where, to continue doing the things that we need to do to the right quality, the two year time period to achieve full cost recovery was the only option that we finally had,” Ms Sutcliffe concedes.

Care homes operators will have little sympathy for the CQC’s 5% cut to its budget, since they will be picking up the entire tab by 2018, and the organisation is not expecting commiserations. “I absolutely understand the concern that people have raised. It is difficult for us, and it is difficult for them,” says Ms Sutcliffe.

The financial situation will not distract the regulator from its core mission, which is to ensure all adult social care services are caring, safe, effective, responsive to people’s needs and well-led. These are the fundamental questions every inspector asks on every visit to a care home, and it is the answers to these questions that determine the overall ranking that ranges from Inadequate to Outstanding.

It is three years since Ms Sutcliffe became chief inspector for adult social care, and the landscape today is far from uniform. In the past month, 833 care home inspection reports have been published, of which 74 are Inadequate,   256 Require Improvement, 499 are Good and just four are Outstanding.

The latest month’s sample is very much the same as last month’s and the month before that. The fact is that very, very few care homes – under 1% – are achieving the Outstanding rating. When challenged to explain a ranking system with an almost unattainable top tier, Ms Sutcliffe is staunch in her defence.

“There is no apology for saying that to be Outstanding, you have got to be really special. That is important. We have set the bar high. It is important for providers to see that bar and to want to get there,” she argues.

Ratings are based on the five criteria of whether a home is safe, effective, caring, responsive and well-led. Each of these criteria has its own ranking from Inadequate to Outstanding. If a service gets two or more Outstandings out of five, it is given an overall Outstanding rating. It used to be three Outstandings out of five to be Outstanding overall, so the CQC has actually made it a little bit easier to reach the high bar.

Ratings systems need to act as both carrot and stick for an industry, but if the Outstanding rating is given to less than 0.5% of care homes, it loses its potency. Since it is impossible for to secure a bed in an Outstanding home, there is no incentive for any operator to strive to be any better than Good. They will not lose any business from CCGs or from self-funders.

The national inspector of schools, Ofsted, rates around 14% of primary and secondary schools as Outstanding. There are around 8 million school places in the UK, with 14% of those places in Outstanding schools, that adds up to 1.12 million Outstanding desks to fill.

There are 487,000 beds available in all UK care homes. If only 0.5% of those beds are in Outstanding homes, that adds up to just 2435 beds in the entire country.

Ms Sutcliffe accepts the arithmetic, but maintains the ranking system is fit for purpose, and predicts that the percentage of Outstanding ratings will rise. “It is attainable, because some services are getting the Outstanding rating. We have not yet completed the programme of inspections, and we started off looking at the services that we believed to be at a higher level of risk. My expectation is that, as we move towards completing the programme, we will get to places that we have been comfortable to leave until a later stage in the programme because we expect them to be Good or Outstanding. I would imagine that the percentage [of Outstanding] will improve,” she insists.

The funding issues facing the care home industry should also be taken into account, Ms Sutcliffe suggests. CQC inspectors have encountered operators arguing on one hand that they don’t have the money to take their service to the very highest level and in the same breath demanding an Outstanding rating.

It appears that, contrary to what some operators believe, the CQC does want the percentage of Outstanding ratings to rise. “I would expect that we will increase the number of Outstandings as we complete the programme and, as we go back [to re-inspect services that have been told what areas to improve] many will go from Good to Outstanding,” says Ms Sutcliffe.

She also encourages people to take the time to read the inspection reports of Good and Outstanding services. Reports on the 60% of homes rated as Good routinely describe homes where teams are providing great service to residents, and they should be applauded for that work, it can often be just a couple of observations from an inspector that stop a home achieving the Outstanding rating.

“People should be positive about the Goods. We should celebrate the fact that there are so many Good services with people doing fantastic jobs in difficult circumstances.  Let’s be really positive about that,” Ms Sutcliffe urges.

Receiving at least a Good rating is vital to commercial care home operators. The CQC website provides vast amounts of information that customers of their service can browse, and the inspector makes it as simple as choosing a mortgage deal on Comparethemarket.com to view the ratings of all care homes in a particular area. There is even a Google map that shows every inspected care home as a dot coloured-in according to its rating.

Interrogating CQC data throws up some surprising results, not least the fact that operators of larger homes are not achieving the best ratings. This should be deeply troubling for an industry told by investment analysts that the most profitable size for a home is around 65 beds.

“We are seeing that the smaller and medium-sized care homes are having much more positive ratings, in terms of Good or Outstanding, compared to the larger or very large services. I think that is very interesting because over the past few years a number of operators have gone for the economies of scale of a larger build and more rooms,” Ms Sutcliffe observes.

“Actually that militates against the person-centred, homely feel and the ability of a manger to be on top of what needs to be done throughout his or her service, in the way that we see in some of the smaller homes. That is a challenge for the market, which is to say: ‘OK, you may have a home of a larger size, now how are you going to ensure that the things people value, which is the care and attention to detail, the way that the home is a community and people know and get on well with each other’. How can you take those really important features from the best small services, and ensure that they are present in larger places where it is undoubtedly more difficult to do that,” challenges Ms Sutcliffe.

The trend for larger care homes isn’t the only problem; CQC inspectors are also reporting that many modern luxury homes, where millions of pounds are being spent making a care home look like a boutique hotel, are falling short when it comes to care. “I do think that there is something about people, particularly at the luxury end of the market, focusing on the presentation; of what looks good as oppose to focusing on what is even more, which is how it feels.

“The environment is really important, and does have an impact on people’s health and wellbeing, but what is really important is what are the staff are like, how do they treat people, do they treat people with dignity and respect. Do they understand what person-centred care is all about? How will they respond to families if they have a problem? How will they share information if something happens? That real focus on the individuals that provide the care, the staff, is absolutely critical,” Ms Sutcliffe states.

Recruiting and retaining nursing staff is a particular problem right now for the whole industry, and this is having a direct impact on the ratings of care homes that provide nursing care. In this month’s interview with Andrew Knight, managing director of Care UK, he admits that it is harder than ever to provide the quality of care he demands at a commercially sustainable rate, when his wage bill for nurses is spiralling. Four Seasons Health Care reported the same challenge in its 2015 financial results, where it shows the soaring cost of agency nurses suppressing profits.

Ms Sutcliffe is sympathetic to the problem. “What we are seeing is that there are greater challenges in the nursing home part of the market, and that very much relates to the ability of operators to recruit and retain good quality nursing staff and care assistance working that environment where there are more complex needs,” she says.

Even in care homes without nursing, residents live with far more challenging health problems than the industry had to manage 10 years ago. This makes it more complicated and labour-intensive to provide the person-centred care that the CQC is looking for.

The environment can make this job more manageable, and Ms Sutcliffe advises that operators focus entirely on what works for people with conditions like dementia, not on what appeals to the resident’s younger, healthier, relatives. “When we are looking for a service for a loved one, we might be superficially impressed by how lovely it looks, and think places that are more appropriate for people living with dementia are a bit cluttered and messy. Well, actually, being a bit messy can be great because old people living with dementia – some of them, not all of them – may find it useful as they are walking down a corridor to pick up things that trigger memories and give them a bit of comfort. That helps them in the way that they are living their lives. It might not be intuitively what other people would think is the way it should look,” she describes.

The traditional Victorian home can compete with the modern new build in this respect, but there is no reason for one to rate more highly than the other with the CQC. “Some new homes are built to a very high standard and specification and will provide, for example, really good en suite facilities. In terms of the expectations that people have now, that is entirely appropriate and proper, and not all of the older buildings will be able to deliver on that,” Ms Sutcliffe says.

Again and again during the course of our interview, Ms Sutcliffe returns to the theme of putting the resident at the heart of every choice an operator makes. Big or small, new or old, luxury or sparse; it makes no difference to a CQC inspector who is looking purely at whether the service is safe, effective, caring, responsive and well-led. “The thing that I would say about the newer builds is build it for the people living there, and really think about what that means about what is going to be important for their lives because that  is what the service is for.” Ms Sutcliffe concludes.

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