Good’ to ‘Inadequate’: what happened?

Although it is clear from the CQC’s latest State of Care report, as well as from their latest ratings data, that overall adult social care services are doing well in terms of their ratings figures, there are some worrying exceptions to the rule.  What I’m referring to in particular are those services that have gone from a ‘Good’ or ‘Outstanding’ rating to a ‘Requires Improvement’ or even ‘Inadequate’ rating in the space of one CQC inspection. The total figure is 1221 as reported in the June 2019 ratings data.   To be fair, this represents approximately 6% of the overall figure of 20,249 services reported on in the latest figures, but for those directly affected this is clearly 1221 services too many!

What is particularly striking about these results is that in approximately 90% of cases, the ‘Well-led’ domain also goes from either ‘Outstanding’ or ‘Good’ to ‘Requires Improvement’ or ‘Inadequate’.  In other words, leadership and governance (the focus of the ‘Well-led’ domain) is a significant factor in the ‘deterioration’ of these 1221 services.  Interestingly, in the 114 services where the overall rating for the first inspection is ‘Outstanding’ or ‘Good’, the ‘Well-led’ rating is ‘Requires Improvement’, which then either remains the same in the second inspection or is reduced further to ‘Inadequate’.  In other words, in nearly 10% of cases, the warning signs regarding issues with leadership and governance are already there in the initial inspections.

And the importance of leadership and governance is something the CQC emphasises in its State of Care report:

Leadership and governance are key factors that underpin quality. Effective governance systems make it easier for senior leaders to monitor quality and risk, and may help to insulate services from external pressures or unexpected changes, such as a key member of staff moving on. A lack of monitoring and oversight can quickly lead to problems with care delivery. (p.64)

I thought it would useful to take a closer look at some of this data, so I carried out a more focused piece of research which looked specifically on those services that had gone from an overall ‘Good’ rating to an overall ‘Inadequate’ rating in the space of a single CQC inspection. The research draws upon two CQC data sets: the current ratings data of all CQC regulated adult social care services produced in June 2018 and the same data produced a year later (June 2019).

The results of analysis shows that 83 services had gone from an overall rating of ‘Good’ to an overall rating of ‘Inadequate’ in the space of one published report. The time period between the first and second reports varies from nearly three and half years to less than a year.  The analysis also shows that in all cases, the services that are rated ‘Inadequate’ overall are also rated the same for ‘Well-led’, i.e. in terms of their leadership and governance.

Looking at a sample of ten of the ‘Inadequately’ rated services, further analysis reveals that in every one of these there are significant issues regarding the monitoring (quality assurance or QA)  of the service.  In the case of three of these services QA issues were picked up in the  first inspection as well, though not enough to impact on the overall rating.  Perhaps more significantly, in seven out of ten of these services, the second inspection was triggered by concerns raised by either a whistleblower from within the service, from a relative or member of the public, or from the local authority.  Why wasn’t the manager or the provider aware of such issues themselves?

I also read through the reports of five of these services in some detail to get a better sense of the problems that had been found by the inspection teams during the second inspection.  These reinforced the statistical evidence that showed a marked deterioration in the safety, leadership and governance of the services in question.

For example, in one service inspectors found:

People were not always protected from the risk of abuse. There was no effective system being used to ensure that safeguarding referrals were made to the local authority and we identified that the service had not made referrals for some incidents when they should have. When safeguarding incidents had occurred, they were not always recorded as such and this meant that the service could not identify trends or themes.

And in another:

The provider had audits in place to check the quality of the service but these were ineffective. For instance the inadequacy of people’s care planning information had not been picked up; deficiencies in the way people’s support was provided had not been identified and the lack of adherence to the MCA had not been addressed. There was little evidence that there were robust processes in place to gain people’s views on the quality and safety of the service or that staff practice at the home was monitored to ensure that it was safe and appropriate.

What is absolutely clear from this analysis is that one of the primary problems for all these services is their leadership and governance, and especially the issue of service monitoring and remediation (often referred to as quality assurance or QA).  In other words, having effective systems and processes in place so the management is able to monitor, on a continuous basis, all aspects of the service.  And also that management addresses, in a timely manner, any issues that are detected by such monitoring systems and processes.

Perhaps the key message to come out of this research is that managers and providers cannot afford to be complacent, even when their services have just had a positive rating.  As I indicated earlier, often the warning signs are already there; for example, if there are any issues regarding leadership and governance in a service that otherwise has been rated ‘Good’ or ‘Outstanding’ then alarm bells should start ringing.  And more generally, if either the manager or the provider are no longer confident they have a firm grasp of what’s going on across the service and where potential problems might be emerging, then it is time for them to take a closer look at the overall governance systems and processes that are in place.

And in case you think it can’t happen to you, just go and talk to those managers and providers who have just had their services downgraded and who also thought it could never happen to them…