At a recent training session that I was delivering one of the participants commented that they thought the CQC was setting the bar for ‘Outstanding’ increasingly higher and higher. It’s not clear whether there is any substance to this claim, but it is certainly the case that statistically few services are rated this highly. For example, at the time of writing, of the 704 published care home reports over the previous month, only 21 (2.9%) were rated as Outstanding, whilst 403 (57%) were rated as ‘Good’. So clearly, only a very select few are deemed to be worthy of such a rating by the CQC.
At the same time, there are a number of reasons why a provider would be aiming for ‘Outstanding’. To start with, in an increasingly competitive market anything that gives a service the edge is bound to be attractive. If you are a prospective resident, client or relative and you had a choice between a ‘Good’ and an ‘Outstanding’ service, and all other things being equal, which would you choose? But it is also the case that there are a number of providers who simply want to do better; they have their ‘Good’ rating, and now they want to ratchet things up a bit. In fact, most of my clients over the last few years have been those who have already had a ‘Good’ rating, and now want to improve things even more. In my view, this seems to suggest they are the ones who take quality assurance (QA) and good governance seriously, which is why they were rated ‘Good’ in the first place!
But given that ‘Outstanding’ is both desirable and yet not something easily obtainable, the inevitable question, perhaps, is how do you get there? In other words, what exactly is ‘Outstanding’ and how do you achieve such a rating?
The CQC does not have a ‘definition’ of ‘Outstanding’ as such. It does specify the characteristics of an Outstanding service, and you can see what these are here. However, there is nothing in this information that actually tells you how to become this type of service. For example, one of the ‘Outstanding’ characteristics for ‘Safe’ is as follows:
People are protected by a strong, empowering and distinctive approach to safety and a focus on openness, transparency and learning when things go wrong.
As astute readers may be aware, this is the ‘Outstanding’ characteristic for key line of enquiry (KLOE) S1. All well and good – but what does it mean in practice? Another way to pose this question is to ask: what evidence would you need to provide in order to demonstrate to the CQC or any other interested party that service users are protected by a strong, empowering and distinctive approach to safety and a focus on openness, transparency and learning when things go wrong? As a matter of fact the CQC does provide a whole list of different types of evidence that it thinks would address this and all the other KLOEs, although it does not claim that any particular pieces of evidence would result in an ‘Outstanding’ rating.
For example, it would seem to make sense for a service to have a comprehensive and up-to-date safeguarding policy and procedures document that every staff member has actually read. And by ‘comprehensive’ I mean sections covering definitions of abuse, the statutory framework of safeguarding, identifying abuse, reporting abuse and other safeguarding issues (both internally and to external agencies such as the CQC and the local safeguarding team), investigating abuse and other safeguarding issues. In other words, simply having a safeguarding policy is not going to help you get a ‘Good’ rating let alone an ‘Outstanding’ one.
At this point it is probably worth taking a step back and considering what it means for a service to be ‘Good’. This is an important question because ‘Good’ is the CQC’s baseline for quality. In other words, ‘Good’ is what is expected. There is probably an argument for saying that ‘Good’ should be renamed ‘Adequate’, because this is what it actually means. However, for some reason the CQC decided that ‘Adequate’ did not resonate well with providers and prospective service users. What this means in practice is that when a CQC inspection team arrives they are ‘looking for Good’; in other words, they expect the service to be Good, because this is the baseline. If it falls short of the baseline it either requires improvement, or in extreme cases is deemed to be inadequate, which normally means it is in breach of multiple regulations and is generally not fit for purpose.
But if a service is ‘baseline’, i.e. ‘Good’, then what does it take for it to move above such a line? Clearly a great deal if you look at the statistic for ‘Outstanding’ that I cited earlier, which shows that it is extremely difficult for a service to receive the top CQC rating. Now this could simply be because the CQC has decided to make it extremely difficult, which seems to be the opinion of some managers and providers. On the other hand, it could simply be that in order to be rated ‘Outstanding’ management and staff need to show some innovation, imagination and creativity with regards to running and developing their services. And ‘innovation’, ‘imagination’ and ‘creativity’ seem be the three particularly significant words when it comes to ‘Outstanding’. In the CQC’s characteristics for ‘Outstanding’, the word ‘imaginative’ crops up five times, ‘creative’ twelve times and ‘innovative’ twenty-four times.
So here we have a massive clue with regards to what makes a service ‘Outstanding’: imaginative, creative and innovative thinking and practice amongst the management and staff teams. And bearing in mind that ‘creativity’ and ‘innovation’ appear to be particularly favoured by the CQC, we might further define an ‘Outstanding’ service as one that actively encourages creative and innovative thinking and practice amongst its management and staff teams. It is perhaps also worth pointing out that organisational learning seems to be another favourite concept of the CQC; in other words, the idea that services learn from their mistakes and embrace the latest good practice in order to evolve and adapt. So our final ‘definition’ could be this: an ‘Outstanding’ service is one that actively encourages creative and innovative thinking and practice amongst its management and staff teams, and is committed to continuous learning and improvement.
This brings me back to the central question of evidence. If we have at least some idea of what ‘Outstanding’ means, i.e. how it links to creativity, innovation and organisational learning, then how can this be evidenced? And this is where, I would argue, there is a problem with regards to the key lines of enquiry as a way of gathering evidence. As I pointed out earlier, ‘Good’ is the CQC’s baseline for service quality, and the primary focus of any CQC inspection is to ensure that that this baseline has been reached.
For this purpose, the KLOEs are extremely helpful, especially when it comes to identifying gaps in the evidence. Going back to my previous example of safeguarding, if a service does not have a comprehensive and up-to-date safeguarding policy and procedures then alarm bells are going to start ringing. Having such a document, coupled with evidence of recent safeguarding training and staff feedback that they clearly understand the concept and practice of safeguarding, goes a long way to satisfying the inspection team that service users are protected from abuse (the essence of KLOE S1). In other words, this type of evidence helps the inspection team to begin to establish its baseline for the service.
But once the baseline has been established how do you ascertain the degree to which the service has ‘risen above’ it, so to speak? And at this point things become more complicated because if innovation, creativity and learning are the key characteristics of ‘Outstanding’ then each service is going to exhibit such characteristics in different and often unique ways. In other words, whereas it’s actually not that difficult to ‘measure’ and evidence ‘Good’ and its deficits (‘Requires Improvement’ or ‘Inadequate’), it is much more difficult to come up with a ‘measure’ or ‘standard’ of innovation, creativity and organisational learning.
In practical terms, once you are satisfied that your service is ‘baseline’, i.e., ‘Good’, and, more importantly, the CQC is equally satisfied, then it is really a matter of making the case for ‘Outstanding’ by pointing out the different ways that your service has embraced creativity, innovation and learning. Remember, the CQC is looking for ‘Good’; you have to point them in the direction of ‘Outstanding’.