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06th June 2016

The Science of Outstanding?

Recent adds on TV frame my article this week. A bride-to-be enters a shop and selects a dress for her wedding day. A member of staff is on hand to take her measurements, puts her hands out and proceeds to roughly guess her measurements.  A guestimation is given to a runner at a marathon.  When she finishes the race, the official tells her ‘roughly’ her time.

I would be displeased with either of those scenarios, thinking of the importance personally of both of the events portrayed. I would wish to see a firm calculation of size, so the fit would be perfect. The time given should accurately reflect what I had done and my hard work in completing the race.

It is important to have an understanding of how your CQC rating is worked out behind the scenes. Is it an exact science? Do you feel it is a personal opinion of an inspector?  Or is it the best fit of a generic sizing? In understanding what goes in, it can be an indicator of what comes out and whether you wish to challenge the process or the outcome or whether you agree with it. Information on the framework can be found here.

Percentages of Outstanding in Adult Social Care

The state of social care report 2014/15 published in October 2015 sets outstanding at just 1% with good at 59%, requires improvement at 33% and inadequate at 7%. In May 2016 these figures were revised on the CQC strategy for 2016-21 page as 4% inadequate, 28% requires improvement, 67% good and still 1% Outstanding.

The above figures are not a surprise as for me excellent has to have a track record, and without this rating system before 2014, it will be hard to prove consistency. However, the bottleneck of good is on one hand fantastic for the sector, but may raise questions as to whether outstanding is too far out of reach for most, or alternatively whether inspectors are too harsh or fearful of putting services forward for the top rating.

CQC’s 2016-2021 Shaping the Future strategy uses people’s confidence that CQC will identify poor and good care by ‘The range of ratings across all four rating categories (outstanding, good, requires improvement and inadequate).’If this is to be realised, there is work to do at the top and bottom end of the scale.

Terminology and understanding

The Collins Online dictionary describes outstanding as superior; excellent; distinguished. The remit of ‘good’ also uses ‘superior’ sharing some of the outstanding description. Language can be a foe rather than a friend in a single word, and the need for more words to understand the differences in the shape of the 5 questions, KLOEs and characteristics are helpful and bring transparency to inspectors and the sector alike.

With any individual there will be a variation in understanding.  You see things differently, and you understand things differently. I have not been immune to seeing evidence differently to other inspectors, is it more likely that those on the cusp will be graded down rather than up from outstanding to good? 1% against 68% feels a little like it.

Within priority 4 ‘Improve our efficiency and effectiveness’ of the new CQC strategy, there is a heading ‘we will develop our people by’.  Highlighted there is tailored training to develop skills and knowledge. This I believe in part is to address the need for greater consistency. Challenging where you feel a rating is wrong will help the CQC improve (yes they are certainly not infallible), and could see an upgrade in rating.

Landscape for outstanding

The challenges in Health and Social care has provided the need for more resourcefulness and has spurred on greater joined up working and changing models of care.

CQC in the past have defined providers and locations in a traditional manor, but as more services adapt to the financial pressures and to the growing needs of the individual, so CQC will be playing catch up in their framework for registration and inspection.

The supporting document for CQC’s new strategy called ‘Sector by sector: what this means for services we regulate’ says, ’ As providers organise themselves in different ways we will increasingly tailor our inspections to changing models – making sure that we have the right combination of expertise on our inspections and that we register, report and rate at a level that is meaningful to the provider and the public.’

What goes in must come out

The assessment draws on pre-existing relevant information, what people who use services has told the commission, Provider Information Returns (PIR) and inspection information. CQC admit there is less quality information available for Adult Social Care, and so there is a great reliance on what is said and observed meaning qualitative information is the largest portion.

The PIR is an important vehicle to outline your information against the 5 questions. This is precious in demonstrating outstanding, and being transparent as to where your service is if it is not. As I have mentioned in previous blogs, CQC will expect more from PIRs as well as other information in targeting where an inspection needs to be carried out where a service has declined or alternatively made significant improvement.

If you feel you have highlighted vital information which is not recognised in your rating, you should very much say so.  CQC plans to be clearer in reporting when services are rated good but have outstanding features. There may be very important aspects of your service that the recognition of outstanding has an impact on potential and existing clients and their families and friends view of your service.

Safety in good?

I am in no doubt that as CQC internally are clearer and more consistent about what constitutes outstanding, the number will grow, and it will be a matter of time before the bar is moved to raise standards.

If you are currently ‘good’ this could see you in the requires improvement zone. This shows that ‘good’ is not a safe space to get comfortable in, and many would argue that you would not want to.

The future

Only time will tell if the bar for outstanding is as it should be. Outstanding should be like the jar on the top shelf (well if it is placed where it is in my house and you are as tall as me). It should be hard to reach, but obtainable…and without doing irreconcilable damage to get it!

I wish you well in your pursuit of Outstanding!

Abi Spence – QCS Registration and Inspection Expert Contributor

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