Lawyers Sarah Knight and Katherine Millray outline how the inspection process works and what action practices can take if they disagree with a CQC rating or report
In its role as the regulator of general practice in England, the CQC monitors, reviews, inspects and rates surgeries across the country. Its priorities are to ensure that services are safe, effective, caring, responsive and well-led.
It keeps track of the level of care being provided by carrying out annual reviews and gathering insight from patients and other parties to keep track of changes in the quality of service provided.
If it identifies a decrease in quality, or a particular issue or concern is raised, the CQC can choose to inspect practices to ensure it has an accurate rating for them, and to determine whether any enforcement activity needs to be undertaken.
This article will answer some of the most common questions around what to expect when your practice / practices are inspected by the CQC, and what to do if you disagree with any of the findings.
How often will my practice be inspected?
The frequency of inspection depends on your existing rating.
If the service is rated ‘inadequate’ then a further inspection will take place after six months, while ‘requires improvement’ will normally mean another inspection is carried out in 12 months. If the service is inadequate, it will be put into special measures and enforcement action including the threat of cancelled registration can follow.
If a service is ‘good’ or ‘outstanding’ then the CQC will carry out a formal regulatory review every year – normally in the form of a structured telephone call – and then it will decide either that no further action is needed, or to carry out an inspection.
What are the types of CQC inspection?
There are two main types of inspections – ‘comprehensive’ and ‘focused’. These may be in-person, virtual or a combination of the two.
A comprehensive inspection is an in-depth and holistic assessment of your practice that looks at all areas of the service being provided. This is broken down into the five categories mentioned above – safe, caring, effective, responsive (to people’s needs) and well-led.
Comprehensive inspections are carried out where the CQC believe there is a risk to the safety or wellbeing of people who use the service, or there has been a significant deterioration in service quality. A comprehensive inspection may also be carried out following a substantial improvement in quality that could increase the overall rating.
Following an inspection, the practice is given a rating of ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’ for each area, as well as an overall rating for the service. Warning notices may also be issued requiring the practice to take action on any concerns raised during the inspection.
Comprehensive inspections are usually unannounced, but the CQC will sometimes let the provider know it is coming if careful planning may be required, or if it’s a smaller provider. Notice given will usually be 48 hours.
Focused inspections look at a specific concern. They may occur following a comprehensive inspection, a change in provider or if specific concerns are raised. These are usually unannounced.
These do not usually look at the five categories as set out above. Instead, they often have a narrower scope and are smaller in scale than a comprehensive inspection. However, they will always assess the ‘well-led’ key question along with any other area of focus.
They may be expanded to a comprehensive inspection once the CQC has completed its review. Again, a focused inspection may result in a change in a practice’s rating for the areas in question – or the overall rating of the practice – and warning notices may be issued requiring action to be taken.
In July 2022, the CQC introduced its new ‘single-assessment framework’, which is built on the five key questions mentioned above and operates based on each practice committing to a ‘quality statement’. These are detailed promises made by the practice that ensure they are in line with CQC expectations and that they are delivering high-quality, person-centred care. These will be amended following inspections and annual regulatory reviews.
For all types of inspection, it’s essential that practices’ documentation is up to date – and that managers know where to access certain documents that the CQC might ask for, such as training documentation.
Regular filing and record-keeping are key. Documents won’t always be asked for by the CQC, but they may be – and practices must be prepared.
What if my practice doesn’t agree with the CQC’s report or rating?
There are three avenues by which a practice can challenge a CQC decision – a ‘factual accuracy challenge’, a ‘ratings review’ and a judicial review.
1. Factual accuracy challenge
Following an inspection, the CQC will send its draft report over to the GP practice so it can confirm the factual accuracy of the material upon which its decisions are based.
At this point, you can challenge the report on the basis of its factual accuracy but, in order to do so, something in the report must be demonstrably incorrect.
You must move quickly with these challenges – there’s only a period of 10 days after the report when a challenge will be admissible.
It’s a good idea to seek the support of a qualified and specialised legal professional as soon as you think the report may be inaccurate, explaining what you disagree with and why you don’t think it’s factually correct. They can help advise you on the best way to approach the challenge.
It’s also worth bearing in mind why you want to challenge the report. Correcting an inaccuracy can be valuable for its own sake but it’s important to note that this won’t always change the rating.
Along with correcting factual inaccuracies, you can also challenge the CQC if you think it hasn’t taken certain critical information into account in its report. Again, even if the CQC accepts this challenge, be aware that this might not change the overall rating.
2. Ratings review
If, after a report is published, you feel that the rating given by the CQC is not accurate, you can ask the CQC for a ‘ratings review’.
However, the only ground for requesting a rating review is that the inspector did not follow the process for making ratings decisions and aggregating them. Guidance on how the CQC inspector should make rating decisions can be found on the CQC’s website.
A request for a ratings review must be submitted within 15 days of the report being published and must include clear evidence of the correct inspection and review process not being followed correctly. Again, a specialist lawyer will be able to advise on the best way to approach this. The CQC’s own report in relation to ratings reviews shows that of 970 applications that were made in 2019 only 27 were successful in having an increase in overall rating and 697 were closed with no grounds.
It is evident that the process is a difficult one. A legal challenge to the process in 2016 led to limited improvements in the factual accuracy process and the recent case of R (on the application of Hexpress Healthcare Limited) v CQC confirmed that in general terms the process is fair, but that the CQC’s gathering of information from a small number of people is inadequate. We will be providing a further briefing on this interesting case and how it may affect services, later this year.
3. Judicial review
While a ratings review is the last formal CQC pathway available to practices wishing to challenge a report, practices can request a judicial review of the CQC’s decision. This must be done within three months of the report publication.
These have become rarer occurrences since the implementation of the factual accuracy check process, which has made it more difficult to argue that inspection reports are unlawful, unreasonable or irrational.
Bear in mind that this can be a complex and time-consuming process, so it’s worth seeking expert legal advice as to whether it is the right option for your practice, and your circumstances. If you have any questions around preparing for, or challenging CQC reports, seeking legal advice is always advised.
As always, thorough preparation, and quick action in the case of any factual inaccuracies or review processes, will put practices in the strongest position for positive outcomes.
Sarah Knight, Legal Director at Weightmans, is an expert in healthcare regulatory law and advises providers – including GPs – on enforcement action brought by CQC (and other regulators).
Katherine Millray, Associate at Weightmans, is an expert in healthcare, with experience in bringing proceedings against the CQC on behalf of healthcare providers, including GPs.