Has the CQC change programme failed?

23rd May 2024

Doctors and Regulators having a meeting

The results of the Care Quality Commission (CQC) People Survey 2024 are in and make for grim reading. It’s often true that people tend to speak up when they have something negative to say, rather than when it’s positive and the People Survey is no exception. With a 78% response rate, it’s fair to say that the results are representative of the staff views at the CQC.

The results were pretty dire, but there were three key areas that stood out for me:

One of the biggest red flags, and one that was highlighted at the CQC March Board meeting, was the fact that only 27% of respondents believed that the values and behaviours of the executive leaders (CEO and Executive Team) were consistent with the CQC’s values.
It was also extremely interesting to hear CQC’s Director of Policy and Strategy, Joyce Frederick say:

“When I went out and did inspections, if I saw survey scores like this – they are so linked, engagement is so linked to leadership and safety. Crucially there is a straight correlation between how safe is an organisation and what its leadership is like with engagement.”

We often see this reflected in CQC inspection reports – the Well-Led and Safe Key Questions often attract the same rating which then limits the overall rating where this is Inadequate or Requires Improvement.

Secondly, only 21% of respondents believed that action would be taken on the results of the survey (and more widely, only 23% believed that any concerns they raise about the way things are done in the organisation would be acted upon”). This yet again, does not reflect well on the leadership of the organisation.

Thirdly, 66% of respondents believe that the work they do helps to improve care for people who use services. This had deteriorated by 19%, from 85% since the 2021 People Survey.

Using the CQC’s own new scoring system, the first issue, barely scrapes an Inadequate, the third doesn’t even hit inadequate (what’s worse than Inadequate?!), and the second one, albeit towards the lower end of Good, on the basis improvement is one of the CQC’s core Strategy principles, it would appear to be falling short in this area.

A disaffected workforce can be dangerous. Organisational culture and leadership are key to motivating staff.

Where has this change programme gone wrong? Research shoes that many change management programmes either don’t really work, or just fizzle out. Kotter’s 8 Step Change model is well known. The first stage is to create a sense of urgency, and create a compelling reason why change is needed. The CQC outlined its Strategy in 2021. We are now in 2024. It was never really clear, to me, why the CQC needed to overhaul its system, and it appeared to be done just for the sake of it – the regulator reinventing the wheel every few years. Additionally, three years on and it doesn’t feel like we are that much further forward.

The second stage is to build a guiding coalition, forming a coalition with enough power to drive the change. Analysis will tell an organisation who the most important players are. Never assume where power is held within an organisation. Within a law firm, frequently it is the secretaries and PA’s that wield power, and not the partners which would be the natural conclusion. Whilst I don’t know if a guiding coalition was created, the Staff Surveys noted that 70% of respondents believed that the values and behaviours of manager and team leaders were consistent with CQC’s Values (not the exec or senior leaders). It would appear that the managers and team leaders would have been best positioned to be the required guiding coalition.

Stages 3 and 4 require a Vision and Strategy to be developed and communicated (and reinforced). This, I would say, the CQC has done well, up to a point. Whilst it has been communicating its Vision and Strategy repeatedly, the issue is that it hasn’t been doing much else. Consider the various webinars that the CQC has rolled out over the last year or so. Everyone joining, waiting, eager to hear more, only for the same old line to be trotted out with very little new, if at all, being added.

Stage 5 requires a broad-based approach, with people being empowered to act by removing barriers to change and encourage a more participative approach. In the CQC March Board Meeting, we heard that staff ability to upload evidence to the Portal was hindered by the length of time it took (2-3 hours). Additionally, the portal appears to have been rolled out to providers at the same time as staff so barriers have not been eliminated before launch. There are also whisperings of issues between assessors and inspectors, with changes being made to the assessment framework to say, in exceptional circumstances, inspectors can now create and lead assessments – suggesting that this was not the case before, and there being obstacles in the way of people being able to do their job.

Stage 6 requires short-term wins to be generated, to bring people along the change path. As mentioned above, the Portal has been a problem, and we have seen it being rolled out, retracted, and rolled out again. The early new style inspection reports made a mockery of the new system – with the majority of the scores being based on ratings from 6 years old. These matters can hardly be called short-term wins, and may be better described as short-term losses.

Stages 7 and 8 requires consolidation of the improvements, reassessment of the change and making necessary adjustments. Changes need to be anchored by demonstrating the relationship between the new behaviours and organisation’s success. It could be argued that the changes and amendments now being made are the adjustments and reassessment that are needed, but, in my view, the removal of barriers and short-term wins has not been achieved. On top of all this, we have been waiting for this roll-out for 3 years now. Rarely do people like change, but change fatigue is real. As part of a firm who advises the sector I’m bored of waiting, so if I feel that way, how does the sector feel, and indeed, how does the staff, the ones who will be implementing the changed framework on a day-to-day basis, feel? When a CQC Board member asks, only a matter of weeks ago, “does this new system allows us, still fully, to use our professional expertise and insight to generate activity that has professional integrity” it requires the CQC to take a re-look at the change programme and urgently re-evaluate.