General practitioner England GP practices

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Duties of the Care Quality Commission (CQC)

The role of the Care Quality Commission (CQC) as an independent regulator, is to register health and adult social care service providers in England and to inspect whether or not standards are being met.

All GP practices in England must be registered with the Commission. 

Find out how to register with the CQC

Since October 2014 a new inspection model has been used by the CQC. We have produced this guidance to explain the new inspection model to help you prepare for when the CQC visits your practice.

 

What are the powers and duties of the CQC?

The Health and Social Care Act 2008 established the Care Quality Commission as the regulator of all health and adult social care services in England.

It is a single Act of Parliament that contains the Commission's powers and duties. It contains some new powers of enforcement that were not held by any of the predecessor organisations.

Read more about the legislative framework behind inspections

 

What regulations does the CQC use to measure standards?

The CQC inspectors measure standards against a set of regulations. Initially there were 16 regulations but these have been replaced by 11 new regulations. These are referred to as fundamental standards of quality and safety.

Read more details on the fundamental standards

The last two of these new regulations came in to force for GP practices in April 2015. Those regulations are known as the Duty of candour and the Fit and proper person requirement.

Duty of candour

This is Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which sets out the Fundamental Standards. It aims to ensure that providers are open and honest with people when something goes wrong with their care and treatment. 

When a service is meeting the duty of candour patients should expect:

  • A culture within the service that is open and honest at all levels.
  • To be told in a timely manner when certain safety incidents have happened.
  • To receive a written and truthful account of the incident and an explanation about any enquiries and investigations that the service will make.
  • To receive an apology in writing.
  • Reasonable support if they were directly affected by the incident.

If the service fails to do any of these things, CQC can take immediate legal action against that provider.

The CQC has also published a mythbuster on the Duty of candour.

Fit and proper person requirement

The fit and proper person requirement applies where a service provider is a health service body. 

The service provider must not appoint or have in place within the practice anyone who is:

  • Not of good character,
  • Who does not have the qualifications, competence, skills and experience which are necessary for the relevant office or position or the work for which they are employed,
  • Not able by reason of their health, after reasonable adjustments are made, of properly performing tasks which are intrinsic to the office or position for which they are appointed or to the work for which they are employed,
  • Has not been responsible for, been privy to, contributed to or facilitated any serious misconduct or mismanagement (whether unlawful or not) in the course of carrying on a regulated activity or providing a service elsewhere which, if provided in England, would be a regulated activity.

The CQC has also published a mythbuster on the fit and proper person requirement.

 

Inspections and how they should be conducted

Inspection types

Under the new approach there will be two types of inspection; comprehensive and focused.

Comprehensive

  • Reviews the provider in relation to the five key questions leading to a rating on each on a four point scale
  • Assesses all six of the population groups
  • Takes place at the same time as CQC inspects a number of practices in a CCG area
  • Usually one day on site and usually announced
  • At least once every three years

Focused

  • Follow up to a previous inspection, or to respond to a particular issue or concern
  • May not look at all five key questions and six population groups
  • Team size and composition depends on the focus of the inspection
  • The inspection may be unannounced

Familiarise yourself with the GP Provider handbook in relation to the Key Lines of Enquiry, prompts and ratings rules generally.

The handbook also sets out how CQC prepares for an inspection, what data they will gather prior to inspection and what will happen when they are on site. All of this should be read thoroughly so that you know what to expect and prepare accordingly.

Also ensure that you review the new fundamental standards and the guidance on how to meet them which will be issued by CQC in due course.

Read the CQC GP provider handbook

Read more details on the fundamental standards

 

Ratings, key questions and bandings

GP practices are now being given ratings. The first GP ratings were published from November 2014 on the CQC's website.

Ratings

GP practices will be rated as:

  • Outstanding
  • Good
  • Requires Improvement
  • Inadequate

There will be no longer be a rating of 'adequate'.

Five key questions

A rating is awarded for each of these five key questions with equal weighting:

  • Is the service safe?
  • Is the service effective?
  • Is the service caring?
  • Is the service responsive?
  • Is the service well-led?

Six population groups

For GP practices there is also one rating for each population group. The six population groups with equal weighting are:

  1. Older People
  2. Long term conditions
  3. Families, children and young people
  4. Working age people (including retired and students)
  5. Vulnerable people (e.g. the learning disabled)
  6. People with a mental health problem (including dementia)

Performance levels

For each GP practice the CQC inspection will rate performance at four levels:

  • Level 1: Rate every population group for every key question
  • Level 2: An aggregated rating for each population group
  • Level 3: An aggregated rating for each key question
  • Level 4: An aggregated overall rating for the practice as a whole

Aggregated ratings

The rules for aggregating ratings are as follows:

  • Outstanding = 2 outstandings + the rest good
  • Good = 1 outstanding + rest good or 1 requires improvement + rest good
  • Requires improvement = 2 requires improvement + rest good or 1 inadequate
  • Inadequate = 2 or more inadequates

The aggregated population group ratings (level 2) do not directly tie into the overall key question ratings (level 3), which can lead to some odd results.

 

Intelligent monitoring

CQC has now categorised all GP practices in England into one of six bands based on priority for inspection:

  • Band 1 representing the highest priority
  • Band 6 representing the lowest

Check your band on the CQC website

The bands have been assigned based on the proportion of indicators that have been identified as a 'risk' or an 'elevated risk'.

They have done this by using existing national datasets for GP practices relating to a number of areas of care. CQC have looked at a total of 38 indicators to decide when, where and what they inspect.

The bandings are supposed to support the wider inspection approach and sources of information available to the CQC. They provide a prompt to GP practices to ask questions, reflect and (if appropriate) take action in respect of their own performance in relation to others.

However, we have expressed concern that the data collection exercise, the banding and the practice rating that results from the exercise, should not have been published prior to inspection as it is potentially misleading for patients.

 

Inspection results and how they affect you

Breaching regulations

The fundamental standards are governed by the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and are set out in Regulations 9-19 as below:

  • person-centred care (Regulation 9)
  • dignity and respect (Regulation 10)
  • premises and equipment (Regulation 15)
  • receiving and acting on complaints (Regulation 16)
  • good governance (Regulation 17)
  • staffing (Regulation 18)
  • fit and proper persons employed (Regulation 19)

The majority of regulations do not amount to direct prosecutable offences if breached but they are still regulatory requirements. So if breached, they can lead to other regulatory action.

GP practices should note that the CQC will be able to prosecute providers for the offences detailed in the new regulations without serving a warning notice.

Regulation 22 will make it an offence punishable by a fine for a registered person to breach the following regulations:

  • 11 (on consent)
  • 16(3) (supplying summaries of complaints to CQC)
  • 17(3) (supplying reports on quality monitoring)

 

Special measures

As set out above the CQC are now inspecting and rating GP practices for five key questions as well as against six population groups.

GP practices rated as inadequate for 1 or more of the 5 key questions or 6 population groups will be given a specified time period for re-inspection. This will be no later than six months after the initial rating is confirmed. During this period the practice must demonstrate improvement, ahead of another CQC inspection.

If after re-inspection, they have failed to make sufficient improvement, and are still rated inadequate for a key question or population group, the CQC will place the practice into 'special measures' following consultation with NHS England.

GP practices will be placed into special measures for a maximum of six months. Being placed into special measures will represent a decision by CQC that a practice has to improve within six months to avoid having its registration cancelled.

 

Support for practices placed into special measures

NHS England is starting work with the Royal College of General Practitioners (RGCP) to develop a pilot programme of intensive peer support to practices that are placed in special measures, but this is likely to involve a cost to the practice.

Practices that might be at risk of being placed into special measures are advised to contact their LMC at the earliest opportunity.

Find your LMC

The CQC has said that where a GP practice is deemed to have such significant problems that patients are at risk, or where they have sufficiently little confidence in the practice's capacity to improve on its own, then the practice will be placed straight into special measures.

The CQC will inspect the practice at the end of the special measures period. If the practice has not improved, and continues to provide inadequate care, it is likely they will cancel the provider's registration.

 

Post inspection

If you believe the rating you receive does not accurately reflect the service you provide, consider challenging the CQC on the ratings and importantly, the underlying facts and judgements.

Although the new regime has yet to be tested fully, we are aware of practices that have successfully challenged statements made in reports and have had them altered.

 

Get in touch

We can offer further support for GP practices before, during and after your CQC inspection.

Contact your LMC