Regulators are rarely popular but the Care Quality Commission (CQC) has few defenders left after several years of what looks like chaos and severe doubts over whether it has been fulfilling its key task — keeping the public safe.

The number of inspections carried out by the CQC has plummeted, it has massive IT problems, backlogs of registrations and notifications of concern to get through, and staff and stakeholder confidence is low (see below). One senior medical figure described it as “having lost its way”.

So there was general applause when Sir Julian Hartley — then head of NHS Providers and a former trust chief executive — took on the job of leading the CQC in December. Former health secretary Jeremy Hunt said Hartley had “a pretty good handle” on the problems, while the NHS Confederation’s Matthew Taylor says Hartley and other senior CQC executives “are being very measured and very reflective and open about the challenges that lie ahead and the changes they need to make to rebuild trust”.

But no one doubts the challenges Hartley faces in turning round an organisation without a chair — although former hospitals chief inspector Sir Mike Richards has recently been named as the preferred candidate to succeed Ian Dilks — and which urgently needed to recruit non-executives and permanent chief inspectors with real standing in the sectors it regulates.  

“If anyone can do it, he probably can,” says MiP chief executive Jon Restell. “It’s a twofold problem — the place of the regulator within the system and also the fact that it’s an organisation which is probably on its knees in terms of morale, sense of purpose, leadership culture and so on.”

Sir Julian will need to balance the need to pacify external stakeholders with nurturing CQC staff and keeping them on board, he says. And there will be bumps in the road which could derail his plans: a scandal about safety or care quality somewhere in the NHS or social care is almost inevitable at some point — so Hartley will need to get his changes in place quickly.

Hunt says the appointment of chief inspectors, who lead the inspection teams for a particular sector, will be “the most important decision he will have to make…..you need someone who has credibility.” The hospitals job, which in the past has been held by such heavyweight medics as Richards himself and Professor Ted Baker, is likely to be crucial.

Although NHS England’s patient safety lead, Professor Aidan Fowler has been appointed interim inspector of healthcare, covering primary, community and secondary care, the CQC is set to return to having separate chief inspectors for primary care, mental health, hospitals and social care. With so few inspections taking place, these senior figures will need to “get out there” and understand what is happening on the ground, adds one informed commentator.

Trusts want to feel they are being judged by a cadre of competent inspectors, Hunt says. He sees this as one of the CQC’s key successes in its early years under David Prior and David Behan, who built an inspection regime which didn’t rely solely on data but also included dozens of inspectors going in and talking to people. “Numbers don’t tell the whole picture, you need to actually go and see the place,” Hunt explains.

This helped build confidence and secured the position of the CQC after it had been shaken by a number of scandals. “I absolutely think we can do the same again and I think Julian is on the right track,” he says.  

But any new model of inspection will also have be financially sustainable. One informed commentator says this could mean relying less heavily on inspections, which inevitably involve lots of staff time. The CQC could instead learn more from regulators in other sectors which are more data driven, they suggest.    

Hartley has promised more co-production and closer working with providers but will need to avoid their involvement being seen as ‘provider capture’. Whether the CQC’s controversial ‘single word’ assessments will survive is unclear, although health secretary Wes Streeting is believed to want to keep them. 

Ofsted, the schools inspectorate, has tried to move away from single word ratings following the suicide of a headteacher whose school was criticised, but its proposed solution has been panned by teachers’ unions as “bewildering”, with multiple ratings for different aspects of the school’s role. Any changes to CQC’s system may run the same risk of losing clarity in search of nuance.

Not all managers see the single word rating as an issue. One senior manager says they offer clarity and assurance to the public and how managers feel about them simply doesn’t matter.

“Inadequate is for those who are really bad and don’t have a plan to improve it. You can game the system. If you know what they’re doing and what they’re looking for. You can tick all the boxes,” they said. “I like the concept of the CQC. Most of the people really unhappy about it are those who’ve had really bad inspections, but If you read thorough the inspection reports, you can see they’re not making it up!”

But another commentator with experience of CQC inspections questions how meaningful a one word assessment can be when a hospital has multiple sites and services. Even comprehensive inspections are unlikely to delve deep into every part of the trust, they warn.

“I think it would help if there was more focus on what actually benefits patients and users,” says the NHS Confed’s Matthew Taylor. Using data to spot problems in the early stages is helpful, he suggests, and was the idea behind the CQC’s risk-based approach. But it’s hard to do well. “CQC’s data capabilities did not match this ambition,” he adds.

Hartley will also need to rebuild the CQC from within. Unison national officer Matthew Egan says that some CQC staff have been “traumatised” by events over the last few years, but he feels “cautiously optimistic. He’s making all the right noises about changing the culture and he has made an effort to listen to staff,” he says.

But Egan warns some issues may be harder to solve. CQC staff pay is tied to the civil service, where pay has been frozen for much of the last decade. This can be off-putting for experienced NHS staff considering a move to the regulator. Although staff shortages have eased recently, there are still teams which are struggling to recruit and retain staff, Egan says.

In last year’s staff survey, the CQC fared particularly badly on the issue of whether staff felt they could speak up about problems at the organisation. “If the organisation had listened to frontline staff, we would not be in the mess we are now,” Egan adds.  

To give people a reason to stay at the CQC, Hartley will need to clearly signal that the organisation is changing and make staff feel they are helping the NHS to improve, suggests MiP’s Jon Restell. “He needs to give people a message that it is tough now but it will get better,” he says. 

The CQC also faces wider questions about the purpose of regulation and whether too much is expected of it. One senior medic suggests it the CQC has to “add value” but points to the difficulties organisations face in a pressurised system and the challenge of recognising that through inspection ratings.

The remit of the CQC — which was formed by merging three existing regulators — has been extended to include both integrated care systems (ICSs) and local authority social care services (the latter are assessed with a percentage rating alongside scores for a number of quality statements). One moment the CQC can be assessing a private ambulance service or home care service with a handful of staff and the next a multi-site trust employing 20,000 people. But 85% of the organisations it assesses have less than 50 employees. Can a single organisation be agile enough to do all this and provide a consistent standard of assessment which holds across these different sectors?