Who decides what 'Outstanding' is?

Sir Julian, we need a new approach.

In the health and social care space, our regulator the Care Quality Commission (CQC) determines how services are benchmarked - from being rated ‘Inadequate’ to ‘Outstanding’. Since 2009 their framework has focused care provider’s attention and has provided care seekers with a guide of how a service is supporting people.

But is the CQC truly the best judge of what "Outstanding" care looks like?

The answer, for many of us working within social care, and especially for the people living in care, is increasingly no. I have yet to meet a registered manager within the last two years who hasn’t had a poor experience and so the current regulatory landscape, while well-intentioned, appears to have let us down.  The CQC’s inspections do not capture the essence of what truly matters for people - personalised, compassionate, enablement driven and emotionally focused care that enriches the lives of those who need our support.

Cracks in the System

The CQC's evaluation framework is built around structured inspections, looking at areas like safety, effectiveness, responsiveness, and leadership. But do these metrics truly reflect the quality of life experienced by someone living in a care home or receiving care in the community? I have spoken to registered managers and responsible individuals who are frustrated that they have not being inspected in 3+ years, homes waiting for registration for 2+ years and now local authorities are even advising people to ignore CQC ratings (Norfolk County Council, October 2024) due to the delay in re-inspections taking place when providers have improved.

Care, especially caring for people living with dementia, is about relationships and should have an emotional focus. It’s about teams knowing the people they support on a deep, personal level—their histories, stories, preferences, and unique needs. It's about creating environments where people feel at home, valued, secure, and understood. The CQC might rate a care home as "Outstanding" based on its paperwork and procedures, but are we asking the right people for their judgment?

Who Should Decide?

People living in homes where care is provided deserve better than a whole system that places too much emphasis on solely the regulator’s opinion. People should be at the heart of the decision-making process. The true measure of excellent care is not just compliance with fixed standards, but whether those receiving the care feel supported, respected, enabled and fulfilled.

Care providers who consistently strive for excellence understand this. I’ve seen them and trust me when I say that they have not always been graded ‘Outstanding’ by the CQC. Their feedback comes not just from regulators, but from listening to the people that make their community. The communities that leaders build are the real experts in determining what works, what needs improving, and what makes a care environment feel like home. You feel this when you walk in and meet the team and you see this in the faces of people living there.

A Call for Change

Sir Julian, it’s time for a new approach. One that doesn’t solely rely on infrequent inspections led by people who are focused on paperwork, but instead focuses on continuous improvement driven by those at the centre of care—the people living and working within it. People’s voices, their faces and their mental and physical wellbeing should be the most powerful factor in determining what Outstanding care looks like.

Outstanding care is not buried amongst data looked at on a screen.

The language used of how we assess a provider needs to change. We need to focus on using language more attached to the care we are striving to deliver. We should be assessing how a home understands the ‘language of social and emotional care’ and which is not focused on rigid, impersonal whitehall-style language.

We need to move away from a one-size-fits-all model of assessment and towards one that considers the unique context of each care setting, embraces person-led care, and values ongoing feedback from people, families and communities. It sounds complex but it really doesn’t need to be – if we can consider and implement person-centred care, surely a regulator can talk about adapting a regulatory framework which has ‘home’ and ‘family’ at the centre?

By shifting our focus, we can move closer to a system where homes are not only held accountable on safety by regulators but are actively shaped by the experiences and opinions of the communities they serve. This will lead to a more loving, compassionate, and holistic definition of what "Outstanding" care truly is.

The CQC has an important role to play, and whether it gets re-branded or re-cycled, it cannot be the sole arbiter of quality in care in 2025 and beyond. We must recognise however that leaders, communities, families and people being supported in care homes up and down the country have the deepest insight into what makes care truly exceptional; their wellbeing should be the key decision making factor.

An offer of support

@julianhartley, I would be happy to help you your new challenge. I am here on Linkedin if you want to DM me.

Please, when you are in your first board meeting discussing where to start re-building the trust that people have lost the CQC please remember that:

·        A mint chocolate chip ice cream can make someone’s day Outstanding.

·        Stroking a puppy in the garden can make someone’s day Outstanding.

·        Supporting a person to make their own cup of tea can make their day Outstanding

·        Caring for passionate teams that deliver care every day, can make their work Outstanding

It’s time for a new approach Sir Julian because people, families and teams deserve better.

Sam Dondi-Smith is a Senior Partner at the National Dementia Care Accreditation Scheme nadcas.org