In January 2023, the Care Quality Commission (CQC) introduced a new single assessment framework, aimed to streamline, and enhance the regulation of health and social care services in England.
The new model combines all three frameworks (hospitals, adult social care, and primary medical services) into one, with a single set of expectations to define quality care and good service.
The Key Lines of Enquiry (KLOEs) are being replaced with 34 Quality Statements, intended to provide a clearer and more comprehensive assessment of care providers.
With the launch of the CQC’s updated single assessment framework, one may inquire if insurers are beginning to question the longstanding reliance on historical ratings as the primary indicator of a care home’s quality and risk.
Melissa Kalsi, Underwriting Manager, Burns & Wilcox, United Kingdom, explores these emerging issues, highlighting the need for insurers and brokers to adapt their approach considering the new framework’s challenges.
Framework Overview and Industry Impact
Under the new framework, CQC continues to address five core questions: Is the service safe, effective, caring, responsive, and well-led?
However, these questions are now aligned with a wide range of evidence categories: people’s experiences, staff and leadership feedback, care observations, partner feedback, processes, and care outcomes. This structured approach is designed to deliver a data-rich evaluation that better captures service and operational quality.
Initial feedback from the framework’s pilot phase highlights both strengths and challenges. Many providers appreciate the enhanced communication and collaborative stance. However, operational challenges, such as IT limitations, expertise shortages among inspectors, and inspection delays, have raised concerns about the CQC’s capacity to reliably support the framework’s goals.
What the Framework Means for Care Homes
For care homes, the updated framework represents a chance to showcase service quality in more detail. Yet, for insurers, it raises questions about the stability of traditional rating-based models. Outdated inspection results, coupled with new challenges in inspection frequency, could impact how accurately an insurer can gauge a care home’s operational effectiveness and risk level.
By moving towards continuous evidence collection and a risk-based inspection approach, the framework is designed to funnel resources toward homes with lower ratings or flagged concerns. While this helps address regulatory attention, it also potentially extends inspection intervals for higher-rated homes, meaning their assessments might not reflect current conditions.
Assessing Care Home Risks
The availability of care home insurance has been scarce and restricted for several years, leading to many questions. For example:
- Does the current regulatory landscape in England mean care homes will find it even harder to get insurance if the care home’s latest CQC rating remains at “Requires Improvement” or “Inadequate,” despite investing in improvements?
- Should insurers rely on a “Good” or “Outstanding” rating where there has been no regulatory oversight for years? This is yet another challenge for care homeowners, who are still recovering from the effects of the pandemic, which saw significant increase in premiums.
- Finally, do we anticipate another period of unstable market conditions for care homes?
Given the evolving regulatory environment, underwriters and brokers must consider alternative methods to assess care homes. Brokers can play an essential role in ensuring that insurers have access to current information, and not rely on outdated ratings to help inform the underwriters assessment of the risk and premium level.
Brokers can help support their clients to improve the quality of information provided to insurers by:
- Gathering Direct Feedback from Residents and Families: Providing this feedback can provide insights that give additional perspective on operational consistency and care delivery.
- Tracking Staff Stability and Training: Metrics like turnover and training levels can highlight workforce stability, which often correlates with operational excellence.
- Reviewing Incidents and Complaints: Patterns in incident reporting and complaints can reveal recurring operational challenges, offering valuable data points for risk assessment beyond inspection results.
- Sharing Internal Quality Audits: Results can highlight what is going well; however, quality audits will uncover areas that need improvement and what actions need to be taken.
- Engaging in Third-Party Audits: Independent audits provide insurers with an unbiased assessment of a care home’s practices.
Brokers can help insurers develop a more comprehensive picture of care home operations, enabling more tailored coverage and reducing reliance on CQC’s timing and resource limitations.
At Burns & Wilcox, we offer specialised Care Home Insurance products designed to meet the unique needs of care homes. These products include direct access to a team of experienced underwriters, who write a broad range of Care Home risks, including those with regulatory issues or outdated rating and scores. As care regulations evolve, working with experienced underwriters becomes invaluable.
To learn more about our insurance solutions, visit Burns & Wilcox.